Study of the Equatorial and Low-Latitude Electrodynamic and Ionospheric Disturbances During the 22-23 June 2015 Geomagnetic Storm Using Ground-Based and Spaceborne Techniques.

We use a set of ground-based instruments (Global Positioning System receivers, ionosondes, magnetometers) along with data of multiple satellite missions (Swarm, C/NOFS, DMSP, GUVI) to analyze the equatorial and low-latitude electrodynamic and ionospheric disturbances caused by the geomagnetic storm of 22-23 June 2015, which is the second largest storm in the current solar cycle. Our results show that at the beginning of the storm, the equatorial electrojet (EEJ) and the equatorial zonal electric fields were largely impacted by the prompt penetration electric fields (PPEF). The PPEF were first directed eastward and caused significant ionospheric uplift and positive ionospheric storm on the dayside, and downward drift on the nightside. Furthermore, about 45 min after the storm commencement, the interplanetary magnetic field (IMF) Bz component turned northward, leading to the EEJ changing sign to westward, and to overall decrease of the vertical total electron content (VTEC) and electron density on the dayside. At the end of the main phase of the storm, and with the second long-term IMF Bz southward turn, we observed several oscillations of the EEJ, which led us to conclude that at this stage of the storm, the disturbance dynamo effect was already in effect, competing with the PPEF and reducing it. Our analysis showed no significant upward or downward plasma motion during this period of time; however, the electron density and the VTEC drastically increased on the dayside (over the Asian region). We show that this second positive storm was largely influenced by the disturbed thermospheric conditions.

Percutaneous Stone Manipulation.

Percutaneous stone manipulation by direct ultrasound disintegration, extraction or chemolysis was done on 34 patients. A total of 15 patients presented with an operatively established nephrostomy, while percutaneous nephrostomy and subsequent dilation of the nephrostomy channel were done in 19. The rate of complete stone clearance was 19 of 20 stones after percutaneous nephrostomy and 8 of 16 stones in the group with an operatively established nephrostomy. The primary goal, to remove obstructing pelvic stones, was achieved in all cases. There were no untoward side effects, such as back pressure damage owing to flushing of the collecting system during ultrasound disintegration, or persistent infection. Complications in 3 patients were managed conservatively.

[Quality and objectifiability of training and advanced training in urology]. / Qualität und Objektivierbarkeit der Aus- und Weiterbildung in der Urologie.

The attraction to study medicine has not changed, however we are facing a lack of trainees especially in surgical subspecialties like urology. Possible explanations are a 70% proportion of female students and different views on the work-life balance in the future. A high burden of theory and unrealistic multiple choice examinations support those who can learn but there are no objective and reproducible criteria to recognize the competence of a good physician early in the career. This problem continues during residency, especially in surgical subspecialities. The different medical boards in Germany responsible for the training programs have no concepts. Many attempts in other countries to objectively measure surgical skills have so far been ignored. If we do not want to lose our traditionally high competence in medicine we should join those who attempt to improve teaching and to use methods for selecting suitable candidates for surgery as soon and as objectively as possible.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[An alternative continence mechanism for continent catheterisable micturation]. / Ein alternativer Kontinenzmechanismus für kontinente katheterisierbare Harnableitungen.

PURPOSE: The creation of a stable, reliable, continent and easily catheterisable continence mechanism is an essential prerequisite for the construction of a continent cutaneous urinary reservoir. Although a substantial number of surgical methods has been described, construction is still a complex surgical procedure. The aim of this study was the evaluation of a new method for a continence mechanism using stapled small or large intestine. MATERIAL AND METHODS: Small and large pig intestine was used for construction. For stapling the tube a 3 cm or 6 cm double row stapling system was used. Two variations using small and large intestine segments were constructed (IL 1, COL 1, COL 2). A 3 or 6 cm long stapler line was placed alongside a 12 Fr catheter positioned at the antimesenterial side creating a partially two-luminal segment. The open end of the non-catheterised lumen and the opposite intestinal end were closed by continuous sutures. The created tube was then embedded into the pouch. Pressure evaluation was performed for each variation. Intermittent external manual compression was used to simulate sudden pressure exposure. RESULTS: Construction times for the IL 1 and COL 1 variations were 10 +/- 1.5 min and 6.2 +/- 1.3 min for COL 2. All variations showed no leakage during filling or external compression. The maximum capacity was lower for the IL 1 compared to the COL variation. The maximum pressure levels reached did not differ significantly. CONCLUSION: The described technique is an easy and fast method to construct a continent and easy to catheterize continence mechanism using small or large intestine.

