Gerd Riedasch

Aetiology, diagnosis and management of spontaneous perirenal haematomas

This study focuses on the diagnostic and therapeutic challenge posed by spontaneous perirenal haematomas (SPHs). The medical records of 18 patients with SPHs seen in the past 8 years were reviewed with respect to aetiology, diagnosis and therapeutic management. SPH was secondary to angiomyolipoma (n = 4), polycystic kidneys (n =4), panarteritis nodosa (n = 3), renal cell carcinomas (RCCs, n = 2), glomerulonephritis, pyelonephritis, Morbus Wegener and cortical adenoma (one each). One case remained unclear. With appropriate imaging techniques (computed tomography and angiography) the underlying disorder was detected in 72%; in 4 cases the diagnosis was revealed by exploration and biopsy. Surgery was necessary in 16 patients. The cause of bleeding can be revealed by appropriate imaging in most cases. When imaging procedures fail to reveal the cause of SPH, exploration and biopsy are mandatory to exclude RCC. If the cause of SPH remains unclear even after exploration, patient monitoring by CT is justified.

Surgical treatment of invasive penile cancer : The Heidelberg experience from 1968 to 1994

OBJECTIVES This study was performed to establish oncological guidelines for the surgical treatment of invasive penile cancer. MATERIALS AND METHODS The medical records of 51 patients with invasive penile cancer seen between 1968 and 1994 were reviewed in respect to treatment and long-term outcome. RESULTS For stage T1 tumors treated with organ-preserving procedures the local recurrence rats was 56%, whereas no patient experienced a local recurrence after partial amputation. For stage T2 tumors, local recurrence rate was 100% (organ preservation) versus 20% (amputative procedures). There was no significant difference related to regional recurrence between surveillance, inguinal radiation and lymphadenectomy for stage N0 tumors. For N+ stages, survival was related to the extent of inguinal metastasis after dissection (5-year survival rate for N1: 71 vs. 33% for N2/3). CONCLUSIONS Organ-preserving procedures include a high risk of local and regional recurrence. Adjuvant regional lymphadenectomy seems beneficial only in patients with solitary metastasis.

Psychogenic Voiding Patterns

A urodynamic analysis was performed on 1,300 patients to precise typical psychogenic voiding patterns. Only 2.7% of this selected group showed voiding alterations derived from a psychosis or neurosis. The psychosomatic voiding alterations were to some degree similar to the alterations which were provoked by exogenous or iatrogenic influences. The voiding pattern of young children differs from that of adults when comparing psychosomatic symptoms such as prostatitis or enuresis. Urine retention and megalocystis were characteristic findings of psychotic patients whereas a polyphasic flow pattern, a delay of micturition and increased sacral reflex activity were typical findings of psychosomatic disorders. The denervation supersensitivity test is a reliable test to differentiate neurogenic from psychogenic voiding patterns.

Stauffer's syndrome in renal cell carcinoma evidence for intravascular coagulation

