Laparoscopic fenestration of lymphoceles after kidney transplantation with diaphanoscopic guidance

In laparoscopic fenestration of lymphoceles after kidney transplantation, identification of the correct site of incision is sometimes difficult. We developed a new technique, using diaphanoscopy in 3 patients. After ultrasound-guided puncture and dilation, the correct incision site is identified by white light with a cystoscope inserted into the lymphocele cavity.

Angiomyolipoma with a caval thrombus

We report the case of a female patient presenting with flank pain. Abdominal ultrasound revealed a tumor of 8 cm in diameter. After abdominal computerized tomography, the tumor was classified as angiomyolipoma with a tumor thrombus in the inferior vena cava. After nephrectomy, the diagnosis was confirmed histologically. To our knowledge, this is the 11th case of a renal angiomyolipoma extending into the vena cava.

Value of transrectal ultrasound in preoperative staging of prostate cancer

BACKGROUND

The aim of the study was to compare preoperative transrectal ultrasound findings with final histopathological stage after radical prostatectomy to determine the value of TRUS in preoperative staging of prostate cancer.

METHODS

The evaluation was performed as a retrospective study. In 114 radical prostatectomy specimens the histopathological, ultrasound and rectal digital findings were correlated. Mean age of patients was 63 years and in all patients a radical retropubic prostatectomy was performed.

RESULTS

Organ confined PC was found correctly with TRUS in 68% and capsular penetration in 32%. Corresponding findings with digital rectal examination (DRE) were 68% and 17% respectively. Sensitivity of TRUS in organ confined PC (T1-2) was 66.1% (DRE 68.5%), specificity 32.6% (DRE 20%) and positive predictive value 55.7% (DRE 49.3%). Sensitivity, specificity and positive predictive value of TRUS for stage T3 (a,b,c) were 32.6%, 68.4% and 45.5% respectively. A separate evaluation of stage T3c revealed for TRUS: sensitivity 41.2%, specificity 81.8% and positive predictive value 36.8%.

CONCLUSION

On the basis of this retrospective analysis, and due to the low sensitivity and specificity, TRUS is not suitable for adequate preoperative staging of prostatic cancer.

[Nephrogenic adenoma after kidney transplantation]

We report five cases of nephrogenic adenoma that arose several years after cadaver kidney transplantation. Cystoscopy was performed in all patients because of gross haematuria and revealed multifocal tumorous lesions in all parts of the bladder. On admission to of hospital graft function was satisfactory in all patients. There were three female and two male patients. In all patients the therapeutic procedure consisted of transurethral resection. Only very small lesions were fulgurated. Postoperatively an indwelling catheter was left in place for 2-4 days, and after a check on kidney parameters and immunosuppressive therapy all patients were discharged. Postoperative management consisted in cystoscopy every 3 months in the first year and then every 6 months. Though the etiology of nephrogenic adenoma remains unclear, mechanical traumatization and recurrent urinary tract infection seem to be the most important factors in its development.

[Laparoscopic ligation of spermatic vessels in varicocele]

Open surgical procedures and percutaneous transvenous radiological techniques are available for the treatment of varicoceles. With the advent of laparoscopic surgery another minimally invasive procedure has become available. In 39 patients with left unilateral and 1 with bilateral, clinically evident, varicocele laparoscopic ligation of the spermatic vessels was performed. In 17 cases both the spermatic veins and the artery were cut, whereas in 24 cases it was possible to spare the spermatic artery. In more than 90% of these cases the artery could be identified as a pulsatile vessel. No serious complications were encountered. All patients were discharged from the hospital on postoperative day 1 or 2. Out of 26 patients who could be followed clinically and by colour coded Duplex sonography, 1 showed signs of persistent and 1 of recurrent varicocele. The quick convalescence of the mostly young patients, the excellent identification of the anatomic structures, and the minimal surgical trauma are advantages of laparoscopic varicocelectomy.

