[Alloplastic material in the treatment of urinary incontinence]. / Alloplastisches Bandmaterial in der Therapie der Harninkontinenz.

Surgery for urinary incontinence is indicated after failure of conservative treatment with pelvic floor therapy. Different sling systems are the established treatment option for urinary incontinence for female and male patients. Tension-free vaginal tapes represent the standard of care in the surgical treatment of female stress urinary incontinence. In male patients with mild or moderate stress urinary incontinence, fixed repositioning slings or adjustable compressive slings represent minimally invasive alternatives to the artificial urinary sphincter. The use of surgical mesh material has been widely discussed within the last years. The current US Food and Drug Administration warning was focused on the use of transvaginal mesh implants in female patients with pelvic organ prolapse. Within the current debate, surgery for stress urinary incontinence and surgery for pelvic organ prolapse have often not been differentiated. With this ongoing discussion about the use of foreign material in reconstructive surgery, laparoscopic colposuspension might be performed more often in the near future.

[Incontinence surgery-quality criteria and structured follow-up]. / Inkontinenzchirurgie ­ Qualitätskriterien und strukturiertes Follow-up.

The following article summarizes the current evidence including postoperative success rates and complications for various surgical options in the treatment of urinary incontinence. Due to different inclusion criteria and inconsistent definitions of study endpoints, the analysis of available studies is difficult. Thus, comparative studies with new devices for established treatment options should be planned. Structured processes used in certified continence centers improve the quality of care. Furthermore by documenting relevant complications, comparisons of treatment results thus become possible and provide evidence for the use of different surgical options in the treatment of urinary incontinence.

[Botulinum toxin for overactive bladder]. / Botulinumtoxin bei überaktiver Blase.

Idiopathic overactive bladder (OAB) is defined as a symptom complex characterized by urinary urgency with or without urinary incontinence, nycturia and increased frequency of micturition without the presence of an infection or other pathological conditions, especially a neurological disease. It is a diagnosis by exclusion. If conservative treatment with behavioral therapy and pelvic floor muscle training alone is not successful, pharmaceutical treatment is recommended according to the OAB staged treatment. For treatment refractory OAB, intravesical injection of onabotulinum toxin A is recommended according to the current guidelines (recommendation level A). The approved dose is 100 U botulinum toxin and is transurethrally injected into the detrusor muscle. The treatment effect lasts on average for 6-9 months and injections can be repeated without limitations. Due to the low rate of complications, the good success rate and the low invasiveness, botulinum toxin offers a good treatment option for treatment refractory OAB.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]. / Einsatz von synthetischen Band- und Netzimplantaten bei der Behandlung von Belastungsinkontinenz und Descensus genitalis der Frau : Stellungnahme des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau der Akademie der Deutschen Gesellschaft für Urologie.

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

[Differentiated surgical treatment of male stress urinary incontinence-between intention and reality?] / Differenzierte operative Therapie der männlichen Belastungsharninkontinenz ­ zwischen Wunsch und Wirklichkeit?

The differentiated surgical treatment of male urinary incontinence is a very interesting and sometimes also emotional topic, in which evidence is increasingly maturing. Nowadays, the most common surgical procedures are fixed sling and adjustable incontinence systems as well as the artificial urinary sphincter. The evidence for the procedures varies and there is currently a lack of prospective, comparative studies. The challenging question is: Which operation is the best for which patient? The following article is intended to give an overview of the surgical options and a constructive attempt to differentiate the indication.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

Test-retest reliability of high angular resolution diffusion imaging acquisition within medial temporal lobe connections assessed via tract based spatial statistics, probabilistic tractography and a novel graph theory metric.

