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OBJECTIVE To evaluate the factor age at the surgery on long-term postoperative outcomes in patients with postprostatectomy incontinence (PPI) after AdVance XP transobturator male sling implantation. METHODS A total of 115 male patients with PPI, who had undergone AdVance XP sling implantation, were included. Patients had PPI with endoscopically confirmed good sphincteric-contractility and a positive coaptive response. Kruskal-Wallis test with Dunn post-hoc tests were used to analyze the postoperative outcome differences between the patient groups aged less than 66, 66-75, and over greater than 75 years. Outcome measures were the 24 h pad test, the number of daily pads used, the International Consultation on Incontinence Questionnaire short form (ICIQ-SF), International Quality of Life Score (IQOL), Patient Global Impression of Improvement (PGI-I), International Index of Erectile Function-5 (IIEF-5), International Prostate Symptom Score (IPSS), and Visual Analog Scale scores. Observation time points were 3, 6, 12, 24, 36, 48, 60, and 84 months after surgery. RESULTS Between the age groups, there was no difference in the success rate of the procedure (defined as 0 pads/24 h and less than 5 g in the 24-h pad test) at any point in time. Subjective parameters measures using the ICIQ-SF, PGI-I, IQOL, and IPSS scores showed no differences between the two cohorts. Only erectile function (IIEF-5 score) was lower in older patients in comparison to the cohort aged less than 66 years (p

Objective: The aim of this study was to assess the security, value, and efficacy of the second-generation AdVance male sling XP (Boston Scientific®), after implementation in 2010 with advantageous modifications in the sling structure and needle shape, in a prospective multicenter long-term follow-up study. Methods: In total, 115 patients were included. Exclusion criteria were earlier incontinence (UI) surgery, nocturnal UI, former radiotherapy, or night-time incontinence. We also excluded patients with a functional urethra Results: The 24-month follow-up (114 patients) revealed 64.0% cured and 28.8% improved patients. Mean urine loss was reduced significantly to 19.0 g (p < 0.001). A mean PGI score of 1.5 and a mean VAS score of 0.2 were obtained. The 60-month follow-up (59 patients) revealed 57.6% cured and 25.4% improved patients. Mean urine loss was reduced significantly to 18.3 g (p < 0.001). A mean PGI score of 1.6 and a mean VAS score of 0.2 were obtained. Conclusions: The AdVance XP displays excellent continence results and secure effectiveness over a 5-year period. Moreover, these data are demonstrating low complication rates and improved quality of life in the long-term use of AdVance XP.

ZusammenfassungStatistisch gesehen sind weltweit mehr als 7 Mio. Menschen von einer Rückenmarkverletzung, darunter 2,7 Mio. von einer manifesten Querschnittslähmung, betroffen. In Österreich sind etwa 50.000 Patienten ausschließlich durch die Hilfe eines Rollstuhls mobil, davon sind etwa 4000 von einer Querschnittslähmung betroffen. Die Betreuung dieser Patienten stellt in der Praxis oft eine besondere Herausforderung dar. Große Bedeutung wird der Nachsorge beigemessen, die aufgrund spezieller Begleitumstände und der Komplikationsgefahren immanent wichtig ist. Aus urologischer Sicht ist eine neurourologische Betreuung unerlässlich. Dabei verändern sich die Therapieoptionen nach dem Maß des Verletzungsniveaus und sind zugleich geschlechterspezifisch. In diesem Artikel wird über die urologischen Aspekte der Versorgung von Frauen diskutiert, die von einer hohen Querschnittslähmung (Tetraplegie) betroffen sind.

OBJECTIVE To evaluate the efficacy and safety of the AdVance XP male sling in a midterm follow-up for the treatment of male urinary incontinence in a selected patient cohort. MATERIALS AND METHODS In all, 115 patients with postprostatectomy incontinence were prospectively enrolled. A previous endoscopic evaluation of a sufficient coaptive zone in the repositioning test was mandatory. Patients with urine leakage in supine position or previous incontinence surgery were excluded. Postoperatively a standardized 24-hour pad test and pad usage were evaluated. To compare pre- and postoperative continence status nonparametric t test was used. A P-value of

Intralesional mitomycin C after direct visual internal urethrotomy for recurrent urethral stricture disease in patients suboptimal for open urethroplasty is an established option. We report a case of urethro-cavernosal-spongiosal fistula after intralesional mitomycin C into an area of previous dorsal inlay urethroplasty. The patient presented with pus draining from the urethral meatus ten days after treatment. Sterile abscesses developed within the corporal and spongious bodies, draining freely into the urethra. Complete spontaneous healing followed short-term transurethral catheterization and antibiotic prophylaxis.

