[Diagnosis and treatment of interstitial cystitis (IC/PBS) : S2k guideline of the German Society of Urology]. / Diagnostik und Therapie der interstitiellen Zystitis (IC/BPS) : S2k-Leitlinie der Deutschen Gesellschaft für Urologie.

In this review article, the authors describe all relevant aspects of the new S2k guideline from the German Society of Urology (Deutschen Gesellschaft für Urologie, DGU) for the diagnosis and treatment of IC/PBS (interstitial cystitis/painful bladder syndrome). A list of necessary and optional examinations and the necessity of diagnosis of exclusion are summarized and evaluated. The treatment options listed (ranging from conservative, oral drug, and complementary medicine to interventional surgical procedures) also give the reader a good overview of the contents of the guideline and possible therapeutic approaches. Finally, the recommendations including consensus of the guideline group are also summarized in various information boxes.

Guiding principles for peptide nanotechnology through directed discovery.

Life's diverse molecular functions are largely based on only a small number of highly conserved building blocks - the twenty canonical amino acids. These building blocks are chemically simple, but when they are organized in three-dimensional structures of tremendous complexity, new properties emerge. This review explores recent efforts in the directed discovery of functional nanoscale systems and materials based on these same amino acids, but that are not guided by copying or editing biological systems. The review summarises insights obtained using three complementary approaches of searching the sequence space to explore sequence-structure relationships for assembly, reactivity and complexation, namely: (i) strategic editing of short peptide sequences; (ii) computational approaches to predicting and comparing assembly behaviours; (iii) dynamic peptide libraries that explore the free energy landscape. These approaches give rise to guiding principles on controlling order/disorder, complexation and reactivity by peptide sequence design.

[Correction of parastomal hernia using meshes]. / Korrektur der parastomalen Hernie mit Netz.

The incidence of parastomal hernia in ileal conduit urinary diversion ranges from 4% to 16%. Surgical correction is necessary in about one third of cases and different techniques of surgical reconstruction have been described. Primary fascial repair has a high recurrence rate of 46-100% whereas stoma translocation is associated with complication rates of up to 88%. The use of alloplastic material (usually polypropylene meshes) has reduced the recurrence rate by up to 100% for primary fascial repair and 71% for stoma translocation down to 33%.Composite meshes consist of two layers, a polypropylene layer and an expanded polytetrafluoroethylene (ePTFE) layer. The former is placed against the abdominal wall for permanent reinforcement by ingrowing connective tissue and the ePTFE layer is placed against the abdominal organs preventing adhesions with the bowel. The intraperitoneal placement of such composite meshes is a standardized, simplified, gentle and controllable surgical procedure. This article reports experiences with the surgical correction of parastomal hernias in ileal conduits using composite meshes.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Breast cancer metastatic to a renal cell carcinoma]. / Metastase eines Mammakarzinoms in einem primären Nierenzellkarzinom.

INTRODUCTION: Renal tumors are often diagnosed during routine radiological-imaging. A newly diagnosed renal tumor next to an existing cancer is challenging since a primary or a secondary renal neoplasm has to be considered in the differential diagnosis. CASE REPORT: A 64-year-old woman underwent radical mastectomy and axillary lymphadenectomy for cancer of the right breast. After surgery, the patient underwent chemotherapy and radiotherapy because of multiple metastases. Six years later, computed tomography (CT) obtained as follow-up examination revealed a solid mass in the left kidney. Because radiological differentiation between metastatic breast cancer and primary kidney tumor was impossible and fine needle biopsy of renal tumors should be avoided, a nephrectomy was performed. Histologic diagnosis was a metastatic breast cancer within a primary renal cell carcinoma. Whereas the primary tumor was receptor negative, the breast cancer metastasis was estrogen receptor positive. CONCLUSIONS: In a renal mass of unknown nature in patients in good general condition and acceptable life-expectancy, surgical exploration with partial or radical nephrectomy is justified in spite of a synchronous metastatic tumor of different origin. This is the only way to obtain a definitive histologic diagnosis. A primary renal tumor can be treated curatively, preventing secondary complications, such as hematuria. In this case, the changed receptor state of the breast cancer metastasis also offered the patient the possibility of new palliative chemotherapy and hormonal manipulation.

