[HIFU in urological oncology]. / HIFU in der Uro-Onkologie.

The growing interest in high-intensity focused ultrasound (HIFU) technology is mainly due to its many potential applications as a new energy source and as noninvasive therapy. It has been introduced to urological oncology as a transrectal treatment for prostate cancer and as extracorporeal treatment for kidney cancer. Although its application in the kidney is still at the clinical feasibility phase, HIFU technology is currently being used in daily practice in Europe for the treatment of prostate cancer. Reports in the literature describing results of HIFU for prostate cancer are mainly based on monocentric, prospective clinical studies. The latest published results suggest that HIFU treatment is a valuable option for well-differentiated and moderately differentiated tumors, as well as for local recurrence after external beam radiation. Two different devices for transrectal treatment of prostate cancer are available, which are essentially different in technology, application mode, published results, and side effects.HIFU in locally recurrent cancer after surgery, as well as adjuvant HIFU for local debulking in locally advanced or metastatic disease, shows promising first results for reducing local disease-induced morbidity and for delay of progression.

[Local recurrence of prostate cancer after curative therapy. HIFU (Ablatherm) as a treatment option]. / Das Lokalrezidiv des Prostatakarzinoms nach kurativer Therapie. Therapieoption HIFU (Ablatherm).

In terms of effectivity and impact, no ideal approach is as yet available for treatment of local recurrence of prostate cancer. We direct our attention mainly toward high-intensity focused ultrasound (HIFU). HIFU therapy (Ablatherm) is only performed in our department when the following criteria are met: the recurrent tumor must be visualizable with imaging procedures (for HIFU, transrectal ultrasound is employed), the tumor must be accessible to the scanner head (penetration depth: 25 mm), and finally the diagnosis of recurrent tumor has to be histologically confirmed. An indisputable advantage of HIFU is the option of easily administering HIFU therapy for a second time in the presence of tumor remnants or in the event of cancer recurrence. Depending on the primary cancer treatment given, salvage HIFU achieves a biopsy-proven tumor-free state in 60-74% of patients. These results are in line with those that can be obtained with other salvage strategies (radical prostatectomy, radiation therapy). However HIFU shows reduced postoperative morbidity with less side effects.

[Shock wave lithotripsy in Germany: Results of a nationwide survey]. / Stoßwellenlithotripsie in Deutschland: Ergebnisse einer deutschlandweiten Umfrage.

BACKGROUND: Following its introduction in the 1980s extracorporeal shock wave lithotripsy (SWL) became the gold standard for therapy of ureteral and renal calculi. The research data published during the last decade suggest a paradigm shift to endourological techniques. OBJECTIVES: The purpose of this study was to compare whether the suggested loss of status for SWL corresponds with actual real-life treatment in Germany. A further aim was to assess the quality of SWL therapy in German hospitals. MATERIALS AND METHODS: The board of the German Society for Shock Wave Lithotripsy (DGSWL) sent a questionnaire to 306 urological departments in Germany, which encompassed medical, technical and organizational topics in the therapy of ureteral and renal calculi. A total of 99 (33%) questionnaires were returned. CONCLUSION: With the exception of a few departments, non-invasive SWL still plays a major role in the treatment of urolithiasis and a loss of the gold standard status is not in sight. The performance of SWL in German hospitals is carried out at a high level of quality. To maintain and optimize this status a structured SWL training and adherence to clinical practice guidelines are needed.

Xenogeneic skin and kidney transplants in a closely related canine system, fox-dog.

Fox kidney and skin grafts were transplanted into dog recipients. Fox kidneys, transplanted en bloc into untreated dogs, survived 6.2 +/- 0.4 days. The skin transplants survived 5.9 +/- 1.4 days. The grafted kidneys showed almost normal function before rejection. Both skin and kidney rejection were mediated through a cellular mechansim. Performed natural antibodies against donor tissue were not present in the serum of the recipients. These results combined with absorption studies suggested a close relationship between fox and dog, but different number and morphology of chromosomes, immunoelectrophoretic patterns of serum proteins, and disparities of the transplantation antigens proved that the fox is a species quite separate from the dog. It was concluded that the fox-dog system, with its similarity to the chimpanzeeman relationship, offers a unique model to study clinically applicable methods of managing xenografts between closely related species.

Treatment of ureteral calculi by extracorporeal shock-wave lithotripsy. UCLA experience.

