Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

[Surgical treatment of erectile dysfunction]. / Operative Therapie der erektilen Dysfunktion.

During the past decades several efforts had been undertaken to treat erectile dysfunction by vascular surgery. Today one option survived: Implantation of Penile Prostheses. A lot of improvements of the material and the process quality lead to very good long term results. Patients with severe erectile dysfunction can be recommended in good conscience for implant surgery.

Expression and function of the vitamin D receptor in malignant germ cell tumour of the testis.

Testicular germ cell tumours (TGCTs) are the most common malignancy in young men aged 18-35 years. They are clinically and histologically subdivided into seminomas and non-seminomas. 1,25-Dihydroxyvitamin D (1,25(OH)(2)D(3)) is the active form of vitamin D and exerts its actions via a specific intracellular vitamin D receptor (VDR). Several investigations in the recent years have revealed, in addition to a physiological occurrence of the VDR in various tissues, VDR expression in different human malignancies. Furthermore, 1,25(OH)(2)D(3) plays an important role in the regulation of cell proliferation and differentiation. In different normal and malignant cell types, antiproliferative and pro-differentiating effects of 1,25(OH)(2)D(3) are described. We investigated whether TGCT express the VDR, wether differences exist between the histological subtypes and if vitamin D has a function on the proliferation of tumour cells. Furthermore, we investigated the potential function of the vitamin D-regulated genes nuclear receptor co-repressor 1(NCOR1), nuclear receptor co-repressor 2 (NCOR2), thyroid receptor interacting protein 15 (TRIP15), Growth Arrest and DNA Damage (GADD45), MAP kinase-activated protein kinase 2 (MAPKAPK2), Cytochrome P450, family 24, subfamily A, polypeptide 1 (CYP24A1) and Cytochrome P450, family 27, subfamily B, polypeptide 1 (CYP27B1) in the pathogenesis of TGCT. We demonstrate, for the first time, that primary TGCT as well as TGCT cell lines, express VDR mRNA and protein. Vitamin D and VDR may play a role in the pathogenesis of TGCTs. Furthermore, vitamin D inhibits proliferation of TGCT cell-lines, potentially via an increase in expression of GADD45. Our data suggest that vitamin D could play a role in antitumour therapy.

Expression and function of protein phosphatase PP2A in malignant testicular germ cell tumours.

Testicular germ cell tumours (TGCT) represent the most common malignancy in young males. We reported previously that two prototype members of the mitogen-activated protein kinase (MAPK) family, the MAPK ERK kinase (MEK) and extracellular signal-regulated kinase (ERK), are inactive in malignant testicular germ cells and become active after drug stimulation, leading to apoptosis of tumour cells. In this study, we asked whether the protein phosphatase PP2A, a known inhibitor of the MEK-ERK pathway, participates in the proliferation and/or apoptosis of primary TGCT (n = 48) as well as two TGCT cell lines (NTERA and NCCIT). Quantitative RT-PCR, immunohistochemistry, western blot analyses and phosphatase assay indicate that primary TGCT as well as TGCT cell lines express PP2A and that PP2A is active in TGCT cell lines. The inhibition of PP2A by application of two PP2A inhibitors, cantharidic acid (CA) and okadaic acid (OA), results in a significant increase in caspase-3-mediated apoptosis of TGCT cell lines. Thereby, PP2A inhibition was accompanied by phosphorylation and activation of MEK and ERK. Functional assays using the MEK inhibitor PD98059 demonstrated that the phosphorylation of MEK and ERK was required for the induction of caspase-3-mediated apoptosis of malignant germ cells. Thus, our data suggest that inhibition of PP2A mediates its apoptosis-inducing effect on TGCT through activation of the MEK-ERK signalling pathway that leads to caspase-3-mediated apoptosis of tumour cells. In addition our results support previous observations that PP2A exerts an anti-apoptotic effect on malignant tumour cells.

Single agent carboplatin for CS IIA/B testicular seminoma. A phase II study of the German Testicular Cancer Study Group (GTCSG).

