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.

Ureteral substitution with reconfigured colon: long-term followup.

PURPOSE: Long defects in the mid and upper ureter are not amenable to end-to-end reconstruction. Therefore, we present the long-term results of our technique with reconfigured colon segments. MATERIALS AND METHODS: Between June 1998 and July 2008, 14 patients underwent ureteral replacement at our institution with reconfigured colon. In 4 patients the substitute was anastomosed to the skin as a modified colon conduit. In 10 patients it was interposed with anastomosis to the ureter in 4, to the bladder in 5 and to the afferent loop of an ileal bladder substitute in 1. RESULTS: At a median followup of 52.4 months (range 7 to 136) excellent renal function was confirmed in 10 of 14 patients. Now at a median followup of 95.8 months (range 38 to 136) 6 patients are alive, all without an indwelling stent and with no sign of obstruction of the ureteral replacement. Metabolic disorders, mucus obstruction and stricture or adhesive ileus were absent during followup. In this series death was unrelated to the procedure. In 7 patients 11 specific reinterventions were necessary including 4 cases of prolonged stenting after surgery, 3 which required secondary drainage, 3 cases of urinary tract infection at 4 weeks and 3 and 112 months, and 1 acute bowel obstruction due to peritoneal carcinosis. CONCLUSIONS: Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.

[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.

[Urethral pain syndrome: fact or fiction--an update]. / Das Urethralsyndrom: Fakt oder Fiktion--ein Update.

BACKGROUND: Urethral pain syndrome is a symptom complex including dysuria, urinary urgency and frequency, nocturia and persistent or intermittent urethral and/or pelvic pain in the absence of proven infection. These symptoms overlap with several other conditions, such as interstitial cystitis bladder pain syndrome and overactive bladder. Urethral pain syndrome may occur in men but is more frequent in women. DIAGNOSTIC: The exact etiology is unknown but infectious and psychogenic factors, urethral spasms, early interstitial cystitis, hypoestrogenism, squamous metaplasia as well as gynecological risk factors are discussed. These aspects should be ruled out or confirmed in the diagnostic approach. Despite the assumption of a multifactorial etiology, pathophysiologically there is a common pathway: dysfunctional epithelium of the urethra becomes leaky which leads to bacterial and abacterial inflammation and ends in fibrosis due to the chronic impairment. THERAPY: The therapeutic approach should be multimodal using a trial and error concept: general treatment includes analgesia, antibiotics, alpha receptor blockers and muscle relaxants, antimuscarinic therapy, topical vaginal estrogen, psychological support and physical therapy. In cases of nonresponding patients intravesical and/or surgical therapy should be considered. The aim of this review is to summarize the preliminary findings on urethral pain syndrome and to elucidate the diagnostic and therapeutic options.

[Avoidance and management of complications in open surgical ureter reconstruction]. / Komplikationsvermeidung und -management bei offenen Harnleiterrekonstruktionen.

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

[Transposition of the stoma in ileal conduits: the "trouble shooting" technique for stomal complications]. / Transposition des Stomas beim Ileum-Conduit "trouble shooting" Technik bei Stomakomplikationen.

OBJECTIVE: To investigate stoma-related complications in ileal conduits we present a series of 4 patients in whom we performed a transposition of the conduit to the contralateral side as a surgical solution for large parastomal hernias. PATIENTS AND METHODS: 4 patients presented between 1998 and 2009 with large parastomal hernias, all in the right hemi-abdomen. A transposition to the contralateral side was carried out. RESULTS: The postoperative course was uneventful in all patients. After a median follow-up of 30 months all patients were free of complaints regarding the new stoma site. No patient presented with peristomal ulcerations or a recurrent hernia during the entire time of follow-up. CONCLUSION: The transposition of an existing conduit and the creation of a new contralateral ostomy site is an effective solution for patients suffering from severe local ostomy complications that are not manageable otherwise.

[Impact of operator experience on TURB of high-grade non-muscle-invasive bladder cancer--analysis of 254 second resections at a university teaching hospital]. / TURB--Welche Bedeutung hat die Erfahrung des Operateurs bei high grade-Tumoren der Harnblase? Analyse von 254 Nachresektionen an einer universitären Ausbildungsklinik.