This study examined the reliability of high angular resolution diffusion tensor imaging (HARDI) data collected on a single individual across several sessions using the same scanner. HARDI data was acquired for one healthy adult male at the same time of day on ten separate days across a one-month period. Environmental factors (e.g. temperature) were controlled across scanning sessions. Tract Based Spatial Statistics (TBSS) was used to assess session-to-session variability in measures of diffusion, fractional anisotropy (FA) and mean diffusivity (MD). To address reliability within specific structures of the medial temporal lobe (MTL; the focus of an ongoing investigation), probabilistic tractography segmented the Entorhinal cortex (ERc) based on connections with Hippocampus (HC), Perirhinal (PRc) and Parahippocampal (PHc) cortices. Streamline tractography generated edge weight (EW) metrics for the aforementioned ERc connections and, as comparison regions, connections between left and right rostral and caudal anterior cingulate cortex (ACC). Coefficients of variation (CoV) were derived for the surface area and volumes of these ERc connectivity-defined regions (CDR) and for EW across all ten scans, expecting that scan-to-scan reliability would yield low CoVs. TBSS revealed no significant variation in FA or MD across scanning sessions. Probabilistic tractography successfully reproduced histologically-verified adjacent medial temporal lobe circuits. Tractography-derived metrics displayed larger ranges of scanner-to-scanner variability. Connections involving HC displayed greater variability than metrics of connection between other investigated regions. By confirming the test retest reliability of HARDI data acquisition, support for the validity of significant results derived from diffusion data can be obtained.

[Urinary incontinence in men]. / Harninkontinenz des Mannes.

Stress urinary incontinence in men is predominantly iatrogenic whereby radical prostatectomy is the most common cause with persistent stress urinary incontinence rates varying between 10 % and 25 %. The first line therapy for postoperative male stress urinary incontinence is physiotherapy, especially pelvic floor muscle rehabilitation. If conservative treatment fails to show sufficient improvement, surgical therapy is recommended. Several treatment options are currently available for the surgical treatment of male stress urinary incontinence including artificial sphincters, adjustable and functional sling systems, bulking agents and implantable balloon systems.

Reduction of obstruction related bladder overactivity by the guanylyl cyclase modulators BAY 41-2272 and BAY 60-2770 alone or in combination with a phosphodiesterase type 5 inhibitor.

AIMS: To assess the urodynamic effects of soluble guanylyl cyclase (sGC) stimulator, BAY 41-2272, and activator, BAY 60-2770, (which both are able to induce cGMP synthesis even in the absence of nitric oxide (NO)) alone or in combination with a phosphodiesterase type 5 (PDE5) inhibitor, vardenafil, in a model of partial urethral obstruction (PUO) induced bladder overactivity (BO). METHODS: Fifty-six male Sprague-Dawley rats were used, 31 of them underwent PUO. Fourteen rats were used for Western blots to assess PDE5 and sGC expression. For drug evaluation cystometry without anesthesia was performed three days following bladder catheterization. RESULTS: Obstructed rats showed higher micturition frequency and bladder pressures than non-obstructed animals (Intermicturition Interval, IMI, 2.28 ± 0.55 vs. 3.60 ± 0.60 min (± standard deviation, SD); maximum micturition pressure, MMP, 70.1 ± 8.0 vs. 48.8 ± 7.2 cmH2O; both P < 0.05). In obstructed rats vardenafil, BAY 41-2272, and BAY 60-2770 increased IMI (2.77 ± 1.12, 2.62 ± 0.52, and 3.22 ± 1.04 min; all P < 0.05) and decreased MMP (54.4 ± 2.8, 61.5 ± 11.3, and 51.2 ± 6.3 cmH2O; all P < 0.05). When vardenafil was given following BAY 41-2272 or BAY 60-2770 no further urodynamic effects were observed. PDE5 as well as sGC protein expression was reduced in obstructed bladder tissue. CONCLUSIONS: Targeting sGC via stimulators or activators, which increase the levels of cGMP independent of endogenous NO, is as effective as vardenafil to reduce urodynamic signs of BO. Targeting the NO/cGMP pathway via compounds acting on sGC might become a new approach to treat BO.

[Use of botulinum toxin type A in non-neurogenic overactive bladder. Recommendations of the Working Group Urological Functional Diagnostics and Urology in Women]. / Botulinumtoxin Typ A bei der nicht-neurogenen überaktiven Blase. Empfehlungen des Arbeitskreises "Urologische Funktionsdiagnostik und Urologie der Frau".

