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Hydronephrosis in infants and children is most commonly due to a congenital, intrinsic obstruction of the uretero-pelvic junction. The Gold standard of care is defined as a dismembered pyeloplasty, nowadays mostly performed in a minimally-invasive procedure, either through a laparoscopic (also robotic-assisted) or retroperitoneoscopic approach. Less common is an extrinsic obstruction of the ureter or the uretero-pelvic junction caused by an aberrant crossing pole vessel, a condition more likely to affect children beyond infancy. This entity most often becomes apparent when it causes intermittent abdominal or flank pain. For this entity, Hellström described a surgical procedure avoiding dismembered pyeloplasty by hitching the crossing vessel in a tunnel at the pyelon. This has been increasingly advocated as a valuable therapeutic alternative to dismembered pyeloplasty. The discussion on whether dismembered pyeloplasty or a vascular hitch procedure is preferable to resolve the obstruction is controversial and ongoing. There is evidence in the literature that in the case of a crossing pole vessel an intrinsic stenosis of the ureter may additionally be present in up to 57 % of cases. However, this finding can only be proven histologically. The intraoperative aspect of a crossing pole vessel and the uretero-pelvic junction does not serve to discriminate between intrinsic and extrinsic stenosis. Therefore, a vascular hitch procedure bears the risk that a remaining intrinsic obstruction will be disregarded, which, in turn, may lead to urodynamic obstruction and consecutive loss of differential renal function. In addition, there is a general risk of compromising the perfusion of the affected kidney while hitching an aberrant vessel providing significant blood supply. Dismembered pyeloplasty can avoid a false selection of patients. In addition, there is sufficient evidence showing that dismembered pyeloplasty is a procedure with a low complication rate ranging from 2 to 3 %, providing very good results in functional outcome in terms of improving drainage and preserving differential renal function. Therefore, we prefer dismembered pyeloplasty as the method of choice for both the treatment of intrinsic as well as extrinsic uretero-pelvic junction obstruction.Die Hydronephrose beim Kind ist zumeist bedingt durch eine (kongenitale) intrinsische Ureterabgangsstenose. Die von Anderson und Hynes etablierte „dismembered“ Nierenbeckenplastik stellt den Goldstandard in der operativen Therapie dar, sei es über einen offenen Zugang oder laparoskopisch (auch robotisch assistiert) bzw. retroperitoneoskopisch durchgeführt. Weniger häufig findet man – zumeist bei Patienten jenseits des Säuglingsalters − eine extrinsische Stenose als Ursache einer – dann zumeist – intermittierenden bzw. dynamischen Hydronephrose. Diese wird verursacht durch ein oder mehrere aberrierende Unterpolgefäße, welche den uretero-pelvinen Übergang obstruieren. Hierfür ist die operative Verlagerung des Gefäßes durch eine Tunnel-Plastik am Nierenbecken, die sog. „vascular hitch“-Operation, von Hellström beschrieben, in zunehmender Weise wieder etabliert worden. Die beiden Möglichkeiten der operativen Therapie werden nach wie vor kontrovers diskutiert. In der Literatur findet sich Evidenz dafür, dass bei Vorliegen eines Polgefäßes in bis zu 57 % zusätzlich eine intrinsische Stenose ist, in bis zu 100 % zumindest histologische Alterationen wie bei einer intrinsischen Stenose vorhanden sind. Der intraoperative Aspekt erlaubt keine Diskriminierung zwischen intrinsischer und extrinsischer Stenose, diese kann nur histologisch objektiviert werden. Bei der Durchführung eines „vascular hitch“ besteht daher das Risiko einer verbleibenden intrinsischen Stenose mit konsekutiver Abflussstörung und der Gefahr einer Partialfunktionsminderung. Auch kann durch den „vascular hitch“ selbst die Durchblutung der Niere kompromittiert werden. Die sog. „dismembered“ Nierenbeckenplastik vermeidet hingegen ein falsches Selektionieren der Patienten. Zudem ist sie mit hinreichender Evidenz belegt als ein Verfahren mit niedriger Komplikationsrate von 2 – 3 % und funktionell sehr guten Ergebnissen hinsichtlich des Erhalts der Partialfunktion und der Verbesserung der Abflussdynamik. Im Vergleich besteht in der Literatur kein vermehrtes Komplikationsrisiko gegenüber der „vascular hitch“-Operation. Daher bevorzugen wir die "dismembered" Nierenbeckenplastik als Methode der Wahl bei der Hydronephrose und dem Vorliegen eines aberrierenden Polgefäßes.

