[Prostate biopsy: Procedure in the clinical routine]. / Prostatabiopsie : Durchführung im klinischen Alltag.

Over the last decade there has been a 25% decrease in the mortality rates for prostate cancer. The reasons for this significant decrease are most likely associated with the application of urological screening tests. The main tools for early detection are currently increased public awareness of the disease, prostate-specific antigen (PSA) tests and transrectal ultrasound (TRUS) guided topographically assignable biopsy sampling. Together with the histopathological results these features provide essential information for risk stratification, diagnostics and therapy decisions. The evolution of prostate biopsy techniques as well as the use of PSA testing has led to an increased identification of asymptomatic men, where further clarification is necessary. Significant efforts and increased clinical research focus on determining the appropriate indications for a prostate biopsy and the optimal technique to achieve better detection rates. The most widely used imaging modality for the prostate is TRUS; however, there are no clearly defined standards for the clinical approach for each individual biopsy procedure, dealing with continuous technical optimization and in particular the developments in imaging. In this review the current principles, techniques, new approaches and instrumentation of prostate biopsy imaging control are presented within the framework of the structured educational approach.

[Are their individual decisions for urinary diversion? Indications and results of 200 consecutive patients]. / Gibt es eine individuelle Entscheidung zur Harnableitung? Indikation und Ergebnisse bei 200 konsekutiven Patienten.

During the past 20 years many continent urinary diversions have been established. The indications includes pelvic tumors, especially bladder cancer, and structural and functional disorders of the lower urinary tract with irreversible damage of storage or continence function. Given the variety of surgical diversion techniques, it seems feasible to consider the patient's individual pathoanatomical situation as well as his/her personal wishes. We report on 200 consecutive patients with supravesical urinary diversion. The analysis includes indications surgical technique, intra-and postoperative complications and patients' quality of life. The peri- and postoperative morbidity rate was 18.5%. Complications mainly comprised infections and obstruction of the urinary tract. The mortality rate was 4.5% and causes of death included bleeding, infection, urinary extravasation and bowel atonia. Patients with malignant disease and only palliative treatment showed disappointing results after on operation including continent urinary diversion: 30% of them had early complications. Several female patients with a catherizable continent urinary diversion could not handle the catheterization of the pouch, although the function of the urinary diversion was excellent. Therefore an indwelling catheter was placed in all these patients. Our analysis shows that the choice of urinary diversion has to consider the patient's pathoanatomical situation, as well as his/her age, general condition, mental and manual skills. In addition, renal function, the metabolic situation and previous therapies may influence the decision regarding supravesical urinary diversion in an individual case.

[Results of surgical treatment of local and locoregional recurrence of rectal carcinoma--an analysis of 54 patients]. / Ergebnisse der operativen Behandlung von lokalen und lokoregionären Rektumkarzinomrezidiven--Eine Analyse von 54 Patienten.

The role of secondary resections of locally and locoregionally recurrent rectal cancer is still unclear concerning local tumor control and survival. A retrospective study of 54 patients undergoing resections of recurrent rectal cancer from 1984 to 1992 was done to define the role of secondary surgery and additive or adjuvant therapies. Extended resections of adjacent organs were performed in 37 patients. Potentially curative surgery was possible in only 7/54 patients, in 14 patients microscopically residual tumor (8 of these patients receiving intraoperative radiation therapy [IORT], and in 33 patients (11 of these cases with distant metastases) macroscopic tumor had to be left. A preoperative or postoperative radiation therapy partly in combination with IORT, hyperthermia or chemotherapy was applied in 26 patients. Median survival was 12.5 months in all patients, 19 months in patients without distant metastases and 8 months in patients with distant metastases, respectively. Radical surgery and localisation of the recurrent tumors were the main prognostic factors: Median survival of patients without distant metastases (n = 43) was 17 months in patients with pelvic wall recurrence, 33 months in patients with anastomotic or perineal recurrence and 39, 20 and 16 months in R0-, R1 and R2-resected patients, respectively. Local tumor control was achieved in only 10 of all patients, but in 4 of 8 patients receiving IORT. In total, only 5 of 54 patients are cured potentially. In conclusion, resection of recurrent rectal cancer, even in combination with additive or adjuvant therapies, only rarely leads to local tumor control and final cure.

