Trends and outcomes of hospitalized patients with priapism in Germany: results from the GRAND study

We aimed to provide evidence on the trends and in-hospital outcomes of patients with low- and high-flow priapism through the largest study in the field. We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2008-2021), and performed multiple patient-level analyses. We included 6,588 men with low-flow and 729 with high-flow priapism. Among patients with low-flow priapism, 156 (2.4%) suffered from sickle cell disease, and 1,477 (22.4%) patients required shunt surgery. Of them, only 37 (2.5%) received a concomitant penile prosthesis implantation (30 inflatable and 7 semi-rigid prosthesis). In Germany, the total number of patients with low-flow priapism requiring hospital stay has steadily increased, while the number of patients with high-flow priapism requiring hospital stay has decreased in the last years. Among patients with high-flow priapism, 136 (18.7%) required selective artery embolization. In men with low-flow priapism, sickle cell disease was associated with high rates of exchange transfusion (OR: 21, 95% CI: 14-31, p < 0.001). The length of hospital stay (p = 0.06) and the intensive care unit admissions (p = 0.9) did not differ between patients with low-flow priapism due to sickle cell disease versus other causes of low-flow priapism. Accordingly, in men with high-flow priapism, embolization was not associated with worse outcomes in terms of length of hospital stay (p > 0.9), transfusion (p = 0.8), and intensive care unit admission (p = 0.5). Low-flow priapism is an absolute emergency that requires shunt surgery in more than one-fifth of all patients requiring hospital stay. On the contrary, high-flow priapism is still managed, in most cases, conservatively.

Perioperative outcomes of penile prosthesis implantation in Germany: results from the GRAND study

We aimed to assess the recommended annual hospital volume for inflatable penile prosthesis implantation (PPI) and to provide evidence on perioperative outcomes of semi-rigid and inflatable PPI in Germany. We used the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021 and report the largest study to date with 7,222 patients. 6,818 (94.4%) patients underwent inflatable and 404 (5.6%) semi-rigid PPI. Inflatable PPI was significantly associated with shorter length of hospital stay (difference of 2.2 days, 95%CI: 1.6-2.7, p < 0.001), lower odds of perioperative urinary tract infections (5.5% versus 9.2%; OR: 0.58, 95%CI: 0.41-0.84, p = 0.003) and surgical wound infections (1% versus 2.5%; OR: 0.42, 95%CI: 0.22-0.88, p = 0.012) compared to semi-rigid PPI. Overall, 4255 (62.4%) inflatable PPIs were undertaken in low- ( < 20 PPI/year) and 2563 (37.6%) in high-volume ( ≥ 20 PPI/year) centers. High-volume centers were significantly associated with shorter length of hospital stay (difference of 1.4 days, 95%CI: 1.2-1.7, p < 0.001) compared to low-volume centers. Our findings suggest that inflatable PPI leads to a shorter length of hospital stay and lower rates of perioperative urinary tract and surgical wound infections compared to semi-rigid PPI. Patients undergoing surgery in high-volume centers for inflatable PPI are discharged earlier from the hospital.

Is cortisol an endogenous mediator of erectile dysfunction in the adult male?

Background

It has been speculated for decades whether there is a significance of the adrenal corticosteroid cortisol in the process of male sexual function, including the control of sexual arousal and penile erection. In order to investigate further the role of the adrenocorticotropic axis in the physiological process of penile erection, we aimed to determine the course of cortisol in the cavernous and systemic blood through different stages of sexual arousal in patients suffering from erectile dysfunction (ED) in comparison to a cohort of healthy males.

Methods

Fifty-four healthy adult males and 45 patients with ED were presented sexually explicit visual material in order to elicit tumescence and (in the healthy males) rigid erection. Blood was collected from the cavernous space (corpus cavernosum penis, CC) and a cubital vein (CV) at different stages of the sexual arousal cycle as indicated by the penile stages flaccidity, tumescence, rigidity (attained only by the healthy males) and detumescence. Cortisol (µg/dL serum) was measured using a radioimmunometric assay (RIA).

Results

In healthy males, cortisol decreased in both the cavernous and systemic blood with the beginning of sexual stimulation (CV: 15 to 13, CC: 16 to 13). At detumescence, in the systemic circulation, no alterations in cortisol levels were registered, whereas it decreased further in the CC (to 12). In the ED patients, no significant changes in cortisol were noticed in the systemic and cavernous blood.

Conclusions

The findings indicate that cortisol might act as an antagonist of the normal sexual response cycle of the adult male. A dysregulation of the secretion and/or degradation of the hormone might well play a role in the manifestation of ED.

Optical analysis of glutamate spread in the neuropil

Fast synaptic communication uses diffusible transmitters whose spread is limited by uptake mechanisms. However, on the submicron-scale, the distance between two synapses, the extent of glutamate spread has so far remained difficult to measure. Here, we show that quantal glutamate release from individual hippocampal synapses activates extracellular iGluSnFr molecules at a distance of >1.5 μm. 2P-glutamate uncaging near spines further showed that alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-Rs and N-methyl-D-aspartate (NMDA)-Rs respond to distant uncaging spots at approximately 800 and 2000 nm, respectively, when releasing the amount of glutamate contained in approximately five synaptic vesicles. The uncaging-induced remote activation of AMPA-Rs was facilitated by blocking glutamate transporters but only modestly decreased by elevating the recording temperature. When mimicking release from neighboring synapses by three simultaneous uncaging spots in the microenvironment of a spine, AMPA-R-mediated responses increased supra-additively. Interfering with extracellular glutamate diffusion through a glutamate scavenger system weakly reduced field synaptic responses but not the quantal amplitude. Together, our data suggest that the neuropil is more permissive to short-range spread of transmitter than suggested by theory, that multivesicular release could regularly coactivate nearest neighbor synapses and that on this scale glutamate buffering by transporters primarily limits the spread of transmitter and allows for cooperative glutamate signaling in extracellular microdomains.

Impact of antiangiogenic treatment on the erectile function in patients with advanced renal cell carcinoma

We longitudinally assessed erectile function as well as the willingness to use pro-erectile treatment in a cohort on AAT for advanced RCC. Thirty-seven patients with advanced RCC completed the five-item version of the International Index of Erectile Function (IIEF-5) and other interview items before (T0) and 12 weeks into therapy (T12) with AAT. Patients were further asked if they were willing to use and pay out-of-pocket for on-demand treatment with phosphodiesterase-5-inhibitors (PDE-5i). Statistical analysis was performed using nonparametric hypothesis testing. The IIEF-5 score at T12 was significantly decreased compared with T0 (p < .001). Subjective patient satisfaction regarding their sexual lives was associated with higher IIEF-5 scores at both time points (p = .006 and p = .03, respectively). At T12, subjective sexual contentment showed a nonsignificant trend towards decline (p = .074). Patients who opted for medical treatment of ED showed significantly better IIEF-5 scores at both time points compared with the rest of the cohort (p < .001 and p = .005, respectively). In summary, AAT seems to have a negative effect on erectile function in RCC patients, however, the role of psychosocial issues warrants further elucidation. Affected patients may benefit from a proactive approach promoting medical treatment of erectile dysfunction during AAT.

