Upper transverse scrotal approach for muscle- and nerve-sparing urethral stricture repair

OBJECTIVE

Open surgery on bulbar urethral strictures has become a widespread procedure. While there is inconsistency which procedure to perform at the bulbar region, there is consistency of the used incisional approach despite of several potential disadvantages. Therefore, to bypass disadvantages, we performed an upper transverse scrotal approach for stricture repair in the pendulous urethra and the distal bulbar urethra as previously reported for the placement of an artificial urinary sphincter.

METHODS

Thirteen patients (n = 13) with bulbar urethral stricture were operated by upper transverse scrotal incision approach. On five patients a free foreskin graft in dorsal onlay technique was performed. Eight patients obtained an end-to-end-anastomosis procedure. Pre- and postoperative uroflowmetry as well as retrograde urethrocystography were done. Pre- and postoperative residual postvoid urine were estimated by transabdominal ultrasound. The patients were followed-up for up to 12 months.

RESULTS

After stricture repair, Qmax improved from mean 9.0 mL/s (SD +/- 3.2) preoperatively to mean 20.3 mL/s (SD +/- 3.1), postoperatively. Postvoid residual urine decreased from mean 90.0 mL (SD +/- 68.7) to mean 41.5 mL (SD +/- 16.1). All retrograde urethrocystographies showed regular reconstructed urethral conditions.

CONCLUSION

The upper transverse scrotal incision may combine the advantages of a less traumatical approach with the excellent results of perineal approach.

Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron-sparing surgery in patients with renal cell carcinoma

OBJECTIVE

To prospectively evaluate health-related quality of life (HRQoL) and perioperative outcomes in patients with T1 and T2 renal cell carcinoma (RCC) after retroperitoneoscopic radical nephrectomy (RRN), open RN (ORN) or open nephron-sparing surgery (NSS).

PATIENTS AND METHODS

The data of 117 patients who had undergone RRN (36), ORN (37) or NSS (44) were evaluated. RRN data were obtained at Basel University Hospital, Switzerland, while the ORN and NSS data were collected at the University of Munich, Germany. Perioperative outcomes were analysed and compared. HRQoL was prospectively evaluated based on the Short Form 36 questionnaire with a mean follow-up of 22 months.

RESULTS

Operative duration was significantly longer in the RRN group compared with the ORN and NSS groups, at a mean (sem) of 146 (42) min vs 113 (48) min and 114 (42) min (P < 0.001). In the RRN group intraoperative blood loss was lower than in the ORN and NSS groups, at a mean (sem) of 231 (153) mL vs 424 (361) mL and 494 (360) mL (P < 0.001). Morbidity rates were 13.9% for RRN, 16.2% for ORN and 20.5% for NSS, the most relevant complications being bleeding requiring transfusions in RRN and NSS patients and haemorrhage (5% of patients in each group). Creatinine values at 6 months after surgery only recovered completely in the NSS group. Patients in the ORN group had a trend towards higher mental well-being scores than patients in the RRN and NSS groups, with a mean Mental Component Summary Score of 48.3 vs 48.0 and 44.5, respectively (not statistically significant), while all patients were in similar physical condition after surgery, with a mean Physical Component Summary Scores of 48.0 (ORN), 47.4 (RRN) and 47.2 (NSS). The physical condition scores of patients in all groups were higher than scores reached by an age and sex-matched population (45.8).

CONCLUSION

These real-world data show that each of the surgical techniques can be considered safe. Importantly, after surgery patients reported high QoL scores independent of the technique used.

Distribution and function of cannabinoid receptors 1 and 2 in the rat, monkey and human bladder

PURPOSE

We investigated the distribution of cannabinoid receptor subtypes 1 and 2 in the detrusor of different species and studied the effects of cannabinoid receptor 1 and 2 agonists on bladder function.