The vascular hitch procedure for pelviureteric junction obstruction caused by crossing lower-pole vessels is a controversial treatment option. Since this minimally-invasive technique has been introduced in patients with aberrant lower-pole vessels, multiple publications have reported successful short, intermediate and long-term outcomes. Success rates of 90 % are similar to those of Anderson-Hynes pyeloplasty. In general, an associated intrinsic stenosis seems to be rare. Histological evidence of muscular hypertrophy may simply indicate a compensatory mechanism and may be reversible to a certain degree. To differentiate between those patients who are eligible for a vascular hitch procedure and those who should receive an initial Anderson-Hynes pyeloplasty, an intraoperative diuretic test should be performed (volume bolus plus intravenous administration of furosemide). An associated intrinsic stenosis seems to be unlikely in a funnel-like and otherwise normal-looking pelviureteric junction, decreasing hydronephrosis after mobilisation of renal pelvis and crossing vessels and effective peristalsis of the renal pelvis after intraoperative diuretic testing. The vascular hitch technique is less demanding than laparoscopic Anderson-Hynes pyeloplasty and less time-consuming with regard to the duration of the surgical procedure and anaesthesia. Further advantages are: no risk of urinary leakage or anastomotic stricture and no need for intra-luminal stenting. Therefore, in a selected group of patients with solely extrinsic pelviureteric junction obstruction, the vascular hitch procedure is a valuable alternative to classic Anderson-Hynes pyeloplasty with seemingly long-term efficiency.Die Möglichkeit, eine durch aberrierende Unterpolgefäße bedingte subpelvine Stenose durch eine gefäßverlagernde Pyeloplastik (‚vascular hitch‘) zu behandeln, wird kontrovers diskutiert. Seit diese Technik bei Patienten mit aberrierenden Unterpolgefäßen minimal invasiv durchgeführt wird, mehren sich Publikationen mit kurz-, mittel- und langzeitiger Nachbeobachtung. Die Erfolgsraten werden hierbei analog zur Anderson-Hynes-Plastik mit 90 % angegeben. Insgesamt scheint eine assoziierte intrinsische Stenose selten zu sein. Eine histologisch nachweisbare muskuläre Hypertrophie kann auch nur Hinweis auf eine Gegenregulation und zumindest bis zu einem gewissen Grad reversibel sein. Für die sicherere Differenzierung der Patienten, bei denen eine Gefäßverlagerung ausreichend ist, von den Patienten, die besser initial eine Anderson-Hynes-Pyeloplastik erhalten sollten, empfiehlt sich ein intraoperativer Diuresetest (Volumenbolus plus intravenöse Furosemidgabe). Eine assoziierte intrinsische Stenose erscheint bei trichterförmigem und ansonsten unauffällig aussehendem pyeloureteralen Übergang, abnehmender Hydronephrose nach Mobilisierung des Nierenbeckens und der aberrierenden Unterpolgefäße und einer effizienten Peristaltik über den pyeloureteralen Übergang während des intraoperativen Diuresetests unwahrscheinlich. Die Vascular-hitch-Technik ist weniger anspruchsvoll als die laparoskopische Anderson-Hynes-Plastik und geht daher mit kürzeren Operations- und Narkosezeiten einher. Weitere Vorteile sind: kein Risiko der Leckage oder späteren Anastomosenstenose und keine Notwendigkeit intraluminaler Stents. Die vascular hitch Operation stellt somit bei einem selektionierten Patientengut mit rein extrinsischer subpelviner Stenose eine scheinbar auch langfristig wirksame Alternative zur klassischen Anderson-Hynes-Plastik dar.

