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Introduction: Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. Method: We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. Results: Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60–145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. Discussion: The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. Conclusion: Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

To investigate the predictors of recurrence and of de novo incontinence in patients treated by transurethral incision or resection for vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy. All patients undergoing endoscopic treatment for VUAS between March 2009 and October 2016 were identified in our multi-institutional database. Digital chart reviews were performed and patients contacted for follow-up. Recurrence was defined as any need for further instrumentation or surgery, and de-novo-incontinence as patient-reported outcome. Of 103 patients undergoing endoscopic VUAS treatment, 67 (65%) underwent transurethral resection (TR) and 36 (35%) transurethral incision (TI). TI was performed more frequently as primary treatment compared to TR (58% vs. 37%; p = 0.041). Primary and repeated treatment was performed in 46 (45%) and 57 patients (55%), respectively. Overall, 38 patients (37%) had a history of radiation therapy. There was no difference in time to recurrence for primary vs repeat VUAS treatment, previous vs no radiation, TR compared to TI (all p > 0.08). Regarding treatment success, no difference was found for primary vs. repeat VUAS treatment (50% vs. 37%), previous radiation vs. no radiation (42% vs. 43%), and TR vs. TI (37% vs. 53%; all p ≥ 0.1). Postoperative de novo incontinence was more common after TI vs. TR (31% vs. 12%; p = 0.032), no difference was observed for previous radiation therapy vs. no radiation therapy (18% vs. 18%; p > 0.9) or primary vs. repeat VUAS treatment (22% vs. 16%; p = 0.5). VUAS recurrence after endoscopic treatment is not predictable. Endoscopic treatment with TI showed a higher risk for de novo incontinence than TR, and previous irradiation and the number of treatments do not influence incontinence.

Thulium laser enucleation of the prostate (ThuLEP) is an established treatment option for benign prostatic enlargement (BPE), but long-term outcomes have not yet been reported.To prove the durability of ThuLEP by investigating its long-term efficacy and morbidity.All patients who underwent ThuLEP at a German tertiary referral center between 2009 and 2021 were retrospectively followed up for reinterventions for persistence or regrowth of prostate adenoma (ReIP) or long-term complications (ReIC).ThuLEP.We calculated the cumulative incidence for ReIP and ReIC at 10 yr. Univariate and multivariate Cox regression models were constructed to identify predictors of ReIP and ReIC.Overall, 1097 patients underwent ThuLEP. The median overall follow-up was 6.0 yr (interquartile range [IQR] 2.4-9.2). For one-third of patients (n = 369), median follow-up of 10 yr (IQR 9.1-11.2) was available. A total of 42 patients (3.8%) underwent ReIP after a median of 2 yr (IQR 0.3-4.9). The rate of long-term ReIC was 2.6% (n = 29) and the median time to ReIC was 0.5 yr (IQR 0.3-1.7). The most frequent ReIC was urethrotomy (n = 16, 1.5%). The cumulative incidence of ReIP and ReIC at 10 yr was estimated at 5.6% and 3.4%, respectively. Enucleation weight ≥60 g was a significant predictor of ReIP (hazard ratio 1.2, p = 0.014). The retrospective study design and the lack of functional outcomes are the main limitations.ThuLEP is a durably effective and safe procedure with low reintervention rates within 12 yr.This study investigated long-term outcomes of thulium laser enucleation of the prostate for benign enlargement of the prostate (BPE). Low rates of repeat treatment for BPE recurrence or for other complications were observed. Our results show the safety and efficacy of this treatment over a period of 12 years.

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months, IQR 4–10) and those without BNC recurrence (10 months, IQR 6–20, p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months, IQR 6–9) compared to those treated successfully (median 12 months, IQR 9–25, p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months, IQR 2–12) and those without a recurrence (6 months, IQR 6–10, p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%, p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

Introduction: Screening for and treating asymptomatic bacteriuria (ABU) or administering antibiotic prophylaxis is recommended during ureteral stent and nephrostomy interventions. This study investigates the frequency of postinterventional infectious complications to gain insight into the need for antibiotics. Methods: Between September 2016 and June 2019, 168 insertions/exchanges of ureteral stents or nephrostomies were recorded in a prospective multicenter study. Patients without a symptomatic UTI did not receive antibiotic treatment/prophylaxis. Asymptomatic patients in whom their urologist already administered an antibiotic treatment served as a comparative group. Follow-up included postinterventional complications within 30 days. Symptoms were assessed by the Acute Cystitis Symptom Score (ACSS) before and after the intervention. Predictors of increasing postinterventional symptoms were analyzed by a multivariable logistic regression model. Results: One hundred forty-five interventions were eligible. One hundred twenty-two (84.1%) interventions were performed without antibiotic treatment. Preinterventional ABU was detected in 54.4% and sterile urine in 22.8% (22.8% without culture). Postinterventional infectious complications did not differ between patients with versus without antibiotics. Transurethral interventions aggravate symptoms (p = 0.034) but do not increase infectious complications compared to percutaneous interventions. Patients without diabetes mellitus are at higher risk for increasing symptoms. Conclusion: Results indicate that peri-interventional antibiotic treatment may be omitted in patients without symptomatic UTI. Symptoms must be differentiated between infectious and procedure-associated origins.

