Long-term results of ProACT primary and repeat implantation for treatment of stress urinary incontinence in men.

INTRODUCTION: Urinary incontinence in men after radical prostatectomy affects strongly quality of life. If conservative treatment fails, surgical treatment consists of implantable devices. If the requirement of manual dexterity in the artificial sphincter is to be avoided, the ProACT system offers a readjustable system, which shows good continence, but also high revision rates. Aim of our single-centre, single-surgeon study was to evaluate the success and revision rates of ProACT over long-term follow-up and if repeat ProACT implantation after failure would be a reasonable strategy. MATERIALS AND METHODS: In May 2017, follow-up of all patients who underwent ProACT implantation between 2003 and 2013 was obtained. Parameters were numbers of pads used, filling volume of balloons, and patient-reported satisfaction. Furthermore, revisions were noted. RESULTS: Between 2003 and 2013, 134 patients were implanted a ProACT system. Median age was 71 years; median follow-up was 118 months. 112 implantations were successful (82.6%) and the number of pads used decreased significantly (p < 0.005). 63 patients were revised and 49 were successful (77.8%). No differences in success rate, pads used, or filling volume were seen (all p > 0.8). In a second revision, again, no differences in success rate or pads used were noted (all p > 0.7). Patients' personal satisfaction was high despite the high revision rate. CONCLUSION: In the hands of an experienced surgeon, ProACT is a safe and effective therapy for post-prostatectomy incontinence especially if mayor surgery is to be avoided. Revision rates are high, but the results of ProACT reimplantation are comparable to the results after the first implantation.

Surgical treatment of large volume prostates: a matched pair analysis comparing the open, endoscopic (ThuVEP) and robotic approach.

OBJECTIVE: To compare open simple prostatectomy, endoscopic enucleation and laparoscopic, robot-assisted enucleation of high-volume prostate in terms of operation time, blood loss, transfusion and complication rates and early continence rates. MATERIAL AND METHODS: Patients with BPH treated endoscopically (ThuVEP, Hamburg and Hannover) or robotically (Mainz) were evaluated prospectively for prostate size, free flow and validated questionnaires (IPSS, QoL). 35 patients were matched to patients after open prostatectomy (Mainz) for age, prostate size, IPSS and QoL scores. Operation time was noted from the first cut to the last suture; blood loss was estimated by the drop of haemoglobin preoperatively and one day after surgery. Transfusion rates were documented. Early continence was estimated by pad use over the first 24 h after catheter removal. Statistical analysis was performed with SPSS 22.0. RESULTS: No significant differences in prostate size, age and preoperative questionnaires were found (p > 0.3). Postoperative flow and the results of the questionnaires were significantly improved (all p < 0.05), without difference between the approaches (p > 0.8). Endoscopic surgery showed superiority in operation time (both p < 0.05); blood loss and transfusion rates were significantly lower compared to open surgery (both p < 0.01) and lower than in robotic surgery without reaching significance (p = 0.18, p = 0.36). Similar results were seen in early continence rates. CONCLUSION: Due to our results, endoscopic surgery should be considered as first-line therapy unless there are comorbidities like diverticula and/or bladder calculi that can be easily treated simultaneously by robotic surgery. Against the background of these findings, indications favouring open surgery are getting sparse.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT: The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE: To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION: PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS: Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS: Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY: In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

[Combined latissimus dorsi and serratus anterior reverse flow pedicle flap. Report of two clinical cases]. / Lambeau de muscle serratus anterior vascularisé par les pédicules mineurs du muscle latissimus dorsi. A propos de deux cas cliniques.

The use of combined flap involving the distally based latissimus dorsi muscle pedicled on the lumber perforating arteries and prolonged by the last digitations of the serratus anterior flap muscle supplied by the thoracic branch of thoracodorsal vessels is uncommon but has ever been described. We describe the use of this flap in two original cases. The first case is for coverage of a controlateral dorsal radionecrosis. The second case describes its use in emergency following ballistic chest trauma.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]. / Einsatz von synthetischen Band- und Netzimplantaten bei der Behandlung von Belastungsinkontinenz und Descensus genitalis der Frau : Stellungnahme des Arbeitskreises Urologische Funktionsdiagnostik und Urologie der Frau der Akademie der Deutschen Gesellschaft für Urologie.

