[CEUS-Use in testicular pathologies]. / CEUS ­ Anwendung am Hoden.

BACKGROUND: The work-up of scrotal diseases forms an essential part of daily work in urology. Sonography plays an important role in the diagnostic process, due to its wide availability and feasibility. OBJECTIVES: Advantages of modern contrast-enhanced ultrasound (CEUS) are illustrated using examples of common testicular pathologies. MATERIALS AND METHODS: Relevant studies regarding the application of CEUS on testicular pathologies are evaluated. PubMed and Medline were screened for reviews and clinical trials. RESULTS: In the differentiation of benign and malignant testicular lesions, contrast medium uptake, e. g. can exclude a hemorrhagic testicular cyst. A differentiation between benign and malignant testicular lesions due to pure enhancement is currently not possible. Evaluation of testicular abscesses, infarctions and infections depends on the assessment of vascularization. Following a scrotal trauma, evaluation of enhancement can distinguish between vital and non-vital areas. A complete absence of perfusion may support the diagnosis of testicular torsion. CONCLUSION: CEUS is a feasible instrument in the diagnostic work-up of testicular pathologies. Results from previous studies are promising. Regarding the application in cases of scrotal trauma, the method could play an essential role in the future. With regard to a classification of unclear testicular lesions, further studies with a larger number of patients are needed in order to confirm previously described perfusion patterns.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models.

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

Shear wave elastography of the testes in a healthy study collective - Differences in standard values between ARFI and VTIQ techniques.

INTRODUCTION: Shear wave elastography (SWE) is a recent technique in the assessment of tissue elasticity. Different elastography techniques have been described over the years.Acoustic Radiation Force Impulse Imaging (ARFI) uses mechanical excitation of tissue to create detectable shear waves, a higher shear wave velocity being associated with an increased tissue stiffness.The Virtual Touch Tissue Imaging Quantification (VTIQ) method uses a mechanical push pulse as well, additionally creating a colour-coded map, in which tissue stiffness can be measured within a stored map on the ultrasound device after measurement.ARFI has been used in determining standard values in testes of a healthy study collective, VTIQ has already been used in the evaluation of unclear scrotal masses.Both techniques allow an operator-independent examination without application of mechanical pressure. The aim of this study was to determine whether there is a statistically significant difference between shear wave velocity values of both techniques in a healthy collective. MATERIAL AND METHODS: Twenty patients without known testicular pathology underwent standard B-mode sonography and additional shear wave elastography in the ARFI mode as well as the VTIQ technique of both testes using the Siemens Acuson S2000™ and S3000™ ultrasound devices (Siemens HealthCare, Erlangen, Germany).Measurements of shear wave velocity were performed in the upper pole, the central portion and the lower pole separately for each testis. Values were described in m/s.Statistical evaluation was performed using paired t-test analysis. RESULTS: We measured a mean shear wave velocity of 0.81 m/s using ARFI and 1.07 m/s with VTIQ.Shear wave velocities determined by VTIQ were all significantly higher than values gained in the ARFI mode. (p < 0.001 to p = 0.007). Values were between 0.22 and 0.29 m/s higher, when the examination was performed using VTIQ. CONCLUSION: ARFI and VTIQ elastography modes both proved to be feasible techniques in the assessment of testicular tissue elasticity. Consideration of higher values for VTIQ is important, when different elastography measurement results are compared, especially for the application of devices in a clinical setting, e.g. in the work-up of scrotal masses.A calculable factor for a comparison between both devices is desirable, but to be further assessed in largerstudies.

Three-dimensional vs. two-dimensional shear-wave elastography of the testes - preliminary study on a healthy collective.