Purpose: Overactive bladder (OAB) is a common condition affecting approximately 11% of individuals worldwide. One of the newest treatment options for OAB symptoms is mirabegron. The objective of this network meta-analysis is to evaluate the extent of the efficacy and tolerability of mirabegron compared both to placebo and first-line anticholinergic pharmacotherapies. Methods: Articles were identified through the MEDLINE, EMBASE, and Cochrane databases using the search term ‘mirabegron’. All original, prospective, randomised, controlled, double-blind clinical trials studying mirabegron in adults receiving initial treatment for OAB were included. Efficacy was assessed based on outcome variables and responder data. Tolerability was evaluated for reported adverse events. Results: Thirteen studies including a total of 13,333 individuals were included. Mirabegron demonstrated better efficacy compared to placebo and tolterodine extended release 4 mg. Compared to placebo, the incidence of tachycardia and nasopharyngitis was greater with mirabegron 50 mg, and the incidence of cardiac arrhythmia was greater in 100 mg treatment groups. Mirabegron 100 mg also demonstrated a lower incidence of cardiac arrhythmia compared to tolterodine. Conclusions: The current study presents new information that may affect patient-centred strategies for the management of OAB, with a particular concern for cardiovascular safety.

BACKGROUND Outcome of partial nephrectomy (PN) depends on anatomic features of the renal tumor, which can be assessed by nephrometry scores. The aim was to externally validate and refine the Arterial Based Complexity (ABC) score and to compare it to established systems. METHODS Tumors of 300 patients undergoing PN were categorized according to the ABC, RENAL, and PADUA score. Size and tumor invasiveness were combined to form the ABCD score. Correlation analysis and multivariate logistic regression was performed to validate and compare the respective scores as predictors of surgical outcome. RESULTS The ABC score shows significant correlation with ischemia time (IT) (P

Background: Little is known about the role of WNT signalling in pathological processes involving the urinary tract stroma. Here the impact of WNT signalling on bladder wall fibroblasts (BWFs) was studied using integrated expression profiling. Material and Methods: WNT ligand and downstream WNT pathway component expression was profiled in human BWFs using qRT-PCR. Highly expressed WNT2B was knocked down using siRNA in BWFs. The expression of 730 mRNAs and 800 miRNAs was analyzed on the nCounter MAX platform in #WNT2B and control transfected BWFs. qRT-PCR was used for validation in vitro and in matched scar and healthy bladder wall tissue samples of 12 patients with vesico-urethral anastomotic stricture (VUAS). Results: Thirteen genes and 9 miRNAs showed differential expression in #WNT2B cells. Among these were TNFSF10, a key apoptosis inductor, (0.22fold, p = 0.011) and miR-1246 (36.2fold, p = 0.031). miRNA target prediction indicated TNFSF10 to be regulated by miR-1246. qRT-PCR analysis confirmed differential expression of miR-1246 and TNFSF10 in #WNT2B BWFs. Furthermore, TNFSF10 was significantly underexpressed in VUAS tissue (p = 0.009). Conclusion: Perturbation of WNT signalling results in an altered expression of the apoptosis inductor TNFSF10. Similar changes are observed in VUAS. Further studies investigating the crosslink between WNT signalling and apoptosis regulation in the urinary tract stroma are warranted.

We examine the ionic migration of Li in LATP [Li1+xAlxTi2−x(PO4)3] solid electrolytes from an atomistic viewpoint by means of density functional theory calculations. We vary the Al content and investigate its effects on the crystal structure of LATP and on the migration energy landscape of interstitial Li ions. The energy profiles governing the Li diffusion are found to be systematically influenced by the position of Al ions in direct vicinity of the migration path, and we derive a simplified classification scheme of three universal energy profile shapes. The overall influence of the Al/Ti-ratio on the Li migration is analyzed by a separation into chemical and geometrical aspects. This work provides a solid basis for a resource-efficient computational examination of the ionic conductivity of Li in LATP with varying Al/Ti concentrations.

A symptomatic pseudoaneurysm (SPA) is a rare but severe complication after partial nephrectomy (PN). Selective trans-arterial embolization (TAE) is the treatment of choice with high success rates. However, the influence of this intervention on postsurgical renal function has not been studied. Between 2005 and 2016 we performed 1047 PNs at our institution. Postsurgical SPA occurred in 40 patients (3.8%). Patients with and without SPA were matched in a 1:2 ratio concerning tumor complexity (RENAL) and pre-operative renal function (CKD stage). Any CKD upstage and a relevant CKD progression (CKD ≥ III) were defined as endpoints. Furthermore, the influence of the amount of contrast agent applied during TAE was assessed. All patients with SPA were treated successfully with TAE. No significant difference could be detected concerning clinical, functional and surgical aspects. Median follow-up time accounted for 12.5 (6.75–27.5) months. Kaplan–Meier analyses detected an increased rate of any CKD upstage (p = 0.066) and relevant CKD progression (p = 0.01) in patients with SPA. Multivariate analysis identified post-operative SPA to be an independent predictor for a relevant CKD progression (HR 4.15, p = 0.01). The amount of contrast agents used did not have an impact on the development of a relevant CKD progression (p = 0.72). Patients treated with TAE after PN show an additional risk for an impairment of renal function over time. Hence, those patients should explicitly be informed about possible consequences and closely monitored by nephrologists.

