Urinary retention: benefit of gradual bladder decompression - myth or truth? A randomized controlled trial.

INTRODUCTION: Urinary retention is a common emergency requiring immediate catheterization. Gradual decompression (GD) of the extended bladder is believed to minimize the risk of complications such as bleeding or circulatory collapse, but to date it has not been compared with rapid decompression (RD) in controlled trials. MATERIALS AND METHODS: Male patients presenting with urinary retention (n = 294) were randomized to rapid or gradual catheterization. For the latter, the transurethral catheter was clamped for 5 min after every 200-ml outflow until the bladder was completely empty. Patients were monitored for at least 30 min thereafter with regular checks of vital signs and presence of macroscopic hematuria. RESULTS: Of 294 patients, 142 (48.3%) were randomized to the GD and 152 (51.7%) to the RD group. Both groups showed no statistically significant difference with regard to age, anticoagulation treatment, catheter size and material, or volume retained. Hematuria occurred in 16 (11.3%) of the GD and 16 (10.5%) of the RD group; 6 patients in the former and 4 in the latter required further treatment. No circulatory collapse occurred. We noted a decrease in the previously raised blood pressure and heart rate in both groups, although without clinical significance. CONCLUSION: In this first randomized trial, no statistically significant difference was noted between gradual and rapid emptying of the bladder for urinary retention. Gradual emptying did not reduce the risk of hematuria or circulatory collapse. Therefore, there is no need to prefer gradual over rapid emptying, which is both easy and safe.

Safety and efficacy of vardenafil versus sertraline in the treatment of premature ejaculation: a randomised, prospective and crossover study.

We investigated safety and efficacy of vardenafil and sertraline in premature ejaculation (PE). Seventy-two men graded their primary PE on a scale of 0-8 (0 = almost never, 8 = almost always). Intravaginal ejaculatory latency time (IELT) was measured. Patients were included if they scored their PE as 4 or greater and their IELTs were less than 1.30 min. After 6 weeks of behavioural psychosexual therapy, 49 patients still had a PE of 4 or greater and an IELT less than 1.30 min and they were randomised: 6 weeks vardenafil (10 mg) or sertraline (50 mg). After a wash-out phase for 1 week, medication was changed in a cross-over design. Initially, all 72 men with PE received behavioural therapy. Twenty-three men were satisfied with treatment and excluded. The remaining 49 men graded their PE as 5.94 +/- 1.6 and IELT was 0.59 min and patients were randomised. Four men discontinued the study. Vardenafil improved PE grading: 2.7 +/- 2.1 (P < 0.01) and IELT increased to 5.01 +/- 3.69 (P < 0.001). PE grading improved 1.92 +/- 1.32, (P < 0.01) and IELT 3.12 +/- 1.89 (P < 0.001) with sertraline. It is concluded that vardenafil and sertraline are useful agents in the pharmacological treatment of PE.

[Is rehabilitation of erectile function following pelvic surgery reasonable? Review of the literature: from sports to PDE5 inhibitors]. / Ist eine Rehabilitation der erektilen Funktion nach beckenchirurgischen Eingriffen sinnvoll? Literaturübersicht vom Sport bis zur PDE-5-Inhibitoren-Gabe.

Increasingly, urologists are seeing patients with erectile dysfunction after pelvic operations. In most cases, radical prostatectomy is the cause. Even when a nerve-sparing procedure is performed, approximately 50% of the patients suffer from erectile dysfunction. This report discusses the causes and theoretical therapies, including lifestyle changes, strategies for neuroregeneration and the associated prevention of apoptosis of the smooth muscle of the corpus cavernosum and improvement of the corpora cavernosa by increased oxygenation. According to the international literature, many of these agents and lifestyle modifications display promise for treating impotence. Early treatment for patients recovering from pelvic operations seems to be reasonable. It is assumed that the natural recovery of erections may take as long as 18 to 24 months postsurgery or even longer; however, treatment modalities may reduce the time to erectile recovery.

[Treatment of specific complications of locally advanced prostate cancer]. / Behandlung von spezifischen Komplikationen des lokal fortgeschrittenen Prostatakarzinoms.

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

[Lifestyle, erectile dysfunction, hormones and metabolic syndrome. Opportunities for gender-specific prevention for men]. / Lifestyle, erektile Dysfunktion, Hormone und metabolisches Syndrom : Möglichkeiten einer geschlechtsspezifischen männlichen Prävention.

