Holmium laser ablation of the prostate (HoLAP): intermediate-term results of 144 patients.

PURPOSE: To retrospectively analyse the intermediate-term outcome of holmium laser ablation of the prostate (HoLAP) of up to 4 years postoperatively in one of the largest series and to define the selection criteria for patients who benefit from potentially lower complications associated with HoLAP. METHODS: Between June 2006 and November 2010, 144 patients with benign prostatic obstruction were treated at two centres with standardised HoLAP (2.0 J/50 Hz or 3.2 J/25 Hz with Versapulse(®) 80-100 W laser Lumenis(®)). Median follow-up was 21 months (range, 1-54). International prostate symptom score and quality of life (IPSS-QoL), PSA, prostate volume, maximal flow rate (Qmax), postvoiding residual volume (Vres) were evaluated pre- and postoperatively. All complications were graded according to CTCAE (v4.03). RESULTS: Mean patient age was 70.1 ± 7.7 years (range, 46-90). With a preoperative median prostate volume of 40 ml (range, 10-130), the median operation time was 50 min (range, 9-138). We observed a median catheterisation time of 1 day (range, 0-12) and hospitalisation time of 2 days (range, 1-16). IPSS-QoL, Qmax and Vres were significantly improved after 3 months, and all parameters remained unchanged after 12, 24 and 36 months. The rate of re-operation was significantly lower in patients with prostate volume <40 ml, compared to patients with prostates ≥ 40 ml (9.1 vs. 25 %, p = 0.04). CONCLUSIONS: HoLAP is a safe and effective procedure for the treatment of prostates <40 ml. Patients benefit from HoLAP because of a low bleeding rate and short hospital stay. Due to high recurrence rates, HoLAP should be avoided in prostates >40 ml.

[Stool behaviour and local pain after radical perineal and retroperitoneal prostatectomy]. / Stuhlverhalten und lokale Schmerzen nach perinealer und retroperitonealer radikaler Prostatektomie∗

PURPOSE: One of the main therapeutic targets of a radical prostatectomy (RP) as a treatment for -localised prostate cancer is the maintenance of quality of life after surgery besides the known oncological and functional effects. This prospective study compared the quality of life after surgery of patients treated with two different surgical methods (perineal RP, RPP; retropubic RP, RRP). The aim of this study was to compare perineal and retropubic RP with regard to stool behaviour and local pain symptoms. PATIENTS AND METHODS: 257  radical prostatectomies (169 RPP, 88 RRP) were performed between July 2003 and December 2004. 208 (151 RPP, 57 RRP) prospectively evaluated patients replied to a physician-independent validated questionnaire (QLQ-C30 with prostate modul, IIEF 75, stool behaviour) followed by a phone survey regarding the continence of all 257  patients. RESULTS: One year after surgery, the complete continence rate (no pads) was 75 % for the RPP group and 61 % for the RRP group. 22 % of the patients reported involuntary stool leakage in the RPP group and 19 % in the RRP group (not significantly different). 29 % of the patients in the RPP group complained of local pain after 12  months, one third of them while sitting. In the RRP group, 28 % of the patients complained of local pain after 12  months, 15 % of them while sitting.17 % in the RPP and 27 % in the RRP group who suffered of stool leakage had these symptoms preoperatively. One year after surgery, 52 % of preoperatively potent patients were still potent after nerve-sparing RPP and 40 % were potent after nerve-sparing RRP. 78 % of patients in the RPP group and 67 % in the RRP group had an overall satisfactory quality of life. CONCLUSION: The application of different surgical methods did not differ with regard to postoperative local pain, stool behaviour, or general health items of quality of life. Stool leakage and perineal pain while sitting were not limited to RPP only and about a quarter of these patients had suffered from stool leakage already be-fore surgery.

[Representation of cystectomy and urinary diversion in the G-DRG system 2010: an example for the complexity of the reimbursement system]. / Kodierung der Zystektomie im DRG-System 2010 : Ein Beispiel für die Komplexität des Abrechnungssystems.

Cystectomy and urinary diversion is an excellent example for the growing complexity of the G-DRG (German diagnosis-related groups) system. Based on different diagnoses (malignant tumor of the urinary tract, benign disease of the urinary tract, malignant tumor of the female genital tract, or malignant tumor of the male genital tract), identical cases may lead to very different codes, resulting in even more differences in reimbursement.

[Holmium laser ablation of the prostate. An alternative to GreenLight photoselective vaporization of the prostate]. / Holmiumlaserablation der Prostata. Eine Alternative zum KTP.