The adjustable transobturator male system (ATOMS) treats post-prostatectomy urinary incontinence by compression of the proximal bulbous urethra. It reminds of the Kaufman prosthesis described in 1978. We describe a case where an excessive fibrotic reaction occurred around the cushion. Furthermore, the bulbous urethra underneath, developed severe atrophy devoid of any visible blood supply. We suspect ongoing shear forces around the cushion while sitting resulting in a chain reaction of acute through chronic inflammation and progressive fibrosis and encapsulation. Does the encapsulation lead to capsular contracture resulting in non-function?

A failed end-to-end anastomosis after membranous urethral distraction injury post-trauma is a surgical challenge. We present a case of a young man after complex pelvic injury. Revision urethroplasty was done utilizing nerve and vessel sparing techniques. Intrasphincteric dissection enabled bulbous urethral pull-through with intrapelvic anastomosis with good success. Low dose tadalafil was given to optimize penile rehabilitation.

Bladder neck closure after severe polytrauma with an absent urethra poses a huge challenge for a young woman wanting to urinate normally. Considerations are reconstruction of a neourethra and operative means to gain continence. We describe a case of trigonal tubularization to function as a neourethra, together with the implantation of an artificial urinary sphincter. Eleven years after suffering from an open book pelvic rim fracture at 18 years, successful reconstruction of a trigonal neourethra enabled continence and residual-free spontaneous voiding at 29 years.

Aggressive angiomyxoma is a rare mesenchymal neoplasm, occurring mainly in females. It is located in the pelvis and perineum, with known metastasis and hormone sensitivity only in females. Local recurrence is relatively common. We describe the case of a 62-year-old man who presented with symptoms and signs of a spermatocele. Scrotal exploration with surgical excision of the lesion was done. Because a benign setting was assumed, no radical inguinal orchiectomy was performed. The specimen sent to pathology confirmed an aggressive angiomyxoma with positive resection margins. Despite the plurality of benign scrotal masses such as spermatoceles or hydroceles, rare neoplasms should always be kept in mind. Hence, complete excision should be performed whenever possible. We selected an active surveillance strategy despite positive margins, since there is no described case of metastasis in men to date. Therefore, regular scrotal ultrasound examinations every 3 months were arranged as follow-up.

Background A supernumerary kidney (SK) is an additional kidney with its own capsule and blood supply that is not fused with the ipsilateral kidney (IK). Because individual case reports indicate a high morbidity rate, the aim of this retrospective study was a detailed analysis of this rare anatomical variant. Methods Our systematic imaging-based search for SKs, conducted in the period from 2000 and to 2017, yielded 9 cases in total (5 men, 4 women; mean age: 51.8 ± 22.8 years). Results The SKs were observed on the right in six and on the left side in three cases. In six subjects (66%) they were located caudal and in three cases (33%) cranial to the ipsilateral kidney. Calculi were found in three (33%) of the renal collecting systems. Five (56%) of the SKs had hydronephrosis grade IV and one SK had recurrent pyelonephritis (11%). Two of the ureters opened into the ipsilateral seminal vesicle (22%). Two (22%) SKs were functional but atrophic. Clinically relevant findings were made in 33% of the IKs: atrophy (n = 2), calculi (n = 1), and reflux with recurrent pyelonephritis (n = 1); another 33% had anatomical anomalies without functional impairment. The correct diagnosis of a SK is possible using CT imaging in all subjects. The prevalence of SK based on CT imaging can be estimated to be 1:26750. Conclusions CT is the method of choice for visualizing SKs. The correct diagnosis is crucial in preventing dispensable surgical procedures and for providing optimal patient treatment and outcome.

Prolonged low-flow priapism causes structural impotence. We describe a case where potency has been preserved by off-centre corporal dilation to spare the cavernosal arteries. The patient suffered from idiopathic priapism lasting more than 72 hours before presentation. Corporoglanular shunts were performed thrice over a period of six days, twice also performing off-centre corporal dilation along the inside of the tunica. The idea was not to damage the central cavernosal arteries. Corporal blood supply spontaneously improved. Successful intercourse was possible after six months. Artery sparing cavernosal dilation techniques might improve spontaneous recovery in select cases. Keywords: Priapism, Corporoglanular shunt, Cavernosal artery sparing dilation, Potency

INTRODUCTION AND OBJECTIVES:In recent years, several studies have shown the effectiveness and safety of the AdVance sling (Boston Scientific, formerly American Medical Systems) for treating male st...

Cuff erosion at the bladder neck of an implanted artificial urinary sphincter (AUS) needs complete explantation of the device. The subsequent scar tissues predispose to repeated cuff erosion, when another AUS is implanted with the cuff at a similar location. We describe a paraplegic patient with exstrophy-epispadias complex that suffered from an AUS cuff erosion at the bladder neck. We use a novel perineal-retropubic route for cuff placement, with preparation similar to a retropubic male sling. At 12 years follow-up the AUS is still functional and the patient continent.

