What was hot at ICS 2016?

The 46th annual conference of the International Continence Society was held in Tokyo, Japan, between September 13th and 16th, 2016. In this article, we present selected highlights of the broad range of excellent research presented by colleagues from around the world from a variety of areas of continence research, from cellular models to population-based epidemiological studies.

Prospective evaluation of a hydrogel spacer for rectal separation in dose-escalated intensity-modulated radiotherapy for clinically localized prostate cancer.

BACKGROUND: As dose-escalation in prostate cancer radiotherapy improves cure rates, a major concern is rectal toxicity. We prospectively assessed an innovative approach of hydrogel injection between prostate and rectum to reduce the radiation dose to the rectum and thus side effects in dose-escalated prostate radiotherapy. METHODS: Acute toxicity and planning parameters were prospectively evaluated in patients with T1-2 N0 M0 prostate cancer receiving dose-escalated radiotherapy after injection of a hydrogel spacer. Before and after hydrogel injection, we performed MRI scans for anatomical assessment of rectal separation. Radiotherapy was planned and administered to 78 Gy in 39 fractions. RESULTS: From eleven patients scheduled for spacer injection the procedure could be performed in ten. In one patient hydrodissection of the Denonvillier space was not possible. Radiation treatment planning showed low rectal doses despite dose-escalation to the target. In accordance with this, acute rectal toxicity was mild without grade 2 events and there was complete resolution within four to twelve weeks. CONCLUSIONS: This prospective study suggests that hydrogel injection is feasible and may prevent rectal toxicity in dose-escalated radiotherapy of prostate cancer. Further evaluation is necessary including the definition of patients who might benefit from this approach. TRIAL REGISTRATION: German Clinical Trials Register DRKS00003273.

Anterior urethral reconstruction using the circular fasciocutaneous flap technique: long-term follow-up.

PURPOSE: The circular fasciocutaneous skin flap technique (FCF) yields excellent short-term results for complex anterior urethral reconstruction. We performed an observational retrospective and descriptive study to report our long-term experience. METHODS: A total of 36 adults with anterior urethral strictures (AUS) exceeding 3 cm underwent single-stage urethroplasty using the FCF. Exclusion criteria were: lichen sclerosus, absence of the urethral plate and hypospadias. All had a minimum follow-up of 7 years. Mean age was 49.7 years. Radiological work-up was supplemented by urethral ultrasound showing a mean stricture length of 5.9 cm. A circumferential island of distal penile skin was mobilized on a vascularized pedicle and used for urethral reconstruction. Tube repairs were not included. Outcome was considered a failure when post-operative instrumentation was needed. The Mann-Whitney U test was used for statistical analysis. RESULTS: Mean follow-up was 96.7 months (86-117). All received a ventral onlay repair secondary to stricturotomy. Complication rate was 8.3% (3/36): A flimsy stricture at the proximal anastomotic site occurred in 1 requiring optical urethrotomy. In 2 patients, glans dehiscence was noted. No penile skin necrosis was observed proximal to the flap-harvesting site. We did not observe neurovascular lower extremity complications. Long-term success rates exceeded 90%. CONCLUSIONS: FCF-urethroplasty yields excellent long-term results with no late stricture recurrence. All complications occurred early after surgery underlining the durability of pedicled genital skin flaps. Despite extensive stricture, disease complication rates and morbidity were low. In case of paucity of local skin or lichen scleroses, oral grafts are required for optimal treatment.

Efficacy, tolerability and safety of propiverine hydrochloride in comparison to oxybutynin in children with urge incontinence due to overactive bladder: Results of a multicentre observational cohort study.

