Continent urinary diversion in childhood: European experience.
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Bladder Exstrophy↗
Biomedical subjects
R Hohenfellner
Publications and source records attributed to R Hohenfellner.
Ureteropelvic junction obstruction in childhood.
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Child, Preschool↗
Conservative surgery of renal cell tumors in 140 patients: 21 years of experience.
Operative method, course and complications were analyzed retrospectively in 140 patients who underwent a conservative operation for renal tumor between June 1969 and December 1990. In 53 patients (20 women and 33 men, mean age 61.2 years, range 38 to 77 years, with 49 renal cell carcinomas and 4 benign renal tumors) there was an imperative indication for an organ preserving operation because nephrectomy would have made dialysis obligatory. In 87 patients (29 women and 58 men, mean age 53.7 years, range 27 to 74 years, with 72 renal cell carcinomas and 15 benign renal tumors) the tumor was conservatively resected in the presence of a normal contralateral unit (elective indication) and 68 of these patients (78%) were symptom-free. In the imperative group 32 of 49 patients (65.3%) with renal cell carcinoma had no evidence of disease after a mean followup of 4.6 years. Known metastases were present in 4 of 7 patients who died of the tumors in this group. In 3 patients with an imperative indication for conservative surgery a second tumor occurred in the kidney: 2 were treated with further parenchyma sparing operations, while in 1 with poor physical condition no further measures were possible. Of 72 patients with renal cell carcinoma who underwent an elective operation 68 (94.4%) had no signs of tumor progression after a mean followup of 3.3 years. One patient died of tumor metastases, and 2 (2.7%) had tumor recurrence in the kidney requiring nephrectomy and enucleation, respectively. The 5-year cause-specific survival rates for the imperative and elective groups were 84% and 96%, respectively. Patients with a local stage T3 tumor were characterized by a significantly worse survival curve than those with a stage T1 or T2 tumor but no significant difference was noted among the various grades of differentiation.
Adult↗
Advanced bladder cancer (stages pT3b, pT4a, pN1 and pN2): improved survival after radical cystectomy and 3 adjuvant cycles of chemotherapy. Results of a controlled prospective study.
A total of 49 bladder cancer patients with tumor stages pT3b, pT4a and/or pelvic lymph node involvement without microscopic or macroscopic evidence of residual tumor was randomized into 2 comparative groups: the chemotherapy group was to receive 3 adjuvant cycles of methotrexate, vinblastine and cisplatin plus doxorubicin (M-VAC) or epirubicin (M-VEC) after radical cystectomy. The control group received no additional treatment. The protocol was activated in May 1987. Patient recruitment was concluded in December 1990 because an interim analysis of the 49 randomized patients revealed a significant prognostic advantage in favor of 26 patients randomized to the chemotherapy group compared to 23 in the control group (p = 0.0015, log rank test for relapse-free survival curves). Of the 26 patients randomized for adjuvant chemotherapy 18 were treated with M-VAC or M-VEC (3 cycles in 16 patients and 2 cycles in 2). Of the remaining 8 patients 7 refused chemotherapy before or during cycle 1 and 1 received chemotherapy without cisplatin because of impaired renal function. An update of the patients in August 1991 revealed a further increase in the prognostic difference between the 2 trial arms (p = 0.0012). Of 18 patients who received treatment with M-VAC or M-VEC only 3 have had tumor progression to date compared to 18 of 23 patients in the control group. Further statistical analysis of the data was performed on the basis of Cox's regression model, incorporating various criteria as explanatory variables, including patient sex and age, pT stage and number of involved lymph nodes. This multivariate analysis revealed a significant decrease in the risk of tumor recurrence (p = 0.0007, 2-sided) after adjuvant chemotherapy. The number of lymph nodes involved was also of prognostic significance (p = 0.0028, 1-sided). The results indicate that the survival time after radical cystectomy can be prolonged considerably by adjuvant polychemotherapy in cases of locally advanced bladder carcinoma. Fortunately, all of these conclusions are not affected by switching from an intent-to-treat analysis to an analysis of the therapy actually performed. The p values obtained from the latter are 0.0005 (log rank test) and 0.0001 (Cox model with the same set of additional regressors).
Adult↗
The buccal mucosal graft for urethral reconstruction: a preliminary report.
Autologous buccal mucosa as a substitute for urethral epithelium was studied in 2 dogs and used in 6 patients with difficult urethral reconstruction problems. The indications for an operation in these patients were failed hypospadias repairs with limited skin in 3, severe structure disease after hypospadias repair in 1, a short urethra in 1 and epispadias in 1. Three urethral fistulas and 1 meatal stenosis occurred in 3 patients. No urethral stricture or diverticulum was noted, and the final outcome was good functionally and cosmetically in all patients. This technique is useful for urethral reconstruction when local skin is not available.
