Kai Uwe Köhrmann

ORGAN SPARING SURGERY FOR MALIGNANT GERM CELL TUMOR OF THE TESTIS

PURPOSE We evaluate the indication, technique and long-term outcome of organ preserving tumor resection rather than standard orchiectomy in 73 patients with bilateral testicular germ cell tumors or tumors of a solitary testicle. MATERIALS AND METHODS Tumor resection was performed in 73 patients with 52 and 17 metachronous and synchronous bilateral testicular germ cell tumors, respectively, and 4 testicular germ cell tumors of a solitary testicle. Histology of the enucleated germ cell tumor revealed seminoma in 42 (57.5%) patients, embryonal carcinoma in 14 (19.2%), mature teratoma in 11 (15.1%), and mixed and combined germ cell tumors in 6 (8.2%). Mean tumor diameter was 15 mm. (range 5 to 30). Associated testicular intraepithelial neoplasia was diagnosed in 82% of patients who underwent local radiation with 18 Gy. RESULTS After a median followup of 91 months (range 3 to 191) 72 (98.6%) patients had no evidence of disease and 1 died of systemic tumor progression. No local relapse occurred in 46 patients with associated testicular intraepithelial neoplasia treated with local radiation. However, local recurrence did develop in 4 patients after 3, 6, 12 and 165 months without radiation but all survived after undergoing inguinal orchiectomy. Testosterone levels were normal in 62 (84.9%) patients, hypogonadism developed in 7 (9.6%) and preoperative levels remained low in 4 (5.5%). Of the 10 patients who postponed local radiation for paternity reasons 5 had successfully fathered a child after organ sparing surgery. CONCLUSIONS After a long-term followup of greater than 7 years organ sparing surgery represents a viable therapeutic approach to bilateral testicular germ cell tumor with an excellent postoperative outcome. Tumor enucleation might be considered a standard approach if the guidelines are respected, including cold ischemia, organ confined tumor less than 20 mm., multiple biopsies of the tumor bed, adjuvant local irradiation postoperatively to avoid local recurrence, close followup and high compliance.

Shock Wave Technology and Application: An Update §

CONTEXT The introduction of new lithotripters has increased problems associated with shock wave application. Recent studies concerning mechanisms of stone disintegration, shock wave focusing, coupling, and application have appeared that may address some of these problems. OBJECTIVE To present a consensus with respect to the physics and techniques used by urologists, physicists, and representatives of European lithotripter companies. EVIDENCE ACQUISITION We reviewed recent literature (PubMed, Embase, Medline) that focused on the physics of shock waves, theories of stone disintegration, and studies on optimising shock wave application. In addition, we used relevant information from a consensus meeting of the German Society of Shock Wave Lithotripsy. EVIDENCE SYNTHESIS Besides established mechanisms describing initial fragmentation (tear and shear forces, spallation, cavitation, quasi-static squeezing), the model of dynamic squeezing offers new insight in stone comminution. Manufacturers have modified sources to either enlarge the focal zone or offer different focal sizes. The efficacy of extracorporeal shock wave lithotripsy (ESWL) can be increased by lowering the pulse rate to 60-80 shock waves/min and by ramping the shock wave energy. With the water cushion, the quality of coupling has become a critical factor that depends on the amount, viscosity, and temperature of the gel. Fluoroscopy time can be reduced by automated localisation or the use of optical and acoustic tracking systems. There is a trend towards larger focal zones and lower shock wave pressures. CONCLUSIONS New theories for stone disintegration favour the use of shock wave sources with larger focal zones. Use of slower pulse rates, ramping strategies, and adequate coupling of the shock wave head can significantly increase the efficacy and safety of ESWL.