German men tend to be less health conscious and show less of an interest in preventative behaviours. However, urological symptoms can provide the grounds for a doctor's visit and conversation. Modifiable lifestyle factors such as obesity, lack of exercise and smoking play a role in the development, progression or remission not only of erectile dysfunction (ED), but also in cardiovascular disease and the metabolic syndrome. Moreover, age-related testosterone deficiency can negatively impact the overall health as well as the sexual function of men. Recommendations to alter behaviours in the context of ED management and, if necessary, testosterone replacement, provide the urologist with the opportunity for broad gender-specific prevention for his male patients.

[Secondary prevention after urological tumor diseases. Focusing on the kidneys, testes, and bladder]. / Sekundärprävention nach urologischen Tumorerkrankungen. Mit Fokus auf Niere, Hoden und Blase.

It is generally agreed upon that patients require a caring as well as careful medical follow-up after cancer treatment. The goal of secondary prevention is to recognize a recurrence at an early stage and to use the curative chance while the tumor mass is still small. There is evidence of a medically effective and successful follow-up for tumors of the testicle and the bladder. For quality reasons, these follow-up regimes should be adhered to for quality reasons. In other diseases, e.g., renal cell carcinoma, prospective randomized studies are missing which demonstrate the effectiveness of follow-ups. In these cases asymptomatic patients should be stratified to individualized follow-up care.

[A Solitary PSA-Negative Late Metastasis of Prostate Cancer on the Penis]. / Solitäre PSA-negative Spätmetastase eines Prostatakarzinoms in der Glans penis.

Metastatic involvement of the penis is rare. Secondary lesions generally originate from pelvic tumours. Bladder and prostate are the most common primary tumours. Commonly, penile metastases occur in cases of disseminated cancer disease. We present the case of a prostatic mucinous adenocarcinoma with a solitary, PSA-negative, asymptomatic metastasis to the glans 6 years after radical prostatectomy, which was successfully treated by local excision.

[Nation-wide questionnaire of cathether use in Germany]. / Bundesweite Umfrage zur Katheterversorgung in Deutschland.

BACKGROUND: Despite the costs that the national health care system faces with regard to treatment of urinary incontinence and related use of urinary catheters, only limited research has been focused on the subject. In collaboration with the German Association of Urologists, we conducted an online-based survey to learn more about the use of urinary catheters and the care of patients in the outpatient setting. METHODS: A comprehensive online survey consisting of 26 questions was sent to all members of the "German Federation of Urologists" (Berufsverband der Deutschen Urologen) in an e-mail. The participation was anonymous and participants were able to complete the survey only once. Data analysis was carried out by the survey provider. RESULTS: Of the 1407 urologists to whom the survey was sent, 482 answered the survey and 406 (84%) responded to all the questions. According to the survey the replacement of urinary catheters is most commonly carried out by the urologist (59%). The replacement of a catheter is usually performed in the urologists' office (59%). In an emergency setting, patients with an obstructed or displaced catheter are most likely to be taken to the nearest hospital where qualified personnel are on duty and can assist. For long-term urinary drainage in male patients, the suprapubic catheter is the primary choice (61%). In female patients, suprapubic and transurethral catheters are more evenly distributed (36% vs. 31%). CONCLUSION: The response rate of 34% to the survey indicates that there is an interest in this topic. The results of the survey suggest that patient care involving a urinary catheter in Germany is subject to heterogeneous indications and standards of care. The management of patients with urinary catheters continues to be a responsibility of the urologist.

Nitric oxide based influence of nitrates on micturition in patients with benign prostatic hyperplasia.

BACKGROUND: Nitric oxide (NO) is involved in the physiologic regulation of smooth muscle relaxation in the prostate. Organic nitrates act as NO donors. In this prospective open study we prove the influence of orally given nitrates on micturition. METHODS: Thirty-two patients underwent a urological medical check-up prior to starting nitrate medication for cardiovascular disease. We examined peak flow rates, residual urine, IPS-score, PSA level and prostate volume. Exact inclusion and exclusion criteria were defined. Fifteen patients suffered from obstructive symptoms, 17 patients reported no subjective micturition problems. Urological re-evaluation was performed two weeks and three months after nitrate medication. RESULTS: A significant improvement of peak urinary flow rates (+3.1 ml/s; p<0.05), IPS score and significant decrease of residual urine volume (-22 ml; p<0.05) were found in the symptomatic patients. No significant changes of micturition parameters were found in asymptomatic patients. PSA levels and prostate volumes did not change in either groups. CONCLUSIONS: Organic nitrates influence micturition parameters in patients with obstructive benign prostatic hyperplasia. This might be explained by the known mechanism of NO donation (smooth muscle relaxation) of nitrates. More functional controlled studies are necessary to describe the grade of influence of nitrates on the prostate. Concomitant oral medication with nitrates must be considered as a relevant bias factor on BPH in future clinical studies.

