[Managing urinary incontinence in stroke rehabilitation--a review]

BACKGROUND

Urinary incontinence following stroke is an extensive problem for the patients and their relatives that influences the well-being and care in the future. There are a lot of therapeutic interventions available, their effectiveness, however, is not known in detail. For rehabilitation practice the ongoing question is how Urinary Incontinence (UI) can best be treated in a way that the patients daily life is not compromised.

METHOD

The search for clinical trials was carried out in PubMed, CINAHL, and Cochrane Library, restricted to German and English papers published between 1989 and April 2005. Medical, nursing and physiotherapeutic interventions for treating UI after stroke were described and analysed.

RESULTS

The clinical trials were divided into process-oriented trials and those looking at individual interventions. The process trials could be divided into three different groups with an overall success of 82-95 %, 50-56 % and 23-36 % respectively. Behavioral methods (caregiver-induced, patient-active and other interventions) and medical interventions are available. The studies of the most successful group include staff education and application of interventions based on an assessment procedure and a guideline. No clinical trial on individual interventions reached a result like the process-oriented studies.

CONCLUSION

For treating urinary incontinence a multimodal approach is necessary: special education of the nurses, applying and acting in a problem-solving process, for example in the Rehabilitation Cycle and delivering care based on an assessment procedure and guidelines. Development of a guideline for treating urinary incontinence after stroke can be recommended. Further research in the efficacy of individual interventions is needed.

A comparative review of extracorporeal shock wave generation

Shock waves are specific sound waves produced by shock-wave generators; the generators currently available have different physical properties and represent different technical solutions. The measurement of shock-wave pressure is necessary in laboratory settings to define the physical characteristics of a given shock-wave source. Under clinical conditions other variables, e.g. the stone-free rate or the percentage of complications, are used to describe the efficacy and safety of a lithotripter.

[Lymph node metastases in penis carcinoma. Therapeutic options and outcome]

Carcinoma of the penis is a malignant epithelial tumor of ominous prognosis if not adequately treated. To a large extent the probability of positive lymph nodes is determined by the grade of the primary lesion. In turn the number of positive nodes greatly influences the survival. In the past the complications of radical ilioinguinal lymphadenectomy have decreased their timely indication. If delayed lymphadenectomy is performed, the survival rate is reduced by approximately 50% as compared to the results of immediate lymphadenectomy. The modified inguinal lymphadenectomy described by Catalona leads to less complications. If performed without delay it should lead to improved survival in patients with higher stage and high grade penile cancer. Recently suggested employment of adjuvant and neoadjuvant chemotherapy may further enhance the survival.

[Extracorporeal shockwave lithotripsy today--an assessment of current status]

Extracorporeal shock wave lithotripsy (ESWL) is standard therapy for urolithiasis. With comparable technical principles, various lithotripters have been developed and are in routine use. Renal pelvic stones, calyceal stones, ureteral stones, and other special forms can be treated with varying results. Currently, the so-called clinically insignificant residual fragments and the recurrence of calculi are under discussion. Whereas the side effects of ESWL are well known, studies comparing ESWL with other endourological procedures are still lacking.

[Significance of "clinically insignificant residual fragments" (CIRF) after ESWL]

Almost 75% of all urinary calculi can be treated by extracorporeal shock wave lithotripsy (ESWL). In contrast to endoscopic and open-surgical procedures the patients are not immediately free of stones. The residual fragments after ESWL are called clinically insignificant residual fragments (CIRF), if the fragments are less than 5 mm in size and if there is the possibility of a spontaneous passage. But CIRF can cause ureteral obstruction. In addition, CIRF play an important role for the risk of stone growth and stone recurrence. The metaanalysis shows that it is not advisable to classify the CIRF only by their size. The morphological conditions of the urinary tract also have to be evaluated. Therefore, stone patients with CIRF after ESWL require a close follow-up and timely adjuvant therapy. All aspects mentioned lead to the conclusion to use the term "CIRF" with caution.

[Complications with portable ESWL--a multicenter study]

An increasing number of urological departments are taking advantage of portable lithotripsy units if a system is not available in their clinic or purchase does not seem feasible; however, infrequent application of ESWL in such a setting should not increase the rate of complications. From 1993 to 1995, up to 54 urological departments using mobile lithotripsy units collected data concerning all major complications. A total of 12,901 treatments were performed which led to 85 major complications (0.66%). Of them 64 were intrarenal or perirenal hematomas. There was no fatal complication. In three patients nephrectomy had to be performed subsequently. The probability of complications can be calculated according to these data. Overall, less frequent application of ESWL does not yield higher complication rates than those at ESWL centers where larger numbers of treatments are performed.

