[Management and follow-up of renal injury-a 10-year experience at a Swiss level 1 trauma center]. / Therapie und Nachsorge traumatischer Nierenverletzungen ­ 10 Jahre Erfahrung eines Schweizer Level­1-Traumazentrums.

INTRODUCTION: The objective was to analyze patterns of injury, management, imaging, and follow-up care of renal trauma at a Swiss level 1 trauma center. METHODS: We examined 138 patients (>16 years) with renal organ injuries who presented to our institution between January 2008 and March 2018. Data on demographics, patterns of injury, clinical presentation, management, and follow-up were recorded. RESULTS: The injury grade of the 142 injured kidneys was grade 1 in 25% (n = 36), grade 2 in 16% (n = 23), grade 3 in 32% (n = 46), grade 4 in 24% (n = 34), and grade 5 in 2% (n = 3). The predominant injury mechanism was winter sports (45%). Conservative management was successful in all grade 1 renal injuries, and 91%, 86%, 35%, and 33% of grade 2, 3, 4, and 5 injuries, respectively. Early follow-up with CT or MRI scan was performed in 23% of grade 1-3 injuries and 57% of grade 4-5 injuries with clinical signs of complications as the most frequent indication for grade 1-3 injuries and routine follow-up imaging for grade 4-5 injuries, respectively. In follow-up care (1-9 months after injury) imaging showed persistent pathologies in 39% of grade 1-3 renal injuries and 62% of grade 4-5 injuries. CONCLUSIONS: Most minor renal injuries (grade 1-3) can be successfully managed conservatively. Early follow-up imaging is indicated for patients showing clinical signs of complications. Routine repeat imaging may not be justified for high-grade renal injuries without clinical symptoms. Re-imaging in follow-up care still lacks evidence-based recommendations.

[Evaluation of a prostate cancer E­health tutorial : Development and testing of the website prostata-information.ch]. / Evaluation eines Online-Tutorials zum Prostatakarzinom : Entwicklung und Überprüfung der Seite prostata-information.ch.

BACKGROUND: Due to the multitude of therapy options, the treatment decision after diagnosis of localized prostate cancer is challenging. Compared to printed booklets, web-based information technology offers more possibilities to tailor information to patients' individual needs. OBJECTIVES: To support the decision-making process as well as the communication with patients, we developed an online tutorial in a systematic process in the German-speaking part of Switzerland and then tested it in a pilot study. The study investigated users' satisfaction, the coverage of information needs, the preparation for decision making, and the subjective quality of the decision. MATERIALS AND METHODS: Based on already existing information material, the online tutorial was developed in an iterative process using focus groups with patients and urologists. For the following evaluation in eight clinics a total of 87 patients were invited to access the platform and participate in the study. Of these patients, 56 used the tutorial and 48 answered both surveys (the first one 4 weeks after the first login and the second one 3 months after treatment decision). The surveys used the Preparation for Decision Making Scale (PDMS), the Decisional Conflict Scale (DCS), and the Decisional Regret Scale (DRS). RESULTS AND CONCLUSION: Satisfaction with the tutorial is very high among patients with newly diagnosed localized prostate cancer. Users find their information needs sufficiently covered. Three months after the decision they felt that they were well prepared for the decision making (mean PDMS 75, standard deviation [SD] 23), they had low decisional conflict (mean DCS 9.6, SD 11), and almost no decisional regret (mean DRS 6.4, SD 9.6). Based on these findings, further use of the tutorial can be recommended.

Chronic scrotal pain syndrome (CSPS): the widespread use of antibiotics is not justified.

Data supporting the widespread use of antibiotics in patients with chronic scrotal pain syndrome (CSPS) are not available. Therefore, the aim of this study was to investigate the presence of bacteria in the genitourinary tract in patients presenting with CSPS. From July 2005 to July 2007 we prospectively enrolled patients presenting with CSPS in our outpatient clinic. The evaluation consisted of a detailed patient's history, physical examination and ultrasound examination of the scrotum. A blood and urinalysis, a Meares-Stamey four-glass test for bacterial cultures and PCR testing for Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis and Neisseria gonorrhoeae as well as a semen culture were performed. We assessed the symptom severity with the chronic epididymitis symptom index (CESI) score according to Nickel et al. (J Urol 2002, 167:1701; based on the NIH-CPSI). A total of 55 eligible men (median age 34 years) with CSPS were enrolled in the study. The median CESI score was 17 (range 4-26). The majority of patients (n = 39; 71%) were seen by a general practitioner or an urologist before. Of these, 25 patients (64%) were treated with antibiotics and 26 (67%) with non-steroidal anti-inflammatory drugs, respectively. A significant bacterial colony count in at least one specimen was detected in 21 of 55 patients (38%). The predominantly detected microorganisms were an Alpha-haemolytic Streptococcus (11 patients) and coagulase-negative staphylococci (10 patients). Thus, only in 12 of 55 (22%) patients isolated bacteria were considered to be of clinical relevance. No factor or condition predictive for a bacterial aetiology for CSPS could be identified. In our microbiological assessment of patients presenting with CSPS we found no evidence for the widely held belief that CSPS is predominantly the result of a chronic bacterial infection. We therefore conclude that the widespread use of antibiotic agents in the treatment of patients with CSPS is not justified.

