[Polypharmacy and medication review in the context of prehabilitation]. / Polypharmazie und Medikamentencheck im Kontext der Prähabilitation.

Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.

[Are there benefits for catheter valves for catheter-associated quality of life? : Results of an investigation in 427 catheter wearers with life-long indication]. / Hat eine Ventilversorgung Vorteile bei der katheterassoziierten Lebensqualität? : Ergebnisse einer Untersuchung an 427 Katheterträgern in lebenslanger Indikation.

BACKGROUND: In urology, a subset of patients with lifelong urine drainage are fitted with a catheter valve. Data on catheter-related quality of life (crqol) in this subset of patients are missing. AIM: Clarification of the whether there are advantages for valve-aided catheters in comparison with continuous urine drainage in catheter wearers with a lifelong indication. METHODS: In all, 357 patients with a catheter with lifelong indication of continuous urine drainage from a previous study were compared with 70 valve-aided patients. The crqol was evaluated by a validated assessment with 25 items and five domains. RESULTS: There were statistically more patients with a suprapubic catheter than with a transurethral indwelling catheter (73.4 vs. 54.4%, p = 0.005), significantly more patients with bladder voiding dysfunction (73.5 vs. 52.6%, p = 0.003) and significantly more patients with small catheter sizes (p = 0.001). Crqol was altogether slightly impaired with a median score of 4.2 (no impairment indicated by 5 points) in valve-aided patients, but crqol was more impaired in valve-aided patients compared to patients with continuous drainage (4.4 points, n. s.). Some items demonstrated more problems dealing with urinary urge in valve-aided patients, but catheter-related pain was more often worse in patients with continuous drainage. CONCLUSION: There is no clear evidence for an advantage of a catheter valve over a continuous urine drainage system. Thus, the decision regarding a catheter-valve system must be made individually according to the indication and the preferences of the patient.

[Quality of life for wearers of a suprapubic or transurethral bladder catheter as lifelong permanent care]. / Lebensqualität bei Trägern eines suprapubischen oder transurethralen Harnblasenkatheters als lebenslange Dauerversorgung.

BACKGROUND: The insertion of a Foley catheter (FC) or a suprapubic catheter (SPC) in lifelong intent is an intervention with significant complications, comorbidities and impact on the further life that has not yet been analyzed. METHODOLOGY: The analysis was based on a validated assessment of catheter-related QoL with 25 items in 5 domains and applied to patients with a Foley or suprapubic catheter in lifelong indication and with the catheter in place for at least 3 months. Assessment data were enriched with information on the type and diameter of the catheter as well as demographic data. RESULTS: Questionnaires from 357 patients (260 male, 97 female, 193 with suprapubic catheter, 162 with Foley catheter, 2 no information) were included in the study. Patients with a Foley catheter were significantly older than patients with a suprapubic catheter (78.9 ± 11.1 years vs. 74.4. ± 12.6 years, p < 0.001). The average QoL score was 4.1 points on a scale from 1 (maximum impairment of QoL) to 5 (no impairment of QoL) indicating a moderately negative impact on QoL. Scores below the average were mainly driven and accompanied by a fear of urine leakage, urine odor, painful catheter changes and urinary infections increasing with age. Additionally, patients were worried about negative effects on their daily life activities due to the catheter. These worries seemed to be more pronounced in females with urinary incontinence, patients with a catheter size ≥ 18 Ch. and with an age of < 70 years. The type of catheter showed a greater impact on the QoL in females with suprapubic catheters when compared with males in contrast to patients with transurethral catheters. CONCLUSION: The results of the study provide further information for the medical clarification for patients and caregivers, having to decide between a lifelong catheter drainage or alternatives, such as provision of an aid or surgical recanalization.

[Concepts in geriatric uro-oncology]. / Uroonkologische Konzepte im Alter.

Uro-oncology is not only concerned with treatment methods themselves but also with therapeutic objectives and decision-making concepts involving algorithms. We discuss whether the latter is applicable to all patients groups or needs to be adapted in order to be suitable for elderly and frail patients with regard to their lifestyle and living situation as well as their altered physiology.

[Prevention of penile cancer. Value of the HPV vaccination and circumcision]. / Primärprävention des Peniskarzinoms. Nutzen der HPV-Impfung und Zirkumzision.

Penile cancer is rare. Penile cancers appear predominantly in non-circumcised men. In addition, the majority of penile cancers are associated with human papillomavirus infection. The present manuscript is concerned with the value of circumcision and HPV vaccination in the prevention of penile cancer.

