H. Schulze

Long-Term Followup in 1,003 Extracorporeal Shock Wave Lithotripsy Patients

We evaluated 1,003 patients treated with extracorporeal shock wave lithotripsy after a mean followup of 19.1 months (range 12 to 26 months). Followup excretory urograms were normal in 97 per cent of the patients. Two-thirds of the patients reported further discharge of residual fragments, mainly during the first 3 months. Rehospitalization was necessary in 57 patients. Over-all, the rate free of stones after followup was 72.2 per cent and it was not different for primary and recurrent stone patients. Rates free of stones were influenced mainly by the primary stone location and the number of stones in a renal unit. Patients with lower caliceal stones had a rate without calculi of only 57.8 per cent. Almost identical results were obtained for stones other than in the lower calix, when fragments were found in the lower calix at the time the patient was discharged from the hospital. The pre-treatment stone volume, as determined by measuring the stone area in square millimeters, did not influence the final rates free of stones for calculi up to 400 mm.2, that is 2.4 cm. of a sphere. Only calculi larger than 400 mm.2 showed an inverse relationship to the final rate free of stones. Multiple stones yielded a success rate of 64 per cent, with 90 per cent of the patients having regrowth of residual fragments. Serious complications during followup were not encountered.

Combined Treatment of Branched Calculi by Percutaneous Nephrolithotomy and Extracorporeal Shock Wave Lithotripsy

Eighty-seven patients with branched renal calculi were treated by a combination of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. Stone debulking was achieved by percutaneous nephrolithotomy and residual stone fragments were destroyed by shock wave lithotripsy. Of the patients 70 (80 per cent) required 2 to 3 treatments, 12 (14 per cent) required 4 treatments and 5 (6 per cent) required 5 to 6 treatments. Results after 3 months indicated that 58 patients were free of stones, 3 had recurrent stones and 12 had disintegrated stone particles (less than 3 mm.) in the collecting system, while 13 were lost to followup. One patient had undergone nephrectomy. This treatment plan minimized the disadvantages of either technique when used alone and made open operative intervention unnecessary. Procedural and fluoroscopy times were reduced drastically compared to reported data on percutaneous nephrolithotomy only. We believe that more than 90 per cent of all branched calculi can be treated with this combined technique.

The Swiss Lithoclast: A New Device for Endoscopic Stone Disintegration

Even in the presence of extracorporeal shock wave lithotripsy there is still the need for endourological treatment of stones in the urinary tract. Stone fragmentation usually is achieved with either ultrasonic, electrohydraulic or laser lithotripsy. We report our early experience with a new, simply constructed machine at a reasonable cost for endoscopic stone disintegration--the Swiss Lithoclast. The principle of this lithotriptor is based on pneumatic shock waves induced by the central compressed air system of a hospital or by a compressor. This device was used to treat 151 patients with stones in the kidney, ureter, bladder or a Kock pouch continent urinary diversion. Endoscopic fragmentation was successful in all patients. Independent of the composition, all stones were disintegrated within a short period, indicating that the device may well represent an attractive alternative to standard endoscopic lithotriptors.

Influence of Different Types of Antiandrogens on Luteinizing Hormone-Releasing Hormone Analogue-Induced Testosterone Surge in Patients with Metastatic Carcinoma of the Prostate

The long-term effect of the luteinizing hormone-releasing hormone analogue-induced initial testosterone surge in the treatment of patients with metastatic carcinoma of the prostate still is unknown. However, acute worsening of the disease has been reported in up to 10% of the patients. To prevent such tumor flare we investigated the endocrinological effects of different types of antiandrogens administered in addition to a luteinizing hormone-releasing hormone analogue. Patients with newly diagnosed metastatic prostate cancer were pre-treated with either the steroidal antiandrogen cyproterone acetate (6) or the nonsteroidal antiandrogen flutamide (5) for 1 week before the initial injection of the depot luteinizing hormone-releasing hormone analogue Zoladex. In another 5 patients flutamide was first given 24 hours before Zoladex therapy was started. Luteinizing hormone, testosterone and prostatic acid phosphatase during month 1 of luteinizing hormone-releasing hormone analogue therapy were compared to data obtained in 5 patients treated by Zoladex alone. Only pre-treatment with cyproterone acetate was capable of preventing the Zoladex-induced testosterone surge. However, both pre-treatment regimens with either cyproterone acetate or flutamide for 1 week prevented an initial increase in prostatic acid phosphatase beyond pre-treatment levels in all patients. In contrast, in 4 of 5 patients treated with Zoladex alone and in 2 of 5 pre-treated with flutamide for 1 day an initial increase in prostatic acid phosphatase beyond the pre-treatment values was seen. Our data indicate that pre-treatment with flutamide for only 1 day may not be sufficient to prevent a luteinizing hormone-releasing hormone analogue-induced tumor flare in all cases.

Critical Evaluation of Treatment of Staghorn Calculi by Percutaneous Nephrolithotomy and Extracorporeal Shock Wave Lithotripsy

The combined use of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy in patients with staghorn calculi has become an established treatment regimen. We evaluated the results of 90 staghorn calculi-bearing kidneys treated with such combination therapy after a mean follow-up of approximately 2 years. A total of 69 kidneys (76.7 per cent) became free of stones at some point after treatment. However, due to stone recurrence this number decreased to 55 kidneys (61.1 per cent) at the end of follow-up. Patients who had undergone a previous open operation on the stone-bearing kidney showed less favorable results than the over-all group. When our results were compared to reported data on open surgery or percutaneous nephrolithotomy alone even better results may have been obtained by such treatment modalities. However, our data indicate that percutaneous stone debulking combined with further destruction of residual stone fragments by shock wave lithotripsy certainly is less invasive than an open operation and provides an alternative to percutaneous treatment alone, which can yield comparable results.

