Margit Mayer

Prospective Evaluation of the Functional Sling Suspension for Male Postprostatectomy Stress Urinary Incontinence: Results after 1 Year

BACKGROUND Although surgical techniques for radical prostatectomy (RP) have been refined significantly, a significant number of patients still suffer from persisting postprostatectomy stress urinary incontinence (SUI). In recent years, various minimally invasive sling systems have been investigated as treatment options for such incontinence. OBJECTIVE The aim of the study was the prospective evaluation of the efficacy of the retrourethral transobturator sling for the functional treatment of male SUI after RP. DESIGN, SETTING, AND PARTICIPANTS The study documents a single-centre prospective evaluation of the outcome of 124 patients with mild to severe SUI following RP in whom an AdVance sling was implanted between February 2006 and September 2008. MEASUREMENTS All patients were comprehensively evaluated preoperatively and after 6 mo and 1 yr regarding daily pad use, 1-h and 24-h pad tests, residual urine, uroflowmetry, Incontinence Quality of Life Scale (I-QOL) score, and Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) score. Data were collected prospectively. RESULTS AND LIMITATIONS After 6 mo, a cure rate (no pads or one dry security pad) of 55.8%, an improved rate (one to two pads or pad reduction≥50%) of 27.4%, and a failure rate of 16.8% were observed. After 1 yr, the cure rate was 51.4%, the improved rate was 25.7%, and the failure rate was 22.9%. Daily pad use and pad weight decreased significantly postoperatively. No significant changes were seen in residual urine and flow rate. Quality-of-life scores improved significantly. Postoperative acute urinary retention was seen in 12.9% of patients. One patient had a local wound infection that was cured with antibiotics. One patient had the sling removed due to misplacement. CONCLUSIONS The retrourethral transobturator sling is an effective and attractive treatment option for male SUI resulting from RP after 1 yr of implantation.

Patient-Reported Side Effects of Intradetrusor Botulinum Toxin Type A for Idiopathic Overactive Bladder Syndrome

Objective: The aim of the study was a prospective assessment of patient-reported side effects in an open-label study after intradetrusor botulinum toxin injections for idiopathic overactive bladder (OAB). Patients and Methods: Botulinum toxin A injection was performed in 56 patients with idiopathic OAB. Patients were followed up for 6 months concerning side effects and patients’ satisfaction. Results: Different types of side effects were assessed such as dry mouth (19.6%), arm weakness (8.9%), eyelid weakness (8.9%), leg weakness (7.1%), torso weakness (5.4%), impaired vision (5.4%) and dysphagia (5.4%). In all cases, symptoms were mild and transient. Urological complications such as gross hematuria (17.9%), acute urinary retention (8.9%) and acute urinary tract infection (7.1%) were noticed. In all cases, acute urinary retention was transient and treated with temporary intermittent self-catheterization. There was no statistically significant correlation between dosage and observed side effects. Patients’ satisfaction rate was high (71.4%). Conclusion: Intradetrusor injection of botulinum toxin was associated with a high rate of neurourological side effects. In general, side effects were transient, mild and did not require special treatment.

Phosphodiesterase inhibitors in female sexual dysfunction

Based on the increasing knowledge on both the physiology of penile erection and the pathophysiology of erectile dysfunction, selective phosphodiesterase (PDE) inhibitors have been successfully introduced in the oral treatment of male erectile dysfunction. Because of their central role in smooth muscle tone regulation, PDEs remain an attractive target for drug development in urology. Since the distribution and functional significance of PDE isoenzymes vary in different tissues, selective inhibitors of the isoenzymes have the potential to exert at least partially specific effects on the target tissue. Currently, PDE inhibitors are under investigation with potential uses in urinary stone disease, overactive bladder and the so-called benign prostatic syndrome. The convincing clinical data on the use of the orally active PDE5 inhibitors sildenafil (VIAGRA), vardenafil (LEVITRA) and tadalafil (CIALIS) in the treatment of erectile dysfunction are accompanied by boosting research activities on intracellular signal transduction and PDE characterisation in female genital tissues with the aid of immunohistochemistry and immunocytochemistry and molecular biology. The expression of various PDE isoforms in the human clitoris, vagina and labia minora was shown by means of immunohistochemistry and RT-PCR analyses and it was concluded from functional studies that an increase in cGMP or cAMP might be involved in the regulation of female genital blood flow and the control of genital non-vascular smooth muscle. As a consequence, the efficacy and safety of the PDE5 inhibitor sildenafil in the treatment of symptoms of female sexual dysfunction (FSD), including female sexual arousal disorders (FSAD), have been evaluated. Although the experiences from these early clinical studies have so far not been conclusive, they suggest that, after appropriate evaluation of patients, inhibition of PDE5 might be of benefit for selected individuals with FSAD. Such research efforts will possibly allow the identification of efficacious and diagnostic tools for erectile dysfunction and of even more selective drugs in its therapy.