To evaluate urethral catheter (UC) versus suprapubic tube (SPT) without stenting the anastomosis at robot-assisted radical prostatectomy (RALP) regarding surgical outcome and catheter-associated discomfort. One year after surgery, continence and patient satisfaction were evaluated. Sixty-two patients undergoing RALP were prospectively randomized to urinary drainage with UC or with SPT. Functional results were assessed with standardized questionnaires (IPSS, IPSS Bother Score, IIEF and Visual Analogue Scale) preoperatively, after catheter removal and 1 year after surgery. Moreover, bother by the catheter as well as pain due to the catheter was assessed. At personal hygiene, SPT was significantly less bothersome on the day of surgery as well as POD 1–6. Pain caused by the catheter did not differ significantly between the two groups except for POD 5 and 6, when the SPT performed significantly better. Differences regarding voiding parameters after catheter removal did not reach statistical significance. One year after surgery, no significant difference between the two groups was found regarding urinary function and IPSS. Though not statistically significant either, the need for the incision of bladder neck contracture (BNC) in two patients in the UC group is of note, as in the SPT group, no BNC occurred. Draining the bladder with SPT only is a feasible option in patients undergoing RALP. Patients with SPT are significantly less bothered by the catheter at personal and genital hygiene compared to UC. The risk of BNC seems to be reduced in the SPT group.

The aim of the study was to externally validate the Zonal NePhRO Score (ZNS) published in 2014 as latest and superior nephrometry score in terms of prediction of perioperative complications and outcome of open partial nephrectomies (OPNs). We identified 200 consecutive patients who underwent OPN. Analysis of preoperative CT or MRI scans and retrospective analysis of the patients’ clinical records were performed. Tumour complexity was stratified according to the ZNS into three categories: low (4–6), moderate (7–9) and high (10–12) complexity. Predictors for perioperative complications and surgical parameters were identified using univariate and multivariate logistic regression. Tumour complexity was graded in 19.8 % of the cases as low, in 50.3 % as moderate and in 29.9 % as high. In the multivariate analysis, ZNS was significantly associated with a higher complication rate (OR 1.25, 95 % CI 1.04–1.49, p = 0.014), longer ischaemia time (IT) (β = 1.19, 95 % CI 0.33–2.05, p = 0.007), postoperative drop of estimated glomerular filtration rate (eGFR) (β = −1.86, 95 % CI −3.71 to −0.01, p = 0.049) and opening of the collecting system (CS) (OR 1.72, 95 % CI 1.40–2.10, p

To re-evaluate safety and efficacy of transperineal reanastomosis (TPRA) as a viable therapeutic option in highly recurrent anastomotic strictures (AS) after radical retropubic prostatectomy (RRP). Retrospective analysis by standardized questionnaire inquiring for recurrence of stricture, stress urinary incontinence (SUI), sexual function, satisfaction, and changes in quality of life (QoL) was performed in all patients undergoing TPRA. Validated questionnaires (ICIQ-UI, EQ-5D, and IPSS) were included. Median follow-up was 45.0 months. The average number of prior operations was 4.69. Success rate was 87% (20/23). Three recurrences were successfully treated via endoscopic means. All patients had urinary incontinence pre-op and post-op. Implantation of an artificial urinary sphincter (AUS) has been performed successfully in 73.9% (17/23). Rate of complications was low (8.7%; 2/23, Clavien–Dindo Grade II + III). EQ-5D-VAS showed a good general state of health (73.5/100). An improvement in QoL was noted in 63.6% (14/22) and patient satisfaction was high (72.7%; 16/22). This extended follow-up confirms the initial results for TPRA as an excellent treatment option for highly recurrent AS after RRP. Postoperative SUI as a consequence of transsphincteric urethral mobilization can be satisfactorily treated by the implantation of AUS. In case of AS recalcitrant to endoscopic treatment, the described procedure—even though technically challenging—represents a valuable treatment option.

