Biomedical subjects
R Hohenfellner
Publications and source records attributed to R Hohenfellner.
New generation shock wave lithotripsy.
Extracorporeal shock wave lithotripsy has been clinically successful for more than 5 years. Currently, several devices commonly termed second generation lithotriptors are under experimental or clinical trials. We present a prototype multifunctional urological table that uses a new mode of shock wave generation along with local coupling to the patient. The results of the first 400 treatments are presented after a brief description of pre-clinical experiments. The prototype has been in operation since March 1986. Particular attention is paid to adjuvant endourological measures, which all have been performed on the same table.
[The ileocecal vagina].
In 3 patients with vaginal aplasia respectively traumatic vaginal loss a neovagina was created out of the separated ileocecal segment. Advantages of this technique are the excellent blood supply of the ileocecal region and the long vascular pedicle. The additional application of terminal ileum for prolongation of the cecal vaginoplasty allows the tensionless anastomosis between neovagina and vulva even in patients with difficult anatomical conditions. The present paper gives a detailed description of the operative technique and the indications of the ileocecal vaginoplasty. Furthermore the common techniques for vaginal replacement are reviewed and discussed.
Microvascular changes in the early stage of reflux pyelonephritis. An experimental study in the pig kidney.
Renal microvascular changes were studied in the pig kidney during the initial stage of reflux pyelonephritis. In 10 piglets vesicoureteric reflux was surgically induced. The animals were then infected with a strain of Escherichia coli and sacrificed 2 weeks following the initiation of infection. Following injection of the kidneys with Microfil, microvascular changes were investigated by a combined stereomicroscopic, microradiographic and histological technique. Renal microcirculation was found to be impaired in the areas involved in the acute inflammatory process, owing to the compression of glomeruli, small peritubular capillaries and vasa rectae by the ensuing interstitial oedema. These findings indicate that acute focal ischaemia caused by microvascular obstruction could be an important factor in the mechanism of renal damage in reflux pyelonephritis.
Immunoperoxidase staining of fine-needle aspiration biopsies of renal cell carcinoma using tumor-specific monoclonal antibody.
In 30 nephrectomy specimens, fine needle aspiration biopsies (FNAB) were performed both in the tumor and in the macroscopically normal part of the kidney: 18 were well differentiated renal cell carcinoma (RCC), 6 were moderately differentiated RCC, 4 were poorly differentiated RCC, and 2 were oncocytomas. FNAB was also performed in a bone metastasis of RCC. FNAB materials were stained using the immunoperoxidase method with RCC-specific monoclonal antibody and were compared with the staining of frozen sections. In all cases where tumor-antigen expression could be demonstrated in the frozen sections, a FNAB had already proven positive. There were only 2 false-negative cases where sufficient cellular material could not be obtained due to extensive tumor necrosis. There was no false-positive case. Oncocytomas showed no expression of antigen. The use of immunoperoxidase staining of FNAB with tumor-specific monoclonal antibody is discussed.
Radical cystectomy--often too late?
From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.
[Plastic surgical correction of megaureter].
Between 1967 and 1986 185 children (246 renoureteral units) and 21 adults (25 renoureteral units) with megaureters have been treated surgically in our department. 85 of the children had primary obstructive megaureters, 77 children showed secondary megaureters, whereas 23 others showed either a gross ureteral dilatation due to an ureterocele or gross reflux. All of the adult patients presented with primary obstructive megaureters. 122 children (65.9%) and 15 adults (71.4%) underwent ureterocystoneostomy (UCN) using various techniques, the Psoas Hitch technique being exclusively the method of choice since 1977 with markedly better results. The indication for ureteral tapering was considered extremely conservatively. In the rest of the patients the elimination of the infravesical obstruction alone was sufficient or a nephrectomy/nephroureterectomy had to be performed due to a non-functioning kidney. The percentage of UCN in primary obstructive megaureters throughout the years (79% in 1967-1971 and 63% in 1977-1986) and its significant decrease in secondary megaureters from 71% to 39% during the same time period displays the conceptional changes in the therapy regimen. The majority of children and adults with primary obstructive megaureters can be treated conservatively. UCN should be indicated for cases with synchronous reflux and/or recurrent febrile urinary tract infections. The indication for ureteral tapering should be considered very carefully. Especially in secondary megaureters the indication for ureteral tapering and reimplantation is rare since the adequate relief of the infravesical obstruction may be sufficient alone in many of the cases.
[Extracorporeal shockwave lithotripsy of gallstones. Results and perspectives].
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The Mainz pouch for augmentation or substitution of the bladder and continent diversion.
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[Local shockwave lithotripsy with a second-generation lithotriptor].
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The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion.
The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.
Coincident vesical transitional cell carcinoma and prostatic carcinoma. Clinical features and treatment.
