Multiple Injuries to the Lower Urinary Tract: Two Cases and Comparison with the EAU Guidelines.

Blunt trauma to the lower urinary tract is usually associated with pelvic fractures. The European Association of Urology (EAU) provides guidelines to diagnose and treat these injuries. The guidelines summarise the available evidence and provide recommendations on diagnosis and treatment of these patients. Therefore, these guidelines are important adjuncts to the urologist and emergency physician in the clinical decision-making. However, strict adherence to the guidelines is not always easy or possible because of concomitant injuries obscuring the clinical picture. This is illustrated by two case reports of concomitant injuries of the lower urinary tract (bladder with urethral injury). The clinical decisions will be discussed point by point and should serve as a practical teaching moment for the reader.

[Conservative management of postoperative urinary incontinence in men]. / Konservative Therapie der postoperativen Harninkontinenz des Mannes.

Urinary incontinence in men most commonly occurs after radical prostatectomy. Of these patients, 3-23% remain incontinent a year after prostatectomy. Data on conservative therapy for postoperative incontinence is contradictory. Nonetheless, conservative treatment strategies must generally be attempted before any operative technique. Early pelvic floor muscle training with or without biofeedback therapy and duloxetine seem to have a positive effect on continence. Further randomised controlled studies are necessary to accurately assess other conservative therapeutic options such as extracorporeal magnetic innervation and electrical stimulation therapy.

[Artificial sphincter for the treatment of incontinence]. / Der artifizielle Sphinkter für die Inkontinenztherapie.

The artificial urinary sphincter (AUS) has been successfully implanted in the last 40 years. Continuous improvement of the AUS and increasing experience with the device has led to its widespread acceptance. The major indication is still post-prostatectomy incontinence. In this collective patient satisfaction was reported in over 90%. In a number of patients with neurogenic bladder dysfunction and congenital or acquired anatomical disorders of the urethra, an AUS can be an alternative to urinary diversion. Nonetheless, complications such as infections and erosions are still a problem, leading to revisions and secondary procedures in up to 20% of the cases. Therefore, operative expertise and precise execution of aseptic rules are basic prerequisites.

[Reconstructive pelvic surgery. Current status and future perspectives]. / Rekonstruktive Beckenbodenchirurgie. Aktueller Stand und Perspektiven.

Pelvic organ prolapse is a widespread condition that especially affects women. There are a number of conservative and surgical therapeutic options. The choice of therapy should be individually made, depending on factors such as the grade of prolapse and concomitant secondary disorders as well as the age and general condition of the patient. This article presents current surgical options, analyzes recent studies, and offers future perspectives for reconstructive pelvic surgery.

[Kidney injuries]. / Nierentrauma.

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70-80%. Long-term consequences can be hypertension or diminished kidney function.

Hypospadias.

Objective. The great possibility of variations in the clinical presentation of hypospadia, makes its therapy challenging. This has led to the development of a number of techniques for hypospadia repair. This article assesses past and present concepts and operative techniques with the aim of broadening our understanding of this malformation. Materials and Methods. The article not only reviews hypospadia in general with its development and clinical presentation as well as historical and current concepts in hypospadiologie on the basis of available literature, but it is also based on our own clinical experience in the repair of this malformation. Results and Conclusion. The fact that there are great variations in the presentation and extent of malformations existent makes every hypospadia individual and a proposal of a universal comprehensive algorithm for hypospadia repair difficult. The Snodgrass technique has found wide popularity for the repair of distal hypospadias. As far as proximal hypospadias are concerned, their repair is more challenging because it not only involves urethroplasty, but can also, in some cases, fulfil the dimensions of a complex genital reconstruction. Due to the development of modern operating materials and an improvement in current surgical techniques, there has been a significant decrease in the complication rates. Nonetheless, there still is room and, therefore, need for further improvement in this field.

[Kidney trauma]. / Nierentrauma.

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70-80%. Long-term consequences can be hypertension or diminished kidney function.

[Peyronie's disease Current conservative and non-invasive treatment options.] / Die Induratio penis plastica Aktuelle medikamentöse und nicht-invasive Therapiemöglichkeiten.

Peyronie's disease is an aetiologically poorly understood disease of the tunica albuginea, characterized by pain during erection, development of fibrous plaques and penile curvature. Due to incomplete understanding of the pathophysiology of the disease, no causal treatment exists. In the literature, there are many conservative treatment proposals. This report describes the conservative and minimally invasive treatment options for Peyronie's disease.

