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Paraprostatic pheochromocytoma is a very rare localization of extra-adrenal pheochromocytoma. The clinical and anatomical features of a 41-year-old man are described., (Copyright 2005 S. Karger AG, Basel.)

The lymphangioma is a well-recognized benign tumor most frequently encountered in infancy and childhood. The kidneys are rarely involved. Despite its benign nature, most of the patients were treated by partial or radical nephrectomy. We describe a case of bilateral perirenal lymphangioma in a 33-year-old man for whom we chose a conservative approach.

Although untreated/undertreated pain leads to a variety of somatic, psychological and socioeconomic harm, the knowledge of its physiology, diagnosis and adequate treatment is generally low among urologists. This review has the primary goal to sensitize us urologists to this underrated topic.

Introduction: As even experienced urologists have a high percentage of persisting carcinoma after transurethral bladder tumour resection (TUR-B) the importance of a routine second resection in the management of transitional cell carcinoma (TCC) of the bladder is defined., Patients and Methods: The medical records of all patients treated with TUR-B at our institution between January 1989 and September 2000 were reviewed. 214 patients with pTa and pT1 carcinoma undergoing a second resection 4-6 weeks later were included in the analysis. The rate of persisting carcinoma in the second resection was compared to the actual tumour stage and grade, the patient's age, sex and the experience of the urologist performing the resection., Results: Of the 214 patients 99 had pTa and 115 pT1 carcinoma. The rate of persisting tumour in the second resection was 27% in pTa and 37% in pT1 carcinoma. This rate was independent of the patient's age and sex. Urologists in training had an equally low rate of persisting carcinoma in the second resection compared to senior urologists (p = 0.08)., Conclusions: Routine second resection of superficial transitional cell carcinoma of the bladder should be part of the treatment even in larger operative experience., (Copyright 2004 S. Karger AG, Basel)

We report a young male aged 20 who has suffered two episodes of Leydig cell tumor of the testis, the second occurring 5 years after the first in the contralateral testis. The case is outlined briefly, with references taken from the literature. This young man's history is exceptional as this type of tumor is infrequent, and metachronous bilateral presentation extremely rare., (2004 S. Karger AG, Basel.)

Anastomoses between the dorsal artery of penis and the deep penile artery are necessary for revascularization of penile arteries. Radiologic and anatomic proof is provided. Arterio-arterial anastomosis represents a risk factor for thrombosis. For its exclusion the necessary operative course of action is showed. By building an additional arteriovenous shunt close to the arterio-arterial anastomosis the risk of thrombosis is markedly decreased. Our technique produces good results in patients with diagnosed erectile dysfunction of vascular origin with a spontaneous erection when the occasion arises., (Copyright 2003 S. Karger AG, Basel)

Introduction: The aim of this study is to determine the relationship of hydrochloric acid secretion in gastric pouch (GP), an orthotopic neobladder using a stomach segment, to gastrin., Material and Method: Pentagastrin (PG) stimulation test (PGST) was applied in 10 patients who had had GP surgery 5-70 months ago, and their urinary pH changes in the next 2 h were observed., Results: Significant pH decreases (from 6.6 +/- 0.6 to 2.9 +/- 1.0 in the mean) 30-75 min after injection of PG, demonstrating gastrin-triggered acid secretion in GP were observed in all patients. The pH values were normalized in 2 h (6.6 +/- 1.0 in the mean)., Conclusion: In PGST, urinary pH decreases, demonstrating the close relationship between gastrin release and acid secretion in the GP. Inhibition of gastrin by any means may be useful in keeping the urinary pH on physiological levels., (Copyright 2003 S. Karger AG, Basel)

