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As a consequence of the demographic change, the prevalence of female and male bladder and bowel dysfunction, functional pelvic floor disorders and pelvic organ prolapse are steadily increasing. Continence and pelvic floor centers are interdisciplinary facilities that focus on these functional disorders, including malformations, tumors and functional disorders resulting from neurogenic diseases, injuries or surgery. The affected patient clientele includes children, women, and men of all ages. The certification is carried out by the accredited certification company CERT iQ Certification Services. In addition to structural requirements, personal quality criteria are also implemented in the novel harmonized and standardized certification system. The assessment of treatment quality is also a component of the procedure, although it is currently limited to the midurethral sling tracer procedure for the treatment of female stress urinary incontinence. Regarding the other conservative and surgical treatment options for pelvic floor, bladder and bowel functional disorders, no quality of outcome has so far been recorded. Internationally recognized and validated questionnaires to assess preoperative and postoperative quality of life would be valuable tools to define the quality of treatment and outcome. Similarly, supplementary thresholds should be established for complication rates and quality of the success of treatment to identify centers with high expertise. In this context, it is crucial to consider the individual complexity of the patient groups and to distinguish between primary and recurrent interventions., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

Proper indication, preoperative diagnostics and final choice of surgical technique in the operative management of female stress urinary incontinence are subject to somewhat irrational, trend-based changes. For various reasons (insufficient reimbursement, poor expertise, limited therapeutic spectrum) preoperative urodynamic tests are increasingly thought to be unnecessary and are progressively replaced by perineal ultrasound despite lack of evidence. Since the AWMF guidelines (AWMF: Association of the Scientific Medical Societies in Germany) for the diagnosis and treatment of stress urinary incontinence in women were published, individualized planning of therapy is "out". Unconditional guideline adherence in certified pelvic floor centers, which have become very popular in Germany, has furthermore restricted the spread of therapeutic options due to minimum procedure number requirements. With regard to suburethral tension-free alloplastic slings, the retropubic version, which was temporarily unfashionable, has been experiencing a renaissance at the cost of the transobturator alternative. Single-incision slings were developed for the outpatient US market and have never become established in Germany due to lack of proof of superiority. In the setting of a limited spectrum of surgical procedures, adjustable sling systems offer promising treatment options for risk groups with acceptance of higher infection and erosion rates, thus gaining popularity. Reliable and comprehensive preoperative patient information comprising the whole spectrum of therapeutic options with individual risks and opportunities is key to prevent the impending ban of alloplastic implants in female stress incontinence surgery.

Alloplastic transvaginal meshes have become very popular in the surgery of pelvic organ prolapse (POP) as did alloplastic suburethral slings in female stress incontinence surgery, but without adequate supporting data. The simplicity of the mesh procedure facilitates its propagation with acceptance of higher revision and complication rates. Since attending physicians do more and more prolapse surgeries without practicing or teaching alternative techniques, expertise in these alternatives, which might be very useful in cases of recurrence, persistence or complications, is permanently lost. It is doubtful that proper and detailed information about alternatives, risks, and benefits of transvaginal alloplastic meshes is provided to every single prolapse patient according to the recommendations of the German POP guidelines, since the number of implanted meshes exceeds the number of properly indicated mesh candidates by far. Although there is no dissent internationally about the available mesh data, thousands of lawsuits in the USA, insolvency of companies due to claims for compensation and unambiguous warnings from foreign urological societies leave German urogynecologists still unimpressed. The existing literature in pelvic organ prolapse exclusively focusses on POP stage and improvement of that stage with surgical therapy. Instead, typical prolapse symptoms should trigger therapy and improvement of these symptoms should be the utmost treatment goal. It is strongly recommended for liability reasons to obtain specific written informed consent.

