C. Seif

Effect of subthalamic deep brain stimulation on the function of the urinary bladder

Detrusor hyperreflexia is a relevant clinical symptom for patients suffering from Parkinsons disease. In a series of 16 patients, we demonstrated that subthalamic deep brain stimulation has a significant and urodynamically recordable effect leading to a normalization of pathologically increased bladder sensibility.

Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy.

PURPOSE The exact process and time required for rehabilitation of erectile function after nerve sparing prostatectomy remain unclear to date. Different theories of the pathophysiology of postoperative erectile dysfunction are currently being discussed. In a prospective study we performed recordings of nocturnal penile tumescence and rigidity during the acute phase after nerve sparing radical prostatectomy, ie in the first night after removal of the catheter, to assess the organic penile integrity. MATERIALS AND METHODS In 27 patients with local prostate carcinoma who had been sexually active before the intervention, we performed unilateral or bilateral nerve sparing radical prostatectomy. Preoperative sexual function of all patients was evaluated by the International Index of Erectile Function-5 questionnaire. On the day of catheter removal (postoperative day 7 to 14) an NPTR recording was performed on the following night with an erectometer (RigiScan). RESULTS All patients had a preoperative IIEF score greater than 18. After removal of the catheter 25 of 27 patients (93%) showed 1 to 5 nocturnal rigidity increases by greater than 70% for at least 10 minutes. In a control group of 4 patients who underwent radical prostatectomy without nerve sparing, no nocturnal erections were recorded. CONCLUSIONS NPTR recording during the acute phase after nerve sparing radical prostatectomy showed residual erectile function as early as the first night after catheter removal. These results are significant for selecting adequate pharmacological treatment for optimal therapy and rehabilitation of satisfactory erections and sexual function. In cases of early nocturnal tumescence, application of a PDE5 inhibitor can support successive organ rehabilitation. However, if tumescence does not occur, penile injection therapy is recommended.

Priapism: etiology, pathophysiology and management

The understanding of erectile physiology has improved the prompt diagnosis and treatment of priapism. Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation and failure to subside despite orgasm. Numerous etiologies of this condition are considered. Among others a disturbed detumescence mechanism, which may due to excess release of contractile neurotransmitters, obstruction of draining venules, malfunction of the intrinsic detumescence mechanism or prolonged relaxation of intracavernosal smooth muscle are postulated. Treatment of priapism varies from a conservative medical to a drastic surgical approach. Two main types of priapism; veno-occlusive low flow (ischemic) and arterial high flow (non-ischemic), must be distinguished to choose the correct treatment option for each type. Patient history, physical examination, penile hemodynamics and corporeal metabolic blood quality provides distinction between a static or dynamic pathology. Priapism can be treated effectively with intracavernous vasoconstrictive agents or surgical shunting. Alternative options, such as intracavernous injection of methylene blue (MB) or selective penile arterial embolization (SPEA), for the management of high and low flow priapism are described and a survey on current treatment modalities is given.

Treatment of penile curvature with Essed-Schröder tunical plication: aspects of quality of life from the patients' perspective

To investigate retrospectively the long‐term functional results and quality of life of patients undergoing the Essed‐Schröder procedure (a simple plication of the tunica albuginea) to correct penile deviation, using a standardized questionnaire.

Male genital injury: diagnostics and treatment

This article reviews the current status of information on external male genital injuries, focusing on cause, diagnostic and therapeutic management of this uncommon entity. Because of the high risk of infection and the major importance of preserving fertility, male genital injuries represent a serious urological disorder that demands immediate urological treatment. The diagnostic procedure classically consists of taking a history and inspecting the wound; this provides enough diagnostic information for the correct choice of conservative or surgical treatment. In most cases open injuries of the genitalia require surgical exploration to determine the extent of possible scrotal, testicular, epididymal, cavernosal or urethral damage, to debride nonviable superficial or deep tissue, to drain existing haematomas or to control active bleeding. Furthermore, the correct therapeutic approach is crucial for preserving fertility and penile erection. In cases where bilateral ablation is necessary, measures to preserve sperm, e.g. testicular or microsurgical sperm extraction, or squeezing the ductus during orchidectomy, must be considered.

Unilateral vs bilateral sacral neuromodulation in pigs with formalin-induced detrusor hyperactivity

To investigate the efficacy of unilateral vs bilateral sacral neuromodulation (SNM) under standard experimental conditions by stimulating the dorsal sacral roots in pigs with formalin‐induced detrusor hyperactivity.

Penile Carcinoma (pT1 G2): Surveillance or Inguinal Lymph Node Dissection?

Background: Due to the low incidence of squamous cell penile cancer and lack of well-designed studies, controversies persist over the therapeutic approach in patients with pT1 G2 carcinoma. Patients and Methods: Between 1992 and 2003, 16 patients with T1 squamous penile cancer were treated in our institution either by surveillance or by inguinal lymph node dissection (ILND). Results: A total of 8 primary lesions were classified as pT1 G2 carcinoma with 4 tumors developing early or delayed inguinal metastatic disease. Conclusions: The natural behavior of pT1 G2 squamous penile carcinoma and its metastatic potential has been underestimated in recent literature. Since morbidity after early ILND has markedly decreased and its superiority over delayed ILND has been shown, we advocate the early modified inguinal lymph node dissection until strong prognostic factors for positive inguinal lymph nodes have been validated.

