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Although, penis enlargement is a very common reason especially for young men to visit urologist-andrologist, and even a more common reason for searcing the Internet, the truth on a medical basis is that penile size is not an important factor for female orgasm, given the fact that 90% of the sensory nerve terminals, that trigger the sense of pleasure and the contractions of the muscles of the female perineum, which actually represent an orgasm, are located on the clitoris and in the first one centimetre of the vagina. Thus, even a 5cm long penis in erection can be fully sexually functional.


 

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In fact, although many men are seeking medical help to get their penis longer and thicker, they really do not have any anatomical or functional problems. Generally speaking most of men, if asked, would wish they had a bigger penis, although at the same time they will admit that they have a satisfactory sexual life. However, some men present a psychological disorder that makes them have a negative view for the size of their penis. This disorder is called “penile dysmorphophobia” and is very stressing. The condition may regard the size of their penis in the relaxed phase and it is then called “aesthetic dysmorphophobia”, or in the phase of erection and then it is called “functional dysmorphophobia”. Although it looks a bit strange, aesthetic dysmorphophobia is more frequent than functional dysmorphophobia. The disorder can be caused by one more psychologically traumatic events, such as the rejection of the man by one or more sexual companions due to the penis size, or there can be no obvious initial cause in the patient’s medical history.

 


 

 


Patients with this psychological disorder have frequently serious problems to create sexual relationships, due to shame and lack of self-confidence. Sometimes these negative feelings may cause even erectile dysfunction. On the contrary, patients with anatomical micropenis, which is a very rare condition compared to dysmorphophobia, may have a positive view for their personal image and a satisfactory sexual life. Apart from the poor sexual life, dysmorphophobics have an even more serious problem. Their condition is very persistent and most of the times they do not accept the recommendation of the andrologist to seek psychiatric help. However, even if they do, their problem more frequently will not be solved. Thus, these people are ready to undergo any kind of medication or surgical “therapy” is proposed to them, or they find out on the Internet. This makes them particularly vulnerable to penis enlargement “treatments”, which may in the best case be ineffective and in the worst dangerous. People that seek such solutions must particularly have in mind, that there is no quality control of the information unlimitedly provided on the Internet and therefore the effectiveness and mainly the safety of the proposed methods are not checked

 

The truth about the usually presented on the Internet pharmaceutical methods for penis enlargement, is that they do not really exist. That means, that they are completely ineffective and some times cause severe side effects. Also the use of devices, to stretch the relaxed penis for some hours daily, has not been proven to offer remarkable results. These devices are really useful, after penis surgical operations for various reasons including the enlargement operations or the penile straightening operations in case of Peyronie’s disease. In these cases the postoperative occasional application of stretching for some months can eliminate the shrinkage, which occurs during healing procces of the surgical wound, restoring thus the initial length of the penis.

Surgery can increase both the length and the width of the penis. Many and various techniques are described, both in scientific articles, and on the Internet. Some of them are experimental and some could be also dangerous. The only scientifically documented, safe and acceptable technique for penis enlargement do not, in fact, add centimetres to the penis, but rather try to “dig out” a part of the already existing organ from the surrounding tissues. The operation is performed with general anaesthesia and its duration is 2-3 hours, depending on how many of the following stages will take place.

These stages are:

1

Liposuction of the suprapubic area. It is easy and safe and it unburies a part of the penis from the surrounding fat. The more fat exists in the suprapubic region, the better the result.


2

Resection of the levator of the penis. This levator is responsible for the upward inclination of the erect penis. Its resection “detaches” a section of the back of the penis, which is located within the body, from the pelvis bone and thus, the penis is mobilised and acquires some additional length. In order to avoid a symphysis reattachment, we place a small lipodermal implant between the bone and the back of the penis. This implant is taken by the region of the patient’s thigh and because it is his body part, we avoid complications that could possibly occur from the use of foreign materials. This procedure is safe. Sometimes, a minor instability of the erect penis is reported, however this does not cause problems.

 

 

Ανελκτήρας σύνδεσμος του πέους


 

3

Performance of plastic surgery in order to relax the skin on the dorsal surface of the penis and attach the subcutaneous tissue to the periosteum of the pubic bone. It is thus secured, that there is no “pulling” or limitation of the penis mobilisation by the suprapubic skin, and also the effective “unburying” of the penis


 

4

Performance of  plastic surgery in order to relax the skin on the ventral surface of the penis, aiming to “transform” a part of the scrotum skin to penile skin. Thus, a part of the ventral surface of the penis is getting free from the scrotum. This step is not always necessary and is not performed, when a simultaneous lengthening and thickening of the penis has been selected.


 

5

The application of stretching to the penis by using a special stretching device. This is applied eight weeks after the operation and for 3-6 months. The aim is to get back the all the obtained by our surgery additional centimetres of the penis length, which are possibly lost, due to  postoperative shrinkage caused by the healing process.

Device for the application of casual stretching to the penis with the use of a special stretching instrument.

Device for the application of  stretching to the penis.


 

6

Increase of penis thickness. This can be achieved by two techniques:

  • By placing an implant acting as a “thick sheath” under the skin of the penis and attach it on the base of the penis. This implant can be obtained by the patient’s body and be a “lipodermal” implant taken from the buttocks or the belly. Alternatively an allogeneic implant can be used like pig collagen. The thickness of the implant is added to the diameter of the penis and, thus the overall diameter increases. This technique can be performed simultaneously with penis lengthening. Rare complications can be a partial or total necrosis of penile skin, or fibrosis and shrinkage of the implant. A “foreign” implant, on the other hand, could be infected with devastating results.
  • By the injection by special syringes, of  various thick liquid materials under the skin of  the penis. These materials can be fat coming from the liposuction of the suprapubic region during the first step of lengthening or hyaluronic acid. The use of liquid silicone, paraffin or other unknown materials can cause serious reactions in the skin of the penis, with devastating consequences and must be avoided.  Patient’s fat after a proper processing and centrifugation is placed under the penis skin and is “molded” by the surgeon’s hands, so that it can be evenly distributed under the entire penis surface. The penis is maintained stretched during the whole procedure, in order to achieve a uniform thickening result during the erection also. Use of patient’s fat helps avoiding complications that may be caused by foreign materials. Sometimes, if the patient wishes, the fat injection can be repeated after 6 months with local anaesthesia. The procedure of thickening of the penis can be performed without a simultaneous lengthening by local anaesthesia only.

Πάχυνση πέους με την υποδόρια έγχυση κατεργασμένου λίπους


 

 

7

The performance of a circumcision after lengthening and thickening or only thickening operations offers better aesthetical results and eliminates the problem of persisting preputial edema, which otherwise is very frequent and annoying.


The patient is usually hospitalized for one night and there is no pain at all for him. Before being discharged, the patient receives written instructions about the proper cleaning of the area and how to massage it for faster resolution of the oedema. Urination is not affected after the removal of the catheter. Oral and topical antibiotics are prescribed. We see the patient after one week to ensure proper healing of the traumas and again in five weeks to prescribe him the stretching device and to allow him start having sex.

