Reconstructive urology in the nordic countries--a hospital questionnaire survey.

A hospital survey of adult reconstructive urologic surgery in the Nordic countries is presented. The response rate was 80% and included most general hospitals and university clinics. Despite similarities between the healthcare systems of the various countries several differences were found. Cystectomy was performed in a large number of institutions in all countries except Denmark. The annual number of orthotopic bladder substitutions per institution was calculated as three to four (range of medians for each country) and the number of continent cutaneous diversions as two to seven. Open urethral procedures were performed more frequently in Sweden than in the other countries. Surgery for penile curvature and implantation of three-component prostheses for erectile dysfunction was more commonly performed in Denmark and Iceland compared to Sweden.

Detection of messenger RNA for the beta-subunit of chorionic gonadotropin in urinary cells from patients with transitional cell carcinoma of the bladder by reverse transcription-polymerase chain reaction.

We studied whether detection of messenger-RNA (mRNA) for the beta-subunit of chorionic gonadotropin (CGbeta) in urinary cells from bladder cancer patients could be used as a marker of disease activity. Sixty-eight urine samples from patients under follow-up for bladder cancer and 23 samples from patients with other malignancies and non-malignant surgical conditions, as well as 14 samples from healthy controls were analyzed. RNA was isolated from urinary cells collected by centrifugation. Reverse transcription-polymerase chain reaction (RT-PCR) was used to detect CGbeta mRNA. The results were compared to those obtained by cystoscopy and urinary cytology. For comparison, we determined CG and CGbeta in serum and urine and the core fragment of CGbeta (CGbeta cf) in urine by immunofluorometric assays. CGbeta mRNA was detected in 29 of 68 urine samples from patients with a history of bladder cancer, whereas all 14 samples from healthy controls tested negative. Elevated levels of CGbeta were observed in serum in 18 of 45 bladder cancer patients, but the association with CGbeta mRNA was weak. However, CGbeta mRNA expression in the absence of detectable cancer also occurred in some conditions associated with cellular atypia such as urinary tract infection, instrumentation and certain therapies. There was a highly significant association between histologically verified transitional cell carcinoma of the bladder and CGbeta mRNA in urine (p = 0.0014), implying CGbeta mRNA expression in tumor tissue. We conclude that CGbeta mRNA is a potential new marker for monitoring of bladder cancer. Further studies are needed to evaluate whether it provides independent clinical information.

Metabolic evaluation and medical management of upper urinary tract stone disease. Guidelines from the Scandinavian Cooperative Group for Urinary Stones.

A set of simple guidelines for metabolic evaluation and medical/dietary management of patients with urolithiasis is presented. The evaluation scheme is based on the documented risk factors in the Nordic area and the results of controlled clinical trials, and takes its basis in the severity of the stone disease in the individual stone patient. The initial evaluation in all patients aims at diagnosing conditions with a definitive metabolic, infectious or anatomical/functional cause of stone formation (MIAF urolithiasis). Patients with MIAF urolithiasis are treated according to the nature of the underlying disease. Having excluded/diagnosed MIAF urolithiasis, patients with idiopathic calcium nephrolithiasis remain, and in this group, which comprises approximately 85% of the total stone population in the Scandinavian region, only those with a complicated stone disease are subjected to additional evaluation, which aims at identifying underlying pathophysiological derangements for which medical therapy has been proven to be effective in controlled clinical trials.

Radical prostatectomy for localized prostatic carcinoma in a renal transplant patient.

Long-term immunosuppression increases the incidence of many forms of malignancies. We present a case report of a renal transplant patient who developed a prostatic cancer 4 years after transplantation. Radical prostatectomy is a suitable option in the treatment of localized prostatic cancer in a renal transplant patient.

Neurofibromatosis of the bladder.

Multiple neurofibromatosis, von Recklinghausen's disease, is a rare disease of the neurilemmal cells. It is an inherited disorder transmitted as a mendelian dominant and characterized by multiple subcutaneous tumours and café-au-lait spots. The first time its symptoms were described was by Smith in 1849.

A new system for descriptive classification of stones in the upper urinary tract.

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Hemi-Kock reconstruction following cystectomy: experience and results from a small urological unit.

Between December 1988 and January 1992, 11 men underwent lower urinary tract reconstruction by means of the hemi-Kock ileal reservoir following radical cystoprostatectomy (ten patients) and subtotal cystectomy (one patient). Six of the 11 patients developed an early postoperative complication, with a fatal outcome in two of them. One patient succumbed to subarachnoidal bleeding and one to septic shock. During the follow-up, another two men died of advanced bladder carcinoma. The late complication rate was low. Most patients regained their continence within six months. A good continence was achieved in all the nine remaining patients during the day and in six of them at night. This experience suggests that the hemi-Kock reservoir is a useful method for the urinary tract reconstruction following cystectomy.

Treatment of urinary stones by extracorporeal shock wave lithotripsy.

A total of 1641 ESWL-treatments were performed in 948 patients at Helsinki University Central Hospital between June 1989 and December 1991. In a series of 816 patients and 1287 treatments with data available 681 (76.4%) stones were located in the kidney, 208 (23.3%) in the ureter, and three (0.3%) in the urinary bladder. Auxiliary procedures were performed in 156 (19.1%) and repeated treatments in 300 (36.8%) patients. The most common complication was intensive pain during the procedure in 138 (16.9%) patients. The first 139 patients were followed until six months after their last ESWL-procedure. The six-month stone-free rates of renal and ureteric stones of these patients were 67.4% and 86.7%, respectively. The overall six-month clearance rate was 72.4%.

Contact fibre Nd:YAG laser for partial nephrectomy: experimental study in pigs.

