[Perioperative and postoperative complications of pelvic lymphadenectomy and radical prostatectomy in 320 consecutive patients]. / Perioperative und postoperative Komplikationen der pelvinen Lymphadenektomie und radikalen Prostatektomie bei 320 konsekutiven Patienten.

To examine the intra- and postoperative morbidity of radical retropubic prostatectomy we analyzed the first 320 consecutive patients with clinical stages T1b, T2a-c and negative lymph nodes by frozen section. Patient age varied from 42 to 75 years (mean 63.5 years). In 74.7% the estimated blood loss was less than 1500 ml. With a preoperative autologous blood collection program the intraoperative blood requirement for homologous blood units was only 15%. Intraoperative complications included rectal injuries with vesical rectal fistulas in 2.5% and ureteral injuries in 1.6%. Within the perioperative period the mortality rate was 0.9%. At 12 months after surgery 199 of 218 men (90.9%) were continent, 5.1% had minimal urinary incontinence, and only 4.6% had urinary incontinence grade III. Postoperatively, PSA (prostate-specific antigen) decreased to < 0.5% in 90.4% of the patients after radical prostatectomy. At 12 months after operation PSA was < 0.5 ng/ml in 83.4%. We conclude that radical retropubic prostatectomy is a safe procedure for the curative treatment of localized prostate cancer.

Autologous blood transfusion in radical prostatectomy: results in 263 patients.

The principal benefit of using autologous blood is avoidance of complications associated with conventional homologous blood transfusion such as viral infections, immunosuppression, and allogenic immunization. Since December 1991, a ruling of the Federal Supreme Court has obliged physicians to disclose to their patients the risk of contracting an infection from an intraoperative or postoperative blood transfusion and the possibility of donating their own blood for transfusion into them later. Of 263 patients with localized prostate cancer who underwent radical retropubic prostatectomy, 194 (73.8%) elected to have their blood collected for possible transfusion. Of the patients who needed transfusion, 80.7% received only autologous blood and haemodilution for substitution of haemoglobin. Nearly all patients with blood loss below 1,500 ml used only autologous blood transfusions during their operations. Increasing the number of units of autologous blood collected decreases the likelihood that homologous blood will be needed and thus the risks associated with transfusion of homologous blood.

[Transurethral laser therapy of benign prostatic hyperplasia]. / Transurethrale Lasertherapie der benignen Prostatahyperplasie.

During the last 4 years, transurethral laser therapy for benign prostatic hyperplasia (BPH) has become an increasingly popular alternative to transurethral resection of the prostate (TURP) for the treatment of obstructive BPH symptoms. Clinical data so far published prove the efficacy of this new therapeutic modality, although the results are up to now possibly inferior to those achieved with TURP. On the other hand, the incidence of severe perioperative complications is significantly lower in patients treated with laser prostatectomy than in those undergoing TURP. Therefore, laser prostatectomy is a reasonable adjunct to the therapeutic spectrum for BPH in high-risk patients. Nevertheless, its role in the treatment of obstructive BPH in low-risk patients cannot be defined until long-term follow-up data are available.

[Bile duct carcinoma after abdominal irradiation for urologic malignancies]. / Gallengangkarzinome nach abdomineller Bestrahlung urologischer Malignome.

Malignancies of the biliary tract are rare diseases. Tumor inductions after radiotherapy are reported in several papers. We report about 3 cases with consecutive biliary tract carcinoma 18-32 years after manifestation of an urogenital carcinoma. All 3 patients (52-63 years) were treated with additive radiotherapy after surgical-urological therapy. Icterus was the top-ranging symptom of this secondary carcinoma. In 2 of the 3 cases surgical tumor resection was performed (biliary duct resection with central liver resection; pancreatico-duodenectomy). Because of the bad general condition of health the third patient got only a biopsy of the tumor. All patients died within 2 years after diagnosis. The accidental accumulation of the rare biliary tract carcinoma after urogenital malignancies in our collection of clinical cases (2 seminoma; 1 bladder tumor) give rise the question about the causal association between primary carcinoma, additive therapy and the development of secondary carcinoma.

[Diagnosis of graft rejection]. / Diagnostik der Transplantatabstossung.

