[The unusual case: a foreign body in the urachus]

INTRODUCTION

In literature cystic tumours and carcinomas of the urachus are commonly described, also the secondary infection of a urachal cyst leading to an abscess is not unusual. But a foreign body penetrating after spontaneous perforation into an existing bland urachal cyst leading to an abscess is extremely rare and not described in literature. Although we made a thorough and extensive literature search we were not able to find a similar case.

CASE REPORT

This report concerns a 38-year-old female patient suffering from diffuse pain in the lower abdomen as well as temperatures up to 39 degrees C referred for further diagnostics and treatment. Further examinations showed an infra-umbilical 6 x 6 cm cystic formation. A CT scan confirmed our suspicion of an inflammatory cystic finding in this area. A subsequent laparoscopic transabdominal excision of this region was -performed. The histological analysis showed a central abscess-forming urachal cyst. Centrally located and causal for the inflammatory process we found a 4-cm fishbone. Even after closer question-ing there was no anamnestic evidence of how this foreign body could have got there. A self-manipulation was resolutely and believably denied by the patient.

CONCLUSION

In our opinion this case is an absolute rarity due to the constellation of two extremely seldom components: a urachal cyst and a probable intestinal perforated foreign body.

C-kit-positive multipolar cells in human penile erectile tissue: expression of connexin 43 and relation to trabecular smooth muscle cells

The aim of this study was to evaluate the hypothesis that interstitial cells might play a role in controlling and synchronizing via gap junctions the electrical activity of smooth muscle cells. The expression and distribution of interstitial cells in human penile erectile tissue was evaluated to determine whether or not cavernous interstitial cells express the gap junction protein connexin 43. Specimens of human corpus cavernosum were excised from full preparations of human penises. Cryostat sections (10 microm to 15 microm) of formaldehyde-fixated tissue segments were incubated using a double-labelling technique with antibodies directed against smooth muscle alpha-actin, c-kit, and connexin 43. Then, sections were exposed to secondary antibodies. Visualization was commenced by means of laser fluorescence microscopy. Double-staining techniques revealed immunosignals specific for c-kit (transmembrane receptor protein) and connexin 43 (gap junction protein) in multipolar cells located adjacent to smooth muscle cells. The number of c-kit-positive cells was significantly lower within the smooth musculature than within bundles of connective tissue surrounding smooth muscle cells of corpus cavernosum or cavernous arteries. Our findings demonstrate the distribution of c-kit- and connexin 43-positive interstitial cells in the connective tissue and smooth musculature of the corpus cavernosum. Additional studies are needed in order to evaluate further the ultrastructure of human penile erectile tissue and enable the identification of gap junctions mediating direct cell-to-cell communication.

High- versus low-dose leucovorin in 5-fluorouracil-based oxaliplatin- or irinotecan-containing regimen in metastatic colorectal cancer

e15054

Background: Although leucovorin (LV) is widely used as a modulator of 5-fluorouracil (5-FU) for the chemotherapy of advanced colorectal cancer, the optimal dose has not yet been established. Low-dose LV appears to be as active as high-dose LV in the several studies. So, we tried to compare the efficacy of high-versus low-dose LV in the commonly used palliative chemotherapy regimen. Methods: Between May 2003 and May 2008, 40 patients with metastatic colorectal cancer were randomly treated with high-LV (200mg/m2/i.v.) or low-LV (20mg/m2/i.v.) in 5-FU based oxaliplatin (FOLFOX-4) or irinotecan (FOLFIRI) containing regimen. The primary endpoint of the study was the comparison of response rates and the secondary endpoint was the assessment of survival and tolerability. Results: The response rate was 40% in low-LV group with 2 CR and 6 PR, and 35% in high-LV group with 2 CR and 5 PR, without any significant difference (P = 0.89). The median overall survival was 24.3 months in low-LV group and 25.2 months in high-LV group, with no difference between treatments. Toxicity mainly consisted of gastrointestinal side effects, which were rare and similar in the two groups. Conclusions: In this randomized phase II study, the low and high doses of LV appeared to be equivalent in palliative chemotherapy of metastatic colorectal cancer although large-scale phase III study are necessary.

