Phase II study of MTX-HSA in combination with cisplatin as first line treatment in patients with advanced or metastatic transitional cell carcinoma.

PURPOSE: To assess the efficacy, tolerability and safety of MTX-HSA (methotrexate (MTX) covalently linked to human serum albumin (HSA)) combined with cisplatin as first line therapy for advanced bladder cancer. METHODS: Patients (pat) were treated with a loading dose of 110 mg/m(2) of MTX-HSA followed by a weekly dose of 40 mg/m(2) starting on day 8. Cisplatin was given on day 2 of each 28 day cycle at a dose of 75 mg/m(2). RESULTS: Tumor response evaluation was possible in 7 patients. Complete response (CR) and partial response (PR) was observed in 1 patient each (overall response rate: 29%). Key toxicities included CTC Grade (G) 3/4 stomatitis in 6 patients, vomiting G3 in 1 patient, fatigue G3 in 1 patient and thrombocytopenia G3 in 3 patients. CONCLUSION: The combination of MTX-HSA with cisplatin is feasible and shows antitumor activity against urothelial carcinomas combined with an acceptable toxicity profile.

[Occurrence of lymphoceles after allogeneic kidney transplantation and their therapy]. / Untersuchung zum Auftreten von Lymphozelen nach allogener Nierentransplantation und deren Therapie.

We conducted a prospective evaluation of 301 consecutive renal transplants to define the prevalence and therapy of lymphoceles following renal transplantation. Using a management scheme, we identified in 52 patients (17.3%) perirenal fluid collections. Using this management scheme, we treated 47/52 patients conservatively. Only 5 (1.7%) patients required internal marsupialization. We conclude that groin lympho cysts after renal transplantation can be successfully treated with conservative methods.

Urethral closure pressure changes with age in men.

PURPOSE: The natural history of external urethral sphincter function in elderly men is unknown. MATERIALS AND METHODS: In 257 men 45 to 88 years old external sphincter function changes with aging were analyzed by urodynamic studies, including functional urethral length, maximal urethral pressure, sphincter length and maximum urethral pressure during voluntary contraction. RESULTS: Mean functional urethral length was 51.9 mm. and there was no statistical decrease with age. However, sphincter length decreased with age from 24.3 to 14.8 mm., maximal urethral pressure from 88.7 to 55 cm. water and maximal urethral pressure during voluntary contraction from 221.4 to 166.3 cm. water. CONCLUSIONS: Sphincter function according to urethral pressure profile decreases with patient age.

In situ splitting of the liver in the heart-beating cadaveric organ donor for transplantation in two recipients.

SLT presents an interesting concept to alleviate the organ shortage for children with end-stage liver disease. The procedure has, however, not gained wide acceptance. This is not only related to the complexity of the procedure, but also to the poorer results and the complications reported on the right side graft. We report on a first case in which we applied a new concept for splitting. The liver was split in situ in the heart-beating cadaveric donor with the aim of reducing the problems with the right side graft. This procedure makes splitting of the liver possible without submitting the recipient of the right side to increased risk. Therefore, in situ splitting of the liver has the potential of making splitting of liver grafts the rule rather than the exception, thus increasing the organ pool for small children presently carrying a high risk of dying on the waiting list.

[Treatment of rectal injuries with vesicorectal fistulization in radical prostatectomy]. / Die Behandlung von Rektumverletzungen mit vesikorektaler Fistelbildung bei radikaler Prostatektomie.

In the literature many different ways are described of treating rectal injured during radical prostatectomy. Therefore, following this procedure we evaluated our patients with rectal injuries. Rectal injury occurred in 16 of 299 patients with radical prostatectomy for treatment of localized prostate cancer. Seven developed a vesicorectal fistula, 4 of whom needed no further surgical intervention. Only 3 (1%) had to undergo an additional operation.

Endo-urological cold-knife incision for ureteral stenosis after renal transplantation.

Cold-knife incision of stenoses in the transplant ureter was performed in 11 patients with upper urinary tract obstruction in renal transplants. The operations were complicated by bleeding in 2 patients and the graft had to be removed in 1 of them. The stenoses could be treated successfully in 10 of the 11 patients (91%) and the mean serum creatinine concentration decreased significantly from 3.4 to 1.8 mg./dl. After a mean of 26 months only 1 obstruction recurred, so the long-term success rate was 82%. Because of the favorable long-term results and the low incidence of complications, we recommend endo-urological cold-knife incision of ureteral stenosis as the first-line treatment for upper urinary tract obstruction in renal transplants.

