[A new generation of urethral stents--Allium in the therapy of symptomatic prostatic enlargement of various etiology].

A number of urethral stents made of different materials, with different time of indwelling and different designs, primarily based on the vascular stent concept, have been applied in the clinical practice so far. According to the published studies, urethral stents have justified their clinical application, however with certain limitations. Within an attempt to overcome the limitations, a covered, temporary urethral stent was initially designed by Daniel Yachie and Ijko Markovi in Allium corporation from Israel. With its triangular shape, the stent is a replica of the obstructive prostatic urethral lumen. In has been applied in a series of 14 patients with lower urinary tract symptoms caused by the obstruction at the level of the prostatic urethra. The subjects were averagely aged 77.4 +/- 5.1 years. Allium prostatic stent remained in place in the patients for 4.93 +/- 3.17 months, at the average.

Endourethral prostheses for urethral stricture.

A number of urethral stents made of different materials, with different time of indwelling and different designs, primarily based on the vascular stent concept, have been applied in the clinical practice so far. According to the published studies, urethral stents have justified their clinical application, however with certain limitations. Within an attempt to overcome the limitations, a covered, temporary urethral stent was initially designed by Daniel Yachie and Zeljko Markovic in Allium corporation from Israel. With its triangular shape, the stent is a replica of the obstructive urethral lumen. The follow-up of resuIts was done according to a priori established protocol including the following: UCG, uroflowmetry and interview with patients. Due to stent migration, the stent over stent technique was applied in two case, while reposition by balloon-catheter outward traction was performed in two cases of caudal migration. No irritative discomforts were reported in the first 6 months after stent dwelling. Uroflowmetric controls verified at least four times better results than before the insertion. Given it is the question of covered stent, there is no possibility of proliferative secondary lumen obstruction. On account of soft structure and conic shape of posterior part of stent, no lesions of the external urethral sphincter were manifested. The stent is simply withdrawn after 12 months by outward traction using the forceps at the time when the stent construction turns into soft and straight wire. After 12-16 months in all cases we removel stent and in all patients we find complete recanalisation without any disuric problem. In 5 cases we find new "contact" stricture on anterior part of stent and treated succeed with balloon recanalisation.

Interventional radiology methods of treating ureteral strictures developed on anastomoses after the radical cystectomy in Mainz pouch II and ileal conduit derivation.

UNLABELLED: OBJECTIVE of this work is to evaluate interventional radiology modalities such as balloon catheter dilation (BCD) and stent insertion, as minimally invasive methods in treatment uretero-enteral anastomotic strictures. MATERIAL AND METHOD: Retrospective study enrolled 26 patients (pts) in whom percutaneous BCD (17 pts) and metal stent implantation (9 pts) were done. Study was conducted from June 2005 till August 2007 and included total amount of 470 pts operated during 4 year period from 2003 till 2007. In 26 pts 35 ureteral units were treated, all of them in ambulatory conditions under oral analgosedation, monitored by fluoroscopy. Percutaneous BCD or stent implantation was performed in 24 pts and in 2 pts combined antegrade-retrograde approach for stent delivery, was applied. In all cases percutaneous nephrostomy (PCN) was left for 7 days period after procedure but in 6 units (5 pts) it remained permanent solution. First check up was done 7 days after by contrast media injection through nephrostomy tube prior to its extraction. Second control was done 30 days after by ultrasound exam and the last control (3 months after) by intravenous urography (IVU). RESULTS: In our specimen 17pts had strictures unilaterally (65.4%) and in 9 pts (34.6%) it occurred bilaterally. First check up revealed 82.7% success of BCD, in 17.3% BCD was repeated with the final success rate of 73.5% (19/26). In four pts (26.5%) after BCD reobliteration happened and PCN was left. Patent ureteral lumen was observed in 6 pts (85.7%) with stent inserted while one pt underwent surgical reintervention. No significant difference between BCD and stent insertion success rate was noticed, based upon morphological parameters (ureteral lumen diameter, pelvicaliceal system dilatation) and serum creatinin level. CONCLUSION: BCD and stent insertion showed satisfactory results (following 3 months) in ureteroenteral anastomotic stricture recanalization. They include ambulatory conditions, ability to repeat procedure, without complications -excluding restenosis which finally can be surgically treated.

The Hadera continent reservoir: a new appendico-umbilical continent stoma mechanism for urinary diversion.