The topic of renal transplant rejection diagnosis is reviewed. The immunological and morphological findings and the clinical presentation of hyperacute, acute and chronic rejection are described. The indications for, and the value and limitations of diagnostic techniques such as core biopsy, fine-needle aspiration cytology, duplex Doppler sonography and immunological findings are analyzed. Early diagnosis and treatment are regarded as the central aim to prevent graft loss through rejection.

[Urologic complications after kidney transplantation. Experiences in a center with 539 recipients]. / Urologische Komplikationen nach Nierentransplantation. Erfahrungen eines Zentrums bei 539 konsekutiven Rezipienten.

A total of 539 renal transplantations were performed at the Department of Urology of the University Hospital of Hamburg between 1984 and 1991. 132 (24.5%) patients developed urological complications (by definition, complications occurring as a result of the operative procedure). In 31 cases the transplants had to be removed secondary to urological complications, and 4 patients died of such complications (mortality 0.7%, lethality 3.0%). Urinary tract infections occurred in 13.2% of all patients during the first postoperative year and were by far the most frequent complication, followed by haematomas, which occurred in 9.6%. The incidence of urinary tract and wound infections was significantly reduced during the 8-year period studied by improving antibiotic prophylaxis and adopting a strategy of early removal of indwelling catheters (P < 0.05). Stenting the ureteroneocystostomy with a double-J stent instead of an external ureteral catheter resulted in a definite decrease in the incidence of ureteral leaks (P < 0.05). Continuous control of operative results and efforts to improve operative and perioperative strategies make it possible to reduce the incidence of urological complications in renal transplantation and thus result in an improved graft function and patient survival.

[The diagnosis of female stress incontinence--the value of the clinical examination, anamnesis and urodynamics]. / Diagnostik der weiblichen Stressinkontinenz--Wertigkeit von klinischer Untersuchung, Anamnese und Urodynamik.

A prospective study was performed between November 1989 and August 1990 to evaluate 57 consecutive female patients with urinary incontinence. The aim of the study was to determine whether the indication for surgery could be based solely on an anamnestic evaluation and clinical examination or was corrected by an additional urodynamic test. The anamnestic evaluation alone correctly identified all patients with the diagnosis of stress incontinence in our group of selected patients referred by other urologists. The additional clinical examination confirmed this diagnosis in all patients and additionally led to diagnosis of a vesicovaginal fistula in one patient. The urodynamic testing confirmed the clinical and anamnestic diagnosis in all patients and identified urge incontinence as the leading symptom in one patient with an unclear diagnosis. Our results show that urodynamic studies are important to establish a precise indication for surgery but are not necessary in every patient. A possible alternative to routine urodynamic testing in female urinary incontinence is its application only when there is an obvious discrepancy between the carefully evaluated history of incontinence and the findings of the clinical examination.

[Autologous blood transfusion and hemodilution in planned large interventions exemplified by 132 radical prostatectomies]. / Die autologe Bluttransfusion und Hämodilution bei geplanten grossen Eingriffen am Beispiel von 132 radikalen Prostatektomien.

The hospital records of 132 consecutive patients between May 1988 and August 1991 with biopsy-proven local prostate carcinoma, who were scheduled for radical prostatectomy were reviewed. Seventeen patients had positive lymph nodes at pelvic lymphadenectomy and were subsequently given hormone therapy. The mean blood loss in 115 patients undergoing pelvic lymphadenectomy and radical prostatectomy was 1379 ml. Since September 1988 we have operated a program for predeposit autologous blood donation in all patients prior to radical prostatectomy. Sixty patients were entered into this program and 59 received their autologous blood back during operation. Seventy-eight percent of our patients received only autologous blood. The basis of an efficient autologous blood donation program is a simple logistic schedule for all patients (risk and non-risk), who can choose their dates for autologous blood donation. We hope with this study to encourage other centers to introduce autologous blood donation.

Modified surgical technique to correct congenital and acquired penile curvature.

We treated 37 patients with severe congenital or acquired penile curvature with a modified Essed-Schroeder corporoplasty without excision of the tunica albuginea. After penile straightening, 34 of the 37 patients (91.9%) were able to resume normal coitus and 29 (78.4%) had excellent results, cosmetic and sexual. Postoperative progression of Peyronie's disease and shortening of the erect penis were rare. In 4 patients, partial necrosis of penile shaft skin or of the prepuce complicated the postoperative course, but there were no long-term sequelae in any case. In patients with concomitant preoperative erectile dysfunction, the dysfunction did not improve after corporoplasty; such patients should be treated primarily with a penile implant. We recommend the modified Essed-Schroeder corporoplasty as a safe and simple method to correct penile curvature.