 

P46a

 

Results in the relative literature for penis lengthening vary between 1.5 and 4 centimetres and for thickening between 2 and 2.5 centimetres, after the whole procedure is completed. However, due to the complicated psychological situation of the patients with penile dysmorphophobia, many patients may be still not satisfied from the results. To minimize that, there must be firstly proper selection of the patients, thorough consultation by the andrologist to explain all the details and if a severe psychological disorder is found out, a psychiatric assessment-support must precede. Finally the candidates for the operation should deposit their signed consent and acceptance. After these measurements most of the patients are very happy from the new appearance of their penis.

 

 

Erectile dysfunction is the inability to achieve and maintain an erection hard enough to have a satisfactory sexual intercourse in the last six months. In the international study of Massachusetts USA, that consists globally the principal study regarding the evaluation of sexual dysfunction during aging, is mentioned that, in the group of men aged 40-70 years the incidence of complete impotence amounts from 5.1% at the age of 40 to 15% at the age of 70, while the incidence of moderate dysfunction is 17% at the age of 40 and is doubled to 34% at the age of 70. In Greece it is estimated that approximately 450,000 men have a moderate degree of erectile dysfunction. Of them, 11,500 men will deteriorate to complete impotence every year. However, the problem is usually not mentioned to the andrologists, mainly due to reasons of shame. Thus, it worsens over time and it is finally leads to depression and social isolation.

Erectile dysfunction can be purely psychological or it may have an organic origin, on which psychological factors are also added, as its appearance causes major stress in every upcoming sexual attempt, leading to repeated cycles of failure to achieve and/or maintain hard erection. In older men the causes are usually multifactorial and can include diabetes, cardiovascular diseases, surgical operations for prostate, bladder or sigmoid cancer, neurological diseases, medicines mainly psychotropics and medicines for heart diseases especially  antihypertensive and finally hormonal disorders. In the younger people the causes are mostly psychological factors and chronic prostatitis.

The diagnosis of the cause of the disorder can be made by the andrologist. However, the special causal treatment is usually not possible, except some cases of prostate diseases and hormonal disorders. Fortunately there are ways of non special treatments, which can resolve the problem. These include:

  • Orally administered drugs, which improve the blood circulation in the penis and after sexual stimulation they help a week erection to be harder, more prolonged and easier to be achieved. They are generally safe and easy to be used. However, they are not effective in 30% of the cases, particularly in patients with neurological damages, severe vascular diseases and those, who underwent radical prostatectomy. Furthermore, their use is contraindicated in some cases of coronary heart diseases and their frequent use is quite expensive.
  • The injection of drugs in the corpora cavernosa of the penis produces a hard erection in the most of the patients, even without sexual stimulation. This treatment is more effective than the peels and the drugs act only locally, thus avoiding systemic side effects.  However, there can be severe pain, hematomas and hardening of the corpora cavernosa, due to fibrosis in the injection site. Also priapism (prolonged and painful erection) may appear in some cases, which need urgent hospital admission.  Furthermore, patients do not feel comfortable with penile self injections and the effectiveness of the treatment is reduced over time.
  • The placement of a penile prosthesis consists surgically the most effective, permanent and safe treatment for patients, who do not respond to medications, or when there are serious side effects, or when the patients do not wish peels or self injections. Penile prosthesis is a hydraulic implant, which is placed by a relatively simple operation under general or spinal anaesthesia, lasting usually one hour and with one day hospitalization. The incision is small and invisible on the lower ventral surface of the penis and the material is not perceivable even by the patient’s companion during the intercourse. A recent clinical study presented that the placement of penile prostheses resulted to a much higher satisfaction of men (93%), in comparison with drugs (51%) and injections in the penis (40%). Furthermore, a clinical study in 90 of my personal cases, which has been published in the reputable scientific journal “The journal of sexual medicine”,has shown that there is a full correlation between the sexual satisfaction of the patient after the placement of the prothesis and the sexual satisfaction of his companion. The superiority of the penile prosthesis is related to the fact that it is the only treatment that allows spontaneous sexual intercourse at any time, as the erection is achieved within seconds without the need of a “preparation” or the possibility of failure (as in the case of peels and injections), and the erection is maintained for as long as the man desires. Furthermore, the sensation, the ejaculation and the orgasm are completely natural as would be without any intervention.

 

P41a

 

The penile prosthesis consists of three parts. The two cylinders, which are implanted in the corpora cavernosa, which are the two erectile units of the penis, the pump, which is placed within the scrotum and the reservoir, which is placed on the lateral side of the urinary bladder. All these parts are placed into position through a small incision, which is performed on the lower ventral surface of the penis, where the scrotum begins. Nothing is externally visible and only the pump is palpable by the patient in his scrotum. The function of the prosthesis is purely hydraulic. In order to fill the cylinders with the normal saline existing in the reservoir, thus to inflate the cylinders and achieve a hard erection, is only enough to pump up the lower round part of the pump in a way similar to the inflation of a sphygmomanometer. The erection which is achieved is very hard, the orgasm, the pleasure and the ejaculation are normal, and similar to the sexual intercourse without the aid of the device. The prosthesis can be deactivated, only when the patient wishes so. This is accomplished by pressing and holding the upper part of the pump, resulting to the return of the saline from the cylinders in to the reservoir and the relaxation of the penis.

 

The operation is always effective and safe and offers to the patient the possibility to fully recover his lost sexual activity. The implant is never rejected by the human organism. Its lifetime is unlimited, but if there is a mechanical failure, it can be immediately replaced, in the same way it was initially placed, since it has a lifetime guarantee by the providing company. In the very rare case of an implant infection, which is high unlikely, as its surface is covered by an antibiotic film, we remove it and replace it with by a new implant four to five later. Thus, problems from the operation do practically not exist and it is certain that the benefits are outweighing them.

With the term curvature of the penis we mean the “bending” that may possibly exist on the body of the penis from birth, and in this case it is called congenital curvature, or the one that occurs later in the adulthood, and in this case is called acquired curvature. The curvature can exist in any direction upwards, downwards, to the left or to the right. Usually combinations of the aforementioned curvatures may exist. The curvature can also regard the front half or the rear half of the body of the penis. Finally, the curvature can be small or big, and in this case it can reach or even exceed 90 degrees, making the vaginal penetration difficult or impossible. More rarely, there can be a ring like stenosis somewhere on the body of the penis, and in this case the erect penis has the form of a sandglass.


