Moritz Braun

The prevalence of Peyronie's disease: results of a large survey

Objectives To determine the prevalence of Peyronies disease, a localized connective tissue disorder of the penile tunica albuginea, the symptoms of which include palpable plaque, painful erections and curvature of the penis, in a large sample of men in Germany.

Lower Urinary Tract Symptoms and Erectile Dysfunction: Co-Morbidity or Typical “Aging Male” Symptoms? Results of the “Cologne Male Survey”

OBJECTIVES Due to demographic developments in industrial nations, age-correlated diseases are becoming more important. From many epidemiological studies we know that the prevalence of benign prostatic hyperplasia (BPH) and the loss of erectile function (= erectile dysfunction or ED) increase with advancing age. Are these two illnesses related or/and independent? METHODS We mailed our newly developed and validated questionnaire on male erectile dysfunction (KEED), as well as a set of questions pertaining to voiding problems (IPSS), to a representative population sample of 8000 men from 30 to 80 years of age residing in the city of Cologne. RESULTS The responses included 4489 evaluable replies (56.1%). The response rates in the different age groups ranged from 41 to 61%. The mean age of the men who answered was 51.8 years. The overall prevalence of ED was 19.2% (n=862), with a steep age-related increase from 2 to 53%. Furthermore, 31.2% (n=1957) of all men complained of lower urinary tract symptoms (LUTS), the prevalence and the intensity of which increased with age. Interestingly, a high co-morbidity was found between ED and voiding problems. Prevalence of LUTS in men suffering from ED was about 72.2% (n=621) vs. 37.7% (1367) in men with normal erections. The odds ratio was evaluated with 2.11. The trivariate analysis showed that the occurrence of LUTS can be considered as an age-independent risk factor for the development of ED (p<0.001). CONCLUSIONS Even though the pathogenetic relationship between LUTS and ED is not yet completely understood, one has to postulate a direct association between these two typical symptom complexes in the aging male.

Effectiveness of Oral L-Arginine in First-Line Treatment of Erectile Dysfunction in a Controlled Crossover Study

Background and Aims: Relaxation of cavernous smooth muscle is a parasympathetic and non-adrenergic, non-cholinergic mediated process which requires nitric oxide (NO). NO is synthesized from L-arginine by NO synthase (NOS). Some studies report good clinical results under oral L-arginine medication in the treatment of erectile dysfunction. We examined the effectiveness and safety of L-arginine in the treatment of mixed-type impotence. Methods: 32 patients (mean age 51.6 years) with mixed-type impotence diagnosed according to the results of sexual history and urological examination were enrolled in a randomized, placebo-controlled, crossover comparison of an oral placebo with 3 × 500 mg L-arginine/day. A validated questionnaire (KEED) was used to define the grade of impotence with a score. The treatment consisted of two 17-day courses (50 tablets). After a 7-day washout period the patients who initially received the placebo for 17 days were switched to L-arginine and vice versa. We assessed the efficacy with the validated questionnaire at the end of each drug period. Results: 30 patients (94%) completed the whole treatment schedule. Five (17%) patients reported a significant improvement in erectile function at the end of the L-arginine phase and 6 (20%) patients after the placebo period. 17 (56%) patients showed little improvement with L-arginine and 13 (43%) with placebo. In 8 patients (27%) of the verum group there was either no change in the ED score or even a slight worsening. No statistical difference in the impotence scores were found. No drug-related adverse effects occurred with L-arginine treatment. Conclusion: Oral L-arginine 3 × 500 mg/day is not better than placebo as a first-line treatment for mixed-type impotence.

Results and 10-Year Follow-Up in Patients with Squamous Cell Carcinoma of the Penis

Penile malignancies are infrequent but represent a diagnostic and therapeutic challenge as patients tend to disregard early asymptomatic lesions of the disease. Due to the lack of studies involving large patient numbers, the therapeutic concepts for different stages of the disease could not be defined by prospective studies. Long-term results are rare. We present the therapeutic concepts and the 10-year results of our experience with 42 cases of penile carcinoma treated at our institution between 1973 and 1986. Therapy included radical circumcision in 10 cases, local excision of the tumor in 4, partial or total glandular resection in 6 patients, partial penectomy in 20, and total penectomy in 2 cases. Inguinal lymphadenectomy was performed initially in 14 cases with positive histology in 7 patients (50%). Complications included meatal stenosis in 8 cases (19%), urethral stricture in 1 case, death due to fulminant pulmonary embolism in 1 case and local infections in 2 cases. Follow-up of patients with initially nonmetastatic disease showed a progression to death in 4 of 35 patients (11.6%) with a mean survival of 30 (range 11.5–56) months, in patients with initial lymph node metastases progression to death occurred in 5 of 7 patients (71.4%) with a mean survival of 9.76 months (range 9 days to 24 months). Stage-related disease-specific 10-year survival rates are 100% for stages 0 and 1, 90.9% for stage 2, and 20% for stage 3, while no patient in stage 4 survived for 5 years. From our data we conclude that the single most important prognostic factor in the treatment of carcinoma of the penis is lymph node involvement. Therefore increased attention has to be paid to the recognition of early stages of this potentially curable disease.

