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.

[Immunomodulatory treatment approaches for prostate cancer]. / Immunmodulatorische Therapieansätze beim Prostatakarzinom.

During the last 10 years different strategies for immunotherapy of prostate cancer have been investigated. These included unspecific and specific strategies to modulate or stimulate the immune system. For unspecific immunotherapy of prostate cancer innate humoral or cellular immune mechanisms are being stimulated, which are not specific to malignant cells. The global stimulation of the innate immune system is supposed to augment the immune reaction to prostate cancer by initiating an inflammatory reaction or other existing immune mechanisms. The main mediators and effectors of the unspecific immune system include humoral factors such as cytokines, complement system, and acute phase proteins and cellular components such as neutrophils, macrophages/monocytes, mast cells, and natural killer cells.In contrast, specific immunotherapy aims at adaptive immunity. This portion of the immune system can be amplified and thus specifically target tumor cells. Generation of a tumor-specific T cell reaction by vaccination or application of antibodies are the most promising approaches of specific immunotherapy. In a PubMed-based search of the current literature, publications regarding immunotherapy of prostate cancer were identified. The present article focuses on publications presenting clinical studies which investigate immunomodulatory treatments of prostate cancer. The results of these publications are described and discussed.

[LHRH analogues for the treatment of prostate cancer: an evidence level-based analysis]. / LHRH-Analoga zur Androgendeprivation beim Prostatakarzinom. Eine Evidenzlevelanalyse.

In this review the current indications and the options for LHRH analogues are elucidated. For this purpose, a literature search in PubMed and the Cochrane-Database was performed. In addition, the EAU and AUA guidelines as well as actual meeting abstracts up to 2008 were taken into account. Since the first prospective study in 1991 showed the same effectivity for LHRH analogues and orchiectomy in metastasised prostate cancer patients, the use of LHRH analogues increased thereafter. Testosterone levels do not need to be checked regularly, but rather only when PSA rises again under treatment. After cessation of LHRH analogue treatment the time to testosterone level recovery is longer when the treatment time was longer. One must especially recognise the risks of diabetes and osteoporosis after more than 3 years of LHRH analogue treatment. In the case of neoadjuvant and adjuvant LHRH analogue treatment, several points have to be taken into consideration: LHRH analogues before radical prostatectomy lead to a lower positive margin rate and lower rate of lymph node metastasis, but tumour-specific survival is not improved. In contrast, neoadjuvant LHRH analogue treatment before radiation therapy leads to better tumour-specific and overall survival. An increased cardiovascular toxicity was not observed. Intermittent androgen ablation has been proved to be equivalent with a reduction of side effects. Hormonal salvage therapy should be initiated when the PSA doubling time is short or the PSA velocity is > 2 ng / mL / year. The benefit of early initiation (PSA < 10 ng / mL, PSA doubling time < 12 months) is that it can prolong the metastasis-free survival time.

[Kidney injuries]. / Nierentrauma.

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70-80%. Long-term consequences can be hypertension or diminished kidney function.

[Kidney trauma]. / Nierentrauma.

Most renal injuries in industrialized countries are caused by blunt trauma to the kidney. The management of renal trauma has always been and will always be controversial. Conservative management and aggressive intervention both have their proponents, but conservative treatment is generally favored nowadays, even in the case of grade IV/(V) trauma. Urinary diversion by nephrostomy tube or ureteral stenting is not mandatory in most cases because the extravasation resolves in up to 90% of cases. Overall, there is a tendency toward a multimodal approach in which the interventional radiologist is more and more often part of the team that takes care of the patient with high-grade injuries. The success rate of angioembolization is 70-80%. Long-term consequences can be hypertension or diminished kidney function.

[Advances in the staging of renal cell carcinoma with high-resolution imaging]. / Fortschritte im Staging des Nierenzellkarzinoms mittels hochauflösender Bildgebung.