No significant financial relationships to disclose.

[Castrati--everything to achieve fame]

The phenomenon of castration is wedded to the baroque era. This epoch stands for pure sensual pleasure. Those who could afford it tried to arrange their earthly days to be as enjoyable as possible. A perverse bloom of this ambition was the angel-like voices of the castrati. The supernatural sound of the voice was meant to let the opera visitors escape into another world. High society was almost addicted to those voices. On the other hand nobody showed any interest in the spiritual life of the castrati. Farinelli, Nicolini, and Senesino, three of the most famous castrati, were the first musical superstars of the eighteenth century. Their voices moved the decadent baroque audience to tears and enraptured them to the point of standing ovations. But the price for this fame was high. Only through castration in their early boyhood could this bell-like voice be kept. Because of the sensational success of the castrati, a huge wave of castration swept over Italy. Ambitious parents had their boys castrated, hoping that they would also become famous opera stars. It is estimated that in Italy alone over half a million boys were victims of this mutilating procedure during the eighteenth century. Because castration was officially forbidden it was done"behind closed doors" by untrained barbers and of course was associated with a high morbidity and mortality rate. The height of the castrati ended with the fading eighteenth century. The last castrato, Alessandro Moreschi, was engaged as a chorister and soloist at the Sistine Chapel in the Vatican. He was pensioned off by Pope Pius X in the year 1912 after an official ban on castrated singers was imposed. With that a very impressive part of music history had ended.

[Manifestation of malakoplakia in a urethral diverticulum in a female patient]

We report about a rare case of malakoplakia in a female urethral diverticulum. A 25-year-old patient with a long history of recurrent urinary tract infections and a plum-sized, painful swelling on the vaginal roof presented for operative treatment. In the anamnesis the patient reported about two spontaneous perforations, emptying several millilitres of pus each time. After total operative excision using a vaginal approach the histology showed malakoplakia in a urethral diverticulum. We found the typical intracytoplasmatic "Michaelis-Gutmann bodies" as well as "von Hansemann cells". Postoperatively we excluded an underlying tumour disease or a chronic infection. The further urological diagnostics (cystoscopy and MRI) were without any pathological findings. In patients with atypical cystic tumours of the urogenital tract, especially with an immune deficiency, malakoplakia should be taken in consideration. The preferred therapy is surgical management followed by long-term antibiosis as well as a close follow-up as recurrences are frequent.

[Nephropexy in the course of time. Aspects of an historical surgical technique]

The first successful nephropexy was performed in the year 1881. From this time, surgical therapy of nephroptosis has always been a subject of discussion. A partly uncritical acceptance led to nephropexy being the most performed urological operation at the beginning of the 20th century, with up to 200 different surgical variations. As early as the 15th century, a first description of ren mobilis was made by Alessius de Pedemontanus. The first surgical intervention for the treatment of nephroptosis was performed by Gilmore in 1870. In 1877, the American Dowell from New Orleans tried a fixation of the kidney through a seton, however, this operation failed. Eventually in 1881, Eugen Hahn from Berlin was able to perform the first successful nephropexy, he named this method "nephroraphy". In 1882, the first modification was made by Bassini with sutures through the renal capsule. Finally, the gynaecologist George Edebohl led nephropexy into a great popularity and secured the method through numerous technical innovations. By 1936, approximately 170 different surgical methods existed for fixation of the kidney. An accurate diagnosis is imperative before performing nephropexy. There were times in which this operation was carried out much too often and, therefore, had a bad reputation. However, it is not correct to drop nephropexy altogether as some would prefer. The statement by Professor Voelcker from Halle in the year 1911 that for all those who have a urinary obstruction and those with a beginning dilation, nephropexy is still justified and may - when correctly performed provide many blessings". Nothing needs to be added to this.