PURPOSE: Creating a reliable continence mechanism for a continent reservoir is a great challenge. We describe an easily formed mechanism for allowing complete continence in such patients. MATERIALS AND METHODS: The native appendix attached to a detubularized right colonic reservoir was used as the catheterizable efferent limb. The continence mechanism was created by crossing 2 nondetached right rectus muscle strips around the appendix. RESULTS: At a mean followup of 32 months (range 4 to 52) in 17 patients complete continence was obtained between 2 to 4-hour self-catheterizations in all positions and even during straining. CONCLUSIONS: This continence mechanism is easy to construct and creates a reliable continent stoma in all patients who are not candidates for orthotopic bladder replacement and who retain the native appendix. In patients who have undergone appendectomy an alternate method is to create a small caliber efferent limb from a tailored terminal ileum and build the continence mechanism around it.

Transurethral water-induced thermotherapy for the treatment of benign prostatic hyperplasia: a prospective multicenter clinical trial.

PURPOSE: We evaluate the effectiveness and safety of transurethral water-induced thermotherapy for the treatment of lower urinary tract symptoms of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 125 patients with lower urinary tract symptoms due to BPH were enrolled at 8 study centers. Pretreatment evaluation included determination of International Prostate Symptom Score (I-PSS), peak urinary flow rate and quality of life score. Patients also completed a sexual function questionnaire. Patients were evaluated 3, 6 and 12 months after water-induced thermotherapy. RESULTS: Significant improvements in I-PSS, peak urinary flow rate and quality of life score were observed as early as 3 months after water-induced thermotherapy. At 12 months I-PSS had improved by a median of 12.5 (95% confidence interval 11.5 to 13.5) versus baseline, peak urinary flow rate by 6.4 ml. per second (5.6 to 7.5) and quality of life score by 2.5 (2.0 to 2.5). I-PSS, peak urinary flow rate and quality of life score improved by 50% or more at 12 months in 61.5%, 71.3% and 71.6% of patients, respectively. No adverse impact of water-induced thermotherapy on sexual function was noted, and preexisting discomfort during ejaculation and interference in sexual function due to lower urinary tract symptoms were significantly ameliorated after treatment. Serious adverse events were infrequent and manageable. CONCLUSIONS: Water-induced thermotherapy significantly alleviates lower urinary tract symptoms of BPH, increases peak urinary flow rate and enhances patient quality of life. This novel catheter based, minimally invasive treatment is easily administered in the outpatient setting. Water-induced thermotherapy holds promise as a useful and cost-effective option for the clinical management of BPH.

Management of bladder outlet obstruction by insertion of stents in the radiological suite.

Intraurethral mechanical support using prosthetic devices known as stents has become an increasingly used therapeutic approach in bladder outlet obstructions. This article is an overview on the stents used in the obliterated prostate and urethra which can be inserted in a radiological suite. The insertion of each currently available stent under fluoroscopy, transabdominal and transrectal sonography is described.

Dose perturbation due to the presence of a prostatic urethral stent in patients receiving pelvic radiotherapy: an in vitro study.

Temporary metallic intraprostatic stent is a new alternative treatment for patients with urinary obstructive syndrome caused by prostate cancer. Definitive radiotherapy is a treatment of choice for localized prostate cancer. This study evaluates in vitro the effect of a urethral intraprostatic metallic stent on the dose absorbed by the surrounding tissue. The study was designed to mimic the conditions under which the prostatic stent is placed in the body during pelvic irradiation. A urethral stent composed of a 50% nickel-50% titanium alloy (Uracoil-InStent) was imbedded in material mimicking normal tissue (bolus) at a simulated body depth of 10 cm. The distribution of the absorbed dose of irradiation was determined by film dosimetry using Kodak X-Omat V film. Irradiation was done in a single field at the isocenter of a 6 MV linear accelerator with a field size of 7 x 7 cm. The degree of film blackening was in direct proportion to the absorbed dose. The measurements showed an increase in dose of up to 20% immediately before the stent and a decrease of up to 18% immediately after the stent. These changes occurred within a range of 1-3 mm from both sides of the stent. In practice, irradiation in prostate cancer is given by two pairs of opposed co-axial fields; a total of four fields (Box Technique). The dose perturbations are partly cancelled in a pair of opposed beams resulting in a net variation of +/- 4%; therefore, the presence of the intraprostatic stent should not influence radiotherapy planning for prostate cancer.

A new continent vesicostomy technique: preliminary report.

