P. Alken

Alterations of Cortical Electrical Activity in Patients with Sacral Neuromodulator

OBJECTIVESnSacral neuromodulation represents chronic stimulation of the sacral (S3) nerve. So far, the mode of action and neuro-anatomical basis is unclear. Sacral reflex mechanisms as well as pontine or cortical centers of modulation have been postulated. Our aim was to evaluate possible alterations in electroencephalogram (EEG) activity as an indicator of a supraspinally mediated mechanism of sacral neuromodulation.nnnMATERIALS AND METHODSnWe analyzed serial EEGs (apparatus: Kölner Vitaport System) using electrodes placed at Fz, Cz, Cz and Pz in 10 patients. Subsequently, the sacral (S3) nerve was stimulated by means of an impulse generator (Medtronic, Interstim 3023) using an on-off paradigm with a 1.5s on interval followed by a 10s stimulation break. Raw data were analyzed using both Matlab 4.0 software and a specially developed averaging routine.nnnRESULTSnAll patients demonstrated a cortical potential complex following sacral root stimulation with an early electronegative component at 50 ms with a mean amplitude of 23 microV followed by a late potential component with a mean latency of 253 ms and a mean amplitude of 5 microV, both with a maximum at Cz, corresponding to the post-central gyrus. This finding occurred irrespective of patients reports of actually feeling the neuromodulator being switched on and off.nnnCONCLUSIONnIn neuromodulation responders, both short and long latency cortical potentials can be reproduced with a maximum at the sensory cortical area. Although these potentials are similar to cognitively mediated event-related potentials, they are clearly distinct from any subjective sensory or even painful response since several patients of this series have not been able to feel any neuromodulator action. Therefore, this pilot study indicates a supraspinally mediated site of modulation, most probably in sensory cortex areas.

Treatment of penile curvature with Essed-Schröder tunical plication: aspects of quality of life from the patients' perspective

To investigate retrospectively the long‐term functional results and quality of life of patients undergoing the Essed‐Schröder procedure (a simple plication of the tunica albuginea) to correct penile deviation, using a standardized questionnaire.

Methylene Blue as a Successful Treatment Alternative for Pharmacologically Induced Priapism

Objective: Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation. Etiologies of this condition are numerous. Treatment of priapism varies from a conservative medical to a drastic surgical approach. Recent findings indicate methylene blue (MB), a guanylate cyclase inhibitor, to be a potential inhibitor of endothelial–mediated cavernous relaxation. This prompted us to assess the feasibility, use and effectiveness of MB in the treatment of priapism. Methods: 12 patients were treated for priapism. Etiologies were: 10 drug–mediated (PGE1 or papaverine/phentolamine mixture) after corpus cavernosum injection therapy (CCIT); 1 leukemia–induced, and 1 idiopathic high–flow priapism. The age range for all patients was 13–67 years, the average duration of priapism was 5.5 h after CCIT. MB was administered after blood aspiration of the corpora cavernosa. 5 ml of MB was injected intracavernously (i.c.) and left for 5 min. MB was then aspirated and the penis compressed for an additional 5 min. Results: All patients with CCIT–induced priapism were cured with MB alone. The 2 patients who did not respond to MB underwent i.c. phenylephrine administration and embolization of the pudendal artery, respectively. The etiology and duration of priapism were the strongest predictors for success with i.c. administered MB. The primary side effects were a transient burning sensation and blue discoloration of the penis on injection of MB. The initial baseline erectile status was restored in all patients cured by MB. Conclusion: These results confirm that MB is a safe and highly effective treatment agent for short–term pharmacologically induced priapism. The application of MB shows virtually no significant side effects compared to the systemic and local complications induced by α–adrenergic agonists.