[Syndrome of persisting mullerian duct with first manifestation in an adult]. / Syndrom des persistierenden Müller-Ganges mit Erstmanifestation beim Erwachsenen.

INTRODUCTION: We report on a 22-year-old male patient who presented with an intrapelvic tumor. CASE REPORT: CT and MRI showed a left pelvic abscess, which was drained. After regression of the abscess, we removed the causative tubular structure surgically, revealing a rudimentary genital structure with parts of the Mullerian and Wolffian ducts. CONCLUSIONS: This case report demonstrates an abscess formation as complication of a previously asymptomatic rudimentary genital structure, which was associated with further abnormalities, such as left testicular agenesia, perineoscrotal hypospadias and transverse testicular ectopia.

[Paraneoplastic hyperthyroidism in a patient with metastasizing teratocarcinoma and excessively high HCG]. / Paraneoplastische Hyperthyreose bei metastasiertem Teratokarzinom mit exzessiver HCG-Erhöhung.

Clinically manifest hyperthyroidism is a rare paraneoplastic syndrome in patients with excessive HCG production due to testicular cancer. A 40-year-old patient with right testicular cancer (teratoma, embryonal cell carcinoma), diffuse pulmonary metastases and high serum HCG levels presented with symptomatic hyperthyroidism. The patient received immediately thyrostatic therapy and 4 cycles of PEI chemotherapy (Cisplatin, Etoposide, Ifosfamide). Thyroid function had returned to normal by the beginning of the second course of chemotherapy. After right orchiectomy and resection of residual pulmonary masses which revealed vital tumor cells, two additional courses of chemotherapy were performed. The patient is well and without evidence of disease 11 months after therapy. All patients with testicular cancer and excessive HCG production should be evaluated for biochemical and clinical signs of hyperthyroidism and treated accordingly with antithyroidal medication and immediate cytoreductive chemotherapy.

Early changes of oxalate and calcium urine excretion in those with calcium oxalate stone formation after extracorporeal shock wave lithotripsy.

OBJECTIVES: To determine the extent of transient changes of tubular function in idiopathic calcium-oxalate (CaOx) stone-bearing patients after extracorporeal shock wave lithotripsy (ESWL), calcium and oxalate excretion were measured before and after ESWL. METHODS: In 22 patients with renal CaOx stones, the plasma values and urine excretion of creatinine, calcium, oxalate, magnesium, and citrate were measured before and on days 1 and 2 after ESWL under conditions of a standardized diet. Overnight urine collection for an 8-hour period was used to measure the urine excretion, and the values were extrapolated to a 24-hour period. For calculation of the urine ion activity, the AP(CaOx) index EQ(s) and the CaOx risk index were used. RESULTS: After ESWL, hyperoxaluria was noted in 10 patients compared with 2 before ESWL. Hypercalciuria was seen in 11 patients after ESWL compared with 3 before. Combined hyperoxaluria and hypercalciuria was found in 7 patients after ESWL compared with 1 before. Both the oxalate/creatinine and calcium/creatinine ratios were significantly increased after ESWL. The AP(CaOx) index EQ(s) and the CaOx risk index were significantly increased after ESWL in patients with increased post-ESWL calcium and/or oxalate excretion. CONCLUSIONS: Increased calcium and/or oxalate excretion can be seen in patients with CaOx stones early after ESWL. This increased excretion of lithogenic substances represents an increased risk of fragment apposition after ESWL for the group with a significantly increased AP(CaOx) index EQ(s) and CaOx risk index. Therefore, prophylactic measures in patients at risk early after ESWL might be warranted to prevent possible recurrent stone formation.

Primary renal non-Hodgkin's lymphoma - a difficult differential diagnosis.

INTRODUCTION: Primary renal lymphoma (PRL) as a clinical entity is not undisputed because the kidneys do not contain lymphatic tissue and the mechanism of development of PRLs is unclear. Most of the few cases reported showed rapid systemic progression and a poor prognosis. Although there are no clearly defined diagnostic criteria for renal lymphomas, abdominal and thoracic computed tomography as well as renal and bone marrow biopsy are recommended. 3 cases of renal lymphoma are reported and their diagnosis and management discussed. CASE REPORTS: Between 1996 and 2001, 3 male patients with renal lymphoma were diagnosed and treated at our institution. In patient No. 1, because of persisting macroscopic hematuria a bilateral PRL was diagnosed by renal biopsy, without any detectable lesions on CT imaging. Patient No. 2 presented with a large renal mass which, on biopsy, was diagnosed as a lymphoma. Patient No. 3 showed lymphoma on renal biopsy and bone marrow involvement. All 3 patients were treated with systemic chemotherapy which resulted in death of disease in 2 patients and a complete remission in 1 patient after adjuvant radiotherapy and nephrectomy. CONCLUSION: PRL represents a rare entity which must nevertheless be considered in cases of unusual renal masses or otherwise unexplained renal symptoms. If diagnosed early, cure is possible, and multimodal treatment should be considered.

