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Objective: To demonstrate robot-assisted transvesical prostatectomy for a very large prostate. The management of benign prostatic hyperplasia (BPH) has developed quickly in the last few years. Modern minimally invasive surgical methods are continuously gaining a fixed status in the therapy. The transurethral approach is currently the ‘gold standard’, but what can we do with a very large prostate? Does robot-assisted surgery play, as a minimally invasive method, any role in the treatment of BPH? Methods: An 80-year-old man with severe lower urinary tract symptoms without relevant comorbidities. His International Prostate Symptom Score (IPSS) was 21, quality of life score was 4, and his prostate-specific antigen level was 4.8 ng/mL. Transrectal ultrasonography showed a very large prostate (volume 240 mL). The residual urine volume was ∼200 mL. He had no previous abdominal surgery and the preoperative cystoscopy showed no abnormalities. Results: We performed a robot-assisted transvesical prostatectomy. We used zero optic and three robotic arms. The patient was in Trendelenburg position. The operation duration was 88 min, without significant blood loss. We used a morcellator to aid the removal of the prostate and avoid a big incision to extract the specimen. Irrigation was only required for the first 24 h after the operation. The patient was discharged on the fourth postoperative day. The transurethral catheter was removed on the sixth postoperative day and voiding was excellent. Conclusion: The management of a very large prostate remains very difficult. The robot-assisted technology allows us to perform this difficult operation in a minimally invasive way and without significant blood loss. Despite the size of the prostate, we did not need to make a big incision for extraction and the operation could be performed without any complications. Try always to be innovative and think about using some gynaecological instruments to be more minimally invasive.

Introduction Cross-sex hormone treatment of gender dysphoria (GD) patients changing from male to female a prerequisite for sex reassignment. For initial physical adaptation, a combined treatment of anti-androgens and estrogens is used. Provided that patients fulfill specific criteria, sex reassignment surgery (SRS) presents the final step toward physical adaptation. However, systematic studies analyzing effects of hormone treatment regimens are lacking. Aim The aim of this study was to compare the effects of three different hormonal treatment strategies regarding endocrinological parameters and testicular histology. Methods Testicular tissues were obtained in a multicenter study from 108 patients on the day of SRS from three clinics following different treatment strategies. Patients either discontinued treatment 6 weeks (clinic A) or 2 weeks (clinic B) prior to SRS or not at all (clinic C). Testicular tissues, ethylenediaminetetraacetic acid blood and questionnaires were obtained on the day of SRS. Main Outcome Measures Blood hormone and intratesticular testosterone (ITT) levels were measured. Testicular weight and histology were evaluated and the percentage of luteinizing hormone/choriogonadotropin receptor (LHCGR) positive cells was determined. Results According to the questionnaires, patients showed desired phenotypical changes including breast growth (75%) and smooth skin (32%). While patients from clinics A and B presented with rather virilized hormonal levels, patients from clinic C showed generally feminized blood serum levels. Histological evaluation revealed highly heterogeneous results with about 24% of patients presenting with qualitatively normal spermatogenesis. In accordance with serum endocrine profile, ITT levels were lowest in clinic C and correlated with testosterone and free testosterone, but not with the spermatogenic state. The percentage of LHCGR-positive cells and ITT levels did not correlate. Conclusion Only patients that did not discontinue hormonal treatment showed feminized blood levels on the day of SRS. The ones who stopped re-virilized quickly. Interestingly, testicular histology was highly heterogeneous irrespective of the treatment strategy, a phenomenon that requires further investigation.