Chronische sakrale bilaterale Neuromodulation Einsatz einer minimalinvasiven Implantationstechnik bei Patienten mit Blasenfunktionsstörungen

ZusammenfassungIn der Literatur werden die Misserfolgsraten mit der von Tanagho und Schmidt beschriebenen unilateralen Stimulation mit bis zu 50% angegeben. Zur Verbesserung der Modulationseffektivität und besseren Elektrodenplatzierung und Fixation führen wir eine minimale sakrale Laminektomie mit bilateraler Elektrodenplatzierung durch.Bei insgesamt 20 Patienten wurde nach erfolgreichem PNE-Test (periphere Nervenevaluierung) ein sakraler Neuromodulator mit bilateraler Elektrodenplatzierung implantiert. Zur besseren Elektrodenplatzierung und Fixierung wurde eine minimal-invasive Laminektomie durchgeführt.Bei den Patienten mit Detrusorinstabilität reduzierten sich die Inkontinenzepisoden von durschnittlich 7,2 auf 1 pro Tag, die Blasenkapazität stieg von 198 auf 352 ml. Bei den Patienten mit hypokontraktilem Detrusor reduzierten sich die Restharnwerte von 450 auf 108 ml. Der maximale Detrusorkontraktionsdruck während der Miktion stieg von 12 auf 34 cm H2O.Mit der bilateralen sakralen Neuromodulation und mit der von uns entwickelten Implantationstechnik sind optimale Ergebnisse bei Patienten mit therapierefraktären Detrusorinstabilitäten und Patienten mit hypokontraktilem Detrusor zu erzielen.AbstractThe implantable neuromodulation system described by Tanagho and Schmidt enables unilateral sacral nerve stimulation. Reports have been made on sacral neuromodulation failures of up to 50% in patients undergoing this procedure. We chose the bilateral electrode implantation and a minimal invasive laminectomy to ensure a more effective modulation and better placement and fixation of the electrodes.After successful assessment using a peripheral nerve evaluation test, 20 patients (14 with detrusor instability, 6 with hypocontractile detrusor) underwent minimally invasive laminectomy and bilateral electrode placement. In the patients with detrusor instability, the incontinence episodes were reduced from 7.2 to 1 per day and the bladder capacity improved from 198 to 352 ml. In patients with hypocontractile detrusor, the initial residual urine level of 450 ml dropped to 108 ml. Maximum detrusor pressure during micturition rose from 12 cmH2O initially to 34 cmH2O. The average follow up period was 17.5 months. There was no sign of deterioration in the modulation effect in any of the patients.Bilateral electrode implantation and the new sacral approach allow optimal neuromodulation in patients with bladder dysfunction. Laminectomy enables optimum electrode placement and fixation with minimal trauma.

[Hans-Christian Jacobaeus (1879-1937): The inventor of human laparoscopy and thoracoscopy].

ZusammenfassungIm Jahre 1910 führte der schwedische Internist Hans-Christian Jacobaeus den ersten laparoskopischen Eingriff am Menschen in Stockholm durch. Grundlage seiner Pioniertat waren die tierexperimentellen Studien von Georg Kelling (1866–1945) aus Dresden, der im Jahre 1901 die erste Laparoskopie mittels eines Nitze-Zystoskops am Hund durchführte. Jacobaeus veröffentlichte 1910 in der Münchener Medizinischen Wochenschrift seine Erfahrungen mit den ersten 17 Laparoskopien unter dem Titel: „Über die Möglichkeit die Zystoskopie bei Untersuchungen seröser Höhlen anzuwenden“.Hierbei nutzte er die neue Technik insbesondere zu diagnostischen Zwecken bei unklaren abdominellen Beschwerden und Funktionsstörungen. Er war auch der Erste, der explizit auf die Gefahr der Darmverletzung bei Eröffnung der Bauchhöhle im Rahmen der Einführung der Optik hingewiesen hat. Er erkannte damals bereits die immensen diagnostischen und therapeutischen Möglichkeiten, aber auch ihre Schwierigkeiten und Grenzen. Die Absolvierung von Trainingseinheiten an Tieren und Leichen wurde von ihm ebenso erkannt, wie die Notwendigkeit spezielle laparoskopische Instrumente zu konstruieren um den Eingriff zu optimieren und zu erleichtern.AbstractAlready 94xa0years ago in 1910, Dr. Hans Christian Jacobaeus performed the first clinical laparoscopic surgery in Stockholm. His pioneering procedure was based on the animal experiments of Georg Kelling (1866–1945), a German physician from Dresden, who performed the first laparoscopic intervention in 1901 using a Nitze cystoscope in a dog. In 1910 Jacobaeus published his first experiences with laparoscopic surgery in the Münchner Medizinische Wochenschrift under the title “The possibility to perform cystoscopy in examinations of serous cavities.” He used this technique for diagnostic purposes in unclear abdominal complaints and functional impairment.Jacobaeus was the first who pointed out the possibility of causing injury to organs, especially the gut, by inserting the trocar. In 1910 Jacobaeus recognized the immense diagnostic and therapeutic possibilities of laparoscopic surgery, but also the difficulties and limits. He also was the first who recognized the need to complete training sessions on animals and corpses. He demanded the development of special laparoscopic instruments to optimize and simplify the operation.

