Whole-body SPECT/CT for bone scintigraphy: diagnostic value and effect on patient management in oncological patients.

PURPOSE: This study was designed to assess the additional value of SPECT/CT of the trunk used in conjunction with conventional nuclear imaging and its effects on patient management in a large patient series. METHODS: In 353 patients, whole-body scintigraphy (WBS), SPECT, and SPECT/CT were prospectively performed for staging and restaging. SPECT/CT of the trunk was performed in all patients. In the 308 evaluable patients (211 with breast cancer, 97 with prostate cancer), clinical follow-up was used as the gold standard. Bone metastases were confirmed in 72 patients and excluded in 236. Multistep analyses per lesion and per patient were performed. Clinical relevance was expressed in terms of downstaging and upstaging rates on a per-patient basis. RESULTS: In the total patient group, sensitivities, specificities, and negative and positive predictive values on a per-patient basis were 93 %, 78 %, 95 % and 59 % for WBS, 94 %, 71 %, 97 % and 53 % for SPECT, and 97 %, 94 %, 97 % and 88 % for SPECT/CT, respectively. In all subgroups, specificity and positive predictive value were significantly (p<0.01) better with SPECT/CT. Downstaging of metastatic disease in the total, breast cancer and prostate cancer groups using SPECT/CT was possible in 32.1 %, 33.8 % and 29.5 % of patients, respectively. Upstaging in previously negative patients by additional SPECT/CT was observed in three breast cancer patients (2.1 %). Further diagnostic imaging procedures for unclear scintigraphic findings were necessary in only 2.5 % of patients. SPECT/CT improved diagnostic accuracy for defining the extent of multifocal metastatic disease in 34.6 % of these patients. CONCLUSIONS: SPECT/CT significantly improved the specificity and positive predictive value of bone scintigraphy in cancer patients. In breast cancer patients, we found a slight increase in sensitivity. SPECT/CT had a significant effect on clinical management because of correct downstaging and upstaging, better definition of the extent of metastases, and a reduction in further diagnostic procedures.

Pneumatic v electrokinetic lithotripsy in treatment of ureteral stones.

Recently, a new device (Combilith) for electrokinetic lithotripsy (EKL) has become available which is very similar to the well-known device for pneumatic (ballistic) lithotripsy (Swiss Lithoclast). The Lithoclast uses air pressure to push a projectile within the handpiece against the end of a metal probe, which is thereby accelerated and thrown like a jackhammer against the stone. In principle, the same stroking movement of a small metal probe is provided by EKL; the difference is that instead of a projectile, a magnetic core within the handpiece is accelerated by the electromagnetic principle. This paper compares the clinical efficacy and the features of the two devices. Testing the devices on a stone model, taking into account stone propulsion, the systems turned out to equally effective regarding stone disintegration. However, stone displacement was more pronounced with the Lithoclast applied on easily breaking stones. In a second experiment, an optoelectronic movement-measuring apparatus (Zimmer camera) was employed to measure the range and velocity of the movement of the probe tip without any contact. The linear acceleration velocity ranged from 5 to a maximum of 12.5 m/sec with both systems, but the maximum height of the stroke was 2.5 mm with the Lithoclast and 1 mm with EKL. After the initial break-up of soft stones, further impact of the probe tip against the stone resulted merely in propulsion; thus, the greater probe stroke height is the cause of the stone displacement. In a clinical trial, 22 ureteral stones were treated with the Lithoclast and 35 with the EKL. The two devices were equally effective in terms of stone disintegration and safety margin. Fixation using a Dormia basket was necessary in 12 cases (8 Lithoclast, 4 EKL). Although a difference in probe stroke height was noted when comparing pneumatic and electrokinetic lithotripsy, there were no clinically significant differences in the efficacy of stone fragmentation or stone-free rates. At the current time, EKL is less costly.

Biochemical classification of kidney carcinoma biopsy samples using magic-angle-spinning 1H nuclear magnetic resonance spectroscopy.

