Peter Rehder

Treatment of Postprostatectomy Male Urinary Incontinence With the Transobturator Retroluminal Repositioning Sling Suspension: 3-Year Follow-up

BACKGROUND The AdVance male sling (American Medical Systems, Minnetonka, MN, USA) has been shown to be an efficacious device in short-term studies for postprostatectomy incontinence (PPI), but long-term studies are lacking. OBJECTIVE Examine the intermediate-term outcome with the AdVance sling for PPI management. DESIGN, SETTING, AND PARTICIPANTS A multicentre prospective evaluation was conducted on consecutive patients treated for PPI in three European tertiary reference centres. INTERVENTION Patients were implanted with the AdVance male sling with no associated surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Measurements included daily pad usage, maximum flow rate (Qmax), postvoid residual urine (PVR), the International Consultation on Incontinence Questionnaire-Short Form, the Incontinence Quality of Life questionnaires, and complications of surgery. Paired Wilcoxon signed rank test univariable and multivariable analyses were used. RESULTS AND LIMITATIONS Follow-up was available for 156 patients for the majority of parameters. Pad usage was significantly decreased compared with baseline at 12 mo and 3 yr (p<0.0001). At 12 mo, 76.9% of patients could be classified as cured or improved; this percentage was maintained at 3 yr (76.8%). Cure rates (58.6% vs 42.3%) and improvement rates (23.2% vs 25.0%) were higher in patients with mild or moderate incontinence compared with severe incontinence. Univariable analysis showed that pretreatment pad usage and severity of incontinence were both significant predictors of success (p=0.0355 and p=0.0420, respectively). However, in multivariable analysis, only pad usage was an independent predictor of success. There were no perioperative or severe postoperative complications. Most complications were Dindo grade I. Seven patients required a second treatment for stress urinary incontinence. There was no worsening over time. Limitations of this study included no comparator group, quality of life questionnaires in only two centres, and no 24-h pad test. CONCLUSIONS The transobturator retroluminal repositioning sling suspension is effective and safe in the longer term for treating PPI.

The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence.

1 Rehder P, Mitterberger MJ, Pichler R, Kerschbaumer A, Glodny B. The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence. BJU Int 2010 [Epub ahead of print]. DOI: 10.1111/j.1464-410X.2010. 09400.x 2 Rehder P, Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol 2007; 52 : 860–6 3 Cornel EB, Elzevier HW, Putter H. Can advance transobturator sling suspension cure male urinary postoperative stress incontinence? J Urol 2010; 183 : 1459–63

Kidney fusion anomalies revisited: clinical and radiological analysis of 209 cases of crossed fused ectopia and horseshoe kidney

To analyse the morphological appearance of horseshoe kidneys (HKs) and crossed fused ectopia (CFE) and to assess the frequency and clinical significance of associated anomalies and diseases.

Normal kidney size and its influencing factors - a 64-slice MDCT study of 1.040 asymptomatic patients

BackgroundNormal ultrasound values for pole-to-pole kidney length (LPP) are well established for children, but very little is known about normal kidney size and its influencing factors in adults. The objectives of this study were thus to establish normal CT values for kidney dimensions from a group of unselected patients, identify potential influencing factors, and to estimate their significance.MethodsIn multiphase thin-slice MDCTs of 2.068 kidneys in 1.040 adults, the kidney length pole to pole (LPP), parenchymal (PW) and cortical width (CW), position and rotation status of the kidneys, number of renal arteries, pyelon width and possible influencing factors that can be visualized, were recorded from a volume data set. For length measurements, axes were adjusted individually in double oblique planes using a 3D-software. Analyses of distribution, T-tests, ANOVA, correlation and multivariate regression analyses were performed.ResultsLPP was 108.5 ± 12.2 mm for the right, and 111.3 ± 12.6 mm for the left kidney (p < 0.0001 each). PW on the right side was 15.4 ± 2.8 mm, slightly less than 15.9 ± 2.7 mm on the left side (p < 0.0001), the CW was the same (6.6 ± 1.9 mm). The most significant independent predictors for LPP, CW, and PW were body size, BMI, age, and gender (p < 0.001 each). In men, the LPP increases up to the fifth decade of life (p < 0.01). It is also influenced by the position of the kidneys, stenoses and number of renal arteries (SRA/NRA), infarctions suffered, parapelvic cysts, and absence of the contralateral kidney; CW is influenced by age, position, parapelvic cysts, NRA and SRA, and the PW is influenced in addition by rotation status (p < 0.05 each). Depending on the most important factors, gender-specific normal values were indicated for these dimensions, the length and width in cross section, width of the renal pelvis, and parenchyma-renal pyelon ratio.ConclusionsDue to the complex influences on kidney size, assessment should be made individually. The most important influencing factors are BMI, height, gender, age, position of the kidneys, stenoses and number of renal arteries.