MATERIALS AND METHODS

Cannabinoid receptor 1 and 2 expression was studied with Western blot and immunohistochemistry in rat, monkey and human detrusors. Co-staining was done for markers of sensory nerves using calcitonin gene-related peptide (Euro-Diagnostica, Malmö, Sweden) and transient receptor potential vanilloid 1, and for cholinergic nerves using VAChT (Santa Cruz Biotechnology, Santa Cruz, California). Actions of the endogenous cannabinoid receptor-1 and 2 agonist anandamide (Sigma(R)), and the cannabinoid receptor 1 and 2 agonist CP55,940 (Sigma) on isolated detrusor and during cystometry in conscious rats were recorded.

RESULTS

Higher expression of cannabinoid receptor 2 but not cannabinoid receptor 1 was noted in the mucosa than in the detrusor. Compared to the detrusor larger amounts of cannabinoid receptor 2 containing nerves that also expressed transient receptor potential vanilloid 1 or calcitonin gene-related peptide were observed in the suburothelium. Nerve fibers containing cannabinoid receptor 2 and VAChT were located in the detrusor. Neither anandamide nor CP55,940 affected isolated detrusor carbachol (Sigma) contractions. Nerve contractions were enhanced by 10 muM anandamide and decreased by 10 muM CP55,940 (p<0.05). In vivo CP55,940 increased the micturition interval by 46% and threshold pressure by 124% (p <0.05). Anandamide increased threshold pressure by 26% and decreased the micturition interval by 19% (p <0.05 and <0.01, respectively).

CONCLUSIONS

The distribution of cannabinoid receptor 2 on sensory nerves and in the urothelium, and effects by CP55940 on the micturition interval and threshold pressure suggest a role for cannabinoid receptor 2 in bladder afferent signals. Co-expression of VAChT and cannabinoid receptor 2, and effects by CP55940 on nerve contractions suggest a cannabinoid receptor 2 mediated modulatory effect on cholinergic nerve activity. Anandamide may not be a good tool for cannabinoid receptor studies due to its activity at other receptors.

Laser therapy for upper urinary tract transitional cell carcinoma: indications and management

CONTEXT

Ureteroscopically guided laser techniques are commonly used in the treatment of upper urinary tract transitional cell carcinoma (UUTT); however, there is an ongoing debate with regard to indication and management.

OBJECTIVE

To review the indication, feasibility, and treatment outcome of laser application for definitive endoscopic treatment of UUTT, focusing on technical aspects of different laser devices and their impact on tissue.

EVIDENCE ACQUISITION

PubMed and Medline were searched for reports on laser therapy in UUTT from 1980 to 2008, with particular focus on the technical background of various laser systems.

EVIDENCE SYNTHESIS

For decades, nephroureterectomy has been considered the gold standard for treating UUTT. With the intent to preserve functioning renal parenchyma, minimally invasive approaches, initially advocated for patients requiring a nephron-sparing approach (ie, single functioning kidney, renal insufficiency or significant comorbidities), have gained widespread acceptance due to advances in ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopically guided laser ablation has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%, depending on stage and grade at diagnosis.

CONCLUSIONS

To obtain the highest treatment success, the initial staging and grading of the tumour is crucial. Because low-grade tumours rarely if ever progress in stage or grade, the success rate of ureteroscopic therapy parallels that of endoscopic resection of identical bladder tumours. In the treatment of higher grade, advanced tumours, ureteroscopic therapy is less likely to be curative, and thus, endoscopic manoeuvres can only be palliative. Due to the relatively low prevalence of this tumour and the lack of comparable randomised, multicentre trials, the indications for an endoscopic laser treatment option has to be defined based on the patient's individual situation.

Effects of long-term dietary soy treatment on female urethral morphology and function in ovariectomized nonhuman primates

PURPOSE

Agonistic effects of estrogen on the female urethra include an increase in contractile function, blood flow and mucosal hyperplasia. Whether such effects can be achieved by soy based phytoestrogen diets is unclear. We studied the effects of chronic phytoestrogen treatment on the structural and functional properties of the urethra in ovariectomized monkeys.