Effects of estrogen deprivation on human benign prostatic hyperplasia

Sex steroids are thought to play an essential role in the pathogenesis of human benign prostatic hyperplasia (BPH). Since recent studies in animal models and in men have shown that estrogens might be causally linked to the onset and maintenance of BPH, we examined the effect of 1-methyl-androsta-1,4-diene-3,17-dione (Atamestane), a newly developed aromatase inhibitor, in men with BPH. In an open multicenter study 49 men (mean age 70.1 years, range 55 to 84) with obstructive BPH were treated with atamestane (3 x 200 mg/day) for 3 months. Of the 49 patients 44 completed the treatment period; the other patients discontinued the study for reasons unrelated to treatment. With treatment BPH-related symptoms such as daytime voiding frequency, nycturia, peak flow and residual urine improved considerably; however, these parameters did not reach statistical significance. The mean prostatic volume decreased significantly from 74.2 +/- 31.7 to 64.0 +/- 31 ml (mean +/- SD). Serum estrogen levels decreased markedly during treatment. In addition intraprostatic estrogen concentration decreased with treatment as compared to estrogen levels in hyperplastic prostates from untreated patients. The following conclusions can be drawn from this study: first, estrogens appear to have an important supportive role in established BPH, and second, estrogen deprivation improved BPH-related symptoms and reduced significantly prostatic volume.

Rupture of ileal neobladder due to urethral obstruction by mucous plug.

We report a case of ileal neobladder rupture after radical cystectomy due to mucus obstruction of the bladder neck. Since mucus production in bowel neobladders cannot be sufficiently influenced pharmacologically, patients with a continent urinary diversion connected to the urethra should learn self-catheterization.

Influence of Continental Ileal Urinary Diversion on Vitamin B12 Absorption

PURPOSE Because vitamin B12 is mainly absorbed in the terminal ileum, we evaluated potential absorption deficiencies in continent ileal reservoirs. MATERIALS AND METHODS Eight to 25 months (mean 13) after surgery we evaluated 25 patients with a Kock pouch and 29 with an ileal neobladder. A Schilling test and red blood count were done, and serum levels of vitamin B12 and folic acid were determined. RESULTS Absorptive capacity was decreased in 20 of the 25 Kock pouch patients but none of the 29 ileal neobladder patients. Four patients in each group had low vitamin B12 levels. No patient had megaloblastic anemia. Folic acid levels were normal in all patients. CONCLUSIONS A loss of 50 cm. of terminal ileum seems to be the critical margin sufficient vitamin B12 absorption.

Immunohistochemical determination of age related proliferation rates in normal and benign hyperplastic human prostates

SummaryTo study whether benign prostatic growth in aging men correlates with an increase in proliferation, proliferation rates were determined immunohistochemically using the antibody Ki-67 in 20 benign hyperplastic prostates (BPH) and in four normal prostates (NPR). There was no significant correlation between age and proliferation rate in epithelium or stroma in BPH. In addition, no significant correlation between prostate weight and proliferation rate could be demonstrated in either compartment. In NPR the proliferation rate in epithelium and stroma was 9 times and 37 times lower, respectively, than in BPH. Obviously the induction of BPH from NPR may be associated with a distinct increase in proliferation. The further increase in BPH volume, however, is not correlated with a further increase in proliferation rate.

Suramin treatment in hormone- and chemotherapy-refractory prostate cancer.

OBJECTIVES Suramin, a polysulfonated naphtylurea with anti-growth factor activity, was used in the treatment of metastatic, hormone- and chemotherapy-refractory prostate cancer. Recent studies have proved the effect of suramin on prostate cancer. METHODS Between March 1990 and January 1994, 27 patients with metastatic prostate cancer were enrolled in this study. Treatment regimen consisted of a loading phase, allowing patients to reach suramin serum levels between 180 and 250 microg/mL using a suramin dose of 1.4 g/m2 at 3-day intervals. Constant suramin serum levels were maintained by a 0.5 to 1-g/m2 dose every 7 to 10 days. Because previous studies showed suramin to have serious toxicity, compromised organ status was excluded by repeated examinations. RESULTS Six patients did not complete the suramin loading phase because of side effects and were removed from the study. With an average cumulative suramin dose of 14.2 g, 33% of the assessable patients (7 of 21) experienced a more than 50% reduction of prostate-specific antigen (PSA) and/or alkaline phosphatase (AP) serum levels. Mean survival in these suramin-responsive patients was 495 days. Two of these patients experienced a remarkable reduction of metastases in bone scan examinations. Another 48% of the patients (10 of 21) had essentially unchanged AP and PSA serum levels during suramin treatment, indicating stable disease. Mean survival of these patients was 341 days. In 4 patients undergoing suramin treatment, continuous clinical progression of the disease was observed (mean survival 79 days). Toxicity was less or comparable to prior reported studies; the most common side effects were polyneuropathy, allergic skin rash, and vortex keratopathy. CONCLUSIONS Suramin has limited, but significant, efficacy even in chemotherapy- and hormone-refractory prostate cancer, without serious toxicity.