The Use of Vasoactive Drugs in the Treatment of Male Erectile Dysfunction: Current Concepts

It is widely accepted that disorders of the male (uro)genital tract, such as erectile dysfunction (ED) and benign diseases of the prostate (lower urinary tract symptomatology or benign prostatic hyperplasia), can be approached therapeutically by influencing the function of both the vascular and non-vascular smooth muscle of the penile erectile tissue or the transition zone/periurethral region of the prostate, respectively. As a result of the discovery of nitric oxide (NO) and cyclic guanosine monophosphate (GMP) as central mediators of penile smooth muscle relaxation, the use of drugs known to increase the local production of NO and/or elevate the intracellular level of the second messenger cyclic GMP have attracted broad attention in the treatment of ED of various etiologies. Specifically, the introduction of vasoactive drugs, including orally active inhibitors of the cyclic GMP-specific phosphodiesterase (PDE) 5, has offered great advantage in the pharmacotherapy of ED and other diseases of the genitourinary tract. These drugs have been proven efficacious with a fast on-set of action and an improved profile of side-effects. This review summarizes current strategies for the treatment of ED utilizing the application of vasoactive drugs via the oral, transurethral, topical, or self-injection route.

Volumetry of Mesiotemporal Structures Reflects Serostatus in Patients with Limbic Encephalitis

BACKGROUND AND PURPOSE

Limbic encephalitis is an autoimmune disease. A variety of autoantibodies have been associated with different subtypes of limbic encephalitis, whereas its MR imaging signature is uniformly characterized by mesiotemporal abnormalities across subtypes. Here, we hypothesized that patients with limbic encephalitis would show subtype-specific mesiotemporal structural correlates, which could be classified by supervised machine learning on an individual level.

MATERIALS AND METHODS

T1WI MPRAGE scans from 46 patients with antibodies against glutamic acid decarboxylase and 34 patients with antibodies against the voltage-gated potassium channel complex (including 10 patients with leucine-rich glioma-inactivated 1 autoantibodies) and 48 healthy controls were retrospectively ascertained. Parcellation of the amygdala, hippocampus, and hippocampal subfields was performed using FreeSurfer. Volumes were extracted and compared between groups using unpaired, 2-tailed t tests. The volumes of hippocampal subfields were analyzed using a multivariate linear model and a binary decision tree classifier.

RESULTS

Temporomesial volume alterations were most pronounced in an early stage and in the affected hemispheric side of patients. Statistical analysis revealed antibody-specific hippocampal fingerprints with a higher volume of CA1 in patients with glutamic acid decarboxylase-associated limbic encephalitis (P = .02), compared with controls, whereas CA1 did not differ from that in controls in patients with voltage-gated potassium channel complex autoantibodies. The classifier could successfully distinguish between patients with autoantibodies against leucine-rich glioma-inactivated 1 and glutamic acid decarboxylase with a specificity of 87% and a sensitivity of 80%.

CONCLUSIONS

Our results suggest stage-, side- and antibody-specific structural correlates of limbic encephalitis; thus, they create a perspective toward an MR imaging-based diagnosis.

Effects of Flow Disruptions on Mental Workload and Surgical Performance in Robotic-Assisted Surgery

BACKGROUND

Robotic systems introduced new surgical and technical demands. Surgical flow disruptions are critical for maintaining operating room (OR) teamwork and patient safety. Specifically for robotic surgery, effects of intra-operative disruptive events for OR professionals' workload, stress, and performance have not been investigated yet. This study aimed to identify flow disruptions and assess their association with mental workload and performance during robotic-assisted surgery.

METHODS

Structured expert-observations to identify different disruption types during 40 robotic-assisted radical prostatectomies were conducted. Additionally, 216 postoperative reports on mental workload (mental demands, situational stress, and distractions) and performance of all OR professionals were collected.

RESULTS

On average 15.8 flow disruptions per hour were observed with the highest rate after abdominal insufflation and before console time. People entering the OR caused most flow disruptions. Disruptions due to equipment showed the highest severity of interruption. Workload significantly correlated with severity of disruptions due to coordination and communication.

CONCLUSIONS

Flow disruptions occur frequently and are associated with increased workload. Therefore, strategies are needed to manage disruptions to maintain OR teamwork and safety during robotic-assisted surgery.

Course of transforming growth factor ß1 in the systemic and cavernous blood of healthy males through different penile conditions

Studies on erectile dysfunction (ED) have revealed a relationship between smooth muscle atrophy and the accumulation of collagen in the corpus cavernosum (CC). Transforming growth factor ß1 (TGF ß1) is a cytokine which has been proposed to be involved in the fibrotic process in the CC. We aimed to evaluate the course of TGF ß1 in the systemic and cavernous blood of 17 healthy males through different phases of the sexual arousal response (exemplified by the penile conditions flaccidity, tumescence, rigidity and detumescence). An enzyme-linked immunoassay was used to measure the concentration of TGF ß1 (ng/ml) in both the systemic and cavernous blood at the stages of flaccidity, tumescence and detumescence. TGF levels were significantly higher in the cavernous compartment than in the systemic blood. A linear decrease was evident in the cavernous blood when the flaccid penis became tumescent (24.3 ± 14.5 to 13.9 ± 6.5) and rigid (to 8.7 ± 3.1). At detumescence, TGF increased to 18.3 ± 10.4. In contrast, the levels in the systemic circulation remained unchanged. The results are in support of the hypothesis that the concentration of TGF ß1 in the CC is regulated by adequate blood flow and oxygenation.

Seizure control and cognitive improvement via immunotherapy in late onset epilepsy patients with paraneoplastic versus GAD65 autoantibody-associated limbic encephalitis

OBJECTIVE

To determine the efficacy of immunotherapy in limbic encephalitis (LE) associated epilepsies with autoantibodies against intracellular antigens in the forms of paraneoplastic autoantibodies versus glutamic acid decarboxylase 65 (GAD)-autoantibodies.

METHODS

Eleven paraneoplastic-antibodies+ and eleven age- and gender-matched GAD-antibodies+ patients with LE were compared regarding EEG, seizure frequency, MRI volumetry of the brain, and cognition. All patients received immunotherapy with corticosteroids add-on to antiepileptic therapy. A few patients underwent additional interventions like immunoglobulins or immunoadsorption.

RESULTS

Immunotherapy led to a significantly greater proportion of seizure-free patients in the paraneoplastic antibodies+(55%) as compared to GAD-antibodies+(18%) patients (p<0.05). Impaired cognition was evident initially (total cognitive performance score based on attentional-executive function, figural/verbal memory and word fluency) in 100% of the paraneoplastic-antibodies+ and 73% of the GAD-antibodies+ group. After therapy, cognition improved significantly in the paraneoplastic-antibodies+, but not in the GAD-antibodies+ patients (p<0.05). Cognitive change did not correlate with the change in the number of antiepileptic drugs over time. MRI showed larger and unchanged volumes of the amygdala, presubiculum and subiculum in GAD-antibodies+as compared to paraneoplastic-antibodies+patients (p<0.05) over time.