ZusammenfassungEin Stauffer-Syndrom (erhöhte alkalische Phosphatase und verlängerte Prothrombinzeit) wurde bei 18 von 40 Hypernephrom-Patienten gefunden. Es konnte gezeigt werden, daß die verlängerte Prothrombinzeit nicht auf eine Verminderung Vitamin K-abhängiger Gerinnungsfaktoren, sondern auf zirkulierende Fibrinogen-Fibrinomer-Fibrinspaltproduktkomplexe zurückzuführen ist. Der Alkoholtest nach Godal war bei 28 von 48 Patienten positiv und erhöhte Mengen an zirkulierenden Fibrinmonomeren wurden bei 38 von 40 Patienten gefunden. Eine gesteigerte Fibrinolyse ließ sich in 19 von 40 Patienten nachweisen. Die Verlängerung der Thrombinkoagulase-und Reptilasezeit wird auf die zirkulierenden Fibrinmonomer-Fibrinspaltproduktkomplexe zurückgeführt, die die gestörte Umwandlung von Fibrinogen in Fibrin verursachen. Die vorliegenden Befunde sprechen für eine latente kompensierte intravasale Verbrauchskoagulopathie, die wahrscheinlich innerhalb des gefäßreichen Tumors ausgelöst wird. Als empfindlicher Indikator für diagnostische Zwecke erwies sich die Thrombinkoagulasezeit.Die Thrombinkoagulasezeit normalisierte sich nach chirurgischer Entfernung des Tumors und wurde nach Auftreten von Metastasen wieder pathologisch.Die Erhöhung der alkalischen Phosphatase war in der Regel nur auf einen Anstieg des hepatischen Isoenzyms zurückzuführen. Zum Nachweis des Stauffer-Syndroms erwiesen sich das hepatische Isoenzym der alkalischen Phosphatase und die Gamma-GT empfindlicher als die Gesamt-alkalische Phosphatase.SummaryIn 40 patients with non-metastasising (n=31) and metastasising (n=9) renal cell carcinoma, evidence of Stauffers syndrome (increase in alkaline serum phosphatase and prolongation of prothrombin time) was found in 18 patients.Prolongation of prothrombin time was not due to depletion of vitamin K-dependent coagulation factors or manifest fibrinolysis, but due to the presence of circulating fibrinogen fibrinmonomer-FDP complexes. Ethanol gelation test was found to be positive in 28/40 subjects and soluble fibrin monomer complexes were increased in 38/40 patients. The resulting disturbance of fibrinogen-fibrin conversion was reflected by an increase in thrombin coagulase time and reptilase time. These findings suggests a state of latent compensated intravascular coagulation (presumably triggered within the vascular tumor). For diagnostic purposes the most sensitive indicator is thrombin coagulase time. Thrombin coagulase time normalised after tumor resection and was positive in patients with recurrent metastases.The increase in alkaline serum phosphatase was due to an increase in the hepatic isoenzyme. Such an increase was much more common than the elevation of total alkaline serum phosphatase. Regans isoenzyme was only found in 1 subject. In parallel, gamma-GT was elevated in 24 patients.The study shows that Stauffers syndrome occurs more frequently than commonly assumed when thrombin coagulase time, gamma-GT and the hepatic isoenzyme of alkaline serum phosphatase are determined in patients with renal cell carcinoma. DIC and low grade fibrinolysis may account for the coagulation abnormalities of the syndrome.

Concentration of Ofloxacin in Prostatic Tissue during TURP

Antibiotic prophylaxis before transurethral resection of the prostate (TURP) seems to be justified, since more than 70% of TURP specimens show clinical or microscopic signs of infection. Elderly patients, especially, seem to be at risk of developing serious complications after TURP. The aim of prophylactic administration of antibiotics in TURP in particular is to achieve bactericidal drug concentrations at the time and site of resection, i.e. the urethra and prostatic tissue.

Do antibody-coated bacteria prove bacterial prostatitis?

SummaryUsing the immunofluorescence technique in 187 patients with bacteriologically proven prostatitis according to the Meares-Stamey test demonstrated a significant amount of antibody-coated bacteria (ACB) in their ejaculates. The ACB test was useful to discriminate between chronic bacterial prostatitis and prostatodynia with a sensitivity of 65% and a specifity of 92%; likewise the ACB test is superior to complement and coeruloplasmin estimation in the ejaculate by radial immunodiffusion usually recommended for the differential diagnosis of inflammatory and psychosomatic diseases of the prostate.ZusammenfassungBei 187 Patienten mit der Verdachtsdiagnose einer Prostatitis wurde der immunofluoreszenzmikroskopische Nachweis von Antikörpern auf Bakterien im Ejakulat, der sogenannte Antibody-Coated-Bacteria (ABC)-Test verglichen mit den Ergebnissen der 4-Gläser-Probe nachMeares undStamey. Der ABC-Test konnte mit einer Sensitivität von 65% und einer Spezifität von 92% zwischen einer chronisch bakteriellen Prostatitis und einer Prostatodynie unterscheiden. Der Nachweis von Komplement und Coeruloplasmin im Ejakulat mit Hilfe der radialen Immundiffusion eignet sich dagegen weniger zur Differentialdiagnostik einer erregerbedingten Prostatitis und einer psychosomatischen Erkrankung der Prostata.