Background: Certified Prostate Centers proclaim congruent process and outcome quality results for treatment of prostate carcinoma. Therapy in accordance with the guidelines after presentation of the patient in an interdisciplinary conference and regular documented follow up are not in themselves a guarantee for good quality results (complication free, continence, erectile function, negative surgical margins, biochemical recurrence free), and are significantly influenced by factors not contained within the certification framework., Discussion: An association between exceeding the minimum number of operations and quality assurance exists, if at all, only vaguely and on no account justifies the absolute numbers necessary for certification. Although good measuring instruments for a Pentafecta analysis are available, the gathering of quality results for a center are limited to questionnaires for functional quality results and in the non-differentiated request for a pT2R1 rate of under 10 % for oncological quality results., Conclusions: The reasons for this systematic ignoring of the for the patient so important quality results with a simultaneous excessive regard for standardizing organizational procedure processes are manifold. They comprise valid verifiability of process quality, the unclear effects of standardized treatment pathways on actual operation quality and the capitulation to statistical and patient determined problems with sufficient acquisition of comparable functional OP results. Whereas the outcome quality is more important than the process quality for patients with prostate carcinoma, the certified centers conduct themselves in exactly the opposite manner, thus creating a virtually insoluble dilemma.

Background: Vesicovaginal fistulae are much more common in developing countries along the equatorial fistula belt than in industrialized countries. However, although the classical obstetric fistula caused by lack of medical support through pregnancy and delivery in adolescent primiparae has almost vanished in Germany, we are now facing new and predominantly iatrogenic variants. Increasing frequency of gynecological surgery as well as pelvic radiation, forgotten vaginal foreign bodies, or uninhibited cancer growth are the modern causes for vesicovaginal fistula in elderly patients. Comorbidities and genital atrophy impair surgical therapy in view of a limited success rate of conservative transient transurethral catheterization., Methods: Diagnostics should start early and should be initially limited to vaginal inspection, cystourethroscopy, and the blue dye test. Radiological investigations including CT and MRI are only indicated in patients suspicious for ureterovaginal fistula or with inconclusive findings or malignant fistula. The surgical armamentarium comprises vaginal, abdominal, and combined approaches, which all underlie basic principles of fistula repair: protection of the ureteral orifices, complete excision of the fistula canal, accurate separation of the organs connected to the fistula, sufficient tissue mobilization for tension-free suturing, interposition of padding material for prevention of recurrency., Conclusion: Depending on the degree of sphincter damage, stress urinary incontinence might persist despite successful fistula repair, requiring further incontinence surgery or ultimate urinary diversion in recurrent cases that are hopeless.

Sacrocolpopexy has remained standard procedure for correction of pelvic organ prolapse regardless of the affected compartment. Assuming the appropriate indication, it is characterized by an excellent long-term cure rate. Asymptomatic pelvic organ prolapse is no indication for surgery and should not be corrected in view of possible complications. This article summarizes general and method-specific complications of sacrocolpopexy, identifies causes, and allows error management to be tailored to each individual patient to increase treatment and outcome quality.

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a standard approach for surgical treatment of organ-confined prostate cancer. Despite additional costs, RALP seems to provide better functional and oncological outcomes and less blood loss compared to open radical prostatectomy (ORP). However, prospective randomized studies are still missing., Purpose: Based on the current literature, this review reports about the role of RALP in prostate cancer treatment. Its functional and oncologic outcomes as well as complication rates are compared to ORP. Particularly, the role of RALP in nonorgan-confined tumors will be discussed., Results: Based on the current literature, RALP provides better continence and potency rates as compared to ORP. Moreover, the incidence of positive surgical margins seems to be reduced. However, there is conflicting data regarding the role of RALP in nonorgan-confined prostate cancer. Regarding long-term oncologic outcomes, RALP seems to be comparable to ORP.

Background: In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm., Results: Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively., Conclusion: Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 20 years. The procedure is easy to perform, minimally invasive with a short operating time in an outpatient setting and has proven efficacy comparable to retropubic colposuspension. The frequency of surgery for female stress incontinence has tripled within one decade which has to have an impact on the number of complications. In contrast, sacrocolpopexy has remained the gold standard in urological prolapse surgery as none of the new techniques has reached similar efficacy or safety; however, possible complications have to be named and their causes have to be understood to maintain the highest quality of care in the future. Possible complications of TFAS are potentially underestimated with respect to prevalence and manageability. Possible complications of prolapse and incontinence surgery are presented and the underlying causes are identified. Knowledge of the pathophysiology and the cause of complications together with the results of a postoperative diagnostic work-up, allow complication management to be tailored to each individual patient. To prevent complications all conservative treatment options should have been tried preoperatively and a complete evaluation (including urodynamics) should have been carried out for every patient. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

Today, for the surgical treatment of postprostatectomy incontinence, several treatment options are available, e.g., adjustable and functional sling systems, artificial sphincter, bulking agents, and balloons. However, no recommendations in terms of specific diagnostic tools and differentiated treatment options for everyday life are available. Our aim is to provide some clinically relevant recommendations for the necessary diagnostic workup and different treatment options of postprostatetectomy incontinence to support clinical decisions in everyday life. Treatment selection should be based on contraindications. However, there is a broad overlap of the various surgical options.