Ureteropelvic stenosis, also known as ureteropelvic junction obstruction, is an obstruction in the region of the pyeloureteral junction resulting in a urinary discharge disorder of the renal pelvis, which requires treatment.Since the first description of pyeloplasty by Trendelenburg in 1886 and the successful establishment of open pyeloplasty by Anderson and Hynes in 1949, the treatment strategies for ureteropelvic junction obstruction have developed considerably, especially in the last two decades. Although open pyeloplasty is still considered to be the gold standard, this concept is supplemented by modern minimally-invasive techniques today. These include laparoscopic pyeloplasty, laparoscopic single-site pyeloplasty, robot-assisted pyeloplasty, robot-assisted single-site pyeloplasty, and endopyelotomy. This article provides an overview of the different treatment strategies for ureteropelvic junction obstruction as well as the complication management of pyeloplasty in adult age.Die ureteropelvine Stenose, synonym Subpelvin- oder Nierenbeckenabgangsstenose, beschreibt eine Obstruktion im Bereich des pyeloureteralen Übergangs, in deren Folge eine renale Harnabflussstörung resultiert, die es zu behandeln gilt.Seit der Erstbeschreibung der Pyeloplastik durch Trendelenburg 1886 und der erfolgreichen Etablierung durch Anderson und Hynes 1949 haben sich die Behandlungsstrategien der Nierenbeckenplastik vor allem in den letzten zwei Jahrzehnten weiterentwickelt. Zwar gilt die offene Pyeloplastik nach wie vor als Goldstandard, doch wird diese heutzutage durch moderne minimal-invasive Techniken ergänzt. Dies inkludiert u. a. die laparoskopische Pyeloplastik, laparoskopische Single-Site Pyeloplastik, roboter-assistierte Pyeloplastik, roboter-assistierte Single-Site Pyeloplastik sowie die Endopyelotomie. Dieser Artikel gibt eine Übersicht über die Therapie der ureteropelvinen Stenose sowie das Komplikationsmanagement der Pyeloplastik im Erwachsenenalter.

The increasing experience obtained through laparoscopy has resulted in the evolution of ablative and reconstructive procedures in the field of paediatric urology. Apart from the established methods of laparoscopic nephrectomy and orchidopexy, nowadays laparoscopic hemi-nephrectomy and pyeloplasty have become standard therapeutic surgical alternatives. Nevertheless, many of these procedures require a high level of experience in laparoscopic preparation and stitching techniques and are thus performed in institutions with greater laparoscopic experience. With the introduction and evolution of the robotic-assisted technique and the availability of smaller instruments and ports (8 and 5 mm), there has been an evolution in the spectrum of complex ablative and reconstructive procedures in the field of paediatric urology as well. Nevertheless, there is a lack of randomised trails and the literature available in this area consists manly of case reports. The purpose of this article is to present the current status and perspectives of robotic-assisted surgery in the field of paediatric urology.

In contrast to epidermoid cysts of the dermis, epidermoid cysts of the kidneys are rare. We report on a female patient with recurrent renal colic caused by an epidermoid cyst of her right kidney. A malignant tumor was suspected by computed tomography but was ruled out through ureterorenoscopic biopsy. The epidermoid cyst was removed by a partial nephrectomy.

Urothelial tumors of the renal pelvis and the ureter do not differ from those of the urinary bladder concerning histopathological phenotypes. However, with respect to tumor biology there are relevant differences between the two tumor locations. The originating tissue (urothelium) of the bladder and of the upper urinary tract varies significantly with respect to developmental origin, morphology and physiological function. Specific pathways of tumorigenesis (e.g. hereditary non-polyposis colorectal cancer, HNPCC) and tumor propagation (seeding) are described for tumors of the upper urinary tract. Clinical epidemiological data indicate specific correlations between the two tumor locations.

Upper urinary tract transitional cell carcinomas represent 5-6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.

Squamous cell carcinoma (SCC) of the upper urinary tract is a rare condition. The late stage of the tumour at diagnosis and the absence of evidence-based guidelines for therapy give rise to a poor prognosis in most cases. The patient with SCC described here showed an above-average survival of 18 months after adjuvant radiochemotherapy. Treatment was initiated according to the guidelines for squamous cell carcinoma in non-urological localisations.

The spectrum of percutaneous stone treatment was significantly widened following the introduction of the miniaturized percutaneous nephrolitholapaxy. At the end of the procedure usually a nephrostomy tube was placed to avoid urine paravasation and prolonged bleeding. In this work the tube-less mini-PCNL with direct closure of the access tract was compared to traditional mini-PCNL with placement of the nephrostomy tube.Twenty consecutive patients undergoing mini-PCNL with placement of a nephrostomy tube at the end of the procedure were compared to 20 consecutive patients with direct closure of the access tracts following percutaneous stone removal. Clinical data like decrease in Hb, complications, need for analgesics and duration of hospital stay were compared.Both groups underwent the procedure without complications. There was no need for blood transfusions. The difference in total analgetic dose was not statistically significant; however, patients in the nephrostomy group needed analgetics for a longer period of time. There was no difference in duration of hospital stay (3.2 days in the tube-less group versus 3.4 days in the nephrostomy group). The primary stone-free rate was higher in the group with direct closure of the access tract (95 versus 85%).Closure of the percutaneous access following mini-PCNL with a gelatine-thrombin-haemostatic sealant is a safe alternative to the commonly used nephrostomy tube and can help to reduce postoperative pain and patient discomfort.