High resolution 1H nuclear magnetic resonance (NMR) spectra using spinning at the magic angle (1H MAS NMR) have been obtained on intact normal and pathological kidney tissue samples from patients undergoing surgery for renal cell carcinoma (RCC). The spectra were measured on ca. 80 mg samples and provided high resolution 1H NMR spectra in which effects of dipolar couplings, chemical shift anisotropy and magnetic susceptibility differences are minimised thus yielding high spectral resolution. Conventional one-dimensional and spin-echo spectra and two-dimensional J-resolved, TOCSY and 1H-13C HMQC spectra were also measured on selected samples and these allowed the assignment of resonances of endogenous substances comprising both cytosolic and membrane components. The tumour tissues were characterised principally by an increased lipid content. These are the first reported results on human tumour tissues using this technique and the approach offers potential for the rapid classification of different types of tumour tissue.

[Complete urethral rupture with symphysis injury and anterior pelvic ring fracture during spontaneous delivery]. / Komplette Urethraruptur mit Symphysensprengung und vorderer Beckenringfraktur unter Spontangeburt.

We report on a complete longitudinal rupture of the urethra in combination with a rupture of the pubic symphysis and pelvic fracture during spontaneous vaginal delivery. Only after stabilisation of the pelvic fracture by external skeletal fixation adaptation of the urethra was possible. Three weeks later after removing of the transurethral catheter a mild stress incontinence could be observed. In the follow up one year later the patient was completely continent. The cosmetic result was satisfactory. There was no cystocele. An unclear haematuria after delivery needs a meticulous urological examination. Early repair of urethral disruption minimize the risk of severe incontinence. Coordinated care between the trauma surgeon and urologist is required for successful treatment of this rare combined injury after birth.

Paternity in patients with bilateral testicular germ cell tumors.

We report on the finding of paternity in 1 patient with metachronous bilateral testis germ cell tumor (BTGCT) and in another patient with a unilateral testicular germ cell tumor and contralateral carcinoma in situ (CIS). These cases demonstrate that patients with BTGCT or CIS in their solitary testicle are not necessarily infertile. Surveillance might be a therapeutic modality in patients with contralateral CIS and active spermatogenesis and the desire for paternity assumed that they are included in close follow-up protocols.

Nuclear medical assessment of penile hemodynamics following revascularization surgery.

Variations of Hauri's penile revascularization have been in clinical use since 1983. The hemodynamics of the so-called three-vessel anastomosis remain uncertain despite successful, clinically reproducible results. The goal of this study was to depict the increased perfusion of the erectile system of the penis following revascularization by means of the inferior epigastric artery. Ten milliliters of heparinized peripheral venous blood was drawn from 10 patients prior to surgery. The radioactively tagged erythrocytes (1 mCi 99mTc) were reinjected via an additional incision in the donor vessel proximal to the anastomosis following completion of the three-vessel anastomosis and intracavernous injection of 20 micrograms PGE1. Once again, blood was drawn during the tumescence phase from both a peripheral vein and the corpora cavernosa within the normal circulatory duration and compared to the original specimen. Eight of ten patients displayed evidence of primary reperfusion of the corpora cavernosa via the inferior epigastric artery as the donor vessel. Using strict indications, revascularization of the penis is an effective mode of therapy for arterial erectile dysfunction.

Expression of immunohistochemical markers (PCNA, Ki-67, 486p and p53) on paraffin sections and their relation to the recurrence rate of superficial bladder tumors.

We present a retrospective study using four different immunohistochemical markers (PCNA, Ki-67, 486p and p53) on paraffin sections from 104 selected cases with primary superficial transitional cell carcinomas of the bladder (59 cases pTa, 45 cases pT1, 40 cases G1, 64 cases G2). 53 of the 104 patients experienced recurrence of their bladder lesion, while 51 remained free of tumor. The distribution of staging, grading and multifocality was comparable in both groups of patients. Overall, the tumors that recurred had a significantly higher proportion of labeled cells for PCNA (p < or = 0.0001), Ki-67 (p < or = 0.006) and 486p (p < or = 0.0001). The latter antigen proved to be the most reliable marker. A less significant difference in staining pattern was found for p53 (p < or = 0.01). Evaluating the predictive value of the various antibodies separately for the groups with G1 vs. G2 carcinomas and pTa vs. pT1 tumors revealed a lower significance for all antibodies. The technique of immunostaining on paraffin sections facilitates further retrospective studies on archival material. These markers may provide additional information about the probability of recurrence of superficial bladder tumors. But at the moment they should only be utilized in selected cases.

