Behandlung der Belastungsinkontinenz nach radikaler Prostatektomie

Background

The adjustable transobturator male system (ATOMS?) is a new method for the treatment of male stress urinary incontinence. This article presents the results of a prospective multicenter observational study with this system.

Patients and methods

Between March 2009 and March 2011 a total of 124 patients with persistent stress urinary incontinence after radical prostatectomy received the ATOMS system. Postoperative adjustments via the implanted port chamber were performed after 6 weeks and thereafter when necessary. Postoperative evaluation consisted of medical history, mictionary protocol, 24-h pad tests, 24-h pad counts and sonography.

Results

The mean age of the patients was 71.2±5.5 years (range 58-85 years). Previous incontinence surgery had been carried out in 36.3% of patients while 34.5% of patients had a previous history of radiation treatment. The mean operation time was 48.3±11.2?min (range 36-116?min) and the mean hospital stay was 3.8±1.2 days (range 2-6 days). No intraoperative urethral or bladder injuries occurred. After removal of the transurethral catheter on the first postoperative day, temporary urinary retention occurred in 3 patients who were conservatively treated. Transient perineal/scrotal pain or dysesthesia was observed in 75 patients (60.5%) and resolved after 3-4 weeks of non-opioid analgesics. There were no perineal infections; however, infections at the port site occurred in 3 patients (2.4%) leading to explantation of the system in all cases. The average number of adjustments to achieve the desired result was 4.3±1.8 (range 2-7). After a mean follow-up of 19.1±2.2 months (range 12-36 months), there was a significant reduction in the mean number of pads/24?h from 8.8 to 1.8 (p<0.001). The overall success rate was 93.8% with 61.6% of the patients being dry and 32.2% of the patients showing improvement.

Conclusions

The results of the study demonstrate the safety and efficacy to date of the ATOMS system for treatment of stress urinary incontinence after radical prostatectomy.     

Antiproliferative stent coatings: Taxol and related compounds.

The implantation of stents can prevent vessels from post interventional elastic recoil and appears to limit adverse remodelling. In order to inhibit in-stent restenosis, an additional release of antiproliferative agents from the stent itself might lead to a synergistic reduction of lumen renarrowing. Paclitaxel (Taxol) is a microtubule-stabilizing agent with potent antiproliferative activity. Unlike other antimitotic agents of the colchicine type, it shifts the microtubule equilibrium towards assembly, leading to reduced proliferation, migration and signal transduction. Moreover, important biological processes, such as the activation of some protein kinases, are associated with microtubule depolymerization and are therefore inhibited by paclitaxel. Several experimental in vitro and in vivo studies using local paclitaxel delivery to inhibit proliferation and lumen renarrowing have been performed already--with very encouraging results.     

Isradipine (PN 200-110), a new dihydropyridine calcium antagonist with slight negative inotropic properties in comparison with nifedipine

The influence of isradipine (PN 200-110), a new dihydropyridine calcium antagonist, in comparison to nifedipine and placebo on hemodynamics and left ventricular function was investigated in patients with coronary artery disease (10 patients in each group). The drugs were infused intravenously within 30 min in a dosage which led to a comparable afterload reduction (nifedipine [N] 2 mg, isradipine [I] 0.5 mg, AOP mean decrease: N, 14.7%, I, 13.1%). Increase of cardiac output (N +12.5%, I +15%) and decrease of systemic vascular resistance (N -29.2%, I -25%) were equal in both groups. Nifedipine caused a significant reflex increase of heart rate (+9.2%, p less than 0.001), which was not present with isradipine. The consequence was a significant decrease of the rate-pressure product with isradipine only (-12.5%, p less than 0.001) and not with nifedipine. Although afterload reduction was equal in both groups, isradipine caused a more pronounced decrease of LV volumes (EDVI: N -10%, I -16%) and an increase of ejection fraction (N +8%, I +14%). A significant increase of dp/dtmax, as a result of the afterload reduction, occurred after isradipine only (+13.5%, p less than 0.001) with no changes of dp/dtmax after nifedipine. Since changes of parameters (preload, afterload, HR, LVSP), which influence dp/dtmax independent of the inotropic state, were equal in both groups, the increase of dp/dtmax after isradipine should be a result of less negative inotropic properties of isradipine compared to nifedipine.     