In cases of inadequate or insufficient conservative treatment of non-compliant bladders the function of the upper urinary tract is jeopardized. We present our experience with ureterocystoplasty as one possible treatment option.A total of eight children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in five children, posterior urethral valves in two children, and in one child after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. Following nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE procedure was performed in three patients, antireflux surgery for the contralateral kidney in two patients, and one patient underwent stone removal in the remaining kidney. In one patient the ureter was used as a free transplant and was covered by an omental flap. In addition a simultaneous living donor kidney transplant was performed. The storage function could be improved in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years. Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.

Nonparasitic chyluria is rare. Spontaneous remission occurs in 50% of patients. Conservative treatment includes diet with medium-chain triglycerides, lymphangiography, and the instillation of sclerosing solutions of silver nitrate. If conservative management fails, open or retroperitoneoscopic nephrolysis is the treatment of choice. We present a case of spontaneous recumbent nonparasitic chyluria from the left kidney treated twice by endoscopic application of neodymium-YAG laser. This is new to the literature. The chyluria disappeared for several months. The temporary cessation of chyle flow after local laser application should encourage further use of this treatment modality after failure of conservative treatment.

About 5% of injuries of the urinary tract affect the renal pelvis and ureter and constitute a severe complication. Around 75% of these injuries are iatrogenic and only about 25% are caused by blunt abdominal trauma or perforation. To avoid complications and improve prognosis, immediate diagnosis and therapy are essential. The diagnostic accuracy of preoperative studies is low, therefore frequently injuries are detected during explorative laparotomy. The management of upper urinary tract lesions depends on severity and localization, whereas the ultimate ambition should always be the preservation of the kidney. As a basic rule, ureteral stenting is mostly sufficient for small lesions, and only larger injuries require open reconstructive techniques. Longitudinal studies document a high degree of functional reconstitution if adequate and immediate treatment is carried out.

Watchful waiting has become the standard therapy in most cases of asymptomatic unilateral congenital hydronephroses with normal renal function. Simple, reliable, and noninvasive prognostic parameters that predict an increased risk of functional deterioration either at the initial evaluation or during follow-up would be most useful. At the moment the diameter of the renal pelvis and especially its increase is the most useful prognostic parameter, while an "obstructed" washout at furosemide isotope renography is of limited prognostic value. Preclinical and preliminary clinical studies indicate that the measurement of molecules in the urine of affected children such as TGF-31 and MCP-1 that are involved in the signal transduction during hydronephrotic atrophy might become well accepted as useful prognostic parameters in the near future.

The aim of this analysis is the evaluation of the activity and toxicity of gemcitabine and carboplatin in patients with advanced urothelial transitional carcinoma (TCC) with special regard to patients with impaired renal function.30 consecutive patients with metastatic TCC [mean age: 68 (range: 47 - 82) years, median ECOG-PS:1] were treated with gemcitabine (1000 mg/m (2) on days 1 and 8 of a 21-day schedule) and carboplatin (AUC 4.5 day 1). In 15 patients (considered as renal unfit) a creatinine clearance of less than 60 mL/min (range: 31 - 59 mL/min) was seen.Concerning the survival rate, no significant difference noticed between the two subgroups of renal impaired patients and patients with normal renal function was detected (median 13 vs. 14 months, p = 0.901). An overall response rate of 50 % was obtained. In 16.7 % and 33.3 % of all cases a complete or a partial response was noted. Median time to progression was 5.34 months. The 1-year-survival rate has been calculated as 51.8 %. There was no restriction of renal function under chemotherapy in any single patient.The chemotherapy combination of gemcitabine and carboplatin is definitely powerful for a first-line-therapy in patients with advanced TCC. Toxicity is well manageable. Due to the dosage for carboplatin by AUC an adaptation to the glomerular filtration rate is possible. Decreases of effectiveness in cases of impaired renal function were not detected. Patients with metastatic TCC should be entered onto well designed, randomised clinical trials with the gemcitabine/carboplatin combination to afford a tailored chemotherapy.