CONCLUSIONS

Our data provide evidence of a beneficial effect of immunotherapy added to antiepileptic drugs on seizure frequency and cognition only in the paraneoplastic-antibodies+ subgroup of LE presenting autoantibodies against intracellular antigens.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

Probe-based confocal laser endomicroscopy (pCLE) - a new imaging technique for in situ localization of spermatozoa

In azoospermic patients, spermatozoa are routinely obtained by testicular sperm extraction (TESE). However, success rates of this technique are moderate, because the site of excision of testicular tissue is determined arbitrarily. Therefore the aim of this study was to establish probe-based laser endomicroscopy (pCLE) a noval biomedical imaging technique, which provides the opportunity of non-invasive, real-time visualisation of tissue at histological resolution. Using pCLE we clearly visualized longitudinal and horizontal views of the tubuli seminiferi contorti and localized vital spermatozoa. Obtained images and real-time videos were subsequently compared with confocal laser scanning microscopy (CLSM) of spermatozoa and tissues, respectively. Comparative visualization of single native Confocal laser scanning microscopy (CLSM, left) and probe-based laser endomicroscopy (pCLE, right) using Pro Flex(TM) UltraMini O after staining with acriflavine.

Pelvic floor muscle function is an independent predictor of outcome after retrourethral transobturator male sling procedure

PURPOSE

To evaluate the impact of the retrourethral transobturator sling (RTS) on pelvic floor muscle function (PFMF) and whether preoperative PFMF is associated with RTS outcome.

METHODS

Between May 2008 and December 2010, 59 consecutive men with postprostatectomy stress urinary incontinence (PSUI) underwent PFMF assessment before RTS and 6 months thereafter in a prospective cohort study. The assessments included demographic and clinical characteristics, and quality of life (QoL) questionnaires. PFMF was evaluated by digital rectal examination on the modified 6-point Oxford scale and by surface electromyography. The primary outcome measurement was success after RTS defined as PSUI cure with use of no or one dry "security" pad. For secondary outcome, PFMF, 1-h pad test, and impact of PSUI on QoL were evaluated. Uni- and multivariate analyses were performed.

RESULTS

After 6-month follow-up, the cure, improvement (>50 % pad reduction) and failure rates were 50 % (29/58 patients), 24 % (14/58 patients) and 26 % (15/58 patients), respectively. Significant improvement of QoL, clinical and PFMF parameters occurred after RTS. On multivariate analysis, weak PFMF (OR 86.29) and greater muscle fatigue (OR 3.31) were significant independent predictors of RTS failure. The final model demonstrated good calibration (p = 0.882) and excellent discriminative ability (0.942, 95 % CI 0.883-1.0) to predict success after RTS.

CONCLUSIONS

PFMF improved significantly after RTS procedure. Higher muscle fatigue and weak PFMF were independent predictors of RTS failure. Digital rectal evaluation of PFMF is a simple and reliable clinical tool, which can be used by urologists in daily routine to predict the RTS outcome.

Selective suppression of excessive GluN2C expression rescues early epilepsy in a tuberous sclerosis murine model

Tuberous sclerosis complex (TSC), caused by dominant mutations in either TSC1 or TSC2 tumour suppressor genes is characterized by the presence of brain malformations, the cortical tubers that are thought to contribute to the generation of pharmacoresistant epilepsy. Here we report that tuberless heterozygote Tsc1^+/− mice show functional upregulation of cortical GluN2C-containing N-methyl-D-aspartate receptors (NMDARs) in an mTOR-dependent manner and exhibit recurrent, unprovoked seizures during early postnatal life (<P19). Seizures are generated intracortically in the granular layer of the neocortex. Slow kinetics of aberrant GluN2C-mediated currents in spiny stellate cells promotes excessive temporal integration of persistent NMDAR-mediated recurrent excitation and seizure generation. Accordingly, specific GluN2C/D antagonists block seizures in Tsc1^+/− mice in vivo and in vitro. Likewise, GluN2C expression is upregulated in TSC human surgical resections, and a GluN2C/D antagonist reduces paroxysmal hyperexcitability. Thus, GluN2C receptor constitutes a promising molecular target to treat epilepsy in TSC patients.

Tuberous sclerosis complex (TSC) is a rare genetic condition characterized by epileptic seizures that start in infancy. Here, the authors show that these seizures are modulated by GluN2C-containing NMDA receptors in the cortex of a mouse model of TSC, and that suppressing their activity attenuates seizures.

Prospective comparison of one year follow-up outcomes for the open complete intrafascial retropubic versus interfascial nerve-sparing radical prostatectomy

Current work provides a prospective direct comparison between Open complete intrafascial-radical-prostatectomy (OIF-RP) and interfascial-RP in all outcomes in single centre series. Both techniques were done prospectively in 430 patients. Inclusion criteria for OIF-RP (n=241 patients) were biopsy Gleason-score ≤6 and PSA ≤10 ng/ml while for interfascial-RP (n=189) were Gleason-score ≤7 and PSA ≤15. The perioperative parameters (e.g. operative time, complications etc.), pathologic results, surgical margins and revisions were reviewed. Pre- and postoperative (3 and 12 months) evaluation of continence and potency was performed. All patients have preoperative IIEF-score of ≥15. Continence was classified as complete (no pads), mild (1-2 pads/day) and incontinence (>2 pads/day). Median patients’ age was 63.7 vs. 64.5 years for OIF-RP vs. Interfascial-RP, respectively. Preoperative PSA-level was significantly lower in OIF-RP (5.8 vs. 7.1), otherwise, similar perioperative data in both groups except for more frequent pT3-tumors in interfascial-RP group (18%). No statistical significance regarding continence was observed between OIF-RP vs. Interfascial-RP groups at 3 (82% vs. 85%) and 12 months (98% vs. 96%) postoperatively. Potency rates (IIEF ≥15) after OIF-RP were 96% (≤55 years), 72% (55-65), and 75% (>65 years) at 12 months. The respective rates for interfascial-group were 58%, 61% and 51%. There was an advantage for OIF-RP potency-outcomes without significance over Interfascial-RP in weak potency patients (IIEF=15-18). We conclude that OIF-RP is associated with better functional results without compromising early oncological results compared to interfascial-RP. Complete preservation of periprostatic fasciae provides significantly better postoperative recovery of sexual function even for weak potency patients. Longer follow-up is mandatory to further evaluate the outcome results of this technique.

Is the type and extent of hippocampal sclerosis measurable on high-resolution MRI?

INTRODUCTION

The purpose of this study is to relate hippocampal volume and FLAIR signal intensity to Wyler grading of hippocampal sclerosis (HS).

