[Therapy-refractory overactive bladder: alternative treatment approaches]

The treatment of patients with overactive bladder (OAB) refractory to conventional treatment is gaining clinical significance. This article intends to review alternative therapy options for patients with OAB refractory to conventional treatment. A search of the PubMed database as well as the abstracts presented at the European Association of Urology and the American Urological Association annual meetings was conducted. Keywords used during this search included overactive bladder (OAB) refractory to conventional treatment, electromotive drug administration (EMDA), sacral neuromodulation, augmentation cystoplasty and cystectomy. Eighteen articles with an adequate number of patients were identified. All articles published before 2001 were not included in this analysis. Because of first-line treatment failure, 30% of the patients required alternative treatment. This included EMDA, botulinum toxin injections into the detrusor, sacral neuromodulation, augmentation cystoplasty or cystectomy. Based on this review it appears that a significant improvement in micturition parameters, continence and in quality of life was achieved. Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains the last choice of treatment in refractory cases.Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains to be the last choice of treatment in refractory cases.

A novel ultrapressure liquid chromatography tandem mass spectrometry method for the simultaneous determination of androstenedione, testosterone, and dihydrotestosterone in pediatric blood samples: age- and sex-specific reference data

CONTEXT

Current immunoassays for analysis of plasma androgens in children have several limitations due to antibody-specific variations of data and normal ranges. Mass spectrometry-based methods are available for individual steroids but need complex sample preparation and report only fragmentary reference data for the pediatric population.

OBJECTIVE

Our objective was to develop a state of the art sensitive and specific tandem mass spectrometry method for high-throughput simultaneous determination of plasma concentrations of androstenedione (A), testosterone (T), and dihydrotestosterone (DHT) and to report age-, sex-, and pubertal stage-specific reference levels for these steroids in children aged 0-18 yr.

SUBJECTS AND METHODS

Plasma (100 microl) was mixed with internal standard and extracted by solid-phase extraction. Androgens were measured by ultrapressure liquid chromatography tandem mass spectrometry. Samples of 138 boys and 131 girls with neither signs of endocrine nor systemic disease were considered for the generation of reference data. The following age groups were used: less than 1 wk, 2 wk to 2 months, 3-5 months, 6-11 months, 1-3 yr, 4-6 yr, 7-9 yr, 10-12 yr, 13-15 yr, and over 16 yr.

RESULTS

Lower quantification limit was 2.9 ng/dl (0.1 nmol/liter) for A, T, and DHT. No relevant interference with other steroids was detected. Reference data for A, T, and DHT are reported as functions of age, sex, pubertal maturation, and testicular volume.

CONCLUSION

Simplicity, velocity, sensitivity, specificity, and the availability of pediatric reference data allow application of our new method in clinical routine as well as in research settings.

