Imaging the renal mass: a historical review.

A matter of months after Roentgen's landmark discovery in 1895, Roentgen's rays were focused on diseases and disorders of the urinary tract, specifically the kidney. At the dawn of the 20th century, urologists in the United States and around the world quickly recognized that by using a variety of metal stylets and radiopaque contrast agents, such as silver salts, the upper urinary tract, namely the ureter, pelvis, and calyces, could be depicted with radiography. Renal cysts and tumors were diagnosed on the basis of deformities in the kidney. Retrograde pyelography dominated the imaging evaluation of the kidney until the discovery of a safe intravenous method for urinary tract imaging (ie, intravenous pyelography). Pioneers and pathfinders in the field of contrast media development and radiologic procedures helped give radiologists the lead role in the work-up of renal masses, an area where urologists once held forth. The subspecialty of uroradiology was born in the middle of the 20th century. Intravenous urography, nephrotomography, and diagnostic angiography with pharmacologic manipulation followed by cyst or mass puncture and biopsy yielded unrivaled specificity for the diagnosis and staging of benign and malignant renal masses. The advent of cross-sectional and multiplanar imaging and the profound effects they had and continue to have on the discovery and characterization of renal masses has been detailed in the pages of Radiology since the 1920s. Ultrasonography, nuclear imaging, computed tomographic scanning, magnetic resonance imaging, and positron emission tomography each have made a claim to a part of the imaging algorithm of modern uroradiologic practice.

[Transparency regime: semiotics of radiographical images in urological diagnostics]. / Durchsichtbarkeitsregime : Zur Semiotik radiographischer Bilder in der urologischen Diagnostik.

Shortly after Röntgen discovered x-rays urology became one of the main test fields for the application of this new technology. Initial scepticism among physicians, who were inclined to cling to traditional manual methods of diagnosing, was replaced by enthusiasm for radiographic technologies and the new method soon became the standard in, for example the diagnosis of concrements. Patients favoring radiographic procedures over the use of probes and a convincing documentation of stones in radiograms were factors that impacted the relatively rapid integration of radiology into urology. The radiographic representation of soft tissues and body cavities was more difficult and the development of contrast agents in particular posed a serious problem. Several patients died during this research. A new diagnostic dimension was revealed when radiography and cystography were combined to form the method of retrograde pyelography. However, the problem of how urologists could learn how to read the new images remained. In order to allow trainee physicians to practice interpreting radiograms atlases were produced which offered explanatory texts and drawings for radiographic images of the kidneys, the bladder etc. Thus, urologists developed a self-contained semiotics which facilitated the appropriation of a unique urological radiographical gaze.

[Research perspectives on the history of urology in Germany, 1933-1945]. / Forschungsperspektiven zur Geschichte der Urologie in Deutschland, 1933-1945.

Between 1933 and 1945, German medical practitioners were easily persuaded to align themselves with Nazi ideology. Jewish urologists were forced out of academia, editorial boards of medical journals and medical practice. Like most German physicians, urologists quickly accepted their new role as caretakers of public health instead of individual patients' wellbeing. The specialty of urology profited from this collaboration with Nazi policies as it gained further independence.

[Urology and National Socialism: the fate of Alexander von Lichtenberg 1880-1949]. / Urologie und Nationalsozialismus : Alexander von Lichtenberg 1880-1949.

Alexander von Lichtenberg (1880-1949) was one of the famous members of the German Urological Society (DGU) in pre-war Germany. He introduced excretion urography and a special TURP Instrument. In 1928 he was president of the 8th meeting held in the German capital Berlin. His Handbook of Urology, released by Ferdinand Springer publishing house, was a trendsetter in establishing urology as a specialty in Germany and bringing together the whole wisdom of all aspects of urology. He was the founder of the famous Maximilian Nitze Award of the DGU. As a Jew he-like many others-was forced to leave Nazi Germany after 1933. Even in Hungary, his native country, he again had to resist anti-Semitic hostility. Later on he lived in Mexico. Alexander von Lichtenberg has to be remembered with special focus on the exodus of German Jewish scientists during the Nazi time.

El laboratorio del urólogo / The laboratory of the urologist

Aportación de la relación personal del autor con D.Luis Cifuentes. Se enfatiza sobre la importanciade visualizar el sendimento urinario en la consulta del urólogo (AU)

Description of the author’ personal relation-ship with Dr. Luis Cifuentes. We emphasize the importance of microscopic evaluation of urine sediment in the office of the urologist (AU)

Obstrucción del tramo urinario superior. Revisión años 80 / Obstruction of the upper urinary tract. State of the art of the 80´s

El Dr. Solé –Balcells ha tomado apuntes sistemáticamente durante toda su larga carrera como urólogo, convirtiéndolos en lecciones o en documentos de revisión y estudio. Perfectamente ordenadas y muy completas, estas notas raramente han sido publicadas. Recuperamos aquí un manuscrito original redactado en los años 1980 sobre uno de sus temas prediclectos: la uropatía obstructiva. El texto mantiene la vigencia en cuanto a la urodinámica de la obstrucción ureteral y, al mismo tiempo, es un documento histórico que refleja el quehacer urológico hace 25 años. Se trata de un repaso breve e intenso de la fisiopatología ureteral, con apuntes sorprendentes como la “super-sonda” peristáltica de la urografía o la descripción de medios neurofisiológicos de exploración ureteral como la EMG y el manómetro intraluminal

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[Doctor Manuel Cobas Núñez (1885-1956), pioneer of urology and uroradiology in Galicia]. / El Doctor Manuel Cobas Núñez (1885-1956), pionero de la urología y de la uro-radiología en Galicia.