Modified seromuscular tube: serosa lined bowel wall imbrication as a continent outlet for continent cutaneous urinary diversion.

PURPOSE: We created a simplified modification of the seromuscular tube technique for continent cutaneous urinary diversion. MATERIALS AND METHODS: We applied a simplified modification of our seromuscular tube technique in 1 woman and 2 men with a mean age of 53 years in whom outlet failure developed after continent cutaneous urinary diversion, and in whom adiposity and postoperative adhesions rendered revision difficult. We constructed a continent outlet conduit by imbricating the whole bowel wall and suturing it into a tube. RESULTS: At a followup of 4 to 13 months (mean 7) all 3 patients are completely continent without leakage. Catheterization is performed at 3 to 5-hour intervals (mean 4) with 14 to 16Fr catheters. CONCLUSIONS: The wall imbrication technique involves the flap valve principle, as does the seromuscular tube, and it is easy to perform. To date followup is too short for judging the long-term reliability of this continence mechanism. If the outcome stands the test of time in this series, which represents the worst case scenario, application of this technique may be extended to continent cutaneous urinary diversion.

Neo-adjuvant and adjuvant treatment of locally invasive bladder cancer.

Since Sternberg et al. in 1985 first published preliminary results of polychemotherapy in patients with metastatic bladder cancer, it became apparent that transitional carcinoma of the bladder is highly responsive to chemotherapy. Response rates up to 70% with combination therapy regimens like methotrexate, vinblastine, doxorubicin or adriamycin and cisplatin promised that transitional carcinoma might be able to cure even in advanced stages. Chemotherapy has either been applied prior to the local treatment (such as radical cystectomy or radiotherapy) in a neo-adjuvant regimen, or after local therapy in an adjuvant regimen. Although a large number of studies have been published in the past 20 years, the role of the different chemotherapeutic approaches has not been clearly defined. Therefore, neither neo-adjuvant nor adjuvant chemotherapy can be recommended as 'gold standard' treatment for advanced bladder cancer.

Radical cystoprostatectomy combined with Mainz pouch bladder substitution to the urethra: long-term results.

OBJECTIVE: To analyse, in a retrospective study, the oncological outcome, pouch-related complications, continence and micturition after radical cystoprostatectomy combined with Mainz pouch orthotopic bladder substitution to the urethra for the treatment of bladder cancer. PATIENTS AND METHODS: Between 1986 and 1996, three urological departments contributed 108 male patients to the review. The same exclusion criteria from orthotopic bladder substitution were applied by all centres, i.e. multifocal or concomitant carcinoma in situ, tumour at the bladder neck, positive biopsy from the prostatic urethra, locally advanced tumour and lymph node involvement. In all, 103 patients were evaluable for follow-up, with a mean (range) follow-up of 42 (3-132) months. RESULTS: Pathological examination of the cystectomy specimen revealed 81% organ-confined tumours. During follow-up, 84% of patients remained free of tumour, 7% developed distant metastases, 5% local recurrences, 4% urethral recurrences, and 1% upper tract urothelial cancer; 85% of patients are capable of spontaneous voiding, with a mean pouch capacity of 720 mL. Daytime continence was achieved in 88%, including 17% wearing one safety pad; 9% had stress incontinence and 3% total incontinence; 67% could sleep through the night, with either complete continence (34%) or one safety pad (33%). Nocturnal incontinence occurred in 11%. Uretero-intestinal stenosis occurred in 15 of 205 (7%) renal units, requiring ureteric reimplantations in 11, nephrectomy in three and antegrade dilatation in one. Reflux was not noted in any patient. About half the patients were on anti-acidotic prophylaxis. CONCLUSION: The large bowel segment in the Mainz-pouch technique of orthotopic bladder substitution provides good reservoir capacity and continence rates, with less ileum used than in all-ileum pouches. The surgical technique is simple and reproducible, and in particular the antireflux ureteric implantation into the caecum protects the upper urinary tracts.

Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association.

PURPOSE: The centers of the laparoscopy working group of the German Urologic Association collected data to prove the efficacy, safety and reproducibility of laparoscopic nephrectomy. MATERIALS AND METHODS: At 14 centers 482 laparoscopic nephrectomies have been performed until December 1996 via a transperitoneal approach in 344 (71%) and a retroperitoneal approach in 138 (29%). All 482 laparoscopic nephrectomies were performed by a total of 20 surgeons with an average of 24 procedures per surgeon (range 4 to 105). The indications for nephrectomy were benign renal pathology in 444 patients (92%), including renovascular disease in 28%, hydronephrosis in 20%, reflux nephropathy in 15%, chronic pyelonephritis in 12%, end stage nephrolithiasis in 11%, renal dysplasia in 4% and renal tuberculosis in 1%. Of the remaining 38 patients (8%) laparoscopic radical nephrectomy was performed for renal cell carcinoma in 5% and for upper tract transitional cell carcinoma in 3%. RESULTS: Operating time depended mainly on the pathology of the kidney (that is small dysplastic organ versus large hydronephrosis) and the learning curve of the surgeon. However, the average operating time did not vary significantly among the different centers (maximum 277.6 and minimum 81.9 minutes). Intraoperative or perioperative complications were noted in 29 patients (6.0%), including bleeding in 22 (4.6%), bowel injury in 3, hypercarbia in 2 and pleura lesion in 1 and pulmonary embolism in 1. The conversion rate was 10.3% (bleeding, bowel injury, difficult dissection), including 4 patients with renal tuberculosis, 2 with xanthogranulomatous nephritis, and 1 each following renal trauma and embolization. The re-intervention rate was 3.4% due to bleeding in 6 cases, abscess formation in 3, intestinal stenosis in 2 and a pancreatic fistula and port hernia in 1. Mean hospital stay was 5.4 days. CONCLUSIONS: Laparoscopic nephrectomy has become a well established procedure in those urology departments focusing on laparoscopy. The indications and results are reproducible at these centers. However, for patients with severe perinephritis (that is renal tuberculosis, xanthogranulomatous nephritis, posttraumatic atrophy) a higher likelihood of open conversion must be considered.

Urologic intestinal reservoirs: the continent outlet.

General use of standardized terminology and assessment of functional characteristics suggested by the International Continence Society will enable better comparison of the results and technical specifications of different continent outlets. According to the basic functional principle, continence mechanisms can be classified into extraluminally and intraluminally located continent outlets. Extraluminal continent outlets are easy to construct, but are associated with the risk of overflow incontinence. The use of invagination or intussusception nipple valves is associated with a long learning curve, tedious surgical technique and high complication rate. There is an increasing tendency to use the flap valve principle for construction of continent outlets, which guarantee a high rate of complete continence with an acceptable complication rate.

[Extracorporeal shockwave lithotripsy in childhood]. / Extrakorporale Stosswellenlithotripsie im Kindesalter.

In general, the criteria for treatment of urolithiasis in children are the same as those for adults. Today, extracorporeal shock wave lithotripsy (ESWL) is the method of choice for treatment of most pediatric urinary stones. Stone-free rates between 57% and 97% at short-term follow-up and 57%-92% at long-term follow-up have proven the efficacy of ESWL treatment in children. So far, there is no evidence of negative side effects of ESWL treatment in children in the long-term, confirming the safety of ESWL treatment seen in the short-term results. In particular, neither induction of hypertension nor deterioration of renal function have been detected in children when limitation of shock wave energy and shock wave numbers have been carefully observed.

[Calculation of lavage volume in transurethral prostate resection (TURP)]. / Uber die Berechnung des Einschwemmvolumens bei der Transurethralen Prostataresektion (TURP).