Until recently, tissue fibrosis—ultimately leading to permanent scaring—has been considered an irreversible process. However, recent findings indicate that it may be reversible after all. Vesicourethral anastomotic stenosis (VUAS) as fibrous narrowing is a frequent complication after radical prostatectomy with high recurrence rates and requires invasive treatment. The pathophysiology is poorly understood. Therefore, a combined mRNA and miRNA transcription profiling in tissue from VUAS was performed using nCounter technology. To assess tissue morphology and fiber composition, histochemical staining was performed. RNA expression of healthy and fibrotic tissue of twelve patients was analyzed using the human miRNA panel v3 and mRNA PanCancer pathway panel on the nCounter gene1 system and qRT-PCR. Differential expression data analysis was performed using the nSolver software implementing the R-based advanced pathway analysis tool. miRWalk2.0 was used for miRNA target prediction. More linearized tissue architecture, increased collagens, and decreased elastic fibers were observed in VUAS samples. 23 miRNAs and 118 protein coding genes were differentially expressed (p

The aim of this study was to analyze the impact of metabolic syndrome (MetS) on outcome of patients with localized renal cell carcinoma (RCC). A retrospective database was compiled consisting of 646 patients who underwent surgery for localized RCC between 2005 and 2014. A total of 439 patients were eligible for final analysis. For diagnosis of MetS, the WHO criteria of 1998 were used. Median follow-up was 32 months (ranging from 2 to 119). Kaplan-Meier and log-rank analyses were performed to compare patients with and without MetS or its components. Univariate and multivariate logistic regression identified prognostic factors for progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). In our cohort, 9.8% (n = 43) of patients were diagnosed with MetS. There were no differences between patients with and without MetS regarding clinicopathological parameters with the exception of patients’ age (p = 0.002). Kaplan-Meier and log-rank analyses revealed a shorter PFS for patients with MetS (p = 0.018), whereas no differences were found for each of the single components of MetS, namely, diabetes mellitus (DM) (p = 0.332), BMI >30 kg/m2 (p = 0.753), hypertension (p = 0.451), and hypertriglyceridemia (p = 0.891). Logistic regression identified age (HR = 1.92, p = 0.03), tumor stage (HR = 4.37, p

Objectives To assess fistula recurrence rate and health-related quality of life (HRQL) after repair, as well as the impact on continence and erection in patients with recto-anastomotic fistula after radical prostatectomy (RP). In recent publications, the numbers of cases of recto-urinary fistulae after RP are relatively small. Success rates at fistula closure are good; however, data about functional outcomes and HRQL are more restricted. Patients and Methods A retrospective study of patients treated for recto-urethral fistulae after RP between 1993 and 2008. All 17 patients were assessed for fistula recurrence in 2007 and received a standardised non-validated questionnaire to assess HRQL in 2011; furthermore, a patient's chart review was performed. Surgical technique: fistula closure was abdominal in 10 patients, perineal in five and combined abdominal and perineal in two, some with tissue interposition. Results In 2007, follow-up was available for 14 patients, one was deceased and two were lost to follow-up. The mean follow-up was 73.3 months and the mean patient age was 63 years. In two of the 17 patients, rectal injury during the initial surgery was reported; another three had undergone adjuvant radiation therapy (18%). In 2011, another two patients were deceased; the mean (range) follow-up was 99.5 (44–184) months. There was a great improvement in HRQL as compared with before surgery in seven of the 12 evaluable patients, a slight improvement in one and no change in three. In all, eight of the 12 patients were very satisfied with the surgery and four were satisfied. Conclusion Perineal or abdominal fistula repair yields excellent success rates and high patient satisfaction. However, urinary incontinence can be found in some patients postoperatively, requiring further treatment.

To evaluate safety and efficacy of open transperineal reanastomosis (TPRA) for highly recurrent anastomotic strictures (AS) after radical prostatectomy. While the majority of AS can be managed successfully by endoscopic treatment, in highly recurrent AS, open reanastomosis represents a viable therapeutic option. Retrospective analysis by standardized questionnaire, inquiring for recurrence, incontinence, sexual function, satisfaction and changes in quality of life (QoL) in 15 patients undergoing TPRA 08/2007–03/2010. Mean patient age was 65 years (51–75) and mean follow-up 20.5 months (5.8–37.0). Success rate was 93.3 % (14/15). The single recurrence was successfully treated by cold knife incision. Incontinence was found in 93.3 % (14/15) preoperatively and aggravated in 60 % (9/15) after surgery; no de novo incontinence occurred. Implantation of an artificial urinary sphincter (AUS) has been performed successfully in 10 patients, 2 refused implantation and 2 are scheduled for surgery. Erectile dysfunction was present in 86.7 % (13/15); 13.3 % (2/15) reported a severely declined rigidity. Compared to preoperative status, 33.3 % (5/15) complained about impaired erectile function after TPRA. A good or very good subjective overall health status and an improvement in QoL were noted in 86.7 % (13/15). Patient satisfaction with the outcome of TPRA was high or very high in 13; two were undecided. After repeated endoscopic treatment, TPRA is a valuable therapeutic option in selected patients with an overall success rate of 93.3 % (14/15) for anastomotic patency, which can even be raised to 100 % by further transurethral surgery. Incontinence can be easily treated by implantation of an AUS.

