In vitro and in vivo experiences with ureterorenoscope by Gelet.

Using ureterorenoscopes with unidirectional flow, the urologist faces a conflict between a good view on one hand and high pressure in the ureter and the pelvic collecting system of the kidney on the other hand. The ureterorenoscope designed by Gelet, which has continuous (bidirectional) flow and separate irrigation and working channels, was compared with the instrument by Pérez-Castro, which has a common irrigation and working access. The features investigated were optical quality, flow-irrigation characteristics, and handling. The latest generation of ureterorenoscopes provides small total diameters because of minimized working channels and fiberoptic image and light transmission. These semirigid instruments combine the features of flexible endoscopes and traditional ureterorenoscopes. The Gelet instrument offers continuous flow, achieved by separation of the irrigation and working channel, and provides a good view even when working instruments are inserted. The additional outlet channel prevents high pressure in the ureter and renal pelvis and offers another access for instrumentation, if necessary, which means maximum safety for the patient. Because the connection of camera and light source on a flexible system is separated from the instrument, ureterorenoscopy is a more convenient procedure for the urologist.

Rotoresect: new technique for resection of the prostate: experimental phase.

We developed a new resection device-the Rotoresect -with the aim of reducing morbidity during transurethral resection of the prostate (TURP). During rotoresection, a rotating ablator electrode enables simultaneous tissue coagulation by high-frequency current and mechanical tissue ablation. The tissue ablation rate and the extent of bleeding were quantified ex vivo using a blood-perfused porcine kidney (N = 30) and then compared with loop resection and electrovaporization (grooved roller/Rollerball). Additionally, transurethral rotoresection of the prostate and open partial resection of the liver were carried out in five dogs. With the blood-perfused porcine kidney, we demonstrated that the tissue ablation rate increases with increasing of the coagulation current and rotation speed of the ablator electrode. The Rotoresect achieved a tissue ablation rate comparable to that of the resection loop (5.5-6.0 g/min), which was more than twice the rate achieved by electrovaporization (1.7-2.0 g/min). The extent of bleeding during standard loop resection was many times higher (16.5-18.0 g/min) than that induced by rotoresection and electrovaporization (< 2.3 g/min). In our in vivo canine trials, we performed transurethral prostate resection and open segmental liver resection with minimal bleeding. The Rotoresect is a promising instrument for ablation of parenchymal organs during transurethral, laparoscopic, and open surgical procedures.

[Burch vs. Stamey comparison. Long-term outcome of 2 competing surgical methods]. / Vergleich Burch vs. Stamey. Langzeitergebnisse von zwei konkurrierenden Operationsverfahren.

Stress incontinence is the most frequent form of incontinence found in females. The usual method of surgery for this is to lift the bladder neck towards cranial and ventral. Two competitive techniques--bladder neck suspension in accordance with Stamey and colposuspension in accordance with Burch--were retrospectively investigated. A total of 95 women underwent surgery and it was possible to evaluate the postoperative course in 46 and 30 (total 76) patients respectively. Initially, both surgical techniques demonstrated a very good success rate (91.3% and 96.7% resp.). However, the continence rate of the Stamey patients deteriorated after 6 weeks down to 78.3% and after more than 2 years only 28.6% of these patients were still completely continent (mean follow-up 40.4 mths), whereas deterioration in the Burch patients was only 87% (mean follow-up 44.25 mths). The disappointing results with the Stamey technique did not correlate with the degree of initial continence. It was noted here that obese patients showed a greater tendency towards regression. The three cases of recurring incontinence after Burch colposuspension were already relapses at the time of surgery. With respect to long-term follow-up, our results with the Stamey method were distinctly poorer than with the Burch technique: Therefore, in our opinion, the Burch colposuspension procedure and fascioplasty should be the method of choice for the management of stress incontinence.

[Current therapy standards in treatment of genuine stress incontinence in the woman with urethral mini-devices]. / Aktueller Therapiestandard in der Behandlung der genuinen Stressinkontinenz der Frau mittels Harnröhren-Mini-Devices.

