C. Ziesel

Psoas hitch and Boari flap ureteroneocystostomy.

Introduction In the middle of the last century, Dolff [1], Paquin [2] and Zimmermann et al. [3] developed principles for ureteroneocystostomy after gynaecological ureter injuries. Turner-Warwick and Worth [4] adopted these techniques, named it the ‘Psoas Bladder-Hitch Procedure’ and applied this technique of ureteroneocystostomy for the treatment of distal ureteric obstruction, ureteric fistulas and ‘distended duplication’ of the upper urinary tract.

Bladder augmentation using bowel segments (enterocystoplasty).

Gastric segments, small and large bowel segments as well as the ureter are used for bladder augmentation [ 1 ] . Since the late 19th century, ileal segments have been used for bladder augmentation (ileocystoplasty) [ 2,3 ] . Later, these segments were detubularised and reconfi gured to create, together with the remnant bladder, a spherical reservoir [ 4 ] . In the middle of the past century, the use of caecum for bladder augmentation was reported [ 5,6,7,8 ] . In ileocaecocystoplasty, the presence of the appendix is advantageous for patients who are unable to perform clean intermittent self-catheterisation (CISC) through the urethra. In these cases, the submucosally embedded appendix can be used as an additional continent cutaneous stoma to evacuate the augmented bladder, as in patients with heterotopic continent cutaneous diversion [ 9 ] . If ureteric re-implantation is necessary, the ileocaecal valve can be used as anti-refl ux mechanism for severely dilated ureters [ 10,11 ] . Nondilated ureters can be implanted into the large bowel by the submucosal tunnel technique [ 12 ] . At the beginning of the 20th century, the use of sigmoid colon was reported for bladder augmentation (colocystoplasty) [ 13,14 ] . Gastrocystoplasty was reported in 1978 by Leong and Ong [ 15,16 ] . However, complications of bladder augmentation by gastric segments, e.g. hyponatraemic, hypochloraemic alkalosis, haematuria-dysuria syndrome [ 17,18 ] and secondary malignancies after the 10th postoperative year [ 19,20,21,22 ] made this type of bladder augmentation obsolete. ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

Differences in Overall and Cancer-specific Survival of Patients Presenting With Chromophobe Versus Clear Cell Renal Cell Carcinoma: A Propensity Score Matched Analysis

OBJECTIVES To investigate prognostic parameters for the oncological outcome of patients treated for chromophobe renal cell carcinoma (chRCC) in comparison with patients treated for clear cell RCC (ccRCC) using propensity score matching for survival analysis. METHODS From 1969 to 2009, we identified 1010 from 3567 patients with RCC. Survival was analyzed using Kaplan-Meier estimate for histological subtypes including 109 chRCC and 901 ccRCC. Uni- and multivariate Cox regression was used to analyze prognostic factors for overall survival (OS) and cancer-specific survival (CSS). Propensity score matching was performed to adjust for differences in patient characteristics among histological subgroups. RESULTS The median follow-up was 61 months (range 0-289). chRCC showed longer OS (5 year, 90.1%; 10 year, 74.2%; 15 year, 61.4%) and CSS (94.2%, 89.7%, 89.7%) compared with ccRCC (OS 75.7%, 54.9%, 46.1% and CSS 84.7%, 75.4%, 72.2%; P = .002). Multivariate Cox regression revealed histology as a significant prognostic factor. Propensity score matching showed a difference in 72.4% (OS) and 87.2% (CSS) of matching attempts confirming the significant impact of histology. Univariate Cox regression showed nephron sparing surgery, no metastasis and no symptoms at presentation, age <65, eosinophilic features, low American Society of Anesthesiologists score, and Charlson Comorbidity Index to be beneficial for CSS. Only age at surgery, metastasis at presentation, and American Society of Anesthesiologists and Charlson Comorbidity Index scores were significant factors for OS in chRCC patients. CONCLUSION ChRCC appears to have a favorable outcome compared with ccRCC. Even after adjustment for differences in characteristics known to have an influence on survival by propensity score matching, histology remains a significant prognostic factor.

Presentation, Management and Long-Term Outcome of Ureteropelvic Junction Obstruction in Duplex Kidneys

PURPOSE Ureteropelvic junction obstruction in association with a duplex collecting system is a rare but challenging upper urinary tract pathology. We report our 21-year experience with this anomaly in terms of presentation, diagnostic evaluation and management. MATERIALS AND METHODS We retrospectively identified all patients with ureteropelvic junction obstruction in a duplex collecting system between 1991 and 2012. We reviewed each case for presenting symptoms, anatomy and management. Median followup was 10.8 years (range 2 to 22). RESULTS Ureteropelvic junction obstruction in duplex kidneys was diagnosed in 21 patients. Ten patients presented with clinical symptoms such as flank pain and urinary tract infection but 11 were asymptomatic. Six patients were diagnosed by prenatal ultrasound. The lower pole and the upper pole were affected in 22 and 3 renal units, respectively. Bilateral ureteropelvic junction obstruction was found in 4 cases. Duplication was complete in 5 patients, incomplete in 11 and undetermined in 5. Surgery was performed in 14 patients, including pyelopyelostomy or ureteropyelostomy in 7, dismembered pyeloplasty in 6 and heminephrectomy in 1. Reintervention was required in 1 case. Conservative treatment was adopted in 7 patients with clinically insignificant obstruction and unimpaired renal function. In all of these patients upper urinary tract dilatation gradually improved during 3 years. CONCLUSIONS Ureteropelvic junction obstruction in a duplex kidney is a rare but challenging anomaly that requires careful evaluation. Treatment should be individualized according to clinical presentation (symptomatic/asymptomatic), anatomy (lower/upper pole), duplication type (complete/incomplete) and obstruction with time (severity/development) on dynamic renogram.

