[Preoperative imaging in 78 living kidney donors using CE-MRA and DSA]. / Donor-Evaluation vor Lebendnierenspende: Vergleich von CE-MRA und DSA an 78 Patienten.

PURPOSE: To evaluate contrast-enhanced 3D magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) in comparison with the intraoperative findings in living kidney donors. MATERIALS AND METHODS: A total of 156 kidneys in 78 potential kidney donors were prospectively examined using CE-MRA (0.2 mmol Gd/kg, voxel size 1.3 x 0.8 x 2.0) and DSA. Two experienced radiologists assessed the images in consensus regarding the renal vascular anatomy and variants. The results for the 67 candidates accepted for donation were compared to the intraoperative findings. In the other kidneys not accepted for donor nephrectomy, MRA and DSA were compared with each other. RESULTS: Nineteen arterial variants were identified intraoperatively, of which 11 (58%) were also detected by preoperative CE-MRA and 10 (53%) by preoperative DSA. Of the 10 venous variants found intraoperatively, CE-MRA detected 8 (80%) and DSA 3 (30%). The agreement (kappa test) between MRI and DSA for all 156 evaluated kidneys was 0.7 for arterial variants (McNemar p=0.12) and 0.3 for venous variants (McNemar p=0.01). The preoperative choice of kidney (right or left) made on the basis of the renal vascular anatomy seen on CE-MRA and DSA differed in 22% of the 78 potential donors (McNemar p=0.3). CONCLUSION: Our results in a large group of potential living kidney donors suggest that CE-MRA and DSA are comparable for detecting arterial renal variants while CE-MRA is superior for identifying venous variants. The preoperative choice of transplant kidney was not significantly influenced by the different results of CE-MRA and DSA.

[Urological problems in patients with meningomyelocele. Diagnostic studies and management]. / Urologischer Erkrankungen bei Patienten mit Meningomyelozele. Diagnostik und Management.

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

Laparoscopic versus open donor nephrectomy in Germany: impact on donor health-related quality of life and willingness to donate.

INTRODUCTION: Laparoscopic living donor nephrectomy (LDN) offers multiple advantages to the donor. Since 1999 LDN has become the only surgical approach for living kidney donation in our department. To our knowledge a donor health-related quality of life (QoL) has not yet been performed with standardized and validated questionnaires to compare laparoscopic with open nephrectomy. We therefore performed a study with two questionnaires (SF-36/GBB-24) and one set of open questions for all donors in our department. METHODS: Questionnaires were sent out to all donors between 1983 and 2001 with at least a 1-year follow-up. To exclude a bias a maximum response rate was sought; donors who did not answer were recontacted as well as their recipients or their physicians to motivate them for participation. RESULTS: The response rate was (89.8%). Except for less limb pain in the laparoscopy group, no difference could be detected for donors QoL with respect to the surgical method. Willingness to donate again was not affected by the surgical method. Nevertheless if asked again today, most donors want laparoscopic kidney retrieval. CONCLUSIONS: Donors health-related QoL is not affected by the surgical method when queried retrospectively. Nevertheless, most donors today would favor laparoscopy, if they could chose again. How laparoscopy affects a reluctant donor to step forward must be determined in a prospective study.

[Eugen Rehfish--pioneer of modern urodynamics]. / Eugen Rehfisch-Pionier der modernen Urodynamik.

Eugen Rehfisch published two important articles on vesical sphincter function and innervation of the bladder in the Archives of Pathologic Anatomy, Physiology and Clinical Medicine edited by R. Virchow in 1897 and 1900. A figure from his first urodynamic article (1897) became well known in the urodynamic literature. It shows the first simultaneous registration of vesical pressure and urinary volume in a human. Eugen Rehfisch's ingenious experimental design for examining the process of micturition has remained to this day. For this reason, the board of the Forum Urodynamicum, a registered society in Germany, named its innovation prize donated by the Pfizer company after Eugen Rehfisch. Eugen Rehfisch was born in Kempen/Posen on March 6 1862. He studied at the Friedrich Wilhelms University in Berlin and at the Bavarian Julius Maximilian University in Wurzburg. From approximately 1889, he worked as a physician in Berlin and was a co-worker of Leopold Casper (1859-1959) for some time. He performed his important urodynamic studies at the Institute of Physiology of the Friedrich Wilhelms University between 1896 and 1900. After this, he turned to cardiology. Besides articles on urology, he published papers on psychiatry and cardiology. He was an active member of medical societies in Berlin and was awarded the title of a professor. Eugen Rehfisch died on October 7, 1937 in Berlin. His grave is in the cemetery of the Jewish congregation in Berlin Weissensee. The Eugen Rehfisch innovation prize is an expression of our admiration.