OBJECTIVE: To compare, in a retrospective observational cohort study, the efficacy, tolerability and safety of propiverine and oxybutynin in children with urge incontinence (UI) due to overactive bladder. PATIENTS AND METHODS: Medical records were scrutinized for children with UI. As a primary efficacy outcome variable the achievement of continence after treatment with variable doses of propiverine or oxybutynin was assessed. Weekly UI episodes and daily voiding frequency were evaluated as secondary efficacy outcomes. Tolerability was evaluated by the rate of adverse events, adverse drug reactions caused by antimuscarinics and premature treatment termination. RESULTS: At 16 study centres, 621 children aged 5-14 years with UI due to overactive bladder were enrolled. After anticholinergic treatment (437 propiverine, 184 oxybutynin) continence was achieved in 61.6% and 58.7% of the patients after 186 and 259 days, respectively. There were clinically relevant improvements in voiding frequency across treatment groups. Daily doses of propiverine were markedly below the recommendations (0.54 vs 0.8 mg/kg body weight), daily doses of oxybutynin were according to the recommendations (0.31 vs 0.2-0.4 mg/kg body weight) at treatment initiation. There was a significantly more favourable tolerability to propiverine than oxybutynin for the overall rate of adverse events (3.9% vs 16.3%, odds ratio 4.813), adverse drug reactions caused by propiverine or oxybutynin (2.8% vs 9.2%) and premature treatment termination due to adverse drug reactions (1.6% vs 4.4%). CONCLUSION: Propiverine and oxybutynin are effective in children with UI due to overactive bladder. Sufficient treatment periods of at least 2, preferably 3-4, months are the crucial factors for a successful treatment. The tolerability profile of propiverine is better than for oxybutynin.

Objective long-term evaluation after distal hypospadias repair using the meatal mobilization technique.

OBJECTIVE: Meatal mobilization (MEMO) by distal urethral preparation has been demonstrated to be an efficient surgical technique for the correction of distal hypospadias offering excellent short-term success rates. This study objectively evaluates individual patient satisfaction using a validated score in the long term. MATERIAL AND METHODS: A total of 218 patients who underwent hypospadias repair using the MEMO technique was identified. Of these, 104 (mean age at time of surgery 4.9 years, range 2-28 years) had a minimum follow-up of 5 years and were eligible for the study. They were investigated by physical examination and self-assessment. An objective evaluation using the validated Hypospadias Objective Scoring Evaluation (HOSE) was done in all patients. RESULTS: Mean follow-up was 6.3 (range 5-8) years. Ninety-nine patients participated in the investigation, an overall survey response rate of 95.2%. One urethrocutaneous fistula occurred, but no cases of stenosis were noted. One patient developed a mild penile deviation during the postoperative follow-up. Ninety-three out of 99 patients reached the maximum of 16 points (median 15, range 12-16) on the HOSE symptom score. CONCLUSION: The MEMO technique demonstrates a surgical success rate of 97% after 2 years. Even in the long-term follow-up of a mean 6.3 years objective outcome data and individual patient satisfaction were excellent. MEMO is a reliable and versatile method for distal hypospadias repair, as reflected by high patient satisfaction.

Failure of monotherapy in primary monosymptomatic enuresis: a combined desmopressin and propiverine treatment regimen improves efficacy outcomes.

OBJECTIVE: To evaluate, in a prospective study, the combination of the antimuscarinic propiverine and the antidiuretic hormone-agonist desmopressin in children and adolescents not responsive to previous monotherapy, as in primary monosymptomatic enuresis (PME), combined treatments are considered a second-line approach after the failure of monotherapy. PATIENTS AND METHODS: The study included 122 children and adolescents (mean age 10.8 years, range 5-21) with PME and so far unresponsive to single or multiple monotherapy. Propiverine (body weight <30 kg, 15 mg/day; >or=30 kg, 20 mg/day) and desmopressin (0.4 mg/night) were administered over 3 months, followed by successive structured withdrawal programmes for propiverine and desmopressin, depending on the amount of loss of urine at night before treatment. RESULTS: The re-evaluation of unresponsive patients, incorporating video-urodynamics, showed neurogenic detrusor overactivity, isolated detrusor sphincter dyssynergia and vesicorenal reflux in 12.3% (15/122) of patients, so far falsely treated as enuresis. In 107 of 122 patients the diagnosis of PME was confirmed. The primary efficacy outcome, continence at night, was achieved in 104 of 107 patients (97.2%). During the individual follow-up periods (3-12 months), 23 of 107 (21.5%) patients relapsed after withdrawal of both medications. Adverse events of moderate intensity were rare (3.7%). CONCLUSION: Re-evaluation of patients after monotherapy has failed is justified, because other entities can be discovered in patients so far treated unsuccessfully for enuresis. The combination of propiverine and desmopressin is highly effective in children with PME. Our results support the case for further optimizing the inaugurated treatment algorithm of PME for treatment duration, dose-titration and structured withdrawal programmes, thus possibly further decreasing relapse rates.