INTRODUCTION: Shear wave elastography (SWE) and its derivative Supersonic Shear Imaging (SSI) are newer techniques for the determination of tissue elasticity by measuring the velocity of generated shear waves (SWV), which correlates positively with tissue stiffness.The techniques are integrated into many modern ultrasound systems and have been examined in the evaluation of viscoelastic properties of different organ systems. Two-dimensional shear wave elastography (2D SWE) of the testes has been found to be a useful tool in recent studies which included the determination of standard values in healthy volunteers. Three-dimensional shear wave elastography (3D SWE) is the latest development in elastography and is made possible by generation of a multiplanar three-dimensional map via volumetric acquisition with a special ultrasound transducer. This technique allows the assessment of tissue elasticity in a three-dimensional, fully accessible organ map.The aim of this preliminary study was to both evaluate the feasibility of 3D SWE and to compare 2D and 3D SWE standard values in the testes of healthy subjects. MATERIAL AND METHODS: We examined the testes of healthy male volunteers (n = 32) with a mean age of 51.06±17.75 years (range 25-77 years) by B-mode ultrasound, 2D and 3D SWE techniques in September of 2016. Volunteers with a history of testicular pathologies were excluded. For all imaging procedures the SL15-4 linear transducer (bandwidth 4-15 MHz) as well as the SLV16-4 volumetric probe (bandwidth 4-16 MHz) of the Aixplorer® ultrasound device (SuperSonic Imagine, Aix-en-Provence, France) were used. Seven regions of interest (ROI, Q-Box®) within the testes were evaluated for SWV using both procedures. SWV values were described in m/s. Results were statistically evaluated using univariateanalysis. RESULTS: Mean SWV values were 1.05 m/s for the 2D SWE and 1.12 m/s for the 3D SWE.Comparisons of local areas delivered no statistically significant differences (p = 0.11 to p = 0.66), except for the region in the central portion in the superior part of the coronal plane (p = 0.03). Testicular volume was significanty higher by a mean of 1.72 ml when measured with 3D SWE (p = 0.001). CONCLUSION: 3D SWE proved to be a feasible diagnostic tool in the assessment of testicular tissue, providing the examiner with a fully accessible three-dimensional map in a multiplanar or multislice view. With this technique a more precise testicular imaging - especially if combined with the display of tissue stiffness in SWE - is available and therefore could improve the diagnostic work-up of scrotal masses or the routine investigation of infertile men. Further studies for a better understanding in the context of various testicular pathologies will be required.

Differences of standard values of Supersonic shear imaging and ARFI technique - in vivo study of testicular tissue.

PURPOSE: To investigate the difference of standard values of Supersonic shear imaging (SSI) and Acoustic Radiation Force Impulse (ARFI) technique in the evaluation of testicular tissue stiffness in vivo. MATERIALS AND METHODS: 58 healthy male testes were examined using B-mode sonography and ARFI and SSI. B-mode sonography was performed in order to scan the testis for pathologies followed by performance of real-time elastography in three predefined areas (upper pole, central portion and lower pole) using the SuperSonic® Aixplorer ultrasound device (SuperSonic Imagine, Aix-en-Provence, France). Afterwards a second assessment of the same testicular regions by elastography followed using the ARFI technique of the Siemens Acuson 2000™ ultrasound device (Siemens Health Care, Germany). Values of shear wave velocity were described in m/s. Parameters of elastography techniques were compared using paired sample t-test. RESULTS: The values of SSI were all significantly higher in all measured areas compared to ARFI (p < 0.001 to p = 0.015). Quantitatively there was a higher mean SSI wave velocity value of 1,1 compared to 0.8 m/s measured by ARFI. CONCLUSION: SSI values are significantly higher than ARFI values when measuring the stiffness of testicular tissue and should only be compared with caution.

Shear-wave elastography of the testis in the healthy man - determination of standard values.

PURPOSE: Real-time shear-wave elastography (SWE) is a newly developed technique for the sonographic quantification of tissue elasticity, which already is used in the assessment of breast and thyroid lesions. Due to limited overlying tissue, the testes are ideally suited for assessment using shear wave elastography. To our knowledge, no published data exist on real-time SWE of the testes. MATERIALS AND METHODS: Sixty six male volunteers (mean age 51.86±18.82, range 20-86) with no known testicular pathology underwent normal B-mode sonography and multi-frame shear-wave elastography of both testes using the Aixplorer ® ultrasound system (SuperSonic Imagine, Aix en Provence, France). Three measurements were performed for each testis; one in the upper pole, in the middle portion and in the lower pole respectively. The results were statistically evaluated using multivariate analysis. RESULTS: Mean shear-wave velocity values were similar in the inferior and superior part of the testicle (1.15 m/s) and were significantly lower in the centre (0.90 m/s). These values were age-independent. Testicular stiffness was significantly lower in the upper pole than in the rest of the testis with increasing volume (p = 0.007). CONCLUSION: Real-time shear-wave elastography proved to be feasible in the assessment of testicular stiffness. It is important to consider the measurement region as standard values differ between the centre and the testicular periphery. Further studies with more subjects may be required to define the normal range of values for each age group. Useful clinical applications could include the diagnostic work-up of patients with scrotal masses or male infertility.

[Conservative therapy of erectile dysfunction]. / Konservative Therapie der erektilen Dysfunktion.