Unenhanced versus multiphase MDCT in patients with hematuria, flank pain, and a negative ultrasound.

OBJECTIVES: To compare the impact of unenhanced and contrast-enhanced multi-detector computed tomography (MDCT) for the detection of urinary stones and urinary obstruction in patients with suspected renal colic. METHODS: 95 patients with suspected renal colic underwent a three-phase MDCT for evaluation of the urinary tract. The unenhanced scan and the multiphase examination were reviewed retrospectively by two radiologists for the characterization of urinary stones and signs of obstruction. Results of unenhanced MDCT were compared with those obtained during the second review of the entire multiphase examination. RESULTS: Overall diagnosis of urinary stones revealed an accuracy of 97.0% for unenhanced, and 98.9% for multiphase MDCT with a significant difference between both protocols (mixed-effects logistic regression: odds ratio 3.3; p=0.019). With 3 versus 15 false positive ratings, multiphase MDCT was superior to unenhanced MDCT for the diagnosis of urinary stones. There was no significant difference in detecting signs of obstruction. Inter-reader agreement for overall stone detection was excellent on both unenhanced (kappa 0.84) and multiphase (kappa 0.88) MDCT. CONCLUSION: Contrast-enhanced multiphase MDCT offers distinct advantages compared to an unenhanced approach for the assessment of urinary stone disease, and therefore should be considered as a complementary examination for patients with inconclusive findings.

Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics.

PURPOSE: In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs. MATERIALS AND METHODS: A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment. RESULTS: Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase. CONCLUSIONS: Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Neurovascular bundle block as predictor of postoperative erectile function after radical prostatectomy.

We assessed audiovisually induced erections after nerve block of the neurovascular bundle during prostate biopsy. We evaluated neurovascular bundle nerve block to mimic non-nerve-sparing radical prostatectomy in an experimental setup. Patients undergoing a transrectal ultrasound-guided prostate biopsy were randomized to bilateral injection of 5 ml ropivacaine hydrochloride 0.75% or NaCl 0.9% into the neurovascular bundle. The patients completed the International Index of Erectile Function 5-item questionnaire (IIEF-5) questionnaire, and a detailed patient history was obtained. A routine prostate biopsy was performed. Thereafter, patients were exposed to 60 min of audiovisual stimulation. Erections were recorded using a Rigiscan-Plus device. A total of 11 patients were randomized. Five patients received NaCl (group 1) and six patients ropivacaine (group 2). Patient characteristics were comparable in terms of age (group 1: 59.8 y; group 2: 61.8 y), mean PSA (4.1 vs 4.7 ng/ml), mean IIEF-5 score (20.5 vs 22) and risk factors for erectile dysfunction, respectively. Patients of group 1 showed significantly stronger and longer erections after audiovisual stimulation than patients in group 2. Patients with bilateral infiltration of saline solution to the neurovascular bundle showed significantly stronger erections than patients receiving local anesthesia of the neurovascular bundle. Thus, this experiment might serve as a model to assess postoperative erectile function after a unilateral nerve-sparing radical prostatectomy.

Extracorporeal shockwave therapy for Peyronie's disease does not correct penile deformity.

To evaluate whether extracorporeal shockwave therapy (ESWT) offers an effective treatment for the main complications of Peyronie's disease (PD), that is, penile deformity and angulation, painful erection and most importantly unsatisfied sexual intercourse. From September 1999 to January 2001, 52 patients with PD were treated with ESWT. Pain during erection was assessed with a visual analogue scale. Penile deviation was determined by photographs with a goniometer. Five treatment sessions were performed at weekly intervals. Each consisted of 3000 shockwaves with an emission frequency of 120 shockwaves/min and a mean intensity of 0.17 mJ/mm(2). A Storz Minilith SL 1 with integrated inline ultrasound probe was used. In all, 52 patients were evaluated 6 weeks after ESWT for early follow-up. Before ESWT intercourse was difficult or impossible for 40 men; 29 patients suffered mainly from penile deformity, 14 from painful erection and eight mainly from loss of distal rigidity. A total of 30 patients mentioned painful erection before treatment. In 28 patients (93%) pain reduction was achieved. A total relief of pain was observed in 19 patients (63%). Mean pain score dropped from 4.2 to 1.3 in patients who suffered predominantly from painful erections. Intercourse satisfaction improved in 11 patients after therapy. Mean angulation before (40 degrees ) and after (37 degrees ) ESWT did not change significantly. Late follow-up after 11.1 months (4-17 months) could be completed in 36 patients. In total, 19 men reported that ESWT improved their PD. Of these, 16 noted no change. Only one of the patients noticed a worsening of his disease during or after treatment. Complication rate was low with only minor side effects such as minimal skin bruising; one urethral bleeding occurred. ESWT did reduce pain during erection in patients suffering mainly from painful erection due to PD. However, penile angulation did not improve significantly in our setup and thus intercourse difficulties did improve only in 28% of the patients. Therefore, we do not recommend ESWT as a primary treatment for PD.