To assess bothersome results of surgery and changes in quality of life (QoL) in patients with redo-urethroplasty, comparing the functional results of penile and bulbar cases. As after previous urethroplasty scar tissue formation is likely to occur, less favorable functional results than at primary repair could be expected. Yet data on these items for techniques currently used are limited. Retrospective analysis with standardized questionnaire including 33 consecutive patients treated with redo-urethroplasty for bulbar or penile strictures. Previous surgeries, recurrence rate, complications, incontinence, erectile function, satisfaction with the surgery and QoL were assessed. Overall success rate was 78.8 %, number of previous open urethroplasty once in 24 patients (72.7 %), and more than once in 9 (27.3 %). Urinary stress incontinence Grade I occurred in 5 patients (15.2 %) and Grade II in 2 patients (6.1 %). In 24 patients (72.7 %), no penile shortening occurred and in 28 (84.8 %), no deviation was observed. Eight patients (24.2 %) reported their glans sensitivity to be altered, in 3 (9.1 %) a disturbing alteration occurred. Overall satisfaction with the surgery was high (70 %), and an improvement in QoL was seen in 72.7 % (24 patients). Urethroplasty after failed open repair gives good functional results and shows a high patient satisfaction rate. However, results are not quite as good as for primary repair, emphasizing the importance of a successful primary repair.

To evaluate the therapeutic methods and algorithms currently used in the treatment of bladder neck contracture (BNC) after radical prostatectomy (RP).Heads of 170 urologic departments in Germany, listed at the German Society of Urology (DGU), were invited to participate in an Internet-based customized survey. The questions consisted of an epidemiologic part (kind of hospital, state of practice) and questions inquiring used surgical techniques with their respective incidence and given algorithms for therapy.Of 170 contacted heads of urologic departments in Germany, 84 responded to the questionnaire (return rate 49.41%). The most common treatment modalities are transurethral resection, cold knife incision, hot knife incision, and dilation in descending order. For those institutions using several treatment modalities, 56 (66.67%) follow a therapeutic algorithm, while 28 (33.33%) follow no set order of treatment. However, among the 56 institutions with a set algorithm, 33 different approaches were identified. Of 84 institutions, 29 (34.52%) perform open reanastomosis in case of recurrent BNC, the remaining 55 (65.48%) do not.Despite several published guidelines on urethral strictures, numerous self-employed treatment algorithms are used to treat BNC. Although treatment results of these algorithms and the underlying treatment modalities cannot be determined with this work, it highlights the necessity for further studies comparing the different surgeries to allow for a more evidence-based approach.

Nephrometry scores are designed for standardized reporting of renal tumors and predicting complications. Multiple scores are available, but there is a lack of systematic comparison.A total of 305 consecutive patients admitted for open partial nephrectomy to 2 urological hospitals were prospectively assessed. Five cases with conversion to radical nephrectomy were excluded from further analysis. RENAL, PADUA, C-index, and NePhRO scores were obtained from preoperative sectional imaging. Additionally, interobserver variance between 2 urologists and a radiologist was analyzed for 50 patients. Linear and ordered logistic regression was used to evaluate the association between scores and surgical parameters. Receiver operating characteristic analysis was employed to assess the predictive value for requirement of ischemia and opening of the collecting system.High interobserver agreement was observed for RENAL (0.92 and 0.80), PADUA (0.81 and 0.85), NePhRO (0.94 and 0.82), and the C-index (0.98 and 0.95). All scores showed a significant association with opening of the collecting system (P .016), requirement of on-clamp excision (P .001), and ischemia time (P .001). Logistic regression identified RENAL, PADUA, and NePhRO score to be an independent predictor for severe complications (P = .016, P = .011, and P = .005). No correlation was found for the C-index (ß = 0.98; P = .779). Predictive effectiveness for opening of the collecting system and for on-clamp excision showed comparable area under the curve values for the 4 scores.All scoring systems represent objective and reproducible measurement tools for renal tumor complexity, that correlate well with surgical outcome. RENAL, PADUA, and NePhRO score are comparable and seem to be superior to the more complex C-index system.

What's known on the subject? and What does the study add? Urethral strictures can be treated by various methods, e.g. dilatation and endoscopic treatment, as well as with open surgery. However, transurethral treatment shows low long-time success rates, while open urethral reconstruction yields good long-term results. One of the standard procedures to reconstruct the strictured penile urethra is the Barbagli technique, which was introduced in 1996. However, a potential drawback of this technique is the suturing of the urethral margins to the second side of the graft, because the buccal mucosa is already fixed to the corpus cavernosum and the last line is sutured in the back side of the urethra out of sight. The present study aims to assess whether the functional results are compromised by a modified Barbagli technique, which enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique. OBJECTIVE • To evaluate stricture recurrence rate as well as the satisfaction with the surgery of patients treated with a modified Barbagli technique published by our study group in 2009. PATIENTS AND METHODS • Retrospective analysis by patient's chart review and unvalidated standardised questionnaire of patients treated by the modified Barbagli technique for urethral stricture between May 2008 and September 2010. • In all, 22 patients were treated with the modified Barbagli technique for urethral stricture during this time, and 18 patients were available for follow-up. • Previous surgeries, recurrence rate, complications, incontinence, erectile function, satisfaction with the surgery, and oral numbness were assessed. • As described in the original technique, also in the modified technique the access to the urethra is achieved through a midline incision. Subsequently, the urethra is completely mobilised. However, it is then rotated 180 ° using stay sutures. Afterwards, the buccal mucosa is sutured into the opened urethra on both sides under vision, giving free access to the margins. Once the buccal mucosa is completely sutured in, the urethra is back-rotated using stay sutures and the margin of the buccal mucosa and the urethra is sutured to the tunica albuginea, stretching and supporting the buccal mucosa. RESULTS • Follow-up was available for 18 patients with a mean (range) age of 67.5 (27–74) years. • Open previous surgeries had been performed in 27.8% and transurethral surgeries in 72.2%. • The mean (range) length of the oral mucosa graft was 7.8 (2.5–13) cm and the mean operative duration was 106 (73–193) min. • The success rate was 83.2%; there was no de novo erectile dysfunction and no relevant penile curvature. • There was oral numbness in two patients (9%). None of the recurrence-free patients (83.3%) were dissatisfied with the surgery. CONCLUSIONS • The technique simplifies the original technique without compromising the functional results. The modification of the technique enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique. • The success rate was comparable with the original technique and patient satisfaction with the surgery was high.