[Georg Kelling (1866-1945): the man who introduced modern laparoscopy into medicine].

ZusammenfassungDer Dresdner Gastroenterologe und Chirurg Georg Kelling (1866–1945) führte am 23. September 1901 in Hamburg an einem Hund eine Bauchspiegelung mit einem Nitze-Zystoskop durch. Dies war die Geburtsstunde der Laparoskopie.Kelling befasste sich bereits im Rahmen seiner Doktorarbeit mit der Anatomie und Physiologie des Magen-Darm-Traktes. Aufgrund dieser Erfahrungen und seinen Erkenntnissen über die abdominelle Luftinsufflation entwickelte er als Erster die von ihm als „Coelioskopie „ bezeichnete Methode. Er formulierte in diesen Pioniertagen der Laparoskopie bereits verschiedene Grundthesen, die auch heute noch Bestand haben, und zeigte erstaunliche visionäre Fähigkeiten. Seine endoskopische Pionierleistung ist bisher kaum gewürdigt worden.Die heutige Laparoskopie basiert auf der wissenschaftlichen Arbeit Kellings und bestätigt seine Forderungen in nahezu allen Punkten. Daher verdient sein Name einen festen Platz in der Geschichte der Endoskopie.AbstractOn 23 September 1901, Georg Kelling (1866–1945) from Dresden performed a celioscopy with a Nitze cystoscope on a dog in Hamburg. This was the beginning of the era of laparoscopy.His doctoral thesis already reflected his early interest in the anatomy and physiology of the gastrointestinal tract. This experience, together with his knowledge on air insufflation of the abdomen, enabled him to be the first to develop the procedure he named “celioscopy.” During this pioneer time of laparoscopy, he developed various basic principles that are still valid today and demonstrated astonishingly visionary skills.Although his pioneering achievements have hardly been acknowledged to this day, modern laparoscopy has confirmed Kelling’s visions and scientific work in almost all aspects. His name and achievements have most definitely earned a place in the history of endoscopy.

Sakrale Neuromodulation in der Behandlung von Funktionsstörungen des unteren Harntrakts

