Long-term functional success and patient-reported outcomes after female one-stage buccal mucosal graft urethroplasty.

INTRODUCTION AND OBJECTIVES: Female urethral strictures are a rare condition that significantly impacts patients' quality of life. Patient-reported outcomes are crucial, yet data regarding sexual function and treatment satisfaction are scarce. We aimed to provide insights from a reconstructive referral center. PATIENTS AND METHODS: We conducted a retrospective analysis of women treated with ventral onlay one-stage buccal mucosa graft urethroplasty for urethral strictures between 2009-2023. We assessed objective (retreatment-free survival, ΔQmax) and subjective outcomes (validated patient-reported outcomes). RESULTS: Of 12 women, 83% and 17% had iatrogenic and idiopathic strictures, respectively. Median number of prior interventions was 6. Strictures were located meatal and mid-urethral in 25% and 75%, respectively, 22% had the bladder neck involved. Median graft length was 2 cm. At median follow-up of 66 months, 33% of patients underwent stricture retreatment, but only one case occurred within the first 2 years postoperatively. The median improvement in maximum flow rate (ΔQmax) was 10 ml/s. Median International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) scores were 8 for filling symptoms, 6 for voiding symptoms, and 3 for incontinence symptoms. Median ICIQ-FLUTSsex score was 4. Higher scores indicate a higher symptom burden. Median ICIQ-Satisfaction outcome and satisfaction scores were 18 and 7, respectively, reflecting high treatment satisfaction. CONCLUSIONS: Buccal mucosal graft urethroplasty by ventral onlay for female urethral strictures yields effective, durable, and positively received outcomes. However, larger studies across multiple institutions are necessary to further assess its efficacy, especially regarding patient-reported experiences and sexual function.

[Urological problems in patients with meningomyelocele. Diagnostic studies and management]. / Urologischer Erkrankungen bei Patienten mit Meningomyelozele. Diagnostik und Management.

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

Adaptation to life after surgical removal of the bladder-an application of graphical Markov models for analysing longitudinal data.

Graphical Markov models have been developed particularly for the analysis of observational data. They allow the control of various background variables when analysing theoretically relevant associations. This paper demonstrates the application and some advantages of graphical Markov models in comparison to conventional statistical analyses. The aim of the study was to identify patients at risk for developing decreased health-related quality of life (QoL) after cystectomy and to explore the influence of coping on QoL in this situation. Therefore, the method was applied to analyse the data of a prospective study, in which 81 patients with bladder cancer were interviewed pre-operatively and in a 1-year follow-up. QoL was assessed both times, and two basic coping strategies (active and depressive) were measured preoperatively. The explanatory variables of theoretical interest were active and depressive coping strategies. As a result of the analysis, relevant proportions of variance in the development of QoL could be explained by the suggested model (60 per cent in mental component, 40 per cent in physical component of QoL). Active coping was positively related to QoL, depressive coping negatively. These effects were linear in the physical component of QoL, moderated by working status and the type of urinary diversion in the mental component of QoL.

Rhabdomyosarcoma of the bladder, prostate or vagina: the role of surgery.

OBJECTIVE: To retrospectively analyse the outcome of children with rhabdomyosarcoma (RMS) of the bladder, prostate or vagina who were treated with chemotherapy, with or without radical surgery or additional radiotherapy, at our institution since 1968. PATIENTS AND METHODS: From a total of 107 children with RMS seen between 1968 and December 2001, 22 (mean age 5.9, range 0.5-18) had RMS of bladder/prostate or vagina. Twenty of the patients received primary polychemotherapy (vincristine, actinomycin D, cyclophosphamide, adriamycin, and more recently including etoposide and ifosfamide), two had primary surgery and seven had additional radiotherapy. Fourteen patients had radical cystoprostatectomy, with continent cutaneous urinary diversion with an ileocaecal pouch in seven, in one each a transverse colonic pouch, orthotopic ileocaecal bladder substitution, a rectal reservoir and rectosigmoid pouch and a colonic conduit diversion in two patients. RESULTS: After a mean (range) follow-up of 8.6 (1.0-26) years, 17 patients had no evidence of disease. Five patients presenting initially with advanced tumour stages died from progressive RMS. Two patients with a continent urinary diversion required ureteric reimplantation for stenosis. In two patients severe bladder contraction after radiotherapy required bladder augmentation. CONCLUSION: Primary chemotherapy followed by radical surgery of RMS of the prostate and/or bladder allows complete tumour resection in most cases, and yields excellent cure rates.