Due to rising life-expectancy and increasing use of tomography more elderly patients with incidental renal tumors are being diagnosed. The current article gives an overview of kidney function after renal surgery in the elderly and the aim is to give assistance in clinical practice for deciding how to adequately treat these patients.

Objective: Extracorporeal magnetic innervation (ExMI) is a non-invasive therapy for treatment of urinary incontinence (UI). The aim of the current study was to evaluate the efficacy of ExMI in a prospective case series., Patients and Methods: Over a period of 1.5 years 63 consecutive patients with a clinically and urodynamically confirmed diagnosis of urinary incontinence were enrolled. All patients requested an additional non-surgical therapy option and the ExMI system (Neo control™, Kitalpha, USA) was used. The therapy consisted of 12 treatment sessions two to three times a week. Primary outcome parameter was reduction of the number of pads per 24 h and secondary outcome parameters were patient satisfaction, adverse events and duration of the therapeutic effect., Results: A total of 63 patients (57 male and 6 female), mean age 68±7.1 years were recruited. After completion a significant (p=0.001) reduction of the number of pads used per 24 h was observed (from 5.4±3.7 to 2.7±2.5) which persisted after a median follow-up of 12.5 months (2.3±2.2 pads per 24 h). Also patients suffering from UI after prostatectomy revealed a significant (p=0.001) reduction in the number of pads from 4.8±2.9 to 2.6±2.6 with persistence at 2.5±2.5 at follow-up. Transient, self-limiting perineal pain in three patients was the only reported side effect., Conclusions: The ExMI procedure is an additional non-invasive therapy option for patients with urinary incontinence. However, sham-controlled studies are required to corroborate the therapy effect.

Abdominal sacrocolpopexy is a standard procedure for the correction of pelvic organ prolapse of all three compartments and can also be performed minimally invasively without compromising efficacy as by open techniques. In comparison to conventional laparoscopy robotic-assisted laparoscopic sacrocolpopexy benefits from several technical stand-alone features, such as three-dimensional view, increased degrees of freedom through angulated instruments, tremor filter and up and down scaling of instrument movements. These advantages facilitate preparation of the vesicovaginal and rectovaginal spaces as well as suturing and reperitonealization, which should lead to decreased operation time and anesthesia time in extreme Trendelenburg position. Surgeon also benefit from the much more ergonomic working conditions of the da Vinci® system: however, comparative studies are rare and conclusions are preliminary. The German reimbursement system (DRG) does not adequately cover da Vinci expenses which, despite the obvious advantages represents the most significant obstacle in the propagation of this technique.

Stenosis of the ureteroenterostomy and symptomatic reflux are among the most dangerous complications of all forms of urinary diversion. Variations in ureter implantation techniques and different surgical expertises are responsible for the heterogeneity of the available prevalence data. Antirefluxive implantation techniques seem to be more vulnerable to stenosis and obstruction than refluxive techniques, although no difference in kidney function deterioration over time was shown according to the presence or absence of reflux protection. Despite frequent controls, approximately one quarter of all obstructed renal units show a complete loss of function. The reimplantation rate of stenotic ureters exceeds 30%.The development of an implantation stenosis may be silent and subtle. The loss of renal function often remains unnoticed if sonography and creatinine measurements are the only follow-up tools employed. Neither of these tests is reliable in estimating kidney function and may mislead both doctor and patient. DMSA scintigraphy and retrograde contrast studies (conduitogram, pouchogram) are the most sensitive tools available to evaluate a symptomatic reflux, whereas MAG-3 renal scans and antegrade function tests (nephrostogram, renal pelvic pressure measurement) are recommended for investigating ureteric obstruction. Stenosis of the ureteroenterostomy usually occurs within 2 years after urinary diversion; delayed occurrence of ureteric obstruction is indicative of malignant local recurrence or compressive metastases.There are various minimally invasive treatment options such as balloon dilatation, internal ureterotomy, stenting and nephrostomy placement. However, the technical challenge of a ureteroenterostomy should not be a deterrent. In fact, if surgically possible, the patient should be offered open revision, since this is the only way to durably cure the underlying pathology and re-establish the already impaired quality of life of patients with urinary diversion as much as possible.

