Abstract: PURPOSE: In 2002, the first completely laparoscopic cystectomy and orthotopic ileal neobladder procedure was reported to take more than 10 hours, with the most time-consuming portion being suturing. Therefore, to improve the quality and reduce the time to place running sutures, we developed a new sewing device for laparoscopic use. MATERIALS AND METHODS: We compared running sutures made by hand with those made by machine in the ilea of six pigs. The tightness of the closures was examined and the suturing time recorded. Two animals each were sacrificed after 3, 6, and 9 days, and then the explanted ilea were examined at both the macroscopic and microscopic levels. RESULTS: No animal died during the course of the experiment and no leaks were found postoperatively. Moreover, no significant differences were seen on macroscopic or microscopic examination in the quality of the two sets of sutures. The time taken to place 1 cm of running suture, including initial preparation, was 7.2 and 3 minutes for hand and machine suturing, respectively. The hand sutures were always initially tight, whereas those placed by machine required adjustment to stop leaks on four occasions. CONCLUSION: Using the Endosew device reduces the time needed to place running sutures by 2.4-fold. The quality of the hand- and machine-made sutures was nearly identical at both the macroscopic and microscopic level. Thus, the functionality of this new sewing device is more than satisfactory, and the amount of time saved by using it far outweighs the need for occasional adjustments to stop suture leakage.

Abstract: BACKGROUND: The aim of this study was to establish the incidence of potential postoperative anorectal, bladder, and sexual dysfunction in women following excision of rectal cancer with total mesorectal excision (TME). MATERIALS AND METHODS: All women who underwent a transabdominal rectal resection with TME for cancer between 2000 and 2003 were included. Women with a colonic resection for cancer during the same time period served as the control group. Exclusion criteria were strict. Standardized questionnaires were sent to all patients. RESULTS: Twenty-six patients fulfilled the inclusion criteria and were evaluated. Fifteen patients had TME and 11 patients had colonic resection. The median Wexner score showed a higher rate of anal incontinence in the rectal group. The difference was due to a higher rate of severe incontinence in the rectal group. The King's Health Questionnaire showed normal urinary function in both groups. The Female Sexual Function Index showed worse sexual function in the rectal group, reaching statistical significance in the categories 'arousal' and 'lubrication'. CONCLUSION: After rectal excision, the women showed impairment of their anorectal and sexual function. Urinary function was normal. This is in contrast to the incidence of urinary dysfunction in men observed by others. Our study indicates that women seem to have less functional problems when compared to literature data on dysfunction in male following rectal surgery for cancer.

Abstract: Since 2001 magnetic stimulation therapy has been available in Germany for treating urinary incontinence as an alternative to traditional electrical stimulation therapy. The results of 83 patients who underwent magnetic stimulation therapy for stress incontinence, OAB, and pelvic pain syndrome were evaluated. The results differed depending on the underlying disease. Patients with stress incontinence who could not properly contract pelvic floor muscles before could do so in 74% when clinically evaluated and patients with OAB symptoms improved in 54% as assessed by objective and subjective criteria, whereas patients with pelvic pain syndrome only benefited in 23%. Comparison of the results according to age revealed no significant difference between patients >65 years and younger patients.

Abstract: OBJECTIVE: To evaluate the potency in patients after radical perineal prostatectomy with wide excision of both neurovascular bundles. MATERIAL AND METHODS: In this prospective study, a quality-of-life questionnaire was completed by 128 patients at the preoperative stage, and 6 and 12 months postoperatively. Ten questions concerning the patient's sexuality were included on the pre- and both postoperative questionnaires. In addition, 6 patients who recorded some erectile function were sent a separate questionnaire containing eight more detailed questions. RESULTS: Preoperatively, 74/128 (57.8%) patients reported erections sufficient for sexual intercourse, and of these 74, 6 (8.1%) described having spontaneous erections 1 year postoperatively. These spontaneous erections occurred 1-5 times per week. The reply to the separate mailing made clear that the reported erections were insufficient for intercourse. CONCLUSIONS: Patients undergoing standardized radical prostatectomy with wide excision of the neurovascular bundle have a very small chance of spontaneous erections sufficient for intercourse postoperatively.

