[Pelvic floor reconstruction-update 2024: prolapse-associated symptoms and their treatment]. / Rekonstruktive Beckenbodenchirurgie ­ Update 2024: prolapsassoziierte Symptome und deren Heilung.

Pelvic organ prolapse (POP) and associated symptoms of urinary incontinence, fecal incontinence, obstructive micturition, defecation, and pain are frequent and a widespread disease with relevant reduction of quality of life and high costs. New insights into functional anatomy and pathophysiology of these pelvic floor dysfunctions let us recognize how ligamentous laxities/defects lead to these dysfunctions. Results of the PROpel study (ClinicalTrials.gov-Identifier: NCT00638235) are shown in which a detailed observation of symptoms (patient-related outcome measures) pre- and postoperatively was performed. Ligamentous vaginal repair of POP enables symptom cure in high percentages for urinary urge incontinence (up to 82%), nocturia (up to 92%), obstructive micturition (up to 87%), fecal incontinence (58-72%), obstructive defecation (71-84%), and pain (53-90%), if caused by POP. Women with POP­Q stage 2 have similar symptom frequencies as women with POP­Q stage 3-4, and also similar cure rates of their symptoms. If good anatomical prolapse repair (in responders) was achieved, the cure rates for obstructive micturition, urinary urgency incontinence, and nocturia were significantly higher than in those women with less effective surgical repair. In the future, pelvic floor surgery should have symptom cure as the primary objective and should lead to improved quality of life. The different, currently performed techniques for POP repair have to be investigated concerning this matter.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement. METHODS: Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement. RESULTS: Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02). CONCLUSIONS: The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

The impact of transvaginal, mesh-augmented level one apical repair on anorectal dysfunction due to pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the symptom prevalence of anorectal dysfunction (AD) in women with pelvic organ prolapse (POP) and whether symptom improvement can be achieved by pelvic floor surgery. METHODS: Secondary analysis of the Propel Study data from 277 women with POP stage II-IV regarding bothersome AD symptoms, which were assessed using the Pelvic Floor Distress Inventory (PFDI) questionnaire preoperatively, and 6, 12, and 24 months after transvaginal prolapse repair with Elevate anterior and posterior. RESULTS: Prevalence of AD was high in the study cohort (14.4-56.3%) and could be reduced significantly throughout a 2-year follow-up (cure rates 44.3-83.1%). AD symptoms decreased in a similar manner after posterior/apical fixation to the way they did after anterior/apical fixation (e.g., feeling of incomplete bowel emptying 66.7% to 25.5% vs 46.5% to 10.7% respectively). Hemorrhoids and loss of loose stool decreased even more after anterior/apical fixation than after posterior/apical fixation. Even though AD symptoms decreased significantly more in patients with POP stage III-IV, there was still a considerable improvement in patients with POP stage II (e.g., pain when passing stool 31.1 to 7.7% vs 21.4 to 0% respectively). Notably, even symptoms of hemorrhoids and rectal prolapse improved substantially (cure rates 44.2% and 70.1% respectively). CONCLUSIONS: Symptoms of AD were frequent in our study cohort, and they significantly improved after vaginal mesh-augmented sacrospinous prolapse repair with Elevate anterior and posterior throughout the follow-up period. Anterior/apical fixation showed results that were almost as good as those after posterior/apical fixation. Patients with POP stage II experienced considerable symptom improvement, but cure rates were significantly higher in patients with POP stage III-IV. Vaginal mesh-augmented prolapse repair with good apical fixation is efficacious in resolving AD symptoms with low de novo rates in women suffering of POP.

[Gender affirmation female to male-metaidoioplasty]. / Geschlechtsangleichung von Frau zu Mann ­ Klitorispenoid.

BACKGROUND: Description of an improved technique of metaidoioplasty (clitoris penoid) and presentation of the follow-up of our own patients in comparison to results in the literature. PATIENTS AND METHODS: To reduce the complication rate of urethral strictures and urethrocutaneous fistula, the technique of metaidoioplasty was modified: After elongation of clitoris by incision of chorda the urethra-including the clitoral hood-was reconstructed by distally, broadly based flap of labia minora. In a retrospective follow-up study over 4 years, 75 patients completed questionnaires to assess complications and satisfaction/quality of life and urinary symptoms (ICIQ-FLUTS questionnaire). The same questionnaires were completed by 25 patients pre- and 3 months postoperatively. RESULTS: In the retrospective study, urethral strictures were detected in 1.4% of patients and urethrocutaneous fistulas in 9.4% of patients, which could be repaired in all cases. Furthermore, 39.5% of patients did not decide for phalloplasty and were satisfied with the appearance of the clitoris penoid in 85% and with their function in 88%. A small proportion of the patients developed urinary symptoms, which were mainly of minor severity and significantly dependent on age. In the prospective study, postoperative-versus preoperative-symptoms of urinary incontinence, nocturia, and obstructive micturition were slightly elevated, but mainly of minor severity. CONCLUSIONS: The improved technique of metaidoioplasty using distally broadly based labia-minora flaps resulted in high satisfaction with low urethral complication rates.

[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.

Micro-endoscopy of the human vas deferens: a feasibility study of a novel device in several ex vivo models.