Objective To demonstrate robot-assisted right-sided partial nephrectomy for a large central renal mass. Based on current available oncological and quality of life (QoL) outcomes, localised renal masses are better managed by nephron-sparing surgery [partial nephrectomy (PN)] rather than radical nephrectomy (RN), but central tumours are very challenging for surgeons. From our standpoint, robot-assisted surgery is not only a minimally invasive method, but the only choice for performing a very complicated operation that we usually cannot do laparoscopically or conventionally. Methods A 77-year-old woman with bilateral renal masses. She underwent a robot-assisted PN on the left side 4 weeks ago. The mass on the right side is central and ∼8 cm big. Results We performed a right-sided robot-assisted PN. The ischaemia time was 15 min. The operation duration was 85 min without significant blood loss. The patient was discharged on the fourth postoperative day. The pathology report described a clear renal cell carcinoma (RCC) pT1b GII R0. Conclusion Robot-assisted PN for RCC for large and centrally located real masses can be done by minimally invasive intervention. It is a challenging but safe and feasible option in carefully selected patients.

Introduction Erectile dysfunction (ED) affects up to 70% of men with diabetes, occurring with a higher prevalence in those with type 1 diabetes than with type 2 diabetes. Studies investigating treatment of ED in men with diabetes have largely been conducted in a total male population with diabetes. Limited data are available on the efficacy and safety of the potent oral phosphodiesterase‐5 inhibitor vardenafil in men with ED and type 1 diabetes. Aims To evaluate the safety and efficacy of flexible‐dose vardenafil therapy in a prospective randomized study in phosphodiesterase 5 inhibitor‐naive subjects with type 1 diabetes and ED. Methods In this multicenter, double‐blind, placebo‐controlled clinical trial, phosphodiesterase‐5 inhibitor‐naive patients were randomized to receive placebo (N = 149) or flexible‐dose (5–20 mg) (N = 153) vardenafil. Main Outcome Measure Sexual Encounter Profile diary questions 2 and 3, concerning success rates of vaginal insertion and maintenance of erection to allow successful intercourse, respectively. Results Vardenafil significantly improved mean success rates for Sexual Encounter Profile 2 and 3 compared with baseline and placebo at 4, 8, and 12 weeks (P 7–≤8%, moderate glycemic control; and HbA1c > 8%, poor glycemic control). Vardenafil treatment also significantly improved the Erectile Function domain score (P Conclusion These data suggest that vardenafil significantly improves erectile function in men with type 1 diabetes and is well tolerated, regardless of the level of glycemic control. Ziegler D, Merfort F, van Ahlen H, Yassin A, Reblin T, and Neureither M. Efficacy and safety of flexible‐dose vardenafil in men with type 1 diabetes and erectile dysfunction. J Sex Med 2006;3:883–891.

Aim The aim of this article is to evaluate the efficacy and safety of 20‐mg tadalafil taken on demand or three times per week and its effect on the sexual activity of patients with diabetes mellitus and erectile dysfunction (ED). Methods The scheduled use vs. on‐demand regimen evaluation (SURE) was a randomized, crossover, open‐label study with 4,262 patients in 14 European countries. The efficacy measures for the 762 patients with diabetes and ED included changes from baseline in the erectile function (EF) domain of the International Index of Erectile Function (IIEF), and the proportion of “yes” responses to patient Sexual Encounter Profile (SEP) questions 2 (SEP2) and 3 (SEP3). The treatment satisfaction was measured with responses to SEP question 4 (SEP4) and SEP question 5 (SEP5), and sexual attempts data were collected. Patient preference for either regimen was determined by the treatment preference question (TPQ). Results At end point on both regimens, the mean IIEF EF domain score was 22, and >40% of the patients had a normal EF domain score (≥26). The proportion of “yes” responses was ≥73% for SEP2 (penetration), ≥58% for SEP3 (successful intercourse), >46% for SEP4 (hardness of erection), and ≥45% for SEP5 (overall satisfaction). Efficacy was maintained up to 36 hours post‐dosing. More than 70% of sexual attempts while on the three‐times‐per‐week regimen and approximately 50% of the attempts on the on‐demand treatment occurred >4 hours post‐dosing. Tadalafil was well tolerated, with dyspepsia and headache as the most frequent adverse events reported. Treatment preference was 57.2% for on demand and 42.8% for three times per week. Conclusions Tadalafil, when taken on demand or three times per week, is efficacious and safe in men with diabetes and ED. Buvat J, van Ahlen H, Schmitt H, Chan M, Kuepfer C, and Varanese L. Efficacy and safety of two dosing regimens of tadalafil and patterns of sexual activity in men with diabetes mellitus and erectile dysfunction: Scheduled use vs. on‐demand regimen evaluation (SURE) study in 14 European countries. J Sex Med 2006;3:512–520.

