Dirk M. Wilbert

Evaluation of the Acute Scrotum by Color-Coded Doppler Ultrasonography

Color-coded Doppler ultrasonography is a combination of real-time sonography and duplex sonography for noninvasive imaging of arterial and venous blood vessels. In 40 patients with acute onset of scrotal pain this diagnostic procedure was correlated with the findings at surgical exploration: 11 had testicular torsion, 4 hydatid torsion, 13 spontaneous detorsion, 2 blunt scrotal trauma and 10 epididymitis. For testicular torsion color-coded Doppler ultrasonography had a sensitivity of 82% and a specificity of 100%, and for epididymitis the sensitivity was 70% and specificity was 88%. Color-coded ultrasonography readily demonstrates testicular perfusion. In cases of incomplete or early torsion some residual perfusion may be detected leading to false-negative results. Despite this fact, color-coded Doppler ultrasonography currently is the most valuable diagnostic modality in the evaluation of the acute scrotum.

Local Microwave Hyperthermia of Benign Prostatic Hyperplasia

Recently, hyperthermia has been used for treatment of benign prostatic hyperplasia. The preliminary results reported were promising. However, apart from patients with total urinary retention, objective voiding parameters have not been reported in detail for patients with prostatism. In a phase II study we treated 30 patients with benign prostatic hyperplasia by local microwave hyperthermia (915 MHz.). The prostate was heated transrectally to 42 to 43C, with the treatment consisting of 8 sessions of 60 minutes each given twice a week. To assess the results of treatment several parameters were determined before and 4 weeks after hyperthermia therapy, including transrectal ultrasound of the prostate with volumetry, urinary flow rate and residual volume. Of the patients 28 could be evaluated and only 2 showed a relevant improvement. Neither the voiding parameters nor the size of the prostate could be changed significantly by hyperthermia. The success rate of 7.1% is even lower than the spontaneous temporary regression rate of benign prostatic hyperplasia. Thus, we believe that hyperthermia cannot be regarded as an effective treatment for benign prostatic hyperplasia comparable to transurethral resection.

Protective Effect of Verapamil on Shock Wave Induced Renal Tubular Dysfunction

In a prospective randomized study, the effects of the calcium entry blocker verapamil on shock wave induced tubular impairment were examined. A total of 24 patients with renal pelvis or caliceal stones undergoing anesthesia-free extracorporeal shock wave lithotripsy (ESWL*) without auxiliary measures was randomly assigned to the verapamil group (12) or the control group (12). Four doses of verapamil (80 mg. each) were given orally starting the night before ESWL. Controls received no medication. To assess renal tubular function the urinary excretion of alpha 1-microglobulin, N-acetyl-beta-glucosaminidase and Tamm-Horsfall protein were determined before, immediately, and 12 and 24 hours after ESWL. After ESWL there was an increase in urinary alpha 1-microglobulin and N-acetyl-beta-glucosaminidase, which was significantly higher in the control than in the verapamil group. Tamm-Horsfall protein, a glycoprotein synthesized by the distal tubules, decreased significantly less in the verapamil group compared to the controls. Our results indicate that verapamil exhibits a protective effect on shock wave induced tubular damage. The underlying mechanisms are not elucidated yet, and direct actions on tubular cells and interference with renal hemodynamics are to be discussed.

Damaging effects of high energy shock waves on cultured Madin Darby Canine Kidney (MDCK) cells

SummaryShock wave lithotripsy (ESWL) has become an almost non-invasive standard treatment modality for urolithiasis. Several investigations, however, demonstrated that ESWL is not completely free of side effects. Among others alteration of renal tubular function has been reported. To study the effect of shock waves on tubular cells directly an in-vitro model with cultured Madin Darby Canine Kidney (MDCK) cells was established. Suspensions of MDCK cells (7 groups of 6 containers each) were exposed to 0, 16, 32, 64, 128, 256 shock waves (Dornier HM4, 18 kV). Before and 0, 1, 3, 6, 9, 12, 24 h after ESWL the following parameters were measured in the nutrient medium: lactate dehydroxygenase (LDH), glutamate oxalacetate transaminase (GOT), electrolytes. LDH and GOT increased depending on the number of shock waves indicating a membrane damage of MDCK cells. The MDCK model seems suitable for further studies on the effect of shock waves on renal tubular cells.

Alveolar Echinococcosis with Involvement of the Ureter and Testis

Alveolar echinococcosis is a rare disease of the liver, and occasionally of the lungs and brain, that is endemic across areas of Central Europe, the Soviet Union and Alaska. We describe a case of alveolar echinococcosis with involvement of the ureter and testis overshadowing the liver manifestation. The unusual presentation and nondemonstrable exposure to the organism caused misinterpretation of the histological findings and an initial misdiagnosis of tuberculosis.

Current Controversies in Surgical and Endourological Management of Urolithiasis

The current treatment of urolithiasis has dramatically reduced the need for open surgical removal of renal and ureteral stones to as much as 1% (1). However, there still exist situations where open surgery is indicated: a) large ureteral stones which can not be reached with endourological instruments or extra-corporeal shock-wave lithotripsy (ESWL); b) extreme staghorn calculi; and c) renal pelvic stones, and ureteral stones with concomitant ureterpelvic junction (UPJ) obstruction or ureteral strictures.

Initial Experience with the Second-Generation Lithotripter, Dornier HM-4

In addition to the widely-used first-generation lithotripter (Dornier HM-3), an increasing number of second-generation devices are now in clinical use. We are currently reporting our initial experience with the Dornier HM-4. The main improvements over the previous device with this model are the coupling of the shock waves by means of a water cushion, a modified shockwave generation with an enlarged ellipsoid and decreased generator energy, and computer-assisted handling. Additionally, a system for respirational triggering is installed. Treatment-related technical data are printed out by a small computer. The modification of shock-wave delivery with less energy through a larger-diameter ellipsoid is believed conducive in decreasing the need for anesthesia. However, an increasing number of secondary treatments are being reported from other centers.

Renal Functional Alterations after Extracorporeal Shock-Wave Lithotripsy Assessed by Measurement of Urinary Proteins

Currently, extracorporeal shock-wave lithotripsy (ESWL) is the method of choice for treatment of renal and ureteral calculi. From various animal experiments, it is known that renal damage can occur when large doses of these high-energy pressure waves are directed towards the kidney. On the other hand, routine treatment does not seem to jeopardize renal function too much. In approximately 1% of the patients, perirenal or intrarenal hematomas lead to clinical symptoms. It has been difficult to quanititative-ly assess renal damage after ESWL. Imaging techniques like axial computerized tomography or nuclear scans can show morphological changes only after ESWL, such as diminished perfusion or perirenal fluid collection of edema of the kidney in 30 to 50%. However, radionuclide scans do not show these alterations regularly.