Two-staged urethroplasty: buccal mucosa and mesh graft techniques.

PURPOSE: The purpose of this study was to describe indications, the operative technique and results of the two-staged buccal mucosa (BM) and mesh graft urethroplasty for treatment of urethral strictures. MATERIAL AND METHODS: Between 3/1993 and 12/1999, urethral reconstructions were performed in 267 consecutive patients (group I), including 68 mesh graft urethroplasties (25 %) and 30 BM urethroplasties (12 %). Between 1/2000 and 8/2004, additional 249 urethroplasties were performed: Of those, 12% were mesh graft and 50% BM urethroplasties (group II). RESULTS: In patient group I, stricture recurrence was found to be the main complication of both procedures (BM 17 %, mesh 16 %). However, erectile dysfunction and curvature only occurred in the mesh graft group with 4% and 9 %, respectively. Patient satisfaction was high in both groups (BM 96.7%, mesh 83.3%). Between 1/2000 and 8/2004 (group II) the number of BM urethroplasties increased to 50%, whereas the number of mesh graft urethroplasty decreased (12%). More than 80% of the patients were satisfied with the results. CONCLUSIONS: Long strictures with severe spongiofibrosis represent an indication for two staged urethro-plasty (BM and mesh graft). Excellent results can be achieved with both techniques with a similar rate of complications. The mesh graft technique remains the last option for a complex patient group.

[Clinical value of native and contrast enhanced MRI in staging prostatic carcinoma before planned radical prostatectomy]. / Klinischer Stellenwert der nativen und KM-unterstützten MRT im Staging des Prostatakarzinoms vor geplanter radikaler Prostatektomie.

PURPOSE: To assess the clinical value of MRI with and without contrast agent in the staging of prostatic carcinoma. Relevance for surgical management. METHODS: 60 patients with carcinoma proven by biopsy or suspected prostatic carcinoma were evaluated with MRI. The examinations were performed in a 1.5 T (Philips ACS-NT Gyroscan) imager with multiplanar orientations before and after intravenous application of 0.1 mmol/kg/bw Gadodiamide (Omniscan-Nycomed/Amersham). The gold standard was histology after radical prostatectomy and in case of non-operability the consensual final staging. RESULTS: Compared to histology MRI revealed a sensitivity of 75% and a specificity of 82% in the differentiation of locally advanced carcinoma (T 3/4). Including the non-surgical cases MRI showed a sensitivity of 82.5% and a specificity of 86%. Interindividual analysis showed no difference in diagnostic accuracy between the non-enhanced and the contrast-enhanced techniques. In 23% of cases (n = 14) MRI induced changes in patient management. CONCLUSIONS: MRI is an accurate procedure in the local staging of prostatic carcinoma. In combination with clinical findings, PSA, and grading scores MRI has a significant influence on treatment selection. Contrast agent administration does not seem to increase the diagnostic accuracy significantly.

Surgery of the penis: reconstruction and prostheses.

Implantation of penile prostheses was a very popular topic in the published literature on reconstructive urological surgery in the year 2000. Monocomponent, multicomponent, semirigid and inflatable prosthesis techniques were investigated. The best results were obtained with multicomponent inflatable prostheses. For penile reconstruction, various techniques were described. All authors used myocutaneous sensitive forearm flaps. Good results were reported.

[Diagnosis of urethral stricture--what is necessary?]. / Diagnostik der Harnröhrenstriktur-was ist notwending?

For therapy of strictures of the urethra several procedures are available. The choice of the adequate strategy requires a rational diagnostic, answering questions about localisation, length, shape and functional effect of the stricture. The most important method is the miction-cyst-urethrography (MCU). Statements about the dimensions of scarred alterations in the corpus spongiosum urethrae are to receive from urethral ultrasonic. In addition you can perform the retrograde urethrography. The functional effects of the urethral stricture should be investigated by uroflowmetry and examinations of the upper urinary tract (ultrasonic/urography).

[Anatomy and blood supply of the penis and urethra]. / Anatomie und Blutversorgung des Penis und der Harnröhre.

The exact knowledge of the topographic anatomy of the urethra as well as the macro- and microcirculation of the penis [6] are the basics of reconstructive urethral surgery. Adherence to the fundamentals and principles of tissue transfer [5] are necessary to fascilitate conditions for successful treatment of the various disorders of the male urethra. Mutural description of the anatomy of the male urethra in conjunction with external male genitals is necessary because of developmental similarities as well as the close anatomical relationship. The arterial and venous blood supply of the urethra and the penis have to be taken into account if vascularized flaps from the penile skin or the prepuce are used in urethral reconstruction. The dual arterial and venous vascularity of the genital skin is of fundamental importance to a successful outcome of the operative treatment. The purpose of this article is, to summarize the relevant anatomical knowledge of reconstructive urethral surgery.