INTRODUCTION: Ablative laser methods for treating benign prostatic obstruction (BPO) have gained importance because of potentially lower complication rates than outpatient therapy methods. The aim of this prospective phase II study was to record the effectiveness and complications of holmium laser ablation of the prostate (HoLAP) in the first postoperative year. MATERIAL AND METHODS: June 2006 to December 2007, 86 of 343 consecutive patients with BPO [International Prostate Symptom Score (IPSS) >10] were treated with the VersaPulse 100-W laser (Lumenis), 2.0 J/50 Hz or 3.2 J/25 Hz. Preoperative and postoperative prostate-specific antigen (PSA), peak urinary flow rate (Q(max)), IPSS, prostate gland volume, and postvoid urine volume were prospectively measured. The median follow-up time was 8 months (3-21). RESULTS: Median patient age was 71 (50-83) years, and mean operating time was 77.5 (9-135) min. There was only one case of significant bleeding. In 14 of 86 cases (16%), HoLAP was combined with transurethral resection of the prostate (TURP). Short-term voiding complaints were expressed by 26.7% of the questioned patients. The length of hospital stay was in most cases <48 h. IPSS, Q(max), PSA, postvoid urine, gland volumes, and quality of life improved significantly after 3 months, and all parameters remained unchanged after 12 months. The reoperation rate within 12 months was 6.8%. CONCLUSIONS: The advantage of HoLAP over TURP is the very low bleeding rate and thus a shorter hospital stay and possible outpatient therapy. In particular, patients with prostate gland volume <50 ml profit from HoLAP. Postoperative voiding complaints are comparable to those with TURP. Long-term results are needed to confirm the low reoperation rate.

[Seminal vesicle sparing radical perineal prostatectomy]. / Samenblasenerhaltende radikale perineale Prostatektomie.

BACKGROUND: The early and mid-term oncological and functional results of a seminal vesicle sparing modification of perineal nerve sparing radical prostatectomy (SV-RPP) was compared to the classical perineal (RPP) and retroperitoneal (RRP) approaches. MATERIALS AND METHODS: From July 2003 to December 2007, 702 radical prostatectomies (417 RPP, 285 RRP) were performed by 3 surgeons (mean follow-up 17 months, range 0-48 months). RPP was chosen under the following conditions: PSA<10 ng/ml, Gleason sum<7 and volume<50 ml. A seminal vesicle sparing technique (SV-RPP) was used in 47% of the RPPs. RESULTS: With a significantly shorter average operation (OR) time (SV-RPP 90 min, RPP 144 min, RRP 165 min), transfusion rate (SV-RPP 3%, RPP 9.1%, RRP 11.9%) and rate of anastomotic leaks at day 10 (SV-RPP 6.4%, RPP 10.3%, RRP 27.8%) the pT2 positive surgical margin rate with SV-RPP (3.4%) was significantly lower than with RPP (9.6%) and RPP (8.4%). For pT2-R0 tumors PSA relapse>0.2 ng/ml occurred in 12.5%, 13.6% and 8.2%, respectively (not significant). Continence rates (0-1 pad) for SV-RPP were significantly better compared to RPP and RRP after 4 weeks (59.3%, 41.0% and 45.4%, respectively) and 12 months (95.7%, 86.4% and 86.8%, respectively) CONCLUSIONS: SV-RPP represents an improved perineal technique with respect to intraoperative and postoperative complications whilst maintaining an oncological outcome comparable to RPP and RRP. Leaving seminal vesicles in situ did not result in increased PSA relapse rates.

[Pigmented pheochromocytoma. Case report with immunohistochemical and electron microscopic characterization]. / Pigmentiertes Phäochromozytom. Fallbericht mit immunhistochemischer und elektronenmikroskopischer Charakterisierung.

We present a case of pigmented adrenal paraganglioma in a 39-year-old female patient with associated neurofibromatosis type 1 (NF1). Histology showed features typical for phaeochromocytomas except for varying amounts of brown pigment within the cytoplasm of tumour cells, which proved to be melanin by histochemical and ultrastructural analysis. The occurrence of melanin is believed to reflect the origin of this neoplasm from multipotent cells of the neural crest. Pigmented phaeochromocytoma has to be taken in consideration in the differential diagnosis of pigmented neoplasms, especially in the adrenal gland, where it has to be discriminated from pigmented cortical adenoma (so-called black adenoma) and primary malignant melanoma.

Iomeprol versus iopromide for intravenous urography.

