The role of antimuscarinics in the management of men with symptoms of overactive bladder associated with concomitant bladder outlet obstruction: an update

CONTEXT

This review focuses on the contemporary role of antimuscarinics in the management of men with symptoms of bladder outlet obstruction (BOO) and concomitant overactive bladder (OAB). Safety issues of antimuscarinics in this subpopulation of men are also reviewed.

OBJECTIVE

We reviewed the current literature and performed an analysis of the efficacy, suitability, and the safety of antimuscarinics in this subpopulation of men.

EVIDENCE ACQUISITION

We performed a systematic search of Medline/PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews for relevant articles published between 1990 and September 2010, restricted to studies in humans published in English. In addition, published abstracts presented at the annual meetings of the European Association of Urology, the American Urological Association, and the International Continence Society in the last decade (2000-2010) were hand-searched and evaluated. Each article's title and abstract were reviewed for their appropriateness and relevance to the use of antimuscarinics in patients with BOO and concomitant OAB. Relevant articles were fully reviewed and included in the final data acquisition.

EVIDENCE SYNTHESIS

Treatment options include combination treatment with α-blockers and antimuscarinics, sequential use of α-blockers and antimuscarinics, monotherapy with antimuscarinics, and a combination of antimuscarinics and 5α-reductase inhibitors. The sequential use of α-blockers and antimuscarinics seems to be the most appropriate approach, and the use of antimuscarinics and α-blockers appears generally to be safe and efficacious. Data are insufficient for a possible stratification of patients for a specific sequence of the drugs reviewed.

CONCLUSIONS

This review infers that the existing data confirm the safety of antimuscarinics administered for the treatment of these patients. The efficacy of antimuscarinics has been proven in different trials regarding different storage symptom end points, but not all end points regarding OAB reached significance. All the reported trials are of short duration (4-12 wk) and include only men with low postvoid residual urine volumes at baseline (<200ml). Overall, the addition of an antimuscarinic to the treatment of a patient with BOO and concomitant OAB seems to offer an amelioration of the symptoms and a moderate improvement in quality of life.

The "all-seeing needle": initial results of an optical puncture system confirming access in percutaneous nephrolithotomy

BACKGROUND

In percutaneous nephrolithotomy (PNL), the best possible way to access the collecting system is still a matter of debate. There is little possibility of correcting a suboptimal access.

OBJECTIVE

To describe our initial experience using a micro-optical system through a specific puncture needle to confirm the quality of the chosen access prior to dilatation of the operating tract.

DESIGN, SETTING AND PARTICIPANTS

Micro-optics of 0.9- and 0.6-mm diameter were used. The micro-optic with integrated light lead was inserted through the working sheath of the puncture needle. The modified needle had a 1.6-mm (4.85-Fr) outer diameter. The optical fiber was connected via a zoom ocular and light adapter to a standard endoscopic camera system. For sufficient intraoperative sight, an irrigation system was connected.

INTERVENTION

The optical puncture needle was used in 15 patients for renal access prior to standard PNL procedures.

MEASUREMENTS

The optical assessment included determination of the distortion, resolution, angle, and field of view. The irrigation flow was assessed in an ex vivo setting, with the puncture stylet or the needle shaft either empty or with a 0.018-in guidewire inserted.

RESULTS AND LIMITATIONS

In all cases, visualization of the punctured kidney calyces was successful and the presence of the target calculi could be confirmed prior to guidewire placement and tract dilation. The 0.9-mm optic was found to be significantly superior in all optical parameters in contrast to the 0.6-mm optic. No significant complications were observed.

CONCLUSIONS

The optical puncture needle for PNL appears to be most helpful for confirming the optimal percutaneous access to the kidney prior to dilation of the nephrostomy tract, improving the safety of the technique.

Impact of collateral damage to endourologic tools during laser lithotripsy--in vitro comparison of three different clinical laser systems

BACKGROUND AND PURPOSE

During laser lithotripsy, working instruments are often in close proximity to the distal fiber tip and may be damaged accidentally or even intentionally. The aim of this study was to compare the amount of damage to a standard guidewire and the nitinol wires of endourologic retrieval baskets that were affected by three different clinically available laser systems.