Measurement of free radicals and NO by chemiluminescence to identify the reperfusion injury in renal transplantation.

Oxygen free radicals are generated during the reperfusion of ischaemic organs. Several experimental studies have demonstrated that the damage produced by reperfusion can be prevented by a scavenger of free radicals. Furthermore, a significantly improved 5 year graft survival rate after cadaveric renal transplantation has been reported in patients treated with scavengers of free radicals (Land et al., 1993). Therefore, a question remains to be answered: whether a routine monitoring of the radical-mediated reperfusion injury with renal transplantation is useful, and whether there is a necessity for a generalized protective treatment in transplant patients. In a prospective trial, we evaluated a group of eight patients during and after renal cadaveric transplantation (three men, five women), using the chemiluminometric measurement of serum free radicals and NO. The serum quantities of free radicals and NO were significantly increased after reperfusion of the transplant kidney (p < 0.02). The mean time of noticeably increased levels of serum free radicals was 4.8 +/- 1.2 h after reperfusion. The results thus showed an increased liberation of free radicals in the peripheral blood of transplant recipients as possible evidence of free radicals-mediated reperfusion injury in renal transplantation. The generation of free radicals measured by chemiluminescence allow a controlled therapy to decrease the generation of free radicals with antioxidants during the early transplantation period e.g. in older recipients.

Relationship of comorbidity, age and perioperative complications in patients undergoing radical prostatectomy.

OBJECTIVES: To investigate the prevalence and distribution of comorbidity and its association with perioperative complications in patients undergoing radical prostatectomy (RPE). METHODS: In 431 unselected RPE patients, the American Society of Anesthesiologists Physical Status classification (ASA-PS), the New York Heart Association classification of cardiac insufficiency (NYHA), the classification of angina pectoris of the Canadian Cardiovascular Society (CCS), height, weight, the body mass index (BMI), and the number of concomitant diseases (NCD) were assessed and related to perioperative cardiovascular complications. RESULTS: In RPE patients less than 70 years old, comorbidity rose nearly continuously with increasing age. However, after reaching an age of 70 years, the proportion of NYHA-0 patients increased (60-64 years, 86%; 65-69 years, 85%; >or=70 years, 87%). Furthermore, the severe comorbidities decreased in patients selected for RPE aged 70 or more years. There was a nonsignificant trend towards higher comorbidity in patients with perioperative cardiovascular complications. CONCLUSIONS: These data suggest that documentation of the distribution of ASA-PS, CCS, NYHA and of concomitant diseases might be helpful to characterize the general health status and the degree of selection of prostate cancer treatment populations especially in series with a high portion of patients aged 70 or more years. Concerning perioperative complications, the individual predictive value of comorbidity seems to be poor in the radical prostatectomy setting.

Durable complete remission of metastatic sarcomatoid carcinoma of the bladder with cisplatin and gemcitabine in an 80-year-old man.

A patient with a durable, complete, local and pulmonary remission of a metastatic sarcomatoid carcinoma of the bladder treated with gemcitabine and cisplatin is presented. Sarcomatoid carcinoma arising in the bladder is a rare and notoriously aggressive variant of urothelial carcinoma for which an effective systemic treatment has not been reported up to now.

Application of the Mitrofanoff principle for intermittent self-catheterization in quadriplegic patients.