Lapides has revolutionized the treatment of neurogenic patients by introducing routine intermittent catheterization in 1971. This drastically lowered mortality from urosepsis. Scott introduced the artificial urinary sphincter (AUS) in 1972. This gave a completely new perspective for incontinent patients by dramatically increasing the quality of life. In patients with neurogenic urinary incontinence, the principles of care are preserving renal function, maintaining a low-pressure reservoir, allowing unobstructed urine flow and providing continence. We describe a male patient that received an AUS with a bladder neck cuff that functioned without revision for 29 years. After 30 years, AUS exchange proved successful.

For the treatment of persistent post-prostatectomy incontinence (PPI), several surgical treatment options including male slings are available. In 2010, the second generation of the retrourethral male sling Advance, AdVanceXP, was introduced. Aim of the study was to examine in a prospective multicentre study the outcome of AdVanceXP in the treatment of PPI.Ninety-four patients were treated with AdVanceXP. Patients with nocturnal incontinence, previous incontinence surgery, with coaptive zone1 cm and irradiated patients were excluded. Measurements included: daily pad usage, 24-h pad weight test, post-operative pain in the visual analogue scale, International Quality of Life questionnaire, International Consultation on Incontinence Questionnaire short form, IEEF5 and Patient Global Impression of Improvement. Adverse events were recorded. All patients with no pads and 0-5 g in the 24-h pad test were defined as cured and those with a reduction in urine loss50 % as improved.Preoperatively, the median 24-h pad weight test was 274 g and daily pad usage was 3. At 1-year follow-up, 66.3 % of patients could be classified as cured and 25.3 % as improved. After 2 years, 73.1 % could be classified as cured and 19.6 % as improved. Urine loss decreased (p 0.001), and quality of life improved significantly (p 0.001). Mean PGI was 1.5 after 1 year and 1.4 after 2 years. Majority of complications were minor. No intraoperative complications and five serious post-operative events occurred (grade IIIB complications). No explantation was necessary.AdVanceXP, when correctly indicated, shows good effectiveness and low complication rates after up to 2 years.

The question is whether the urethral sphincter may be reconstructed after longitudinal injury similar to anal sphincter injuries. Analogue to obstetric, anal sphincter repair, an approximation repair of the sphincter may be feasible. An overlap repair is possible in anal sphincter repair, but because of the little tissue available in the urethral sphincter this is not an option. We describe three cases of urethral sphincter injury of different aetiologies. All resulted in a total longitudinal disruption of the muscular components of the urethral sphincter complex. After making the diagnosis of urethral sphincter injury, a primary approximation repair was done. Follow-up of at least two and up to three years is promising with one male patient being completely continent and the two female patients needing one safety pad per day. Longitudinal disruption of the muscular elements of the sphincteric urethra may be primarily reconstructed with good success using an approximation technique with simple interrupted sutures.

To establish a method for estimating the probability of renal artery stenosis (RAS) based on the calcium volume score of the aorta (ACS).In a retrospective observation study, CT angiographies acquired on a 64-slice MDCT scanner were analyzed for 1351 patients (female: 531; male 826; mean age 60.9 ± 17.7 years). A volumetric scoring method was used, detecting plaques with a density of more than 600 HU.13.8% of the patients showed a stenosis50%, 4.1% a stenosis70%. The ACS was 0.61 ± 1.01 ml calcium. The sensitivity for detection of RAS50% and RAS80% was 0.9572 and 1.0, respectively. The negative predictive value (NPV) of a lack of calcification for excluding RAS50% and RAS80% was 0.9752 and 1, respectively. As ACS increased, the specificity for RAS50% increased to 0.9390. With an ACS of 0.380 ml, accuracy reached a maximum of 0.6585. ROC analyses yielded an area under the curve of 0.88 (p0.0001). Sensitivity, specificity, NPV and PPV are indicated in relation to the degree of RAS, as well as the diagnostic yield of the method, which is valuable in patients older than 50 years.Due to its extremely high sensitivity and NPV, the ACS is a very useful screening method for RAS. The validity of the method, as well as its diagnostic value is equivalent to that of coronary artery calcium scoring. Lack of calcifications of the aorta renders atherosclerotic RAS highly improbable.

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.Examine the intermediate-term outcome with the AdVance sling for PPI management.A multicentre prospective evaluation was conducted on consecutive patients treated for PPI in three European tertiary reference centres.Patients were implanted with the AdVance male sling with no associated surgery.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.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 (p0.0001). 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.The transobturator retroluminal repositioning sling suspension is effective and safe in the longer term for treating PPI.