METHODS

Of 100 consecutive patients with temporal lobe epilepsy and HS as histopathological diagnosis, 32 had high-resolution 3 Tesla MRI and anatomically well-preserved hippocampi following amygdalo-hippocampectomy. Hippocampal volume on 3D T1-weighted gradient echo and signal intensity on coronal FLAIR sequences were determined using FreeSurfer and SPM tools and related to Wyler grading. Seizure outcome was determined after 1 year.

RESULTS

Histopathology showed four Wyler II, 19 Wyler III, and 9 Wyler IV HS. Hippocampal volumes were 3.08 ml for Wyler II (Wyler II/contralateral side: p > 0.05), 2.19 ml for Wyler III (p < 0.01), 2.62 ml for Wyler IV (p = 0.01), and 3.08 ml for the contralateral side. Normalized FLAIR signals were 1,354 (p = 0.0004), 1,408 (p < 0.0001), 1,371 (p < 0.04), and 1,296, respectively. Wyler II hippocampi were visually normal. Two of four (50%) Wyler II, 16/19 (84%) Wyler III, and 6/9 (66%) Wyler IV patients achieved Engel I outcome.

CONCLUSIONS

Combined volumetry and quantitative FLAIR signal analysis clearly identifies Wyler III and IV HS. Quantitative FLAIR signal analysis may be helpful to identify Wyler II HS.

Is a wider angle of the membranous urethra associated with incontinence after radical prostatectomy?

PURPOSE

To investigate whether differences in the anatomy and dynamics of the pelvic floor (PF) in patients after radical prostatectomy (RP) depicted on magnetic resonance imaging (MRI) are associated with continence status.

METHODS

In the prospective designed study, 24 patients with post-prostatectomy stress urinary incontinence were enrolled. Additionally, 10 continent patients after RP were matched for age, body mass index and perioperative parameters. All patients underwent continence assessment and MRI (TrueFISP sequence; TR 4.57 ms; TE 2.29 ms; slice thickness 7 mm; FOV 270 mm) 12 months after RP. Images were analyzed for membranous urethra length (MUL), angle of the membranous urethra (AMU), severity of periurethral/urethral fibrosis, lifting of the levator ani muscle, lowering of the posterior bladder wall (BPW), bladder neck (BN) and external urinary sphincter (EUS), and symphyseal rotation of these structures during the Valsalva maneuver and voiding.

RESULTS

Compared to continent controls, incontinent patients showed a significant wider AMU during voiding (p = 0.002) and more pronounced lowering of the BN and EUS (p < 0.001). No differences between the groups were found in symphyseal rotation of the analyzed structures, MUL and severity of periurethral/urethral fibrosis.

CONCLUSIONS

The angle of the membranous urethra as a result of anchoring of the BN and EUS in the PF appears to be an important functional factor with an essential impact on continence after RP. Functional MRI seems to be a helpful imaging tool for morphologic and dynamic evaluation of the PF.

18F-Fluoroethylcholine PET/CT identifies lymph node metastasis in patients with prostate-specific antigen failure after radical prostatectomy but underestimates its extent

BACKGROUND

The detection of lymph node metastases (LNMs) is one of the biggest challenges in imaging in urology.

OBJECTIVE

To evaluate the accuracy of combined 18F-fluoroethylcholine (FEC) positron emission tomography (PET)/computed tomography (CT) in the detection of LNMs in prostate cancer (PCa) patients with rising prostate-specific antigen (PSA) level after radical prostatectomy.

DESIGN, SETTINGS, AND PARTICIPANTS

From June 2005 until November 2011, 56 PCa patients with biochemical recurrence after radical prostatectomy underwent bilateral pelvic and/or retroperitoneal lymphadenectomy based on a positive 18F-FEC PET/CT scan.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The findings of PET/CT were compared with the histologic results.

RESULTS AND LIMITATIONS

Median PSA value at the time of 18F-FEC PET/CT analysis was 6.0 ng/ml (interquartile range: 1.7-9.4 ng/ml). In 48 of 56 (85.7%) patients with positive 18F-FEC PET/CT findings, histologic examination confirmed the presence of PCa LNMs. Of 1149 lymph nodes that were removed and histologically evaluated, 282 (24.5%) harbored metastasis. The mean number of lymph nodes removed per surgical procedure was 21 (standard deviation: ± 18.3). A lesion-based analysis yielded 18F-FEC PET/CT sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 39.7%, 95.8%, 75.7%, and 83.0%, respectively. A site-based analysis yielded sensitivity, specificity, PPV, and NPV of 68.4%, 73.3%, 81.3%, and 57.9%, respectively. Patients with negative PET/CT did not undergo surgery, thus sensitivity, specificity, and negative predictive value on a patient basis could not be calculated.

CONCLUSIONS

A positive 18F-FEC PET/CT result correctly predicted the presence of LNM in the majority of PCa patients with biochemical failure after radical prostatectomy but did not allow for localization of all metastatic lymph nodes and therefore was not adequately accurate for the precise estimation of extent of nodal recurrence in these patients.

Effects of oral rehydration and external cooling on physiology, perception, and performance in hot, dry climates

Only limited research evaluates possible benefits of combined drinking and external cooling (by pouring cold water over the body) during exercise. Therefore, this study examined cold water drinking and external cooling on physiological, perceptual, and performance variables in hot, dry environments. Ten male runners completed four trials of walking 90 min at 30% VO(2max) followed by running a 5-km time trial in 33 ± 1 °C and 30 ± 4% relative humidity. Trials examined no intervention (CON), oral rehydration (OR), external cooling (EC), and oral rehydration plus external cooling (OR + EC). Investigators measured rectal temperature, skin temperatures, heart rate, thirst, thermal sensation, and ratings of perceived exertion (RPE). Oral rehydration (OR and OR + EC) significantly lowered heart rate (P < 0.001) and thirst (P < 0.001) compared with nondrinking (CON and EC) during low-intensity exercise. External cooling (EC and OR + EC) significantly reduced chest and thigh temperature (P < 0.001), thermal sensation (P < 0.001), and RPE (P = 0.041) compared with non-external cooling (CON and OR) during low-intensity exercise. Performance exhibited no differences (CON = 23.86 ± 4.57 min, OR = 22.74 ± 3.20 min, EC = 22.96 ± 3.11 min, OR + EC = 22.64 ± 3.73 min, P = 0.379). Independent of OR, pouring cold water on the body benefited skin temperature, thermal sensation, and RPE during low-intensity exercise in hot, dry conditions but failed to influence high-intensity performance.

