Biomedical subjects
Publications and source records attributed to F Schreiter.
Since 1977 124 patients with complicated urethral strictures have been treated by using free-foreskin grafts or split-thickness skin grafts to construct a neourethra in a two-stage procedure. Excellent functional and anatomical results have been achieved in 115 patients. The technique is even useful in exceedingly long or problematic strictures, such as in patients with spinal cord injuries.
Since may 1989 a urethral Wallstent has been used for the treatment of short urethral strictures and for DSD in paraplegic patients with reflex bladder activity. Forty-nine patients have now been followed-up, which exceeds the 6-month margin. Out of these, 25 suffered from a short stricture of the bulbous urethra and 24 had spastic bladders with severe DSD. Eighteen of the 25 patients with strictures had previous unsuccessful direct vision urethrotomies; 17 in the DSD group had undergone failed sphincterotomies. In all but 2 cases the infravesical obstruction could be treated effectively solely by stent implantation. The results obtained equal those of a well-performed end-to-end anastomosis of the bulbous urethra or a 12, o'clock sphincterotomy.
In 22 patients with advanced transitional cell carcinoma of the bladder, neoadjuvant chemotherapy according to the MVEC regimen was given. Subsequent radical cystectomy showed down-staging in 7 patients (32%). The preoperative clinical staging revealed regression of the bladder cancer in 77% of all cases. Down-grading was seen in only 2 patients. Because of the discrepancy between preoperative clinical staging and the histopathological staging after radical cystectomy, invasive tumour surgery is necessary even when clinical staging has not revealed a tumour after chemotherapy.
The therapy of Peyronie's disease is an operative one primarily. Indication for the operative treatment is the penile deviation which prevents the patient from intercourse. The method of choice is plaque excision and subsequent corporoplasty with dermal graft. Good long-term results can also be achieved with a sole straightening of the penile shaft without plaque excision. However, this procedure (Nesbit's operation) results in a shortening of the length. In patients who are suffering from an additional erectile dysfunction an implantation of a penile prosthesis is done accompanied by plaque excision and a corporoplasty with alloplastic material (Dacron, Goretex). In 80% of all cases good postoperative results can be achieved with the operative treatment of Peyronie's disease. Patient's satisfaction is very good with all procedures described above. The exact diagnosis of the erectile quality seems to have a prognostic value for the postoperative result.
From 1973 to 1990 a total of 340 male patients suffering from incontinence of various etiologies were treated by implantation of an artificial urinary sphincter. In 165 patients the sphincter was placed at the bladder neck, while 175 needed an implantation at the bulbous urethra. Because of the better results with regard to continence, we prefer the bladder neck implantation. The youngest patient treated was 12 years old and the oldest, 91. Most of the patients were between 40 and 80 years old. The highest continence rates were achieved in patients with postprostatectomy urinary incontinence. Among those with a bladder neck implant continence was achieved in 93.3% of all cases, while 87.4% of those with an artificial sphincter at the bulbous urethra achieved continence. The mechanical complication rate was low with 7.05%, whereas tissue-related complications occurred in a total of 25.3% of cases. Revision was necessary in 30.9% of cases during the first few years after implantation; it was striking that the incidence of revision fell dramatically 1 year after implantation. This is also true for any second revision, which usually becomes necessary within the first year after the first revision. In total, however, two-thirds of the patients do not require revision during the first 5 years. These data show that the implantation of an artificial sphincter is the safest and most successful method for the treatment of urinary incontinence in the male. This method is superior to all other operative treatments and should be considered the first-line treatment, especially in post-prostatectomy urinary incontinence.
Fibrosis of the cavernous bodies is a rare but serious condition resulting in erectile impotence. When the fibrosis is extensive a simple penile prosthesis sometimes cannot be implanted. In addition, perforation of the tunica albuginea is not uncommon in damaged cavernous bodies, and this will compromise a reimplantation. In such cases, the use of an alloplastic vascular prosthesis permits replacement of lost cavernous wall tissue and insertion of an inflatable penile implant. We used this technique in 10 patients with severely damaged cavernous bodies. In 7 of them, surgery was successful and enabled satisfactory intercourse. This type of surgery, however, should be reserved for selected cases of penile prosthetic surgery.