The effect of diet composition on tryptophan requirement of young piglets

The aim of the study was to evaluate the requirement for Trp in relation to diet composition in piglets in the period after weaning (BW range of 9 to 24 kg). Two Trp-deficient [relative to the Dutch (CVB, 1996) and NRC (NRC, 1998) requirement values for piglets of 10 to 20 kg of BW] basal diets were formulated: one based on corn and soybean meal and a second one based on wheat, barley, soybean meal, peas, and whey powder [10.0 g/kg of apparent ileal digestible (AID) Lys; 1.4 g/kg of AID Trp; 1.5 g/kg of standardized ileal digestible (SID) Trp]. Both basal diets were supplemented with 0.3, 0.6, and 0.9 g of l-Trp per kg of diet to obtain diets with 1.7, 2.0, and 2.3 g of AID Trp per kg (1.8, 2.1, and 2.4 g of SID Trp per kg), respectively. Each of the 8 treatments was evaluated in 8 replicates (pens with 8 male or female piglets). Average daily feed intake, ADG, and G:F were measured as response criteria. Over the 28-d experimental period, ADG and G:F were greater for the treatments on the wheat/barley diet compared with those on the corn/soybean meal and were increased by the level of Trp in the diet (P < 0.05). Average daily feed intake was only increased by the level of Trp supplementation (P < 0.05). Increasing the Trp level increased ADFI for the corn/soybean meal diet up to 2.3 g of AID Trp per kg (2.4 g of SID Trp per kg) and up to 2.0 g of AID Trp per kg (2.1 g of SID Trp per kg) in the wheat/barley diet (P < 0.05). For both diet types supplementation of free l-Trp increased the G:F up to 1.7 g of AID Trp per kg (1.8 g of SID Trp per kg). Nonlinear regression analysis of the response curves for ADFI using an exponential model for estimating a requirement value for Trp (defined as the Trp level resulting in 95% of the maximum response) revealed a requirement estimate of 2.3 g of AID Trp per kg for the corn/soybean meal-based diet and 2.1 g of AID Trp per kg for the wheat/barley-based diet, equivalent to 2.4 and 2.2 g of SID Trp per kg of diet, respectively. For ADG, a requirement estimate of 2.1 g of AID Trp per kg for both types of diets was derived, equivalent to 2.2 g of SID Trp per kg of diet. The Trp requirement for young piglets seems to be greater than indicated by some commonly used recommendations and does not seem largely dependent on diet ingredient composition.

The effect of sanitary status degradation and dietary tryptophan content on growth rate and tryptophan metabolism in weaning pigs

Health degradation modifies Trp metabolism through induction of Trp catabolism. This could limit the amount of Trp available for growth. The aims of the present experiment were to investigate the effects of a low grade inflammation and dietary Trp on growth and Trp metabolism. Eighty weaned pigs were assigned to 4 experimental treatments according to a 2 x 2 factorial arrangement: 2 sanitary statuses x 2 dietary Trp contents. The Trp content was deficient (low-Trp: 2.4 and 1.9 g of Trp/kg of the phase I and phase II diets, respectively) or adequate (high-Trp: 2.9 and 2.4 g of Trp/kg of the phase I and phase II diets, respectively). A low grade inflammatory response was induced by housing pigs in unsanitary environment, whereas control pigs were housed in good sanitary conditions. Pigs were not fed ad libitum to avoid feed refusals. Growth performance was calculated 3, 5, and 7 wk after weaning. Blood was sampled 12, 33, and 47 d after weaning for the determination of plasma concentrations of Trp and related metabolites, kynurenine and pyridoxal-5-phosphate. The interaction between sanitary status and dietary Trp was not statistically significant in all measured criteria. Pigs kept in poor sanitary conditions grew slower (P < 0.001) during the entire experimental period and had greater plasma concentrations of haptoglobin (P < 0.001) than pigs housed in good sanitary conditions. Pigs housed in poor sanitary conditions had also decreased Trp plasma concentrations (P < 0.001), but plasma kynurenine concentrations were not affected. Our results indicated that a moderate inflammatory response was obtained by degrading the sanitary quality of environment. Additionally, poor sanitary conditions modified Trp metabolism, indicating that the amount of Trp available for growth and other metabolic functions might be reduced.

A tryptophan-enriched diet improves feed intake and growth performance of susceptible weanling pigs orally challenged with Escherichia coli K88

