[25 years of Integral Theory by Petros : What remains and what's next?] / 25 Jahre Integraltheorie nach Petros : Was bleibt? Was kommt?

BACKGROUND: The Integral Theory (IT) states that urinary stress and urge symptoms mainly arise from lax suspensory ligaments, which are a consequence of altered collagen/elastin. Four important muscle groups (pubococcygeal muscle, levatorplate, longitudinal muscle of the anus, and the puborectalis muscle) are only able to guarantee the opening and closure mechanism of the bladder, the urethra and the anal tube if the suspensory ligaments are intact. The first practical application of the IT was the repair of the pubourethral ligament (PUL) known as tension-free vaginal tape (TVT). OBJECTIVES: What is the practical impact of the IT today? Do lax suspensory ligaments play a role in stress and urge urinary incontinence, fecal incontinence, voiding difficulties, and pelvic pain? MATERIALS AND METHODS: Evaluation of the literature, data, and experiences concerning IT. RESULTS: The pathophysiology of pelvic floor disorders has been widely proven and surgical concepts were developed to reconstruct the ligaments with the result of regaining function. Suburethral tapes are accepted as the standard of care for urinary stress incontinence. In addition, the correction of cervical ring defects, the lateral and central cystoceles, the uterosacral ligaments, the perineal body, and the rectovaginal fascia were adapted and newly developed with the aim of alleviating symptoms. Newly published data prove the cure of symptoms in a high percentage of cases. The complex conditions and function of the pelvic floor can be understood much better by using the diagnostic algorithm and with knowledge of the basic pathophysiology. CONCLUSION: The basic IT message: repair the structure (ligaments) and you will restore the function is true for all pelvic floor ligaments.

[Uncommon manifestation of prostate cancer : Sister Mary Joseph's nodule]. / Ungewöhnliche Manifestation eines Prostatakarzinoms : Sister-Mary-Joseph-Knoten.

We report on the case of an 81-year-old man suffering from prostate cancer for several years. In recent months, PSA levels increased, and 68Ga-PSMA-PET-CT (PSMA: prostate-specific membrane antigen) imaging demonstrated suspicious lesions in the paravesical area and an umbilical tumor mass. Local excision was performed. Histologically, the tumor mass was diagnosed as metastasis of the prostate cancer, which is also designated as Sister Mary Joseph's nodule. Umbilical metastases of primary prostate cancer are extremely rare; however, they are of clinical importance since they are commonly associated with tumor progress and with a particularly poor prognosis.

[Female urethral obstruction and bladder neck stenosis - fact or myth - how to proceed]. / Die Harnröhrenenge und Blasenhalsstenose der Frau - Fakt oder Mythos - Was ist zu tun?

The female urethra is probably the most neglected organ in women. Female urethral stricture and primary bladder neck obstruction are rare clinical entities. Traditional and new surgical techniques have been described for the treatment of female urethral stricture. However, they are based on limited data. There is no consensus on best management. The techniques of urethroplasty all have a higher mean success rate (80-94%) than urethral dilatation (< 50%), albeit with shorter mean follow-up. Urethroplasty performed by experienced surgeons appears to be a feasible option in women who have failed urethral dilatation, although there is a lack of high-level evidence to recommend one technique over another.Primary bladder neck obstruction (PBNO) is a condition in which the bladder neck fails to open adequately during voiding. This leads to increased striated sphincter activity or obstruction of urinary flow without another anatomic cause being present, for example an obstruction caused by genitourinary prolapse in women. Watchful waiting, pharmacotherapy and surgical intervention are possible treatments.

Defecation 1: Testing a hypothesis for pelvic striated muscle action to open the anorectum.

BACKGROUND: We conducted an observational study to assess the hypothesis that the pelvic muscles actively open the anorectal lumen during defecation. METHODS: Three groups of female patients were evaluated with video imaging studies of defecation using a grid or bony reference points. Eight patients with idiopathic fecal incontinence had video myogram defecography; eight with obstructive defecation had magnetic resonance imaging (MRI) defecating proctograms; and four normal patients had video X-ray or MRI defecating proctogram studies. RESULTS: In all three groups, the anorectum was stretched bidirectionally by three directional muscle force vectors acting on the walls of the rectum, effectively doubling the diameter of the rectum during defecation. The anterior rectal wall was pulled forwards, and the posterior wall backwards and downwards opening the anorectal angle, associated with angulation of the anterior tip of the levator plate (LP). These observations are consistent with a staged relaxation of some parts of the pelvic floor during defecation, and contraction of others. First, the puborectalis muscle relaxes. Puborectalis muscle relaxation frees the posterior rectal wall so that it can be stretched and opened by contraction of the LP and conjoint longitudinal muscle of the anus. Second, contraction of the pubococcygeus muscle pulls forward the anterior rectal wall, further increasing the diameter of the rectum. Third, when the bolus has entered the rectum, the external anal sphincter relaxes, and the rectum contracts to expel the fecal bolus. CONCLUSIONS: Our results are consistent with the hypothesis that pelvic striated muscle actively opens the rectal lumen, thereby reducing internal anorectal resistance to expulsion of feces. Controlled studies of electromyographic activity would be useful to further test this hypothesis.

Defecation 2: Internal anorectal resistance is a critical factor in defecatory disorders.

