Extracorporeal shock wave lithotripsy of urinary calculi: experience in treatment of 3,278 patients using the Siemens Lithostar and Lithostar Plus.

Between March 1986 and June 1989, 3,278 patients with upper urinary tract calculi were treated at our medical center with the Lithostar lithotriptor. The stones were located in the calices in 41.9% of the cases, renal pelvis in 25.7% and ureter in 32.4%. Perirenal hematoma was noted in 0.5% of the patients but this resolved spontaneously within a few days. Auxiliary procedures were performed in 37.3% of the cases, including Double-J stent and ureteral catheter in 26.8%, ureterorenoscopy in 2.1%, percutaneous nephrostomy in 1.6%, Zeiss loop in 4.3% and percutaneous nephrolithotripsy in 3.5%. Of the treatments 83.1% were performed without general or regional anesthesia. Followup after 3 months showed a 63.8% rate free of stone. The Lithostar upgraded with the overhead lithotripsy module is called Lithostar Plus. A total of 25 patients with upper urinary stones underwent treatment with the overhead module. Initial experience revealed fragmentation of stones after the first session in 20 patients, while a second session was necessary in 5. Analgesic sedation was used in 4 patients in whom a Double-J stent was inserted.

Bellini duct carcinoma: further evidence for this rare variant of renal cell carcinoma.

Bellini duct carcinomas have recently been identified as a new entity in the spectrum of renal cell carcinomas and 10 cases have now been reported. The present paper adds detailed clinical and morphological data on six new cases. In addition, immunohistological and electronmicroscopical results support the origin of these tumours from the renal collecting ducts, especially the papillary ducts (Bellini ducts). A set of immunohistological reactions, including reactions to cytokeratins 13 and 19, vimentin and UEA-1 was found to facilitate the differential diagnosis of Bellini duct carcinomas from other renal cell carcinomas and infiltrating urothelial carcinomas of renal pelvis.

[Organ preserving surgery in kidney tumors]. / Organerhaltende Chirurgie bei Nierentumoren.

Between 1967 and 1989 102 patients underwent conservative surgery for renal tumors at the Department of Urology, Mainz Medical School. In 39 patients the indication for organ preserving surgery was imperative because of single kidney, bilateral tumors, benign pathology of the contralateral kidney or chronic renal failure. In the elective group 63 patients underwent tumor enucleation for small, peripheral lesions of uncertain dignity. Tumors removed for imperative indications varied in diameter from 2-11 cm (mean 5.5 cm) whereas those which were electively resected ranged from 1-7 cm (mean 3.2 cm). 74% of the electively enucleated tumors were detected in an early asymptomatic stage by routine ultrasound investigations. 58 of the 63 patients with elective indications are alive with no evidence of tumor after a mean follow-up of 35 months (5-90 months). One patient was lost to follow-up, 3 patients died of reasons unrelated to cancer, and only 1 patient died of progressive disease. These results indicate, that tumor enucleation is a safe and reliable technique in small, peripheral renal tumors and offers an adequate alternative to radical nephrectomy in selected patients.

Percutaneous litholapaxy. Indications and limitations of the technique in complex nephrolithiasis.

In the present study, the authors analyze the radical change in the treatment of complex renal lithiasis. They advocate the use of this combined approach in patients with a large stone mass or those with obstructive problems of the urinary tract. They discuss the contraindications of this technique; i.e., pelvic kidney, septic urinary infections and severe cardiopulmonary disease. From 1983 to June 1988, a total of 5,657 stone patients were treated at their department; 921 were treated by PCNL combined with ESWL. In 92% of the cases, PCNL was successful in removing most of the stone mass. The complications encountered were fever, hemorrhage, colon perforation, stenosis of UPJ post-PCNL and intrathoracic extravasation. Nephrectomy was warranted in 2 cases due to complication.

Immunotherapy of metastasizing renal cell carcinoma. Results of a multicentered trial.

