K.-H. Bichler

Urinary infection stones

Infection stones make up approximately 15% of urinary stone diseases and are thus an important group. These stones are composed of struvite and/or carbonate apatite. The basic precondition for the formation of infection stones is a urease positive urinary tract infection. Urease is necessary to split urea to ammonia and CO(2). As a result, ammonia ions can form and at the same time alkaline urine develops, both being preconditions for the formation of struvite and carbonate apatite crystals. When these crystals deposit themselves infection stones form. If these infections are not treated and the stones are not removed, the kidney will be damaged. For stone removal modern methods are available, e.g. ESWL and/or instrumental urinary stone removal. Here especially less invasive methods are preferable. Any treatment must be adjusted to the patient individually. Patients should be examined frequently for recurrent urinary tract infections and stone recurrences and, newly arising infections must be resolutely treated. Good therapy and prophylaxis are possible with present-day treatment modalities.

Minimally Invasive PCNL in Patients with Renal Pelvic and Calyceal Stones

Stones of the renal pelvis can be treated either by extracorporeal shock wave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). As a low–risk procedure with a longer treatment period, SWL often leads to persistent residual stone fragments, whereas conventional PCNL achieves a higher stone–free rate and allows a shorter treatment period albeit with a somewhat higher surgical risk. To reduce the invasiveness of conventional PCNL, the application of a miniaturised instrument for PCNL (MPCNL) was evaluated. For MPCNL a rigid nephroscope with a calibre of 12 F was developed and used in 19 patients. After puncture of the kidney under ultrasound control and single–step dilatation, a 15 F Amplatz sheath was placed. Data on the stone size and location, stone–free rate, blood transfusions, operating time and complications were recorded. In all patients, the part of the kidney afflicted by the stone was successfully punctured. On average, retreatment rate was 0.7. The mean stone size was 2.4 cm2. The average operating time was 99.2 min. In every case, the absence of residual stones was confirmed radiologically and nephroscopically. Hemorrhages requiring a blood transfusion did not occur. A febrile pyelonephritis occurred as a postoperative complication in one patient (= 5.3%). MPCNL represents an alternative to SWL for renal calculi with a size from 1 to 2 cm located in the renal pelvis and calices, especially the lower calix. The advantages are the short treatment time, the high stone–free rate and the accessibility of lower pole stones which are less amenable to SWL. MPCNL is not suitable for large concrements since the limited sheath diameter would increase the operating time. Due to this limitation, MPCNL represents an extension of the indication for conventional PCNL that it can in no way replace.

Melatonin and 6-sulfatoxymelatonin circadian rhythms in serum and urine of primary prostate cancer patients: Evidence for reduced pineal activity and relevance of urinary determinations

The circadian rhythms of melatonin and 6-sulfatoxymelatonin (aMT6s) were analyzed in serum and urine of young men (YM, n = 8), of elderly patients with benign prostatic hyperplasia (BPH, n = 7) and of patients of similar age with primary prostate cancer (PC, n = 9). The data expressed as concentration and in urine also as hourly excreted quantity were analyzed chronobiologically by the single cosinor method and, subsequently submitted to linear regression analyses. Circadian rhythms were detected in all cases except for the excreted quantity of melatonin. The circadian patterns of melatonin and aMT6s in serum were very similar in the different groups and regression analyses showed close correlations between both variables. MESOR and amplitude were significantly depressed in PC (40-60%) as compared to BPH and YM indicating that the depression of serum melatonin in PC is due to a reduced pineal activity and is not caused by an enhanced metabolic degradation in the liver. Acrophases of serum melatonin occurred between 01:34 and 03:26 h and of serum aMT6s between 03:58 and 04:35 h. Circadian rhythms similar to those of serum melatonin and aMT6s were found in urine, particularly for aMT6s excretion as well as melatonin concentration; the determination of both parameters in overnight urine samples closely correlated with the nocturnal peak of circulating melatonin. These results imply that it is feasible to estimate changes in pineal function of prostate cancer patients by means of non-invasive determination using urinary melatonin and aMT6s.

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.

Schistosomiasis: a critical review.

Precise data on epidemiology, morbidity, post-treatment resolution, reinfection, and resurgence of schistosomiasis could be helpful in establishing purposeful treatment plans for the disease in endemic populations. Here we give a concise overview of recent publications on bilharziasis. A main emphasis is placed on studies on the prevalence of schistosomiasis, partly including long term surveillance of morbidity following treatment with praziquantel. As genito-urinary schistosomiasis may be a risk factor for the spread of HIV, the involvement of the reproductive tract has become another focus in research on the disease. A novel diagnostic tool, eosinophil cationic protein (ECP), is proposed to correlate with the degree of inflammation of the genito-urinary tract.

Comparison of cytology and nuclear matrix protein 22 for the detection and follow-up of bladder cancer.