The use of botulinum toxin for the treatment of neurogenic detrusor overactivity was first described in 2000 and thereafter botulinum toxin has also been used in non-neurogenic overactive bladder. In current guidelines intravesical injection of onabotulinumtoxin A in refractory patients is recommended. Our aim is to provide some clinically relevant recommendations from the Working Group Urologische Funktionsdiagnostik und Urologie der Frau for diagnostics and treatment with onabotulinumtoxin A of patients with non-neurogenic overactive bladder.

[Diagnosis and surgical treatment of postprostatectomy stress incontinence: recommendation of the working group Urologische Funktionsdiagnostik und Urologie der Frau]. / Diagnostik und operative Therapie der Postprostatektomie-Belastungsinkontinenz : Empfehlungen des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau.

Today, for the surgical treatment of postprostatectomy incontinence, several treatment options are available, e.g., adjustable and functional sling systems, artificial sphincter, bulking agents, and balloons. However, no recommendations in terms of specific diagnostic tools and differentiated treatment options for everyday life are available. Our aim is to provide some clinically relevant recommendations for the necessary diagnostic workup and different treatment options of postprostatetectomy incontinence to support clinical decisions in everyday life. Treatment selection should be based on contraindications. However, there is a broad overlap of the various surgical options.

[Adjustable transobturatoric sling system in men : diagnosis and therapy recommendations to persistent pain]. / Adjustierbare transobturatorische Schlingensysteme beim Mann : Diagnostik und Therapieempfehlungen bei persistierenden Schmerzen.

BACKGROUND: In addition to artificial sphincters, male slings are recommended in the current guidelines for the treatment of persistent male stress incontinence. Today, several sling systems are available. Well-known complications of all sling systems are infections, erosion, residual urine/urinary retention, de novo urgency, and postoperative pain. DISCUSSION: Compared to retropubic implanted adjustable sling systems or functional slings, pain is more common after transobturatoric implantation of adjustable sling systems. Early postoperative pain is very common. In contrast, persistent pain is rare. However, the treatment of persistent pain is a large challenge for urologists and patients. There are no recommendations for diagnostic workup or treatment. RESULTS: After pain classification, pain management should be started with nonsteroidal anti-inflammatory drugs and/or tricyclic antidepressive agents, if necessary treatment escalation with a weak opioid and if not effective interventional procedures should be performed. Sling explantation is only necessary in rare cases.

[Rates of prostate-specific antigen testing for early detection of prostate cancer: a first comparison of German results with current international data]. / PSA-basierte Früherkennung des Prostatakarzinoms durch den Hausarzt: Erste deutsche Ergebnisse im internationalen Vergleich.

OBJECTIVE: Measurement of prostate-specific antigen (PSA) is not only used as a screening instrument by urologists, but also by general practitioners and internal specialists (GP-IS). Until now, there are neither data on the approach of German GP-IS in practicing this nor have data been classified in the context of available international literature on this topic. MATERIALS AND METHODS: Between May and December 2012, a questionnaire containing 16 items was sent to 600 GP-IS in Brandenburg and Berlin. The response rate was 65% (392/600). Six indicator questions (IQ1-6) were selected and results were set in the context of available international data. The quality of present studies was evaluated by the Harden criteria. RESULTS: Of the 392 responding physicians, 317 (81%) declared that they would use PSA testing for early detection of PCA (IQ1) and, thus, formed the study group. Of these GP-IS, 38% consider an age between 41 and 50 years as suitable for testing begin (IQ2), while 53% and 14% of the GP-IS perform early detection until the age of 80 and 90 years, respectively (IQ3). A rigid PSA cut-off of 4 ng/ml is considered to be reasonable by 47% of the involved GP-IS, whereas 16% prefer an age-adjusted PSA cut-off (IQ4). Patients with pathological PSA levels were immediately referred to a board-certified urologist by 69% of the GP-IS. On the other hand, 10% first would independently control elevated PSA levels themselves after 3-12 months (IQ5). Furthermore, 14% of the interviewed physicians consider a decrease of PCA-specific mortality by PSA screening as being proven (IQ6). Knowledge regarding PCA diagnostics is mainly based on continuous medical education for GP-IS (33%), personal contact with urologists (6%), and guideline studies (4%). While 53% indicated more than one education source, 4% did not obtain any PCA-specific training. The results provided by this questionnaire evaluating response of German GP-IS to six selected indicator questions fit well into the international context; however, further studies with sufficient methodical quality are required. CONCLUSIONS: Despite current findings and controversial recommendations of the two large PCA screening studies on this issue, German GP-IS still frequently use PCA screening by PSA measurement. Primary strategies of early detection as well as follow-up after assessment of pathologically elevated PSA levels poorly follow international recommendations. Thus, an intensification of specific education is justified.