INTRODUCTION: In departments with urological training of residents, part of the TURB procedures are performed as "teaching surgery". Does resection quality and early recurrence depend on the operator's experience? PATIENTS AND METHODS: From July 2007 to February 2012 254 second resections (TURB) after Ta high-grade and T1 high-grade bladder tumours were performed at our institution. The surgeons were stratified into "junior residents" (first and second year of training), "experienced residents" (3rd-5th year of training), board certified urologists, consultants and chief surgeons. We analysed the risk of recurrence at second resection and characteristics of the initial TURB. RESULTS: 87 patients presented with a Ta high-grade tumour (34.3%) and 167 had a T1 high-grade lesion (67.7%). Most TURBs were performed by "experienced residents" (3rd-5th year) and the chief of department. The recurrence rate at second resection was 52.4%. A significant association with the recurrence rate was shown for the number of initial tumours, size and T-stage. No association was found for the training level of the surgeon. Additionally, there was no different detrusor rate for the surgeons, as a parameter for a correct, muscle-deep TURB. A bias that surgeons in training had more favourable tumours (solitary, less than 3 cm) could be excluded. CONCLUSIONS: In our data detrusor rate and recurrence risk at second resection are independent of the surgeon's experience. The results of "teaching-TURBs" are not inferior compared to TURBs performed by board certified urologists or consultants under the conditions of undisturbed communication and personal supervision.

[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.

[T1 bladder cancer: role of documentation for bladder tumor findings and targeted second resection]. / Das T1-Blasenkarzinom : Bedeutung der Dokumentation des Tumorbefundes und der gezielten Nachresektion.

BACKGROUND: For control resection of T1 bladder tumors an exact relocalization of the previously infiltrating tumor spread can be complicated by postreactive alterations, multiple scar tissue or change of surgeons. In this study the results of control transurethral resection of the bladder (TURB) after T1 high grade bladder tumors with the focus on localization and importance of standardized exact documentation were analyzed. PATIENTS AND METHODS: From July to February 2012 a control resection was performed in 167 patients due to a T1 high grade bladder cancer. The rates of residual tumor tissue and localization were investigated with standardized tumor documentation. RESULTS: Out of 167 patients with T1 bladder cancer who underwent a control resection tumor tissue was found in 58.1 % (97 out of 167) and in 85.6 % (83 out of 97) the primary site was affected (41.2 % only at primary site and 44.3 % additionally at other locations). In 11 patients (11.3 %) residual tumor tissue at the initial site was only detected histologically. CONCLUSIONS: Our results indicate that T1 high grade bladder cancers show a relevant rate of residual tumor tissue at control resection which confirms the clinical guidelines of the European Association of Urology (EAU) on mandatory resection. In most cases the primary tumor site is affected. The standardized bladder tumor documetation allows well-directed control resection also in patients with multiple scars and post-TUR alterations, even when performed by a different surgeon.

[Diagnostic puncture of the renal pelvis: avoidance of urinary diversion in cases of hydronephrosis and non-specific fever]. / Diagnostische Nierenbeckenpunktion : Vermeidung der Harnableitung bei Patienten mit Hydronephrose und unspezifischem Fieber.

INTRODUCTION: There are individual cases especially of elderly or palliative patients with hydronephrosis and non-specific fever where a urinary diversion should be avoided in favor of quality of life. For these purposes this study presents the method and the results obtained with a diagnostic puncture of the renal pelvis. METHODS: Demographic data, indications for urinary diversion and the disease leading to hydronephrosis were retrospectively recorded from the operation reports of all percutanous nephrostomy procedures from 2007 to 2012. All cases in which a diagnostic puncture of the renal pelvis was conducted to potentially avoid placing a nephrostomy tube were considered separately. RESULTS: From January 2007 to May 2012 a total of 476 percutanous nephrostomies were accomplished in this department. The most frequent indication for nephrostomy was acute renal failure in 55.3% of cases followed by septic laboratory constellations (33.1%) and colic (10.9%). Of the 148 cases of hydronephrosis combined with sepsis, a diagnostic puncture of the renal pelvis was accomplished in 20.1%. In these cases the hydronephrosis had an underlying urological origin in 71.0%, reaching statistical significance with reference to the complete collective (p=0.034). In 21 out of 34 nephrology units (61.8%) it was possible to avoid nephrostomy due to clear urine and immediate urinanalysis without any evidence for infection. In the other cases a nephrostomy tube was placed. CONCLUSIONS: Using a diagnostic puncture of the renal pelvis a nephrostomy could be avoided in over 50% of cases with a combination of hydronephrosis and non-specific fever in favor of quality of life.

[Hyperbaric oxygen in the treatment of hemorrhagic radiogenic cystitis after prostate cancer]. / Hyperbare Sauerstofftherapie bei hämorrhagischer Strahlenzystitis nach Prostatakarzinom.

