[Rational imaging in locally advanced prostate cancer]. / Sinnvolle bildgebende Diagnostik des lokal fortgeschrittenen Prostatakarzinoms.

Prostate cancer is one of the principal medical problems facing the male population in developed countries with an increasing need for sophisticated imaging techniques and risk-adapted treatment options. This article presents an overview of the current imaging procedures in the diagnosis of locally advanced prostate cancer. Apart from conventional gray-scale transrectal ultrasound (TRUS) as the most frequently used primary imaging modality we describe computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). CT and MRI not only allow assessment of prostate anatomy but also a specific evaluation of the pelvic region. Color-coded and contrast-enhanced ultrasound, real-time elastography, dynamic contrast enhancement in MR imaging, diffusion imaging, and MR spectroscopy may lead to a clinically relevant improvement in the diagnosis of prostate cancer. While bone scintigraphy with (99m)Tc-bisphosphonates is still the method of choice in the evaluation of bone metastasis, whole-body MRI and PET using (18)F-NaF, (18)F-FDG, (11)C-choline, (11)C-acetate, and (18)F-choline as tracers achieve higher sensitivities.

[Overview and evolving strategies of ventral hernia repair]. / Narbenhernienchirurgie. Ubersicht und aktuelle Trends.

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with high morbidity and significant socioeconomic costs. Techniques for reinforcing and/or replacing the abdominal wall with alloplastic meshes have reduced the recurrence rate in comparison to suture techniques from about 40% to less than 10%. A number of mesh types and surgical repair procedures are available, namely the onlay, inlay, sublay, underlay, and intraperitoneal onlay mesh (IPOM) techniques. Evolving strategies include precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into the planning of the surgical approach. The authors herein present an overview of the current surgical trends, focusing on mesh reinforcement (sublay technique) and mesh replacement (IPOM technique). Additionally, they review a classification of incisional hernias that is self-explanatory, practicable in routine clinical practice, and based on the cornerstones of morphology, hernia size, and risk factors for recurrence. Evidence for the indications and limitations of the main surgical repair techniques are illustrated and discussed.

[MRI after renal transplantation with dysfunctional allograft: are there typical diagnoses in the early and late postoperative phases?]. / MRT bei Nierentransplantatdysfunktion: Gibt es typische Diagnosen im frühen und späten postoperativen Verlauf?

PURPOSE: The aim of this study was to evaluate the different MRI diagnoses in the early and late post-operative period after renal transplantation with dysfunctional allograft. MATERIALS AND METHODS: Due to unknown transplant dysfunction, 49 patients (30-male, 19 female) received a total of 74 MRI studies. According to the date of examination all MRI studies were divided in an early (< or = 60 days, ETP) and a late post-transplant time period (> 60 days, LTP). All MRI studies were performed on 1.5 T MRI systems using a standardised imaging protocol consisting of a morphological (pre- and post-contrast enhanced T (1)- and T (2)-weighted TSE sequences), a vascular (contrast-enhanced 3D MRA) and a urographical part (Flash 3D sequences). Frequencies of diagnoses in ETP and LTP, and diagnoses within each transplant time period were analysed. RESULTS: 44/74 MRI studies were performed in ETP, 30/74 in LTP. In total 80 diagnoses were obtained: Renal artery stenosis (ETP, n = 21; LTP, n = 5), renal vein stenosis (ETP, n = 2), renal vein thrombosis (ETP, n = 2), renal perfusion defect (ETP, n = 11), rejection (ETP, n = 1; LTP, n = 2), abscess (ETP, n = 1), urinary outflow obstruction (LTP, n = 4), without MRI pathology (ETP, n = 11; LTP, n = 20). Renal artery stenosis was the most prevalent diagnosis in ETP, and a more frequent finding in ETP compared to LTP (p < 0.05). Renal perfusion defects were more frequent in ETP than in LTP (p < 0.05). In the ETP vascular diseases (34/49 diagnoses) were more frequent (p < 0.05) than uropathological diseases (0/49 diagnoses). CONCLUSIONS: Our results indicate that vascular diseases are a more frequent occurrence in the early post-operative course after renal transplantation than uropathological diseases. However, a transplant follow-up MRI study needs to contain a morphological, vascular and functional imaging part to answer combined clinical questions.

