[Laparoscopic pyeloplasty in a complicated duplicated collecting system]. / Laparoskopische Nierenbeckenplastik bei komplizierter Doppelniere.

Laparoscopic pyeloplasty has been established as an effective and minimally invasive technique for treating ureteropelvic junction obstruction. Only case reports are available describing the use of laparoscopic pyeloplasty in patients with duplicated collecting systems. We report the case of a patient presenting with a short stenotic connection between the hydronephrotic lower pole system and a solitary ureter coming from the upper pole. In this patient, a side-to-side anastomosis between the renal pelvis and the ureter was successfully performed. The present data demonstrate that laparoscopic pyeloplasty is an applicable tool even in patients with upper urinary tract anomalies such as duplicated collecting systems.

Adjuvant interferon alpha therapy in renal cell carcinoma (RCC): prognostic value of DNA cytophotometry.

BACKGROUND: Adjuvant immunotherapy with interferon alpha in non-metastatic RCC is still controversial. It was the aim of the present study to investigate whether tumor ploidy can help to isolate a group of patients profitting from this treatment. MATERIALS AND METHODS: Survival data of 119 patients undergoing tumor nephrectomy because of a non-metastatic RCC were analyzed retrospectively. Ploidy was measured in every tumor by means of DNA-cytophotometry. 24 patients received an adjuvant therapy with interferon alpha for one year. Statistical evaluation was performed by the Kaplan-Meier-Method with the logrank-test. RESULTS: Ploidy could be measured in all tumors. 56 (47%) tumors showed a diploid, 63 (53%) an aneuploid DNA-distribution. Ploidy was seen to be a good prognostic factor in RCC with significantly better survival in patients with diploid than those with aneuploid tumors. The adjuvant interferon therapy provided a marginal however not significant better survival in diploid tumors. Patients with aneuploid RCC had no benefit from this treatment. CONCLUSIONS: The data show that an interferon treatment in non-metastatic RCC might improve survival in patients with the prognostic better diploid tumors. However further investigations are necessary to give a general recommendation for this therapy in this group of patients. Additional molecular tumor factors like S-phase analysis and others might also improve patient selection.

Adjuvant immunotherapy in renal cell carcinoma--comparison of interferon alpha treatment with an untreated control.

BACKGROUND: Adjuvant immunotherapy of RCC with interferon alpha is still controversial. It was the aim of this study to investigate, whether a selected group of patients with a non-metastatic RCC can profit from this therapy. MATERIALS AND METHODS: Survival data of 125 patients with a non-metastatic RCC, who underwent a tumor-nephrectomy were analyzed retrospectively, 33 of these patients received an adjuvant immunotherapy with interferon alpha for 1 year. All tumors were classified by the TNM-system. Statistical evaluation was performed by the Kaplan-Meier-Method and the logrank-test. RESULTS: Tumor stage was seen to be an important prognostic factor in RCC with a significantly better outcome in pT2- as compared to pT3-tumors. Tumor grading was without any prognostic relevance. Adjuvant interferon alpha therapy had no effect on overall survival. After separation of the patients into pT2- and pT3/4-tumors again interferon alpha showed no significant benefit for one of the 2 groups. CONCLUSIONS: The adjuvant therapy with interferon alpha shows no significant benefit in the treatment of non-metastatic RCC. Tumor stage is no suitable factor to select a group of patients, who might profit from an interferon alpha therapy. Further studies are necessary to isolate better selection factors.

Special considerations for restorative dentistry in geriatric patients.

Restorative dental procedures for the elderly patient should be conservative. The principal objectives should be to do what is most constructive to keep the dental structures intact, functional, comfortable, and cosmetically pleasing. The dentist has the responsibility to do whatever is possible or most expedient to improve and maintain the quality of life for the aged.

[Tissue engineering of the urethra and ureter]. / Tissue Engineering der Harnröhre und des Harnleiters.

Congenital or acquired disorders of the urethra or ureter often require adequate tissue transfer for reconstruction. A variety of biomaterials have proved to be useful in the reconstruction of the urethra or ureter in animal models and meanwhile even clinically. Innovative tissues such as acellular matrices can be placed in the host and function as a scaffold to allow the natural process of tissue regeneration. Biodegradable scaffolds can also be used as cell transplantation vehicles for the reconstruction of urethral or ureteral tissue. One of the limitations of cell-based tissue engineering techniques however is the difficulty of growing genitourinary-associated cells in large quantities in primary cultures. It can be speculated that stem cell research might help to overcome this specific problem in the future.