Adolescent↗
[MR tomography in testicular processes. The significance of Gd-DTPA enhanced sequences in comparison with plain T2-weighted sequences].
The value of T1-weighted sequences after intravenous administration of Gd-DTPA and of T2-weighted sequences was compared in 43 patients suspected of having scrotal abnormalities. T2-weighted sequences gave better demonstration of the tunica albuginea and better contrast between tumor and parenchyma. The two techniques were equally sensitive for demonstrating testicular tumors but orchitis was better demonstrated on the contrast enhanced sequences. Motion artifacts were less marked in the T1-weighted sequences with contrast enhancement. In selected cases, contrast enhancement may be a valuable addition to native protocols. Our experience has indicated that MRI provides specific findings in cases of orchitis which are clinically atypical; this facilitates the decision to conservative treatment and prevents unnecessary exploration of the testes.
Adolescent↗
[Cystic space-occupying lesions of the seminal vesicles. Their demonstration with MRT].
Between October 1990 and March 1991, 8 patients with cystic lesions in the region of the posterior bladder wall, the seminal vesicles and the prostate were examined by MRI. In all cases there was accurate characterisation of the lesion and of its anatomy. In 3 patients with abnormalities in the retrovesical space there was very good agreement with the operative findings. 4 patients were treated conservatively. In these patients there was good agreement with the findings on cystoscopy, CT and sonography.
Adult↗
Pediatric urinary diversion: review and own experience.
New insights into the diseases of childhood, profound improvements and new developments in surgical techniques as well as the knowledge gained from long-term follow-up have altered the strategies and indications for urinary diversion in childhood. Continent urinary diversion is generally the method of choice. We are able to construct high capacity, low pressure reservoirs to protect the upper urinary tract and achieve continence. Nowadays, there is hardly any indication for permanent cutaneous urinary diversion. Temporary and intermediate cutaneous diversion are used only when serious conditions such as renal function deterioration occur. The possibility to convert any incontinent form of urinary diversion into a continent form changed the status of intermediate diversion. The indications for urinary diversion, the procedures available, the operative technique, a literature review, our own experience, contemporary strategies and controversies are described and discussed.
Child↗
The appendix as a continence mechanism.
Although we have progressed very well in creating large capacity, low pressure reservoirs, the construction of a simple and reliable continent outlet still remains a problem. The appendix vermiformis serves well as a continence mechanism for either the bladder or intestinal reservoirs for urine. The different surgical techniques described in the literature are reviewed and discussed in this context. Moreover, we report on our clinical and experimental results of using the appendix during the Mainz pouch procedure for continent urinary diversion.
Adolescent↗
Extracorporeal shock wave lithotripsy with ultrasound-guided lithostar plus.
Since 1989, the Siemens lithostar plus, an upgrade of the lithostar with the ultrasonically guided overhead module, has been available for clinical use. This unit may be used for the treatment of either biliary or urinary calculi. We report on 75 patients with urinary calculi treated between March 1989 and June 1990 with the lithostar overhead module. Stone localization showed a rate of: caliceal stones 33.5%, pelvic stones 44%, upper ureteral stones 9.3% and lower ureter stones 13%. The overall disintegration rate was 86%, with a stone-free rate after 3 months of 78%.
Humans↗
[Pelvic multivisceral resection from the viewpoint of gynecology].
The pelvic exenteration procedure must be considered a multimodal therapeutic concept from a humanistic-medical point of view. Careful patient selection, radical resection of all tumor-infiltrated organs, complete interdisciplinary organ reconstruction, and optimal perioperative management including full psychosomatic rehabilitation are mandatory. This concept should only be realized in medical centers with highly sophisticated infrastructures.
Female↗
[The "Mainz pouch" technique (bladder augmentation with ileum and cecum) for bladder augmentation, bladder substitution, and continent urinary diversion].
Back in 1983 we created a continent urinary reservoir, called the MAINZ pouch, using 10 to 15 cm. of cecum as well as two terminal ileal segments of equal length. Following detubularization, the posterior wall of the pouch is established by anastomosis of the ascending colon with the terminal ileal loop starting at the inferior aspect. The latter is then anastomosed with the next proximal ileal segment. The ureters are implanted in an antirefluxive manner in the open end technique through a submucosal tunnel of 4 to 5 cm length. For bladder augmentation the pouch is anastomosed to the bladder remnant. For bladder substitution a buttonhole incision at the most inferior aspect of the cecal pole is placed or the appendix is used for end-to-end anastomosis to the membranous urethra. For continent diversion an additional 7 to 12 cm of ileum are isolated in order to create an ileal intussuscepted valve. Alternatively the appendix can be used. Continence is achieved by submucosal embedding of the appendix into the cecal pole. A total of 346 patients underwent the MAINZ pouch procedure in Mainz and Wuppertal; 56 for bladder augmentation, 49 for bladder substitution and 241 for continent urinary diversion. We encountered early complications in 29 of the 346 patients (8.38%). Late complications were observed in 72 patients (20.8%). The major complications we encountered were stone formation inside the pouch in 19 patients and stomal stenosis in 21. 54 of the 56 patients with a bladder augmentation are completely continent (mean follow-up: 50 months, range: 10 to 83 months). All of the 49 patients who received a bladder substitution after radical cystectomy are continent during daytime. Three of these patients who do not empty their bladder at regular four hour intervals have leakage during the night (follow-up: 23 to 69 months). The revision rate due to nipple gliding and subsequent incontinence could be greatly reduced by the use of staples for fixation of the ileal nipple and the use of the appendix. For correction of the most frequently occurring complications standardized techniques have been developed.
