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.

[Stress incontinence in elderly women]. / Belastungsinkontinenz der Frau im Alter.

Stress incontinence is one of the major challenges in geriatric medicine. This is becoming more apparent in routine urology practice with the demographic changes in the population. A thorough diagnosis for a correct treatment of stress incontinence is as important in elderly women as it is in younger patients. This includes assessing the risk factors of incontinence and obesity, parturition, pelvic surgery and changes in hormone levels are risk factors usually found in elderly women. These are the main reasons why this patient group is most frequently affected. Treatment options do not differ significantly from these of younger women. Lifestyle modification, weight loss and supervised pelvic floor training are the mainstays of conservative therapy and surgical treatment should only be considered after these options have been exhausted. In these cases minimally invasive surgical techniques offer clear advantages especially for elderly often multimorbid women.

Impact of ureteral stenting prior to ureterorenoscopy on stone-free rates and complications.

OBJECTIVE: To date, only few studies have evaluated the impact of ureteral stenting prior to ureterorenoscopy. This study is to clarify the role of preoperative ureteral stenting in the treatment for ureteral stones. METHODS: We retrospectively reviewed 550 ureterorenoscopies from 1998 to 2008. Patients were classified into two groups depending on whether they had a stent placed before URS. Baseline characteristics of patients and stone properties, stone-free rates, complications, and operation times were compared between both groups. Subanalysis was performed regarding stone localization. We retrospectively reviewed data from patient documentation, X-ray imagery, intravenous urography, and operation reports. RESULTS: Baseline characteristics of patients were similar in both groups. The majority of patients underwent stent placement before the ureteroscopic stone treatment (88.4%). The mean operation time in the prestented group was longer (43.3 vs. 38.4 min). Stone-free rate of patients with stent was 72.2%, compared to 59.4% without preoperative stenting. The rate of minor complications was 4.7% with stent versus 9.4% without stent, major complications 0.6% versus 1.6%, respectively. Patients with distal ureter stones had similar stone-free rates regardless of a stent placement (90.1% with stent vs. 87.6% without), and no difference in complication rates was observed (3.5% with stent vs. 3.1% without), respectively. CONCLUSIONS: Stent placement prior to ureteroscopic stone treatment in distal ureter is not reasonable and does not considerably improve stone-free rates.

[Prolapse surgery. With abdominal or vaginal meshes?]. / Prolapschirurgie. Mit abdominal oder vaginal eingesetzten Netzen?

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.

[Intermittent androgen deprivation as therapy for androgen-sensitive prostate cancer. Sense or nonsense?]. / Intermittierende Hormontherapie beim androgensensiblen Prostatakarzinom. Sinn oder Unsinn?

Androgen deprivation is the predominant therapy for advanced prostate cancer. There is accumulating evidence that phases of intermission in androgen deprivation may have benefits regarding side effects, albeit there is as yet no general recommendation for intermittent androgen deprivation therapy. Recent systematic reviews at least substantiate a benefit from such regimens for general quality of life without therapy compromisation. In addition, preclinical data revealed further potential strategies for intermittent androgen deprivation therapy. Future studies must prove, however, that such approaches can be implemented in the clinical situation.

[Laser now also to be used in organ-preserving kidney surgery?]. / Laser nun auch in der organerhaltenden Nierenchirurgie?

Kidney surgery is subject to continuous change. Partial nephrectomy is the prevailing method for small and medium-sized tumours and proven to be superior to radical nephrectomy. The conventional technique usually includes clamping the renal vessels. The duration of the ischaemia caused determines the outcome of the remaining renal function. The shorter the ischaemic time the more likely the renal function will be preserved. Thus, new techniques are needed to abandon renal vessel clamping. Essential is a combination of good cutting abilities and assured haemostasis. To date, the commonly used techniques for cutting in partial nephrectomy only partially fulfil these requirements. Establishment of laser in urology offers a new surgical technique that combines both. In spite of the still limited data on laser use in kidney surgery, this method can be assessed favourably. Laser offers a possibility of both open and laparoscopic partial nephrectomy avoiding renal vessel clamping without additional risks or complications.

