[Minimally invasive PCNL (mini-perc). Alternative treatment modality or replacement of conventional PCNL?]. / Minimal-invasive PCNL (Mini-Perc). Alternative oder Ersatz für konventionelle PCNL?

Extracorporeal shock wave lithotripsy (SWL) is the current treatment modality of choice for upper urinary tract calculi. For stones with a diameter >2 cm and in lower calyceal stones and diverticular stones, the stone-free rate of SWL is rather poor. In these cases, conventional percutaneous nephrolithotomy (PCNL) leads to an increased stone-free rate, but morbidity with conventional PCNL is significant higher than in SWL. With the invention of miniaturized nephroscopes (mini-perc), new treatment options are available. The experience based on hundreds of treatments using mini-perc show comparable results of mini-perc to conventional PCNL and a complication rate comparable to that for SWL. These favorable results are independent of stone size, stone location, and patient age. In summary, mini-perc can be recommended as a primary approach to stones of the upper urinary tract exceeding 1 cm, larger lower-pole stones, and calyceal diverticular stones. Mini-perc can be regarded as an alternative treatment modality to conventional PCNL.

[CAS in rhino-surgical procedures in the growing age]. / CAS bei rhinochirurgischen Operationen im Wachstumsalter.

BACKGROUND: Rhinosurgery in children and adolescents meets special requirements: Limited cooperation and reduced limits for the organ dose for ionizing radiological examinations aggravate diagnostics. On the other side, bone sutures and bone growth areas have to be respected intraoperatively, and regions of bones not yet calcified have to be distinguished from possible tumor infiltration. Computer assisted surgery (CAS) can help to identify these areas safely. METHOD: 5 patients, from the first to the 20 (th) year of life, suffering from tumors, malformation syndromes or therapy resistant nasal polyposis were treated with CAS in rhinosurgery. RESULTS: In addition to radiological diagnostics, we performed 3D computed tomography of the skull for CAS. CAS enabled us to intraoperatively respect possible areas of bone growth, to identify regions with thin, not bonily developed cranial vault and to safely distinguish bone sutures from ethmoidal cells. CAS helped the surgeon to navigate in the not yet developed paranasal sinus system. CONCLUSIONS: CAS is a useful complementary method in rhinosurgery of the developing skull of the child. In spite of the additional 3D computed tomography, the calculated organ dose of the ocular lense amounted to 5 millisievert, so a recommended maximal organ dose for the ocular lense of 15 millisievert was not exceeded.

Imaging procedures in cochlear implant patients--evaluation of different radiological techniques.

The purpose of this study was to evaluate the feasibility and usability of different radiologic methods (single-slice computed tomography (CT), multi-slice CT and rotational tomography (RT)) for assessment of the position of cochlear implant electrodes. Cochlear implants in an isolated human temporal bone and in a complete formalin-fixed cadaver head were examined and the electrode position was determined. Subsequently, the labyrinth bone was isolated out of the cadaver head and histologically examined to compare the results of histology with imaging. Single-slice CT reliably identifies the electrode inside the human cochlea; however, due to the technically based large electrode artifact its position inside the cochlear spaces (e.g. electrode position in scala tympani or scala vestibuli) cannot be detected. Multi-slice CT of the cadaver head also showed artifacts that complicate the assessment of electrode position. Using RT the electrode artifact is small and therefore the electrode position within the cochlear spaces, scala tympani versus scala vestibuli, can be assessed. This technique was also applicable in a complete cadaver head, which is in contrast with former studies. In conclusion, CT allows the identification of electrode arrays inside the human cochlea. Multi-slice CT permits a much more precise depiction of the electrode inside the cochlea. RT alone has minimized electrode artifacts to a high extent and permits the assessment of the electrode position within the scala tympani or scala vestibuli. As RT was performed successfully in a complete cadaver head, further studies for evaluation of the intracochlear electrode position can now be performed in patients.

Parkes Weber or Klippel-Trenaunay syndrome? Non-invasive diagnosis with MR projection angiography.

Klippel-Trenaunay and Parkes Weber (Klippel-Trenaunay-Weber) syndromes consist of vascular malformations of the capillary, venous and lymphatic systems combined with soft tissue and bone hypertrophy of the affected extremity. Klippel-Trenaunay syndrome is a pure low-flow condition, while Parkes Weber syndrome is characterized by significant arteriovenous fistulas. The distinction of both entities is relevant, since the prognosis and therapeutic strategies differ significantly. Our purpose is to demonstrate that thick-slice dynamic magnetic resonance projection angiography (MRPA) is a non-invasive tool to detect arteriovenous shunting in Parkes Weber syndrome. Four patients underwent MR imaging and MRPA. MRPA demonstrated arteriovenous shunting in three patients. Arteriovenous shunting was characterized by early appearing draining veins. The time of arrival between normal arteries and pathological veins varied between less than 0.5 and 1.0 s. Therefore, the diagnosis in these cases could be specified as Parkes Weber syndrome. In all these cases, arteriovenous shunting was confirmed by intraarterial digital subtraction angiography. One patient showed normal results in MRPA and could be diagnosed as having Klippel-Trenaunay syndrome.

Imaging procedures in cochlear implant patients - evaluation of different radiological techniques.

