Infection of an urachal cyst during etanercept therapy in juvenile idiopathic arthritis.

Etanercept, a tumor necrosis factor (TNF) receptor alpha antagonist is licensed for the treatment in patients affected by polyarticular juvenile idiopathic arthritis, who do not tolerate or had an inadequate response to methotrexate. Infections related to immunosuppression by etanercept are of major concern. We report on a 17-year-old boy with enthesitis-related arthritis who developed a major infection of an urachal cyst 18 months after initiation of etanercept therapy, which required surgery. The urachus had not been symptomatic before.

Ileal ureteric replacement in complex reconstruction of the urinary tract.

OBJECTIVE: To report 10 years' experience with ileal ureteric replacement as a last resort in complex reconstruction of the urinary tract. PATIENTS AND METHODS: From March 1991 to February 2002 ileal segments were used for partial or total substitution of the ureter in 43 patients (mean age 45.6 years) with structural or functional ureteric loss secondary to irradiation, surgical complications or various other pathological conditions. Ileum was either implanted into the native urinary bladder (in 14) or an intestinal reservoir (in 29). In the latter group the technique was used at the time of primary urinary diversion in eight, in a secondary approach for treating early or late complications in nine and in undiversion or conversion procedures in 12. The ileal ureter was implanted into the urinary reservoir using a serous-lined extramural tunnel or distal intussusception for reflux prevention (in 31). All patients were followed prospectively according to a standardized protocol. RESULTS: There were no perioperative deaths; the mean (range) follow-up was 40.8 (1.5-109.5) months. In 41 patients with dilatation of the upper urinary tract before surgery there was a significant improvement radiographically in 34, no change in five and deterioration in two. The serum creatinine level decreased or remained stable in all. Reflux occurred in the 12 cases without and in three with an antireflux mechanism. Shortening of an elongated kinking ileal ureter became necessary because of recurrent severe metabolic acidosis and mucus obstruction in two; in one case mucus obstruction was treated endoscopically. There was pyelonephritis only in three patients with refluxing implantation into an intestinal reservoir. CONCLUSION: Ileal ureteric replacement is a safe and reliable last resort even in difficult cases. Whenever feasible, antirefluxing implantation into intestinal urinary reservoirs is recommended.

Ten years' experience with the submucosally embedded in situ appendix in continent cutaneous diversion.

OBJECTIVE: To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs. MATERIAL AND METHODS: Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol. RESULTS: There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night. CONCLUSION: Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

Complications related to different continence mechanisms in ileocecal reservoirs.

PURPOSE: We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir. MATERIALS AND METHODS: From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus. RESULTS: In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple. CONCLUSIONS: In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

[Painless ESWL by cutaneous administration of Vaseline]. / Schmerzfreie ESWL durch kutane Applikation von Vaseline.

In a prospective clinical study we investigated how effective cutaneous Vaseline application was in pain reduction during ESWL. In 150 patients (group 1) Vaseline was applied on a skin area corresponding to the entry site of shockwaves directly before lithotripsy; in 75 patients (group 2) ESWL was performed without Vaseline. Analgesic sedation was needed by 10/150 (6.7%) in group 1 and 27/75 (36.4%) in group 2 (P < 0.001). The median pain score in group 1 was 2.5 +/- 1.05 and that in group 2 was 4.25 +/- 1.13 (P < 0.05). Local Vaseline application significantly reduces pain during ESWL independent of stone location. Most pain results from cavitation at the skin surface and is blocked by Vaseline. Cutaneous Vaseline application to reduce the need for analgesic sedation might be especially useful in outpatient ESWL procedures.

Painless ESWL by cutaneous application of vaseline.

In a prospective study we investigated the efficacy of cutaneous vaseline application in pain reduction during ESWL. In 150 patients (group 1) vaseline was applied on a skin area of 10 x 20 cm corresponding to the entry site of shock waves directly before ESWL was started. In 75 patients (group 2) ESWL was performed without vaseline. 10/150 (6.7%) in group 1 and 27/75 (36.4%) in group 2 (p < 0.001) needed additional analgesic sedation. Requirement for supplementary analgosedation was most pronounced for patients with lower calyceal and distal ureteral stones [20% and 19% in group 1; 53% and 78% in group 2 (p < 0.03)]. The median pain score in group 1 was 2.5 +/- 1.05, in group 2 4.25 +/- 1.13 (p < 0.05). Local vaseline application significantly reduced pain during ESWL independent from stone location. Because of its high viscosity vaseline inhibited the development of cavitation bubbles at the skin surface. Cutaneous vaseline application reducing the need for analgesic sedation might especially be useful in outpatient ESWL procedures.