[Bulbo-bulbar and bulbo-prostatic anastomosis of the urethra]. / Bulbobulbäre und bulboprostatische Anastomose der Harnröhre.

Strictures of the bulbous and membranous urethra up to 2.5 cm in length and after visual urethrotomy should be managed with an one-stage perineal anastomotic repair. With description of the surgical techniques the results of 41 patients, treated between 1977 and 1996, are presented. 28 patients had bulbomembraneous strictures as result from urethral disruption at the time of pelvic fracture. In 13 cases with bulbar strictures, 11 had been caused iatrogenously and 2 by infection. A successful outcome was achieved in over 90% (37 patients), equivalent to a maximum uroflow over 15 ml/s, an empty bladder after voiding and a radiographic wide anastomosis. Only 4 patients (9.8%) after surgery required an urethrotomy; two of them are dilated frequently.

[Two-stage urethra-plasty]. / Die zweizeitige Urethraplastik.

Between 1977 and 1996 we treated 176 patients suffering from complicated urethral strictures with the mesh-graft urethroplasty. This operation technique has replaced the Bengt-Johanson-Operation which had been used frequently until that date. The Cecil-Operation has been totally abandoned, because in our opinion the usage of scrotal skin in urethral reconstruction is obsolete today. The mesh-graft technique is based on the free transfer of meshed prepuce (full-thickness skin or split-thickness skin) in a two stage procedure. In 37 patients the inner layer of the prepuce was used, in 63 patients we only used split-thickness skin grafts and in 76 patients we applied a combination of both, the inner layer of the prepuce in addition to a split-thickness skin graft. After complete healing of the graft (first stage) the formation of the neourethra follows as the second stage procedure. The mesh graft procedure can be used to treat all kinds of strictures independent of the etiology or localisation. Hair growth, diverticula development and stone formation that are observed frequently as complications with scrotal skin substitutes can be avoided. Due to these advantages encouraging long term results could be obtained with the mesh graft urethroplasty. In 162 patients (92%) with a minimum follow-up of 7 years we achieved a successful result of the operations, a significant improvement could be obtained in 7 patients (4%). Unfortunately in further 7 cases (4%) the operation method ultimately failed. In particular in patients with complicated and severe strictures after numerous unsuccessful prior reconstructive attempts, extensive long strictures and strictures in paraplegic patients, mesh graft urethroplasty has been shown to be a safe and reliable treatment option.

[Therapy of female urinary incontinence with the AMS 800 artificial sphincter. Indications, outcome, complications and risk factors]. / Therapie der weiblichen Harninkontinenz mit dem artifiziellen Sphinkter AMS 800. Indikationen, Ergebnisse, Komplikationen und Risikofaktoren.

Indications, results and complications of 144 women who have undergone implantation of the current model AMS 800 since 1983 and remained in continuous follow-up in our department are presented. Included are 70 patients suffering from stress urinary incontinence (SUI) type III after 208 previously unsuccessful incontinence procedures, 54 patients with incontinence due to neurogenic bladder dysfunction (NBD) and 20 patients with congenital or acquired internal sphincter weakness of other causes. In the NBD group, apart from sphincter implantation a total of 113 additional operations were necessary due to complex malfunctions of the urinary tract: augmentation ileocystoplasty in 51 patients, ureterocystoneostomy in 23 patients and 43 operations at the bladder neck. One hundred and twenty-six patients (86%) achieved total continence and 5 patients (3%) were significantly improved. In 9 females (6%) incontinence persisted, and 4 patients ultimately underwent urinary diversion into a Kock pouch. With the implanted artificial sphincter 116 patients (81%) are able to empty their bladder spontaneously, without residual urine and without the necessity of intermittent self catheterisation. Under the aforementioned conditions implantation of the artificial urinary sphincter AMS 800 is the most effective therapy for complex female incontinence.

[Cavernous insufficiency after dermal graft corporoplasty]. / Kavernöse Insuffizienz nach Dermalgraftkorporoplastik.

From 1987 to 1993, a total of 27 patients suffering from Peyronie's disease were treated by plaque excision and dermal graft repair. The deformity of the penis was adequately corrected in 25 patients. Preoperatively 18 patients (66.6%) had firm erections, while postoperatively only 4 patients (14.8%) could have sexual intercourse. The loss of rigidity is due to venous leakage. Pre- and postoperative cavernosometric studies in 11 patients showed an increase in maintenance flow from 17 ml/min to 77 ml/min. Cavernosography reveals venous leakage from the deep dorsal vein. Disintegration of the tunica albuginea is discussed as a possible reason for the venous leakage.

