Pubic symphysitis after transurethral resection of the prostate.

PURPOSE: Pubic symphysitis (PS) after urological operations is uncommon. This is a systematic single-institution review of patients with transurethral resection of the prostate (TUR-P) with the aim to determine the incidence of PS after TUR-P and to identify a risk profile. MATERIALS AND METHODS: In the past 15 years, 12,118 transurethral operations were performed in our department, 33.4% (n = 4045) were TUR-P, and 84.6% (n = 3421) had routine suprapubic trocar placement. A systematic retrospective analysis identified 12 patients, who developed PS (0.297%). RESULTS: Median age was 69.5 years (64-83). All patients had voiding difficulties. Urine culture had been positive in three cases. All 12 TUR-Ps were monopolar resections, and n = 11 patients had a suprapubic trocar. Median resection weight was 47.5 g (10-100). Two patients had a perforation of the capsule. Histopathological examination revealed chronic prostatitis in nine cases. After 1.0 ± 1.2 months, all patients developed pain in the pubic region. All patients underwent MRI, which suggested PS. Symptomatic and antibiotic medications were administered. Final outcome was resolution of symptoms in all patients after 3.8 ± 5.6 months. No patient retained voiding difficulties. CONCLUSION: PS remains a rare complication after TUR-P. We could not identify a single cause for developing PS. In our study, suprapubic trocar placement (11/12), chronic prostatic inflammation (9/12), previous UTI (3/12) and extended resection (2/12) were overrepresented. Inflammatory, thermic and/or surgical damage of the capsule may be causative. Patients require antibiotic and symptomatic medication. However, prognosis for remission is excellent.

[Radical prostatectomy - pro robotic]. / Radikale Prostatektomie - pro robotisch.

Anatomical radical prostatectomy was introduced in the early 1980s by Walsh and Donker. Elucidation of key anatomical structures led to a significant reduction in the morbidity of this procedure. The strive to achieve similar oncological and functional results to this gold standard open procedure but with further reduction of morbidity through a minimally invasive access led to the establishment of laparoscopic prostatectomy. However, this procedure is complex and difficult and is associated with a long learning curve. The technical advantages of robotically assisted surgery coupled with the intuitive handling of the device led to increased precision and shortening of the learning curve. These main advantages, together with a massive internet presence and aggressive marketing, have resulted in a rapid dissemination of robotic radical prostatectomy and an increasing patient demand. However, superiority of robotic radical prostatectomy in comparison to the other surgical therapeutic options has not yet been proven on a scientific basis. Currently robotic-assisted surgery is an established technique and future technical improvements will certainly further define its role in urological surgery. In the end this technical innovation will have to be balanced against the very high purchase and running costs, which remain the main limitation of this technology.

[Epidemiology and etiology of male urinary incontinence]. / Epidemiologie und Atiologie der männlichen Harninkontinenz.

Compared to female urinary incontinence, the prevalence and socioeconomic impact of male urinary incontinence has not gained much attention from epidemiologists. Moreover, the few available epidemiological surveys vary in their use of definitions and methodology, which are known to have great impact on the resulting prevalences. Therefore, the interpretation of the findings is difficult. Depending on definitions and methods, the prevalence of male urinary incontinence ranges between 5.4 and 15%. Urgency incontinence is the predominant subtype in all age groups, although the relative proportion shifts towards stress incontinence with rising age. Neurological and posttraumatic causes for male stress incontinence become less important as the frequency of iatrogenic interventions (radiation, prostate surgery) increase. Additional risk factors for male urinary incontinence are age, immobility, and neurological diseases. Surgery of the prostate (TURP, radical prostatectomy) is especially associated with postoperative urinary incontinence if bladder and/or sphincter dysfunctions are preexisting, if the patient is particularly old, and the surgeon's experience is limited. The etiology of male urgency incontinence comprises detrusor instability caused by obstruction, age-related detrusor degeneration, insufficient inhibitory CNS control over afferent detrusor overstimulation, and neurological diseases. The pathophysiological key factors of male continence are functional urethral length and maximum closure pressure, the preservation of which should receive the unrestricted attention of every prostate surgeon.