[Antiphospholipid antibody syndrome: a priori a contraindication to kidney transplantation?]. / Antiphospholipidantikörpersyndrom: a priori eine Kontraindikation zur Nierentransplantation?

BACKGROUND: The antiphospholipid antibody syndrome (APLS) is characterised by the presence of antiphospholipid antibodies in association with thrombotic disorders of the arterial and/or venous system, spontaneous abortion and thrombocytopenia. Several studies have shown that end-stage renal disease patients with APLS are at extremely high risk for graft thrombosis and graft loss after kidney transplantation. MATERIAL AND METHODS: We report on the treatment and clinical courses of 6 APLS renal transplant patients. RESULTS: Of 3 patients treated with low-dose subcutaneous heparin two had early graft loss due to venous graft thrombosis; of those patients treated by systemic heparin (PTT goal 45-55 s) and followed by coumadin (INR 2.5-3.0) only one had early graft loss whereas 2 grafts are doing well 2 years post-transplant. CONCLUSION: Our experience as well as recently published data suggest that kidney transplantation can be performed successfully in APLS patients if anticoagulation therapy is performed consistently. A general APL antibody screening prior to kidney transplantation does not seem to be justified at present. A prospective, randomised multicenter study is warranted to evaluate the management of these patients with respect to intensity, type and duration of anticoagulation therapy.

The effect of enterocystoplasty on bone strength assessed at four different skeletal sites in a rat model.

The objective of the study was to investigate bone strength at four different skeletal sites in a chronic animal model of urinary diversion. Young male Wistar rats (120) were allocated randomly to four groups undergoing ileocystoplasty; ileocystoplasty and resection of the ileocecal segment; colocystoplasty; or sham operation (controls). After 8 months the lumbar vertebrae, femora, and tibiae were harvested at necropsy. Bone strength was assessed biomechanically at four different skeletal sites: vertebra L3, femoral middiaphysis, femoral neck, and distal femoral metaphysis. Bone mass and architecture were assessed using standard static histomorphometry of the proximal tibial metaphysis (trabecular bone volume [BV/TV]; trabecular number [Tb.N]) and ash weight. Statistically significant differences of biomechanical parameters between groups were observed at three skeletal sites with corresponding changes in tibial histomorphometry. Isolated ileocystoplasty resulted in decreased maximum load values of L3 (-16.4%; p < 0.0035) and a substantial reduction in tibial BV/TV (-34.7%; p < 0.05). Ileocystoplasty combined with resection of the ileocecal segment led to a significant loss of bone strength of L3 (-32.4%; p < 0.0015) and a dramatic reduction of tibial BV/TV (-45.9%; p < 0.01). Loss of tibial metaphyseal bone mass was predominantly caused by a decrease in Tb.N. (p < 0.01). Colonic augmentation had no significant effect on bone strength or histomorphometric values. In conclusion, this is the first experimental study to demonstrate the relevance of histomorphometrically proven bone loss after enterocystoplasty in terms of biomechanical variables.

Continent urinary diversion in preparation for renal transplantation: a staged approach.

BACKGROUND: We prospectively assessed the safety of kidney transplantation into continent urinary intestinal reservoirs as a planned two-stage procedure in patients with absent or dysfunctional lower urinary tract. METHODS: Between November 1990 and June 1999, 12 patients have undergone renal transplantation into continent urinary reservoirs, and a further patient with a diversion is awaiting transplantation. This was part of a larger series of 356 patients who had undergone continent diversions during that period. A further 174 patients (33%) had diversions into ileal conduits. FINDINGS: Within a mean follow-up of 26.1 months (5-72) after transplantation renal function was stable with serum creatinine values ranging from 0.9 to 1.8 mg/dl. There were 5 reoperations in the 12 patients (40%). Two patients needed their continence mechanism replaced. One had renal vein thrombosis with loss of the transplant. The cause for this was unknown but it had been speculated that it could have been caused by graft/body size disproportion. A second kidney was successfully transplanted after 12 months. Two further revisions were required for ureteric kinking and lymphocele. The patient with orthotopic substitution voids to completion. The other patients are continent day and night with easy catheterization. INTERPRETATION: This is one of the largest single series reported to date of renal transplantation into continent urinary diversions, and we commend the approach in carefully selected patients, but the difficulties must not be underestimated and the specific problems of intestinal urinary reservoirs have to be reckoned with. These procedures should be confined to centers with considerable experience with this type of surgery and its complications. Lifelong close surveillance is critical for the success of this concept.