We assessed the success rate of open reanastomosis for highly recurrent bladder neck stenosis resistant to transurethral treatment. Due to the paucity of available data the success rate of this procedure is not well defined, although it can be a last treatment option before urinary diversion.A total of 158 patients were treated for bladder neck stenosis in 1998 to 2007, of whom 20 underwent open reanastomosis for highly recurrent or complex bladder neck stenosis after radical prostatectomy and were seen for followup 3 months postoperatively. They received a standardized questionnaire at the time of data acquisition in this retrospective analysis.The 20 patients underwent a mean of 3.7 previous surgeries. Median followup was 59.2 months. Stenosis recurred after reanastomosis in 8 patients (40%) while the remaining 60% were recurrence free. Seven recurrences were successfully treated endoscopically, resulting in an overall combined 95% success rate. Urinary diversion was performed in 1 patient with another recurrence after reanastomosis and transurethral resection. Four patients (31%) had new onset incontinence and 13 were completely incontinent, of whom 9 were successfully treated with artificial urinary sphincter implantation. In another patient artificial urinary sphincter implantation is scheduled and 3 elected no further treatment.Open reanastomosis for recurrent bladder neck stenosis is a good therapeutic option in cases of endoscopic treatment failure. The initial success rate after reanastomosis was 60%, which increased to 95% after secondary treatment. There was a relatively high risk of new onset incontinence after reconstructive surgery but this was successfully treated with artificial urinary sphincter implantation in most patients.

To assess bothersome results of surgery and changes in quality of life (QoL) in patients with two-staged urethral reconstruction. In patients requiring two-staged urethroplasty a functional corpus spongiosum is usually absent, and complications such as urinary dribbling, ejaculation problems and penile deviation can be expected. Data on these complications, patient satisfaction and QoL is limited.Retrospective analysis by chart review and a standardized questionnaire of 19 consecutive patients with urethral strictures treated by two-staged urethroplasty with buccal-mucosa-graft or mesh-graft.Overall success rate was 84%. Mean follow up 11.2 months, mean length of graft 10 cm (3 cm-18 cm). Urinary stress incontinence occurred in 3 patients (16%). No penile shortening occurred in 9 (47%), no deviation in 11 (58%). Two patients (11%) reported a disturbing alteration in glans sensitivity. Regarding bother by both surgeries and the interval in between, 21% judged the first surgery as hardly or not bothersome. The time in between surgeries was hardly or not bothersome in 52% and the second surgery not or hardly bothersome in 26%. Overall satisfaction with surgery was high (79%) and an improvement in QoL was reported by 63%. Differences between the two groups did not reach statistical significance.Two-staged urethroplasty is a viable therapeutic option in patients with severe spongiofibrosis. However, specific counseling for possible complications is of utmost importance.

Objectives.A symptomatic renal pseudoaneurysm (RPA) is a severe complication after open partial nephrectomy (OPN). The aim of our study was to assess incidence and risk factors for RPA formation. Furthermore, we present our management strategy.Patients and Methods.Clinical records of consecutive patients undergoing OPN were assessed for surgical outcome and postoperative complications. Renal masses were risk stratified for tumor complexity according to the PADUA score. Uni- and multivariate analysis for symptomatic RPAs were performed using thet-tests and logistic regression.Results.We identified 233 patients treated with OPN. Symptomatic RPAs were observed in 13 (5.6%) patients, on average 14 (4–42) days after surgery. Uni- and multivariate analysis identified tumor complexity to be an independent predictor for symptomatic RPAs (p=0.004). There was a significant correlation between RPAs and transfusion and the duration of stay (p<0.001andp=0.021). Symptomatic RPAs were diagnosed with CT scans and successfully treated with arterial embolization.Discussion.Symptomatic RPAs are not uncommon after OPN for high-risk renal masses. A high nephrometry score is a predictor for this severe complication and may enable a risk-stratified followup. RPAs can successfully be located by CT angiography, which enables targeted angiographic treatment.