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.

The AdVance ® male sling (American Medical Systems, Minnetonka, MN, USA) is a retrourethral transobturator sling that offers an effective surgical approach for the treatment of postprostatectomy stress urinary incontinence (SUI). Clinical studies have demonstrated success rates of 80–90% at 1-yr follow-up. The most appropriate candidate patients for the AdVance ® sling may be those with mild to moderate incontinence, but success rates may not be markedly lower in patients with severe incontinence. Clinical experience with the AdVance ® sling suggests that cystoscopically confirmed residual sphincter function is an important requirement for good outcome. Assessment of SUI should be modified to include a consideration of sphincter function in addition to the currently accepted definitions of incontinence severity (pad weight and number). The AdVance ® male sling may be considered a first-line surgical treatment as well as a salvage treatment for some patients who have failed previous surgical treatment. More data are needed to better understand the patient-related factors that affect the short- and long-term outcomes of this minimally invasive treatment for male SUI.

A number of anatomic components work in concert to produce precise control of micturition in the healthy male, including the sphincter with its striated and smooth muscle components, the surrounding muscular and ligamentous support structures, neural components, and the urothelium. Radical prostatectomy is often associated with injury to one or more of these tissues, culminating in stress urinary incontinence (SUI). Although the causes of urinary incontinence can vary, among patients with residual urethral sphincter function, the increased laxity and reduced functional length of the membranous urethra are thought to play key roles in incontinence. Most surgical treatments for urinary incontinence, such as the artificial urinary sphincter and various slings, achieve continence via compression of the urethra, but the AdVance ® transobturator retrourethral sling (American Medical Systems, Minnetonka, MN, USA) repositions the urethral sphincter complex back into the pelvis and increases the functional membranous urethral length. Emerging reports on the AdVance ® sling suggest favourable cure rates and few complications. Thus, the AdVance ® sling provides an alternative approach to treating postprostatectomy SUI that is both less obstructive and more dynamic.

Aim: Prostate biopsies are usually done with transrectal ultrasound (TRUS) in B-mode (B TRUS) but multiparametric MRI (mpMRI) is the gold imaging standard for the visualization of clinically significant prostate cancer (PCa), since a lowPCa detection rate is reported for B TRUS. The aim of this study was to assess the visibility of MRI lesions on B TRUS and to determine which factors may influence the visibility on B TRUS.Material and methods: 142 men with 148 lesions reported on mpMRI underwent a B TRUS/mpMRI fusion targeted biopsy of the prostate and were included in this retrospective study. During the biopsy, images were obtained and stored in the institution’s PACS. These images were reviewed by two radiologists to determine, whether an mpMRI lesion was or was not visible on B TRUS.Results: Overall 92 from 148 mpMRI lesions (62.2%) were visible on B TRUS. The location of the lesion in the prostate, the PIRADS classification of the lesions and the size of the lesion had no significant influence on the visibility on B TRUS. Only the prostate volume had a significant influence on visibility: in smaller prostates significantly more lesions were visible on B TRUS than in large glands (p+0.041; 45.1 ml vs 54 ml).Conclusion: The use of newer high-end ultrasound units as well as experience gained from fusion biopsies enables us to see 62.2 % of all suspicious mpMRI lesions on B TRUS. B TRUS images merit a thorough examination during a conventional biopsy setting.

Study Type – Therapy (outcomes research) Level of Evidence 2c OBJECTIVE To evaluate the efficacy and safety of a transobturator retroluminal repositioning sling suspension in the treatment of male stress urinary incontinence (SUI) after prostate surgery. PATIENTS AND METHODS In 118 men with SUI after prostatic surgery, a transobturator retroluminal repositioning sling suspension was implanted. Patients were evaluated including: complete history and physical examination, 24-h pad test, a questionnaire (International Consultation on Incontinence Questionnaire, Short-Form), urodynamic evaluation and endoscopy. The surgical technique was described previously. The findings before and at 1 year after sling placement were compared. RESULTS At the 12-month follow-up, 73.7% of the men were cured, 16.9% were improved, and 9.3% were still incontinent. After sling placement the daily pad use decreased significantly (P < 0.001), while the ICIQ-SF improved significantly (P < 0.01). The detrusor voiding pressure, postvoid residual urine volume and maximal flow rates remained unchanged, while the Valsalva leak-point pressure improved significantly (P < 0.01). In 19.5% of the men, there was transient scrotal pain or perineal discomfort. In 5.1% of the men, postoperative urinary retention occurred but resolved spontaneously after a few weeks of catheter placement. In 1.7% of the men adductor pain was reported, which resolved spontaneously. There were no major complications. CONCLUSION The transobturator retroluminal repositioning sling suspension for the treatment of male SUI is effective and safe with a low complication rate after 1 year of follow-up.

