Treatment of full thickness focal cartilage lesions with a metallic resurfacing implant in a sheep animal model, 1 year evaluation.

BACKGROUND: Full depth focal cartilage lesions do not heal spontaneously and while some of these lesions are asymptomatic they might progress to osteoarthritis. Treatment for these lesions is warranted and the gold standard treatment at younger age remains biological healing by cell stimulation. In the middle-age patient the success rate of biologic treatment varies, hence the surge of non-biological alternatives. Our objective was to evaluate the efficacy and safety of a metallic implant for treatment of these lesions with respect to the long-term panarticular cartilage homeostasis. METHODS: The medial femoral condyle of 16 sheep was operated unilaterally. A metallic implant was inserted in the weight-bearing surface at an aimed height of 0.5 mm recessed. Euthanasia was performed at 6 or 12 months. Implant height and tilt was analyzed using a laser-scanning device. Damage to cartilage surfaces was evaluated macroscopically and microscopically according to the Osteoarthritis Research Society International (OARSI) recommendations. RESULTS: Thirteen sheep were available for evaluation and showed a varying degree of cartilage damage linearly increasing with age. Cartilage damage of the medial tibial plateau opposing the implant was increased compared to the non-operated knee by 1.77 units (p = 0.041; 95% CI: 0.08, 3.45) on a 0-27 unit scale. Remaining joint compartments were unaffected. Implant position averaged 0.54 recessed (95% CI: 0.41, 0.67). CONCLUSIONS: Our results showed a consistent and accurate placement of these implants at a defined zone. At this position cartilage wear of opposing and surrounding joint cartilage is limited. Thus expanded animal and human studies are motivated.

Priapism of the glans and corpus spongiosum. Report of two cases with angiography.

Priapism, whether of the arterial or veno-occlusive type, mainly affects the cavernous bodies, leaving the low-pressure system in glans and corpus spongiosum soft without urethral compression. In the present 2 case reports, the pathologically increased pressure primarily affected the corpus spongiosum. One had arterial priapism following penile revascularization and the other veno-occlusive priapism due to thrombosis of the internal pelvic veins. Both had ulcerations of the glans and urinary retention requiring suprapubic catheterization. Arteriography revealed the disease mechanism in both, and led to embolization in 1.

Clinical trial designs: is it possible to have a unified approach and common end points?

The accelerating development during the last 5 y of new compounds for the medical treatment of erectile dysfunction (ED) demands standardized high-quality protocols for evaluation of the therapeutic effect of these treatments. Outcome analyses have to rely on prospective, placebo-controlled trials within predefined populations, where the results are based on good biostatistics, self-administered questionnaires that include partner assessments, quality-of-life measures, and treatment satisfaction. Currently, we have access to different drug application procedures for clinical use in the treatment of ED, and soon we will have new competitive analogues for optional oral treatment. From a wider perspective, we will naturally see second- and third-generation compounds and drugs related to different effector mechanisms. In many subpopulations, ED has a close relation to specific comorbidities, such as cardiovascular diseases and diabetes. Regarding these aspects, the baseline for all clinical trials should be unified and structured not only to evaluate the clinical outcome assessment (subjective and objective) and adverse events as end points, but also to relate the defined therapeutic response to good current clinical practice.

Buttock placement of the implantable pulse generator: a new implantation technique for sacral neuromodulation--a multicenter study.

OBJECTIVE: In the standard operation procedure for sacral neuromodulation, the implantable pulse generator (IPG) is implanted in a subcutaneous pocket at the lower part of the anterior abdominal wall. This procedure requires a long operation time and three incisions. With the IPG in the abdominal wall, some patients complain of displacement or pain at the IPG site postoperatively. By modifying the technique of placement of the IPG, these disadvantages are overcome. METHODS: Between August 1999 and July 2000, 39 patients underwent a buttock implant of the IPG. In 2 of these patients the position of the IPG was changed from abdominal region to the buttock. During follow-up, complications concerning the operation and location of the IPG were compared to the published literature. RESULTS: Operation time is reduced in all patients by approximately 1 h. No repositioning of the patient is required during surgery. Only a short subcutaneous tunnel is required to connect the lead to the IPG. Pain at the level of the IPG was noted in 10% of the patients, which needed no further treatment. No infections were seen and the IPG did not displace postoperatively. CONCLUSION: Buttock placement of the IPG in sacral nerve stimulation leads to shorter operation time; only two incisions are needed instead of three and a shorter subcutaneous tunnel is needed. Using this technique there are less complications and a lower re-operation rate.

The clinical value of dynamic magnetic resonance imaging in normal and incontinent women--a preliminary study on micturition.