MATERIALS AND METHODS

The impact of pulsed laser irradiation on a standard hydrophilic guidewire and a retrieval basket were investigated. One infrared (IR) laser system (holmium:yttrium-aluminum-garnet [Ho:YAG]: λ = 2100 nm) and two laser systems emitting light in the visible (VIS) spectral range (frequency-doubled double-pulse neodymium:YAG [FREDDY]: λ = 532 nm/1064 nm and flashlamp pulsed dye [FLPD]: λ = 598 nm) were used. Experimental parameters were fiber core diameter, laser pulse energy, and distance between the fiber tip and the investigated tool. Damage was evaluated by microscopic investigation and by quantifying the damage size and magnitude by creating laser impact related damage factors.

RESULTS

After application of one single laser pulse, IR-laser related maximum damage to guidewires occurred, depending on the pulse energy and the fiber core diameter, either in contact mode or in a distance of maximum 2 mm. Maximum VIS-laser related damage occurred in a distance range of 2 to 3 mm. The nitinol wires of the extraction tools could be destroyed completely by IR laser irradiation at pulse energies E(P) > 1200 mJ, depending on the fiber core diameter used. VIS lasers were solely able to set visible damage to guidewires without any disruption of nitinol wires.

CONCLUSIONS

Ho:YAG laser induced damage to endourologic tools is significantly higher compared with the impact of the FREDDY or the FLPD-laser. Because complete disruption of guidewires and stone extraction tools occurred, a safety clearance must be kept between the fiber tip and the endourologic tool during Ho:YAG stone disintegration. If disruption is intended, such as in the case of basket-retrieval problems, it can easily be performed with Ho:YAG irradiation.

α1-adrenoceptor activation induces phosphorylation of β2-adrenoceptors in human prostate tissue

OBJECTIVE

• To test whether β1-adrenoceptor activation leads to phosphorylation of the β2-adrenoceptor in human prostate tissue.

PATIENTS AND METHODS

• Prostate tissue from patients undergoing radical prostatectomy was stimulated in vitro with the α1-adrenergic agonist phenylephrine (10 µM). • α2-adrenoceptor phosphorylation at serines 345/346 was studied using Western blot analysis with a phospho-specific antibody. • The role of second messenger kinases was assessed by studying the effects of the protein kinase C (PKC) inhibitor Ro 31-8425 and the protein kinase A (PKA) inhibitor H89 on phenylephrine-induced phosphorylation. • The expression of G protein-coupled receptor kinases (GRKs) 2/3 was analysed using quantitative reverse-transcriptase-polymerase chain reaction (RT-PCR), Western blot analysis and immunohistochemistry.

RESULTS

• Stimulation of prostate tissue with phenylephrine resulted in phosphorylation of the β2-adrenoceptor (5, 10 and 20 min after stimulation). • This α1-adrenoceptor-induced phosphorylation of β2-adrenoceptors was resistant to inhibition of PKC and PKA. • Changes in phosphorylation levels were not attributable to changes in receptor levels, as these remained constant during stimulation. • RT-PCR and Western blot analysis showed expression of GRK2/3 in human prostate tissues. • Immunohistochemical staining showed that GRK2/3 expression in human prostate tissue is located to stromal and smooth muscle cells.

CONCLUSIONS

• Activation of α1-adrenoceptors causes phosphorylation of β2-adrenoceptors in the human prostate. This may enhance α1-adrenergic contraction and is possibly mediated by GRK2, which is expressed in prostate smooth muscle. • Mutual regulation between different adrenergic receptors might be involved in the therapeutic effects of α1-blockers in patients with benign prostate hyperplasia.

The role of the transient receptor potential (TRP) superfamily of cation-selective channels in the management of the overactive bladder

