[New WSES-AAST guidelines on trauma of the urogenital tract-Summary and comments]. / Neue WSES-AAST-Leitlinie zum Trauma des Urogenitaltraktes ­ Zusammenfassung und Kommentar.

Different perspectives exist among the various specialist disciplines on the treatment of trauma patients with injuries of the urogenital tract. The multidisciplinary consensus guidelines of the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST), which appeared in autumn 2019, are summarized in this article. They should constitute an aid to making decisions on the optimal treatment of trauma patients with urogenital injuries.

[Renal carbuncle and perirenal abscess in children and adolescents]. / Nierenkarbunkel und perinephritischer Abszess im Kindes- und Jugendalter.

Renal abscesses are rare in childhood. The diagnosis is often complicated by non-specific symptoms and the typical signs of urinary tract infections are frequently absent. The currently available imaging methods are necessary and helpful for a differentiated therapeutic approach; nevertheless, cases are continuously being found in which a renal abscess is only diagnosed intraoperatively. In most patients a combined intravenous therapy including an antibiotic which is effective against staphylococci is sufficient. The therapy is supported if necessary by percutaneous abscess drainage. Open revision or even nephrectomy is rarely required.

[Biopsies of the kidney, prostate and urinary bladder]. / Biopsie der Prostata und Punktion der Niere und Blase.

BACKGROUND: Biopsies of the kidney, prostate and urinary bladder are amongst the most frequent interventions in urology. A correct indication, preparation and performance are important to achieve good results and low complication rates. OBJECTIVES: In this review complication management in biopsies of the kidney, prostate and urinary bladder are discussed. MATERIALS AND METHODS: A selective search of the literature, with emphasis on systematic reviews and larger cohort studies was performed. RESULTS: Complication rates are generally low. However, certain factors such as coagulation disorders, anatomical malformations, accompanying morbidities or antibiotic resistance may play a significant role and increase rates of complications. Especially complications such as hematuria and injury of contiguous organs are described in the literature. DISCUSSION: Biopsies of the kidney, prostate and urinary bladder can be performed with low complication rates if general and specific factors in the planning of the intervention and prevention of complications are considered.

Acute epididymitis in ultrasound: results of a prospective study with baseline and follow-up investigations in 134 patients.

OBJECTIVES: To perform a comprehensive follow-up analysis of ultrasonographic scrotal features and associated signs in patients with acute epididymitis. METHODS: Between 2007 and 2012, 134 adults (median age 54 years) with acute epididymitis underwent scrotal ultrasonography and palpation at first presentation and after 2 weeks and 3 months. RESULTS: At first presentation, 61 patients (45.5%) had hydrocele, 63 (47.0%) concomitant orchitis, and 8 (5.9%) epididymal abscess. Epididymitis was predominantly located in 24 cases (17.9%) in the head, 52 cases (38.8%) in the tail, and 58 cases (43.3%) in both. On the affected side, testicular volume was 16.9 ± 6.8 ml and peak systolic velocity of the testicular artery was 23.7 ± 7.5 cm/s, compared to the healthy side with 12.3 ± 4.4 ml and 9.5 ± 3.6 cm/s respectively (P<0.001). Concomitant orchitis was associated with hydrocele, testicular enlargement and pain (P<0.01). Orchiectomy due to secondary testicular infarction was necessary in four cases, while in all other patients ultrasound parameters normalized. Only 16/90 patients (17.8%) showed a persistent epididymal swelling after 3 months. CONCLUSIONS: Common ultrasound features include hydrocele, epididymal enlargement, hyperperfusion, and testicular involvement. Under conservative treatment, ultrasound parameters normalize without evidence of testicular atrophy even in patients with epididymal abscess or concomitant orchitis.

[Acute urinary retention in children: initial manifestation of caudal regression syndrome]. / Akuter Harnverhalt im Kleinkindalter : Erstmanifestation eines kaudalen Regressionssyndroms.