Evaluation of urolithiasis: a link between stone formation and diabetes mellitus?

INTRODUCTION: The pathogenesis of calcium oxalate stone formation is not completely understood. Recently, an influence of vascular phenomena like arteriosclerosis on the crystallization process was hypothesized. Thus, stone formation should be more common in patients with diabetes mellitus (DM) who are at risk of developing angiopathy. The aim of the study was to determine the prevalence of urolithiasis (UL) in patients with DM and to identify specific risk factors. MATERIAL AND METHODS: 350 patients with DM were evaluated with respect to DM-related history, and a total of 179 patients was included (83 female, 96 male; age 23-84 years). All patients were interviewed to assess the history of stone formation. These data were compared to epidemiological data in Germany. RESULTS: The overall prevalence of UL in the diabetic group was 7.82% (vs. 4.73% in Germany, p = 0.0485; binominal test). The prevalence was significantly higher in patients with coronary heart disease (25%; p < 0.0001; Fisher's exact test). We could not demonstrate an increased prevalence of UL for patients with occlusive arterial disease or arterial hypertension as diabetic nephropathy was not a risk factor for developing urinary lithiasis (p = 0.7184, p = 1.000, p = 0.6266, respectively; Fisher's exact test). Thiazide medication lowered the prevalence of stone formation (p = 0.0399; Fisher's test). Calcium or magnesium supplementation did not influence stone formation significantly (p = 0.5279; p = 1.000; respectively; Fisher's test). CONCLUSIONS: In Germany, patients with DM are at higher risk of UL compared with patients without diabetes. We demonstrated a significantly higher prevalence of urinary stones in patients with coronary heart disease. These findings are consistent with the hypothesis that urinary stone formation has a vascular pathogenesis in part.

[Medical treatment of metastatic renal cell carcinoma after the approval and market entry of multitargeted tyrosine kinase inhibitors in Germany]. / Medikamentöse Therapie des metastasierten Nierenzellkarzinoms: eine Standortbestimmung nach Einführung der Multi-Tyrosinkinaseinhibitoren in Deutschland.

PURPOSE: To describe the current use and administration of multitargeted tyrosine kinase inhibitors (sunitinib and sorafenib) in the management of metastatic renal cell carcinoma (RCC) and to characterise frequent adverse events. MATERIALS AND METHODS: A questionnaire was sent to 104 urologists and medical oncologists having their own practice. The common use of medical treatment with sunitinib and sorafenib in patients with metastatic RCC was recorded. Data on the most frequent drug-associated adverse events were registered and described in a preliminary patient cohort. RESULTS: Medical oncologists in private practice treat over twice as many patients with metastatic RCC (8/year) as established urologists. Most medical oncologists but not urologists already use multitargeted tyrosine kinase inhibitors. For the initiation of treatment, most urologists admit patients to a hospital, whereas medical oncologists start and carry out medical treatment themselves. In all patients adverse events occurred due to medical treatment, leading to therapy stop or pause in 53% of patients. The most frequent adverse events were abnormal fatigue, arterial hypertension, diarrhoea and the hand-foot skin syndrome. CONCLUSIONS: Multitargeted tyrosine kinase inhibitor therapy in Germany is currently done predominantly by medical oncologists rather than urologists. Adverse events caused by sunitinib and sorafenib frequently required medical care, and in our initial series of patients prompted physicians to pause treatment.

[Blindness after prostate biopsy]. / Erblindung nach Prostatabiopsie.

We report on a case of sepsis-associated irreversible blindness in a patient after transrectal rebiopsy of the prostate. The patient was on immunosuppressive and long-term antibiotic treatment. Such a severe complication after transrectal biopsy of the prostate is unusual. Peri-interventional antibiotic prophylaxis reduces the general risk for infections after needle biopsy of the prostate. To avoid severe complications, suitable antibiotic prophylaxis in high-risk patients is recommended.

Effects of propiverine and its metabolite propiverine-N-oxide on bladder contraction and salivation in mini pigs.