OBJECTIVE • To evaluate the success of endoscopic dextranomer/hyaluronic acid copolymer (DHAC) application in the treatment of patients with recurrent urinary tract infections (UTIs) and vesico-ureteric reflux (VUR) into the transplanted graft after renal transplantation. PATIENTS AND METHODS • Between January 2008 and April 2009, 19 patients with recurrent UTIs presented VUR proven by voiding cystourethrography. • To correct VUR of the transplanted ureter, DHAC was injected endoscopically using hydrodistention technique. • Pre- and postoperative serum creatinine levels, the number of pre- and postoperative UTIs, postoperative complications and reflux resolution rate were recorded. The mean follow-up was 6.5 months. RESULTS • The average number of UTIs was reduced significantly from 4.89 (range 2-14) to 1.31 (range 0-4) on pre- and postoperative follow-up, respectively, of 6 months (P < 0.001). The success rate increased from 57.9% after the first injection to 78.9% after the second injection. • The remaining four patients with residual VUR received long-term low dose antibiotic prophylaxis. In total, two (10.5%) patients developed increasing creatinine levels postoperatively as a result of distal ureteral obstruction, and temporary urinary drainage was necessary in both patients. CONCLUSIONS • DHAC appears to be an efficient and minimal invasive method for treating VUR after renal transplantation with respect to short-term success. • Further investigation with a larger group of patients and longer follow-up is needed to evaluate the prolonged effect, as well as any potential side effects.

Study Type – Diagnosis (exploratory cohort) Level of Evidence 2b OBJECTIVE To correlate a subjective blood-flow rating scale from contrast-enhanced colour Doppler (CECD) transrectal ultrasonography-targeted prostate biopsy with the histopathological outcome of the biopsy. PATIENTS AND METHODS In all, 760 men with a serum total prostate-specific antigen (PSA) level of ≥1.25 ng/mL and a free-to-total PSA ratio of

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To report a new dorsal labia minora skin-graft urethroplasty as a simple, safe and effective therapeutic alternative for female urethral strictures, as although distal urethral strictures can be treated by meatoplasty, proximal and mid-urethral strictures need appropriate urethroplasty. PATIENTS AND METHODS Eight women with a confirmed proximal or mid-urethral stricture had indications for urethroplasty with the use of a thin free labia minora skin graft using a dorsal (6 o’clock position) urethroplasty technique. Full informed consent was obtained. From the inner aspect of one labium minora a thin free skin flap was prepared. The strictured urethra and the anterior vaginal wall were transected and the graft sutured into the defect. All scar tissue was removed and the anterior vaginal wall closed in two layers over the area of the urethroplasty. Continence was evaluated by a stress test with a full bladder. RESULTS All patients were operated on with no complications during or after surgery. After 1 and 2 years of follow-up seven and six of the eight patients had no recurrence of stricture disease. All patients remained continent. CONCLUSION The urethroplasty using an inlay of free thin genital skin graft was safe, uncomplicated and effective.

Ultrasound is a widely used imaging modality for evaluation of the prostate. The main topic of diagnostic imaging is an improvement of prostate cancer diagnosis. The current available systematic prostate biopsy is performed only under ultrasound guidance, but new imaging techniques allow prostate cancer visualization and therefore improved detection. Evolving methods such as contrast-enhanced colour Doppler imaging, contrast-specific ultrasound techniques and elastography may dramatically change the role of ultrasound for prostate cancer diagnosis. The purpose of this review is to provide an overview of ultrasound and its different techniques for imaging of the prostate and to discuss current trends and future directions.

Purpose: To compare the detection of urinary stones using standard gray scale ultrasound for diagnostic accuracy using the color Doppler "twinkling sign". Material and Methods: Our study population consisted of forty-one patients who demonstrated at least one urinary stone on unenhanced CT evaluation of the kidneys or ureters. Each patient was evaluated using gray scale ultrasound and color Doppler imaging by an observer who was blinded to the CT results. Results: Seventy-seven stones were present in 41 patients, including 47 intrarenal stones, 5 stones in the renal pelvis, 8 stones at the ureteropelvic junction, 5 ureteral stones and 12 stones at the ureterovesical junction. Based upon gray scale sonography the diagnosis of stone was made with confidence in 66% (51/77) of locations. Based upon Doppler sonography using the twinkling sign, the diagnosis of stone was made with confidence in 97% (75/77) of locations. Clustered ROC analysis demonstrated that the Doppler twinkling sign (Az = 0.99) was significantly better than conventional gray scale criteria (Az = 0.95) for the diagnosis of urinary stones (p = 0.005, two-sided test). Conclusions: The color Doppler twinkling sign improves the detection, confidence and overall accuracy of diagnosis for renal and ureteral stones with minimal loss of specificity.