[Bladder dysfunction and surgery in the small pelvis. Therapeutic possibilities]. / Blasendysfunktion und Operationen im kleinen Becken.Therapiemöglichkeiten.

The more extensive a surgical procedure in a small pelvis, the higher the risk for the lower urinary tract with its nerve supply and nerve plexus. This concerns mainly the sympathetic chains, the parasympathetic structures and, rarely, the visceral supply of the pelvic floor. Direct trauma to the bladder and its vascular supply as well as indirect injury by displacement of the bladder need to be seriously considered. Problems with micturition and impaired storage capacity of the bladder are the result. Complete urodynamic examination and follow-up can help in differentiating between temporary and persisting disturbances and in taking therapeutical decisions. The most evident postoperative complication is disturbed micturition, managed initially by suprapubic urinary diversion, followed as soon as possible by intermittent self-catheterisation. This is the only way to avoid overstretching of the bladder, recurring urinary tract infection and damage to the upper urinary tract. Restoration of spontaneous micturition can be supported by drug treatment with parasympatholytics and/or alpha-blockers if the measured bladder pressure and residual urine are within tolerable limits. For electrostimulation of micturition, intravesical therapy, although timeconsuming, is best suited because it can easily be done on an outpatient basis. More promising seems bilateral sacral neuromodulation, which, however, is a rather complicated and expensive procedure. Surgical procedures to reduce the voiding resistance of the bladder involve the risk of postoperative incontinence because the sphincter function in those patients is often disturbed too. Persisting problems with bladder storage capacity as a result of tumor surgery in the small pelvis are frequently secondary to retention of urine (overflow incontinence). In these cases, regular evacuation of the bladder by intermittent self-catheterisation can lead to social acceptance. Reduced bladder compliance and lowering of the urethral leak pressure point may result in stress and urge incontinence, which, according to the established rules, should be managed by physiotherapy and behaviour therapy as well as drug therapy and only in exceptional cases by surgical measures. Prevention of postoperative bladder dysfunction can be tried by tissue- and nerve-sparing surgical techniques, but is always determined by oncological aspects.

[Overactive bladder--which diagnosis investigations are necessary before initiating primary treatment?]. / Die überaktive Blase ("Overactive Bladder Syndrome"). Welche Diagnostik ist vor Beginn der Primärtherapie notwendig?

The symptom complex of frequency and urgency with or without urge incontinence is termed overactive bladder (OAB) according to the new definition by the International Continence Society. The background for this change in definition is the great economic and social importance of the disease, the rising costs in medicine, and the tendency to develop the simplest possible therapeutic strategies. Therapy consists of the administration of an anticholinergic/spasmolytic drug for at least 3 months. Although a great percentage of patients with OAB can be clinically identified, the required exclusion of "local pathologic and metabolic factors" calls for a minimal diagnostic program to come to fairly exact findings. This includes a detailed case history with standardized and evaluated questionnaires, a bladder diary, detailed clinical examination, urine analysis consisting of microscopic and microbiologic examination, uroflowmetry including measurement of residual urine, and examination of the kidneys and the upper urinary tract (determination of creatine and sonography). Minimally invasive tests to improve validity regarding obstruction and detrusor overactivity are being developed. These tests are intended to make an invasive pressure-flow study unnecessary. However, using the above-described minimal diagnostic program, one has to take into account that patients suffering from complaints without underlying idiopathic detrusor overactivity and with urgency/urge incontinence due to bladder outlet obstruction are referred for primary therapy with anticholinergic/antispastic drugs. In cases of neurologic signs, pathologic urinary findings, reduced urinary flow rate with residual urine, and problems of the upper urinary tract, further diagnostic studies are necessary. In any case, such patients need not undergo primary therapy on the basis of a clinical diagnosis. An ex iuvantibus therapy with anticholinergic drugs--even if limited to 3 months--is not acceptable if the diagnostic minimal program is not used.

[Therapeutic possibilities in functional disorders of micturition]. / Therapiemöglichkeiten bei funktioneller Blasenentleerungsstörung.

Functional voiding disturbances can be due to failure of the detrusor or to discoordinated sphincter function during micturition. Therapeutical options are directed either to strengthening the contraction up to an adequate magnitude or to lowering the voiding resistance or can be aimed at influencing both. In a brief survey mechanical, pedagogical, electrotherapeutical, and surgical measures as well as drug treatment are critically examined. Conservative methods should always be attempted before surgical procedures are performed. Depending on the degree of severity and the etiology of the disease, a combined therapy can be useful. In the case of resistance to therapy, intermittent autocatheterism is to be preferred to permanent deviation via an indwelling catheter.