BACKGROUND: Postradiation hemorrhagic cystitis is a well known long-term complication of radiation therapy occurring in 3-6 % of patients. Hyperbaric oxygen (HBO) has been demonstrated to be an effective treatment for radiation-induced hemorrhagic cystitis not responding to conventional management. This article reviews experiences with HBO for radiogenic cystitis after prostate cancer. METHODS: All patients treated for hemorrhagic cystitis with HBO between 2006 and 2012 were retrospectively reviewed. The HBO procedure was performed for 130 min/day at 1.4 atmospheres overpressure. Patient demographics, type of radiotherapy, onset and severity of hematuria and time between first hemorrhagic episode and beginning of HBO were evaluated. The effect of HBO was defined as complete or partial (lower RTOG/EORTC grade) resolution of hematuria. RESULTS: A total of 10 patients with radiogenic cystitis and a median age of 76 years were treated with a median of 30 HBO treatment sessions. Patients received primary, adjuvant, salvage and high dose rate (HDR) radiotherapy (60-78 Gy). First episodes of hematuria occurred after a median of 41 months following completion of radiotherapy and HBO was performed 11 months after the first episode of hematuria. After a median 35-month follow-up 80% experienced complete resolution, one patient suffered a one-off new hematuria and in one patient a salvage cystectomy was necessary. No adverse effects were documented. CONCLUSIONS: The experiences indicate that HBO is a safe and effective therapy option in treatment-resistant radiogenic cystitis but prospective clinical trials are needed for a better evaluation.

[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.

[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.

[Ureteral realignment with the rendezvous procedure in complex ureteral injuries - aspects of technique and our experience]. / Ureter-Realignment mittels Rendez-Vous-Technik bei komplexen Harnleiterverletzungen - Methodik und eigene Erfahrungen.

PURPOSE: The rendezvous procedure for re-establishing ureteral continuity after complex ureteral injuries is introduced and we present our experience with this technique. MATERIAL AND METHODS: Aspects of the technique are described in a detailed step-by-step instruction using intraoperative radiographs. We evaluated our patient data from 1998 until 2009 for cases in which the rendezvous procedure was attempted. RESULTS: The rendezvous procedure was used in a total of 11 patients. Realignment was successful in 10 cases (90.9 %) and the initial nephrostomy could be removed. In 3 of 7 cases postoperative removal of the JJ ureteric stent was successful. In 7 patients the final surgical ureter reconstruction was performed after a medium period of 7 months. 5 cases of ureteroneocystostomy and 2 cases of reconstruction of the ureter either with colon or ileum segments were accomplished. In 1 patient a permanent maintenance of the DJ ureteral stent was necessary. CONCLUSION: Ureteral realignment with the rendezvous procedure enables disposition of the ureteral stent in many cases, exclusively antegrade or retrograde procedures failed. By this means nephrostomy could be spared as a temporary or permanent solution and a better chance of restitutio ad integrum could be realised.

[Ureteral reconstruction after ureterorenoscopic injuries]. / Harnleiterrekonstruktion nach ureterorenoskopischen Verletzungen.

Ureteral injuries are caused by iatrogenic reasons in about 75% of cases. Among urological procedures ureterorenoscopy (URS) is mainly described as the reason for ureteral injury, although complication rates of URS are generally low. Injuries of the ureter are divided into five grades by the AAST. Grades I-II are referred to as partial and grades III-V as complex ureteral injuries. To avoid higher complication rates there should be no delay in confirmation of diagnosis and initiation of therapy. Correct therapy depends on grade of injury. Partial ureteral injuries are treated by endoscopic inlay of a ureteral stent for approximately 14-21 days. In complex injuries endoscopic ureteroureterostomy could be attempted but leads to rather poor long-term results depending on the length of devascularization of the injured ureter.Procedures with and without use of bowel for ureteral reconstruction and replacement have been described. The type of operative procedure should be selected based on location and degree of ureteral injury. Besides ureteral reconstruction, autotransplantation of the affected kidney can be required in individual cases.

[Myth or truth. Cranberry juice for prophylaxis and treatment of recurrent urinary tract infection]. / Mythos oder Wahrheit. "Cranberry-Saft" in der Prophylaxe und Behandlung von rezidivierenden Harnweginfektionen.

Recurrent urinary tract infections are a frequent problem in urological practice. Long-term antibiotic prophylaxis can cause resistance of some intestinal bacteria, and after therapy is stopped, infections often resume. In controlled studies, general recommendations for prophylaxis were shown to inhibit reinfection. One of these recommendations is the consumption of cranberries. A review of the literature in PubMed as well as the recently published Cochrane database systematic review confirmed that daily consumption of cranberries prevents recurrent urinary tract infections. In vitro studies have shown that binding of the P fimbriae of Escherichia coli to the uroepithelial tissue can be inhibited in the presence of proanthocyanidins, the active ingredient of cranberries. In clinical studies, the evidence is not so pronounced. Many other bacteria have fimbriae, but only a few subpopulations have P fimbriae. P fimbriae are frequent in E. coli, so this adhesion can be prevented. However, in a subanalysis of randomized and controlled studies, it was shown that women with recurrent urinary tract infections might profit from consuming cranberries.