PURPOSE: Evaluation of the relationship between ethanol concentration in expired air and the amount of absorbed irrigation fluid in patients who undergo a transurethral resection of the prostate. METHODS: 76 patients were evaluated in a prospective study. The irrigation fluid contained 1.92 w/w% of ethanol. The ethanol concentration in breath was measured at least every 10 minutes with a Alcotest 7410 (Dräger) or a Biomed 3010 (Biotest). Documented values: breath ethanol concentration, mean arterial pressure, heart rate, haemoglobin concentration, serum sodium concentration, the amount of irrigation fluid, the time of operation, special events, therapeutic interventions. A modification of the Widmark formula was used for calculating the amount of absorbed irrigation fluid from the breath ethanol concentration. RESULTS: A rise of the ethanol level above 0.2/1000 was observed in 10 patients. No clinically significant difference in heart rate and blood pressure during surgery between the 24 patients with no alcohol in breath and the 10 patients with more than 0.2/1000 was observed. Prolonged duration of resection and greater amount of used irrigation fluid correlated with higher ethanol concentration in breath. During the study period no patient developed the clinical features of a transurethral resection syndrome. CONCLUSIONS: If 2 w/w% of ethanol is added to the irrigation fluid, breath ethanol concentration under 0.2/1000 may be considered harmless, while values above 0.2/1000 are predictors of massive absorption of irrigation fluid. In our patients, the addition of ethanol to the irrigation fluid has been a suitable and easy way to monitor the absorption of irrigation fluid, if the ethanol concentration in the breath is measured every ten minutes. If 2 w/w% of ethanol have been added to the irrigation fluid, the absorbed volume (E) can be estimated using the formula: E = 37.5 x body weight (kg) x ethanol concentration (/1000).

Experimental evaluation of free versus pedicled fascial flaps for sling surgery of urinary stress incontinence.

PURPOSE: Bladder neck suspension using an autologous fascial sling is an established surgical technique for treatment of urinary stress incontinence. However, the biological fate and physical properties of autologous fascial sling yet remain to be determined. MATERIALS AND METHODS: Our study was designed to evaluate in an animal model of twenty rabbits fascial slings from free and pedicled fascial flaps of two different widths (7 mm and 15 mm.) and uniform length (60 mm.) in respect to changes of length, width, tensile strength and histological criteria of vitality and integrity 3 months after surgery. RESULTS: The results 3 months after surgery revealed shrinkage in length by 37% (31%-46%) of the original length, shrinkage in width by 63% (60%-69%) of the original width and reduction of tensile strength of 53% (51%-55%) without consistent differences between free and pedicled flaps or 7 mm. and 15 mm. wide flaps. In the groups with 7 mm. wide flaps a total of two dystrophic slings (1 pedicled, 1 free) were seen; however, no dystrophies were seen in 15 mm. wide flaps. On microscopy, all slings were vital regardless of their surgical configuration. CONCLUSIONS: In summary, on macroscopic, microscopic and physical examination no gross differences between free and pedicled slings could be detected, so that preferences for use of free or pedicled fascial flaps could not be established for clinical applications in sling surgery. However, 15 mm. wide flaps had a lower incidence of dystrophy and retained greater absolute tensile strength than 7 mm. wide flaps.

Appendix carcinoma invading the urinary bladder.

We report a case of an appendix carcinoma invading the urinary bladder. In contrast to other bowel tumors invading the bladder, history and symptoms were consistent with a primary bladder tumor. This is due to the unique anatomical position of the appendix where the tumor did not hinder passage of bowel contents or cause melena. Findings on physical examination as well as diagnostic imaging and transurethral resection were inconclusive. Consideration of local progression of an appendix carcinoma is an important differential diagnosis. In contrast to other vesical or extravesical T4 tumors, the appendix carcinoma offers a good chance for resection en bloc by right-sided hemicolectomy and partial cystectomy.