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In 7 patients with deeply infiltrating bladder cancer an ileal S-pouch was constructed for bladder replacement after radical cysto-vesiculo-prostatectomy and pelvic lymph node dissection. The operative technique and early clinical results are described.

In the present study 19 patients with rare forms of renal hypertension were investigated: 6 patients with renal artery aneurysm, 6 cases with unilateral hydronephrosis, 4 patients with unilateral simple renal cyst, 2 cases with coarctation of the abdominal aorta and associated renal artery stenosis and 1 patient with radiation nephritis.

Twenty-four men aged 20-67 years (mean 42 years) were examined by selective arteriography for secondary impotence. The angiographic technique used as well as the normal anatomy and its variations are described. Arterial occlusive disease of vessels leading to the penis and the corpora cavernosa was found in 71% of the patients examined. This high incidence of arterial occlusive disease corresponds with the findings of other authors. The significance of these findings is discussed. In our limited experience of 3 patients, arterial anastomosis from the inferior epigastric artery to the corpora cavernosa has not been successful.

Based on the findings upon arteriography, cavernosography and clinical features two different kinds of priapism are differentiated: Type I ("low flow priapism") is characterized by severe blood stasis within the corpora cavernosa and reduction of arterial perfusion through compression of the deep arteries of the penis. The penis is very hard and painful upon palpation. A delay of treatment over 48 hours will result in a damage of the corpora cavernosa and impotence. Type II ("high flow priapism") is characterized by arterial hyperperfusion. Outflow obstruction is absent. The penis is erected but of an elastic consistence, pain is absent. Even with a delay of treatment of up to 6 months the corpora cavernosa remain intact, normal erectile function is preserved.

Prostatectomy is an operation a lot of men have to undergo. Because this is an intervention which involves the intimate sphere of a man, we tried to investigate the postoperative sexual problems of 200 men prostatectomised without complications. As a result, we would like to point out that exact preoperative information by a doctor is very important. With these precautions, no impairment of sexual functions is to be expected.

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.

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.

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.

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 resultswith acontinent intra-abdominal ileumpouch 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, intraabdominal ileum pouch for urine will be possible.

Die Harnableitung feiert ihre Renaissance. Damit treten auch wieder ihre damit verbundenen charakteristischen Probleme in die Diskussion.

Extracorporal shock wave lithotripsy has rapidly become established world wide 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, 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 until now. This parenchymal damage is probably also the cause of the macrohaematuria that is always observed during therapy. The resulting tissue damage is not extensive enough to cause demonstrable reduction of function as measured by the usual methods (serum creatinine, creatinine clearance, isotopy renography, i/v-urography). The main clinical complication is the large subcapsular haematoma which, according to present knowledge, could well result from a lesion of the larger peripheral vessels. Damage to other organs such as subserous colonic and small bowel haematomata are to be expected although they do not lead to clinical symptoms.

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.

A retrospective study was conducted in 13 patients with phlebographically diagnosed tumor-induced renal vein occlusion to evaluate the incidence and extent of proteinuria and/or nephrotic syndrome. In 5 patients minimal proteinuria was found, but in none of the patients were the criteria of nephrotic syndrome fulfilled. These data can be used as additional evidence that renal vein occlusion is not the cause of nephrotic syndrome. They underline the hypothesis that, in cases of nephrotic syndrome associated with renal vein occlusion, the thrombic occlusion of the renal vein is a complication of the excessive renal protein loss and developing hypercoagulability.

Definitionsgemas handelt es sich beim Priapismus um eine krankhafte Dauererektion, die weder durch Kohabitation noch Masturbation ruckgangig gemacht werden kann, wobei pathognomonischerweise nur die Corpora cavernosa und nicht das Corpus spongiosum urethrae und die mit ihm verbundene Glans penis erigiert sind.

Ten patients with common bile duct stones not removable by endoscopic measures after sphincterotomy were treated by extracorporeally generated shock waves. In 9 patients stones up to 30 mm in diameter were disintegrated. Two patients became free of stone fragments spontaneously within one day and in 7 patients the stone fragments were extracted endoscopically. No complications occurred. Extracorporal shock wave treatment represents a promising alternative to surgery in cases where common bile duct stones cannot be extracted endoscopically.

We report our experience with the directly to the urethra anastomosed continent ileal reservoir. Our results suggest that the S-Pouch is superior to the proceeding suggested by Kock both from clinical and urodynamic view. Continence is to be expected at an anastomosis of this pouch with the bladder neck, whereas at an anastomosis with the posterior urethra occasional cases of nightly incontinence were registered. This always happened when the neurovascular bundle had not been preserved intraoperatively. If an ileal reservoir is installed metabolic acidosis has to be carefully avoided.

Based on the findings upon arteriography, cavernosography and clinical features two different kinds of priapism are differentiated: Type I ("low flow priapism") is characterized by severe blood stasis within the corpora cavernosa and reduction of arterial perfusion through compression of the deep arteries of the penis. The penis is very hard and painful upon palpation. A delay of treatment over 48 hours will result in a damage of the corpora cavernosa and impotence. Type II ("high flow priapism") is characterized by arterial hyperperfusion. Outflow obstruction is absent. The penis is erected but of an elastic consistence, pain is absent. Even with a delay of treatment of up to 6 months the corpora cavernosa remain intact, normal erectile function is preserved.

