Joachim Dörsam

Failure of subureteral bovine collagen injection for the endoscopic treatment of primary vesicoureteral reflux in long-term follow-up

OBJECTIVESnTo evaluate the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of primary vesicoureteral reflux (VUR).nnnMETHODSnWe prospectively studied 36 patients (58 ureteral renal units), 30 girls and 6 boys with a median age of 6 years (range 2 months to 18 years). All patients had primary VUR and were treated with a single subureteral collagen injection (GAX 35). The patients were followed up by voiding cystography.nnnRESULTSnAccording to the International Reflux Study Classification, we found the following reflux grades preoperatively: grade I, 2 ureteral units; grade II, 21 units; grade III, 28 units; grade IV, 4 units, and grade V, 3 units. All patients were treated with subureteral bovine collagen injection (GAX 35, mean volume 1.7 mL, range 0.7 to 3.5). All but 3 cases of reflux resolved initially. The mean follow-up was 13 months (range 1 to 108). After 37 months of follow-up, only 5 (9%) of 57 treated units remained reflux free. One unit was followed up for 17 months and also remained reflux free.nnnCONCLUSIONSnThese data suggest that a single endoscopic subureteral collagen injection is not effective in the long-term follow-up of patients with primary VUR. In the future, it will be important to determine whether the new, currently used, and soon be approved bulking agents show better long-term clinical results to prevent VUR recurrence than bovine collagen does.

Inhaled nitric oxide inhibits platelet aggregation after pulmonary embolism in pigs

Background Inhaled nitric oxide (NO) is reported to prolong bleeding time in animals and humans and to inhibit platelet aggregation in persons with acute respiratory distress syndrome. In pulmonary embolism (PE), inhibition of platelet aggregation appears useful because further thrombus formation may lead to right ventricular dysfunction that results in circulatory failure. In the present study, the effect of inhaled NO on platelet aggregation after acute massive PE was investigated. Methods After acute massive PE was induced in 25 anesthetized pigs by injecting microspheres, 5, 20, 40, and 80 parts per million inhaled NO were administered stepwise for 10 min each in 11 animals (NO group). In the control group (n = 14), NO was not administered. Adenosine diphosphate‐induced initial and maximal platelet aggregation were measured before PE (t0), immediately after induction of PE (PE), at the end of each 10‐min NO inhalation interval (t10‐t40), and 15 min after cessation of NO inhalation (t55) in the NO group, and at corresponding times in the control group, respectively. Results Two animals in the control group and one in the NO group died within 10 min after PE induction and were excluded from analysis. Peaking at t40 and t55, respectively, initial (+13 +/‐ 6%; P < 0.05) and maximal (+44 +/‐ 17%; P < 0.05) platelet aggregation increased significantly after PE in the control group. In contrast, NO administration after PE led to a significant decrease in initial (maximum decrease, ‐9 +/‐ 3% at t40; P < 0.05) and maximal (maximum decrease, ‐15 +/‐ 7% at t30; P < 0.05) platelet aggregation. In the NO group, platelet aggregation had returned to baseline levels again at t55. In addition, NO administration significantly decreased mean pulmonary artery pressure and significantly increased end‐tidal carbon dioxide concentration and mean systemic blood pressure. Conclusions Inhaled NO has a systemic and rapidly reversible inhibitory effect on platelet aggregation after acute massive PE in pigs. This may be beneficial in treating acute massive PE.

LONG-TERM EFFICACY OF SUBURETERAL COLLAGEN INJECTION FOR ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX IN NEUROGENIC BLADDER CASES

PURPOSEnWe evaluated the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of vesicoureteral reflux in patients with neurogenic bladder dysfunction due to meningomyelocele.nnnMATERIALS AND METHODSnWe prospectively studied 12 women and 8 men (26 ureteral renal units) with a median age of 8 years (range 1 to 51) who had neurogenic bladder due to meningomyelocele. Reflux into single collecting systems was treated with subureteral collagen injection (GAX 35). Followup with video urodynamics included voiding cystography.nnnRESULTSnAll patients performed intermittent catheterization to control the bladder. During the study all bladders were areflexic with normal compliance. Preoperative reflux according to the International Reflux Study Classification was grade I in 1, II in 9, III in 10, IV in 4 and V in 2 ureteral renal units. All patients were treated with subureteral collagen injection (mean volume 1.9 ml., range 0.7 to 3.5). Reflux resolved initially in all but 2 cases. Mean followup was 16 months (range 1 to 71). Reflux was still absent in only 15% of treated units after 24 months.nnnCONCLUSIONSnOur data suggest that endoscopic subureteral collagen injection in neurogenic bladder cases is not effective with long-term followup. New biocompatible and biodegradable materials should be tested to control vesicoureteral reflux.