 

P37aThe congenital curvature can be due to fibrous chords that are located under the skin of the body of the penis. This condition can present alone or usually may accompany a lower position of the urethral meatus on the glance or on the body of the penis. This situation is called hypospadias. More rarely, there can be a disproportion of the length of the corpora cavernosa, which are the basic erectile units of the penis. In this case the penis bends towards the shortest corpus cavernosum. The acquired curvature is due to thickening and hardening of a part of the fibrous sheath, which covers externally the corpora cavernosa, resulting to the formation of a hard fibrous plaque, of a different size in each case, which can easily be palpated. This condition is called Peyronie’s disease, from the name of the French doctor who discovered it and the plaque is called Peyronie’s plaque. This disease has an unknown cause. Sometimes an over bending injury with or without fracture of the erected penis during sex is mentioned, but mostly the medical history is clean. This condition is not  cancer.

 

The hard plaque pulls back during erection and does not allow the proper dilatation and stretching of the corpora cavernosa consequently leading in bending and angulation of the penis. The extent of the curvature depends on the size and the position of the plaque. The Peyronie’s plaque in its initial appearance can be accompanied by  painful erection, which is an indication of inflammation in the acute phase of the disease. Over time the pain goes away and only the curvature remains. The acute phase of the disease, which is characterised by the appearance and augmentation of the plaque, can last up to 6 months. After this period the plaque and consequently the curvature are usually stabilized. In 10% of the cases the plaque may resolve and the penis may become straight again without treatment.

Penile curvatures often causes severe psychological problems, and sometimes in cases of curvatures bigger than 30 degrees functional problems during vaginal penetration may appear. In these cases patients have to straighten their penis by holding it to achieve penetration and they also have to avoid specific positions during sex . Pain during sexual contact can become a serious problem. Finally, this condition may cause erectile dysfunction due to psychological and anatomical reasons, especially if other reasons  such as diabetes, atherosclerosis, use of sedatives and antihypertensives drugs or neurological diseases, preexist.

The diagnosis is easily accomplished by the medical history and the palpation of the plaque, and the penile ultrasound can verify possible calcification of the plaque. In cases of  Peyronie’s disease with erectile dysfunction, a control of the blood supply of the penis  by color Doppler could be performed to exclude dysfunction of the venoocclusive mechanism.

Various medications have been tried for conservative treatment of Peyronie’s disease, such as oral administration of vitamin E, paraminobenzoic acid (Potaba), colchicine and tamoxifen and  injections of collagenase, corticosteroids and interferon in the fibrous plaque. Recently Xiaflex injections in the plaque given promissing results. The oral pharmaceutical treatment is usually not effective. However, since the surgical repair of the curvature is recomended after the resolution of the acute phase and the stabilization of the curvature, which usually takes at least six months after its appearance, the patient may try some medical treatment during this waiting period. Recently a combination of tadalafil 5mg once a day for six months with daily use of a penile strecher device have presented promissing results in penile straightening.


 

The most effective treatment for the repair of the curvature of the penis is surgery. There are three categories of surgical techniques to straight te penis. The selection of the method depends on anatomical parameters, that is the length of the erected penis and the degree of the curvature, the  presence and the severity of a possible preexisting erectile dysfunction, the patient’s desire and the doctor’s experience.

 

Η τοποθέτηση ραμμάτων από την αντίθετη πλευρά της κάμψης προκαλεί μια αντίθετη κάμψη, που αντιρροπίζει την ήδη υπάρχουσα με αποτέλεσμα τον ευθειασμό του πέουςThe first category includes the techniques of shrinking of the corpora cavernosa in the oposite site of the curvature by sutures, with or without removal of “windows” of the fibrous sheath of the corpora (tunica albuguinea). This creates actually an opposite curvature, which counterbalances the existing curvature and thus the penis is straightened. The surgeon controls the repair of the curvature during the operation by causing artificial erections and may put more sutures until the desired result is achieved. These techniques are effective, easy, fast, can be performed with spinal anesthesia and the duration of hospitalization is one day. They do not affect adversely the erections  and also do not present serious complications. The patient can fully return to his activities after two or three days. He can have a sexual contact after a month. Many patients afraid, that with these techniques  may have an additional loss of length of their penis, due to the shrinkage. However, this is not really the case, because the lost length is due to the curvature that was caused by their disease and not by the straightening operation.

 

P39aThe second category include techniques of complete removal or cutting out the Peyronie’s plaque and closing of the created gap of the fibrous sheath (tunica albuguinea) by an implant. Cutting out the plaque usually in the shape of an a H results to loosening of the corpora cavernosa during erection and consequently to straightening of the penis. This tecnique is easier than complete removal of the Peyronie’s plaque, with the same good results and fewer complications. Various implants are used to cover the gap of the tunica. The problems with these implants, whether they become from the patient himself (autologous), like skin or venous implants collected from the legs, or from animals, like the bovine pericardium (heterologus), or are synthetic, are related with the significant prolonging of the operation, significantly higher cost and with the intervention of the surgeon andrologist on tissues he is not familiar with. A pioneering technique, that I have applied, is the coverage of the gap, after cutting out the plaque, by a free graft  from the patient’s prepuce. The preputial graft is cheap, easy and fast to be collected, familiar to the urologist and without the disadvantages of the skin grafts like shrinkage and “ballon” formation on the graft site resulting to dysmorphia of the penis. The main advantage of  these techniques is, that the penis is “unshrinking” during straightening, getting back its initial length. However, these operations are prolonged, expensive, relatively difficult, they require general anesthesia and hospitalization of three to four days. A circumcision is always performed. The sexual contact is allowed after one to two months. Complications, which may sometimes occur, include reduction of sensory of the glans and the appearance or deterioration of a preexisting erectile dysfunction. For these reasons, these operations are proposed only to patients with relative short penis, and/or big curvature more than 90 degrees or with a sandglass deformity of their penis. The use of a stretching device after the full healing can aid the full recovery of the length of the penis.

 

Η τοποθέτηση για 3-6 ώρες την ημέρα για 3-6 μήνες μιας ελκτικής συσκευής μετεγχειρητικά βοηθά στην αποκατάσταση του αρχικού μήκους του πέους σε περιπτώσεις σοβαρής κάμψηςFinally the third category of techniques are used in cases whith coexisting of severe erectile dysfunction and curvature. In these cases the placement of a penile prostheses with or without the application of appropriate mechanical handling of the plaque (modeling) during the implantation of the prostheses, repair both conditions with excellent results. There are no further problems regarding the function of the prostheses, due to the preexisting curvature, although sometimes the intense fibrosis, due to Peyronie’s disease, may makes the implantation difficult. However, in the hands of an experienced surgeon the results are always excellent.

 

 

Urinary incontinence in men is rarer than in women. Its frequency ranges between 12-17% in men and is divided intoThus, the urge incontinence with a non neurological cause can be usually observed in older men and is principally due to the obstruction of the outflow of the urine, due to prostatic hyperplasia. More rarely, it can be due to a tumor or stone of the urinary bladder. In younger men it is very rare, and if it suddenly occurs, the patient should be examined for some emerging neurological disease, usually multiple sclerosis.