Iomeprol (B16880) is a new non-ionic tri-iodinated radiographic contrast medium. It was the aim of this double blind randomized phase III clinical trial to compare the local and systemic tolerance of iomeprol-300 (300 mg I ml-1) with the commercially available iopromide-300 (300 mg I ml-1) in a group of 198 patients needing intravenous urography. The contrast medium was injected rapidly into an antecubital vein within 2-3 min in most cases, using a standard dosage of 1 ml kg-1 body weight. The proportion of patients with an allergic diathesis was 25% in the iomeprol group and 17.3% in the iopromide group. There were no life-threatening adverse reactions. Eight patients (8%) receiving iomeprol and 6 (6.1%) receiving iopromide had a sensation of heat related to the injection of contrast medium. Only one patient (1%) in the iomeprol group and two patients (2%) in the iopromide group noted pain on injection. Although the incidence of all other side-effects was relatively high (7% after iomeprol and 11.2% after iopromide) these reactions were generally harmless. The most common symptom was nausea and/or vomiting, which occurred with the same incidence (5%) in both groups. Only one patient in each group developed urticaria or erythema. Vital parameters remained essentially unchanged in all patients. The results suggest that iomeprol is a safe contrast medium, with a tendency to produce fewer side effects than iopromide, which is known to be particularly well tolerated.

[Faulty voiding and drinking habits--a contribution to the genesis of enuretic syndrome?]. / Miktions- und Trinkfehlverhalten--Ein Beitrag zur Genese des enuretischen Syndroms?

In 122 children (85 girls, 37 boys) with nocturnal enuresis, information on drinking and voiding patterns was elicited. Many of them (60% of the girls and 40% of the boys) had previously been continent for 1-5 years. It turned out that the children tried to suppress voiding and had the habit of drinking primarily during the second half of the day. After changing these habits, 119 children became permanently continent.

Randomized, double-blind, multicenter trial on treatment of frequency, urgency and incontinence related to detrusor hyperactivity: oxybutynin versus propantheline versus placebo.

Clinical efficacy and adverse effects of oxybutynin and propantheline in the treatment of symptoms related to detrusor hyperactivity were studied in a randomized, controlled, double-blind multicenter trial. Of 169 patients entered into the study 154 were evaluable for statistical analysis. Mean grade of improvement (visual analogue scale) was significantly higher with oxybutynin (58.2%) versus propantheline (44.7%) and placebo (43.4%). Mean bladder volume at first involuntary cystometric contraction was significantly increased with oxybutynin (+57.0 ml.) versus placebo (-9.7 ml.). Mean maximum cystometric bladder capacity was also significantly increased with oxybutynin (+80.1 ml.) versus placebo (+22.5 ml.). Rate of inquired possible adverse effects was significantly higher for oxybutynin (63%) versus propantheline (44%) and placebo (33%). However, only 5 patients dropped out of the study because of adverse effects (oxybutynin 2 and propantheline 3). No serious or lasting adverse effects were encountered with dryness of the mouth being the major complaint. Oxybutynin has statistically significant effects on subjective symptoms and objective urodynamic parameters in patients with detrusor hyperactivity compared to propantheline.

[Neurotherapy of the hyperactive bladder]. / Neuraltherapie der hyperaktiven Blase.

Results in the treatment of non-neurogenic bladder hyperactivity are unsatisfactory. However, the first promising results from neurostimulation and our own findings in the neuroanatomy and neurophysiology of the lower urinary tract have led us to consider peripheral neurostimulation of the S2 - dorsal root or dorsal nerve of the penis for treating patients with hyperactive bladder dysfunction. We report on the first 14 cases treated by peripheral neurostimulation and S2-dorsal root blockade with local anesthesia for bladder hyperactivity. The bladder function became normal, and the bladder capacity increased up to 400% under neurotherapy. The methods, results and complications are discussed.

[Panurography -- a new method of combination excretory and micturitional urography]. / Panurographie - eine neue Methode der kombinierten Ausscheidungs- und Miktionsurographie.

To diagnose a vesicoureteral reflux, a new examination X-ray procedure was developed avoiding bladder catheterization: panurography. Panurography is a combination of excretion and micturition urography which for screening purposes can be performed in a single investigation without bladder catheterization. Recent advances in uroradiological imaging techniques with growing application of low-dose large-format image intensifier urography (14" image intensifier) not only reduce radiation exposure to less than 20% of that in conventional film-screen radiography, but also permit obtaining voiding cystograms which include the whole urinary tract from the kidneys to the urethra in children. Voiding conditions are improved by means of a comfortable micturition seat coupled with a uroflowmeter which automatically triggers exposures by a 10 cm-camera at preselected intervals as long as a measurable urine flow exists.

Hemospermia owing to utricular cyst: embryological summary and surgical review.

We report the first case of hemospermia owing to a utricular cyst. The embryologic distinction between utricular cysts, which are of endodermal origin, and müllerian duct cysts, which are of mesodermal origin, is described. The surgical management of utricular and müllerian duct cysts is reviewed, stressing the difficulty and hazards of attempts at complete excision and the efficacy of less heroic surgical procedures.