• The pathophysiology of lower urinary tract symptoms (LUTS), detrusor overactivity (DO), and the overactive bladder (OAB) syndrome is multifactorial and remains poorly understood. • The transient receptor potential (TRP) channel superfamily has been shown to be involved in nociception and mechanosensory transduction in various organ systems, and studies of the LUT have indicated that several TRP channels, including TRPV1, TRPV2, TRPV4, TRPM8, and TRPA1, are expressed in the bladder, and may act as sensors of stretch and/or chemical irritation. • However, the roles of these individual channels for normal LUT function and in LUTS/DO/OAB, have not been established. • TRPV1 is the channel best investigated. It is widely distributed in LUT structures, but despite extensive information on morphology and function in animal models, the role of this channel in normal human bladder function is still controversial. Conversely, its role in the pathophysiology and treatment of particularly neurogenic DO is well established. • TRPV1 is co-expressed with TRPA1, and TRPA1 is known to be present on capsaicin-sensitive primary sensory neurones. Activation of this channel can induce DO in animal models. • TRPV4 is a Ca(2+)-permeable stretch-activated cation channel, involved in stretch-induced ATP release, and TRPV4-deficient mice exhibit abnormal frequencies of voiding and non-voiding contractions in cystometric experiments. • TRPM8 is a cool receptor expressed in the urothelium and suburothelial sensory fibres. It has been implicated in the bladder-cooling reflex and in idiopathic DO. • The occurrence of other members of the TRP superfamily in the LUT has been reported, but information on their effects on LUT functions is scarce. There seem to be several links between activation of different members of the TRP superfamily and LUTS/DO/OAB, and further exploration of the involvement of these channels in LUT function, normally and in dysfunction, may be rewarding.

Lymph node density affects cancer-specific survival in patients with lymph node-positive urothelial bladder cancer following radical cystectomy

BACKGROUND

The prognosis for patients with lymph node (LN)-positive bladder cancer (BCa) is likely affected by the extent of lymphadenectomy in radical cystectomy (RC) cases. Specifically, the prognostic significance of the LN density (ratio of positive LNs to the total number removed) has been demonstrated.

OBJECTIVE

To evaluate the prognostic signature of lymphadenectomy variables, including the LN density, for a large, multicentre cohort of RC patients with LN-positive BCa.

DESIGN, SETTING, AND PARTICIPANTS

The clinical and histopathologic data from 477 patients with LN-positive urothelial BCa (pN1-2) were analysed. The median follow-up period for all living patients was 28 mo.

MEASUREMENTS

Multivariable Cox regression analysis was used to test the effect of various pelvic lymph node dissection (PLND) variables on cancer-specific survival (CSS) based on colinearity in various models.

RESULTS AND LIMITATIONS

The median number of LNs removed was 12 (range: 1-66), and the median number of positive LNs was 2 (range: 1-25). Two hundred ninety (60.8%) of the patients presented with stage pN2 disease. The median and mean LN density was 17.6% and 29% (range: 2.3-100), respectively, where 268 (56.2%) and 209 (43.8%) patients exhibited am LN density of ≤20% and >20%, respectively. In separate multivariable Cox regression models adjusted for age, sex, pTN stage, grade, associated Tis, and adjuvant chemotherapy, the interval-scaled LN density (hazard ratio [HR]: 1.01; p=0.002) and the LN density, ordinal-scaled by 20% (HR: 1.65; p<0.001) exhibit independent effects on CSS. In addition, an independent contribution appears from the pT but not the pN stage. Limitations include surgeon selection bias when determining the extent of lymphadenectomy.

CONCLUSIONS

Our results support the prognostic relevance of LN density in patients with LN-positive BCa, where a threshold value of 20% stratifies the population into two prognostically distinct groups. Before LN density is integrated into the clinical decision-making process, these results should be validated by prospective studies with defined LN templates and standardised histopathologic methods.

Cannabinor, a selective cannabinoid-2 receptor agonist, improves bladder emptying in rats with partial urethral obstruction

PURPOSE

We studied the effects of chronic treatment with the novel selective cannabinoid 2 receptor agonist cannabinor (Procter & Gamble Pharmaceuticals, Cincinnati, Ohio) on bladder function in conscious rats with partial urethral obstruction and on the functional properties of isolated detrusor muscle.

MATERIALS AND METHODS

A total of 24 female Sprague-Dawley® rats with surgically created partial urethral obstruction received daily intraperitoneal injections of 3 mg/kg cannabinor (12) or saline as controls (12) for 2 weeks. Cystometry was done, the rats were sacrificed and the bladders were prepared for in vitro studies.