The disappointing long-term results of alternative treatments for erectile dysfunction have led to increasing interest in penile implants. Against this backdrop, the development of reliable penile prostheses which offer easy implantation and excellent function is a challenge to bioengineers and urologists with a special interest in the treatment of erectile dysfunction.
From 1983 to May 1991, the artificial sphincter AS800 has been applied in 106 female patients for the treatment of complicated cases of urinary incontinence. Of these, 80 remained in continuous follow-up and have now been followed up for at least 1 year, with a mean of 3.8 years. In 40 of our female patients the urethra was afunctional secondary to failure of previous anti-stress-incontinence procedures. Neurogenic incontinence with sphincteric involvement affected 30, while 10 of the patients had congenital sphincter anomalies or traumatic sphincter weakness. Following implantation of the artificial sphincter, 86.3% of these patients are completely continent and do not need a pad. With regard to emptying, 81.3% are able to empty their bladder without residual urine after opening the sphincter, and 8 have to perform clean intermittent catheterization (CIC) once or twice daily in addition. A further 7 void exclusively by CIC. As preparation for implantation of the AS800 sphincter, 24 additional procedures were performed, including 5 antireflux operations and 6 bladder-flap procedures. In 38 of 80 patients a total of 62 revisions were performed. Infection and erosion were the most common reasons for revision, accounting for 48.2% of all revisions. The next most common reason was tissue atrophy underneath the cuff. However, 25% of the revisions were due to device failures, most often cuff leakage.
A total of 46 patients with reflex bladder activity who failed conservative treatment underwent bladder augmentation in some cases in combination with the implantation of an artificial sphincter. Twenty were a result of a spinal cord injury and 26 had myelomeningocele. Acceptable continence has been achieved in 42 patients. In order to accomplish this 39 simple bladder augmentations with ileum, 5 total bladder replacements and 2 augmentations with sigma were performed. Additionally 6 antireflux operations, 8 bladder-flap procedures and 26 implantations of an artificial sphincter were carried out. Overall patient satisfaction was 88 percent.
Low pressure continent urinary diversions with abdominal wall stomas alike the Kock-pouch have shown good results. However, if urethral function can be saved without risk, an anastomosis of a bowel bladder to the urethral stump is more favorable in regards of continence, ease of the procedure and cosmetics. The S-bladder developed on the basis of the S-pouch from Parks, is conceptualized to be a complete replacement of the lower urinary tract, offering a low pressure reservoir, safe antireflux mechanisms, continence and voiding per urethra with abdominal straining. 52 patients (46 males and 6 females) were treated with an S-bladder. Continence in daytime and nighttime was achieved in 44 patients, while 49 patients remain continent during the day. To achieve this result 16 of our patients had to be treated with an artificial sphincter implanted at the bulbous urethra. Eleven of these 16 patients suffered from neurogenic bladder disease with preoperative urethral incompetence. Indications was TCC of the bladder in 38, neurogenic bladders in 11 and low-compliance bladders in 3 patients. The complication rate of 13.5% was acceptable. Emptying by abdominal straining was possible in all patients. Residuals were less than 50 cc, even in those patients with artificial sphincters.
Meshgraft urethroplasty has become one of the standard operative procedures for the treatment of long and complicated urethral strictures. The original method used meshed foreskin for urethral reconstruction. To extend the application of the method to circumcized patients, a split-thickness skin graft was used to construct a neo-urethra. In a first stage, a split thickness skin graft is harvested from the medical part of the thigh and transplanted alongside the opened urethra. After complete healing of this transplant, the neo-urethra is formed in a second stage 12 weeks later. Since 1980 meshgraft urethroplasty using a split-thickness skin graft has been performed in 34 patients. In all patients excellent anatomic and functional results have been achieved. This technique was found to be most useful in exccedingly long or problematic strictures, e.g. in spinal cord-injured patients.