BACKGROUND: The aim was to investigate the use of single agent carboplatin in patients with seminoma stage IIA/B. PATIENTS AND METHODS: In a prospective phase II trial, single agent carboplatin at a dose of AUC 7 mg.min/ml every 4 weeks for three cycles in stage IIA (n=51) or four cycles in stage IIB (n=57) was given to 108 patients with previously untreated seminoma stage IIA/B. Patients with residual masses of >or=3 cm were scheduled to receive secondary surgery. RESULTS: A complete response (CR) was achieved by 88/108 (81%) patients, 17/108 (16%) achieved a partial response (PR), two of 108 (2%) showed no change, and one patient progressed. In all patients with PR the residual disease was

[Aftercare in testicular cancer is worthwhile. Recurrences are curable]. / Nachsorge beim Hodentumor lohnt sich. Rezidive sind heilbar.

Patients with germ cell tumours of the testis can have an extremely favourable chance of cure when compared to other malignancies. Therapeutic problems may arise with recurrent disease. High tumour burden can result when relapses are diagnosed too late and the prognosis will deteriorate, consecutively, even in spite of intensified therapeutic endeavours. Apart from early detection of recurrent disease, the follow-up schedule of germ cell cancer aims to identify and manage treatment-related morbidities, e.g. vascular problems and second neoplasms, respectively. Follow-up examinations should be tailored to the individual situation taking into account the particular risk of relapse based on histology, stage and treatment previously applied. In light of the rarity of the disease and according to the complexity of managing this malignancy, follow-up should be conducted by particularly experienced institutions.

[Urinary retention with ruptured fornix caused by a maggot. An autoerotic accident]. / Harnstauung mit Fornixruptur durch Schmeissfliegenlarve Ein autoerotischer Unfall.

Foreign bodies in the urinary tract represent a possible cause for genitourinary disease. A huge variety of objects are inserted into the urinary tract for therapeutic, autoerotic, or psychiatric reasons and the symptoms for foreign bodies can be rather unspecific. Dysuria, hematuria, and urinary tract infection can suggest the presence of intravesical foreign bodies. Symptomatic urinary retention is more seldom and the causal foreign bodies are mostly iatrogenically applied. We present a unique case of maggots self-inserted into the urinary tract for autoerotic reasons causing symptomatic urinary retention with fornix rupture.

Gene expression profiling in seminoma and nonseminoma.

PURPOSE: Gene expression profiles of seminoma were compared with nonseminoma to get insights into tumorigenesis. MATERIALS AND METHODS: Eleven testicular tumor biopsies (five pure seminoma, six nonseminoma; pT1N0M0 to pT2N2M1) and biopsies from unaffected sites were analyzed once per patient using a macroarray (1,176 genes). On the same patients, six genes were validated using real-time quantitative (RTQ) polymerase chain reaction (PCR). Additionally, in a separate cohort of 19 patients, 24 genes selected from the macroarray were measured using RTQ-PCR. RESULTS: (1) The agreement in gene expression was 94% between the two methods and two different patient cohorts. (2) Two features in gene expression were independent of the tumor entity: Most changes of gene expression occurred in five functional groups like "cell cycle" and "apoptosis." Genes within these groups were almost similarly (> 80%) up- or downregulated. (3) Nonseminoma were characterized by downregulated genes (75%), but in seminoma, upregulated genes (64%) prevailed. Furthermore, 64.4% of those genes that were differentially expressed in both tumor entities were usually upregulated in seminoma but downregulated in nonseminoma. A reverse pattern was found in 24.4% of such genes. Eleven percent of these genes showed a similar up- or downregulation in gene expression in both tumor entities. CONCLUSION: Seminoma in this preliminary study can be differentiated from nonseminoma due to almost opposing gene expression profiles (89% of the significantly differentially expressed genes) and are in line with the histological discrimination of both tumor entities. Underlying mechanisms and implications regarding the origin and tumor progression of both entities are discussed.

[Retroperitoneal lymph node dissection in testis cancer]. / Retroperitoneale Lymphadenektomie beim Hodentumor.

According to the rules of the European Interdisciplinary Consensus, retroperitoneal lymph node dissection (RPLND) will be indicated less frequently in patients with nonseminomatous testis cancer. In clinical stage I it will be done only exceptionally and in stage II A only in marker-negative patients. In all other stages RPLND will be recommended as residual tumor resection and additionally in "growing teratoma syndrome" and in rare situations as "desperation surgery." It will be difficult in future using the minor operations to enter the learning curve. Only advanced situations will have to be managed by urological surgeons. These operations will have to be performed predominantly in specialised centres.

