Evaluation of asymptomatic microscopic haematuria--influence and clinical relevance of osmolality and pH on urinary erythrocyte morphology.

OBJECTIVE: To determine whether the morphological distinction between 'dysmorphic' and 'eumorphic' erythrocytes in urinary sediment differentiates microscopic haematuria (MH) from reno-parenchymal and post-renal bleeding. MATERIALS AND METHODS: The erythrocyte morphology of 2145 urinary sediments from 1391 patients with MH was evaluated by interference-contrast microscopy and compared with the osmolality, pH and specific gravity of the urine samples. RESULTS: Compared with more concentrated urine specimens, samples of < 700 mOsmol/kg showed significantly lower percentages of dysmorphic erythrocytes; there was a similar reduction in this percentage at a pH > or = 7. In addition, erythrocytes lysed in diluted or alkaline urine and therefore, under these conditions, no diagnosis could be made. CONCLUSION: The assessment of erythrocytes in urinary sediment should be performed only under 'standard conditions', i.e. in concentrated and acidic urine, > or = 700 mOsmol/kg and a pH < 7. The presence of > or = 90% dysmorphic erythrocytes in patients with asymptomatic MH, the absence of proteinuria, a normal blood pressure and normal radiological examination indicates 'reno-parenchymal MH', requiring a long-term follow-up with a routine evaluation twice a year, but no immediate treatment in most cases. In contrast, the presence of > or = 90% eumorphic erythrocytes or even 'mixed' results (10-90% eumorphic erythrocytes) indicates 'post-renal MH', requiring a complete urological evaluation.

Hydronephrosis in malignant tumors: rationale and efficiency of endo-urological diversions.

The improvement of minimal invasive endo-urological urinary diversions in patients with malignant ureteral obstruction (MUO) provides an alternative to open surgery. Endo-urologic procedures cause less morbidity than conventional surgical techniques. From April 1986 to April 1989, 52 patients suffering from MUO representing 64 reno-ureteral units were treated by endo-urological diversions. Proper drainage was achieved in all cases. Initial retrograde JJ-stenting was successfully performed in 30 instances. Percutaneous nephrostomy tubes were primarily placed in 34 units. Fourteen of these were finally changed to a JJ-stent in eleven cases and an ileal conduit in three. Percutaneous ureteral occlusion was performed in 7 units. A positive response regarding the effect of endo-urological treatment on the patient's quality of life was obtained in 81%. Further therapies of the underlying diseases were performed in more than 30% after stabilized renal function. MUO can be treated in most cases with little morbidity and frequently without the use of external collecting devices.

Percutaneous transrenal ureteral occlusion: indication and technique.

Several techniques for achieving palliative ureteral occlusion in cases of underlying malignant diseases are known to exist. We performed nine ureteral occlusions on seven patients, using two different techniques (occlusion by detachable balloon and by "Harzmann Olive"). Initially, complete occlusion of all ureters was attained; in two cases a second occluding intervention had to be carried out after a period of 6 and 14 weeks. Six of seven patients enjoyed a marked improvement of their quality of life after occlusion. Complications were down to a minimum. In comparison with other techniques described in the literature, Harzmann's method seems to be the simplest, as well as the most fully developed one. It may also be recommended for patients in an advanced tumor stage.

Autologous everted vein graft for repairing long-section urethral defects.

In 21 male dogs a 4- to 10-cm sections of the urethra was replaced by an autologous vein graft. After an observation period of 21-380 days (mean 118), the results of radiological, endoscopic, macroscopic and histological examination were evaluated for 19 animals; 2 of the animals died perioperatively. Micturition was normal in 18 of 19 animals until they were killed. One animal died on the 30th day due to a high-grade meatal stenosis with a subsequent episode of urine retention and ascending urinary infection. Gross examination of the graft in this animal, however, revealed a good result. The local surrounding tissue was found to be ideal in 11 animals, and 5 showed satisfactory results. Three times we observed a pronounced stenosis, so that in these cases results were judged to be unsatisfactory. Postmortem examinations showed the neo-urethra to be a tube made up of connective tissue completely lined by urothelium. In our opinion the results of these animal experiments could at least be equalled in clinical application.