Outpatient lumbar myelography. Initial results in 79 examinations using a low-dose metrizamide technique

Seventy-nine patients underwent lumbar myelography on an outpatient basis, with a low (3.75 g) dose of metrizamide as the radiocontrast agent and a 25-gauge spinal needle used for lumbar puncture. No patient experienced significant neurotoxicity following the examination; 70.8% (56 of 79) experienced minimal (23%) or no (48%) side effects. Three patients (3.8%) were admitted to the hospital for management of common side effects (headache, nausea/vomiting, back pain). We obtained postmyelographic computed tomographic scans on 96% (76 of 79) of the patients. Our initial results suggest that outpatient lumbar myelography is safe and can be performed with a very acceptable incidence of side effects.     

Detection of ischemia with thallium-201 single photon emission computerized tomography (SPECT) and radionuclide ventriculography in comparison with stress cineventriculography

The accuracy of radionuclide techniques for detection of exercise-induced myocardial ischemia was analyzed with TL-201 single-photon emission computer tomography (SPECT) and gated blood pool ventriculography in 31 patients. Reversible and persistent perfusion defects in the biphasic SPECT studies, parametric phase and amplitude images and global indices of left ventricular function were evaluated and compared to the results of exercise cineventriculography. Out of 25 patients with coronary heart disease, 20 had exercise-induced ischemia and 17 patients had a prior myocardial infarction. SPECT detected ischemia with a sensitivity of 85% and a specificity of 100%, gated blood pool ventriculography had a sensitivity of 60% and a specificity of 91%. Both scintigraphic methods were comparable in the detection of myocardial infarcts (SPECT/gated blood pool ventriculography: sensitivity 88%/82%; specificity 100%/93%; positive predictive value 100%/93%). A difference in detection of ischemia between both methods was found in patients with myocardial infarct and additional ischemia: all patients with additional ischemia were detected by SPECT, whereas gated blood pool ventriculography failed to identify the additional ischemia in 1/4 of these patients (p less than 0.05).     

Quantitative segmental analysis of wall function of the right ventricle in probands with healthy hearts

To investigate and determine the local wall motion of normal right ventricles, biplane angiograms from 14 normal subjects were analyzed. In all patients, organic heart disease was excluded by angiography and right heart catheterization under exercise. Using a radial model, segmental systolic area shortening was determined for the anterior, anteroapical and inferior segment in the RAO-projection and the inferior, anteroapical and anterior (free wall) segment in the LAO-projection. The highest segmental shortening was found for the anterior wall in the RAO-projection (45.6 +/- 7.8%) and for the free wall in the LAO-projection with 42.7 +/- 11.3% (RAO: anteroapical 28.1 +/- 6.3%; inferior: 26.5 +/- 7.8%. LAO: anteroapical: 34.7 +/- 18.8%; inferior: 30.6 +/- 21.6%). Corresponding to these different segment shortenings, right ventricular contraction seems to have a disharmonic pattern in comparison to the left ventricle. Normal local wall motion of segmental area shortening was predicted by the means-2SD (95.5%) confidence interval. The confidence interval of the inferior (-12.6%) and anteroapical (-2.9%) segment in the LAO-projection was poor compared to the other segments (RAO: anterior 30.0%; anteroapical 15.5%; inferior: 10.9%; LAO: free wall: 20.1%). For the LAO-inferior and LAO-anteroapical segment, even akinesia was within the 95.5% confidence interval. In conclusion, quantification of local wall motion seems possible with reasonable confidence for RAO segments and the free wall in the LAO-projection only.