Tanja Hüsch

Nomenclature in PCNL or The Tower Of Babel: a proposal for a uniform terminology

In addition, the system states whether the access tract is sealed after the procedure in case of totally tubeless interventions (t treatment). Each parameter is characterised by an acronym added to the term “PCNL” (see Table 2). For example, a PCNL in prone position with an access tract diameter of 16 FR using low-pressure continuous-flow irrigation without the placement of a ureteric stent and immediate sealing of the tract would be referred to as “PCNL (pP, cM, fCF, uTT, tSL)”, whereas a conventional PCNL in supine position with a 26 FR access sheath and the placement of a nephrostomy tube would be described as “PCNL (pS, cL, fCL, uTU)”. We believe that the introduction of this novel nomenclature might contribute significantly to a better overview and comparability of the literature in endourology and suggest a broader discussion and validation of these acronyms. Dear Editor,

Risk Factors for Failure of Male Slings and Artificial Urinary Sphincters: Results from a Large Middle European Cohort Study

Introduction: We analysed the impact of predefined risk factors: age, diabetes, history of pelvic irradiation, prior surgery for stress urinary incontinence (SUI), prior urethral stricture, additional procedure during SUI surgery, duration of incontinence, ASA-classification and cause for incontinence on failure and complications in male SUI surgery. Materials and Methods: We retrospectively identified 506 patients with an artificial urinary sphincter (AUS) and 513 patients with a male sling (MS) in a multicenter cohort study. Complication rates were correlated to the risk factors in univariate analysis. Subsequently, a multivariate logistic regression adjusted to the risk factors was performed. A p value <0.05 was considered statistically significant. Results: A history of pelvic irradiation was an independent risk factor for explantation in AUS (p < 0.001) and MS (p = 0.018). Moreover, prior urethral stricture (p = 0.036) and higher ASA-classification (p = 0.039) were positively correlated with explantation in univariate analysis for AUS. Urethral erosion was correlated with prior urethral stricture (p < 0.001) and a history of pelvic irradiation (p < 0.001) in AUS. Furthermore, infection was correlated with additional procedures during SUI surgery in univariate analysis (p = 0.037) in MS. Conclusions: We first identified the correlation of higher ASA-classification and explantation in AUS. Nevertheless, only a few novel risk factors had a significant influence on the failure of MS or AUS.

Antibiotic Coating of the Artificial Urinary Sphincter (AMS 800): Is it Worthwhile?

OBJECTIVE To investigate the impact of the antibiotic coating InhibiZone on the infection and explantation rates of the AMS 800 in comparison to the AMS 800 without InhibiZone. MATERIALS AND METHODS We retrospectively identified 305 patients with an AMS 800 in a multicenter cohort study. Patients were subsequently divided into InhibiZone and without InhibiZone-coated groups. Infection and explantation rates were analyzed by univariate and consecutively by multivariate logistic regression adjusted to variable risk factors. The infection-free interval was estimated by Kaplan-Meier plot and compared by the log-rank test. A P value below .05 was considered statistically significant. RESULTS We identified 47 patients with InhibiZone and 258 without InhibiZone coating. In univariate analysis, we could not identify a significant difference in infection (P = .932) or explantation (P = .715) rates between the groups. In multivariate analysis, impaired wound healing (P = .008) and urethral erosion (P < .001) were independent predictors for infection. The InhibiZone coating neither demonstrated significant influence on the infection rate (P = .534) nor on the explantation rate (P = .214). There was no significant difference in estimated infection-free survival between the groups (P = .265). CONCLUSION The antibiotic coating of the AMS 800 had no significant impact on infection or explantation rates in our cohort.

The hydrodynamic basis of the vacuum cleaner effect in continuous-flow PCNL instruments: an empiric approach and mathematical model.