In situ extracorporeal shock wave lithotripsy of ureteral calculi with the MPL-9000X lithotriptor

Within the wide armamentarium of urinary stone treatment modalities extracorporeal shock wave lithotripsy (ESWL) has been established as the first line procedure. With the Dornier MPL-9000X lithotriptor one has the choice of ultrasound or fluoroscopic localization of calculi throughout the entire urinary tract. Except for the kidney, ultrasound guidance is preferred for calculi in the distal ureter, while fluoroscopy is generally used on the proximal two-thirds of the ureter. Between January and December 1990, 123 ESWL treatments were performed on 83 patients suffering from ureteral calculi with an average stone size of 9.3 x 6 mm. Median treatment parameters were 1,597 shock waves at 19.3 kv. for 43 minutes. For stones in the upper two-thirds of the ureter sedation analgesia was given, while ESWL on the pelvic ureter did not create intolerable pain. Of the treatments 69% were done on an outpatient basis. In situ ESWL treatment of urinary calculi was successful in 72 patients (86.7%), and 20 patients (24.1%) were treated with multiple treatment sessions. ESWL therapy for 47 stones in the distal ureter showed better results than for 33 stones plus 2 steinstrasse in the proximal part (95.5% versus 80% stone-free rate). Of 4 patients with mid ureteral calculi 2 could be rendered stone-free by ESWL alone. Auxiliary procedures, such as percutaneous nephrostomy or ureteral splints, had to be performed in 15.7%. Final endoscopic stone extraction was done in 7 cases and open surgery in 4, constituting a 13.3% failure rate for ESWL therapy. The results prove that the MPL-9000X lithotriptor is effective for primary noninvasive stone treatment.

[Combined ultrasound-urodynamic study in paraplegic patients]

Over a period of 2 years (1989-1991), combined urodynamic and ultrasonic investigations of the lower urinary tract were performed in 80 patients with spinal cord injuries. The main advantage of this procedure proved to be the lack of irradiation to both patient and investigator. Besides the real-time image of the bladder, bladder neck, prostate, pelvic floor and urethra, functional conclusions were possible, especially when urodynamic pressure curves were also considered.

Ultrasonography of urinary tract and micturition as an alternative to radiologic investigations in the spinal-cord-injured patient

Over a period of 1.5 years (July 1989-Jan. 1991), a total of 504 patients, 442 of them suffering from spinal cord injuries with subsequent voiding disorders, were investigated by ultrasonography of the genitourinary tract. Ultrasonography of the upper urinary tract as well as the bladder and prostate provided and accurate image of the pathomorphological changes which go along with this kind of malfunction of the lower urinary tract in this group of patients. The application of rectal ultrasonography using a linear array rectal transducer was able to provide equal or even better images of the micturition process than micturition cystourethrography (MCU). An adequate and accurate real time image of the bladderneck, the prostatic urethra and the external rhabdosphincter could be obtained in all instances. Combined micturition cytourethrosonography (MCUS) with urodynamic evaluation has also been performed, which made the observation and judgement of the bladder outlet as well as the position of the catheter possible throughout the procedure without the interference of X-rays.

Results after organ-preserving surgery for renal cell carcinoma. An Austrian multicenter study

Data from 120 patients diagnosed as having renal cell carcinoma (RCC), and treated in an organ-preserving surgical manner were analyzed from 11 participating Austrian urological centers. The male to female ratio was 66:54. The subjects age ranged from 27 to 75 years with mean age of 59 years. The indication for conservative tissue-saving surgery was a solitary kidney in 48 instances, a bilateral RCC in 18 cases and, in 2 patients, a horseshoe kidney tumor. In 52 cases the indication for conservative surgery was a peripheral, easily resectable, low-stage tumor (elective indication). Results were comparable to radical nephrectomy of low-stage tumors especially relating to survival rates. Ninety-nine patients survived and were tumor free at the point of check up (December 1988). Thirteen patients had either local tumor recurrence and/or metastases and 5 patients died from the disease. The operative mortality and the morbidity rate was very low.

Evaluation of ileum interposition in ureterosigmoidostomy: experimental studies

Experiments in juvenile house pigs with a valved uretero-ileosigmoidostomy were performed, and the advantages of this procedure as against common methods were assessed. Postoperative studies up to 6 months revealed encouraging results in respect of function, infection rate, kidney function, serum electrolyte pattern and as to macro- and microhistological appearances. The results were considered superior to those obtained by simple ureterosigmoidostomy as shown by control groups.