In this preliminary study in nine volunteers and nine women with genuine stress incontinence (GSI) dynamic magnetic resonance imaging (MRI) was used to study the voiding phase in the sitting position after physiological filling of the bladder by urine. The MRI technique has been documented as being useful for this purpose, but in this small group of women it was not possible to determine any specific difference in the voiding pattern between the volunteers and the G

Hydrophilic versus non-coated catheters for intermittent catheterization.

Since Lapides reintroduced clean intermittent catheterization (CIC) in 1972, this procedure has been used routinely in individualized programmes for bladder evacuation in various bladder disorders. It has been suggested that in clinical practice hydrophilic catheters are preferable to non-coated catheters. In reviewing the literature on CIC, many of the reports were found to rely on data from non-randomized retrospective studies. In some recent prospective studies, involving a limited number of patients, hydrophilic and non-coated catheters have been evaluated and compared, especially with regard to bacteriuria and urethral irritation. The available data indicate that using hydrophilic catheters for CIC may induce lower rates of bacteriuria and long-term urethral complications such as urethral strictures. However, to reach a reliable conclusion about the supposed advantage of the hydrophilic catheters, there is a need for a prospective, randomized long-term multicentre study. It is important in such a study to define patient characteristics including age, gender, diagnosis of bladder dysfunction, reason for CIC, physical and mental handicap, manual dexterity and previous treatments. Effect parameters should include number of catheterizations, urinary tract infection, early and long-term urethral complications, patient satisfaction, preferences and dropout rates. It is obligatory to include factors such as cost-benefit and cost-effectiveness.

Hypertension and pseudoaneurism on the renal artery following retrograde endopyelotomy (Acucise).

Acucise endopyelotomy has gained widespread use in the treatment of ureteropelvic junction obstruction. Acute postoperative bleeding is a well-known complication. We report one case with a delayed postoperative formation of pseudoaneurism, and one case which developed arterial hypertension postoperatively.

Interstitial laser coagulation in patients with lower urinary tract symptoms from benign prostatic obstruction: treatment under sedoanalgesia with pressure-flow evaluation.

OBJECTIVES: To evaluate the effects on lower urinary tract symptoms and pressure-flow variables after interstitial laser coagulation (ILC) of the prostate using the Indigo diode laser system (Indigo, Palo Alto, USA). PATIENTS AND METHODS: Forty-nine men (median age 68 years, range 52-80) were assessed using symptom scores and voiding variables before and at 3 and 12 months after ILC. A subset of 26 men (median age 68 years, range 63-72) underwent pressure-flow measurements before and at 6 months after ILC. All treatments were performed in the outpatient department using sedoanalgesia. RESULTS: The International Prostate Symptom Score decreased from 22 to 11 at 12 months after ILC. The peak urinary flow (Qmax ) was 8.6 mL/s at baseline and increased to 9.9 mL/s at 12 months. Residual urine volumes were unchanged. The median duration of urinary retention after ILC was 3 days. From pressure-flow recordings, 17 patients were categorized as obstructed and seven as equivocally obstructed before ILC (using the International Continence Society definition). Their Qmax increased from 7.7 to 9.0 mL/s after 6 months, the detrusor pressure at Qmax decreased from 68 to 51 cmH2O and the Abrams-Griffiths number decreased from 54 to 29 (P<0.01). Patients with moderate to equivocal obstruction had a greater relief of symptoms than those who were clearly obstructed. Patients with prostate volumes of >40 mL had a greater decrease in the Abrams-Griffiths number than had patients with smaller prostates. Postoperative perineal pain was reported by 72% of patients; the pain subsided after 1-2 weeks. The re-treatment rate was 15% within the first year. CONCLUSION: Treatment with ILC produced substantial effects on symptoms and moderate to small changes in urodynamic variables. Patients with moderate or equivocal bladder outlet obstruction or large prostates seem to be the best candidates for this treatment. However, treatment was followed by perineal pain for 1-2 weeks in most cases. A long-term follow-up is necessary to determine the role of ILC.

Continued improvement in pressure-flow parameters in men receiving finasteride for 2 years. Finasteride Urodynamics Study Group.