Objective: To investigate the ultrastructure of the trigonal muscle (= superficial trigone), relate it to normal function, and identify any changes it may undergo in voiding dysfunction., Materials and Methods: 20 men (median age 67 years) with low-stage prostatic carcinoma, 10 with and 10 without bladder outlet obstruction, were selected by urodynamic evaluation. Trigonal biopsy was performed at radical prostatectomy, and processed for electron-microscopic study by standard procedures. Biopsies were evaluated independently by 2 examiners without prior knowledge of urodynamic data., Results: Three obstructed and 1 unobstructed bladder had impaired detrusor contractility, and 1 obstructed bladder had detrusor overactivity. Compared to the previously investigated detrusor, the trigonal muscle had smaller compact bundles and fascicles with less collagen and more elastic tissue. Muscle cells had no or rare intermediate junctions that mediate mechanical coupling in normal detrusor, but predominant close cell appositions that mediate electrical coupling. Smooth muscle in most biopsies had widespread or focal features characteristic of the aged detrusor. None, however, had the features previously associated with obstructed detrusor, or detrusor with impaired contractility., Conclusions: The trigonal muscle does not undergo structural changes as previously described in the detrusor in association with voiding dysfunction. Its contraction depends on electrical coupling of its muscle cells, and has a supportive role in normal micturition, mooring the terminal ureters to the bladder base, to allow efflux and guard against reflux of urine. Activation of volume and tension sensory neuroterminals may contribute to some storage and voiding micturition reflexes, and may be related to normal and abnormal perception of urge., (Copyright 2001 S. Karger AG, Basel)

Primary erectile dysfunction in combination with congenital malformation of the cavernous bodies has only rarely been reported. We report on 2 young patients with different congenital malformations. To our knowledge this is the first time partial aplasia of the distal part of the cavernous bodies is described, whilst complete isolation of the cavernous bodies in combination with veno-occlusive dysfunction has yet been described in 3 cases. After complete examination, including penile angiography and cavernosometry, a surgical correction with a fully satisfying result was achieved in the patient with distal aplasia. In case of isolated cavernous bodies with severe veno-occlusive dysfunction, the implantation of a penile prosthesis remains the treatment of choice.

The development of HIV protease inhibitors has dramatically improved the treatment prognosis of HIV-infected patients. The treatment, however, is associated with the potential for adverse events that are unique to protease inhibitors. One of them, Indinavir, can lead to the development of urinary stones. Three weeks after starting treatment with Indinavir, Zidovudine and Lamivudine, a 66-year-old patient developed symptomatic hydronephrosis on the right side due to multiple Indinavir stones blocking the ureter. Microhematuria and characteristic crystals were found in the urine. After interruption of treatment and increased fluid intake, the crystallurea was not longer detectable and the patient became asymptomatic within 3 days. Nephrostomy and ureteral stent placement were not necessary. Patients on treatment with Indinavir are required to maintain a fluid intake of at least 1.5-2 l/day to reduce the risk of crystallization and urinary stones. Pharmacologic metaphylaxis to prevent crystallization is not recommended.

Optimal treatment parameters and appropriate methods of examination for Nd:YAG laser coagulation of the human prostate in dependence of power-setting and time using the SideFocus side-firing delivery system have been determined. Transurethral free-beam laser coagulation was performed in 10 patients prior to planned radical prostatectomy or cystoprostatectomy. Thereof, 6 patients underwent transperitoneal laparoscopic lymphadenectomy and laser coagulation of the prostate between 4 and 9 days prior to open surgery. These same patients had undergone MRI examination with an endorectal coil during staging and prior to radical prostatectomy. Depth and volume of coagulated prostatic tissue of a 4-quadrant laser application were measured at power-settings of 40 W/90 s and 60 W/60 s. There was no difference in volume coagulation between the two treatment modalities. In contrast there was a significant difference in volume coagulation between those prostates removed at 4-9 days and those removed at 60-210 min after laser coagulation. In histological and MRI examination, however, there was a strong correlation with view to coagulation volume in histological and MRI examination. Using the SideFocus side-firing laser fiber, both treatment modalities showed comparable volume coagulation. Laser-induced changes are conclusively discernible by 4 days, MRI examination with an endorectal coil thus being perfectly suitable for assessment.

We report a case of massive perirenal hemorrhage owing to an inferior segmental arterial rupture of an aneurysm, alongside a primarily inapparent polyarteritis nodosa associated with hepatitis B and C. We come to speak of the diagnostic procedure such as angiography, computerized tomography and MRI as well as the intervening measures like catheter embolization and surgical revision.

