Search

Seasonal variations in renal colic have been described by many authors for different countries worldwide. In most studies, there was no differentiation with regard to stone composition. Recently, we demonstrated that there was no seasonal variation in renal colic and urine chemistry for calcium oxalate stone formers in Germany. As we have many uric acid stone formers (UASFs) in our region, we were interested in learning the situation of this type of stone.We studied 286 consecutive UASFs with symptoms of renal colic. We divided them into four groups according to the quarters of the year. For stone analysis, X-ray diffraction/polarizing microscopy was used. Additionally, the following general parameters were examined in all patients: age, BMI, blood pressure, stone frequency, diabetes mellitus; blood: creatinine, glucose, uric acid, calcium, sodium and potassium; urine: pH, volume, calcium, uric acid, citrate, ammonia, and urea. Using the statistical program Prism 5 (GraphPad Software, San Diego, USA), significant differences between the four groups were calculated by the Kruskal-Wallis test.We observed significantly more UASFs with renal colic in the third and fourth quarters of the year. This is in contrast to our findings in calcium oxalate patients. However, there was no variation in metabolic parameters.The reasons are unclear; different temperatures are not a sufficient explanation, as one quarter is in the warm season and the other one is in the cold season. Unfortunately, no data have been reported in the literature thus far. Further studies are required to better understand these findings.

Jeder 20. Deutsche leidet an Harnsteinen, bei jedem zweiten Patienten kehren sie wieder. Damit kann man die Urolithiasis nicht nur getrost als Volkskrankheit, sondern auch als relevanten Kostenverursacher fur das Gesundheitssystem bezeichnen. Sorgfaltige Rezidivprophylaxe ist also nicht nur medizinisch, sondern auch okonomisch dringend angezeigt.

Metabolic evaluation is not suitable to forecast the course of the disease in idiopathic calcium oxalate stone formation (iCaOxU). An important pathway in CaOx stone formation is the overgrowth on interstitial apatite papillary plaques. Therefore, we studied whether the extent of such plaques may be used as a prognostic factor in CaOxU. Prospectively, we studied n = 100 patients with iCaOxU. For stone analysis, X-ray diffraction/polarizing microscopy was used. During flexible ureteroscopy and flexible percutaneous nephrolithotomy, all the renal papillae were inspected, counted and the severity of calcifications assessed. A calcification index (CI) was calculated: sum of the No. of papillae × calcification grade (1-3) × No. of calcified/total No. of papillae. Furthermore, the following parameters were examined in all patients: age, sex, BMI, arterial blood pressure, stone episodes, DM; blood: creatinine, glucose, uric acid, calcium, sodium and potassium; urine: pH, volume, calcium, uric acid, citrate, ammonia and urea. Using the statistic programme Prism 5 (GraphPad), summary statistics and non-parametric correlations (Spearman) and their significance were calculated. The CI correlated significantly (r = 0.37; p = 0.012) with the No. of stone episodes. Apart from citrate (r = 0.51; p = 0.002), none of the conventional metabolic parameters correlated significantly with the No. of stone episodes. Paradoxically, the citrate excretion-although citrate being an inhibitor of CaOx stone formation-positively correlated to the recurrence rate. The endoscopic assessment of papillary plaques/calcifications and the calculation of the CI are a more suitable prognostic factor in CaOx than conventional metabolic evaluation.

The incidence of urolithiasis increased dramatically during the last decades in adults as well as in children. Today, when a urinary stone is suspected, the imaging modality used most frequently is non-contrast enhanced computed tomography (NCCT). Due to the high sensitivity and specifity, NCCT is regarded as the gold standard. Its major drawback is the high dose of radiation administered with this examination. This is of special concern in children. Children with urinary stones are at high risk for multiple recurrences during their life. NCCT increases the risk for abdominal and pelvic cancer in children significantly. With respect to therapeutic success, however, conventional imaging modalities like ultrasound are not inferior and are without any harm. Therefore, ultrasound is recommended as the primary imaging technique in children by several guidelines. Nevertheless, as could be shown by Tasian et al., ultrasound was the first imaging study in only 24% of children with urolithiasis. NCCT was the modality used most frequently (63%) in the USA between 2003 and 2011. There was a wide regional variation within the USA with highest CT use in the Northwestern and Southern and lowest in the New England states. It is hypothesized that engrained practice patterns and specific local medical resources as well as a lower confidence in ultrasound with its operator dependence are potential reasons. Regarding the fact that ultrasonography is highly reliable in the diagnosis of urolithiasis and is without any harm, it is essential to make all efforts to increase the adherence to the guidelines.