OBJECTIVE 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. PATIENTS AND METHODS The findings and images of 209 patients with fused kidneys (FKs) were reviewed; in all, 244 scans from computed tomography (CT), 233 ultrasonograms and 89 micturition cysto-urethrograms, urograms, magnetic resonance images and angiograms were taken. RESULTS HKs (found in one of 474 abdominal CT scans) and CFEs (found in one of 3078 CT scans) showed a high variability of vasculature that could not be classified. However, some generalized conclusions were possible about the renal vasculature (430 arteries in 103 kidneys). Variants of the most cephalad artery of both sides were rare. The second artery on the right had a pre-caval course. The origins of vessels located further caudal were more ventral. CFEs were anatomically different from HKs with respect to lower position, greater axial rotation, smaller pelvic width, more caudal origin, and fewer vessels, but not in accompanying anomalies. Severe anomalies or malformations were found in 23% of patients, with half of them in the urogenital system. Malformations were found considerably more often in children than in adults. There was no increased incidence of diseases such as stones or inflammation of the renal pelvis. CONCLUSION Concomitant anomalies and diseases were equally frequent for HK and CFE, but less frequent than generally assumed. Individual cases of complex anatomical situations require special examination strategies, and CT appears to be the most reliable imaging method.

The ever rising number of radical prostatectomies entails an increasing number of patients suffering from postoperative stress incontinence. Several minimally invasive techniques exist as surgical intervention options. All these procedures are based on an obstruction of the urethra. The functional retrourethral sling is a new and innovative sling suspension, which offers for the first time a non-obstructive functional therapeutic approach. The sling adjusts the changed anatomy after radical prostatectomy and exerts its effect by repositioning the lax and descended supporting structures of the sphincter in the former preoperative position. Thus continence can be achieved again. The success rate of this new technique is very good, yielding good results regarding both improving incontinence and continence rate. This new technique is secure and the results are reproducible.

This is a report of a case of a 26-year-old patient suffering from progressive renal insufficiency with a neurogenic bladder disorder due to a lipomyelomeningocele. She had renal agenesis on the left side and grade III hydronephrosis of both segments of a right duplex kidney with a bifid ureter joining further distal to the kidney. Both ureters were dilated. The cause was found to be a yo-yo reflux between the two halves of the kidney. Following bladder augmentation and pyelopyelostomy, renal insufficiency improved to stage III and has now been stable for four years. Due to the contralateral renal agenesis, the case is a unique illustration of the functional effect of the yo-yo reflux and pyelopyelostomy.

The proximal urethral bulb in men is enlarged, surrounds the bulbous urethra, and extends dorsally towards the perineum. During intercourse engorgement takes place due to increased blood flow through the corpus spongiosum. Antegrade ejaculation is facilitated by contraction of the bulbospongiosus muscles during climax. Micturition during sexual stimulation is functionally inhibited. Supporting the bulb may indirectly facilitate continence in a certain subset of patients with postprostatectomy incontinence. During physical activity with increased abdominal pressure, reflex contraction of the pelvic floor muscles as well as the bulbospongiosus muscles occurs to support sphincter function and limit urinary incontinence. Operations to the prostate may weaken urinary sphincter function. It is hypothesized that the distal urinary sphincter may be supported indirectly by placing a hammock underneath the urethral bulb. During moments of physical stress the “cushion” of blood within the supported corpus spongiosum helps to increase the zone of coaptation within the sphincteric (membranous) urethra. This may lead to urinary continence in patients treated by a transobturator repositioning sling in patients with postprostatectomy incontinence. This paper describes the possible role of the urethral bulb in male urinary continence, including its function after retroluminal sling placement (AdVance, AdVance XP® Male Sling System, Minnetonka, USA).

The primary goal in neurourologic management of patients with myelomeningocele is the preservation of renal function. In addition, achieving continence or at least improving urinary incontinence becomes imperative given the impact of continence on quality of life. Initial neurourologic and urodynamic examination of children with myelomeningocele is strongly recommended as early as possible, ideally on the day of birth or within 2 weeks after closure of the myelomeningocele defect. Examination is decisive for the therapeutic strategy as it allows definition of the dysfunctional pattern of the lower urinary tract and detection of risk factors (low bladder compliance, intravesical pressure > 40 cm H2O, detrusor sphincter dyssynergia) before major upper urinary tract changes occur. Thereby, the appropriate treatment can be initiated to preserve both upper and lower urinary tract function and to achieve urinary continence.