RESULTS

Mean ± SEM bladder weight was 0.97 ± 0.15 gm in controls and 0.53 ± 0.08 gm in cannabinor treated rats (p <0.05). There was no difference between the groups in the mean micturition interval, or mean baseline, threshold, flow or maximum pressure. In controls and cannabinor treated rats mean post-void residual volume was 0.28 ± 0.07 and 0.06 ± 0.02 ml, mean micturition compliance was 0.032 ± 0.006 and 0.069 ± 0.016 ml/cm H(2)O, and mean bladder wall force at the start of flow was 950 ± 280 and 1,647 ± 325 mN/gm, respectively (each p <0.05). Nonvoiding contractions were significantly less frequent in cannabinor treated rats than in controls. We noted no difference in carbachol (Sigma®) half maximum concentration between the groups but the carbachol maximum response in detrusor strips from cannabinor treated rats was significantly higher than that in control strips.

CONCLUSIONS

In rats with partial urethral obstruction treated daily for 14 days with cannabinor bladder weight was lower, the ability to empty the bladder was preserved and nonvoiding contraction frequency was low compared to those in controls. Detrusor preparations from cannabinor treated rats showed a higher response to nerve stimulation than those from controls. Selective cannabinoid 2 receptor activation may be a novel principle to enable improved bladder function after partial urethral obstruction.

The PolyScope: a modular design, semidisposable flexible ureterorenoscope system

PURPOSE

To characterize the mechanical and optical properties of the PolyScope endoscope system and to examine the clinical outcome in patients who were undergoing ureteronephroscopy.

MATERIALS AND METHODS

Mechanical assessment involved measurement of the deflection angle and irrigation flow rate. Optical resolution and distortion, field and angle of view, and light transmission and output formed the optical assessment. Clinical assessment was made in a series of consecutive ureteronephroscopy procedures. The optical cord was disconnected after each procedure, and the image fiber was assessed for damage.

RESULTS

The mean value for the angle of maximum active tip deflection with an empty working channel was 265 degrees (261-275 degrees). Deflection was impaired most with insertion of the 3.0 F basket (10% decrease) and least with an indwelling 220 microm laser fiber (2% decrease). Irrigation flow rate was 57 mL/min with an empty working channel. Flow was reduced by 50% and 68%, with the insertion of a 200 microm or 365 microm laser probe, respectively, and by 92.5% with a 3.2F basket. No damage to the image fiber occurred. The PolyScope optics system could identify a target of about 0.125 mm at a distance of 2 to 4 mm, based on 3 line-pairs/mm needed for clear identification. Lithotripsy of renal calculi was performed for 40 stone burdens in 32 patients; the resulting stone-free rate was 87.5%.

CONCLUSION

The novel semidisposable ureteroscope system PolyScope was simple to use, effective, and reliable in this preliminary clinical evaluation. It overcomes the inherent fragility of comparable devices, which renders the need for maintenance unnecessary.

Activated RhoA/Rho kinase impairs erectile function after cavernous nerve injury in rats

PURPOSE

RhoA and rho kinase serve as key regulators of penile vascular homeostasis. The role of RhoA/rho kinase signaling in the penis after cavernous nerve injury has not been fully investigated. We characterized the molecular expression profiles of RhoA/rho kinase signaling that occur in the penis after cavernous nerve injury. We hypothesized that erectile dysfunction after bilateral cavernous nerve injury is accompanied by up-regulation of RhoA/rho kinase activity in the rat penis.

MATERIAL AND METHODS

We used 2 groups, including sham operation and bilateral cavernous nerve injury. At 14 days after nerve injury each group underwent cavernous nerve stimulation to determine erectile function at baseline and after intracavernous injection of the rho kinase inhibitor Y-27632 (Tocris Bioscience, Ellisville, Missouri). Penes were assessed at baseline for protein expression of neuronal nitric oxide synthase, RhoA, and rho kinase 1 and 2 by Western blot, immunoreactivity of neuronal nitric oxide synthase, rho kinase 1 and 2, RhoA-guanosine triphosphatase and rho kinase activity.

RESULTS

Erectile function was decreased in nerve injured rats. Neuronal nitric oxide synthase protein was significantly decreased while RhoA and rho kinase 2 protein levels were significantly increased in rat penes with nerve injury. Rho kinase 1 protein expression was equivalent. Rho kinase immunoreactivity was qualitatively increased in the corporeal smooth muscle of nerve injured rats. RhoA-guanosine triphosphatase and rho kinase activity was significantly increased in injured rat penes compared to that in sham operated penes. Intracavernous injection of Y-27632 caused a significantly greater increase in intracavernous pressure in nerve injured rats compared to that in sham operated rats, suggesting increased rho kinase activity.

