Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers.

PURPOSE: We evaluated the prognostic criteria for salvage surgery in patients with persistent marker elevation after chemotherapy for metastatic germ cell tumors. MATERIALS AND METHODS: Of 125 men who underwent post-chemotherapeutic resection of residual tumors 30 had persistent marker elevation at surgery. This group was subdivided into 17 patients with no evidence of disease, 7 dead of disease and 6 others. Outcome analysis was performed in the subgroups with regard to preoperative and postoperative parameters. Mean followup was 120.3 months (range 1 to 228) after surgery. RESULTS: Of the 30 patients 17 (57%) with persistently elevated tumor markers after chemotherapy were long-term survivors after salvage surgery. Overall persistent viable cancer and teratomatous elements were identified in 64% and 11% of cases, respectively. Significantly more patients died of disease who had a poor prognosis according to International Germ Cell Cancer Collaborative Group guidelines. Embryonal carcinoma was the predominant initial histology in this group and residual disease was more often located at various sites, for example the viscera, with a lower chance of complete surgical resection. Marker status before surgery, and chemotherapeutic pretreatment and postoperative histological findings did not differ significantly in patients with no evidence of disease and those dead of disease. CONCLUSIONS: Salvage surgery results in long-term success in greater than 50% of patients. Complete resection is the most important single parameter for a favorable outcome. Even patients with visceral metastasis benefit from surgery. Our data do not justify omitting surgery in certain subgroups.

Tumour induction as a consequence of immunosuppression after renal transplantation.

Immunosuppressed recipients of organ transplants have a higher incidence of carcinoma than the general population. A retrospective analysis was made at the Department of Urology of Bonn University, investigating 236 renal allograft recipients as to the incidence of neoplasms before and after transplantation. Eleven patients developed malignant tumours after transplantation. In 4 out of these 11 patients, case history showed pre-existing malignancies. Two of the 4 patients developed a second tumour, while the other two had tumour progression (latency period 21-77 months). Three of the 4 patients died of their tumours 21, 42 and 77 months after transplantation, whereas one female patient is still alive and free of neoplasms 32 months after transplantation. In 7 out of these 11 patients de novo tumours were diagnosed (latency period 3-88 months). All of them are still alive (NED between 15 and 85 months), six of them with good transplant function. There was no difference to be seen in the incidence of malignancies between kidneys supplied by Eurotransplant (n = 40) and ABO compatible kidneys from our own donors (n = 196). The higher incidence rate of neoplasms in transplant recipients requires high standards in preventive measures. Any suspicious change that may occur in the course of a thorough follow-up of transplant recipients must be removed and examined histologically. Patients with previous malignant diseases must be payed special attention, since they frequently tend to develop another malignant tumour and progression of existing tumours, respectively. As far as immunosuppression is concerned, therapeutic guidelines for the treatment of transplant recipients do not differ from those set up for patients on haemodialysis. Since immunosuppression with increased rates of tumour incidence can also be observed in dialysis patients, the mere fact of increased incidence of neoplasms cannot be taken as an argument against transplantation. With a more or less equal risk of tumour incidence the crucial factor should be the higher quality of life for transplant recipients.

[Comparison of kidney transplantation with and without regard to HLA typing]. / Vergleich der Nierentransplantation mit und ohne Berücksichtigung der HLA-Typisierung.

OBJECTIVE: To compare the functional results after transplantation of locally obtained and assigned kidneys (without taking into account HLA typing) with those after transplantation of kidneys obtained via Eurotransplant (with HLA typing as principal criterion for assignment). PATIENTS AND METHODS: Between December 1983 and December 1993 a total of 236 kidneys were transplanted into 234 patients, 40 kidneys having been obtained via Eurotransplant and 196 removed locally and transplanted directly into patients on the local waiting list according to strict criteria: same blood group; waiting time since decision on transplantation; negative current crossmatch between recipient's serum and donor lymphocytes. Transplantation results were analysed retrospectively according to: ischaemia time, HLA mismatch, postoperative renal failure, postoperative renal function, rejection rate and transplant survival. Mean observation period was 55 months for the local and 50 months for the Eurotransplant kidneys. RESULTS: The number of HLA matches was higher in Eurotransplant group (P < 0.001). However, the cold ischaemia time was greater for this group (20.2 vs 15.7 hours; P < 0.01). Acute renal failure was less common with locally assigned kidneys (33 vs 53%: P < 0.02). There were no significant differences with regard to one-year and five-year renal function (serum creatinine; percentage of normal): 90.2% local vs 88.3% Eurotransplant and 81.8% vs 62.3%, respectively). Survival rates were also similar (96.9% local vs 95% Eurotransplant after one year, 94.4% vs 90% after 5 years). CONCLUSION: Local assignment by waiting time and blood group gave results that were similar to those via Eurotransplant based on HLA typing criteria.