Treatment of caliceal calculi.

We analysed the course of 80 "stone periods" (the time that elapses between making a diagnosis and passage of a stone, operation, or an out-patient's last check-up) in 62 patients with caliceal stones prior to the development of extracorporeal shockwave lithotripsy (ESWL) and endourology. The observation time per patient averaged 7.4 years; 16% of the stones passed spontaneously and 40% were removed surgically. The infection rate was 68% and 45% of the stones increased in size during the observation period. Retrospective evaluation showed that of 32 patients who underwent surgery, only 11 procedures were performed at the appropriate time. In the remaining 21 cases the timing of surgery was judged to have been too late because of the ensuing complications. In 8 patients stone growth led to staghorn calculi, 8 had acute obstruction with incipient urosepsis, 3 had chronic urinary infection and 1 had loss of kidney function. We believe that 83% of all caliceal stones require intervention (ESWL or percutaneous nephrolithotomy) within 5 years of diagnosis. Only 11% of patients with caliceal calculi remain symptom-free after 10 years.

Prostaglandin E1 in erectile dysfunction. Efficiency and incidence of priapism.

Prostaglandin E1 (PGE1) was used for diagnostic and therapeutic purposes in 149 men with erectile dysfunction over a period of 20 months (February 1987-October 1988). The intracavernous application of PGE1 in varying doses resulted in an erection sufficient for sexual intercourse in 79% of cases. In order to differentiate between vascular and non-vascular impotence, 5 micrograms PGE1 were found to be a sufficiently high and safe dose for the first intracavernous injection. Local discomfort, ranging from mild to severe pain after injection, was recorded in 40% of patients. A significant difference in severe side effects was found between arterial, venous and non-vasculogenic impotence, the highest incidence of local pain occurring in non-vasculogenic patients. The most striking result was the occurrence of 4 cases of priapism, all in the non-vascular group, 1 of these occurring after the injection of only 5 micrograms PGE1.

Value of urinary erythrocyte morphology in assessment of symptomless microhaematuria.

To assess the value of microscopic analysis of urinary erythrocyte morphology as the initial step in the investigation of patients with isolated symptomless microhaematuria, 316 consecutive patients were grouped according to whether they excreted eumorphic or mixed forms of erythrocytes or only dysmorphic forms. The former group was investigated fully, and urological disease was found in 85% of 123 patients. The 192 patients with exclusively dysmorphic erythrocytes in their urine and normal renal function (benign renal microhaematuria) were assigned to annual follow-up examinations of urinary red cell morphology and renal function, and subjected to invasive diagnostic procedures when a change was noted. In only 2 of the 132 patients followed up for at least 2 years did a new disease develop; this was easily identified at one of the annual examinations. Microscopic analysis of urinary erythrocyte morphology is therefore an effective method for identifying patients with symptomless microhaematuria needing specific diagnostic investigation.

[The value of sonography and intravenous urography in the preoperative diagnosis before prostate adenoma operations]. / Wertigkeit von Sonographie und i.v. Urographie in der präoperativen Diagnostik vor Prostataadenomoperationen.

In 50 patients with benign prostatic hyperplasia the preoperative diagnostical value of ultrasonography was compared with urography. The results show the sufficient efficacy of both methods in the case of bland history and normal urinary findings. In the estimation of adenoma weight the rectal ultrasonography is superior to other techniques.

[Ultrasound controlled kidney cyst puncture: significance for diagnosis and therapy]. / Ultraschall-gezielte Nierenzystenpunktion: Bedeutung für Diagnostik und Therapie.

Renal cyst puncture under ultrasonic guidance has proved an excellent and safe method in the differential diagnosis of cystic renal masses. The use of ultrasound in the follow-up of patients with renal cyst puncture is mandatory for evaluation of complications and results. The therapeutic success of renal cyst puncture is poor and estimated at about 25%. New percutaneous techniques with resection of the cystic wall lead us to expect much better results than with open surgical management.