CONCLUSIONS

Data suggest that RhoA/rho kinase up-regulation in response to cavernous nerve injury contributes to penile vasculature dysfunction after cavernous nerve injury. Thus, the RhoA/rho kinase pathway may be a suitable target for treating post-radical prostatectomy erectile dysfunction.

Current status of ultrasound imaging in prostate cancer

Carcinoma of the prostate (PC) is the most common cancer in men. Ultrasound (US)-guided prostate biopsy with 10-12 cores is considered to be the gold standard in the diagnosis of PC, although a systematic biopsy may miss a considerable percentage of prostate cancer. Substantial efforts have been made to improve the detection rates with extensive prostate biopsy schemes. Today, the most promising tools to improve the detection rate are various imaging procedures. This review focuses on the current stautus of ultrasound imaging in the detection of PC, such as contrast-enhanced colour Doppler ultrasound and real-time elastography. With the use of these techniques, it is the intention not only to improve the detection rate but they could also serve beneficial for staging and in order to reduce the number of biopsy cores. However, further clinical trials will be needed to determine the value of these new US advances.

Comparison of guideline recommendations with daily practice in patients with renal cell carcinoma

Objectives and Aims

To compare guideline recommendations with daily practice patterns in a German patient cohort with renal cell carcinoma.

Patients and methods

81 patients with T1 oder T2 renal cell carcinoma (RCC) were included in this prospective single-center study. All patients were operated in a single institution either by open radical nephrectomy (ORN) or nephron sparing surgery (NSS). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. Follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated.

Results

The majority of patients (72%) were followed up by their urologists. Follow-up examinations included abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (CT) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). There were no significant differences between patients operated by ORN or NSS. In total, 12.5% of patients were asking for psycho-oncological support.

Conclusions

In general, patients were followed up according to existing guideline recommendations. Only a small proportion of patients asked for psycho-oncological treatment.

Anatomy, physiology, and pathophysiology of erectile dysfunction

INTRODUCTION

Significant scientific advances during the past 3 decades have deepened our understanding of the physiology and pathophysiology of penile erection. A critical evaluation of the current state of knowledge is essential to provide perspective for future research and development of new therapies.

AIM

To develop an evidence-based, state-of-the-art consensus report on the anatomy, physiology, and pathophysiology of erectile dysfunction (ED).

METHODS

Consensus process over a period of 16 months, representing the opinions of 12 experts from seven countries.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of scientific and evidence-based medical literature, internal committee discussion, public presentation, and debate.

RESULTS

ED occurs from multifaceted, complex mechanisms that can involve disruptions in neural, vascular, and hormonal signaling. Research on central neural regulation of penile erection is progressing rapidly with the identification of key neurotransmitters and the association of neural structures with both spinal and supraspinal pathways that regulate sexual function. In parallel to advances in cardiovascular physiology, the most extensive efforts in the physiology of penile erection have focused on elucidating mechanisms that regulate the functions of the endothelium and vascular smooth muscle of the corpus cavernosum. Major health concerns such as atherosclerosis, hyperlipidemia, hypertension, diabetes, and metabolic syndrome (MetS) have become well integrated into the investigation of ED.

CONCLUSIONS

Despite the efficacy of current therapies, they remain insufficient to address growing patient populations, such as those with diabetes and MetS. In addition, increasing awareness of the adverse side effects of commonly prescribed medications on sexual function provides a rationale for developing new treatment strategies that minimize the likelihood of causing sexual dysfunction. Many basic questions with regard to erectile function remain unanswered and further laboratory and clinical studies are necessary.

Minimizing complications during retropubic radical prostatectomy - Is ureteral stenting necessary?

OBJECTIVES AND AIMS

To avoid damage to the ureters during bladder neck preparation in radical prostatectomy for prostate cancer, it may be helpful to insert ureteral stents temporarily or to intravenously administer indigo carmine dye for enhanced visualisation of ureteric orifices. We evaluated our bladder neck preserving technique at radical prostatectomy with regard to ureteric injuries.

PATIENTS AND METHODS

We analysed 369 consecutive radical prostatectomies operated in our clinic in a bladder neck preserving technique. The following parameters were assessed in this retrospective study: number of prophylactic ureteric stent insertions, application of indigo carmine dye, observed injuries of the ureters by the surgeon, postoperative increase of serum creatinine and postoperative status of kidney ultrasound.

