M. Horstmann

Evaluation of the anti-peristaltic effect of glucagon and hyoscine on the small bowel: comparison of intravenous and intramuscular drug administration

PurposeTo evaluate prospectively duration and effectiveness of aperistalsis achieved by glucagon(GLU) or hyoscine N-butylbromide(HBB) following various administration routes.Materials and methodsSix volunteers underwent Magnetic Resonance Imaging (MRI) after standardized oral preparation in random order five separate MR examinations with both spasmolytic agents (HBB intravenous(i.v.) or intramuscular(i.m.), GLU i.v. or i.m., and a combined scheme). The MR protocol included a sagittal 2D cross-section of the small bowel with a temporal resolution of 0.55xa0s acquired over 60 to 90xa0min. To quantify bowel motility, small bowel cross-sectional areas were summated over time.ResultsThe anti-peristaltic i.v. effects of HBB and glucagon started on average after 85xa0s/65xa0s and ended after 21xa0min/23.3xa0min, respectively. By comparison, the anti-peristaltic effects of i.m. HBB and glucagon started significantly later 5.1/11.6xa0min (Pu2009=u20090.001; Wilcoxon signed ranks test) and lasted for 17.7/28.2xa0min with greater inter-individual differences (Pu2009=u20090.012; Brown-Forsythe test). The combined scheme resulted in a rapid onset after 65xa0s with effect duration of 31xa0min.ConclusionAnti-peristaltic effects on the small bowel are drug dependant, i.e., their onset is faster and more reliable when administering i.v. than i.m.. Combining i.v. GLU with i.m. HBB provides an early onset of effect, sustained spasmolysis and the highest degree of motility impairment.Key Points• Anti-persitaltic agents are widely used before various diagnostic procedures of the abdomen.• The combination of iv-glucagon with im-hyoscine provides reliable spasmolysis with early onset.• Intravenous spasmolysis is more reliable compared to intramuscular administration.• Intravenous glucagon has a prolonged spasmolytic effect compared to intravenous hyoscine.

Clinical experience with survivin as a biomarker for urothelial bladder cancer

ObjectivesThis study was carried out as a prospective pilot study to evaluate the potential of survivin mRNA measurement in patients suspicious for urothelial bladder cancer (BC). Data were also analyzed for possible influences of secondary urological findings on survivin measurements.MethodsSurvivin was measured by an mRNA assay in voided urine samples of 50 patients with suspicion of new or recurrent BC prior to transurethral resection. Sample evaluation was possible in 49 cases. Histopathology revealed no malignancy in 17 (35%) and BC in 32 (65%) patients. Survivin mRNA was quantitated by real-time PCR from frozen cell pellets of centrifuged urine samples. A ROC analysis of the survivin data was performed.ResultsROC analysis identified the best cut-off level at 10,000 mRNA copies, resulting in a sensitivity of 53% and a specificity of 88%. Seven of the 20 pTa tumors (35%), all four pT1 (100%) and all four muscle-invasive tumors (100%) were detected. Of four patients with carcinoma in situ (Cis), 50% could be identified. Only two patients (4%) were assessed as false positive. Histologically confirmed cystitis and concomitant urological findings (inflammatory cells in urine, microhematuria and others) had no detectable influence on survivin measurements.ConclusionIn present group of patients, survivin was a reliable biomarker for high-grade urothelial BC (sensitivity 83%), but not for low grade (sensitivity 35%) urothelial BC with a high specificity (88%). No confounders influencing the results of survivin measurements could be identified.

Single-centre evaluation of the extraperitoneal and transperitoneal approach in robotic-assisted radical prostatectomy

Abstract Objective. Robotic-assisted radical prostatectomy (RARP) is feasible using either an extraperitoneal (EP) or a transperitoneal (TP) approach. This study reports on the experience of a single hospital using both techniques. Material and methods. From July 2009 to March 2011, 170 patients underwent RARP. EP was chosen in 103 patients and TP in 67. TP was preferred in cases previous mesh hernia repair or if extended lymph-node dissection (LND) was considered necessary. Otherwise, EP was performed; it was preferred in cases of obesity (body mass index (BMI) > 30kg/m2)) or previous intra-abdominal surgery. Results. There were no significant differences in preoperative mean age (64.4 vs 65.6 years), BMI (26.5 vs 26.3 kg/m2) or prostate size (51.8 vs 55.8 cm3) between EP and TP patients. Owing to preoperative selection criteria, prostate-specific antigen levels and the average Gleason score were significantly lower in EP than in TP patients (p < 0.001). Whereas access time and time for anastomosis did not differ significantly (21 vs 19 min, p = 0.11, and 26 vs 24 min, p = 0.36, respectively), overall surgical time was significantly longer in TP (225 vs 191 min, p < 0.001). Blood loss was equal in both groups (EP 276 vs TP 281 ml, p = 0.88). Complication rates were lower in EP (n = 7, 6.8% vs n = 8, 12%, p = 0.024). Time until first defecation and last analgesic treatment were significantly shorter in EP (p < 0.05). Conclusions. The results of the current evaluation underline the clinical advantages of an extraperitoneal approach for RARP. However, a transperitoneal approach is still considered necessary for extended LND or special clincial conditions. Robotic teams should be trained using both approaches.