The influence of ejaculation on serum levels of prostate specific antigen.

PURPOSE: While prostatic manipulation and surgery have been shown to increase serum prostate specific antigen (PSA), the influence of ejaculation on serum PSA remains controversial. We examined the effect of ejaculation on serum PSA levels. MATERIALS AND METHODS: We evaluated 100 men 25 to 35 years old with no history of surgery or inflammatory disease of the urogenital tract. Serum PSA was evaluated 1 and 24 hours after ejaculation, and serum testosterone and seminal fluid PSA levels were determined. RESULTS: In all men a baseline PSA level was detected. There were no statistically significant changes in serum PSA and testosterone 1 and 24 hours after ejaculation. Mean PSA concentration was significantly higher in seminal plasma than in serum. However, we did not observe a correlation between serum and seminal plasma PSA levels. CONCLUSIONS: Based on our data ejaculation does not affect serum PSA concentration in young men, and there seems to be no physiological relationship between ejaculation and PSA level.

Renal milk of calcium: contraindication to extracorporeal shockwave lithotripsy.

Renal milk-of-calcium (MOC) cysts are rare findings, with only approximately 60 cases reported in the literature. The diagnosis depends on the demonstration of the typical "half-moon" configuration on horizontal beam radiography; classical ultrasound finding is a gravity-dependent, echogenic shadowy material in a renal cyst. The importance of the MOC syndrome lies in its recognition and differentiation from a renal stone in order to avoid unwarranted surgery or extracorporeal shock-wave lithotripsy (ESWL). We have encountered five patients with renal MOC and present the typical clinical and radiological features in order to facilitate differential diagnosis.

Testicular tissue oxygen pressure.

PURPOSE: We evaluate the feasibility of continuous, intratesticular tissue oxygen pressure (IT-pO2) measurement under various conditions. MATERIALS AND METHODS: Flexible, polarographic microcatheter systems (1.5 F) for continuous pO2 measurements have been used. The measurements were conducted on 37 adult male albino rats. The probes could be placed intratesticularly under controlled temperatures by microsurgical techniques. The IT-pO2 of the ipsilateral and contralateral testicle was determined after unilateral torsion. Furthermore the influence of intratesticular temperature on IT-pO2 was determined. RESULTS: Intratesticular pO2 was found to be 21 +/- 5 mm.Hg under normal conditions. Under complete ischemia, pO2 dropped within 3 to 5 minutes to a level of approximately 1 mm.Hg. A counterclockwise unilateral testicular torsion of 720 degrees led to a decrease of the IT-pO2 within 5 to 7 minutes to 5 +/- 1.5 mm.Hg. After detorsion the IT-pO2 recovered within 15 minutes, while the IT-pO2 of the contralateral testicle remained unchanged. Simple surgical exposure of the testicle led to a reversible decrease of the intratesticular pO2 to 7 +/- 2.5 mm.Hg correlating with an intratesticular temperature decrease from approximately 31.5 to 23.5 C. CONCLUSIONS: The measurements are feasible and may provide a continuous intraoperative assessment of intratesticular oxygen pressure. The contralateral IT-pO2 after unilateral torsion remained unchanged. The IT-pO2 and testicular blood flow depend, if the utilization of oxygen is unchanged, on intratesticular temperature.

First temporal and spatial quantification of single-shot electrohydraulic lithotripsy in vitro.