Hydronephrotic atrophy after stable mild or severe partial ureteral obstruction: natural history and recovery after relief of obstruction.

After stable mild or severe partial unilateral ureteral obstruction in rats, the ratio of renal dry weight to whole body weight changes in two phases. In a "destructive phase" of two to six weeks, slight weight reduction occurs in the kidneys with mild obstruction and pronounced weight reduction occurs in those with severe obstruction. Then, in a "steady-state phase", there is no further weight reduction in kidneys with either mild or severe obstruction. Relief of ureteral obstruction during the steady-state phase does not result in an increase in renal dry weight. We conclude that the development of hydronephrotic atrophy after stable mild or severe partial unilateral ureteral obstruction can not be influenced by relief of obstruction in the steady-state phase.

[Papaverine-induced priapism. Experiences with a new urologic emergency]. / Der papaverin-induzierte Priapismus. Erfahrungen mit einem neuen urologischen Notfall.

Ten patients with priapism after self-administered intracavernous papaverine injection for erectile impotence had to be treated as emergencies between September 1985 and February 1988. In half the patients it was possible to achieve penile detumescence by puncture of the corpora cavernosa, injection of 2-5 mg metaraminol or both, but failed in the remainder, requiring the intracavernous injection of 10-30 mg metaraminol in 500 ml physiological saline. Surgical treatment was necessary in one case. Papaverine-induced priapism constitutes a urological emergency which, because of the danger of hypertensive crises, demands treatment in hospital.

A new test to predict reversibility of hydronephrotic atrophy after stable partial unilateral ureteral obstruction.

In previous studies we showed that hydronephrotic atrophy develops only in the first weeks after stable partial ureteral obstruction, and does not progress thereafter. Relief of obstruction only in the "destructive phase" and not in the later "steady-state phase" seems to improve or prevent hydronephrotic atrophy. Since the duration of partial ureteral obstruction is often not known, we studied urinary enzymes of rat kidneys after stable partial unilateral ureteral obstruction to identify the destructive phase. We chose as an example of the tubular lysosomal enzyme N-acetyl glucosaminidase (NAG) and as an example of the brush border enzyme gamma-glutamyl-transferase (Gamma-GT). NAG concentration but not so much Gamma-GT concentration was higher in the urine of the obstructed kidneys than in the urine of the contralateral control kidney, in the first two weeks after operation, and then returned to normal. These observations lead to the conclusion that the "destructive phase" after ureteral obstruction can be identified by the appearance of high urinary tubular lysosomal enzyme content. The clinical implication is that the timing of relief of asymptomatic stable partial ureteral obstruction of unknown duration can be based on the concentrations of urinary lysosomal enzymes.

Spermatic venography in undescended testes.

In patients with undescended testes the demonstration of the pampiniform plexus (i.e. venous network surrounding the testis) by selective retrograde contrast filling of the internal spermatic vein gives exact information about the existence and localization of the gonadal tissue. Especially with small hypoplastic testes and/or an intraabdominal position of the gonad the results of this technique are superior to those of ultrasound and computed tomography. The venographic information often helps to reduce the extent of the surgical exploration, most of all in those cases in which after an ineffective first procedure a second operation is planned. Venography can be done on an outpatient basis in children from an age of about 6 years upwards without general anesthesia and serious complications. Personal experiences with the spermatic venography in 11 patients (age: 7-32 years) with 18 undescended testes are demonstrated. Comparing the roentgenologic and surgical findings in 7 patients with 12 explored veins the results corresponded completely in 75%. In the remaining cases roentgenologic demonstration of one of the testicular veins with its pampinifom plexus suggested important information about the localization of the contralateral testis, surgically confirmed later.

[Realtime sonography of intrascrotal space-occupying lesions]. / Real-time-Sonographie intraskrotaler Raumforderungen.