Penile fractures: controversy over surgical or conservative treatment.

Patients typically present with complaints of a classic ‘cracking’ sound, sharp penile pain, rapid detumescence and swelling with or without ecchymosis of the penile shaft. The penis may be bent as well as having ecchymosis confined to Buck’s fascia, resulting in massive oedema. Additionally, injured fascial compartments will lead to an extension of the ecchymosis into the scrotum, perineum, the suprapubic area and the inguinal regions [7]. The massive swelling will involve lateral penile deviation in the direction of the unaffected penile side [1,2,10], except for the rare case of a bilateral rupture, which will lead to dorsal or ventral deviation [15]. Sometimes there is a palpable defect in the tunica.

Findings with Bilateral Sacral Neurostimulation: Sixty-two PNE-Tests in Patients with Neurogenic and Idiopathic Bladder Dysfunctions.

We performed bilateral PNE (peripheral nerve evaluation) tests to identify which diagnostic groups are the most likely to profit from bilateral sacral neuromodulation since the results published so far have been obtained exclusively on the basis of unilateral sacral root stimulation. In contrast to the original unilateral technique, we performed bilateral PNE test stimulation in 62 patients (36 with urinary retention symptoms and 26 with overactive detrusor; 21 with idiopathic and 41 with neurogenic bladder dysfunction) over 3–4 days. We used an advanced electrode, model #3057 (Medtronic, Inc. Minneapolis, MN). The stimulation amplitudes were adjusted individually for each side. Retrospectively, we analyzed our data according to diagnostic characteristics (retention vs. overactive bladder and neurogenic vs. idiopathic) of those patients who had positive PNE test results. The PNE test was successful in 32 patients (51.6%). Of these, 27 suffered from neurogenic bladder dysfunction; in five cases the cause was idiopathic. We conclude that bilateral PNE test stimulation with side‐specific amplitude adjustment and the use of advanced PNE electrodes led to a positive PNE result in 51.6% of the patients, which is a substantially increased response rate compared to previous studies. Of the diagnostics groups, the group with neurogenic bladder dysfunctions showed the highest response rate.

Chronische sakrale bilaterale Neuromodulation Einsatz einer minimalinvasiven Implantationstechnik bei Patienten mit Blasenfunktionsstörungen

ZusammenfassungIn der Literatur werden die Misserfolgsraten mit der von Tanagho und Schmidt beschriebenen unilateralen Stimulation mit bis zu 50% angegeben. Zur Verbesserung der Modulationseffektivität und besseren Elektrodenplatzierung und Fixation führen wir eine minimale sakrale Laminektomie mit bilateraler Elektrodenplatzierung durch.Bei insgesamt 20 Patienten wurde nach erfolgreichem PNE-Test (periphere Nervenevaluierung) ein sakraler Neuromodulator mit bilateraler Elektrodenplatzierung implantiert. Zur besseren Elektrodenplatzierung und Fixierung wurde eine minimal-invasive Laminektomie durchgeführt.Bei den Patienten mit Detrusorinstabilität reduzierten sich die Inkontinenzepisoden von durschnittlich 7,2 auf 1 pro Tag, die Blasenkapazität stieg von 198 auf 352 ml. Bei den Patienten mit hypokontraktilem Detrusor reduzierten sich die Restharnwerte von 450 auf 108 ml. Der maximale Detrusorkontraktionsdruck während der Miktion stieg von 12 auf 34 cm H2O.Mit der bilateralen sakralen Neuromodulation und mit der von uns entwickelten Implantationstechnik sind optimale Ergebnisse bei Patienten mit therapierefraktären Detrusorinstabilitäten und Patienten mit hypokontraktilem Detrusor zu erzielen.AbstractThe implantable neuromodulation system described by Tanagho and Schmidt enables unilateral sacral nerve stimulation. Reports have been made on sacral neuromodulation failures of up to 50% in patients undergoing this procedure. We chose the bilateral electrode implantation and a minimal invasive laminectomy to ensure a more effective modulation and better placement and fixation of the electrodes.After successful assessment using a peripheral nerve evaluation test, 20 patients (14 with detrusor instability, 6 with hypocontractile detrusor) underwent minimally invasive laminectomy and bilateral electrode placement. In the patients with detrusor instability, the incontinence episodes were reduced from 7.2 to 1 per day and the bladder capacity improved from 198 to 352 ml. In patients with hypocontractile detrusor, the initial residual urine level of 450 ml dropped to 108 ml. Maximum detrusor pressure during micturition rose from 12 cmH2O initially to 34 cmH2O. The average follow up period was 17.5 months. There was no sign of deterioration in the modulation effect in any of the patients.Bilateral electrode implantation and the new sacral approach allow optimal neuromodulation in patients with bladder dysfunction. Laminectomy enables optimum electrode placement and fixation with minimal trauma.