Effects of extracorporeal shock wave lithotripsy on plasma concentrations of endothelin and renin in humans

PURPOSE

There is ongoing controversy regarding blood pressure changes after extracorporeal shock wave lithotripsy (ESWL*). Experimental data suggest a role for renin but only few data are relevant to humans. It has been shown that renin secretion is stimulated by endothelin, a recently discovered peptide with strong vasoconstrictive properties and stimulating effects on renin secretion. Endothelin is relevant in the development of hypertension and acute renal failure.

MATERIALS AND METHODS

In a prospective study of 48 normotensive patients undergoing ESWL for renal stones the influence of high energy shock waves on plasma endothelin and active renin was analyzed. These substances are secreted by renal cells in response to hemodynamic alterations, and inflammatory and traumatic processes. Peripheral blood samples were analyzed for active renin and endothelin before, and immediately, 1, 3 and 5 days after ESWL. Blood pressure was measured before, and 1, 3 and 5 days after ESWL.

RESULTS

Only a slight and transient increase was noted in active renin, which was in the same range as that found after mental stress. Endothelin and blood pressure were not significantly influenced by ESWL. There was no correlation between endothelin and active renin. Thus, the increase in active renin was not mediated by endothelin.

CONCLUSIONS

The transient increase in active renin cannot be attributed to the development of hypertension. The lack of influence of ESWL on endothelin indicates that ESWL, at least in the routine clinical setting, does not cause severe renal trauma.

Combined endoscopic closure of rectourethral fistula

PURPOSE

Rectourethral fistula formation is a rare complication of radical prostatectomy and other pelvic surgical procedures.

MATERIALS AND METHODS

In 2 patients endoscopic closure of the fistula was performed by combined transrectal endoscopic excision of the fistula, endoscopic suture, and simultaneous transurethral fulguration and fibrin application.

RESULTS

This combined approach resulted in closure of the fistula in both patients as proved by rectoscopy, retrograde urethrography and disappearance of all clinical symptoms. The latest postoperative followup was 18 months.

CONCLUSIONS

Any open procedure to correct a rectourethral fistula is considered major surgery. Therefore, the minimally invasive approach described should be attempted first in patients with a small rectourethral fistula.

[Painless ESWL by cutaneous administration of Vaseline]

In a prospective clinical study we investigated how effective cutaneous Vaseline application was in pain reduction during ESWL. In 150 patients (group 1) Vaseline was applied on a skin area corresponding to the entry site of shockwaves directly before lithotripsy; in 75 patients (group 2) ESWL was performed without Vaseline. Analgesic sedation was needed by 10/150 (6.7%) in group 1 and 27/75 (36.4%) in group 2 (P < 0.001). The median pain score in group 1 was 2.5 +/- 1.05 and that in group 2 was 4.25 +/- 1.13 (P < 0.05). Local Vaseline application significantly reduces pain during ESWL independent of stone location. Most pain results from cavitation at the skin surface and is blocked by Vaseline. Cutaneous Vaseline application to reduce the need for analgesic sedation might be especially useful in outpatient ESWL procedures.

Painless ESWL by cutaneous application of vaseline

In a prospective study we investigated the efficacy of cutaneous vaseline application in pain reduction during ESWL. In 150 patients (group 1) vaseline was applied on a skin area of 10 x 20 cm corresponding to the entry site of shock waves directly before ESWL was started. In 75 patients (group 2) ESWL was performed without vaseline. 10/150 (6.7%) in group 1 and 27/75 (36.4%) in group 2 (p < 0.001) needed additional analgesic sedation. Requirement for supplementary analgosedation was most pronounced for patients with lower calyceal and distal ureteral stones [20% and 19% in group 1; 53% and 78% in group 2 (p < 0.03)]. The median pain score in group 1 was 2.5 +/- 1.05, in group 2 4.25 +/- 1.13 (p < 0.05). Local vaseline application significantly reduced pain during ESWL independent from stone location. Because of its high viscosity vaseline inhibited the development of cavitation bubbles at the skin surface. Cutaneous vaseline application reducing the need for analgesic sedation might especially be useful in outpatient ESWL procedures.