OBJECTIVES This study was designed to determine the clinical usefulness of the nuclear matrix METHODS 84 patients suffering from bladder cancer or suspected bladder cancer, 25 patients with benign urological lesions and 60 healthy controls participated in a prospective study. Freshly voided spot urine samples were taken for cytological examination and determination of NMP 22 levels by enzyme-linked immunoassay. RESULTS The sensitivity of the NMP 22 test according to the tumor grading was (results of cytology in brackets): G1 25.0% (20.0%); G2 68.2% (59.1%), and G3 100.0% (66.7); overall sensitivity was 62.5% (45.0%). The sensitivity for superficial bladder cancer was 46.7% (36.7%) and for invasive bladder cancer 90.0% (70.0%). The specificity was 65.9% (88.9%). CONCLUSIONS NMP 22 is a reliable tool for detecting invasive bladder cancer. Results for the frequently occurring low grade superficial bladder cancer are as poor as those obtained with cytology. In addition benign lesions such as urolithiasis or urinary tract infection lead to false-positive results. Therefore cystoscopy has to be performed when trying to detect and follow-up bladder cancer.

Guidelines for the perioperative prophylaxis in urological interventions of the urinary and male genital tract

Almost 50 years after its introduction, perioperative prophylaxis is still controversial. Whereas a clear benefit was established for certain surgical operations especially for those of the categories ‘clean-contaminated’ and ‘contaminated’, e.g. elective colonic surgery [1], there was no general consensus on the use of antibacterial prophylaxis for elective operations of the category ‘clean’. This is because studies including sufficient number of patients for meaningful statistical analysis are absent. Moreover, the traditional classification of surgical procedures according to Cruse [2] into ‘clean’, ‘clean-contaminated’, ‘contaminated’ and ‘dirty’ does not adequately describe the risk of infection. Numerous patients and surgical conditions, such as duration of operation, blood loss etc. have been demonstrated to correlate with risk of infection [3]. Such risk factors can also lead to infectious complications even in ‘clean’ operations [4]. The significance of each factor, however, is not yet quantified. This is especially true for open operations and endoscopic procedures in urology [5]. Prospective randomised studies are absent. Currently, most studies are poorly designed. The differentiation between therapy and prophylaxis is not clear. Evaluation of risk factors is unsatisfactory, and the terms ‘bacteriuria’ and ‘infection’ are not critically used [6]. In addition, many of these studies lack knowledge of pharmacokinetics and pharmacodynamics of the antimicrobial agents, bacterial pathogenicity and resistance, and the role of nosocomial infections [6,7]. It is thus not surprising that the literature is inconclusive in regard to prophylaxis, showing negative, as well as positive results for every type of urological intervention. A survey of 320 German urologists revealed controversial opinions about perioperative antibiotic prophylaxis [8]. Antibiotic prophylaxis was administered in more than half of the procedures involving the urinary tract, and most urologists used prophylaxis, when opening the intestine. There was, however, little agreement on the choice of antibiotics and the duration of prophylaxis. Consequently, guidelines for the indication of perioperative prophylaxis in urology are certainly necessary. In this paper, we present practical recommendations. These recommendations are based on clinical studies, expert opinion, and professional consensus. The common principles for perioperative prophylaxis (Table 1), a result of a consensus conference of the Paul Ehrlich Society for Chemotherapy [9], were also considered.

Collagen Fleece for Defect Coverage Following Plaque Excision in Patients with Peyronie’s Disease

Abstract Objectives: Surgical correction of penile deviation in patients with Peyronies disease by tunical plication often leads to shortening of the penis. It is, thus, recommendable to combine tunical plication with plaque incision or excision. The resulting tunical defect, however, requires grafting, and various techniques have been described. In comparison with tunical plication, all of these combined techniques are associated with increased operation time, mainly due to additional procedures necessary at the donor site, and may result in defects at the donor site. We here report a novel surgical technique by which tunical defects after partial excision of plaques are covered by a ready-to-use collagen fleece coated with tissue sealant (TachoComb ® ). Method: A prospective clinical observation trial was conducted in 19 patients with penile deviation due to Peyronies disease. Results: In all patients, a reliable closure of the Tunica albuginea was achieved, and no postoperative haematoma formation was observed. Postoperatively, none of the patients suffered from erectile dysfunction. During the follow-up period of 25 months, objective and subjective improvement was 83% and 72%, respectively. Conclusion: The present data indicate that this novel surgical technique may be of benefit in patients with Peyronies disease and should thus be further evaluated.

Limitation of shock-wave-induced renal tubular dysfunction by nifedipine.

In a prospective randomized study, the effects of the calcium entry blocker nifedipine on shock-wave-induced tubular impairment were studied. 24 patients with renal pelvic or calyceal stones undergoing anesthesia-free extra-corporeal shock wave lithotripsy (ESWL) without ancillary measures were randomly assigned to the nifedipine group (n = 12) or the control group (n = 12). Four doses of nifedipine (10 mg t.i.d.) were given orally, starting the night before ESWL. Controls received no medication. To assess renal tubular function, the urinary excretion of alpha 1-microglobulin (A1M), N-acetyl-beta-glucosaminidase (NAG) and Tamm-Horsfall protein (THP) were measured before, immediately, 12 and 24 h after ESWL. After lithotripsy, there was a rise in urinary A1M and NAG which was significantly higher in the control than in the nifedipine group. THP, a glycoprotein synthesized by distal tubular cells, fell significantly less in the nifedipine group compared to the controls. Our results indicate that nifedipine exhibits a protective effect on shock-wave-induced tubular damage similar to verapamil. The underlying mechanisms are not clarified yet, direct actions on tubular cells and interference with renal hemodynamics have to be discussed.