Percutaneous Stone Manipulation.

Percutaneous stone manipulation by direct ultrasound disintegration, extraction or chemolysis was done on 34 patients. A total of 15 patients presented with an operatively established nephrostomy, while percutaneous nephrostomy and subsequent dilation of the nephrostomy channel were done in 19. The rate of complete stone clearance was 19 of 20 stones after percutaneous nephrostomy and 8 of 16 stones in the group with an operatively established nephrostomy. The primary goal, to remove obstructing pelvic stones, was achieved in all cases. There were no untoward side effects, such as back pressure damage owing to flushing of the collecting system during ultrasound disintegration, or persistent infection. Complications in 3 patients were managed conservatively.

[Percutaneous embolization of the kidney: indications and clinical results]. / Perkutane Totalembolisation der Niere: Indikationen und klinische Ergebnisse.

OBJECTIVE: Renal embolisation offers a minimal invasive means of renal ablation under primary palliative indication. We evaluated our experience with this technique in a series of 40 patients. PATIENTS AND METHODS: From 1996 to 2002 a total of 40 patients underwent total embolisation of the kidney. Our patients encompassed 15 females and 25-males (median age: 68 years, 46 - 89 years). In 15 patients indication for embolisation was to ablate a non-functioning kidney following obstruction due to advanced cancer, in 9 patients preoperatively with advanced renal cell carcinomas invading the vena cava, in 8 patients for control of hematuria and in 8 patients with non-operable advanced renal cancers. The embolisation was carried out in DAS-technique with a 7 Fr. selective catheter and central placement of macrocoils, from 2000 on we additionally performed a peripheral embolisation with polyvinylalcohol (PVA) particles. The intervention took place in epidural anesthesia. RESULTS: Perioperatively in all patients a complete occlusion of the renal artery as well as acessory arteries (n = 6) could be documented radiographically, perioperative complications were not observed. A post-embolisation syndrome occured in 32 patients. Reinterventions with repeat embolisation became necessary in 5 patients (persistent urine production-n = 4, persistent hematuria-n = 1). SUMMARY: The combined central and peripheral embolisation of the kidney in epidural anesthesia is a valuable means in selected patients under palliative indication for defunctionalisation of the kidney as well as control of hematuria.

Sacral bladder denervation for treatment of detrusor hyperreflexia and autonomic dysreflexia.

OBJECTIVES: Detrusor hyperreflexia after spinal cord injury may cause urinary incontinence and chronic renal failure. In patients refractory to conservative treatment and not eligible for ventral sacral root stimulation for electrically induced micturition, we investigated the therapeutic value of sacral bladder denervation as a stand-alone procedure. METHODS: Nine patients (8 men and 1 woman) between 21 and 58 years old (mean 30.2) with traumatic suprasacral spinal cord lesions underwent sacral bladder denervation for treatment of detrusor hyperreflexia and/or autonomic dysreflexia. RESULTS: Detrusor hyperreflexia and autonomic dysreflexia were eliminated in all cases. Bladder capacity increased from 177.8 +/- 39.6 to 668.9 +/- 64.3 mL; intravesical pressure decreased from 89.3 +/- 19.1 to 20.2 +/- 2.7 cm H(2)O. For facilitating clean intermittent catheterization (CIC), 4 patients received a continent vesicostomy in a second-stage procedure; one of them in combination with bladder augmentation. Four patients empty their bladder by way of urethral CIC. One completely tetraplegic patient has an indwelling urethral catheter. In the 5 patients with autonomic dysreflexia, the systolic blood pressure was lowered from 196 +/- 16.9 to 124 +/- 9.3 mm Hg and the diastolic blood pressure from 114 +/- 5.1 to 76 +/- 5.1. The annual frequency of urinary tract infections decreased from 9 +/- 1.2 to 1.8 +/- 0.7. In all patients, renal function remained stable. CONCLUSIONS: In selected patients with detrusor hyperreflexia and/or autonomic dysreflexia, sacral bladder denervation is a valuable treatment option. It is only moderately invasive in nature, requires neither sophisticated nor expensive medical equipment, and is an attractive alternative to urinary diversion using intestinal segments.