OBJECTIVES: Patients with cervical spinal cord lesions have impaired hand function, which often prohibits clean intermittent self-catheterization (CIC), especially in female patients. Enabling these patients to perform CIC gives them control of their bladder management and can improve their quality of life considerably. We have used an appendicovesicostomy to provide easy access for CIC in such patients. METHODS: Five patients (4 women, 1 man) with a mean age of 31 years (range 20 to 52) and a mean duration of the cervical cord lesion of 22 months (range 7 to 37) underwent appendicovesicostomy. Three patients were young victims of motor vehicle accidents, 1 patient had a progressive rheumatoid arthritic disorder, and 1 patient had a complex functional paraplegia syndrome and underwent bladder augmentation at the same time. RESULTS: The surgical procedure with the creation of a catheterizable stoma in the right lower abdominal quadrant was successful in all cases but was complicated by mechanical ileus in the patient with simultaneous bladder augmentation. All patients learned to perform independent CIC with continuing anticholinergic medication. Stomal stenosis did not occur in any of the 5 patients, and urinary tract infections occurred once in 2 patients and repeatedly in 1 patient. Three of 5 patients have been enabled by independent bladder management to achieve occupational rehabilitation. CONCLUSIONS: Appendicovesicostomy is a suitable procedure in patients with cervical spinal cord lesions who are otherwise unable to perform independent CIC. The creation of a catheterizable abdominal stoma enables these patients to gain independent control of their bladder management. However, caution in patient selection is advisable as probably the best results are achieved in highly motivated, younger patients with traumatic cervical cord lesions.

Spontaneous late rupture of orthotopic detubularized ileal neobladders: report of five cases.

OBJECTIVES: To report five spontaneous ruptures in 4 patients. Spontaneous late rupture of orthotopic ileal bladder replacements is a rare complication of continent urinary diversion. METHODS: Four recurrence-free patients aged 36 to 68 years experienced apparently spontaneous rupture of continent orthotopic ileal bladder replacement 3 months to 3 years after curative radical cystectomy and urinary diversion for invasive bladder cancer. Ileal bladder rupture occurred twice in 1 patient with an interval of 9 months. RESULTS: All 4 patients had had a good result from their diversion procedure and had reported complete day and nighttime continence before the spontaneous rupture. The spontaneous rupture was evidently caused by overdistension of the ileal neobladder in four of five instances. In addition to overdistension, a second factor such as minor blunt abdominal trauma or urethral occlusion was identifiable in two instances. The rupture occurred in the right upper corner of the ileal bladder in four of five instances and led to acute and severe abdominal pain. Cystography was done in three instances, but was diagnostic in only 2 cases. The histologic examination of the excised bladder wall margins revealed nonspecific inflammatory changes in 3 cases. Open surgical drainage and repair was successfully undertaken in all cases. CONCLUSIONS: The circumstances of the cases described suggest that late spontaneous rupture of an orthotopic ileal bladder replacement is not related to the surgical technique but rather to factors of patient compliance and medical management.

Is transurethral vaporesection of the prostate better than standard transurethral resection?

OBJECTIVE: The aim of this study was to undertake an evaluation of the comparative efficacy and morbidity of transurethral vaporesection (TUVRP) and standard transurethral resection (TURP), two resection techniques using loops of different thickness and power settings. METHODS: In a prospective study, 185 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction and benign prostatic enlargement were randomized to undergo either TUVRP or standard TURP. Inclusion criteria were benign prostatic enlargement, moderate or severe lower urinary tract symptoms and/or a significant urinary residual (>60 ml), while patients with previous prostatic surgery, prostate cancer or neurogenic bladder disorders were excluded. Prostate size, residual urine, urinary flow rate and symptoms as well as associated bother (using the International Prostate Symptom Score (IPSS) and the American Urological Association Bother Score (AUA-BS)) were assessed preoperatively. Intraoperative blood loss and fluid absorption were evaluated by measuring serum hemoglobin and respiratory alcohol concentration. Patients were followed for 1 year with the evaluation of flow rates, residual urine volumes, symptom scores and complications at 3, 6 and 12 months. RESULTS: A significant difference was seen in the weight of the resected tissue (TURP 30.3 g vs. TUVRP 21.9 g, p<0.003). There were no significant differences in blood loss, intraoperative fluid absorption or procedure time between TUVRP and TURP, although more patients in the TURP group required blood transfusions (13 vs. 7) and mean procedure time was longer for TUVRP (71.0 vs. 65.9 min). The postoperative improvements in IPSS, AUA-BS, residual and Q(max) were significant in both groups (p<0.01 for each) but without difference between the two groups. The rate of complications (urinary tract infections, urethral stricture, reintervention rate) during follow-up was the same in both groups. CONCLUSIONS: In this prospective randomized comparison of the clinical outcome and morbidity of standard TURP versus TUVRP, there were no significant differences in any of the parameters evaluated except for the weight of the resected tissue.

Morbidity and discomfort of ten-core biopsy of the prostate evaluated by questionnaire.