Moderate activity of systemic chemotherapy for advanced urothelial cancer has been reported for more than 30 years. Only with the advent of potent combination therapy clinically significant response rates as well as prolonged survival were documented. The therapeutic effect of a “second-line” polychemotherapy in metastatic upper tract urothelial cancer is largely unknown caused by the small number of cases and poor prognosis. We report an interesting case of a 59-year-old man suffering from urothelial cancer of the renal pelvis with pulmonary, lymphogenic and bone metastases who showed an unexpected response to a “second-line”chemotherapy after only 2 treatment cycles of Gemcitabine/Paclitaxel (partial remission) after 24 treatment cycles Gemcitabine / Cisplatin in “stable disease” and progression between the treatment intervals. We performed maintenance “second-line” therapy for 24 cycles and the patient showed a remarkable persisting response 54 months after operation.

We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience.A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months.There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/ Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant.The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.

Purpose: Using a compression technique instead of the classical invagination technique in cases of total nephroureterectomy improves traction during transurethral stripping of the ureteral stump.Materials and Methods: Eight patients underwent our modified compression technique. After nephrectomy a kinked 5F ureteral catheter is attached to the ureteral stump with a double ligation. Traction on the ureteral catheter is used to achieve ureteral compression.Results: There were no intraoperative difficulties except for 1 dislodged ureteral catheter. No complications were associated with ureteral detachment or resection.Conclusions: Our technique offers an alternative to the classic invagination technique by increasing transurethral traction on the ureteral stump, while substantially decreasing the risk of ureteral catheter dislodgment.

Introduction Several treatment regimens for rehabilitation of erectile function (EF) after nerve‐sparing radical prostatectomy (nsRP) are currently discussed. The optimal and most cost‐effective therapy is still not found yet. Aim To evaluate the effect of vardenafil, a PDE5 inhibitor, dose escalation on recovery of EF after unilateral nsRP. Methods Thirty‐six sexually active patients received a unilateral nsRP. All patients completed an International Index of Erectile Function—5 items (IIEF‐5) questionnaire concerning EF preoperatively. Group 1 (N = 12 patients) received vardenafil 5 mg/day vs. group 2 (N = 12) who received vardenafil 10 mg/day at night beginning the day of catheter removal. A control of 12 patients underwent follow‐up without PDE5 inhibitors. Main Outcome Measure The IIEF‐5 was the primary end point. IIEF‐5 questionnaires were completed at baseline, 3, 6, and 12 months after nsRP. Results In group 1 (5 mg/day vardenafil) the IIEF‐5 score decreased from a preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, and 13.4 mean score at 12 months after nsRP vs. preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, and 12.8 mean score at 12 months in group 2 (10 mg/day vardenafil). In the control group the preoperative IIEF‐5 mean score of 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, and 8.9 at 12 months. Statistical evaluation showed significant difference in IIEF‐5 score and time to recovery of EF between groups 1 and 3 and between groups 2 and 3 ( P Conclusions Daily low‐dose vardenafil lead to significant improvement of recovery of EF. In this study doubling the dosage did not improve the recovery of EF further. Bannowsky A, van Ahlen H, Loch T. Increasing the dose of vardenafil on a daily basis does not improve erectile function after unilateral nerve‐sparing radical prostatectomy. J Sex Med 2012;9:1448–1453.