Metabolische Langzeitprobleme bei der Harnableitung

Metabolic long-term complications and consequences after urinary diversion are somewhat neglected. Subclinical metabolic disturbances are quite common; however, complications are rare. The absorptive surface of the bowel segment is lost for the physiological function of the gastrointestinal tract. Some studies demonstrated that at least some of the absorbent and secreting properties of the bowel are preserved if exposed to urine. For each bowel segment typical complications are reported. Using ileal and/or colon segments, hyperchloremic metabolic acidosis may occur. Studies demonstrated that metabolic effects are not as severe as suspected and could be prevented if a prophylactic treatment is started early.The resection of ileal segments is responsible for malabsorption of vitamin B(12) and bile acid; when using colonic segments, electrolyte disturbances are more common. Careful patient selection, meticulous follow-up and prophylactic treatment are crucial to prevent metabolic complications.

Primärer vesikoureteraler Reflux

ZusammenfassungDie derzeitige Diskussion zum vesikoureteralen Reflux (VUR) bewegt sich zwischen diagnostischem Nihilismus und invasiver Therapie und erinnert an den Disput um das Prostatakarzinom im Erwachsenenalter. Gemeinsames Ziel aller derzeit konkurrierenden diagnostischen Strategien und Therapieansätze ist es, pyelonephritische Nierenschädigungen mit dem wirksamsten und gleichzeitig am wenigsten belastenden Konzept zu verhindern.Der VUR kann konventionell radiologisch, sonographisch, nuklearmedizinisch oder auch mittels Magnetresonanztomographie (MRT) verifiziert werden. In den Leitlinien der „European Association of Urology“/“European Society for Paediatric Urology“ (EAU/ESPU) wird die Refluxprüfung nach der ersten fieberhaften Harnweginfektion (HWI) im Säuglings- und Kleinkindesalter gefordert. Rezidivierende HWI und Parenchymnarben stellen wesentliche Risikofaktoren bei Patienten mit einem VUR dar. Diese Patienten sollten einer patienten- und risikoadaptierten Therapie zugeführt werden. Säuglinge mit einem dilatierenden Reflux haben ein höheres Risiko für Nierenschädigungen als diejenigen ohne eine Nierenbeckendilatation. Blasenfunktionsstörungen bzw. die Entleerungsstörungen (Blase und Darm) stellen in Kombination mit einem Reflux einen altbekannten jedoch früher sehr vernachlässigten Risikofaktor dar. Bei Patienten mit Blasenfunktionsstörungen sollten diese vor jedweder Intervention abgeklärt und – wenn möglich – behandelt werden.Aktuelle Behandlungsstrategien berücksichtigen neben Alter und Geschlecht, das Vorhandensein dysplastischer oder pyelonephritischer Nierenparenchymdefekte, die klinische Symptomatik, Blasenfunktionsstörungen und die Häufigkeit bzw. Schwere rezidivierender HWI als Kriterien für die Therapieentscheidung. Die endoskopische Therapie kann für Patienten mit niedriggradigem VUR eine Alternative zur antibakteriellen Prophylaxe oder zu einer rein abwartenden Haltung sein. Bei Patienten mit einem dilatierenden VUR kann eine endoskopische Therapie angeboten werden, wenn eine antibakterielle Prophylaxe nicht infrage kommt. Allerdings sollten die Eltern zuvor über die deutlich schlechtere Erfolgsquote gegenüber offen operativen Verfahren aufgeklärt werden. Die offen operativen Techniken sind bei weitem nicht in jedem Fall durch die subureterale Implantation von „bulking agents“ ersetzbar. Sie garantieren die höchsten operativen Erfolgsraten und sollten nach wie vor bei Patienten mit einem dilatierenden VUR und hohem renalem Schädigungsrisiko zum Einsatz kommen.AbstractThe never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

[Metabolic long-term complications after urinary diversion].