The value of the MACE (Malone antegrade colonic enema) procedure in adult patients.

BACKGROUND: We report our experience with the Malone antegrade colonic enema (MACE) procedure in adult patients suffering from urinary incontinence and intractable constipation with or without fecal soiling. STUDY DESIGN: Since June 1990, the MACE procedure was initiated in 4 female and 12 male patients 14-54 years old (mean age, 29.9 years) with different pathologic conditions (myelodysplasia, n = 7; anorectal anomaly, n = 3; spinal cord lesion, n = 4; neuropathic disease of unclear cause, n = 2). Three surgical techniques were used: reversed and in situ appendix and tapered ileum). Complex simultaneous urologic continence procedures were performed in nine patients. Two patients had undergone previous operations in the lower urinary tract. RESULTS: After 6.6 years of followup (average, 41.7 months), eight patients (50%) were still using the MACE successfully. They were completely clean day and night and were relieved of symptoms of constipation. Eleven complications related to the MACE procedure occurred in seven patients (44%). Eight patients abandoned the procedure for various reasons. The failure rate was higher in chronically constipated patients without fecal soiling. CONCLUSIONS: The MACE procedure is associated with a high failure rate when used in adults, but it may be possible to identify a subgroup of patients in whom the procedure could be beneficial. Success would depend on overcoming technical problems and difficulties with patient compliance.

The influence of lymph node counts on the detection of pelvic lymph node metastasis in prostate cancer.

The present study was done to determine the influence of tumor stage and the patients' age on the number of pelvic lymph nodes obtained during standard pelvic lymphadenectomy before radical retropubic prostatectomy. Furthermore, we assessed whether the number of pelvic lymph nodes examined affects the sensitivity of pN-classification. The data of 283 consecutive patients who had undergone standardized open pelvic lymphadenectomy and radical retropubic prostatectomy for clinically organ-confined prostate cancer were reviewed retrospectively. There were striking interindividual differences in the number of lymph nodes (5-40; median: 16). The quantity was independent of pathologic tumor stage (pT) and the patients' age. In cases with 13 or more lymph nodes examined, the rate of metastatic involvement was twice as high as in lower lymph node counts. The detection of lymph node metastases--and consequently the prognostic accuracy of pN-classification--is mainly influenced by the total number of lymph nodes examined. These data suggest that at least 13 lymph nodes should be investigated to achieve optimum information.

Multiple (five) synchronous primary malignant neoplasms of dissimilar histogenesis including a malignant fibrous histiocytoma of the bladder.

A unique case was recently encountered involving the synchronous presentation of five primary malignancies of different histology. Malignant neoplasms of the colon, kidney, prostate and bladder were treated surgically. Bladder was affected by two separate tumours: a transitional cell carcinoma and a malignant fibrous histiocytoma. The latter constitutes an extremely rare malignant lesion of the organ. The pathologic characteristics, histogenesis, differential diagnosis and treatment considerations of this soft tissue sarcoma, and the incidence, terminology and incriminating factors of multiple primary malignant neoplasms, as well as their association with the genitourinary system are reviewed.

[Focal necrotising vasculitis of the testis. Testicular manifestations of immunologic diseases in differential diagnosis of testicular cancer]. / Fokale nekrotisierende Vaskulitis des Hodens. Testikuläre Manifestationen immunologischer Erkrankungen in der Differentialdiagnostik des Hodentumors.

We report on the case of a 31-year-old male patient with focal testicular vasculitis as the only clinical manifestation of endangiitis obliterans (Winiwarter-Buerger disease), who presented with acute scrotal pain and swelling suggestive of a testicular tumor. Doppler sonography revealed significantly increased vascularization at the borders of the lesion, which rather indicated a vascular process; however, the presence of solid areas meant that the possibility of testicular cancer could not be excluded. Left inguinal orchiectomy was performed. The surgical specimen revealed histological patterns compatible with endangiitis obliterans; Raynaud phenomenon was the only sign of systemic disease, and no other organs were found to be affected. Despite the high sensitivity and specificity of ultrasound/Doppler sonography, in the differential diagnosis of an unexplained testicular mass surgical exploration is still mandatory. The different types of focal vasculitis are described and discussed with reference to the literature.

