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Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11 percent, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes.The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92 percent of the patients were continent by day and after 2 years 80 percent were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has s...

Objective To analyse the clinical and therapeutic consequences of early treatment failure after bacille Calmette-Guerin (BCG) instillation therapy for carcinoma in situ of the bladder. Patients and methods A total of 115 patients with carcinoma in situ (Tis) of the bladder were treated by intravesical instillation of living BCG vaccine (Immun BCG Pasteur F). Twenty five patients had primary Tis and 90 had secondary Tis with synchronous or prior superficial papillary tumours. All papillary tumours were resected before instillation of BCG. All patients completed one series of 6 weekly instillations of 120 mg BCG. Results Twenty-two of 25 patients (88%) with primary Tis responded completely, with negative cytology and cystoscopy findings within a median follow-up period of 44 months. Three of the 25 (12%) had cytological evidence of disease within 9 months of therapy and were considered to be early treatment failures. One patient had muscle-invasive bladder cancer, one had Tis and invasive cancer of the prostatic urethra, and the last, in whom a second BCG course also failed, had Tis of both ureters. Seventy of 90 patients (78%) with secondary Tis had a complete response after treatment with BCG, with repeated negative cytology and cystoscopy examinations within a median follow-up time of 40 months. Twenty of the 90 (22%) with secondary Tis had positive cytology within 9 months after BCG therapy and were considered early treatment failures. Five of these 20 had a cystectomy, three for persistent Tis of the bladder and two for a solid urothelial carcinoma of the prostate. The remaining 15 early failures received a second course of BCG. Four of these 15 patients responded and the remaining 11 failed the second course. The 11 failures included two patients with multifocal T1 G3 bladder cancers, four with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of the upper urinary tract. Conclusions According to these data, early treatment failure after 6 weekly instillations of 120 mg Immun BCG Pasteur F is an alarming signal which requires immediate re-assessment of the patient to exclude a muscle-invasive bladder cancer or an extravesical carcinoma in situ, either in the upper urinary tract or in the prostatic urethra.

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.

We report on the retrospective analysis of 61 traumatic lesions of the posterior urethra in a fractured pelvis. In collaboration with the orthopedic surgeons, 44 cases could be classified with regard to the nature and mechanism of the pelvic fracture. No direct relationship between the structural integrity of the dorsal ring segment and the urological pathology could be established. However, the mechanism of injury in 35/44 cases with pelvic girdle injuries and urethral pathology appears to be a predominantly lateral compression force. Ten of the 44 patients received a surgical stabilization of the fracture and open splinting of the urethra at the same time. An infection in the area of surgery developed in only one of these patients; however, this cleared up completely under antibiotic therapy and closed suction irrigation. The primarily conservative treatment of urethral lesions (27/61) is compared with primary open splinting or reanastomosis (34/61), which we prefer, with regard to the number of reoperations and late results. The joint conclusion of urologists and orthopedic surgeons concerns a primary simultaneous surgical treatment both of the urethral lesion and the pelvic fracture.

The perfect bladder substitute has not been devised yet. The ileal orthotopic bladder substitute, however, provides adequate capacity, convenient voiding patterns, optimal continence rate, preservation of renal function, acid-base balance, and calcium metabolism. The authors describe important surgical details based on experience with more than 200 patients. To achieve a good functional result, patient selection, postoperative voiding reeducation, and meticulous follow-up are important.

In 65 patients (pts) (130 renal units) with invasive bladder cancer treated at our institution from 1971 to 1992, ureterosigmoidostomy was performed. Early complications (3 month) occurred in 25 patients: 9 pts had a pyelonephritis, 3 pts underwent surgery for revision of the ureteral anastomosis because of leakage and 3 had abdominal wall revisions. 4 pts had a severe hyperchloremic metabolic acidosis, 2 pts had respiratory problems. Late complications observed were: 12 pts with pyelonephritis, 4 pts with ureteral stenosis and 9 pts with hyperchloremic metabolic acidosis. 5 patients were incontinent and 3 pts had a anastomotic colon cancer after 10, 12 and 17 years respectively. In 26/65 (40%) of patients with survival over 5 years continence and quality of life were evaluated by means of a questionnaire. 23/26 pts (88%) were continent during daytime and complete continence during the night was reported by 14/26 pts (54%). Quality of life was assessed in a global manner (family and social life, sexuality, comfort, travel and sport) and was rated as satisfactory in 24/26 pts (92%). 2 pts were unsatisfied due to diarrhea. In conclusion, good long-term functional results can be obtained with ureterosigmoidostomy with a careful follow-up. Our long-term results may serve as a basis for comparison with other more recently developed continent urinary diversions such as low pressure systems.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3–108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11%, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92% of the patients were continent by day and after 2 years 80% were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has shown 4 left ureteral strictures but not significant upper tract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder, no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pressure reservoir with an afferent isoperistaltic ileal segment and an open end-to-side ureteroileal anastomosis allows for radical cancer surgery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional peristalsis of the ureters and the afferent tubular ileal segment seem to protect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are comparable to other similar reservoir techniques, provided that the patients are carefully selected, well rehabilitated and meticulously followed.