The future of the oral pharmacotherapy of male erectile dysfunction: things to come

The convincing clinical data on the use of the orally active phosphodiesterase inhibitors sildenafil, vardenafil and tadalafil for the treatment of male erectile dysfunction have boosted research activities on the physiology of the male erectile mechanism. This included both peripheral intracellular signal transduction in the corpus cavernosum as well as central brain and spinal cord pathways controlling penile erection. This work provided the basis for the development and introduction of several new therapeutic modalities into the management of erectile dysfunction, some of which are already offered to the patients. As the concept of ‘taking a pill’ as a cure for an illness or the relief of symptoms of a disease has become widely accepted by the consumers, the pharmacologic treatment of erectile dysfunction has primarily focussed on selective, orally available drugs acting by influencing intracellular or central regulatory mechanisms, combining a high response rate and the advantage of an on-demand intake. These agents are regarded as more efficacious, and have a faster onset of drug action in the target tissue and an improved effect to side-effect ratio. The purpose of this review is to describe the major novel and evolving pharmacologic advances in the field of oral pharmacotherapy for the treatment of male erectile dysfunction.

Potential future options in the pharmacotherapy of female sexual dysfunction

Female sexual dysfunction (FSD) is considered a common medical problem estimated to affect millions of women in the westernized countries. FSD has been classified into four different categories including sexual arousal disorder (FSAD), sexual desire disorder (HSDD), orgasmic disorder and sexual pain disorder. The focus of this article is the potential role of pharmacological compounds currently under development, in the treatment of sexual arousal and orgasmic disorders in order to enhance the sexual response in adult females. While a number of potential therapeutic options are available to date, not one of the pharmacological treatment regimens has been yet considered the Gold standard in the management of symptoms of FSD. This article reviews the rationale and potential benefits of using distinct drug formulations in the treatment of FSD.

Female sexual dysfunction: what's new?

Purpose of review The aim of this article is to summarize the most important and interesting achievements which have recently been made in the field of female sexual dysfunction. Recent findings During the last years, the characterization of the female sexual response has been re-examined, resulting in new approaches to the description of female sexual dysfunction, diagnostic criteria and (pharmacological and nonpharmacological) treatment options. The focus of this review is to summarize in brief the latest achievements in the classification, diagnosis, and therapy of symptoms of sexual arousal and orgasmic disorders in adult females. Summary Future research efforts may provide new diagnostic and (pharmacological and nonpharmacological) treatment algorithms suitable for use in daily clinical practice to approach the different categories of female sexual dysfunction symptoms.

Distribution and functional significance of phosphodiesterase isoenzymes in the human lower urinary tract

