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Biomedical subjects

R Wammack

Publications and source records attributed to R Wammack.

At least 19 recordsLinked to original sources
PubMed2003

Can total and transition zone volume of the prostate determine whether to perform a repeat biopsy?

OBJECTIVES: To compare the ability of total prostate (TP) and transition zone (TZ) volume to predict the outcome of a repeat prostate biopsy in patients with serum prostate-specific antigen (PSA) levels of 4 to 10 ng/mL. METHODS: A total of 1137 patients were included and underwent transrectal ultrasound-guided needle sextant and two transition zone biopsies of the prostate. All patients with a prior negative biopsy (benign prostatic tissue) underwent a repeat biopsy after 6 weeks. The TP and TZ volumes of the prostate were measured by transrectal ultrasonography. RESULTS: Of the 1137 patients, prostate cancer was diagnosed in 364 (32%), in 276 (24.2%) after the first biopsy and in 88 (7.7%) after the repeated biopsy. The TP and TZ volumes were larger in the patients with prostate cancer detected on the repeated biopsy (P <0.0001). Using a cutoff for TP volume of less than 20 cm3 and greater than 80 cm3 and for TZ volume of less than 9 cm3 and greater than 41 cm3 would have spared 7.1% and 10% of repeated biopsies, respectively. CONCLUSIONS: The probability for a positive repeat prostate biopsy increases in a logarithmic function for larger prostates, as well as for larger TP and, especially, for larger TZ volumes. The probability of finding prostate cancer on a repeat biopsy in prostates with small (less than 20 cm3) and large (greater than 79 cm3) TP, as well as in small (less than 9.3 cm3) and large (greater than 41 cm3) TZ volumes, was very low. Therefore, a repeat prostate biopsy within 6 weeks is unnecessary. These patients should be followed up by serial PSA determination.

Aged↗
PubMed2001

Pathological features of prostate cancer detected on initial and repeat prostate biopsy: results of the prospective European Prostate Cancer Detection study.

PURPOSE: We evaluated pathological features of prostate cancer detected on repeat prostate biopsy in men with a serum total prostate-specific antigen (PSA) level between 4 and 10 ng/ml who were diagnosed with benign prostatic tissue after an initial biopsy and compared them to those cancers detected on initial prostate biopsy. MATERIALS AND METHODS: In this prospective European prostate cancer detection study, 1,051 men with a total PSA level between 4 and 10 ng/ml underwent transrectal ultrasound (TRUS)-guided sextant biopsy and two additional transition zone biopsies. All subjects whose biopsy samples were negative for prostate cancer (CaP) underwent a repeat biopsy after 6 weeks. Those with clinically localized cancers underwent radical prostatectomy. Pathological and clinical features of patients diagnosed with cancer on either initial or repeat biopsy and clinically organ confined disease who agreed to undergo radical prostatectomy were compared. RESULTS: Initial biopsy was positive (CaP) in 231 of 1,051 enrolled subjects and negative (benign histology) in 820 subjects. Of these 820 subjects, CaP was detected in 10% (83/820) upon repeat biopsy. Of cancers detected on initial and repeat biopsy, 148/231 (64%) and 56/83 (67.5%) had clinically localized disease, respectively, and were offered radical prostatectomy. 10/148 (6.7%) and 3/56 (5.3%), respectively, opted for radiation therapy and thus, 138/148 (93.3%) and 53/56 (94.7%), respectively, underwent radical retropubic prostatectomy. There were statistically significant differences with respect to multifocality (P = 0.009) and cancer location (P < 0.001) with cancers on repeat biopsy showing a lower rate of multifocality and a more apico-dorsal location. In contrast, there were no differences with respect to stage (P = 0.2), Gleason score (P = 0.36), percentage Gleason grade 4/5 (P = 0.1), serum PSA (P = 0.62), and patient age (P = 0.517). CONCLUSIONS: At least 10% of patients with negative prostatic biopsy results will be diagnosed with CaP on repeat biopsy. Despite differences in location and multifocality, pathological and biochemical features of cancers detected on initial and repeat biopsy are similar, suggesting similar biological behavior and thus advocating for a repeat prostate biopsy in case of a negative finding on initial biopsy. Cancers missed on initial biopsy and subsequently detected on repeat biopsy are located in a more apico-dorsal location. Repeat biopsies should thus be directed to this rather spared area in order to improve cancer detection rates.

