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PURPOSE The aim of this study was to evaluate the different MRI diagnoses in the early and late post-operative period after renal transplantation with dysfunctional allograft. MATERIALS AND METHODS Due to unknown transplant dysfunction, 49 patients (30-male, 19 female) received a total of 74 MRI studies. According to the date of examination all MRI studies were divided in an early ( 60 days, LTP). All MRI studies were performed on 1.5 T MRI systems using a standardised imaging protocol consisting of a morphological (pre- and post-contrast enhanced T (1)- and T (2)-weighted TSE sequences), a vascular (contrast-enhanced 3D MRA) and a urographical part (Flash 3D sequences). Frequencies of diagnoses in ETP and LTP, and diagnoses within each transplant time period were analysed. RESULTS 44/74 MRI studies were performed in ETP, 30/74 in LTP. In total 80 diagnoses were obtained: Renal artery stenosis (ETP, n = 21; LTP, n = 5), renal vein stenosis (ETP, n = 2), renal vein thrombosis (ETP, n = 2), renal perfusion defect (ETP, n = 11), rejection (ETP, n = 1; LTP, n = 2), abscess (ETP, n = 1), urinary outflow obstruction (LTP, n = 4), without MRI pathology (ETP, n = 11; LTP, n = 20). Renal artery stenosis was the most prevalent diagnosis in ETP, and a more frequent finding in ETP compared to LTP (p < 0.05). Renal perfusion defects were more frequent in ETP than in LTP (p < 0.05). In the ETP vascular diseases (34/49 diagnoses) were more frequent (p < 0.05) than uropathological diseases (0/49 diagnoses). CONCLUSIONS Our results indicate that vascular diseases are a more frequent occurrence in the early post-operative course after renal transplantation than uropathological diseases. However, a transplant follow-up MRI study needs to contain a morphological, vascular and functional imaging part to answer combined clinical questions.

BACKGROUND: The antiphospholipid antibody syndrome (APLS) is characterised by the presence of antiphospholipid antibodies in association with thrombotic disorders of the arterial and/or venous system, spontaneous abortion and thrombocytopenia. Several studies have shown that end-stage renal disease patients with APLS are at extremely high risk for graft thrombosis and graft loss after kidney transplantation. MATERIAL AND METHODS: We report on the treatment and clinical courses of 6 APLS renal transplant patients. RESULTS: Of 3 patients treated with low-dose subcutaneous heparin two had early graft loss due to venous graft thrombosis; of those patients treated by systemic heparin (PTT goal 45 - 55 s) and followed by coumadin (INR 2,5 - 3,0) only one had early graft loss whereas 2 grafts are doing well 2 years post-transplant. CONCLUSION: Our experience as well as recently published data suggest that kidney transplantation can be performed successfully in APLS patients if anticoagulation therapy is performed consistently. A general APL antibody screening prior to kidney transplantation does not seem to be justified at present. A prospective, randomised multicenter study is warranted to evaluate the management of these patients with respect to intensity, type and duration of anticoagulation therapy.

Nocturnal enuresis (bedwetting) is one of the most frequent urological symptoms in children, affecting about 20% of five year olds. It is a heterogeneous disorder with a whole variety of etiologic factors (genetic, endocrinological, neurobiological), particularly a dysfunction of the lower urinary tract. Despite the prevalence of enuresis many questions regarding the complex pathophysiological mechanisms remain unanswered. While nocturnal enuresis per se is clearly not a disease, psychosocial problems have been reported in up to 40% of affected children. Management strategies comprise behavioural and pharmacological approaches, either in isolation or combined. Although expectations were high, especially with pharmacological interventions, the results are usually disappointing with high recurrence rates. Extensive analyses of the available literature on the efficacy of enuresis treatment modalities reveal a poor quality of many trials with a whole range of methodological flaws. Therefore, further comparative studies of adequate methodological quality are needed.