Influence of age on false positive rates of urine-based tumor markers

IntroductionSeveral influencing factors on false positive rates (FPRs) of urine-based tumor markers in the detection of urothelial cancer (UC) have been identified. We evaluated age as a possible influencing factor.MethodsUrinary cytology (Cyt), UroVysion (FISH), ImmunoCyt (uCyt+) and NMP22 were determined in 1,554 patients suspicious for UC of the bladder before cystoscopy and in case of cancer detection before TURB. Additionally, upper urinary tract imaging was performed. Maker sensitivity, specificity and FPRs were evaluated in the entire cohort and in subgroups divided by age into <50, ≥50–70 and ≥70xa0years. Contingency tables and the Cochrane Armitage tests were used for statistical comparisons.ResultsUC was found in 377 and no UC in 1,177 (75xa0%) patients. A total of 336 patients were diagnosed with UC of the bladder and 41 with UC of the upper urinary tract. Overall sensitivity and specificity for Cyt were 82 and 82xa0%: for FISH, 73 and 79xa0% and for uCyt+, 79 and 75xa0%, respectively. For NMP22, regardless of the exclusion criteria they were 72 and 34xa0% and after exclusion of urinary tract infection (UTI) or prior to manipulation 46 and 86xa0%, respectively. Significantly higher FPRs were found with increasing age for Cyt (pxa0=xa00.001), a trend to higher FPRs for uCyt+ (pxa0=xa00.11) and almost no difference for FISH (pxa0=xa00.63). For NMP22, differences became significant after exclusion of patients with UTI or prior manipulation (pxa0=xa00.02).ConclusionsThe results of the present study give evidence that false positive rates of Cyt and NMP22 increase with age indicating that age should be respected for their correct interpretation.

Laparoscopic radical cystectomy: initial experience using the single-incision triangulated umbilical surgery (SITUS) technique

IntroductionAs could be demonstrated for simple and radical nephrectomy, single-incision triangulated umbilical surgery (SITUS) is an interesting alternative to laparoscopic single-site surgery. We present our initial experience with the SITUS technique in radical cystectomy.Materials and methodsBetween September 2010 and September 2011, eight patients underwent SITUS radical cystectomy (SITUS Cx), pelvic lymph node dissection and extracorporeal urinary diversion. A cutaneous ureterostomy was performed in three, an ileum conduit in one and an ileal neobladder in four patients. Data were collected prospectively, including patients’ characteristics, intraoperative parameters, pathological stage and postoperative outcome.ResultsMean age of the patients was 67xa0years and the mean body mass index 24xa0kg/m2. SITUS Cx was successfully completed in all patients without conversion to conventional laparoscopic or open surgery. Mean surgical time was 434xa0min and mean estimated blood loss 643xa0ml. No major intra- or postoperative surgical complications occurred. All patients recovered quickly reporting low postoperative pain levels. Mean hospital stay was 16 (7–24xa0days). Histopathological evaluation revealed a mean of 16 (6–33) retrieved lymph nodes and no positive margins.ConclusionIn the present experience, SITUS Cx proved to be feasible with surgical outcome comparable to conventional techniques. Because SITUS Cx combines the advantages of traditional laparoscopy (straight instruments and triangulation) with those of single-port surgery (superior cosmesis and minimal invasiveness), it presents an attractive alternative to other minimally invasive techniques.

Pre- and Postoperative Urodynamic Findings in Patients After a Bulbourethral Composite Suspension with Intraoperative Urodynamically Controlled Sling Tension Adjustment for Postprostatectomy Incontinence

OBJECTIVESnTo compare pre- and postoperative urodynamic findings in patients with a bulbourethral composite suspension and intraoperative urodynamically controlled sling tension adjustment.nnnMETHODS AND PATIENTSnAll data were prospectively collected from 10 patients (mean age 66 years) who successfully underwent bulbourethral composite suspension for moderate to severe postprostatectomy incontinence. Patients were evaluated preoperatively and 3-6 months postoperatively by urodynamic measurements, including urethra pressure profiles (UPPs) and pressure flow studies (PFSs). Clinical outcome was evaluated by patient-reported pad use and questionnaires (ICIQ-UI SF and I-QOL). Intraoperatively sling tension was adjusted under repeated urodynamic measurements of abdominal leak point pressure. Data were evaluated using the Kruskal-Wallis Wilcoxon test.nnnRESULTSnSling implantation was successful in all patients. Pre- to postoperative pad use decreased significantly (P < .005). Five patients were pad-free, 3 used 1 pad, and 2 used 2 pads per day. Continence and quality of life improved significantly (ICIQ-UI SF: pre-op 17 vs post-op 4.9; I-QOL: pre-op 66 vs post-op 91; P < .05 for both). Urodynamic parameters during the filling phase remained unchanged. UPPs revealed a significant increase of the maximal urethral closure pressure (pre-op 40 cm H(2)O vs post-op 58 cm H(2)O) and functional length (pre-op 31 mm vs post-op 40 mm; P < .05 for both). Postoperatively, urodynamic maximal flow rates were slightly reduced from 16 mL/s to 12 mL/s (P = .4). PFSs revealed an unobstructed voiding in all patients.nnnCONCLUSIONSnAccording to the present evaluation, a bulbourethral composite suspension with intraoperative urodynamically controlled sling tension adjustment improves continence without causing prolonged clinically or urodynamically significant voiding obstruction.

