Alloplastic replacement of the urinary bladder.

PURPOSE: The loss of a functioning bladder is nowadays mostly managed by replacement with gastrointestinal segments. Management of these urinary diversions is difficult and the long-term effects are unknown. We developed a silicone rubber prosthesis for alloplastic replacement of the urinary bladder and tested it in an animal experiment. MATERIAL AND METHODS: Two artificial bladders were implanted into subcutaneous pockets on each side of the anterior abdominal wall. Cystectomy was performed and each prosthesis was connected to one kidney. Distally, a Y-shaped tube sutured to the urethral stump joined the two bladder outlets. The whole system was successfully implanted in 5 sheep with a mean follow-up of 11.5 months (5-19 months). RESULTS: Adequate capacity, effective and reliable mechanical function and patent anastomoses to the renal pelvis and the urethra could be achieved. Blood chemistry and renal ultrasound were performed at regular intervals demonstrating neither morphological nor functional deterioration of the renal parenchyma. Histopathological examination in the end of the experiment confirmed the excellent clinical results. CONCLUSIONS: The positive outcome of these animal experiments suggests this system would be useful for human bladder substitution. Standardized industrial production of the prostheses will be needed prior to implantation in humans.

[Microsurgical treatment for erectile impotence]. / Mikrochirurgische Therapie der erektilen Impotenz.

Using strict selection criteria, peripheral microsurgical revascularization was performed in 23 of 180 patients with erectile dysfunction (seen between February 1987 and December 1988). Average age of the 23 men was 51.8 (44-59) years. In 14 patients, the epigastric artery was transposed end-to-side to a side-to-side anastomosis between the dorsal artery and vein of the penis, while in two a piece of inferior epigastric vein was interposed. In the other seven patients an end-to-side anastomosis was constructed between the inferior epigastric artery and the deep dorsal vein of the penis. After three months, 19 of 20 patients who were followed-up had regular intercourse without intracavernous administration of drugs, after six months 15 of 17, after one year 11 of 14. In two patients irreversible thromboses of the anastomoses occurred when anticoagulant administration, required postoperatively, had been discontinued. The results indicate that with careful selection microsurgical treatment can achieve good results.

Fournier's gangrene in hypersensitivity vasculitis.

Fournier's gangrene in IgE positive hypersensitivity vasculitis demands concurrent high dose immunosuppression, radical surgery and intensive treatment of septic sequelae. Even extended autologous skin grafting is possible with immunosuppression. A case of fulminant necrotizing infection of the genitalia, perineum and abdominal wall during the acute generalization phase of IgE positive hypersensitivity vasculitis is described. Apart from the radical surgical approach, medical treatment demands a different strategy than in classical Fournier's gangrene. The favorable outcome in a 21-year-old man after several months of intensive care could be realized only by close cooperation of internal specialists, urologists and plastic surgeons.

Enhancement of chemically induced bladder carcinoma by cyclosporin A.

The effects of cyclosporin A (CsA) on the induction of bladder carcinoma were investigated in Wistar rats using N-butyl-N (4 hydroxybutyl) nitrosamine (BBN) as a known initiator of carcinogenesis. Rats treated with 0.05% BBN + 5 mg/kg per day CsA or 0.05% BBN + 12.5 mg/kg per day CsA developed a dose-dependent (two to fourfold) enhancement of bladder tumor expansion and infiltration as compared to those treated with 0.05% BBN alone. In control rats receiving CsA at doses of 5 mg/kg per day or 12.5 mg/kg per day, no bladder carcinoma occurred. All CsA-treated groups, with or without 0.05% BBN, displayed slight or moderate medullary atrophy of the thymus. The results indicate that immunosuppression with CsA enhances the induction of bladder tumors by BBN. Furthermore, the immunosurveillance theory that effective expression of the immune response may be important in the control of tumor development was confirmed in the carcinogenesis of epithelial cell tumors.

Natural history and treatment of low and high risk superficial bladder tumors.