Continent reconstruction of detrusor hyperreflexia by sacral bladder denervation combined with continent vesicostomy.

We describe a two-stage surgical procedure for complex hyperreflexic detrusor dysfunction refractory to conservative therapy. First, ventral and dorsal sacral rhizotomies (S2 to S4/5) are performed to restore vesical storage function and abolish autonomic dysreflexia. Then, after an interval of several weeks to allow for detrusor relaxation, continent vesicostomy is performed for suprapubic clean intermittent catheterization. The procedure is effective both objectively and subjectively, is only moderately invasive, and requires neither sophisticated nor expensive medical equipment.

Neourethra: a new two-stage procedure for reconstruction of the functional urethra.

In 14 male dogs, the functional urethra was replaced by a bladder flap tube in a 2-stage procedure. In the 1st stage of the operation a bipedicle strip from the anterior bladder wall was tubularized around a 10F or 12F catheter. After 10 to 12 weeks the 2nd stage of the procedure was performed: the bladder neck was transected and sutured, and the cranial pedicle of the bipedicle tube was transected and pulled through the bluntly dissected pelvic floor muscles. From the distal end of the tube a perineal urostoma was created to facilitate radiological and urodynamic followup. Eight dogs completed a followup 5 months after the 2nd procedure. Urodynamic and x-ray studies were done preoperatively, after the 1st, and twice after the 2nd operation. All dogs were continent as a result of a mean functional urethral length of 8 cm. with a maximum closure pressure of 82.9 cm. H2O. Closure pressure was related to the tone of the smooth muscular tube and additional compression of the tube by the pelvic floor muscles. The method is considered to be applicable in cases of congenital defects or total loss of the functional urethra.

Localization of segmental arteries in renal surgery by Doppler sonography.

To avoid damage to major arteries of the renal parenchyma during nephrotomy, intraoperative Doppler sonography was used experimentally and clinical as an artery finder. In experiments with 7 beagles segmental arteries were detected easily and reliably by sonography, and the arterial course thus indicated correlated perfectly with arteriograms and casts. In a clinical trial the Doppler artery finder was used in 7 patients with staghorn calculi that were removed via the renal pelvis and additional multiple selective nephrotomies with as many as 7 selective nephrotomies in a single kidney there was no damage to the major arteries in any of these patients. Selective, avascular nephrotomy with the aid of the simple, quick and reliable technique of Doppler sonography promises improved functional results of transparenchymal stone manipulation.

Percutaneous kidney stone removal.

Percutaneous nephrostomy has proved to be a reliable method to establish access to the collecting system of the kidney. Without adding any significant morbidity, this access can be used for the removal of kidney stones by simple extraction, chemolysis or ultrasound lithotripsy. A nephrostomy channel of the required size is rapidly and atraumatically established with a telescope dilation set. A set of instruments especially developed for intrarenal instrumentation is necessary to guarantee a low residual stone rate. With the use of intrarenal ultrasound disintegration the technique is successful regardless of stone composition and size.

Percutaneous stone manipulation.

Percutaneous stone manipulation by direct ultrasound disintegration, extraction or chemolysis was done on 34 patients. A total of 15 patients presented with an operatively established nephrostomy, while percutaneous nephrostomy and subsequent dilation of the nephrostomy channel were done in 19. The rate of complete stone clearance was 19 of 20 stones after percutaneous nephrostomy and 8 of 16 stones in the group with an operatively established nephrostomy. The primary goal, to remove obstructing pelvic stones, was achieved in all cases. There were no untoward side effects, such as back pressure damage owing to flushing of the collecting system during ultrasound disintegration, or persistent infection. Complications in 3 patients were managed conservatively.