Urethral stricture repair: results in 179 patients.

From 1977 till April 1990 169 operative reconstructions of urethral strictures were carried out in this clinic. 49 patients with a short stricture (less than 2 cm) underwent excision and end to end anastomosis. In 18 patients with a long stricture (2-6 cm) one stage urethroplasty with a transverse distal penile or preputial island of skin flap was used. 102 patients with extensive or otherwise problematic strictures were subjected to two-stage mesh skin graft urethroplasty. In 10 patients with a short stricture we have recently implanted a new urethral stent in the strictured area after visual urethrotomy. During a long-time follow-up a good anatomical and functional result was achieved in all but 2 patients who underwent an excision and end to end anastomosis. In the island flap urethroplasty group a restricture occurred in one patient, and mesh graft urethroplasty was successful in all but 3 patients. In the urethral stent patients the primary results are excellent.

[Urethroplasty using a free dermo-epidermal of preputial mesh graft: Meshgraft urethroplasty]. / Urétroplastie par greffe libre en grillage dermo-épidermique ou préputial: urétroplastie Meshgraft.

Long urethral strictures raise serious problems in terms of appropriate treatment. Reconstruction techniques using scrotal skin have a high recurrence rate. In order to avoid complications, a dermoepidermal or preputial Meshgraft was used to reconstruct a new urethra in two stages. In the first stage, the graft was raised and transplanted onto the open urethra. 8 to 12 weeks later, in the second stage, the new urethra is closed. Since 1977, Meshgraft urethroplasty has been performed in 128 patients, using the skin of the foreskin (n = 75) or medial surface of the thigh (n = 53). A good anatomical and functional result was obtained in all but three cases, regardless of the graft donor site. This operative technique constitutes a very effective method for the lasting treatment of long or complicated urethral strictures, for example in patients with spinal cord injuries.

[Mesh graft urethroplasty]. / Meshgrafturethroplastik.

Since 1977 124 patients with complicated urethral strictures have been treated by using free-foreskin grafts or split-thickness skin grafts to construct a neourethra in a two-stage procedure. Excellent functional and anatomical results have been achieved in 115 patients. The technique is even useful in exceedingly long or problematic strictures, such as in patients with spinal cord injuries.

[Wall-stent for treatment of bulbar urethral stricture and DSD in spastic bladder]. / Der Wallstent zur Behandlung der bulbären Harnröhrenstriktur und der DSD bei spastischer Blase.

Since may 1989 a urethral Wallstent has been used for the treatment of short urethral strictures and for DSD in paraplegic patients with reflex bladder activity. Forty-nine patients have now been followed-up, which exceeds the 6-month margin. Out of these, 25 suffered from a short stricture of the bulbous urethra and 24 had spastic bladders with severe DSD. Eighteen of the 25 patients with strictures had previous unsuccessful direct vision urethrotomies; 17 in the DSD group had undergone failed sphincterotomies. In all but 2 cases the infravesical obstruction could be treated effectively solely by stent implantation. The results obtained equal those of a well-performed end-to-end anastomosis of the bulbous urethra or a 12, o'clock sphincterotomy.

[Is down-staging of advanced bladder cancer by neoadjuvant chemotherapy possible?--MVEC protocol]. / Gibt es ein Downstaging des fortgeschrittenen Blasenkarzinoms durch neoadjuvante Chemotherapie?--MVEC-Schema.

In 22 patients with advanced transitional cell carcinoma of the bladder, neoadjuvant chemotherapy according to the MVEC regimen was given. Subsequent radical cystectomy showed down-staging in 7 patients (32%). The preoperative clinical staging revealed regression of the bladder cancer in 77% of all cases. Down-grading was seen in only 2 patients. Because of the discrepancy between preoperative clinical staging and the histopathological staging after radical cystectomy, invasive tumour surgery is necessary even when clinical staging has not revealed a tumour after chemotherapy.

[Hydraulic penis prosthesis in fibrosis of the cavernous body. The alloplastic tunica albuginea]. / Hydraulische Penisprothesen bei Schwellkörperfibrose. Die alloplastische Tunica albuginea.

Fibrosis of the cavernous bodies is a rare but serious condition resulting in erectile impotence. When the fibrosis is extensive a simple penile prosthesis sometimes cannot be implanted. In addition, perforation of the tunica albuginea is not uncommon in damaged cavernous bodies, and this will compromise a reimplantation. In such cases, the use of an alloplastic vascular prosthesis permits replacement of lost cavernous wall tissue and insertion of an inflatable penile implant. We used this technique in 10 patients with severely damaged cavernous bodies. In 7 of them, surgery was successful and enabled satisfactory intercourse. This type of surgery, however, should be reserved for selected cases of penile prosthetic surgery.