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

[Management of complications after sling and mesh implantations]. / Komplikationsmanagement nach Band- und Netzimplantationen.

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 15 years. The procedure is easy to perform, minimally invasive with short operation time in an ambulatory setting, and has proven efficacy comparable to the gold standard procedure of retropubic colposuspension.Possible TFAS complications are potentially underestimated with respect to prevalence and manageability. We report our experience with major complications following TFAS and mesh implantation in patients referred to our interdisciplinary continence center. Patient history, risk factors, and preoperative diagnostics were analyzed for development of individualized treatment strategies. Overcorrections with formation of postvoid residual (PVR) can occur in retropubic TFAS as well as in transobturator TFAS. However, the most prevalent and challenging complication is de novo urgency. Major complications like urethrovaginal fistula, sling arrosions of the urethra, bladder, and vagina as well as infected gangrene and complete urethral loss requiring urinary diversion were seen at a frequency suggesting underrepresentation of these complications in the literature. The large amount of implanted artificial mesh material used for pelvic organ prolapse (POP) correction represents a particular challenge in cases of dyspareunia or persisting pelvic pain.Complication management has to be based on cystoscopic, urodynamic, and physical examination findings to be individualized to each patient and must take potential risks of recurrent incontinence or persisting complaints into account.To prevent TFAS or mesh complications, every patient should have tried all conservative treatment options and should be completely evaluated (including urodynamics) preoperatively. Artificial meshes should only be used in cases of prolapse recurrence or in otherwise inoperable patients. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

[Ins and outs in the surgical treatment of female stress urinary incontinence]. / "Ins" und "outs" in der operativen Therapie der weiblichen Belastungsinkontinenz.

Proper indication, preoperative diagnostics and final choice of surgical technique in the operative management of female stress urinary incontinence are subject to somewhat irrational, trend-based changes. For various reasons (insufficient reimbursement, poor expertise, limited therapeutic spectrum) preoperative urodynamic tests are increasingly thought to be unnecessary and are progressively replaced by perineal ultrasound despite lack of evidence. Since the AWMF guidelines (AWMF: Association of the Scientific Medical Societies in Germany) for the diagnosis and treatment of stress urinary incontinence in women were published, individualized planning of therapy is "out". Unconditional guideline adherence in certified pelvic floor centers, which have become very popular in Germany, has furthermore restricted the spread of therapeutic options due to minimum procedure number requirements. With regard to suburethral tension-free alloplastic slings, the retropubic version, which was temporarily unfashionable, has been experiencing a renaissance at the cost of the transobturator alternative. Single-incision slings were developed for the outpatient US market and have never become established in Germany due to lack of proof of superiority. In the setting of a limited spectrum of surgical procedures, adjustable sling systems offer promising treatment options for risk groups with acceptance of higher infection and erosion rates, thus gaining popularity. Reliable and comprehensive preoperative patient information comprising the whole spectrum of therapeutic options with individual risks and opportunities is key to prevent the impending ban of alloplastic implants in female stress incontinence surgery.

Manifestation of congenital urethral diverticula in a 57-year-old male.

Congenital urethral diverticula are a rare finding in adult males. Most cases are diagnosed in childhood or adolescence because of voiding symptoms such as urinary dribbling. Diagnostic workup should include radiography and urethroscopy. The standard therapeutic approach is open surgical excision or endoscopic marsupialization. An unusual case of male congenital urethral diverticula that remained asymptomatic until age 57 is presented.

[Prevalence of lymph node metastases in non-muscle-invasive bladder cancer. Delay of radical cystectomy and upstaging in the cystectomy specimen as risk factors]. / Prävalenz von Lymphknotenmetastasen beim nicht muskelinvasiven Blasenkarzinom. Verzögerung der Zystektomie und Upstaging im Zystektomiepräparat als Risikofaktoren.