[Antiandrogen strategies in prostate cancer: reconstitution of oestrogen receptor beta]. / Antiandrogene Strategien im Prostatakarzinom : Rekonstitution des beta-Ostrogenrezeptors.

In advanced prostate cancer, albeit castration resistant, an active androgen receptor is still pivotal for growth and cell survival. Recent therapies involving more effective antiandrogens such as MDV3100 proved to be successful. Furthermore, blocking de novo intracrine androgen synthesis, e.g. with abiraterone acetate, provides additional benefit. Besides these antiandrogen measures, compounds which enable the reconstitution of the oestrogen receptor beta as a tumour suppressor restrain aberrant androgen receptor signalling.

[Problems, objective, and substance of early detection of prostate cancer]. / Probleme, Zielsetzung und Inhalt der Früherkennung beim Prostatakarzinom.

The current S3 guideline for early detection of prostate cancer initiates a change to the paradigm in early detection from the detection of all prostate cancers to the identification of aggressive prostate cancers. Early detection is performed annually and starts at the age of 40 years; it should be terminated at a life expectancy of less then 10 years. The choice of the frequency of early detection should be risk adapted. The digital rectal examination is supplemented by determination of PSA. Previous to the first PSA test the patient has to be informed concerning possible consequences such as biopsy recommendation and treatment options. A threshold of 4 ng/ml is defined as an indication for prostate biopsy for the first administration. In the following early detections the PSA velocity should be considered. Today imaging methods do not play a major role in early detection of prostate cancer. Early detection identifies many latent prostate cancers and patients may receive overtreatment. The recent S3 guideline for early detection is discussed against this background on the basis of the recent literature.

The carboxyproxyl-derived spin trap (CP-H) is an appropriate detector-compound for oxidative stress.

Reperfusion of ischemic tissue disturbs the balance between reactive oxygen species (ROS) and the cellular antioxidative defense. This imbalance is known as oxidative stress. In this study the spin trap 3-carboxy-2,2,5,5-tetramethylpyrrolin-1-hydroxide (CP-H) with its ESR-detectable paramagnetic analogue 3-carboxy-2,2,5,5-tetramethylpyrrolin-1-oxyl (*CP) was analyzed in vitro and in vivo. In preliminary in vitro experiments we studied the interaction of CP-H with reactive compounds like hydroxyl radicals (*OH) and alkylperoxyl radicals (ROO*) which are formed during organ reperfusion or tissue reoxygenation. The increase in the peak intensity of the ESR signal of the *CP-radical was used as a measure for CP-H oxidation by the above-mentioned oxidizing radicals. It could be clearly shown that *OH as well as ROO* induce CP-H oxidation. The intensity of the ESR signal (*CP) depends on the concentration of the applied oxidant. In a further set of in vitro experiments we analyzed some factors influencing the stability of the generated *CP. Cellular reductants are able to interact with many radicals whereby their paramagnetic signal intensity decreases. We could show that glutathione (GSH) up to 5 mM does not influence *CP concentration. On the other hand, ascorbate at a concentration of 0.6 mM significantly reduces 55% of *CP within 60 min to the ESR-silent CP-H. At 1 mM ascorbate the *CP derived ESR signal is reduced within 60 min by 90%. Lower concentrations of ascorbate (0.1-0.3 mM) do not significantly decrease signal intensity within 1 h. Homogenization of ischemic rat kidney in the presence of an air-equilibrated buffer obviously induces the formation of oxidizing radicals which in turn are able to convert diamagnetic CP-H into paramagnetic *CP. The intensity of the formed *CP was analyzed in a 600 g supernatant with ESR spectroscopy at 25 degrees C. It could be demonstrated that at least 3.0 +/- 0.5 microM *CP is formed 15 min after starting tissue homogenization and reoxygenation. Subsequent measurements of the *CP concentration indicated that its signal intensity continuously decreases. After 75 min a residual *CP concentration of 0.7 +/- 0.3 microM was monitored. Removal of mitochondria from the homogenate by centrifugation at 6,000g decelerates the disappearance of *CP but does not block it completely. In summary it could be shown that the marker (CP-H) is able to indicate the formation of oxidizing radicals during reoxygenation of ischemic tissue. This method underestimates the amount of produced oxidizing radicals. One reason for this is the reduction of *CP by some cellular reductants. Other reasons will be discussed. We assume that the used method allows a nearly real-time determination of radical production during organ reoxygenation.