[Advantages of nerve-sparing pelvic surgery. Animal experiments and clinical results]. / Vorteile der nerverhaltenden Beckenchirurgie. Tier experimentelle und klinische Ergebnisse.

Traditionally, oncological factors have been the only ones used in the evaluation of treatment outcome for urological tumor patients. With increased diagnoses of early, curable tumors in younger individuals, health-related quality of life and functional aspects are gaining importance. Sexual and urinary function are significant aspects of quality of life, which are especially vulnerable in urological patients. New insights into the anatomy and physiology of the pelvic organs have resulted in an improvement in surgical therapy. In this article, we present the results of current experimental and clinical studies, which underline the importance of nerve sparing techniques for maintaining a satisfying urinary and sexual function in this patient population.

[Telerobotic surgery between Baltimore and Munich]. / Telerobotische Chirurgie zwischen Baltimore und München.

The rapid development of laparoscopy in urology necessitates the training of specialists to guarantee the high standard of patient care. The real-time data communication of medical information between physicians in different locations is known as telemedicine. Telementoring describes the assistance of an experienced surgeon, while telerobotics requires the use of robots. Two robots, the established AESOP and the PAKY + RCM developed at the Johns Hopkins Hospital (JHH), were used to perform a telerobotic laparoscopic renal cyst ablation in cooperation between Baltimore and Munich. The telementor maneuvered the robots over a distance of 8000 km using eight ISDN lines and a PC. AESOP moved the camera, while PAKY allowed the use of a fan retractor in the abdomen. The telerobotic operation was performed without complications or system and communication failures. Telementoring can be used for training purposes but also for consultation between specialists in emergency settings.

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population.

OBJECTIVE: Despite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique. PATIENTS AND METHODS: From August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9-67) months. In all cases, a non-functioning upper pole with an obstructive (n=4) or refluxing (n=1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars. RESULTS: Mean follow-up was 42.4 (+/-7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170-210)min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4-7) days. All patients were followed using duplex sonography. CONCLUSIONS: These data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.

Laparoscopic retroperitoneal lymphadenectomy in the management of low-stage testicular cancer: technique and results.

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for detection of lymph node metastases of testicular cancer. Because of its invasiveness and morbidity the acceptance of open RPLND has decreased significantly resulting in a diagnostic deficit. To reduce morbidity and to increase the acceptance of RPLND, laparoscopy has been introduced. Meanwhile, clinical data with long-term follow-ups are available demonstrating the technical feasibility and oncological safety of laparoscopic RPLND. Studies comparing laparoscopy and open surgery could show advantages for the laparoscopic approach concerning blood loss, intraoperative complications and operative time. Antegrade ejaculation can be preserved in the majority of patients. In conclusion, laparoscopic RPLND is a safe method for the management of low-stage germ cell tumors with minimal invasiveness and excellent clinical results. With an increasing number of urologists trained in laparoscopy and an increasing number of published data, it may become a standard approach for low-stage nonseminomatous testicular cancer.

[A retroperitoneal hydatid cyst--a rare manifestation of Echinococcus granulosus]. / Die retroperitoneale Hydatidzyste--eine seltene Manifestation des Echinococcus granulosus.

A rare case of a retroperitoneal cyst of Echinococcus granulosus in a male adult is presented. Due to its extension and infiltration of important anatomical structures the hydatid cyst could not be completely removed by operation. Therefore the patient was treated with albendazole for 10 months after surgery. The efficiency of this combined therapy was documented by CT-scan, specific blood tests and histopathological findings.

Leukocyte/endothelial interactions and blood-brain barrier permeability in rats during cerebral superfusion with LTB4.