In 848 examinations of the testes in 317 patients, including 253 follow-up and/or multiple follow-up examinations and 36 unilateral testicle examinations (e.g., orchidectomy, aplasia or nondescent) it was shown that sonography is a diagnostic method which is on the one hand capable of clearly differentiating cystic from solid space-occupying processes, and on the other hand also offers certain possibilities for evaluating the status of solid findings. Histologic identification of malignant tumors was only achieved with teratomas. The differential diagnostic problem was in differentiating scrotal tumors from focal orchitis, chronic epididymitis, testicular torsion and contusion, and in differentiation between paratesticular neoplasms and epididymitides. The testicular findings included testicular neoplasms, cicatrization and cysts of the tunic, sequelae of trauma, orchitis, cryptorchism, hypoplasia, aplasia, and testicular cysts. Paratesticular findings included hydroceles, spermatoceles, varicoceles, paratesticular neoplasms, epididymitides, paratesticular scars, and thickening of the testicular coat.

Influence of thromboxane A2 inhibition on the development of hydronephrotic atrophy.

The development of hydronephrotic atrophy as measured by dry and wet weight in relation to wholebody weight, in rats after complete unilateral ureteral obstruction could be influenced by oral administration of OKY 1581, an inhibitor of thromboxane A2 synthesis. The data are consistent with the thesis that preglomerular thromboxane A2-mediated active vasoconstriction is involved, most likely by ischemia, in the development of hydronephrotic atrophy, at least in the renal cortex.

[Kidney cysts in the computerized tomogram--incidence and therapeutic consequences]. / Nierenzysten im Computertomogramm--Häufigkeit und therapeutische Konsequenz.

In 2000 consecutive abdominal computertomograms it was 788 times possible to receive accurate evaluation of both kidneys. Incidence and shape of renal cysts were identified as well as subsequent urologic evaluation and therapy of these patients, which was done in a surprising small number of cases. The incidence of simple renal cysts is that high (5.6%), that diagnostic exploration of each renal cyst is not possible. This should be done only in those patients where the results of nonsurgical diagnosis is not possible or cannot definitely exclude renal tumor. If operative diagnosis is indicated it can be done without risk for the patient an the kidney, since our own experience show no kidney loss or mortality in 65 consecutive cases. However, the diagnosis renal cyst in those, not surgically explored, should be confirmed by ultrasound with cyst puncture and analysis.

Reversibility of preglomerular active vasoconstriction in the first weeks after complete unilateral ureteral obstruction by inhibition of prostaglandin synthesis.

In previous studies our group has shown that unilateral complete ureteral ligation is followed by flow reduction, which clearly precedes renal atrophy and contributes to hydronephrotic renal cortical damage by ischemia. Long-term followup studies in dogs have demonstrated that increased hydronephrotic vascular resistance could be eliminated by infusion of 2-benzyl-2-imidazole, an inhibitor of thromboxane A2 synthesis. This was shown after 1 and 4 weeks of complete renal obstruction, and there was no such effect on the vascular resistance of the contralateral, unobstructed kidney. Flow reduction and vascular resistance were not influenced by the same inhibition of prostaglandin synthesis after 8 weeks of ureteral occlusion, although renal perfusion still responded to a nonspecific vasodilator, such as dopamine. Thus, active preglomerular vasoconstriction, influenced by imidazole, is present only when renal atrophy develops. Irreversible parenchymal loss, judged by renal cortical thickness, begins after 1 to 2 weeks and is complete 6 to 8 weeks after ureteral ligation. Once renal atrophy is established (that is, after 8 weeks of ureteral occlusion), flow reduction represents loss of renal parenchyma, and not active vasoconstriction. The specificity of the possible thromboxane A2 reaction in flow reduction is shown by its absence in the kidney that has been obstructed for 5 to 8 hours when postglomerular vasoconstriction is the cause of flow reduction (indicated by high renal pelvic pressure and intrarenal pressure). If we accept that imidazole selectively inhibits thromboxane A2 synthesis, we reach 2 conclusions that are clinically relevant: 1) thromboxane A2-mediated active vasoconstriction is 1 factor in the pathophysiology of hydronephrotic atrophy, and 2) the presence of thromboxane A2-mediated active vasoconstriction indicates when hydronephrotic atrophy develops and (more importantly) when it is still reversible, with respect to renal function. These findings can be used as a physiologic basis of a clinical test to predict reversibility of hydronephrotic damage.