Caudal regression syndrome is a rare and sporadic congenital developmental defect of the lower spinal segments and the neural tube. Movement disorders and sensory neurological deficits of the lower extremities in conjunction with impaired bladder and bowel control are the major symptoms. Abnormal visual aspects of the sacral region in combination with maternal gestational diabetes are further diagnostic indications. This article reports the unusual case of a toddler presenting with acute urinary retention as the initial symptom of caudal regression syndrome.

Reference values for testicular volume, epididymal head size and peak systolic velocity of the testicular artery in adult males measured by ultrasonography.

PURPOSE: To obtain ultrasonography-based reference values for testicular volume, epididymal head size and peak systolic velocity (PSV) of the testicular artery in adult males of all ages. MATERIALS AND METHODS: Between 2009 and 2011, 306 Caucasian adult males (median age: 51 years; range: 18-88 years) without scrotal pathology underwent prospective scrotal ultrasonography. The testicular volume was calculated from the length (L), width (W), and height (H) using three formulas: a) 0.52 × L × W × H, b) 0.52 × L × W², and c) 0.71 × L × W × H. Thickness and height of the epididymal head and PSV of the testicular artery were measured. RESULTS: The median testicular volumes on the right (left) side were 13.9 (12.7) ml, 18.1 (16.5) ml, and 18.9 (17.3) ml for formula a), b), and c) respectively, and thus significantly different (p < 0.01 for all). The left testes were significantly smaller than the right testes (p < 0.01). The thickness and height of the right (left) epididymal head measured 7.5 (7.7) mm and 11.6 (11.3) mm, respectively. Median PSV of the right (left) testicular artery was 8.7 (8.6) cm/sec. No significant side-specific differences were documented with respect to epididymal size and PSV. CONCLUSION: It was possible to obtain virtually age-independent reference values for testicular volume, epididymal head size and PSV of the testicular artery in adults. With regard to testicular volumetry, it is essential to consider which formula has been used, since the calculated volumes differ significantly from formula to formula.

Role of human papillomaviruses in persistent and glucocorticoid-resistant juvenile phimosis.

BACKGROUND: In adults, human papillomaviruses (HPV), lichen sclerosus et atrophicus (LSA) and phimosis are considered to be major risk factors for penile cancer. In boys, a possible association between phimosis, LSA and HPV has been suggested. OBJECTIVE: To investigate the role of HPV in the persistence of phimosis in children. PATIENTS AND METHODS: Out of a cohort of 420 boys presenting with foreskin problems, we prospectively sampled the preputial tissue of 82 patients during circumcision: 46 with steroid-naïve and 36 with steroid-resistant phimosis. All foreskins were assessed clinically and histopathologically with regard to appearance, inflammation, oedema, epithelial degeneration and fibrosis. The viral status of the foreskins was determined by immunohistochemistry and highly sensitive PCR, with subsequent subtyping by DNA hybridization (HPV types 6, 11, 16, 18, 31, 33, 35, 39, 42, 44, 45, 51-54, 56, 58, 59, 61, 62, 66-68, 70, 72, 73, 81-84, 90, 91). RESULTS: The foreskins appeared normal in 62 boys and suggestive of LSA in one single case. Small cracks or white scars were present in seven steroid-naïve and 12 steroid-resistant foreskins. LSA was diagnosed microscopically in two of the steroid-naïve and six of the steroid-pretreated group. No evidence of HPV was found in any of the juvenile foreskins. CONCLUSIONS: Our prospective study has provided evidence that HPV is not usually present in the foreskin of boys with persistent phimosis after their first year of life and that topical glucocorticoid treatment failure is not associated with HPV or any specific histopathological changes.

Mixed testicular atrophy related to atherosclerosis: first lessons from the ApoE(-/-)/ LDL receptor(-/-) double knockout mouse model.