OBJECTIVE: To study clinical and histopathologic parameters after cystectomy and lymphadenectomy in non-muscle-invasive transitional cell carcinoma (TCC) of the bladder and their association with the prevalence of lymph node metastases (N+). PATIENTS AND METHODS: Of 866 patients treated with radical cystectomy and lymphadenectomy, 219 had non-muscle-invasive TCC of the bladder. The prevalence of N+ was related to parameters such as gender, age, number of transurethral resections of the bladder (TURBs), intervals between first TURB and cystectomy, adjuvant therapy, maximum histopathologic tumor stage and grade at TURB, and tumor upstaging in the cystectomy specimen by univariate and multivariate analysis. RESULTS: A total of 33 patients (15%) had N+. By multivariate analyses, tumor upstaging and the number of TURBs were independent predictors of N+ at cystectomy. The number of TURBs increased the prevalence of N+ from 8% (one TURB) to 24% (two to four TURBs). Tumor upstaging in the cystectomy specimen increased the prevalence of N+ from 4% to 36%. CONCLUSION: Inappropriate delay and staging errors of"high risk" non-muscle-invasive TCC of the bladder contribute to an increased prevalence of N+ and should be avoided. In our series, the number of TURBs and tumor upstaging in the cystectomy specimen were independent predictors for N+ by multivariate analysis.

[Established treatment options for male stress urinary incontinence]. / Etablierte Methoden in der Behandlung der Belastungsinkontinenz des Mannes.

Nowadays, male stress urinary incontinence is rare and almost always of iatrogenic origin (radiotherapy, pelvic surgery). However, the prognosis of urinary incontinence following surgery is good and can be improved by pelvic floor muscle exercises in combination with biofeedback systems. For the remaining patient cohort with persistent urinary incontinence, several established surgical treatment options are available. Suburothelial injections of bulking agents can easily be performed in an ambulatory setting. However, regardless of the material used, long-term results are disappointing. Moreover, the residual urethral function deteriorates due to cicatrization of the suburothelial plexus with consequent loss of urethral elasticity. The fascial sling procedure in males has to be performed in preoperated areas and is as technically demanding for the surgeon as it is burdening for the patient. Alloplastic material is not used, thus minimizing risks for arrosion or infection. Since the sling tension can neither be standardized nor postoperatively readjusted, the risk of overcorrection is considerable and the success of the procedure is heavily dependent on the surgeon's experience. Despite wear and high revision rates, the technically mature artificial sphincter produces excellent continence results and has become the gold standard in the therapy of male stress urinary incontinence. The circumferential and continuous urethral compression by the cuff is highly effective, but at the price of an almost inevitable urethral atrophy. To overcome this problem, various surgical techniques have been developed (tandem cuff, cuff downsizing, transcorporal cuff placement). However, the expensive artificial sphincter is not a nostrum for every incontinent man, since it requires certain minimal cognitive and manual capabilities. Therefore, the search for less demanding treatment alternatives seems to be necessary, even if one has to accept lower continence rates.

[Which are reasonable diagnostic procedures in the evaluation of urinary incontinence in the elderly?]. / Welche Untersuchungen sind beim alten Menschen mit Harninkontinenz sinnvoll?

The ageing of our society continuously increases the number of frail elderly patients in the incontinence cohort. Shortage of financial and personnel resources demands reasonable and purposeful use of the diagnostic armamentarium. All intended diagnostic procedures should follow an algorithm hierarchized for invasiveness and should be limited to the minimum extent necessary for initiation of a conservative first-line treatment. Reasonable diagnostics objectify patients' complaints, differentiate between subgroups, reveal underlying pathologies and comorbidities, classify incontinence severity, support the therapeutic strategy, identify possible treatment complications and serve as follow-up tools. Diagnostic results have to be documented in detail and the procedures must be as easy and minimally invasive as possible. Basic diagnostics in urinary incontinence comprise patient history, clinical examination, urinalysis, uroflowmetry and sonographic post-void residual measurement, voiding diary and evaluation of the mental status. With these procedures, the vast majority of elderly patients can be classified correctly and a conservative first-line treatment can be started. Only a minority of patients with incongruent diagnostic results or recurrent incontinence refractory to conservative therapy should undergo further special diagnostics (urethrocystoscopy, urodynamics, morphologic and functional radiologic imaging, perineal or introital ultrasound) if they lead to therapeutic consequences. If not, expensive special diagnostics should be omitted in elderly patients due to their inherent morbidity.