OBJECTIVES: To assess the long-term effects of finasteride on pressure-flow parameters in men with urodynamically documented bladder outflow obstruction (BOO). METHODS: One hundred twenty-one men with benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS) underwent a pressure-flow study (PFS) at 1 of 11 clinical centers. The PFS technique was standardized, and all tracings were read by a single reader unaware of the treatment group. Patients who were obstructed according to a modified Abrams-Griffiths nomogram were randomized to 5 mg finasteride (n = 81) or placebo (n = 40) for 12 months; all patients continuing into an open extension received finasteride during the second 12 months of therapy. Results of the initial 12-month study demonstrated the benefit of finasteride treatment on PFS parameters. To examine the continuing effects over time, an analysis of the data from 54 patients who completed 24 months of treatment with finasteride is provided. RESULTS: Detrusor pressure at maximum flow (PdetQmax) continued to decrease during the second 12 months of therapy (decreases of 5.3 and 11.7 cm H2O at months 12 and 24, respectively). The percentage of patients obstructed by Abrams-Griffiths classification decreased from 76.2% at baseline to 66.7% at month 12 and 59.6% at month 24. An intention-to-treat analysis yielded similar results. CONCLUSIONS: Finasteride improves urodynamic measures of obstruction in men with BPE and LUTS, with continued improvement during the second 12 months of therapy.

Improvement of pressure flow parameters with finasteride is greater in men with large prostates. Finasteride Urodynamics Study Group.

PURPOSE: We assess the effect of finasteride, a 5alpha-reductase inhibitor, on objective voiding parameters in men with lower urinary tract symptoms and benign prostatic enlargement on digital rectal examination (known as clinical benign prostatic enlargement) in a double-blind placebo controlled multicenter study using strict standard pressure flow study techniques. MATERIALS AND METHODS: A modification of the Abrams-Griffiths nomogram was used by 1 reader to ensure that all patients met objective criteria for bladder outlet obstruction at baseline. After performing a pressure flow study patients with obstruction were randomized 2:1 to receive 5 mg. finasteride (81) or placebo (40) daily. A second pressure flow study was performed at month 12. At baseline and month 12 free urinary flow studies and transrectal ultrasound were performed, and International Prostate Symptom Score questionnaires were completed. Patients were treated between May 1994 and July 1996. RESULTS: Finasteride caused a significant decrease (-8.1 cm. water) in detrusor pressure at maximum flow (p <0.05 versus placebo p = 0.02), increase (+1.1 ml. per second) in maximum flow rate (p <0.05 versus placebo p = 0.02) and decrease (-22.8%) in prostate volume (p <0.05 versus placebo p <0.001). Men with prostates larger than 40 cc had greater improvement in detrusor pressure at maximum flow (between group difference -14.5 cm. water, 95% confidence interval -26.2 to -2.6, p = 0.02) and maximum flow rate (mean treatment effect +1.6 ml. per second, 95% confidence interval -0.2 to 3.0, p = 0.02) compared to those with prostates 40 cc or less (between group differences not significant). CONCLUSIONS: Finasteride treatment resulted in improvements in urodynamic parameters, which were greater in men with large prostates.

Repeated pressure-flow studies in the evaluation of bladder outlet obstruction due to benign prostatic enlargement. Finasteride Urodynamics Study Group.

Test-retest reliability of repeated voids in pressure-flow studies and the influence on maximum flow rate (Q(max)pQ), detrusor pressure at maximum flow rate (p(det)Qmax), voided volume, and residual urine were studied. Also the agreement in interpretation of pressure-flow tracings between investigators and a single blinded central reader acting as a quality control center (QCC) were assessed. In addition, correlations between p(det)Qmax and patient age, International Prostate Symptom Score (IPSS), free maximum flow rate (Qmax), and prostate volume were calculated. Using suprapubic pressure recording, 216 men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) were investigated in 11 centers. In each pressure-flow study, three sequential voids were performed, and quality controlled recordings were analyzed for Q(max)pQ and p(det)Qmax by the QCC. Trans rectal ultrasound was used to measure the prostate volume. Mean Q(max)pQ did not change, but p(det)Qmax decreased significantly in the second and third sequential voids. Using the Abrams-Griffiths nomogram definition of obstruction, 125 patients (67%) were classified as obstructed from the first void, but only 111 patients (59%) from the third void. The agreement between the investigator assessment and that of a single blinded reader was good. There was no significant correlation between p(det)Qmax and patient age, IPSS, and Qmax, whereas a modest correlation was found between p(det)Qmax and prostate volume. In summary, there was no significant change in Q(max)pQ, but p(det)Qmax decreased for the three consecutive voids, which can be explained by a decrease in outlet resistance. The agreement between the investigator and QCC interpretations shows the value of a standardized technique, supporting the feasibility of multicenter urodynamic studies. There is a modest, but statistically significant, correlation between detrusor pressure and prostate size, supporting the hypothesis that prostate size is a contributing factor in symptomatic BPH.

Association of the aggrecan keratan sulfate-rich region with collagen in bovine articular cartilage.

