[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

A human arterial organ culture model of postangioplasty restenosis: results up to 56 days after ballooning.

BACKGROUND: Restenosis is a reparative process that is activated in response to injury induced by angioplasty. Despite numerous experimental models of restenosis the number of human arterial organ culture systems is very limited and long-term experiences do not exist. METHODS AND RESULTS: During routine nephrectomies parts of the renal arteries of 88 patients were extracted, 47 were suitable for organ culture preparations. Sections were made at 3 mm intervals perpendicular to the vessel wall axis. The arterial segments were treated with 3 mm standard balloon-catheters (Medtronic 14K2030E) for 60 s with 3, 6, 9, and 12 bar. After angioplasty, the organ segments were cultured in a mixture of Waymouth's MB 752/1 and Ham F-12, supplemented with 15% fetal calf serum. After 0, 4, 14, 21, 28, and 56 days the organ cultures were fixed in 4% para-formaldehyde and embedded in paraffin. After staining with a modified elastica-van Gieson technique the intimal wall thickening was analyzed with a computerized morphometric system. For the identification of smooth muscle cells (SMC) a monoclonal antibody against smooth muscle alpha-actin was used. Endothelial cells were identified using an anti-human von Willebrand factor. To determine the number of cells undergoing DNA synthesis, bromodeoxyuridine (BrdU), a thymidine analogue, was added to the culture media 18 h prior to fixation. BrdU was detected with a monoclonal antibody, as secondary antibody a biotinylated horse-anti-mouse antibody was used. After 14, 21, and 28 days in culture BrdU-positive cells were detected in the neointima of the organ cultures, indicating mitotic activity in this area. After 28 and 56 days in culture a clear increase of neointimal thickening was found in the morphometric analysis. By positive reaction with antibodies against smooth muscle alpha-actin these cells were partly identified as SMC. CONCLUSIONS: The organ culture model offers opportunities for in vitro investigations of postangioplasty restenosis. The data emphasize the importance of a relatively late proliferative response of SMC in the human arterial organ culture model.

Altered expression of extracellular matrix in human-cytomegalovirus-infected cells and a human artery organ culture model to study its biological relevance.

The influence of human cytomegalovirus (HCMV) on the transcription of 11 selected, representative extracellular matrix genes was investigated in cell culture. Northern blot hybridization indicated the downregulation of all mRNAs investigated. Based on our results and the known repression of other extracellular matrix transcripts and the beta-actin transcription during HCMV infection, we suggest that one molecular mechanism contributing to the cytopathic effect may be the transcriptional downregulation of genes encoding proteins involved in cell structure and intercellular connection. To further study the biological relevance of this and other pathogenetic mechanisms, we established a human renal artery organ culture system and characterized this new infection model for HCMV. Our model is a new suitable system for the investigation of molecular as well as functional consequences of HCMV infection in a more physiological microenvironment.

Radical retropubic prostatectomy: morbidity and urinary continence in 418 consecutive cases.

OBJECTIVE: To evaluate morbidity and mortality after standard retropubic radical prostatectomy with special attention to postoperative urinary continence. METHODS: Four hundred eighteen consecutive patients undergoing radical prostatectomy for treatment of localized prostatic cancer were reviewed. Both clinical and pathologic staging was assessed retrospectively according to the new TNM classification (International Union Against Cancer, 1992). Postoperative urinary continence was assessed according to the criteria of the International Continence Society. RESULTS: There were no operative deaths. Perioperative mortality was 1.2 percent, with 3 patients dying of myocardial infarction and 2 of pulmonary embolism after uneventful operations. Rectal injury, which was primarily closed, occurred in 2.9 percent. In 1 case (0.2%), reimplantation of the left ureter had to be performed. A total of 20 patients (4.7%) required reoperation: abscess 1.7 percent; postoperative hemorrhage, 1.7 percent; anastomotic urinary leakage, 1.2 percent: massive lymphocele, 0.2 percent. Complications that were treated conservatively occurred in 73 patients (17.4%): lymphocele, 6.4 percent; hemorrhage, 5.7 percent; thromboembolism, 2.6 percent; secondary wound healing, 2.6 percent. Of all patients who were followed for one year or longer, 80 percent achieved complete urinary control or reported occasional spotting only; 15 percent experienced stress incontinence grade II; and 3 percent were totally incontinent. CONCLUSIONS: Despite extensive surgical experience, our continence rates are far from the optimistic 1-3 percent incontinence rates reported in the literature. In our experience, radical retropubic prostatectomy can be performed with acceptable morbidity and without significantly affecting the quality of life in the majority of patients.

The ileal neobladder: 6 years of experience with more than 200 patients.