Cecum↗
Ureterosigmoidostomy: past, present and future.
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Adult↗
[Diagnosis and therapy of benign and malignant kidney tumors].
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Humans↗
[The clinical picture of renal cell carcinoma. The place of diagnostic imaging].
Surgery continues to be the only treatment of proven efficiency for renal cell carcinoma. Chemo- and radiotherapy must be regarded as ineffective. Antagonists of the multiple drug-resistance gene, which is responsible for the chemoresistance of renal cell carcinoma as well as immunotherapy, are new experimental approaches in the treatment of renal cell carcinoma. The broad use of ultrasonography as a screening method has led to an increase in the diagnosis of small, asymptomatic renal tumors. At present, almost 65% of the renal tumors referred for surgery at our institution are asymptomatic. We found parenchyma-sparing surgery to be adequate treatment for many of these tumors. Advanced stages of renal cell carcinoma, on the other hand, can be cured by ultra-radical surgery (e.g., tumor thrombectomy or metastasectomy) in a considerable percentage of patients, as long as diffuse distant metastases are absent. Utilization of a broad range of imaging techniques is mandatory to rule out diffuse dissemination when considering such an operation.
Carcinoma, Renal Cell↗
Seven years experience with the Mainz pouch procedure.
In 1983 we created a form of continent urinary diversion termed the Mainz pouch procedure utilizing cecum and ileum. For creation of the reservoir 10 to 15 cm of cecum and ascending colon as well as two terminal ileal segments of equal length are isolated and detubularized. The posterior wall of the pouch is completed by anastomosis of the ascending colon with the terminal ileal loop starting at the inferior aspect. The latter is then anastomosed with the next proximal ileal segment. The ureters are implanted in an antirefluxive manner in the open end technique through a submucosal tunnel of 4 to 5 cm of length. For bladder augmentation the pouch is anastomosed to the bladder remnant. For bladder substitution a buttonhole incision at the most inferior aspect of the cecal pole or the appendix is used for end-end anastomosis to the membrancus urethra. For continent diversion and additional 8 to 12 of ileum are isolated in order to create an ileal intussuscepted valve. Alternatively the appendix can be used. Continence is achieved by submucosal embedding of the appendix into the cecal pole. A total of 281 patients underwent the Mainz pouch procedure, 54 for bladder augmentation, 7 for bladder replacement and 200 for continent urinary diversion. We encountered early complications in 15 of the 281 patients (5.3%). Late complications were observed in 63 patients (22.4%). The major complications we encountered were stone formation inside the pouch in 17 patients and stomal stenosis in 19. Fifty-two of the 54 patients with a bladder augmentation are completely continent (mean follow-up: 50 months, range: 10 to 83 months). All of the 27 patients who received a bladder substitution after radical cystectomy are continent during daytime. Three of these patients who do not empty their bladder at regular four hour intervals have leakage during the night (follow-up: 23 to 69 months). The revision rate due to nipple gliding and subsequent incontinence could be greatly reduced by the use of staples for fixation of the ileal nipple and the use of the appendix. For correction of the most frequently occurring complications standardized techniques have been developed.
Cecum↗
Characterization of conservatively resected renal tumors using automated image analysis DNA cytometry.
The DNA histograms of 57 conservatively resected renal tumors were studied using automated image analysis DNA cytometry (Leytas II). Forty-nine of the analyzed tumors were renal cell carcinomas, six were oncocytomas, one was an angiomyolipoma, and one was a renal cell adenoma. On the basis of their DNA histograms, diploid, tetraploid, and aneuploid tumors could be distinguished. Aneuploid tumors could be subtyped further according to the DNA content of the stem cell line as hyperdiploid, hypertriploid, or hypertetraploid. Eight of the tumors were characterized by a combination of diploid and hypertriploid stem cell lines. During a mean follow-up of 5 years, only the two patients with a pure hypertriploid tumor died of distant metastases. These results indicate that automated DNA image analysis cytometry is able to differentiate among several types of renal tumors with obviously different prognoses.
Adenoma↗