Frequency and causes of fluid absorption: a comparison of three techniques for resection of the prostate under continuous pressure monitoring

OBJECTIVE: To compare in a prospective study three techniques for draining irrigation fluid during transurethral resection of the prostate (TURP) and to assess which method minimizes the risk of increased intravesical pressure and decreased plasma sodium level, as a sign of fluid absorption. PATIENTS AND METHODS: The study included 90 patients with benign prostatic hyperplasia (BPH), randomized into three equal groups, who underwent TURP using different techniques for draining the irrigation fluid. Group 1 had suprapubic drainage via the Freka(R) CystTUR Standard device (Fresenius, Germany); group 2 underwent TURP with an Iglesias continuous-flow resectoscope; and group 3 had suprapubic drainage using the Korth 'flow controller' (Olympus, Germany). The intravesical pressure was monitored continuously during surgery; an 'increased' pressure was defined as being >20 cmH2O. As fluid absorption decreases the plasma sodium level during surgery, the latter was also determined and the difference before and after surgery calculated. RESULTS: The intravesical pressure was increased in 10% of those in group 1, 90% in group 2 and none of group 3. The differences between group 1 and 2 and between group 2 and 3 were significant (P<0.001). The differences in the decrease of plasma sodium levels in groups 1-3 were not significant, but there was a significant correlation (P=0.0075) between increased intravesical pressure and minimum levels of plasma sodium. CONCLUSIONS: The three techniques for draining irrigation fluid produced significant differences in 'increased' intravesical pressure. In general, the levels of plasma sodium were not significantly different among the three techniques but patients with lower plasma sodium levels tended to have an increased intravesical pressure. In these cases, fluid absorption seems to be avoidable by an appropriate drainage technique. Nevertheless, considerable fluid absorption can occur at pressures of <20 cmH2O.     

Weibliches Genitale

Ohne Zusammenfassung     

Hypochlorhydria‐induced calcium malabsorption does not affect fracture healing but increases post‐traumatic bone loss in the intact skeleton

Efficient calcium absorption is essential for skeletal health. Patients with impaired gastric acidification display low bone mass and increased fracture risk because calcium absorption is dependent on gastric pH. We investigated fracture healing and post‐traumatic bone turnover in mice deficient in Cckbr, encoding a gastrin receptor that affects acid secretion by parietal cells. Cckbr?/? mice display hypochlorhydria, calcium malabsorption, and osteopenia. Cckbr?/? and wildtype (WT) mice received a femur osteotomy and were fed either a standard or calcium‐enriched diet. Healed and intact bones were assessed by biomechanical testing, histomorphometry, micro‐computed tomography, and quantitative backscattering. Parathyroid hormone (PTH) serum levels were determined by enzyme‐linked immunosorbent assay. Fracture healing was unaffected in Cckbr?/? mice. However, Cckbr?/? mice displayed increased calcium mobilization from the intact skeleton during bone healing, confirmed by significantly elevated PTH levels and osteoclast numbers compared to WT mice. Calcium supplementation significantly reduced secondary hyperparathyroidism and bone resorption in the intact skeleton in both genotypes, but more efficiently in WT mice. Furthermore, calcium administration improved bone healing in WT mice, indicated by significantly increased mechanical properties and bone mineral density of the fracture callus, whereas it had no significant effect in Cckbr?/? mice. Therefore, under conditions of hypochlorhydria‐induced calcium malabsorption, calcium, which is essential for callus mineralization, appears to be increasingly mobilized from the intact skeleton in favor of fracture healing. Calcium supplementation during fracture healing prevented systemic calcium mobilization, thereby maintaining bone mass and improving fracture healing in healthy individuals whereas the effect was limited by gastric hypochlorhydria. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1914–1921, 2016.

     

Beckenbodendysfunktion und ihre Therapie aus urologischer Sicht

The function of the pelvic floor and sphincter muscles consists of the maintenance of continence by a sufficient and stable tone and a normal reflex contraction and of a micturition without any obstruction by complete relaxation. The dysfunction can exist as overfunction in form of spastic condition, hyperreactivity or detrusor sphincter dysfunction or as underfunction in form of hyporeactivity or areflexia. The spastic condition is caused by a insufficient inhibition by the somatic A- and C-fibers. This dysfunction leads to urge-syndrome, urge-incontinence, pelvic pain-syndrome or residual urine and is diagnosed by urethral pressure profile or urethral calibration. The therapy is performed by antispastic drugs, biofeedback training and neuromodulation. The detrusor sphincter dysfunction is characterized by a missing relaxation of the striated muscles during micturition and leads to recurrent urinary tract infections, residual urine and finally to decompensation of the detrusor muscle and overflow incontinence. Therapeutically antispastic drugs, neuromodulation and intermittent catheterisation are used. The underfunction shows hyporeactivity or areflexia of the pelvic floor muscles and leads to stress incontinence by insufficient or missing pelvic floor contractions under stress. For therapy of choice, pelvic floor reeducation is performed, in case of failure suspension techniques are used.     

Pelvic floor stress response: reflex contraction with pressure transmission to the urethra

There is still controversy regarding the active role of striated intramural and periurethral muscles and their relative share of function for urinary continence under stress conditions. To evaluate the function of the periurethral muscles, we subjected a dog model to the physiologic stress condition created by sneezing. Simultaneous measurements of intravesical and three urethral pressures were obtained in the intact urinary tract and in a noncontractile substitute urethra, which was pulled through the pelvic floor and studied with and without additional pelvic floor suspension. The data clearly confirm the active role of striated sphincteric muscles for continence under stress conditions. The reflex contraction of the striated sphincteric muscles constitutes the majority of the distal urethral closure mechanism under stress conditions and generates intraurethral pressures, which exceed those of passive transmission of intra-abdominal pressure. The intramural striated sphincter contributes a share of less than 10% to this stress response, while the vast majority of the pressure rise is generated by the periurethral striated muscles. Surgical suspension of the pelvic floor can enhance effectivity of this stress mechanism, and thus seems to be a sound physiological concept in surgical treatment of incontinence.     

Interdisciplinary care of urinary incontinence in the elderly

World Journal of Urology -