[Adjustable systems for the treatment of male incontinence]. / Adjustierbare Systeme zur Behandlung der männlichen Inkontinenz.

The principle of adjustment with the possibility to react to changing needs of specific patients even years after placing an implant is convincing. Experience has taught that urodynamic parameters as well as personal demands of a patient may change individually for instance as a result of resuming physical activities. Such demands can be met by simple adjustment.Results of Argus and Remeex can be considered equally sustainable as first publications date back from 2006 and 2004. With follow-up periods of more than 2 years realistic success rates of up to 90% have been observed. Adjustment will be needed in one third of cases.The ProAct balloons are attractive by virtue of the low invasiveness of both implantation and adjustment. A series published in 2005 revealed a success rate of 77%; these experiences have been confirmed by several other papers. Limiting factors for ProAct are irradiation therapy and scarred bladder neck.

Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis.

PURPOSE: Symptomatic nephroptosis is a rare disease requiring surgical therapy only in select cases. Laparoscopic nephropexy has been reported as minimally invasive treatment for symptomatic patients. We evaluated our long-term outcome after laparoscopic fixation of the kidney with an alloplastic mesh graft. MATERIALS AND METHODS: Since 1992, 30 patients have undergone laparoscopic transperitoneal nephropexy for symptomatic nephroptosis. All patients were preoperatively investigated by excretory urography (IVP) and split renal scan in the supine and upright positions. For fixing the kidney to the abdominal wall a polyglactin and polypropylene mesh graft was used in 6 and 24 cases, respectively. A total of 17 patients with a minimum followup of 5 years participated in an assessment of long-term outcome. Clinical examination, IVP and split renal function testing were performed with patients lying and standing. Patients were further questioned about postoperative satisfaction and whether they would undergo the procedure again. RESULTS: Of 17 patients 10 completed all investigations, 3 were contacted by telephone and 4 were lost to followup. Median followup was 5.9 years. Improvement in symptoms was reported in all cases with complete relief in 11 and intermittent flank pain requiring no medication in 2. There were no postoperative urinary tract infections or hematuria observed with improved hypertension requiring no postoperative medication in 1 case. Postoperatively IVP showed no recurrence in 8 of 10 patients but there was 5 cm. or greater recurrent ptosis in 2. Recurrence developed after using the polyglactin and polypropylene mesh grafts. Comparing preoperative and postoperative (123)iodine renal scans revealed significant improvement in renal function in 9 cases (p <0.05). There was no postoperative difference in split renal function and only 1 patient did not improve. No complications were noted except 1 symptomatic recurrence 3 months after the initial operation that required open surgical fixation. A total of 11 patients were completely satisfied with the long-term outcome and 2 were moderately satisfied. Of the patients 12 would undergo the procedure again, including 2 with persistent slight flank pain. One patient was inconsistent in regard to whether she would undergo the procedure again. CONCLUSIONS: Symptomatic nephroptosis is a bothersome disease requiring therapy only after thorough evaluation, including IVP and split renal scan with patients supine and upright. The good clinical outcome and highly satisfactory cosmetic result support laparoscopic nephropexy as the treatment of choice. Short-term and long-term results prove the efficacy of renal fixation with alloplastic mesh graft as minimally invasive therapy with a high success rate.

Bacterial colonization of ureteral stents.

OBJECTIVES: The aim of this study was to assess the frequency of bacterial stent colonization and stent-associated bacteriuria, and to evaluate the significance of urinary cultures for identification of colonizing microorganisms. METHODS: A total of 93 ureteral stents from 71 patients were examined: 9 patients with permanent ureteral stenting due to malignant ureteral obstruction (27 stents), and 62 patients with temporary ureteral stents (66 stents). RESULTS: Bacteriuria and bacterial stent colonization were found in all patients with permanent stents. In patients with temporary stents, colonized stents were found in 69.3% (43/62), mainly in combination with sterile urine (45.2%, 28/62). Mean indwelling times did not differ between patients with sterile urine and sterile stents (11.8 days) and patients with sterile urine and colonized stents (11.2 days). Prophylactic antibiosis in 42/62 temporarily stented patients did not reduce colonization rates compared to patients without antibiotics (70 vs. 65%). Enterococci were the bacteria most frequently cultured from urine and stents. CONCLUSIONS: In the present study, ureteral stent colonization rates were 100% in permanently and 69.3% in temporarily stented patients. Antibiotic prophylaxis did not prevent stent colonization and should not be routinely administered. Since urinary cultures correctly identified all colonizing microorganisms in only 21%, removal/replacement and bacteriologic evaluation of ureteral stents may be necessary in case of urosepsis.

Comparison of intraurethral liposomal and intracavernosal prostaglandin-E1 in the management of erectile dysfunction.