Residual tumor resection after high-dose chemotherapy in patients with relapsed or refractory germ cell cancer.

PURPOSE: To assess the role of residual tumor resection performed after high-dose chemotherapy (HDCT) in patients with relapsed or refractory germ cell tumors (GCT). PATIENTS AND METHODS: Between July 1987 and October 1999, postchemotherapy resections of residual tumors were performed in 57 patients who had been treated with HDCT for relapsed or refractory GCT and who had achieved a partial remission to this treatment. RESULTS: Complete resections of residual masses were achieved in 52 (91%) of 57 patients who were rendered disease free; in five (9%) of 57 patients, the resections were incomplete. Resection of a single site was performed in 39 (68%) of 57 patients, and the remaining 18 (32%) of 57 patients required interventions at two or more residual tumor sites. Necrosis was found in 22 (38%) of 57 patients, mature teratoma with or without necrosis was found in nine (16%) of 57 patients, and viable cancer with or without additional necrosis or mature teratoma was found in 26 (46%) of 57 patients. Viable cancer consisted either of residual germ cell or undifferentiated cancer in 22 (85%) of 26 patients, with additional non-GCT histologies in the remaining four patients. Patients with viable cancer had a significantly inferior outcome after surgery compared with patients with necrosis and/or mature teratoma even if all cancer was completely resected. Pulmonary lesions with a diameter of more than 2 cm were the only predictive variable for viable cancer in univariate analysis. CONCLUSION: Resections of all residual tumors should be attempted in patients with relapsed or refractory GCT and partial remissions after HDCT.

Tu-M2-PK in the blood of testicular and cubital veins in men with testicular cancer.

We wanted to verity whether M2-PK is a useful marker in testicular cancer. In a prospective study of 20 consecutive patients, blood was drawn from the testicular and the cubital vein before semicastration and later. For the detection of M2-PK we used the Assay of ScheboTech. In the testicular vein M2-PK was 11.2 U/ml. In the cubital vein it was 6.2 U/ml before semicastration, increasing in the following days. There were no significant differences between testicular and cubital vein blood, between the non-metastasized patients and the metastasized stages and between the patients with seminoma and non-seminomatous tumors. There is no profit in the diagnosis of testicular cancer using Tu-M2-PK.

Angiogenic switch and vascular stability in human Leydig cell tumours.

The high degree of vascularisation, accompanied by the low malignancy of human Leydig cell tumours, offers an interesting model to study the neovascularisation and structural stabilisation of the vascular wall. We report here that Leydig cell tumours are characterised by an increased level of vascular endothelial growth factor (VEGF) in testicular veins, the presence of VEGF mRNA and of its receptor, KDR, and an absence of detectable VEGF receptor Flt-1, in blood vessels of tumour marginal zones and of peri-tumour areas. This is in contrast to the capillaries within normal Leydig cell clusters which demonstrate both Flt-1 and KDR. Ultrastructural destabilisation of the vascular wall, evident as a lack of basement membrane and of peri-endothelial cells was also present in nearly 85% of blood vessels of the peri-tumour areas. In contrast, approximately 89% of the blood vessels of the tumour centre region demonstrated a stabilised vascular wall including basement membrane and peri-endothelial cells. Local application of VEGF(165) to the normal testicular tissue induced significant ultrastructural destabilisation in the capillary walls which only expressed KDR. These results suggest an autocrine role of VEGF on endothelial cells of tumour blood vessels in a region-specific manner and implicate that VEGF interactions with KDR, in the absence of Flt-1, may be involved in vascular destabilisation. In addition, the finding that most (79%) of Leydig tumour blood vessels are stabilised may account for the low malignant potential of these tumours.

[Anatomy and blood supply of the penis and urethra]. / Anatomie und Blutversorgung des Penis und der Harnröhre.

The exact knowledge of the topographic anatomy of the urethra as well as the macro- and microcirculation of the penis [6] are the basics of reconstructive urethral surgery. Adherence to the fundamentals and principles of tissue transfer [5] are necessary to fascilitate conditions for successful treatment of the various disorders of the male urethra. Mutural description of the anatomy of the male urethra in conjunction with external male genitals is necessary because of developmental similarities as well as the close anatomical relationship. The arterial and venous blood supply of the urethra and the penis have to be taken into account if vascularized flaps from the penile skin or the prepuce are used in urethral reconstruction. The dual arterial and venous vascularity of the genital skin is of fundamental importance to a successful outcome of the operative treatment. The purpose of this article is, to summarize the relevant anatomical knowledge of reconstructive urethral surgery.

