Georg Bartsch

THE FEMALE URETHRAL SPHINCTER: A MORPHOLOGICAL AND TOPOGRAPHICAL STUDY

PURPOSE We reassess the anatomy and topography of the female urethral sphincter system and its innervation in regard to urethra sparing anterior exenteration and other surgical procedures. MATERIALS AND METHODS Anatomical and histological studies were performed on 9 fetal specimens and 4 adult cadavers. Using graphics software the anatomical structures of the true pelvis were reconstructed based on computerized tomography cross sections and digitized histological sections. On the adult cadavers anterior exenteration was performed to study the implications of the isolated urethra and its sphincter mechanism. RESULTS Strata of connective tissue were found to divide the smooth muscles of the proximal two-thirds of the female urethra into 3 layers. Computer guided 3-dimensional reconstruction of digitized histological sections showed that thin fibers of the pelvic plexus course to this part of the urethra. The majority of these fibers may be preserved by carefully dissecting the bladder neck and the proximal portion of the urethra, leaving the lateral vaginal walls intact. The striated rhabdosphincter, which is innervated by fibers of the pudendal nerve, was in the caudal third of the urethra. CONCLUSIONS A well-defined sphincteric structure or sphincter could not be anatomically recognized in the bladder neck region. The majority of rhabdosphincter fibers were found in the middle and caudal thirds of the urethra. Thus, in patients undergoing removal of the bladder neck and part of the proximal portion of the urethra continence can be maintained by the remaining urethral sphincter system, provided that innervation remains essentially intact.

Oncological Followup After Radical Cystectomy for Bladder Cancer—Is There Any Benefit?

PURPOSE Tumor recurrence after radical cystectomy for bladder cancer can be detected in an asymptomatic patient by regular followup or in a symptomatic patient by symptom guided examination. To our knowledge it is still unknown whether detecting tumor recurrence at an asymptomatic stage offers a better survival rate. MATERIALS AND METHODS A total of 1,270 radical cystectomies for bladder cancer were performed at a single institution between January 1, 1986 and December 2006. All patients had regular followup examinations with chest x-ray and abdominal ultrasound every 3 months, computerized tomography of the abdomen every 6 months, and bone scan and excretory urography every 12 months. Additional examinations were required for symptomatic disease. We analyzed the first site and date of tumor recurrence. Survival was compared using the log rank test. RESULTS The 20-year recurrence rate was 48.6% in the complete series. Tumor recurrence developed in 444 patients, including 154 asymptomatic and 290 symptomatic patients, with a mean time after radical cystectomy of 20 and 17.5 months, respectively. The most frequent symptoms were pain, ileus, acute urinary retention, hydronephrosis with flank pain, hematuria, neurological symptoms and a palpable mass. Of the 444 patients 182 (41%) had local recurrence and 324 (73%) had distant failure at the time of first recurrence. The overall survival rate 1, 2 and 5 years after first recurrence was 22.5%, 10.1% and 5.5% in asymptomatic patients, and 18.9%, 8.2% and 2.9% in symptomatic patients, respectively (log rank not significant). CONCLUSIONS This study fails to demonstrate a survival benefit for detecting tumor recurrence early at an asymptomatic stage by regular followup examinations. These data show that symptom guided followup examinations may provide similar results at lower cost.

Effect of a pT0 cystectomy specimen without neoadjuvant therapy on survival

In some cases of radical cystectomy for bladder cancer, no residual tumor is found in the cystectomy specimen (the pT0 classification). The aim of this study was to evaluate the outcome of such patients in a large cystectomy series.

Changing diagnostic and therapeutic concepts in high-flow priapism

High-flow priapism (HFP) is defined as pathological increased arterial influx into the cavernosal bodies. Since 1960, 202 cases have been published in the literature. This study evaluates the effect of the changing diagnostic and therapeutic concepts. The data of 202 cases of HFP was evaluated regarding diagnostic and therapeutic procedures and long-term results. Success was defined as restored erectile function without recurrent priapism. The major etiology of HFP is trauma, especially in children or young adults; in older men, HFP is a rare event mainly caused by malignoma. Cavernosal blood-gas analysis, color-Doppler ultrasound and angiography were the most effective diagnostic tools to distinguish high- from low-flow priapism. The success rate was 20% for shunt operations and 89% for arterial embolization. In conclusion, embolization was effective in the majority of cases of traumatic HFP, while shunt surgery remained disappointing. For HFP caused by inherited diseases and malignoma conservative therapy is mandatory.