Ejaculation-preserving transurethral resection of prostate and bladder neck: short- and long-term results of a new innovative resection technique.

INTRODUCTION: Loss of antegrade ejaculation is a risk with conventional resection of the prostate (transurethral resection of the prostate [TURP]). The aim of this study was to determine the short- and long-term preservation of antegrade ejaculation and functional results with the novel ejaculation-preserving TURP (epTURP). PATIENTS AND METHODS: Prospective evaluation of 89 consecutive patients with bladder outlet obstructions aged 27 to 78 years, enrolled from June 2001 to January 2005. Endpoints were change in objective (uroflowmetry, postvoid residual [PVR]), and subjective (International Prostate Symptoms Score [IPSS], Life Quality Index [LQI]; International Index of Erectile Function-5 [IIEF-5+] with two additional questions) measures of function. All patients received follow-up examinations at 3 and ≥60 months. RESULTS: Overall, 87 and 63 patients were evaluated after 3 and 60 months, respectively. Antegrade ejaculation was preserved in 79 of 87 (90.8%) patients at 3 months. Significant improvements in maximum flow rate (+14.3 mL/s), micturition volume (+71.6 mL), and PVR (-59 mL; p≤0.002 for all) were observed at 3 months. Micturition symptoms, as measured by IPSS and LQI, were also significantly reduced (mean change of 18.3 and 2.9, respectively; p<0.001). Improvements were maintained at 60 months. No serious adverse events were reported. Eight (12.7%) patients received a second epTURP due to the development of bladder neck scar tissue during long-term follow-up. CONCLUSION: Antegrade ejaculation was preserved with the use of epTURP with excellent outcome. Observed symptomatic and functional outcomes were comparable with conventional TURP. The results from this study underline the necessity of reviewing the old concept of ejaculation physiology.

Upper urinary tract laparoendoscopic single-site surgery based on a novel cost-effective reusable platform.

BACKGROUND AND PURPOSE: Several disposable platforms have been introduced for laparoendoscopic single-site (LESS) surgery. Besides technical issues, cost is one of the main limiting factors for their widespread use. We present our experience with LESS surgery for kidney pathologies using the first completely reusable LESS platform. PATIENTS AND METHODS: We performed LESS kidney procedures in 29 patients including nephrectomy (18), partial nephrectomy (3), pyeloplasty (4), and renal cyst ablation (4). All procedures were performed using a completely reusable single-port device (X-Cone) with a simplified combination of standard and prebent instruments. We obtained perioperative and demographic data including a visual analog pain scale (VAS); complications were recorded using Clavien grading. RESULTS: Mean patient age was 49.31 years. Conversion to standard laparoscopy was necessary in one and addition of a needlescopic instrument in four cases. No open conversion was necessary. Intra- and postoperative complications occurred in two (Clavien II) cases. Mean operative time was 110, 90, and 89 minutes, and hospital stay was 4.9, 3.1, and 3.6 days for nephrectomy, partial nephrectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.67, and 1.5 while blood loss was 81.3 mL, 140 mL, and 17.5 mL, respectively. There were no positive resection margins. CONCLUSIONS: LESS with a completely reusable platform is feasible for different upper urinary tract procedures yielding favorable functional and cosmetic results. A simplified combination of standard straight instruments and a single prebent grasper facilitates handling and shortens the learning curve. Reusable materials significantly reduce cost and may help to further adopt LESS surgery in surgical practice.