Nuclear karyopherin a2: a novel biomarker for infiltrative astrocytomas

The karyopherin (KPNA) protein family is involved in nucleocytoplasmic trafficking. Increased KPNA levels have been found to predict poor prognosis for a variety of solid tumors, including breast, ovarian, cervical, and prostate cancer, and melanoma. The purpose of this study was to evaluate karyopherin a2 as novel biomarker for astrocytic gliomas of WHO grades II-IV. We semiquantitatively measured nuclear expression of karyopherin a2 and the MIB1 labeling index, by immunohistochemical analysis, for 94 primary (23 astrocytomas WHO grade II, 24 astrocytomas WHO grade III, 47 glioblastomas) and 12 recurrent gliomas. In addition, IDH1 mutation status and Nijmegen breakage syndrome 1 protein expression were assessed, by immunohistochemical analysis, for all 71 malignant (WHO grade III and IV) and all 94 primary gliomas, respectively. Statistical analysis was performed by use of standard techniques. Karyopherin a2 expression correlated significantly with histological grade (p < 0.001), with proliferative activity as assessed by the MIB1 index (p < 0.001), with IDH1 mutation status (p = 0.032), and with Nijmegen breakage syndrome 1 protein expression (p = 0.001). Recurrent tumors expressed significantly higher levels of karyopherin a2 (p = 0.045) than primary growths. Multivariate analysis of the overall series identified low karyopherin a2 expression (defined as less than 5 %) as an independent prognostic predictor of overall (p = 0.041) and progression-free survival (p = 0.004). Survival of glioblastoma patients >5 years was seen only in those with KPNA2 expression levels ≤1 % (p = 0.014). KPNA2 expression may have potential as a novel diagnostic and prognostic biomarker for astrocytic gliomas.

Laparoscopic marsupialisation of pelvic lymphoceles in different anatomic locations following radical prostatectomy

BACKGROUND

Pelvic lymphoceles (LCs) following radical prostatectomy (LC-RPs) are a well-described complication. Symptomatic LC-RPs are the most frequent, nonfunctional, postradical prostatectomy complications.

OBJECTIVES

Description of the clinical presentations of LC-RPs and the detailed technique of laparoscopic pelvic LC marsupialisation (LM), including perioperative results and follow-up.

DESIGN, SETTING, AND PARTICIPANTS

Data from 105 patients (age range: 57-76 yr) with symptomatic LC-RPs who underwent surgery in our institute were evaluated retrospectively. Pelvic ultrasound (US) and computed tomography scans, performed on all patients, revealed LC volumes ranging from 100 to 1200 ml. Fifty-five patients were refractory to prior percutaneous tube drainage and/or sclerotherapy. LM was performed using a three-trocar (n=60 patients) or two-trocar technique (n=45 patients).

SURGICAL PROCEDURE

With the patient in Trendelenburg position, LCs were accurately identified by inspection, compressibility, and/or laparoscopic needle aspiration. A Foley catheter was inserted. Through one or two working trocars in the left lower abdomen, an adequate peritoneal window (wide ellipse) was excised. The LC cavity was inspected and septae, membranes, and haematomas were removed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Perioperative surgical outcomes, analgesic medication, and inflammation parameters were recorded. Follow-up and success rates were estimated with US for LC recurrence.

RESULTS AND LIMITATIONS

Five pelvic LC locations could be identified: paravesical, lateral pelvic (encapsulated and uncapsulated), prevesical, and with retroperitoneal extension. These were relevant for clinical diagnosis and management options. Pelvic LCs were right-sided in 37 patients, left-sided in 15, and on both sides in 53. All LM were uneventful and operating time (mean) ranged from 15 to 265 (31.7) min, which became shorter with increasing experience. One conversion with postoperative blood transfusion was necessary. Patients were discharged between 2 and 4 (mean: 2.3) d postoperatively. Postoperative US revealed primary success in all cases. Three patients developed recurrence from 1 to 3 wk posthospitalisation; otherwise, none had treatment for LC during a mean follow-up of 20 mo. Limitations include the retrospective study design and the small number of patients.

CONCLUSIONS

LC-RPs are common and can be classified into five different patterns of clinical/anatomic presentation. LM is simple, feasible, and safe as the first-line treatment for large, noninfected, symptomatic or refractory LC-RPs with fewer complications and an overall 97% success rate.

Ex vivo comparison of the tissue effects of six laser wavelengths for potential use in laser supported partial nephrectomy

Laparoscopic/robotic partial nephrectomy (LPN) is increasingly considered for small renal tumors (RT). This demands new compatible surgical tools for RT-resection, such as lasers, to optimize cutting and coagulation. This work aims to characterize ex vivo handling requirements for six medically approved laser devices emitting different light wavelengths (940, 1064, 1318, 1470, 1940, and 2010 nm) amenable for LPN. Incisions were made by laser fibers driven by a computer-controlled stepping motor allowing precise linear movement with a preset velocity at a fixed fiber-tip distance to tissue. Optical parameters were measured on 200 μm tissue slices. Cutting quality depended on power output, fiber velocity and fiber-tip distance to tissue. Contact manner is suitable for cutting while a noncontact manner (5 mm distance) induces coagulation. Ablation threshold differs for each wavelength. Ablation depth is proportional to power output (within limit) while axial and superficial coagulation remains mostly constant. Increased fiber velocity compromises the coagulation quality. Optical parameters of porcine kidney tissue demonstrate that renal absorption coefficient follows water absorption in the 2 μm region while for other spectral regions (900 to 1500 and 1 μm) the tissue effects are influenced by other chromophores and scattering. Tissue color changes demonstrate dependencies on irradiance, scan velocity, and wavelength. Current results clearly demonstrate that surgeons considering laser-assisted RT excisions should be aware of the mentioned technical parameters (power output, fiber velocity and fiber-tip tissue-distance) rather than wavelength only.

Follow-up results of a pure retroperitoneoscopic/extraperitoneal nephroureterectomy for upper tract urothelial tumors

We present the results of a pure retroperitoneoscopic/ extraperitoneal nephroureterectomy (RENU) for upper urinary tract transitional cell cancer (UT-TCC). After establishment of RENU in benign indications (n=21 Patients), 14 patients (age range 51-92 years, mean 71.6) with UT-TCC have undergone the technique in our clinic from October 2005 to October 2008. This paper reports the operative procedure, clinical results and follow up. Total operative time was 110-240 minutes (median 154.5). Average blood loss was 132 mL. Tumor localization in oncology patients was renal pelvis (63.6%), ureter (18.2%) or both (18.2%). Postoperative tumor stages were Ta (n=2), Tis (n=2), T1 (n=3), T2 (n=3) and T3 (n=4) without lymph node involvement. No perioperative complications were observed. Urethral catheters were removed on Day 6-8 post surgery (median Day 7). Recovery to normal life activity ranged from 8 to 30 days (mean 17.8). During the 4-36 month (median 23) follow-up period, there was one mortality due to cancer progression. Four patients had developed superficial bladder cancer disease requiring regular cystoscopic resections. One patient had coincidental Bellini duct renal tumor and developed psoas metastasis after eight months. The 2-year tumor specific survival rate is 91%. The retroperitoneoscopic/ extraperitoneal nephroureterectomy is a lowrisk and minimally invasive procedure to be used whenever nephroureterectomy is indicated. It is an attractive alternative to both laparoscopic and open techniques and adheres to the oncological principles of radical nephroureterectomy. Short-term follow-up data showed no increased risk of tumor recurrence. However, long-term results are needed before this technique can be established as standard UT-TCC therapy.