Complications of a buried penis in an extremely obese patient

The buried penis syndrome in adults is a rare condition of different aetiologies. Today extreme obesity is considered as a major contributor. We present a case of a 30‐year‐old extremely obese patient (BMI 65u2003kg/m2) with purulent infection of the penile cavity, a phlegmon of the mons pubis and urinary retention due to a buried penis. Whereas acute complications of a buried penis in obese patients include local infection and urinary retention, chronic problems are undirected voiding, disturbed vaginal penetration and erectile dysfunction. Even though several surgical techniques are described, weight reduction should be primarily preferred.

Diagnostik von Urothelkarzinomen des oberen Harntrakts

Upper urinary tract transitional cell carcinomas represent 5-6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.ZusammenfassungUrothelkarzinome des oberen Harntrakts machen etwa 5–6% aller Urothelkarzinome aus. Die Makrohämaturie ist das häufigste Symptom, welches auf das Vorkommen dieses Tumors hinweist. Die primäre diagnostische Abklärung umfasst Anamnese, klinische Untersuchung, Zystoskopie, Urinzytologie, Sonographie und Ausscheidungsurogramm. Bei gegebenem Verdacht wird die retrograde Pyeloureterographie mit Abnahme der selektiven Urinzytologie durchgeführt. Die Ureterorenoskopie zur bioptischen Sicherung des Befunds ist bei zweifelhaften radiologischen Befunden oder vor geplanter konservativer Behandlung indiziert. Computertomographie und Magnetresonanztomographie sind zur Beurteilung der lokalen Ausbreitung von invasiven Tumoren und zur Metastasensuche geeignet. Die Anwendung von Harnmarkern bei der Diagnostik von Urolhelkarzinomen des oberen Harntrakts ist in prospektiven Studien zu evaluieren.AbstractUpper urinary tract transitional cell carcinomas represent 5–6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.

Comparison of standardized pre- and postoperative functional pelvic cine-MRI in patients with a bulbourethral composite suspension due to post-prostatectomy incontinence.

ObjectivesTo compare functional pelvic cine-MRI in patients with post-prostatectomy incontinence before and after implantation of a bulbourethral composite suspension.Patients and methodsFunctional pelvic 1.5 T cine-MRI was performed at rest, under standardized Valsalva pressure and during micturition in six patients with post-prostatectomy incontinence before and 3xa0months after a bulbourethral composite suspension. Visibility and positioning of the implant as well as membranous urethral length (MUL) and positioning of the bladder neck (BN) in comparison with the pubococcygeal line (PCL) were evaluated. Clinical outcome was measured by patient-reported pad use and standardized questionnaires (ICIQ-UI SF and I-QOL). Paired data were tested with a Wilcoxon signed-ranks test.ResultsSurgery was successfully performed in all patients. All patients returned to complete voiding. The ICIQ-UI SF score decreased significantly from median 16.5 to 5 (pxa0=xa00.016). I-QOL increased significantly from 70.5 to 93.5 (pxa0=xa00.047). Pad use improved from median 2 pads to 0 pads postoperatively (pxa0=xa00.031). Four of six patients were completely pad-free, and 2 were failures with persisting urinary incontinence. MRI revealed significant differences of the MUL at rest with median of 8xa0mm pre- and 13xa0mm postoperatively (pxa0=xa00.016). BN showed a significant elevation with respect to PCL under Valsalva with in median 0.5 to 5xa0mm postoperatively (pxa0=xa00.016). No significant MRI differences were found between patients showing clinical success or failure.ConclusionsThe bulbourethral composite suspension was associated with an increase in urethral length, urethral coaptation zone and bladder neck elevation, implying a non-compressive mode of action.

Successful Removal of a 3.6-cm Long Metal Band Used as a Penile Constriction Ring

INTRODUCTIONnPenile constriction rings are either used for autoerotic stimulus or to increase sexual performance. Potentially, they can become irremovable and cause urologic emergencies.nnnAIMnWe describe the successful removal of a 3.6-cm long piece of heavy metal tubing used as a penile constriction ring.nnnMETHODSnAn angel grinder was used to open the metal tubing on both lateral sides. During the cutting procedure, the soft tissue parts were protected by two metal spatulas. Wet towels and cool running water prevented thermal injury.nnnRESULTSnAfter removal of the band, no iatrogenic injury was visible and the further recovery of the patient remained uneventful. Postoperatively, one of the surgeons suffered from conjunctivitis of the left eye possibly due to metal sparks.nnnCONCLUSIONnDepending on the constricting object, heavy-duty technical equipment might become necessary for their removal. In such cases, special care should be taken to avoid injury to the patient and the medical crew.