RESULTS

In 7/369 prostatectomies (1.90%) a ureteric stent insertion was performed, indigo carmine was not applied to any patient at all, yet no intraoperative injury of a ureter was observed by a surgeon. No revision was necessary due to a ureteral injury within the observation period of one year after surgery. In 17 patients with preoperative normal creatinine value a pathological value was observed on the first postoperative day (mean 1.4 mg/dl). In these patients no consecutive postrenal acute renal failure was observed, no hydronephrosis was monitored by ultrasound and no further intervention was necessary.

CONCLUSIONS

Bladder neck preserving operation technique does not implicate the need of prophylactic ureteric stent insertions and has no higher incidence of ureteric injuries.

[Diagnostic work-up for lymph node metastases of urological tumors]

Both CT and MRI are currently the most frequently used and recommended modalities for lymph node staging of uro-oncological diseases. Their diagnostic usefulness is limited particularly for recognition of micrometastases and lymph nodes <10 mm. FDG- and choline-based PET/CT procedures also do not offer much improvement in these cases. Meanwhile however PET/CT has been included in the EAU guidelines for seminomas and is recommended for further management of residual tumors after chemotherapy. Magnetic resonance imaging with lymphotropic monocrystalline iron oxide nanoparticles appears to exhibit great potential and can detect smaller metastases and micrometastases even in normal-sized lymph nodes in uro-oncological diseases. Nevertheless, Guerbet has withdrawn its application to the EMEA for marketing authorization of its product Sinerem (superparamagnetic iron oxide nanoparticles). In the meantime diffusion-weighted MRI represents a promising technique and is already being evaluated in fields outside the realm of urology.

Effects of cannabinor, a novel selective cannabinoid 2 receptor agonist, on bladder function in normal rats

BACKGROUND

Cannabinoid (CB) receptors may be involved in the control of bladder function; the role of CB receptor subtypes in micturition has not been established.

OBJECTIVES

Our aim was to evaluate the effects of cannabinor, a novel CB2 receptor agonist, on rat bladder function.

DESIGN, SETTING, AND PARTICIPANTS

Sprague Dawley rats were used. Distribution of CB2 receptors in sensory and cholinergic nerves of the detrusor was studied. Selectivity of cannabinor for human and rat CB receptors was evaluated. Effects of cannabinor on rat detrusor and micturition were investigated.

MEASUREMENTS

Immunohistochemistry, radioligand binding, tritium outflow assays, organ bath studies of isolated bladder tissue, and cystometry in awake rats were used.

RESULTS AND LIMITATIONS

CB2 receptor immunoreactivity was expressed in the urothelium and in sensory and cholinergic bladder nerves. Cannabinor exhibited similar binding at human and rat CB2 receptors and a 321-fold functional selectivity for the CB2 receptor versus the CB1 receptor. Cannabinor had no effect on isolated detrusor muscle function. In vivo, cannabinor 3.0mg/kg increased micturition intervals and volumes by 52% (p<0.05) and 96% (p<0.01), respectively, and increased threshold and flow pressures by 73% (p<0.01) and 49% (p<0.001), respectively. Cannabinor 0.3 or 1.0mg/kg or vehicle did not affect urodynamic parameters.

CONCLUSIONS

Considering that CB2 receptors are localized on sensory nerves and on the urothelium and that cannabinor had effects on "afferent" urodynamic parameters, peripheral CB2 receptors may be involved in sensory functions of rat micturition. Effects of cannabinor on cholinergic nerve activity in normal bladder tissue appear to be limited.

Ho:YAG-laser: treatment of vesicourethral strictures after radical prostatectomy

OBJECTIVE

To review the indication, feasibility and treatment outcome of Ho:YAG laser application for definitive endoscopic treatment of anastomotic stricture formation after radical prostatectomy.

EVIDENCE SYNTHESIS

Currently, no universally accepted regime for managing post-prostatectomy anastomotic strictures exists. Cold knife incision is the most commonly utilized invasive technique for the treatment of bladder neck contractures. The Ho:YAG laser with its shallow tissue absorption of <0.5 mm offers favorable cutting properties including low blood loss and less induction of scar tissue formation and could be a valid alternative to endoscopic knife incision.