INTRODUCTION: The development of urologic radiology with intracavitary and intravenous contrast agents played an essential role in the rise of Urology as a surgical speciality, in agreement with other circumstances that made it both possible (the invention of endoscopic instruments and laboratory technics to study the urine and the kidney function, advances in anaesthesia, asepsis, control of hemorrhage and infection), and necessary (because of social request for these specialised medical services). MATERIAL AND METHOD: Study of the life and work of Manuel Cobas Núñez (1885-1956), whose surgical practice and publications pioneered the modern Urology and Uroradiology in Galicia (Spain). RESULT: After being trained in Necker Hospital (Paris) and Instituto Rubio (Madrid), Cobas was one of the first to practice urology in Galicia, with a high interest in surgical diseases of the upper urinary tract. His knowledge of renoureteral surgery was outstanding for the time. In august 1931 he published "Pielografia ascendente y pielografia descendente", one of the first and best documented books on upper urinary tract examination using retrograde and intravenous pyelography, written only months after marketing of the first intravenous contrasts agents. COMMENT: Working in private practice, out of the academic fields, Cobas was a protagonists of the beginning of Galician modern urology. His publications and book on pyelography show that he was one of the first experts in renal surgery and must be also recognized as a pioneer of uroradiology in Galicia and Spain.

The discovery of renal contrast media in Berlin.

After X-rays were detected and cystoscopes had become available, progress in nephrology depended on the development of contrast media which would permit imaging of the kidneys and the urinary system. We describe how A. Binz and C. Räth, two chemists at the Agricultural Academy in Berlin, synthesized iodinated derivatives which were potent chemotherapeutics. Moses Swick tested the substances in the clinics of L. Lichtwitz (Hamburg) and A. von Lichtenberg (Berlin) and discovered a rapid renal excretion. He also observed that an iodinated N-acetylated derivative, later named Uro-Selectan, amplified X-ray contrast after intravenous application. With this substance and other derivatives which were produced by Schering-Kahlbaum AG, the door was open for excretion urography.

[Retirement plan for a 70-year-old. Intravenous urography disembarks from uroradiology]. / Aftraedelsesordning for en 70-årig. Intravenøs urografi går fra borde i uroradiologien.

Over the last 70 years, intravenous urography (IVU) has played a major role in the work-up of diseases in the kidneys and the upper urinary tract. However, modern cross-sectional modalities have shown that IVU does not fulfill current requirements. Patients with renal colic are better examined by non-enhanced CT scanning, as it finds more stones (60 versus 100%). Furthermore, a disease outside the upper urinary tract is found in about 15% of patients with renal colic, and in 3% another kidney or upper urinary tract disease is found. For patients with haematuria, CT urography is a better alternative, as it combines the advantages of CT with those of IVU. IVU misses about 15% of renal tumours above 3 cm in diameter and almost all below 3 cm. MR urography is the newest way of imaging the upper urinary tract; its exact role is still undetermined, but it is recommended for children, young persons, and pregnant women. After 70 years of good performance, it is time for IVU to retire.

[Bladder cancer]. / Cáncer vesical.

OBJECTIVE: For optimum treatment planning and to establish the prognosis, the main objectives of diagnostic imaging techniques after detecting a tumor in the urinary bladder are to determine 1) its nature and histological structure, 2) depth of bladder wall invasion, 3) tumor localization and involvement of the ureter and trigone, 4) involvement of bladder wall lymphatics, and (5) to determine if there is or no regional and/or distant mestatasis. The capabilities of the diagnostic imaging techniques in regard to achieving the foregoing objectives are analyzed. METHODS: This study comprised 160 patients with a suspected or confirmed bladder tumor. The imaging methods utilized were: conventional radiology including IVP, retrograde and double contrast cystography, ultrasound, CT and MRI. RESULTS: Analysis of the images allowed assessment of 18 morphological parameters, of which the following were among the most relevant: presence of ureterohydronephrosis, filling defect(s), tumor localization, tumor base, tumor-mucosa angle, wall stiffness, total wall thickness, changes observed in the perivesical space and degree of pelvic lymph node involvement. Visualization of a bladder filling defect confirms a bladder tumor. The predictors of the biological behaviour of bladder tumors, such as wall stiffness and lumen asymmetry, characteristically express tumor invasiveness. The tumor-mucosa angles in relation to tumor base and peritumoral edema express a higher grade of infiltration for the obtuse angles and a lower grade for the acute angles. Determining tumor stage with accuracy is the essential challenge of the imaging methods in the assessment of bladder cancer. Both CT and MRI are used to analyze four basic aspects prior to treatment: 1) tumor appearance, 2) presence or absence of perivesical invasion, 3) presence or absence of invasion of the adjacent organs, and 4) presence or absence of lymphadenopathies. The accuracy of CT for tumor staging is estimated to be 88%-92% for stage D1 and 80%-85% for stages C and B2, respectively, while MRI has an accuracy of 95% for stage B2 and 85% for tumor stages that compromise adjacent organs such as the prostate, uterus or vagina. CONCLUSIONS: Conventional radiological methods, together with transabdominal or transrectal ultrasound, have a high rate of accuracy for tumor detection. Determination of the stage of tumor invasion requires analysis of wall thickness, width of tumor base, tumor-mucosa angles and perivesical space. CT and MRI provide highly reliable diagnostic information on the foregoing. CT may present some difficulty in determining the stage of bladder wall invasion. With contrast enhancement, MRI has shown a greater capability to differentiate tumor stages B2 and C and is very similar to CT in detecting pelvic or retroperitoneal lymph node involvement.