This article shall give a state-of-the-art review about the treatment of neurogenic and idiopathic detrusor overactivity with botulinum toxin injections into the detrusor muscle. We searched PubMed for original articles up to December 2006. Abstracts published at international congresses were also considered if they provided substantial new information. Based on this review it appears that a majority of patients with spinal cord injury regains continence after botulinum toxin A injection and that in children with myelomeningocele a significant improvement in continence can also be achieved. A concomitant reduction of intravesical pressure protects the upper urinary tract in these patients. In idiopathic detrusor overactivity, injection of botulinum toxin A also resulted in improvement of continence and reduction of daily micturition frequency.For both indications a high success rate could be achieved with an average duration of the effect of 6 months. Repeated injections into the detrusor seem to have no adverse effects in terms of duration or strength of the effect. Side effects were marginal and systemic side effects were experienced only in individual cases; in some patients with idiopathic detrusor overactivity intermittent self-catheterization was required. Overall intradetrusor injections of botulinum toxin seem to be a new, highly effective, and safe alternative in the treatment of neurogenic and idiopathic detrusor overactivity.

Dieser Reviewartikel soll einen Überblick über den momentanen Stand in der Behandlung der neurogenen und idiopathischen Detrusorüberaktivität durch Botulinumtoxin-A-Injektionen in den Detrusor geben. Berücksichtigt wurden Originalarbeiten, die durch eine Online-Recherche unter PubMed bis Dezember 2006 ermittelt wurden, sowie auf internationalen Kongressen als Abstracts veröffentlichte Arbeiten, sofern sie wesentliche neue Informationen erbrachten. In Zusammenschau der Arbeiten ergab sich übereinstimmend, dass die überwiegende Mehrheit der Patienten mit einer traumatischen Querschnittslähmung nach der Botulinumtoxin-Injektion wieder eine vollständige Kontinenzsituation zwischen den intermittierenden Einmalkatheterismusereignissen zurückgewinnt, und dass bei Kindern mit einer Meningomyelozele ebenfalls eine signifikante Verbesserung der Kontinenzsituation resultiert. Aus der begleitenden Senkung des intravesikalen Druckes ergibt sich für diese Patienten eine Schonung des oberen Harntraktes. Auch bei der idiopathischen Detrusorüberaktivität stellte sich eine Verbesserung der Inkontinenz sowie eine Reduktion der täglichen Miktionsfrequenz ein.

Cabanas, working 30 years ago, was the first to use the term "sentinel lymph node" in urology. His definition of the sentinel lymph node was based on typical anatomical patterns and therefore could not do justice to any individual variability in lymphatic drainage. This meant that application of the technique yielded high false-negative rates, and because of this it was largely abandoned. Dynamic visualization of lymphatic drainage by blue dye in melanoma patients resulted in a renaissance of the sentinel node concept in penile cancer in the mid-1990s. With constant improvements and standardization of the technique it proved possible to reduce the incidence of false-negative results from the initial 22% to 4.8%. This technique requires that specialists in urology, pathology, and nuclear medicine collaborate closely, and high standards are also essential in quality control.

To evaluate an intervention for improving the delivery of early enteral nutrition (EN) in patients receiving mechanical ventilation with prone positioning (PP).Eligible patients receiving EN and mechanical ventilation in PP were included within 48 h after intubation in a before–after study. Patients were semi-recumbent when supine. Intolerance to EN was defined as residual gastric volume greater than 250 ml/6 h or vomiting. In the before group (n = 34), the EN rate was increased by 500 ml every 24 h up to 2000 ml/24 h; patients were flat when prone and received erythromycin (250 mg IV/6 h) to treat intolerance. In the intervention group (n = 38), the EN rate was increased by 25 ml/h every 6 h to 85 ml/h, 25° head elevation was used in PP, and prophylactic erythromycin was started at the first turn.Compared to the before group, larger feeding volumes were delivered in the intervention group (median volume per day with PP, 774 ml [IQR 513–925] vs. 1170 ml [IQR 736–1417]; P < 0.001) without increases in residual gastric volume, vomiting, or ventilator-associated pneumonia.An intervention including PP with 25° elevation, an increased acceleration to target rate of EN, and erythromycin improved EN delivery.

Im vorliegenden Fall stellte sich eine 20-jährige Patientin mit einer seit der Kindheit bestehenden Giggle-Inkontinenz vor. Eine ausreichende anticholinerge Therapie zeigte keine wesentliche Besserung der Symptomatik. Daraufhin erfolgte die Injektion von Botulinumtoxin A. Nach Wirkungseintritt der Injektion trat selbst bei stärkstem Lachen kein unwillkürlicher Urinverlust mehr auf. Bei konservativ nicht beherrschbarer Giggle-Inkontinenz ist bei hohem Leidensdruck eine Botulinumtoxin A Injektion eine therapeutische Alternative.