Abstract: OBJECTIVES: To assess, in a prospective study, the incidence of fecal incontinence after radical perineal prostatectomy. METHODS: Bowel symptoms were evaluated with questionnaires mailed to 132 patients preoperatively and 6 months postoperatively, and annually thereafter. All patients had undergone extrafascial perineal prostatectomy for Stage cT1-cT3N0M0 prostate cancer. The data of 116 patients (88%), who answered at least the preoperative and 12-month questionnaires, were analyzed. Reduced sensibility, reduced discrimination, urgency, or stool smearing were symptoms indicative of fecal incontinence. Patients with one symptom of fecal incontinence were evaluated further with a structured telephone interview. RESULTS: Daily stool smearing was reported preoperatively by 4% of the patients. Two symptoms related to fecal incontinence were present preoperatively in 6% of the patients. At 12 months postoperatively, 15 patients (13%) reported at least two symptoms of fecal incontinence. The structured telephone interview revealed that 6 of these 15 patients had symptoms of fecal incontinence that were related to the perineal prostatectomy; 9 patients had newly developed symptoms not related to surgery or symptoms due to tumor recurrence or radiotherapy. Patients with the presence of at least one symptom of fecal incontinence before surgery had an almost fourfold increased risk of developing at least two symptoms of fecal incontinence postoperatively compared with patients without any symptom of fecal incontinence. CONCLUSIONS: Significant fecal incontinence after radical extrafascial perineal prostatectomy is a rare event. The results of questionnaires should be supplemented by additional interviews to obviate wrong interpretations.

Abstract: AIM: We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function. PATIENTS AND METHODS: Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months. RESULTS: Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire. CONCLUSIONS: Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.

Abstract: OBJECTIVE: To assess the quality of life in patients with prostate cancer after permanent brachytherapy (BT) or radical perineal prostatectomy (RP). PATIENTS AND METHODS: The American Brachytherapy Society recommends the permanent implantation of radioactive seeds as a monotherapy for patients with T1-T2aN0M0 prostate cancer and a prostate-specific antigen (PSA) level of < or = 10 ng/mL, a Gleason score of <7 and a prostate volume of <60 mL. Using these criteria, 132 patients with low-risk prostate cancer were selected; 52 had BT with 125I-seed implantation, 38 had RP with unilateral nerve-sparing (RP + NS) and 42 extended RP (RP group). Only patients with unilateral tumour on biopsy were considered. Before therapy and 6, 12 and 24 months afterward, patients completed questionnaires to assess perceived health and function. PSA relapse was diagnosed with a PSA of >0.1 ng/mL for patients in the RP groups, and three consecutive PSA increases for those after BT. RESULTS: Extraprostatic tumours were found in 18% of specimens taken during RP, and bilateral tumours in 63% of patients. After a mean follow-up of 27 months, there was PSA relapse in two of the 80 patients in the RP and RP + NS groups, and six of the 52 patients in the BT group; a significant difference, with a hazard ratio of 5.2. The acute morbidity was low in all groups. At 1 year, more than two incontinence pads were used by 5% of patients after RP and by 4% after BT. Similarly, at 1 year 15% of patients after RP and 13% after BT were bothered by urinary incontinence. Newly-developed fecal soiling was reported by 4%, 5% and 11% of the RP, RP + NS and BT groups respectively; none of the patients after RP and 4% after BT were bothered by this symptom. The duration and stiffness of erection was assessed after 1 year and reported to be equal or slightly decreased by a third after RP + NS and 38% after BT. Taking a 5-10 point difference as clinically relevant, role, emotional and social functioning were improved considerably after RP + NS than after BT, but sexual activity was impaired significantly after RP + NS than after BT. CONCLUSIONS: Both therapies showed typical acute and late morbidity; the most bothersome late symptoms were urinary incontinence for patients after RP and fecal soiling after BT. Sexual function was impaired significantly in patients who were potent before RP + NS, whereas after BT men reported only a minor change in sexual performance at 1 year. Tumour control after a median follow-up of 27 months was better after RP but biochemical recurrence may still occur after > or = 5 years; therefore the present results are not mature enough and there were too few patients to provide a more definitive statement. As approximately 18% of patients considered to be appropriate candidates for BT had tumours extending beyond the prostate capsule or invading the seminal vesicles, nomograms are needed for more accurate information before therapy.

