[Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]. / Die ureterointestinale Anastomose : Achillesferse der Harnableitung unter Verwendung von Darm.

A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Pompe disease : anesthesiological special features]. / Morbus Pompe : Anästhesiologische Besonderheiten.

Pompe disease is a very rare disorder of glycogen metabolism. Due to a deficiency of the enzyme glucosidase glycogen accumulates inside the lysosomes. The clinical picture varies widely as a consequence of varying participation of skeletal and heart muscle. In adults respiratory insufficiency can occur which must be taken into consideration during anesthesiology procedures for affected patients. This case report describes a 60-year-old patient scheduled for punch biopsy of the prostate.

[Plasmocytoma of the ureter--a rare cause of hydronephrosis: case report and review of the literature]. / Plasmozytom des Harnleiters--seltene Ursache einer Harnstauung: Fallbericht und Literaturübersicht.

INTRODUCTION: Plasmocytoma is an aggressive B-cell lymphoma with diffuse and multi-located-infiltration of the bone marrow. There are only a few cases in the literature reporting an extraosseous manifestation of plasmocytoma, e. g., in the urinary tract. CASE REPORT: We report on an 80-year-old female patient with known plasmocytoma presenting with renal colics. Ultrasonography demonstrated marked hydronephrosis and retrograde pyelography disclosed a short and filiform stenosis of the ureter. Surgical exploration revealed an infiltration of the distal ureter by the known plasmocytoma. The affected ureter segment could be removed completely and ureterocystoneostomy was performed successfully. CONCLUSIONS: To the best of our knowledge, we present the first case of an isolated plasmocytoma of the ureter. Although extremely rare, it should be considered as a differential diagnosis of circumscribed ureteral strictures.

Sonographic diagnosis of an unusual case of multilocular cystic nephroma mimicking polycystic kidney disease.

The following is a report of the unusual case of a multilocular cystic nephroma in an 8-year-old boy who was transferred to our unit with a palpable abdominal tumor. The patient suffered from thoracic pain and night sweating. The laboratory values were normal. Abdominal sonography showed a huge kidney tumor on the right side consisting of numerous small cysts transversed by irregular septa of variable thickness. The cysts had a diameter of 1 -5 mm; larger cysts of more than 1 cm in diameter were not able to be shown. In the center of the tumor a normal renal parenchyma was able to be shown. The tumor arose like a mushroom from the kidney. Color Doppler sonography showed good vascularity of the normal renal parenchyma while the tumor had only a few internal vessels. The tumor was surgically removed. The histologic diagnosis was cystic nephroma. Unusual features of this tumor were the small size of the numerous cysts similar to polycystic kidney disease and the mushroom-like growth of the tumor.

[Adrenalectomy within the scope of tumor nephrectomy--overtreatment?]. / Adrenalektomie im Rahmen der Tumornephrektomie--ein Overtreatment?

Metastatic spread to the ipsilateral adrenal gland occurs in 1.2-10% of patients with renal cell carcinoma (RCC). In the majority of these cases, the primary tumor is locally advanced with poor differentiation, venous invasion, and involvement of the regional lymph nodes. Adrenal metastases are usually detected preoperatively by CT scan or MRI. Adrenal metastases are indicators of systemic disease with poor prognosis quo ad vitam. Only 0.5-2.3% of patients with RCC and adrenal metastases are free of venous invasion or lymphatic disease. In this small subset of patients, cure is possible by surgical removal of the adrenal gland. In 97.7-99.5% of patients with RCC, ipsilateral adrenalectomy has no impact on their prognosis. We therefore conclude that this procedure should be performed only if there is radiological suspicion of an adrenal mass.

Ten years' experience with the submucosally embedded in situ appendix in continent cutaneous diversion.

OBJECTIVE: To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs. MATERIAL AND METHODS: Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol. RESULTS: There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night. CONCLUSION: Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

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.

Prostate specific membrane antigen (PSM) is expressed in various human tissues: implication for the use of PSM reverse transcription polymerase chain reaction to detect hematogenous prostate cancer spread.

Detection of prostate-specific membrane antigen (PSM)-mRNA expression in blood samples using reverse transcription polymerase chain reaction (RT-PCR) is discussed as a new diagnostic marker of circulating micrometastases in prostate cancer patients. We applied the RT-PCR technique to different human tissues and obtained positive signals for PSM transcripts in human genital and multiple extra-genital tissue sites. The cDNAs were prepared from different human tissues and prostatic cell lines. RT-PCR and nested RT-PCR for PSM was performed with primers derived from the published PSM cDNA. The RT-PCR fragments obtained were cloned and showed 100% sequence homology to PSM. Southern blot hybridization with labeled probes was used to confirm the specificity of the amplicons. In addition to the known PSM expression in the human brain, PSM-mRNA was detected in cDNA isolated from human testis, epididymis and seminal vesicles and in the PC-3 prostatic cancer cell line. Furthermore, we found PSM-mRNA in heart, liver, lung, kidney, spleen, and thyroid gland. The results indicate that PSM expression is not restricted to the prostate gland, but represents a more general component of genital and extra-genital human tissues. This must be considered when RT-PCR and nested RT-PCR screening for PSM expression is performed as a diagnostic measure in blood from prostate cancer patients.

Changes of urodynamic findings after radical retropubic prostatectomy.