[Therapy choices of German urologists and radio-oncologists if personally diagnosed with localized prostate cancer]. / Bevorzugte Behandlungsoptionen des lokalisierten Prostatakarzinoms von deutschen Urologen und Radioonkologen bei eigener Erkrankung.

INTRODUCTION: We evaluated the currently preferred primary treatment options among German urologists and radio-oncologists if personally diagnosed with localized prostate cancer, taking into consideration the different prognostic risk groups. MATERIALS AND METHODS: A questionnaire was mailed to 3,217 urologists and 598 radio-oncologists. They were asked to choose their preferred primary treatment option if they were personally diagnosed with prostate cancer, taking into consideration the different prognostic risk groups: low risk [Gleason score < or =6, prostate-specific antigen (PSA) < or =10 microg/l, T1c], intermediate risk (Gleason score 7, PSA 11-19 microg/l, T2), and high risk (Gleason score > or =8, PSA> or =20 microg/l, T3). Surgical options were further subdivided according to technique (retropubic, laparoscopic, perineal). RESULTS: The questionnaire return rate was 49% for urologists and 41% for radio-oncologists. The mean age was 48 years (28-86) for urologists and 47 years (29-68) for radio-oncologists. Primary surgical treatment was selected by 62% of urologists for low-risk prostate cancer, 90% for intermediate-risk prostate cancer, and 77% for high-risk prostate cancer. Radiotherapy as a primary treatment option was elected by 71% of radio-oncologists for low-risk prostate cancer, 84% for intermediate-risk prostate cancer, and 89% for high-risk prostate cancer. Retropubic, laparoscopic, and perineal prostatectomy would be chosen by 61%, 28%, and 10% of urologists, respectively, for low-risk prostate cancer; by 70%, 24%, and 6%, respectively, for intermediate-risk prostate cancer, and by 80%, 15%, and 5%, respectively for high-risk prostate cancer. CONCLUSION: Urologists prefer surgery and radio-oncologists radiotherapy for primary treatment of prostate cancer, irrespective of the prognostic risk group. Particularly for high-risk prostate cancer, the majority of radiooncologists would still choose radiotherapy as a primary treatment option. In the age of minimally invasive surgery, radical retropubic prostatectomy is still the preferred surgical treatment option among urologists for any prognostic risk group.

[Management of complications after sling and mesh implantations]. / Komplikationsmanagement nach Band- und Netzimplantationen.

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 15 years. The procedure is easy to perform, minimally invasive with short operation time in an ambulatory setting, and has proven efficacy comparable to the gold standard procedure of retropubic colposuspension.Possible TFAS complications are potentially underestimated with respect to prevalence and manageability. We report our experience with major complications following TFAS and mesh implantation in patients referred to our interdisciplinary continence center. Patient history, risk factors, and preoperative diagnostics were analyzed for development of individualized treatment strategies. Overcorrections with formation of postvoid residual (PVR) can occur in retropubic TFAS as well as in transobturator TFAS. However, the most prevalent and challenging complication is de novo urgency. Major complications like urethrovaginal fistula, sling arrosions of the urethra, bladder, and vagina as well as infected gangrene and complete urethral loss requiring urinary diversion were seen at a frequency suggesting underrepresentation of these complications in the literature. The large amount of implanted artificial mesh material used for pelvic organ prolapse (POP) correction represents a particular challenge in cases of dyspareunia or persisting pelvic pain.Complication management has to be based on cystoscopic, urodynamic, and physical examination findings to be individualized to each patient and must take potential risks of recurrent incontinence or persisting complaints into account.To prevent TFAS or mesh complications, every patient should have tried all conservative treatment options and should be completely evaluated (including urodynamics) preoperatively. Artificial meshes should only be used in cases of prolapse recurrence or in otherwise inoperable patients. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

Manifestation of congenital urethral diverticula in a 57-year-old male.