PERCUTANEOUS NEPHROSTOMY VERSUS URETERAL STENTS FOR DIVERSION OF HYDRONEPHROSIS CAUSED BY STONES: A PROSPECTIVE, RANDOMIZED CLINICAL TRIAL

PURPOSE Urinary diversion with percutaneous nephrostomy or ureteral stent is indicated by symptoms, such as persistent colic, high temperature and uremia, of hydronephrosis caused by stones. We evaluate which of these 2 methods is superior concerning the course of procedure, relief of accompanying symptoms and quality of life in regard to patient age and sex. MATERIALS AND METHODS A total of 40 patients with stone induced hydronephrosis were randomized into either percutaneous nephrostomy or stent insertion groups. These patients were then evaluated by procedure (use of analgesics, x-ray exposure, success of insertion), relief of accompanying symptoms (duration of diversion, intravenous administration of antibiotics for high temperature) and quality of life (questionnaire immediately and 2 to 4 weeks postoperatively). RESULTS Two comparable groups of patients were formed, with an average age of 55 versus 49 years and a male-to-female ratio of 12:8 versus 9:11 for those who underwent percutaneous nephrostomy versus those who received a stent, respectively. Percutaneous nephrostomy was successfully completed in 100% of patients and stents were successful in 80%, with a 20% conversion to percutaneous nephrostomy. The x-ray exposure was shorter in the percutaneous nephrostomy group (p = 0.052). Administration of analgesics was more frequent in the stent group (p = 0.061). Percutaneous nephrostomy indwelling time was shorter (50% less than 2 weeks) than that of stents (25% less than 2 weeks, p = 0.043). Antibiotics were administered for greater than 5 days in 0% of patients who underwent percutaneous nephrostomy versus 64% in those with stents (p = 0.174). Reduction in quality of life was moderate but more pronounced in patients with stents compared to those who underwent percutaneous nephrostomy, and was more distinct in males and younger patients. The quality of life progressively improved in the course of diversion with percutaneous nephrostomy but deteriorated with stents. CONCLUSIONS Our results demonstrated that percutaneous nephrostomy is superior to ureteral stents for diversion of hydronephrosis caused by stones, especially in patients with a high temperature, as well as in males and juveniles.

Extracorporeally induced ablation of renal tissue by high-intensity focused ultrasound

Authors from Germany describe the use of percutaneously applied high‐intensity focused ultrasound for non‐invasive tissue ablation. They found that the lessons they learned from the use of this technology in animals could be transferred to its use in humans, both of which are described. They indicate that refinements in the technology are essential before this treatment can be used outside the departmental stage.

Flexible ureterorenoscopy for the treatment of lower pole calyx stones: influence of different lithotripsy probes and stone extraction tools on scope deflection and irrigation flow.

The 7.5 and 9.0 F flexible ureterorenoscopes are used widely in endourology. These scopes, along with new available tools and probes, enable intrarenal ureteroscopic access to renal stones in the lower pole. Following individual clinical experiences the infundibulopelvic angle has to be respected for the selection of different scopes, tools and probes. The aim of this study was to determine the influence of different scopes, tools and probes on the angle of the active and passive flexion of the flexible ureterorenoscope. The angles of the active and passive flexion and maximum irrigation flow of different flexible ureterorenoscope (9.0 F Wolf, 7.5 F Olympus, 7.5 F Storz) were measured repeatedly in vitro using nine different inserted tools and/or probes. In addition, the maximum allowing for easy passage of the nine different tools/probes through the channel of the scope were measured. The Olympus scope without working instrument present, allows for the greatest deflection. The flexible Lithoclast, the non-nitinol baskets, and the 365 microns laser probes significantly inhibit the deflection of all scopes. The greatest deflection with inserted working tool was possible using the Wolf and Storz scopes. Both nitinol tools as well as the 200 microns laser probe had only minimal influence on the deflection. The 200 microns laser probe reduces the irrigation flow from 50 to 28 ml/min. In contrast, the baskets reduce the irrigation flow from 50 to 2 ml/min. There are significant differences of the active and passive flexion depending on the ureterorenoscopes itself and the different tools. In order to perform a successful flexible ureterorenoscopic stone treatment in the lower pole, the inhibition of the flexion of the different scopes together with the individual infundibulopelvic angle must be respected when selecting different tools and probes.