One hundred sixteen patients underwent extracorporeal shock-wave lithotripsy (ESWL) for ureteral stones. In 108 patients, the stones were manipulated pre-ESWL whereas 8 patients underwent ESWL without prior stone manipulation. Ureteral lubrication using a 2% Xylocaine jelly solution greatly facilitated the retrograde advancement of the calculus or the passage of ureteral catheters alongside the stone. ESWL disintegrated all but 4 stones for an overall success rate of 96.6 per cent. It is considered that the combination of retrograde ureteral stone repositioning and ESWL is a highly successful alternative in the management of ureteral calculi.

Transurethral ultrasonic ureterolithotripsy using a solid-wire probe.

A multicenter study evaluates a new technique for transurethral ultrasonic ureterolithotripsy utilizing a solid-wire probe. The transverse vibrations of the probe cause greater stone disintegration. A small ureteroscope is used and a basket is not required. There was a 96.6 per cent success rate in 118 cases. This technique has significantly improved ultrasonic lithotripsy. It has proved to be useful for upper ureteral stones not amenable to extracorporeal shock-wave lithotripsy and lower ureteral stones including "steinstrasse."

Extracorporeal shock-wave lithotripsy (ESWL) for treatment of urolithiasis.

We present our experience with extracorporeal shock wave lithotripsy (ESWL) and the new therapeutic aspects it has generated. The current state of technology also will be discussed.

Shock wave treatment for stones in the upper urinary tract.

The authors report on their clinical experience in the use of extracorporeally generated, focused shock waves in the treatment of stone disease in the upper urinary tract. Generation of shock waves, arrangement of equipment, treatment, results, and indications are discussed.

Results and side effects of high-intensity focused ultrasound in localized prostate cancer.

At the time of diagnosis, prostate cancer is organ confined in 70% of the cases. A quarter of these patients undergo local therapy (surgery/radiation); 75% risk disease progression by "watchful waiting" or systemic side effects through hormonal ablation. Local high-intensity focused ultrasound (HIFU), as minimal invasive tissue coagulation (85 degrees C), ablates prostatic tissue with high precision. Since April 1996, 184 patients have undergone 232 sessions of transrectal HIFU therapy (average 90 min) under spinal anesthesia at 2.25/3.0 MHz, 50 W, and a penetration depth of 25 mm. The follow-up serum prostate specific antigen (PSA) concentration, sextant biopsies, International Prostate Symptom Score (IPSS), quality of life measures (QoL), and complaint registration provide the foundation for this clinical evaluation. Follow-up sextant biopsies (an average of 1.9) showed 80% of the patients to be cancer free. In men with residual cancer, the tumor mass was reduced more than 90%. The PSA nadir in 97% was <4 ng/mL, including 61% with values <0.5 ng/mL. After primary HIFU, no severe side effects (fistula, second or third grade incontinence, rectal mucosal burns) occurred. All patients had a suprapubic tube (average 29 days), and 33% needed a transurethral debris resection averaging 7 g. They were discharged within 23 hours. According to the short-term follow-up transrectal HIFU enables minimal invasive local prostate tissue ablation with high rates of negative biopsies, low PSA nadir, and low complication rate.

High-intensive focused ultrasound in localized prostate cancer.

BACKGROUND AND PURPOSE: The results of the standard treatment for prostate cancer-radical prostatectomy-are not entirely satisfactory. A new local therapy, transrectal high-intensive focused ultrasound (HIFU), has been developed. We reviewed our experience with HIFU for palliation of localized prostate cancer. PATIENTS AND METHODS: Our series included 65 men with confirmed prostate cancer without detectable metastases who were not suitable candidates for radical prostatectomy. After prophylactic suprapubic cystostomy, the patients were treated using the Ablatherm version 2.32 under spinal anesthesia. The effects were monitored by serum prostate specific antigen assays, digital rectal examination, and biopsy. The mean follow-up is 10 months (range 1-18 months). RESULTS: There were no intraoperative or postoperative deaths, and there have been no deaths from prostate cancer. Residual cancer was detected in 35% of the patients in whom only biopsy-positive portions of the prostate were treated and 17% of those in whom the entire gland was treated. Retreatment was performed 1 month after the first session in these patients. The prostate volume increased an average of 30% after treatment, but by 3 months, the gland was 10% to 20% smaller than its original size. Three patients suffered complications secondary to overheating of the rectal wall or treatment too close to the external urethral sphincter. CONCLUSION: The low morbidity, minimal invasiveness, avoidance of systemic side effects, and potentially curative effect make HIFU a potentially useful option for the treatment of localized prostate cancer.