To date, it is widely accepted that several disorders of the male and female urogenital tract, such as erectile dysfunction, bladder overactivity, urinary stone disease and the benign prostatic syndrome, can be therapeutically approached by influencing the function of the smooth musculature of the respective organs. In order to achieve a pronounced drug effect without significant adverse events, especially on the cardiovascular system, a certain degree of tissue selectivity is mandatory. Selective intervention in intracellular pathways regulating smooth muscle tone has become a promising strategy to modulate tissue function. Since the concept of taking a pill as a cure for an illness or the relief of symptoms has become widely accepted by the consumers, the pharmacological treatment of urological diseases has focused on selective, orally available drugs, acting via influencing intracellular regulatory mechanisms, thus combining a high response rate and the advantage of an on-demand intake. PDEs play a central role in controlling the levels of cyclic nucleotides (i.e. cAMP and/or cGMP), which are important second messengers in many transmitter pathways involved in the regulation of biological processes of urogenital tissues. Specifically, the use of isoenzyme selective phosphodiesterase (PDE) inhibitors offers great hope in the medical treatment of various genitourinary diseases. These agents are regarded efficacious, having a fast onset of drug action in the target tissue and an improved effect-to-side-effect ratio. The growing experience with the use of this class of compounds in urology is mainly based on basic research efforts and this field will remain the most exciting and innovative subject in genitourinary physiology and pharmacology for the next few years. These tremendous research efforts may lead to a vast pharmacological armamentarium of possible new treatment options. The purpose of this review is to summarize the current knowledge on the distribution and potential functional significance of PDE isoenzymes in the human lower urinary tract.

Belastungsinkontinenz nach radikaler Zystektomie

Stress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30-60% and is - despite a better understanding of the male (and female) pelvic anatomy - still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction. Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.ZusammenfassungDie Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Ileumneoblase stellt nach wie vor ein herausragendes Problem dar. Die Inzidenz einer Belastungsinkontinenz nach diesem Eingriff wird in der Literatur mit 30–60% angegeben und zählt – trotz eines besseren Verständnisses der männlichen und weiblichen Anatomie des Beckenbodens – zu den typischen Komplikationen dieses Eingriffs.Die Behandlungsmöglichkeiten sind bislang begrenzt und beinhalten verschiedene konservative (pharmakologisch, Beckenbodentraining) und/oder minimal-invasive Therapiemaßnahmen mit oftmals nur moderater Verbesserung der Symptome und nicht akzeptablen Nebenwirkungen. Die Lebensqualität wird jedoch ganz entscheidend von dem Wiedererlangen der Kontinenz beeinflusst.Im Rahmen dieser Kasuistik stellen wir erstmals die perineale Anlage der funktionellen retrourethralen Schlinge (AdVance) bei einem Patienten mit Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Neoblase (nach Hautmann) vor, die ihre Wirkung – im Gegensatz zu den anderen minimal-invasiven Verfahren – nichtobstruktiv entfaltet. Durch die Schlinge wird die veränderte Anatomie im Sinne gelockerter und deszendierter Haltestrukturen des Sphinkters nach radikaler Zystektomie korrigiert und in ihre ursprüngliche Position gebracht, so dass die Kontinenz wiedererlangt werden kann.Die Anwendung der retrourethralen Schlinge bei einem Patienten nach radikaler Zystektomie und Anlage einer (Ileum)neoblase ist bislang nicht publiziert worden, das hier vorgestellte Ergebnis bezüglich Kontinenz und Sicherheit scheint viel versprechend.AbstractStress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30–60% and is – despite a better understanding of the male (and female) pelvic anatomy – still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction.Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.

[Stress urinary incontinence after radical cystectomy: neobladder construction and placement of the functional retrourethral sling].