[PSA--Quo vadis?]. / PSA--Quo vadis?

Prostate cancer is the most frequent cancer in males. Because of the high cure rates, early detection of prostate cancer should identify organ-confined prostate cancers. An early detection examination should be performed annually starting at the age of 50 years and ending when life expectancy is less than 10 years. Digital rectal examination is supplemented by determination of prostate-specific antigen (PSA). Before the first PSA test, the patient must be informed of possible consequences such as biopsy recommendation and treatment options. A threshold of 4 ng/ml is defined as the indication for prostate biopsy. Imaging methods do not play a major role in early detection of prostate cancer today. Early detection identifies many latent prostate cancers, and patients may receive overtreatment. A possible solution is to change the early detection paradigm from detection of all prostate cancers to identification of aggressive ones. In this article, early detection is discussed based on the recent literature.

[Vaginal pelvic repair. Always with mesh or not?]. / Vaginaler Beckenbodenrepair. Immer mit Netz?

Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

Transperitoneal, hand-assisted laparoscopic donor nephrectomy: surveillance of renal function by immune monitoring.

UNLABELLED: The history of living donor nephrectomy has undergone several development phases with respect to medical, immunologic, and operative aspects. Due to the shortage of postmortem organ donations and the rising number of patients with terminal renal insufficiency who are awaiting kidney transplantation, living kidney donation has become increasingly important during recent years. METHODS: From December 2004 to May 2005, we performed hand-assisted laparoscopic donor nephrectomies on 15 female and 9 male patients of median age 37 years. Our immunosuppressive regimen included tacrolimus, mycophenolate mofetil, methylprednisolone, and a monoclonal antibody. RESULTS: The median operative time was 138 minutes (113-180 minutes), and the median warm ischemia time was 87 seconds (63-150 seconds); results comparable to those of open donor nephrectomy. The hospitalization periods of the donors were between 5 and 7 days. The renal function and acute-phase parameters showed a transient increase during and after the operation. Most of the patients reached baseline levels by postoperative day 3 or 4. CONCLUSION: Together with the clinical data, these findings confirmed the efficacy and minimal invasiveness of laparoscopic donor nephrectomy. It is thus possible that in the future this operative method will become the procedure of choice.

Formation of ascorbate radicals as a measure of oxidative stress: an in vitro electron spin resonance-study using 2,2-Azobis (2-amidinopropane) dihydrochloride as a radical generator.

Reactive oxygen species (ROS) are continuously formed in biological systems. Any increase in radical production or decrease in the defense against ROS induces oxidative stress. This imbalance between ROS formation and ROS detoxification is believed to be involved in a variety of pathogenic processes, including ischemia-reperfusion injury. Various markers indicating oxidative stress has been used in experimental and clinical studies. One of them is ascorbate free radical (AFR), electron spin resonance intensity of which correlates with the severity of radical formation. We investigated the impact of alkyl peroxyl radicals produced by 2,2-Azobis (2-amidinopropane) dihydrochloride decomposition on the magnitude of the AFR signal. Our data confirmed the principal applicability of AFR as a nontoxic marker of radical generation.

Diagnostics and therapy of lymphoceles after kidney transplantation.

Lymphocele incidence after kidney transplantation is as high as 18%. We retrospectively studied the therapy of 42 lymphoceles that occurred in our clinic between 1990 and 2005, focusing on possible predisposing factors for their formation and the results of several therapy variants: conservative, operative, percutaneous puncture, and laparoscopic or open marsupialization. There was no connection between lymphocele formation and the following parameters: the extent to which the iliac vessels had been prepared, the materials used for the preparation, or whether clips or ligatures were applied. Lymphoceles may originate either from the lymphatic system of the recipient or the transplanted kidney. The most sensible measures to prevent their occurrence therefore seems to be to restrict the transplant bed to the smallest permissible level with careful ligature of the lymphatic vessels in the area of the kidney hilus. Treatment for lymphoceles should start with minimally invasive measures. We use the following algorithm in our clinic: puncture to differentiate between urinoma/lymphocele and to test for bacterial infection, sclerotization (200 mg doxycyclin), and finally marsupialization if persistent. The choice of operative technique depends on the location. This algorithm resulted in a relapse rate of 9.5% during the postoperative observation period of up to 15 years.