ZusammenfassungWährend der letzten Jahre hat sich die sakrale Neuromodulation zu einer etablierten Behandlungsmöglichkeit von Funktionsstörungen des unteren Harntraktes entwickelt. Sie füllt damit eine Lücke zwischen konservativen Therapieoptionen und aufwändigen invasiven Verfahren, wie z.xa0B. der Harnableitung über ein ausgeschaltetes Darmsegment.Am Anfang war die klinische Wertigkeit der sakralen Neuromodulation selbst unter Neurourologen umstritten. Die Ursachen hierfür lagen in der unzureichenden Kenntnis über die physiologischen Abläufe und Prinzipien des Wirkmechanismus, der unsicheren Indikationsstellung, dem Design der Hardware und einem Operationsgebiet mit einer den meisten Urologen relativ unbekannten Topographie. Mittlerweile ist die sakrale Neuromodulation jedoch ein fest integrierter Bestandteil der klinischen Routine bei der Behandlung von Funktionsstörungen des unteren Harntraktes geworden und wird regelmäßig in den verschiedenen urologischen Institutionen in Europa und den USA angewandt.Aufgrund neuer Modifikationen kann diese Therapieform bei Patienten, die sich nach vielen frustranen Behandlungsversuchen am Ende der Fahnenstange glaubten, z.xa0T. auch ambulant erfolgreich durchgeführt werden. Neueste Daten aus unserer Klinik, sowie Beiträge zum DGU-Kongress 2002 in Wiesbaden zeigen die Tendenz auf, dass Patienten mit einer neurogenen Harnretention am besten von dieser Behandlungsmöglichkeit profitieren.AbstractOver the last few years, sacral neuromodulation has become an established treatment option for dysfunctions of the lower urinary tract. It fills the gap that used to exist between conservative therapy and costly invasive methods such as urinary drainage via a deactivated bowel segment.Initially, the clinical value of sacral neuromodulation was controversial even among neurourologists. This was mainly due to a lack of understanding of the physiological processes, uncertain diagnostics, the design of the hardware, and a surgical topography relatively unknown to the urologist. In the meantime, however, sacral neuromodulation has become a standard part of clinical routine with respect to the treatment of dysfunctions of the lower urinary tract, and it is regularly employed in various urological institutions across Europe and the USA.This form of treatment, which is the final straw for patients who believed themselves—after many frustrated therapy attempts—to be hopeless cases, can now also successfully be employed as an ambulatory measure. The latest data from our hospital, as well as contributions presented at the last DGU Congress in Wiesbaden, indicate that patients with neurogenic urinary retention are the most likely to profit from this treatment option.

Rotoresect for bloodless transurethral resection of the prostate: a 4-year follow-up

To report the results and long‐term follow‐up of transurethral resection of the prostate (TURP) with a new resection device, the Rotoresect (Karl Storz, Tuttlingen, Germany).

Stimulation signal modification in a porcine model for suppression of unstable detrusor contractions

OBJECTIVESnTo investigate, in an experimental study, the efficacy of a different stimulation signal in a porcine model to suppress formalin-induced unstable detrusor contractions. The current mode of stimulation in peripheral nerve evaluation tests and sacral neuromodulation is based on rectangular signal shapes. Published reports, however, have revealed that up to 80% of patients do not respond to peripheral nerve evaluation stimulation.nnnMETHODSnAfter placement of electrodes at S3 in 12 anesthetized Göttinger minipigs, unstable contractions were induced by intravesical instillation of formalin. Ten-minute stimulation phases with a quasi-trapezoidal signal and a rectangular signal followed. An interval of 30 minutes elapsed between the two series of stimulations. The pressure values were registered on a urodynamic unit and evaluated as contractions and amplitudes per minute. Six minipigs were treated in the same way but were not stimulated and served as the control group.nnnRESULTSnAfter formalin instillation, the average number of involuntary detrusor contractions was 3.5/min (+/- 0.8) and the sum of amplitudes was 7.2/min (+/- 1.1). Subsequent NaCl instillation and quasi-trapezoidal stimulation reduced the contractions to 0.3/min (+/- 0.3) and the sum of amplitudes to 0.8/min (+/- 0.4). A contraction rate of 1.1/min (+/- 0.1) and a sum of amplitudes of 5.1/min (+/- 2.4) were recorded under stimulation with a rectangular signal. In the control group, no significant reduction was recorded.nnnCONCLUSIONSnThe acquired data demonstrate that quasi-trapezoidal stimulation suppresses unstable detrusor contractions in the minipig more effectively than does conventional rectangular stimulation as presently applied in sacral neuromodulation.

Improved sacral neuromodulation in the treatment of the hyperactive detrusor: signal modification in an animal model.

To investigate different stimulation signals for the peripheral nerve evaluation test (PNE, carried out before implanting a sacral neuromodulator for functional voiding dysfunction) in an animal model and to determine their efficacy, as up to 80% of patients do not respond to the PNE test.