Objective To study the anatomical effects of placing a transobturator tape (TOT) in cadavers as well as determining the clinical outcome in men with urinary incontinence. Methods The study was a two stage study. The first phase was a cadaver study to examine the placement of the sling. The second part involved the placement of the sling in 20 men with incontinence, which occurred post-radical prostatectomy in 15 men. All patients had pre-operative and post-operative videourodynamics, maximum flow rate (Qmax) and residual urine measurement. Urethral pressure profiles and membranous urethral length were measured in five patients pre- and postoperatively. Incontinence was assessed on the basis of pad usage. Patients' satisfaction was recorded using a non-validated patient questionnaire at 6 weeks post-operatively. Results The cadaver study revealed that a leak point pressure of 60cmH 2 O was achieved on tensioning of the tape. In the clinical series, the mean (range) urethral closure pressure improved from 13.2 (8–22) to 86.4 (70–100) cmH 2 O following placement of the TOT. The membranous urethral length increased from a mean (range) of 3 (0–7) to 17.2 (10–22) mm following tensioning of the tape. No significant differences in Qmax pre- and postoperatively were observed. Incontinence cure rate (no pad usage) was 40% and improved rate (1–2 pads per day) was 30%. The majority of patients (12/20) were very satisfied with the procedure. Conclusions The TOT, a novel procedure for treatment of post-radical prostatectomy incontinence, was shown to be effective and well accepted by patients.

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.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.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.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.

Objectives The present retrospective study was designed to investigate the value of transition zone (TZ) biopsies for prostate cancer (PC) detection rate in a combined contrast enhanced color Doppler targeted (CECD) and gray-scale systematic biopsy (SB) approach. Methods PSA screening participants totalling 1475 with tPSA of >1.25ng/ml (fPSA≤18%) were assessed. Ten SB and additionally 5 or fewer CECD were performed. The impact of TZ biopsies on the PC detection rate and the biological significance of the detected TZ-cancers were analyzed. Results Out of 1475 biopsied patients, 395 (26.8%) were identified as PC patients; 5925 biopsy cores from these patients were analyzed. In 86 patients (21.8% of PC), we found 102 PC- positive cores in the TZ, and only in 9 of them solitary TZ-cancers without any other PC-location (2.3% of PC or 0.6% of all investigated patients). Pathologic findings after retropubic prostatectomy (RPE) revealed multifocal adenocarcinoma including involved peripheral zone (PZ) in eight of these nine patients, and solitary TZ-cancer in one patient. There was no positive correlation between prostate volume and TZ-detection rate and no patient with solitary TZ-PC after rebiopsy. Conclusion Biopsy revealed 9 solitary TZ cancers (1.8%) and RPE revealed only one of them to be truly TZ-confined cancer (0.6%). Furthermore PC-detection did not improve, even in patients with rebiopsy, and there was no correlation between detection of TZ-cancers and prostate volume. A combined use of CECD and SB to investigate participants of a PSA-screening program suggests that TZ-biopsies do not improve PC detection rate and are therefore unnecessary.

In der transrektalen dreidimensionalen Sonographie ist es erstmals moglich, das zu untersuchende Areal gleichzeitig in 3 Schnittebenen zu analysieren. Dadurch kann eine sehr genaue Beurteilung der anatomischen Strukturen des kleinen Beckens und der Beckenbodenregion durchgefuhrt werden. Mit Hilfe dieser neuen Untersuchungstechnik konnen die Glandulae bulbourethrales routinemasig untersucht sowie Zysten dieser Drusen diagnostiziert werden. Die Zonen der Prostata und ihre Relationen zueinander, insbesondere das Wachstum der Transitionalzone im Rahmen der benignen Prostathyperplasie, konnen exakt bestimmt werden. Die transrektale 3D-Sonographie ermoglicht auch, die Morphologie und die Funktion des Rhabdosphinkters zu untersuchen und zu quantifizieren. Die 3D-sonographisch gezielte Punktion und Drainage von Prostataabszessen stellt ein attraktives und minimal-invasives Behandlungsverfahren dar. Diese Methode kann generell zur Punktion und zur Applikation von Nadeln oder Implantaten im unteren Harntrakt eingesetzt werden. Die transrektale dreidimensionale Sonographie bietet somit neue diagnostische und therapeutische Moglichkeiten bei der Beurteilung von Veranderungen des unteren Harntraktes.