A conservative approach to bilateral testicular germ cell tumors

We report on 6 patients with bilateral testicular germ cell tumors treated by organ sparing surgery. Tumors 6 to 30 mm. in diameter were enucleated, and biopsies of the tumor bed and peripheral parenchyma were taken. Histological examination revealed seminoma in 4 cases, embryonal carcinoma in 1 and a Leydig cell tumor in 1. All patients underwent testicular radiation therapy with 20 Gy. for carcinoma in situ. A testicular biopsy was performed 6 months postoperatively to evaluate therapeutic success. Median followup was 43 months, all patients were free of disease and there was no local recurrence. Luteinizing hormone and testosterone were within the normal range and no androgen substitution was necessary. Our study suggests that organ sparing surgery for bilateral testicular germ cell tumors represents a new therapeutic approach with endocrinological and psychological advantages. In our experience conservative surgery is possible under certain prerequisites, including organ confined tumor without infiltration of the rete testis, obtaining multiple biopsies of the tumor bed and peripheral parenchyma, associated carcinoma in situ treated by radiation therapy and close followup of patients.

[Current status of extracorporeal shockwave lithotripsy]

Extracorporeal shockwave lithotripsy has become an established standard procedure for the treatment of nephrolithiasis. Almost 100 lithotripters are installed in large and medium-sized urological departments in Germany. The number of treatments per year averages 660 ESWL sessions per hospital. Multifunctional use and non-urological ESWL therapy ensure maximum utilization of the lithotripter units. In additional hospitals mobile lithotripsy is provided. At present there is a trend toward ambulatory ESWL treatment.

Verapamil limits shockwave-induced renal tubular damage in vivo

Previous investigations on Madin Darby Canine Kidney (MDCK) cells demonstrated the protective effect of verapamil against shockwave-induced tubular dysfunction. In the present study, we investigated whether verapamil is also protective against shockwave-induced damage in vivo. Male rates were randomly assigned to three groups: verapamil (N = 18) (Group I), control (N = 18) (Group II), or sham treatment (N = 4) (Group III). Groups I and II were treated with 500 shockwaves to each kidney with the Dornier MFL 5000 at 18 kV. Animals assigned to Group III received only anesthesics. Verapamil was given to the animals in Group I for 5 days starting 1 day before shockwave exposure. Urine was collected for 8 hours the day before and immediately, 1.7, and 28 days after shockwave exposure (SWE) for measurement of volume, osmolality, hemoglobin, protein, N-acetyl-beta-glucosaminidase (NAG), beta 2-microglobulin (beta 2M), sodium, and creatinine. Kidneys were perfused and removed for histologic study 1, 7, and 28 days after SWE in six animals of Groups I and II. Blood was taken in these rats (Day 1 after SWE) for the determination of creatinine and sodium and the calculation of the creatinine clearance (CCr) and the fractional excretion of sodium (FENa). After SWE, there was strong diuresis and significantly increased excretion of NAG and beta 2M in the controls, while urine osmolality decreased. These changes were significantly less pronounced in the verapamil-treated rats. The CCr was higher and FENa lower than in the latter group.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound in the evaluation of urethral stricture disease: a prospective study in 175 patients

OBJECTIVE

To investigate the characteristic ultrasonic appearance of urethral stricture disease in men.

PATIENTS AND METHODS

Between 1990 and 1992 a prospective study in 175 men with the suspicion of urethral stricture was performed using urethral ultrasound as the first diagnostic procedure, followed by retrograde urethrography, voiding cystourethrography or urethroscopy.

RESULTS

The sensitivity and specificity in detecting urethral strictures were 98% and 96% respectively. Ultrasound offers a three-dimensional study in the evaluation of the urethra without exposing the gonads to ionizing radiation. The exact length and depth of the stricture, the severity of the strictured segment as well as the anatomy of the periurethral scars were diagnosed accurately.

CONCLUSION

Ultrasound is a simple, inexpensive and rapid investigation of the urethra which requires no exposure of the patient to ionizing radiation and should be the preferred diagnostic procedure in the evaluation of strictures in the anterior urethra in men.

