Epidemiologie und �tiologie der instabilen Blase

Die instabile Blase ist eine Volkskrankheit von vergleichbarem Ausmas wie der Diabetes mellitus. Mit zunehmender Uberalterung der Gesellschaft ist von einer Aggravierung des Problems auszugehen. Die Internationale Kontinenz-Gesellschaft (ICS) hat im Jahr 2002 die Terminologie der instabilen Blase uberarbeitet und den symptomorientierten Begriff des Blasenuberaktivitatssyndroms geschaffen. Atiologisch kommen dafur eine neurogene und nichtneurogene Detrusorhyperaktivitat sowie die Detrusorhypersensitivitat in Betracht.

ORTHOTOPIC BLADDER SUBSTITUTION IN WOMEN: FUNCTIONAL EVALUATION

AbstractPurpose: Orthotopic bladder substitution following cystectomy in women has recently been introduced at some specialized centers. Studies of such a procedure should consider the oncological and functional outcomes. We analyzed only the functional results of orthotopic bladder substitution since followup is too short (about 2 years) for a valid oncological assessment.Materials and Methods: From October 1994 to November 1997, 60 women with a mean age of 48.3 years underwent standard radical cystectomy and orthotopic diversion (ileal W-neobladder with subserous tunnel in 47 and hemi-Kock reservoir in 13). The oncological criterion was organ confined invasive bladder cancer.Results: Ther…

Inhibition of human detrusor contraction by a urothelium derived factor.

Stimulating muscarinic receptors in pig bladder urothelium causes the release of a diffusable factor that inhibits contractions of the underlying detrusor muscle. We investigated whether the contractions of human detrusor strips elicited by the muscarinic agonist carbachol, electrical field stimulation, KCl or the neurokinin receptor agonist neurokinin A are affected by the urothelium.Paired intact and urothelium denuded muscle strips were placed in modified gassed Tyrode's solution at 37C. Cumulative concentration-response curves to carbachol or KCl were constructed. In other tissues the strips were stimulated electrically (1 to 40 Hz) with trains of square wave pulses 20 seconds in durati…

The Nutcracker Syndrome: New Aspects of Pathophysiology, Diagnosis and Treatment

Magnetic resonance imaging (MRI) was used to study vascular anatomy in 3 patients with the nutcracker syndrome and in 10 healthy volunteers. From these studies an abnormal branching of the superior mesenteric artery from the aorta was identified as being the cause of the nutcracker syndrome. Consequently, surgical transposition of the left renal vein to achieve an unobstructed renal venous backflow was performed successfully in 2 patients, while 1 underwent nephrectomy. In 1 patient adjuvant ureteral instrumentation became necessary to aid occlusion of persisting shunts between peripelvic venous varicosities and the urinary tract. Awareness of the pathophysiology of the nutcracker syndrome …

RETROVESICAL MASS IN MEN

We review the differential diagnosis and treatment of retrovesical masses in men.During the last 8 years 21 male patients 3 to 79 years old (mean age 47.1) presented with symptoms or signs of a retrovesical mass. Clinical features and diagnostic findings were reviewed, and related to surgical and histopathological findings.The retrovesical masses included prostatic utricle cyst in 3 cases, prostatic abscess in 1, seminal vesicle hydrops in 6, seminal vesicle cyst in 2, seminal vesicle empyema in 3, large ectopic ureterocele in 1, myxoid liposarcoma in 1, malignant fibrous histiocytoma in 1, fibrous fossa obturatoria cyst in 1, hemangiopericytoma in 1 and leiomyosarcoma in 1. In 17 patients …

Behandlung der Analsphinkterinsuffizienz durch sakrale Spinalnervenstimulation mit implantierten Neurostimulatoren

Die Anwendbarkeit der sakralen Spinalnervstimulation zur Behandlung der Stuhlinkontinenz wurde bei inkontinenten Patienten mit Analsphinkterinsuffizienz ohne einen klaren morphologischen Defekt untersucht. Mittels akuter perkutaner Stimulation der sakralen Spinalnerven mit Nadelelektroden wurde der im Hinblick auf die Funktion der quergestreiften Beckenbodenmuskulatur funktioneil relevantesten Spinalnerv (S3, S4) identifiziert und, um die therapeutische Potenz der Sakralnervstimulation zu prufen, mit Drahtelektroden temporar stimuliert. Bei vier Patienten wurden Elektroden zur permanenten Stimulation implantiert. Die chronische Stimulation der sakralen Spinalnerven verbesserte die anale Kon…