OBJECTIVE: To compare the intraurethral application of liposomal prostaglandin-E1 (PGE1) with intracavernosal injection of PGE1 in patients with organic or psychogenic erectile dysfunction (ED). PATIENTS AND METHODS: Penile tumescence and rigidity were classified by palpation in 25 patients (10 with psychogenic and 15 with organic ED: median age 45 years, range 23-67). All patients were undergoing primary treatment for ED, the median (range) duration of which was 2 3 (2-44) months. After administering PGE1 by each route (1 mg intraurethral and 0.02 or 0.01 mg intracavernosal), the degree of erection was assessed and duplex ultrasonography of the deep penile artery was performed. RESULTS: After the intraurethral application of liposomal PGE1, there was mild penile tumescence in 12 patients with organic ED, the others having no response. In contrast, intracavernosal injection produced sufficient rigidity in 13 patients with organic ED, while two only had a slight increase in tumescence. In patients with psychogenic ED, intraurethral application gave adequate rigidity in six, with four having little or no tumescence, and intracavernosal injection induced sufficient rigidity for intercourse in all. Duplex ultrasonography of the deep penile artery of the penis showed that intraurethral application induced lower flow rates than intracavernosal injection. No patient reported pain after intraurethral application but two of 25 reported severe pain after intracavernosal injection. CONCLUSIONS: The intraurethral application of liposomal PGE1 did not produce sufficient rigidity and was not effective in patients with organic ED. However, it did produce sufficient rigidity in six of 10 patients with psychogenic ED and may thus provide a therapeutic alternative in selected patients.

Laparoscopic implantation of temporary electrodes for bladder stimulation in dogs.

Five female mongrel dogs were used in an acute animal experiment. Under general anesthesia two monopolar wire electrodes armed with needles on either side were implanted into the bladder wall, the leads of both electrodes were then pulled through the abdominal wall. Filling of the bladder and intravesical pressure measurement were achieved through a suprapublic percutaneous cystostomy. Electrostimulation was carried out using the XEJ-2 experimental electroejaculator (biphasic pulses, pulse width 2.5 msec, approximately 70 mAmp, 50 Hz). The pressure changes within the bladder following electrostimulation were recorded, the effect of stimulation was observed endoscopically. Electrostimulation of the bladder wall resulted in micturition in all cases, showing an initial pressure peak at the commencement of electrostimulation followed by a decrease after onset of evacuation. We believe that laparoscopic implantation of temporary wire electrodes followed by percutaneous electrostimulation may open up new possibilities for bladder rehabilitation as well as for diagnostic investigations into the contractile capabilities of the bladder.

Functional replacement of bladder and urethra after cystectomy for bladder cancer in a female patient.

We describe a new concept for female bladder replacement introducing an ileocecal pouch with the intact appendix vermiformis used as an orthotopic neourethra. Based upon the results of preceding experimental studies this procedure was performed on a woman with the diagnosis of focal invasive bladder cancer. Eight months after the operation the patient is completely continent and back to work. This new type of urinary diversion with improved body image can be offered to female patients undergoing cystectomy for bladder cancer.

[The small urinary calculus: natural course and current treatment concepts]. / Der kleine Harnstein: natürlicher Verlauf und aktuelle Behandlungskonzepte.

Depending on size, duration of symptoms and their location in the collecting system urinary calculi may pass spontaneously in 16 to 93% of cases. The rate of infection and increase in size of stones in the renal pelvis or calix reaches 70% within months to years. Ureteral stones, however may lead to complications during a period of days to weeks. New minimally invasive treatment modalities have liberalized the indications for early intervention in cases of small stones.

Intracavernous injection of prostaglandin E1 plus procaine in the treatment of erectile dysfunction.

Despite the availability of prostaglandin E1 for more than 7 years as a diagnostic and therapeutic tool in patients with erectile dysfunction, the problem of penile discomfort after prostaglandin E1 application has remained unsolved. In a randomized, double-blind, crossover study we investigated the effect of 2 different prostaglandin E1-procaine concentrations on 24 patients suffering from pain following intracorporeal injection of prostaglandin E1 alone. Intracavernous injection of 20 micrograms. prostaglandin E1 with 10 mg. procaine (study 1) failed to improve local painful sensations. The combination of 20 micrograms. prostaglandin E1 with 20 mg. procaine (study 2) decreased the incidence of local pain significantly (p < 0.01). These preliminary results show that the combination of prostaglandin E1 plus procaine represents a beneficial alternative in patients with penile pain due to the single substance.

Laparoscopic nephropexy.