Surgical treatment of invasive penile cancer : The Heidelberg experience from 1968 to 1994

OBJECTIVESnThis study was performed to establish oncological guidelines for the surgical treatment of invasive penile cancer.nnnMATERIALS AND METHODSnThe medical records of 51 patients with invasive penile cancer seen between 1968 and 1994 were reviewed in respect to treatment and long-term outcome.nnnRESULTSnFor stage T1 tumors treated with organ-preserving procedures the local recurrence rats was 56%, whereas no patient experienced a local recurrence after partial amputation. For stage T2 tumors, local recurrence rate was 100% (organ preservation) versus 20% (amputative procedures). There was no significant difference related to regional recurrence between surveillance, inguinal radiation and lymphadenectomy for stage N0 tumors. For N+ stages, survival was related to the extent of inguinal metastasis after dissection (5-year survival rate for N1: 71 vs. 33% for N2/3).nnnCONCLUSIONSnOrgan-preserving procedures include a high risk of local and regional recurrence. Adjuvant regional lymphadenectomy seems beneficial only in patients with solitary metastasis.

PITFALLS OF REPEAT SUBURETERAL BOVINE COLLAGEN INJECTIONS FOR THE ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX

PURPOSEnCollagen has been used for the endoscopic subureteral treatment of vesicoureteral reflux since the late 1980s. We evaluated the long-term efficacy of repeat subureteral glutaraldehyde bovine cross-linked collagen injections for the endoscopic management of vesicoureteral reflux.nnnMATERIALS AND METHODSnWe prospectively evaluated 14 girls and 2 boys (21 ureteral units) 6 months to 16 years old (median age 6 years). In all patients initial treatment failed or reflux recurred after a single subureteral collagen injection and injection was repeated. Patients were followed with voiding cystography. Reflux-free periods after each injection and reflux grade were documented.nnnRESULTSnAll patients were treated twice with subureteral bovine collagen injection. Mean injected collagen volume of injections 1 and 2 was 1. 5 ml. (range 0.7 to 3.0) and 1.6 ml. (range 1.0 to 2.3), respectively, at a concentration of 35 mg./ml. In all but 4 cases reflux disappeared after injection 2. Mean followup was 11 months (range 1 to 41) after treatment 2. However in 10 patients (13 ureteral units) treatment failed or reflux recurred a mean of 10 months after injection 2. The reflux-free period after injection 2 was prolonged compared to that after injection 1 (p <0.05).nnnCONCLUSIONSnOur results suggest that repeat endoscopic subureteral bovine collagen injections prolong the reflux-free period but remain ineffective at long-term followup for correcting vesicoureteral reflux.

Impaired Bone Metabolism following Augmentation Cystoplasties in Growing Rats

Objective: The aim of this study was to evaluate the possible risk of impaired bone metabolism following augmentation cystoplasties with different gastrointestinal segments.Method: 60 young rats underwent augmentation cystoplasties using gastric, ileal or sigma segments, or sham operations. An additional group undergoing sigma–cystoplasty received the bisphosphonate ibandronate to inhibit osteoclast–mediated bone resorption. Bone mass in the lumbar spine and tibia was analyzed monthly by in vivo densitometry. Bone turnover was assessed monthly using current bone metabolism markers for a period of 16 weeks. Bone ashing and serum analyses of the osteotropic hormones parathyroid hormone (PTH), and 25–OH vitamin D3 were performed at study conclusion.Results: Following ileocystoplasty, reduced bone mineral density (BMD) was seen throughout the observation period; this was pronounced in the trabecular bone. The decline in BMD was associated with decreased serum 25–OH vitamin D3 levels. Following sigmacystoplasty, bone calcium content was significantly decreased; this could be prevented by ibandronate. No skeletal changes occurred in the gastrocystoplasty group. Serum pH was not altered in any group, and markers of bone resorption indicated normal bone resorption rates.Conclusion: There is a significant correlation between impaired bone metabolism and the type of segment used for bladder augmentation. While the use of the ileum (and probably the colon too) causes osteopenia, gastrocystoplasties seem to have little influence on bone turnover.