[Penile- and urethral anomalies]. / Penis- und Harnröhrenmissbildungen.

Penile and urethral anomalies are common congenital disorders with some rare variations. For example, the floppy penis is dealt with in only a few publications with a small numbers of cases. Other anomalies have not been published at all, i.e., the ectopic penis. Some anomalies become apparent immediately at birth, others remain undiscovered until adolescence. To date there is no established classification system dealing with urethral and penile anomalies. Also, no established guidelines exist for diagnosing and treating these anomalies. Surgical corrections of penile and urethral anomalies should follow standardized procedures on the one hand, but must respect the individual anatomical situation on the other. Since genital anomalies are frequently part of a syndrome, interdisciplinary approaches are advisable. The following article presents a classification of penile and urethral anomalies. Since posterior urethral valves usually affect the bladder and upper urinary tract, this disorder is not included in this review.

Use of water jet resection in organ-sparing kidney surgery.

BACKGROUND AND PURPOSE: The morbidity of organ-sparing renal surgery is related to intraoperative hemorrhaging and secondarily to urinary fistulae and urinoma. Various tools have been developed for gentle transection and precise control of bleeding. Water jet technology is already established in clinical practice for surgery of the liver and other parenchymatous organs. We report our clinical experience with a new water jet resection device in kidney surgery and the histologic effects of water jet resection on kidney tissue. PATIENTS AND METHODS: A series of 24 patients underwent open surgery for renal-cell carcinoma, nephrolithiasis, complicated cysts, or oncocytoma. In tumor patients, a partial nephrectomy; in two stone patients, a nephrolithotomy; and in the third stone patient, a lower-pole resection were performed. The cysts and the oncocytoma were enucleated in toto. In one patient, an endoscopic pyeloplasty was performed because of ureteropelvic stenosis. Tissue samples were investigated histologically using standard light microscopy after hematoxylin-eosin staining and compared with those subjected to thermal dissection techniques. RESULTS: The water jet produced a corridor in the desired dissection line without interfering with the intrarenal vessels and pelvicalical system. This way, precise hemostasis was possible, and damages to the surrounding tissue was avoided. Resection took between 14 and 40 minutes with minimal intraoperative blood loss. No significant postoperative complications occurred. Histologic evaluation demonstrated a sharp dissection line without thermal alterations or deep necrosis. Only a small disruption zone could be seen at the margins of the dissection. CONCLUSIONS: Water jet resection is a gentle method for dissection of kidney tissue. Histologic examination confirmed minimal traumatic parenchymal alteration. In our opinion, the water jet dissector is a useful device for renal transection in organ-sparing kidney surgery.

Use of water jet resection in renal surgery: early clinical experiences.

OBJECTIVE: Various surgical techniques have been developed to reduce the risk of bleeding during dissection of renal tissue. Water jet technology has been designed for a gentle transection of parenchymal organs. We report about first experiences with a new water jet resection device in kidney surgery. METHODS: 7 patients underwent open surgery because of renal cell carcinoma or nephrolithiasis. In tumor patients a partial nephrectomy, in 1 stone patient a nephrolithotomy, and in the other 1 a lower pole resection were performed. RESULTS: By means of water jet resection tissue was dissected effectively avoiding damage to the vascular structures, which were then ligated selectively. Resection time was between 14 and 30 min with a minimal intraoperative blood loss. No significant problem was seen postoperatively. CONCLUSIONS: The results demonstrate that water jet technology is an applicable tool for transection of renal parenchyma. It has been shown to reduce the risk of blood loss significantly compared to other techniques.

Penile disassembly technique for epispadias repair: variants of technique.

PURPOSE: We present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee. MATERIALS AND METHODS: Between 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1. RESULTS: Mean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each. CONCLUSIONS: Our variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

[Penile disassembly technique: a new approach in the surgical reconstruction of hypospadias]. / Technique de désassemblage du pénis: une nouvelle approche de la chirurgie reconstructrice de l'hypospade.