Laparoscopic nephropexy was done in 10 women with the diagnosis of a mobile kidney. The indications for laparoscopic nephropexy were confirmed by 123iodine-hippurate renal scan with the patient in the supine and sitting positions, which revealed decreased renal perfusion in all cases. Via a laparoscopic approach, the kidney is fixed to the abdominal wall at a high position according to the desired axis using a polyglactin net, which is stapled to the abdominal wall. Tissue adhesive also is applied over the net. All procedures were uneventful. Early postoperative excretory urography showed the treated kidneys to be in the desired position with free drainage of contrast medium through the ureteropelvic junction. Postoperative renal scans demonstrated significant improvement in all cases. In our opinion, laparoscopic nephropexy represents a technique of adequate invasiveness in relation to the disease to be treated.

Drainage and reflux characteristics of antireflux ureteral double-J stents.

We tested three antireflux double-J stents and compared them with common double-J stents in ex vivo canine urinary systems. At a physiologic flow rate, the drainage function of the antireflux stents proved to be sufficient; however, at a supraphysiological flow rate, drainage was inferior to that of the common double-J stent. Our reflux study demonstrated high-grade reflux with the common double-J stent, which transmitted more than 90% of the bladder pressure to the renal pelvis. The antireflux stents prevented this to a certain degree by both a reduction in and a delay of pressure transmission to the renal pelvis. In preliminary clinical trials, vesicorenal reflux was not detectable radiologically with the antireflux stents.

Percutaneous resection of renal cysts: a long-term followup.

Renal cysts are incidentally seen in ultrasonographic studies and are usually asymptomatic. However, some patients still present with symptoms due to a renal cyst. Various techniques have been reported for the treatment of renal cysts. Percutaneous resection of symptomatic cysts has been performed at our hospital since 1984. We investigated the long-term results of 10 patients who underwent percutaneous resection of renal cysts after a median followup of 45.7 months regarding the recurrence rate, late sequelae and clinical efficiency. Successful resection with no evidence of renal cysts was obtained in 50% of the patients at followup, a recurrence in 30% and residual cysts with up to a 45% decrease in size in 20%. All patients were cured of the symptoms and none had any late complications. We believe that percutaneous resection of renal cysts represents a valuable technique for the treatment of patients with symptomatic renal cysts. Neither postoperative nor late complications occurred after a median followup of 45.7 months.

Laparoscopic implantation of electrodes for stimulation of the hypogastric nerve and the vas deferens in dogs.

The minimal invasiveness of laparoscopy prompted us to investigate its use for placement of electrodes for stimulation of the hypogastric nerve and the vas deferens. In an acute canine model, pressure changes in the vas deferens secondary to electrostimulation were recorded. The laparoscopic approach included four ports. Monopolar cuff electrodes were placed around the hypogastric nerve and the vas deferens, and the leads of both were pulled through the abdominal wall. After multiple percutaneous stimulations (20 mAmp., 20 Hz. and 200 microsecond pulse width), the abdomen was opened through a midline incision to check the position of the electrodes. Electrostimulation was repeated with the abdomen open. Electrostimulation of both the hypogastric nerve and vas deferens resulted in marked pressure rises in the vas. These increases were similar in response to both surface and percutaneous stimulation. We thus believe that laparoscopic implantation of electrodes followed by percutaneous preliminary stimulation of the superior hypogastric plexus or the vas deferens may be a viable future approach to anejaculation.

Hydronephrosis in malignant tumors: rationale and efficiency of endo-urological diversions.

The improvement of minimal invasive endo-urological urinary diversions in patients with malignant ureteral obstruction (MUO) provides an alternative to open surgery. Endo-urologic procedures cause less morbidity than conventional surgical techniques. From April 1986 to April 1989, 52 patients suffering from MUO representing 64 reno-ureteral units were treated by endo-urological diversions. Proper drainage was achieved in all cases. Initial retrograde JJ-stenting was successfully performed in 30 instances. Percutaneous nephrostomy tubes were primarily placed in 34 units. Fourteen of these were finally changed to a JJ-stent in eleven cases and an ileal conduit in three. Percutaneous ureteral occlusion was performed in 7 units. A positive response regarding the effect of endo-urological treatment on the patient's quality of life was obtained in 81%. Further therapies of the underlying diseases were performed in more than 30% after stabilized renal function. MUO can be treated in most cases with little morbidity and frequently without the use of external collecting devices.

Urethral function after cystectomy: a canine in vivo experiment.