OBJECTIVES: We wanted to evaluate the urodynamic changes of radical retropubic prostatectomy in patients with localized prostate cancer and identify specific factors that could influence the postoperative continence status. METHODS: Sixty-six consecutive patients (mean age 68 years) were studied urodynamically within 1 week before surgery, and 44 of them at a mean 7.6 months after radical intervention. RESULTS: Complete urinary continence was achieved in 37/44 men (84. 1%) after 6 months and in 43/44 patients (97.7%) 1 year after surgery. Stress incontinence of varying degree improved with time. Seven patients demonstrated a moderate incontinence 4 months after radical prostatectomy and 1/7 was still incontinent after 1 year. Mean flow rate, maximum detrusor pressure, maximum urethral closure pressure (at rest and voluntary contraction of the sphincter) and functional urethral length showed significant changes after surgery. Detrusor instability, which was present in 31.8% of the 66 patients preoperatively, was not responsible for any case of postoperative incontinence. The urethral pressure profile was significantly reduced in all patients after surgery. CONCLUSIONS: The present study indicates that there are no preoperative alterations in bladder function such as detrusor instability to identify patients at risk for postoperative incontinence. Postoperative incontinence seems to depend upon sphincteric deficiency as expressed by the reduced pressures in the sphincteric mechanism.

Experience with the Mainz modification of ureterosigmoidostomy.

BACKGROUND: The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion. METHODS: Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1.9-76.9 (mean 55.8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid-base balance. RESULTS: There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients. CONCLUSION: Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.

Endothelial cell proliferation activity in benign prostatic hyperplasia and prostate cancer: an in vitro model for assessment.

PURPOSE: Urinary excretion of several pro-angiogenic and antiangiogenic substances has been correlated with malignant tumor growth. The aim of this study was to assay angiogenic activity in urine from patients with cancer of the prostate and benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Urine specimens from 22 healthy male volunteers (control), 33 patients with BPH and 29 with organ confined prostate cancer were analyzed for angiogenic activity in a bovine capillary endothelial cell proliferation assay. In parallel the concentration of basic fibroblast growth factor and vascular endothelial growth factor was determined by enzyme immunoassay in the corresponding urine specimens. RESULTS: Urine samples from patients with BPH and prostate cancer increased bovine capillary endothelial cell proliferation by 13.1% and 15.1%, respectively, whereas urine from the control group showed a significantly lower angiogenic activity, increasing endothelial cell proliferation by only 0.7% (p = 0.001). Urinary basic fibroblast growth factor and vascular endothelial growth factor were highest in patients with BPH and lowest in the group with prostate cancer (p = 0.0001). CONCLUSIONS: Urine from patients with BPH and prostate cancer stimulates endothelial cell proliferative activity. The degree of endothelial cell stimulation does not correlate with the concentration of basic fibroblast growth factor or vascular endothelial growth factor. Whether the observed pro-angiogenic activity is due to an increased production or release of (an) other angiogenic factor(s) and/or loss of (an) angiogenesis inhibitor(s), deserves further investigation.

Infections and vesicoureteral reflux.

Vesicoureteral reflux (VUR) is a common condition in children. It may cause and maintain urinary tract infections, eventually leading to progressive renal damage and end-stage renal disease. Ideally, VUR should be detected and treated before renal scarring occurs. Although fetal hydronephrosis on antenatal ultrasound may be the first indicator, the role of further diagnostic investigations in these newborns is still controversial. Because VUR is an inherited condition, offspring of women with a family history of VUR and urinary tract infection should be screened closely for early detection of VUR. Once diagnosed, however, the optimal management of VUR (i.e. medical or surgical treatment) remains controversial. Evidence-based treatment recommendations, like the American Urological Association guidelines, may aid physicians in their therapeutic decision making, but cannot replace personal experience or surgical skill.

Complications related to different continence mechanisms in ileocecal reservoirs.

PURPOSE: We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir. MATERIALS AND METHODS: From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus. RESULTS: In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple. CONCLUSIONS: In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Quality of life after cystectomy and urinary diversion: results of a retrospective interdisciplinary study.

PURPOSE: Now that creation of continent urinary reservoirs has become a standardized and clinically well established surgical technique with known morbidity and mortality rates, we reassessed the psychological and social aspects of this treatment compared with wet urostomy. MATERIALS AND METHODS: We developed a questionnaire (102 items) addressing general aspects of quality of life, disease related social support, coping strategies and stoma related issues. It was mailed to 600 patients with ileal conduits and 130 with continent reservoirs. Final analysis was restricted to 192 patients operated upon within the last 5 years (mean followup 2.7 years). RESULTS: The resulting groups were matched and paralleled regarding most treatment related and sociodemographic data. Final analysis did not reveal differences between the groups in disease related social support, coping strategies or quality of life when expressed as a total score. We found statistically significant superiority of continent reservoirs regarding all stoma related items, patient global self-assessment of their quality of life (single item, p < 0.005), physical strength, mental capacity, leisure time activities and social competence (p < 0.05). CONCLUSIONS: Continent diversion is clearly advantageous with respect to all items directly related to the stoma. The significant superiority of continent diversion in patient global self-assessment of their quality of life reflects the highly subjective dimension of the concept. Superiority in self-ratings of physical strength, mental capacity, leisure time activities and social competence could be interpreted as indicators of enhanced vitality in those patients, thus, supporting our understanding that women and men who actively participate in life have a special benefit from continent reservoirs.