Risk factors for antisperm antibodies in infertile men

PROBLEM

The prevalence of anti-sperm antibodies (ASAs) in the general population is 0 to 2%; the prevalence in infertile men is much higher at 7 to 26%. However, the role of ASAs in male infertility remains controversial to date. Although several risk factors for ASA development have been defined (such as testicular torsion, varicocele, cryptorchidism, vasectomy, and genital tract infection), there are no specific indications for ASA testing.

METHOD

In order to examine if a single parameter exists identifying patients with elevated ASA titers, serum ASA testing was performed with an enzyme-linked immunosorbent assay (ELISA) in 226 consecutive male patients. The new assay, synchron ELISA (Synelisa) used in our study represents a new type of ELISA without fixation of the sperm surface antigens by formaldehyde or glutaraldehyde. Therefore, the quantitative assay is highly sensitive and reproducible since the structure of sperm surface antigens is not altered by the fixation process.

CONCLUSIONS

The prevalence of ASAs in this population was 14%, while the prevalence of the control group was 2.5%. Of all factors analyzed only a history of vasectomy, an acute epididymitis, and an abnormal result in the bovine mucus penetration test was associated with elevated ASA titers (P < .001). In addition, we could demonstrate a time related formation of ASAs in men after vasectomy.

Limitation of shock-wave-induced renal tubular dysfunction by nifedipine

In a prospective randomized study, the effects of the calcium entry blocker nifedipine on shock-wave-induced tubular impairment were studied. 24 patients with renal pelvic or calyceal stones undergoing anesthesia-free extra-corporeal shock wave lithotripsy (ESWL) without ancillary measures were randomly assigned to the nifedipine group (n = 12) or the control group (n = 12). Four doses of nifedipine (10 mg t.i.d.) were given orally, starting the night before ESWL. Controls received no medication. To assess renal tubular function, the urinary excretion of alpha 1-microglobulin (A1M), N-acetyl-beta-glucosaminidase (NAG) and Tamm-Horsfall protein (THP) were measured before, immediately, 12 and 24 h after ESWL. After lithotripsy, there was a rise in urinary A1M and NAG which was significantly higher in the control than in the nifedipine group. THP, a glycoprotein synthesized by distal tubular cells, fell significantly less in the nifedipine group compared to the controls. Our results indicate that nifedipine exhibits a protective effect on shock-wave-induced tubular damage similar to verapamil. The underlying mechanisms are not clarified yet, direct actions on tubular cells and interference with renal hemodynamics have to be discussed.

Protective effect of verapamil on shock wave induced renal tubular dysfunction

In a prospective randomized study, the effects of the calcium entry blocker verapamil on shock wave induced tubular impairment were examined. A total of 24 patients with renal pelvis or caliceal stones undergoing anesthesia-free extracorporeal shock wave lithotripsy (ESWL*) without auxiliary measures was randomly assigned to the verapamil group (12) or the control group (12). Four doses of verapamil (80 mg. each) were given orally starting the night before ESWL. Controls received no medication. To assess renal tubular function the urinary excretion of alpha 1-microglobulin, N-acetyl-beta-glucosaminidase and Tamm-Horsfall protein were determined before, immediately, and 12 and 24 hours after ESWL. After ESWL there was an increase in urinary alpha 1-microglobulin and N-acetyl-beta-glucosaminidase, which was significantly higher in the control than in the verapamil group. Tamm-Horsfall protein, a glycoprotein synthesized by the distal tubules, decreased significantly less in the verapamil group compared to the controls. Our results indicate that verapamil exhibits a protective effect on shock wave induced tubular damage. The underlying mechanisms are not elucidated yet, and direct actions on tubular cells and interference with renal hemodynamics are to be discussed.

Evaluation of the acute scrotum by color-coded Doppler ultrasonography

Color-coded Doppler ultrasonography is a combination of real-time sonography and duplex sonography for noninvasive imaging of arterial and venous blood vessels. In 40 patients with acute onset of scrotal pain this diagnostic procedure was correlated with the findings at surgical exploration: 11 had testicular torsion, 4 hydatid torsion, 13 spontaneous detorsion, 2 blunt scrotal trauma and 10 epididymitis. For testicular torsion color-coded Doppler ultrasonography had a sensitivity of 82% and a specificity of 100%, and for epididymitis the sensitivity was 70% and specificity was 88%. Color-coded ultrasonography readily demonstrates testicular perfusion. In cases of incomplete or early torsion some residual perfusion may be detected leading to false-negative results. Despite this fact, color-coded Doppler ultrasonography currently is the most valuable diagnostic modality in the evaluation of the acute scrotum.