Age-related testicular changes are associated with declining spermatogenesis and testosterone levels. A relationship to atherosclerosis has never been investigated systematically. The ApoE(-/-)/LDL receptor(-/-) double knockout mouse model, providing a remarkable homology to human atherosclerosis, is an ideal tool to investigate spermatogenetic alterations in this context. Testes (n = 10) from ApoE(-/-)/LDL receptor(-/-) double knockout mice at the age of 80 weeks were perfused in vivo with contrast agent, harvested and scanned with micro-CT at (4.9 µm³) voxel size. Testes (n = 8) of C57/BL mice at the same age served as controls. Testis volume (mm³) and total vascular volume fraction (mm³) were quantified using micro-CT. Serum testosterone levels were determined. Testicular histology and epididymal sections were analysed for tubular structure, spermatogenetic scores and sperm count. The expression of protamine 2 as a marker for elongated spermatids, inflammation markers (CD4, F4/80) and hypoxia inducible factor 1 alpha (HIF1 alpha) were investigated using immunohistochemistry. ApoE(-/-)/LDL receptor(-/-) double knockout mice exhibit diminished testis and vascular volume fraction with respect to that of controls (p < 0.001). These findings were associated with a reduction of testosterone levels (p < 0.001). Mixed atrophy was present in 41% of the seminiferous tubuli in ApoE(-/-)/LDL receptor(-/-) double knockout mice at the age of 80 weeks. Sperm counts from the epididymis demonstrated a significant decrease in ApoE(-/-)/LDL receptor(-/-) double knockout mice (p < 0.001). In addition, sperm specific protamine 2 expression was decreased in testicular tissue and epididymis of ApoE(-/-)/LDL receptor(-/-) double knockout mice compared with that of control mice. Peritubular inflammatory infiltration and the expression of the hypoxia related marker was observed. Mixed testicular atrophy in ApoE(-/-)/LDL receptor(-/-) double knockout mice is linked to reduced testis volume, vascular volume fraction and low testosterone serum levels, suggesting a direct relation between atherosclerosis and disturbed spermatogenesis.

[New concepts for varicolele treatment in male infertility: the current situation]. / Neues in der Varikozelen-Therapie bei männlicher Infertilität: Eine Momentaufnahme.

There is no question that therapy for a varicocele in cases of male infertility improves the ejaculate quality. New data provide hints for an additional influence on the pregnancy rates in infertile partnerships.

Color Doppler ultrasound imaging in varicoceles: is the venous diameter sufficient for predicting clinical and subclinical varicocele?

PURPOSE: Investigating the diagnostic value of color Doppler ultrasound for defining the varicocele grade according to WHO criteria. METHODS: A total of 217 men (129 with clinical varicocele and 88 without clinical varicocele) were investigated by physical examination and color Doppler ultrasound and categorized according to WHO varicocele criteria (0, subclinical, I, II, and III). Diameter and reflux of the largest vein in the pampiniform plexus were measured bilaterally with the patient in the supine position in rest and during the Valsalva maneuver. To assess the possibility of differentiating varicocele grade by venous diameter, optimal cut-point values were determined by receiver-operator characteristic (ROC) analysis. RESULTS: With increased varicocele grade, a larger vein diameter was more significant in rest and during Valsalva (in all cases P < 0.05), except between grade I and grade II. Retrograde peak flow velocities were similar in every group (in all cases P > 0.1). Only grade III varicoceles demonstrated significantly increased peak flow values compared with all other grades (P < 0.001). There were no side-related differences when comparing identical varicocele grades (in all cases P > 0.1). Venous diameters above 2.45 mm in rest (sensitivity 84%, specificity 81%) or 2.95 mm during Valsalva (sensitivity 84%, specificity 84%) predicted the presence of a clinical varicocele. CONCLUSIONS: Our findings support the hypothesis that clinical varicoceles can be predicted with high accuracy based only on the diameter of testicular veins using cut-point values of >2.45 mm in rest or >2.95 mm during Valsalva maneuver in the supine position.