Treatment of Benign Prostatic Hyperplasia through Transurethral Needle Ablation (TUNATM)

Following FDA clearance and the establishment of Medicare coverage, transurethral needle ablation (TUNA) has become an established and widely-adopted treatment method for BPH in the USA. Germany is lagging behind at present, though a change can also be recognized there. The lack of long-term data has often been criticized. This review presents an overview of clinical outcomes of TUNA, long-term results and patient selection criteria.

Sacral Colpopexy with Concurrent Burch Colposuspension in Patients with Vaginal Vault Prolapse

Introduction: Abdominal sacral colpopexy (SC) is one option in the management of vaginal vault prolapse. In patients who are additionally incontinent an anti-incontinence procedure such as a Burch colposuspension or pubovaginal sling is usually performed at the same time. For those patients undergoing SC who are continent there are no clear guidelines for the use of a ‘prophylactic’ anti-incontinence procedure. We describe our experience with SC and concurrent Burch colposuspension. Patients and Methods: 47 patients (mean age 65 years) underwent SC and concurrent Burch colposuspension. The preoperative diagnostic check-up included a validated questionnaire, clinical examination, urodynamic tests, ultrasound and colpocystorectography. Patients were also evaluated using Stress, Emptying, Anatomic, Protection and Instability (SEAPI) scores. All patients had a uterine or vaginal vault prolapse in combination with a cystocele, enterocele or rectocele. Thirty-three of 47 (70%) patients were continent and 14 (30%) incontinent. Nineteen (40%) of the 33 ‘continent’ patients were found to have occult incontinence. Clinical examination according to the Halfway system showed 9 of 47 (19%), 21 of 47 (45%) and 17 of 47 (36%) patients with grade 2, 3 and 4 vaginal vault prolapse, respectively. Thirty-five of 47 (74%) patients demonstrated a grade-4 cystocele and 12 of 47 (26%) a grade-3 cystocele. The mean follow-up was 34 months and included a questionnaire (SEAPI), clinical examination and ultrasound. Results: Postoperative SEAPI scores showed a statistically significant improvement in all SEAPI domains (p < 0.001). Ninety-four percent of the patients were satisfied, continent and would undergo the surgery again. Three patients were incontinent. No continent patient who underwent concurrent Burch colposuspension had obstructive symptoms or residual urine. Five patients (11%) who had dyspareunia preoperatively were free of this symptom postoperatively. Complications were: dilatation of the upper urinary tract in 2 patients (4%) secondary to distal ureteric deviation by suturing the posterior peritoneum. One patient underwent psoas hitch neoureterocystostomy and 1 patient was successfully treated by insertion of a ureteric stent for 6 weeks. One patient (2%) had a mesh infection necessitating removal of the Gore-Tex mesh. Conclusions: Sacral colpopexy provides good patient satisfaction, durable pelvic support and restores vaginal function. Due to excellent continence rates concurrent Burch colposuspension should be considered as a joint procedure even in continent patients.

Cryoablation of Localized Prostate Cancer

Objectives: As the first German center to perform perineal cryoablation of localized prostate cancer, we present our experience in a series of 48 consecutive patients. Methods: 7 patients staged T1, 21 with T2 disease and 20 patients with T3 tumor were treated. 62.5% of the patients received neoadjuvant hormonal downsizing. Follow-up ranged from 4 to 27 months with a median of 15 ± 5.7 months. Results: Positive control biopsies after 6 months were obtained in 0% of T1 tumors, 16.7% of T2 tumors and 26.7% of T3 tumors. Prostate-specific antigen persistence above 1 ng/ml was diagnosed in 14.3, 33.3, and 40%, respectively. Complications were acceptable. 22.9% of the patients had prolonged urinary retention, requiring transurethral resection in 5 patients (10.4%) to relieve obstruction. In 5 cases (10.4%) incontinence was found, in 2 of these patients mild urge incontinence declined over time, in 3 cases moderate to severe stress incontinence developed. Two of these patients were pretreated with radiotherapy. No fistulae were noted. Conclusions: Cryoablation of the prostate is not a substitution for radical prostatectomy but enables the surgeon to perform a radical curative procedure in patients unfit for other radical forms of treatment or unwilling to undergo these. Long-term follow-up and prospective studies are necessary to define the clinical significance of this procedure.