Age Factors↗
PubMed2001

Morbidity of transrectal ultrasound-guided prostate needle biopsy in patients receiving immunosuppression.

OBJECTIVES: To prospectively evaluate the safety and early and delayed morbidity of transrectal ultrasound-guided needle biopsies in patients receiving immunosuppressive therapy. METHODS: A total of 59 men receiving immunosuppressive agents after kidney transplantation, with a total prostate-specific antigen level between 4 and 10 ng/mL, were prospectively studied. All patients underwent transrectal ultrasound (TRUS)-guided sextant biopsy plus two additional transition zone biopsies. Biopsy samples were also obtained from suspicious areas identified during TRUS and digital rectal examination. The immediate and delayed morbidity, patient satisfaction, and complication rates were recorded and compared with the morbidity data recorded in the same period from 1051 men in the European Prostate Cancer Detection study. RESULTS: Of the 59 subjects, prostate cancer was detected in 17; 231 men were found to have cancer in the European Prostate Cancer Detection Study. Minor or no discomfort was observed in 88% and 92% of the transplant recipients and controls, respectively (P = 0.31). Twelve percent versus 8% experienced pain. Early morbidity included rectal bleeding (2.6% versus 2.1%, P = 0.19), severe hematuria (0.8% versus 0.7%, P = 0.08), and moderate to severe vasovagal episodes (1.9% versus 2.8%, P = 0.04). Late morbidity included fever (3.5% versus 2.9%, P = 0.1), hematospermia (11.0% versus 9.8%, P = 0.1), recurrent mild hematuria (17.4% versus 16.8%, P = 0.08), persistent dysuria (6.4% versus 7.2%, P = 0.2), and urinary tract infections (12.0% versus 10.9%, P = 0.08). Major complications were rare: urosepsis (0% versus 0.1%). CONCLUSIONS: The results of our study demonstrate that TRUS-guided biopsy of the prostate is generally well tolerated, with minor morbidity, in patients receiving immunosuppression. No differences were noted in pain apprehension or early and delayed morbidity, suggesting that TRUS-guided biopsies can be performed safely in these patients.

Aged↗
PubMed2000

Outcome predictors of high-energy transurethral microwave thermotherapy.

PURPOSE: Despite the good results of high-energy transurethral microwave thermotherapy (TUMT) for treatment of benign prostatic hyperplasia (BPH), it still is difficult to predict the response to treatment on an individual basis. In addition to clinical baseline parameters, histologic parameters seem to play a role in response variance after TUMT. High-energy TUMT has become widely accepted as a minimally invasive outpatient treatment in patients with lower urinary tract symptoms and BPH. Most patients benefit substantially from targeted microwave thermotherapy; however, little is known about optimal patient selection and the most relevant outcome parameters. MATERIALS AND METHODS: We evaluated Medline-based studies published between 1989 and 2000, including 900 patients suffering from lower urinary tract symptoms due to BPH who were undergoing TUMT. We evaluated outcome predictors for TUMT, such as histopathological parameters, prostate-specific antigen, and volume. RESULTS: Histologic and clinical outcome parameters were identified. Patient-to-patient differences in stromal-to-epithelial ratio of prostate tissue did affect outcomes. Poor responders to TUMT seemed to have a higher vessel density and a lower epithelial/stromal ratio. Relatively more abundant epithelial cells in the prostate tissue may lead to more favorable outcomes. Use of higher energy, patients with higher grade of obstruction, younger patient age, larger prostate volume (>25 mL), and higher prostate-specific antigen levels seemed to be associated with a better response to TUMT. CONCLUSIONS: New energy protocols could help tailor treatment to the individual needs of each patient. Nomograms based on volume, age, and pressure-flow parameters could assist in making clinical recommendations and identifying treatment responders; however, the total amount of energy appeared to have a high impact on the prediction of response.

Humans↗
PubMed2000

Microwave thermotherapy in patients with chronic urinary retention.