BACKGROUND: The aim of this study was to test our hypothesis that the reason why imaging is of little assistance in diagnosing "constipation" causes may be related to the high sensitivity of internal anorectal flow resistance in defecation to small changes in geometry. We applied a mathematical model to describe the effects on flow mechanics of observed changes in the shape of the rectum and anus during defecation. METHODS: Three groups of patients were studied with video proctograms. Group 1 comprised 4 patients with normal defecation studied with video proctography or magnetic resonance imaging (MRI). Group 2 comprised 8 patients with fecal incontinence, studied by video X-ray electromyography. Group 3 comprised 8 patients with constipation evaluated by video MRI. RESULTS: Three muscle vectors open the anorectal angle prior to defecation, causing the anorectal luminal diameter to increase to approximately twice its resting size. These vectors are forwards (anterior wall), backwards and downwards (posterior wall). Resistance to passage of a fecal bolus through the anorectum is determined by viscous friction against the anorectal wall and by the energy required to deform the bolus as it flows. The observed changes in anorectal geometry serve to reduce both the viscous friction in the anus and the deformation of the bolus, which reduces the force required to facilitate its passage through the anus. For example, if the effective diameter of the anus is doubled during defecation, the frictional resistance is reduced by a factor of 8. CONCLUSIONS: The sensitivity of flow resistance to geometry explains why MRI or computed tomography (CT) scans taken during defecation are not often helpful in diagnosing causation. Small changes in geometry can have a disproportionate affect on flow resistance. Combining accurate directional measurements during dynamic MRI or CT scans taken during defecation with observations of bolus deformation, and if possible, simultaneous anorectal manometry, may provide clinically helpful insights on patients with anorectal evacuation disorders.

Surgical reconstruction of pelvic floor descent: anatomic and functional aspects.

INTRODUCTION: The human pelvic floor is a complex structure and pelvic floor dysfunction is seen frequently in females. MATERIALS AND METHODS: This review focuses on the surgical reconstruction of the pelvic floor employing recent findings on functional anatomy. A selective literature research was performed by the authors. RESULTS: Pelvic floor activity is regulated by 3 main muscular forces that are responsible for vaginal tension and suspension of the pelvic floor organs, bladder and rectum. A variety of symptoms can derive from pelvic floor dysfunctions, such as urinary urge and stress incontinence, abnormal bladder emptying, fecal incontinence, obstructive bowel disease syndrome and pelvic pain. These symptoms mainly derive, for different reasons, from laxity in the vagina or its supporting ligaments as a result of altered connective tissue. Pelvic floor reconstruction is nowadays driven by the concept that in case of pelvic floor symptoms, restoration of the anatomy will translate into restoration of the physiology and ultimately improve patients' symptoms. CONCLUSION: The surgical reconstruction of the anatomy is almost exclusively focused on the restoration of the lax pelvic floor ligaments. Exact preoperative identification of the anatomical lesions is necessary to allow for exact anatomical reconstruction with respect to the muscular forces of the pelvic floor.

[Functional aspects of pelvic floor surgery]. / Funktionelle Aspekte der Beckenbodenchirurgie.

Pelvic floor dysfunctions are frequently seen in females. The human pelvic floor is a complex structure and heavily stressed throughout female life. Recent findings in the functional anatomy of the pelvic floor have led to a much better understand-ing, on the basis of which enormous improvements in the therapeutic options have arisen. The pelvic floor activity is regulated by three main muscular forces that are responsible for vaginal tension and suspension of the pelvic floor -organs, bladder and rectum. For different reasons laxity in the vagina or its supporting ligaments as a result of altered connective tissue can distort this functional anatomy. A variety of symptoms can derive from these pelvic floor dysfunctions, such as urinary urge and stress incontinence, abnormal bladder emptying, faecal incontinence, obstructive bowel disease syndrome and pelvic pain. Pelvic floor reconstruction is nowadays driven by the concept that in the case of pelvic floor symptoms restoration of the anatomy will translate into restoration of the physiology and ultimately improve the patients' symptoms. The exact surgical reconstruction of the anatomy is there-fore almost exclusively focused on the restoration of the lax pelvic floor ligaments. An exact identification of the anatomic lesions preoperatively is eminently necessary, to allow for an exact anatomic reconstruction with respect to the muscular forces of the pelvic floor.

[The transobturator tape (TOT). A minimally-invasive procedure for the treatment of female urinary stress incontinence]. / Das transobturatorische Band (TOB). Ein minimal-invasives Verfahren zur Behandlung der weiblichen Stressharninkontinenz.

The transobturator tape, a new technique for the treatment of female urinary stress incontinence, was evaluated with a 1 year follow-up.A total of 124 patients were treated with a low elasticity polypropylene tape according to the technique described by Delorme. The operative procedure is described step by step. All patients were followed-up after 3, 6 and 12 months. No intra-operative complications were observed. After 12 months 88.7% of the patients were cured and an additional 6.4% showed improvement. The transobturator technique (from exterior to interior) is, given proven indications and an exact consideration of the instructions, a simple, safe and efficient surgical procedure for the treatment of female urinary stress incontinence. The technique avoids complications such as bladder, intestinal and vascular lesions. It is suitable for genuine incontinence and patients with recurrent stress incontinence.

[Diagnosis of poly-orchidism]. / Zur Diagnostik der Polyorchie.

In a patient referred for sclerotherapy of a varicocele, three testicles and focal atrophy in one testicle were additionally diagnosed by ultrasound and MR. In the literature other diseases are occasionally described accompanying this rare benign congenital anomaly.