Congenital urethral diverticula are a rare finding in adult males. Most cases are diagnosed in childhood or adolescence because of voiding symptoms such as urinary dribbling. Diagnostic workup should include radiography and urethroscopy. The standard therapeutic approach is open surgical excision or endoscopic marsupialization. An unusual case of male congenital urethral diverticula that remained asymptomatic until age 57 is presented.

[Prevalence of lymph node metastases in non-muscle-invasive bladder cancer. Delay of radical cystectomy and upstaging in the cystectomy specimen as risk factors]. / Prävalenz von Lymphknotenmetastasen beim nicht muskelinvasiven Blasenkarzinom. Verzögerung der Zystektomie und Upstaging im Zystektomiepräparat als Risikofaktoren.

OBJECTIVE: To study clinical and histopathologic parameters after cystectomy and lymphadenectomy in non-muscle-invasive transitional cell carcinoma (TCC) of the bladder and their association with the prevalence of lymph node metastases (N+). PATIENTS AND METHODS: Of 866 patients treated with radical cystectomy and lymphadenectomy, 219 had non-muscle-invasive TCC of the bladder. The prevalence of N+ was related to parameters such as gender, age, number of transurethral resections of the bladder (TURBs), intervals between first TURB and cystectomy, adjuvant therapy, maximum histopathologic tumor stage and grade at TURB, and tumor upstaging in the cystectomy specimen by univariate and multivariate analysis. RESULTS: A total of 33 patients (15%) had N+. By multivariate analyses, tumor upstaging and the number of TURBs were independent predictors of N+ at cystectomy. The number of TURBs increased the prevalence of N+ from 8% (one TURB) to 24% (two to four TURBs). Tumor upstaging in the cystectomy specimen increased the prevalence of N+ from 4% to 36%. CONCLUSION: Inappropriate delay and staging errors of"high risk" non-muscle-invasive TCC of the bladder contribute to an increased prevalence of N+ and should be avoided. In our series, the number of TURBs and tumor upstaging in the cystectomy specimen were independent predictors for N+ by multivariate analysis.

Biphasic expression of stromal cell-derived factor-1 during human wound healing.

BACKGROUND: Chemokines tightly regulate the spatial and temporal infiltration of invading leucocyte subsets during wound healing. Stromal cell-derived factor-1 (SDF-1/CXCL12) is a homeostatic chemokine with multiple functions; its role during cutaneous wound healing, however, needs to be explored. OBJECTIVES: To elucidate expression of the multifunctional CXC chemokine SDF-1/CXCL12 during human wound healing. METHODS: Skin biopsies were obtained from 14 volunteers between 1 and 21 days after incisional wounding and processed for in situ hybridization and immunohistochemistry. RESULTS: We analysed the spatial and temporal distribution of SDF-1/CXCL12 after artificial wounding and detected a complete downregulation at both the mRNA and the protein level within the fibrous stroma that replaces the initial wound defect. However, increased levels of SDF-1/CXCL12 were observed at the wound margins. Focusing on mediators regulating SDF-1/CXCL12 expression in vitro we realized that both tumour necrosis factor-alpha and interferon-gamma downregulated its expression in human dermal microvascular endothelial cells and fibroblasts. CONCLUSIONS: Our data suggest that SDF-1/CXCL12 is tightly regulated during wound repair. Increased expression at the wound margin may contribute to the accumulation of endothelial progenitor cells, thus accelerating neovascularization.

[Which are reasonable diagnostic procedures in the evaluation of urinary incontinence in the elderly?]. / Welche Untersuchungen sind beim alten Menschen mit Harninkontinenz sinnvoll?