PURPOSE: The objective of this study was to evaluate the influence of propiverine-HCl (P4) and propiverine-N-oxide (P4NO), one of the major metabolites of P4, on bladder contraction in a standardized in vivo model. Additionally, salivary flow measurements enabled the evaluation of hyposalivation, one of the most predominant anticholinergic side effects. MATERIALS AND METHODS: Ten male mini pigs were anesthetized. P4 (0.4 mg/kg b.w.) and P4NO (0.422 mg/kg b.w.) were administered intravenously. Bladder contractions were induced through sacral anterior root stimulation and cystometrogram evaluation was performed. For stimulation-induced salivary flow measurements, the lingual nerve was exposed for neurostimulation. The effects of P4 and P4NO on stimulation-induced bladder contraction and salivation were evaluated in 5 mini pigs, respectively. RESULTS: In all experiments, for each animal reproducible intravesical pressure values (Pves) were elicited during sacral anterior root stimulation before administration of the study drug. After administration of P4, Pves decreased by 64% whereas P4NO decreased Pves by 28%. Inhibition of salivary flow with P4 and P4NO was 71 and 32%, respectively. Directly following intravenous administration of P4, a short-term and reversible period of mild fluctuations in heart rate was observed. Administration of P4NO revealed no changes in either heart rate, or blood pressure. CONCLUSION: All of the investigated parameters revealed less anticholinergic effects for P4NO compared to P4. Under the experimental conditions described above, it may be assumed that P4NO behaves as a substance with poor anticholinergic effects with respect to side effects. As expected, P4 showed anticholinergic effects on bladder contraction and salivation.

New endourologic technology for simultaneous holmium:YAG laser lithotripsy and fragment evacuation for PCNL: ex-vivo comparison to standard ultrasonic lithotripsy.

Percutaneous nephrolithotomy (PCNL) is a well established procedure and accepted as the standard of care for the treatment of large renal calculi. Since the introduction of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser into clinical practice in 1990, it has been used successfully to treat various urologic conditions. Today it is the modality of choice for retrograde intracorporeal stone disintegration ureteroscopically, and has also been used successfully for PCNL. One disadvantage when using the Ho:YAG laser for disintegration of renal calculi is the need for graspers to extract fragments and the mobilization of fragments due to the lack of simultaneous suction. We present our experience with a Ho:YAG laser in combination with simultaneous suction in an in-vitro model using a new endourologic technique in comparison to conventional ultrasonic lithotripsy.

[Solitary fibrous tumour of the testes (SFT)]. / Solitärer fibröser Tumor des Hodens (SFT).

INTRODUCTION: Testicular masses in adults are most likely seminomatous or non-seminomatous germ cell tumours. Paratesticular tumours are far less frequent. Most lesions within this category are variants of fibrous pseudotumours. Solitary fibrous tumours (SFT) with characteristic (hemangiopericytoma-like) vascular structures are rare neoplasms that in the vast majority arise in the pleura, although extrapleural localisations in virtually every organ have been reported. CASE REPORT: A 64-year-old male nursing case was presented with a testicular swelling on the left side and recurrent testicular pain. Physical examination revealed a distinct mass at the left spermatic cord. The tumour marker levels were normal. The patient's history included an HIV infection as well as neurosyphilis. The sonographic examination showed a heterogeneous and hyperperfused tumour, MRI examination a 3.2 x 4.3 cm measuring heterogeneous tumour above the left epididymis. An inguinal orchiectomy was performed due to the unclear dignity. The histological examination revealed a solitary fibrous tumour. CONCLUSIONS: In cases of paratesticular tumours, rare tumours like solitary fibrous tumours have to be considered. Certainty regarding the dignity of the tumour can only be achieved by surgical exposure and excision.

[Manifestation of malakoplakia in a urethral diverticulum in a female patient]. / Manifestation einer Malakoplakie im Urethraldivertikel der Frau.

We report about a rare case of malakoplakia in a female urethral diverticulum. A 25-year-old patient with a long history of recurrent urinary tract infections and a plum-sized, painful swelling on the vaginal roof presented for operative treatment. In the anamnesis the patient reported about two spontaneous perforations, emptying several millilitres of pus each time. After total operative excision using a vaginal approach the histology showed malakoplakia in a urethral diverticulum. We found the typical intracytoplasmatic "Michaelis-Gutmann bodies" as well as "von Hansemann cells". Postoperatively we excluded an underlying tumour disease or a chronic infection. The further urological diagnostics (cystoscopy and MRI) were without any pathological findings. In patients with atypical cystic tumours of the urogenital tract, especially with an immune deficiency, malakoplakia should be taken in consideration. The preferred therapy is surgical management followed by long-term antibiosis as well as a close follow-up as recurrences are frequent.