[Botulinum toxin for the treatment of neurogenic detrusor hyperactivity. Consensus paper on use for neurogenic bladder dysfunction]. / Botulinumtoxin in der Therapie der neurogenen Detrusorhyperaktivität. Konsensuspapier zum Einsatz bei einer neurogenen Blasenfunktionsstörung.

Due to elevated intravesical storage pressures, neurogenic bladder dysfunction carries a high risk of renal damage. Thus, the goals of neurourologic treatment are reduction of intravesical storage pressure and intermittent bladder emptying in order to protect renal function and to achieve continence. If anticholinergic medication is either ineffective or intolerable, several open and controlled studies showed that the injection of botulinum toxin A into the detrusor muscle is a minimally invasive, safe, and effective treatment option. These studies demonstrated an effective reduction of storage pressures and a significant increase in bladder capacity. The effect has been shown to last up to a year. As this treatment is not approved by European administrations, botulinum toxin A treatment fulfills all criteria for "justified off-label use." The reduction of intravesical storage pressure leads to an improvement of life expectancy due to upper urinary tract protection. Furthermore, quality of life can be improved by low incidence of urinary tract infections, secure continence, and physiologic catheterization intervals.

[Implants for genital prolapse : Contra mesh surgery]. / Implantate bei Genitalprolaps : Kontra Mesh-Operation.

Alloplastic transvaginal meshes have become very popular in the surgery of pelvic organ prolapse (POP) as did alloplastic suburethral slings in female stress incontinence surgery, but without adequate supporting data. The simplicity of the mesh procedure facilitates its propagation with acceptance of higher revision and complication rates. Since attending physicians do more and more prolapse surgeries without practicing or teaching alternative techniques, expertise in these alternatives, which might be very useful in cases of recurrence, persistence or complications, is permanently lost. It is doubtful that proper and detailed information about alternatives, risks, and benefits of transvaginal alloplastic meshes is provided to every single prolapse patient according to the recommendations of the German POP guidelines, since the number of implanted meshes exceeds the number of properly indicated mesh candidates by far. Although there is no dissent internationally about the available mesh data, thousands of lawsuits in the USA, insolvency of companies due to claims for compensation and unambiguous warnings from foreign urological societies leave German urogynecologists still unimpressed. The existing literature in pelvic organ prolapse exclusively focusses on POP stage and improvement of that stage with surgical therapy. Instead, typical prolapse symptoms should trigger therapy and improvement of these symptoms should be the utmost treatment goal. It is strongly recommended for liability reasons to obtain specific written informed consent.

[Urethroplasty and simultaneous perineal prostatectomy after traumatic urethral disruption and carcinoma of the prostate]. / Harnröhrenplastik nach Urethraabriss und simultane perineale Prostatektomie.

We present a case of post-traumatic posterior urethral stricture and localized prostate cancer, which could be treated successfully with simultaneous radical perineal prostatectomy and membranous urethral stricture excision. After 6 months follow-up, the patient is continent with no evidence of stricture recurrence. Post-traumatic posterior urethral strictures can be managed surgically through a perineal approach with high success rates. Prostate surgery after pelvic fracture with posterior urethral distraction defects does not necessarily lead to stress urinary incontinence.

[Bone and soft tissue loss of the proximal interphalangeal joint of the long fingers: emergency treatment with a Swanson implant: prospective study of ten patients with mean 2.7 year follow-up]. / Perte de substance ostéo-articulaire de l'IPP des doigts longs: traitement en urgence par implant de Swanson: étude prospective de 10 cas avec 2,7 ans de recul moyen.