MATERIALS AND METHODS

Following ovariectomy 18 monkeys were fed a diet containing soy (9) or casein (9) based protein for 32 months. At necropsy the urethra and bladder were removed and the urethra was separated into 3 segments of equal length, including a proximal, a middle and a distal segment. Each urethral segment and 1 bladder segment was tested in vitro for functional responses to electrical field stimulation and pharmacological stimulation, and the proximal to distal segments were tested for urothelial thickness and mucosal area.

RESULTS

Electrical field stimulation produced frequency dependent contractile responses in the bladder, proximal and middle segments but not in the distal segment. Carbachol, phenylephrine and endothelin-1 produced concentration dependent contractions in all urethral segments. The maximum response decreased from the proximal to the distal segment (p </=0.05). The maximum response in the proximal and bladder segments to pharmacological stimulation and electrical field stimulation as well as mucosal area and urothelial thickness were significantly higher in the treatment than in the control group (p < or =0.05).

CONCLUSIONS

Chronic phytoestrogen treatment results in increased responsiveness of the proximal urethra to pharmacological and electrical stimulation, which is associated with an increase in urothelial thickness and mucosal area. This study indicates that dietary soy may have estrogen agonist effects on the urethra and bladder in estrogen deficient females.

[Organ-sparing surgery for penile cancer]

In patients with penile cancer health-related quality of life is closely related to organ-sparing surgery. To achieve an ideally suited treatment modality for this rare but aggressive tumor entity different operating techniques like micrographic surgery, laser treatment, and glansectomy were developed. These should offer optimal oncological treatment while preserving sexual function. This article gives an overview of indications and limits of organ-sparing treatment in penile cancer.

Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients

PURPOSE

Transurethral resection of the prostate has for decades been the standard surgical therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia, the most common benign neoplasm in men. To generate a contemporary reference for evolving medical and minimally invasive therapies we analyzed complications and immediate outcomes of transurethral prostate resection in a statewide multicenter study.

MATERIALS AND METHODS

We prospectively evaluated 10,654 patients undergoing transurethral prostate resection in the state of Bavaria, Germany from January 1, 2002 until December 31, 2003. Case records containing 54 items concerning preoperative status, operation details, complications and immediate outcome, were recorded for each patient.

RESULTS

The mortality rate for transurethral prostate resection was 0.10%. The cumulative short-term morbidity rate was 11.1%. The most relevant complications were failure to void (5.8%), surgical revision (5.6%), significant urinary tract infection (3.6%), bleeding requiring transfusions (2.9%) and transurethral resection syndrome (1.4%). The resected tissue averaged 28.4 gm. Incidental carcinoma of the prostate was diagnosed by histological examination in 9.8% of patients. Urinary peak flow rate increased significantly to 21.6 +/- 9.4 ml per second (baseline 10.4 +/- 6.8 ml per second, 1 tail p <0.0001), while post-void residual decreased to 31.1 +/- 73.0 ml (baseline 180.3 +/- 296.9 ml, 1-tail p <0.0001).

CONCLUSIONS

In a large scale evaluation comprising 44 mostly nonacademic urological departments in Bavaria, unique real-world data for transurethral prostate resection were prospectively generated. This most contemporary information should be of use to potential patients and facilitate subsumption of emerging surgical and nonsurgical benign prostatic hyperplasia treatment options.

[Diode laser. Ex vivo studies on vaporization and coagulation characteristics]

INTRODUCTION AND OBJECTIVES

Laser therapy of symptomatic benign prostatic hyperplasia (BPH) remains a challenge for most urologic surgeons. The main goal of laser surgery is to achieve a marked volume reduction and to decrease bladder outlet obstruction and lower urinary tract symptoms with minimal morbidity. Laser therapy encompasses a variety of techniques using different laser wavelengths, application systems, and surgical techniques to achieve contrasting tissue effects. In an in vitro animal model we compared the vaporization and coagulation effects of the potassium-titanyl-phosphate (KTP) laser, holmium:yttrium-aluminum-garnet (Ho:YAG) laser, and diode laser (980 nm).