Extracorporeal shock-wave lithotripsy (ESWL) has rapidly become established worldwide as a routine method for treatment of nephro- and ureterolithiasis. Although initial studies showed no tissue-damaging effect by the shock waves, we found, in an animal experiment using canine kidneys, that the ESWL-induced damage to the renal parenchyma is more marked than originally assumed. The damage is limited to the area that was focused on, and heals relatively rapidly by connective tissue encapsulation with final cicatrisation without any further residual effects being observed up to the present. This parenchymal damage is probably also the cause of the macrohematuria that is always observed during therapy. The resulting tissue damage is not extensive enough to cause a demonstrable reduction of function as measured by the usual methods (serum creatinine, creatinine clearance, isotopy renography, i.v. urography). In serum we observed a transient decrease of calcium, an immediate increase of lactate-dehydrogenase, transaminases (SGOT and SGPT) and a delayed increase of alkaline phosphates. Creatinine, blood urea nitrogen, sodium, potassium and amylase remained within normal limits. In urine, a decrease of creatinine and an increase of glucose excretion were noted. We believe that these changes represent a relatively mild and transient damage of renal cells and do not reflect the occasionally heavy morphological changes observed after shock-wave exposure. The main clinical complication is the large subcapsular hematoma which, according to the present knowledge, could well result from a lesion of the larger peripheral vessels. Damage to other organs such as subserous colonic and small bowel hematomata are to be expected although they do not lead to clinical symptoms.

The usefulness of routine clinical application of the urokinase plasminogen activator in prostate cancer was evaluated. The urokinase values of prostate cancer confined to the organ, with extraprostatic spread and with metastatic disease did not differ and showed no significant difference in comparison with benign prostatic hyperplasia. Urokinase is not a useful parameter in clinical routine.

The gastropouch shows some crucial advantages compared to intestinal reservoirs. Insufficient capacity of the gastropouch may cause problems. By using the adequate operative technique described in the following these problems can be solved.

A case of papillary renal cell carcinoma in a patient suffering from autosomal dominant polycystic kidney disease is described. The occurrence of papillary renal cell carcinoma in polycystic kidneys in the literature is reviewed and the implications of operative management and further surveillance in case of a papillary renal cell carcinoma are discussed.

According to our opinion, so-called venous leakage is no venous disease but a result of impaired cavernous tissue. Since in over 90% of all patients with venous leakage also arterial disease was discovered and since ultrastructural degenerative processes in the cavernous bodies were detected, we consider traditional corrective venous surgery as unphysiological and illogical. We suggest arterial revascularization combined with a mechanical penis banding as a new therapeutical concept.

Twenty-two patients with locally advanced prostatic carcinoma stage T3, N0, M0 have been treated with LH-RH agonists during a mean time of 5 months prior to radical retropubic prostatectomy. Although tumors appeared to be confined to the organ in 68% of the patients after endocrine treatment, pathological examination of the surgical specimens showed in 89% evidence of extraprostatic disease, which questions the clinical impression of 'downstaging'. A disparity between the tumor grade of the biopsy and that of the operative specimen as well as an increased size of tumor-involved lymph nodes despite endocrine treatment led us to speculate that a certain proportion of patients will bear the risk of disease progression during preoperative androgen deprivation. Furthermore, there was local recurrence early in the postoperative course and at the high rate of 39%.

Ninety-five patients with erectile dysfunction underwent standardized cavernosometry and cavernosography. In a first stage, the investigation was performed in each patient without and in a second stage with 60 mg papaverine injected intracavernously. A pathological maintenance flow rate between 20 and 120 ml/min decreased by 55% on average. The induction flow is of considerable variability and of poor diagnostic value. For quantification of venous leakage, the maintenance flow rate is of great importance and in correlation with the time of pressure decrease. Our results with a sensitivity of 59% suggest that cavernosography as the only screening method for venous leakage is not sufficient. In most of the cases, cavernosography is indicated only in consideration of venous leakage surgery.

We present 2 cases of malignant fibrous histiocytoma (MFH) of the retroperitoneum. Only 12-14% of all MFH occur in the retroperitoneum. Both patients were operated with the diagnosis of a kidney tumor. The surgical exposure showed a tumor arising from the retroperitoneum, infiltrating or surrounding the kidney. We would like to emphasize that large tumors of the retroperitoneum which resemble kidney tumors can also arise from mesenchymal tissue.