 

Η ανατομία της περιοχής του έξω σφιγκτήρα της ουρήθρας. Είναι φανερό, ότι σε ριζική αφαίρεση του προστάτη, η πιθανότητα κάκωσης του σφιγκτήρα μπορεί να είναι αναπόφευκτη, ώστε να εξασφαλισθεί η πλήρης απαλλαγή από τον καρκίνοHowever, the milder type of an overactive bladder, of which the stronger clinical form is the urge incontinence, is frequent urination. This phenomenon is also very frequently observed in younger men, usually due to chronic prostatitis. Overflow incontinence is sometimes observed in men with severe obstruction of the urine outflow, which is usually due to a prostatic hyperplasia. The stress urinary incontinence in men, in contrast with women, is always due to the weakness of the external mechanism of the urethral sphincter, which surrounds anatomically the section of the urethra which is located on top of the prostate. The sphincter weakness is more rarely due to neurological damages, and is usually due to surgical operations. The radical prostatectomy for the treatment of prostate cancer is the most common operation that causes stress incontinence and its frequency ranges in various studies between 2%- 43%. Practically, experience shows that approximately 10% of the patients who undergo any kind of radical prostatectomy will have, 12 months after the operation, a very disturbing urinary incontinence. If we also consider that prostate cancer is the most common cancer in men, and 45 new cases out of 1000 men who are 60 years old occur per year, and that one out of six men will present prostate cancer during his lifetime, we can understand how serious the problem is. The transurethral prostatectomy for the benign prostatic hyperplasia is also relate, at a percentage of 1%-3%, with urinary incontinence. Finally, both the external and the internal radiotherapy for prostate cancer are accompanied by urinary incontinence in 1%-16% of the cases.

 

Urinary incontinence in men, as in women, is not a life or health threatening disease for the patient. However, it can create a serious life quality problem, with psychological effects that sometimes lead to depression. Furthermore, it is accompanied by a high cost for the purchase of incontinence diapers. Finally, due to the permanent maceration of the genital area by urine, dermatitis and mycoses are generated, which are very disturbing and difficultly treatable. Of course, if the incontinence is due to an underlying disease, the symptoms of this underlying disease coexist. For example, urinary hesitation in cases of prostatic hyperplasia.
 


 

Diagnostically and therapeutically the treatment of male urinary incontinence must be performed by the specialized urologist. In the case of urge incontinence must be controlled the possible presence of an underlying disease, the treatment of which will improve or even resolve the problem. If an underlying disease cannot be found or if its treatment did not improve the incontinence, there are medicines that can be used. In the case of overflow incontinence the obstruction must be treated, for example with an operation in case of benign prostatic hyperplasia.

The problem the specialized urologist can really help resolving, is the urinary incontinence after prostatectomy and more usually after radical prostatectomy, for the treatment of prostate cancer, as it has been mentioned before. We recommend to our patient to wait for one year after the operation, because up to then the operated tissues are still recovering and the incontinence can disappear or significantly improve and it cannot eventually disturb the patient. If this does not happen, we will examine our patient with specific special urological tests and we will propose to him the surgical treatment for his incontinence.

 

Γραφική παράσταση των τριών τμημάτων του σφιγκτήρα τοποθετημένων στην ανατομική τους θέση. Όλη η επέμβαση γίνεται με μία τομή στη βάση του πέουςThere are various ways to treat the urinary incontinence in men which is due to the weakness of the sphincter, and their selection is made by specialized doctors. They all include the placement of protheses. The most effective way is the placement of an artificial sphincter. This treatment is globally characterized as the “gold standard”, and the effectiveness of all other types of surgical treatment of incontinence are compared to it. The artificial phincter is a silicone implant that consists of three sections and its function is purely hydraulic. The material is always accepted by the human organism. These sections are the cuff which is placed around the urethra, the pump and the water reservoir.The placement of the entire device is performed today through an incision that is made on the base of the penis., which is a better technique than the classical placement with two incisions.

 

According to the European Association of Urology, the effectiveness of the artificial sphincter is up to 60%-90%, depending on the studies, and it is the highest compared to any other operation for the treatment of incontinence after prostatectomy. The frequency of complication ranges between 4.5%-15% and in 25% of the cases the replacement of the artificial sphincter will be necessary at some point. However, the cost of the material that is going to be used in case of replacement is covered by a lifetime guarantee and is absolutely free. The National Health Insurance Fund (EOPYY) covers 90% of the cost of the material, after an approval is granded after the examination of the necessary supporting documents. The replacement, if necessary is a simple procedure in the hands of an experienced urologist.

 

kirsokili1A varicocele is a pathological cirsoid dilatation of the spermatic venous plexus of the testicle. It is due to a reflux of blood in the internal spermatic vein, which is the principal drainage vein of the testes, due to the insufficiency of valves that exist normally in the veins and allow the one-way blood flow towards the main vein that drains blood from the testicle, which is the renal vein. The insufficiency of these valves is usually congenital and the reflux of the blood increases with standing and severe fatigue, causing thus the dilatation of the veins.

 

 

The incidence of varicocele in the general population ranges between 4.4-22.6%; in subfertile men it ranges between 21-41% regarding primary infertility (that is when these men have no children at all) and 75-81% regarding secondary infertility. In the majority of cases (90%) the varicocele occurs on the left side, in 30-50% of the cases bilaterally and in 2% of the cases only on the right side.

The venous plexus, which exists around each testicle, as it has a winding form, acts as a heat exchanger with the environment, like the radiator of a car, so that the testicles can maintain a temperature that is at least one degree Celsius lower than the one of the abdomen. It is for this reason that the testicles are located outside the abdomen, in the scrotum. The formation of a varicocele, even in one testicle only, is harmful to this thermoregulatory mechanism, resulting to a sperm production disorder and therefore a fertility disorder. Furtermore, in patients with varicocele, due to the stasis of blood in the veins, free oxygen radicals are generated, which are particularly harmful to the sperm.

 


 

 

kirsokili2The diagnosis of varicocele takes place by the palpation of the dilated veins of the scrotum with the patient in standing position. In case of a varicocele of a small degree, where the veins are not easily palpable and visible, the patient is asked to strain himself with his mouth shut (the Valsalva maneuver), in order for the veins to fill with blood so that they can be palpable.

In the subclinical forms of the disease (non palpable even after the aforementioned maneuver), a diagnostic tool is the ultrasound of the scrotum and the color Doppler ultrasound (triplex). A dilatation of the spermatic veins which is greater than 3.5mm, with the simultaneous reversal of the venous flow during the Valsalva test, delimit the diagnosis. This examination must be also performed in the varicoceles that are palpable, so that the diagnosis can be verified.