Objectives: This study evaluates the feasibility and safety of open-partial nephrectomies in the ZIRK-technique (Zero Ischemia Resection in the Kidney) for renal masses with high-risk anatomical features - objectified by the PADUA score. Methods: We identified 40 consecutive cases of partial nephrectomies performed without clamping of the renal artery in our department of urology. Retrospective analysis of the preoperative CT or MRI scans showed 27 cases with a PADUA score ≥8, of which 15 cases had a score ≥10. Cases were in particular assessed regarding operation time (ORT), estimated blood loss (EBL), surgical margins and postoperative complications using the Clavien classification. Results: The mean age of the study population was 67.6 years with an average BMI of 26.8 kg/m2. The mean ORT was 1:46 with an average EBL of 521 ml. Clavien grade II complications were observed seven times, while 3 patients had a grade IIIa complication. Despite complex and adverse location of the tumors, nephron-sparing surgery without ischemia could be performed with negative surgical margins for all cases. EBL, transfusion rate and complication were considerably more frequent in high-risk tumors. Conclusion: Highly complex renal tumors, PADUA ≥10, can be resected in ZIRK-technique with good operative outcome and a low complication rate.

To assess fistula recurrence rate and health-related quality of life (HRQL) after repair, as well as the impact on continence and erection in patients with recto-anastomotic fistula after radical prostatectomy (RP). In recent publications, the numbers of cases of recto-urinary fistulae after RP are relatively small. Success rates at fistula closure are good; however, data about functional outcomes and HRQL are more restricted.A retrospective study of patients treated for recto-urethral fistulae after RP between 1993 and 2008. All 17 patients were assessed for fistula recurrence in 2007 and received a standardised non-validated questionnaire to assess HRQL in 2011; furthermore, a patient's chart review was performed.fistula closure was abdominal in 10 patients, perineal in five and combined abdominal and perineal in two, some with tissue interposition.In 2007, follow-up was available for 14 patients, one was deceased and two were lost to follow-up. The mean follow-up was 73.3 months and the mean patient age was 63 years. In two of the 17 patients, rectal injury during the initial surgery was reported; another three had undergone adjuvant radiation therapy (18%). In 2011, another two patients were deceased; the mean (range) follow-up was 99.5 (44-184) months. There was a great improvement in HRQL as compared with before surgery in seven of the 12 evaluable patients, a slight improvement in one and no change in three. In all, eight of the 12 patients were very satisfied with the surgery and four were satisfied.Perineal or abdominal fistula repair yields excellent success rates and high patient satisfaction. However, urinary incontinence can be found in some patients postoperatively, requiring further treatment.

Only few comparative reports about different urethroplasties have been published, addressing success rate (SR), adverse events (AE), and quality of life (QoL). Our purpose was to evaluate SR, AE, and QoL in a contemporary cohort of patients undergoing urethroplasty in the short-term follow-up (FU).Between December 2008 and June 2010, 205 patients underwent urethroplasty for anterior urethral strictures at our institution. A standardized questionnaire was sent to all patients. The primary end point was SR. Secondary end points were AE and QoL. To assess the risk of SR, the Kaplan-Meier method and log-rank test were used. To assess risk factors for urethral stricture recurrence (SRec), univariable Cox regression analysis was used.Overall, 140 (68%) patients responded to our questionnaire and were used for analysis. Of these 9%, 85%, and 6% were treated by excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), and mesh graft urethroplasty (MGU), respectively. At 10 months of FU, SR was 87.5%. SRs of EPA, BMGU, and MGU were 100% (n=13/13), 85.7% (n=102/119), and 87.5% (n=7/8), with no significant differences between the groups. In univariable analysis, ≥ 2 vs 1 previous urethroplasties showed a trend toward a reduced SR (hazard risk 2.95; P=0.057). Streaking the urethra (P=0.024) and penile curvature (P=0.026) were significantly more often associated with MGU compared with EPA and BMGU. Postoperative total median (mean) scores were 3.5 (4.8) for the International Consultation on Incontinence Questionnaire Male lower urinary tract symptoms, 15 (15.2) for the International Index of Erectile Function, and 80 (73) for EuroQol visual analogue score; there was no difference between urethroplasty types.In the short-term FU, urethroplasty demonstrates an excellent SR. Specific SRs of EPA, BMGU, and MGU seem comparable. Despite significant differences in AE, patient reported QoL is high with no difference between the applied techniques.