MATERIAL AND METHODS

In an in vitro model using isolated perfused porcine kidneys we investigated the vaporization, the coagulation effect, and the bleeding rate of the KTP, Ho:YAG, and diode lasers on five porcine kidneys each. The application of each laser type was standardized. The area of laser application was 1 cm x 1 cm. The KTP group received an application with 80 W, the Ho:YAG group an application with 10-30 W, and the diode group an application with 30, 60, and 100 W. Hemostasis was measured semiquantitatively. Ablation and coagulation were investigated macro- and microscopically.

RESULTS

Concerning the ablation capacity, the diode laser is most effective (more than fivefold) compared to the KTP and Ho:YAG lasers but demonstrated a rather large coagulation zone of up to tenfold in comparison to the KTP and Ho:YAG lasers. Semiquantitatively, in terms of bleeding rate, all lasers were equivalent in this ex vivo model.

CONCLUSIONS

Our very early and limited experience indicates that KTP (80 W) and Ho:YAG (30 W) laser application are equivalent in terms of tissue ablation capacity and coagulation in an experimental setting. The diode laser at 980 nm is superior in terms of ablation capacity but has a large coagulation zone. Concerning the bleeding rate all tested lasers are equivalent in this ex vivo model.

[PDE5 inhibitors. A new option in the treatment of ureteral colic?]

BACKGROUND

PDE5 inhibitors represent the gold standard in the medical therapy of erectile dysfunction (ED). Promising results have been published regarding further urological indications such as treatment of ureteral colic. The aim of the present study was to evaluate the functional effects of the PDE5 inhibitors sildenafil (SIL), vardenafil (VAR), and tadalafil (TAD) on tissue tension and cyclic nucleotide levels of human ureteral smooth muscle segments in vitro.

METHODS

Relaxant responses of human ureteral smooth muscle were investigated in vitro using the organ bath technique. Cyclic nucleotides cAMP and cGMP were determined by specific radioimmunoassays.

RESULTS

Relaxing effects of ureteral muscle tension were observed in the rank order VAR>SIL>TAD. While only VAR significantly elevated cGMP levels 3.3-fold over control, no increase for cAMP levels was observed.

CONCLUSIONS

Our data provide evidence that cGMP is involved in the control of the normal function of the smooth musculature of the human ureter. Our findings suggest the potential of using selective inhibitors of PDE isoenzymes in the treatment of ureteral colic.

A mutation in the inner mitochondrial membrane peptidase 2-like gene (Immp2l) affects mitochondrial function and impairs fertility in mice

The mitochondrion is involved in energy generation, apoptosis regulation, and calcium homeostasis. Mutations in genes involved in mitochondrial processes often result in a severe phenotype or embryonic lethality, making the study of mitochondrial involvement in aging, neurodegeneration, or reproduction challenging. Using a transgenic insertional mutagenesis strategy, we generated a mouse mutant, Immp2lTg(Tyr)979Ove, with a mutation in the inner mitochondrial membrane peptidase 2-like (Immp2l) gene. The mutation affected the signal peptide sequence processing of mitochondrial proteins cytochrome c1 and glycerol phosphate dehydrogenase 2. The inefficient processing of mitochondrial membrane proteins perturbed mitochondrial function so that mitochondria from mutant mice manifested hyperpolarization, higher than normal superoxide ion generation, and higher levels of ATP. Homozygous Immp2lTg(Tyr)979Ove females were infertile due to defects in folliculogenesis and ovulation, whereas mutant males were severely subfertile due to erectile dysfunction. The data suggest that the high superoxide ion levels lead to a decrease in the bioavailability of nitric oxide and an increase in reactive oxygen species stress, which underlies these reproductive defects. The results provide a novel link between mitochondrial dysfunction and infertility and suggest that superoxide ion targeting agents may prove useful for treating infertility in a subpopulation of infertile patients.

The Diode Laser: A Novel Side-Firing Approach for Laser Vaporisation of the Human Prostate—Immediate Efficacy and 1-Year Follow-Up

OBJECTIVES

A prototype diode laser was used to evaluate the feasibility and postoperative outcome of diode laser vaporisation of the prostate in patients with bladder outlet obstruction (BOO) necessitating interventional desobstruction.