During 1986 and 1987, 47 patients with renal cell carcinoma were evaluated preoperatively with CT, angiography and MRI. The preoperative tumor stage (T), lymph node metastases and venous involvement determined with the three methods were compared to the operative and histopathological findings. For T stage, angiography proved less accurate (54%) than CT (64%) or MRI (63%). MRI was found to be superior to CT in assessing lymph nodes, with an overall accuracy of 89% and sensitivity of 100% compared to 77 and 60%, respectively, of CT. For venous involvement CT was overall more accurate (74%) than angiography (65%) or MRI (63%). All three methods expressed a low sensitivity (between 31 and 41%) and a high specificity (between 95 and 100%) for detecting venous involvement. The minimal advantages of MRI compared to its high cost do not justify its routine use. CT remains the method of choice in staging preoperatively renal cell carcinoma.

For normal erection two mechanisms are essential: the first provides increased arterial inflow, most probably this is obtained due to the activity of the intimal cushions within the arteriae helicinae and within the shunt vessels. The second mechanism uses increased arterial blood flow; this could be obtained due to the activity of the trabecular muscle fibers of the corpora cavernosa. In consequence, we would deal with two different types of priapism: one type--high-flow priapism--occurs at the level of the arteriae helicinae and the intimal cushions and provokes a high-flow situation, and the second type, with blood stasis in the corpora cavernosa, occurs at the level of the trabeculae due to persistent contraction of the smooth muscle fibers. The prognosis of the second type is much less favorable and should be cured by surgery within the first 48 h.

Urinary continence is guaranteed by many factors. The most important are an intact bladderneck and a normally operating proximal urethra. Predominantly the smooth muscular system is involved. The striated external sphincter is primarily not responsible for continence. At prostatectomy the bladderneck and a great part of the smooth muscles of the proximal urethra inevitably are removed. Postoperatively only a small distal segment of the posterior urethra continues to guarantee continence. This segment may be changed by the growth of the prostate and can be destroyed by an untrained operator. Then, urinary incontinence is the result.

In the present study the feasibility and effectiveness of transureteral dilatation with a double-lumen balloon-tipped dilatation catheter was investigated. In 6 dogs with experimentally induced unilateral fibrotic stenosis and hydronephrosis a total of 13 dilatations were performed through a cutaneous ureteroneostomy. The stenosis diameter could markedly be distended from 1.7 +/- 0.9 to 4.8 +/- 1.6 mm (p less than 0.001). The pyelon size changed not significantly during the intervention. Follow-up urographies 1 week after dilatation revealed partial or total restenosis in all but 2 dogs. The stenosis diameter had decreased by 2.6 +/- 1.5 mm (p less than 0.01). The mean pyelon size changed only slightly (28.2 +/- 14.7 vs. 26.1 +/- 6.2 cm2). In the 2 dogs with persistent distension of the stenosis a reduction in pyelon size was achieved. Blood pressure during acute ureteral ligation showed no change. Follow-up studies after 1 week revealed a significant fall of the mean arterial pressure from 100 +/- 22 to 83 +/- 19 mm Hg (p less than 0.005), which was also seen at the long-term follow-up in 5 dogs 13 +/- 8 weeks after ureteral ligation. Histological analysis showed mild to severe inflammation and distension of the collecting system and mild to moderate inflammation, atrophy, and glomerular cysts in the renal parenchyma. Interestingly, the 2 dogs with a successful result of dilatation showed no relevant inflammation in the dilated stenotic segment. In conclusion, transureteral dilatation of experimental ureteral stenosis with a balloon catheter proved to have an impressive acute effect.(ABSTRACT TRUNCATED AT 250 WORDS)

We present 2 cases from our clinic with complications due to unilateral multicystic dysplastic kidneys: 1 case with arterial hypertension, another case with a renal carcinoma in a multicystic dysplastic kidney. Compared with the 62 cases already published, these are the 2nd case of hypertension and the 3rd case of carcinoma in multicystic dysplastic kidneys. Because of such complications nephrectomy of multicystic dysplastic kidneys is indicated.

The pathophysiological considerations for regaining continence are discussed first. Our operation method for postprostatectomy incontinence is described and the results enumerated. The success rate is approximatively 80%.

After radical prostatectomy--the own curable treatment in prostatic carcinoma--there is a great incidence of postoperative urinary incontinence. By forming a tube of the 'base plate' after Hutch's description, it is possible to get a new urinary sphincter. We have proven this facts with urodynamic and radiologic investigations.