The erectile dysfunction (ED) with a prevalence of 19.2% and a steep age-related increase up to 53.4% in men over 70 years is a common sexual disorder. Especially after market launch of the phosphodiesterase 5 inhibitors the possibility of an easy-to-use and well-tolerated therapy is available. In case of nonresponse, vasoactive substances can be applied in different forms. In case of an additional hypogonadism, testosterone substitution is indicated. Simultaneously the causes of ED should always be treated, including a change of lifestyle with elimination of exogenous noxa. The use of mechanic tools as single or combination therapy can lead to improved erection. This article provides a critical overview of the latest conservative therapy options, it explains previous unsuccessful therapeutic trials and gives an outlook into potential ED therapy concepts of the future.

The role of VTIQ as a new tissue strain analytics measurement technique in testicular lesions.

PURPOSE: Virtual touch tissue imaging quantification (VTIQ) is a newly developed technique for the sonographic quantification of tissue elasticity. It has been used in the assessment of breast lesions. The purpose of this study was to determine the diagnostic performance of VTIQ in indeterminate testicular lesions. METHODS: Twenty patients with known testicular pathology underwent conventional B-mode sonography with additional VTIQ of the testicular lesions using a Siemens Acuson S2000™ and S3000™ (Siemens Medical Solutions, Mountain View, CA, USA) system. Tissue mechanical properties were analysed in the VTIQ examination. The pathologic diagnosis was established after surgery or in the follow-up examination for suspected benign lesions. RESULTS: Over 36 months, 22 focal testicular lesions (median lesion size, 18 mm; range, 4-36 mm in 20 patients (median age, 43 years; range, 22-81 years) were examined. Lesions were hyperechoic (n = 1), hypoechoic (n = 14), isoechoic (n = 1), of mixed echogenicity (n = 3) or anechoic (n = 3). Histological examination showed one benign lesion (6.25%) with a mean size of 7 mm and 15 malignant lesions (93.75%) with a mean size of 20 mm. Mean shear wave velocity for normal testicular tissue was 1.17 m/s. No shear wave velocity could be measured in cystic lesions. The rest of the benign lesions showed a mean shear wave velocity of 2.37 m/s. The value of the shear wave velocity in germ cell tumours showed a mean shear wave velocity of 1.94 m/s and for seminoma it showed a mean shear wave velocity of 2.42 m/s. CONCLUSIONS: VTIQ is a reliable new method for measuring qualitative and quantitative stiffness of testicular lesions and tissue. The qualitative shear-wave elastography features were highly reproducible and showed good diagnostic performance in unclear testicular lesions. The VTIQ technique is also useful in assessing small testicular nodules and pseudolesions.

[Remuneration distribution - should morbidity-dependent overall remuneration also be distributed after adjustments for morbidity?]. / Honorarverteilung - sollte die morbiditätsbedingte Gesamtvergütung auch morbiditätsadjustiert verteilt werden?

INTRODUCTION: In the 2009 reform of the German collective remuneration system for outpatient medical care, on the level of overall remuneration, the morbidity risk was transferred to the health funds fulfilling a long-term demand of physicians. Nevertheless not transferring morbidity adjustment to the levels of physician groups and singular practices can lead to budgets not related to patient needs and to incentives for risk selection for individual doctors. METHODS: The systematics of the distribution of overall remuneration in the German remuneration system for outpatient care are analysed focusing on the aspect of morbidity adjustment. Using diagnostic and pharmaceutical information of about half a million insured subjects, a risk adjustment model able to predict individual expenditures for outpatient care for different provider groups is presented. This model enables to additively split the individual care burden into several parts attributed to different physician groups. Conditions for the use of the model in the distribution of overall remuneration between physician groups are developed. A simulation of the use of diagnoses-based risk adjustment in standard service volumes then highlights the conditions for a successfull installation of standard service volumes representing a higher degree of risk adjustment. RESULTS: The presented estimation model is generally applicable for the distribution of overall remuneration to different physician groups. The simulation of standard service volumes using diagnosis-based risk adjustment does not provide a more accurate prediction of the expenditures on the level of physician practices than the age-related calculation currently used in the German remuneration system for outpatient medical care. CONCLUSION: Using elements of morbidity-based risk adjustment the current German collective system for outpatient medical care could be transformed towards a higher degree of distributional justice concerning medical care for patients and more appropriate incentives avoiding risk selection. Limitations of the applicability of risk-adjustment can be especially pointed out when a high share of lump-sum-payments is used for the remuneration of some physician groups.

Is there a significance of histamine in the control of the human male sexual response?