Objectives Urolithiasis is a considerable economic burden for health systems, especially in industrialised countries where the incidence of stone disease has increased during the last few decades, and probably will further increase for several reasons. Methods The survey was based on investigations in collaboration with a German health insurance company and on a literature search (PubMed, and the author’s collection of proceedings of urolithiasis conferences: The keywords included economics, cost, urolithiasis, nephrolithiasis, renal stone disease, metaphylaxis, recurrence) during 1999–2011. In all, 1221 articles were found but only those cited here were sufficient for the purpose of the study. Due to the nature of the subject it is not possible to give levels of evidence, as economic data on stone treatment cannot be obtained with randomised studies. Results The costs for the treatment and diagnosis of stones vary tremendously among different healthcare systems. Several calculation models showed that metaphylaxis is medically and economically effective when used rationally. Rational metaphylaxis is restricted to patients with a high risk of recurrence (brushite, uric acid, cystine and infected stones, patients with residual fragments after stone treatment and recurrent calcium oxalate stone formers). Conclusions For the groups identified, metaphylaxis is cost-effective in almost all healthcare systems, but the cost saved differs. The savings increase even more when adding the economic loss avoided from days off work due to treatment of recurrent stones. In most countries, stone frequency must exceed one stone per patient per year before medical therapy is more cost-effective than dietary measures.

Study Type – Practice patterns (retrospective cohort) Level of Evidence 2b OBJECTIVE • To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS • The data of 363 patients who underwent a LA were prospectively collected in 23 centres. • All centres were stratified into three groups according to their experience: group A ( 20 LAs/year). • In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. • Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS • The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). • In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. • The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. • The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION • LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Percutaneous endourological procedures require an advanced level of skills. To facilitate the training of the proper technique, some years ago we developed a porcine ex vivo model for training percutaneous endourological procedures. When dilating the percutaneous tract silicone and gelatine were frequently damaged thus inhibiting proper working with the endoscopes. To circumvent these problems we improved our ex vivo model in order to be as close to the clinical situation as possible. The kidney with the ureter was dissected off the retroperitoneal organ package of the freshly slaughtered pigs. The kidneys were put into bags cut into parts of the thoracic/abdominal wall of these pigs. The renal pelvis can be filled with saline to simulate hydronephrosis; stones can be implanted for PCNL. Our new model allows for even better training of all percutaneous endourological procedures (e.g. percutaneous nephrostomy, PCNL, endopyelotomy). Especially puncturing is extremely close to the situation in humans as the porcine thoracic/abdominal wall in principal has the same anatomy as the human one. The new model has been already used with great success in hands-on courses. Concerning "tissue feeling", the anatomic relations and the great variety of procedures that can be trained, it is superior to non-biological models. Nevertheless, it is easily available and inexpensive.

Bei den Unfallversicherungen sind zwei Formen zu unterscheiden, die gesetzliche und die private. Die Aufgaben der gesetzlichen sind im Sozialgesetzbuch VII geregelt. Sie soll arbeitsbedingte Gesundheitsschaden verhindern und im Schadensfall entschadigen. Die fur die urologische Begutachtung entscheidenden Begriffe, Bestimmungen und Kriterien sowie fur die gesetzliche Unfallversicherung wichtige urologische Erkrankungen werden im Text erlautert. Die private Unfallversicherung unterscheidet sich wesentlich von der gesetzlichen. Hier gilt der Invaliditatsgrad und die Bemessung ausschlieslich an medizinischen Kriterien.