EVIDENCE ACQUISITION

PubMed and Medline were searched for reports on Ho:YAG laser therapy in strictures from 1980 to 2009 with particular focus on the operating techniques using the Ho:YAG laser system.

CONCLUSION

Ho:YAG laser endourethrotomy tends to be a safe and at least minimally invasive therapeutic modality for the treatment of bladder neck contractures after radical prostatectomy. No cohort study that evaluates the use of laser for this modality is available in literature. Due to the lack of comparable randomized multicentre trials, the indications for a laser-related endoscopic treatment option has to be defined based on the operators expertise and the patient's individual situation.

Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence

OBJECTIVE

To evaluate prospectively the complication rate of the retrourethral transobturator sling (AdVance sling) for the functional treatment of male stress urinary incontinence (SUI).

METHODS

In 230 patients with SUI due to nonintrinsic sphincter deficiency (without direct sphincter lesion) after radical prostatectomy (n=213), radical cystoprostatectomy with ileal neobladder (n=2) and transurethral resection of the prostate (n=15) a retrourethral transobturator sling was implanted. Patients were followed up for a median of 17 months (range, 4-42 months) with regard to intraoperative, early postoperative, and midterm postoperative complications.

RESULTS

Overall complication rate of the AdVance sling was 23.9%. Despite one accidental sling misplacement, no intraoperative complication occurred. Forty-nine patients (21.3%) experienced urinary retention postsurgery. Two slings were explanted (0.9%), 1 due to initial wrong placement and the other due to a symphysitis, attributed to a Guillain-Barré syndrome and not to a sling infection. One sling was transected (0.4%) due to slippage of the sling with obstruction of the urethra. Further complications were local wound infection (0.4%), urinary infection with fever (0.4%), and persistent moderate perineal pain (0.4%). There was no correlation between postoperative acute urinary retention and age at sling implantation, time of incontinence before sling implantation, preoperative daily pad use, or prior invasive incontinence treatment, respectively.

CONCLUSIONS

The retrourethral transobturator AdVance sling is a safe treatment option for male nonintrinsic sphincter deficiency SUI, with the main postoperative complication being transient acute urinary retention. Severe intra- and postoperative complications are rare and sling explantation rate is very low.

Organ-preserving neodymium-yttrium-aluminium-garnet laser therapy for penile carcinoma: a long-term follow-up

OBJECTIVE

To retrospectively analyse the long-term follow-up of 54 patients treated with organ-preserving laser therapy for penile carcinoma, as such therapy provides excellent cosmetic and functional results, but recurrence rates are high, which might impair the oncological outcome and worsen tumour-related survival.

PATIENTS AND METHODS

Between 1979 and 2008, 54 patients with penile carcinoma were treated with the neodymium-doped yttrium-aluminium-garnet (Nd:YAG) laser at our institution; 11 were classified as having carcinoma in situ (Tis), 39 as T1 and four as T2.

RESULTS

There was local recurrence in 16 patients (42%); the mean (range) time to local recurrence was 53 (9-132) months. In half the patients the time to local recurrence was >53 months, with the latest recurrence at 132 months after initial therapy of primary tumour. There was no statistically significant difference in recurrence rates with Tis or invasive penile carcinoma. In lymph-node-negative patients at initial presentation, there were no newly developed positive lymph nodes during the follow-up.

CONCLUSIONS

Organ-preserving laser therapy showed a relatively high recurrence rate in patients with a long-term follow up, but the oncological outcome and survival were not compromised by local recurrence. Therefore, laser therapy appears to be appropriate for treating premalignant lesions and early stages of penile carcinoma. Patients should be informed about the potential for late recurrence.

Intermediate-differentiated invasive (pT1 G2) penile cancer--oncological outcome and follow-up

OBJECTIVES AND AIMS

Due to the low prevalence of penile cancer, little evidence exists on the metastatic potential and the ideal treatment strategies in intermediate-differentiated invasive (pT1 G2) penile cancer. The current study aimed to analyze the oncologic outcome of patients with penile carcinoma with long-term follow-up in a single-center study.

PATIENTS AND METHODS

In this retrospective study, 38 patients with histologically proven T1 G2 squamous cell carcinoma of the penis were included. Only the 'classic' subtype was analyzed. Treatment of the primary tumor was Nd:YAG laser-therapy, excision, or partial amputation. Follow-up was performed according to EAU guidelines (2004).