[Laparoscopic diagnosis and therapy of cryptorchism]. / Laparoskopische Diagnostik und Therapie beim Kryoptorchismus.

Between May 1987 and December 1991, laparoscopy was performed in 33 selected children with 40 nonpalpable testes, to localize the testes. Of 40 testes sought, 16 were present (14 intra-abdominal and 2 inguinal), and in 24 cases testicular aplasia was verified. The authors describe the technique of laparoscopy for unilateral and bilateral undescended testes. Exact anatomical localization of the testes by laparoscopy facilitated accurate planning of operative repair. The advantages of laparoscopy compared with ultrasound and MR imaging in 14 selected patients are described. In 3 patients with an intra-abdominal hypoplastic testis we performed laparoscopic orchiectomy. This new operative procedure is described. Laparoscopic orchiectomy is minimally invasive, offering a practicable alternative to orchiectomy in the case of an atrophic or hypoplastic abdominal testis. No complications were noted.

[Diagnostics of functional bladder disorders in children]. / Abklärung kindlicher Blasenfunktionsstörungen.

Functional bladder disorders are one of the most frequent urinary disorders in children. Today, we strictly differentiate enuresis from pediatric urinary incontinence. In most cases, these classifications will be achieved with non-invasive, primary diagnostic procedures. In monosymptomatic enuresis, further invasive examinations are not necessary. However, in pediatric urinary incontinence invasive diagnostic tools such as video-urodynamic studies are mandatory for a correct classification. Recently established guidelines on the diagnostic procedures for the evaluation of pediatric bladder disorders will help to standardize the diagnostic work-up.

[Experiences with laparoscopic lymphocele drainage]. / Erfahrungen mit der laparoskopischen Lymphozelendrainage.

Lymphoceles are among the most frequent surgical complications of pelvic surgery. In ten patients with large lymphoceles in the pelvis after successful kidney transplantation or radical suprapubic prostatectomy we performed laparoscopic drainage of the lymphocele. Laparoscopic windowing of lymphoceles is a safe, minimally invasive form of treatment and a successful alternative to open surgical marsupialization, percutaneous puncture or external drainage of the lymphocele.

[Laparoscopic radical prostatectomy. Experiences with 145 interventions]. / Die laparoskopische radikale Prostatektomie. Erfahrungen mit 145 Eingriffen.

Encouraged by the groups in Paris, we performed 145 laparoscopic radical prostatectomies between June 1999 and the end of November 2000. The indication for laparoscopic prostatectomy is the same as for open surgery: an organ-confined cancer. Previous abdominal surgery, transurethral resection, and/or relative adiposity are not considered to be contraindications for this laparoscopic procedure. The mean operating time was 255 min; the last 60 procedures took an average of 200 min. In no case was it necessary to convert to open surgery. Worthy of note was the low blood loss of 185 ml on average so that in 98% of the patients no blood transfusion was required. After completing the learning curve, the average indwelling catheter time was only 5.5 days. The postoperative complication rate was 11.7%, consisting mainly of minor complications. Also with regard to continence and potency, the results were representative. Postoperatively, 75%, 86%, 92%, and 93% of the patients were continent after 3, 6, 9, and 12 months, respectively. In our opinion, laparoscopic radical prostatectomy is an alternative to open prostatectomy, offering a number of advantages for the patient and surgeon as well.

[Kidney donors and kidney transplantation in the elderly]. / Nierenspende und Nierentransplantation im Alter.

The likelihood of terminal renal insufficiency escalates with age, increasing the risk of dying as a patient requiring dialysis. In 1999, Eurotransplant initiated the Eurotransplant Senior Programm (ESP), in which the kidneys of old donors (>64 years) are allocated to recipients 64 years and older. Allocation does not take HLA-matching into account and is performed regionally only according to blood-group-compatibility to keep the storage time short. As a consequence of the short ischemic time, and thus reduced non-immunological damage to the anyways susceptible old kidney, graft-function and graft-survival in the ESP are very good. The results of the initial 5 years of this program show that it successfully utilizes more kidneys from old donors and that more old recipients are being transplanted, with a satisfactory graft-function. Increased donor- and/or recipient age require a thorough evaluation to exclude malignant and other diseases. Furthermore, short term controls on the waiting list and following kidney transplantation are prerequisites for successful transplantation in the aged recipient. If this is guaranteed, kidney transplantation in the old recipient-even with old donor organs-is a good alternative to the morbidity of a prolonged dialysis. Nevertheless, the role of HLA-matching should be reconsidered to reduce rejections.