A 20-year-old woman reported about giggle incontinence despite antimuscarinic therapy. Therefore we injected botulinum toxin A into the detrusor muscle. The effect of botulinum toxin A appeared about 1 week after injection and no more leakage was observed even during vigorous laughter. A control uroflowmetry showed a good voiding rate without any residual volume. Botulinum toxin A might be an alternative for patients with giggle incontinence after unsuccessful antimuscarinic treatment.

BACKGROUND:The introduction of a transscrotal access for implantation of an artificial urinary sphincter (AUS) offers an alternative to the perineal approach for dealing with post-prostatectomy incontinence. Should a revision be necessary, the entire implant can be explored via this access and only one incision is needed. The aim of our study was to present the advantage of the transscrotal approach in different malfunctions of AUSs (AMS 800).MATERIALS AND METHODS:Surgical exploration was exemplary indicated in three male patients because of recurrent incontinence after artificial sphincter implantation. The reasons for malfunction were urethral atrophy, a mechanical defect of the device, and urethral erosion of the cuff, which led to explantation via the perineal approach of the entire artificial sphincter system. The patient whose sphincter system had a mechanical defect had the entire system substituted by the transscrotal route. In the case of perineal explantation a complete new AMS 800 system was implanted transscrotally at the unaffected bulbar ureter following complete healing. In the case of urethral atrophy a tandem-cuff was implanted by a transscrotal approach. Because of mechanical complications the whole system was exchanged, a completely new AUS (AMS 800) system being implanted by the transscrotal approach after perineal explantation.RESULTS:There were no complications of any of the revision operations. The postoperative course was uneventful and after activation of the system all patients regained their former continence status. Three months after implantation all patients remained continent and their AMS 800 sphincter systems were fully functional.CONCLUSION:When a revision operation is needed, the transscrotal access offers a quick and easy alternative to the perineal method. Our patients had no postoperative complications, and their continence rates were satisfactory. Further studies are needed to reveal whether this approach will prove superior to the perineal approach in the long term.

In addition to motor symptoms, patients with Parkinsons disease (PD) show deficits in sensory processing. These deficits are thought to result from deficient gating of sensory information due to basal ganglia dysfunction in PD. Deep brain stimulation of the subthalamic nucleus (STN-DBS) has been shown to improve sensory deficits in PD, e.g. STN-DBS normalizes the perception of urinary bladder filling in patients with PD. This study aimed at investigating how STN-DBS modulates the processing of urinary bladder information to elucidate the (patho-)physiology of sensory gating mechanisms in PD.Nine PD patients with bilateral STN-DBS switched on (STN-DBS ON) or off (STN-DBS OFF) were studied during dynamic bladder filling and an empty bladder condition (for control), while changes in regional cerebral blood flow (rCBF) were measured by PET. Urinary bladder filling led to an increased rCBF in the periaqueductal grey (PAG), the posterior thalamus, the insular cortex as well as in the right frontal cortex and the cerebellum bilaterally. A significant interaction between bladder condition and STN-DBS was observed in the posterior thalamus and the insular cortex, with enhanced modulation of these areas during STN-DBS ON compared to STN-DBS OFF. Furthermore, regression analyses revealed a modulation of the neural activity in the thalamus and the insular cortex by the PAG activity during STN-DBS ON only. Thus, STN-DBS led to a significant enhancement of afferent urinary bladder information processing. The data suggest that STN-DBS facilitates the discrimination of different bodily states by supporting sensory perception and the underlying neural mechanisms. Furthermore, this is the first imaging study, which shows an effect of STN-DBS on sensory gating in PD patients and its neural basis.

Mit Einführung des transskrotalen Zugangs zur Implantation einer artefiziellen Sphinkterprothese (AMS 800®) steht eine Alternative zur perinealen Implantation bei Postprostatektomieinkontinenz zur Verfügung. Dieser Zugang ermöglicht, im Falle einer notwendigen Revision, das gesamte Implantat über nur eine Inzision zu explorieren. Ziel dieser Arbeit ist es, den Vorteil des transskrotalen Zugangs bei verschiedenartigen Fehlfunktionen des Sphinktersystems darzustellen.

Mesonephroide Adenokarzinome der Harnblase stellen höchst wahrscheinlich eine maligne Form der nephrogenen Adenome oder der nephroiden Metaplasie dar. Diese Neoplasie ist in der Harnblase extrem selten und es sind derzeit nach unserem Kenntnisstand 19 Fälle in der Literatur beschrieben. Wir berichten über zwei weitere Fälle eines mesonephroiden Adenokarzinoms der Harnblase, welche durch radikale Zystektomie therapiert wurden.