[Current developments in hydraulic penis prostheses]. / Neuentwicklungen bei hydraulischen Penisprothesen.

The disappointing long-term results of alternative treatments for erectile dysfunction have led to increasing interest in penile implants. Against this backdrop, the development of reliable penile prostheses which offer easy implantation and excellent function is a challenge to bioengineers and urologists with a special interest in the treatment of erectile dysfunction.

[The AS800 artificial sphincter for the treatment of female incontinence]. / Der artefizielle Sphinkter AS800 zur Behandlung der weiblichen Inkontinenz.

From 1983 to May 1991, the artificial sphincter AS800 has been applied in 106 female patients for the treatment of complicated cases of urinary incontinence. Of these, 80 remained in continuous follow-up and have now been followed up for at least 1 year, with a mean of 3.8 years. In 40 of our female patients the urethra was afunctional secondary to failure of previous anti-stress-incontinence procedures. Neurogenic incontinence with sphincteric involvement affected 30, while 10 of the patients had congenital sphincter anomalies or traumatic sphincter weakness. Following implantation of the artificial sphincter, 86.3% of these patients are completely continent and do not need a pad. With regard to emptying, 81.3% are able to empty their bladder without residual urine after opening the sphincter, and 8 have to perform clean intermittent catheterization (CIC) once or twice daily in addition. A further 7 void exclusively by CIC. As preparation for implantation of the AS800 sphincter, 24 additional procedures were performed, including 5 antireflux operations and 6 bladder-flap procedures. In 38 of 80 patients a total of 62 revisions were performed. Infection and erosion were the most common reasons for revision, accounting for 48.2% of all revisions. The next most common reason was tissue atrophy underneath the cuff. However, 25% of the revisions were due to device failures, most often cuff leakage.

[Surgical therapy of penis shaft induration in congenital penis deviation and induratio penis plastica]. / Chirurgische Therapie der Penisschaftverkrümmung bei kongenitaler Penisdeviation und Induratio penis plastica.

The therapy of Peyronie's disease is an operative one primarily. Indication for the operative treatment is the penile deviation which prevents the patient from intercourse. The method of choice is plaque excision and subsequent corporoplasty with dermal graft. Good long-term results can also be achieved with a sole straightening of the penile shaft without plaque excision. However, this procedure (Nesbit's operation) results in a shortening of the length. In patients who are suffering from an additional erectile dysfunction an implantation of a penile prosthesis is done accompanied by plaque excision and a corporoplasty with alloplastic material (Dacron, Goretex). In 80% of all cases good postoperative results can be achieved with the operative treatment of Peyronie's disease. Patient's satisfaction is very good with all procedures described above. The exact diagnosis of the erectile quality seems to have a prognostic value for the postoperative result.

[Surgical therapy of urinary incontinence in the male]. / Operative Therapie der Harninkontinenz des Mannes.

From 1973 to 1990 a total of 340 male patients suffering from incontinence of various etiologies were treated by implantation of an artificial urinary sphincter. In 165 patients the sphincter was placed at the bladder neck, while 175 needed an implantation at the bulbous urethra. Because of the better results with regard to continence, we prefer the bladder neck implantation. The youngest patient treated was 12 years old and the oldest, 91. Most of the patients were between 40 and 80 years old. The highest continence rates were achieved in patients with postprostatectomy urinary incontinence. Among those with a bladder neck implant continence was achieved in 93.3% of all cases, while 87.4% of those with an artificial sphincter at the bulbous urethra achieved continence. The mechanical complication rate was low with 7.05%, whereas tissue-related complications occurred in a total of 25.3% of cases. Revision was necessary in 30.9% of cases during the first few years after implantation; it was striking that the incidence of revision fell dramatically 1 year after implantation. This is also true for any second revision, which usually becomes necessary within the first year after the first revision. In total, however, two-thirds of the patients do not require revision during the first 5 years. These data show that the implantation of an artificial sphincter is the safest and most successful method for the treatment of urinary incontinence in the male. This method is superior to all other operative treatments and should be considered the first-line treatment, especially in post-prostatectomy urinary incontinence.

Opposite renal pelvic metastasis of renal adenocarcinoma. Case report.

We report on a 72-year-old patient who was nephrectomized because of renal adenocarcinoma and who developed five years later a tumour in the contralateral renal pelvis. Histological study of the completely resected tumour revealed a metastase from the renal cell carcinoma. A short review of the literature concerning the rare cases of contralateral renal pelvic or ureteral metastases of renal carcinoma is made.