The pharmacokinetics of vasoactive substances injected into the corpus cavernosum for the treatment of erectile dysfunction have not been investigated to date. We measured the local intracavernous and peripheral venous concentration curves of papaverine and prostaglandin E1, and its primary metabolite 15-keto-13,14-dihydro-prostaglandin E1 in an intra-individual comparison after intracavernous injection. Papaverine was measured with high performance liquid chromatography and prostaglandin E1 was measured with a specially adapted radioimmunoassay.The results demonstrate that papaverine is slowly draining into the systemic circulation, showing slightly elevated levels in the peripheral blood 30 and 60 minutes after injection. Prostaglandin E1 shows a much faster decrease in local concentrations with no measurable increase in the periphery, probably due to the short half-time after lung passage. Measurement of the primary metabolite proves a local degradation of prostaglandin E1 in the corpus caverno...

The Real-Life Safety and Efficacy of vardenafil study is an international, open-label, prospective, noncomparative, noninterventional study in men with erectile dysfunction (ED).To determine the safety and efficacy of vardenafil in a large international pool of men with ED (aged ≥ 18 years) and associated underlying conditions (N=73,946), in a real-life setting.Patients attended an initial physician visit and one to two follow-up visits. Data were acquired by physician interviews and patient diaries and recorded in case report forms (CRFs). Data were pooled from 47 countries in Europe, Asia-Pacific, Latin America, and the rest of the world (excluding the United States and Japan for methodological reasons). Results were stratified by baseline ED severity, body mass index (BMI), and the presence of hypertension, diabetes, lipid metabolism disorder, or cardiovascular disease (CVD).CRFs and patient questionnaires containing questions on overall improvement of erection, satisfaction with efficacy, and desire to continue vardenafil use.Many participants had hypertension (32.0%), diabetes (22.1%), lipid metabolism disorder (14.6%), or CVD (42.2%). High percentages of patients reported improvements in erectile function, irrespective of baseline ED severity (mild, 97.0%; moderate, 96.2%; severe, 85.5%), BMI (25, 94.1%; ≥ 25 and30, 94.6%; ≥ 30, 92.9%), or the presence of hypertension (93.6%), diabetes (92.6%), lipid metabolism disorder (94.7%), or CVD (93.3%). Over 90% of patients, including those with underlying conditions, reported being "satisfied" or "very satisfied" with vardenafil efficacy, and stated their intention to continue vardenafil use after the end of the study period. The incidence of adverse events was low, and 97.0% of patients were either "satisfied" or "very satisfied" with vardenafil tolerability.These data from a worldwide population of men with ED and associated underlying conditions show that vardenafil is effective and well-tolerated for the treatment of ED in a real-life setting, supporting its use as a first-line ED therapy.

Congenital or acquired anatomical abnormalities of the penis may interfere with cohabitation and normal deposition of semen. These congenital anatomical variations especially include abnormal position of the urethral meatus (hypospadias/epispadias), but also, penile deviations due to induratio penis plastica (IPP; Peyronie's disease) which represents the most common clinical problem.

Sexuelle Funktionsstorungen beim Mann konnen vielfaltig sein. Rein mechanische Storungen der Samendeposition aufgrund anatomischer Gegebenheiten sind von funktionellen Libidostorungen und Orgasmusstorungen, von Ejakulationsproblemen oder der Unfahigkeit, eine kohabitationsfahige Erektion zu erreichen oder aufrechtzuerhalten, zu differenzieren. Wahrend reine Orgasmusstorungen nahezu in allen Fallen auf psychische oder psychiatrische Ursachen zuruckzufuhren sind, konnen bei Libido- und Erektionsstorungen auch hormonelle Ursachen vorliegen und damit Symptome eines Androgendefizites sein. Zusatzliche klinische Symptome oder objektivierbare Befunde wie eine Hodenatrophie, Veranderungen der sekundaren Geschlechtsmerkmale oder des Ejakulatvolumens lassen in ausgepragten Fallen die organische Genese erkennen, in anderen Fallen muss aktiv nach entsprechenden Hinweisen gesucht werden. Wahrend somit funktionelle Orgasmus- und Libidostorungen eine Domane psychologisch-psychiatrischer (▸ Kap. 25 und 26) oder endokrinologischer Therapieansatze sind, befasst sich dieses Kapitel vorwiegend mit funktionell oder organisch bedingten Storungen der Kohabitation und der Ejakulation.