To study the function of the pelvic floor and the isolated urethra after removal of the bladder, 5 male and 5 female mongrel dogs were used in an acute in vivo experiment. Urethral pressure changes secondary to unilateral stimulation of the pelvic and pudendal nerves were recorded. After baseline data of the intact system were documented, the following procedures were carried out: separation of the urethra from the bladder neck (prostate), nerve-sparing cystectomy (cystoprostatectomy), and cold-knife incision through the entire length of the proximal urethra. Pressure recordings were repeated after each step of surgery. Pudendal nerve stimulation resulted in rapid and large pressure rises in the distal urethra (reaction typical of striated muscle). This response remained unchanged after all three surgical steps. Pelvic nerve stimulation provoked pressure rises within the urethra of a pattern typical of smooth muscle. The findings persisted after separation of the urethra from the bladder neck (prostate) and after cystectomy, but were not observed after urethrotomy. Contractions secondary to pudendal nerve stimulation were inhibited by curare, which did not affect the reaction to pelvic nerve stimulation. Our experiments demonstrate that in the dog the continuity of bladder and urethra is not required for the function of urethral closure mechanisms. The contractile potency of the urethral smooth muscles remains intact after nerve-sparing cystectomy. We believe that problems with the baseline continence of surrogate bladders should mainly be ascribed to a lack of surgical caution in preserving the autonomic nerves of cystectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional bladder replacement after radical cystectomy in the female: experimental investigation of a new concept.

We investigated the possibility of forming a continent surrogate bladder for female patients with the (ileo-) cecal pouch and the in situ appendix as a neo-urethra. Five female mongrel dogs were used for an acute animal model. Cuff electrodes were placed around the pelvic and pudendal nerve under general anesthesia and urethral pressures in response to stimulation were recorded. Baseline data were obtained, a nerve-sparing cystectomy was carried out, and the pressure response to stimulation was reassessed. The pressures obtained with pelvic nerve stimulation ranged from 20 to 35 cm H2O (average 28 cm H2O) before and from 10 to 30 cm H2O (average 25 cm H2O) after cystectomy. Urethral pressure changes secondary to pudendal nerve stimulation remained nearly unchanged after cystectomy. Four female human cadavers were used to demonstrate a technique of nerve-sparing cystectomy, comparable to that for male patients. Preservation of the nerves supporting the urethra and the pelvic floor can be achieved by careful preparation close to the bladder in the region between the uterine and vaginal arteries and in the distal perivesical area. The autonomic nerve fibers appear to be protected by the perivesical vascular plexus. As it is not necessary to perform an anastomosis in the true pelvis when using this method, the procedure appears comparatively straightforward. The continence mechanisms of the pelvic floor would not be affected by sutures and subsequent scarring.

Natural history and current concepts for the treatment of small ureteral calculi.

Six studies providing information on 2,704 patients were included into a retrospective analysis. The incidence of spontaneous passage relating both stone size and location was determined from these collated studies. The rate of spontaneous passage for stones smaller than 4 mm was 38% compared to 1.2% for those larger than 6 mm, irrespective of their position in the ureter at the time of presentation. Calculi discovered in the distal third of the ureter had a spontaneous passage rate of 45%, compared with the mid third of 22%, and the proximal third of 12%. Two thirds of all stones which passed did so within 4 weeks after the onset of symptoms. These data from the literature were compared to the treatment modalities applied for the last 100 consecutive patients treated with the diagnosis of ureteral stone at UCSF. 42% of the stones were found in the proximal, 13% in the mid and 45% in the distal third of the ureter. Treatment modalities included ureteroscopic stone extraction (36), ESWL (31) and watchful waiting for stone passage (30). Oral litholysis was performed in 2 cases and percutaneous removal of a proximal stone in 1. No calculus larger than 6 mm passed spontaneously. The passage rate from the proximal ureter was 18%, from the mid ureter 15%, and 38% from the distal ureter disregarding the size of the stones. The rate of complications reached 20% when symptoms exceeded 4 weeks in duration compared to 7% in patients with symptoms lasting less than 4 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

The double-J ureteral stent: in vivo and in vitro flow studies.

Although most ureters can now be stented, the rate of ureteral obstruction from extrinsic compression remains relatively high. To illuminate the mechanisms of obstruction in these patients we performed 20 in vivo pressure-flow investigations in 14 patients with indwelling ureteral Double-J stents. All patients had a percutaneous nephrostomy tube in place. Our investigations revealed proper drainage to the bladder in 17 of the 20 studies at an average renal pelvic pressure of 19.9 cm. water. Vesicorenal reflux was noted at an average bladder pressure of 20 cm. water in 17 studies. Three stents appeared to be obstructed. They showed no drainage to the bladder but also no reflux. To evaluate the in vivo results we then performed an in vitro study of pressure-flow characteristics under conditions simulating ureteral obstruction. At physiological flow rates different ureteral stents showed no major differences in pressure-flow characteristics. With compression and kinking, flow resistance in softer stents was notably greater than in hard stents. Therefore, we believe that in patients with suspected extrinsic compression of the ureter hard Double-J stents should be used. Vesicorenal reflux appears to be a reliable predictor of stent function.