Endoscopic inguinofemoral lymphadenectomy--extended follow-up.

BACKGROUND AND PURPOSE: Inguinofemoral lymphadenectomy (IFLA) is a standard procedure for cancer of the external genitalia. Open lymphadenectomy (O-IFLA) exhibits complication rates of more than 50%. We are demonstrating our extended experience with a modified endoscopic approach (E-IFLA) for groin lymphadenectomy. PATIENTS AND METHODS: Patients with nonpalpable as well as those with palpable nodes who had IFLA were identified. O-IFLA comprised both superficial and deep inguinal lymph node dissection. E-IFLA was performed using a three-trocar approach in the same field. We used a reduced CO2-pressure of <5 mm Hg. A suction drain was always placed. Perioperative data and postoperative outcomes were systematically assessed followed by statistical analysis. RESULTS: We performed 62 IFLAs in 42 patients. Twenty-eight procedures were completed endoscopically. Follow-up was 55.8 months (2-87 mos). Mean operative time for O-IFLA was 101.7 minutes (38-195 min), being shorter than for E-IFLA (136.3 min, 87-186 min), P<0.001. Both groups are comparable regarding the number of nodes (O-IFLA 7.2, 2-16 vs E-IFLA 7.1, 4-13) as well as with regard to the number of positive nodes (O-IFLA 1.8 vs E-IFLA 1.6). Secondary wound healing and leg edema were extremely rare events (1/28) after E-IFLA. The overall complication rate was 7.1%. Complications appeared in 55.3% of the O-IFLA-cases. There were no problems related to CO2 insufflation. Local recurrence rates were identical in both groups. CONCLUSIONS: O-IFLA and E-IFLA are efficient with respect to oncologic safety. E-IFLA is technically more challenging. E-IFLA can avoid secondary wound healing and lymphatic complications. E-IFLA is a safe procedure while a reduction of CO2 pressures optimizes the safety profile. Because cancer control rates remained equivalent during an extended follow-up, oncologic durability could be confirmed.

Single-stage dorsal inlay full-thickness genital skin grafts for hypospadias reoperations: extended follow up.

PURPOSE: To report our extended experience with single-stage genital skin graft urethroplasty for complex hypospadias reoperations. MATERIALS AND METHODS: Thirty-one patients with failed hypospadias surgery were included. The urethral plate had been removed or was scarred in all. After excision of fibrotic tissue a free full-thickness skin graft was quilted to the corpora cavernosa. The neourethra was then tubularized followed by glanuloplasty. Voiding cystograms, urethral ultrasound and flow measurements were performed in all. Outcome was considered a failure when postoperative instrumentation was needed. RESULTS: Follow up was 78.45 +/- 18.18 months. Shaft skin was used in 13 and internal prepuce in 18. Average graft length was 3.66 +/-1.56cm. Eighteen patients required glanuloplasty. Initial graft healing was successful in all. There was no postoperative infection involving the inlay. We did not note complications from the graft donor sites. Four patients underwent redo surgery yielding a complication rate of 12.9%. Urethral stricture of the proximal anastomosis was most frequent. CONCLUSIONS: This single-stage approach using dorsal inlay skin grafts is reliable, creating a substitute urethral plate in the long term. Complication rates are equivalent to those of staged strategies. This is a safe option for hypospadias reoperations if the urethral plate is compromised.

Urethral ultrasound as a screening tool for stricture recurrence after oral mucosa graft urethroplasty.