Metabolic long-term complications and consequences after urinary diversion are somewhat neglected. Subclinical metabolic disturbances are quite common; however, complications are rare. The absorptive surface of the bowel segment is lost for the physiological function of the gastrointestinal tract. Some studies demonstrated that at least some of the absorbent and secreting properties of the bowel are preserved if exposed to urine. For each bowel segment typical complications are reported. Using ileal and/or colon segments, hyperchloremic metabolic acidosis may occur. Studies demonstrated that metabolic effects are not as severe as suspected and could be prevented if a prophylactic treatment is started early.The resection of ileal segments is responsible for malabsorption of vitamin B(12) and bile acid; when using colonic segments, electrolyte disturbances are more common. Careful patient selection, meticulous follow-up and prophylactic treatment are crucial to prevent metabolic complications.

Primary vesicoureteral reflux

ZusammenfassungDie derzeitige Diskussion zum vesikoureteralen Reflux (VUR) bewegt sich zwischen diagnostischem Nihilismus und invasiver Therapie und erinnert an den Disput um das Prostatakarzinom im Erwachsenenalter. Gemeinsames Ziel aller derzeit konkurrierenden diagnostischen Strategien und Therapieansätze ist es, pyelonephritische Nierenschädigungen mit dem wirksamsten und gleichzeitig am wenigsten belastenden Konzept zu verhindern.Der VUR kann konventionell radiologisch, sonographisch, nuklearmedizinisch oder auch mittels Magnetresonanztomographie (MRT) verifiziert werden. In den Leitlinien der „European Association of Urology“/“European Society for Paediatric Urology“ (EAU/ESPU) wird die Refluxprüfung nach der ersten fieberhaften Harnweginfektion (HWI) im Säuglings- und Kleinkindesalter gefordert. Rezidivierende HWI und Parenchymnarben stellen wesentliche Risikofaktoren bei Patienten mit einem VUR dar. Diese Patienten sollten einer patienten- und risikoadaptierten Therapie zugeführt werden. Säuglinge mit einem dilatierenden Reflux haben ein höheres Risiko für Nierenschädigungen als diejenigen ohne eine Nierenbeckendilatation. Blasenfunktionsstörungen bzw. die Entleerungsstörungen (Blase und Darm) stellen in Kombination mit einem Reflux einen altbekannten jedoch früher sehr vernachlässigten Risikofaktor dar. Bei Patienten mit Blasenfunktionsstörungen sollten diese vor jedweder Intervention abgeklärt und – wenn möglich – behandelt werden.Aktuelle Behandlungsstrategien berücksichtigen neben Alter und Geschlecht, das Vorhandensein dysplastischer oder pyelonephritischer Nierenparenchymdefekte, die klinische Symptomatik, Blasenfunktionsstörungen und die Häufigkeit bzw. Schwere rezidivierender HWI als Kriterien für die Therapieentscheidung. Die endoskopische Therapie kann für Patienten mit niedriggradigem VUR eine Alternative zur antibakteriellen Prophylaxe oder zu einer rein abwartenden Haltung sein. Bei Patienten mit einem dilatierenden VUR kann eine endoskopische Therapie angeboten werden, wenn eine antibakterielle Prophylaxe nicht infrage kommt. Allerdings sollten die Eltern zuvor über die deutlich schlechtere Erfolgsquote gegenüber offen operativen Verfahren aufgeklärt werden. Die offen operativen Techniken sind bei weitem nicht in jedem Fall durch die subureterale Implantation von „bulking agents“ ersetzbar. Sie garantieren die höchsten operativen Erfolgsraten und sollten nach wie vor bei Patienten mit einem dilatierenden VUR und hohem renalem Schädigungsrisiko zum Einsatz kommen.AbstractThe never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

Tapering of the Megaureter

The term ‘megaureter’ describes a grossly dilated ureter comprising a wide spectrum of anomalies associated with an increased ureteric diameter [1,2] . Cussen [3] showed in autopsy studies, that a normal ureter in children usually has a diameter of < 5 mm. Hellstrom et al . [4] were able to confi rm this fi nding by reviewing IVUs performed in children for a range of indications. A normal ureter in infancy and childhood generally does not exceed 6 mm in diameter. The current defi nition of megaureter is a ureter with a diameter of > 6 mm. In 1976, during a joint meeting of pediatric urology societies in Philadelphia, a nomenclature and classifi cation of megaureters was agreed upon and later reported and presented by Smith et al . [5] and Stephens [6] . This ‘ABC classifi cation’ included the refl uxing ureter (A), the obstructed ureter (B) and the non-refl uxing, non-obstructed ureter (C). A megaureter is commonly referred to as primary megaureter, when the dilatation is due to an intrinsic pathology of the ureter and secondary when the dilatation is the result of a dysfunction of the bladder or the outlet. In 1980, King [7] added as fourth group the refl uxing, obstructed megaureter, keeping the primary and secondary subclassifi cations.

Die wirksamste Therapieoption wählen

Die derzeitige Diskussion zum vesikoureteralen Reflux bewegt sich zwischen diagnostischem Nihilismus und invasiver Therapie. Gemeinsames Ziel aller derzeit konkurrierenden diagnostischen Strategien und Therapieansätze ist es, pyelonephritische Nierenschädigungen mit dem wirksamsten und gleichzeitig am wenigsten belastenden Konzept zu verhindern.