To obtain a better understanding of the prognostic factors influencing treatment outcome after extracorporeal shock wave lithotripsy (ESWL), a multivariate logistic analysis of the data from 246 patients has been undertaken. All of the patients were treated with the Dornier lithotriptor HM-3 for radiopaque renal calculi. Treatment success was defined as stone-free within 3 months of one ESWL session and without adjuvant measures after ESWL. In a first analysis, 210 patients with solitary and multiple calculi without adjuvant measures before ESWL were studied. Of 210 patients, 141 (67%) were free from stones after 3 months). Significant influences on the success rate were body mass index and stone number. In a second analysis only those 160 patients with solitary calculi were considered. In this group, age, body mass index, stone location, stone burden and serum calcium significantly influenced the prognosis. When patients with adjuvant measures were added to the analysis an increasing prognostic importance of the stone burden was seen. In patients with a small to medium stone burden (< 4.0 cm3), the number of stones seemed to be more important than the stone burden. Patients appear to have the best chance for successful ESWL when their body mass index is between 20 and 28, their age is between 40 and 60 years, their stones are in the renal pelvis and solitary, the stone burden is < 1.0 cm3, and when their serum calcium is normal.

A total of 110 patients with upper ureteral calculi was admitted to a prospective trial and randomly allocated to 2 groups: 1 group treated with in situ extracorporeal shock wave lithotripsy (ESWL) and 1 group treated with ureteral manipulation before ESWL. All patients had solitary upper ureteral calculi without urinary infection. The stones had to be smaller than 1 cm. and located more than 2 cm. lateral to the spine. ESWL was performed with the Dornier HM3 lithotriptor. One patient in the in situ ESWL group had to be treated twice because disintegration of the stone was insufficient after the initial treatment session. All other patients underwent only 1 treatment session. Because 16 patients were lost to followup, 94 were evaluable for the analysis of immediate and long-term results. For disintegration of the stones in situ ESWL needed significantly more shock waves (1,844 +/- 639 versus 1,297 +/- 473, p < 0.001) and a higher voltage (19.5 +/- 1.4 versus 18.7 +/- 0.9 kv., p < 0.001). There were no severe complications in either treatment group. At 3 months 44 of 46 patients (96%) after in situ ESWL and 45 of 48 (94%) after ureteral manipulation before ESWL were free of stones. In view of these results it is suggested that uncomplicated upper ureteral calculi (as defined previously) should be treated first with in situ ESWL, thus, avoiding an invasive procedure.

In 18 patients with renal cell carcinoma in anatomical or functional single kidneys, with limited renal function or bilateral tumors, partial renal resection was absolutely indicated to preserve renal function. In 17 patients with small peripheral tumors and intact contralateral kidney, partial renal resection was performed electively. One patient of each group died during postoperative care. During follow-up, 4 patients with absolute indication for partial renal resection showed progression of the disease. Three developed distant metastases, and in one patient local relapse with infiltration of the inferior cava vein occurred. These 4 patients had had a bilateral synchronous or asynchronous stage pT2 or pT3 renal cell carcinoma and died from the neoplasm within 10-36 months postoperatively. 13 of 18 patients with absolute indication remained tumorfree during a median follow-up period of 57 months. Partial renal resection saved 15 of these 17 patients from dialysis. Sixteen of 17 patients in whom partial renal resection was performed electively remained tumorfree during a median follow-up period of 28 months. The results suggest that, given an absolute indication to prevent dialysis, partial renal resection should be performed whenever technically possible. In patients with small peripherally located tumors and intact contralateral kidney, partial renal resection as an elective procedure must be considered a genuine alternative to radical nephrectomy.