METHODS

Ten patients were included in this pilot study. The prostate was vaporised via a side-fire laser fibre (diode laser at 1470 nm, 50 W; Biolitec-AG, Jena, Germany). IPSS, quality of life, Q(max), and PVR volume were measured pre- and postoperatively and 1 yr after the intervention.

RESULTS

Prostate volumes were 35-78 ml. A mean 121 kJ (61-200 kJ) of energy was delivered. No patient had significant blood loss or fluid absorption. Three-way catheters were removed after a median of 33 h. Q(max) increased from 8.9 ml/s (3.6-13.2 ml/s) preoperatively to 15.7 ml/s (10.5-22 ml/s) (p<0.01) postoperatively. After the 12-mo follow-up, Q(max) increased to 22.35 ml/s (+/-4.32 ml/s; p<0.001). PVR volume changed from a baseline of 243 ml to 26.9 ml (p<0.001) after 12 mo. Volume reduction was estimated by transrectal ultrasound postoperatively (15 cc+/-6.39), and by PSA levels before surgery (3.8 ng/ml+/-2.3) and after 6 mo (2.64 ng/ml+/-1.51). No patient is incontinent. Two patients required recatheterisation postoperatively on days 1 and 2, respectively. Two patients required TURP within 2 mo. All patients without reintervention have presented for the 1-yr follow-up examination and are satisfied with the outcome.

CONCLUSIONS

Our preliminary findings indicate that 50-W diode laser vaporisation prostatectomy at 1470 nm is feasible and appears to be effective for acutely relieving BOO.

[Benign prostatic hyperplasia: background and diagnosis]

Lower UrinaryTracts Symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH) represent an increasing prevalent condition in ageing men. Patients often seek primarily consultation at their general practitioner. Aetiology and natural history of LUTS due to BPH have not been completely clarified. The development of symptomatic LUTS is age-dependent and determined to varying degrees by the presence of Benign Prostatic Hyperplasia (BPH), Benign Prostatic Enlargement (BPE) as well as Bladder Outlet Obstruction (BOO). A causal relationship does not always exist. Basis for a specific medical or surgical treatment in the individual patient with LUTS due to BPH is an exact diagnosis by the practising urologist.

[Benign prostatic hyperplasia: medical therapy]

Primary aims of the medical therapy for BPH are improvement of subjective symptoms and quality of life as well as the prevention of long-term complications such as acute urinary retention and renal failure. Secondary goal is inhibition of disease progression. The medical therapy should be tailored to each patient according to the individual complaints and risk of progression. Plant extracts, alpha-blockers and 5-alpha reductase inhibitors represent the most common prescribed substances. Recent data suggest beneficial effects for the use of antimuscarinic agents and phosphodiesterase type 5 inhibitors.

[Benign prostatic hyperplasia: surgical treatment]

According to the current treatment algorithm, surgical treatment of benign prostatic syndrome (BPS) is the next step after a pharmacological treatment. In addition to conventional transurethral resection of the prostate (TURP), much interest is shifting towards alternative sugical techniques such as transurethral microwave therapy (TUMT),transurethral needle ablation of the prostate (TUNA) and several laser techniques.

Bildgebende Verfahren bei der Diagnose des Prostatakarzinoms

Prostate cancer is one of the most frequent malignant diseases in men. Despite constant progress achieved in imaging procedures, prostate biopsy is the gold standard for diagnosing prostate cancer. For the assessment of lymph node status, only staging lymphadenectomy provides valid information. The aim of this work is to analyze the imaging procedures available in Germany and their value in primary and lymph node staging as well as biochemical recurrence.

Knee cartilage morphologic characteristics and muscle status of professional weight lifters and sprinters: a magnetic resonance imaging study

BACKGROUND

Whereas muscle and bone mass have been shown to strongly depend on mechanical stimulation (loading history), this relationship has not been established for articular cartilage.