[Follow-up care - consequences of urinary diversion after bladder cancer]. / Nachsorge - Konsequenzen der Harnableitung nach Harnblasenkarzinom.

Radical cystectomy is the standard of care for muscle-invasive bladder cancer. Continent urinary diversions utilizing both small and large bowel are becoming more prominent: therefore, the postoperative follow-up has to focus on different aspects. In the first instance after radical cystectomy functional issues with respect to potential stenosis, post-void residual urine and micturition disorders are important. In the early phase the oncological follow-up aims to detect local, urethral and systemic recurrences and new data show the importance of the first 3 years after surgery. Long-term follow-up focuses on metabolic aspects, such as cobalamin or bile acid deficits, acidosis and disorders of calcium and bone metabolism. Follow-up care should consider specific complications of different types of urinary diversions; however to date standardized follow-up guidelines are lacking.

[Use of hydrogel as spacer in Denovier's space: optimization of IMRT radiotherapy of localized prostate cancer]. / Hydrogelapplikation als Spacer in den "Denovier-Raum" : Optimierung der IMRT-Radiotherapie des lokalisierten Prostatakarzinoms.

BACKGROUND: Radiotherapy is an appropriate primary therapy for localized prostate cancer in accordance with urological guidelines. Especially in tumors of higher grade malignancy, dose escalation up to 80,0 Gy seems to be an advantage; however rectum toxicity can be a problem. By injecting a synthetic hydrogel (SpaceOAR®) as a spacer between the prostate and rectum, rectal toxicity can be reduced. We report on our experiences with 47 patients and an average follow-up of 241 days. METHODS: From February 2012 to November 2012, 47 patients were included in the study series. Before external radiotherapy the hydrogel was injected between prostate and rectum in the so-called Denovier space. This interdisciplinary procedure was carried out with the patient under general anesthesia using transrectal ultrasound guidance and video documentation. The patients were hospitalized for 1 day. The exact position of the gel was assessed by means of magnetic resonance imaging (MRI). Radiotherapy was initiated 7-14 days after gel application in a dose escalation manner by means of intensity modulated radiation therapy (IMRT) up to a dose of 80,0 Gy. Average follow-up was 241 (100-386, SD 91) days. RESULTS: No early side effects specific for the application were observed. The achieved distance between rectum and the mid-plane of the prostate gland was on average 13.8 (6-24, SD=3.8) mm. Calculated V70 (rectal volume irradiated with 70.0 Gy or more) could be reduced to an average of 1.5 (0-8, SD=1.7) %. One patient showed an asymptomatic lesion of the rectal mucosa after irradiation with 38,0 Gy. This lesion was closely controlled and gel penetration was found. As a result radiotherapy was discontinued. Without further treatment the necrosis had completely healed 3 months later. CONCLUSIONS: Hydrogel application between prostate and rectum allows dose escalation up to 80,0 Gy and seems to reduce morbidity in patients with localized prostate cancer receiving radiotherapy. However, before final judgement of the new technique further studies must follow.

[Premature ejaculation in urological routine practice]. / Die Ejaculatio praecox in der urologischen Praxis.

Premature ejaculation is a frequent male sexual complaint or sexual disturbance found in urological practices and outpatient units. The frequency in the individual practices varies considerably. In large studies the prevalence is strongly dependent on the definition and ranges between 3% and 25%. Subjectively, the inability to delay ejaculation and the distress resulting from it, is relevant for the patient and his partner. Intravaginal ejaculation latency time (IELT) is used as an objective parameter. Nevertheless, in the everyday routine practice this objective parameter is not practical. Clinically 2 questionnaires have asserted themselves (Premature Ejaculation Profile and Index of Premature Ejaculation). Studies have shown that the self-assessment of patients correlates relatively well with the objective IELT measured by means of a stopwatch. Beside topical anaesthetics and elective serotonin reuptake inhibitors (SSRI), especially Dapexetine which has been approved in Germany since 2009, are treatment options. These drugs differ particularly in their use (daily or on-demand) and their effectiveness (measured by x-fold increase of IELT). This article deals with the clinical approach to EP. Beside the definition, prevalence, aetiology and neurophysiology of EP, the different pharmacological therapies as well as the guidelines of the International Society for Sexual Medicine are discussed.