The introduction of laparoscopic pyeloplasty was the first step towards the development of suturing and knotting techniques. The final breakthrough came with the development of radical prostatectomy since the performance of the urethrovesical anastomosis required highly developed skills in reconstructive surgery. For most laparoscopic surgeons suturing and knot tying became quite familiar henceforth. As a consequence, the interest for other reconstructive procedures has increased tremendously since. Within a very short time pyeloplasty was developed to a surgical standard, and the results compare very favorably with open surgery. A very attractive method is the ureteral reimplantation according to the psoas hitch technique, which, however, does not completely duplicate the open surgical operation. Many patients can potentially be attracted by sacrocolpopexy to treat genital prolapse. The long-term success rate is 92% which is excellent for this indication. Urinary diversion following cystectomy is usually not performed completely intracorporeally, but laparoscopically assisted.

Villous adenomas of the urinary tract are extremely rare tumours belonging to the adenoepithelial metaplasias. They can be associated with other neoplasias, especially with carcinomas. We describe the case of an 85-year-old female patient suffering from a villous adenoma of the renal pelvis and ureter.

The acute flank pain is the most frequent urological emergency. Patients with renal colic are usually treated in emergency care units or by their family doctors and require immediate diagnosis and treatment. Up to 10 % of the population is estimated to suffer from kidney colic at least once in their lifetime. Besides, renal colic can occur during pregnancy and childhood, which require special attention when deciding therapy. Differential diagnosis of acute flank pain contains a series of diseases which belong not only in the urological field but need adequate directly therapy. Particularly, these principles should give useful advice, wherever patients are treated without urological department.

Moderate activity of systemic chemotherapy for advanced urothelial cancer has been reported for more than 30 years. Only with the advent of potent combination therapy in the mid-1980s have clinically significant response rates and prolonged survival been documented. Due to the small number of cases and poor prognosis, knowledge is scant about the therapeutic effect of "second-line" polychemotherapy in metastatic upper tract urothelial cancer. We report an interesting case of a 59-year-old man suffering from urothelial cancer of the renal pelvis with pulmonary, lymphogenous, and bone metastases who had an unexpected response to "second-line" chemotherapy with only 2 treatment cycles of gemcitabine/paclitaxel (partial remission) after 24 treatment cycles of gemcitabine/cisplatin in "stable disease" with progression between the therapeutic intervals.

Identification of prognostic factors for tumor recurrence in nephronsparing surgery and tumor progression after organ-preserving surgery.From June 1989 to February 2003, 43 patients (47 nephron units) underwent organ-preserving surgery or the upper urinary tract because of urothelial carcinoma, with 26 (60.5 %) having an elective indication (healthy contralateral kidney).The mean follow-up was 39.2 months with a range of 10.6 to 168.3 months. Ipsilateral recurrences occurred in 13 (27.6 %) of reno-ureteral units. Recurrences were significantly more common for tumors located in the renal pelvis or opposite the ureteral origin (p = 0.018). Tumor progression occurred in 8 of 43 patients (18.6 %) and significantly correlated with the T- and G-stage of the primary tumor (p = 0.006 and p = 0.002). Of the 47 conservatively treated reno-ureteral units, 38 (80.8 %) could be preserved.Organ-preserving resection of the urothelial carcinoma of the upper urinary tract is an alternative in some patients with well-differentiated superficial tumors. A follow-up for life and a good patient compliance are necessary. Tumors of the renal pelvis have a significantly higher recurrence rate than ureteral tumors. Poorly differentiated tumors should undergo organ-preserving surgery only if the goal is palliation and in patients with solitary kidney after intensive consultation about the high risk of invasive recurrences and the development of metastases.