AbstractPurposePassive removal of stone fragments in the irrigation stream is one of the characteristics in continuous-flow PCNL instruments. So far the physical principle of this so-called vacuum cleaner effect has not been fully understood yet. The aim of the study was to empirically prove the existence of the vacuum cleaner effect and to develop a physical hypothesis and generate a mathematical model for this phenomenon. Methods In an empiric approach, common low-pressure PCNL instruments and conventional PCNL sheaths were tested using an in vitro model. Flow characteristics were visualized by coloring of irrigation fluid. Influence of irrigation pressure, sheath diameter, sheath design, nephroscope design and position of the nephroscope was assessed. Experiments were digitally recorded for further slow-motion analysis to deduce a physical model.ResultsIn each tested nephroscope design, we could observe the vacuum cleaner effect. Increase in irrigation pressure and reduction in cross section of sheath sustained the effect. Slow-motion analysis of colored flow revealed a synergism of two effects causing suction and transportation of the stone. For the first time, our model showed a flow reversal in the sheath as an integral part of the origin of the stone transportation during vacuum cleaner effect. The application of Bernoulli’s equation provided the explanation of these effects and confirmed our experimental results.ConclusionsWe widen the understanding of PCNL with a conclusive physical model, which explains fluid mechanics of the vacuum cleaner effect.

Complications and Short-Term Explantation Rate Following Artificial Urinary Sphincter Implantation: Results from a Large Middle European Multi-Institutional Case Series.

Background/Aims/Objectives: To analyze perioperative complication and short-term explantation rates after perineal or penoscrotal single-cuff and double-cuff artificial urinary sphincter (AUS) implantation in a large middle European multi-institutional patient cohort. Methods: 467 male patients with stress urinary incontinence underwent implantation of a perineal single-cuff (n = 152), penoscrotal single-cuff (n = 99), or perineal double-cuff (n = 216) AUS between 2010 and 2012. Postoperative complications and 6-month explantation rates were assessed. For statistical analysis, Fishers exact test and Kruskal-Wallis rank sum test, and a multiple logistic regression model were used (p < 0.05). Results: Compared to perineal single-cuff AUS, penoscrotal single-cuff implantation led to significantly increased short-term explantation rates (8.6% (perineal) vs. 19.2% (penoscrotal), p = 0.019). The postoperative infection rate was significantly higher after double-cuff compared to single-cuff implantation (6.0% (single-cuff) vs. 13.9% (double-cuff), p = 0.019). The short-term explantation rate after primary double-cuff placement was 6.5% (p = 0.543 vs. perineal single-cuff). In multivariate analysis, the penoscrotal approach (p = 0.004), intraoperative complications (p = 0.005), postoperative bleeding (p = 0.011), and perioperative infection (p < 0.001) were independent risk factors for short-term explantation. Conclusions: Providing data from a large contemporary multi-institutional patient cohort from high-volume and low-volume institutions, our results reflect the current standard of care in middle Europe. We indicate that the penoscrotal approach is an independent risk factor for increased short-term explantation rates.

Targeting Moderate and Severe Male Stress Urinary Incontinence With Adjustable Male Slings and the Perineal Artificial Urinary Sphincter: Focus on Perioperative Complications and Device Explantations

Purpose To analyze perioperative complications and postoperative explantation rates for selected readjustable male sling systems and the perineal single-cuff artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. Methods Two hundred eighty-two male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in the study (n=127 adjustable male sling [n=95 Argus classic, n=32 Argus T], n=155 AUS). Perioperative characteristics and postoperative complications were analyzed. The explantation rates of the respective devices were assessed using the Fisher exact test and the Mann-Whitney U-test. A Kaplan-Meier curve was generated. Potential features associated with device explantation were analyzed using a multiple logistic regression model (P<0.05). Results We found significantly increased intraoperative complication rates after adjustable male sling implantation (15.9% [adjustable male sling] vs. 4.2% [AUS], P=0.003). The most frequent intraoperative complication was bladder perforation (n=17). Postoperative infection rates did not vary significantly between the respective devices (P=0.378). Device explantation rates were significantly higher after AUS implantation (9.7% [adjustable male sling] vs. 21.5% [AUS], P=0.030). In multivariate analysis, postoperative infection was a strong independent predictor of decreased device survival (odds ratio, 6.556; P=0.001). Conclusions Complication profiles vary between adjustable male slings and AUS. Explantation rates are lower after adjustable male sling implantation. Any kind of postoperative infections are independent predictors of decreased device survival. There is no significant effect of the experience of the implanting institution on device survival.