Influence of transrectal hyperthermia on prostate-specific antigen in prostatic cancer and benign prostatic hyperplasia

The prostate-specific antigen (PSA) is a glycoprotein synthesized exclusively by the prostate. Since manipulations on the prostate can increase PSA serum levels, we investigated the effects of transrectal hyperthermia on PSA levels in prostate cancer (PC) and benign prostatic hyperplasia (BPH). Patients and treatments were the following: group 1a, PC St.D (n = 12): 8 hyperthermia sessions (twice a week) and LHRH-agonists plus flutamide; group 1b, PC St.D (hormone resistant; n = 10): 8 hyperthermia sessions (once a week) and epirubicin (50 mg intravenously, once a week); group 1c, PC St.C (n = 5): 6 hyperthermia sessions (once a week) and radiotherapy (60 Gy); group 2, BPH (n = 10): 8 sessions (twice a week). PSA levels were determined before, during (immediately before each hyperthermia session) and 1 week after therapy. Apart from hormone-/hyperthermia-treated patients, who showed a continuous decrease in PSA during therapy, all the other groups revealed a transient increase in PSA during the hyperthermia treatment. This effect is attributed to manipulations on the prostate and hyperthermia-specific effects on prostatic cells. The decrease in PSA on hormone/hyperthermia therapy can be explained by the tremendous effect of androgen deprivation on PSA levels overshadowing the hyperthermia effect.

[Local hyperthermia in prostate cancer]

We conducted a clinical trial evaluating the effects of hyperthermia in patients with carcinoma of the prostate, treating 20 patients with newly diagnosed carcinoma of the prostate with local microwave hyperthermia (915 MHz). Histological examination revealed hypoeremic effects and diffuse oedema with interstitial lymphoplasmatic cellular infiltration. However, necrotic tumour cells were not found in any of specimens. A second series consisted of 10 patients with metastasizing carcinoma of the prostate (n = 4 untreated; n = 6 hormone-resistant). For 8 weeks, epirubicin was administered once weekly, followed each time by local microwave hyperthermia 1 h later. The efficacy was evaluated according to the EORTC criteria. In 4 patients with untreated carcinoma no change was found in the size of the prostate or metastases. In 3 of the 6 patients with hormone-resistant carcinoma progressive disease was found, while the other 3 had stable disease. Only in 2 of the 10 patients did the grading of tumour regression reveal any improvement. Cytophotometric studies showed no change of DNA ploidy. Currently we consider hyperthermia unsuitable as monotherapy for carcinoma of the prostate, and the combination of epirubicin and hyperthermia is no more favourable than monotherapy with epirubicin alone. Further studies are necessary to evaluate other cytotoxic regimens and various patterns of application for hyperthermia.

Angiodynography (color-coded duplex sonography) in the evaluation of vasculogenic impotence

The penile arteries of 18 men with erectile dysfunction were examined by angiodynography (color-coded duplex sonography). Blood flow velocity was measured before and after intracavernous injection of papaverine/phentolamine. The angiodynographic findings were compared to arteriography. Normal values of peak flow velocity (after injection) were obtained from 6 men with normal arteriographic findings (deep artery greater than 25 cm/s, superficial artery greater than 30 cm/s). Angiodynography enables good imaging of the four penile arteries superior to duplex sonography. A strong correlation with the arteriographic findings could be found. Thus noninvasive angiodynography may replace penile arteriography for the routine evaluation of impotence.

Local microwave hyperthermia of benign prostatic hyperplasia

Recently, hyperthermia has been used for treatment of benign prostatic hyperplasia. The preliminary results reported were promising. However, apart from patients with total urinary retention, objective voiding parameters have not been reported in detail for patients with prostatism. In a phase II study we treated 30 patients with benign prostatic hyperplasia by local microwave hyperthermia (915 MHz.). The prostate was heated transrectally to 42 to 43C, with the treatment consisting of 8 sessions of 60 minutes each given twice a week. To assess the results of treatment several parameters were determined before and 4 weeks after hyperthermia therapy, including transrectal ultrasound of the prostate with volumetry, urinary flow rate and residual volume. Of the patients 28 could be evaluated and only 2 showed a relevant improvement. Neither the voiding parameters nor the size of the prostate could be changed significantly by hyperthermia. The success rate of 7.1% is even lower than the spontaneous temporary regression rate of benign prostatic hyperplasia. Thus, we believe that hyperthermia cannot be regarded as an effective treatment for benign prostatic hyperplasia comparable to transurethral resection.