[Topographic-quantitative EEG-analysis of the paradoxical arousal reaction. EEG changes during urologic surgery using isoflurane/ N2O anesthesia]. / Topographisch-quantitative EEG-Analyse der paradoxen Arousalreaktion. EEG-Veränderungen bei urologischen Eingriffen unter Isofluran-/N2O Narkose.

Increases in slow-wave (delta) activity in the EEG may reflect increased depth of anaesthesia provided that hypoxia, haemodynamic instability and drug overdose have been excluded. In contrast, similar intraoperative EEG responses have been described as paradoxical arousal reactions. The aim of this study was to assess the effects of surgical stimulation on spatial EEG changes during anaesthesia with 0.6% isoflurane/66% nitrous oxide. METHODS. The present study investigated changes in EEG power and frequencies in 20 patients (mean age 36 +/- 8 years; ASA I or II) scheduled for elective urological surgery during steady-state anaesthesia with 0.6% isoflurane and 66% nitrous oxide. The following variables were measured: heart rate (HR), mean arterial blood pressure (MAP), end-tidal isoflurane (PetISO) and carbon dioxide concentrations (PetCO2), arterial oxygen saturation (SaO2%) and body temperature (degree C). Patients were randomly assigned to one of two groups: group 1 (n = 10; without surgery) and group 2 (n = 10; with surgical procedure). The EEG was recorded over 20 min. The first 5 min were taken as baseline. In group 2 surgical stimulation (skin incision with subsequent surgical preparation) was started 1-2 min after recording of baseline values. Topographical distribution of EEG output was recorded from 17 electrodes (international 10-20 system), digitized and stored on disk (CATEEM) after establishment of steady-state anaesthesia (PetISO: 0.6%; PetCO2: 35-37 mmHg). Data are given as medium (microV2/Hz) and relative changes (%) +/- SD with respect to baseline. Statistical significance was tested for F4 versus C4 for the delta- and alpha-1-frequency bands using Wilcoxon's test (P < 0.05). RESULTS. In group 1 (without surgical stimulation) all parameters did not change over time. EEG slowing with an increase in power (> 100%) was noted in 8 patients of group 2 (n = 10; during surgical stimulation). By visual inspection of the original EEG tracings paradoxical arousal patterns were seen in these patients. In group 2, delta output changed from 69.6 microV2/Hz (baseline) to 147.4 microV2/Hz at frontal leads (F4) 5-6 min after the start of surgery. Only minimal changes were observed for theta activity. At the same time, in most cases fast wave activity (alpha 1, alpha 2, beta 1 and beta 2) was decreased by more than 50% at identical cortical areas. Increases in MAP were noted continuously after start of surgery up to a maximum of 19.8% from baseline, which became significant at the 16-min level. Heart rate did not change over time. DISCUSSION. Our data demonstrate that EEG slowing may be induced by surgical stimulation during steady-state anaesthesia with 0.6% isoflurane/66% nitrous oxide in oxygen. These findings are consistent with previous reports indicating the occurrence of slow wave patterns following sensory stimulation in comatose patients. Since these events occur predominantly at frontal areas they may not be detected with single-channel parietal recordings. Our data suggest that topographical EEG monitoring may useful for assessing painful events during surgery. Using EEG monoparameters like spectral edge frequency or median the occurrence of paradoxical arousal reactions may be falsely interpreted as an increased depth of anaesthesia.

[Obstructive uropathy after kidney transplantation. Experiences with endourologic incision of ureteral stenoses]. / Die obstruktive Uropathie nach Nierentransplantation. Erfahrungen mit der endourologischen Schlitzung von Ureterstenosen.

Between 1985 und March 1991 we have managed 8 upper urinary tract obstructions in kidney transplants using an endourological approach. After a graft rejection was excluded an obstruction was initially diagnosed by nephrosonography and further confirmed by IVP or antegrade pyelography. To investigate the urodynamic relevance of the stenosis, all patients underwent preoperative diuretic isotope renography. In all cases a percutaneous pyelostomy was done to preserve renal function. 7 of these 8 patients demonstrated a stenosis of the ureter, while in one case, the obstruction was caused by a coagulum in the renal pelvis. Incision of the stricture then was performed with a flexible knife antegrade or retrograde and stented for 4-6 weeks. In 6 out of 7 cases with a proven stenosis of the ureter, the cold knife incision lead to a successful outcome, while in one patient, the kidney had to be removed due to uncontrolled bleeding 12 days after successful percutaneous incision. Our results indicate, that the cold-knife-technique for the management of upper urinary tract obstructions in kidney transplants is a promising, fast and in most of the cases effective method. Due to its minimalinvasive character and excellent results, this approach is able to replace open reintervention in most cases.