Absorption of Vitamin B12 Administered to Continent Ileal Reservoirs for Urinary Diversion

Urinary diversion through intestinal segments is a widely used method after radical cystectomy. During the last few years, new methods of bladder substitution, continent ileal neobladders, were developed. We used the method described by Hautmann et al. in 1986. 70 cm of ileum is used to form a reservoir. The ureters are implanted into the reservoir, which is then anastomosed to the urethral stump. A known problem when intestine is used for urinary diversion is the absorption of urinary solutes leading to metabolic disturbances. Therefore, the absorption of vitamin B12, instilled into the neobladders of 20 patients, was measured and related to the postoperative interval. The results show a high absorption rate 2 weeks postoperatively that is reduced quickly and significantly (p < 0.001) within the first 10 months (from more than 30 to below 5%). One year to 23 months after the operation, some neobladders absorbed no vitamin B12 at all, whereas others still absorbed significantly but only small quantities. These results may probably be attributed to the loss of villous structure as well as atrophy of the epithelial surface.

Antibody coated bacteria in ejaculatein bacterial prostatitis

In patients with bacteriologically proved prostatitis (Stamey test) ejaculate was examined for antibody-coated bacteria (ACB). Forty-four of the 68 patients (65%) with bacteriologically proved prostatitis had ACB in the ejaculate, but only 7 of 89 patients (8%) with prostatodynia. Concomitantly, coeruloplasmin and complement (C3) concentrations in the ejaculate were examined by radial immunodiffusion (RID). The ACB test had much higher specificity (92%) than RID, and the sensitivity of ACB was 65 per cent.

Estrogens influence antibody coating in experimental urinary tract infection.

SummaryFemale rats were infected with E. coli 0.25 by intravesical instillation. After 4 weeks, significantly higher bacterial counts (bladder puncture and renal homogenates) were found in estradiol treated rats (0.5 mg/kg/week) than in solvent controls, but the proportion of antibody-coated bacteria was significantly (P<0.01) lower in bladder urine and renal homogenates. There was no influence of estrogens on renal histology or ureteral width. The results are compatible with an effect of estrogens on local immune response in the urinary tract.

Application of an improved methodology to demonstrate bacterial adherence during the menstrual cycle

SummaryWe studied bacterial adherence to uroepithelial cells of female patients in relation to the menstrual cycle. We determined the number of bacteria demonstrable on native cells and the number of adhering bacteria after incubation withE. coli. Free bacteria and uroepithelial cells with adhering bacteria were optimally separated by differential centrifugation using sodium metrizoate (9.6%) and dextran (5.6%) (Lymphoprep). Thus, contamination of the cell preparation by free (non-adhering) bacteria was avoided and results were well reproducible.A median of five bacteria/cell (range 0–19) was observed for uroepithelial cells obtained from urine of female patients. Such bacteria were mostly rods.After in vitro incubation withE. coli cultures, a median of 33 bacteria/cell (range 17–54) was counted.Our improved methodology failed to demonstrate a relationship between bacterial adhesion and the menstrual cycle.ZusammenfassungDie bakterielle Haftfähigkeit an Uroepithelien weiblicher Probandinnen wurde in Abhängigkeit vom Menstrualzyklus überprüft. Untersucht wurden die Zahl der an nativ gewonnenen Zellen nachweisbaren Bakterien und die Zahl der nach Inkubation mitE. coli-Kulturen haftenden Bakterien. Eine optimale Trennung zwischen Bakterien und Epithelzellen mit anhaftenden Bakterien wurde erreicht durch Differential-Zentrifugation mit Hilfe von Natrium-Metrizoat (9,6%) und Dextran (5,6%) (Lymphoprep). Dieser Schritt gestattet, die Kontamination des Präparates durch nichthaftende Bakterien zu vermeiden und gewährleistet gute Reproduzierbarkeit.An nativen Uroepithelzellen wurde ein Median von fünf Bakterien/Zelle (Spannbreite 0–19) ermittelt. Die haftenden Bakterien waren in der Regel Stäbchen.Nach in vitro-Inkubation mit Bakterien-Kulturen wurden im Schnitt 33 Bakterien/Zelle (Spannbreite 17–54) ermittelt.Mit der verbesserten Methode zeigte sich keine Abhängigkeit der bakteriellen Haftfähigkeit vom Menstrualzyklus.