The 1 year outcome of the transobturator retroluminal repositioning sling in the treatment of male stress urinary incontinence: TRANSOBTURATOR RETROLUMINAL REPOSITIONING SLING FOR MALE STRESS URINARY INCONTINENCE

Study Type – Therapy (outcomes research)
Level of Evidence 2c

Status of Transrectal Ultrasound Imaging of the Prostate

PURPOSE To describe the current and new developments in transrectal ultrasound (US) imaging of the prostate. PATIENTS AND METHODS Grayscale imaging of the prostate is the standard method for diagnostic evaluation and biopsy guidance. Color Doppler (CD) imaging, including CD and power Doppler US, allows for detection of macrovascularity and may therefore be helpful for assessment of prostatic blood flow. The use of US microbubbles for CD imaging and new contrast-specific techniques enable assessment of prostate microvascularity associated with prostate cancer (PCa). Recently, real-time elastography has been introduced to improve detection of cancer based upon changes in tissue stiffness. RESULTS Contrast-enhanced CD imaging has shown to enable PCa detection by performing targeted biopsies into suspicious areas. Comparisons between systematic and contrast-enhanced targeted biopsies have shown that the targeted approach detects more cancers and cancers with higher Gleason scores with a reduced number of biopsy cores. New microbubble-specific US techniques can improve sensitivity and specificity of US imaging for PCa detection. Real-time elastography has been demonstrated to be useful for the detection of PCa, and may further improve PCa staging. CONCLUSIONS The new US techniques seem to have the potential to improve PCa detection, and also PCa grading and staging. As these diagnostic methods improve, the ultimate hope is to eliminate biopsy in patients without cancer.

Tratamiento de la incontinencia urinaria post prostatectomía con el cabestrillo retroluminal transobturatriz de reposicionamiento (Advance®): lecciones aprendidas de la experiencia acumulada

OBJETIVO: Resumir las lecciones aprendidas despues de haber realizado mas de 250 intervenciones de insercion de la malla AdVance®.La incontinencia despues de la prostatectomia es una realidad deprimente, frecuentemente subestimada por el cirujano. El esfinter urinario artificial ha sido el �gold standard� en el tratamiento de la incontinencia urinaria severa. No existe un consenso similar para la incontinencia leve-moderada. Este articulo trata sobre una operacion para la incontinencia con el objetivo de dar soporte a la laxitud del esfinter uretral despues de la prostatectomia. METODO: La hipotesis de la laxitud esfinteriana post-prostatectomia es nueva, asi como la restauracion de la continencia mediante la reubicacion proximal del cuerpo esponjoso proximal. Resumimos los trabajos que tratan este tema. Destacamos puntos seleccionados de la tecnica quirurgica, incluyendo las modificaciones que se han introducido con la experiencia. Finalmente, comparamos los primeros y ultimos 20 pacientes tratados en esta serie de 250 pacientes, analizando indicacion quirurgica, tecnica quirurgica y resultados del tratamiento. Anadimos algunas definiciones para aportar claridad. RESULTADOS: Se pudo demostrar que la posicion final del AdVance® es retroluminal, es decir 5-10 mm dorsal/detras de la luz de la uretra membranosa (= uretra esfinteriana). Comparando los primeros y ultimos 20 casos, en estos ultimos no hay ningun fracaso del tratamiento. El seguimiento a dos anos muestra una tasa de continencia del 65% en el primer grupo comparada con el 85% del segundo, teniendo en cuenta una mediana de tiempo de seguimiento corta en el segundo grupo, de 4,1 meses. La tunelizacion subcutanea del cabestrillo disminuyo significativamente el aflojamiento postoperatorio. CONCLUSIONES: El cabestrillo AdVance® es un metodo seguro de tratamiento de la incontinencia urinaria leve-moderada postprostatectomia, con ausencia de erosiones en esta serie. La hipotesis de la laxitud esfinteriana parece desempenar un papel definitivo en la fisiopatologia de la incontinencia masculina. La correccion de este descenso del soporte uretral o �prolapso� parece ser altamente eficaz. Son necesarios nuevos estudios para definir precisamente el mecanismo exacto de accion del cabestrillo AdVance®

Dorsal urethroplasty with labia minora skin graft for female urethral strictures

Study Type – Therapy (case series)
Level of Evidence 4

Interim Outcome of the Single Stage Dorsal Inlay Skin Graft for Complex Hypospadias Reoperations

PURPOSE Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations. MATERIALS AND METHODS A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements. RESULTS Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding. CONCLUSIONS This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.

Diagnosis and management of pediatric urethral injuries.

Objective: The incidence of urethral injuries in children is rare due to the fact that the urethra is short, mobile and protected by the pubic bone. The management of urethral trauma in childhood remains controversial because of the limited expertise of most urologists. Material and Methods: We performed a literature review by searching the Medline database for articles published between 1975 and 2010 based on clinical relevance. Electronic searches were limited to the keywords ‘pediatric’, ‘urethral injury’, ‘trauma’ and ‘reconstruction’. Results: Retrograde urethrography is considered the gold standard for diagnosis of urethral injuries. The initial management should ensure drainage of the bladder either by suprapubic cystostomy or urethral realignment if possible: in complete anterior urethral disruption as well as in children with life-threatening pelvic and intra-abdominal injuries after posterior urethral injuries, a deferred repair after 3 months is necessary. Immediate primary suturing of disrupted and dislocated urethral ends should be avoided because of high complication rates. Primary repair, however, of the defect is possible in girls avoiding a 2-stage approach. Conclusion: The aim of therapy is minimizing remote damages such as urethrocutaneous fistulae, periurethral diverticulae, strictures, incontinence and impotence with different therapeutic management depending on classification of the injury and the presence of life-threatening injuries.