We report our experiences with penile disassembly technique in the treatment of severe hypospadias. During a period from November 1995 to December 1997 the technique was applied to 102 patients, aged from 9 months to 32 years. The principle of the technique involves separation of the penis into its component parts: glans cap with neurovascular bundle (dorsally) together with undivided or divided urethra and urethral plate (ventrally), and corpora cavernosa. After correction of the curvature and different techniques of urethroplasty the penile entities are joined into normal anatomical relationships. Our goal was also to achieve some degree of penile enlargement in small hypospadiac penises. The patients were followed from 4 to 29 months (mean 19.2 months). Straightening of the penis was achieved in all cases without recurrence of curvature. Complications were related to urethroplasty: 3 urethral stenoses, 2 fistulas and 2 diverticulum. Penile disassembly technique is very effective for most severe hypospadias. Possibility of penile augmentation is real with this technique.

A new approach to the treatment of penile curvature.

PURPOSE: Techniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair. MATERIALS AND METHODS: From November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis. RESULTS: Mean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients. CONCLUSIONS: Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.

The penile disassembly technique in hypospadias repair.

OBJECTIVE: To report experience and results with penile disassembly in hypospadias repair. PATIENTS AND METHODS: From November 1995 to May 1997 penile disassembly was used in 92 patients aged from 9 months to 32 years. The indications for operation were hypospadias with severe penile curvature (especially with curvature in the distal third of the corpora cavernosa), chordee without hypospadias, and small penis with hypospadias. The technique involves separating the penis into its component parts, i.e. the glans cap with neurovascular bundle dorsally, together with the undivided or divided urethra and urethral plate ventrally, and the corpora cavernosa. The manoeuvre allows any curvature to be corrected, especially when in the distal third of the corporal bodies, glans tilt to be rectified, and the penis to be enlarged, particularly elongated, which is a significant gain in small penises with hypospadias. RESULTS: The patients were followed for 3-20 months (mean 14); the penis was straightened in all cases, with no recurrence of curvature. In 37 patients (40%) penile disassembly combined with extensive urethral mobilization resolved the hypospadiac meatus with no need to form a neourethra; the penis was larger after surgery. Complications were related to urethroplasty and included four urethral stenoses, two fistulae and three diverticula. There was no injury to the neurovascular bundle and urethra; sensitivity and erection were preserved in all patients. CONCLUSION: The penile disassembly technique is most effective for hypospadias with severe curvature, especially for glans tilt and curvature located distally. Penile augmentation is possible using this technique.

Natural erection induced by prostaglandin-E1 in the diagnosis and treatment of congenital penile anomalies.

OBJECTIVE: To report the use of a natural erection induced by prostaglandin EI (PGE1) in the diagnosis and therapy of congenital penile anomalies as an alternative to artificial erection. PATIENTS AND METHODS: From February 1991 to December 1995 a natural erection was induced in 672 patients (mean age 5.7 years, range 12 months-47 years) to diagnose and treat congenital anomalies, e.g. simple penile curvature, chordee with and without hypospadias, epispadias, micropenis, cripple penis, etc. The dose injected intracavernosally was dependent on the patient's age, penile size and response, and ranged from 0.5 to 15 micrograms. RESULTS: A natural dilatation of erectile tissue was achieved in all forms of penile anomalies except in seven patients who did not respond. The mean duration of erection was 80 min, but a prolonged erection, for up to 6 h, occurred in two patients. CONCLUSION: The natural erection achieved by injecting PGE1 into the corpora cavernosa is a useful alternative to artificial erection in the diagnosis and treatment of congenital penile anomalies.

Basal cell carcinoma treated with interferon.

Human natural leukocytic interferon (HNLI) and recombinant interferon (rIFN) alpha 2c can be used in the therapy of basal cell carcinoma. Seventy-two patients were treated for 3 to 6 weeks with a single dose of 400,000 to 1,200,000 units (HNLI) and 2,000,000 to 5,000,000 units (rIFN alpha 2c). According to histopathologic and clinical findings, 52 patients were cured, and cancer cells were not found in the biopsy material taken after HNLI treatment for the second biopsy. In nine of 72 patients the cancer lesion was reduced 25% to 90%. In 11 patients it was not reduced or was reduced less than 25%. With rIFN alpha 2c therapy given five times per week for 4 weeks, histopathologic and clinical findings showed that five patients out of 12 were cured, and cancer cells were not found in the biopsy material taken after treatment. In seven patients out of 12 the cancer lesion was reduced 25% to 90%. Both types of interferons are effective in the treatment of basal cell carcinoma. Side effects were mild.