The first reconstructive procedure for ureteropelvic junction (UPJ) obstruction was performed by Trendelenburg in 1886. The important milestones in the reconstruction of UPJ are discussed and all available historical papers and reports since 1886 are reviewed. Kuster published the first successful dismembered pyeloplasty 5 years later, but his technique was prone to strictures. In 1892, the application of the Heineke-Mickulicz principle by Fenger resulted in bulking and kinking with obstruction. Plication of the renal pelvis, first introduced by Israel in 1896, was modified by Kelly in 1906. After the principle of the Finney pyloroplasty, von Lichtenberg designed his pyeloplasty in 1921, best suited to cases of high implantation of the ureter. Foley modified flap techniques, first introduced by Schwyzer in 1923 after the application of the Durante pyloroplasty principle, successfully to Y-V pyeloplasty in 1937. Culp and de-Weerd introduced the spiral flap in 1951. Scardino and Prince reported about the vertical flap in 1953. Patel published the extra-long spiral flap technique in 1982. In order to decrease the likelihood of stricture, Nesbit, in 1949, modified Kuster's procedure by utilizing an elliptic anastomosis. In the same year, Anderson and Hynes, published their technique. With the advent of endourology, several minimally invasive procedures were applied: antegrade or retrograde endopyelotomy, balloon dilation, and laparoscopic pyeloplasty. The concept of full-thickness incision of the narrow segment followed by prolonged stenting was first described in 1903 by Albarran and was popularized by Davis in 1943. Several basic principles must be applied in order to ensure successful repair: the resultant anastomosis should be widely patent, performed in a watertight fashion without tension. Endopyelotomy represents an alternative to open surgery.

Diagnosis of afunctional duplex systems may be delayed as they are often associated with misleading and atypical symptoms. A 40-year-old female with no history of urological disease exemplifies this thesis.Symptoms at admission were fever with pain in the right flank and lower abdomen. Sonography showed a large unclear structure at the upper pole of the right kidney and a paravaginal abscess, which was drained primarily. Rising temperature led to examination by CT-scan, which revealed a renal abscess of the upper pole, suggesting a right extopic ureter. After percutaneous drainage, further examinations (antegrade pyelography and IVP) confirmed an ectopic, blind-ending duplex ureter with a hydropyonephrotic upper renal system on the right side. Upper poole resection with ureterectomy was performed.In patients with unclear abscesses in the area of the external genitalia, congenital anomalies of the urinary tract should be considered as an underlying disease.

Iatrogenic fornix rupture caused during retrograde manipulation of the ureter is a rather rare or rarely diagnosed phenomenon. A 22 year-old female patient presented with fornix rupture following endoscopic ureteral stone extraction under ureterorenoscopy, the rupture having become symptomatic 2 days later. Diagnostics were done by means of sonography and radiography and confirmed by CT-scan performed to rule out abscess formation which may have occurred in this case of delayed symptoms. Conservative antibiotic therapy was sufficient in this case. Ca. 10 % of all perirenal abscesses are attributed to urinary extravasation due to fornix ruptures, requiring surgical intervention. Regular sonographic control is therefore strongly recommended when fornix rupture is suspected to ensure appropriate counter measures.

Traumatic rupture of the renal pelvis junction has been reported only rarely in the literature. Surgical exploration of the right kidney in a young man with blunt abdominal trauma showed a formerly unknown stenosis at the renal pelvis junction with hydronephrosis. Rupture of the renal pelvis by blunt abdominal trauma was related to obstruction of the ureteropelvic junction. Routine ultrasound examinations could show this pathological findings and help the patient to undergo early urological treatment.

Since 2/02 to 2/03 a total of 13 patients underwent either pyelovesical bypass (10 patients) or pyelocutaneous bypass (3 patients). A composite implant, consisting of two coaxial tubes internal pure smooth silicone covered by coiled e-PTFE has been designed to serve as the ureteral replacement. This prothesis in inserted percutaneously into the renal pelvis, tunnelled subcutaneously, and introduced through a small suprapubic incision in the bladder or out directly through a cutaneous orifice.One encrustation of the subcutaneous pyelocutaneous bypass was observed, no angulation or dislocation during a mean follow up of 6.2 month. Improvement in the quality of life was stressed in all patients.The subcutaneous urinary division using a silicone-PTFE prothesis is an efficient and minimal-invasive technique to attend malignant obstructions of the ureter.

Complex reconstructive laparoscopic procedures in the field of urology such as radical prostatectomy and pyeloplasty have attracted increased attention in the past 2 years. However, extensive laparoscopic experience is required to master these procedures. Therefore, it remains questionable whether these techniques, which have been shown to be of profit to the patient in the hands of a specialist, will achieve widespread distribution. We have employed computer technology to bridge the gap between open surgery and laparoscopic access and used the daVinci Surgical System to establish laparoscopic radical prostatectomy as well as pyeloplasty and other retroperitoneal procedures at our institution. With experience of more than 70 procedures, we find that with the assistance of the daVinci Surgical System both radical prostatectomy and retroperiteoneal procedures can be easily translated from open to minimally invasive procedures with a considerably shorter learning curve and without compromising patient safety. We expect that large incisions will be soon a thing of the past in urologic surgery. Computer technology, together with mechanical engineering, will play a major role in enabling us to achieve better results despite minimal invasiveness.