[Nocturia--an often misjudged problem]. / Nykturie--ein oft verkanntes Problem.

Nocturia--waking up during the night due to the urge to urinate and empty the bladder--is a serious problem for affected patients. In the past decades, nocturia has been primarily regarded as an irritative symptom of benign prostate hyperplasia (BPH). This symptom is however frequently not influenced by different BPH treatments. In the last couple of years one has come to the conclusion that the prostate is less involved and in part responsible for the symptoms since women are also frequently affected. For these reasons nocturia is looked at differently. It is a highly prevalent symptom which neither qualitatively nor quantitative differs between men and women. Many factors lead to nocturia. The following diseases are involved: coronary heart disease, diabetes mellitus or insipidus, lower urinary tract symptoms (LUTS), states of anxiety or insomnia as well as behavioural and environmental factors. Nocturia can be categorised in nocturnal polyuria (overproduction of nightly urine) or a diminished bladder capacity or a combination of both. These entities can be easily differentiated by arithmetic analysis, e.g., a 48-hour voiding diary. Only recently nocturia has been classified according to the aetiology and pathogenesis, making a differentiated treatment possible. However, even in the cases in which the underlying cause cannot be found behavioural changes can help. Nevertheless, pharmacological treatments are inevitable. Medical treatments include: desmopressin, anticholinergics and antimuscarinics, general-medical measures like support stockings, different time for the intake of diuretics or in specific cases the nasal CPAP artificial respiration (continuous positive airway pressure). In spite of the partly high effectiveness of these measures, treatment should be customised taking possible side effects in account.

[T1 high-grade bladder cancer - value of second operation with prognostuic parameters of first operation: analysis of 167 cases]. / T1 high grade-Blasentumor - Wertigkeit der Nachresektion mit prognostischen Parametern der Initialresektion: Analyse von 167 Fällen.

We have evaluated the results of second transurethral resections of the bladder (TURB) after T1 high-grade bladder cancer over a 4.5-year period.From July 2007 to February 2012, 2172 TURB procedures were performed at our institution, of which 1130 were initial resections owing to primary tumour or relapse. Of these, 258 revealed T1 high-grade bladder cancer, and here we investigated tumour characteristics of the initial TURB and results of the second resection.The incidence of T1 high-grade tumours was 22.8% (N=258). Of 167 patients who underwent a second resection, tumour was found in 58.1% (97 of 167). Tumours were mostly multifocal (61.9%) and smaller than 3 cm (69.1%). Histology of the second resection revealed Ta low-grade in 8.4%, Ta high-grade in 16.2%, T1 high-grade in 19.8% and an upstaging to T2 and more in 6.6%. A significant association with the recurrence rate was found for the number of tumours at initial TURB: patients with multiple tumours at initial TURB had a recurrence rate of 69.0% compared with only 46.3% of patients with solitary tumour. For tumour-size and detrusor muscle in specimen a non-significant association was shown.T1 high-grade bladder cancers show a relevant rate of tumour at second TURB which confirms the clinical guidelines of the EAU. A significant association for a tumour-free second TURB in our data was shown for solitary tumours. A non-significant association was shown for tumour-size and when detrusor muscle was present in the specimen. Currently there is no data to determine the best time interval before second resection.

[Carcinoma of the rete testis with lymphogenous metastasis: multimodal treatment]. / Rete-testis-Karzinom mit lymphogener Metastasierung : Multimodale Behandlung.

Cancers of the rete testis are uncommon and usually occur in the 6th or 7th decade of life. The prognosis is dreadful. Approx. 40% of the affected patients die within 1 year after diagnosis due to progression of the disease. The primary therapy is surgical. Until now there is no effective chemotherapy. In our case following primary inguinal orchiectomy and confirmation of the diagnosis, a radical retroperitoneal lymphadenectomy and wide local resection were performed. One positive lymph node was found and adjuvant radiotherapy was performed. In this case preoperative PET/CT was not helpful. For the last 3 years now the patient has been disease free. Since cancers of the rete testis are very rare and the literature is scarce, we would like to recommend the introduction of a national registry.

[Imperative cystectomy in patients at risk. Ileal conduit or ureterocutaneostomy?]. / Imperative Zystektomie beim Risikopatienten. Transintestinale Harnableitung oder Harnleiterhautfistel?