Screening for renal cell carcinoma using ultrasonography: a feasibility study.

OBJECTIVE: To assess the practicability and efficacy of systematic screening for renal cell carcinoma (RCC) by ultrasonography (US), as more small RCCs are being detected incidentally by US. SUBJECTS AND METHODS: A 2-year screening programme for RCC was established for the general population (aged >or= 40 years) in two German cities, Mainz and Wuppertal. In cooperation with different health insurers, the organisers recruited general practitioners, internists and urologists in private practice who were experienced in and equipped to conduct renal US. The screening was offered in the form of cost-free renal US in the first year and a re-examination in the second. For any equivocal or positive renal mass, a reference ultrasonogram was provided by the urology departments at the two university hospitals. RESULTS: In all, 9959 volunteers participated in the screening programme (49% men, 51% women, mean age 61 years, range 40-94) in the first year. Of these participants, 79% returned for re-examination in the second year. Thirteen (0.1%) subjects were found to have a renal mass, of which nine were RCC. The sensitivity of the programme was 82% (at the 1-year follow-up), and the predictive value 2% for equivocal findings on initial examination and 50% for positive findings. The incidence of other abnormal findings was 12%. CONCLUSION: The screening programme was well accepted by physicians in private practice and by the eligible population. The method was effective, especially if equivocal findings were re-assessed by reference US before using further imaging studies, e.g. computed tomography or magnetic resonance imaging.

[Ultrasound screening of renal cell carcinomas]. / Sonographisches Screening von Nierenzellkarzinomen.

The increasing number of incidentally by ultrasound detected small renal cell carcinomas raises the question of the practicability and efficacy of a systematic screening for renal cell carcinoma by ultrasound. A two year screening program for renal cell carcinoma (RCC) was established for the general population (age > 40 years) in two cities, Mainz and Wuppertal. In cooperation with different health insurers, the organizers recruited general practitioners, internists and urologists in private practice who were experienced in and equipped for performing renal ultrasound. The screening was offered in the form of a cost free renal ultrasound in the first year and a re-examination in the second year. For any equivocal/positive renal mass, a reference ultrasound was provided the urology departments at the two university hospitals. 9959 volunteers participated in the screening program (49% male, 51% female) in the first year. The mean age was 61 (40-94) years. 79% of these participants returned for re-examination in the second year. Thirteen (0.1%) subjects were found to have a renal mass, of which nine were RCC. The sensitivity of the program was 82% (one year of follow-up). The predictive value was 2% for equivocal findings on initial exam and 50% for positive findings. The incidence of other abnormal findings was 12%. The screening program was well accepted by physicians in private practice and by the eligible population. The method proved effective, especially if equivocal findings were re-studied by reference sonography before further imaging studies such as CT and MRI were performed.

Surgery for urogenital rhabdomyosarcoma.

The treatment and prognosis of rhabdomyosarcoma of the urogenital tract have changed dramatically over the past few decades. Until the 1970s radical cystectomy and pelvic exenteration were the only therapeutic options in rhabdomyosarcoma of the bladder/prostate and of the vagina/uterus. Since then, multiagent chemotherapy has achieved remarkable cure rates. Consequently, organ-saving surgical techniques were advocated, with the goal to improve patients' quality of life. The available long-term survival data with these techniques demonstrate excellent survival in rhabdomyosarcoma of the vagina/uterus, with a high percentage of organ preservation. On the contrary, increased rates of local recurrence and death from disease in patients with rhabdomyosarcoma of the bladder/prostate who undergo primary chemotherapy with or without tumour excision, and complications following combined radiotherapy critically question the long-term benefit of these organ-sparing surgical techniques in this group.

Vaginal reconstruction/fistulae.