 

 

The main indication regarding the treatment of varicocele is infertility. At this point the patients can feel a great anxiety and confusion for the following reason: The indication, which is set by the European and the American Association of Urology for the treatment of varicocele, regards men in couples that have not been able to have a child, despite their regular sexual intrecourses for a year and the man has a clinical (palpable) varicocele and an abnormal spermiogram. However, even then, the couple should be aware that the fact that the possibility of having a child seems to increase, that does not mean that this couple will certainly have a child, which is of course what they desire, although the spermiogram has improved, which does not mean in its turn that it will certainly happen: all this does not mean that the treatment has not been properly performed. It is therefore obvious that, when the diagnosis of varicocele is made after a medical control which the patient desired to be performed, usually after a search on the Internet or the disorded has been diagnosed accidentally during a regular examination by a urologist, who was visited by the patient for some other reason, the question that arises is whether the disease should be immediately treated or not, as the issue of having a child has never been set forth. A normal spermiogram somewhat reassures the patient, but the doubts if a disorder occurs in the future, or if there is a possibility, despite the normal spermiogram, that there is a difficulty in having a child in the future, exist as tormenting questions on the patient’s mind, and sometimes on the doctor’s mind, as they cannot be answered for the time being. All this occurs from the fact that the issue is having a child and nothing else.
 

Another important question, that occurs for varicocele is that, if the only treatment indication of varicocele is the one that has been mentioned and is included in the instructions of the European and the American Association of Urology or if there are indications that its treatment helps other fields. It seems that such indications indeed exist, and although they have not been yet adequately documented, so that they could be included in the instructions of the two scientific associations, the research towards this direction still goes on. However, this documentation does not regard the safety of the treatment anyway, since its safety is granted, but only its effectiveness. Therefore, since the treatment of varicocele is simple, fast, easy, and without complications and without risk of relapsing, it could be applied in addition to the classical indication, in order to prevent or to improve the following conditions:

 

1Azoospermia

By this term we mean the absence of sperm in the semen, a diagnosis that can be made by a spermiogram. This condition is the only one that is related to the complete male infertility and, consequently, with the full incapacity to have a child in a normal way. All other sperm weaknesses, as they can be reflected in the spermiogram, do not exclude having a child in a normal way, they do just reduce the possibilities, depending on their gravity.

The prevailing opinion until today is that, since, in cases of azoospermia, the couple will either way follow the solution of in vitro fertilization, there is no need to treat a possible coexisting varicocele in the man. However, there is evidence today that the treatment of varicocele in the man before the in vitro fertilization increases the chance of finding sperm by a testicle biopsy, increases the pregnancy and birth rates and reduces the spontaneous abortion rates.

 


 

2Progressive testicular damage

The far greater frequency of presence of varicocele in patients with secondary infertility, compared to the ones with primary infertility, supports the view of the progressive testicular damage. There are reports regarding the progressive worsening of the spermiogram image and of the testosterone levels in the blood of patients with varicocele, who have not undergone a surgical repair of the disease.

New data show that 87.5% of the patients with testicular dysfunction and 20% of nomospermic men with varicocele presented a progressive deterioration of the spermiogram, within a period of 63.2 months.

 


 

3Pain

The effect of testicular pain in patients with varicocele ranges between 2-14%. Predisposing factors to the presence of testicular pain in patients with varicocele with a normal spermiogram are:

-the temperature of the scrotum

-the frequency of the reflux

-low body mass

-the distance of the renal sinus from the scrotum

It must be mentioned that the three last factors are statistically greater in patients with intense pain, than in patients with mild and moderate pain. The repair of the varicocele relieves testicular pain in 75% of the cases.

 


 

4Reduction of the testosterone production

There are contradictory opinions regarding how much the repair of varicocele improves the production of testosterone in the testicles, which has already been reduced.

 


 

5Damage to the genetic material (DNA) of the sperm

The damage to the DNA of the sperm is related with lower natural pregnancy rates, after artificial insemination, intracytoplastic sperm injection (ICSI) and classical in vitro fertilization (IVF).

The varicocele is related with a damage to the DNA of the sperm, which is possibly due to oxidative stress. The varicocele causes the generation of oxidative stress even in fertile men with normal sperm. Thus, it is well understood that there is a threshold of oxidative stress beyond which the fertility is affected. The repair of varicocele improves significantly the percentage of sperm with damage to its DNA.

 


 

6Infertility in a normal couple

There are cases of couples with infertility, where the woman is perfectly normal and the man has a varicocele and his spermiograms are quite normal. In these cases, on the basis of what has been mentioned before, it is possible that the varicocele affets the microenvironment of the sperm, without altering the parameters of the spermiogram. Thus, its treatment could reverse these abnormalities and allow a pregnancy.

The treatment of varicocele is only surgical. There are various techniques with almost similar effectiveness. They all aim at stopping the abnormal reflux of blood to the venous network of the testicle, by interrupting the venous drainage of the organ by the ligature and incision of the internal spermatic vein and/or its branches. Attention must be paid to the fact that some of them are particularly overestimated (for example laparoscopic surgery), and they are not optimal regarding their advantages. The complications are either way minor in the hands of an experienced surgeon. The varicocele is not a relapsing disease. There may be a presence of dilated veins in the postoperative ultrasound, but this is not a sign of relapse or of an unsuccessful operation, because it is possible that there is no regression of the dilatation, but the reflux of the blood stops, which is the aim of the treatment. Respectively, the spermiogram needs 3 months after the operation in order to start improving, which improvement can continue for another 9 months. However, there is a chance that this does not happen, but this again does not mean that the operation has failed. Furthermore, even if the spermiogram does not improve, it is not impossible that a pregnancy is achieved.

 


 

Conclusions

The repair of the varicocele improves qualitatively and quantitatively the sperm, even in men over 40 years old and, the sooner it is treated, the better are the results. It inhibits the progressive deterioration of the sperm. It increases the chance of spontaneous pregnancy in patients with weak sperm, regarding the sperm count and/or motility. It increases the possibility of presence of sperm in the semen and the possibility of pregnancy in patients with azoospermia. It improves the outcomes of in vitro fertilization and reduces the rate of miscarriage after it. It increases the serum levels of testosterone, even in men over 40 years old. It eliminates or improves substantially a possible disturbing chronic testicular pain. Finally, it reduces the oxidating stress of the sperm and improves the percentage of the sperm with normal intact DNA, which is theoretically related with the improvement of fertility.

Consequently, given the fact that there is a low morbidity, a low rate of complications and a low cost, in contrast with the assisted reproduction method, particularly in couples where the woman also has infertility problems, should varicocele be operated more frequently than the classical indication of the European and the American Association of Urology?

 

 

Prostate cancer consists the most frequent malignancy in men and the second cause of death from cancer, after lung cancer. One in six men will develop prostate cancer, while men whose father or brother (first degree relatives) has been affected by cancer are 2.4 times more likely to develop cancer. And if cancer has been diagnosed in this relative at a relatively young age (for example in the 5th decade of their life), chances are doubled. Chances of developing prostate cancer increase with age. Thus, 30% of men will be affected by the age of 50 and 80% by the age of 80. Although there are no symptoms, it can be effectively treated if diagnosed in early stages. The exact cause of prostate cancer is not known, however there are many ways to prevent it. It is important for someone to know that, given the fact that prostate cancer has no symptoms in early stages, if there are no preventive examinations, the diagnosis will be made from the symptoms of metastases (for example pain from bone metastases), that is, when it will be to late.