119 patients with stage-IV renal cell carcinoma were treated using immunotherapy with autologous tumor vaccine. The immunization was carried out at monthly intervals, the patients were restaged every 3 months using X-ray, ultrasound scanning or computed tomography as well as bone scintigraphy in the follow-up. The patients' follow-up periods run from 6 to 66 months averaging in 38.5 months. 6 complete remissions, 4 partial responses and 29 stable diseases were seen, whereas 54 patients had progressive disease. Patients with a T1 primary tumor all survived the follow-up period irrespective of whether lymph node metastases (n = 2), venous invasion (n = 12) or distant metastases (n = 6) were present at the time of operation. Follow-up periods run from 12 to 48 months (averaging 23 months). Patients with T2 tumors showed survival up to 50 months postoperatively, of these only 3 died. Follow-up averages 30 months. The 3 patients died within the first year after operation. Patients with very large primary tumors showed the poor prognosis normally expected. 23 of these 40 patients died after a mean follow-up of 15 months. These results may indicate that immunotherapy can slow down tumor progression and induce objective responses. Those patients with small primary lesions apparently benefit from the treatment even though metastases are present at the time of diagnosis.

Slightly radiopaque uric acid calculi: impact upon therapeutic considerations?

Ten patients with slightly radiopaque urinary calculi were treated by percutaneous litholapaxy or even open surgery. The stone analysis revealed uric acid as the main stone composite suggesting that these patients should have been treated by oral litholysis alone alkalinizing the urine and decreasing uric acid levels with allopurinol. CT density measurements proved that concrements with HE less than 600 can be successfully dissolved by oral medication alone. Twenty-four patients were subsequently treated by oral citrate alkalinizing the spontaneous urine to pH 6.8-7.2 dissolving even large staghorns within 6-8 weeks. CT density measurements have become a routine diagnostic procedure when poorly radiopaque calculi are found on the standard plain film. The patient can thus be spared invasive treatment which is unnecessary in most cases.

Effect of lectins on KK-47 bladder cancer cell line.

The effect of three lectins, Ricinus communis agglutinin (RCA II), concanavalin agglutinin (ConA), and wheat germ agglutinin (WGA), on KK-47 bladder cancer cell line was studied, RCA II showed effective inhibition of H3-uridine and H3-thymidine uptake by KK-47. ConA showed a stimulatory effect in all three concentrations used. WGA also showed stimulatory effect, but it was less pronounced than ConA.

In vitro chemosensitivity testing of renal cell cancer. Short-term culture technique.

In an attempt to solve the problem of chemosensitivity testing of renal cell carcinoma in vitro, a modified short-term culture technique was developed. The kinetic study of hypernephroma cells and normal renal cells showed that the uptake of H3-uridine and H3-thymidine is at its maximum after eighty hours. The effect of doxorubicin, cisplatinum, vinblastine, and mitomycin C in different concentrations was tested. Tumors generally showed more resistance than sensitivity. Some tumors showed sensitivity to one or more drugs, but no one drug was persistently effective in all tumors. Our short-term culture technique solved the discrepancy between cell kinetics and test duration found in the Volm test and the problem of nongrowth in the clonogenic assay.

Karyotype analysis and marker chromosomes of renal cell carcinoma.

Karyotyping was performed in 46 human renal cell carcinomas of various histological grades. Controls included chromosome analysis of normal renal parenchymal cells from the same patients. Various numerical chromosome aberrations were found as well as marker chromosomes. They are specific of the individual tumor but no single marker was identified occurring in all tumors tested. Only trisomy 3 was found in different tumors (31%), suggesting a more general character of this aberration. Histological dedifferentiation and large tumor size correlate with focusing of the karyotype towards distinct chromosomal modes indicative of distinct tumor cell subclones within these tumors. Their rapid growth, reflecting biological aggressiveness, is most probably responsible for the patients' poor prognosis.

Tumor-specific antigen for human renal cell carcinoma. Ultrastructural localization of the antigen by immunoelectron microscopy.