Elective nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) has gained general acceptance as an alternative to radical nephrectomy. To achieve haemostasis without risk of local ischaemia and necrosis of kidney parenchyma after standard haemostatic suturing, we investigated TachoSil's efficacy and safety as atraumatic haemostatic treatment after kidney tumour resection.A total of 185 patients scheduled for NSS for small, superficial kidney tumours were included in an open, randomised, prospective, multicentre, parallel-group trial. Primary objectives were to test haemostatic efficacy and safety of TachoSil versus standard suturing. Efficacy was tested by comparing intraoperative time to haemostasis (primary end point). Secondary objectives included proportion of subjects with haemostasis after 10 min of trial treatment, occurrence of haematoma on day 2 after surgery, volume and haemoglobin concentration of postoperative drainage fluid, and surgeon's rating of usefulness of trial treatments. Safety was evaluated by occurrence of adverse events.In the intent-to-treat population, time to haemostasis was significantly shorter with TachoSil versus standard suturing (mean: 5.3 vs. 9.5 min [p0.0001]). Haemostasis was obtained within 10 min in 92% of patients in the TachoSil group and in 67% in the standard treatment group (p0.0001). Differences in other secondary end points were not statistically significant. Both treatments were well tolerated. Surgeons rated TachoSil higher in terms of convenience to prepare and apply, and impression of efficacy.TachoSil was superior to standard suturing in obtaining intraoperative control of haemorrhage and was as well tolerated as standard haemostatic treatment during NSS.

The calculation model which we developed for the cost of stone therapy and metaphylaxis in Germany some years ago with a social health insurance company is based on estimates of stone incidence, types and recurrence rates, actual costs for stone removal, and metaphylaxis (based on data from a district of the social health care system). There are 200,000 stone recurrences per year in Germany. Costs for treatment of these stones amount to $687,000,000. Stone metaphylaxis reduces the recurrence rate by some 40%. The annual cost for stone removal could be lowered by $275,300,000. Metabolic evaluation/metaphylaxis amount to $70,100,000 per year, resulting in a net saving of $205,200,000. In 1997, there were 96 days off work per stone patient resulting in 5,800,000 days off work in Germany per year. Metaphylaxis is not only medically effective in stone formers but also can lower health care cost significantly. Although health care conditions may vary from country to country, in principle this calculation model is applicable also to other countries.

Durch nervenschonende Operationstechniken konnte die Rate sexueller Funktionsstorungen nach Rektumoperationen deutlich gesenkt werden. Dennoch werden in 10–30% der Patienten nach Rektumoperationen Erektions- und Ejakulationsstorungen beobachtet. Ursache sind in erster Linie Lasionen der autonomen Nervenplexus des kleinen Beckens, daneben aber auch vaskulare Lasionen im Bereich der Pudendagefase. Bereits vor einer geplanten Rektumoperation sollte eine Sexualanamnese erhoben werden. Rund 10–30% der Patienten weisen schon praoperativ Sexualfunktionsstorungen auf. Bei postoperativ neu aufgetretener erektiler Dysfunktion erfolgen Erhebung der Anamnese, korperliche Untersuchung und ein Therapieversuch mit oralen Medikamenten (Sildenafil, Apomorphin). Lasst sich damit keine ausreichende Erektion erzielen, sind weitere diagnostische Masnahmen erforderlich: Testosteronmessung, Pharmakontest (intrakavernose Injektion vasoaktiver Substanzen) mit farbkodierter Duplexsonographie der Penisgefase. Bei Ejakulationsstorungen muss durch Untersuchung des Urins nach Masturbation gepruft werden, ob eine retrograde Ejakulation oder Anejakulation vorliegt. Orale Medikamente wie Sildenafil oder Apomorphin wirken nur bei einem Teil der Patienten nach Rektumoperationen, da eine zumindest teilweise erhaltene autonome Nervenversorgung Voraussetzung ist. Weitere Therapieoptionen sind die Schwellkorperautoinjektionstherapie (SKAT) oder intraurethrale Behandlung mit vasoaktiven Substanzen (z.B. Alprostadil). Damit lasst sich fast immer eine ausreichende Erektion erzielen. Als Ultima Ratio ist die Implantation einer hydraulischen Penisprothesemoglich. Bei Ejakulationsstorungen wird primar mit direkt oder indirekt sympathikomimetischen Substanzen (z.B. Midodrin, Imipramin) behandelt. Bei der retrograden Ejakulation besteht die Moglichkeit, Spermien aus dem postejakulatorischen Urin zu gewinnen und fur die assistierte Reproduktion aufzubereiten. Das Auftreten postoperativer Sexualfunktionsstorungen muss nichtschicksalhaft hingenommen werden. Je nach Art und Auspragung der Storung stehen effektive Therapiemoglichkeiten zu Verfugung.

