Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

[Incontinence after radical prostatectomy : Male Sling or "best option" first?] / Inkontinenz nach radikaler Prostatektomie : "Male sling" oder gleich "die richtige Lösung"?

Postprostatectomy incontinence (PPI) is a rare complication of radical prostatectomy, and it may lead to severe limitations for the patient and loss of quality of life. Several different surgical options for the therapy of PPI are available and may be chosen depending on severity of incontinence, residual urethral sphincter function, and previous history of radiotherapy. Alternatives to artificial urinary sphincters which over the last few decades have represented the gold standard for treatment of PPI are fixed slings and adjustable devices. In cases of mild or moderate incontinence, male slings can be used. Adjustable devices can also be adopted in irradiated patient with good results. Artificial urinary sphincters represent the ideal option in case of severe incontinence. Absolute contraindications for the implant of this device are impaired dexterity and cognitive capacity of the patients that may make use of the pump difficult. One type of therapy for all patients does not exist and must be individually determined. It is influenced by the grade of incontinence, the anatomical conditions, and the patient's expectations. Thus, appropriate counselling is mandatory. A common opinion is that these devices are direct competitors in the treatment of PPI. In reality, these devices are completely different surgical methods that rely on different principles and therefore have different indications.

Bicentric prospective evaluation of corporoplasty with porcine small intestinal submucosa (SIS) in patients with severe Peyronie's disease.

INTRODUCTION: Advanced Peyronie's disease (PD) with severe penile deviation demands grafting procedures following plaque incision or partial plaque excision in order to avoid penile shortening and to improve quality of life of affected patients. Small intestinal submucosa (SIS) is an established xenograft. The objective of the present study was to validate external results in a bicentric prospective manner. METHODS: Patient selection criteria, surgical technique and standards for pre- and postoperative care were defined. Consecutively, patients with severe penile deviation in stable disease and sufficient erectile function were included between 2007 and 2015. After plaque incision, grafting was performed using SIS in a standardized manner. The postoperative evaluation using a non-validated questionnaire included complications, correction of curvature, pre- and postoperative erectile function, change in penile length and general satisfaction with the procedure. RESULTS: Forty-three patients underwent surgery between 2007 and 2015. The mean degree of preoperative curvature was 73.8° (range 60-90°). No intraoperative or major postoperative complications were reported. After a mean follow-up of 33.0 months (range 10-59), complete straightening of the penis was achieved in 74.4%. 88.4% of all patients were able to achieve satisfying sexual intercourse (67.4% unaided, 21.0% with assistance). The IIEF-5 score was improved in 69.8% (mean improvement 4.0 points). Overall 86.0% were satisfied with the surgical treatment. CONCLUSION: Corporoplasty with SIS in patients with PD and severe penile curvature is a safe approach and shows good long-term results. A thorough patient selection and a standardized pre-, intra- and postoperative procedure are decisive for a satisfying outcome.

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.

[Urethral strictures--operative strategy]. / Urethralstriktur--operative Konzepte.

Urethral strictures are very commonly encountered in urologists' day-to-day work. Many specific therapeutic and reconstructive procedures are available for treatment of the different types of urethral stricture, all of which can be recommended when the indications for each are carefully observed. This paper highlights operative concepts that allow a surgical therapy that is tailored to the localisation and length of the stricture and the severity of spongiofibrosis.

[Retroperitoneoscopy to extract an amorphous matrix calculus of the right kidney]. / Retroperitoneoskopische Pyelotomie zur Extraktion eines amorphen Matrixausgusssteins der rechten Niere.

The female patient underwent multiple extracorporal shockwave treatments and an ureterorenoscopy during which an amorphous renal mass was found. A retroperitoneoscopy was performed with extraction of a large amorphous matrix calculus. Today, the prevalence of matrix calculi is very low. They are associated with and caused by urinal-infections. Delayed diagnosis in radiological-imaging procedures is typical for these stones. The minimal-invasive approach via retroperitoneoscopy seems to be an intriguing alternative to the established procedures like percutaneous nephrolitholapaxy.

[Bladder injury. Diagnostics and treatment]. / Das Blasentrauma. Diagnostik und Behandlung.

Bladder injuries are caused by high-energy blunt trauma that disrupt the bony pelvis, a direct blow to a distended bladder, penetrating injuries, or various iatrogenic causes. When diagnosis is prompt and treatment adequate respecting the other possible injuries, complications from bladder injuries are rare. Problems may occur when the diagnosis is delayed. A systematic approach following the prescribed guidelines will help to successfully manage these cases.

[Infected upper renal pole in a duplex system with paravaginal abscess]. / Infizierter oberer Doppelnierenanteil rechts mit paravaginalem Abszess.

INTRODUCTION: Diagnosis of afunctional duplex systems may be delayed as they are often associated with misleading and atypical symptoms. A 40-year-old female with no history of urological disease exemplifies this thesis. CASE REPORT: Symptoms at admission were fever with pain in the right flank and lower abdomen. Sonography showed a large unclear structure at the upper pole of the right kidney and a paravaginal abscess, which was drained primarily. Rising temperature led to examination by CT-scan, which revealed a renal abscess of the upper pole, suggesting a right extopic ureter. After percutaneous drainage, further examinations (antegrade pyelography and IVP) confirmed an ectopic, blind-ending duplex ureter with a hydropyonephrotic upper renal system on the right side. Upper poole resection with ureterectomy was performed. CONCLUSIONS: In patients with unclear abscesses in the area of the external genitalia, congenital anomalies of the urinary tract should be considered as an underlying disease.

[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.

[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.