 


 

Prostate cancer can be detected in time by a preventive medical control, that includes the digital rectal examination and the detection in the blood of the prostate specific antigen (PSA). PSA is a substance which is normally produced by the prostate. The presence of normal or low levels of PSA in the blood does not necessarily rule out the presence of cancer, as, on the other hand, its increase does not necessarily mean that there is prostate cancer. Thus, attention must be paid because, on one hand, prostate cancer which is accompanied by normal or low PSA levels is more undifferentiated and consequently more agressive and, on the other hand, patients with high PSA levels could undergo useless examinations that cause mental suffering to them and their environment. Thus, PSA is an examination, which must be taken into account correctly, by evaluating in parallel other parameters. The only competent person to carry out this procedure is the specialized urologist and not other doctors of different specializations or the patient, considering only the reference values of the examination.
 


 

The detection of prostate cancer in time significantly reduces the mortality of the disease and the danger of development of metastases and of cancer in advanced stage. The instructions of the European Association of Urology recommend the measurement of a reference value of the prostate specific antigen (PSA) at an age of 40-45 years and the individualisation of periodic monitoring, depending on the PSA reference value and the presence of other risk factors.

 


 

P49aIf the urologist judges that there is a possibility to diagnose prostate cancer, he performs a biopsy by getting prostate particles, with the aid of a thin needle which is directed by ultrasounds, through the rectum. This is the only way to diagnose the disease. Unfortunately there is no other examination or any other way to absolutely exclude the disease and thus, if the biopsy is negative, the chances of prostate cancer are reduced but not eliminated. Consequently, the monitoring must keep going on and, if it is deemed necessary, the biopsy must be repeated.

 

 

When the disease is diagnosed in early stages, it can be treated and it is usually fully cured. The treatment includes three methods. The surgical removal of the whole prostate gland, of the seminal vesicles and, sometimes, of the lymph nodes of the region and then it is called radical prostatectomy, the external radiotherapy and the internal radiation of the prostate, with implants of radioactive material, which is called brachytherapy. The pharmaceutical treatment is not the proper treatment for prostate cancer in early stages and its application, although that it can be initially effective, will delay the radical treatment of the disease, with possible dangerous results. Although all three techniques present equally good therapeutical results in the relative literature, my opinion is that radical prostatectomy is the optimal treatment for localised prostate cancer because, compared to the external or internal radiation method, it is more advantageous due to the fact that the disease is fully removed from the body, is examined histologically and thus the complete surgical removal or not can be fully confirmed. Besides that, it seems that for younger patients it has the best long-term disease-free survival results.
 


 

 

Η λαπαροσκοπική ριζική προστατεκτομή εκτελείται με τη βοήθεια εργαλείων, που εισάγονται στη διατεταμένη από διοχετευόμενο διοξείδιο του άνθρακα κοιλιά, διαμέσου 4-5 μικρών οπών Today, radical prostatectomy can be performed in three ways: the classical open operation with a moderate incision in the lower part of the abdomen, the laparoscopic operation which is performed with the aid of special instruments and of a camera, that pass through 4-5 small punctures in the abdomen, of a size of 0.5-1cm, after the abdomen has been previously dilated with the aid of an inactive gas and, finally, the robotic operation, which is a laparoscopic operation, where the laparoscopic instruments are moving with the aid of robotic arms, that are directed by the surgeon through a control panel. The parameters that must be taken into account in the selection of a method include parameters of the tumour (size of the prostate, possibility of metastases to lymph nodes, coexisting local disorders, for example inguinal hernia, pervious operations and therefore symphyses in the area, for example open prostatectomy of benign hyperplasia), parameters of the patient (body type, concomitant aggravating diseases), adequacy of materials for the laparoscopic and robotic operations and experience of the surgeon in each method. It is important to consider that the latest techniques may be more advantageous, in some factors, than the classical operation, but, on one hand, they do not consist a universal remedy and, on the other hand, the selection of the method is finally performed by the doctor, with the agreement of the patient.

 

 Ένα ρομποτικό σύστημα Da Vinci . Ο χειρουργός ελέγχει από μία κονσόλα ελέγχου την κίνηση των βραχιόνων, που χειρίζονται τα λαπαροσκοπικά εργαλεία με αποτέλεσμα καλύτερη όραση και μεγαλύτερο εύρος, ακρίβεια και σταθερότητα των χειρουργικών κινήσεων με αποτέλεσμα λιγότερες κακώσεις παράπλευρων ιστώνThe laparoscopic and the robotic surgery are more advantageous, firstly, due to the use of camera for the operation. This allows a singificant magnification (zoom in) and consequently a better vision and, therefore, the minimalisation of injury of the nearby healthy tissues. Particularly in a robotic operation, the surgeon has the capacity of tridimensional (3D) vision. At the same time, the use of robotic arms allows the execution of movements that cannot be made by the human hand, with a high precision and stability. This helps avoiding pointless injuries of the nearby tissues. In parallel, due to the excellent vision and to the high manipulation precision, the surgeon can save the erection nerves, which lie in parallel to the prostate capsule, so that the patient could maintain his erection postoperatively, at least with the use of adjuvant pills. Furthermore, the mechanism of the urethral sphincter can be more easily protected and thus the postoperative urinary incontinence can be partially or completely prevented.

The verification of the aforementioned logical conclusions from the use of newer techniques must be also confirmed by the relative literature in order to be accurate. Thus, the latest data from the most recent guidelines of the European Association of Urology show that the robotically assisted laparoscopic radical prostatectomy is accompanied indeed by a smaller blood loss and need for blood transfusion, a shorter hospitalization time and a smaller need for painkiller treatment, in comparison to the open operation. The catheter can be removed postoperatively more fastly and the patient can return sooner to his activities. Regarding the oncologic result, which is the main concern of the doctor and the patient, it seems that regarding the excision of the tumour on healthy tissues, it is equivalent with the open radical prostatectomy. However, regarding the recurrence of the disease and the overall survival of the patients, there are no comparable data yet, because the robotic operation is a new procedure and has not been yet evaluated. Finally, regarding the long-term complications of the radical prostatectomy, that is incontinence and erectile dysfunction, it seems that there is some superiority of the robotically assisted operation, but many more properly designed studies are needed, so that this can be proven.


 

In order to select the appropriate method of radical prostatectomy must be also considered some other factors. Thus, the cost of the robotically assisted operation primarily is much higher, and the one of the simple laparoscopic operation is relatively higher, compared to the cost of open operation. This is due to the cost of investment and maintenance of the expensive robotic device, of the laparoscopic instruments, but also to reasons of medical competition, since the robotic operation can be performed only by few specialized surgeons.