PURPOSE: A continent vesicostomy was constructed without use of segments taken from other organs, providing a continent and esthetically acceptable stoma. MATERIALS AND METHODS: We used this technique in 4 female and 3 male patients. A bladder wall flap with the base near the bladder neck was tubularized creating a neourethra. To add to the resting closure pressure at the neourethra this tube was passed through crossed strands separated from the right and left rectus muscles near the pubis. The crossing strands of the rectus muscles provided lateral pressure to the neourethra, which added to the resting closure pressure. The stoma opened at the level of the pubic hair line in 6 patients and under the umbilicus in 1. RESULTS: Mean followup was 28 months (range 3 to 42). During this period all patients remained dry day and night between self-catheterizations. CONCLUSIONS: This technique allows for good continence with an easily accessible stoma without use of segments from other organs.

Overview: role of stents in urology.

Catheterization of the urinary tract for drainage is the mainstay of urologic manipulations. Although the material of which the catheters are made changed during the years, they all remained external communicating devices, causing ascending infections and discomfort. A concept of completely internal catheters for use in urology developed during the last few decades. Although the first self-retaining internal ureteral catheters (stents) were developed for use in open surgical procedures or on malignant obstructions, later, they caused a considerable leap in the development of minimally invasive endourologic procedures. The development of intraurethral stents also started to change some of the approaches to the management of bladder outlet obstruction. This paper summarizes the subject of urologic stents, which is presented in detail in this special issue of the Journal of Endourology.

Temporary metal stents in bladder outflow obstruction.

The use of stents in the management of prostatic obstruction started in 1980 with the development of the "partial catheter" by Fabian in Germany. Since then, a variety of metals and biostable and biodegradable polymers have been made into temporary or permanent stents for the management of infravesical obstructions such as benign or malignant prostatic enlargement, bladder neck stenoses, or urethral strictures. This paper is an overview of two generations of temporary metal stents used in the patients with infravesical obstruction.

The use of a removable stent in patients with prostate cancer and obstruction.

PURPOSE: A second generation temporary stent (ProstaCoil*) was inserted into the prostatic urethra of patients with obstruction due to prostate cancer to allow spontaneous voiding during hormonal therapy given to decrease the size of the prostatic mass. MATERIALS AND METHODS: The stent was inserted under fluoroscopic guidance using topical anesthesia in 27 patients (mean age 77 years) who presented with urinary retention due to advanced carcinoma of the prostate. All patients underwent operative or nonoperative hormonal therapy shortly after insertion of the stent. RESULTS: Followup of our patients was 3 to 48 months after stent removal and 15 void spontaneously. In 6 patients the stent was removed 9 to 19 months after insertion due to slow regression of the prostatic mass. Two of these patients required transurethral resection of the prostate and in 3 a new stent was inserted because of recurrent obstruction. two recently treated patients await stent removal and 3 died before removal of the stent. During followup no patient had urinary infection, either with the stent indwelling or after its removal. CONCLUSIONS: Temporary internal stenting of the prostate should be the treatment of choice for relieving obstruction during hormonal therapy given for prostate cancer.

Comparison between first-generation (fixed-caliber) and second-generation (self-expanding, large caliber) temporary prostatic stents.

In this study our aim was to compare a first-generation intraprostatic stent (Prostakath) with a second-generation one (ProstaCoil) in patients with prostatic obstruction. The comparison was made in terms of ease of insertion, need for repositioning, migration, infection, stone formation and length of time in place. One hundred and seventeen patients with an age range of 52-94 years were included in this study. Forty-nine of the patients were treated with gold-plated stainless-steel-made stent (Prostakath) inserted under sonographic and 68 of the patients were treated with a nitinol-made stent (ProstaCoil) inserted under fluoroscopic guidance. Indications for stent insertion were similar for both groups. We found that immediate correct positioning was 83% for the Prostakath and 100% for the ProstaCoil. In 42% of the cases the Prostakath necessitated later repositioning because of partial migration and in 12% of the cases removal because of complete migration into the bladder or the anterior urethra. No migration was observed with the ProstaCoil. In 10% of these cases the Prostakath could not be inserted because of the instability of the stent. Due to its larger caliber the second-generation stent caused more transient irritative symptoms. No difference was found in stent-induced infections (10% for all stents). Encrustations were found in 40% of the patients at 1 year with the Prostakath, but in 30% with the ProstaCoil at 2 years. Maximal indwelling time was 12 months with the Prostakath and 36 months with the ProstaCoil. We conclude that the second-generation stent was more advantageous because of its larger caliber allowing catheterization and endoscopic examinations, more flexibility and much longer indwelling time.