Expression of transforming growth factors beta-1, beta 2 and beta 3 in human bladder carcinomas

We previously detected elevated transforming growth factor beta-1 (TGF-beta1) serum levels in patients with invasive bladder carcinomas. In this study, we therefore investigated whether elevated serum levels correlate with enhanced TGF-beta expression in human bladder tumours. mRNA levels of TGF-beta1, -beta2 and -beta3 were reduced in bladder tumour tissue to 86%, 68% and 56%, respectively, of the levels in normal urothelium. On the other hand, TGF-beta1 protein levels were found to be higher in superficial tumours (Ta-T1) (mean level of 0.153 ng mg(-1)) and in invasive T2/T3 tumours (mean level of 0.104 ng mg(-1)) compared with normal urothelium (mean level of 0.065 ng mg(-1)). Invasive T4 tumours, however, contained only low amounts of TGF-beta1 (mean level of 0.02 ng mg(-1)). Neither in mean nor in individual patients were serum and tissue TGF-beta levels correlated with each other. Cell culture experiments on primary bladder cells revealed a 57% decrease in TGF-beta1 mRNA levels in tumour compared with normal epithelial cells. Tumour epithelial cells contained about two times higher levels of TGF-beta2 and TGF-beta3 mRNA than normal epithelial cells. Fibroblasts expressed about the same amount of TGF-beta1 or TGF-beta2 as epithelial cells. Yet, fibroblasts released only 19% and 13% of the amount secreted by tumour epithelial cells into the supernatant. TGF-beta3, on the other hand, was expressed by fibroblasts with higher levels than by epithelial cells. TGF-beta1 was the predominent isoform in bladder tissue and cells at protein as well as on mRNA levels indicating that TGFs-beta2 and -beta3 are of minor importance in bladder cancer. In summary, there is a lack of correlation between TGF-beta serum levels and TGF-beta expression in tumour tissue in bladder cancer.

Intensifying the saturation biopsy technique for detecting prostate cancer after previous negative biopsies: a step in the wrong direction.

To report the results using an extensive saturation biopsy in men with negative prostate biopsies but in whom there is still a clinical suspicion for carcinoma.

Incidence of urethral tumor involvement in 910 men with bladder cancer

SummaryUrethral tumor involvement was examined in 910 patients treated for bladder cancer at a single institution over a period of 25 years. The overall incidence in 2,052 primary and recurrent bladder-tumor events was 6.1%. Risk factors for urethral tumor occurrence are tumors at the bladder neck and recurrent multifocal tumors. Carcinoma in situ (CIS) of the bladder not involving the bladder neck and muscle-invasive tumors with or without lymph-node involvement are not significantly correlated with urethral cancer. Patients at risk for urethral tumors as outlined should be worked up very carefully (multiple urethral biopsies and/or urethral brushings, frozen section of the membranous urethra) before they are considered for an orthotopic neobladder. Altogether, 17 of 89 patients had 1–6 urethral tumor recurrences. The majority of urethral tumors were treated with a single conservative treatment session and did not recur thereafter. A conservative approach toward superficial urethral tumor recurrences in patients with an orthotopic neobladder to the urethra may therefore be feasible.

Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap.

&NA; This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so‐formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder‐like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder‐like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap. (Plast. Reconstr. Surg. 100: 402, 1997.)

Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp.

To report a laparoscopic device that facilitates regional ischaemia in laparoscopic partial nephrectomy (LPN).

Influence of nitrate levels in drinking water on urological malignancies: a community-based cohort study.

To evaluate the effect of nitrate levels in the drinking water on the incidence of urological malignancies in a German community.