PURPOSE OF THE STUDY: Injury of the proximal interphalangeal joint (PIP) with loss of bone and soft tissue (joint surface, tendon, skin cover) can compromise finger vascularization. Fusion or amputation is often proposed. We report our experience with another solution, emergency implantation of the Swanson implant. MATERIAL AND METHODS: Thirteen patients, mean age 47.4 years (range 18-76) underwent emergency surgery between 1997 and 2003. In twelve patients, the finger injury occurred when working with wood. For ten of the thirteen patients, the injury occurred during recreational activity. The index was involved when only one ray was injured. The thumb was spared in all patients. Joint tissue was lost in all patients. The head of P1 was injured in all cases creating a situation incompatible with fusion without loss of finger length. All patients underwent an emergency surgery for complete reconstruction of the PIP joint with Swanson implant, tendon reconstruction or suture, and skin cover performed during the same procedure. RESULTS: Ten patients, 16 implants, were reviewed at mean 2.7 years (range 1-6 years). Mean flexion reached 41.8 degrees (range 20-80 degrees). Maximal amplitude of flexion was achieved at one year and remained unchanged thereafter. There were no cases of infection, or secondary amputation. Two implant fractures were noted with no functional impact at six years. There were four cases of instability. DISCUSSION: Most reports in the literature concern composite blast or firearm injuries. Ours appears to be the first series involving injuries occurring while working with wood. Most of the lesions caused by the circular saw were tangential, damaging the dorsal aspect of several PIP joints. Classically, it would be logical to propose arthrodesis if the bone and cartilage loss is not excessive, but with the loss of joint motion provided by implants. Like Nagle, we propose emergency implantation of a Swanson prosthesis if soft tissue and tendon reconstruction can be achieved, avoiding amputation. Although the technique is relatively simple, implantation of a Swanson prosthesis implies certain prerequisites, particularly ligament repair and correct alignment. Oversized implants appear to be better. We did not have to perform any secondary arthrodesis.

[Drug therapy of female urinary incontinence]. / Medikamentöse Therapie der weiblichen Harninkontinenz.

Drug treatment for female urinary incontinence requires a thorough knowledge of the differential diagnosis and pathophysiology of incontinence as well as of the pharmacological agents employed. Pharmacotherapy has to be tailored to suit the incontinence subtype and should be carefully balanced according to efficacy and side effects of the drug. Women with urge incontinence require treatment that relaxes or desensitizes the bladder (antimuscarinics, estrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetine), whereas patients with stress incontinence need stimulation and strengthening of the pelvic floor and external sphincter (alpha-mimetics, estrogens, duloxetine). Females with overflow incontinence need reduction of outflow resistance (baclofen, alpha-blockers, intrasphincteric botulinum toxin A) and/or improvement of bladder contractility (parasympathomimetics). If nocturia or nocturnal incontinence are the major complaints, control of diuresis is obtained by administration of the ADH analogue desmopressin. Future developments will help to further optimize the pharmacological therapy for female urinary incontinence.

[Osteocartilaginous autograft after proximal resection of the scaphoid for radioscaphoid osteoarthritis]. / Arthrose radioscaphoïdienne traitée par autogreffe ostéocartilagineuse après résection proximale du scaphoïde: technique et résultats d'une série préliminaire de 10 cas.

PURPOSE OF THE STUDY: Radioscaphoid osteoarthritis is usually a complication of scaphoid pseudarthrosis or chronic scapholunate disjunction. As an alternative to the classical surgical techniques used for this lesion, we propose a novel reconstruction method consisting In partial proximal resection of the scaphoid associated with interposition of a biological spacer composed of a osteocartilaginous rib graft. The purpose of this study was to present the technical aspects of this procedure and to report preliminary results in ten patients with radioscapular osteoarthritis treated between 1994 and 2001. MATERIAL AND METHODS: We performed a retrospective analysis of the ten patients who underwent surgery from 1994 to 2001 for early-stage radioscaphoid osteoarthritis associated with scaphoid osteoarthritis in eight and chronic scapholunate disjunction in two. The procedure consisted in partial resection of the proximal portion of the scaphoid and insertion of an osteocartilaginous autograft harvested from a rib. Outcome was based on the clinical results (pain, motion, grip force, activity) and patient satisfaction. Bone healing was measured with plain x-rays and vitality of the osteocartilaginous graft with MRI. RESULTS: Mean follow-up was 4.6 years. Clinical outcome was considered excellent or good in eight patients, fair in one and poor in one (graft dislocation). All patients were satisfied or very satisfied except one (one failure). Radiological healing was achieved at three months in nine patients. Four patients underwent an MRI examination at thirteen months which demonstrated, in all patients: no sign of necrosis, healing of the graft-scaphoid interface, and no bony metaplasia in the cartilage. DISCUSSION: Compared with partial carpal arthrodesis and resection of the first row of the carpus, this palliative technique can be used to reconstruct the proximal portion of the carpal scaphoid in young patients with early-stage radioscaphoid osteoarthritis. As for arthroplasty or scaphoid implants, our goal was to achieve a satisfactory scaphoid height using a biological spacer after resection of the proximal 3/4 of the bone. The results of this technique are encouraging but must be examined with precaution due to the small number of patients and the short follow-up to date.