Vaginal reconstruction is required in congenital absence of the vagina in the paediatric population and in patients with surgical (anterior exenteration) or traumatic loss of the vagina. Although vaginal agenesis is rare, its description and attempts at replacement vaginoplasty date back to antiquity. Different forms of vaginal reconstruction are described, including the use of split-thickness or full-thickness grafts, amnion, peritoneum or bowel. Experience with bowel segments for vaginoplasty, with few complications and high success rates, have expanded the indications for this technique, rendering it of great importance in the field of vaginal reconstruction, especially when large bowel segments are utilized. Most vaginal fistulae occur after gynaecological surgery. There is a multitude of established techniques for closure of vaginal fistulae with comparable success rates, and two different approaches (vaginal or abdominal) may be used. Preferable for complicated or recurrent fistulae is the abdominal approach because a well vascularized pedicled omentum majus flap can be interposed. Postirradiation fistulae, although rare, represent a challenge for the reconstructive surgeon. Fistula excision and closure fails in a high percentage of patients, and in cases of additional bladder and vaginal shrinkage urinary continence can only be achieved by urinary diversion.

Vaginal reconstruction using the bladder and/or rectal walls in patients with radiation-induced fistulas.

OBJECTIVE: In irreparable or recurrent vesicovaginal fistulas and cloacal defects following high-dose irradiation therapy for gynecological malignancies, urinary diversion is the last resort to achieve a socially acceptable solution. In a select group of young and tumor-free patients, additional vaginal reconstruction may be indicated. Multiple operative procedures are available, but the results are often disappointing in the previously irradiated area. MATERIALS AND METHODS: In six such patients with large radiogenic vesicovaginal defects (n = 5) or a cloacal fistula (n = 1), a continent reservoir using the transverse colon with an umbilical stoma was performed. At the end of the operation, the bladder was incorporated into a neovagina by incising the urethra, anterior vaginal wall, and the posterior bladder wall with electrocautery from the urethral meatus to the dome of the fistula. RESULTS: No postoperative complications related to the vaginal reconstruction occurred. After a mean follow-up of 4.7 years, all patients had a capacious vagina and a wide introitus; the neovagina measured a mean of 18 cm in length. Five patients with a partner reported a normal sexual life. No dyspareunia or discomfort from bladder or urethral mucosa during intercourse was reported. CONCLUSIONS: Following continent urinary diversion due to irreparable vesicovaginal fistulas, a neovagina can be created by simple dissection of the posterior bladder and anterior vaginal wall. When a colostomy is present, the neovagina can additionally be augmented with a bowel flap of the Hartmann stump or by incising the rectovaginal septum. The technique affords good functional and cosmetic results.

Quality of life in patients with bladder carcinoma after cystectomy: first results of a prospective study.

This study reports the changes in the quality of life (QoL) of 44 patients observed prospectively from pre-surgery to one year post-surgery. Two kinds of surgeries were compared: continent and incontinent urinary diversion. In most areas the QoL returned to the prior level within one year after surgery. However, patients were restricted in their physical activity, sexual activity, and emotional well-being. Using individual weights for different aspects of life (Fragen zur Lebenszufriedenheit--Module FLZM), QoL was higher than when using an unweighted measurement (Short Form 36, MOS). Two trends for the different developments in the QoL were established: general life satisfaction and social functioning tended to improve after a continent diversion but decreased after an incontinent diversion. The perceived global satisfaction with both kinds of diversion was high--75% of the patients would choose the same kind of diversion again.

Nephron-sparing surgery of renal cell carcinoma with a normal opposite kidney: long-term outcome in 180 patients.

OBJECTIVES: To investigate the long-term outcome of an organ-saving approach for renal cell carcinoma (RCC) with a normal opposite kidney (elective indication). METHODS: Since 1979, 180 patients have undergone nephron-sparing surgery at our institution for RCC in the presence of a normal contralateral kidney. The mean age was 56 years (range 23 to 83), and the mean follow-up was 4.7 years (maximum 14. 8). Most of these tumors were found incidentally, with a mean tumor diameter on ultrasound of 3.3 cm (range 1.0 to 8.6). RESULTS: The postoperative course was unremarkable in 173 patients. Postoperative bleeding was encountered in 4 patients and urinary extravasation in an additional 3 patients. No surgical reintervention was necessary. One hundred seventy-five RCCs were pT1 and 5 were pT3a; 73 were grade 1, 100 grade 2, and 7 were grade 3. The mean tumor diameter (surgical specimen) was 3.2 cm (range 0.5 to 7). In 132 cases, the tumor was less than 4 cm and in 48 cases, greater than 4 cm. Three patients experienced local tumor recurrence (1.6%) during follow-up, and two others developed distant metastases. The 5-year tumor-specific survival rate was 98.0%. CONCLUSIONS: Nephron-sparing surgery for RCC under an elective indication in selected patients offers excellent long-term survival and an acceptably low local tumor recurrence rate. These results support the concept of nephron-sparing surgery in the presence of a normal contralateral kidney.