Effect of low-power density laser radiation on healing of open skin wounds in rats.

We performed a study to determine whether laser radiation of low-power density would affect the healing of open skin wounds in rats. The wounds were irradiated daily with a helium-neon laser (wavelength, 632.8 nm) and an argon laser (wave-length, 514.5 nm) at a constant power density of 45 mW/sq cm. The rate of wound closure was followed by photographing the wounds in a standardized way. The collagen hydroxyproline concentration in the scar tissue was determined on the 18th postoperative day. Helium-neon laser radiation had a statistically significant stimulating effect on collagen synthesis in the wound, with a maximum effect at an energy density of 4 joules/sq cm. The rate of wound closure was enhanced significantly between the third and 12th postoperative days. The argon laser exposure produced a significant increase in collagen concentration both in irradiated and nonirradiated contralateral wounds. However, an acceleration of the healing rate was not registered in this case. The wound contraction up to the fourth day of the experiment was inhibited under helium-neon and argon laser exposure to 20 joules/sq cm. The described effects were not specific for the laser light. There may be a wavelength-selective influence of coherent light on the metabolic and proliferation processes in wound healing, with the associated problem of the possible carcinogenic effects of laser radiation.

Transplantation of a free peritoneal patch in surgery of the renal pelvis and ureter.

Operations on the urinary collecting system successfully utilized the free peritoneal patch in a variety of situations, as animal experiments have shown. When used to cover defects the peritoneum works as a multipotent matrix for invasion of urothelium; when used as an envelope it prevents stricture due to perihilar/periureteral scarring. We used a free peritoneal patch in 31 operations on the renal pelvis and ureter between 1975 and 1980. The indications for the patch were; defects of the renal pelvis of ureteropelvic junction due to surgery for recurring stones or carcinoma of the pelvis; and pyelocalicotomy of an intrarenal pelvis if it was impossible to suture the pelvis. We also used the patch to envelop renal pelvis and ureter in extended perihilar inflammation or stenosis of the pyeloureteral junction and proximal ureter due to scarring. The results, as shown by urography, were excellent or good in 25 or the 31 cases. The transplantation of a free peritoneal patch is a simple, reliable technique that can be recommended for covering defects or preventing stricture in surgery of the renal pelvis and ureter.

[Postoperative complications: the value of sonography for their diagnosis and therapy]. / Postoperative Komplikationen: Die Bedeutung der Sonographie für ihre Diagnostik und Therapie.

The final diagnosis of a retroperitoneal abscess is made, on the average, 3--17 weeks after the first appearance of uncertain clinical symptoms. The accuracy of sonography for the recognition of postoperative complications such as hematoma, urine extravasation, abscesses or lymphoceles is 78--86%. In addition to computer tomography, sonography is the only diagnostic method available for early recognition of retroperitoneal processes. Ultrasonically guided puncture is used to confirm the diagnosis. If left in place, the puncture serves simultaneously as a urinary extravasation drainage.

[Wound healing after laser and red light irradiation]. / Wundheilung nach Laser- und Rotlichtbestrahlung.

Laser irradiation and red light irradiation, daily 2 respectively 4 J/cm2, do not bring any acceleration of wound healing in rats. No significant effect was evident in the cell pattern of wounds during various phases of healing through the irradiation. The tensile strength of cicatrices increased by laser irradiation, but not by red light irradiation (monochromatic lambda = 633 nm).

[Case report: percutaneous nephrostomy and instrumental extraction of a blocking renal claculus under local anesthesia (author's transl)]. / Fallbericht: Perkutane Nephrostomie und instrumentelle Steinentfernung in Lokalanästhesie.