Objectifs Evaluer l’efficacite et la tolerance des bandelettes sous-uretrales AdVanceTM pour le traitement de l’incontinence urinaire d’effort persistante apres chirurgie prostatique. Methodes Il s’agit d’etude observationnelle prospective multicentrique portant sur des patients souffrant d’une incontinence urinaire d’effort persistante apres prostatectomie totale ou resection endo-uretrale. Les patients inclus avaient un pad-test de 24 h inferieure a 250 g. La bandelette etait implantee par voie perineale selon la meme procedure. Les patients etaient revus a 6 semaines, 3, 6, 12 et 24 mois. La continence etait evaluee par le pad-test de 1 h et de 24 h, par le nombre de protection et par le questionnaire ICIQ-SF. La qualite de vie associee a l’incontinence etait recueillie par le questionnaire I-QoL. Les complications peri-operatoires et tardives ont ete repertoriees. Resultats Entre janvier 2007 et novembre 2012, 113 patients sur 114 inclus ont ete implantes avec succes. A 24 mois de l’intervention, le pad-test de 1 h moyen a diminue de 48,7 g a 6,6 g ( p p Conclusion La bandelette sous-uretrale AdVance TM est un traitement efficace de l’incontinence urinaire d’effort modere. Les complications sont rares et les resultats a 24 mois satisfaisants.

Study Type – Diagnosis (case series) Level of Evidence 4 OBJECTIVE To compare the results of contrast-enhanced colour Doppler (CECD)-targeted prostate biopsy with a systematic 10-core grey-scale biopsy scheme in patients initially diagnosed with high-grade prostatic intraepithelial neoplasia (HGPIN), as although HGPIN is thought to be a precursor to invasive adenocarcinoma, its diagnosis is no longer considered an indication for repeat prostate biopsy and patients should be followed by prostate-specific antigen levels and a digital rectal examination. PATIENTS AND METHODS In all, 104 patients (aged 45–78 years) diagnosed with HGPIN on initial prostate needle biopsy were referred for a repeat biopsy within 6 months. Two independent examiners evaluated each patient; one used CECD-targeted biopsy (up to five cores) into hypervascular regions in the peripheral zone only, and subsequently the second took a systematic 10-core grey-scale biopsy. Cancer detection rates of both techniques were compared. RESULTS Overall, 26 of the 104 men (25%) had prostate cancer in the repeated biopsy. Using the CECD technique cancer was detected in 21% (22 of 104). The positive re-biopsy rate using the systematic technique was 9.6% (10 of 104; P

Objective To determine the assumed influence of the number of renal arteries, the distribution and extent of renal artery stenosis (RAS), and the kidney length on calcified aortic atherosclerotic plaque burden. Methods The computed tomographic angiographies of 1381 patients were analyzed retrospectively using a volumetric aortic calcium scoring method. The Spearman method was used to calculate the correlation between kidney length, number and diameter of renal arteries, as well as number, degree, and location of RASs on main or additional renal arteries with the extent of aortic atherosclerosis. Logistic regression analyses were conducted with the target variable “calcification present or absent.” Results Patients with multiple renal arteries (38.3%) had lower plaque volumes than patients without such variants (0.55 ± 0.97 vs 0.64 ± 1.06 mL; P < 0.05). Renal artery stenoses affected all renal vessels with equal frequency. The aortic calcium score correlated with the number of RASs ( P < 0.0001) and the maximum degree of RAS up to a threshold of 60%. Location of an RAS in the various renal arteries was irrelevant. In regression analyses, the presence of RAS (Wald = 5.523), the degree of RAS (Wald = 6.251), and age (Wald = 223.1) were positive predictors of the aortic calcium score, whereas kidney length (Wald = 9.564) proved to be a negative predictor. Conclusion The aortic calcium score correlates with both the number of RASs and the maximum degree of RAS up to a threshold of 60% but correlates inversely with the number of renal arteries. Renal artery stenosis affects all renal vessels with equal frequency, and this finding should be considered in screening procedures.

Objectives: We evaluated whether real-time 3D ultrasound (4D-US) together with clinical evaluation is an alternative to voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR) in children at postoperative follow-up. Material and Methods: We reviewed 178 children who underwent endoscopic therapy with dextranomer/hyaluronic acid copolymer in grade II or III VUR between 2002 and 2005. 4D-US was performed in all patients 1 day and 3, 9 and 18 months after endoscopic therapy. Only children with postoperative urinary tract infections (UTIs) and/or nonorthotopic position of the bulking agent were referred for VCUG. Results: In 93% of the ureteral units, the depot could be detected in the orthotopic position after 3, 9 and 18 months. None of these children developed UTIs in the postoperative follow-up. Twelve children demonstrated a shifting of the depot, indicating a possible therapy failure. Eight of these 12 patients (66.7%) presented a positive VCUG, and 50% of them sustained UTIs. Conclusions: 4D-US seems to be a sufficient protocol in the follow-up of children after endoscopic treatment of low-grade VUR. VCUG should be performed in cases of a shifted position of the depot; invasive investigations are unnecessary in asymptomatic children with orthotopic bulk.