[Treatment of complicated recurrent hypospadias]. / Behandlung komplizierter Hypospadierezidive.

Between January 1985 and December 1990, a total of 40 patients aged 2-40 years underwent surgical reconstruction for complicated failure of hypospadias repair. These included 19 patients with multiple previous operations, severely scarred skin, penile deviation, long urethral defects and scarred or cleft glans, who were classified as hypospadias cripples (group I). The remaining 21 patients had distal urethral defects and a scarred or cleft glans but better skin condition; this group was classified as having defects of the distal urethra and glans (group II). Island flaps were used in 17 patients, and transversal or axial random penile skin flaps in 18. In 4 patients the urethra was reconstructed with mesh graft and in 1 case, with a bladder mucosa graft. With the designed single-session procedure primary treatment was successful and free of complications in 52% of the patients in group I and 67% in group II. In each of 3 patients three further operations were required. In 15 patients revision surgery was confined to simple fistula closure, stricture incision or correction of scarred skin. Follow-up examination at 7-72 months showed that treatment had been successful in all patients.

[Prenatal ultrasound diagnosis in congenital abnormalities of the kidneys and efferent urinary tract from the pediatric nephrology viewpoint]. / Antenatale Ultraschalldiagnostik bei angeborenen Fehlbildungen der Nieren und des ableitenden Harntraktes aus pädiatrisch-nephrologischer Sicht.

Antenatal foetal abnormalities are found in 0.5% of all pregnancies. 30-50% of these abnormalities are related to the urinary tract. Although congenital abnormalities of the urinary tract can be detected as early as in the 15th-18th weeks of gestation, most abnormalities are detected between the 28th-30th weeks of gestation. At this time irreversible damage of the kidneys has taken place and the foetus will not benefit from antenatal therapy. On the other hand, a foetus with late onset of obstruction will benefit from antenatal intervention. Repeated ultrasonography is crucial for initiating further invasive diagnostic procedures, antenatal therapy and for planning the time of labour. There is a great risk of overdiagnosis and inadequate therapy because 25% of all antenatally diagnosed dilatations of the urinary tract could not be confirmed postnatally.

Primary obstructed megaureter in neonates. Treatment by temporary uretero-cutaneostomy.

During the last 10 years we have treated 24 newborn and young infants (27 ureters) in whom the diagnosis of primary obstructed megaureter was established by diuresis-enhanced radionuclide renography and/or by antegrade pressure flow studies (Whitaker test). Temporary uretero-cutaneostomy was performed immediately after diagnosis. After 1 year a second modified Whitaker test showed normal passage of the contrast medium into the bladder in 23 ureters. In only 4 ureters did obstruction persist and uretero-cystoneostomy was performed. Ureterocystoneostomy was also performed on 8 ureters without obstruction but with persistent vesicoureteric reflux, ectopic ureter or diverticula. In 11 patients a temporary uretero-cutaneostomy was closed without corrective surgery at the vesicoureteric junction. Temporary uretero-cutaneostomy is a safe and effective therapy in primary obstructed megaureter in newborns. Spontaneous relief of obstruction appears to be possible in primary obstructed megaureter.

[Prenatal ultrasound diagnosis of the kidneys and efferent urinary tract. Possibilities, applications and dangers]. / Die antenatale Ultraschalldiagnostik der Nieren und der ableitenden Harnwege. Möglichkeiten, Nutzen und Gefahren.

Congenital abnormalities of the urinary tract can be detected as early as during the 15th-18th week of gestation. Nevertheless, most abnormalities are detected between the 28th-30th week of gestation. Antenatal fetal abnormalities vary between physiological dilatation to bilateral hydronephrosis and polycystic kidney disease. Abnormalities in antenatal fetal ultrasonography are found in 0.5% of all pregnancies, 30-50% of these abnormalities are related to the urinary tract. Though most of the abnormalities are diagnosed late in pregnancy, irreversible damage of the kidneys has already taken place by that time and the fetus will not profit from antenatal therapy. On the other hand, a fetus with late onset of urinary tract obstruction may profit from antenatal intervention or early labor. Repeated ultrasonography is crucial for initiating further invasive diagnostic procedures, antenatal therapy and for planing the time of labor. There is a great risk of overdiagnosing and inadequate therapy because too little is known about physiological development of the fetal urinary tract in ultrasonography and so physiological and pathological development cannot be differentiated safely.