A conservative approach to bilateral testicular germ cell tumors.

We report on 6 patients with bilateral testicular germ cell tumors treated by organ sparing surgery. Tumors 6 to 30 mm. in diameter were enucleated, and biopsies of the tumor bed and peripheral parenchyma were taken. Histological examination revealed seminoma in 4 cases, embryonal carcinoma in 1 and a Leydig cell tumor in 1. All patients underwent testicular radiation therapy with 20 Gy. for carcinoma in situ. A testicular biopsy was performed 6 months postoperatively to evaluate therapeutic success. Median followup was 43 months, all patients were free of disease and there was no local recurrence. Luteinizing hormone and testosterone were within the normal range and no androgen substitution was necessary. Our study suggests that organ sparing surgery for bilateral testicular germ cell tumors represents a new therapeutic approach with endocrinological and psychological advantages. In our experience conservative surgery is possible under certain prerequisites, including organ confined tumor without infiltration of the rete testis, obtaining multiple biopsies of the tumor bed and peripheral parenchyma, associated carcinoma in situ treated by radiation therapy and close followup of patients.

Ultrasound in the evaluation of urethral stricture disease: a prospective study in 175 patients.

OBJECTIVE: To investigate the characteristic ultrasonic appearance of urethral stricture disease in men. PATIENTS AND METHODS: Between 1990 and 1992 a prospective study in 175 men with the suspicion of urethral stricture was performed using urethral ultrasound as the first diagnostic procedure, followed by retrograde urethrography, voiding cystourethrography or urethroscopy. RESULTS: The sensitivity and specificity in detecting urethral strictures were 98% and 96% respectively. Ultrasound offers a three-dimensional study in the evaluation of the urethra without exposing the gonads to ionizing radiation. The exact length and depth of the stricture, the severity of the strictured segment as well as the anatomy of the periurethral scars were diagnosed accurately. CONCLUSION: Ultrasound is a simple, inexpensive and rapid investigation of the urethra which requires no exposure of the patient to ionizing radiation and should be the preferred diagnostic procedure in the evaluation of strictures in the anterior urethra in men.

Risk factors for antisperm antibodies in infertile men.

PROBLEM: The prevalence of anti-sperm antibodies (ASAs) in the general population is 0 to 2%; the prevalence in infertile men is much higher at 7 to 26%. However, the role of ASAs in male infertility remains controversial to date. Although several risk factors for ASA development have been defined (such as testicular torsion, varicocele, cryptorchidism, vasectomy, and genital tract infection), there are no specific indications for ASA testing. METHOD: In order to examine if a single parameter exists identifying patients with elevated ASA titers, serum ASA testing was performed with an enzyme-linked immunosorbent assay (ELISA) in 226 consecutive male patients. The new assay, synchron ELISA (Synelisa) used in our study represents a new type of ELISA without fixation of the sperm surface antigens by formaldehyde or glutaraldehyde. Therefore, the quantitative assay is highly sensitive and reproducible since the structure of sperm surface antigens is not altered by the fixation process. CONCLUSIONS: The prevalence of ASAs in this population was 14%, while the prevalence of the control group was 2.5%. Of all factors analyzed only a history of vasectomy, an acute epididymitis, and an abnormal result in the bovine mucus penetration test was associated with elevated ASA titers (P < .001). In addition, we could demonstrate a time related formation of ASAs in men after vasectomy.

[Application of mixed homologous/autologous full-thickness skin transplants preserved by freezing following 3d degree burns in animal experiments]. / Applikation gemischt homolog/autologer gefrierkonservierter Vollhauttransplantate nach drittgradigen Verbrennungen im Tierexperiment.

In 5 white piglets 3rd-degree burns were applied. After escharectomy the wound-dressing was done by intermingled homo/autografts. In variation of the Chinese method reported, in our experiments the homografts consisted of full-thickness skin preserved by freezing (-27 degrees C). In all piglets this procedure caused a perfect epithelialization and brought good cosmetic and clinical results.