Single-Incision Laparoscopic Surgery (SILS) in Reconstructive Urological Cases

Single-incision laparoscopic surgery (SILS) is a recent development in minimally invasive surgery. This is an initial SILS experience in reconstructive urology to prove feasibility and provide a comparison with conventional laparoscopy during perioperative and convalescent periods. A single surgeon performed two complex SILS operations (psoas bladder hitch with Boari flap for high ureteric stricture [SILS-PB] and nephropexy for severe nephroptosis [SILS-Np]). A group of 6 patients with previous experience with conventional laparoscopy by the same surgeon with the same operation complexity was selected for retrospective comparison. SILS was performed through multichannel port (intraumbilical or retroperitoneal). There was no conversion to laparoscopy. Operative time (Or-t) was 365 and 185 minutes for SILS-PB and SILS-Np, respectively. Blood loss was 100 ml for SILS-PB without any intraoperative complications. Baseline demographics, Or-t, blood loss, and hospital stay were comparable to the laparoscopic group. Except for prolonged Or-t, patients undergoing SILS had similar surgical outcomes and comparable convalescent periods. Follow-up was uneventful for both groups. Patients' global satisfaction and willingness to recommend their procedure to others were favorable and equivalent between groups. Thus, SILS-reconstructive operations for high ureteric strictures and severe nephroptosis are feasible. It seems equally as efficacious as conventional laparoscopy maintaining surgical standards without differences in perioperative outcomes and convalescence.

Management of pelvic lymphoceles after radical prostatectomy: a multicentre community based study

Introduction

Pelvic lymphoceles (LC) following radical prostatectomy (LC-RP) have an incidence up to 27%. LC-managements constitute 50% of surgical interventions performed in post-RP patients.

Objectives

To describe a therapeutic algorithm for LC-managements based on a community based representative retrospective study.

Patients and methods: Multicentre data from 304 patients with LC-RP were retrospectively examined for LC-managements. RPs were performed by various surgeons from 67 urological departments. All patients had undergone 3 weeks rehabilitation in a specialized hospital where the data base was generated. Indications and results of therapeutic manoeuvres were used to develop a general concept for planning therapy decisions.

Results

Median age was 64 years. Complications occurred in 9% (28/304) of patients. Median LC-volume was 36 ml (range 20-1800 ml). There were more complications for LCs with ≥100 ml volume than those < 100 ml (27% versus 17%, p = 0.346). Conservative therapy was the standard in uncomplicated cases (87%, 239 of 276 patients), while intervention was done in 13% (puncture and/or drainage, surgery). Surgical intervention was performed significantly more often in complicated cases (82%, 23 from 28 patients; p < 0.001). Based on these data, LCs can be stratified into 3 groups depending on the size and clinical presentation. Therapeutic decisions were used to develop the illustrated new therapy algorithm.

Conclusions

This study based treatment algorithm provides a rationale approach with an accurate LC-classification as regard the indications and decision making for the available LC-RP-therapies. This could facilitate management decisions. Evaluation of this concept prospectively in large patient cohort is mandatory.

Urodynamic parameters after retrourethral transobturator male sling and their influence on outcome

OBJECTIVE

To evaluate prospectively detailed urodynamic parameters before and after retrourethral transobturator sling (RTS) placement and the impact of adverse preoperative urodynamic parameters on postoperative outcome.

METHODS

Fifty-five consecutive patients with postprostatectomy stress urinary incontinence (SUI) underwent urodynamics with pressure flow and abdominal leak point pressure (ALPP) measurements, quality of life, 1-hour pad test, and daily pad use assessment before RTS (AdVance) and 12 months postoperatively. Volume of first sensation and first desire to void, maximum cystometric capacity (MCC), ALPP, maximum flow rate (Qmax.), average flow rate, time to Qmax., detrusor voiding pressure at Qmax., voiding time, and postvoid residual urine volume (PVR) were assessed. The success rate was defined as cure (no or one dry "security" pad) or improvement (1-2 pads or pad reduction≥50%). Adverse parameters included ALPP≤30 cm H2O, Qmax.≤10 mdL/s, and MCC≤200 mL.

RESULTS

Success rate after RTS was 73% (40/55 patients). Mean follow-up was 21±11.7 (range, 12-41) months. Only ALPP changed significantly (61±14.2 vs 79±20.4 cm H2O). No PVR>30 mL, de novo reduced bladder compliance and hypo- or overactivity were observed. Urine loss by 1-hour pad test (136.1±119.4 vs 39.4±77.0) and daily pad use (4.6±2.0 vs 1.9±2.1) decreased significantly. Adverse preoperative urodynamic parameters were not associated with postoperative outcome.

CONCLUSION

The RTS is an effective and safe device for SUI treatment without signs of compression or obstruction of the urethra or any influence on voiding parameters. Adverse preoperative urodynamic parameters have no influence on postoperative outcome.

Systemic and cavernous plasma levels of neuropeptide Y during sexual arousal in healthy males

Neuropeptide Y (NPY) has been shown to induce contraction of isolated human penile erectile tissue and potentiate the response to noradrenaline. The purpose of our study was to measure in the cavernous and systemic blood of healthy male volunteers the course of NPY through different stages of sexual arousal. Whole blood was drawn simultaneously from the corpus cavernosum and the cubital vein of 16 healthy male volunteers during penile flaccidity, tumescence, rigidity and detumescence. Tumescence and erection were induced by applying audiovisual and tactile stimulation. Plasma levels of NPY (given in pmol l(-1)) were determined by means of an enzyme-linked immunoassay. NPY significantly decreased in the cavernous blood on sexual arousal, when the flaccid penis became tumescent and, finally, rigid (F: 88.8 ± 35.8, T: 62.4 ± 22.7, R: 62.3 ± 19.7), and only slightly rose in the phase of detumescence (64.8 ± 23). In the systemic circulation, no pronounced alterations in the concentration of NPY were registered (F: 64.4 ± 27, T: 65.8 ± 19, R: 59.6 ± 25, D: 67.6 ± 29.3). Our findings are in favour of the hypothesis that NPY could contribute to the maintenance of the resting state of cavernous smooth muscle.

Risk factors for pelvic lymphoceles post-radical prostatectomy

BACKGROUND

Lymphoceles (LC) represent a well-described rare complication post-radical prostatectomy (RP). Our aim was to determine risk factors and to develop possible prevention strategies for LC in a community-based study.

METHODS

Data from 1163 RP-patients from 67 clinics between January 2002 and December 2004 were retrospectively evaluated. Patients underwent pelvic imaging procedures/LC-management during 3 weeks of rehabilitation post-RP.

