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We report on a rare case of bilateral oncocytic kidney tumors in a patient with Birt-Hogg-Dubé syndrome (BHD). BHD is an autosomal inherited cancer syndrome associated with multiple kidney tumors, benign cutaneous tumors, and pulmonary cysts with spontaneous pneumothorax. To date about 50 BHD families have been described. Patients are best treated with nephron-sparing surgery. Close follow-up is mandatory because recurrence in previously operated kidneys and metastatic tumor progression can occur. Family members at risk should also early be screened for BHD.

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Therapy of superficial bladder tumors is transurethral resection (TUR), and in cases of pT1 or high-grade tumors a re-TUR is indicated. Patients with carcinoma in situ receive intravesical chemotherapy or BCG for at least 3 months. Persistent carcinoma in situ may be treated by radical cystectomy. With the provision of a functionally adequate urinary diversion, cystectomy represents an effective treatment for patients with muscle-invasive bladder cancer without metastatic spread. Regional lymph node metastases can be found in up to 15% of stage T1 disease and are present in 33% of stage T3/4 lesions. Thus, lymphadenectomy gains diagnostic and possibly also therapeutic importance. For selected patients, who cannot be treated by radical cystectomy, multimodal concepts aiming to preserve the bladder are discussed. After or prior to cystectomy systemic chemotherapy may become necessary for some patients to positively affect the course of the disease in cases of locally advanced or metastatic lesions.

Laser therapy for benign prostatic hyperplasia (BPH) is now the most impressive alternative to transurethral resection of the prostate (TUR-P). Transurethral laser ablation of the prostate (TULAP) is a new technique that combines non-contact and contact laser treatment of BPH. From November 1992 to August 1994, 188 patients were treated by the TULAP technique. Their median age was 70.3 (58-87) years. The mean prostatic volume determined by transrectal ultrasound, was 49.2 ml. A 6-month follow up was possible for 102 patients. The AUA 7-Symptom Score decreased from 29 points preoperatively to 6 points after 6 months. Residual urine volume decreased from 205 ml to 27 ml after 6 months. Maximum flow rate increased from 7.2 ml/s to 19.3 ml/s after 6 months. No severe complications were observed, and in particular no major bleeding or TUR syndrome. We regard the TULAP procedure as an effective treatment alternative for obstructive symptoms caused by BPH.

The creation of an ileal neobladder or another continent bladder substitute can improve the psychological well-being of patients who need cystectomy. The excellent surgical outcome and continence that can be obtained with an ileal neobladder mean it can be constructed for reversal of diversion even in cystectomized male patients. Selection, indications and results in five patients with reversal of diversion are presented.

From April 1986 to April 1989 an ileal neobladder was constructed in 101 male patients for complete bladder substitution following radical cystectomy. The patients were retrospectively stratified by age: 86 were over, 15 under the age of 70. No major differences were found in terms of early and late postoperative complications. However, the functional results differed markedly: whereas 89% of the younger patients achieved complete daytime and nighttime continence, only 50% of the older patients reached the same status. It is concluded that strict indications should be observed for complete continent bladder substitution in the elderly.

In 18 patients (20 kidneys) with struvite/apatite-, uric acid- and cystine stones antegrade local chemolysis was performed via percutaneous or operative nephrostomy. Complete stone dissolution was achieved in 11 kidneys, while in six kidneys partial dissolution of stones was performed. In these six cases added instrumental manipulations shortened the time of therapy. In three cases chemolysis was unsuccessful. Average irrigation time was 21 days per renal unit. Only minor complications like dysuria and skin rashes were seen. Due to long time of irrigation we recommend chemolitholysis mainly as an additional form of therapy in case of residual stones after operative or percutaneous nephrolithotomy.

The techniques and possible applications of automated image analyser systems with regard to the organs of the urogenital tract are shown and critically assessed. In contrast to fully automated image analysis, semi-automated systems have already become established as standard investigation procedures for scientific questions. It is hoped they will make a contribution towards objectivizing typical therapeutic or specific pathological changes in the target tissue. Fully automated systems are used mainly for the derivation of diagnostic-prognostic tumor criteria in cytological urine analyses. However, routine utilization is still unsatisfactory on account of inadequate diagnostic reliability, so that further development of hardware, software and preparative techniques is necessary. Nevertheless, there is already a striking level of agreement between the automated diagnoses and those made on assessment by an experienced investigator. Special aspects of measuring techniques as they relate to morphometry of the organs in the urogenital tract are discussed.

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)

Torsion of the testes is the most frequent urogenital emergency in childhood. Bilateral intrauterine torsion of the testes is a rare event. Only 15 cases have been reported up till now. We add two patients. Clinical findings, consequences and therapy of bilateral torsion of the testes are discussed. Etiology and symptomatology of testicular torsion in the newborn and the adult are different. Predisposing factors are lacking in the extravaginal torsion of the newborn but are present in the intravaginal torsion of the adult. The diagnosis is made by inspection, palpation, Doppler sonography and, if necessary, by immediate surgical exploration. Except for the local findings there are usually no symptoms in the newborn. Following bilateral torsion of the testes with consecutive bilateral orchiectomy the loss of exocrine function remains irreversible. Androgenic substitution therapy should begin at the age of 14. The full dose of hormone should not be given before the termination of bone growth. For psychological and cosmetic reasons a testicular prosthesis can be recommended.

Currently we are witnessing an increase of interest in bladder substitution enterocystoplasty. The goal of this presentation is to describe operative technique and first clinical results of a ileal neobladder for total bladder replacement. Creation of a ileal neobladder for total bladder replacement is described in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressures lower than 30 cm water and no reflux. Eight of the 11 patients with the neobladder are completely dry day and night. Three are stress incontinent grade I. All 11 patients developed recognizable sensations of bladder distension closely simulating those of their earlier bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers a stoma free alternative to urinary diversion resulting in a highly compliant low pressure bladder. A urodynamic comparison between the most recent developments (Kock-pouch, Camey, Mainz-pouch, "Le Bag") is made and this clearly shows the ileal neobladder to have several distinct advantages: the ileocolonic junction and the terminal ileum are saved; the operative technique is safe, simple and reliable (no Kock valve, no 180 degree rotation of the reservoir, simple antireflux technique); development of recognizable sensations of bladder filling in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)