Objective and subjective comparison of transurethral resection, transurethral incision and balloon dilatation of the prostate. A prospective study.

Each of the treatment alternatives of benign prostatic hyperplasia (BPH) has its own advantages and disadvantages. The needs and the condition of the patient should be considered in choosing the proper treatment. After the treatment, patient satisfaction should also be considered because objective criteria do not always reflect the efficacy of the treatment. The long-term efficacy of the three alternative treatments of BPH (TURP, TUIP, TUBDP) were compared in a total of 60 men with obstructive symptoms. TUIP was found to be the method of treatment we recommended in young patients with a small and symptomatic adenoma, whereas TURP is still the 'gold standard'.

Bio-fragmentable anastomosis ring in urological surgery involving the gastrointestinal tract: early experience and a historical review of mechanical intestinal anastomosis.

We present our experience with use of a bio-fragmentable mechanical device for intestinal anastomosis in 14 patients. No anastomotic leakage occurred in our patients. The technique was easy to learn and shortened the operating time by at least 30 minutes. Our impression is that during time-consuming extensive onco-urological procedures involving the gastrointestinal tract, the use of such a device allows for a shorter operative time to the benefit of the patient and surgeon.

Testicular mass as a presenting symptom of isolated polyarteritis nodosa.

Isolated polyarteritis nodosa (PAN) of the male testes has rarely been reported. The authors describe two young men with testicular mass as a presenting symptom of isolated PAN, which was diagnosed following orchiectomy. The clinical features of the reported cases are reviewed.

Our experience with penile deformations: incidence, operative techniques, and results.

Between the initiation of the "Penile Deformity Clinic" in 1988 in our Department of Urology, and the end of 1992, 1,862 males aged 0 (less than 24 hours old) to 78 years old were examined. Five hundred of them were newborns, aged 0 to 5 days; they were examined to determine the incidence of congenital penile curvature. Two hundred and seventeen congenital curvatures were seen, and 102 of them were corrected surgically using four different corporoplasty techniques. From the 116 Peyronie's Disease patients, 37 were treated surgically, either by corporoplasty or prosthesis implantation. From the 29 iatrogenic penile deformities, all the result of previous hypospadias repairs or urethroplasties for stricture repairs, 18 needed surgical intervention, mostly for cosmetic reasons. Three congenital curvatures, corrected by plication, and one by Nesbit corporoplasty, recurred. Three other cases corrected by Nesbit corporoplasty reported temporary loss of glans sensation, and in a fourth one the sensory loss was permanent. It is our opinion that concentrating the care of these deformities in the hands of a small group of surgeons specialized in penile reconstructive surgery yields the best functional and esthetic results.

A new, large calibre, self-expanding and self-retaining temporary intraprostatic stent (ProstaCoil) in the treatment of prostatic obstruction.

OBJECTIVE: To determine the benefits of a new self-expanding and self-retaining large calibre temporary intraprostatic coil stent in patients with bladder outflow obstruction due to benign prostatic hypertrophy. PATIENTS AND METHODS: Sixty-five patients with bladder outflow obstruction have been studied with a follow-up period of 3-28 months (mean 16). RESULTS: Thirty patients became eligible for surgery and had their stent removed without difficulty 3-12 months after stent insertion. Only one stent was removed because of urgency and incontinence. Stent repositioning was required in five patients and 14 complained of temporary dysuria or perineal pain. Twenty-seven patients continue to pass urine through their stent without difficulty. CONCLUSION: Because of its large diameter and its temporary nature this new stent allows endoscopic examination of the bladder and has few side effects. This stent should be considered as an alternative to a urethral catheter or other temporary stents in patients who are unfit for surgery.

Cleft glans penis associated with midshaft epispadias: a successfully treated rare anomaly of the penis.

A rare case of cleft glans penis associated with midshaft epispadias is presented. Because no dorsal curvature was present, roofing of the deep urethral groove and closure of the cleft glans over the urethra yielded excellent cosmetic and functional results.

The incidence of congenital penile curvature.

To determine the incidence of congenital penile curvature a group of 500 consecutive male neonates at our institution were examined for this anomaly. In this group there were 3 cases of congenital penile curvature, for an incidence of 0.6%.