Transitional cell carcinoma of the renal pelvis is relatively uncommon, and only 5% of all urothelial carcinomas occur in the renal collecting system. Invasive tumors are often aggressive in their biological behavior and show a high tendency for systemic progression. Conservative therapy should only be considered an option in patients with imperative indications (solitary functioning kidney, bilateral tumor, renal insufficiency). In some cases, organ-sparing techniques such as open resection or endourological treatment (percutaneous or by ureteroscopy) can be performed. However, nephroureterectomy with excision of a bladder cuff is considered to be the standard treatment and should be performed whenever possible.

A retrospective case-control study (1990-1995), the Berlin Urothelial Cancer Study (BUS), examined analgesics and laxatives as risks for the induction of urothelial cancer in renal pelvis, ureter and bladder. Especially for renal pelvis cancer could observe substance and dose specific risk of compound analgesics. The analgesic substances Phenacetin, Paracetamol, Acetylsalicylic acid (ASA) and Pyrazolones were assessed. Besides a risk of contact laxatives (chemical or anthranoide ingredients) for urothelial cancer was found, not yet described. The highest risk shows the anthranoide plant Senna. Thus this study confirms the risk of specific analgesic ingredients and found an evidence for a new risk of contact laxatives. As both, analgesics and contact laxatives, are typical OTC--("Over the counter") products, a severe controlling is demanded and for laxatives further studies are needed.

We observed two patients with stone formation in the renal pelvis two and five years after pyeloplasty. In both cases there was no obstruction of the pyeloureteral junction detectable. We consider the use of Polyglactin (Vicryl) for the pelvis suture as reason for the stone formation. For stone removal we favourite an endoscopic procedure, in which a removal of residuums of the suture is even possible as the verification of the pyeloureteral junction.

We report a 44-year-old female patient who underwent surgery because of a suspected primary tumor of the renal pelvis in imaging procedures. Histology revealed the diagnosis of mesoblastic nephroma. This tumor represents a special entity of nephroblastoma that rarely occurs in adults. There is no unanimous opinion on the biological behavior of mesoblastic nephroma because the tumor behaves differently. The question of whether nephrectomy is indicated if there are no malignant features is also open. The decision depends on the given case. Nephrectomy can only be avoided if the intraoperative situation allows the tumor to be removed with an adequate distance from healthy tissue. The safety margin is necessary because mesoblastic nephroma shows fingerlike spread into the surrounding tissue.

We report on the eighth known case of a mature metastasis of a mature teratoma of the testis. In a 19-year-old patient who had undergone a pyeloplasty of the left renal pelvis 6 years before, a mature metastasis of an occult mature teratoma of the testis was found at the former operation site. This case--in addition to those published previously--emphasizes the fact that a mature teratoma of the testis has to be regarded as a malignant tumor in adults. It is supposed that the mature teratoma originates, as other testicular tumors, from carcinoma-in-situ-cells, which are responsible for metastasize and are not detected after lysis.

For routine evaluation of ureteropelvic junction obstruction in children, sonography, voiding cystogram, IV pyelogram and a renal scan in combination with administration of furosemide are available. Furthermore, often preoperative antegrade or retrograde ureteropyelography is performed. However, the significance of retrograde ureteropyelography in the world literature remains controversial. Therefore, we reviewed the records of 41 children who underwent a pyeloplasty in our department. In 9 children the ureter was visualized by IV pyelogram, voiding cystogram or antegrade ureteropyelography; a retrograde examination of the ureter was performed in 21 children before pyeloplasty in the OR. In 11 children the ureter was not visualized preoperatively. Retrograde ureterography neither gave additional information in any patient nor did it change the operative technique. In the children where the ureter was not visualized preoperatively, no ureteric abnormality was found in association with ureteropelvic junction obstruction. Hence, we conclude that retrograde ureteropyelography before pyeloplasty in children is not necessary, provided that sonography does not show ureteral dilatation.