C. Hampel

Definition of overactive bladder and epidemiology of urinary incontinence

OBJECTIVES To review the definition of the overactive bladder and to summarize the results of epidemiologic studies on this specific disorder as well as urinary incontinence (UI) in general. METHODS From a literature search covering the time period from 1954 through 1995, 48 epidemiologic studies and several other publications dealing with the prevalence and natural history of UI were reviewed. A meta-analysis of reported data was performed with respect to incontinence definitions, investigation methods, home country of survey, sex, and age groups. RESULTS Differences in definitions of incontinence, target populations, and study design in different investigations resulted in inhomogeneity and difficulties of comparing the available data. By grouping the studies with respect to similarities in the above-mentioned criteria and analyzing the results for each group of studies, an attempt was made to understand the great variation of reported results. Differences in prevalence of incontinence were identified for all examined groups of studies and for distinct ethnic populations. Scarce information about incidence, spontaneous remission rates, and risk factors was used to elucidate the natural history of UI in women and men. CONCLUSIONS Although generally accepted definitions of the overactive bladder specifically and UI in general are highly desirable, they have not yet been established. Such definitions should comprise aspects of severity and demonstrability of the condition, bother factor, and impact on quality of life. Moreover, basic requirements for epidemiologic surveys of incontinence, such as validation of questionnaire results, need to be defined and standardized to create a sensible basis for useful epidemiologic studies in the future.

EAU guidelines on urinary incontinence

CONTEXT The first European Association of Urology (EAU) guidelines on incontinence were published in 2001. These guidelines were periodically updated in past years. OBJECTIVE The aim of this paper is to present a summary of the 2009 update of the EAU guidelines on urinary incontinence (UI). EVIDENCE ACQUISITION The EAU working panel was part of the 4th International Consultation on Incontinence (ICI) and, with permission of the ICI, extracted the relevant data. The methodology of the 4th ICI was a comprehensive literature review by international experts and consensus formation. In addition, level of evidence was rated according to a modified Oxford system and grades of recommendation were given accordingly. EVIDENCE SUMMARY A full version of the EAU guidelines on urinary incontinence is available as a printed document (extended and short form) and as a CD-ROM from the EAU office or online from the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/). The extent and invasiveness of assessment of UI depends on severity and/or complexity of symptoms and clinical signs and is different for men, women, frail older persons, children, and patients with neuropathy. At the level of initial management, basic diagnostic tests are applied to exclude an underlying disease or condition such as urinary tract infection. Treatment is mostly conservative (lifestyle interventions, physiotherapy, physical therapy, pharmacotherapy) and is of an empirical nature. At the level of specialised management (when primary therapy failed, diagnosis is unclear, or symptoms and/or signs are complex/severe), more elaborate assessment is generally required, including imaging, endoscopy, and urodynamics. Treatment options include invasive interventions and surgery. CONCLUSIONS Treatment options for UI are rapidly expanding. These EAU guidelines provide ratings of the evidence (guided by evidence-based medicine) and graded recommendations for the appropriate assessment and according treatment options and put them into clinical perspective.

Modulation of bladder α1-adrenergic receptor subtype expression by bladder outlet obstruction

Purpose: α1-Adrenergic receptor (α1AR) antagonists are effective for relieving obstructive and irritative symptoms in patients with bladder outlet obstruction. While the α1aAR is responsible for prostate smooth muscle relaxation and outlet obstruction relief, to our knowledge the mechanisms underlying the relief of irritative symptoms remain to be determined. Therefore, we investigated mechanisms by which bladder α1AR subtypes may be involved in this process.Materials and Methods: We studied 42 rats, including 6 unoperated controls, 17 sham operated controls and 19 obstructed animals. Animals were characterized for baseline voiding pattern, followed by surgical intervention or sham surgery to establish obstruction (1.09 mm. restricted opening). After 6 weeks to enable the development of detrusor hypertrophy, voiding behavior was reexamined, the animals were sacrificed and bladder tissue was immediately placed in liquid nitrogen. α1AR subtype messenger (m)RNA was quantitated using quantitative competitive ...

Nephron Sparing Surgery for Renal Cell Carcinoma With Normal Contralateral Kidney: 25 Years of Experience

PURPOSE We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979. MATERIALS AND METHODS A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression. RESULTS Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively. CONCLUSIONS The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.

Cancer‐specific survival after radical cystectomy and standardized extended lymphadenectomy for node‐positive bladder cancer: prediction by lymph node positivity and density

To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer‐specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN‐positive bladder cancer.

Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up

OBJECTIVES To assess the therapeutic value of left renal vein transposition for treatment of the nutcracker phenomenon in long-term follow-up. METHODS Eight patients (4 women and 4 men) between 23 and 58 years old (mean 39.1) underwent transposition of the left renal vein for treatment of the nutcracker phenomenon associated with recurrent gross hematuria and flank pain. The postoperative follow-up was 41 to 136 months (mean 66.4). RESULTS No perioperative complications were encountered. The postoperative complications comprised deep vein thrombosis (n = 1), retroperitoneal hematoma necessitating surgical revision (n = 1), and paralytic ileus that resolved with conservative management (n = 1). One patient underwent laparotomy for treatment of mechanical ileus due to adhesions 4 years after the initial surgery. In 7 of 8 patients, transposition of the left renal vein efficiently relieved the symptoms related to the nutcracker phenomenon. In 1 patient, the hematuria persisted despite postoperative normalization of the pressure gradient between the left renal vein and the inferior vena cava. CONCLUSIONS Transposition of the left renal vein is an efficient surgical approach for the treatment of the nutcracker phenomenon and is associated with an acceptable risk of complications. However, rare cases may be encountered in which the shunted connections between the renal veins and the collecting system are so matured that, despite removal of the obstruction of the renal venous backflow, gross hematuria may persist.