OBJECTIVE The assumption that enterocystoplasty in children has a detrimental effect on linear growth has been based almost exclusively upon a chance finding in a retrospective study 10 years ago. We re-evaluated the same research question in a larger cohort and with a longer follow-up. PATIENTS AND METHODS Between 1982 and 1997, 242 children and adolescents underwent enterocystoplasty. Patients with conditions involving organ systems apart from the urinary tract, and those with myelomeningocele, malignant diseases, reduced glomerular filtration rate and incomplete notes were excluded. In the definitive study cohort (123; mean age at operation 8.6 years; mean age at investigation 16.8 years), enterocystoplasty had been undertaken using colon in 70, ileum in 37, a combination of both in 11, ileocaecal segments in three and stomach in two patients. RESULTS In all, 1215 height and weight measurements had been recorded. The distribution of percentile positions before and after enterocystoplasty showed a normal configuration, with 83 % and 80 % of patients growing within two standard deviations of the 50th percentile. After surgery, 85 % either remained the same or reached a higher percentile. Nineteen (15.5 %) were in a lower position, with a similar tendency in the weight percentile. A clinically relevant growth disorder was recognized in four patients with a complete endocrinological evaluation; in none of these was enterocystoplasty thought to be a causal factor. CONCLUSIONS It is very unlikely that loss of the preoperative percentile position on the growth curve in 15 % of children after enterocystoplasty is a consequence of that particular surgery. Rather, it is a non-specific phenomenon that has to be considered in any clinical population of the same size and age distribution after the same length of time.

Background The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion. Methods Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1·9–76·9 (mean 55·8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid–base balance. Results There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients. Conclusion Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.

Background: We report our experience with the Malone antegrade colonic enema (MACE) procedure in adult patients suffering from urinary incontinence and intractable constipation with or without fecal soiling. Study Design: Since June 1990, the MACE procedure was initiated in 4 female and 12 male patients 14–54 years old (mean age, 29.9 years) with different pathologic conditions (myelodysplasia, n=7; anorectal anomaly, n=3; spinal cord lesion, n=4; neuropathic disease of unclear cause, n=2). Three surgical techniques were used: reversed and in situ appendix and tapered ileum). Complex simultaneous urologic continence procedures were performed in nine patients. Two patients had undergone previous operations in the lower urinary tract. Results: After 6.6 years of followup (average, 41.7 months), eight patients (50%) were still using the MACE successfully. They were completely clean day and night and were relieved of symptoms of constipation. Eleven complications related to the MACE procedure occurred in seven patients (44%). Eight patients abandoned the procedure for various reasons. The failure rate was higher in chronically constipated patients without fecal soiling. Conclusions: The MACE procedure is associated with a high failure rate when used in adults, but it may be possible to identify a subgroup of patients in whom the procedure could be beneficial. Success would depend on overcoming technical problems and difficulties with patient compliance.

A unique case was recently encountered involving the synchronous presentation of five primary malignancies of different histology. Malignant neoplasms of the colon, kidney, prostate and bladder were treated surgically. Bladder was affected by two separate tumours: a transitional cell carcinoma and a malignant fibrous histiocytoma. The latter constitutes an extremely rare malignant lesion of the organ. The pathologic characteristics, histogenesis, differential diagnosis and treatment considerations of this soft tissue sarcoma, and the incidence, terminology and incriminating factors of multiple primary malignant neoplasms, as well as their association with the genitourinary system are reviewed.

It is important that any patient with a urinary diversion can accept the psychological impact alongside the surgical and physical aspects. However, there are currently no validated methods or instruments available to allow direct measurement of this phenomenon in these patients. Health-related quality of life (HRQoL) is often high following different types of urinary diversion-this may suggest a high acceptance level and thus may act as a secondary end point. Such an assessment is a retrospective validation of successful patient selection, allowing us to redirect the nihilistic misinterpretation that urologists should return to offering ileal conduits as a standard. In modern urinary diversion, high patient acceptance develops from comprehensive counselling providing a realistic expectation, careful patient-to-method-matching, strict adherence to surgical detail during the procedure and a meticulous lifelong follow-up. Coping strategies, disease-related social support and confidence in the success of treatment are among other factors which contribute to acceptance of urinary reconstruction as either independent or combined factors. Significant experience is required in every respect, as misjudgement and mistakes in any of these issues may be detrimental to the patients' health. It should be acknowledged that there is no 'best' urinary diversion in general terms. A reconstructive surgeon must have all techniques available and choices need to be tailored to the individual patient.