When urinary diversion is indicated, patient information concerning the advantages and disadvantages of different types of urinary diversion and their choices is of utmost importance for the functional outcome and patient satisfaction. There is a variety of choices for incontinent urinary diversion (ureterocutaneostomy, ileal conduit, colonic conduit) and continent urinary diversion (continent anal urinary diversion, continent cutaneous urinary diversion and urethral bladder substitution). In the individual case, the choices may be limited by patient criteria and/or medical criteria. Important patient criteria are preference, age and comorbidity, BMI, motivation, underlying disease and indication for cystectomy. Medical criteria which possibly limit choices of type of urinary diversion are kidney function/upper urinary tract status and limitations concerning the gastrointestinal tract, concerning urethra/sphincter as well as the ability and motivation to perform intermittent self-catheterization. Preoperative information may use simulation of certain postoperative scenarios (urethral self-catheterization, fixation of water-filled conduit bags, holding test for anal liquids) to allow the individual patient to choose the optimal type of urinary diversion for his/her given situation from the mosaic of choices and possible individual limitations.

Idiopathic detrusor overactivity (motory urge) negatively affects the live of patients. Conservative treatment is not always effective and has multiple side effects. Sacral neuromodulation is a second line therapy for the treatment of idiopatic detrusor overactivity. Over the last decade, botulinum toxin injections have been increasingly used as alternative although there are only few randomized studies. Goal of this review is to compare efficiacy, safety and cost effectiveness of both methods.

Compared to female urinary incontinence, the prevalence and socioeconomic impact of male urinary incontinence has not gained much attention from epidemiologists. Moreover, the few available epidemiological surveys vary in their use of definitions and methodology, which are known to have great impact on the resulting prevalences. Therefore, the interpretation of the findings is difficult. Depending on definitions and methods, the prevalence of male urinary incontinence ranges between 5.4 and 15%. Urgency incontinence is the predominant subtype in all age groups, although the relative proportion shifts towards stress incontinence with rising age. Neurological and posttraumatic causes for male stress incontinence become less important as the frequency of iatrogenic interventions (radiation, prostate surgery) increase. Additional risk factors for male urinary incontinence are age, immobility, and neurological diseases. Surgery of the prostate (TURP, radical prostatectomy) is especially associated with postoperative urinary incontinence if bladder and/or sphincter dysfunctions are preexisting, if the patient is particularly old, and the surgeon's experience is limited. The etiology of male urgency incontinence comprises detrusor instability caused by obstruction, age-related detrusor degeneration, insufficient inhibitory CNS control over afferent detrusor overstimulation, and neurological diseases. The pathophysiological key factors of male continence are functional urethral length and maximum closure pressure, the preservation of which should receive the unrestricted attention of every prostate surgeon.

The number of patients on the renal transplant waiting list has remained constantly high. In this article we highlight two strategies to extend the donor pool and focus on AB0 incompatible and cross-over renal transplantation. Increased immunologic knowledge and improved therapeutic management have facilitated successful AB0 incompatible renal transplantation with very good long-term results. However, this method has only been applied in very few German transplant centers and should be explored further. The term cross-over transplantation implies the exchange of organs between two otherwise incompatible couples enabling compatible transplantation in both couples. The German transplantation law allows only living transplantation in emotionally related couples. However, in specific cases of close interpersonal relationships cross-over transplantation between two couples is acceptable.