Furthermore, the patient for whom is decided to undergo a laparoscopic or robotic operation must always be informed that this operation may become an open operation, if this is deemed necessary, for safety reasons and in order to get the right oncological result.

Furthermore, incontinence and erectile dysfunction occur frequently with the aforementioned operations too, and it is not possible to predict in advance the possibility of their occurrence and, thus, to assure the patient that they will not occur. Moreover, the protection of the nerves of the erection and of the mechanism of the urethral sphincter can take also place in an open operation, folllowing specific surgical steps. It must be remarked that the first neuroprotective radical prostatectomies that were performed by Patrick Walsh were open operations, with excellent results regarding erectile dysfunction and incontinence.

The laparoscopic operations, either the simple, or the robotically assisted ones, have also complications, some of which are specific complications of these operations only, while some others – that also occur in the open operations – are more frequent, more severe and more difficultly treatable. Thus, the use of carbon dioxide for the dilatation of the abdomen and the longest duration of the laparoscopic operation, compared to the open one, presents specific metabolic, but also cardiovascular and respiratory risks. Recently, Kavoussi et al. analyzed the complications in a large series of 2,775 laparoscopic urologic operations, that have been performed in a period of 12 years. The most common complication is the injury of the vessels. Intraoperatively, there can be hemorrhage at any point during a laparoscopic operation. In an open surgical operation, the identification of the hemorrhage point and its control is clearly easier and faster, compared to a laparoscopic operation.

Therefore, in conclusion, regarding the patient and his environment, and in order to select the proper method of radical prostatectomy, someone should consider the following:

-The laparoscopic and particularly the robotically assisted laparoscopic radical prostatectomy consist an evolution of the classical open operation and are accompanied by good therapeutical results, and they consist lower gravity operations for the patient, having a faster recovery

-They cannot be applied in all cases.

-The robotically assisted operation has a much higher cost.

-The laparoscopic and the robotically assisted laparoscopic radical prostatectomy are not free of intraoperative complications, neither of a subsequent incontinence or erectile dysfunction; however these occur less frequently than in the case of classical open operation.

-They are considerably overestimated and are frequently presented in a over-optimistic way on the Internet, but also by the surgeons who perform them.

-As in the case of every new method, their value must be proven with accurate and long-term clinical studies.

 

 

 Κλασική διουρηθρική προστατεκτομήThe benign prostatic hyperplasia is a very common disease in usually over 60 year old men, that leads to significant urination problems and sometimes to serious complications. There are many ways of treatment, surgical and with administration of drugs. The pharmaceutical treatment, however, does not usually consist a permanent treatment and has the disadvantage of the permanent use of drugs along with their possible side effects, such as hypotension and erectile dysfunction. The open operation, on the other hand, is always permanently effective, but is a relatively heavy operation, that requires a hospitalization and a catheterization for a week. The transurethral prostatectomy is effective, but is applied in relatively small prostates, there is hemorrhage and, although it is lighter than the open operation, it is also relatively heavy and requires a four day hospitalization.

 

 

 

Η ακτίνα laser εξαχνώνει τον προστατικό ιστό αναίμακτα, γρήγορα και αποτελεσματικάA new type of procedure for the removal of the prostate in case of its benign enlargement is the use of Laser. This particular method is also performed with spinal anesthesia and through the urethra without an incision, as the classical transurethral prostatectomy, where the prostatic tissue is vaporized with the aid of laser. However, this particular technique is more advantageous, after the proper selection of patients, in the following points:

 

 

 

  1. The duration of hospitalization is limited to one day, in comparison with the classical transurethral operation which is 3 days and with the open prostatectomy which is 7 days.
  2. The catheter remains for one day only, and in 30% of the patients there is no requirement of postoperative catheterization at all, in contrast with the aforementioned techniques, where it remains for 3 or 7 days respectively.
  3. The blood loss is minor, in contrast with the aforementioned operations, where the loss reaches 300-600ml.
  4. The interruption of the anticoagulant therapy is not required.
  5. The gravity of the laser technique is much lower than the one of classical operations.
  6. The retrograde ejaculation and consequently the absence of ejaculation, which consists the usual case after classical prostatectomies, is rare after a KTP laser technique operation.
  7. The erectile function is not affected at all.

So, it seems that this technique is equally effective with the classical ones, but it has a much lower morbidity and less discomfort for the patient. A relative contraindication are the large prostates with a size greater than 80-90cm3, because in this case the open prostatectomy has better results and the suspicion of prostate cancer, because with the KTP laser technique cannot be collected biopsy samples.

Θέσεις ενσφήνωσης λίθου στον ουρητήρα και πρόκληση απόφραξης των ούρων.A definitive result offered by the endoscopic laser lithotrispy. The ureter lithiasis consists a common problem, which can cause from a simple colic to the complete obstruction of the ureter with a progressive infection and destruction of the kidney. Colic and haematuria are the most common effects, but there are also cases where the pain can be mild, or deep, where there is no haematuria and, sometimes, where there are no symptoms at all.

The diagnosis of lithiasis is made very easily with a simple x-ray, an intravenous pyelogram and, if necessary, a CT scan, given the fact that all stones do not appear in simple x-rays.

 


 

Άκαμπτο (επάνω) και εύκαμπτο τηλεσκόπιο για τον έλεγχο του ουρητήρα και τη θραύση των λίθων.The ultrasound does not directly show the ureteral stones, as it can show kidney and urinary bladder stones, but it can show the presence of a dilatation, which can be caused by an obstruction by the stone.Surgical operations for the removal of stones are very limited today, after the application of extracorporeal lithotripsy, which is the optimal method for Ουρητηροσκοπικές εικόνες σφηνωμένων λίθων.renal radiopaque stones with a diameter up to 2 centimeters. Larger kidney stones can be also successfully removed, under some conditions, with extracorporeal lithotripsy. Extracorporeal lithotripsy can be also applied for the elimination of ureteral stones. However, there are some limitations here. Thus, stones that cause a complete obstruction of the ureter must be immediately treated in order to avoid renal complications. Extracorporeal lithotripsy cannot assure the immediate removal of the ureter obstruction and consequently prevent some possible complications. Furthermore, stones that have remained for a long time in the ureter are “anchored”, due to inflammation and edema, at its wall and thus the extracorporeal lithotripsy is not effective regarding the removal of these stones. Furthermore, stones that are found lower in the inferior part of the ureter can be difficultly focused by extracorporeal lithotripsy and consequently its effectiveness is significantly reduced. The success of extracorporeal lithotripsy is also limited in case of ureteral stones in obese patients or in patients with skeletal abnormalities, due to the difficulty to focus the shock waves.