Alveolar echinococcosis with involvement of the ureter and testis

Alveolar echinococcosis is a rare disease of the liver, and occasionally of the lungs and brain, that is endemic across areas of Central Europe, the Soviet Union and Alaska. We describe a case of alveolar echinococcosis with involvement of the ureter and testis overshadowing the liver manifestation. The unusual presentation and nondemonstrable exposure to the organism caused misinterpretation of the histological findings and an initial misdiagnosis of tuberculosis.

Damaging effects of high energy shock waves on cultured Madin Darby canine kidney (MDCK) cells

Shock wave lithotripsy (ESWL) has become an almost non-invasive standard treatment modality for urolithiasis. Several investigations, however, demonstrated that ESWL is not completely free of side effects. Among others alteration of renal tubular function has been reported. To study the effect of shock waves on tubular cells directly an in-vitro model with cultured Madin Darby Canine Kidney (MDCK) cells was established. Suspensions of MDCK cells (7 groups of 6 containers each) were exposed to 0, 16, 32, 64, 128, 256 shock waves (Dornier HM4, 18 kV). Before and 0, 1, 3, 6, 9, 12, 24 h after ESWL the following parameters were measured in the nutrient medium: lactate dehydroxygenase (LDH), glutamate oxalacetate transaminase (GOT), electrolytes. LDH and GOT increased depending on the number of shock waves indicating a membrane damage of MDCK cells. The MDCK model seems suitable for further studies on the effect of shock waves on renal tubular cells.

[Therapy of interstitial and radiogenic cystitis with D-glucosamine]

Twelve patients with interstitial or radiation cystitis were treated by D-glucosamine, a precursor of glycosaminoglycans. D-glucosamine was given for 3 months (500 mg t.i.d. orally). Urinary glycosaminoglycans which were low before the treatment could be increased significantly by D-glucosamine. Endoscopic findings and subjective symptoms could be markedly improved. D-glucosamine may be a new treatment modality in interstitial and radiation cystitis.

Tumor volume, CT scan, lymphography, sonography, intravenous pyelography, and tumor markers in testis tumors

Correlation of tumor volume to tumor stage in 134 patients with nonseminomatous testicular tumors, which were classified according to the TNM system, revealed similar tumor load for N0 and N1 patients. CT scans (n = 92), lymphangiography (n = 47), intravenous pyelography (IVP) (n = 134), sonography (n = 118) and serial tumor markers (n = 82) were evaluated for sensitivity, specificity and accuracy, both separately and in different combinations. The best individual results were obtained by lymphangiography (sensitivity 0.77, specificity 0.73, accuracy 0.75) and CT scan (sensitivity 0.52, specificity 0.91, accuracy 0.70). In combination CT scan and lymphangiography were the most valuable diagnostic tools (accuracy 0.79) with high sensitivity (0.88) and specificity (0.77). For patients with negative CT scans, subsequent lymphangiography is recommended for accurate staging, as seems mandatory in stage 1 patients entering surveillance programs.

Treatment of paediatric urolithiasis by extracorporeal shock-wave lithotripsy

Non-surgical removal of renal and ureteral stones has proven successful in adults. In this study, 21 paediatric patients have been treated with the first generation extracorporeal shock-wave lithotriptor and an additional 13 children with a second generation local shock-wave lithotriptor. A total of 47 stones was treated. Treatment-related complications such as colics (17%/18.8%) or fever (8.3%/6.2%) were minimal. Stone passage occurred in 93% and 100%, respectively of each group. Open surgery is still the treatment of choice for large staghorn calculi. Extracorporeal shock-wave lithotripsy can be performed successfully in paediatric nephrolithiasis with stones of limited size.