RESULTS

Mean follow-up was 78.1 months (range: 9-285 months). Local recurrence was seen in 12 patients (31.6%), but was not correlated with disease related death (P = 0.7944). Rate of local recurrence was not dependent on treatment modality (P = 0.3481); 13 patients died, accounting for a disease related survival rate of 81.6% during observation period. Positive lymph nodes were seen in 28.9% of patients and were significantly correlated with disease related death (P = 0.00004). Clinically enlarged inguinal lymph nodes were not correlated with histologically confirmed positive lymph nodes (P = 0.5785).

CONCLUSIONS

For patients with T1 G2 penile cancer, organ preserving therapy appears to be a suitable treatment option. In our series, nearly one third of patients developed inguinal lymph node metastases, which highlights the potential benefit of surgical staging. Larger prospective multicenter studies are needed to define the best treatment strategy for intermediate-differentiated invasive penile cancer.

Regional, age and gender differences in architectural measures of bone quality and their correlation to bone mechanical competence in the human radius of an elderly population

An accurate prediction of bone strength in the human radius is of major interest because distal radius fractures are amongst the most common in humans. The objective of this study was to determine gender and age-related changes in bone morphometry at the radius and how these relate to bone strength. Specifically, our aims were to (i) analyze gender differences to get an insight into different bone quantities and qualities between women and men, (ii) to determine which microarchitectural bone parameters would best correlate with strength, (iii) to find the region of interest for the best assessment of bone strength, and (iv) to determine how loss of bone quality depends on age. Intact right forearms of 164 formalin-fixed cadavers from a high-risk elderly population were imaged with a new generation high-resolution pQCT scanner (HR-pQCT). Morphometric indices were derived for six different regions and were related to failure load as assessed by experimental uniaxial compression testing. Significant gender differences in bone quantity and quality were found that correlated well with measured failure load. The most relevant region to determine failure load based on morphometric indices assessed in this study was located just below the proximal end of the subchondral plate; this region differed from the one measured clinically today. Trends in bone changes with increasing age were found, even though for all morphometric indices the variation between subjects was large in comparison to the observed age-related changes. We conclude that HR-pQCT systems can determine how gender and age-related changes in morphometric parameters relate to bone strength, and that HR-pQCT is a promising tool for the assessment of bone quality in patient populations.

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.

Plasma vaporisation of the prostate: initial clinical results

BACKGROUND

Laser vaporisation of the prostate has had a considerable impact in recent years. In an attempt to achieve tissue vaporisation with bipolar high-frequency generators, plasma vaporisation was recently introduced.

OBJECTIVE

To provide the first clinical information on bipolar plasma vaporisation of the prostate for patients with lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO).

DESIGN, SETTING, AND PARTICIPANTS

Thirty patients were included in this prospective bicentre study.

INTERVENTION

All patients underwent bipolar plasma vaporisation with a novel electrode (Olympus Winter & Ibe GmbH, Hamburg, Germany).

MEASUREMENTS

International Prostate Symptom Score (IPSS), bother score, maximum flow rate (Q(max)), and postvoid residual were evaluated at baseline and at the time of discharge as well as at 1, 3, and 6 mo after the intervention.

RESULTS AND LIMITATIONS

Mean preoperative prostate volume was 59±32 ml (range: 30-170), and mean operating time was 61±26 min (range: 20-140). Besides one reoperation (conventional transurethral prostatectomy) due to persistent obstruction, no major complication occurred intra- or postoperatively and no blood transfusion was required. Catheterisation time averaged 41±35 h (range: 18-192). Transient mild to moderate dysuria was noted in four patients (13%). At 1, 3, and 6 mo, Q(max) increased from 6.6±2.7 ml/s preoperative to 17.3±4.7 ml/s (p<0.01), 18.5±4.6 ml/s (p<0.01), and 18.1±5.0 ml/s (p<0.01), respectively. The IPSS decreased from 20.8±3.6 to 10.4±3.5 (p<0.01), 8.2±2.9 (p<0.01), and 8.1±3.1 (p<0.01), respectively. These data represent a small nonrandomised study cohort with limited follow-up.

CONCLUSIONS

Our initial experience indicates that bipolar plasma vaporisation might be a safe and effective treatment option for patients with LUTS due to BOO. To define the potential role of this novel technique, randomised trials with longer follow-up are mandatory.