Malignant tumor resection in the solitary kidney: use of hypothermic hyperosmolar renal preservation method

In 4 out of 8 patients with a malignant tumor in a single or in a solitary kidney, partial nephrectomy was performed under ischemic conditions. To avoid severe ischemic damage the kidneys have been flushed with a cold hyperosmolar intracellular-type electrolyte solution. In all cases excellent kidney function was obtained postoperatively and no tumor recurrence was observed 18 months to 5 years later.

[Pathophysiology of kidney lesions after temporary ischemia and measures for their prevention]

The efficacy of the so-called "hyperosmolar kidney preservation" is pointed out with respect to protecting the kidney from the otherwise lethal effect of protracted periods of normothermic ischemia. Furthermore the protective effect of various pharmacologic agents against 2 and 3 hours of normothermic ischemia is investigated and the morphology and pathophysiology of renal ischemic damage is pointed out. In further experiments extracorporeal renal operations were performed in 12 dogs to determine the efficacy of a new renal preservation method.

Urinary calculous disease in childhood

Reviewed are 56 cases of children suffering from urinary calculous disease between 1970 and 1977; 27 were female and 29 male. The age distribution was from one month to fourteen years. In 34 per cent of the children urodynamic disorders were responsible for stone formation, 23 per cent had identifiable metabolic disorders, and in 43 per cent the cause of stone formation was unknown. Urinary infection was present in 60 per cent of the patients. Forty-five of the 56 children (80 per cent) had to undergo surgery. After surgery 78 per cent remained stone free, while 16 per cent had recurrent stones, only half requiring a second operation. In cases of active stone disease, especially in the group with underlying metabolic disorders, specific therapeutic measures have been applied and the patients regularly investigated afterward.

Uric acid calculi: results of conservative treatment

A total of 140 patients with uric acid diathesis have been treated for the last five years with a standardized mixture of sodium and potassium citrate and citric acid (Uralyt U) together with forced fluid intake and, if necessary, the addition of allopurinol. The results have been encouraging; 80 per cent of the patients showed complete dissolution of the stones and relief of symptoms.

[Bone marrow acid phosphatase determination in patients with carcinoma of the prostate (author's transl)]

Acid phosphatase was determined in bone marrow aspirates in a consecutive series of 28 patients, 19 of whom had a proven carcinoma of the prostate. The value of this procedure is pointed out in respect to the diagnosis and staging of a prostatic carcinoma and the literature is reviewed.

[Pathophysiological damage to the kidney due to temporary ischemia and measures to avoid these changes (author's transl)]

The efficacy of the so-called 'hyperosmolar kidney preservation' is proved experimentally and clinically with respect to protecting the kidney from the otherwise lethal effect of protracted periods of warm ischemia. Furthermore, the protective effect of various pharmacologic agents against 2 and 3 h of normothermic ischemia is investigated and the pathophysiology of renal ischemic damage is pointed out.

External velour dacron grafts in renal artery reconstruction

Aortorenal interposition grafts were performed in dogs using a new external velour knitted Dacron graft. Encapsulation and endothelialization of these grafts occurs as early as two weeks postoperatively. Complete healing is seen by six weeks, and the cellular lining of these grafts appears to be continuous with, and histologically similar to, the endothelium of contiguous arteries. The healed nonthrombogenic characteristics of this graft material represents a considerable improvement over graft materials of conventional design.

[Extracorporeal renal surgery using a new preservation method(author's transl)]

Extracorporeal renal operations were performed in 12 dogs to determine the efficacy of a new renal preservation method. Serveral ex vivo surgical techniques are described, illustrated and the literature reviewed. A single perfusion of the totally ischemic kidney with a new hyperosmolar intracellular electrolyte solution provided sufficient protection from the otherwise lethal effect of 5 hours ambiothermic exposure. Pre- and postoperative serum creatinine levels were assessed to determine renal function.