Twenty-two patients with vesical urothelial carcinoma associated with prostatic carcinoma were reviewed. They represented 1.5% of the bladder and prostatic tumours treated in our department within a 12-year period from 1968 to 1979. Their management included several treatment policies, based on the separate assessment of each tumour variant. For non-infiltrating bladder tumours, transurethral tumour resection was combined with hormonal treatment, external radiotherapy or resection of the prostate depending on the stage of the prostatic tumour. Radical cystoprostatectomy was performed for two cases of infiltrating bladder tumour with well localised prostatic tumours. A conservative primary approach seems justifiable in the management of double carcinoma of the bladder and prostate. The coincidence of bladder urothelial carcinoma and prostatic carcinoma per se is not an adverse prognostic factor; prognosis is more closely related to the pathological stage and grade of the bladder tumour. Cystoprostatectomy for patients with infiltrating bladder tumours could be curative, in selected cases, for the prostatic cancer as well.
Surgical techniques in invasive bladder cancer.
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[Diagnosis and operative therapy of vesico-renal reflux].
Detection and accurate grading of vesico-renal reflux is rendered difficult by the limited reliability of the different diagnostic procedures. Therapeutic decisions are therefore to a large extent influenced by the clinical situation. Properly performed antireflux surgery combines a high cure rate with a low complication rate.
[Clinical course and scar development in operated vesico-renal reflux in a long-term study].
62 patients (14 boys, 48 girls) representing 85 refluxive renal units (Grade 2-4) were investigated after successful operation for the development of further urinary tract infections (UTI) and renal scars (RS). The mean follow-up was 9.3 years. With the exception of one boy, none of the male patients developed any UTI or new RS. A similar result was obtained for about 45% of the girls. These two groups of patients presented with high-grade reflux before surgery. The remaining female patients (about 55%), however, presenting with lower-grade reflux before surgical treatment, developed further UTI as well as new RS despite surgical correction of their reflux. Investigations on the capacity of uroepithelial cells (UEC) to suppress bacterial growth revealed a deficient antibacterial effect of UEC in these patients. Such an UEC defect has also been shown in patients with asymptomatic bacteriuria. In conclusion, different reasons seem to be responsible for recurrent UTI and the development of RS in patients with reflux.
[Complications of the efferent urinary tract in gynecologic operations].
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Tumor-specific monoclonal antibodies for renal cell carcinoma.
Monoclonal antibodies, tumor-specific for renal cell carcinoma (RCC), were produced in Balb/C mice, hyperimmunized with tumor cell suspensions from a histological grade II tumor. Boosting with lectin-immobilized tumor-antigen rendered high yields of specific antibody-producing hybrids. Hybridoma supernatants were screened for specificity using a solid-phase enzyme-linked immunoassay. Testing in parallel for reactivity with tumor tissue and corresponding autologous normal kidney material, only those hybrids producing antibodies exclusively reactive with RCC were propagated, resulting in 4 stable, highly productive subclones. Using the immunoperoxidase staining technique, tissue sections from 97 different RCC specimens and corresponding normal kidneys were evaluated for reactivity with the monoclonal antibodies. Over 90% of RCC were strongly positive, whereas normal kidney tissue did not react. Other normal human organ sections, including pancreas, liver, lung, stomach, small intestine, spleen, lymph node, arteries, veins, skeletal muscle, heart, skin and fetal tissues were negative for tumor-associated antigens. Mucous substances and Panet's granular cells in colon mucosa showed nonspecific binding suppressible by addition of normal human serum. Adenocarcinoma of the stomach, colon, pancreas or breast did not demonstrate cross-reactivity with the antibodies to RCC. These monoclonal antibodies apparently recognize a tumor-associated antigen possibly specific for RCC. They could prove to be potent tools in the search for specific tumor markers applicable in the early diagnosis of the disease and immunotargeting cancer therapy.
The Mainz pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent urinary diversion.
A new technique for fashioning an ileocecal pouch, applicable for both bladder augmentation and continent urinary diversion, is described. A low pressure reservoir is achieved by antimesenteric longitudinal transsection of ileum and cecum and formation of a pouch from the cecum and two ileal loops. The antireflux procedure consists of submucosal tunnel implantation of the ureters into the cecum. Clinical application of the operative technique in 4 cases for bladder augmentation and in another 6 cases for urinary diversion has proven the validity of our functional concept: all patients with Mainz pouch bladder augmentation are completely dry day and night with normal intervals of bladder evacuation. Of the 6 patients with Mainz pouch urinary diversion, 2 rely on a an all alloplastic stomal prosthesis for continence, another 2 have achieved continence with isoperistaltic ileo-ileal invagination, and the remainder are awaiting implantation of a sphincteric device.