 

Θραύση του λίθου με χρήση ακτίνων laser, που εστιάζονται στο λίθο υπό άμεση όραση με τη βοήθεια του ουρητηροσκοπίουΣύλληψη ουρητηρικού λίθου με ειδικό «καλάθι» σύλληψης.The solution for all these cases is ureteroscopic laser lithotripsy. This method is performed with the aid of a special thin instrument, which is called ureteroscope, that passes through the regular exiting way of the urine, without any incision, is entering the ureter under direct view with the aid of a camera and locates the stone. Then, through the working channel of the instrument passes the laser fiber, that breaks the stone into smaller pieces.

 


 

Θραύσματα λίθου μετά από ουρητηροσκοπική λιθοθρυψία με laser.

These pieces are afterwards either removed by themselves, or removed with special collection “baskets”, that pass again through the working channel of the ureteroscope. This method is performed either with general or with epidural anesthesia and the patient can be discharged from the clinic on the same day, without even one night of hospitalization. The effectiveness of the method is almost 100% and the complications are negligible.

 

 


 

Το ειδικό «καλάθι» συλλήψεως των θραυσμάτων του λίθου.The use of the flexible ureteroscope, in contrast with the rigid one, offers the possibility of accessing kidney stones too, as it can, in contrast with the rigid instrument, pass in the drainage system of the kidney and fragment kidney stones. Of course, the effectiveness of this technique cannot reach the effectiveness of percutaneous nephroscopy (refer to treatment of nephrolithiasis on the questions page), but it is more advantageous, due to the fact that it is minimally invasive, in contrast with nephroscopy, as there is no disruption of tissues and, if combined with the non-invasive extracorporeal lithotripsy for the stone residues that are not accessible with the flexible ureteroscope, the ratio effectiveness -morbidity is excellent.

 

 

Treatment without pills. The type of incontinence that is characterized by a sudden urinating desire, that cannot be controled by the patient and is called urge incontinence, is a tormenting feeling and creates a severe social problem, as well as hygiene problems. Also, the cost of incontinence diapers is by no means inconsiderable. This kind of incontinence can be due to certain diseases. These diseases can be neurological or diseases of the bladder wall, such as inflammations or tumours.

However, in the majority of cases there is no known cause for this type of incontinence and thus it is called idiopathic. In order to exclude the presence of serious diseases, some simple medical tests, such as the ultrasound of the urinary tract, the urine test and, sometimes, the cystoscopy, must be performed.

Ένεση της βουτυλινικής τοξίνης στη κύστη.The urodynamic test is a relatively simple examination that records the spasms of the bladder and the increase of pressure in the bladder, at the spasm phase. In the case of incontinence which is due to neurological reasons, the increase of pressure in the bladder due to the highly intense spasm causes, apart from incontinence, a reflux of the urine to the kidneys, which results to their rapid destruction and to a renal failure. The urge incontinence is treated mainly with medicines. Newer medicines, that have even less side effects compared to the older oxybutynin – that causes intense dry mouth, constipation and tachycardia -, are added to the therapeutical arsenal of the urologist. However, the newer medicines are not totally free of side effects, and they are not always effective or tolerable. A new alternative therapeutical method for an overactive urinary bladder is the administration of botulinum toxin, with injections directly in the urinary bladder with the aid of a cystoscope. This medicine has the characteristic that it temporarily relaxes the muscular wall of the urinary bladder and can, thus, improve and, at most times, fully stop this type of incontinence.

P41The injection is applied with local anesthesia and there is no need of hospitalization of the patient. The final result can be observed up to one week after the injections. This treatment result can last up to six months. After this period, the administration of the medicine can be repeated. This treatment is safe, without any considerable side effects, when the instructions and indications that regard its applications are properly observed, although the patients should be informed that, in a small percentage of cases, intermittent catheterization may be temporarily needed. The great advantage of this treatment is the fact that it is minimally invasive, cheap, safe, very effective, that the patient avoids possible problems caused by medication and a possible surgical operation – when drugs are not effective -, while patients with neurological diseases ensure, without any operation, apart from the improvement or even the elimination of their incontinence, the protection of their kidneys against the high pressures that are developed due to the uncontrollable spasms of the bladder.

 

Ταινία ελεύθερη τάσης. Η ταινία ελεύθερης τάσης, που τοποθετείται με μια απλή επέμβαση κάτω από την ουρήθρα εμποδίζει τη κάθοδο της ουρήθρας κατά την αύξηση της ενδοκοιλιακής πίεσης και έτσι εμποδίζει την ακράτεια από προσπάθειαSurgical repair within 20 minutes. Stress incontinence is the type of incontinence which is related with the leakage of urine due to coughing, laughing, fast moving and, in general, to all situations where pressure in the abdomen area is increasing. In more severe forms, the loss of urine can be massive and can take place even during calmer activities. This type of incontinence, although it can occur in both sexes, is more frequent in women and is due to the relaxation of the muscular floor of their pelvis, usually due to atrophy of these muscles, due to childbirth and the lack of estrogens after menopause.

 

Ταινία ελεύθερη τάσης εξερχόμενη δια του κοιλιακού τοιχώματος (κλασικό TVT).More rarely, this type of incontinence can be due to weakness of the continence mechanism of the sphincter, caused by neurological diseases, diabetes, or injuries of the pelvic nerves due to accidents, or more frequently after large scale operations in the pelvis for the removal of tumours. The most common type of stress urinary incontinence, that is the one that is caused by a relaxation of the pelvic floor in women, is treated with various conservative and more frequently with surgical means. The most usual operations include the placement of tapes of polypropylene under the urethra in women. These tapes do not exercise pressure in order to block the urethra, when they are correctly placed, but act as a support of the urethra at the moment when, due to the increase of intra-abdominal pressure, the urethra moves from its position, allowing thus the leakage of urine.

Ταινία ελεύθερη τάσης εξερχόμενη δια των θυροειδικών τρημάτων της λεκάνης (TVTO, TOT).These tapes are very effective in controlling incontinence and are easily placed with simple operations, with epidural or local anesthesia. They are perfectly tolerated by the human body and, very soon, they are integrated in the tissues, without any problems. These operations, in order to offer the optimal results, must be performed by specialized in incontinence urologists.

The oldest and most proven of all tapes is the TVT tape. For its placement, the two edges of this band must be pulled out of the lower abdominal wall, with the aid of special needles. Although the method is quite safe in the hands of an experienced specialist, there is still some danger of organ injury due to the use of needles.

Ταινία ελεύθερη τάσης εξερχόμενη δια των θυροειδικών τρημάτων της λεκάνης (TVTO, TOT).The attempts to simplify this operation has lead to two variations of the placement of the tape, by passing the tape not through the lower abdominal wall, but through the thyroid foramina in the internal surface of the thighs (TOT and TVTO tapes).

This technique reduces the duration of the operation and the danger of possible injury of the urinary bladder, the intestine and the iliac vessels. Another simplification of the TVT tape is the recently used TVT Secure tape. This tape is even more advantageous than the others due to the fact that no needles are used for the tape to pass through and, thus, its application is fast and safe, and it can be performed with local anesthesia. Its effectiveness remains to be evaluated.