[Andrology: varicocele: an update]. / Andrologie: Varikozele: Ein Update.

Varicocele is a common finding in approximately 20% of adolescents and adult men and in about 40% of infertile patients. Although numerous theories addressing the deteriorating impact on the testis are known, the direct connection between varicocele and infertility is not clear. It is well known that after operative therapies an improvement in sperm quality is found. However, the impact on pregnancy in an infertile coupleship is controversial. While the most recent meta-analysis found an increased pregnancy rate after therapy, the Cochrane Reviews with the last update in 2009 did not. In summary, operative therapy seems justified in selected patients with infertility.

[Diagnosis of erectile dysfunction]. / Diagnostik der erektilen Dysfunktion.

Erectile dysfunction is a disorder with multifactorial causes. The pathophysiological origin can be severe general disease. Consequently each patient has to undergo a general diagnostic procedure so that severe disease is not missed. The diagnostic work-up of erectile dysfunction follows a three-step scheme of increasing invasiveness. The non-invasive step is the most important. These investigations comprise taking an extensive general history including a detailed sexual history, psychological diagnosis, physical examination, and laboratory tests. The semi-invasive procedures include the intracavernous injection test, colour-coded duplex sonography and optional neurophysiological examinations. The invasive investigations include dynamic infusion pharmacological cavernosography and cavernosometry, and penile angiography. The extensiveness of the diagnostic procedures should be adapted to the complexity of the history and the therapeutic expectations. However, if there is any suspicion of a severe disease remaining undiagnosed, the diagnostic procedures should be adequately comprehensive.

Extracorporal shock wave therapy in the treatment of Peyronie's disease. First results of a case-controlled approach.

OBJECTIVE: To test whether extracorporal shock wave therapy (ESWT) has an effect in the treatment of Peyronie's disease. METHODS: 22 patients with Peyronie's disease and previous unsuccessful oral drug therapy were treated with ESWT in a prospective design with a follow-up of at least 3 months; 23 age-matched patients without previous therapy received oral placebo drug for 6 months daily as control. The standard follow-up included palpation, ultrasound, autophotography and evaluation of symptomatology based on a symptom score. The shock waves were applied under ultrasound guidance using the 'Storz Minilith SL1' lithotripter. RESULTS: The results show a significant decrease in penile curvature in the patients treated with ESWT. Concerning the decrease in pain, subjective improvement and improvement in the quality of sexual intercourse, there was no significant difference to the case-control group. The inhomogeneity of the 2 groups may influence these results due to the questionable varying natural history. CONCLUSIONS: A prospective, controlled multicenter study with standardized parameters (concerning technique and patients) is urgently required to test the effect of ESWT.

[Clinical aspects of hydatid torsion. Diagnosis and therapy in 104 consecutive patients]. / Die Klinik der Hydatidentorsion. Diagnostik und Therapie bei 104 konsekutiven Patienten.

At the department of the urology of the university hospital in Giessen we observed 104 hydatid torsions with acute scrotal pain between 1977 and 1998. The average age of the affected patients showed a peak in boys with 12 years of age. 33.7% of the patients underwent primary conservative treatment and 66.3% were operated primarily. We only recommend conservative treatment after careful clinical evaluation and definitive detection of testicular perfusion. Scrotal ultrasound and color duplex sonography hereby serve as decisive tools.

Prostaglandin E1 long-term self-injection programme for treatment of erectile dysfunction--a follow-up of at least 5 years.