The experimental study analyses the vasomotor response (change of diameter of pial arterioles and venules), and blood-brain barrier function of the pia-arachnoidea at the rat brain surface before, during and after cerebral superfusion with 1.5 or 15.0 nM LTB4 in mock CSF. Leukocyte dynamics were studied by assessment of their centerline velocity, of rolling along ("roller") and attachment to ("sticker") the venular wall of white blood cells intravitally stained by Rhodamin 6G. Superfusion of the brain with LTB4 at both dose levels led to dilation of arterioles to 130% (p < 0.001), while of venules to 117% (p < 0.001) of control. The centerline velocity of leukocytes increased from 0.7 to 0.9 mm/s, however, only after superfusion with LTB4 at the high dose level. LTB4 induced a dose-dependent rolling (p < 0.01) and sticking of leukocytes (p < 0.001). Yet, a delay of about 60 min between cerebral administration of LTB4 and the maximal response of leukocyte rolling and sticking was observed. Whereas the blood-brain barrier was not opened by cerebral superfusion with 1.5 or 15.0 nM LTB4, for i.v. Na(+)-fluorescein, barrier leakage was promptly induced by 30.0 nM. The present findings demonstrate that cerebral administration of LTB4 by superfusion of the exposed brain surface is eliciting a pronounced vasomotor response, whereas the induction of leukocyte/endothelial interactions is less impressive.

Use of hydro-jet cutting for laparoscopic partial nephrectomy in a porcine model.

OBJECTIVES: To evaluate whether a laparoscopic hydro-jet device can provide a safe and effective partial nephrectomy. Partial nephrectomy is still one of the most challenging operations in urologic laparoscopy. The control of hemorrhage is very difficult to achieve with laparoscopic techniques. In open surgery, hydro-jet resection is used to cut the renal parenchyma selectively, avoiding damage to the vascular structures or collecting system.Methods. Laparoscopic wedge, as well as pole, resections of the kidney were performed in 5 pigs under general anesthesia. After exposure of the kidney, the renal capsule was incised using electrocautery. The hydro-jet was then used to dissect the renal parenchyma. In pole resections, the collecting system and central vessels were divided using an Endo-GIA. Hemostasis was achieved by electrocoagulation or clips. The dissection time and intraoperative complications were evaluated.Results. The operations were performed successfully in all animals without temporary ischemia. The hydro-jet generator allowed precise and effective tissue dissection without significant hemorrhage. The parenchymal vessels were selectively coagulated. The collecting system and central vessels remained intact and could be divided after application of the Endo-GIA. The mean dissection time was 42 +/- 6 minutes for the wedge resections and 54 +/- 8 minutes for the pole resections. CONCLUSIONS: These experimental results demonstrate the suitability of hydro-jet dissection for safe laparoscopic partial nephrectomy without temporary ischemia and with reduction of the operative trauma to the kidney. On the basis of our own experiences with other techniques, including electrocautery and laser technology for partial nephrectomy, we conclude that laparoscopic hydro-jet resection represents an interesting alternative to other techniques.

Effect of stimulation of leukocyte chemotaxis by fMLP on white blood cell behaviour in the microcirculation of rat brain.

The role of white blood cells in acute cerebral disorders such as ischemia or stroke is still unclear. Therefore, in the present study we investigated the effects of the leukotaxin n-formyl-methionyl-leucyl-phenylalanine (fMLP) on white blood cell endothelial-cell interactions in the rat brain surface microcirculation. An improved closed cranial window technique was applied. Superfusion of fMLP in rising concentrations (10(-8) - 10(-5) M) was seen to induce rolling and adherence of leukocytes to teh endothelium of small venules. Rolling was more effectively stimulated than firm attachment. fMLP-induced vasodilation was more pronounced in arterioles than in venules. In this study it has been shown that the hydrophilic fMLP is effectively stimulating neutrophil chemotaxis across the blood-brain barrier. Further, the closed cranial window preparation is useful to analyze quantitatively properties of activated leukocytes, which may be pertinent in injury to the blood-brain barrier and induction of microcirculatory disturbances.

An in vitro model for videoimaging of human bladder smooth muscle cell contractions.