Using an in vitro model with Madin-Darby canine kidney (MDCK) cells, we showed that shock wave-induced renal injury could be ameliorated by selenium. We examined the influence of selenium, a free radical scavenger, in shock wave-induced tubular cell injury in vivo. Male rats were randomly assigned to three groups: 1 control (n= 18), 2 selenium (n = 18), 3 sham treatment (n = 4). Groups 1 and 2 were treated with 500 shock waves on each kidney. Animals assigned to group 3 (sham treatment) received only anesthetics. Selenium (80 microg/kg per 24 h intraperitoneally) was given to the animals in group 2 for 5 days, starting 1 day before shock wave exposure. Urine was collected for 8 h on the day before and immediately, 1, 7 and 28 days after shock wave exposure (SWE) for the measurement of urine volume, N-acetyl-beta-glucosaminidase (NAG), beta-2-microglobulin (beta2 M), and creatinine. Blood was taken from these rats on day 1 after SWE for the determination of creatinine and the calculation of the creatinine clearance (CCr). After SWE, there was a significantly increased diuresis in group 1 and 2. The excretion of NAG and beta2 M was also increased in both groups. These changes were significantly less pronounced in the selenium treated rats. CCr was higher in the selenium group than in the controls. No changes were observed in the sham treated group. These results demonstrate that selenium is able to ameliorate the damaging effects of high energy shock waves on renal tissue not only in vitro, but also in vivo.

Hintergrund: Harn- und Stuhlinkontinenz kommen haufig gemeinsam vor. 6 bzw. 9,5% aller Manner bzw. Frauen uber 50 Jahre leiden an einer solchen kombinierten Inkontinenz. Eine gleichzeitige Harninkontinenz findet sich bei rund 50 bzw. 60% aller Manner bzw. Frauen mit Stuhlinkontinenz. Das uberzufallig haufige Zusammentreffen von Stuhl- und Harninkontinenz beruht auf der weitgehend identischen Nervenversorgung von Harnblase und Enddarm und den engen nachbarschaftlichen Lagebeziehungen der beiden Schliesmuskelapparate. Einteilung: Die Ursachen der Harn- und Stuhlinkontinenz lassen sich in zwei Gruppen einteilen: 1. neurogene Funktionsstorungen, 2. Beckenbodenfunktionsstorungen. Bei den neurogenen Funktionsstorungen sind Storungen des Zentralnervensystems und Schadigungen der peripheren Nerven zu unterscheiden. Beckenbodenfunktionsstorungen konnen neurogen oder unmittelbar muskular bedingt sein. Die Harninkontinenz wird folgendermasen klassifiziert: 1. Stressinkontinenz, 2. Urge-Inkontinenz, 3. Reflexinkontinenz, 4. Uberlaufinkontinenz, 5. extraurethrale Inkontinenz. In Zusammenhang mit der analen Inkontinenz kommen insbesondere die ersten vier Formen vor. Diagnostik: Die Diagnostik umfasst die sorgfaltige Anamnese, die korperliche einschlieslich neurourologischer Untersuchung, Urinstatus, Sonographie des Harntrakts mit Restharnmessung, Uroflowmetrie, ggf. Harnblasendruckmessung, transkavitare Beckensonographie, laterales Zysturethrogramm, Kernspintomographie und Rektumdiagnostik. Schlussfolgerung: Fur ein optimales Therapiekonzept mussen bei kombinierter Stuhl-Harn-Inkontinenz immer beide Aspekte interdisziplinar abgeklart werden.