[The effect of enterocystoplasty in childhood on linear growth]. / Längenwachstum nach Harnblasenaugmentation mit Darmsegmenten.

OBJECTIVE: The assumption that enterocystoplasty in children has a detrimental effect on linear growth has been based almost exclusively upon a chance finding in a retrospective study 10 years ago. We re-evaluated the same research question in a larger cohort and with a longer follow-up. PATIENTS AND METHODS: Between 1982 and 1997, 242 children and adolescents underwent enterocystoplasty. Patients with conditions involving organ systems apart from the urinary tract, and those with myelomeningocele, malignant diseases, reduced glomerular filtration rate and incomplete notes were excluded. In the definitive study cohort (123; mean age at operation 8.6 years; mean age at investigation 16.8 years), enterocystoplasty had been undertaken using colon in 70, ileum in 37, a combination of both in 11, ileocaecal segments in three and stomach in two patients. RESULTS: In all, 1215 height and weight measurements had been recorded. The distribution of percentile positions before and after enterocystoplasty showed a normal configuration, with 83 % and 80 % of patients growing within two standard deviations of the 50th percentile. After surgery, 85 % either remained the same or reached a higher percentile. Nineteen (15.5 %) were in a lower position, with a similar tendency in the weight percentile. A clinically relevant growth disorder was recognized in four patients with a complete endocrinological evaluation; in none of these was enterocystoplasty thought to be a causal factor. CONCLUSIONS: It is very unlikely that loss of the preoperative percentile position on the growth curve in 15 % of children after enterocystoplasty is a consequence of that particular surgery. Rather, it is a non-specific phenomenon that has to be considered in any clinical population of the same size and age distribution after the same length of time.

[Patients' acceptance of urinary diversion. The pouch of Sisyphus]. / Aspekte der Akzeptanz von Harnableitung: Der Pouch des Sisyphos.

It is important that any patient with a urinary diversion can accept the psychological impact alongside the surgical and physical aspects. However, there are currently no validated methods or instruments available to allow direct measurement of this phenomenon in these patients. Health-related quality of life (HRQoL) is often high following different types of urinary diversion-this may suggest a high acceptance level and thus may act as a secondary end point. Such an assessment is a retrospective validation of successful patient selection, allowing us to redirect the nihilistic misinterpretation that urologists should return to offering ileal conduits as a standard. In modern urinary diversion, high patient acceptance develops from comprehensive counselling providing a realistic expectation, careful patient-to-method-matching, strict adherence to surgical detail during the procedure and a meticulous lifelong follow-up. Coping strategies, disease-related social support and confidence in the success of treatment are among other factors which contribute to acceptance of urinary reconstruction as either independent or combined factors. Significant experience is required in every respect, as misjudgement and mistakes in any of these issues may be detrimental to the patients' health. It should be acknowledged that there is no 'best' urinary diversion in general terms. A reconstructive surgeon must have all techniques available and choices need to be tailored to the individual patient.

Urological complications of laparoscopic inguinal hernia repair: a case series.

OBJECTIVES: To illustrate urological complications of laparoscopic inguinal hernia repair and discuss their management. PATIENTS: Between April 2002 and February 2004, four men (aged 38-63 years) were treated for serious complications 2 days to 11 years after unilateral (1 patient) or bilateral (3 patients) laparoscopic inguinal hernioplasty. RESULTS: In all cases (extra and intraperitoneal bladder injury, purulent urocystitis due to mesh-erosion of the bladder, secondary retroperitoneal fibrosis) open revision with complete drainage of the urinary tract was chosen as an efficacious therapeutic strategy. CONCLUSIONS: Awareness of rare complications of laparoscopic inguinal hernia repair may lead to early diagnosis and appropriate management.

Nosocomial outbreak of VIM-2 metallo-ß-lactamase-producing Pseudomonas aeruginosa associated with retrograde urography.