RESULTS

LC were identified in 304 patients (26%). Lymphadenectomy was carried out in 92% of patients (1001/1086 patients), from which 28% had LC (n = 277) versus 14% without lymphadenectomy (12/85, P = 0.007). Complications (lower limb edema, pain, thrombosis, infection and bladder compression) were observed in 9% of patients (28/304; 2.4% of total patients); necessitating therapy. LC therapy was carried out in 59 patients (5.9%) with pelvic lymph node dissection (PLND) and in no patients (0%) without PLND (P = 0.021). Risk factors included were patients' age, body mass index, prostate volume, TNM-classification, number of removed lymph nodes, previous surgery/therapy, heparin prophylaxis, surgical instruments and pelvic lymphadenectomy. Univariate analysis showed lymphadenectomy as the only significant risk factor for the development of LC post-RP (P = 0.007). When applying multivariate analyses using stepwise logistic regression, only lymphadenectomy was associated with a significant risk for lymphoceles (odds ratio = 2.6, 95% CI = 1.3-4.9, P = 0.004). Adjusting for other factors, no other factor came close to being significant (P < 0.05). All symptomatic LC were successfully treated without further sequelae.

CONCLUSIONS

Subclinical LC post-RP are more common than thought, and rarely necessitate intervention. Pelvic lymphadenectomy represents the only significant factor contributing to LC-development. Because of this, prevention remains difficult.

Risk factors of treatment failure after retrourethral transobturator male sling

PURPOSE

Prospective evaluation of independent risk factors for failure of the retrourethral transobturator sling suspension (RTS) with special attention on sphincter function and surgical technique.

METHODS

A total of 189 patients with postprostatectomy stress urinary incontinence (SUI) were treated with RTS (AdVance(®) sling) in a prospective clinical study with a mean follow-up of 20.8 months. Eleven patients were lost to follow-up. Uni- and multivariate analyses were performed to identify independent risk factors for RTS failure. The success rate was defined as cured (no pad use or one dry 'security' pad) or improved (one to two pads and pad reduction ≥ 50%).

RESULTS

At a mean follow-up of 20.8 months, the overall success rate was 73.1%. Multivariate analysis revealed that weak residual function and incomplete closure of the sphincter (OR, 29.0), no elongation of the coaptive sphincter zone (OR, 26.9), no sling tunnelling (OR, 22.6) and use of resorbable sutures with a small number (≤ 4) of stitches (OR, 8.4) are significant predictors for RTS failure.

CONCLUSIONS

Preoperative selection of the patients with regard to residual sphincter function and a special attention on better sling fixation may increase RTS efficacy.

Modified laparoscopic lymphocele marsupialization for the treatment of lymphoceles after radical prostatectomy: first results

OBJECTIVES

The objective of this study was to describe a simple modification of the laparoscopic pelvic lymphocele marsupialization (LL) following radical prostatectomy lymphoceles (RP-LC).

PATIENTS AND METHODS

Forty-eight patients (57-76 years) with symptomatic RP-LC underwent surgery in our institute. This was through an open approach in 6 (open drainage [OL]) and LL in rest of the patients (12 with 3 [LL3] and 30 with 2 [LL2] trocars). All except 2 patients were refractory to percutaneous tube drainage and/or sclerotherapy. Pelvic ultrasound and/or computed tomography scans revealed LC size (4 × 5-11 × 12 cm) and volumes (100-1100 mL).

RESULTS

All surgeries were uneventful with an operative time of 15-60 minutes for LL and 35-90 minutes for OL and it became shorter with increasing experience with LL2 (15-25 minutes). Mean hospitalization time was 2.3 and 8 days after LL (LL2 and LL3) and OL, respectively. LC were at the right side in 10 patients, at the left side in 6, and at both sides in 14. Postoperative ultrasound revealed primary success in all cases. No patient developed recurrence of or had treatment for lymphocele during a mean follow-up time of 19 months.

CONCLUSION

LL2 is a simple, feasible, and safe procedure that could be used as a first-line treatment for large, noninfected symptomatic or refractive RP-LC.

Repeat retrourethral transobturator sling in the management of recurrent postprostatectomy stress urinary incontinence after failed first male sling

BACKGROUND

A failure rate between 20% and 45.5% after retrourethral transobturator sling (RTS) is reported. Recommendations for the management of persistent or recurrent postprostatectomy stress urinary incontinence (SUI) after failed male sling do not exist.

OBJECTIVE

The aim of this study was the prospective evaluation of the efficacy of repeat RTS (RRTS) in patients after failed first RTS.

DESIGN, SETTING, AND PARTICIPANTS

Between March 2007 and August 2009, 35 patients with mild to severe SUI after failed first RTS were treated with a second AdVance sling (American Medical Systems, Minnetonka, MN, USA).

MEASUREMENTS

Preoperative and postoperative evaluation included daily pad use, 1-hr pad test, postvoiding residual (PVR) urine, uroflowmetry, and quality-of-life (QoL) scores.

RESULTS AND LIMITATIONS

After 6 mo, 45.5% (15 of 33 patients) showed no pad use; 30.3% (10 of 33 patients), one dry "security" pad; 3% (1 of 33 patients), one wet pad; 6.1% (2 of 33 patients), two pads; 3% (1 of 33 patients), pad reduction ≥50%; and 12.1% (4 of 33 patients), treatment failure. After 16.6 mo, 34.5% (10 of 29 patients) showed no pad use; 37.9% (11 of 29 patients), one dry "security" pad; 3.4% (1 of 29 patients), one wet pad; 3.4% (1 of 29 patients), two pads; 10.3% (3 of 29 patients), pad reduction ≥50%; and 10.4% (3 of 29 patients), treatment failure. Daily pad use and pad weight decreased significantly. PVR and uroflowmetry results showed no significant change. QoL improved significantly. Postoperative acute urinary retention was observed in 23.6% of patients.

CONCLUSIONS

RRTS is an effective and safe treatment option for the management of SUI after failed first RTS.

[Laparoscopic radical and partial nephrectomy: an overview]

Laparoscopy has been progressively gaining acceptance in the urologic arena. The start with renal surgery was slow; however, after complete establishment for benign indications the breakthrough occurred due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy for stage T1 and T2 tumours, whether transperitoneal or retroperitoneal, can be performed safely. The surgical steps duplicate the open procedure. The overall complication rate is low and does not significantly differ from that of the open procedure. Laparoscopic partial nephrectomy is, in contrast, a technically challenging procedure despite its realisation laparoscopically. Although the intermediate outcomes are comparable to those of the open procedure, there are concerns related to warm ischemia time and the risk of major complications such as urinary leakage and haemorrhage requiring transfusion, so that it should be performed only in centres with expertise.

Conservative management of rectal perforation after nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) in a patient with a past history of polypectomy

Introduction

Rectal polypectomy causes thinning (or even perforation) of the rectal wall in addition to thermic injury at the polypectomy site.

Case report

We present a rare case of spontaneous rectal perforation after uncomplicated nerve sparing endoscopic extraperitoneal radical prostatectomy in a patient with a previous history of rectal polypectomy at the perforation site. The patient could be treated conservatively. There was complete healing of the fistula without any effect on functional results. This Conservative therapy for such rectal perforations is indicated if the patient's general condition remains stable without any signs of infection.