The use of isolated caecal bowel segment in complicated vaginal reconstruction.

OBJECTIVE: To report a one-stage procedure, using a segment of caecum, both to overcome failed previous procedures and for primary vaginal replacement in patients with congenital vaginal aplasia, where primary reconstruction often results in vaginal obstruction and fistula formation. PATIENTS AND METHODS: The vagina was reconstructed using a 15-cm isolated caecal segment placed between the bladder and rectum and anastomosed to the introitus. Between 1985 and 1997 the technique was used in 17 patients (mean age 23 years). Indications included congenital malformations and vaginal loss through anterior exenteration or trauma. Seven of the 17 patients had undergone previous complex reconstructions; four of these had undergone previous fistula formation. Fourteen patients were followed for a mean of 3.6 (1-9) years. The surgical outcome was evaluated using a questionnaire completed by the patients. RESULTS: The postoperative course was unremarkable in all patients. Four patients developed an introital stenosis requiring surgical intervention. Two patients were minors at the time of follow-up, while all the others had had sexual intercourse and reported that they were very satisfied with the functional and cosmetic result. CONCLUSION: In patients in whom previous vaginal reconstruction has failed, the caecal segment should be used to create a neovagina. By considering the patient's age, the surgeon can optimize the surgical result.

Nephron sparing surgery for central renal tumors: experience with 33 cases.

PURPOSE: Nephron sparing surgery is standard treatment for small, peripherally located renal cell carcinoma. In patients with a solitary kidney, bilateral tumors or impaired renal function nephron sparing surgery provides the only option to nephrectomy and subsequent hemodialysis or transplantation. We retrospectively investigated the value of nephron sparing surgery for centrally located renal cell carcinoma. MATERIALS AND METHODS: Between 1969 and 1997, 311 renal tumor enucleations were performed at our institution. The tumor was centrally located in 33 cases. The indication for enucleation was elective in 7 cases and imperative in 26, including bilateral tumor in 16 (metachronous in 9 and synchronous in 7), chronic renal failure in 4 and solitary kidney in 6. Four patients had metastasis at enucleation. RESULTS: Convalescence was unremarkable in 28 cases. Hemorrhage occurred in 1 patient, a urinary fistula in 2 and a local abscess secondary to a urinary fistula in 1. One patient died postoperatively of heart failure. Average serum creatinine was 1.25, 1.63 and 1.33 mg./dl. preoperatively, at hospital discharge and at a mean followup of 33 months, respectively. Hemodialysis was necessary transiently during convalescence in 1 patient and permanently starting 6 years after enucleation in another. Definitive histology revealed oncocytoma in 4 cases and renal cell carcinoma in 29. Disease was stages pT1 to pT3 in 9, 18 and 2 cases, and grades 1 to 3 in 6, 18 and 5, respectively. Local recurrence developed in 2 patients. Mean followup was 5.2 years (range 0.3 to 16.7). At a mean followup of 6.2 years (range 0.7 to 16.7) 20 patients were free of disease. In addition to the patient who died postoperatively, 9 died of renal cell carcinoma at a mean of 1.6 years (range 0.3 to 5.3) and 3 died of other causes at 5, 11 and 12 years postoperatively, respectively. No patient who underwent elective enucleation died. CONCLUSIONS: Nephron sparing surgery for centrally located kidney tumors is technically feasible and associated with an acceptable complication rate. Local tumor control is excellent, and the overall prognosis depends on contralateral disease and metastasis. Benign tumors may be diagnosed and removed without loss of the kidney. By avoiding hemodialysis quality of life is improved.