The ageing of our society continuously increases the number of frail elderly patients in the incontinence cohort. Shortage of financial and personnel resources demands reasonable and purposeful use of the diagnostic armamentarium. All intended diagnostic procedures should follow an algorithm hierarchized for invasiveness and should be limited to the minimum extent necessary for initiation of a conservative first-line treatment. Reasonable diagnostics objectify patients' complaints, differentiate between subgroups, reveal underlying pathologies and comorbidities, classify incontinence severity, support the therapeutic strategy, identify possible treatment complications and serve as follow-up tools. Diagnostic results have to be documented in detail and the procedures must be as easy and minimally invasive as possible. Basic diagnostics in urinary incontinence comprise patient history, clinical examination, urinalysis, uroflowmetry and sonographic post-void residual measurement, voiding diary and evaluation of the mental status. With these procedures, the vast majority of elderly patients can be classified correctly and a conservative first-line treatment can be started. Only a minority of patients with incongruent diagnostic results or recurrent incontinence refractory to conservative therapy should undergo further special diagnostics (urethrocystoscopy, urodynamics, morphologic and functional radiologic imaging, perineal or introital ultrasound) if they lead to therapeutic consequences. If not, expensive special diagnostics should be omitted in elderly patients due to their inherent morbidity.

[Established treatment options for male stress urinary incontinence]. / Etablierte Methoden in der Behandlung der Belastungsinkontinenz des Mannes.

Nowadays, male stress urinary incontinence is rare and almost always of iatrogenic origin (radiotherapy, pelvic surgery). However, the prognosis of urinary incontinence following surgery is good and can be improved by pelvic floor muscle exercises in combination with biofeedback systems. For the remaining patient cohort with persistent urinary incontinence, several established surgical treatment options are available. Suburothelial injections of bulking agents can easily be performed in an ambulatory setting. However, regardless of the material used, long-term results are disappointing. Moreover, the residual urethral function deteriorates due to cicatrization of the suburothelial plexus with consequent loss of urethral elasticity. The fascial sling procedure in males has to be performed in preoperated areas and is as technically demanding for the surgeon as it is burdening for the patient. Alloplastic material is not used, thus minimizing risks for arrosion or infection. Since the sling tension can neither be standardized nor postoperatively readjusted, the risk of overcorrection is considerable and the success of the procedure is heavily dependent on the surgeon's experience. Despite wear and high revision rates, the technically mature artificial sphincter produces excellent continence results and has become the gold standard in the therapy of male stress urinary incontinence. The circumferential and continuous urethral compression by the cuff is highly effective, but at the price of an almost inevitable urethral atrophy. To overcome this problem, various surgical techniques have been developed (tandem cuff, cuff downsizing, transcorporal cuff placement). However, the expensive artificial sphincter is not a nostrum for every incontinent man, since it requires certain minimal cognitive and manual capabilities. Therefore, the search for less demanding treatment alternatives seems to be necessary, even if one has to accept lower continence rates.

[Urethroplasty and simultaneous perineal prostatectomy after traumatic urethral disruption and carcinoma of the prostate]. / Harnröhrenplastik nach Urethraabriss und simultane perineale Prostatektomie.

We present a case of post-traumatic posterior urethral stricture and localized prostate cancer, which could be treated successfully with simultaneous radical perineal prostatectomy and membranous urethral stricture excision. After 6 months follow-up, the patient is continent with no evidence of stricture recurrence. Post-traumatic posterior urethral strictures can be managed surgically through a perineal approach with high success rates. Prostate surgery after pelvic fracture with posterior urethral distraction defects does not necessarily lead to stress urinary incontinence.

Pudendal nerve branch injury during radical perineal prostatectomy.