The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference?

PurposeTo compare the efficacy and perioperative complications of the AdVanceXP with the original AdVance male sling.MethodsWe retrospectively enrolled 109 patients with an AdVance and 185 patients with an AdVanceXP male sling. The baseline characteristics and complication rates were analyzed retrospectively. Functional outcome and quality of life were evaluated prospectively by standardized, validated questionnaires. The Chi2-test for categorical and Mann–Whitney U test for continuous variables were performed to identify heterogeneity between the groups.ResultsRegarding operation time, there was no significant difference between the slings (p = 0.146). The complication rates were comparable in both groups except for postoperative urinary retention. This occurred significantly more often in patients with the AdVanceXP (p = 0.042). During follow-up, no differences could be identified regarding ICIQ-SF, PGI or I-QoL or number of pad usage.ConclusionsThe AdVance and AdVanceXP are safe and effective treatment options for male stress urinary incontinence. However, the innovations of the AdVanceXP sling did not demonstrate a superiority over the original AdVance sling regarding functional outcome.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status

AbstractPurpose To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort.Methods658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann–Whitney U test were used.ResultsPatients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients’ perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001).ConclusionsPatients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

Sensation of Cold during the Ice Water Test Corresponds to the Perception of Pain during Botulinum Toxin Bladder Wall Injections

Aims: To investigate the association of bladder cold sensation (BCS) during the ice water test (IWT) and pain perception when botulinum toxin injections (BTI) are administered into the bladder wall. Material and Methods: In 86 patients with idiopathic overactive bladder, the BCS during the IWT was investigated. Patients were divided into 2 groups: with and without BCS. During subsequent administration of BTI, the number of perceived and painful injections as well as the pain levels on a 0-100 pain scale were compared in both groups using Student t test. Results: Thirty-five patients reported a BCS, while 51 did not. After 10 BTI, the mean number of perceived injections was 7.9 in patients with and 2.4 in patients without BCS (p < 0.0001). The mean number of painful injections was 5.4 in patients with BCS and 4.3 in patients without (p < 0.001). Mean levels on a 0-100 pain scale were 33.7 in patients with and 17.8 in patients without cold sensation (p < 0.0001). Conclusion: The association of BCS during the IWT and pain to during BTI may implicate that the perceptions of cold and pain in the urinary bladder may use similar receptors and neuronal pathways.

A Nomogram to Characterize the Severity of Detrusor Overactivity during the Ice Water Test: Description of the Method and Proof of Concept

Aims: To develop a nomogram with severity categories for detrusor overactivity (DO). Methods: By conducting ice water tests (IWT) in 55 patients with Parkinson’s disease, we identified criteria to describe characteristics of the detrusor pressure curves: (1) a gradient of Δpdet over Δt at the maximum detrusor pressure and (2) the area under the curve. In a nomogram, 10 severity categories of DO were established: 1 and 2 were assigned to group A (mild), 3 and 4 to group B (moderate) and 5–10 to group C (severe). Results: In the nomogram, negative IWT (20) appeared in category 1. Positive IWT (35) spread over the categories 1–8, 17 in group A, 11 in group B and 7 in categories 5–10. A relationship of incontinence episodes and nomogram category was observed. The nomogram category was reproducible in repeated IWT. Therapeutic interventions to treat DO lowered the nomogram category. Conclusion: From the relationship of detrusor pressure and time in the IWT, a nomogram with 10 severity categories of DO was developed. First observations show a relationship of nomogram category and the number of incontinence episodes, reproducibility in repeated tests and the representation of effects of therapeutic interventions to treat DO.