Percutaneous nephrostomy under ultrasonic guidance is a reliable method for suprapublic urinary diversion with a low complication rate. Indications are acute or chronic obstruction of the upper urinary tract from the intravesical ureter to the neck of renal calyx. Etiology of the obstruction may be a renal or ureteral calculus, an intrinsic or extrinsic (radiogenic, inflammatory, tumorous) stenosis of the ureter or a functional ureteral obstruction (megaureter, reflux). In the reported case of an ultrasonically guided percutaneous nephrostomy, the indication for urinary diversion was blocking renal calculus with urosepsis. Any operative procedure was contraindicated because of several internal disease. With sufficient urinary drainage, fever subsided and gradual dilatation of the nephrostomy channel with instrumental extraction of the calculus could be performed under local anesthesia. Percutaneous nephrostomy is recommended for urinary diversion in cases of blocking renal calculi with infection if an operation cannot be performed. This approach bears the option of a later cure by intrumental extraction, litholypaxy or chemical dissolution of the stone.

The value of sonography and lymphography in the detection of retroperitoneal metastases in testicular tumors.

Lymphography has led to falsely negative or falsely positive diagnoses in 10 to 45 per cent of the cases of testicular tumor metastases reported in the literature. In our comparative study of lymphography and sonography in the preoperative staging of 29 malignant testicular tumors lymphography was accurate in 58.5 per cent of the cases, while sonography had an accuracy rate of 82.5 per cent. Sonography was superior to lymphography in the evaluation of hilar lymph node metastases and their extent, as well as for routine checkups after lymphadenectomy or irradiation.

[Percutaneous nephrostomy under ultrasound guidance (author's transl)]. / Ultraschall-gesteuerte perkutane Nephrostomie.

34 ultrasonically guided percutaneous nephrostomies were performed without complications. The procedure seems to be applicable in routine clinical use for temporary or permanent urine diversion in hydronephrotic kidneys. The simple technique the low complication and high success rate and independence of kidney function make the technique superior to the standard methods of the percutaneous puncture under radiological control.

[Double urologic tumors: reduced immunocompetence?]. / Urologische Doppeltumoren: verminderte immunkompetenz?

55 patients with primary multiple neoplasias underwent immunostaging with determination of the immunoglobulins, B- and T-lymphocyte counting, H3-lymphocyte stimulation (ConA, PWM, PHA) and DNCB-epidermal test. There were no significant differences between the PMN-group and a group of patients with solitary tumors, whereas both cancer patient groups revealed a diminished immunocompetence compared with a non-malignant control group of patients.

[Parenteral feeding after ureterosigmoidostomy: nitron balance, free plasma amino acids and state of proteins]. / Parenterale Ernährung nach Harnableitungsoperation in den Dickdarm: Stickstoffbilanz, freie Aminosäuren im Plasma und Eiweissstatus.

The postoperative protein metabolism of 11 patients who had required either a colon conduit or ureterosigmoidostomy urinary diversion was examined. From the 3rd to 10th postoperative day day, each patient received a standard parenteral alimentation (100 g amino acids and 2000 kcal/24 h). Nitrogen balance, plasma level of the free amino acids, and the C3c-, C4-complement and transferrin fraction in plasma were determined regularly. The results showed that this substitution therapy succeeded in avoiding serious alterations in the parameters measured.

The free peritoneal transplant as substitute for the urinary bladder wall.

In 13 rabbits the fundus of the bladder was resected and the defect repaired by a free peritoneal transplant from the lateral abdominal wall. One animal died postoperatively of purulent peritonitis. In the remaining animals the transplant healed with no signs of irritation. The mean reduction of bladder capacity per body weight between the 5th and 18th postoperative week was only 13 per cent. Histologic tests after 5 weeks showed a germinating epithelium on the transplant which was replaced by a fibromuscular lamina after 10 weeks. The successful results of these animal experiments seem to justify the clinical use of free peritoneal transplants. The good healing tendency and matrix function of this tissue permit transplantation of the peritoneum wherever intraoperative defects occur or suture dehiscence may be expected.