A calculation model was developed for the cost of stone therapy and metaphylaxis in Germany based on estimates of stone incidence, types and recurrence rates, actual costs for stone removal and metaphylaxis (based on data from a district of the social health care system). There are 200,000 stone recurrences per year in Germany. Cost for treatment of these stones amount to $687,000,000. Stone metaphylaxis reduces the recurrence rate by some 40%. The annual cost for stone removal could be lowered by $275,300,000. Metabolic evaluation/metaphylaxis amount to $70,100,000 per year, resulting in an net saving of $205,200,000. In 1997, there were 96 days off-work per stone patient resulting in 5,800,000 days off-work in Germany per year. Metaphylaxis in stone formers can lower health care cost significantly. Although health care conditions may vary from country to country, in principle this calculation model is applicable also to other countries.

164 patients with prostatitic symptoms were evaluated by segmented urinalysis and culture and classified according to the National Institutes of Health classification system: 64 patients (38%) suffered from chronic bacterial prostatitis; 12 (7%) from inflammatory chronic pelvic pain syndrome, and 92 (55%) from non-inflammatory chronic pelvic pain syndrome. Transrectal ultrasound of the prostate, uroflowmetry and measurement of residual urine were also performed. Complaints were recorded using a questionnaire. Our studies revealed that leukocytes in expressed prostatic secretions could be detected in only 24 and 36% of patients with positive bacterial or chlamydial culture. Complaints, ultrasound and urodynamic findings were similar in the 3 groups. Therefore the differential diagnosis and therapy, based on the results of the 4-glass test and cultures as well as on transrectal ultrasound of the prostate, seem to be difficult.

Objective: Several studies reported increased blood pressure (BP) values following extracorporeal shock wave lithotripsy (ESWL) treatment of renal stones. It is unclear, however, wh

In shock-wave-induced renal injury cavitation-generated free radicals play an important role. Using an in vitro model with Madin-Darby canine kidney (MDCK) cells, we investigated the influence of selenium, a free radical scavenger, in shock-wave-induced tubular cell injury. Suspensions of MDCK cells (33 x 10(6) cells/ml) were placed in small containers (volume 1.1 ml) for shock wave exposure. Two groups of 12 containers each were examined: (1) control (no medication), (2) selenium (0.4 microg/ml nutrient medium). Six containers in each group were exposed to shock waves (impulse rate 256, frequency 60 Hz, generator voltage 18 kV), while the other six containers in each group served as a control. After shock wave exposure, the concentration of cellular enzymes such as lactate dehydrogenase (LDH), N-acetyl-beta-glucosaminidase (NAG), glutamate oxaloacetate transaminase (GOT) and glutamate lactate dehydrogenase (GLDH) in the nutrient medium was examined. Following shock wave exposure there was a significant rise in LDH, NAG, GOT and GLDH concentrations. Selenium reduced this enzyme leakage significantly. Thus we conclude that selenium protects renal tubular cells against shock-wave-induced injury. Since selenium is an essential part of glutathione peroxidase, this effect seems to be mediated by a reduction in reactive oxygen species.

