Biomedical subjects
Publications and source records attributed to J Flamm.
A distinction is made between stenosis of the vesical cervix and a layered stricture. No aetiological parameter is certain. Besides uroflow, miction cystourethrography (MCU is of diagnostic importance. The aim of treatment is to restore a urodynamically active elastic posterior urethra. TUR and sphincterotomy are the methods of choice.
136 patients with carcinoma of the bladder were followed up after cystectomy and ileal conduit (n = 50), and TUR with post-operative irradiation (n = 86) with betatron (n = 35) or telecobalt (n = 51). The 3-year survival rate after cystectomy was 40% for all stages, the early mortality rate was around 14%. The complication rate was 16%. In the second half the survival rate was improved to 69.2% and the early mortality rate was lowered to 7.9%. After TUR and irradiation the 3-year survival rate was 48% for all stages, whereby 41% of the survivors or 20% of all patients had no further recurrence of tumours. Understaging with questionable removal in the healthy person and high persistence and recurrence are the methodic limits to TUR; a high early mortality rate and secondary late complications are the burden of cystectomy, besides psychological factors. Indications and results are discussed on the basis of the literature and an individual approach is recommended.
From 1969 to 1977 117 patients with malignant kidney tumours were treated. Because of the slow tumour growth, the absence of early symptoms, the uncharacteristic clinical picture and a case history of long duration most of the tumours were in a very advanced stage. Only 69 patients (58.9%) were qualified for tumour-nephrectomy. The five years survival rate was 49%. An improvement of these unsatisfactory results can be achieved only if the diagnosis is made as early as possible and if adequate surgical treatment is ensured. As far as possible excretory urography should be indicated as a real screening method. Angiographic analysis and surgical treatment by transperitoneal radical tumour-nephrectomy are the methods of choice.
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45 patients with urothel cancer of the bladder were examined clinically and immunologically and treated after transurethral resection with intravesical application of BCG as active unspecific immune therapy. The results of immunological cutaneous tests and the grade of peritumoral infiltration with immune competent cells were compared with histological grading and staging of the tumour. No significant relation between the results could be found. In a 2.5 years follow-up period a persistent tumour was found in 36% and a recurrence of the tumour in 59% of the patients. The intravesical instillation of BCG did not improve the prognosis. From the results of the immunological cutaneous tests together with the staging and grading of the tumour no reliable prediction of prognosis is possible.
The problems of diagnosis and treatment of avascular malignant tumour of the kidney are discussed on the basis of 5 cases. Attention is drawn to the importance of arteriography and to the need for operative exposure. In view of the possibility of false diagnosis during operation examination by means of immediate histological examination is recommended. Puncture is considered to be obsolete because of the danger of tumour cell dissemination.
32 patients whose condition was diagnosed as carcinoma of the urinary bladder were subjected to weekly intravesical instillation treatment with adriamycin for a period of 6 weeks after transurethral resection of the tumours. The oncolytic and thus recurrence-preventive value of treatment was determined by endoscopic controls with exploratory excisions. All in all a persistent tumour was found in 31% of the cases and a recurrence-free course in 69% over a minimum observation period of 1 year. These results are definitely better than those for comparable instillation treatments with surface-active or immunologically active substances.
In the urological department of the Wilhelminenspital altogether 22 patients with incurable bone pains in metastasizing carcinoma were treated with radioisotopes between 1976 and 1980. 32P and 89Sr were used in a dosage of 3 times 3 mCi and once 1 mCi. A reaction to the therapy could be proved in 46%, in 23% the success could be estimated as very good. Clinic and therapy were discussed with the help of own cases and literature.
The authors investigated the histological findings in various embolization materials and at various interval before operation in 11 hypernephroid renal carcinoma patients who had been subjected to a preoperative transfemoral catheter embolization of the renal artery. The embolization materials used were fibrin-thrombin, pieces of gelatine sponge, collagen and GAW-spirals. The periods at which nephrectomy was carried out ranged from immediately after the embolization to six weeks later. From the histological point of view, total necrosis of the tumour did not occur in any case; only in three cases could a subtotal necrosis be achieved and in all the other cases the tumour-free parenchyma showed greater damage as a result of more pronounced ischemic infarction than did the tumour. A complete and lasting elimination of a tumourous kidney cannot be achieved by embolization of the renal artery. The obvious reasons for this are the tendency towards recurrence of canalization and the formation of collateral circulation.