Since 1979 a prospective randomized trial was done to examine the efficacy of intravesical doxorubicin as prophylaxis against recurrence. After complete transurethral resection of the tumor, patients were divided into 3 groups at random: group 1-no further treatment after transurethral resection, group 2-doxorubicin twice weekly for 6 weeks and group 3-doxorubicin for 1 year. A total of 268 patients entered the study. Neither frequency of recurrences, tumor progression nor survival rate was improved significantly by the adjuvant treatment, so that only a limited number of patients will profit by instillation therapy. Analysis of previously reported data suggests that patients with superficial bladder tumors can be stratified into groups with appreciable differences in risk of progression. With regard to these results a differentiated use of a "wait and see" adjuvant intravesical therapy and more aggressive treatment after transurethral resection of superficial bladder tumors seems to be indicated rather than a general practice of chemoprophylaxis.

Superselective embolization of inoperable renal carcinoma in patients with solitary kidney.

Arterial embolization is a palliative procedure in the management of advanced renal carcinoma. In solitary kidneys tumors may also be embolized under certain circumstances, i.e. patients with resectable tumors but inoperable because of poor general condition or patients with nonresectable tumors presenting with hemorrhage or paraneoplastic activity. Experience with 2 cases of selective embolization of inoperable renal cancer in solitary kidneys is presented and the indications for embolization, considering deterioration of renal function, are outlined.

[Pharmacologic modification of ureteral activity]. / Pharmakologische Beeinflussung der Harnleiteraktivität.

The renal pelvis and the ureter represent a functional system with myogenic excitation generation and conduction. The activity of this system is modulated by the autonomic nervous system: alpha-adrenergic and cholinergic substances stimulate, beta-adrenergic drugs inhibit the pyeloureteral activity. Besides the sympathetic nervous system with adrenergic postganglionic excitation conduction and the parasympathetic nervous system with cholinergic transmission, non-adrenergic, non-cholinergic systems appear to exist. Vasoactive intestinal peptide (VIP), e.g., markably decreases the frequency and amplitude of the ureteral activity. Calcium antagonists (e.g. nifedipin) lead to a direct inhibition of the ureteral activity: the quick phasic contractions are selectively oppressed without any influence on the tonic activity of the pyeloureter. A direct therapeutic modulation of the ureteral activity, however, e.g. to treat a colic or to accelerate the spontaneous discharge of stones, seems to be only rarely possible: Glucagone shows a markable decrease of ureteral peristalsis in animal experiments. Antagonists of prostaglandine proved to have not only an antiinflammatory and central analgetic effect but they also influence the pyeloureter directly by relaxing the muscular layer.

Differential diagnosis and therapy of rare testicular tumors.

The origin, differential diagnosis and therapy of rare testicular tumors are reviewed. 5% of all testicular tumors are rare tumors. Most of these rare tumors are of non-germ cell origin.

[Exogenous heat exposure--a cause of subfertility]. / Exogene Wärmeexposition--eine Ursache der Subfertilität.

In the diagnostics of subfertility three main factors have to be considered: Endogenous testicular heat exposure, genitourinary tract infection and endocrinologic abnormality. The possibility of exogenous heat exposure is emphasized. An exact anamnesis is important, because exogenously induced subfertility is reversible in general.

[Complication of ureterorenoscopy]. / Die Komplikation der Ureterorenoskopie.

We describe failures and complications of ureterorenoscopy based on our own experience and the literature. There is usually no consequence when perforating the ureter--which happens in 10 per cent of the cases--if a splint or a percutaneous nephrostomy is applied. Ureteral rupture makes an open intervention necessary, but happens rarely. Since complications of ureterorenoscopy are rare and the rate of success very high, open operations on the ureter should become less frequent.

[Intra- and postoperative complications in interventions of the kidney, kidney calices and upper ureter]. / Intra- und postoperative Komplikationen bei Eingriffen an der Niere, am Nierenbeckenkelchsystem sowie am oberen Harnleiter.