The cause of reduced Tamm-Horsfall protein excretion in patients suffering from uric acid diathesis is still unknown. Our investigation was conducted based on the hypothesis that the solubility of uric acid is increased by Tamm-Horsfall protein and that an increased uric acid content in the urine might cause a decrease in Tamm-Horsfall protein. In 20 patients with uric calculi the excretion of Tamm-Horsfall protein, uric acid, calcium, and citrate was measured. 65% of the patients had pure uric acid stones (group I) and 35% showed mixed stones with at least 30% of uric acid (group II). Reduced Tamm-Horsfall protein excretion was found in 63% of the patients of group I and in 43% of the patients of group II. The excretion of Tamm-Horsfall protein was significantly reduced in pure uric acid stone formers compared to normal subjects (p < 0.0001). The excretion of uric acid was elevated in 61% of the patients of group I and in 86% of the patients of group II. There was no significant correlation between Tamm-Horsfall protein excretion and uric acid excretion (r = 0.2139). Calcium excretion was elevated in 57% of the patients with mixed stones. The excretion of citrate was reduced in almost all of the patients of groups I and II. Our results do not support the hypothesis that an increased content of uric acid in the urine causes a decrease in Tamm-Horsfall protein. In our opinion the lower excretion of Tamm-Horsfall protein in some of the stone patients might be caused by damage in the distal tubular epithelium. Moreover, it has to be supposed that there are defects both in the distal and the proximal tubule in patients prone to develop uric acid calculi.

In a retrospective study we examined whether follow-up of prostate cancer (PC) patients can be managed by using prostate-specific antigen (PSA) as a unique tool as postulated recently.According to strict criteria established in the eighties, at our institution PC patients were monitored by PSA, prostatic acid phosphatase (PAP), alkaline phosphatase (AP), digital-rectal examination, renal and bladder ultrasound every 3 months, abdominopelvic computerized tomography (CT) and bone scan every 6 months. Between 1988 and 1994, 80 patients with PC cancer were eligible (mean follow-up 29.5, range 12-81 months). Patients were categorized into 4 groups: localized tumor (n = 44); lymph node metastases (n = 9); distant metastases (n = 18), and lymph node and distant metastases (n = 9). The parameters mentioned were compared for the assessment of progression, regression and stabilization of the disease.Our examinations showed that PSA is superior to all the other parameters used. In all groups, there were no patients with progressive disease detected by PAP, AP, CT and bone scan, but not by PSA. PSA anticipated the other parameters in detecting progression by several months. Renal ultrasound, however, detected new hydronephrosis in 6 patients with stable or decreasing PSA. Hydronephrosis was caused by surgery or radiotherapy, not by progressive PC.PSA can be used as a unique tool in the follow-up of PC patients in all stages. However, patients who underwent therapy potentially afflicting the urinary tract should have additional renal and bladder ultrasound.

146 patients whose ureteral stones did not pass spontaneously participated in a prospective study on optimal management. Patients were offered two treatment options: extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS). The stone was treated with the technique preferred by the patient. In case of treatment failure after first-line therapy, patients again could decide on how to proceed. Stone analysis could be obtained from 72.6% patients. ESWL was the primary treatment in 66.4% patients. In 2 patients, ESWL was the secondary treatment after failed URS. URS was the first-line therapy in 33.6% patients. In 29 patients URS was done after failed ESWL. For analgesia, sedoanalgesia or spinal anesthesia were used. Analgesia was required in 74.2% ESWL and 100% URS sessions. Following ESWL, 70.1% patients became stone free. In 29.9% ESWL failed. Distal stones had a higher failure rate than proximal or mid-ureteral calculi. Distal stones treated without success were significantly larger than those treated successfully. Failures were switched to URS. Stone analysis could be obtained in 26 patients with failed ESWL: 23/26 consisted of pure whewellite or mixed whewellite stones. Clinically relevant complications were not observed. After URS, 94.9% of the patients became stone free. In distal stones, the stone-free rate was 97.5%. There was only 1 relevant complication: a proximal ureteral lesion requiring surgical repair. Our study demonstrates that URS is a safe and highly effective treatment option for ureteral stones. In patients with distal ureteral stones, it should be offered as a first-line treatment. When whewellite is expected as the stone mineral, URS is the treatment of choice.

Unbestritten ist die Metaphylaxe bei Harnsteinleiden sinnvoll. In der Praxis reicht es jedoch nicht, nur die medizinischen Masnahmen umzusetzen. Vielmehr sind Urologen und Hausarzte gefordert, auch die Compliance ihrer Patienten zur starken. An dieser scheitert die Metaphylaxe in der Praxis haufig.