Prostaglandin E1 (PGE1) is currently the vasoactive drug of choice for intracavernous self-injection therapy in the treatment of erectile dysfunction. PGE1 is often said to have a low incidence of side-effects. However, real long-term follow-up reports are rare. Here, a report is presented on 32 patients who joined a long-term self-injection programme in which they used PGE1 for a minimum of 5 years under standardized protocol conditions. All these patients had an organic aetiology of erectile dysfunction, and their mean age was 58.7 +/- 8.6 years. The period of observation was on average 75.4 +/- 16.9 months, and the PGE1 dosage 13.5 +/- 5.9 micrograms. A total of 6799 injections were registered. The average number of injections was 213 +/- 127 per patient, which is 2.8 injections per month and patient. As regards side-effects, haematomas were registered in 1.9% of the patients and five cases of prolonged erection (0.07%) caused by unauthorized redosing were noted. Three patients developed reversible penile nodules. In 10 patients, the initial dosage had to be increased. Five patients dropped out after 5 years, none of them due to treatment complications. It is concluded that PGE1 self-injection therapy is a simple and reliable method for long-term use with hardly any side-effects. The patients do not stop treatment because of complications.

[Induratio penis plastica]. / Induratio penis plastica.

The symptoms of Peyronie's disease consist of fibrotic plaque formation, penile deviation and painful erection. The etiology is still unknown. During its progress the disease can cause erectile failure. The plaques mainly involve the dorsal tunica of the penis. The diagnosis is made by palpation of the penis. The ultrasound examination evaluates the plaque localization and possible calcifications. Autophotography of penile deviation and duplex sonography of the cavernous arteries used to measure arterial blood flow complete the diagnostic efforts. Spontaneous remissions occur as well as chronic courses. Oral medication is the first step in therapy. In cases with severe penile deviation leading to disability to perform intercourse, persisting pain or erectile failure operative management is indicated. Plaque surgery, modified corporal plication or implantation of a penile prosthesis must be evaluated individually.

Historical milestones regarding torsion of the scrotal organs.

PURPOSE: The clinical syndrome of the acute scrotum, whereby the spermatic cord or appendix testis becomes twisted, commonly affects young men. Our knowledge of this condition, however, is of relatively recent origin. MATERIALS AND METHODS: We performed an historical survey of torsion of the scrotal organs dating back to 1703. In Bologna in 1703 Morgagni observed the first hydatid on the caput epididymis. He described 10 hydatid cases of the testis and epididymis producing, in his opinion, the fluid of hydroceles. The first illustration of appendix testis dates from Cooper 1841. Later these testicular appendages, or hydatids, were shown to be vestigial remnants of either the müllerian duct or the wolffian structures, depending on location. Actual torsion of the appendix testis was mentioned by Ombrédanne in 1913 but the first case report was published in 1922 by Colt. Appendix testis torsion was first schematically illustrated in 1923 by Mouchet and was characterized by Dix in 1931 in a manner that is still valid today. Interestingly, the great majority of case reports since 1932 have originated from America. In 1810 Hunter described a typical case of testicular torsion, and in 1840 Delasiauve presented the first case of surgically treated testicular torsion. A schematic and original illustration of a contorted undescended testis was published in 1894 by Lauenstein. RESULTS: Testicular torsion was, and still is, a true urological emergency but the historical survival rate of the testis was extremely low. Searching for improvement in clinical diagnosis, physicians have noted helpful specific signs, 1 of which is that the period of ischemia determines loss of the testis. CONCLUSIONS: The historical development of diagnosis of torsion of the appendix testis and spermatic cord highlights the ever present need for careful examination, a high index of suspicion and timely therapy.

Interferon inhibits herpes simplex virus-specific translation: a reinvestigation.

Reports on the arrest of herpes simplex virus type 1 (HSV-1) replication by interferon (IFN) are inconsistent. By the use of immunofluorescence and immunoblot assays with monoclonal and polyclonal antibodies, effective arrest of viral translation by human IFN-alpha in human fibroblasts was detected for the HSV-1 strains KOS and McIntyre. In HeLa cells which are less sensitive to IFN inhibition and in 444 cells, a HeLa-fibroblast hybrid cell line, the inhibition was less pronounced. These results confirm earlier observations that IFN or polyinosinic.polycytidylic acid block the replication of HSV-1 in human, monkey and mouse cells no later than the immediate early phase of infection.