Modern imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) allow high-resolution imaging of the abdomen. Modern scanners made high temporal as well as high spatial resolution available. Therapeutic approaches to the treatment of renal cell carcinoma have been improved over the recent years. Besides conventional and open laparoscopic tumor nephrectomy and nephron sparing, surgical approaches such as local tumor cryotherapy and radiofrequency ablation (RF) are ablative modalities and are used increasingly. Improved anesthesiological methods and new surgical approaches also allow curative treatment in extended tumors. Prerequisites for preoperative imaging modalities include visualization of the kidney tumor as well as its staging. Tumor-related infiltration of the renal pelvis or invasion of the perinephric fat and the renal hilus has to be excluded prior to nephron sparing surgery. In cases with extended tumors with infiltration of the inferior vena cava, it is necessary to visualize the exact extension of the tumor growth towards the right atrium in the vena cava. The radiologist should be informed about the diagnostic possibilities and limitations of the imaging modalities of CT and MRI in order to support the urologist in the planning and performance of surgical therapeutical approaches.

Corticosteroid-induced chemotherapy resistance in urological cancers.

PURPOSE: Glucocorticoids such as dexamethasone are widely used for medication of urological diseases, e.g., as cotreatment of advanced prostate cancer, to improve appetite, weight loss, fatigue, relieve bone pain, diminish ureteric obstruction, to reduce the production of adrenal androgens, as an antiemetic in patients undergoing chemo- and/or radiotherapy together with serving as "standard" therapy arm in randomized studies. While the potent pro-apoptotic properties and the supportive effects of glucocorticoids to tumor therapy in lymphoid cells are well studied, the impact to growth of prostate and other urological carcinomas is unknown. METHODS: We isolated cells from surgical resections of 21 prostate tumors and measured apoptosis and viability in these primary cells and 17 established cell lines from human prostate, bladder, renal cell and testicular carcinomas. RESULTS: We found that dexamethasone induces resistance regarding exposure to several cytotoxic agents such as taxol, gemcitabine, cisplatin, 5-FU and gamma-irradiation in 86% of the freshly isolated prostate tumors and in 100% of the established urological cell lines. No difference in dexamethasone-mediated protection was found in normal, benign and malignant prostate tumors. CONCLUSIONS: These data show for the first time that dexamethasone induced therapy resistance in urological carcinomas is not the exception but a more common phenomenon and implicate that glucocorticoids may have two faces in cancer therapy, a beneficial and a dangerous one.

[Vesicovaginal fistulas]. / Vesikovaginale Fisteln. Diagnostik und Therapie.

Vesicovaginal fistulas are often the result of obstetric trauma in third world countries or gynaecologic surgery in developed countries. The incidence of obstetric trauma is approximately 3-4/1000 births in West Africa. The incidence of fistulas as a result of surgery has remained relatively unchanged for years; 75% occur during gynaecologic procedures. The main clinical symptom of a vesicovaginal fistula is urine loss. Different surgical techniques with similar repair results are available: transvaginal approach, transvesical approach and transperitoneal approach. Irrespective of the approach used, requirements for successful repair include adequate surgical exposure, wide mobilization of the bladder and vagina, excision of the fistula tract, tension-free closure of the bladder and vagina, and placement of an interposition flap, i.e. Martius flap, omentum, peritoneum, when indicated. Using these surgical techniques, around 85% of women can be cured from their vesicovaginal fistula with a single operation.

[Does a Combined Fascial Sling - Burch Colposuspension Display Advantages over a Fascial Sling alone for Treatment of Urinary Stress Incontinence in Females?]. / Bringt die Kombination einer Faszienzügelplastik mit der Kolposuspension nach Burch in der Therapie der weiblichen Stressinkontinenz Vorteile gegenüber der alleinigen Faszienzügelplastik?

PURPOSE: Despite the development of new surgical techniques, the fascial sling procedure remains an important surgical technique for the treatment of female urinary stress incontinence. An advantage of combining it with an additional Burch colposuspension has been suggested. The objective of our study was to evaluate retrospectively selected patients who had undergone a fascial sling procedure with and without Burch colposuspension. MATERIALS AND METHODS: Of a total of 390 females who underwent an incontinence operation at our department between 1990 and 1999, 56 patients had had a fascial sling plasty. A total of 50 patients (89 %) were followed for a median of 59.5 months. The median age was 60 years. 56 % of the patients displayed recurrent stress incontinence. The previous operations had been performed via a vaginal approach in 42.9 % and an abdominal approach in 57.1 %. The sling procedure used was that of Narik and Palmrich. Of the 50 patients, 14 had an additional Burch colposuspension. RESULTS: The continence rates (no pads) were for patients with a fascial sling procedure alone 63.9 % and for the combination of both operations 64.4 %. An improvement (1-3 pads) was seen in 27.8 % and 21.4 %, respectively. No changes were seen in 5.6 % and 7.1 % and impairment was seen in 2.7 % and 7.1 %, respectively. After a five-year follow-up, the total patient satisfaction rate was 78 %. CONCLUSIONS: The fascial sling is effective operative technique for treating female urinary stress incontinence, especially in severe and type III incontinence and in patients who had undergone previous operations for incontinence. The operation is safe and is the only technique that offers controlled overcorrection in desperate cases. An advantage of adding a Burch colposuspension to the fascial sling procedure was not detected in our patient group.