Stress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30-60% and is - despite a better understanding of the male (and female) pelvic anatomy - still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction. Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.ZusammenfassungDie Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Ileumneoblase stellt nach wie vor ein herausragendes Problem dar. Die Inzidenz einer Belastungsinkontinenz nach diesem Eingriff wird in der Literatur mit 30–60% angegeben und zählt – trotz eines besseren Verständnisses der männlichen und weiblichen Anatomie des Beckenbodens – zu den typischen Komplikationen dieses Eingriffs.Die Behandlungsmöglichkeiten sind bislang begrenzt und beinhalten verschiedene konservative (pharmakologisch, Beckenbodentraining) und/oder minimal-invasive Therapiemaßnahmen mit oftmals nur moderater Verbesserung der Symptome und nicht akzeptablen Nebenwirkungen. Die Lebensqualität wird jedoch ganz entscheidend von dem Wiedererlangen der Kontinenz beeinflusst.Im Rahmen dieser Kasuistik stellen wir erstmals die perineale Anlage der funktionellen retrourethralen Schlinge (AdVance) bei einem Patienten mit Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Neoblase (nach Hautmann) vor, die ihre Wirkung – im Gegensatz zu den anderen minimal-invasiven Verfahren – nichtobstruktiv entfaltet. Durch die Schlinge wird die veränderte Anatomie im Sinne gelockerter und deszendierter Haltestrukturen des Sphinkters nach radikaler Zystektomie korrigiert und in ihre ursprüngliche Position gebracht, so dass die Kontinenz wiedererlangt werden kann.Die Anwendung der retrourethralen Schlinge bei einem Patienten nach radikaler Zystektomie und Anlage einer (Ileum)neoblase ist bislang nicht publiziert worden, das hier vorgestellte Ergebnis bezüglich Kontinenz und Sicherheit scheint viel versprechend.AbstractStress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30–60% and is – despite a better understanding of the male (and female) pelvic anatomy – still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction.Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.

Belastungsinkontinenz nach radikaler Zystektomie@@@Stress urinary incontinence after radical cystectomy: Anlage einer Neoblase und Einlage der funktionellen retrourethralen Schlinge@@@Neobladder construction and placement of the functional retrourethral sling

Stress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30-60% and is - despite a better understanding of the male (and female) pelvic anatomy - still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction. Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.ZusammenfassungDie Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Ileumneoblase stellt nach wie vor ein herausragendes Problem dar. Die Inzidenz einer Belastungsinkontinenz nach diesem Eingriff wird in der Literatur mit 30–60% angegeben und zählt – trotz eines besseren Verständnisses der männlichen und weiblichen Anatomie des Beckenbodens – zu den typischen Komplikationen dieses Eingriffs.Die Behandlungsmöglichkeiten sind bislang begrenzt und beinhalten verschiedene konservative (pharmakologisch, Beckenbodentraining) und/oder minimal-invasive Therapiemaßnahmen mit oftmals nur moderater Verbesserung der Symptome und nicht akzeptablen Nebenwirkungen. Die Lebensqualität wird jedoch ganz entscheidend von dem Wiedererlangen der Kontinenz beeinflusst.Im Rahmen dieser Kasuistik stellen wir erstmals die perineale Anlage der funktionellen retrourethralen Schlinge (AdVance) bei einem Patienten mit Belastungsinkontinenz nach radikaler Zystektomie und Anlage einer Neoblase (nach Hautmann) vor, die ihre Wirkung – im Gegensatz zu den anderen minimal-invasiven Verfahren – nichtobstruktiv entfaltet. Durch die Schlinge wird die veränderte Anatomie im Sinne gelockerter und deszendierter Haltestrukturen des Sphinkters nach radikaler Zystektomie korrigiert und in ihre ursprüngliche Position gebracht, so dass die Kontinenz wiedererlangt werden kann.Die Anwendung der retrourethralen Schlinge bei einem Patienten nach radikaler Zystektomie und Anlage einer (Ileum)neoblase ist bislang nicht publiziert worden, das hier vorgestellte Ergebnis bezüglich Kontinenz und Sicherheit scheint viel versprechend.AbstractStress urinary incontinence (SUI) following radical cystectomy and orthotopic ileal neobladder construction represents a challenging problem. The incidence of incontinence following this surgery is reported to be 30–60% and is – despite a better understanding of the male (and female) pelvic anatomy – still regarded as an adverse outcome of this surgery.Therapeutic options have been limited up until now and include pharmacological agents, surgical treatment and pelvic floor training with only moderate amelioration of the symptoms and often unacceptable side effects. Nevertheless, urinary continence is probably the most important key to patient satisfaction.Here we introduce the perineal approach of the functional retrourethral mesh as a new and innovative sling suspension based on a non-obstructive procedure in a patient with urinary stress incontinence after ileal neobladder. The sling adjusts the changed anatomy after radical cystectomy returning it to the former preoperative position and thus continence can be achieved again. The approach of the sling in a patient with ileal neobladder is safe and the good result concerning continence is promising.