Sakrale Neuromodulation der Harnblase

Simplified Orthotopic Ileocecal Pouch (Mainz Pouch) for Bladder Substitution

Objective To report operative modifications that render construction of the orthotopic Mainz pouch more simple, namely formation of the pouch using absorbable staples and utilization of the ileocecal valve as an antireflux mechanism. Patients and methods Between January 2001 and May 2002 out of 92 cystectomy cases, 21 patients (20 males and 1 female) underwent a simplified orthotopic Mainz pouch. The ureters were implanted via Wallace or Nesbit technique in the supravalvular portion of the ileocecal valve. The mean (range) age was 58 (43 - 74) years and the mean follow-up is 11.6 months (range 1 - 27). Results No staple-related complications were encountered. Four renal units (8.8 %) were d…

Orthotopic bladder augmentation and substitution.

Orthotopic bladder augmentation or substitution using intestinal segments has become a standard procedure for many disorders that cause a loss of functional or anatomical bladder capacity. From the technical point of view, reservoir configuration by detubularizing the intestinal segments is the general practice. Various techniques exist, depending which types of segments and which techniques of ureteral implantation are used. Common problems include urinary incontinence, retention, metabolic disorders, and the possibility of secondary malignancies. As a result, research has been conducted into utilizing tissues other than intestine for bladder augmentation or substitution.

Reservoir characteristics of Mainz pouch studied in animal model

In a canine model of the Mainz pouch, intracavitary pressure and compliance were measured during instillation of isosmotic and hyperosmotic (900 mmol/kg water) solutions of saline. Wall properties of small- and large-bowel segments of the pouch were assessed individually by sonomicrometry. Intraluminal pressures increased more steeply during filling with hyperosmotic solution, resulting in reduced distensibility of small- and large-bowel segments. Additionally, instillation of the hyperosmotic solution resulted in increased amplitudes and frequency of intracavitary pressure waves. The results indicate that this was the result of a combination of intensified bowel contractions and an increas…

Sacral neuromodulation for treatment of lower urinary tract dysfunction

Despite initial reservations, sacral neuromodulation has begun to develop as a new therapeutic tool for the treatment of lower urinary tract dysfunction. It bridges the gap between conservative treatment options and highly invasive procedures, such as urinary diversion. At present, there are no clinical variables that can reliably predict the efficacy of neuromodulation in an individual patient. All patients, regardless of indication, must therefore undergo a test stimulation before they can be offered chronic sacral neuromodulation with an implanted system. Evaluations in various clinical trials have confirmed that sacral neuromodulation, based on unilateral sacral foramen electrode implan…

Chronic sacral neuromodulation for treatment of neurogenic bladder dysfunction: long-term results with unilateral implants

Abstract Objectives. To investigate the therapeutic value of sacral neuromodulation in patients with neurogenic disorders in whom conservative treatment options were unsuccessful. Neurogenic disorders may result in various forms of lower urinary tract dysfunction. Methods. Twenty-seven patients (19 women, 8 men) aged 18 to 63 years (mean 44.9 years) were subjected to percutaneous test stimulation of the sacral spinal nerves. Their urologic symptoms consisted of bladder storage failure (n = 15) due to detrusor hyperreflexia and/or bladder hypersensitivity, failure to empty due to detrusor areflexia (n = 11), and combined bladder hypersensitivity and detrusor areflexia (n = 1). Twelve patient…

Sacral bladder denervation for treatment of detrusor hyperreflexia and autonomic dysreflexia

Objectives. Detrusor hyperreflexia after spinal cord injury may cause urinary incontinence and chronic renal failure. In patients refractory to conservative treatment and not eligible for ventral sacral root stimulation for electrically induced micturition, we investigated the therapeutic value of sacral bladder denervation as a stand-alone procedure. Methods. Nine patients (8 men and 1 woman) between 21 and 58 years old (mean 30.2) with traumatic suprasacral spinal cord lesions underwent sacral bladder denervation for treatment of detrusor hyperreflexia and/or autonomic dysreflexia. Results. Detrusor hyperreflexia and autonomic dysreflexia were eliminated in all cases. Bladder capacity inc…

Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up

Abstract Objectives To assess the therapeutic value of left renal vein transposition for treatment of the nutcracker phenomenon in long-term follow-up. Methods Eight patients (4 women and 4 men) between 23 and 58 years old (mean 39.1) underwent transposition of the left renal vein for treatment of the nutcracker phenomenon associated with recurrent gross hematuria and flank pain. The postoperative follow-up was 41 to 136 months (mean 66.4). Results No perioperative complications were encountered. The postoperative complications comprised deep vein thrombosis (n = 1), retroperitoneal hematoma necessitating surgical revision (n = 1), and paralytic ileus that resolved with conservative managem…

RETRACTILE MESENTERITIS MIMICKING AN ADRENAL TUMOR

Retractile mesenteritis is a nonspecific inflammatory process involving the adipose tissue of the mesentery.1 It is a diagnostic challenge to identify this benign condition and, thus, avoid unnecessary surgery. Although approximately 100 cases have been published describing stomach and intestine involvement,z to our knowledge involvement of the urological organs has not been described previously. Consequently the urological literature lacks any information on this pathological entity. We report a rare case of retractile mesenteritis presenting as an adrenal tumor. were obtained and sent for frozen section, which revealed fibrotic tissue similar to retroperitoneal fibrosis. Due to the extens…

Perineal complications following radical perineal prostatectomy.

PURPOSE Radical perineal prostatectomy has recently attracted renewed interest and wider acceptance as an alternative route to the retropubic approach. While presumed lower morbidity is one reason for perineal prostatectomy we evaluated our patients for complications that are specific for the perineal approach. PATIENTS AND METHODS We have retrospectively analyzed 412 patients who underwent perineal prostatectomy from 10/1996 to 12/2000. Patients for the perineal approach were selected on the base of preoperative PSA (10 ng/ml) and biopsy Gleason score (< 7) without the need for simultaneous lymphadenectomy. A cystogram was performed routinely on day 7 p. o. and the catheter removed when pa…

Tumor in the Horseshoe Kidney: Clinical Implications and Review of Embryogenesis

We report on 3 patients with tumor in a horseshoe kidney, 1 of whom had bilateral tumor (renal cell cancer on the right side and urothelial cancer on the left side). Tumors that arise predominantly in the bridge of a horseshoe kidney can mimic the symptoms of an intra-abdominal disease process. Besides routine diagnostic procedures, angiography is essential to plan the surgical approach, which in principle should be organ-sparing. The literature of the embryology of the horseshoe kidney was reviewed for a relationship between the abnormal renal development and the site of tumorigenesis, and for development of a key for the wide variation of blood supply. Recently reported data suggest that …

Chronic sacral spinal nerve stimulation for fecal incontinence: long-term results with foramen and cuff electrodes.

PURPOSE: Sacral spinal nerve stimulation is a new therapeutic approach for patients with severe fecal incontinence owing to functional deficits of the external anal sphincter. It aims to use the morphologically intact anatomy to recruit residual function. This study evaluates the long-term results of the first patients treated with this novel approach applying two techniques of sacral spinal nerve stimulator implantation. METHODS: Six patients underwent either of two techniques for electrode placement: one “closed” (electrodes placed through the sacral foramen) and one “open” (cuff electrodes placed after sacral laminectomy). Follow-up evaluation of their continence status ranged from 5 to …

Schlingenplastiken in der Therapie der weiblichen Harninkontinenz

Traditionally, women with type III stress incontinence (intrinsic sphincter deficiency) are treated with sling procedures, which have undergone multiple modifications during the last 90 years regarding surgical approach, sling course, and materials. The latest variation of the established sling concept is the tension-free vaginal tape (TVT) procedure. The choice of sling material influences the postoperative complication rate and reveals a conflict between unrestricted availability (alloplastic material) and optimal tissue compatibility (autologous material). Although valid information about the surgical outcome of sling procedures is rare, at least some evidence-based conclusions may be dr…

CONVERSION FROM COLONIC OR ILEAL CONDUIT TO CONTINENT CUTANEOUS URINARY DIVERSION

ABSTRACT Purpose: After ileal or colonic conduit diversion some patients, particularly adolescents, desire conversion to a continent diversion to improve quality of life. We report our long-term results on conversion from conduit diversion to continent cutaneous diversion. Materials and Methods: Between 1986 and 2001, 39 patients (mean age 24 years, range 6 to 49) underwent conversion from a colonic (21) or ileal conduit (18) to an ileocecal pouch (Mainz pouch I) with a mean followup of 102 months (range 18 to 192). Conversion was performed after a mean of 11 years (range 1 to 36) of conduit urinary diversion by incorporating the preexisting colonic/ ileal conduit and the ileocecal pouch. R…