Open routine operations on the kidney and the renal calyces have diminished in favour of endourological methods. Renal and renal pelvis calculi as well as ureteral calculi are rarely approached through open operation. Selective indications for operation depend on special situations and anatomy, since complications such as injury to large abdominal wall nerves, the peritoneum or the pleura present no problem for the skilled surgeon. The control of a sudden and serious hemorrhage coming from the renal hilus or the vena cava surely is an important complication, which should not be underestimated, and stopping such hemorrhages requires knowledge of the peritoneal stepwise method of stopping a hemorrhage. Secondary and multiple operations on the kidney need a clear tactical treatment concept. This is presented in a four-phase-concept. To avoid or control intra- and postoperative complications when operacting on the renal calyces or the upper ureter it is still important to respect the old rules of temporary diversion of urine and to know reconstructive methods of the urinary tract.

[Complications of percutaneous kidney surgery--prevention and control]. / Komplikationen der perkutanen Nierenchirurgie - Vermeidung und Beherrschung.

Possibilities and types of complications, how to avoid and deal with them, are outlined in our material of 43 exactly defined cases. Extravasation and perforation of the renal calyces, the leaving behind of small concrements, perforation of neighbouring organs, hemorrhage, infection and late complications are discussed. Other published series, are analyzed (about 4000 patients up to now). However, often no information about incidence and type of complications is given. One must assume that several complications are not mentioned depending upon the way each author judges the complications. In general mild complications like extravasation of irrigation water and/or contrast medium and even hemorrhage diminish with practise. Inspite of our small material of about 50 percutaneous operations on the renal calyces a critical view of the larger series in the literature concerning complications is necessary. The most important points are avoiding and dealing with the discussed complications. Since percutaneous surgery on the kidney does not utilize a natural channel like the other endoscopic procedures, but creates its own channel, one should call this method a "half-open" operation.

Resolution of proteins in the kidney stone matrix using high-performance liquid chromatography.

The organic matrix accounts for 2-3% of the total stone weight and has been considered to play a role in stone formation and growth. Thus far, fractionation of the matrix proteins has been insufficient due to low resolution and reproducibility. In this report the matrix proteins of 22 stones were resolved by means of high-performance liquid chromatography. Following pulverization, the organic matrix was obtained by dialysis against EDTA. The average content of nondialyzable extractable proteins was 1.6% of the total stone weight. Analysis of the matrix proteins with high-performance gel permeation liquid chromatography and high-performance ion-exchange liquid chromatography has indicated that the protein composition of the stone matrix is identical regardless of the mineral composition. The major component of the matrix proteins was identified as glycoprotein and/or proteoglycan from their absorption to a concanavalin A Sepharose column. Higher molecular weight matrix proteins seem to be polymers or condensation products, since they have been degraded into lower molecular weight subfractions by sodium dodecyl sulfate treatment.

Quantitative analysis of glycosaminoglycans in urothelium and bladder wall of calf.

Glycosaminoglycans (GAG) were described by histochemical staining procedures in the normal urothelium of the urinary bladder; they are supposed to be involved in the antibacterial defense mechanism. Our quantitative analysis, however, demonstrated only heparan sulfate in the normal calf urothelium (less than 600 nmol/Gm d.wt.); only trace amounts of other GAG were to be analyzed. High concentrations of GAG were found in the submucosa and muscle layers as to be expected in mesoderm originating tissues. According to these results there were no GAG with the exception of heparan sulfate at the surface of the normal urothelium; therefore, glycoproteins detected in mumol/Gm d.wt. ranges are more likely to be involved in the antibacterial defense mechanism.

Glycosaminoglycans in urothelial carcinomas.

The glycosaminoglycan (GAG) content in human urothelial carcinomas was biochemically determined and compared to that of normal urothelium and bladder wall of the calf. The total GAG content was elevated in urothelial carcinomas, and the distribution pattern differed from that of normal urothelium and bladder wall. Whereas urothelial carcinomas contained heparan sulphate, dermatan sulphate, chondroitin 4-sulphate and chondroitin 6-sulphate, only heparan sulphate could be detected in the normal urothelium. The GAG determination was based on hexosamine analysis and thin layer chromatography after elution on Dowex 1 X 2 columns.