The aim of this study was to show limitation as well as potential of micro-endoscopy techniques as an innovative diagnostic and therapeutic approach in andrology. Two kinds of custom-made micro-endoscopes (ME) were tested in ex vivo vas deferens specimen and in post-mortem whole body. The semi-rigid ME included a micro-optic (0.9 mm outer diameter [OD], 10.000 pixels, 120° vision angle [VE], 3-20 mm field depth [FD]) and an integrated fibre-optic light source. The flexible ME was composed of a micro-optic (OD = 0.6 mm, 6.000 pixels, 120° VE, 3-20 mm FD). The ex vivo study included retrograde investigation of the vas deferens (surgical specimen n = 9, radical prostatectomy n = 3). The post-mortem investigation (n = 4) included the inspection of the vas deferens via both approaches. The results showed that antegrade and retrograde rigid endoscopy of the vas deferens were achieved as a diagnostic tool. The working channel enabled therapeutic use including biopsies or baskets. Using the flexible ME, the orifices of the ejaculatory ducts were identified. In vivo cadaveric retrograde cannulation of the orifices was successful. Post-mortem changes of verumontanum hindered the examinations beyond. Orifices were identified shaded behind a thin transparent membrane. Antegrade vasoscopy using flexible ME was possible up to the internal inguinal ring. Further advancement was impossible because of anatomical angle and lack adequate vision guidance. The vas deferens interior was clearly visible and was documented by pictures and movies. Altogether, the described ME techniques were feasible and effective, offering the potential of innovative diagnostic and therapeutic approaches for use in the genital tract. Several innovative indications could be expected.

[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.

[Catheter-associated urinary tract infections]. / Katheterassoziierte Harnwegsinfektionen.

In patients with indwelling urethral catheters significant bacteriuria develops within 4 weeks of indwelling time in practically 100% of the cases. Catheter encrustation and obstruction can occur in approximately 40% of patients. Symptomatic ascending urinary tract infections, urethral complications and urolithiasis can occur in significant numbers in the long term. Regular educational and surveillance programs in nursing homes, hospitals and in home care are important to instruct personnel in hygiene procedures, to learn the indications for catheterization, to keep the indwelling time of catheters as short as possible, to detect any complications early and to initiate appropriate diagnostics and therapy by the urologist.

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.

Fertilizer potential of liquid and solid effluent from thermophilic anaerobic digestion of poultry waste.

Thermophilic anaerobic treatment of poultry litter produces an effluent stream of digested materials that can be separated into solid and liquid fractions for use as a crop fertilizer. The majority of the phosphorus is partitioned into the solid fraction while the majority of the nitrogen is present in the liquid fraction in the form of ammonium. These materials were tested over six years as an alternative fertilizer for the production of vegetable, fruit, and grassland crops. Application of the solids as a field crop fertilizer for vegetables and blueberries resulted in lower yields than the other fertilizer treatments, but an increase in soil phosphorus over a four-year period. Application of the digested liquids on grass and vegetable plots resulted in similar or superior yields to plots treated with commercially available nitrogen fertilizers. Hydroponic production of lettuce using liquid effluent was comparable to a commercial hydroponic fertilizer regime; however, the effluent treatment for hydroponic tomato production required supplementation and conversion of ammonium to nitrate. While not a total fertilizer solution, our research shows the effectiveness of digested effluent as part of a nutrient management program which could turn a livestock residuals problem into a crop nutrient resource.

[Treatment of urinary incontinence in the elderly woman]. / Harninkontinenz bei der älteren Frau; Teil 2: Therapie. Trainieren oder operieren--was gibt schwachen Blasen Halt?

In the treatment of urinary incontinence in women account needs to be taken of a variety of factors. reversible causes in particular must be painstakingly identified and treated. for the various different forms of urinary incontinence well-evaluated therapeutic concepts are available, with the aid of which elderly patients are enabled to continue to function in their usual social environment while enjoying a good quality of life.

[The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy]. / Fortentwickelte Konzepte zur weiblichen (In-)Kontinenz. Pathophysiologie, Diagnostik und operative Therapie.

The integral theory postulates that defect ligaments and fascias, which impair the supporting function of the vaginal wall, can cause stress urinary incontinence as well as urgency and voiding dysfunction. The anatomical and pathophysiologic basis for these dysfunctions are presented. Voiding dysfunctions can be treated by the substitution of defect structures using the principle of "restoration of structure leads to restoration of function". Essential elements of this therapeutic algorithm are suburethral vaginal slings (retropubic or transobturatoric), further a posterior sling, which runs through the fossa ischiorectalis and suspends the vaginal vault near the sacrospinal ligaments, thus reconstructing defect uterosacral ligaments. In cystoceles, lateral and medial defects can be restored by ventral meshes, which are fixed at the arcus tendineus fasciae pelvis by lateral transobturatoric slings. The use of polypropylene slings and meshes is well-founded because they are well tolerated in the tissues and through the development of scar tissue lead to neoligaments with long-lasting therapeutic effects.

[Management of urinary incontinence in the aging man]. / Harninkontinenz des alternden Mannes: Nicht immer ist die Prostata schuld.

The increasing prevalence and incidence of male urinary incontinence in senium-necessitate a specific as well as symptom and etiologically-oriented therapy. In addition to the conservative care with absorbent products, catheterization methods are available. Moreover, the problem can be successfully controlled in the majority of the patients through very specific drug and surgical therapeutic concepts.