Conclusions

Polypectomy is an important risk factor for rectal perforation during nsEERPE. Adequate time interval should be given to allow healing and avoid adding further thermal wall damage which may obscure healing leading to complications like fistula. Conservative therapy for small missed rectal perforations constitutes an attractive, feasible and non invasive treatment entity. Following this principle we have not faced this complication in following similar cases.

Limbic encephalitis as a precipitating event in adult-onset temporal lobe epilepsy

OBJECTIVE

Temporal lobe epilepsy with hippocampal sclerosis (TLE-HS) is the most frequent diagnosis in autopsy and surgical epilepsy series. TLE-HS usually starts during childhood or adolescence. There have been few studies of adult-onset disease. We recognized that some adult individuals have evidence of limbic encephalitis (LE), an autoimmune condition of adult life, which we proposed might lead directly to this syndrome.

METHODS

We performed a retrospective analysis of history, clinical and paraclinical findings, brain MRI, and outcome of surgical treatment including histopathology (if available) of all patients with TLE-HS presenting to this tertiary center within 6 years of epilepsy onset between 1999 and 2005.

RESULTS

Thirty-eight patients were identified, with median age at epilepsy onset of 37.8 years. Eleven patients (29%) were classified as having secondary HS (e.g., after head trauma, febrile seizures). Seven patients (11%) were classified as idiopathic. However, 9 patients (24%) had a diagnosis of definite LE, and another 11 individuals (29%) showed the typical LE pattern of MRI findings with hippocampal swelling evolving into atrophy with continuous FLAIR/T2 signal increase; they were diagnosed as possible LE. Bilateral abnormalities were more frequent in the two LE subgroups (60%) than in the two non-LE subgroups (22%; p = 0.025). Histopathology was performed in one patient with possible LE shortly after disease onset and showed a typical T cell infiltration and loss of hippocampal neurons.

CONCLUSIONS

Temporal lobe epilepsy with hippocampal sclerosis can manifest in adult life. Around half the patients have evidence consistent with an autoimmune process. If confirmed, this should have implications for diagnosis, prevention, and treatment.

Non-genomic effects of androgens on isolated human vascular and nonvascular penile erectile tissue

OBJECTIVES

To evaluate non-genomic effects of testosterone and dihydrotestosterone (DHT) on isolated human cavernosal arteries (HCA) and corpus cavernosum (HCC) using organ-bath studies and radio-immunoassays (RIA), as non-genomic effects of androgens are reported for vascular smooth musculature and there is evidence that the relaxant response involves a modulation of cyclic nucleotide tissue levels.

MATERIALS AND METHODS

The relaxation induced by the cumulative addition of testosterone and DHT (0.01-10 microm) was studied using circular segments of HCA and strip preparations of HCC. To evaluate the effects of testosterone and DHT on tissue levels of cAMP and cGMP, specimens were exposed to increasing concentrations of the hormones. Forskolin and sodium nitroprusside (SNP) served as reference compounds.

RESULTS

Testosterone and DHT dose-dependently reversed the noradrenaline-induced tension of vascular segments and HCC strips. At the maximum concentration, testosterone and DHT reduced the mean (sd) tension to 79.8 (4.43)% and 83.9 (10.94)%, respectively. SNP and forskolin significantly stimulated the production of cGMP and cAMP. No effects of testosterone and DHT on cGMP and cAMP levels were detected.

CONCLUSION

Rapid androgen-induced relaxation of HCA and HCC occurs via non-genomic mechanisms. In penile erectile tissue, non-genomic relaxant effects of testosterone and DHT are not mediated via modulation of cyclic nucleotide tissue levels. Additional studies are required to establish if non-genomic relaxant effects are important in ensuring a basal level of perfusion to maintain overall penile function.

Semen Quality in Men with Malignant Diseases before and after Therapy and the Role of Cryopreservation

OBJECTIVE

To review the literature and answer questions about semen quality in young cancer patients before and after therapy and the importance of sperm cryopreservation.

METHODS

All aspects of sperm cryopreservation and effects of therapies on semen quality were examined on the basis of MedLine database searches.

RESULTS

Chemotherapy, radiation, or their combination results in a significant reduction of sperm quality and as a consequence an indefinite time of infertility follows. The type of cancer and the pretreatment sperm concentrations were the most significant factors governing posttreatment semen quality and recovery of spermatogenesis. Due to their age, fertility and sexual functioning are key issues for these patients. Yet there is no medical protection of the germinal epithelium available. Male germ cell transplantation is in its infancy and still there are no therapeutical options to improve spermatogenesis after damage has occurred. Consequently, cryopreservation represents the only preemptive measure for conserving fertility.

CONCLUSION

This manuscript updates the current knowledge of diverse chemotherapeutic treatment regimens and their gonadotoxic effects as well as the development of posttreatment fertility in cancer patients. The importance and rationale of sperm cryopreservation are discussed and possible future options are highlighted.

Mutational and expression analysis of CDK1, cyclinA2 and cyclinB1 in epilepsy-associated glioneuronal lesions

Gangliogliomas and focal cortical dysplasias (FCDs) constitute glioneuronal lesions, which are frequently encountered in biopsy specimens of patients with pharmacoresistant focal epilepsy and relate to impaired differentiation and migration of neural precursors. However, their molecular pathogenesis and relationship are still largely enigmatic. Recent data suggest several components of the insulin-pathway, including TSC1 and TSC2 mutated in tuberous sclerosis complex (TSC), to be altered in gangliogliomas and FCD with Taylor type balloon cells (FCD(IIb)). The proteins tuberin (TSC2) and hamartin (TSC1) constitute a tumour suppressor mechanism involved in cell-cycle control. Hamartin and/or tuberin were reported to colocalize and/or interact with CDK1, cyclinB1 and cyclinA2 that are critically involved in cell-size and cell-growth control. Here, we have carried out mutational and expression analyses of CDK1, cyclinB1 and cyclinA2 in gangliogliomas and FCD(IIb). Mutational screening was performed by single-strand conformation polymorphism analysis in gangliogliomas (n = 20), FCD(IIb) (n = 35) and controls. CyclinB1 revealed a polymorphism (G to A, cDNA Position 966, GenBank: NM_031966) in exon 7 with similar frequencies in FCD(IIb), gangliogliomas and control specimens (FCD n = 9/35; gangliogliomas n = 5/20; control n = 20/100). We used real-time reverse transcription polymerase chain reaction to determine expression levels of CDK1, cyclinB1 and cyclinA2 in 10 FCD(IIb) and nine gangliogliomas compared with unaffected adjacent control tissue of the same patients. We observed significantly lower expression of CDK1 and cyclinA2 in FCD(IIb) vs. controls whereas no significant expression differences were present for CDK1, cyclinB1 and cyclinA2 in gangliogliomas. Our data strongly argue against mutational events of CDK1, cyclinB1 and cyclinA2 to play a role in gangliogliomas or FCD(IIb). However, a potential functional significance of lower expression for the cell-size and cell-cycle regulators CDK1 and cyclinA2 in FCD(IIb) composed of large dysplastic neurones and balloon cells needs to be further resolved.