With intensified screening and the use of new diagnostic tools for prostate cancer (prostate-specific antigen, rectal ultrasound, magnetic resonance imaging with rectal coils, etc), the number of newly diagnosed cases of prostate cancer is rising rapidly, whereas the frequency of death due to prostate cancer remains almost stable. It must therefore be assumed that the number of patients in whom a diagnosed prostate cancer will not be fatal is also increasing. Consequently, not every prostatic carcinoma requires radical treatment when diagnosed. Also, it must be concluded that not every man who is a long-term survivor after radical prostatectomy owes his survival to the treatment. Long-term survivorship may reflect the relatively benign biological potential of this disease in an individual patient. Therefore, there is an inherent risk of overtreating patients and this must be weighed against the costs, the postoperative morbidity and the, albeit low, mortality of a radical prostatectomy. Nevertheless, as long as we do not have diagnostic tools which, at an early stage of prostate cancer, enable us to determine whether a carcinoma will ultimately have a fatal outcome, we are obliged to offer radical prostatectomy to younger patients (who have a life expectancy of more than 10 years) as long as they have organ-confined disease.

Die radikale Prostatektomie ist heute die anerkannte Behandlungsform beim lokalisierten Prostatakarzinom. Urologische Zentren weltweit berichten anhand groser Serien uber ihre Ergebnisse mit Verlaufsbeobachtungen von 5, seltener jedoch von 10 und 15 Jahren. Die Operationsmortalitat ist klein, die postoperative Morbiditat tolerierbar.

When a urinary reservoir intended to replace the bladder is made from bowel, it should meet several requirements: good capacity, viscoelasticity and compliance, voluntary control of micturition without residual (infected) urine, a sensation of the filled state and urinary continence. In addition, there should be no major metabolic changes due to malabsorption after bowel resection or due to reabsorption of urinary constituents by the reservoir. In this review several conflicting aspects of bladder reconstruction are addressed: the persisting intestinal peristalsis and urinary incontinence, the volume of the reservoir and its metabolic impact, the bowel segment to be used and the amount that can be resected without the risk of long-term sequelae. Our clinical experience with ileal bladder substitutes in 80 patients underlines the theoretical aspects. After careful instruction, our patients increased the functional capacity of their reservoirs to 500 ml, a precondition for good urinary continence. Provided that the patients were regularly followed-up, the functional, clinical and metabolic results were good. The operative procedure was easy to perform, and no major metabolic sequelae occurred during a maximal observation time of 6 years. Nevertheless, continuing careful follow-up for the detection of potential long-term sequelae, such as disturbances in lipid metabolism or chronic bone demineralisation, are required before definitive statements on the role of intestinal bladder substitutes can be made.

The relationship between renal disease and hypertension has been known for over 150 years [165]. Goldblatt showed that clamping of the main renal artery leads to reversible elevation of the systemic arterial pressure [166, 167], Butler [23] reported a case of unilateral pyelonephritic kidney and severe hypertension in a young patient. Nephrectomy relieved the high blood pressure. On the basis of these results nephrectomies were carried out in many patients with small kidneys and hypertension. However, an analysis of the results showed that hypertension was cured in only 26% of cases [138].

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

Preoperative axial computerized tomography scans in 163 patients with renal cell carcinoma were reviewed to assess the predictive value for the diagnosis of regional lymph node metastases. Computerized tomography was falsely negative in 5 patients: 2 had metastatic lymph nodes in the renal hilus adjacent to the primary tumor measuring 2 and 2.5 cm., and 3 had micrometastases in nodes of less than 1 cm. In 43 patients enlarged lymph nodes with a diameter of 1 to 2.2 cm. (median 1.4 cm.) were diagnosed on the preoperative scan and this was confirmed at nephrectomy and pathologically. In 18 of these 43 patients (42%) histological study showed metastases of the renal cell carcinoma in the enlarged lymph nodes. In the other 25 patients (58%) the enlarged nodes showed only inflammatory changes and/or follicular hyperplasia. This finding was significantly more frequent in patients with tumor involvement of the renal vein and tumor necrosis (p = 0.0044). We conclude that the sensitivity of preoperative computerized tomography is good for the detection of enlarged lymph nodes in patients with renal cell cancer (95%). However, significant lymph node enlargement frequently may be caused by inflammatory changes, especially in the presence of tumor necrosis. This radiological finding should not be misinterpreted as metastatic disease, unless it has been proved cytologically by fine needle aspiration.

Familiarity with the surgical therapy of adrenal tumors is desirable for any surgeon, regardless to what surgical discipline endocrine surgery is assigned. The basic preconditions for surgical treatment include not only mastery of technique but also knowledge regarding the biology of the individual tumor and experience in dealing with endocrine tumors. Collaboration with radiologists, endocrinologists, and anesthetists is crucial. The surgeon is the last or next to last link in the long chain from diagnosis to therapy.