Measurement of Renal Anatomy for Prediction of Lower-Pole Caliceal Stone Clearance: Reproducibility of Different Parameters

BACKGROUND AND PURPOSE The architecture of the lower renal pole seems to have a considerable influence on caliceal stone clearance after different therapeutic modalities. The published data are partially inconsistent, and publications on reproducibility are completely lacking. The aim of this study was to evaluate the intraobserver and interobserver reproducibility of different measures of lower-calix anatomy. MATERIALS AND METHODS We studied the intraobserver and interobserver reproducibility of parameters describing the lower-pole anatomy that are significant for treatment outcome. Forty renal units without urologic disease were analyzed by five independent urologists. Infundibular length (IL), infundibular width (IW), and lower infundibulopelvic angles (LIP) were measured by the Elbahnasy (LIP I), Keeley (LIP II), and Gupta (LIP III and LIP IV) methods. Statistical analysis of each parameter and investigator was performed. RESULTS All LIP angles showed low interobserver correspondence: correlation coefficients (CC) did not exceed 0.44 (P < 0.05). Even the relatively clearly defined parameters IW and IL achieved CCs of only 0.63 and 0.49, respectively. The intraobserver correlation achieved better results: 0.73 (LIP I), 0.84 (LIP II), 0.73 (LIP III), 0.65 (LIP IV), 0.88 (IL), and 0.82 (IW). With the Elbahnasy method, almost all renal units were classified as favorable for stone persistence after shockwave lithotripsy. With the Keeley and Gupta methods, more than 50% of the kidneys were defined as having low clearance probability. CONCLUSIONS Assessment of the chosen parameters is difficult and shows high interobserver variation. Inexperience in measuring the specific angles and low imaging quality can limit correct evaluation. The large number of kidneys with anatomy inappropriate for clearance of lower-pole stones may explain the poor outcome of shockwave treatment for stones in a lower calix. Prospective studies will determine the clinical value of anatomic assessments.

Objective and Subjective Changes in Patients with Peyronie's Disease after Management with Shockwave Therapy

BACKGROUND AND PURPOSE Very few reports have been published on the management of Peyronies disease by shockwave therapy. Existing publications on this topic are based on subjective improvement described by the patients themselves. Our aim was to determine objectively the effect of shockwave therapy on the signs and symptoms caused by Peyronies disease. PATIENTS AND METHODS To date, 65 patients (age 58.4 +/- 8.7 years) have been enrolled in a therapeutic pilot study. The disease duration was 33.7 +/- 42.9 months. Inclusion criteria were palpable plaque together with deviation, pain (visual pain scale), or loss of distal rigidity. Clinical examination (prior to first therapy and 1, 6, and 18 months after last shockwave delivery) included palpation and sonography of the plaque (mean surface size 2.2 +/- 1.1 cm(2)), measurement of deviation, assessment of pain and distal loss of rigidity (artificial erection induced by intracavernosal injection of 5 microg of alprostadil [Caverject]). Shockwaves (1,000 impulses at 12 kV per square centimeter of plaque) were delivered to the nonerect penis once a week for a period of 5 weeks with the Minilith; Storz Medical. RESULTS Eighteen months (N = 35) after the last shockwave session, the deviation angle had decreased from 59.3 degrees +/- 38.1 degrees to 49.3 degrees +/- 32.5 degrees (N = 24; P = 0.1496). Pain during erection disappeared in 15 of 17 patients and was reduced in 1 other patient (P < 0.0001). There was no effect on distal rigidity in any patient. Six patients achieved satisfactory sexual intercourse (vaginal penetration) before and 15 patients after shockwave therapy. The adverse effects were small skin hematomas in 90% of patients and initial transient macrohematuria in 30%. CONCLUSION Our study demonstrates objective and subjective changes in patients with Peyronies disease after shockwave therapy. Artificial erection served as a control to assess improvement of the deviation angle.