[Laparoscopic dismembered pyeloplasty with Anderson-Hynes technique]. / Die laparoskopische Nierenbeckenplastik mit Kontinuitätstrennung nach Anderson-Hynes.

Because of the minimal invasiveness of the laparoscopic approach, we introduced the laparoscopic dismembered pyeloplasty in our treatment modalities for patients with primary UPJ obstruction. We report on our technique and the results after a median follow-up of more than 2 years. Between August 1997 and September 2002, 52 patients underwent a laparoscopic dismembered pyeloplasty at our institution. All patients had a symptomatic primary PJ obstruction. We prefer the transperitoneal route with laterocolic exposure of the kidney. After preparation and exposure of the ureter and the renal pelvis, we performed in each case the dismembered Anderson-Hynes pyeloplasty with resection of the pelvis and reanastomosis between the ureter and renal pelvis. Intracorporeal suturing and knotting techniques were used exclusively. All procedures could be performed successfully. In no case was conversion to open surgery necessary. The mean operative time was 180 min. Crossing vessels were present in 57% of patients. The mean postoperative hospital stay was 4 days. The first patient had an anastomosis insufficiency, which required laparoscopic repair. The same patient failed in the follow-up. He developed a late recurrence of the stenosis and needed an open repair. In all other patients the obstruction was resolved or significantly improved. The long-term success rate is 98% with a follow-up of 25 months. Our results with laparoscopic dismembered pyeloplasties compare favorably with those achieved by open pyeloplasties with less perioperative morbidity and discomfort. We do believe that laparoscopic dismembered pyeloplasty will be the method of choice in the treatment of UPJ obstruction.

[Laparoscopic living donor nephrectomy of kidneys with multiple renal vessels]. / Multiple Nierengefässe bei der laparoskopischen Lebendnierenspende.

Due to the increasing waiting time for transplantation of a cadaveric kidney, living donor kidney transplantation is an increasingly oncoming issue. Laparoscopic donor nephrectomies (LDN) have been performed since 1995 and presently more than 100 transplant centers offer this minimally invasive surgical approach. The advantages for the donor of less pain, shorter hospital stay, earlier return to work, better cosmetic results in combination with an organ function equal to open donor nephrectomy are the reasons for an enormous increase in LDN. Since up to 30% of the donor kidneys have multiple vessels for blood supply, an increase of these organs for LDN can be expected. We performed a retrospective study of LDN at our center and compared donors with multiple vs single vessel supply. From February 1999 to September 2002, 63 LDN were performed at the department of Urology, Charité University Hospital, Berlin. A comparison between 18 donor kidneys with multiple vessel supply and 45 donor organs with single vessels showed no difference for the time of laparoscopic explantation (207 vs 201 min, p=0.4) or the warm (166 vs 148 s, p=0.2) and cold ischemic times (117 vs 103 min, p=0.66). As could be expected, the mixed ischemic time, i.e., the time for anastomosis of the kidney with the recipient's vessels, showed a significant difference (53 vs 46 min, p=0.02). Intra- and postoperative complication rates for donors and recipients were not different in both groups. Laparoscopic donor nephrectomy for kidneys with multiple vessels is feasible and safe for donor and recipient.

[Laparoscopic radical cystectomy with intracorporeal creation of a continent urinary diversion. Future or present?]. / Laparoskopische radikale Zystektomie mit intrakorporaler Anlage einer kontinenten Harnableitung. Zukunft oder Gegenwart?

Once laparoscopic radical prostatectomy has been mastered, the step to performing a radical cystectomy is not that far. The challenge is to create the urinary diversion by laparoscopy. In this report we describe our experience with 11 laparoscopic radical cystectomies and intracorporeal construction of a continent urinary diversion (Mainz pouch II) as a treatment option in patients with muscle-invading bladder cancer. All 11 procedures could be performed successfully. A conversion to open surgery was not required in any case. The mean surgery time was 6.7 h. Except for two pouch fistulas we did not observe any intra- or postoperative complications. The functional as well as the oncological results are convincing. Less morbidity and faster recovery are the main advantages of this minimally invasive procedure. In addition, the low levels of blood loss, fluid shifts, and electrolyte loss considerably reduce cardiovascular stress. Radical cystectomy and construction of a continent urinary diversion represent the limit of technically feasible laparoscopy and should be done exclusively in specialized centers.