Tension-free alloplastic slings (TFAS) have revolutionized surgery for female stress urinary incontinence for more than 15 years. The procedure is easy to perform, minimally invasive with short operation time in an ambulatory setting, and has proven efficacy comparable to the gold standard procedure of retropubic colposuspension.Possible TFAS complications are potentially underestimated with respect to prevalence and manageability. We report our experience with major complications following TFAS and mesh implantation in patients referred to our interdisciplinary continence center. Patient history, risk factors, and preoperative diagnostics were analyzed for development of individualized treatment strategies. Overcorrections with formation of postvoid residual (PVR) can occur in retropubic TFAS as well as in transobturator TFAS. However, the most prevalent and challenging complication is de novo urgency. Major complications like urethrovaginal fistula, sling arrosions of the urethra, bladder, and vagina as well as infected gangrene and complete urethral loss requiring urinary diversion were seen at a frequency suggesting underrepresentation of these complications in the literature. The large amount of implanted artificial mesh material used for pelvic organ prolapse (POP) correction represents a particular challenge in cases of dyspareunia or persisting pelvic pain.Complication management has to be based on cystoscopic, urodynamic, and physical examination findings to be individualized to each patient and must take potential risks of recurrent incontinence or persisting complaints into account.To prevent TFAS or mesh complications, every patient should have tried all conservative treatment options and should be completely evaluated (including urodynamics) preoperatively. Artificial meshes should only be used in cases of prolapse recurrence or in otherwise inoperable patients. Postoperative urodynamics may help to document treatment success and to identify and quantify complications.

Introduction: We evaluated the currently preferred primary treatment options among German urologists and radio-oncologists if personally diagnosed with localized prostate cancer, taking into consideration the different prognostic risk groups., Materials and Methods: A questionnaire was mailed to 3,217 urologists and 598 radio-oncologists. They were asked to choose their preferred primary treatment option if they were personally diagnosed with prostate cancer, taking into consideration the different prognostic risk groups: low risk [Gleason score < or =6, prostate-specific antigen (PSA) < or =10 microg/l, T1c], intermediate risk (Gleason score 7, PSA 11-19 microg/l, T2), and high risk (Gleason score > or =8, PSA> or =20 microg/l, T3). Surgical options were further subdivided according to technique (retropubic, laparoscopic, perineal)., Results: The questionnaire return rate was 49% for urologists and 41% for radio-oncologists. The mean age was 48 years (28-86) for urologists and 47 years (29-68) for radio-oncologists. Primary surgical treatment was selected by 62% of urologists for low-risk prostate cancer, 90% for intermediate-risk prostate cancer, and 77% for high-risk prostate cancer. Radiotherapy as a primary treatment option was elected by 71% of radio-oncologists for low-risk prostate cancer, 84% for intermediate-risk prostate cancer, and 89% for high-risk prostate cancer. Retropubic, laparoscopic, and perineal prostatectomy would be chosen by 61%, 28%, and 10% of urologists, respectively, for low-risk prostate cancer; by 70%, 24%, and 6%, respectively, for intermediate-risk prostate cancer, and by 80%, 15%, and 5%, respectively for high-risk prostate cancer., Conclusion: Urologists prefer surgery and radio-oncologists radiotherapy for primary treatment of prostate cancer, irrespective of the prognostic risk group. Particularly for high-risk prostate cancer, the majority of radiooncologists would still choose radiotherapy as a primary treatment option. In the age of minimally invasive surgery, radical retropubic prostatectomy is still the preferred surgical treatment option among urologists for any prognostic risk group.

Objective: To study clinical and histopathologic parameters after cystectomy and lymphadenectomy in non-muscle-invasive transitional cell carcinoma (TCC) of the bladder and their association with the prevalence of lymph node metastases (N+)., Patients and Methods: Of 866 patients treated with radical cystectomy and lymphadenectomy, 219 had non-muscle-invasive TCC of the bladder. The prevalence of N+ was related to parameters such as gender, age, number of transurethral resections of the bladder (TURBs), intervals between first TURB and cystectomy, adjuvant therapy, maximum histopathologic tumor stage and grade at TURB, and tumor upstaging in the cystectomy specimen by univariate and multivariate analysis., Results: A total of 33 patients (15%) had N+. By multivariate analyses, tumor upstaging and the number of TURBs were independent predictors of N+ at cystectomy. The number of TURBs increased the prevalence of N+ from 8% (one TURB) to 24% (two to four TURBs). Tumor upstaging in the cystectomy specimen increased the prevalence of N+ from 4% to 36%., Conclusion: Inappropriate delay and staging errors of"high risk" non-muscle-invasive TCC of the bladder contribute to an increased prevalence of N+ and should be avoided. In our series, the number of TURBs and tumor upstaging in the cystectomy specimen were independent predictors for N+ by multivariate analysis.