Single electrohydraulic lithotripsy (EHL) discharges from a human ureter were analyzed with a mechanical high-speed motion analysis camera. We found a cavitation bubble, at 650 mJ, 4-11 mm in size, with a lifetime of 400-500 microseconds. Varying sizes and lifetimes were found using single-shot analysis, as well as in different shot-sequences. This supports similar observations by recent investigations of cavitation bubble size with high-shutter-speed videofilm, which have depicted events at shutter speeds of 4000/s, i.e., an approximate exposure time of 250 microseconds. Due to the occurrence of high-voltage interference from the EHL high-voltage generator, no other technical electronic event timing equipment has so far been available capable of mechanical high-speed film motion analysis, while at the same time avoiding high-voltage interference.

Recurrent bleeding of angiomyolipomas in tuberous sclerosis.

The diagnostic and therapeutic problems of renal hamartomas are illustrated by a case of recurrence of bleeding angiomyolipomas associated with tuberous sclerosis. Ultrasound and computed tomography provide clear evidence of lipomatous formation while, in rare instances, angiography can demonstrate the existence of multiple vascular tumor compartments. In view of the risk of bleeding, multiple or very large angiomyolipomas should be treated by interventional radiology in the form of superselective tumor embolization or by the most conservative surgery possible.

[Testicular epidermoid cyst: orchiectomy or enucleation resection?]. / Testikuläre Epidermiszyste: Orchiektomie oder Enukleationsresektion?

Our experience with 18 patients with simple epidermoid cysts of the testis is reported. In each patient the tumour was enucleated completely and two biopsies of the adjacent parenchyma were obtained for exclusion of associated germ cell cancer, scars or carcinoma in situ. There was no evidence of malignancy in any of the biopsy specimens. Preoperative evaluation included physical examination, testicular sonography, and determination of AFP and hCG serum levels. Although epidermoid cyst can be strongly suspected on sonography the ultrasound appearance is not specific, and inguinal testicular exploration was required in these patients. In 1 patient multiple epidermoid cysts of the right testis were associated with an adult teratoma containing embryonal carcinoma and choriocarcinoma of the left testis; no similar case has been described in the literature. On the basis of our results and experience we consider tumour enucleation and biopsy of the adjacent parenchyma to be adequate treatment for benign epidermoid cyst. The world literature concerning organ-sparing surgery in testicular epidermoid cyst is reviewed.

[Value of urethral ultrasound in evaluation of pathologic urethral changes]. / Stellenwert der Urethralsonographie in der Beurteilung pathologischer Harnröhrenveränderungen.

AIM: To compare the evaluation of urethral stricture disease using ultrasonic urethrography and standard retrograde urethrography (RUG). METHOD: 175 male patients suspected of having urethral stricture disease underwent urethral sonography prior to RUG in a prospective, non-randomized study. RESULTS: A correct positive diagnosis was established in 98% of the cases; a correct negative diagnosis in 96%. The sensitivity and specificity of urethral ultrasound in detecting urethral strictures were 98% and 96%, respectively. CONCLUSION: Ultrasound offers a three-dimensional study to evaluate the urethral without exposing the gonads to ionizing radiation. The exact length and depth of a stricture, the severity of the strictured segment as well as the anatomy of the periurethral scars were diagnosed accurately. Urethral ultrasound is a simple, inexpensive and rapid investigation of the urethra which should be the preferred diagnostic procedure in the evaluation of strictures in the anterior urethra of men.

[Follow-up of contralateral intratesticular oxygen pressure in unilateral testicular torsion]. / Verlauf des kontralateralen intratestikulären Sauerstoffdrucks während einseitiger Hodentorsion.