E-cadherin: a marker for differentiation and invasiveness in prostatic carcinoma.

Considerable controversy exists concerning the value of histomorphological data in the assessment of the malignant potential of prostatic carcinomas. We investigated the expression pattern of E-cadherin in human prostate at the translational level. E-cadherin is a specific epithelial cell-cell adhesion molecule which has previously been found to be expressed in well-differentiated non-invasive carcinoma cell lines but is lost in many poorly differentiated invasive cell lines. The E-cadherin expression pattern in the prostate samples was correlated with histopathological findings in the same specimens. We found strong E-cadherin expression in normal prostate and benign prostatic hyperplasia. A decrease in or loss of E-cadherin was seen in 13 of 14 locally advanced and in 8 of 9 poorly differentiated prostatic carcinomas. We conclude that downregulation of E-cadherin expression plays a role in prostate carcinogenesis and invasiveness.

[Congenital malformations of the urinary tract. Rational postpartum diagnosis]. / Angeborene Fehlbildungen des Harntrakts. Rationelle postpartale Diagnostik.

More than one third of the anomalies diagnosed antenatally by ultrasound comprises the urinary tract. The criteria of the diagnostic and therapeutic approach, which resulted from our experience in children with symptomatic urinary tract anomalies cannot be necessarily applied to asymptomatic newborns. Not all urinary tract anomalies are obstructive and need surgical correction. Therefore, rational diagnostic approach after birth is necessary, which starts with ultrasonography. The first radiological diagnostic procedure is always a voiding cystourethrography in order to diagnose or exclude infravesical obstruction or a vesicoureteric reflux. The dynamic radionuclide nephrography (123I-Hippuran) under standardized conditions with adequate hydration and Furosemide-induced diuresis is able to detect a significant obstruction at the pelvi-ureteric or uretero-vesical junction. The intravenous urography is limited to specific questions and a computerized tomography is rarely indicated. In rare cases when dynamic investigations are equivocal, antegrade pressure flow studies according to Whitaker can be reliably exclude or prove obstruction.

The forgotten double J stent. Case report of a multifractured ureter stent.

An 81-year-old male patient was admitted to hospital because of macrohematuria. The clinical examination revealed a multifractured double J stent which had been placed 17 months before in another clinic because of hydronephrosis. In the reported case, a combined endoscopic and open surgical management was necessary to remove all fragments from the renal pelvis, the ureter and the bladder. Occlusion, encrustration and migration are among the most frequent risks of ureter stenting. The breakage of the stent, however, is a rare but severe complication. Therefore, patients should generally be controlled by sonography every 2 months and when malfunction of the stent is suspected, a cystogram should follow. In general, a stent exchange should be performed after 12 months.

Hyperthermia in eccentrically located pelvic tumors: excessive heating of the perineal fat and normal tissue temperatures.

Regional hyperthermia in deep-seated tumors can be limited by excessive heating of normal tissues, usually associated with pain or local discomfort. In this report, 57 hyperthermia treatments in 8 patients with locally advanced presacral recurrences of colorectal cancer were analyzed with respect to normal tissue temperatures, especially with respect to the perineal fat temperature. In 27 treatments, 1 to 2 catheters had been inserted from the perineal region through a large part of the perirectal and presacral fat into the tumor, so that temperature profiles of the perineal fat could be obtained. The mean maximum temperature (+/- SD) of the vagina, rectum, bladder, muscle tissue, and perineal fat was 40.8 +/- 1.2 degrees C, 40.9 +/- 1.6 degrees C, 40.5 +/- 1.6 degrees C, 39.8 +/- 0.7 degrees C, and 42.6 +/- 1.1 degrees C, respectively. The mean maximum systemic temperature (+/- SD) was 37.7 +/- 0.7 degrees C. In 42% of the treatments, the temperature in the perineal fat ranged between 43 and 46 degrees C and was treatment-limiting. In conclusion, overheating of the perineal fat is a problem in the treatment of eccentrically located tumors of the presacral region when relatively high temperatures in the tumor will be maintained for longer time periods.

Prenatal diagnosis and postpartal therapy of fetal obstructions related to the urinary tract.