PURPOSE: To evaluate the efficacy of high-energy transurethral microwave thermotherapy (TUMT) in the treatment of chronic urinary retention (CUR) due to benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: In this prospective cohort study, 29 patients with CUR due to BPH underwent high-energy TUMT. Prior to treatment and during a 12-week follow-up, the following parameters were determined: quality of life (QOL) score, peak flow rate (Qmax) by uroflowmetry, and postvoid residual urine (PVR). In those with treatment failure (PVR > 150 mL or urinary retention), pressure-flow studies were performed and compared to pre-TUMT urodynamics. RESULTS: Of the 29 patients, 21 (72%) regained the ability to void spontaneously at 5 weeks. The actuarial median time for spontaneous voiding to be restored was 3.5 weeks (95% confidence interval [CI] 2.9-4.8 weeks). Mean QOL score at 12 weeks post-TUMT (2.2; 95% CI 1.5-2.7) was lower than that at 1 week (4.6; 95% CI 3.9-5.8) by 51% (p < 0.0005). Further, a 55% increase in mean Qmax (p < .0005) determined by uroflowmetry was observed by 12 weeks vs. 1 week after high-energy TUMT. TUMT failed in 8 patients due to a hypocontractile detrusor. CONCLUSIONS: We concluded that high-energy TUMT is a potentially useful option for patient with CUR who are not candidates for prostatectomy.

Aged↗
PubMed1996

The sigma rectum pouch (Mainz pouch II).

A low-pressure reservoir for urine is created by antimesenteric splitting and side-to-side anastomosis of the rectosigmoid, the expectation being to obtain better continence rates and better protection of the upper tract than are achievable by ureterosigmoidostomy. Between 1990 and August 1993 the procedure was performed in 73 patients (59 adults and 14 children) whose mean age was 43.5 years. The indications were malignancy (n = 55), bladder exstrophy/epispadias (n = 14), trauma (n = 3), and sinus urogenitalis (n = 1). Of the 73 patients, 69 were followed for a mean period of 127 (range, 1-34) months. In all, 5 early complications were encountered (6.8%). In addition, 8 late complications occurred (10.9%), stenosis at the ureteral implantation site being the most common one. Daytime continence was 94.5% and night-time continence, 98.6%. The sigma rectum pouch achieves excellent continence rates. Despite implantation of the ureters into a low-pressure reservoir, stenosis at the site of ureteral implantation occurred in 6.8% of the patients, demonstrating the profund vulnerability of ureterointestinal anastomosis.

Adolescent↗
PubMed1994

Ileocecal valve reconstruction during continent urinary diversion.

During construction of an ileocecal reservoir, such as the Mainz or Indiana pouch, the ileocecal valve is lost. Subsequently, the intestinal transit time is shortened and malabsorption as well as diarrhea may result. Patients having undergone previous bowel resection as well as children with myelomeningocele who often already have frequent defecations will be heavily affected by the loss of the ileocecal valve. We have functionally reconstructed the ileocecal valve by embedding ileum into the ascending colon via a submucosal tunnel in analogy to the technique used when creating the continence mechanism during the Mainz pouch procedure using the appendix. Experimental results in 15 dogs demonstrated that the surgically reconstructed valve genuinely mimics the physiological function of the authentic valve and confirmed a marked transit time prolongation without evidence of obstruction. Our first clinical experience in 12 patients using this operative technique is promising. Equally, the morphological appearance of the newly created valve closely resembles the genuine ileocecal valve during barium enema as well as endoscopic investigations.

Adolescent↗
PubMed1994

The Mainz pouch II.

The Mainz pouch II procedure has proved to be a substantial modification of the classical technique of ureterosigmoidostomy at many institutions. To date we have used this procedure in 72 patients, including 15 children. Detubularization causes a low pressure and eliminates high-pressure contractions. Without the risk of compromising the blood supply the pouch is fixed at the promontory which reduces the risk of ureteral kinking and upper urinary tract dilatation as it is sometimes observed after ureterosigmoidostomy. The technique is not only indicated in cases of failed ureterosigmoidostomy but also for primary urinary diversion. Of the 72 patients operated, all are evaluable with a follow-up of 1-31 months. All patients are continent during the daytime with a mean emptying frequency of 5. All but one elderly woman are dry at night with a mean frequency of 1. The described urodynamic/rectodynamic evaluation enables a reliable prediction of postoperative continence. With the reservoir full the basal pressure was 24 cm H2O and the highest peak pressure recorded was 35 cm H2O.