Hybridoma technology enabled the production of tumor-specific monoclonal antibodies reactive exclusively with human renal cell carcinoma. Intracellular localization of the antigen was undertaken in order to gain understanding of its possible physiological role in cellular metabolism and to investigate its future clinical applicability for immunoscintigraphy in tumor localization. For immunoelectron microscopy a special paraformaldehyde-periodate fixation process (PLP fixation) had to be employed, in order to preserve the cell's ultrastructure without destruction of the antibody-binding epitope. The antigen was found to be strictly intracytoplasmic in close correlation to the glycogen particles characteristic for human renal cell carcinoma. These findings suggest that this antigen may be involved in the pathological glycogen synthesis, explaining the specific staining pattern of these monoclonal antibodies.

Immunoperoxidase staining of fine-needle aspiration biopsies of renal cell carcinoma using tumor-specific monoclonal antibody.

In 30 nephrectomy specimens, fine needle aspiration biopsies (FNAB) were performed both in the tumor and in the macroscopically normal part of the kidney: 18 were well differentiated renal cell carcinoma (RCC), 6 were moderately differentiated RCC, 4 were poorly differentiated RCC, and 2 were oncocytomas. FNAB was also performed in a bone metastasis of RCC. FNAB materials were stained using the immunoperoxidase method with RCC-specific monoclonal antibody and were compared with the staining of frozen sections. In all cases where tumor-antigen expression could be demonstrated in the frozen sections, a FNAB had already proven positive. There were only 2 false-negative cases where sufficient cellular material could not be obtained due to extensive tumor necrosis. There was no false-positive case. Oncocytomas showed no expression of antigen. The use of immunoperoxidase staining of FNAB with tumor-specific monoclonal antibody is discussed.

Conservative surgery of renal cell carcinoma.

From 1967 to 1985 conservative surgery (enucleation, n = 49; partial resection, n = 7) was performed for renal tumors in 57 patients (age 31-77, mean 54.8 years). Imperative indications for conservative surgery (n = 29) were chronic renal failure, benign pathology of contralateral kidney, functional or anatomical solitary kidney, and bilateral tumors. Elective conservative surgery (n = 28) was done for small, peripherally located lesions, in cases of uncertain malignancy and in one tumor detected by chance during stone surgery. Tumors removed for imperative indications were 2-11 cm (mean 5.8 cm) in size. In the elective group, tumor size ranged from 1 to 7 cm (mean 3.3 cm). Follow-up was 6-103 months (mean 35.8 months). In the group with imperative indications, there was 1 postoperative mortality; 18 of 29 patients are alive without evidence of disease, 2 with metastases, and 2 were reoperated conservatively for local recurrences; 1 was lost to follow-up, 2 died of metastases, and 3 died due to unrelated reasons. In the elective group all 28 patients are living free of cancer.

Local excision of urothelial cancer of the upper urinary tract.

In 9 of 93 patients (9.7%) with urothelial cancer of the upper tract (7 renal pelvis tumors, 3 ureteral tumors), conservative surgery was employed using a free peritoneal autotransplant for replacement of the renal pelvis in 5 kidneys. Absolute indications for conservative surgery were solitary kidneys/nonfunctioning contralateral kidneys in 4 patients and bilateral tumors in 1 patient. Local recurrences developed 1-3 years after operation in 4 of 6 kidneys (3 patients), 3 of which had grade-2 and grade-3 primary lesions. All patients were treated successfully by repeated local excision. In the presence of a normal contralateral kidney, local tumor excision was done electively in 4 patients (3 low-grade/low-stage lesions, 1 high-risk patient), none of these patients developed recurrences. Two patients died without evidence of tumor recurrence, 7 patients are free of tumor at an average follow-up of 23 months (range 5-65 months). Local excision of urothelial cancer should be considered not only for solitary kidneys, bilateral tumors and cases with renal failure, but also for low-stage/low-grade localized tumors, leaving the patient better prepared for later treatment of a possible recurrence due to the well recognized chance of a multiplicity of tumors in time and space.

Effect of lectins on 3H-uridine and 3H-thymidine uptake by cultured renal cell carcinoma and normal renal cells.