Due to the demographic trends, the incidence of bladder cancer will rise. Based on progress in perioperative management, radical cystectomy has become feasible also in elderly patients with muscle-invasive bladder cancer. Also caused by the increase of age-related comorbidities, the question arises as to the optimal urinary diversion in patients at risk. The ileal conduit is the accepted standard due to its safe, well-proven, and low-risk performance. Nevertheless, it was shown to have relevant complication rates in patients at risk, mostly because of the bowel involvement. The ureterocutaneostomy is a safer and easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stent-free rate is comparable to the ileal conduit. In addition, quality of life analyses show comparable results. Therefore, ureterocutaneostomy should be considered as an option for urinary diversion in patients at risk.

[Cryptorchidism and infertility from the perspective of interdisciplinary guidelines]. / Hodenhochstand und Infertilität unter besonderer Berücksichtigung der interdisziplinären Leitlinie.

Cryptorchidism is the most common genital disorder in boys. Early-born boys are affected in up to one third of the cases, while about 2-5% of full-term newborns suffer from at least one undescended testicle. As a result of short-term endogenous testosterone secretion after birth the prevalence decreases to 1-2% after 3 months. According to most studies, watchful waiting after 6 months is not justified because after this time spontaneous testicular descent only very rarely occurs. Even though the effects of testicular development and fertility in undescended testis have been extensively examined, the only fact that remains certain is that approximately 90% of untreated men with bilateral cryptorchidism develop azoospermia. The remaining scenarios of cryptorchidism (unilateral, ectopic, inguinal, treated or not treated) exhibit unpredictable fertility and likelihood of fatherhood.

[Counselling for erectile dysfunction during inpatient rehabilitation after radical prostatectomy]. / Beratung zur erektilen Dysfunktion während stationärer Rehabilitation nach radikaler Prostatektomie.

For men erectile function is essential for quality of life. Besides urine incontinence postsurgical erectile dysfunction (ED) following radical prostatectomy (RPE) represents a significant and prevalent problem. One of the first approaches to this condition should be a consultation performed by professionals in a rehabilitation clinic.A total of 149 patients post RPE participated in this prospective study. All patients were questioned about their understanding of postoperative surgical ED after RPE and if affected they were asked about their own psychological burden as well as their knowledge of possible therapy options. The qualities of presurgical patient information as well as the modules of information pertaining to ED during the rehabilitation were evaluated. Of the patients, 53% expressed that they experienced a considerable burden due to postsurgical ED during their follow-up rehabilitation (AR group) and 70% of the patients during oncological rehabilitation treatment (rehab group). Men who were sexually more active prior to surgery suffered more from postsurgical ED than their less active counterparts. A negative correlation between psychological burden and age was found in the AR group, which however was levelled in the rehab group. Particularly in older patients the burden of ED increases with more time elapsing after the operation. The medical information on ED therapy options provided during the inpatient rehabilitation was considered to be essential by 60% of the men in the AR group and 48% of the patients in the rehab group.Therapeutic possibilities for postsurgical ED following RPE cannot always be given to patients in the preoperative phase or during their stay in the hospital. Since however a large majority of men suffer from postoperative ED following RPE a specialized inpatient urological rehabilitation is suited for a comprehensive consultation.

[Non-bacterial cystitis: principles, diagnostics and etiogenic therapy options]. / Abakterielle Zystitis: Grundlagen, Diagnostik und kausale Therapiemöglichkeiten.

The therapy for non-bacterial cysitides is often based on purely symptom-oriented measures which in many cases relieve the patient's symptoms but cannot stop the chronic progression of the disease. The present article summarises the most common forms of non-bacterial cystitis (interstitial, radiogenic, chemotherapy-induced) with their common pathophysiology and then introduces the most common therapeutic procedures. With regard to radiogenic and chemotherapy-induced cystitis it must be considered that optimal preventative measures can often markedly delay or even prevent the development of the inflammatory processes. The preventative therapeutic measures mentioned in this article should thus constitute a fixed part of the accompanying therapy within the framework of tumour-related treatment. As alternatives or supplements to symptomatic therapy, causal therapy options show good response rates. Besides successful hyperbaric oxygen therapy, this also holds for hyalurane that is instilled with the aim of repairing the damaged glycosamine layer in the endothelium of the urinary bladder and so opens new curative options in cases that were previously considered as therapy resistant. A prior potassium-sensitivity test is recommended as this allows the putative success of the therapy to be predicted with a high probability. However. It is equally important, especially in cases of interstitial cystitis, that the diagnosis is made as early as possible which was often not done in the past.