The antiphospholipid antibody syndrome (APLS) is characterised by the presence of antiphospholipid antibodies in association with thrombotic disorders of the arterial and/or venous system, spontaneous abortion and thrombocytopenia. Several studies have shown that end-stage renal disease patients with APLS are at extremely high risk for graft thrombosis and graft loss after kidney transplantation.We report on the treatment and clinical courses of 6 APLS renal transplant patients.Of 3 patients treated with low-dose subcutaneous heparin two had early graft loss due to venous graft thrombosis; of those patients treated by systemic heparin (PTT goal 45-55 s) and followed by coumadin (INR 2.5-3.0) only one had early graft loss whereas 2 grafts are doing well 2 years post-transplant.Our experience as well as recently published data suggest that kidney transplantation can be performed successfully in APLS patients if anticoagulation therapy is performed consistently. A general APL antibody screening prior to kidney transplantation does not seem to be justified at present. A prospective, randomised multicenter study is warranted to evaluate the management of these patients with respect to intensity, type and duration of anticoagulation therapy.

Nocturnal enuresis (bedwetting) is one of the most frequent urological symptoms in children, affecting about 20% of five year olds. It is a heterogeneous disorder with a whole variety of etiologic factors (genetic, endocrinological, neurobiological), particularly a dysfunction of the lower urinary tract. Despite the prevalence of enuresis many questions regarding the complex pathophysiological mechanisms remain unanswered. While nocturnal enuresis per se is clearly not a disease, psychosocial problems have been reported in up to 40% of affected children. Management strategies comprise behavioural and pharmacological approaches, either in isolation or combined. Although expectations were high, especially with pharmacological interventions, the results are usually disappointing with high recurrence rates. Extensive analyses of the available literature on the efficacy of enuresis treatment modalities reveal a poor quality of many trials with a whole range of methodological flaws. Therefore, further comparative studies of adequate methodological quality are needed.

The assumption that enterocystoplasty in children has a detrimental effect on linear growth has been based almost exclusively upon a chance finding in a retrospective study 10 years ago. We re-evaluated the same research question in a larger cohort and with a longer follow-up.Between 1982 and 1997, 242 children and adolescents underwent enterocystoplasty. Patients with conditions involving organ systems apart from the urinary tract, and those with myelomeningocele, malignant diseases, reduced glomerular filtration rate and incomplete notes were excluded. In the definitive study cohort (123; mean age at operation 8.6 years; mean age at investigation 16.8 years), enterocystoplasty had been undertaken using colon in 70, ileum in 37, a combination of both in 11, ileocaecal segments in three and stomach in two patients.In all, 1215 height and weight measurements had been recorded. The distribution of percentile positions before and after enterocystoplasty showed a normal configuration, with 83 % and 80 % of patients growing within two standard deviations of the 50th percentile. After surgery, 85 % either remained the same or reached a higher percentile. Nineteen (15.5 %) were in a lower position, with a similar tendency in the weight percentile. A clinically relevant growth disorder was recognized in four patients with a complete endocrinological evaluation; in none of these was enterocystoplasty thought to be a causal factor.It is very unlikely that loss of the preoperative percentile position on the growth curve in 15 % of children after enterocystoplasty is a consequence of that particular surgery. Rather, it is a non-specific phenomenon that has to be considered in any clinical population of the same size and age distribution after the same length of time.