The purpose of this study was to evaluate the feasibility and usability of different radiologic methods (single-slice computed tomography (CT), multi-slice CT and rotational tomography (RT)) for assessment of the position of cochlear implant electrodes. Cochlear implants in an isolated human temporal bone and in a complete formalin-fixed cadaver head were examined and the electrode position was determined. Subsequently, the labyrinth bone was isolated out of the cadaver head and histologically examined to compare the results of histology with imaging. Single-slice CT reliably identifies the electrode inside the human cochlea; however, due to the technically based large electrode artifact its position inside the cochlear spaces (e.g. electrode position in scala tympani or scala vestibuli) cannot be detected. Multi-slice CT of the cadaver head also showed artifacts that complicate the assessment of electrode position. Using RT the electrode artifact is small and therefore the electrode position within the cochlear spaces, scala tympani versus scala vestibuli, can be assessed. This technique was also applicable in a complete cadaver head, which is in contrast with former studies. In conclusion, CT allows the identification of electrode arrays inside the human cochlea. Multi-slice CT permits a much more precise depiction of the electrode inside the cochlea. RT alone has minimized electrode artifacts to a high extent and permits the assessment of the electrode position within the scala tympani or scala vestibuli. As RT was performed successfully in a complete cadaver head, further studies for evaluation of the intracochlear electrode position can now be performed in patients.

Head and neck vascular malformations: time-resolved MR projection angiography.

Extracranial vascular anomalies can be divided into haemangiomas and vascular malformations. The latter can be subdivided on the basis of the predominant type of vascular channels. Separation of high- and low-flow vascular malformations is of clinical importance. We report preliminary observations on time-resolved magnetic resonance projection angiography (MRPA) of vascular malformations of the head and neck. We examined eight patients with vascular anomalies of the head and neck. On MRPA the time between the early arterial phase and enhancement of the malformation could be used to distinguish high- and low-flow lesions. High-flow arteriovenous malformations showed early, intense enhancement. Venous malformations were either not visible on MRPA or showed late enhancement of veins. One patient was examined after embolisation of an arteriovenous fistula of the mandible. Normal MRPA was taken to indicate absence of a residual lesion.

Contrast-enhanced near-infrared laser mammography with a prototype breast scanner: feasibility study with tissue phantoms and preliminary results of imaging experimental tumors.

RATIONALE AND OBJECTIVES: Near-infrared (NIR) optical mammography without contrast has a low specificity. The application of optical contrast medium may improve the performance. The concentration-dependent detectability of a new NIR contrast medium was determined with a prototype optical breast scanner. In vivo imaging of experimental tumors was performed. METHODS: The NIR contrast agent NIR96010 is a newly synthesized, hydrophilic contrast agent for NIR mammography. A concentration-dependent contrast resolution was determined for tissue phantoms consisting of whole milk powder and gelatin. A central part of the phantoms measuring 2 x 2 cm2 without contrast was replaced with phantom material containing 1 micromol/L to 25 nmol/L NIR96010. The composite phantoms were measured with a prototype NIR breast scanner with lasers of lambda1 = 785 nm and lambda2 = 850 nm wavelength. Intensity profiles and standard deviations of the transmission signal in areas with and without contrast were determined by linear fit procedures. Signal-to-noise ratios and spatial resolution as a function of contrast concentration were determined. Near-infrared imaging of five tumor-bearing SCID mice (MX1 breast adenocarcinoma, tumor diameter 5-10 mm) was performed before and after intravenous application of 2 micromol/kg NIR96010. RESULTS: Spectrometry showed an absorption maximum of the contrast agent at 755 nm. No spectral shifts occurred in protein-containing solution. Signal-to-noise ratio in the transmission intensity profiles ranged from 1.1 at 25 nmol/L contrast to 28 at 1 micromol/L. At concentrations <40 nmol/L, no differentiation from the background was possible. The transitional area between the contrast-free edge of the phantom and the central contrast-containing part appeared in the profiles as a steep increase with a width of 4.2 +/- 1.8 mm. The experimental tumors were detectable in nonenhanced images as well as contrast-enhanced images, with better delineation after contrast administration. In postcontrast absorption profiles, a 44.1% +/- 11.3% greater absorption increase was seen in tumor tissue compared with normal tissue. CONCLUSIONS: The laser wavelength lambda1 of the prototype laser mammography device was not situated at maximum absorption of the contrast agent NIR96010 but on the descending shoulder of the absorption spectrum. This implies a 20% signal loss for contrast detection. Despite the nonideal measurement conditions, concentrations as low as 40 nmol/L were detectable in vitro. In vivo, all tumors were detectable in color-coded nonenhanced scans as well as in contrast-enhanced scans, with better delineation after contrast administration.

First experiences in using a new ultrasound mode and ultrasound contrast agent in the diagnosis of blunt renal trauma: a feasibility study in an animal model.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic value of the new ultrasound mode "wide-band harmonic" (WBH) using an ultrasound contrast agent in blunt renal trauma in an animal model. METHODS: A defined blunt renal trauma was induced in 10 rabbits according to published standards. Ultrasound (B-mode, color and power Doppler, WBH) was performed before and after trauma, with and without using a contrast agent (Levovist). Ultrasound features were compared with histologic findings. RESULTS: In 2 of the 10 rabbits, three focal renal intraparenchymal lesions with diameters ranging from 1.0 to 1.8 mm were found that could be identified only using WBH with contrast. Six of the 10 rabbits developed a subcapsular hematoma with a thickness of up to 1.5 mm, which was identified by conventional B-mode as well as WBH. Histologic workup confirmed these findings of intraparenchymal hematomas and did not reveal further lesions. CONCLUSIONS: Only 20% of the experimental subjects developed parenchymal lesions with diameters of 1.0 mm or larger. All these lesions were identified only using WBH. These results indicate the potential to use WBH plus contrast for the diagnosis of blunt renal trauma.