Transurethral Incision of the Prostate Following Renal Transplantation

Urinary retention in male patients after renal transplantation may cause serious complications in terms of graft function and even patient survival. Only few data concerning the management and outcome of these patients are reported in the literature. Therefore, we retrospectively analyzed the outcome of patients who underwent transurethral incision of the prostate immediately after renal transplantation. Between 1990 and 1993, we performed 259 renal transplantations and 15 patients had symptoms of urinary retention postoperatively. These patients underwent a midline transurethral incision of the prostate from the bladder neck to the verumontanum. Median peak flow preoperatively was 7 ml. per second (range 0 to 11.4) and median residual urine volume was 100 ml. (range 30 to 500). Median prostate volume was 28 ml. (range 12 to 45). After transurethral incision of the prostate a significant improvement (p < 0.001) in peak flow rates (19.6 ml. per second, range 8 to 49) as well as a significant decrease in residual urine volumes (40 ml., range 20 to 80) could be achieved. After a median followup of 19 months the effect was still present.

Ergebnisse der endoskopischen Refluxtherapie mit bovinem Kollagen

ZusammenfassungZiel der Untersuchung: Erfassung der Langzeitergebnisse der endoskopischen subureteralen Kollageninjektion bei vesikoureteralem Reflux (VUR).nMaterial und Methode: Untersucht wurden prospektiv 86 Patienten (Durchschnittsalter 8 Jahre) mit 128 refluxiven ureterorenalen Einheiten (URU). Alle Patienten wurden mit subureteraler Kollageninjektion behandelt und mittels Miktionszysturethrographien oder videourodynamischen Untersuchungen nachbeobachtet.nErgebnisse: Bei 128 URU wurden 157 subureterale Kollageninjektionen durchgeführt. Dies beinhaltet 27 Zweitinjektionen und 2 Drittinjektionen. Bei 65 behandelten URU lag ein primärer, bei 19 URU ein sekundärer Reflux vor. Bei 28 URU lag ein sekundärer Reflux infolge einer neurogenen Blasenfunktionsstörung vor, 7 URU wurden nach erfolgloser offen-chirurgischer Antirefluxplastik mit Kollageninjektionen behandelt, 9 URU bei Ureter duplex. Nach einer Nachbeobachtungszeit von 24 Monaten fand sich ein Refluxrezidiv bei 83% der URU nach primärem Reflux, bei 56% der URU nach sekundärem Reflux, bei 85% der URU nach Reflux bei neurogener Blasenfunktionsstörung, bei 67% der URU nach Reflux im Rahmen eines Ureter duplex und bei 34% nach zuvor fehlgeschlagener offen-chirurgischer Antirefluxplastik. Nach Zweitinjektion waren nach einer Nachbeobachtungszeit von 24 Monaten noch 35% der Patienten refluxfrei.nBeurteilung: Aufgrund dieser Daten halten wir die subureterale Kollageninjektion im Langzeitverlauf für nicht geeignet, vesikoureterale Refluxe dauerhaft zu beseitigen.AbstractPurpose: This study has been conducted to evaluate the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injections for endoscopic treatment of vesicoureteral reflux (VUR).nMethods: We prospectively studied 86 patients (mean age 8 years) with 128 refluxing ureteral units. All patients were treated with subureteral collagen injections and were followed up by voiding cystographies or videourodynamic evaluation.nResults: 157 subureteral collagen injections have been performed on 128 ureteral units. This includes 27 second injections and 2 third injections. In 65 ureteral units a primary VUR was present, in 19 a secondary VUR. 28 ureteral units presented with secondary reflux due to neurogenic bladder dysfunction. 7 ureteral units were treated with subureteral collagen injections after the VUR persisted following open surgical reimplantation, in 9 ureteral units a double ureter was present. After a follow up of 24 months a reflux recurrence was observed in 83% of ureteral units with primary VUR, in 56% of ureteral units with secondary VUR, in 85% of ureteral units with VUR due to neurogenic bladder dysfunction, in 67% of ureteral units of double ureters and in 34% of ureteral units after open surgical reimplantation. After a second injection and a follow up of 24 months 35% of patients remained reflux free.nConclusion: Our results suggest, that endoscopic subureteral bovine collagen injections remain ineffective in the long term follow up to correct VUR.