Although histamine has been suggested to be involved in the control of male sexual function, including the induction of penile erection, its role in the human corpus cavernosum penis is still poorly understood. The aim of our study was to evaluate the course of histamine plasma levels through different stages of sexual arousal in the systemic and cavernous blood of healthy male subjects. Thirty four (34) healthy men were exposed to erotic stimuli to elicit penile erection. Blood was aspirated from the corpus cavernosum and a cubital vein during the penile conditions flaccidity, tumescence, rigidity and detumescence. Blood was also collected in the post-ejaculatory period. Plasma levels of histamine (ng ml(-1)) were determined by means of a radioimmunoassay. Histamine slightly decreased in the cavernous blood when the penis became tumescent. During rigidity, histamine decreased further but remained unaltered in the phase of detumescence and after ejaculation. In the systemic circulation, no alterations were observed with the initiation or termination of penile erection, whereas a significant drop was registered following ejaculation. Results are not in favour of the hypothesis of an excitatory role of histamine in the control of penile erection. Nevertheless, the amine might mediate biological events during the post-ejaculatory period.

Systemic and cavernous plasma levels of neuropeptide Y during sexual arousal in healthy males.

Neuropeptide Y (NPY) has been shown to induce contraction of isolated human penile erectile tissue and potentiate the response to noradrenaline. The purpose of our study was to measure in the cavernous and systemic blood of healthy male volunteers the course of NPY through different stages of sexual arousal. Whole blood was drawn simultaneously from the corpus cavernosum and the cubital vein of 16 healthy male volunteers during penile flaccidity, tumescence, rigidity and detumescence. Tumescence and erection were induced by applying audiovisual and tactile stimulation. Plasma levels of NPY (given in pmol l(-1)) were determined by means of an enzyme-linked immunoassay. NPY significantly decreased in the cavernous blood on sexual arousal, when the flaccid penis became tumescent and, finally, rigid (F: 88.8 ± 35.8, T: 62.4 ± 22.7, R: 62.3 ± 19.7), and only slightly rose in the phase of detumescence (64.8 ± 23). In the systemic circulation, no pronounced alterations in the concentration of NPY were registered (F: 64.4 ± 27, T: 65.8 ± 19, R: 59.6 ± 25, D: 67.6 ± 29.3). Our findings are in favour of the hypothesis that NPY could contribute to the maintenance of the resting state of cavernous smooth muscle.

Management of pelvic lymphoceles after radical prostatectomy: a multicentre community based study.

INTRODUCTION: Pelvic lymphoceles (LC) following radical prostatectomy (LC-RP) have an incidence up to 27%. LC-managements constitute 50% of surgical interventions performed in post-RP patients. OBJECTIVES: To describe a therapeutic algorithm for LC-managements based on a community based representative retrospective study. PATIENTS AND METHODS: Multicentre data from 304 patients with LC-RP were retrospectively examined for LC-managements. RPs were performed by various surgeons from 67 urological departments. All patients had undergone 3 weeks rehabilitation in a specialized hospital where the data base was generated. Indications and results of therapeutic manoeuvres were used to develop a general concept for planning therapy decisions. - RESULTS: Median age was 64 years. Complications occurred in 9% (28/304) of patients. Median LC-volume was 36ml (range 20-1800ml). There were more complications for LCs with ≥ 100ml volume than those <100ml (27% versus 17%, p = 0.346). Conservative therapy was the standard in uncomplicated cases (87%, 239 of 276 patients), while intervention was done in 13% (puncture and/or drainage, surgery). Surgical intervention was performed significantly more often in complicated cases (82%, 23 from 28 patients; p<0.001). Based on these data, LCs can be stratified into 3 groups depending on the size and clinical presentation. Therapeutic decisions were used to develop the illustrated new therapy algorithm. CONCLUSIONS: This study based treatment algorithm provides a rationale approach with an accurate LC-classification as regard the indications and decision making for the available LC-RP-therapies. This could facilitate management decisions. Evaluation of this concept prospectively in large patient cohort is mandatory.

[Drug therapy options for oligoasthenoteratozoospermia syndrome]. / Medikamentöse Therapiemöglichkeiten des Oligo-Astheno-Teratozoospermie-Syndroms.

Medical treatment of oligoasthenoteratozoospermia (OAT) syndrome includes many different treatment concepts. The targeted causes in the treatment of OAT syndrome are either hormonal, as for example hypothalamic, pituary, or, seldom, hyperprolactinemic disturbances, or acute or chronic urogenital infections, as well as ejaculatory disorders. Often no pathogenic reason for OAT syndrome can be found and targeted. Most treatment concepts in the past tried to improve sperm quality. Administration of antiestrogens, antioxidants, hormones, and micronutrients has been tried and used to improve sperm quality. The present article provides an overview of current medical treatment options for OAT syndrome, including former unsuccessful treatment concepts. The article furthermore sketches out potential treatment options, which might be available in the future.