Conservative treatment of genuine stress urinary incontinence in females gained more and more interest. The use of mini-devices is one of the newly developed therapeutical options however, its clinical relevance and longterm-results are still under debate. This review article gives a critical evaluation of the available urethral plugs and regulators and new developments as well according to the long-term-follow-up studies in the literature and own experience with those devices. The continence rates that can be obtained with the different plugs or regulators are dependent upon the degree of stress incontinence, ability to insert the plug and compliance of the patient. Reported longterm results vary between 48% and 100%. The most frequent side effects are urinary infection, haematuria and/or handling problems with the devices. According to the published material it is impossible to give therapeutical standards for treatment of female stress urinary incontinence with urethral mini-devices. Although proper Patient selection might give excellent longterm-results in patient continence rates.

[Remnants of the Mullerian duct. Case report based on a complex urogenital abnormality]. / Residuen des Müller-Gangs. Fallbeispiel anhand einer komplexen urogenitalen Missbildung.

Persistent remnants of the caudal müllerian ducts can manifest in several forms and are often associated with other urogenital disorders, especially hypospadias. Inadequate activity of the müllerian inhibiting factor, in addition to fetal testosterone deficiency, is responsible for this syndrome. The etiology, diagnosis and management of müllerian duct remnants are discussed. A complex case of penile-scrotal hypospadia, hypoplastic prostate gland, testicular ectopia and retrovesical cyst is presented.

[Transurethral laser ablation of the prostate (TULAP). Initial results with 188 patients]. / Transurethrale Laserablation der Prostata (TULAP). Erste Ergebnisse bei 188 Patienten.

Laser therapy for benign prostatic hyperplasia (BPH) is now the most impressive alternative to transurethral resection of the prostate (TUR-P). Transurethral laser ablation of the prostate (TULAP) is a new technique that combines non-contact and contact laser treatment of BPH. From November 1992 to August 1994, 188 patients were treated by the TULAP technique. Their median age was 70.3 (58-87) years. The mean prostatic volume determined by transrectal ultrasound, was 49.2 ml. A 6-month follow up was possible for 102 patients. The AUA 7-Symptom Score decreased from 29 points preoperatively to 6 points after 6 months. Residual urine volume decreased from 205 ml to 27 ml after 6 months. Maximum flow rate increased from 7.2 ml/s to 19.3 ml/s after 6 months. No severe complications were observed, and in particular no major bleeding or TUR syndrome. We regard the TULAP procedure as an effective treatment alternative for obstructive symptoms caused by BPH.

Metabolic evaluation and medical therapy for stone formation.

There is little debate that nephrolithiasis is an increasing problem for public health. In the USA, the treatment of renal stone disease costs more than two billion dollars per year. The lack of prospective randomized trials reflects the problem of subjecting stone-formers to prospective studies and placebo treatment, and studies often use a single-group design. Nevertheless, investigation of metabolic abnormalities often makes the identification of an etiologic factor, and consequent treatment, possible, and stone formation can be reduced.

The role of the papilla in idiopathic calcium oxalate nephrolithiasis.

The complex and multifactorial phenomenon of urinary stone disease remains unclear. Anatomical and physiochemical theories do not adequately deal with certain aspects of idiopathic calcium oxalate nephrolithiasis in particular or of nephrolithiasis. One of the reasons for this could be that nephrolithiasis is not only a primary disorder but may also be a symptom of other disorders or various pathologic changes in the metabolism of lithogenic substances. Both affirmative and contradictory reports have been published since Randall's first description of papillary calcifications and their possible active role in the genesis of calcium oxalate nephrolithiasis. Our intention is to discuss focal calcified lesions as an etiologic factor of renal stone disease as well as the change from historical to modern concepts regarding the development of medullary calcifications and their relationship to idiopathic calcium oxalate nephrolithiasis.

High-flow priapism leading to the diagnosis of lung cancer.

We report on a patient with spontaneous high-flow priapism. Magnetic resonance imaging showed a sacral tumor. Prior to tumor surgery, signs of lung cancer were found on chest X-ray. The diagnosis was confirmed by bronchoscopy. Priapism in this case can be explained either as a paraneoplastic symptom or as an isolated manifestation of cauda compression. Both are very uncommon reasons for priapism.

Treatment update on pediatric urolithiasis.