[General and method-specific complications of sacrocolpopexy]. / Allgemeine und methodenspezifische Komplikationen der Sakrokolpopexie.

Sacrocolpopexy has remained standard procedure for correction of pelvic organ prolapse regardless of the affected compartment. Assuming the appropriate indication, it is characterized by an excellent long-term cure rate. Asymptomatic pelvic organ prolapse is no indication for surgery and should not be corrected in view of possible complications. This article summarizes general and method-specific complications of sacrocolpopexy, identifies causes, and allows error management to be tailored to each individual patient to increase treatment and outcome quality.

[Gap between postulated and real outcome quality of radical prostatectomy]. / Kluft zwischen postulierter und realitätsbezogener Ergebnisqualität nach radikaler Prostatektomie.

BACKGROUND: Certified Prostate Centers proclaim congruent process and outcome quality results for treatment of prostate carcinoma. Therapy in accordance with the guidelines after presentation of the patient in an interdisciplinary conference and regular documented follow up are not in themselves a guarantee for good quality results (complication free, continence, erectile function, negative surgical margins, biochemical recurrence free), and are significantly influenced by factors not contained within the certification framework. DISCUSSION: An association between exceeding the minimum number of operations and quality assurance exists, if at all, only vaguely and on no account justifies the absolute numbers necessary for certification. Although good measuring instruments for a Pentafecta analysis are available, the gathering of quality results for a center are limited to questionnaires for functional quality results and in the non-differentiated request for a pT2R1 rate of under 10 % for oncological quality results. CONCLUSIONS: The reasons for this systematic ignoring of the for the patient so important quality results with a simultaneous excessive regard for standardizing organizational procedure processes are manifold. They comprise valid verifiability of process quality, the unclear effects of standardized treatment pathways on actual operation quality and the capitulation to statistical and patient determined problems with sufficient acquisition of comparable functional OP results. Whereas the outcome quality is more important than the process quality for patients with prostate carcinoma, the certified centers conduct themselves in exactly the opposite manner, thus creating a virtually insoluble dilemma.

[Vesicovaginal fistula. Incidence, etiology and phenomenology in Germany]. / Urogenitalfistel. Inzidenz, Ätiologie und Phänomenologie in Deutschland.

BACKGROUND: Vesicovaginal fistulae are much more common in developing countries along the equatorial fistula belt than in industrialized countries. However, although the classical obstetric fistula caused by lack of medical support through pregnancy and delivery in adolescent primiparae has almost vanished in Germany, we are now facing new and predominantly iatrogenic variants. Increasing frequency of gynecological surgery as well as pelvic radiation, forgotten vaginal foreign bodies, or uninhibited cancer growth are the modern causes for vesicovaginal fistula in elderly patients. Comorbidities and genital atrophy impair surgical therapy in view of a limited success rate of conservative transient transurethral catheterization. METHODS: Diagnostics should start early and should be initially limited to vaginal inspection, cystourethroscopy, and the blue dye test. Radiological investigations including CT and MRI are only indicated in patients suspicious for ureterovaginal fistula or with inconclusive findings or malignant fistula. The surgical armamentarium comprises vaginal, abdominal, and combined approaches, which all underlie basic principles of fistula repair: protection of the ureteral orifices, complete excision of the fistula canal, accurate separation of the organs connected to the fistula, sufficient tissue mobilization for tension-free suturing, interposition of padding material for prevention of recurrency. CONCLUSION: Depending on the degree of sphincter damage, stress urinary incontinence might persist despite successful fistula repair, requiring further incontinence surgery or ultimate urinary diversion in recurrent cases that are hopeless.