Conventional stone operations have decisively receded into the background due to modern methods of stone removal, e.g., extracorporeal shock-wave lithotripsy and endoscopic stone removal. The disadvantages of these modern methods are discussed. Because there are no complications by the conventional technics, which are still practised, the technical details are also discussed.

Prostatic carcinoma can be cured by a radical operation. In radical prostatectomy the whole so-called internal sphincter is removed. It is generally accepted and often proved that the external sphincter which is mostly somatically innervated cannot resume the funciton of continence. The postoperative urinary incontinence after radical prostatectomy is frequent and therefore the radical prostatectomy is not performed in many places. The problem of postoperative continence as well as incontinence after enucleation of the adenoma will be briefly discussed. In 1966, HUTCH described the so-called 'baseplate'. It is a bundle of smooth muscle fibers, circulary arranged around the bladder neck, which are also responsible for passive continence. He proposed that a certain sphincter function can be achieved by a tubular anastomosis of this anatomical substratum with the distal urethral stump. We were able to prove this anatomical hypothesis urodynamically. A specially constructed double-lumen perfusion catheter enabled us to register the so-called functional urethra profile and simultaneously register a new sphincter pressure wave in the transformed 'baseplate' which was responsible for the continence. We could observe this new sphincter region in all continent patients after radical prostatectomy whereas in the incontinent patients it was absent. Since 1972 we have employed the procedure proposed by HUTCH and have performed 20 radical prostatectomies. All these patients have been postoperatively completely continent. We are of the opinion that undue restraint concerning radical prostatectomy is no more justified.

A new surgical treatment for post-prostatectomy incontinence is described. The intact urogenital diaphragm and a peripheral elastic resistance are the two most essential factors to assure continence. In addition to stabilizing the urogenital diaphragm, an elastic peripheral resistance is created by this technique. Contience is achieved by imbedding the urethra between the two corpora cavernosa and followed by median rotation and adaptation of the ischiocavernosi muscles. The proof of continence is given urodynamically by the function urethral profile.

It has become fashionable to perform radical prostatovesiculectomy for carcinoma of the prostate using the nerve-sparing method. In cases with a not too large prostate and a locally limited tumor, it is possible to preserve erectile potency. Our anatomic and radiologic preparation proved that postoperative impotence is not only due to lesions of the nerves but, almost as frequently, the consequence of obliterations of the vessels or a combination of both. If the lesion is purely arterial, revascularization surgery guarantees normal erections.

From April 1985 to March 1987 181 patients with ureteral stones were treated by means of extracorporeal shock wave lithotripsy (ESWL). Management for proximal calculi changed from in situ ESWL treatment (group n = 27) or placement of a ureteral catheter below calculi (group II, n = 30) to retrograde stone manipulation into renal pelvis (group IV, n = 52) or ESWL treatment under intraoperative irrigation of saline in cases where repositioning failed (group III, n = 50). The best stone-free rate for upper ureteral stones was obtained in group IV with 96% after 6 weeks, presenting also the shortest hospital stay (4.2 days) and lowest quota of postoperative auxiliary procedures (2%). Stones, not being dislodged into renal pelvis (49%), could be treated successfully in 86% by irrigation with saline during ESWL (group III). The stone-free rate decreased in patients with in situ treatment (group I: 67%) or ureteral catheter placement (group II: 83%). Treatment of these stones increased the need of postoperative ancillary procedures to approximately 30%. For distal ureteral stones ESWL and preoperative Zeiss placement achieved a stone-free rate of 95%.

Ileum conduit is a good method for supravesical diversion of urine. The disadvantage is, however, that it does not have a reservoir function. For the first time, in 1969 Kock had shown good results with a continent intra-abdominal ileum pouch for feces, and this gave us the idea to try a similar pouch for urine on 15 dogs. To make reservoirs of the small intestine was technically not simple and often led to complications. Urine continency could be attained by invagination of the small intestine. Primary and secondary reflux as well as stenoses of the ureter implantations led in 50% of the cases to ascending infections. Complications of urine reabsorption did not occur. Further studies of the continency, reflux and reabsorption problems indicate that a continent, intra-abdominal ileum pouch for urine will be possible.

The arterially originated erectile disturbances are the most common form of impotence due to morphological reasons. The concepts of therapy range from the surgical revascularization, to the intracavernous self-injection of vasoactive substances and to the implantation of penis prostheses. The advantages and disadvantages are discussed and weighed against each other.