Pseudomonas aeruginosa is well adapted to the hospital setting and can cause a wide array of nosocomial infections that occasionally culminate in recalcitrant outbreaks. In the present study, we describe the first nosocomial outbreak of infection caused by bla(VIM-2)-positive P. aeruginosa in Germany. In November and December 2007, highly resistant P. aeruginosa isolates were recovered from the urine of 11 patients in the Department of Urology of a University Hospital. Bacterial isolates were typed by multilocus sequence typing and screened for known metallo-ß-lactamase (MBL) genes by PCR. Environmental sources of transmission were tested for bacterial contamination using surveillance cultures. Furthermore, a matched case-control study was performed in search of medical procedures significantly associated with case status. Typing of recovered isolates confirmed VIM-2 MBL-producing P. aeruginosa of sequence type 175 in all cases. Surveillance cultures did not lead to the identification of an environmental source of the outbreak strain. Case-control analysis revealed retrograde urography as the only exposure significantly associated with case status. The analyses suggest the transmission of a single clone of VIM-2 MBL-producing P. aeruginosa leading to the infection of 11 patients within 47 days. Events in temporal proximity to retrograde urographies appear to have facilitated infection in the majority of cases. Department-specific infection control measures, including reinforced hygiene procedures during retrograde urography, quickly terminated the outbreak.

[Therapy of monosymptomatic nocturnal enuresis in childhood and adolescence: what is the evidence?]. / Therapie der monosymptomatischen Enuresis im Kindes- und Jugendalter--Was ist gesichert?

Nocturnal enuresis (bedwetting) is one of the most frequent urological symptoms in children, affecting about 20% of five year olds. It is a heterogeneous disorder with a whole variety of etiologic factors (genetic, endocrinological, neurobiological), particularly a dysfunction of the lower urinary tract. Despite the prevalence of enuresis many questions regarding the complex pathophysiological mechanisms remain unanswered. While nocturnal enuresis per se is clearly not a disease, psychosocial problems have been reported in up to 40% of affected children. Management strategies comprise behavioural and pharmacological approaches, either in isolation or combined. Although expectations were high, especially with pharmacological interventions, the results are usually disappointing with high recurrence rates. Extensive analyses of the available literature on the efficacy of enuresis treatment modalities reveal a poor quality of many trials with a whole range of methodological flaws. Therefore, further comparative studies of adequate methodological quality are needed.

The transverse ileal tube as second-line modification of the Mitrofanoff principle.

With the advantages of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high mobility of the tube), minimized risk of stone formation (no use of staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice for the Mitrofanoff conduit. A longer period of follow-up is needed to determine whether it deserves a permanent place in the reconstructive surgeons' repertoire.

Ileal ureteric replacement in complex reconstruction of the urinary tract.

OBJECTIVE: To report 10 years' experience with ileal ureteric replacement as a last resort in complex reconstruction of the urinary tract. PATIENTS AND METHODS: From March 1991 to February 2002 ileal segments were used for partial or total substitution of the ureter in 43 patients (mean age 45.6 years) with structural or functional ureteric loss secondary to irradiation, surgical complications or various other pathological conditions. Ileum was either implanted into the native urinary bladder (in 14) or an intestinal reservoir (in 29). In the latter group the technique was used at the time of primary urinary diversion in eight, in a secondary approach for treating early or late complications in nine and in undiversion or conversion procedures in 12. The ileal ureter was implanted into the urinary reservoir using a serous-lined extramural tunnel or distal intussusception for reflux prevention (in 31). All patients were followed prospectively according to a standardized protocol. RESULTS: There were no perioperative deaths; the mean (range) follow-up was 40.8 (1.5-109.5) months. In 41 patients with dilatation of the upper urinary tract before surgery there was a significant improvement radiographically in 34, no change in five and deterioration in two. The serum creatinine level decreased or remained stable in all. Reflux occurred in the 12 cases without and in three with an antireflux mechanism. Shortening of an elongated kinking ileal ureter became necessary because of recurrent severe metabolic acidosis and mucus obstruction in two; in one case mucus obstruction was treated endoscopically. There was pyelonephritis only in three patients with refluxing implantation into an intestinal reservoir. CONCLUSION: Ileal ureteric replacement is a safe and reliable last resort even in difficult cases. Whenever feasible, antirefluxing implantation into intestinal urinary reservoirs is recommended.