Local shock-wave lithotripsy of distal ureteral calculi

Since the initiation of the clinical trial utilizing a second-generation lithotripor (Lithostar, Siemens, Erlangen, FRG), 96 patients with distal ureteral calculi (i.e. calculi below the pelvic brim) underwent local shock-wave lithotripsy. Routine treatment was conducted under intravenous sedation and light analgesia only. Complete stone disintegration was achieved in 84 patients (87.5%), 11 requiring two sessions and 1 patient, three. In 7 patients ureteroscopy became necessary after unsuccessful local shock-wave treatment. In 2 of these patients a 9-french flexible ureteroscope and the Storz Q-switched neodymium-YAG laser was used for stone disintegration. In 3 cases loop extraction and in 2 cases open surgery had to be performed for definitive stone removal. All pre- and postoperative manipulations (except open surgery) were done on the Lithostar. Local shock-wave lithotripsy is a highly successful, noninvasive, time-saving and easily applicable technique. It has become our primary approach in the treatment of distal ureteral calculi.

[Extracorporeal shockwave lithotripsy of the ureteral calculus--clinical results with local shockwave lithotripsy]

Second generation local shockwave lithotripsy appliances (Lithostar) were used for the treatment of upper and lower ureteral stones in 199 patients, 145 of whom had upper ureteral stones. In 78 patients the calculi were pushed back and all but one disintegrated. In 33 patients a catheter was inserted past the stone, which resulted of primary disintegration in 66%. In 19 of 34 patients (56%) in whom the stones could not be moved, primary disintegration was achieved. Distal ureteral stones were present in 54 patients and these were treated successfully by ESWL alone in 83.3%. Auxiliary measures (total 10%) included ureteroscopy, percutaneous extraction and ureterolithotomy. The results are discussed under the aspects of 'in situ' versus 'push-and-smash' procedures.

New generation shock wave lithotripsy

Extracorporeal shock wave lithotripsy has been clinically successful for more than 5 years. Currently, several devices commonly termed second generation lithotriptors are under experimental or clinical trials. We present a prototype multifunctional urological table that uses a new mode of shock wave generation along with local coupling to the patient. The results of the first 400 treatments are presented after a brief description of pre-clinical experiments. The prototype has been in operation since March 1986. Particular attention is paid to adjuvant endourological measures, which all have been performed on the same table.

Characterization of the cytosol androgen receptor of the human prostate

Direct measurement of the binding of endogenous androgens to the androgen receptor of human tissues has not been possible because of contamination of tissue with traces of plasma proteins, such as testosterone-binding globulin (TeBG), that contain more androgen-binding capacity than does the receptor itself. Molybdate is known to stabilize the 8-9S forms of other steroid hormone receptors. We took advantage of this phenomenon to characterize the androgen receptor of hyperplastic prostates removed at surgery, using sucrose density gradient centrifugation in a vertical rotor. In 10 mM sodium molybdate, the androgen receptor sediments as a distinct 9.2 +/- 0.5S moiety, easily separable from TeBG. Unlike TeBG, the 9S receptor is not removed by absorption with Concanavalin A. [3H]Dihydrotestosterone (3H-labeled 17 beta-hydroxy-5-alpha-androstan-3-one) binding to the 9S receptor is not removed by absorption with Concanavalin A. [3H]Dihydrotestosterone (3H-labeled 17 beta-hydroxy-5 alpha-androstan-3-one) binding to the 9S receptor is not competed for by excess triamcinolone acetonide (9 alpha-fluoro-11 beta, 16 alpha, 17 alpha, 21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetonide) or promegestone (17,21-dimethyl-19-non-pregna-4,9-diene-3,-20-dione), which are known to bind to the progestin receptor. In contrast, [3H]methyltrienolone (3H-labeled 17 beta-hydroxy-17 alpha-methyl-estra-4,9,11-trien-3-one) binds to both androgen and progestin receptors, and consequently, the binding of this ligand to the androgen receptor was assessed in the presence of a 500-fold excess of triamcinolone acetonide. The amounts of 9S binding (7.8 and 5.8 fmol/mg protein) are similar for dihydrotestosterone and methyltrienolone. The amount of 9S binding of testosterone to the receptor was also similar to that of dihydrotestosterone, but the affinity of testosterone for the 9S receptor was only a fifth or less of that for dihydrotestosterone. The observation that testosterone binds less avidly than dihydrotestosterone to the receptor may explain the role of dihydrotestosterone formation in androgen physiology.