29 patients with biochemically proven hyperparathyroidism underwent a 201Tl/99mTc subtraction scanning before neck exploration was done. The scanning technique seems not to be reliable for hyperplastic glands in secondary hyperparathyroidism, but in 19 of 21 patients with primary hyperparathyroidism a solitary adenoma was correctly located. This accuracy of 90.5% justifies to investigate all patients with primary hyperparathyroidism with this noninvasive double tracer technique prior to any surgery.

Among the 153 patients who had undergone cystectomy for primary bladder cancer, the expected deterioration of survival occurred as tumor stage advanced. Of 10 patients with either solitary, small resected intraabdominal metastases or involvement of the urethral margin, none survived longer than 3 years. Another 12 patients were found to have regional lymph node metastases; in 11 of these the positive nodes were located along the iliac or obturator vessels; these individuals also died within 3 years. The 12th patient, who had microscopic metastases in a lymph node from the perivesical fat, was alive with no evidence of disease at 42 months. Among the remaining 131 patients who had no evidence of lymphatic, intraperitoneal or distant metastases, nor tumor at the urethral margin, survival rates were not significantly different for the various pT categories. Our results suggest that patients with deeply invasive bladder carcinoma, but no evidence of extravesical spread (which becomes less likely the deeper the tumor infiltrates) have the same 5-year survival rate as patients with superficially invasive cancer of comparable grade. They also show that lymph node metastases along the pelvic wall portend an unfavorable outcome. However, those who have limited microscopic lymph node metastases, particularly if located in the perivesical fat, may expect a better prognosis as suggested by our patient and the reports in the literature.

Summary 60 patients with carcinoma of the prostate of all clinical stages were investigated by lymphography. Positive lymphographic findings were present in about 50% of the cases. The more advanced tumours were found to metastasise more frequently. Lymphography is indispensable to select patients with clinically limited disease to the prostate for radical prostatectomy. The anatomical display of the iliac and aortic lymph nodes on the lymphogram facilitates the selection of the portal fields in external beam megavoltage radiotherapy.

Radiation therapy with negative pi-mesons (pions) was administered to 36 patients with bladder cancer. According to a Phase I/II study, doses varied from 3000 to 3600 pion rad. Although only two complete responses were achieved among 8 evaluable patients who had predominantly papillary bladder tumors, more promising results were obtained in 22 evaluable patients who had sessile, invasive carcinomas: 19 bladders were cystoscopically and cytologically cleared of tumor after 6 months. Although the side effects during the ambulatory treatment were minimal or tolerable, a steep dose-response curve for late side effects was observed with severe complications in 7 of 11 patients who received 3600 or more pion rad. Cancer 56: 1943-1952, 1985.

Ureteroendoscopy is used by most authors to approach distal ureteral calculi. With increasing experience extracorporeal shock wave lithotripsy (ESWL) of distal ureteral calculi has gained importance. The success rate of 96% in a large series of 264 consecutive patients treated in this manner, confirmed the results of other authors. Excluding women of child-bearing age and very large calculi (over 2 cm), ESWL is a suitable treatment modality for distal ureteral calculi.

Ten pyeloureteral systems in 8 patients (mean age 74 years) with cytologically proved ureteral carcinoma in situ (1 combined with ureteral papillary tumors) were perfused with bacillus Calmette-Guerin via a percutaneous nephrostomy tube. In 4 patients cytology results remained negative after 1 treatment course during an observation time of 18 to 28 months. In 1 patient a papillary tumor persisted while cytology results became negative for carcinoma in situ. Two patients with bilateral disease had repeated perfusion of bacillus Calmette-Guerin until cytology results became negative and they remained negative during observation for 18 months in 1. The other patient had a multifocal recurrence of carcinoma in situ, combined with a stage T1, grade 3 urothelial cancer in the bladder after 12 months and a recurrence of carcinoma in situ in 1 ureter after 24 months. In 1 patient treatment was stopped prematurely after severe septicemia. Although our short-term results are promising, percutaneous perfusion of bacillus Calmette-Guerin for carcinoma in situ of the upper urinary tract should be considered as an investigational treatment modality until long-term results are available.