Urinary continence is guaranteed by the system of smooth urethral musculature, the so-called sphincter internus. The striated sphincter externus has primarily no responsibility for continence. One of its most important functions is the initiation of a voluntary micturition. Further functions are: the voluntary interruption of the urinary stream, the reflectory occlusion by elevated intraabdominal pressure (coughing, sneezing, laughing, heavy physical work), expression of the rest of urine in the urethra after micturition, stabilization of the proximal urethra in the urogenital diaphragm. To get an optimal function after prostatectomy an intact sphincter externus becomes important for the smooth urethral muscular system which is further responsible for the continence. About 90% of all patients with a postprostatectomy incontinence have an intact sphincter externus. In these cases we have a high incidence of incontinence cure. Only in 10% of incontinence after prostatectomy the sphincter externus is damaged. In those cases the incontinence operation is inadequate.

Results after internal urethrotomy under direct vision are comparable to the results after open plastic procedures for strictures of the urethra. Internal urethrotomy at present is preferred to plastic procedures because of its simplicity. But plastic procedures maintain their indication for some special types of strictures. Postoperative treatment after internal urethrotomy under direct vision varies with the etiology of the stricture. In iatrogenic strictures results are better using an indwelling catheter for a period up to 6 weeks after internal urethrotomy under direct vision.

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.

In order to improve the accuracy of bladder and urethral pressure recording, a measurement system has been tested experimentally. It is possible to measure absolute pressure values during withdrawal of the catheter only when the system is constantly perfused. The optimum relationship between catheter diameter, perfusion rate, withdrawal rate, measurement inertia and systemic resistance has been analysed.

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.

The prognosis of testicular tumors is largely depending on an early as possible tinning of the diagnosis. The present tumormakers do not bring a diagnostic security. However they are important for the continuing observation of the patients, especially of those with cytostatic chemotherapy. Today's acknowledged treatment of malignant testicular tumors is the high semicastratio, for Seninoms the additional highvoltage radiotherapy, for the Teratocarcinomas the additional retroperitoneal lymphnode extirpation and for the cases with retroperitoneal metastases the subsequent high-voltage radiotherapy and the adjuvant cytostatic chemitherapy. Between the alternative of the transperitoneal and the thoracoretroperitoneal lymphadenextomy we prefer the latter. The operation is radical, the thoracic complication are minimal and this technic besides advantages because the postoperative number of patients with a loss of ejaculation is much lower.

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.

We are of the opinion that in most cases of erectile dysfunction morphological factors are involved. These have to be defined by means of adequate diagnostic procedures. When vascular disease is responsible it is necessary to distinguish between arterial, venous and arteriovenous conditions. Whereas arterial failure can often be corrected, the treatment of venous leakage is problematic, as the primary disease seems to affect the cavernous bodies directly.

Cryosurgical technique as therapy of infravesical obstruction is of palliative character. Experience and results with patients from the years 1973-1978 are reported. The incidence and the rate of complications influence our technique and the precise indication for cryosurgery of the prostate to avoid failures in the future.

Priapism is a pathological and mostly painful permanent penile erection. Typically only both corpora cavernosa and not the corpus spongiosum urethrae and the glans penis are involved. The vascular and nervous preconditions for a normal erection are discussed and a new concept presented. On this basis the conditions for a priapism are enumerated and the principles of therapy are discussed.

Fallen bei Ureterlasionen aufgrund ihrer Lokalisation oder ihrer Ausdehnung einfachere rekonstruktive Masnahmen wie End-zu-End-Ureterostomie oder Uretero-Zysto-Neostomie auser Betracht, so stehen mit der Autotransplantation der Niere und dem Ureterersatz durch Ileuminterposition zwei rekonstruktive operative Moglichkeiten zur Nierenerhaltung zur Verfugung.

The diagnostic and predictive value of renal venous renin determinations was investigated in 73 patients who had various forms of hypertension associated with unilateral renal disease and who were operated upon. Patients with fibromuscular hyperplasia showed a markedly higher cure rate than cases with arteriosclerotic renal artery stenosis (64% vs. 25%) and were less frequently not improved (4% vs. 12%). Patients with unilateral (non-vascular) small kidney and patients with unilateral hydronephrosis showed comparable high cure rates (53% and 50%, respectively), whereas in no patient with a unilateral renal cyst did postoperative blood pressure return to normal. In the present study no statistically significant correlation was found between postoperative pressure reduction and PRA-ratios in either the whole group of patients or in the various subgroups. A negative PRA-ratio (less than or equal to 1.4) was found in 36% of all cured patients. In particular, cured patients with fibromuscular hyperplasia showed a high percentage (38%) of falsely negative tests. As expected, characteristic differences were observed in simple clinical data between cured and improved patients. Patients with normal postoperative blood pressure were significantly young (34.7 +/- 13.6 years) than improved cases (47.3 +/- 10.8 years; P less than 0.001) and cured patients showed lower preoperative blood pressure values (192 +/- 29/119 +/- 15) than improved ones (214 +/- 31/126 +/-117 mm Hg). Thus our results document a limited prognostic value of renal venous renin determination in patients with hypertension due to unilateral renal disease.