Urinary diversion and orthotopic bladder substitution in children and young adults with neurogenic bladder: a safe option for treatment?

PURPOSE: Combined pharmacotherapy, clean intermittent catheterization and infection prophylaxis is currently the gold standard of treatment for neurogenic bladder. However, as the adolescent gains independence from parental supervision, the intervals of clean intermittent catheterization compliance with medical treatment and regularity of followup examinations may decrease, and neurological and/or orthopedic status may change. This situation sometimes leads to failure of conservative treatment, resulting in incontinence and/or deterioration of the upper urinary tract. A multidisciplinary team was established at our institution 30 years ago to assess all aspects of care for patients with neurogenic bladder, of which urological function is just 1 aspect of the complex problem. Patient desires and essential medical goals, such as preservation of renal function, are considered by this team. An adequate compromise is sought and achieved in some cases by urinary diversion. We investigated the long-term safety of urinary diversion in these patients and its ability to protect the upper urinary tract. MATERIALS AND METHODS: Between 1967 and 1997 urinary diversion was performed in 149 patients with neurogenic bladder. Mean followup was 11.8 years (range 0.8 to 28.5) in 129 cases. Mean patient age at surgery was 12.1 years (range 0.8 to 20). A colonic conduit was created in 59 patients, mainly before the era of clean intermittent catheterization and continent diversion, while orthotopic bladder substitution was performed in 12 and continent urinary diversion (Mainz pouch I) in 58, of whom 50% were wheelchair bound. RESULTS: The upper urinary tract improved or remained stable in 97% of the renal units in patients with a colonic conduit or Mainz pouch I, and in 95% of the renal units in those with orthotopic bladder substitution. All patients with bladder substitution were continent during the day, 1 required occasional pads at night and 7 of 12 performed clean intermittent catheterization. Complete continence was achieved in 98% of those with a continent stoma. CONCLUSIONS: After failure of conservative treatment in patients with neurogenic bladder urinary diversion represents a safe long-term compromise. Daytime and nighttime continence is provided by the Mainz pouch bladder substitution and urinary diversion, while the upper urinary tract is protected by antireflux ureteral implantation.

The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine.

OBJECTIVE: To investigate the histological and immunohistochemical behaviour of free buccal mucosa and full-skin grafts after exposure to urine. MATERIALS AND METHODS: A buccal mucosal graft and a full-skin graft were freely transferred into the bladder of 12 minipigs, after stripping the bladder mucosa. Endoscopic investigations were carried out 2 and 5 months after surgery, and the grafts examined after death at 7 months, both histologically and immunohistochemically. RESULTS: Shrinkage of the full-skin graft was apparent endoscopically in five cases. Of the nine full-skin grafts, four showed severe inflammatory reactions, two necrosis and two ulcerations. Conversely, the 10 buccal mucosal grafts had fewer pathological findings (three minimal inflammation and three with scars) and a pronounced similarity on immunohistochemistry. CONCLUSION: The buccal mucosal graft showed significantly fewer adverse histopathological findings after long-term exposure to urine than the full-skin graft and is therefore a preferable material for urethral reconstruction.

[Pilot study on early diagnosis of renal cell carcinoma by sonography]. / Pilotstudie zur sonographischen Früherkennung des Nierenzellkarzinoms.

UNLABELLED: The goal of this study was to investigate the practicability and effectiveness of a systematic screening for renal cell carcinoma by ultrasound in the course of the established German Health Ministry screening programs. METHODS: In two centers (Mainz and Wuppertal) a screening program for renal cell carcinoma for all citizens (age > 40 years) was established. The screening was divided into two phases (time period 1 year): (1) All citizens over 40 years could attend voluntarily a cost-free ultrasound investigation. (2) A follow-up investigation for the entire screening population was provided. RESULTS: Ten thousand volunteers attended the screening program. Mean age was 60 years. Thirteen renal cell carcinomas were detected. The incidence of other findings was 15%; none of those required further treatment. CONCLUSION: Systematic screening for renal cell carcinoma by ultrasound is cost-effective and showed high acceptance and practicability in a German population. The rate of detection of renal cell carcinoma was higher than initially statistically calculated.