[Bulbo-bulbar and bulbo-prostatic anastomosis of the urethra]. / Bulbobulbäre und bulboprostatische Anastomose der Harnröhre.

Strictures of the bulbous and membranous urethra up to 2.5 cm in length and after visual urethrotomy should be managed with an one-stage perineal anastomotic repair. With description of the surgical techniques the results of 41 patients, treated between 1977 and 1996, are presented. 28 patients had bulbomembraneous strictures as result from urethral disruption at the time of pelvic fracture. In 13 cases with bulbar strictures, 11 had been caused iatrogenously and 2 by infection. A successful outcome was achieved in over 90% (37 patients), equivalent to a maximum uroflow over 15 ml/s, an empty bladder after voiding and a radiographic wide anastomosis. Only 4 patients (9.8%) after surgery required an urethrotomy; two of them are dilated frequently.

Elevated human chorionic gonadotropin concentrations in the testicular vein and in peripheral venous blood in seminoma patients. An analysis of various parameters.

OBJECTIVE: Human chorionic gonadotropin (HCG) elevations in the testicular vein (TV) are correlated with those in the cubital vein (CV). Their significance was tested regarding various prognostic parameters. METHOD: Within the framework of a large multicentre study to assess the prognosis of HCG-positive seminomas 726 eligible patients were recruited from 1986 to 1991. A total of 378 had elevated and 348 had normal HCG measured in the CV. In 144 patients samples were taken from the TV. Histological diagnosis of seminoma was confirmed by two reference pathologists. Three groups (group I: elevated HCG in CV and normal or elevated HCG in TV; group II: normal HCG in CV and elevated HCG in TV; group III: normal HCG in CV and normal or unknown HCG in TV) were compared in relation to the presence or absence of metastases, stage of the disease, size of the primary tumour, pT category, vascular invasion and lactate dehydrogenase. RESULTS: Of the TV serum samples, 85% were HCG-positive. Regression analysis revealed higher values in the TV compared to the CV according to the following equation: HCGTV = 520 + 1.12 x HCGCV, R = 0.766, with a mean variation of 14%. Patients in group I had significantly higher stages and larger primary tumours than patients with normal HCG in the CV, irrespective of the HCG values in the TV blood (groups II and III). Therefore, HCG is associated with tumour mass. No differences of statistical significance were found regarding T category, vascular invasion and lactate dehydrogenase. There were no differences between groups II and III. CONCLUSION: Only HCG values of the CV are associated with known adverse-prognostic factors of seminomas, such as metastases and size of the tumour. HCG in the TV adds no further information for the clinical assessment of patients with seminoma.

[Metastases of germ cell tumors to the ENT area--a rare differential diagnosis of lymph node metastases in unknown primary tumor]. / Metastasierung von Keimzelltumoren in den HNO-Bereich--eine seltene Differentialdiagnose von Lymphknotenmetastasen bei unbekanntem Primärtumor.

BACKGROUND: Germ cell tumors of the testis usually metastasize to retroperitoneal lymph nodes, lungs, and liver. Other lymphatic or organ metastases especially in the head and neck are rare. CASE REPORTS: The cases of two men, ages 21 and 35, are presented. In both cases, the histologic examination of cervical lymph node specimen lead to the correct tumor diagnosis of testicular cancer. Multimodal urooncologic therapy led to long-lasting complete remissions in both cases. CONCLUSIONS: In young men between 20 and 35 years of age with cervical metastases of tumors of unknown primary site, germ cell tumors must be suspected. Histologic findings of non-squamous epithelial metastases (seminoma, embryonal carcinoma, chorionic carcinoma, teratoma, yolk sack tumor, and their combined forms) with or without retroperitoneal, mediastinal, or lung metastases; elevated tumor markers (human-chorionic gonadotropin, alpha-feto-protein, placental alkaline phosphatase, lactate dehydrogenase); and palpable intratesticular mass lead to the correct tumor diagnosis. Early detection of the disease is essential for successful therapy and long-term remission.