Between April 1986 and April 1992, 211 consecutive men underwent lower urinary tract reconstruction by means of the ileal neobladder. There have been 5 perioperative deaths for an operative mortality rate of 2.4%. The early complication rate for issues not directly related to the neobladder was 7.5% compared to a 6.5% directly neobladder-related early reoperation rate. Neobladder-related late complications requiring rehospitalization or reoperation have been acceptable, including ileus (2%), abscess (1%), colon-reservoir fistula (1.5%), hydronephrosis (1%), ureteral stenosis (3.6%) and transurethral incision of the urethroileal anastomosis (7%). Overall, only 29.3% of our patients had no complication, whereas 32% suffered significant problems requiring rehospitalization or reoperation. The remainder of the patients suffered minor but not negligible problems. Excellent continence was achieved early and increased with time: 85% of the patients were perfectly dry night and day by 3 years. At this date only 5.5% of the patients had nighttime incontinence, while 6% wear protection for occasional accidents. Intermittent catheterization is necessary in 3.5% of the patients because of the inability to void or maintain a post-void residual volume of less than 100 ml. Despite the fact that some price must be paid for excellent continence, natural voiding and undisturbed body image, the ileal neobladder continues to be our procedure of choice for male patients after cystectomy provided there is no evidence of prostatic or urethral involvement. Our results should stimulate earlier patient and physician acceptance of cystectomy.

[Kidney carcinoma in Bourneville-Pringle disease]. / Nierenkarzinom beim Morbus Bourneville-Pringle.

We report a case of renal cell carcinoma in a 28-year-old woman with Bourneville-Pringle's disease. A review of the literature revealed 16 cases of renal cell carcinoma associated with tuberous sclerosis. The incidence of angiomyolipoma among patients with Bourneville-Pringle's disease is cited in the literature as 40-80%, but this is based solely on two early publications, while other publications suggest a considerably higher incidence of renal cell carcinoma in Bourneville-Pringle's disease, as in other phacomatoses (Hippel-Lindau's disease). We therefore recommend screening for renal cell carcinoma in patients with Bourneville-Pringle's disease.

The ileal neobladder. Operative technique and results.

Bladder substitution by continent bowel reservoirs has been one of the real advancements in modern urology. Short-term experience with and patients' acceptance of the ileal neobladder have been excellent. As do others, we consider this technique to date the procedure of choice in male patients requiring radical cystectomy.

The ileal neobladder: experience and results of more than 100 consecutive cases.

The ileal neobladder produces a completely detubularized, low pressure, high capacity reservoir constructed from ileum without any valves. From April 1986 through May 1989, 113 patients underwent this procedure at our institution. Of these patients 99 underwent simultaneous radical cystectomy for bladder cancer and 14 underwent bladder augmentation. The mean postoperative followup was 14.4 months, with a range of 1 to 36 months. There was no perioperative mortality. However, 7 patients died more than 2 months postoperatively: 5 of tumor progression, 1 of pneumonia and severe metabolic acidosis, and 1 of septicemia of unknown cause. Reoperation was necessary in only 13 patients; 10 patients required urethrotomy or dilation of urethral strictures. Day and night continence was preserved in 82.1% of all patients. Stress incontinence, which must be corrected by an artificial sphincter, was found in 4 patients (4.2%) and night-time incontinence that required an external device occurred in 5 (5.3%). Eight patients (8.4%) with mild stress incontinence required no further treatment. Pressure waves exceeding 22 cm. water seldom occurred and then only at maximum capacity. Our experience with this relatively simple system without a nipple is an overwhelming success. The need for reoperation is extraordinarily low and the high reservoir capacity results in continence from the beginning in most patients. The concept is sound and offers a genuine alternative to any form of cutaneous urinary diversion with an incidence of complications not higher than after standard supravesical urinary diversion.

What's new in urology?

Urology has undergone remarkable growth and a variety of clinical substantial therapeutic concepts have changed within the last few years. The following short summary incorporates the most actual advances in basic science and clinical medicine as well as surgical technique. Spectacular new concepts have been developed according to therapy of bladder substitution using bowel. Therapy of stone formation in the urinary tract is possible by using extracorporal shockwave therapy in more than 2/3 of the patients. Additionally, promising aspects in the treatment of hypernephroma with immune response modifiers are actually of great interest. The evaluation of prostatic specific antigen (PSA) as a specific marker in prostatic carcinoma and the conflict between indication for lymphadenectomy or surveillance therapy in testicular cancer stage I, as well as tumor regression under chemotherapy influences clinical trials (e.g. surgical debulking). The brief review of diagnostic and therapeutic approaches including some aspects of andrology hopefully may help to understand clinical problems and demonstrate the effectiveness of standard urologic diagnosis and therapy.

[3 years' experience with the ileum neobladder--the first 108 patients]. / 3 Jahre Ileum-Neoblase--die ersten 108 Patienten.