First clinical experience and in situ treatment of ureteric stones using Lithostar Multiline lithotripter.

This article reviews the first experience using the Siemens Lithostar Multiline lithotripter in 372 consecutive treatments of ureteric and kidney stones. The disintegration rate was 97.7%, and a stone-free rate of 87% was achieved at the end of 3 months. Auxillary procedures were required in only 11% of the patients. No medication was required for pain management in 60.4% of the patients. The results were especially impressive in the management of ureteric stones, with a success rate of 91%, these patients being stone free after 1 week using the new booster technique. Analysis of the data indicates that the Siemens Lithostar Multiline is a safe, effective, and economically sound device to treat patients with ureteric and renal stones.

Side effects of high-energy shockwaves in the human kidney: first experience with model comparing two shockwave sources.

The side effects of high-energy shockwaves (HESW) from two different sources on kidney parenchyma obtained from 10 patients treated by radical nephrectomy for renal cell carcinoma were examined. Immediately after nephrectomy, the kidneys were perfused with cold HTK solution and kept in hypothermia (8 degrees C) for a maximum of 4 hours. In five cases, the tumor-free parenchyma was treated at the upper or lower renal pole with 2000 shocks, energy output 21 kV, in an experimental electromagnetic shockwave system (Siemens Co., Erlangen). In the other five cases, the upper or lower poles were treated with 2000 shocks, energy output 24 kV, in an electrohydraulic spark gap system (MFL 5000; Dornier Medizintechnik, Germering). The resulting tissue defects were analyzed by histologic examinations. Changes after treatment with the electromagnetic system were found mainly in the tubules and midsized blood vessels in a well-defined focal area. Treatment with the electrohydraulic system was followed by tubular and glomerular lesions combined with vessel defects in a patchy pattern. The model is able to define the side effects of HESW in the human kidney and to test the side effects of different lithotripters.

[Renal perfusion during experimental hyper-acute rejection. 133-xenon perfusion compared with microscopy and angiography (author's transl)]. / Nierenperfusion bei hyperakuter xenogener abstrssung im Tierversuch. 133-Xenon-Durchblutung im Vergleich zur Mikroskopie und Angiographie.

Twenty-two cat kidneys and 11 pig kidneys were incorporated into canine circulatory systems. The delayed hyper-acute and hyper-acute rejections produced by these models were studied with respect to blood flow and blood distribution with an intra-arterial 133-xenon wash-out technique at intervals of 7-30 minutes until the death of the kidney at 40 minutes to twelve hours. In addition, magnification angiograms and serial cortical biopsies were obtained for continuous histological study of the rejection phenomenon. At the beginning of the rejection process, there is a reduction in blood-flow through the cortex. During delayed hyper-acute rejection, cortical flow could no longer be demonstrated 180 minutes after the period of flow maximum. After A.L.G. treatment of dogs, rejection could be delayed for ten to twelve hours. Magnification angiograms showed characteristic changes consisting of irregular segmental and interlobar arteries, occlusion of small cortical vessels and focal contrast accumulation in the renal cortex. The changes in blood-flow and blood distribution measured with 133-xenon and the vascular findings on the angiogram could be correlated with the microscopic findings. Serial estimations of blood flow and blood distribution with the xenon blood wash-out technique permit differentiation between shock kidney and rejection following renal transplantation.

[Changes in perfusion and blood flow distribution following normo- and hypothermic ischemia of the kidneys]. / Anderung der Durchblutung und Durchblutungsverteilung nach normo- und hypothermer Ischämie der Nieren

Experimental examinations were performed in 22 dogs to find out the mechanism which leads to a permanent or a reversible damage of the renal parenchyma after normo- and hypothermic ischemia. For this reason the perfusion and the distribution were examined with 133Xe, the vascular changes by angiography, and the parenchymal function with 131I-Hippuran. After normothermic ischemia a short-term reactive hyperemia appeared, which however could not compensate the damage of the renal tubular cells and the resulting excretory insufficiency. After hypothermic ischemia the perfusion was reduced, probably as a consequence of a vasconstriction by cold, however, the function of the tubular cells remained intact, because of the protective mechanism of the hypothermia. The importance of these findings for the development of the so-called "shock-kidney" (acute tubular necrosis) and for the conservative renal surgery in hypothermia is discussed and the application of measures beneficial to perfusion, are suggested.