[Magnetic resonance tomography of the kidney: the testing of new pulse sequences and comparison with CT in the differential diagnosis of space-occupying lesions]. / Magnetresonanztomographie der Niere: Erprobung neuer Pulssequenzen und Vergleich mit der CT in der Differentialdiagnose von Raumforderungen.

PURPOSE: To evaluate new pulse sequences (turbo-spin-echo [TSE] and turbo-field-echo [TFE] sequences) for study protocol optimisation and to assess the role of MRI in the differential diagnosis of renal tumours. METHODS: In six volunteers MRI of the kidney was performed at 0.5 T using a conventional T2 weighted spin-echo (SE) sequence (TR/TE 1800/90 ms) and three different TSE sequences (TR 1800-5000 ms, TE 90-150 ms). Additionally CT and MRI was performed in 34 patients with 41 renal masses. Two readers evaluated both images regarding the differentiation between malignant and benign masses. RESULTS: The pilot study showed that the heavily T2-weighted TSE sequence (TR/TE 5500/150 ms) was superior to other sequences with regard to image quality and differentiation of the corticomedullary junction. In the clinical study malignant tumours were correctly classified with CT and MRI in 86.4% and 95.5% of the cases, whereas the accuracy in the diagnosis of benign lesions of CT and MRI was 73.7% and 89.5%, respectively. CONCLUSION: Using new puls sequences MRI is superior to CT in the differential diagnosis of renal tumours. MRI is superior to CT in the differentiation between complicated cysts and cystic or hypovascular renal cell carcinomas.

Wilms' tumor in adults. Review of 10 cases.

A nephroblastoma (Wilms' tumor) is very rarely found in adult patients. We report on 10 cases to demonstrate the diagnostic and therapeutic problems. In case of flank pain, large tumor mass, fast tumor growth, and young age, the possibility of a Wilms' tumor should be taken into consideration even in adult patients. The chances for a successful treatment by primary surgery with adjuvant therapy are favorable for the lower stages I and II. All our patients presenting with tumor stages I and II have survived and are free of disease since 68 months at the time of the study. One of 2 patients with a Wilms' tumor stage III died 8 months postoperatively, while the other is free of disease since 120 months. In the advanced stage IV no patient survived. In cases of inoperable large tumors in adults, the possibility of primary chemotherapy should be considered under certain circumstances. Rapid tumor regression may confirm the diagnosis and will enable salvage operation in some cases.

Acute rejection relapses posttransplant: definition of risk group and evaluation of potent therapeutic regimens.

A group of 113 patients were investigated after allogenic cadaver renal transplantation to analyse whether the small number of patients presenting acute rejection relapses could be defined by risk factors and whether there is an efficacious regimen for the safe therapy of recurrent rejection episodes. According to these results we are aware of a group of "highly reactive rejectors" especially within the younger recipients and there are further characteristics which can be identified as being associated with an elevated risk of recurrent acute rejection. By adequate antirejection therapy we can achieve a favourable transplant survival rate of 97% in the critical first year. An additional benefit may result from ALG consolidation related to suppression of the remaining CD8-positive human natural killer cells.

MESA and TESE: experiences of the German section of urological microsurgery.

The introduction of microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) has enlarged the therapeutic options for irreparable azoospermia. After standardization of the indications and surgical procedure, the German section for urological microsurgery combined the data of all groups performing assisted reproduction. The indication for MESA or TESE is given in cases of congenital aplasia of the vas deferens, irreparable obstruction of the reproductive tract, failure after refertilization, in combination with tubulovasostomy for subsequent cryopreservation and for conservatively untreatable ejaculatory disturbances. Until October 1995, 87 couples were treated by MESA and conventional IVF; the embryo transfer rate (ET) was 4.6%, the pregnancy rate 1.1%. One child (1.1%) was born. 179 couples were treated by MESA and ICSI, the ET was 68.2%, the pregnancy rate 18.4%, and 11 children (6.1%) were born. TESE in combination with ICSI was performed in 65 cases, the ET was 84.6%, the pregnancy rate 23.1% and 6 children (9.2%) were born. Modern technological developments in reproductive medicine and increasing experience in andrological surgery have stabilized the position of interdisciplinary therapeutic concepts for the treatment of infertile couples.