HYPOTHESIS

Subjects with high muscle strength display thicker knee cartilage and larger joint surface areas than nonathletic volunteers, and knee cartilage morphologic characteristics correlate more strongly with muscle force than with muscle cross-sectional areas.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Fourteen young, healthy adult professional athletes (7 weight lifters and 7 bobsled sprinters) were examined and compared with 14 adult nonathletic volunteers who had never performed strength training. Muscle moments were measured with a dynamometer and muscle cross-sectional areas and knee cartilage morphologic characteristics with magnetic resonance imaging.

RESULTS

Weight lifters and sprinters displayed significantly (P < .001) larger extensor muscle moments and cross-sectional areas. They showed significantly greater (P < .01) patellar cartilage thickness than nonathletic volunteers (+14% [95% confidence interval, 6% to 22%] and +17% [95% confidence interval, 9% to 26%], respectively) but no significant differences in the cartilage thickness of the other knee joint cartilage plates or joint surface areas. Muscle moments did not correlate more strongly with knee cartilage volume or thickness than muscle cross-sectional areas of the thigh.

CONCLUSIONS

Direct measurements of muscle forces do not predict cartilage thickness more accurately than muscle cross-sectional areas. These findings suggest that cartilage thickness has much less ability, if any, to adapt to mechanical loading than muscle. Large cohorts of athletes will need to be studied to detect potentially significant differences in cartilage versus nonathletic controls.

Pharmacology of α1-adrenoceptor antagonists in the lower urinary tract and central nervous system

The main use of alpha(1)-adrenoceptor (AR) antagonists in urology has been to treat lower urinary tract symptoms (LUTS) in men with benign prostatic obstruction (BPO). The beneficial effects of these agents are primarily assumed to be because of relaxation of prostatic and urethral smooth muscle. The weak correlation between LUTS and prostatic enlargement, outflow obstruction, or both, however, has refocused interest on the role of extraprostatic alpha-ARs in the pathogenesis of LUTS and their treatment. The alpha(1)-ARs present in the bladder, urethra, vas deferens, peripheral ganglia, nerve terminals, and in the central nervous system could all potentially influence LUTS and, when the receptors are blocked, contribute to both the therapeutic and adverse effects of alpha(1)-AR antagonists. The relevance of alpha(1)-AR-subtype selectivity on the clinical usefulness of existing drug therapies has not been firmly established but it seems that blockade of both alpha(1A/L)- and alpha(1D)-ARs is necessary for the optimum balance between clinical efficacy and adverse effects.

Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study

PURPOSE

We prospectively analyzed the complications and immediate postoperative outcome of open prostatectomy for benign prostatic hyperplasia to provide reference data for emerging techniques, such as holmium laser enucleation of the prostate and laparoscopic prostatectomy.

MATERIALS AND METHODS

A total of 902 patients with a mean +/- 1 SD age of 71.3 +/- 6.8 years were evaluated while undergoing open prostatectomy in Bavaria, Germany from January 1, 2002 to December 31, 2003. We prospectively analyzed 54 parameters concerning preoperative status, surgical details, complications and immediate outcome.

RESULTS

Mean operative time was 80.8 +/- 34.2 minutes. Mean prostate size was 96.3 +/- 37.4 ml. Average enucleated tissue was 84.8 +/- 44.0 gm. Incidental carcinoma of the prostate was found in 28 of 902 patients (3.1%) and the mortality rate was 0.2%. The overall complication rate was 17.3%. The most relevant complications were bleeding requiring transfusion in 68 cases (7.5%), urinary tract infection in 46 (5.1%) and surgical revision due to severe bleeding in 33 (3.7%). Patients had an average International Prostate Symptom Score of 20.7 +/- 7.6 preoperatively. Mean urinary peak flow rate increased significantly to 23.1 +/- 10.5 ml per second from a baseline of 10.6 +/- 6.4 ml per second (p <0.0001). Post-void residual volume decreased to 17.5 +/- 34.8 ml from a baseline of 145.1 +/- 152.8 ml (p <0.0001).