Sacral bladder denervation for treatment of detrusor hyperreflexia and autonomic dysreflexia.

OBJECTIVES: Detrusor hyperreflexia after spinal cord injury may cause urinary incontinence and chronic renal failure. In patients refractory to conservative treatment and not eligible for ventral sacral root stimulation for electrically induced micturition, we investigated the therapeutic value of sacral bladder denervation as a stand-alone procedure. METHODS: Nine patients (8 men and 1 woman) between 21 and 58 years old (mean 30.2) with traumatic suprasacral spinal cord lesions underwent sacral bladder denervation for treatment of detrusor hyperreflexia and/or autonomic dysreflexia. RESULTS: Detrusor hyperreflexia and autonomic dysreflexia were eliminated in all cases. Bladder capacity increased from 177.8 +/- 39.6 to 668.9 +/- 64.3 mL; intravesical pressure decreased from 89.3 +/- 19.1 to 20.2 +/- 2.7 cm H(2)O. For facilitating clean intermittent catheterization (CIC), 4 patients received a continent vesicostomy in a second-stage procedure; one of them in combination with bladder augmentation. Four patients empty their bladder by way of urethral CIC. One completely tetraplegic patient has an indwelling urethral catheter. In the 5 patients with autonomic dysreflexia, the systolic blood pressure was lowered from 196 +/- 16.9 to 124 +/- 9.3 mm Hg and the diastolic blood pressure from 114 +/- 5.1 to 76 +/- 5.1. The annual frequency of urinary tract infections decreased from 9 +/- 1.2 to 1.8 +/- 0.7. In all patients, renal function remained stable. CONCLUSIONS: In selected patients with detrusor hyperreflexia and/or autonomic dysreflexia, sacral bladder denervation is a valuable treatment option. It is only moderately invasive in nature, requires neither sophisticated nor expensive medical equipment, and is an attractive alternative to urinary diversion using intestinal segments.

Orthotopic bladder augmentation and substitution.

Orthotopic bladder augmentation or substitution using intestinal segments has become a standard procedure for many disorders that cause a loss of functional or anatomical bladder capacity. From the technical point of view, reservoir configuration by detubularizing the intestinal segments is the general practice. Various techniques exist, depending which types of segments and which techniques of ureteral implantation are used. Common problems include urinary incontinence, retention, metabolic disorders, and the possibility of secondary malignancies. As a result, research has been conducted into utilizing tissues other than intestine for bladder augmentation or substitution.

Surgery for local recurrence or distant metastases in patients aged 75 years or older.

Between 1982 and 1997, a total of 105 patients aged 75 years or older (median age 78 years) underwent surgical treatment for recurrent solid tumours. The most frequent primary tumours were melanoma, colorectal carcinoma and breast cancer. Sixty-one patients had complete removal of recurrent tumour. Post-operative mortality was 3.8% (four of 105 patients). The median hospital stay was 16 days and the post-operative hospital stay was 10 days. At a median follow-up of 57 months, 77 patients had died. Twenty one patients died of causes unrelated to the tumour. The overall survival of 105 patients was 35% at 3 years and 27% at 5 years. Following R0 resection, 5-year survival was 43%, (n = 61) and in the absence of post-operative complications even reached 50% (n = 47). Survival correlated with completeness of tumour resection (P<0.0001) and post-operative complications (P=0.021). No significant correlation could be established between survival and age, ASA score, blood replacement, primary tumour location or sex. Elderly patients presenting with recurrent tumour should be evaluated for surgical resection. If tumour removal is complete and post-operative complications are avoided, a 5-year survival rate of over 40% may be expected.