Use of catheters with the AgION antimicrobial system in kidney transplant recipients to reduce infection risk.

Microbial blood infection represents a high risk for immuno-suppressed patients. Of all catheter-related infections in the bloodstream, 90% result from the use of central venous catheters, the main cause being microbial colonization at the catheter's insertion point or the catheter hub. Between January 2003 and December 2004, 102 patients received a renal transplant including 57 who received a triple-lumen central venous catheter (CVC) during the procedure. Two catheters were used: a standard polyurethane catheter placed in the jugular veina or the subclavian veina for group I, and polyurethane catheters with the AgION antimicrobial system always placed in the subclavian veina for group II. Care and maintenance of the CVCs was standardized in both groups. After catheter removal, the tips were analyzed microbiologically. Of 57 (43.9%) CVCs, 25 were found to be contaminated. In the first group 24 out of 41 CVCs (58.5%) showed bacterial growth, whereas in group II only one catheter (6.6%) had a biofilm. The most common contaminant (18 out of 25, 72%) was Staphylococcus epidermidis. In group II, two patients had positive blood cultures yet a microbiologically sterile CVC. None of the catheters with the AgION antimicrobial system had to be removed owing to local infection or intolerance. The continuous release of silver ions increases the protection against bacteria and fungi during the entire time of catheterization. Use of catheters with the AgION antimicrobial system lead to a marked reduction in catheter-associated infections of the bloodstream.

Subcutaneous penile vein thrombosis (Penile Mondor's Disease): pathogenesis, diagnosis, and therapy.

OBJECTIVES: In international studies, only a few data are available on subcutaneous penile vein thrombosis. The pathogenesis is unknown, and no general recommendation exists regarding therapy. METHODS: A total of 25 patients with the clinical picture of a "superficial penile vein thrombosis" were treated at our policlinic. All patients had noted sudden and almost painless indurations on the penile dorsal surface. The extent of the thrombosis varied. Detailed anamnesis, ultrasonography, and routine laboratory tests were performed for all patients, knowing that primary therapy was conservative. RESULTS: No patient indicated any pain. Some reported a feeling of tension in the area of the thrombosis. In all patients, the thrombosis occurred in the dorsal penis shaft. It was close to the sulcus coronarius in 21 patients, near the penis root in 3, and in the entire penis shaft in 1 patient. The length of the thrombotic vein was between 2 and 4 cm. The ultrasound results were similar for all patients. The primary treatment was conservative for all patients. Recovery was achieved in more than 92% of cases (23 of 25 patients) using conservative therapy, which consisted of local dressing with heparin ointment (10,000 IU) and oral application of an antiphlogistic for 14 days. In 2 cases, thrombectomy was necessary. CONCLUSIONS: Extended imaging diagnosis does not improve the evaluation of the extent of a superficial penile vein thrombosis. Conservative primary therapy consisting of heparin ointment and oral application of antiphlogistics is sufficient. If the thrombosis persists after conservative therapy, surgery is indicated.

[Diagnostics and treatment of prostate cancer after kidney transplantation]. / Diagnostik und Therapie des Prostatakarzinoms nach Nierentransplantation.

The number of patients with prostate cancer and end-stage renal disease or prostate cancer following kidney transplantation has continuously increased in industrialized countries. According to the data generated by Penn et al. a higher incidence of prostate cancer following kidney transplantation can be seen but is probably due to a more intense screening of the recipients. It is rather a common opinion that no elevated risk of prostate cancer following kidney transplantation exists. In patients with strictly localized prostate cancer curative treatment should be the aim also after kidney transplantation. Kidney transplantation does not interfere with surgical access to the prostate gland (retropubic or perineal). Nonlocal tumors of the prostate should also be treated following the general recommendations regarding prostate cancer. Looking at the current literature, a reduction or change of immunosuppression seems reasonable. It is necessary to establish a nationwide (or even European) cancer register, especially for patients before and after transplantation.

[Questionnaire on crossover renal transplantations in Germany]. / Umfrage zur Uberkreuznierentransplantation in Deutschland.