CONCLUSIONS

Open prostatectomy showed a satisfactory early postoperative outcome with a complication rate that was within the expected range compared to that in the recent literature. It represents an important option in the treatment of patients with significant benign enlargement of the prostate for surgeons with no access to modern techniques, such as holmium laser enucleation of the prostate or laparoscopy.

[Scrotal masses]

Any intrascrotal space-consuming process needs to be investigated without delay. The risk of the lesion being a malignant tumor can be assessed on the basis of the differential diagnoses and investigative procedures described herein. If there is the slightest suspicion that the patient has a testicular malignancy he must be immediately referred to a specialist who will investigate any unclear space-consuming lesion by exposing the testis via an inguinal incision. Immediate treatment of a testicular tumor is of decisive importance for the patient's prognosis.

[Standards for the punch biopsy of the prostate]

If, within the framework of screening examinations for the early detection of cancer of the prostate, the patient wishes a PSA test, the physician should accommodate him, but only after providing comprehensive information about the possible consequences and complications. If a certain threshold value is exceeded, a punch biopsy of the prostate is recommended. This procedure must be performed in accordance with accepted standards to enable, within the diagnostic chain, the reliable detection of a carcinoma of the prostate

In vitro effects of PDE5 inhibitors sildenafil, vardenafil and tadalafil on isolated human ureteral smooth muscle: a basic research approach

Cyclic nucleotide phosphodiesterase (PDE) isoenzymes are key proteins regulating intracellular cyclic nucleotide turnover and thus smooth muscle tension. Several in vitro studies have indicated that the cyclic GMP and cyclic AMP-mediated signaling may play a role in the control of human ureteral muscle. The aim of the present study was to evaluate the functional effects of PDE5 inhibitors sildenafil (Sil), vardenafil (Var) and tadalafil (Tad), as well as nitric oxide (NO)-donating agent sodium nitroprusside (SNP) and non-selective muscarinic antagonist butylscopolamine (BSC) on the tension induced by KCl and the turnover of cyclic nucleotides in isolated human ureteral smooth muscle. In vitro relaxant responses of human ureteral smooth muscle to the PDE5 inhibitors mentioned above were investigated using the organ bath technique. Cyclic nucleotides cAMP and cGMP were determined by means of specific radioimmunoassay following incubation of the tissue with Sil, Var, Tad and SNP. The tension induced by KCl of the ureteral tissue was dose dependently reversed by the drugs with the following rank order of efficacy: SNP > Var >or= Sil > Tad > BSC. R(max) values ranged from 25 +/- 9% (SNP) to 5 +/- 3% (BSC). Relaxant responses were paralleled by threefold to fourfold increase in tissue levels of cGMP. Our results indicate that PDE5 inhibitors can reverse the tension of isolated human ureteral smooth muscle via cGMP-mediated pathways. Nevertheless, further studies are indicated in order to evaluate as to whether there might be a use for PDE5 inhibitors in the treatment of ureteral stone disease.

[Painless enlargement of the scrotum]

Painless swelling of the scrotum may be due either to an increase in bulk of the scrotal contents or to changes affecting the skin of the scrotum. The reliable and rapid differentiation of harmless from serious conditions such as cancer of the testicles, is essential.

Preliminary Results on the Off-Label Use of Duloxetine for the Treatment of Stress Incontinence after Radical Prostatectomy or Cystectomy

OBJECTIVES

Stress urinary incontinence (SUI) is a common compliant of patients after pelvic surgery. To date, no pharmacotherapy for men is available, but duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, has been successfully introduced and tested for SUI in women. The aim of our study was to evaluate if duloxetine is safe and effective for men with stress incontinence after radical prostatectomy or cystectomy.

METHODS

Twenty patients were included in our study, 15 after radical prostatectomy and 5 after radical cystectomy and orthotopic ileal neobladder reconstruction. Each patient reported at least 3 wk of SUI despite doing consequent pelvic floor exercises. After exclusion of a urinary tract infection, we administered 40 mg duloxetine twice daily for a mean of 9.4 wk (range: 1-35 wk).