Aggrecan, the predominant large proteoglycan of cartilage, is a multidomain macromolecule with each domain contributing specific functional properties. One of the domains contains the majority of the keratan sulfate (KS) chain substituents and a protein segment with a proline-rich hexapeptide repeat sequence. The function of this domain is unknown but the primary structure suggests a potential for binding to collagen fibrils. We have examined binding of aggrecan fragments encompassing the KS-rich region in a solid-phase assay. A moderate affinity (apparent Kd = 1.1 microM) for isolated collagen II, as well as collagen I, was demonstrated. Enzymatic digestion of the KS chains did not alter the capacity of the peptide to bind to collagen, whereas cleavage of the protein core abolished the interaction. The distribution of the aggrecan KS-rich region in bovine tarsometatarsal joint cartilage was investigated using immunoelectron microscopy. Immunoreactivity was relatively low in the superficial zone and higher in the intermediate and deep zones of the uncalcified cartilage. Within the pericellular and territorial matrix compartments the epitopes representing the aggrecan KS-rich region were detected preferentially near or at collagen fibrils. Along the fibrils, epitope reactivity was non-randomly distributed, showing preference for the gap region within the D-period. Our data suggest that collagen fibrils interact with the KS-rich regions of several aggrecan monomers aligned within a proteoglycan aggregate. The fibril could therefore serve as a backbone in at least some of the aggrecan complexes.

Management of benign prostatic hyperplasia in Scandinavia. A hospital questionnaire on pretreatment evaluation and treatment. The Scandinavian Urologic Association Subcommittee on Benign Prostatic Hyperplasia.

In order to describe the present status in Scandinavia of evaluation and treatment of patients presenting with symptomatic benign prostatic hyperplasia (BPH), a questionnaire was mailed to 261 relevant hospitals. In total 76% of the departments answered. Several differences between hospital types in each country were revealed, as well as differences between countries. Generally, symptom scores and urodynamics were used more often in university hospitals as compared to other types of hospitals. Symptom scores were most popular in Denmark and Sweden, while uroflowmetry generally was employed in Denmark and Finland, but less frequently in Sweden and Norway. The highest frequency of prostatic surgery was noted in Denmark. Watchful waiting accounted for the handling of 30% of the BPH patients in Finland and Sweden, in contrast to only 15% in Denmark.

Colorectal resection and anal anastomosis with an intraluminal stapler in Hirschsprung's disease

Twenty patients aged 5 months - 4 years (mean 14 months) with Hirschsprung's disease were operated upon. In all cases a pull-through resection and stapled circular coloanal anastomosis was performed, in 11 with a single-stapling technique and in 9 with double-stapling. Isopaque rectography 4 - 10 days postoperatively showed an intact anastomosis in all 20 patients, i. e., there were no clinical or subclinical leaks. On palpation 4 - 6 weeks postoperatively, there were signs of stenosis in 4 patients. However, no. 9 - 11 Hegar dilators passed easily and there was no residual stenosis at follow-up 3 months after surgery. The technique can be recommended in children over 6 months of age.

Colorectal resection and anal anastomosis with an intraluminal stapler in Hirschsprung's disease.

Twenty patients aged 5 months - 4 years (mean 14 months) with Hirschsprung's disease were operated upon. In all cases a pull-through resection and stapled circular coloanal anastomosis was performed, in 11 with a single-stapling technique and in 9 with double-stapling. Isopaque rectography 4 - 10 days postoperatively showed an intact anastomosis in all 20 patients, i. e., there were no clinical or subclinical leaks. On palpation 4 - 6 weeks postoperatively, there were signs of stenosis in 4 patients. However, no. 9 - 11 Hegar dilators passed easily and there was no residual stenosis at follow-up 3 months after surgery. The technique can be recommended in children over 6 months of age.

[Benign prostatic hyperplasia. Shared care between urologists and general practitioners]. / Benign prostatahyperplasi. Delt omsorg mellom urolog og allmennlege.

Clinical treatment of benign prostatic hyperplasia has been considered to be a task for the urologist alone. The urologist has been the only person capable of providing relief from the urethral obstruction through open and transurethral surgery. In recent years, knowledge about the physiology and pharmacology of the lower urinary tract and about the normal development of the condition has increased considerably. This has led to the development of new pharmacological drugs with positive effects on the symptoms caused by the obstructing hyperplastic prostate gland. The general practitioner now has a means of caring for patients with benign prostatic hyperplasia as long as the obstruction is not too pronounced and the symptoms are mild or moderate. Provided that urinalysis and creatinine level are normal, and there is no suspicion of malignancy, medical treatment can be considered. In cases with mild or moderate symptoms without suspicion of serious obstruction, even expectancy ("watchful waiting") may be preferred. When there is doubt about the diagnosis or when the effect of treatment is not as expected, the patient should be referred to a urologist. Benign prostatic hyperplasia is a condition where the care can suitably be shared between urologist and general practitioner.