Due to increasingly better long-term survival rates with dialysis the number of patients with renal failure constantly increases by 4% annually worldwide. Despite great progress in operative and perioperative management as well as improved immunosuppressive drugs, kidney transplantation still faces two major problems. First of all there is a huge deficit of donor organs and secondly the long-term results of the kidney grafts must be improved. One way to relieve this tense situation may be live kidney donation. In many countries not participating in Eurotransplant, especially the United States and Scandinavia, live kidney donation is performed more often than kidney transplantation from deceased donors. Germany implemented a transplantation law in December 1997. This law also regulates living donation, with exclusion of crossover transplantations. Cross-over transplantation is a special variation of live donation for couples who cannot donate/receive in their respective couple constellation. Therefore, the donor of the one couple donates his/her kidney to the recipient of the other couple and vice versa. According to German legislation this is illegal. We performed a study in order to evaluate the opinions of the German kidney transplant centers on crossover kidney transplantations. The majority of the German transplantation centers believe that crossover transplantation is acceptable with regard to ethical and medical concerns. To enable this kind of kidney transplantation the transplantation law would have to be changed. Nevertheless, nationwide polls show that live kidney donation represents only a very small portion of all transplantations taking place. Live kidney donation should be granted higher priority as dialysis triggers psychological and physical damage, especially in children. For many patients live kidney donation is the only chance for early transplantation with an excellent long-lasting kidney graft function.

The use of complexed PSA for the early detection of prostate cancer.

UNLABELLED: The advent of complexed PSA (cPSA) raised great expectations concerning the role of this parameter for improving the early detection of prostate cancer. MATERIALS AND METHODS: Total PSA (tPSA), free PSA (fPSA) and cPSA were evaluated from the serum of 178 of our clinic's patients (74 patients with prostate carcinoma, 104 patients with benign prostate illness) prior to prostate histology. ROC curves were calculated for all of these parameters as well as for the ratios fit-PSA, c/t-PSA and f/c-PSA. RESULTS: The ROC analysis for the whole examined PSA area and PSA levels of 4 to 10 ng/ml showed a statistically significant difference between the AUCs of the ratios on the one hand and the cPSA and tPSA parameters on the other hand. However, there was no difference between these parameters in PSA levels of up to 6 ng/ml. In the comparison of specificities at PSA levels of 4 to 10 ng/ml, the best results were achieved for the c/tPSA ratio. Neither in the PSA level area between 4 and 10 nglml, nor in the whole examined PSA area, could a difference between the cPSA and tPSA parameters be detected. CONCLUSION: Firm conclusions regarding low PSA concentrations cannot be drawn because of the small number of cases included in our study. However, 5 out of 13 patients with prostate carcinoma, whose tPSA values were still in the employed method's reference area, would have been identified as carcinoma-suspicious and brought to further diagnosis by determining the cPSA value with a recommended cut-off of 2.5 ng/ml.

PSA quick test in capillary blood.

UNLABELLED: The use of PSA quick testing methods with capillary blood (test strips) to screen for carcinoma of the prostate has been a controversial method. MATERIALS AND METHODS: The results determined visually from whole capillary blood were compared with the PSA values obtained from serum through quantitative assay and their correspondence was evaluated. PSA values <4 ng/ml obtained through quantitative assay were regarded and as negative results and PSA > or = 4 ng/ml as positive results. RESULTS: Of 371 usable assays, 100 quantitatively obtained PSA values were positive and 271 negative. Seven test strips showed false-negative and 49 false-positive results. In comparison with the quantitative assay, this is equivalent to a sensitivity of 93% and a specificity of 82%. Comparing the distinction between PSA >4 and <4 ng/ml only, there was no significant difference between the results of the quick test and the quantitative assay (Fischer exact test, p < 0.000). Considering the PSA values between 4 and 10 ng/ml, 10.3% of the results of both methods differed. CONCLUSION: Our series of experiments ascertained a relatively high rate of false-positive PSA test strip results. In practice this can lead to an unpredictable increase of costs, as every positive result requires a quantitative assay. Even more alarming is the loss of sensitivity in the PSA "between 4 and 10 ng/ml" range, which gives false-negative results leading to a delay of diagnosis and therapy.