Wilms' tumour in adults. Review of 10 cases.

Nephroblastoma (Wilms' tumour) is very rarely found in adult patients. We report on 10 cases to demonstrate the diagnostic and therapeutic problems. In case of flank pain, large tumour mass, fast tumour growth and young age, the possibility of Wilms' tumour should be taken into consideration even in adult patients. The chances for a successful treatment by primary surgery with adjuvant therapy are favourable for the lower stages I and II. All our patients presenting with tumour stages I and II have survived and have been free of disease for 68 months now. One of the patients with stage III Wilms' tumour died 8 months postoperatively while the other one has been free of disease for 120 months now. In the advanced stage IV no patient survived. In cases of inoperable large tumours in adults, the possibility of primary chemotherapy should be considered under certain circumstances. Rapid tumour regression may confirm the diagnosis and will make feasible a salvage operation in some cases.

Laparoscopic varicocelectomy: indication, technique and surgical results.

OBJECTIVE: To assess the efficacy of laparoscopic techniques for the operative therapy of varicocele. PATIENTS AND METHODS: Fifty-one patients who underwent laparoscopic varicocelectomy due to subfertility and/or pain between June 1992 and December 1994 were evaluated. RESULTS: In all patients, except one with a remaining slight reflux on post-operative Valsalva's manoeuvre, operative therapy was effective and no major complications occurred. The procedure was minimally invasive, effective and, because the anatomy was readily seen, multiple veins and/or collaterals were easily assessed and the surgery precise. CONCLUSION: The laparoscopic technique is an efficient, minimally invasive operation with optimal results. After a brief period of training the operation can be performed in 15-30 min and is therefore no longer than embolization techniques. Treatment of both sides in one session was not a problem.

Is the transplant-preserving management of renal allograft rupture justified?

OBJECTIVE: To evaluate the transplant-preserving management of renal allograft rupture. PATIENTS AND METHODS: From April 1982 to January 1994 a total of 238 renal transplantations were performed on 227 patients. Eight cases (3.5%) of renal allograft rupture occurred. Transplant nephrectomy was necessary in one patient. Seven patients were surgically treated with collagen foam, fibrin glue and vicryl mesh. RESULTS: In all seven cases treated conservatively, renal salvage and satisfactory graft function was achieved. After a mean follow-up of 52.9 months (range 2-94) the mean creatinine level was 15.6 mg/L (range 11-21). Of these seven patients with renal allograft rupture one returned to haemodialysis 22 months after transplantation and had several episodes of rejection. Almost 4.5 years after renal allograft rupture, the creatinine value in six of the seven patients was only slightly higher than the mean creatinine values of all donor kidney recipients (14.4 +/- 5.5 mg/L). CONCLUSION: There should be an attempt to salvage the transplant after allograft rupture in all cases. Using these transplant-preserving techniques, renal function could be achieved for all patients with allograft rupture.

Dynamic magnetic resonance imaging of the contralateral testis in patients with malignant tumor of the testis.

OBJECTIVES: Dynamic magnetic resonance imaging (MRI) was tested using a dynamic technique to evaluate the possibility of differentiating between normal contralateral testes and testes with a carcinoma in situ. METHODS: Since March 1990, 20 volunteers and 21 patients with a malignant tumor of the testis were examined in a field strength of 1.5 Tesla (Philips Gyroscan S15) with a multislice T1-weighted fast field echo sequence before and every 63 seconds after the injection of 0.1 mmol/kg gadolinium-diethylenetriamine pentaacetic acid. RESULTS: Significant differences (p < 0.001) in signal changes of contralateral testes were detected in dynamic MRI. This increased signal enhancement is detected even 45 months after orchiectomy in the contralateral testes. The signal increase is reduced in follow-up controls. These observations are explained by an increased perfusion which seems to be induced after a postoperative irritation, an unspecific inflammation, or postoperative bleeding. CONCLUSIONS: To avoid false-positive diagnoses of tumors or carcinomata in situ in contralateral testes, these increased enhancements caused by postoperative reactions have to be kept in mind.

Prevalence of paraneoplastic erythropoietin production by renal cell carcinomas.