In den Jahren 1973–1983 wurde an der urologischen Universitatsklinik Bern bei insgesamt uber 1500 Patienten die Diagnose eines Prostatakarzinoms gestellt. Wahrend der gleichen Zeitspanne konnten lediglich 54 Patienten einer radikalen Prostatektomie zugefuhrt werden, die Zahl jener, welche eine perkutane Strahlentherapie in kurativer Absicht erhielten, ist nicht wesentlich groser (83). Demnach erhielten uber 90% der Patienten mit einem neudiagnostizierten Prostatakarzinom keine kurative Therapie. In einem kleinen Prozentsatz der Patienten waren die Grunde das fortgeschrittene Alter, ein reduzierter Allgemeinzustand oder auch der Wille des Patienten. In der grosen Mehrzahl der Falle war das Prostatakarzinom zum Zeitpunkt der Diagnose bereits zu fortgeschritten, als das eine lokale Therapie mit kurativer Intention noch moglich gewesen ware. Nachdem der weitaus groste Anteil (uber 90%) der der urologischen Universitatsklinik zugewiesenen Patienten Miktionsbeschwerden als Leitsymptom hatten, drangt sich zwingend die bekannte Schlusfolgerung auf, das es fur eine kurative Therapie des Prostatakarzinomes in der Regel zu spat ist, wenn dieses bereits Miktionsbeschwerden verursacht.

Diversion and cystectomy have often been considered at length in the literature but little attention has been paid to the relevance and feasibility of these procedures performed specifically in the elderly patient. We describe here the results of urinary diversion in 45 patients of over 70 years of age. Most received an ileal conduit though ureterosigmoidostomy, cutaneous ureterostomy and transureterocutaneous ureterostomy were occasionally performed. In most patients diversion was done as part of a scheme of radical treatment of bladder cancer, but in others it was undertaken for palliative purposes or benign disease. The results of this retrospective study are sufficiently encouraging for us to continue to recommend such apparently extreme measures to patients whose life expectancy may be as much as 9 years. Furthermore diversion provides good palliation in preterminal disease. Moreover in patients with limited life expectancy ureterostomy should be seriously considered as a procedure which is quickly performed and with few early postoperative complications.

Most episodes of bacterial cystitis are recurrent infections due to ascending bacteria of different serotypes. The causes of diagnostic problems, especially of false-positive and false-negative urine-cultures are discussed and the possible importance of chlamydia and mycoplasma is stressed. Finally, the therapeutic possibilities are discussed, with the indication for single-dose and long-term therapy.

Treating a patient with a superficial bladder tumour has responsibilities far beyond performing a good TUR of the tumour. Choosing the optimum treatment policy for the patient depends on the urologist having a wide understanding of the disease, a sound knowledge of bladder tumour pathology and a critical appraisal of all the therapeutic modalities available. Treatment is likely to be prolonged over many years, and the follow-up is an essential part of this treatment. The urologist must set out prepared to use all the available forms of treatment, including intravesical chemotherapy and total cystectomy. If he is not, the patient should be referred on at an early stage, rather than persist with ineffective treatment for this may deny the patient the opportunity of cure.

Twelve experimentally induced blunt renal lesions in pigs were treated either with an alloplastic renal capsule made of semi-elastic Vicryl mesh or with homologous pig fibrin adhesive or with through-and-through chromic catgut sutures as controls. The Vicryl mesh capsule was made by the Ethnor Company (Paris, France) to our specifications. The postoperative isotope nephrograms, which were repeated until the Vicryl had been fully resorbed, showed good renal function in every case. However, when compared to the controls, the kidneys which had been repaired with Vicryl mesh contained considerably less scar tissue at the site of parenchymal rupture and showed neither perirenal fibrosis nor atrophy of the parenchyma in the vicinity of the capsule. Our preliminary results seem to confirm that simple and rapid surgical treatment of moderately severe blunt renal lesions is possible using the alloplastic Vicryl mesh capsule. The method may also be suitable for reconstruction of the parenchyma following multiple nephrotomies, such as for removal of staghorn calculus, and experimental investigations are under way to clarify this point.

Two theories of pathogenesis of multifocal transitional cell carcinoma are discussed: 1. Theory of cellular implantation; 2. multifocal tumor growth. The increased incidence of tumors in the upper urinary tract after urinary diversion for bladder cancer supports the multifocal theory. After treatment of papillary bladder cancer the risk of developing a second tumor in the kidney or ureter is much higher. Therefore we emphasize the continuous follow-up with radiological control of the upper urinary tract.

Ziel der prospektiven Arbeit war, die guten Resultate anderer Autoren in der Behandlung des Carcinoma in situ (Cis) der Harnblase mit BCG zu bestatigen.

An internal urinary diversion after radical cystoprostatectomy has been performed in 24 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 3 months to 3 years, the results are in general good: no signs of pyelonephritis or metabolic changes, necessitating a substitution, have been observed. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 2-6 months during the right. According to our experience, preservation of the neurovascular bundles responsible for erection, helps to regain continence. However, loss of several drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night.