On the basis of three years of observation of 48 patients with histologically verified carcinoma of the bladder, a correlation was established between the immune profile (DNCB-test) and the clinical stage. Whereas in early stages of the tumour no correlation could be found between the results of the skin test and the subsequent development of the disease, in invasive advanced carcinoma the prognostic aspect was more favourable when the results of the DNCB-test was positive. The indication for radical cystectomy can be supported by the results of the DNCB-test in addition to staging and grading. Infiltrative growth and negative DNCB-test are indications for cystectomy, whereas a positive immune status seems to justify a observant attitude and endoscopic controls.
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On the basis of 51 patients with a hypernephroid renal carcinoma the prognostic importance of the size of the tumour, of the infraction into the renal hollow system, the invasion of lymphatic and vascular system as well as of the border of the organ after tumour nephrectomy and a 5-year observation time was discussed. While the isolated infraction into the hollow system was not relevant in smaller tumours, it implies an additional prognostically negative factor in advanced tumours. In the same measure the invasion of renal capsule or perihilary tissue resulted in a prognostically negative factor. Invasion of blood or lymphatic vessels proved to be very bad prognostically and resulted in a decrease of the survival rate of about 2/3. The prognostically worst hint was the simultaneous infraction into various systems with a decrease of the survival rate of more than 3/4.
Report on 38 patients with uroepithelial tumours of the urinary tract treated between 1969 and 1977. In 38% of the cases multiple tumours were found. The clinical parameters and diagnostic problems are discussed by means of case reports, pathology and possibilities of treatment are discussed on the basis of the own cases and the literature. In order to achieve the most favourable prognosis in this type of malignant tumour it will be necessary to be more radical in treatment and more intensive in controls after treatment and to subject the high risk groups more frequent check-ups.
A comprehensive clinical and immunological examination was carried out in 32 patients with a condition diagnosed as kidney tumour. The immune status was investigated by in vivo determination of the delayed-type immune reaction by means of cutaneous reactions to primary and recall antigens. The possibilities of differential diagnosis and the value of the individual examinations are discussed from the clinical point of view. Particular importance is attached to angiography and it is pointed out that the first step should always be standard radiography of the aorta suspected because of the pathological vascular structure. On account of the possibility of radiological and clinical masking of renal tumours surgical exposure is recommend if there is the slightest uncertainty. Immunological parameters are not reliable in early and differential diagnosis, since a significant reduction of immunizability does occur in the case of tumours. This phenomenon becomes significant only in patients advanced tumour growth and progressive formation of metastasis.
Between 1966 and 1976 106 ureter reimplantations were performed in 94 patients. Subsequent checks in 48 patients with 53 reimplants showed good results in 39 cases (73.5%). In 5 cases the results were moderately good (9.4%) and in 9 cases (16.9%) poor. Since there was found insufficient correlation between infection and reflux direct reimplantation and/or plastic surgery of the flaps is recommended for the reconstruction operation.
63 patients with multiple sclerosis underwent urodynamic evaluation. Hyperreflexia of the bladder was found in 64% and areflexia in 8%. Hypertrophy or sclerosis of the bladder neck (internal sphincter) was detected in 27% of the patients and a spastic external sphincter (dyssynergia) was encountered in 57%. 16 patients were admitted for surgery: 9 for TUR of the bladder neck, 5 for percutaneous selective sacral nerve block, 2 for ileal diversion, 2 for prolonged bladder distension and 1 for nephrectomy for staghorn calculi of the renal pelvis. Highly effective conservative therapy is available in the form of Lioresal for treatment of the hyperactive detrusor muscle and Dibenzyran - an alpha-adrenergic blocking agent - to relieve bladder neck spasticity.
On the basis of a specific case and of references, the problems concerning the symptoms, diagnoses and the therapy of the Prune-Belly syndrome are presented. The importance of a urodynamic check-up prior to surgical measures is underlined. Due to the many combinations of malfunctions and the lack of sexual specification, it seems preferable to consider mesenchymal dysplasia as the focal point of interest rather than the abdominal muscle defecite--uromalformation--kryptorchism--triad. In view of the high chances of infection, a conservative approach seems advisable, although the possibilities of active measures with due consideration of certain urodynamic parameters are also presented.
On the basis of 4 cases with inoperable hypernephroma the possibilities of the transfemoral catheter embolisation with the GAW-spiral are discussed. Simplicity of the technique and advantages in comparison to the material embolisation methods are discussed. The case in question was in 2 patients a primary embolisation, in 2 patients a secondary one with recanalised material embolisation. Up to now the patients were controlled over 3 months after the vascular occlusion. A recanalisation could not be observed, rather by total occlusion a tendency to the formation of collateral circulations.