We report the first case of direct surgical injury to a pudendal nerve branch during radical perineal prostatectomy. A 65-year-old patient presented with typical symptoms of a pudendal nerve lesion after radical perineal prostatectomy. As the patient did not respond to conservative treatment, surgical exploration and exeresis of the injured sensory branch of the pudendal nerve was necessary, resulting in pain improvement. Urologic surgeons should be aware of the typical symptoms after iatrogenic injury to the pudendal nerve or its branches. Early diagnosis and neurosurgical intervention are important to obtain a more favorable outcome.

[Drug therapy of female urinary incontinence]. / Medikamentöse Therapie der weiblichen Harninkontinenz.

Drug treatment for female urinary incontinence requires a thorough knowledge of the differential diagnosis and pathophysiology of incontinence as well as of the pharmacological agents employed. Pharmacotherapy has to be tailored to suit the incontinence subtype and should be carefully balanced according to efficacy and side effects of the drug. Women with urge incontinence require treatment that relaxes or desensitizes the bladder (antimuscarinics, estrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetine), whereas patients with stress incontinence need stimulation and strengthening of the pelvic floor and external sphincter (alpha-mimetics, estrogens, duloxetine). Females with overflow incontinence need reduction of outflow resistance (baclofen, alpha-blockers, intrasphincteric botulinum toxin A) and/or improvement of bladder contractility (parasympathomimetics). If nocturia or nocturnal incontinence are the major complaints, control of diuresis is obtained by administration of the ADH analogue desmopressin. Future developments will help to further optimize the pharmacological therapy for female urinary incontinence.

Complete gangrene of penis in patient with arterial vascular disease.

We present a clinical case of distal penile gangrene in a patient with peripheral vaso-occlusive disease that did not correlate with the extension of the intraoperative finding and required total penectomy. Surgical intervention at the onset of wet gangrene avoids the complication of sepsis.

Treatment of recalcitrant pustular psoriasis with infliximab: effective reduction of chemokine expression.

Tumour necrosis factor (TNF)-alpha is thought to play a major role in the pathophysiology of psoriasis. Good clinical responses of psoriasis to anti-TNF-alpha-based therapies have recently been demonstrated. We studied the effect of infliximab, a monoclonal antibody against TNF-alpha, on chemokine expression in pustular psoriasis. A 61-year-old man with a 2-year history of severe pustular psoriasis of von Zumbusch type who did not respond to conventional therapies responded rapidly to treatment with infliximab. The clinical response was reflected by an immediate and effective reduction of the neutrophil-attractant chemokines interleukin (IL)-8 and growth-related oncogene (Gro)-alpha as well as of monocyte chemoattractant protein (MCP)-1, as determined by mRNA in situ hybridization of lesional skin. No expression before or after treatment was seen for monokine induced by interferon (IFN)-gamma (MIG) and IFN-inducible protein (IP)-10. Thus, in pustular psoriasis the chemokine expression pattern is dominated by neutrophil-attractant chemokines and MCP-1 while, in contrast to plaque psoriasis, IFN-gamma-inducible lymphocyte-attractant chemokines such as IP-10 and MIG are not abundant. We conclude that anti-TNF-alpha treatment with infliximab is an effective therapy in severe pustular psoriasis which is reflected by downregulation of disease-promoting chemokines such as IL-8, Gro-alpha and MCP-1.

[Changes in the receptor profile of the aging bladder]. / Veränderungen des Rezeptorprofils der alternden Blase.