Apomorphine sublingual as primary or secondary treatment for erectile dysfunction in patients with spinal cord injury.

OBJECTIVES: To evaluate the effectiveness of apomorphine sublingual (SL) 3 mg, as a primary or secondary treatment for erectile dysfunction (ED) in patients with spinal cord injury (SCI), and to determine possible differences in efficacy considering clinical, urodynamic and neurophysiological findings. PATIENTS AND METHODS: The study included 22 patients with chronic SCI and neurogenic ED who were examined physically and by a video-urodynamic evaluation. A neurophysiological evaluation included somatosensory evoked potentials of the pudendal nerve, palmar and plantar sympathetic skin responses and bulbocavernous reflex recordings. Thereafter the patients received 8 tablets of apomorphine SL 3 mg and were asked to complete the International Index of Erectile Function questionnaire before and after treatment. Side-effects, subjective efficacy compared with other treatments and satisfaction with the SL administration were recorded. RESULTS: Of the 22 men, 11 had upper motor neurone lesions (six complete, five incomplete), eight lower motor neurone lesions (seven complete, one incomplete) and three had mixed lesions. In all, 12 patients took sildenafil citrate and five alprostadil intracavernosally beforehand, and five had used nothing to treat their ED. Seven patients had some response and reported that the drug helped them to obtain an erection, but only two reported erections sufficient for intercourse and would agree to continue apomorphine SL as their standard treatment; all the others reported being disappointed. Nine patients reported side-effects. There were no significant correlations for electrophysiological or urodynamic findings and treatment success. Of the 22 patients 20 preferred SL rather than the normal administration. CONCLUSIONS: Apomorphine SL, a D1/D2 dopamine agonist, facilitates erectile function in a heterogeneous group of patients with no significant relationship with any of the assessed urodynamic or electrophysiological variables. The overall low rates of response either for primary or secondary treatment suggests that apomorphine will have limited applicability in patients with SCI.

Excimer laser spectroscopy: influence of tissue ablation on vessel wall fluorescence.

Limited steerability and injury to the normal vessel wall are major drawbacks of laser coronary angioplasty. To overcome these limitations a new generation of laser systems has been developed which allows not only to eliminate the atherosclerotic plaque but to guide the laser beam by analyzing the laser induced tissue fluorescence (= spectroscopy) for the treatment of the atherosclerotic vessel. An excimer laser (MAX 10 LP, 308 nm, Technolas, Munich, Germany) was used with an emitting (phi 1070 microns) and a detecting (phi 130 microns) optical fiber to induce tissue fluorescence which was analyzed quantitatively by a computerized system. Specimens from the descending (thoracic) aorta were obtained from 24 patients (mean age 68.1 years, range 44-92). Tissue fluorescence was induced with ablating (26-30 mJ/mm2) and nonablating (3 mJ/cm2) laser activations. The emitted fluorescence (range 380-575 nm) was normalized to a wavelength of 380 nm; as a measure of tissue fluorescence the intensity ratio at 500 nm divided by 400 nm was calculated in normal (n = 78), mildly atherosclerotic (n = 40), and severely atherosclerotic (n = 48) tissue samples. Repeated laser activations were carried out and tissue fluorescence was checked until the fluorescence spectrum was normalized. All tissue samples were analyzed histologically by a semiquantitative score. Normal tissue samples showed the highest intensity ratios (5.9 +/- 3.4), whereas mildly (2.9 +/- 1.3) and severely atherosclerotic (2.1 +/- 1.0) samples elicited a significantly reduced fluorescence. Repeated tissue ablations were associated with a normalization of fluorescence intensity ratios in the mildly (7.0) as well as in the severely diseased (4.9) vessels. A curvilinear relationship between intensity ratio and the semiquantitative score was observed (r = 0.66) as well as between intensity ratio and intimal wall thickness (r = 0.62). No gender related differences were found but there was an inverse relationship between fluorescence intensity ratio and age (r = 0.56) as well as between intimal thickness and age (r = 0.41). Excimer laser spectroscopy allows reliable detection of atherosclerotic vessel alterations. Fluorescence intensity ratio is inversely proportional to the intimal wall thickness and the severity of the histologic alterations. There is an age dependency of fluorescence intensity ratio which can be explained by an increase in intimal wall thickness. Successful tissue ablation can be obtained by laser angioplasty and allows determination of the optimal point where complete tissue ablation is achieved by laser activation. Thus, excimer laser spectroscopy is an effective method for selective tissue ablation by laser angioplasty.