To investigate skeletal growth and bone metabolism in a chronic animal model of urinary diversion.Young male Wistar rats (120) were allocated randomly to four groups undergoing: ileocystoplasty, ileocystoplasty and resection of the ileocaecal segment, colocystoplasty, and controls. All animals received antibiotics for 1 week after surgery; half of each group remained on oral antibiotics. Bone-related biochemistry was measured in serum and urine. Dual-energy X-ray absorptiometry and peripheral quantitative computed tomography (pQCT) were used to determine bone mass ex vivo.Most (90%) of the rats survived the study period (8 months); six rats died from bowel obstruction at the level of the entero-anastomosis and four had to be killed because of persistent severe diarrhoea. Vital intestinal mucosa was found in all augmented bladders. There were no differences in bone length and volume. Loss of bone mass was almost exclusively in rats with ileocystoplasty and resection of the ileocaecal segment (-37.5%, pQCT, P0.01). There was no hyperchloraemic metabolic acidosis or gross impairment of renal function. Hypomagnesaemia, hypocalcaemia and decreased insulin-like growth factor-binding protein 3 were the only significant findings on blood analysis. Deoxypyridinoline crosslinks in urine were higher in rats with an enterocystoplasty than in controls.Enterocystoplasty in rats neither impairs skeletal growth nor bone quantity, but leads to significant loss of bone mass when combined with resection of the ileocaecal segment. Rarefaction of the trabecular network is confined to the metabolically highly active cancellous compartment, most likely as a consequence of intestinal malabsorption.

Primary carcinoma of the adrenal cortex is an extremely rare neoplasm, accounting for an estimated 0.05-0.2% of all malignancies. Hormonally functioning tumors occur in about 50% of patients with Cushing's syndrome (50%), virilism (30%) and feminization (12%) being the most common clinical manifestations. Isolated aldosteronism caused by adrenocortical carcinoma is found in about 1-3% in patients with the clinical signs of Conn's syndrome. The only preoperative feature suggesting malignancy is a size of more than 5 cm in computed tomography. We report a rare case of a 29-year-old man with biochemically proven primary aldosteronism as the unique manifestation of a carcinoma of the right adrenal cortex.

Primary osteosarcoma of the kidney is an extremely rare phenomenon with less than 20 previously reported cases in the English literature since 1936. Diagnosis usually is made in advanced stages of disease with weight loss, palpable tumor, flank pain and gross hematuria being the characteristic features of clinical presentation. Radiographically bizarre renal calcifications may be suggestive of this uncommon neoplasm. The atypic location is explained by metaplastic changes of originally primitive embryonic mesenchymal tissue. Though the primary treatment for sarcomas is surgical resection, because of their usual late and high stage presentation multimodal adjuvant therapy may be desirable. We describe the clinical course of a 48-year-old male patient with a primary renal osteosarcoma discovered by ultrasound. A marked reduction of vital tumor cells and an impressive increase of neoplastic bone formation following polychemotherapy is demonstrated histopathologically. The principal clinical findings, differential diagnosis, etiology, pathogenesis and treatment modalities of this uncommon malignancy are discussed.

We report on the case of a 31-year-old male patient with focal testicular vasculitis as the only clinical manifestation of endangiitis obliterans (Winiwarter-Buerger disease), who presented with acute scrotal pain and swelling suggestive of a testicular tumor. Doppler sonography revealed significantly increased vascularization at the borders of the lesion, which rather indicated a vascular process; however, the presence of solid areas meant that the possibility of testicular cancer could not be excluded. Left inguinal orchiectomy was performed. The surgical specimen revealed histological patterns compatible with endangiitis obliterans; Raynaud phenomenon was the only sign of systemic disease, and no other organs were found to be affected. Despite the high sensitivity and specificity of ultrasound/Doppler sonography, in the differential diagnosis of an unexplained testicular mass surgical exploration is still mandatory. The different types of focal vasculitis are described and discussed with reference to the literature.

Eosinophilic cystitis is an unusual bladder lesion of unclear etiology first described in 1960. It usually causes irritative voiding symptoms and hematuria and in its rare tumor-like appearance the disease may mimic an invasive bladder neoplasm. In the report herein, a case of an 11-year-old boy with a tumor-forming eosinophilic cystitis is presented which was mistaken for an infiltrative vesical malignancy until the histopathological study was completed. The principal clinical findings, differential diagnosis, etiology, pathogenesis and treatment modalities of this inflammatory disease are discussed.

61 Patients with histologically proved primary mediastinal tumour were examined by computed tomography (CT) of the thorax prior to surgery. The retrospective analysis of the CT scans led to the correct diagnosis in 77% of cases. CT-values (HE), calcifications or form of tumour growth was found to be unreliable in the classification of tumour status.