RESULTS

After duloxetine, the average daily use of incontinence pads was lowered significantly (p < 0.001) from 8.0 (+/-6.5) to 4.2 (+/-5.9). Seven patients were completely dry or used one pad daily at most. Most patients reported mild side effects such as fatigue or a dry mouth, but these symptoms vanished after a short time. Six patients, however, had severe side effects, mainly massive fatigue or insomnia, and discontinued using duloxetine.

CONCLUSIONS

Our preliminary results suggest that duloxetine is effective in men with SUI after prostatectomy or cystectomy. Further prospective studies with more patients included and a longer follow-up are recommended.

High-level virtual reality simulator for endourologic procedures of lower urinary tract

OBJECTIVES

To analyze the limitations of existing simulators for urologic techniques, and then test and evaluate a novel virtual reality (VR) simulator for endourologic procedures of the lower urinary tract. Surgical simulation using VR has the potential to have a tremendous impact on surgical training, testing, and certification. Endourologic procedures seem to be an ideal target for VR systems.

METHODS

The URO-Trainer features genuine VR, obtained from digital video footage of more than 400 endourologic diagnostic and therapeutic procedures, as well as data from cross-sectional imaging. The software offers infinite random variations of the anatomy and pathologic features for diagnosis and surgical intervention. An advanced haptic force feedback is incorporated. Virtual cystoscopy and resection of bladder tumors were evaluated by 24 medical students and 12 residents at our department.

RESULTS

The system was assessed by more than 150 international urologists with varying experience at different conventions and workshops from March 2003 to September 2004. Because of these evaluations and constant evolutions, the final version provides a genuine representation of endourologic procedures. Objective data are generated by a tutoring system that has documented evident teaching benefits for medical students and residents in cystoscopy and treatment of bladder tumors.

CONCLUSIONS

The URO-Trainer represents the latest generation of endoscopy simulators. Authentic visual and haptic sensations, unlimited virtual cases, and an intelligent tutoring system make this modular system an important improvement in computer-based training and quality control in urology.

Benignes Prostatasyndrom (BPS)

Today, the surgical treatment of the benign prostatic syndrome (BPS) often follows a course of drug treatment. Besides conventional transurethral resection of the prostate (TURP), which has represented the standard therapeutic option for decades, and its in part significant modifications ("vaporizing resection"; bipolar resection), much of the interest has shifted to alternative instrumental procedures like transurethral microwave therapy (TUMT), transurethral needle ablation of the prostate (TUNA) or several laser techniques. By reviewing the current literature, preferably from randomized controlled trials, these different procedures are critically assessed. Moreover, the present role of open prostatectomy is discussed.

Techniques and long-term results of surgical procedures for BPH

OBJECTIVE

To provide an overview on the current status of the long-term outcomes of instrumental treatment options for patients with lower urinary tract symptoms that are suggestive of bladder outlet obstruction.

METHODS

Based on MEDLINE database searches, we performed a systematic review of the literature with a focus on peer-reviewed articles about surgical benign prostatic hyperplasia (BPH) therapy published between 2000 and 2005. Special emphasis was given to randomized controlled trials on long-term outcome with a minimum follow-up of five years.

RESULTS

Data on clinical outcome with a follow-up of more than 10 years are available for open prostatectomy (OP), transurethral resection of the prostate (TURP), and transurethral microwave therapy. Studies with a follow-up of at least five years are obtainable for transurethral incision of the prostate, transurethral vaporisation of the prostate, transurethral needle ablation of the prostate, Holmium:YAG laser enucleation of the prostate, potassium-titanyl-phosphate laser vaporization of the prostate, and interstitial laser coagulation of the prostate. Among these long-term reports, OP and TURP provide the most durable results.

CONCLUSIONS

The most substantial long-term data on surgical procedures for BPH are available for conventional therapy, namely TURP. Concerning the techniques that have emerged within the last decade, there is clear evidence that the outcomes are more sustainable for truly ablative and thus deobstructing procedures.