OBJECTIVE: To evaluate the efficacy of sonourethrography (SUG) in combination with voiding pattern analysis to determine success after oral mucosa graft (OMG) urethroplasty. OMG urethroplasty is a standard treatment for men with recurrent urethral stricture. Because of its performance, the optimum follow-up algorithm remains controversial. MATERIAL AND METHODS: Forty-nine patients (mean age 51 years) who underwent OMG urethroplasty were retrospectively identified. All men were subjected to a validated voiding questionnaire (International Prostate Symptom Score [IPSS]), SUG, uroflowmetry, and residual urine measurement. The predictive value was analyzed with regard to stricture recurrence or patency as well as to urethral diameter. Retrograde urethrography was done to confirm the diagnosis. RESULTS: Strictures were bulbar in 39, penile in 4, and combined in 6 patients. Mean stricture length was 3.8 cm (range 1-10). Mean follow-up after surgery was 35 (range 15-70) months. SUG showed a mean diameter of 7.6 mm for bulbar grafts and 4.6 mm for penile grafts. Stricture recurrence was seen in 4 (8%) patients, yielding a significantly lower urethral width of 2.3 mm (P<.005). Retrograde urethrography confirmed the patency status in all. The average maximum flow rate after successful repair was 36.6 mL/s, whereas those with recurrent strictures showed rates of 11.2 (P<.03). Similar results were achieved for residual urine (P<.05). IPSS values increased from 5.1 to 12.5 in patients with recurrence (P<.01). CONCLUSION: An algorithm consisting of SUG, uroflowmetry, residual urine and IPSS assessment reliably identifies stricture recurrence. Routine retrograde urethrography may therefore be unnecessary in the follow-up of OMG urethroplasty.

Long-term results after endoscopic VUR-treatment using dextranomer / hyaluronic acid copolymer - 5-year experience in a single-center.

BACKGROUND: A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present our long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux(®)) for VUR treatment in children. PATIENTS AND METHODS: Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux(®) in 30 ureters as an outpatient procedure. Twelve children had unilateral reflux (2 duplicated systems) and nine had bilateral reflux. Median age was 5-years (6-months to 14.9-years). Six weeks postoperatively, a voiding cystourethrogram was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) in the long-term follow-up as well as QoL (questionnaire of the parents). RESULTS: No intra- or postoperative complications had been noticed. In 25 ureters (83%), VCUG showed no VUR 6-weeks postoperatively. Three children received a 2nd injection (two successful). After a median follow-up of 2.5 years, 27 ureters in 17 children (90%) had no urinary tract infection and VUR. The questionnaire results in regard to quality of life (QoL) were very good in the successfully treated children and the parents would choose the same treatment option again. CONCLUSION: Subureteral injection of Deflux(®) for children with VUR is an effective treatment option with a low complication rate.

Dorsal onlay skin graft urethroplasty in patients older than 65 years.

OBJECTIVES: Single-stage dorsal onlay graft urethroplasty is effective for anterior urethral reconstruction. Despite an aging population, the results of this technique in elderly patients have not yet been explicitly reported. We present our experience with dorsal onlay graft urethroplasty in this cohort. METHODS: We reviewed all urethroplasties performed on males older than 65 years with at least 6 months follow-up. All exhibited extensive anterior urethral strictures precluding anastomotic urethroplasty. Dorsal onlay skin graft urethroplasty was done after stricturotomy using either penile or groin skin grafts. The neourethra was then tubularized in a single stage. Pre- and postoperative urethrograms, urethral ultrasound, and flow measurements were performed in all. RESULTS: Forty-two men (mean age 69.25 years) underwent dorsal onlay urethroplasty. Mean graft length was 5.35 cm (range, 3-12). Penile skin was used in 29 and groin skin in 13. Average follow-up was 57.17 months (range, 29-82). Complications occurred in 4 (9.5%), including fistula formation and stricture recurrence. Final success rate was 90.5%. Compared with patients younger than 65 years, there were slightly more failures. Despite prolonged lithotomy position, we did not observe neurovascular lower extremity injuries. Perioperative complications were uncommon. CONCLUSIONS: Dorsal onlay skin graft urethroplasty can be reliably used in older men with extensive urethral strictures. Although recurrence rates seem to be slightly higher, urethroplasty is generally well tolerated in this cohort of patients. Given the favorable outcome of the dorsal onlay technique, urethral reconstruction should not be withheld solely on the basis of age. Regarding the lifelong benefits of repair, the increased complication rates appear negligible.