Between April 1986 and April 1989, each of 108 patients received an ileum neobladder, 94 patients for total bladder substitution after radical cysto-prostatectomy and 14 for augmentation of a fibrotic and contracted bladder following tuberculosis, interstitial cystitis or radiotherapy of the pelvis. The operative technique is standardized, relatively simple and safe, and it prevents upper urinary tract deterioration and reflux. Continence is preserved in more than 80% of all patients by the function of the external urethral sphincter and by the high capacity and the low internal pressure of the intestinal reservoir. Follow-up of more than 3 months postoperatively was possible in 96 patients, the evaluation including micturition behavior at home and a urodynamic investigation. Stress incontinence requiring correction by an artificial sphincter was found in 3 and nocturnal incontinence necessitating some external device in 6 patients. There was no perioperative mortality. Local tumor recurrence and/or metastases occurred in 14 patients; 7 patients died postoperatively, 5 owing to tumor progression, 1 of pneumonia and serve metabolic acidosis, and 1 owing to septicemia of unknown cause. Re-operation was necessary in 13 patients, in 6 because of mechanical ileus or intra-abdominal abscess, in 3 because of stenosis of the uretero-ileal anastomosis, in 1 because of tumor progression, in 1 because of vesico-vaginal fistula, in 1 patient because of incisional hernia, and in 1 because of wound dehiscence. Urethrotomy or dilatation of urethral strictures was necessary in 8 patients. All other early and late complications were rare and could be managed by conservative means.(ABSTRACT TRUNCATED AT 250 WORDS)

[Can topical chemoprevention modify the rate of recurrence and progression of superficial bladder cancer?]. / Kann die topische Chemoprophylaxe die Rezidiv- und Progressionsrate des superfiziellen Blasenkarzinoms beeinflussen?

Several studies indicate that intravesical chemotherapy is an effective treatment for superficial bladder tumors. We have carried out a retrospective study of 321 patients with superficial bladder cancer who where treated between 1972 and 1982 at our Institute. In 63 of the 321 patients, adriamycin 50 mg or mitomycin C 20 mg was administered topically. In an average follow-up of 20.2 months the overall recurrence rate was 54.2%. In the control group the mean times to recurrence were 21 months for Ta tumors and 17.4 months for T1 tumors, while those in the topically treated patients were 14 and 8 months for the mitomycin and 17 and 6 months for the adriamycin group. The only factor that influenced the recurrence rate was the depth of infiltration of the lamina propria. Our data indicate that topical chemotherapy has no effect in patients with superficial cancer of the bladder.

Endocrine and clinical evaluation of 107 patients with advanced prostatic carcinoma under long-term pernasal buserelin or intramuscular decapeptyl depot treatment.

Three major assumptions emerged from these clinical and endocrine long-term studies. First, buserelin, given pernasally in the conventional doses, and Decapeptyl microcapsules administered intramuscularly in 5-week intervals are equally effective in terms of their long-term castration effect in previously untreated patients with prostatic carcinoma. However, Decapeptyl causes complete LH and subsequent testosterone down-regulation 1 week earlier than buserelin. Furthermore, this treatment is more convenient, and the compliance is better. Both LHRH analogues are equally well tolerated. Second, in groups of prostate cancer patients with far advanced disease treated with palliative intention, only true subjective or objective remission should be considered a positive treatment response. Third, our results comparing PAP and PSA as the two most useful tumor markers with the corresponding testosterone levels suggest a close correlation.

[Treatment of advanced cancer of the prostate with an analog of LHRH, buserelin]. / Traitement du cancer de la prostate évolué par un analogue de la LHRH, la busereline.

Patients with metastatic prostatic cancer were treated by means of an LHRH agonist, Buserelin, by nasal administration. The serum testosterone levels were permanently decreased to castration levels in all patients. The objective response rate (CR + PR) was 50%.

Long-term endocrine profiles of prostatic carcinoma patients under pernasal as well as intramuscular Gn-RH analogue treatment.

The treatment with supraphysiological doses of the gonadotropin releasing hormone analogue Buserelin results in the suppression of serum testosterone to castration range with a probability of 95% after 28 days. This decrease is paralleled by a decline of the intracellularly active androgen dihydrotestosterone, a decrease of the unbound fraction of testosterone and a drop of the production rate of testosterone to values as low as after bilateral orchiectomy. The adrenal steroids androstenedione, DHEA-S and cortisol and the non-steroidal hormones prolactin and thyroxin are not affected by Gn-RH analogue treatment. The beneficial effect of Buserelin in the treatment of prostatic carcinoma is due to medical castration only. Further improvement, regarding practicability and cost effectiveness can be expected by intramuscular depot preparations.

The effect of a 5 alpha-reductase inhibitor on androgen-mediated growth of the dog prostate.

The administration of testosterone cypionate (0.4 mg/kg BW . day) to castrated male dogs caused a doubling of prostate weight within 4 weeks and an increase in the content of testosterone and dihydrotestosterone in the prostate. When the 5 alpha-reductase inhibitor 17-N,N-diethylcarbamoyl-4-methyl-4-aza-5 alpha-androstan-3-one (3 mg/kg BW . day) was administered simultaneously with testosterone cypionate, prostatic testosterone content increased from 0.5 +/- 0.2 to 4.1 +/- 1.3 ng/mg DNA, the increase in prostatic dihydrotestosterone content was prevented, and prostatic size decreased to half the starting weight. These results suggest that dihydrotestosterone formation plays a role in prostatic growth.