The ageing of our society continuously increases the number of frail elderly patients in the incontinence cohort. Shortage of financial and personnel resources demands reasonable and purposeful use of the diagnostic armamentarium. All intended diagnostic procedures should follow an algorithm hierarchized for invasiveness and should be limited to the minimum extent necessary for initiation of a conservative first-line treatment. Reasonable diagnostics objectify patients' complaints, differentiate between subgroups, reveal underlying pathologies and comorbidities, classify incontinence severity, support the therapeutic strategy, identify possible treatment complications and serve as follow-up tools. Diagnostic results have to be documented in detail and the procedures must be as easy and minimally invasive as possible. Basic diagnostics in urinary incontinence comprise patient history, clinical examination, urinalysis, uroflowmetry and sonographic post-void residual measurement, voiding diary and evaluation of the mental status. With these procedures, the vast majority of elderly patients can be classified correctly and a conservative first-line treatment can be started. Only a minority of patients with incongruent diagnostic results or recurrent incontinence refractory to conservative therapy should undergo further special diagnostics (urethrocystoscopy, urodynamics, morphologic and functional radiologic imaging, perineal or introital ultrasound) if they lead to therapeutic consequences. If not, expensive special diagnostics should be omitted in elderly patients due to their inherent morbidity.

Nowadays, male stress urinary incontinence is rare and almost always of iatrogenic origin (radiotherapy, pelvic surgery). However, the prognosis of urinary incontinence following surgery is good and can be improved by pelvic floor muscle exercises in combination with biofeedback systems. For the remaining patient cohort with persistent urinary incontinence, several established surgical treatment options are available. Suburothelial injections of bulking agents can easily be performed in an ambulatory setting. However, regardless of the material used, long-term results are disappointing. Moreover, the residual urethral function deteriorates due to cicatrization of the suburothelial plexus with consequent loss of urethral elasticity. The fascial sling procedure in males has to be performed in preoperated areas and is as technically demanding for the surgeon as it is burdening for the patient. Alloplastic material is not used, thus minimizing risks for arrosion or infection. Since the sling tension can neither be standardized nor postoperatively readjusted, the risk of overcorrection is considerable and the success of the procedure is heavily dependent on the surgeon's experience. Despite wear and high revision rates, the technically mature artificial sphincter produces excellent continence results and has become the gold standard in the therapy of male stress urinary incontinence. The circumferential and continuous urethral compression by the cuff is highly effective, but at the price of an almost inevitable urethral atrophy. To overcome this problem, various surgical techniques have been developed (tandem cuff, cuff downsizing, transcorporal cuff placement). However, the expensive artificial sphincter is not a nostrum for every incontinent man, since it requires certain minimal cognitive and manual capabilities. Therefore, the search for less demanding treatment alternatives seems to be necessary, even if one has to accept lower continence rates.

Due to elevated intravesical storage pressures, neurogenic bladder dysfunction carries a high risk of renal damage. Thus, the goals of neurourologic treatment are reduction of intravesical storage pressure and intermittent bladder emptying in order to protect renal function and to achieve continence. If anticholinergic medication is either ineffective or intolerable, several open and controlled studies showed that the injection of botulinum toxin A into the detrusor muscle is a minimally invasive, safe, and effective treatment option. These studies demonstrated an effective reduction of storage pressures and a significant increase in bladder capacity. The effect has been shown to last up to a year. As this treatment is not approved by European administrations, botulinum toxin A treatment fulfills all criteria for "justified off-label use." The reduction of intravesical storage pressure leads to an improvement of life expectancy due to upper urinary tract protection. Furthermore, quality of life can be improved by low incidence of urinary tract infections, secure continence, and physiologic catheterization intervals.

We present a case of post-traumatic posterior urethral stricture and localized prostate cancer, which could be treated successfully with simultaneous radical perineal prostatectomy and membranous urethral stricture excision. After 6 months follow-up, the patient is continent with no evidence of stricture recurrence. Post-traumatic posterior urethral strictures can be managed surgically through a perineal approach with high success rates. Prostate surgery after pelvic fracture with posterior urethral distraction defects does not necessarily lead to stress urinary incontinence.