We tested the effect of Trp addition to a standard weaning diet and oral challenge with enterotoxigenic Escherichia coli K88 (ETEC) on growth and health of piglets susceptible or nonsusceptible to the intestinal adhesion of ETEC. Sixty-four pigs weaned at 21 d of age were divided into 3 groups based on their ancestry and BW: a control group of 8 pigs fed a basal diet (B), the first challenged group of 28 pigs fed B diet (BCh), and the second challenged group of 28 pigs fed a diet with Trp (TrpCh). The Trp diet was produced by the addition of 1 g of l-Trp/kg to the basal diet. On d 5, pigs were orally challenged with 1.5 mL suspension containing 10(10) cfu ETEC/mL or placebo, and killed on d 9 or 23. Based on in vitro villus adhesion assay, the pigs (except the B group) were classified as susceptible (s(+)) or nonsusceptible (s(-)) to the intestinal ETEC adhesion. Thus, after the challenge, treatments were B, BChs(-), BChs(+), TrpChs(-), and TrpChs(+). Pigs susceptible to ETEC were 50.0% in the BChs(+) group (3 pigs lost included) and 46.4% in the TrpChs (+) group (1 pig lost included). During the first 4 d after challenge, the challenge reduced ADG (P < 0.05), and this reduction was greater in susceptible pigs (P < 0.05) than nonsusceptible ones. Tryptophan increased ADG and feed intake in susceptible pigs (P < 0.05) from challenge to d 4, but not thereafter. Tryptophan supplementation did not improve the fecal consistency and did not reduce the number of pigs positive for ETEC in feces on d 4 after the challenge. The K88-specific immunoglobulin A activity in blood serum tended to be greater in challenged pigs (P = 0.102) and was not affected by the addition of Trp. Villous height was affected by the addition of Trp and challenge in different ways, depending on the site of small intestine. The need to consider the phenotype for the adhesion of the ETEC in studies with different supply of Trp was clearly evident. When compared with practical weaning standard diets, Trp supplementation allowed susceptible pigs to partially compensate for the effects of ETEC challenge by increasing feed intake and maintaining an adequate BW growth. This is of practical importance for the formulation of diets for pigs selected for lean growth because of the presence of an association between this trait and the susceptibility to the intestinal adhesion of ETEC.

[Stone management in children]

The extracorporeal shock-wave lithotripsy (ESWL) is still the treatment of choice for almost all stones in children. But with advances in instrumentation, endourological procedures are being performed more frequently in younger patients. Especially in the treatment of distal ureteral stones retrograde ureteroscopy now competes with ESWL. Finally, the recent literature supports percutaneous nephrolithotomy as a safe and effective treatment option for large renal calculi and staghorn calculi. This gives the clinician the opportunity to choose from a wide range of treatment alternatives. Proper treatment planning, technique and availability of appropriate instrumentation are important to achieve an optimal outcome.

Chronic lung inflammation affects plasma amino acid concentrations in pigs1

Metabolic changes associated with inflammatory processes and immune response can modify protein and AA requirements. Improved knowledge of these processes will provide opportunities for nutritional intervention to sustain growth and animal defense at the same time. The objective of the study was to identify AA whose metabolism is affected by chronic lung inflammation. Six pairs of littermate piglets were selected at 28 d of age on the basis of their BW. After catheterization of the jugular vein, one littermate received complete Freund's adjuvant (CFA) intravenously, whereas its littermate was injected with a sterile saline solution (CON). Piglets within a litter were pair-fed in order to avoid confounding effects of feed intake and inflammation on plasma AA concentrations. Blood samples were taken after an overnight fast and 2 h after the morning meal for 9 d. Rectal temperature, food consumption, weight gain, plasma haptoglobin, and AA concentrations were measured. The CFA injection decreased food intake, and increased body temperature and plasma haptoglobin concentration. Plasma tryptophan, glutamine, proline, glycine, tyrosine, ornithine, total AA concentrations, and the ratio of tryptophan to large neutral AA were less in CFA than in CON (P < 0.05), independent of time and meal. In contrast, plasma histidine concentration was higher (P < 0.05) in CFA than in CON pigs. Plasma serine, arginine, alanine, asparagine, and total AA concentrations were lower in CFA than in CON pigs only in the fed state (P < 0.05). Among essential AA, only plasma tryptophan concentration was lower (P < 0.01) in CFA than in CON pigs in both fasted and fed state. These results show that chronic lung inflammation affects individual AA differently and suggest that the utilization of some AA increased during chronic lung inflammation in pigs. Activation of tryptophan catabolism enzyme indoleamine 2,3-dioxygenase seems a relevant hypothesis to explain the increased tryptophan utilization, although its incorporation in acute-phase proteins and the existence of other catabolic pathways cannot be excluded.