Acoustic radiation force impulse imaging of the testes: a preliminary experience.

PURPOSE: Acoustic radiation force impulse imaging (ARFI) is a newly developed technique for the sonographic quantification of tissue elasticity. It has been used in the assessment of various abdominal organs. The testes are extraabdominal organs with limited overlying tissue, making them ideally suited to ARFI assessment. To our knowledge no published data exist on ARFI elastography of the testes. METHOD: 23 male volunteers (mean age 45.13 ± 17.3, range 23-75) with no known testicular pathology underwent normal B-mode sonography with ARFI elastometry of both testes using a Siemens Acuson S2000™ (Siemens Healthcare, Germany) system. 15 measurements were performed on each testis; 5 each in the upper pole, middle portion and lower pole. Results were statistically evaluated. RESULTS: 95% of the SWV values were found to lie within the reference interval ranging from 0.62 to 1.01 m/s. There was a significant association between measured SWV and age (P = 0.0056) and testicular volume (P = 0.0003). CONCLUSION: ARFI elastometry proved to be feasible in the assessment of testicular stiffness. Older age and lower testicular volumes were associated with increased parenchymal stiffness. Further studies with more subjects may be required to define the normal range of values for each age group.

[Laboratory work-up of testosterone]. / Labordiagnostik des Testosterons.

Measuring testosterone concentration is a central component of routine andrological diagnostics. To avoid complicated and often imprecise direct measurement of bioavailable testosterone, calculation by SHBG and albumin concentration is possible. When interpreting a measured testosterone concentration, numerous influencing factors have to be kept in mind. One main factor is circadian rhythm; furthermore, concentration decreases with advancing age. Changes of testosterone concentration can be caused by illness or the intake of specific drugs. The increase in SHBG concentration with age is of particular importance. Since internationally accepted standard values are missing, especially for elderly patients, their symptoms should always be considered when making a decision on hormone substitution.

CaMn(1-x)Nb(x)O3 (x < or = 0.08) perovskite-type phases as promising new high-temperature n-type thermoelectric materials.

Perovskite-type CaMn(1-x)Nb(x)O(3+/-delta) (x = 0.02, 0.05, and 0.08) compounds were synthesized by applying both a "chimie douce" (SC) synthesis and a classical solid state reaction (SSR) method. The crystallographic parameters of the resulting phases were determined from X-ray, electron, and neutron diffraction data. The manganese oxidations states (Mn(4+)/Mn(3+)) were investigated by X-ray photoemission spectroscopy. The orthorhombic CaMn(1-x)Nb(x)O(3+/-delta) (x = 0.02, 0.05, and 0.08) phases were studied in terms of their high-temperature thermoelectric properties (Seebeck coefficient, electrical resistivity, and thermal conductivity). Differences in electrical transport and thermal properties can be correlated with different microstructures obtained by the two synthesis methods. In the high-temperature range, the electron-doped manganate phases exhibit large absolute Seebeck coefficient and low electrical resistivity values, resulting in a high power factor, PF (e.g., for x = 0.05, S(1000K) = -180 microV K(-1), rho(1000K) = 16.8 mohms cm, and PF > 1.90 x 10(-4) W m(-1) K(-2) for 450 K < T < 1070 K). Furthermore, lower thermal conductivity values are achieved for the SC-derived phases (kappa < 1 W m(-1) K(-1)) compared to the SSR compounds. High power factors combined with low thermal conductivity (leading to ZT values > 0.3) make these phases the best perovskitic candidates as n-type polycrystalline thermoelectric materials operating in air at high temperatures.

[Injuries of the renal pelvis and ureter. Diagnosis and management]. / Verletzungen des Nierenbeckens und des Ureters. Diagnostik und Management.

About 5% of injuries of the urinary tract affect the renal pelvis and ureter and constitute a severe complication. Around 75% of these injuries are iatrogenic and only about 25% are caused by blunt abdominal trauma or perforation. To avoid complications and improve prognosis, immediate diagnosis and therapy are essential. The diagnostic accuracy of preoperative studies is low, therefore frequently injuries are detected during explorative laparotomy. The management of upper urinary tract lesions depends on severity and localization, whereas the ultimate ambition should always be the preservation of the kidney. As a basic rule, ureteral stenting is mostly sufficient for small lesions, and only larger injuries require open reconstructive techniques. Longitudinal studies document a high degree of functional reconstitution if adequate and immediate treatment is carried out.