Transition zone biopsies have been found to increase the detection rates of cancer of the prostate in patients with negative digital rectal examination. There are however no data available whether the higher biopsy rate is associated with greater morbidity. The present study was therefore designed to evaluate the complication rate of extended sextant biopsy. In this prospective study, 162 consecutive patients who presented for prostatic evaluation were included. After starting prophylactic antibiotic treatment 48 h prior to the procedure, transrectal ultrasound-guided core biopsies were obtained from each lobe: three each from the peripheral zone (apex, mid-zone and base) and two from the transition zone of each prostatic lobe. In all patients a questionnaire was obtained 10-12 days after the procedure. Major complications occurred in 3 patients. In 2 of the 3 cases major macroscopic hematuria was treated by an indwelling catheter for 1 or 2 days and 1 patient developed fever >38.5 degrees C for 1 day. Minor macroscopic hematuria was present in 68.5% of the patients. In 17.9% of these cases, the hematuria lasted for more than 3 days. Hematospermia was observed in 19.8% and minor rectal bleeding occurred in 4.9%. Ten-core biopsies did not lead to an increase in adverse effects or complications when compared to the results of sextant biopsies reported in the literature.

Is there a relationship between the amount of tissue removed at transurethral resection of the prostate and clinical improvement in benign prostatic hyperplasia.

OBJECTIVE: To assess in a prospective trial the influence of the amount of tissue resected at transurethral resection of the prostate (TURP) for benign prostatic enlargement on the symptom improvement as assessed by symptom scores. METHODS: Between December 1996 and August 1998 a total of 138 men (mean age 68.2, range 53-89) with symptomatic benign prostatic enlargement who underwent TURP participated in this prospective study. Patients were assessed preoperatively with the International Prostate Symptom Score (IPSS), the American Urological Association Bother Score (AUA-BS) and the Benign Prostatic Hyperplasia Impact Index (BPH-II) as well as urinary flow rate measurements (Qmax) and prostate volume (PV) and residual urine determination by ultrasound. The amount of tissue resected was weighed. Patients were followed with reevaluation of Q(max), residual urine and the symptom and bother scores at 3 and 6 months. RESULTS: A close correlation between preoperative PV (mean 49.0 ml, SD 22.0, range 13-140) and the resected tissue weight (RTW, mean 24.7 g, SD 18.0, range 6-128) was seen (r = 0.75, p < 0.001). Age was correlated with preoperative PV (r = 0.23, p < 0.05). While significant mean improvements in Q(max), residual volume and IPSS, AUA-BS and BPH-II were found 3 and 6 months postoperatively, a negative correlation was seen between the RTW and the IPSS, the AUA-BS and the BPH-II 3 months after TURP (r = -0.23, p < 0.024; r = -0.23, p < 0.025; r = -0.20, p = 0.05). No statistically significant correlation was seen between symptom change and the percentage of PV removed or the residual prostatic weight. Classification of the patients into groups depending on preoperative PV (< 30, 31-50, 51-70 and >70 ml) showed a tendency for patients with larger PV to gain more symptom improvement postoperatively. CONCLUSIONS: Early symptom improvement after TURP will depend on the amount of tissue removed but the relationship is weak and affected by several other confounding factors. Apparently, the symptomatic improvement after TURP is not primarily dependent on the relative completeness of the resection. Patients with larger prostates and larger RTW tend to gain more symptomatic benefit from TURP than do patients with smaller prostates.

Is systematic sextant biopsy suitable for the detection of clinically significant prostate cancer?

BACKGROUND: The optimal extent of the prostate biopsy remains controversial. There is a need to avoid detection of insignificant cancer but not to miss significant and curable tumors. In alternative treatments of prostate cancer, repeated sextant biopsies are used to estimate the response. The aim of this study was to investigate the reliability of a repeated systematic sextant biopsy as the standard biopsy technique in patients with significant tumors which are being considered for curative treatment. METHODS: Systematic sextant biopsy was performed in vitro in 92 radical prostatectomy specimens. Of these patients, 81 (88.0%) had palpable lesions. RESULTS: Of the 92 investigated patients, 70 (76.1%) had potentially curable pT2-3pN0 prostate cancers. In these patients, the cancer was detected only in 72.9% of cases by a repeated in vitro biopsy. In the pT2 tumors, there was a detection rate of only 66.7%. CONCLUSIONS: This study underlines the fact that a considerable number of significant and potentially curable tumors remain undetected by the conventional sextant biopsy. A negative sextant biopsy does not rule out significant prostate cancer.