What's known on the subject? and What does the study add? Urethral strictures can be treated by various methods, e.g. dilatation and endoscopic treatment, as well as with open surgery. However, transurethral treatment shows low long-time success rates, while open urethral reconstruction yields good long-term results. One of the standard procedures to reconstruct the strictured penile urethra is the Barbagli technique, which was introduced in 1996. However, a potential drawback of this technique is the suturing of the urethral margins to the second side of the graft, because the buccal mucosa is already fixed to the corpus cavernosum and the last line is sutured in the back side of the urethra out of sight. The present study aims to assess whether the functional results are compromised by a modified Barbagli technique, which enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique.To evaluate stricture recurrence rate as well as the satisfaction with the surgery of patients treated with a modified Barbagli technique published by our study group in 2009.Retrospective analysis by patient's chart review and unvalidated standardised questionnaire of patients treated by the modified Barbagli technique for urethral stricture between May 2008 and September 2010. In all, 22 patients were treated with the modified Barbagli technique for urethral stricture during this time, and 18 patients were available for follow-up. Previous surgeries, recurrence rate, complications, incontinence, erectile function, satisfaction with the surgery, and oral numbness were assessed. As described in the original technique, also in the modified technique the access to the urethra is achieved through a midline incision. Subsequently, the urethra is completely mobilised. However, it is then rotated 180 ° using stay sutures. Afterwards, the buccal mucosa is sutured into the opened urethra on both sides under vision, giving free access to the margins. Once the buccal mucosa is completely sutured in, the urethra is back-rotated using stay sutures and the margin of the buccal mucosa and the urethra is sutured to the tunica albuginea, stretching and supporting the buccal mucosa.Follow-up was available for 18 patients with a mean (range) age of 67.5 (27-74) years. Open previous surgeries had been performed in 27.8% and transurethral surgeries in 72.2%. The mean (range) length of the oral mucosa graft was 7.8 (2.5-13) cm and the mean operative duration was 106 (73-193) min. The success rate was 83.2%; there was no de novo erectile dysfunction and no relevant penile curvature. There was oral numbness in two patients (9%). None of the recurrence-free patients (83.3%) were dissatisfied with the surgery.The technique simplifies the original technique without compromising the functional results. The modification of the technique enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique. The success rate was comparable with the original technique and patient satisfaction with the surgery was high.

Objective To evaluate the etiology of posterior and/or bulbar strictures in children in an industrialized country and assess the outcome of its repair by perineal approach. Urethral strictures in children are rare and often challenging to treat. Trauma is the main etiology in developing countries. However, data for industrialized countries are sparse. Material and methods Retrospective analysis of 17 patients treated with perineal urethroplasty 2001–2010. Data were assessed by chart review and non-validated standardized questionnaire. Hypospadias cases were excluded. Reconstruction was performed by stricture excision and primary anastomosis, or a single-staged or two-staged buccal mucosa graft. Results Mean age at surgery was 7.9 years (range 1–13) and mean follow-up was 42.6 months (4–115). Eight patients (47.1%) had post-traumatic strictures, five (29.4%) had a history of posterior valves, and previous transurethral catheterization and irradiation each accounted for one patient (5.9%). In the remaining two (11.8%), the etiology was unknown. The success rate was 88.9%. All but one patient were continent postoperatively. Conclusions Most common etiology for open urethral reconstruction in children was trauma and previous valve treatment. In our hands the perineal approach for stricture repair is safe and successful. Stricture recurrence rate is low, and incontinence is only associated with additional bladder neck trauma.

INTRODUCTION AND OBJECTIVES: To evaluate the stricture free survival rate, adverse events and quality of life (QoL) of urethroplasty in the short term follow-up. METHODS: We retrospectively evaluated our patients who underwent urethroplasty between 12/08 and 07/10 at the University Medical Center Hamburg-Eppendorf, Germany. A standardized nonvalidated questionnaire was sent to all patients in September 2010. Primary end point was the stricture free survival rate, defined as no stricture recurrence. Secondary endpoints were adverse events and QoL. RESULTS: Within 19 months 205 patients underwent urethroplasty due to urethral stricture at different localisations and extend. One hundred forty four patients (70%) with a mean age of 56 years (range 14–84) and a mean follow up of 10.2 months (1–22), responded to our questionnaire. Of this cohort 9%, 85% and 6% were treated by primary excision and re-anastomosis (EPA), buccal mucosa graft (BMG) and mesh graft (MG) urethroplasty, respectively. Overall, 18/144 (12.5%) recurrences were documented and specifically 0%, 14.3% and 12.5 % for EPA, BMG and MG. In Kaplan Meier analysis there was no statistical significant difference concerning the stricture recurrence free survival between the three surgical techniques. Furthermore, no risk factor as localisation, stricture length and number of previous surgeries was identified for early stricture recurrence. Adverse events as incontinence, curvature, shortening and post void wiping out of the urethra were most often associated with MG urethroplasty. However, statistical significant difference was not shown (p 0.05). Neither, there was a statistical significant difference found in QoL nor satisfaction with surgical outcome between the three techniques of urethroplasty (p 0.7). CONCLUSIONS: At our center contemporary urethral surgery signifies a BMG for the majority of patients. Stricture recurrence free survival for EPA, BMG and MG seems comparable. However, EPA demonstrates excellent success rates of urethroplasty in the short term follow up. Differences in adverse events are not statistically significant between EPA, BMG and MG and do not seem to have an impact on quality of life and satisfaction of surgical outcome.