Future demographic developments will challenge urology with a steadily increasing incidence of lower urinary tract symptoms (LUTS) derived from the aging bladder. Obstruction, instability and hypocontractility, which may be caused by changes in the receptor profile of the detrusor, are typical pathophysiologic findings in geriatric bladder dysfunction. Benign prostatic hyperplasia and diabetes mellitus are age-associated comorbidities with an additional influence on bladder receptors. Muscarinic (M(2), M(3)), purinergic (P2X, P2Y) and adrenergic receptors (alpha(1), beta(3)) are targets of efferent sympathetic and parasympathetic bladder innervation. Although the results from animal experiments are somewhat inconsistent, aging and bladder outlet obstruction (BOO) probably cause partial cholinergic denervation of the detrusor with a subsequent upregulation of muscarinic receptor sensitivity leading to bladder instability. The non-cholinergic (atropine-resistant) component of the detrusor contraction rises with aging and BOO to 50%, emphasizing the increasing impact of purinergic receptors in geriatric LUTS. alpha(1)-adrenergic receptors are modulated in the aging bladder by a shift from the predominant alpha(1a) subtype to the alpha(1d) subtype, which shows 100-fold higher affinity towards norepinephrine and increases alpha-adrenergic bladder susceptibility. No data are available on the changes in beta(3) receptor density or sensitivity with aging. Moreover, the role of sensory C-fiber receptors in geriatric LUTS remains completely unclear, although specific C-fiber blockers are already under clinical evaluation (capsaicin, resiniferatoxin).

[Diabetes mellitus and bladder function. What should be considered?]. / Diabetes mellitus und Blasenfunktion. Worauf ist zu achten?

Increasing prevalence of diabetes mellitus and rising patient life expectancy are causing an accumulation of urologic late complications-despite or due to steadily improving medical health care. The prevalence of diabetic cystopathy (impaired bladder sensation, increased bladder capacity, sometimes accompanied by voiding difficulties and residual urine) is 25% in non-insulin-dependent diabetics and 48% in insulin-dependent diabetics. Autonomic and peripheral neuropathy lead to detrusor hyposensitivity, and chronic overstretching of the bladder causes myogenic detrusor hypocontractility. Since diabetic cystopathy often develops insidiously and asymptomatically, prevention of secondary complications such as recurrent urinary tract infections, vesicorenal reflux, nephrolithiasis, and pyelonephritis requires the urologist's full attention as well as early and repeated urodynamic diagnostics. Comorbidities can lead to a variety of urodynamic findings. Therapeutic options are generally conservative (timed voiding, micturition training, CIC, pharmacotherapy) and should be part of an integrated interdisciplinary health care approach since undiscovered complications involving non-urologic organ systems create a higher long-term socioeconomic burden than preventive support provided by other specialists.

Perineal complications following radical perineal prostatectomy.

PURPOSE: Radical perineal prostatectomy has recently attracted renewed interest and wider acceptance as an alternative route to the retropubic approach. While presumed lower morbidity is one reason for perineal prostatectomy we evaluated our patients for complications that are specific for the perineal approach. PATIENTS AND METHODS: We have retrospectively analyzed 412 patients who underwent perineal prostatectomy from 10/1996 to 12/2000. Patients for the perineal approach were selected on the base of preoperative PSA (10 ng/ml) and biopsy Gleason score (< 7) without the need for simultaneous lymphadenectomy. A cystogram was performed routinely on day 7 p. o. and the catheter removed when patent anastomosis was confirmed. Intra-, peri- and postoperative complications were recorded and evaluated. RESULTS: Intraoperative complications encompassed 22 cases of rectal injury (5.5 %) with standard primary 2-layer closure, however 4 patients subsequently developed a stool fistula and 3 required a colostomy. Hematoma in the prostatic fossa was diagnosed in 21 patients (5.2 %) and was removed surgically due to infection or increasing size in 4 patients. In 6.5 % of the patients acute urinary retention occurred after catheter removal (91 % after 7 days), while 4.2 % showed urinary extravasation via the perineal wound. Both incidents healed uneventfully with prolonged catheterization in all except 2 cases with concomitant hematoma in whom open fistula closure with a tunica vaginalis graft was performed. The rate of perioperative transfusion was 6.4 %, transient paresthesia and weakness of the leg were observed in 3 patients. CONCLUSIONS: Radical perineal prostatectomy seems to be a procedure with a low rate of complications and surgical reinterventions. However, the spectrum of observed complications is different to that of retropubic prostatectomy and requires specific management.