[The iatrogenic fornix rupture after endoscopic extraction of an ureteral stone via ureterorenoscopy]

Iatrogenic fornix rupture caused during retrograde manipulation of the ureter is a rather rare or rarely diagnosed phenomenon. A 22 year-old female patient presented with fornix rupture following endoscopic ureteral stone extraction under ureterorenoscopy, the rupture having become symptomatic 2 days later. Diagnostics were done by means of sonography and radiography and confirmed by CT-scan performed to rule out abscess formation which may have occurred in this case of delayed symptoms. Conservative antibiotic therapy was sufficient in this case. Ca. 10 % of all perirenal abscesses are attributed to urinary extravasation due to fornix ruptures, requiring surgical intervention. Regular sonographic control is therefore strongly recommended when fornix rupture is suspected to ensure appropriate counter measures.

[Ureterocystoplasty: functional results and possible problem areas]

Surgical procedures such as ileal augmentation cystoplasties are often necessary in neurogenic low-compliance bladders. Whenever possible one should avoid using segments of the GI tract in the urinary tract and preferably use the patient's own ureter for augmentation cystoplasty. This procedure includes transperitoneal nephrectomy of a nonfunctioning kidney with preservation of the renal pelvis and the megaureter, followed by detubularization of the ureter and its integration into the opened urinary bladder. We performed this procedure on four patients, two boys and two girls (aged 6-13 years). In the long-term follow-up they all had good rehabilitation results for their lower urinary tracts with an increase of the storage volume and normalization of their reduced compliance. No deterioration of the remaining upper urinary tract was found. Complications such as partial ureteral necrosis have to be taken into consideration when the vascularization of the ureter is compromised, for example, by multiple prior antireflux procedures.

Extensive surgery in metastatic testicular cancer

Surgery remains an important component in the multimodal treatment of patients with advanced testicular cancer. Recently, however, the indications for post-chemotherapy residual tumor resection have changed. Patients with advanced seminoma very rarely need surgical resection of the residual disease after standard chemotherapy. In contrast, patients with high stage non-seminomatous testis cancer must undergo post-chemotherapy surgery in most cases. Surgical resection in metastatic disease may also be necessary in patients with recurrent tumors, patients with persisting marker elevation during chemotherapy and patients with late relapses. Post-chemotherapy residual tumor resections, "redo"-retroperitoneal tumor operations and other salvage resections are often technically demanding procedures with unusual surgical approaches that require individualized perioperative planning in order to reduce morbidity. This paper summarizes the current indications for post-chemotherapy surgery and discusses various surgical approaches and techniques, perioperative management recommendations, as well as complications of these extensive resection procedures.

[Quality of life after surgical correction of penile deviation with the Schroeder-Essed plication]

PURPOSE

For the correction of congenital and acquired penile deviations, there are two established operative methods: the Nesbit procedure and the Schroeder-Essed technique. However, which operative method is optimal with respect to the specific underlying pathology, is still controversial. The aim of the study was to evaluate patient satisfaction retrospectively after modified Essed-Schroeder plication using quality of life questionnaires.

MATERIAL AND METHODS

Between June 1997 and June 2000, 59 patients underwent Essed-Schroeder at our institution for correction of a penile deviation. Mean patient age was 40 years (18 - 71) and mean follow-up 30 months (19 - 36). A standardised questionnaire was sent to all patients. Of these, the questionnaires completed by 50 patients could be assessed as valid.

RESULTS

Of these 50 patients, 22 suffered from a congenital penis deviation, 28 from Peyronie's disease. The percentage of patients who were able to perform sexual intercourse pre- and postoperatively was 62 % and 90 %, respectively. The proportion of patients who felt hampered during intercourse was reduced from 68 % to 48 %. Frequency of pain occurring during intercourse was diminished by half. Sixty percent of the patients would choose to have the same operation again, while 22 % were dissatisfied with the results. None of the patients showed complete erectile dysfunction after the operation. Seventy-four percent of the patients observed a decrease in penile length.