Incontinence can be the result of impaired functioning of the detrusor muscle and/or the sphincter mechanism. For this reason, the pathomorphology and the pathophysiology should be documented before surgery, so that if it is not successful it is possible to deduce what alterations have been caused by an operation and the reason why the treatment has not been successful. Vaginal reconstruction of the pelvic floor following vaginal prolapse is a safe, effective surgical procedure, particularly for older women. Abdominal fixation of the vaginal stump through open or laparoscopic sacrocolpopexy gives long-lasting and anatomically favourable results especially for younger women who are sexually active, but is associated with a higher mortality rate. Incontinence treatment in men is itself gradually becoming accepted as a subspecialty. Pharmacological treatment that is used for urge incontinence takes the form of substances that relax or desensitize the detrusor (antimuscarinics, oestrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetin), while stress incontinence requires stimulation of the sphincter and pelvic floor (alpha-mimetics, oestrogens, duloxetin). Bladder function disturbances in children can be classified by noninvasive methods, but the therapy remains a difficult endurance test for the children, their parents and the doctor, often extending over years.

Drug treatment for female urinary incontinence requires a thorough knowledge of the differential diagnosis and pathophysiology of incontinence as well as of the pharmacological agents employed. Pharmacotherapy has to be tailored to suit the incontinence subtype and should be carefully balanced according to efficacy and side effects of the drug. Women with urge incontinence require treatment that relaxes or desensitizes the bladder (antimuscarinics, estrogens, alpha-blockers, beta-mimetics, botulinum toxin A, resiniferatoxin, vinpocetine), whereas patients with stress incontinence need stimulation and strengthening of the pelvic floor and external sphincter (alpha-mimetics, estrogens, duloxetine). Females with overflow incontinence need reduction of outflow resistance (baclofen, alpha-blockers, intrasphincteric botulinum toxin A) and/or improvement of bladder contractility (parasympathomimetics). If nocturia or nocturnal incontinence are the major complaints, control of diuresis is obtained by administration of the ADH analogue desmopressin. Future developments will help to further optimize the pharmacological therapy for female urinary incontinence.

Future demographic developments will challenge urology with a steadily increasing incidence of lower urinary tract symptoms (LUTS) derived from the aging bladder. Obstruction, instability and hypocontractility, which may be caused by changes in the receptor profile of the detrusor, are typical pathophysiologic findings in geriatric bladder dysfunction. Benign prostatic hyperplasia and diabetes mellitus are age-associated comorbidities with an additional influence on bladder receptors. Muscarinic (M(2), M(3)), purinergic (P2X, P2Y) and adrenergic receptors (alpha(1), beta(3)) are targets of efferent sympathetic and parasympathetic bladder innervation. Although the results from animal experiments are somewhat inconsistent, aging and bladder outlet obstruction (BOO) probably cause partial cholinergic denervation of the detrusor with a subsequent upregulation of muscarinic receptor sensitivity leading to bladder instability. The non-cholinergic (atropine-resistant) component of the detrusor contraction rises with aging and BOO to 50%, emphasizing the increasing impact of purinergic receptors in geriatric LUTS. alpha(1)-adrenergic receptors are modulated in the aging bladder by a shift from the predominant alpha(1a) subtype to the alpha(1d) subtype, which shows 100-fold higher affinity towards norepinephrine and increases alpha-adrenergic bladder susceptibility. No data are available on the changes in beta(3) receptor density or sensitivity with aging. Moreover, the role of sensory C-fiber receptors in geriatric LUTS remains completely unclear, although specific C-fiber blockers are already under clinical evaluation (capsaicin, resiniferatoxin).

Increasing prevalence of diabetes mellitus and rising patient life expectancy are causing an accumulation of urologic late complications-despite or due to steadily improving medical health care. The prevalence of diabetic cystopathy (impaired bladder sensation, increased bladder capacity, sometimes accompanied by voiding difficulties and residual urine) is 25% in non-insulin-dependent diabetics and 48% in insulin-dependent diabetics. Autonomic and peripheral neuropathy lead to detrusor hyposensitivity, and chronic overstretching of the bladder causes myogenic detrusor hypocontractility. Since diabetic cystopathy often develops insidiously and asymptomatically, prevention of secondary complications such as recurrent urinary tract infections, vesicorenal reflux, nephrolithiasis, and pyelonephritis requires the urologist's full attention as well as early and repeated urodynamic diagnostics. Comorbidities can lead to a variety of urodynamic findings. Therapeutic options are generally conservative (timed voiding, micturition training, CIC, pharmacotherapy) and should be part of an integrated interdisciplinary health care approach since undiscovered complications involving non-urologic organ systems create a higher long-term socioeconomic burden than preventive support provided by other specialists.