Mitigation of hyperacute rejection by antilymphocyte globulin (ALG).

In HR, primarily humoral immunologic factors trigger a sequence of events that finally destroys the transplanted organ. Unspecific trapping of WBC diminishes the RBF, especially in the first compartment--the cortex. Pretreatment with ALG is able to suppress this cellular participation partially, thus postponing the stop of RBF without preventing the influence of humoral factors on the graft. As shown by pathologic and functional criteria recorded for 8 hr, an exclusive measurement of total RBF does not reflect an inhibition of the course of HR.

Kidney transplantation following treatment with cyclophosphamide and bone marrow grafting.

Canine cyclophosphamide (CY) chimeras permanently accept kidney and skin grafts as do radiation chimeras. Three of five dogs with reversion of chimerism rejected their kidney grafts within 11-16 days, while two of them retained their kidney grafts permanently. These results suggest that the reversion of chimerism in CY chimeras may be due to different mechanisms, either immunologic rejection or a nonimmunologic substitution of the grafted marrow by the host's own hemopoiesis.

Extracorporeal shock-wave lithotripsy (ESWL) of kidney and ureteric stones.

A noninvasive method for the treatment of urolithiasis is described. By means of focussed shock waves generated outside the body, stones in the lower urinary tract are destroyed and rendered fit for spontaneous discharge. Thereby the number of operations, as well as the recurrence rate are substantially reduced.

[Therapy of local prostatic carcinoma with high intensity focussed ultrasound (HIFU). Outcome and side-effects]. / Therapie des lokalen Prostatakarzinoms mit hoch intensivem fokussiertem Ultraschall (HIFU). Ergebnisse und Nebenwirkungen.

At the time of diagnosis, prostate cancer is organ confined in 70% of the cases. Of these patients, 25% undergo local therapy (surgery/radiation), and 75% risk disease progression by "watchful waiting" or systemic side effects through hormonal ablation. Local high-intensity focused ultrasound (HIFU) for minimal invasive tissue coagulation (85 degrees C) ablates prostatic tissue with high precision. Follow-up sextant biopsies (1.9) showed 80% of the patients to be cancer free. In those cases with residual cancer, the tumor mass was reduced by more than 90%. The PSA nadir in 97% was < 4 ng/ml, including 61% < 0.5 ng/ml. After primary HIFU, no severe side effects occurred (no fistula, no grade II/III incontinence, no rectal mucosa burn). As auxiliary treatments, all patients received a suprapubic tube (29 days), and 33% needed a transurethral debris resection (TUR 7 g). The patients were released from the hospital within 24 h after treatment. According to the short-term follow-up, transrectal HIFU enables minimal invasive local prostate tissue ablation with high rates of negative biopsies, low PSA nadir, and low complication rate.

[Extracorporeal shock wave lithotripsy: the evolution of a revolution]. / ESWL: die Evolution einer Revolution.

Extracorporeal shockwave lithotripsy has now been in clinical use for 8 years, and it has replaced other treatment techniques for the majority of surgical calculi in the upper urinary tract. For the first time it provides a completely noninvasive method for the treatment of renal and ureteral calculi. The current range of indications means that approximately 70% of nonselected urinary stone patients can be treated by this method, while 25% of the patients with more complex stones in the upper urinary tract can receive treatment with the lithotripter combined with endourological procedures. The clinical role of this method is determined by a high success rate and minimal complications. This has led to a rapid worldwide acceptance in the urological community, and up to now more than 1.5 million patients with urinary stone disease have been treated.

[Experience with extracorporeal shockwave lithotripsy based on 5 years' clinical use]. / Erfahrungen mit der Extrakorporalen Stosswellenlithotripsie nach fünf Jahren klinischer Anwendung.

After 6 years of experimental research at the Departments of Urology and Surgical Research of the Ludwig-Maximilian University in Munich, extracorporeal shock-wave lithotripsy (ESWL) was introduced into clinical use in 1980. Uniquely successful and increasingly requested by stone patients, the method soon became widespread. Currently more than 70 lithotriptors are in operation worldwide and over 30,000 treatments have been carried out successfully. Clinical experience in all centers has proved the safety, reliability and reproducibility of the method. Currently, approximately 70% of nonselected stone patients are eligible to receive ESWL treatment and, when combined with endourological procedures, more than 95% of patients can benefit from this method and thus avoid open surgery.