114 fetal malformations were diagnosed by ultrasound in the years 1983-1987 at our institute. 32 of these malformations involved the urinary tract. Fetuses with multicystic dysplasic kidneys and oligohydramnios have only a poor prognosis. In obstructive uropathy, however, exact antenatal diagnosis makes early leads to specific postpartal urological therapy. Modern ultrasound equipment makes it possible to localize the site of obstruction and/or dilatation in fetuses. The amount of amnion fluid indicates the degree of obstruction and is an important factor the postpartal prognosis of the children. Relieve of obstruction should be the first step of urological therapy directly after birth. We prefer to perform reconstructive surgery as soon as possible in the first 2 to 3 weeks of life. In children with subpelvic stenosis pyeloplasty is performed in the first weeks of life. Our results of 13 pyeloplasties in newborn are favourable. In children with megaureters dynamic scintigraphy or pressure flow studies (Whitaker test) are performed to diagnose or to exclude obstruction as a cause of dilatation (n = 14). In case of obstruction we perform an ureterocutaneostomy (Ring- or Sober procedure) immediately. Urethral valves causing subvesical obstruction could be treated by transvesical antegrade valve ablation, performed in 9 newborn with good success.

[Sonographic imaging of the kidney cavity system using a ultrasonic contrast medium]. / Sonographische Darstellung des Nierenhohlsystems mit einem Ultraschallkontrastmittel.

The echo contrast solution SH U 454 was injected through an ureteral stent into the upper urinary tract ex vivo in human cadaver kidneys and in vivo in kidneys of pigs. Small amounts of this solution gave excellent echogenic contrast to demonstrate the renal pelvis and calices ultrasonographically in percutaneous examination and ex vivo sonography. This sonographic contrast agent promises to be useful for non-roentgenologic voiding cystograms and antegrade or retrograde pyelography.

[Progress in diagnosis of the urinary tract in children]. / Fortschritte in der Diagnostik am Harntrakt bei Kindern.

Ultrasound has enriched the armamentarium of the pediatric urologist. Miniprobes enable examination of preterm children without taking them out of the incubator. Special puncture needles facilitate percutaneous diagnostic procedures. A neonatal nephrostomy set was developed for temporary urinary diversion.

[Preoperative diagnosis of kidney cancers with involvement of the vena cava]. / Präoperative Diagnostik bei Nierenkarzinomen mit Befall der Vena cava.

85 patients with adenocarcinoma of the kidney were operated in 1982 and 1983. 9 patients showed a tumor thrombus extending into the renal vena and vena cava. Ultrasound examination of the retroperitoneal cava up to the liver veins was always able to diagnose the tumor thrombus and its cranial extension. If the end of the thrombus was visualised ultrasonographically below the diaphragma and confluence of the liver veins into the cava, no additional diagnostic procedure except intravenous urography was found to be necessary for planning operative treatment. Arteriography, cavography and computer scanning did not give additional information important for surgical intervention.

[Percutaneous demonstration of ectopic megaureters]. / Perkutane Darstellung ektoper Megaureteren.

Preoperative diagnosis of ectopic megaureter has become much simpler using percutaneous transvesical fine needle puncture of a sonographically visible retrovesical megaureter. Antegrade ureterography using watery contrast material together with indigocarmine dye was able both to demonstrate the megaureter roentgenologically and to help finding the ectopic orifice by direct vision or colposcopy in three girls.

[Complications of percutaneous nephropyelostomy with special reference to the sonographic real-time puncture technic]. / Komplikationen der perkutanen Nephropyelostomie unter besonderer Berücksichtigung der sonographischen Real-time-Punktionstechnik.

99 ultrasonographically-guided percutaneous nephropyelostomies (PNP) were done in 77 patients. Average age at operation was 60 years, most often PNP was done in cancer patients. In 26 cases compound-scanning technique and in 73 cases real-time technique was used. Real-time ultrasound imaging of the kidney is superior to compound-scan technique and allows dynamical imaging of percutaneously introduced canulas. Thus guidance of puncture technique and security of reaching the calix system have been optimized. Correct placement of nephrostomy catheter was achieved in 88.5% using compound-scanning technique compared to 92% using real-time ultrasonography. Moreover puncture of the calix system by needle was successful in every case using real-time ultrasonography. Complication rate was 2%. In one patient the calix system was perforated and one with macrohematuria required open surgery. Real-time ultrasound technique enables us to perform controlled percutaneous nephropyelostomy easily without hazardous complications.