The ideal treatment of urinary incontinence in children must refer to the subsequent subjects: reestablishment of urinary control, long term conservation of renal function and finally the preservation of normal body image. In this follow up 39 children from 4-20 years have been treated by implantation of an artificial sphincter. From 1983 the recent model AS 800 has been implanted. Because of bladder hyperreflexia and functional or mecanical obstruction 31 further operations had to be done to assure the balanced emptying of a low pressure reservoir with good capacity. After treatment 87.2% of the children (95.5% in the AS 800 group) were totally dry. Because of mecanical (27%) and surgical (33.3%) complications 22 revisions were necessary. With the model AS 800 the revision rate declined to 26%. This is due to the mecanical improvement of the devices and the increasing surgical experience. The results are discussed in relation to alternative treatments of urinary incontinence as supravesical diversion, ureterosigmoidostomy and intermittent catheterization. In conclusion the implantation of an artificial sphincter is the most effective treatment of incontinence in children. The remaining problems as infection and mecanical failure of the delice and the risk of upper tract deterioration because of bladder hyperreflexia ask for a long term follow-up with urodynamic and radiological examinations.
Explore the source record for details and available documents.
Many attempts have been made to develop a continent form of urinary diversion. Encouraging results have been obtained with the Kock pouch, which offers a low pressure reservoir, safe reflux protection and a reliable continent abdominal wall stoma. If urethral function could be saved without risk, anastomosis of a bowel bladder to the urethral stump is more favorable as far as cosmetics and continence are concerned. The S bladder, developed on the basis of the S pouch, is conceptualized to be a complete replacement of the lower urinary tract that offers a low pressure reservoir, safe antireflux mechanisms, continence and voiding per urethram with abdominal straining. We treated 78 patients with continent urinary diversion (Kock pouch in 46 and S bladder in 32). Continence was achieved in 87% of the patients treated with a Kock pouch, while 93.8% were continent in the S bladder group. In an effort to achieve continence day and night 43.8% of the patients treated with an S bladder required an artificial sphincter. The over-all complication rate (12.5 compared to 41.8%) and the operative complication rate (6.3 compared to 23.9%) were significantly lower in patients treated with the S bladder. Emptying by abdominal straining was possible in all patients with an S bladder. Residuals were less than 50 cc, even in patients with an artificial sphincter.
Long urethral strictures remain one of the hazards of modern urology. Reconstructive operations with scrotal skin suffer a high rate of recurrent stricture. To avoid complications, meshed split thickness skin graft or foreskin was used to construct a neourethra. In stage 1 split thickness skin graft is harvested and transplanted along the opened urethra. In stage 2 the neourethra is formed 8 to 12 weeks later. Since 1977 mesh graft urethroplasty has been performed in 96 patients using meshed foreskin (76) or split thickness skin grafts (23). In all but 1 patient excellent anatomical and functional results were achieved regardless of which type of graft was used. This technique was most useful in exceedingly long or problematic strictures, for example in spinal cord injury patients.
From 1973 to February 1989 a total of 309 patients with erectile dysfunction were treated with hydraulic penile prostheses. In 169 patients a hydraulic prosthesis type AMSIPP700 was implanted; with this prosthesis the primary success rate was 91.1%. As a result of technical improvements to the device the revision rate, initially 52.3% has fallen to 3.3%. Patient acceptance is better with hydraulic prostheses, which provide optimal simulation of the physiological processes of erection and detumescence, than with any other type of prosthesis.
Estrogene has a tonicising effect upon urethra musculature. There is also the same demonstrable influence of alpha-receptor stimulating drugs upon the urethra pressure profile. After preliminary treatment with estrogene, there is a considerably stronger tonicising effect of alpha-stimulating drugs than without such a treatment. So the combination of estrogene and alpha-stimulating drugs seems a useful addition to the conservative treatment of stress incontinence.
Urodynamic evaluation was performed in 75 patients with congenital neuropathic bladder. Concerning treatment the most important parameters were detrusor tone, detrusor activity and bladder outlet resistance. Based on these findings individual conservative therapy was applied. Reflux or dilatation of the upper urinary tract found in 26 children could be controlled by drugs or transurethral operations in 20, urinary diversion had to be done only 4 times. 26 children were selected for intensive treatment of incontinence; in about 50% satisfying urinary control was achieved. These results still need long-term observation. The main interest, however, was to postpone irreversible surgery and to gain time for possible better treatment in the future.