The intratesticular tissue oxygen tension (= IT-pO2) depends on the testicular perfusion. Polarographic microcatheter probes have recently become available and are suitable for continuous measurements of the tissue oxygen tension. In 20 adult albino rats flexible Clark-type oxygen electrodes (1.5 F) were used for simultaneous monitoring of IT-pO2 of the ipsi- and contralateral testicle during unilateral torsion. A counterclockwise 720 degrees torsion caused a decrease of IT-pO2 from 21 mm Hg (+/- 5 mm Hg) to 5 mm Hg (+/- 1.5 mm Hg) in the twisted testicle within 5-7 min. After detorsion the IT-pO2 returned to normal level in the following 25 min. The IT-pO2 of the contralateral testicle showed no significant changes during torsion for 1 h or after detorsion. Thus, if the oxygen utilization is unchanged a unilateral acute torsion for 1 h does not cause a decrease in perfusion in the contralateral testicle. It will probably also prove possible to use oxygen tissue tension measurements to improve our understanding of testicular perfusion in humans.

Impact of shock wave pattern and cavitation bubble size on tissue damage during ureteroscopic electrohydraulic lithotripsy.

It is known that electrohydraulic lithotripsy (EHL) during ureteroscopy may cause ureteral damage. To evaluate this trauma potential, find its mechanism and make it possible to avoid it, our research employed photographic evaluation, tissue studies, shock wave measurements and disintegration tests. The setup included a 3.3 F probe attached to an experimental generator with adjustable voltages and capacities providing energies from 25 mJ. to 1300 mJ. per pulse. In general, we distinguish between two traumatic mechanisms: (1) After placing the probe directly on the mucosa the rapid initial plasma penetrates the tissue resulting in a small, nonthermal, punched-like defect, whose depth depends on the energy applied. This trauma has minor clinical implications and is avoided by maintaining a minimum safety distance of 1 mm.; (2) According to physics, each plasma is followed by a cavitation bubble. The maximum size of this bubble depends on the energy applied and ranges from 3 mm. (25 mJ) to > 15 mm. (1300 mJ). In proportion to the bubble size, the ureteral wall may be distended or disrupted, even when the probe is not in direct contact with the mucosa. Therefore, the goal should be to obtain a low energy pressure pulse with high disintegration efficacy. Our evaluation of the pressure waves revealed that the selection of a high voltage and a low capacity leads to short and steep "laser-like" pulses. These pulses have a significant higher impact on stone disintegration than the broader pulses of the same energy provided by currently available generators.

[Current trends in clinical urology]. / Aktuelle Trends der klinischen Urologie.

Many recent developments in urologic diagnostic and therapy are also of interest for general surgeons. Flexible and semirigid ureteroscopes (6-8 F) provide easy and atraumatic access to the whole upper urinary tract. Beside extracorporeal shockwave-lithotripsy now various endourologic modalities to treat ureteral stones are available. Although useful, laparoscopic techniques are not yet widely accepted by urologists because there is a lack of indications in urologic laparoscopic surgery. The functional reconstruction of the urinary bladder by means of an ileal neobladder with an anastomosis to the urethra in the male or with a continent stoma and selfcatheterism provides better quality of life in patients after radical cystectomy. Nephron-sparing tumor surgery may become a routine procedure under certain precautions such as small tumor size, patient's compliance and good local medical infrastructure. Especially for urologic microsurgery, neurourology and different treatments of benign prostatic hyperplasia essential new and interesting improvements are expected.

Evaluation of the shock-wave pattern for endoscopic electrohydraulic lithotripsy.

We evaluated the electrical events and the resulting shock waves of the spark discharge for electrohydraulic lithotripsy at the tip of a 3.3F probe. Spark generation was achieved by variable combinations of voltage and capacity. The effective electrical output was determined by means of a high-voltage probe, a current coil, and a digital oscilloscope. Peak pressures, rise times, and pulse width of the pressure profiles were recorded using a polyvinylidene difluoride needle hydrophone in 0.9% NaCl solution at a distance of 10 mm. The peak pressure and the slope of the shock front depend solely on the voltage, while the pulse width was correlated with the capacity. Pulses of less than 1-microsecond duration can be obtained when low capacity is applied and the inductivity of the cables and plugs is kept at a low level. Using chalk as a stone model it was proven that short pulses of high peak pressure provided by a low capacity and a high voltage have a greater impact on fragmentation than the corresponding broader shock waves of lower peak pressure carrying the same energy.