Gene-expression signature of adhesion/growth-regulatory tissue lectins (galectins) in transitional cell cancer and its prognostic relevance.

AIMS: Lectins, and especially galectins, appear to be important in malignancy-associated processes. The aim was to analyse comprehensively the presence of galectins in urothelial tumours. METHODS AND RESULTS: Non-cross-reactive antibodies against seven family members from the three subgroups (prototype: galectin-1, -2 and -7; chimera type: galectin-3; tandem-repeat type: galectin-4, -8 and -9) were used. Gene expression was monitored in specimens of normal urothelium, fresh tumour tissue and cell lines by real-time polymerase chain reaction (PCR). The presence and evidence of tumour-associated up-regulation were shown for galectin-1 and -3. This was less clear-cut for galectin-4 and -8. Galectin-7 was expressed in all cell lines; galectin-2 and -9 were detected at comparatively low levels. Galectin-2, -3 and -8 up-regulation was observed in superficial tumours, but not in muscle-invasive tumours (P < 0.05). Immunoreactivity correlated with tumour grading for galectin-1, -2 and -8, and disease-dependent mortality correlated with galectin-2 and -8 expression. Binding sites were visualized using labelled galectins. CONCLUSIONS: The results demonstrate a complex expression pattern of the galectin network in urothelial carcinomas. Galectin-1, -2, -3 and -8 are both potential disease markers and also possible targets for bladder cancer therapy.

[Complications and side effects of low dose rate brachytherapy for the treatment of prostate cancer: data on a 13 year follow-up study from Mannheim]. / Komplikationen und Nebenwirkungen der LDR-Brachytherapie beim Prostatakarzinom : 13-Jahresdaten aus Mannheim.

BACKGROUND: Brachytherapy (BT) is an established treatment option for low risk prostate cancer. The aim of this study was to determine the long-term complications and side effects of the procedure in an up to 13 year long single center follow-up analysis. MATERIAL: A total of 505 patients were treated by BT for prostate cancer between May 1991 and August 2005. Cohort I (n=412; May 1991 to November 2003) was evaluated by written questionnaire (modified ICS male) and patient chart evaluation in terms of side effects and secondary interventions. In cohort II (n=148; January 2002 to August 2005) perioperative complications were investigated. RESULTS: The mean follow-up was 5.5 years. Perioperative complications were present in 5.4% of patients. Transurethral resection of the prostate was a common secondary intervention, performed in 7% of cases. The rate of incontinence was 6.3% in the long-term follow-up, the rate of potency was 43.5% in those patients who were potent before BT and no hormonal manipulation was performed at any time. CONCLUSION: BT is a minimally invasive procedure for the treatment of localised "low risk" prostate cancer. Perioperative complications are rare, secondary intervention may be necessary and the patient has to be informed of possible impotence, incontinence and lack of ejaculation.

[Therapy options in relapsing prostate cancer after external radiation therapy]. / Salvage-Therapieoptionen beim Rezidiv nach Strahlentherapie der Prostata.

In the near future, the number of young patients suffering from locoregional recurrence of their prostate cancer after external beam radiation will increase. For these patients, androgen deprivation is the most widely used therapy, but it is only palliative. Salvage radical prostatectomy, cryoablation, interstitial brachytherapy, and high-intensity focused ultrasound (HIFU) are treatment options with the potential of curing the patient. Currently, salvage radical prostatectomy offers the best chance for cure. Although a significant reduction in peri- and postoperative complication rates has been reported, surgery remains technically challenging, with a high rate of urinary incontinence. We believe that salvage prostatectomy should be considered only for patients in good general health whose life expectancy is more than 10 years and whose cancer was initially organ-confined before radiation therapy. Salvage cryotherapy might be an alternative to surgery. Complication rates have decreased as technical application has improved considerably within the last years. A major drawback of cryoablation is its lack of reliable and complete ablation of all prostate cells. HIFU and interstitial brachytherapy are minimally invasive salvage options that have been investigated in small clinical studies.