Thirty-two partial nephrectomies were performed without renal cooling on 13 pigs with a contact fibre Nd:YAG laser (10 W) or a steel scalpel with or without a vascular pedicle clamp. Nine pigs had a 2-week follow-up with an abdominal ultrasound 1 week postoperatively. The time for haemostasis was 6.9 +/- 5.2 min (mean +/- SD) with the laser and 9.1 +/- 5.8 min with the steel scalpel when the clamp was used (P = 0.028). There was no significant difference in the total operating time (13.2 +/- 4.5 min with the laser vs 12.6 +/- 4.6 min with the steel scalpel, P = 0.203). Intraoperative blood loss was similar in the two groups when the clamp was used. Clamping the renal pedicle decreased the blood loss by 61% in the laser group and 31% in the steel scalpel group. The number of ligatures used was significantly lower in the laser group (3.7 +/- 2.6) compared with the steel scalpel group (6.6 +/- 3.4) (P = 0.013). Five urinomas developed on the laser side and four on the steel scalpel side. These results indicate that the contact fibre Nd:YAG laser method can be used in partial nephrectomy, but it offers no definitive advantage over the conventional technique.

Urethral stricture repair: results in 179 patients.

From 1977 till April 1990 169 operative reconstructions of urethral strictures were carried out in this clinic. 49 patients with a short stricture (less than 2 cm) underwent excision and end to end anastomosis. In 18 patients with a long stricture (2-6 cm) one stage urethroplasty with a transverse distal penile or preputial island of skin flap was used. 102 patients with extensive or otherwise problematic strictures were subjected to two-stage mesh skin graft urethroplasty. In 10 patients with a short stricture we have recently implanted a new urethral stent in the strictured area after visual urethrotomy. During a long-time follow-up a good anatomical and functional result was achieved in all but 2 patients who underwent an excision and end to end anastomosis. In the island flap urethroplasty group a restricture occurred in one patient, and mesh graft urethroplasty was successful in all but 3 patients. In the urethral stent patients the primary results are excellent.

Adenocarcinoma of the renal pelvis in an elderly woman.

Adenocarcinoma of the renal pelvis is so rare that many reviews of renal tumours fail to include any instance of this lesion. We present a 75-year-old female patient with no previous history of urological disease in whom a renal pelvic tumour was diagnosed. Histological examination after radical nephroureterectomy proved the tumour to be a rare adenocarcinoma. The course of the disease, the possible predisposing factors, the treatment of the tumour and the prognosis are discussed.

Functional and urodynamic characteristics of bladder substitution with detubularised right colonic segment.

A total of 19 patients underwent bladder replacement with a detubularised right colonic segment; 14 males underwent complete substitution after cystoprostatectomy and 5 females had augmentation after subtotal cystectomy. The mean follow-up time was 20 months. Urodynamic evaluation showed a low pressure reservoir with a mean capacity of 580 ml and normal closure pressure. Sensitivity of the bladder to cold was normal in the augmentation group but was lacking in all patients in the total substitution group. In all except 1 patient the neobladder emptied effectively upon straining without significant residual urine. Seventeen patients were completely continent by day and 10 by night; 1 patient developed hyperchloraemic acidosis requiring treatment. Bladder substitution is superior to the standard ileal or colonic conduits with regard to quality of life, and the use of a right colonic segment is functionally comparable with neobladders composed of the ileum or a combination of the right colon and ileum. The latter are more difficult to fabricate and so may have more complications.

Opposite renal pelvic metastasis of renal adenocarcinoma. Case report.

We report on a 72-year-old patient who was nephrectomized because of renal adenocarcinoma and who developed five years later a tumour in the contralateral renal pelvis. Histological study of the completely resected tumour revealed a metastase from the renal cell carcinoma. A short review of the literature concerning the rare cases of contralateral renal pelvic or ureteral metastases of renal carcinoma is made.

Results of the management of ureteric stones with the ureterorenoscope.

Eighty ureterorenoscopies (URS) were performed for stone removal in 67 patients between January 1985 and April 1988. The success rates for stone removal were 54% in the lower third of the ureter, 70% in the middle third, 38% in the upper third, and 33% in the renal pelvis. The overall success rate was 42%. Open ureterolithotomy was performed after failed ureteroscopy nine times. There were two perforations of the ureter: one by the hook of the forceps and the other by the dormia basket. No significant late complications occurred in 51 patients after six to 36 months postoperatively. At the moment ureteroscopy is of value particularly in the treatment of lower or middle ureteric stones.

Intramural ureteric injury due to acute dilatation.

The effect of balloon dilatation of the ureteric orifice and the intramural ureter was evaluated histologically and radiologically in eight piglets. The distal part of the ureter was dilated from its normal calibre of 4F to 12F. Four weeks after the procedure obvious histological signs due to the preceding dilatation were seen in seven of the eight ureters. In simultaneous radiological studies two ureters showed massive and one slight dilatation and two ureters showed vesicoureteral reflux. The results suggest cautious use of dilatation. Small calibre ureterscopes without ureteric dilatation should be preferred.

Percutaneous nephrostomy in the management of urinary leakages and fistulas.

Treatment with percutaneous nephrostomy (PN) without co-existing stents was attempted in 18 patients with urinary fistulas and leakages. Seven patients were cured by PN alone. Two of these developed a ureteral stricture at the site of the lesion: one showed no impairment of urinary flow on the follow-up, the other needed continuous urological surveillance. In the remaining 6 cases PN provided temporary relief of the associated urinary stasis. Percutaneous nephrostomy could not be applied in 5 cases because of the lack of renal pelvic dilatation. Only catheter related complications occurred. Because of its easy and little traumatic technique, simple PN could be used as the primary therapeutic approach in such lesions.