[Modern operative treatment possibilities in male stress urinary incontinence]. / Moderne operative Therapiemöglichkeiten der männlichen Belastungsinkontinenz.

Postprostatectomy incontinence (PPI) is one of the most feared complications of radical prostatectomy with major impact on quality of life and social well-being. In recent years due to improved surgical techniques a reduction of the postoperative incontinence rate was achieved. However, due to the increasing number of radical prostatectomies performed for prostate cancer, a substantial and increasing number of patients are suffering from postoperative stress urinary incontinence. If conservative treatment fails, surgical therapy is recommended. For decades, the artificial urinary sphincter was the reference standard for moderate to severe postoperative male stress urinary incontinence. However, patients' demand on minimally invasive treatment options is high. Age or advanced prostate cancer should not be an exclusion criterion for surgical treatment of persistent PPI.

[Importance of sonography in the diagnostics of functional disorders of the female pelvic floor]. / Stellenwert der Sonographie bei der Diagnostik von Funktionsstörungen des weiblichen Beckenbodens.

Ultrasound now plays an indispensible role in urogynecological diagnostics. Sonographic imaging of the female pelvic floor allows depiction of the urethra, bladder neck, bladder, anorectum and the levator ani muscle and is currently an important clinical component for the diagnostics of functional disorders in the region of the female pelvic floor. Essential aspects in sonography of the female pelvic floor are the dynamic depiction and direct imaging of alloplastic implants. For these reasons sonographic imaging is of great clinical importance especially for the diagnostics of recurrent or postoperative complications. A further important factor which supports the success of ultrasound in the diagnostics of functional disorders of the female pelvic floor is the wide availability of ultrasound devices in patient care. Furthermore, the method is noninvasive, comparatively inexpensive and does not involve radiation.

[Imaging diagnostics of the male pelvic floor]. / Bildgebende Diagnostik des männlichen Beckenbodens.

The understanding of the female pelvic floor during the last 20 years was very much influenced by the new techniques of sonographic and magnetic resonance imaging (MRI). Functional imaging of the male pelvic floor is, however, still in its infancy. In analogy to ultrasound examinations of the female pelvic floor, perineal ultrasound can be also be applied to men. The mobility of the proximal urethra, scarring of the bladder neck or implanted suburethral meshes can be easily visualized. Studies on healthy men provide information about different muscular structures during micturition. Morphology and function of the external sphincter can be visualized with transrectal or intraurethral ultrasound and also with a perineal approach. Using functional MRI the complex interactions of bladder, urethra, external sphincter and pelvic floor muscles can be evaluated. Functional MRI is so far not generally available but enables a better understanding of the function of the male pelvic floor. Imaging of the male pelvic floor makes a substantial contribution for improving surgical procedures for male incontinence in the future.

[Prolapse surgery: vaginal mesh or sacropexy]. / Deszensuschirurgie : Auffangnetze oder Sakropexie?

The systematic assessment of common therapy concepts for female genital prolapse has led to a better understanding of the functional and anatomical connections and given proof of the lasting effectiveness of traditional surgery. Besides the defined evidence-based therapy strategies in vaginal prolapse repair, vaginal meshes are being used with increasing frequency. The lack of reliable therapy recommendations for these methods sounds us a note of caution in their application and underlines the necessity of standardised performance in experienced departments.