At the doorstep of the twenty-first century the role of extracorporeal shock-wave lithotripsy (ESWL) as the treatment of choice for more than 80% of all stones in children is established. ESWL is safe and effective, with very few differences in success rates being observed among different lithotriptors. The present problem with ESWL appears to be the residual stone fragment, which has a proven clinical significance. A thorough metabolic evaluation and metaphylaxis is indicated in all children, and this will enable physicians to deal with the residual fragments in a more cause-specific manner and prevent regrowth. Another subject that needs prospective randomized studies to be unveiled is the assumption that a specific or universal metaphylaxis, possibly with alkaline citrates, will enhance stone clearance, lower the incidence of residual stone fragments, and optimize the ESWL results. Finally, both percutaneous nephrolithotomy and ureteroscopic stone removal have been established in children as safe and effective treatment options. This gives the clinician the opportunity to choose from a wide range of treatment alternatives, including open surgery, and only this approach will ensure 100% stone removal in individual patients along with the prevention of recurrence and, thus, the elimination of long-term morbidities in this vulnerable patient population.

Long-term followup and selection criteria for penile revascularization in erectile failure.

PURPOSE: We report the long-term results of penile revascularization surgery for erectile failure and suggest possible selection criteria for this controversial surgical procedure. MATERIALS AND METHODS: In 7 years 62 impotent men who did not respond to pharmacotherapy underwent microsurgical penile revascularization and completed long-term followup evaluation in 41 months (range 18 to greater than 62) consisting of a detailed questionnaire, duplex sonography and optional pharmacotherapy or angiography. The Virag procedure was chosen for the first 7 patients, the original Hauri technique for the next 13 and the modified Mannheim triple anastomosis for 42. RESULTS: Of all patients 34% achieved spontaneous and another 20% pharmacologically induced erections. Success in diabetics and older patients was lower (43% for diabetics, 39% for those older than 50 years at surgery), while it was high in men with less than 2 risk factors (58%) as well as in younger patients (69% for those up to 50 years old). Shunt patency was 92%. Complications such as glans hyperemia developed in 13% of patients, shunt thrombosis in 8% and inguinal hernias in 6.5%. CONCLUSIONS: Patient selection is vital for the successful outcome of penile revascularization surgery. We adhere to strict selection criteria, such as patient age maximum of 50 years, less than 2 risk factors, no recent diabetes and termination of nicotine abuse. Penile revascularization surgery is highly indicated in this group of patients, especially since it is the only causal therapy for erectile failure.

Interstitial laser coagulation in benign prostatic hyperplasia: A critical evaluation after 2 years of follow-Up.

Since 1993 we have prospectively followed a cumulative cohort of males with benign prostatic hyperplasia and symptomatic bladder outlet obstruction who underwent interstitial laser coagulation (ILC) of the prostate. We evaluated the safety and efficacy of ILC with respect to relief of symptoms and bladder outlet obstruction. In addition to the critical evaluation of our clinical results, the perineal and transurethral approaches were investigated as they may make a substantial impact on the overall success rate, including prostate size, number of sticks per prostate volume and type of application. A total of 59 patients were treated with the Nd-YAG laser (mediLas fibertom) between April 1993 and December 1996. At the time of reevaluation, 47 patients had completed a follow-up of up to 24 months. A perineal approach was used in 34%, transurethral in 23%, and a combined approach in 43% of the patients, depending on the preoperative volume of the prostate. 75% were high-risk patients in accordance with the ASA score (ASA III). The efficacy of treatment was assessed 6, 12, 24 and 52 weeks postoperatively in accordance with the International Prostate Symptom Score (IPS/quality of life), cystomanometric studies, peak urinary flow rate, residual volume and volume reduction of the prostate. Reduction of prostatic volume and sticks used per prostate volume were correlated to the overall success rate. A significant improvement in all voiding parameters (flow rate, residual volume), including the symptom score, was observed. P(det) decreased from an average of 90 cm H(2)O preoperatively to 42 cm H(2)O postoperatively after 24 weeks and the mean reduction in prostate volume was 14 cm(3). Interestingly, it was noted that the overall success rate was not size-related. A distinct positive correlation was found in the number of sticks performed and the improvement in objective and subjective parameters. In view of the low morbidity outcome, especially in high-risk patients, we proclaim Nd-YAG interstitial laser coagulation of the prostate to be an effective and safe alternative method of treatment for symptomatic benign prostatic hyperplasia.