The prevalence of increased serum immunoreactive erythropoietin (Epo) was determined in a prospective study of 49 patients with renal cell carcinoma. Measured by a monoclonal antibody based commercial enzyme-linked immunoassay, the Epo concentration was above the normal range, determined in nonanemic humans, in four of the renal carcinoma patients. Since three of these were anemic, their increased Epo level was considered to be appropriate. The high estimate of serum Epo (218 U/l) in the fourth patient, who was not anemic, was not confirmed when tested by radioimmunoassay. Thus, in contrast with earlier studies, our results indicate that increased Epo is not a clear serological renal cell carcinoma marker. In addition, when monolayer cell cultures of 14 different established human renal carcinoma lines were screened, none of these released immunoreactive Epo in measurable amounts.

[Differentiation of testicular diseases using dynamic MRT]. / Differenzierung von Hodenerkrankungen mit der dynamischen MRT.

Sonography and colour-coded Doppler sonography are the methods of first choice in diagnosing tumors of the testes. The present study aimed at resolving whether dynamic MRT can improve diagnostic relevance in diseases of the testes compared with conventional spin echo images. The testes of 20 healthy volunteers and of 16 patients of the Department of Urology of the University of Bonn were examined by means of MR tomography. Within 12 hours after MR tomography the patients were surgically explored, biopsied and if necessary orchiectomised. Results obtained with the volunteers were uniform and well reproducible, independent of external influences. On comparing the maximal enhancement curves of the examined various testicular tumors with the standard values established by examining the healthy volunteers, the curves obtained with the malignant testicular tumors were always clearly above the chosen confidence range of 3 standard deviations so that malignancy diagnosis was easy. However, the degree of maximal enhancement did not enable us to arrive at a conclusion in respect of the tumor type or the degree of malignancy. The greatest enhancement occurred with the tumor of Sertoli's cell which could thus be clearly differentiated against the other malignant testicular tumors. Due to masking of the gadolinium effect by haemosiderin deposits, haemorrhagica in the tumor tissue should be excluded by means of T2-weighted spin echo sequences before following up a suspicion of malignant testicular tumor. Benign intratesticular changes could be safely separated from malignant findings by means of the maximal enhancement curve lying in the normal range or below the curve of the volunteers. As with other organs, dynamic MR tomography yields definitely more and better information than conventional MR tomography also in the diagnosis of testicular tumours. However, these "pros" do not offset the "cons" of high costs of such examinations, so that both conventional sonography and angiodynography remain the routine methods of choice. Indication for MR examination on suspicion of testicular tumour is therefore confined to cases where sonographic findings are clinically equivocal or technically unsatisfactory.

Induction of carcinoma at ureterosigmoid anastomosis--with and without faecal stream.

The induction of tumours at the site of uretero-intestinal anastomosis was investigated in Hannover: WISTAR rats. The rats were divided into 3 groups. In one group (n = 70) the ureter of the left kidney was implanted into the colon, using microsurgical techniques developed for humans. In 13% of the rats in this group benign tumours developed; in 16% malignant tumours occurred. In a second group (n = 76) the ureter was implanted into a rectal bladder; the faeces were excluded from the anastomosis by a descending colon anus praeter. In this group benign tumours developed in 17% and malignant tumours in 8%, all of them being situated at the site of the anastomosis. In a control group (n = 80) no colonic tumour could be identified.

On the necessity of adrenal extirpation combined with radical nephrectomy.

Adrenal metastasis of renal cell carcinoma usually is an autopsy finding and seldom a clinical diagnosis. The incidence of ipsilateral suprarenal gland involvement also can be identified by histological examination of the organ with radical nephrectomy. The necessity of adrenalectomy performed in combination with nephrectomy is discussed. After a retrospective examination of our patients we discovered 8 adrenal metastases among 138 radical nephrectomies. Five patients who also had metastases in the lymph nodes (stages pN1 to pN2) died after an average of 26.4 months. Three patients without lymph node involvement are free of tumor. In these cases routine adrenalectomy must be regarded as a possible curative treatment.

Simultaneous determination of urinary phosphate and sulphate by ion-chromatography.

An ion-chromatographic system was used for the simultaneous determination of urinary phosphate and sulphate. This method was compared with conventional methods (colorimetric, turbidimetric) with regard to practicability and reliability. All methods showed good precision and accuracy. The comparative analysis of phosphate in 80 samples revealed that both methods lead to identical results. However, in case of sulphate a significant difference of about 8% was found between the two methods. Overestimation of the analyte concentration by the turbidimetric method might be responsible for this difference. From the point of view of economy, routine analysis of urinary phosphate and sulphate by ion-chromatography is acceptable only if automated systems are used.