Knowledge regarding human bladder smooth muscle cell (SMC) physiology is very limited. Only a few specific medical therapies for bladder disorders have therefore been established. The objective of this study was to develop a model for videomicroscopy of bladder SMC contractions. Cells were isolated from human cystoprostatectomy specimens and cultured in a modified EMEM medium. These cells were identified as SMCs by means of immunohistochemistry. For videomicroscopy, the culture flasks were coated with a viscous agent to allow cell contraction. Contractions were visualized by means of a cell culture microscope with a time-lapse videosystem. For cholinergic stimulation of the cells, acetylcholine, in concentrations ranging from 100 microM to 10 mM, was applied. The percentage of contracting cells within the observation field was evaluated for quantitative analysis. In control experiments without contractile stimulant 6% of the cells were observed to contract. Stimulation with acetylcholine induced a significant dose-dependent increase to 47% in contracting cells. These results demonstrated that videomicroscopy is an appropriate tool to investigate the contraction mechanisms of bladder SMCs. This model offers the possibility of studying drug effects on the human detrusor in vitro.

Renal cell carcinoma in a horseshoe kidney--superselective embolization of a vessel in a remaining calix after partial nephrectomy.

A 51-year-old patient underwent partial nephrectomy because of a renal cell carcinoma in a horseshoe kidney. Postoperatively a remaining calix led to persistent urinoma formation. By means of superselective embolization urine extravasation was stopped successfully. This demonstrates that superselective embolization can be an effective tool in the management of complications after open renal surgery.

Human rhabdosphincter cell culture: a model for videomicroscopy of cell contractions.

BACKGROUND: Physiology of the human rhabdosphincter and its innervation are still a subject to controversy. A better understanding of rhabdosphincter function and anatomy might help to solve important urological problems like urinary incontinence. It was the aim of the present study to develop a human sphincter cell culture model for investigation of contraction mechanisms in vitro. METHODS AND RESULTS Cells were isolated from human rhabdosphincter tissue obtained from prostatectomy and cystoprostatectomy specimens. Cultured cells expressed typical features of striated muscle cells. By means of videomicroscopy with a time lapse videosystem cell contractions could be documented. Under control conditions without any contractile stimulant 8% of the cells were seen to contract. Cholinergic stimulation with 10 mM of acetylcholine induced a significant increase in contraction rate to 49%. CONCLUSIONS: These results demonstrate that cholinergic stimulation triggers contraction of cultured human rhabdosphincter cells. This model might help to understand external urethral sphincter physiology and to establish new therapies for the treatment of sphincter dysfunctions. Prostate 47:189-193, 2001.

Simultaneous microsurgical spermatic vein ligation and sclerotherapy. a combined procedure for the treatment of recurrent or persistent varicocele.

OBJECTIVES: Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery and sclerotherapy can provide a safe and effective treatment of varicocele recurrence or persistence. METHODS: Nine patients with recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was performed through one of the dissected veins. RESULTS: Despite difficult anatomical situations after previous surgical interventions, the operations were performed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed. CONCLUSIONS: This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles.

Leukocyte-endothelium-interaction in pial vessels following global, cerebral ischaemia.

BACKGROUND: Investigations have shown an increase of leukocyte-endothelium-interaction in a variety of organs following an ischaemic insult. To elucidate the role of leukocyte-endothelium-interaction following global, cerebral ischaemia the present study was performed. METHODS: Global, cerebral ischaemia was induced for twenty minutes by four-vessel-occlusion (PULSINELLI). Leukocyte-endothelium-interaction was studied in the cerebral microcirculation using a rat closed cranial window and intravital microscopy. Leukocytes were stained intravenously using rhodamine 6G. Diameters of pial vessels, leukocyte centreline velocity and number of rolling or adhering leukocytes were determined off-line up to 2 h following global cerebral ischaemia. To confirm these results immunohistochemistry of the brain was performed. FINDINGS: Four-vessel-occlusion induced an iso-electric EEG, venular stasis and minimal rest flow in arterioles. Reperfusion yielded a significant increase of the arteriolar (p < 0.001) and a smaller increase of the venular diameters (p < 0.01). Up to 2 h after ischaemia no significant increase of the number of rolling or adhering leukocytes was measured which was confirmed by immunohistochemistry. INTERPRETATION: In contrast to other studies, in particular regarding focal cerebral ischaemia, an increase of leukocyte-endothelium-interaction in rat brain following 20 min of global cerebral ischaemia was not observed despite histological evidence of ischaemic damage. Thus in our model leukocytes seem not to contribute to the brain damage following global ischaemia.