Chronic sacral neuromodulation for treatment of neurogenic bladder dysfunction: long-term results with unilateral implants

OBJECTIVES To investigate the therapeutic value of sacral neuromodulation in patients with neurogenic disorders in whom conservative treatment options were unsuccessful. Neurogenic disorders may result in various forms of lower urinary tract dysfunction. METHODS Twenty-seven patients (19 women, 8 men) aged 18 to 63 years (mean 44.9 years) were subjected to percutaneous test stimulation of the sacral spinal nerves. Their urologic symptoms consisted of bladder storage failure (n = 15) due to detrusor hyperreflexia and/or bladder hypersensitivity, failure to empty due to detrusor areflexia (n = 11), and combined bladder hypersensitivity and detrusor areflexia (n = 1). Twelve patients (11 women and 1 man) underwent chronic sacral neuromodulation with unilateral electrode implantation into one of the dorsal S3 foramina. The follow-up was 89.3 months (range 13 to 126). RESULTS Severe side effects were encountered in 2 patients (1 with infection and 1 with adverse sensation during stimulation) and moderate side effects in another 3 patients. In 1 patient, the implant had to be removed during the immediate postoperative period. In 3 patients, the implant was not effective. In 8 patients, the symptoms of lower urinary tract dysfunction were significantly attenuated (50% or more) for 54 months (range 11 to 96). After this period, all implants became ineffective, except one, which was still in use at the last follow-up visit. CONCLUSIONS Unilateral chronic sacral neuromodulation using sacral foramen electrodes can be a valuable, but only temporary, treatment for neurogenic bladder dysfunction. The technique of chronic sacral neuromodulation should be refined to achieve the same and lasting results with implantation systems as achieved with preoperative test stimulation.

Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical Prostatectomy

PURPOSE Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience. MATERIALS AND METHODS From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy. RESULTS Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3). CONCLUSIONS The therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.

Short-Term Functional and Oncologic Outcomes of Nephron-Sparing Surgery for Renal Tumours ≥7 cm

BACKGROUND Nephron-sparing surgery (NSS) for renal tumours preserves renal function and has become the standard approach for small renal tumours. Little is known about perioperative and oncologic outcomes of patients following NSS in renal tumours ≥ 7 cm in the presence of a healthy contralateral kidney. OBJECTIVE To analyse oncologic outcomes and perioperative morbidity in patients treated by NSS for renal tumours ≥ 7 cm. DESIGN, SETTING, AND PARTICIPANTS In total, 5767 patients were treated for renal tumours at two institutions from 1984 to 2009. In 91 patients, elective NSS was performed for renal tumours ≥ 7 cm. MEASUREMENTS Complication rates were assessed in detail and stratified using the Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Logistic regression analysis was used to identify clinical risk factors for complications and prognosticators that have an oncologic impact on OS. RESULTS AND LIMITATIONS The median follow-up was 28 mo (range: 1-247 mo). Twenty-seven patients (29.6%) had perioperative complications and, of these, 89.1% had CDS grade 1 and 2. Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%) died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFS were 88% and 64%, 97% and 83%, and 91% and 78%, respectively. None of the analysed parameters had an impact on morbidity or OS in the univariate analysis. Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome. CONCLUSIONS NSS for renal tumours ≥ 7 cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies. Our findings support NSS whenever technically feasible to reduce the loss of renal function.

Single Center Comparison of Anastomotic Strictures After Radical Perineal and Radical Retropubic Prostatectomy

OBJECTIVES To analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors. METHODS Between 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for AS formation. RESULTS The rate of AS after RPP and RRP was 3.8% (33/863) and 5.5% (113/2048), respectively (P = .067). In multivariate analysis, RRP was a statistically significant risk factor for AS (P = .0002). On survival analysis, the incidence of AS was lower for RPP as compared with RRP at median follow-up (P = .0229). Primary response to endoscopic AS incision or resection was 94% (31/33) and 72.6% (82/113) after RPP and RRP, respectively. On multivariate logistic regression analysis biopsy Gleason score, previous transurethral resection of the prostate, prostate volume, pathologic tumor stage and grade, transfusion requirement, AUR, and surgical technique were independent risk factors for the development of AS. An AS developed in 45.4% (20/44) and 10.9% (5/46) of the postoperative AUR cases treated with a suprapubic cystostomy tube and a transurethral Foley catheter, respectively (P <.05). CONCLUSIONS ASs occur more frequently after RRP in comparison with RPP. Primary endoscopic AS incision or resection are both highly successful. Treating postoperative AUR with a suprapubic cystostomy poses a high risk for AS formation and should be avoided.