We examined metallothionein (MT) expression in bladder cancer and its relationship to clinicopathologic factors, survival data, and outcome of chemotherapy. In 97 patients who underwent radical cystectomy for bladder cancer, 34 of whom received cisplatin-based chemotherapy, MT expression was evaluated immunohistochemically. Results were correlated with histopathologic data, survival rates, and outcome of chemotherapy. MT overexpresison was present in 33 patients (34.0%): strong in 7 (7.2%) and focal in 26 (26.8%). Overexpression was an independent prognostic factor and was significantly associated with poor survival. Patients undergoing chemotherapy showed worse survival if their tumours were MT-positive than if they were MT-negative. MT overexpression predicts unfavorable survival in bladder cancer patients. In those treated with cisplatin chemotherapy, survival is significantly poorer if tumours express MT. Our results show that MT overexpression may mediate resistance to alkylating agents. Therefore, further studies are warranted to define those patients who need a more aggressive therapy.

Erectile dysfunction (ED) affects up to 70% of men with diabetes, occurring with a higher prevalence in those with type 1 diabetes than with type 2 diabetes. Studies investigating treatment of ED in men with diabetes have largely been conducted in a total male population with diabetes. Limited data are available on the efficacy and safety of the potent oral phosphodiesterase-5 inhibitor vardenafil in men with ED and type 1 diabetes.To evaluate the safety and efficacy of flexible-dose vardenafil therapy in a prospective randomized study in phosphodiesterase 5 inhibitor-naïve subjects with type 1 diabetes and ED.In this multicenter, double-blind, placebo-controlled clinical trial, phosphodiesterase-5 inhibitor-naïve patients were randomized to receive placebo (N = 149) or flexible-dose (5-20 mg) (N = 153) vardenafil.Sexual Encounter Profile diary questions 2 and 3, concerning success rates of vaginal insertion and maintenance of erection to allow successful intercourse, respectively.Vardenafil significantly improved mean success rates for Sexual Encounter Profile 2 and 3 compared with baseline and placebo at 4, 8, and 12 weeks (P0.0001, intention to treat and last observation carried forward). These rates were unaffected by stratification into distinct subsets according to the level of HbA(1c) (HbA(1c)7%, good glycemic control; HbA(1c)7-or = 8%, moderate glycemic control; and HbA(1c)8%, poor glycemic control). Vardenafil treatment also significantly improved the Erectile Function domain score (P0.0001) of the International Index of Erectile Function compared with placebo, in addition to scores for the other individual domains of the International Index of Erectile Function. The most commonly reported treatment-emergent adverse events were headache (3.1%) and flushing (2.5%), which were mild to moderate and transient in nature.These data suggest that vardenafil significantly improves erectile function in men with type 1 diabetes and is well tolerated, regardless of the level of glycemic control.

Vardenafil, a phosphodiesterase type 5 (PDE5) inhibitor, was evaluated in a prospective trial in the primary care setting involving hypertensive men with ED who were receiving at least one antihypertensive medication.To investigate the safety and efficacy of flexible-dose vardenafil therapy compared with placebo in PDE5 inhibitor-naïve subjects with arterial hypertension and ED.In this multicenter, randomized, double-blind, placebo-controlled study, 354 patients received placebo or vardenafil (5-20 mg) for 12 weeks. Primary efficacy measures were diary responses to the Sexual Encounter Profile (SEP) questions 2 (vaginal insertion) and 3 (maintenance of erection). Additional efficacy measures included positive responses to the Global Assessment Question (GAQ).Compared with placebo, vardenafil significantly improved mean SEP2 and SEP3 success rates over the 12-week study period (intention-to-treat [ITT] and last observation carried forward [LOCF]) analysis). For LOCF, SEP2 and SEP3 were 83% for vardenafil vs. 58% for placebo and 67% for vardenafil vs. 35% for placebo, respectively (P0.0001 vs. placebo). Improved erections (GAQ) were experienced by 80% of vardenafil-treated patients at study end, compared with 40% for placebo (P0.0001, LOCF). The most commonly reported treatment-emerging adverse events were headache (3.1%) and flushing (1.6%), which were mild-to-moderate and transient in nature. Importantly, there were no significant changes in systolic and diastolic blood pressure or heart rate between the vardenafil and placebo groups. The average number of antihypertensives used per patient was 1.5 and 1.4 in the vardenafil and placebo groups, respectively. Both the incidence of adverse events and the ability to maintain an erection were unaffected by stratification into distinct subsets according to the class of antihypertensive medication being received.Vardenafil significantly improves EF in hypertensive men treated with concomitant antihypertensive medication, is well tolerated, and does not significantly affect blood pressure.