The effect of lectins on cultured renal cell carcinoma and normal renal cells was studied. Ricin II showed effective inhibition of 3H-uridine and 3H-thymidine uptake by renal cell carcinoma and normal renal cells in all cases. Normal renal cells were more resistant to the inhibitory effect of ricin II as compared to renal cell carcinoma. Concanavalin agglutinin and wheat germ agglutinin led to stimulation of 3H-uridine and 3H-thymidine uptake by renal cell carcinoma and normal renal cells at low concentrations (0.2 micrograms/ml), and to suppression at high concentrations (2 and 20 micrograms/ml).

In vitro chemosensitivity testing of KK-47 bladder cancer cell line: a short-term culture technique.

We present our modified technique of short-term culture assay. As an experimental set-up we used the KK-47 bladder cancer cell line for chemosensitivity testing. The technique is very easy and requires only 3 days. The results were found to be reproducible.

Tumor-specific monoclonal antibodies for renal cell carcinoma.

Monoclonal antibodies, tumor-specific for renal cell carcinoma (RCC), were produced in Balb/C mice, hyperimmunized with tumor cell suspensions from a histological grade II tumor. Boosting with lectin-immobilized tumor-antigen rendered high yields of specific antibody-producing hybrids. Hybridoma supernatants were screened for specificity using a solid-phase enzyme-linked immunoassay. Testing in parallel for reactivity with tumor tissue and corresponding autologous normal kidney material, only those hybrids producing antibodies exclusively reactive with RCC were propagated, resulting in 4 stable, highly productive subclones. Using the immunoperoxidase staining technique, tissue sections from 97 different RCC specimens and corresponding normal kidneys were evaluated for reactivity with the monoclonal antibodies. Over 90% of RCC were strongly positive, whereas normal kidney tissue did not react. Other normal human organ sections, including pancreas, liver, lung, stomach, small intestine, spleen, lymph node, arteries, veins, skeletal muscle, heart, skin and fetal tissues were negative for tumor-associated antigens. Mucous substances and Panet's granular cells in colon mucosa showed nonspecific binding suppressible by addition of normal human serum. Adenocarcinoma of the stomach, colon, pancreas or breast did not demonstrate cross-reactivity with the antibodies to RCC. These monoclonal antibodies apparently recognize a tumor-associated antigen possibly specific for RCC. They could prove to be potent tools in the search for specific tumor markers applicable in the early diagnosis of the disease and immunotargeting cancer therapy.

[Is antireflux management of a ureteral lesion occurring during gynecologic surgery absolutely necessary?]. / Ist die antirefluxive Versorgung einer Ureterläsion bei gynäkologischen Operationen zwingend notwendig?

Gynaecological interventions are responsible for most of the (albeit rare) iatrogenic lesions of the ureter in the minor pelvis. After having recognised such a lesion intraoperatively, direct and definitive primary care should always be aimed at, i. e. ureterocystoneostomy according to the antireflux principle. This technique should be used also if a lesion has been recognised at a late stage only, for example, in case of ureteral fistulas and stenoses. Direct ureterocystoneostomy is now considered obsolete on account of the danger of reflux and the ensuing complications. Every surgeon performing surgery in the region of the minor pelvis should be familiar with the methods of bladder mobilisation and ureterocystoneostomy. If not, a urologically skilled expert should be consulted. This will avoid unnecessary re-operations involving additional risks for the patient.

Effect of cimetidine on basal and histamine-induced secretion of parathyroid hormone in vitro.

The effect of cimetidine on basal and histamine-induced PTH secretion was tested using single cell suspensions obtained from (a) primary parathyroid adenomas, and (b) secondary hyperplastic parathyroid tissue from patients undergoing chronic hemodialysis. The histamine-stimulated hormone secretion was dose-dependent. Cimetidine suppressed both basal and histamine-stimulated hormone secretion. Within the therapeutic range the suppressive effect was identical for adenoma and hyperplasia. Both adenomata and secondary hyperplastic glands showed a histamine H2-receptor-related response. The role of histamine in the pathogenesis of hyperparathyroidism is not quite clear so that the possible benefits of cimetidine for medical treatment of primary and secondary hyperparathyroidism will have to be proven by careful clinical trials.