Die Harnsteinerkrankung ist eine weltweit verbreitete Krankheit, die in Abhangigkeit von verschiedenen Faktoren unterschiedlich haufig vorkommt. Die Erkrankungshaufigkeit ist in den letzten Jahrzehnten deutlich angestiegen. Dieser Trend wird sich auch in Zukunft fortsetzen. Die Urolithiasis ist eine multifaktorielle Erkrankung mit komplexer Pathogenese. Neben der Ubersattigung des Urins mit steinbildenden Substanzen spielen bei der Entstehung der haufigsten Steinarten vor allem zellulare Veranderungen in den Endabschnitten der Nierenkanalchen und der Papillen eine wesentliche Rolle.

With the introduction of prostatic specific antigen (PSA), the role of prostatic acid phosphatase (PAP) has been questioned. Some authors still advocate its determination, because PAP may be helpful for identifying patients with organ confined cancer. Tumor progression may be detected earlier in some patients by PAP. With respect to cost, we analyzed whether PAP still has a place as a tumor marker for prostate cancer (PC). In 6,151 men seen for screening or treatment of PC or therapy of benign prostatic hyperplasia (BPH), parallel determinations of PAP and PSA were done. PC was diagnosed in 862 patients, BPH in 5,503 patients, and prostatitis in 86 patients. There were only 16 patients with PSA 5 ng/ml. Five of 16 patients had histologically proven BPH; 11 of 16 patients suffered from metastatic PC. Five of 11 patients were in remission on hormonal therapy; PSA had already normalized and PAP was still elevated. Three of I I patients had hormone resistant PC; PAP detected the progression earlier than PSA. In the absence of an effective treatment, this is not of clinical relevance. In 1 of 11 patients, a falsely low value was assumed. In all, 935 of 6,151 patients showed normal PAP and elevated PSA; 805 of 935 patients suffered from BPH or prostatitis; 130 of the 935 patients had PC. Stage D was found in 56 of 130 patients, stage C in 31 patients, and stage A B in 43 patients, which did not allow the identification of organ confined cancer. Therefore, there is no benefit from the determination of PAP in PC. It is both safe and cost-effective to abandon PAP as a tumor marker for PC.

In a retrospective study we analyzed patients undergoing open stone removal in the Department of Urology of the University of Tübingen. In 2.7% of all urinary calculi, open stone surgery was necessary. Open operation was performed on all patients with complete staghorn calculi as well as on patients with renal pelvic stones and simultaneous morphological obstruction. Partial staghorn calculi were operated on only after endoscopic treatment had failed. Small renal pelvic stones and ureteral stones were surgically removed only after extracorporeal shock wave lithotripsy (ESWL) and endoscopic surgery had been unsuccessful. The treatment of choice for ureteral calculi is ESWL. If ESWL is impossible, an endoscopic approach is advisable. Open operations of ureteral calculi only have to be performed if endoscopic therapy has failed or if there is a simultaneous morphological obstruction. Meta-analysis of publications from 1981 to 1995 confirmed our approach regarding indications for open stone removal. Comparison of the results reported in the literature is very difficult because of the missing, but generally accepted definition of stone free. In addition different examination techniques to determine the status 'stone free' make it difficult to compare the various studies.

OBJECTIVES This prospective study was initiated to assess the significance of spot urine specimens (SU) for the metabolic evaluation of stone formers. METHODS 68 stone patients (51 males, 17 females) and 20 controls (9 males, 11 females) participated. On 3 consecutive days, urine was collected. Fasting (SU1) and postprandial (SU2) SU were obtained. From these, aliquots were taken, all the other urine was mixed to obtain 24-hour timed specimens (24hU). In all specimens, pH, specific gravity, creatinine, calcium, magnesium, phosphate, citrate, uric and oxalic acids were measured. The latter analytes were related to creatinine (mmol/g creatinine). Pearson correlation coefficients with their levels of significance and the day-to-day variation were calculated. Using the values in the control group, normal values (means +/- 2 SD) were established. RESULTS There was a significant correlation (p < 0.0001) between SU and 24hU for all parameters examined. The day-to-day variation of all analytes was considerable in SU and 24hU. CONCLUSIONS Despite a minor inaccuracy by relating parameters to creatinine, SU are sufficient in the routine metabolic evaluation of stone formers, since a third of all 24hU has to be rejected because of considerable collection errors. SU circumvent this problem. Because of the day-to-day variation, 3 SU should be obtained to overcome the doubtful significance of one single specimen.