[The role of perineal ultrasound compared to lateral cysturethrogram in urogynecological evaluations]. / Die Perinealsonographie im Vergleich zum lateralen Zysturethrogramm bei der Inkontinenzdiagnostik der Frau.

PURPOSE: The aim of this study was to evaluate prospectively whether perineal ultrasound is comparable to the lateral cysturethrogram in the evaluation of incontinent women. PATIENTS AND METHODS: Following urodynamic investigations, a lateral cysturethrogram and perineal ultrasound (5 MHz probe, bladder filling 300 mL) were performed in 98 incontinent women. In women with detrusor overactivity and consecutively reduced bladder capacity, ultrasound was performed at maximum capacity. To evaluate differences between perineal ultrasound and the cysturethrogram, the difference between bladder neck and lower border of symphysis and the retrovesicle angle beta were determined at rest and during the Valsalva manoeuvre. RESULTS: Using perineal ultrasound, the differences between bladder neck and symphysis could be determined at rest and during the Valsalva manoeuvre in all patients. The determination of the retrovesical angle beta was possible in all patients at rest and in 89 of the 98 women during the Valsalva manoeuvre. The lateral cysturethrogram enabled the determination of difference between bladder neck and symphysis and the retrovesicle angle beta at rest in 81 of 98 women. During the Valsalva manoeuvre, the difference between bladder neck and symphysis and retrovesicle angle beta could be determined in 72 of the 98 women. In the 26 remaining women, the determination was impossible due to severe adiposity or cystoceles of the second or third degree. CONCLUSIONS: Perineal ultrasound provides comparable data to the lateral cysturethrogram. In patients with adiposity, perineal ultrasound seems to be superior. Within the routine evaluation of women suffering from incontinence, the lateral cysturethrogram can be replaced by perineal ultrasound without any limitations of the diagnostic value.

[Nephropexy in the course of time. Aspects of an historical surgical technique]. / Die Nephropexie im Wandel der Zeit. Aspekte einer historischen Operationstechnik.

The first successful nephropexy was performed in the year 1881. From this time, surgical therapy of nephroptosis has always been a subject of discussion. A partly uncritical acceptance led to nephropexy being the most performed urological operation at the beginning of the 20th century, with up to 200 different surgical variations. As early as the 15th century, a first description of ren mobilis was made by Alessius de Pedemontanus. The first surgical intervention for the treatment of nephroptosis was performed by Gilmore in 1870. In 1877, the American Dowell from New Orleans tried a fixation of the kidney through a seton, however, this operation failed. Eventually in 1881, Eugen Hahn from Berlin was able to perform the first successful nephropexy, he named this method "nephroraphy". In 1882, the first modification was made by Bassini with sutures through the renal capsule. Finally, the gynaecologist George Edebohl led nephropexy into a great popularity and secured the method through numerous technical innovations. By 1936, approximately 170 different surgical methods existed for fixation of the kidney. An accurate diagnosis is imperative before performing nephropexy. There were times in which this operation was carried out much too often and, therefore, had a bad reputation. However, it is not correct to drop nephropexy altogether as some would prefer. The statement by Professor Voelcker from Halle in the year 1911 that for all those who have a urinary obstruction and those with a beginning dilation, nephropexy is still justified and may - when correctly performed provide many blessings". Nothing needs to be added to this.

[Scrotal lymphangioma--a rare cause of acute scrotal pain in childhood]. / Das skrotale Lymphangiom--eine seltene Ursache des akuten Skrotums im Kindesalter.

INTRODUCTION: Scrotal lymphangioma is a rare differential diagnosis in boys with acute scrotal pain. CASE REPORT: A 5-year-old boy presented with acute scrotal pain and swelling. Physical examination demonstrated an unusual cystic scrotal mass with a normal testis. Ultrasound and MRI showed a complex septated cystic mass. The tumor was excised completely via an inguinal and scrotal approach. 2-year follow-up examinations with physical examination and ultrasound have shown no evidence of recurrence. CONCLUSIONS: Scrotal lymphangiomas are commonly misdiagnosed preoperatively. When ymphangioma is suspected, ultrasound and MRI imaging of the adjacent inguinal, perineal and pelvic region should be performed. To prevent recurrence, complete surgical excision is mandatory.