Giant Retroperitoneal Hemangiopericytoma with Paraneoplastic Gynecomastia

We report on a 38-year-old patient with a giant retroperitoneal hemangiopericytoma associated with bilateral paraneoplastic gynecomastia, which led to an almost uncontrollable hemorrhage on initial surgery due to the extreme hypervascularity of the process. After angiographic evaluation and superselective embolization, a complete surgical excision of a hemangiopericytoma weighing almost 1,000 g could be achieved. To reduce the risk of recurrence adjuvant radiotherapy with 49 Gy followed. Follow-up of 24 months showed no sign of recurrence on CT scans. To our knowledge this is the first reported case of hemangiopericytoma associated with a paraneoplastic syndrome. The literature and the therapeutic concepts are presented and discussed.

Transurethral Needle Ablation of the Prostate: An Alternative Minimally Invasive Therapeutic Concept in the Treatment of Benign Prostate Hyperplasia

Alternative minimally invasive methods treating benign prostate hyperplasia (BPH) have become more and more important. Transurethral needle ablation (TUNATM) has been demonstrated to be effective in both canine and the human prostate. The goal of our study was to prove the safety, feasibility and tolerance of this new procedure. In this prospective nonrandomized study, 33 patients underwent TUNATM-treatment. One, 3 and 6 months postoperatively, follow-up examinations were carried out assessing urodynamic parameters such as urinary flow rates, residual urine levels, and IPSS-scores. During the last visit additional cystomanometry and urethrocystoscopy were done. Six months postoperatively IPSS-score and residual urine volumes were decreased by 50% (range: 1–72%) and 75% (range: 12–97%). Improvement in maximum flow rate was 63% (range: 5–125%). No serious postoperative complications occurred. After a short ‘learning period’ most of the treatments where performed as an out-patient-procedure so the patients could leave the hospital without the need for indwelling catheters. The TUNATM appears to be a minimally invasive and safe out-patient procedure for the treatment of selected cases of BPH.

Penetration of Ampicillin and Sulbactam into Human Epididymis and Testis

SummaryUrologic refertilization microsurgery such as vaso-vasostomy or vaso-epididy-mostomy benefits from perioperative antibiotic prophylaxis. The ability of ampicillin and sulbactam to penetrate sufficiently into mixed epididymis or testis tissue was investigated in nine patients (bodyweights ranged from 58 kg to 92 kg, mean 77.3 kg) undergoing orchiectomy for testicular cancer or advanced prostatic cancer. Each patient received a single infusion of 3 g ampicillin/sulbactam (ratio 2 : 1) preoperatively for antibiotic prophylaxis. The concentrations of both components were determined in serum and in epididymis/testis tissue samples taken 30 min to 65 min after infusion. Ampicillin was determined by bioassay and sulbactam was determined by gas chromatography/mass spectrometry. Mean tissue concentrations of ampicillin were 38.5±15.9 mg/kg. Mean tissue concentrations of sulbactam at the same time were 19.8±5.2 mg/kg. Comparison of the tissue/serum ratios for both agents showed no significant difference. These values indicate that both compounds achieve high concentrations in the scrotal organs. The concentrations exceed the MIC (minimal inhibitory concentration) values of important bacterial pathogens such asStaphylococcus aureus involved in postoperative wound infections. The combination of ampicillin and sulbactam may be effective for perioperative prophylaxis in reconstructive scrotal urologic surgery.ZusammenfassungFür urologische mikrochirurgische Refertilisationen wie die Vaso-Vasostomie oder die Vaso-Epididymostomie ist eine perioperative antibiotische Prophylaxe notwendig. Die Penetrationsfähigkeit in Nebenhoden- und Hodengewebe von Ampicillin und Sulbactam wurde bei neun Patienten (Körpergewicht 59 kg bis 92 kg, Mittel 77,3 kg) untersucht, die sich einer Orchiektomie aufgrund eines Hodenkarzinoms oder fortgeschrittenen Prostatakarzinoms unterziehen mußten. Die Konzentrationen beider Substanzen wurden im Serum und in Proben aus Nebenhoden/Hodengewebe, die 30 bis 65 Minuten nach einer einzelnen präoperativen Kurzinfusion von 3 g Ampicillin/Sulbactam im Verhältnis 2:1 gewonnen wurden, bestimmt. Ampicillin wurde mittels Bioassay und Sulbactam mittels Gaschromatographie/Massenspektrometrie bestimmt. Die mittlere Gewebekonzentration von Ampicillin betrug 38,5 ± 14,2 mg/kg. Die entsprechende mittlere Gewebekonzentration von Sulbactam betrug 19,8 ± 5,2 mg/kg. Ein Vergleich der Gewebe/Serum Quotienten für beide Substanzen ergab keine signifikanten Unterschiede. Die gemessenen Werte zeigen, daß beide Substanzen hohe Konzentrationen in den Skrotalorganen erreichen. Diese Konzentrationen übersteigen die MHK-Werte (minimalen Hemm-Konzentrationen) der bei postoperativen Wundinfektionen bedeutsamen Erreger. Die Kombination von Ampicillin und Sulbactam scheint für eine präoperative antibiotische Einzeldosisprophylaxe bei rekonstruktiven skrotalen Eingriffen gut geeignet.