[Hydronephrosis as a late complication in gynecologic neoplasms: current possibilities for sensible urinary drainage]. / Harnstauungsniere als Spät-komplikation bei gynäkologischen Malignomen: Aktuelle Möglichkeiten zur sinnvollen Harnableitung.

By means of new endourological techniques supravesical urinary drainage is possible with minimal invasiveness. In 10 patients suffering from hydronephroses caused by gynaecological malignancies a worthwhile prolongation of lifetime was achieved by palliative urinary drainage (mean follow-up: 9.1 months). Four cases with fistulas and consecutive incontinence were treated successfully by percutaneous ureteral occlusion (3x), inner stenting respectively (1x). The very low invasiveness of the methods described should encourage the decision towards palliative supravesical urinary drainage.

Assessment of the human tumor cloning assay for urologic malignancies with special emphasis on bladder cancer.

Specimens of different urologic malignancies such as cancer of the bladder, renal pelvis, prostate, testis and renal cell carcinomas were sent to our laboratory for cultivation with the clonogenic assay. Of the 62 samples--biopsies, bladder barbotages and effusions--48% were considered to be evaluable; the others had to be excluded from evaluation because of negative histologic/cytologic findings, insufficient cell viability, inadequate tumor material, or contamination. All test procedures were done using a slightly modified human tumor cloning assay originally described by Hamburger and Salmon [Science 197: 461-463, 1977]. Overall growth was seen in about one third of all tumors cultivated; the mean colony count being 13 +/- 8, the mean cloning efficiency 0.0026%. About one third of bladder cancer specimens and half of the renal cell carcinomas showed colony growth. No correlation between tumor stage or grade and the overall colony growth rate in vitro was seen. Furthermore, it was impossible to correlate the growth rate in vitro and the overall survival of the patients included in the study.

Cefotaxime in the treatment of urinary tract infections.

This study divided UTI into three groups: (1) cystitis without involvement of the upper urinary tract or complicating factors; (2) cystitis with complicating factors, or pyelonephritis without significant complications; and (3) pyelonephritis with complications or predisposing factors. Using this classification, the effectiveness of cefotaxime was examined in three dosage regimens. A randomized study was carried out in patients with uncomplicated cystitis, in which a single dose of 0.5 g of cefotaxime was compared to a 5-day treatment of 100 mg nitrofurantoin 3 times a day. An open study was carried out on patients with more complicated infections. In complicated cystitis, on pyelonephritis without significant complications, the patients were treated with 0.5 g twice a day for 10 days. Patients with complicated pyelonephritis received 1 g twice or 3 times a day for 10 days. In uncomplicated cystitis there was no significant difference in efficacy between single-dose treatment with cefotaxime and 5-day treatment with nitrofurantoin. In 128 patients with pyelonephritis or complicated cystitis, a total of 153 strains were isolated. Of these, 145 were eliminated by cefotaxime treatment, but 8 persisted. During the subsequent observation period 4 patients relapsed and 48 developed re-infections. In 153 patients with complicated pyelonephritis the causative micro-organisms were eliminated in 138 cases. In 15, the organism was still present at the end of therapy. During the observation period 21 patients relapsed although 17 of these bacteria were still sensitive. Re-infections occurred in 49 cases.

Absorption of doxorubicin-hydrochloride and mitomycin-C after instillation into noninfected and infected bladders of dogs.

The described investigations were carried out in order to determine the degree of absorption of doxorubicin, and mitomycin-C after intravesical instillation into noninfected or Staphylococcus aureus-infected bladders in beagle dogs. The drug concentrations in the bladder wall were determined using diffusion chambers with permeable membranes. Two hours after end of instillation of 10 mg. doxorubicin, a concentration of 1.4 ng. per ml. was measured in the bladder wall of noninfected animals, and 3.75 ng. per ml. in that of infected animals (p less than 0.05). The simultaneously measured serum concentration reached mean peak levels after 30 minutes. The concentrations in infected animals were 3 times higher (1.9 ng. per ml.) than in noninfected animals (0.6 ng. per ml.) (p less than 0.05). After instillation of 1 mg. per kg. bw. mitomycin-C the concentration in both groups of animals was below 0.06 micrograms per ml. Doxorubicin concentrations were determined with a radioimmunoassay and mitomycin-C with a micro-agar diffusion method.