ESWL, including imaging

More than 10 years after its clinical introduction, extracorporeal shock-wave lithotripsy (ESWL) has proved to be the safest treatment modality for most urinary calculi. After careful preparation, even patients with severe coagulation disorders can be treated by ESWL. Shock-wave lithotripsy for small symptomatic renal stones resulted in a disintegration rate of 84%, a stone-free rate of 50% and a complaint-free rate of 52%. A 50% chance of success may justify ESWL treatment as initial approach for stones in caliceal diverticula. A 70% stone-free rate was reported for stone-bearing horseshoe kidneys, but the recurrence rate was 29%. In the case of nephrocalcinosis in medullary sponge kidneys, the pain-free application of shock waves is a major advantage because multiple sessions are necessary together with medical treatment. The use of indwelling stents has contributed to the extension of indication for ESWL monotherapy, even for staghorn calculi, because acute morbidity is reduced. Double-J stents, however, do not improve the stone-free rate and special attention should be paid to stent morbidity. Depending on stone localization, post-ESWL long-term stone-free rates are 58–84% with a recurrence rate of 6–20% after 2–4 years. The main features of third generation lithotriptors are a combined localization system allowing interdisciplinary lithotripsy and integration of the shock-wave source in an endoscopic treatment table for multifunctional use.

Comparative Investigations on the Retrieval Capabilities of Various Baskets and Graspers in Four Ex Vivo Models

OBJECTIVES The increasing application of ureterorenoscopy for the treatment of urolithiasis has produced a myriad of different help-tools for stone retrieval. In this study, we compared the retrieval capabilities of different baskets and graspers in ex vivo models and attempted to find the most appropriate tool for stone extraction considering the location and size of stone, number of stones and potential harm to urinary tract tissue. METHODS We created four different ex vivo models with porcine kidneys and ureters and natural human stones: (1) single ureteral stone (4mm); (2) single impacted ureteral stone (6mm); (3) Steinstrasse; (4) single lower-pole stone (5mm). With the aid of four baskets of different design (flat-wire basket Segura and Nitinol basket Zerotip, helical Gemini, and Parachute) and three graspers (two-prong, three-prong Tricep, and Nitinol grasper Graspit) we performed repeated stone extraction 10 times in each model. The time for complete stone removal was calculated. Macroscopical evaluation of tissue damage was performed after each series. In the Steinstrasse model the frequency of instrument reinsertion into the ureter was also calculated. RESULTS In the single ureteral stone model, the fastest stone removal was achieved with the two-prong graspers, three-prong graspers and helical basket (20, 26 and 31s, respectively). Segura and Parachute needed more time (55 and 86s, respectively). Impacted stones were removed fastest with the two- and three-prong graspers (38 and 52s, respectively), Segura and Gemini were slower (89 and 114s, respectively). The Steinstrasse was cleared fastest by the helical basket with the lowest frequency of endoscope reinsertion (66s, 1.4 reinsertion). The Segura, 149s with 3.2 reinsertion was needed for the same procedure. With the Parachute and two-prong graspers 163s, 1.8 reinsertion and 261s, 4.6 reinsertion were needed, respectively. During postprocedural macroscopical evaluation of uretral tissue, the Parachute basket and three-prong graspers demonstrated the highest risk of mucosal and muscle damage. In the lower-pole kidney model, the poor deflectability of the ureterorenoscope prevented access to the lower-pole with the two- and three-prong graspers. There was no significant difference in stone retrieval time between the remaining Nitinol basket Zerotip and Nitinol grasper Graspit (87 and 61s, respectively ). The number of failures was 4/10 for Zerotip and 5/10 for Graspit. No significant mucosal damage was noted with these tools. CONCLUSIONS Our ex vivo models demonstrated that the design of graspers and baskets affects the time of stone retrieval in different situations and causes the various grades of tissue damage.

Update on contact lithotripsy.

Despite the development of extracorporeal shockwave lithotripsy, endoscopic stone removal, with or without intracorporeal lithotripsy, is still an effective minimally invasive alternative for special indications. There is no defined all-purpose lithotripsy procedure for contact lithotripsy. The choice of the lithotripsy procedure for endoscopic stone disintegration depends on a number of different factors, the main one being stone localization. Small calibre, flexible probes (electrohydraulic, pneumatic, laser) are especially appropriate for ureterorenoscopy, but the speed of stone disintegration is a limiting factor. In contrast, large calibre rigid probes (ultrasound) are clearly more effective, but are unsuitable in size for flexible ureterorenoscopy. This indicates that the type and size of the endoscope decisively influences the choice of devices for endoscopic stone disintegration. Additional inhibiting factors are the flexibility or the rigidity of the instrument and the diameter of the working channel. It must be noted that total costs are not only calculated on the purchase of the equipment, but must also cover disposable materials.