Objective: To examine the preference for 2 dosing regimens (on demand or 3 times/week) for tadalafil, a phosphodiesterase 5 inhibitor with a duration of effectiveness up to 36hours in men with erectile dysfunction (ED). Design and methods: SURE is a 14 European country, multicenter, crossover, and open-label study. Men with ED ( N =4262) were randomized to tadalafil 20mg treatment on demand (maximum one dose per day and before sexual activity) or 3 times/week for 5–6 weeks. After a 1-week washout period, patients were crossed over to the alternate regimen for 5–6 weeks. The patient's response to a treatment preference question (TPQ) was used to determine the preferred treatment regimen. Results: The mean age of the randomized patients was 55 years and 85.2% reported a history of ED for one year or greater. Overall, the responses of 3861 men to the TPQ assessment showed that 57.8% preferred the on-demand regimen and 42.2% preferred the 3 times/week dosing. Both regimens were efficacious and well tolerated. Conclusions: In this study, while 57.8% of men preferred the on-demand regimen of tadalafil 20mg, a substantial number (42.2%) preferred the 3 times/week treatment. The two regimens provide additional treatment options by giving men with erectile dysfunction unique flexibility in dosing with tadalafil.

The fourth case of primary melanoma of the bladder is presented together with a review of the previously reported cases and the relevant literature on malignant melanoma in urology. The criteria for classification of the bladder lesion as the primary site are discussed. The eighty-one-year-old female patient was felt not to e suitable for extensive surgery and was successfully treated with a combination of radiation and immunotherapy with recombinant alpha 2 interferon. After previous monthly recurrences of the tumor the patient is in complete remission fifteen months after initiation of therapy. It appears that this form of treatment might be a valuable alternative to radical surgery in elderly patients.

Purpose: Nephrostomy catheters are prone to kinking or damage because the thin, flexible silicone tube is too vulnerable against mechanical stress even when the proximal end is carefully fixed. We developed a simple method to reinforce the outside part of a thin catheter protruding from the skin.Materials and Methods: We treated 7 children with nephrostomy catheters or ureteral stents with a diameter of 8F or smaller. After insertion a large plastic tube was wrapped around the small catheter, and fixed to the skin and to the peripheral collection system with adhesive tape.Results: Handling of the catheters improved and there was less need for re-fixation.Conclusions: Thin nephrostomy catheters can be effectively protected by wrapping them into a larger, outer tube after insertion.

Dynamic cavernosography with flow and cavernosometric studies was performed on 140 patients, 18 of whom served as a control group. Of the 122 multidisciplinary investigated patients with erectile dysfunction 66 (54.1 per cent) showed associated venous leakage. Insufficiency of the dorsal penile veins (29 patients, 44 per cent) and complicated venous leakage (23 patients, 34.8 per cent) were predominate. In 63 patients with erectile dysfunction the results of an additional papaverine test were compared to the results of dynamic cavernosography, and they indicated a sensitivity of more than 90 per cent in regard to evidence or exclusion of venous incompetence in erectile dysfunction.