Concentrations of doxorubicin in renal interstitial fluid after peripheral intravenous and intrarenal artery infusion in dogs.

Concentrations of doxorubicin-hydrochloride in renal interstitial fluid were compared following peripheral and intrarenal artery infusion of 2 milligrams per kilogram body weight using a diffusion chamber model. After intra-arterial application, the mean peak concentration in renal interstitial fluid was approximately 30 times higher than that after intravenous infusion (66.49 and 2.38 nanograms per milliliter respectively). After peripheral application, the concentrations in serum and renal interstitial fluid, as well as the cumulative urinary excretion, were measured until day 7 of the experiment, and the pharmacokinetic parameters were calculated. The diffusion chamber model used proved itself to be suitable for simultaneous and continuous measurement of cytostatic drug concentrations in serum and renal interstitial fluid.

[Wound healing disorders in urology]. / Wundheilungsstörungen in der Urologie.

In urology wound infections are of particular importance, since they occur in more than 8 of 100 patients. Of all surgical disciplines, urology in fact, is the one with the highest incidence of secondary wound healing. Thus, defective wound healing is seen in about 20% of unselected nephrectomy cases while adenomectomies associated with pyuria and prostatic abscesses show delayed healing in about 40%. In the presence of pyonephrosis or pyelonephritis surgical wounds are infected in 50% of cases. Prolonged preoperative hospitalization increases the chances of skin contamination and, as a result, the risk of wound infection. In addition, it is associated with a higher incidence of hospital infections, which constitutes another endogenous factor underlying defective wound healing. The rate of postoperative wound infections can only be kept within reasonable limits, if close attention is paid to the many factors which contribute to wound healing (e. g. hygiene and preoperative preparation, removal of hair, skin degerming, draping, preoperative disinfection of hands, prophylactic antibiotics etc.) and if strict aseptic and antiseptic precautions are taken.

[Role of cefotaxime in the treatment of urinary tract infections from the viewpoint of the urologist]. / Stellenwert von Cefotaxim in der Behandlung von Harnwegsinfektionen aus der Sicht des Urologen.

A number of very different clinical pictures are summarized under the diagnosis, urinary tract infection (UTI). Therefore, the effectiveness of chemotherapy depends not only on the quality of the antibacterial substance, but also to a large extent on individual factors. For this reason, dividing UTI into three degrees of severity is proposed. This paper reports on the therapeutic results achieved with Cefotaxime on urological patients with ailments of 3rd degree severity (pyelonephritis and accompanying complications, such as obstruction, renal insufficiency, etc.). In a group of 153 patients, the infection causing organisms were no longer traceable when therapy was ended in 138 cases; in 15 cases, they could not be eliminated. The original bacteria reappeared during the follow-up period (4 weeks) in 20 cases, and in 49 cases, other, new species were cultivated.

Pharmacokinetics of high-dose methotrexate in dogs. An experimental model with diffusion chambers.

The usefulness of a diffusion chamber method for determination of concentrations of cytostatic drugs in the interstitial fluid of tissues was tested. Chambers with a permeable membrane (pore size: 0.45 micrometer) were implanted in the liver, kidney, bladder wall, and prostate of dogs. After administration of high doses of methotrexate (100 mg/kg body wt) the concentrations in the chamber fluid and in serum were measured simultaneously and repeatedly for 72 h. The method proved to be effective for collecting data on the distribution of drugs in different organs. The results show that knowledge of the serum concentration does not permit predictions of the drug concentration in the interstitial fluid of various tissues to be made.