CONCLUSIONS

In patients with Peyronie's disease, the Schroeder-Essed technique with tunica plicature leds to significant improvement in relatively few cases. Alternative methods, such as the Nesbit corporoplasty, appear to be superior in these patients. In cases of congenital penile deviation, however, where the aim is cosmetic correction under maximum protection of erectile function, the Schroeder-Essed tunica plicature has shown good results with regard to penile function and quality of life.

Long term results and morbidity of paraaortic compared with paraaortic and iliac adjuvant radiation in clinical stage I seminoma

BACKGROUND

Radiotherapy is accepted as standard adjuvant treatment for low-stage seminoma and results in excellent survival rates. The optimal radiation field for stage I seminoma, however, is still being discussed.

PATIENTS AND METHODS

In a retrospective study we evaluated long-term results concerning survival, relapse-pattern, and acute and chronic toxicity in patients receiving adjuvant radiotherapy of the paraaortic and ipsilateral iliac lymph nodes (hockey-stick, HS) versus radiotherapy of the paraaortic lymph nodes only (PA). From 1979-1997, 129 patients (median age 32 years) in clinical stage I received adjuvant radiotherapy. Eighty-seven patients were treated with 36 Gy to the HS field and 42 patients were treated with a median of 28 Gy to the PA field.

RESULTS

With a median follow-up of 7.7 years (HS) and 5.2 years (PA) the relapse rate was 3.4% and 2.4%, respectively. There was no abdominal or pelvic recurrence in either group. Radiotherapy was well tolerated in both groups. No significant difference in acute or chronic toxicity was noted. However, lower gastrointestinal tract toxicities and myelotoxicities appeared less frequent in the PA group. Second malignancies only occurred in the HS group. Overall survival in the HS and PA group was 96.6% and 100%, respectively. No patient died of seminoma.

CONCLUSION

With paraaortic radiotherapy only, long-term disease-specific survival was excellent. Decreased risk of acute toxicity and of second malignancies are potential benefits of the reduced radiation field.

Adjuvant chemotherapy in stage I and stage II testicular cancer

Adjuvant chemotherapy in low-stage testis cancer is an accepted treatment option for two clinical situations: (1) chemotherapy after complete removal of the primary tumor by orchidectomy without clinical evidence of metastasis (clinical stage I), and (2) chemotherapy after complete surgical removal of non-seminomatous retroperitoneal metastases up to 5 cm in greatest transverse diameter by retroperitoneal lymph node dissection in clinical stage II. Aim of treatment is the prevention of tumor recurrences. The risk of recurrence depends on the type and stage of disease and ranges from 16% (clinical stage I seminoma) to 50% (pathological stage II B non-seminoma). Thus, 50-84% of patients receive adjuvant treatment unnecessarily. Prognostic factors have been developed in each tumor entity to tailor treatment to patients with high risk of recurrence.

Simultaneous micellar electrokinetic chromatographic determination of isomeric fatty acid hydroperoxides and corresponding hydroxy fatty acids

The high selectivity and efficiency of micellar electrokinetic chromatography with a borax-sodium dodecylsulfate (SDS) or meglumin-SDS buffer make possible the rapid separation of hydroperoxy and hydroxy fatty acids and the non-oxidised unsaturated fatty acids from which they are derived. Nearly all the isomers of the hydroperoxides and hydroxy fatty acids derived from oleic, linoleic, alpha- and gamma-linolenic and arachidonic acids can be determined both qualitatively and quantitatively within ca. 10 min. The system has as many as 1 x 10(6) theoretical plates, and the detection limits with UV diode array detection at 195 or 234 nm are in the micromolar range.