Abstract: PURPOSE. The true incidence of bowel symptoms prior to radical prostatectomy, as evaluated by a differentiated questionnaire, is unknown. We therefore performed a prospective study on patients who were scheduled for radical perineal prostatectomy. MATERIAL AND METHODS. A total of 67 patients with cT1-cT3, N0, M0 prostate cancer underwent an extrafascial, radical, perineal prostatectomy. The patients received a questionnaire prior to surgery as well as 6 months and 12 months after surgery. This took into account demographic data, stool symptoms (Kelly questionnaire) and questions concerning bladder function (ICS male continence questionnaire). The questionnaires were evaluated by three of the authors not involved in patient care. RESULTS. The mean age of the patients was 64 years. The PSA range was 0.9-55.6 ng/ml (mean 12.7 ng/ml). There were 47 pT2, 19 pT3 and a single pT4 tumour. A total of 59 patients had a Gleason score of 6 or less. Positive surgical margins were present in four patients. The 12 months follow-up questionnaire could be evaluated for 82% of the patients (n=55). In addition, 46 patients answered the questionnaire at 6 months post-surgery.Three or more problems in relation to bowel movements were reported preoperatively by 21% of the patients. Straining with bowel emptying was the symptom which was indicated most often. Stool smearing was reported by 13% of patients at least once or twice monthly. In addition, 6% of patients reported that they had difficulties in differentiating soft stool from gas. After 1 year, seven (13%) of the patients reported stool smearing which was not present prior to surgery. Six of these patients observed this problems only once or twice a month. Only one patient had stool smearing once a week. Two patients reported urgency, two had a decreased warning time and one reported decreased sensibility. Two patients used protective pads. The most frequent symptom reported postoperatively was straining with bowel emptying (24% preoperatively and 16% postoperatively). CONCLUSION. It is evident that men scheduled for radical prostatectomy already have significant stool problems preoperatively. Newly developed, postoperative stool smearing on a daily basis occurred extremely seldom. They same is true for the discrimination between soft stool and gas. From our point of view, it is important to use the extrasphincteric approach to the prostate described by Young. Furthermore, the pubo-anal sling should be preserved.

Abstract: AIM: Magnet stimulation therapy has been offered as a new, conservative therapy for stress and urge incontinence in Germany since 2001. Focussed, pulsating magnetic fields are used to stimulate the musculature of the floor of the pelvis. This publication describes our initial experience with this method. PATIENTS AND METHODS: We treated 27 patients with magnetic stimulation. The individual patient sits clothed on a therapy-chair and is treated for 20 min twice a week for 2 weeks. RESULTS: The best results were recorded in female patients with grades I and II stress incontinence who could not actively flex their pelvic-floor musculature during physiotherapy. A marked reduction in the frequency of micturition was obtained in 67% of patients with urge incontinence symptoms and non-responsiveness to anticholinergic therapy. Patients with a non-organically tangible pelvic-pain-syndrome did not benefit from the therapy. CONCLUSIONS: Magnet stimulation therapy can act as a useful addition to conservative therapies for stress and urge incontinence. It is free of complications and does not involve the insertion of an electrode into the patient as is the case for vaginal and anal electrostimulation. However, this method does not appear to be useful for chronic, non-specific pain in the lower pelvis.

Abstract: Radical prostatectomy is a procedure performed with increasing frequency in patients with localized prostate cancer. Although, the operative morbidity is considerably low, urinary incontinence and erectile dysfunction remain an important and persistent problem. Since several years the impact of radical prostatectomy on the quality of life (HRQOL) is investigated. However, there are only few prospective studies dealing with rather small groups of patients. These studies indicate that urinary and sexual function have major impact on HRQOL. Although, there is a steady improvement in urinary function and decrease in urinary bother only about 65% of the patients reach the baseline at the end of the first year. In spite of this almost 90% of patients reach baseline in all other HRQOL domains such as general health perception, physical and social function after a mean period of 5 months. The importance of sexual desire and erectile capacity decreases with age; being important in 75 and 84% of men at the 5th decenium and 48 and 59% at the 6th decenium. After standard radical prostatectomy almost all of the patients are impotent. Applying so-called nerve sparing techniques erectile function may be preserved in careful selected patients. It is the common theme that preservation of the 'neurovascular bundles' equals a high rate, but still age depended postoperative potency; however difficulties in regaining urinary control may embarrass the patient to such an extent to withdraw from sexual activity. Furthermore, the change of sexual ability and quality may have impact on the partner who do not want to initiate sexual activity because of the possible failure. This may cause an increased level of emotional distance, which again is deleterious for sexual activities. Patients who are sexually active prior to surgery report major distress in case of postoperative erectile impotence, but even in case of maintained erectile capacity some patients are bothered by the sexual dysfunction. Sexual counselling and providing the optimal erectile aid is therefore very important. Psychological distress of spouses may be significantly greater than that of the patients; general cancer distress, treatment related worries, concerns on physical limitations and pain are the main reasons. However, it may well be that women are willing to report their problems more often than their partners who may have a grin-and-bear-it attitude. In spite of this caveate, it is important to include the patient's spouse into the discussions on therapy and associated morbidity early on. Since radical prostatectomy for localized prostate cancer is only one of the possible treatment options, the patient has to be informed about the incidence and various types of morbidity which is associated with treatment and their possible impact on HRQOL. Appropriate and honest counselling will have significant influence on the well being of the patient after completing therapy.