Adult↗
PubMed1994

Mechanical and electrophysiological effects of cromakalim on the human urinary bladder.

The effects of cromakalim on spontaneous and induced mechanical activity of human detrusor muscle were investigated in vitro. Cromakalim produces a concentration-related decrease of spontaneous as well as carbachol- and K(+)-evoked contractions. This is the first study to utilize the patch clamp technique to elucidate the mechanism of action of cromakalim on human detrusor cells. Cromakalim hyperpolarizes the detrusor cells by increasing the net outward current which is most likely carried by potassium ions. In the human urinary bladder, this effect is mediated by a glibenclamide-sensitive potassium channel, as glibenclamide is able to diminish the relaxant effect of cromakalim and to prevent the drug-induced hyperpolarization. Our results show that the effectiveness of cromakalim in relaxing the detrusor muscle is about an order of magnitude higher in the rat and guinea pig than in humans. It is therefore deemed unlikely that cromakalim or drugs with the same mode of action and similar tissue specificity will be of value in the clinical treatment of bladder instability and hyperreflexia. Moreover, it is suggested that when studies are undertaken to elucidate the effects and clinical potential of new drugs acting upon the bladder, human detrusor tissue should be used. The rat and guinea pig are unsuitable for this purpose.

Animals↗
PubMed1993

Osseous fixation of a penile prosthesis after transsexual phalloplasty: a case report.

We report on a patient who had undergone female-to-male transsexual surgery and subsequent phalloplasty by means of a free latissimus dorsi muscle graft with pudendal nerve coaptation elsewhere 10 years ago. The surgical strategy for implantation and osseous fixation of a penile prosthesis is described. We discuss whether the primary implantation of a penile prosthesis during 1-stage surgical phalloplasty is more advantageous in comparison with the currently favored secondary implantation. Phalloplasty should be represented by a 1-stage surgical procedure encompassing the creation of a neourethra, restoration of tactile and possibly erogenous sensibility, and implantation of a penile prosthesis. The result should have aesthetic value and be pleasing to the patient.

Adult↗
PubMed1993

The Mainz pouch II (sigma rectum pouch).

A low pressure rectosigmoid reservoir for urine is created obviating the need for colostomy, augmentation or extensive bowel surgery. Antimesenteric splitting of the intestine at the rectosigmoid junction and subsequent side-to-side anastomosis are performed. Urodynamic data demonstrate that the detubularization is effective in rendering high pressure bowel contractions ineffective. Without the risk of damaging the mesentery the pouch is fixed at the promontory, which lessens the risk of ureteral kinking and upper urinary tract dilatation. The technique is indicated not only in cases of failed ureterosigmoidostomy but also for primary urinary diversion. All 47 patients who underwent the operation were evaluable with a followup of 1 to 20 months (mean 10 months). All patients are continent during the daytime with a mean emptying frequency of 5 times. All but 1 elderly woman are dry at night with a mean frequency of 1 episode. With the reservoir full the basal pressure was 24 cm. water and the highest peak pressure recorded was 35 cm. water. The low pressure improves continence, protects the upper urinary tract and even allows dilated ureters to be implanted.

Adult↗
PubMed1993

Sigma-rectum pouch (Mainz pouch II).

A substantial modification of the classic technique of ureterosigmoidostomy is introduced in this article. To date, this procedure has been used in 47 patients. This article reviews the surgical technique of the antemesenterial splitting of the intestine at the recto-sigmoid junction which creates a pouch by subsequent side-to-side anastomosis.

Bladder Exstrophy↗
PubMed1992

Pediatric urinary diversion: review and own experience.

New insights into the diseases of childhood, profound improvements and new developments in surgical techniques as well as the knowledge gained from long-term follow-up have altered the strategies and indications for urinary diversion in childhood. Continent urinary diversion is generally the method of choice. We are able to construct high capacity, low pressure reservoirs to protect the upper urinary tract and achieve continence. Nowadays, there is hardly any indication for permanent cutaneous urinary diversion. Temporary and intermediate cutaneous diversion are used only when serious conditions such as renal function deterioration occur. The possibility to convert any incontinent form of urinary diversion into a continent form changed the status of intermediate diversion. The indications for urinary diversion, the procedures available, the operative technique, a literature review, our own experience, contemporary strategies and controversies are described and discussed.

Child↗