Bladder overactivity (OAB) is a common disease with a socioeconomic impact comparable to diabetes mellitus. As life expectancy rises in industrialized countries the importance of OAB will further increase. The International Continence Society (ICS) recently reported a modified terminology for lower urinary tract function and established the symptom-based term OAB. The etiology of OAB comprises neurogenic and non-neurogenic detrusor hyperactivity as well as detrusor hypersensitivity. Neurogenic detrusor hyperactivity may be caused by insufficient cortical inhibition, degenerative neuropathies, and spinal cord lesions, whereas bladder aging, bladder outlet obstruction, and chronic bladder irritation (UTI, stones, tumors) are possible causes for non-neurogenic detrusor hyperactivity. Since most epidemiologic surveys focus on urge incontinence without considering urgency frequency without incontinence, epidemiologic data concerning OAB are rare. Two recently published multinational prevalence studies from Europe and Asia show different prevalence values [Europe: 15.6% (men), 17.4% (women); Asia: 53.1%(women)], which may be due to methodological differences. Both studies report an increase of OAB prevalence corresponding with age. The cumulative incidence of OAB is rising faster in aging males than in aging females. Two-thirds of the European and one-fourth of the Asian individuals affected by OAB complained about impaired quality of life, but only 60% of the European and 21% of the Asian sufferers have talked to a doctor or sought treatment. One out of four patients visiting their health care professional for OAB symptoms is currently under medication. To avoid high treatment costs and side effects, pharmacotherapy (e.g., antimuscarinics) should only be given after detailed diagnostic evaluation.

Despite recent caveats about the rapid development of resistance to fluoroquinolones in the treatment of urinary tract infections (UTI), the good tolerability, bioavailability and the broad antibiotic spectrum of fluoroquinolons explain their increased use. We investigated the changes of bacterial spectra and cross resistance profiles in ambulatory and hospitalized UTI patients. A total of 430 positive urine cultures and resistograms were classified according to patient status as either ambulatory or hospitalized and retrospectively analyzed. Cross-resistance profiles of the most effective antibiotics (cotrimoxazol, levofloxacin, amoxicillin/clavulanic acid) were made before an analysis of cost-effectiveness was performed. Whereas Escherichia coli remains the predominant cause of UTI in ambulatory patients, Enterococcus faecalis is the most frequently detected bacterium in the urine cultures of hospitalized patients. This is one reason for the unacceptably high rate of primary resistance of UTI bacteria against cephalosporins. Primary resistance to cotrimoxazol, amoxicillin/cavulanic acid and levofloxacin are impressive and tend to favor the use of levofloxacin. However, high cross-resistance rates reduce the usability of one antibiotic in case of the lack of effectiveness of the other. The broad use of potent antibiotics in hospitals has led to a higher primary resistance and cross-resistance of UTI bacteria in hospitalized patients than in ambulatory patients. The primary resistance of UTI causing bacteria is generally high and worrying. The new fluoroquinolone levofloxacin exhibits surprisingly high primary resistance rates and shares high cross-resistance with other antibiotics that are as effective but much cheaper. Thus, we consider that it should not be a first line treatment option for ambulatory UTI patients in the absence of any resistogram, in order to ensure cost-effectiveness and a slow down in the rapid development of resistance.

Traditionally, women with type III stress incontinence (intrinsic sphincter deficiency) are treated with sling procedures, which have undergone multiple modifications during the last 90 years regarding surgical approach, sling course, and materials. The latest variation of the established sling concept is the tension-free vaginal tape (TVT) procedure. The choice of sling material influences the postoperative complication rate and reveals a conflict between unrestricted availability (alloplastic material) and optimal tissue compatibility (autologous material). Although valid information about the surgical outcome of sling procedures is rare, at least some evidence-based conclusions may be drawn from the meta-analysis of the published data: sling procedures and colposuspensions are more efficient and more durable than needle suspensions or anterior repairs in the treatment of female stress incontinence. The complication profile does not show a significant difference between slings and colposuspensions. The lack of long-term results for the TVT procedure precludes any definite assessment of this innovation. In any case, to meet the patient's interests, no surgical approach for correction of stress incontinence should be undertaken without complete diagnostic evaluation of the problem.