Der Kalziumbelastungstest nach Pak kann die verschiedenen Untergruppen der Hyperkalziurie nicht eindeutig voneinander trennen. Zur Klarung der Moglichkeit einer verbesserten Diagnostik und der daraus abzuleitenden Therapie haben wir bei 32 Patienten mit Kalziumurolithiasis und Hyperkalziurie (> 6,25 mmol/die) die relevanten Parameter des Kalziumstoffwechsels untersucht, die vertebrale Knochendichte gemessen sowie einen Pak-Test durchgefuhrt. Die pathophysiologischen Konstellationen, die Pak seiner Hyperkalziurieklassifikation zugrunde legt, konnten zumeist nicht nachgewiesen werden. Durch die bisherige Diagnostik last sich nicht eindeutig entscheiden, welche Genese der Hyperkalziurie zugrundeliegt (Ausnahme: pHPT). Daraus resultiert ein therapeutisches Problem: Die Empfehlung einer kalziumarmen Diat kann grundsatzlich nicht mehr gegeben werden, da bei manchen Patienten langfristig Osteopenien resultieren konnten. Aus unseren Untersuchungen ergeben sich folgende diagnostische und therapeutische Konsequenzen: Drei Gruppen lassen sich unterscheiden: 1. Die Hyperkalziurie bei primarem Hyperparathyreoidismus ist durch die operative Entfernung des Nebenschilddrusenadenoms zu behandeln. 2. Die parathormon-unabhangige osteogene Form sollte mit Thiaziden behandelt werden. 3. Die Hyperkalziurie bei erhohtem 1,25-Dihydroxycholecalciferol kann durch kalziumarme Diat behandelt werden.

Objectives : The treatment of hypercalciuria is controversial. This study investigated whether the osteocalcin response (OCR) to a calcium-restricted diet is a potential tool for the differential therapy of hypercalciuria. 56 patients with calcium urolithiasis were investigated. Methods : Osteocalcin (OC) was measured on a free diet (OC 1) and after a calcium-restricted diet (400 mg/24 h for 1 week, OC 2). The OCR was expressed as 100 x (OC 2 - OC 1)/OC 1. A calcium load test and vertebral mineral density measurements (L 2 -L 4 ) were performed additionally. Results : 27 patients showed diet-dependent hypercalciuria, 15 of them being classified as absorptive hypercalciuria type II (AH II). 12 were normocalciuric (NC). 29 patients had diet-independent hypercalciuria, 22 being classified as renal hypercalciuria (RH), 7 as absorptive hypercalciuria type I (AH 1). 22 patients (42%) showed a positive OCR, indicating an increased bone turnover. Vertebral mineral density was lower in patients with positive than with negative OCR. Generally patients with RH or NC showed a positive OCR, patients with AH a negative or no OCR. 2 patients with AH, however, showed highly positive OCR, indicating negative calcium balance. Long-term follow-up on a low calcium diet showed a steady decrease in bone mineral density. Conclusions : This demonstrates that the OCR is more reliable to determine the appropriate management of hypercalciuria than calcium load tests. For practical purposes, we suggest treating hypercalciuric patients with positive OCR with thiazides ; diet-dependent hypercalciuria with negative OCR should be treated with a low calcium diet.

Purpose: There is ongoing controversy regarding blood pressure changes after extracorporeal shock wave lithotripsy (ESWL*). Experimental data suggest a role for renin but only few data are relevant to humans. It has been shown that renin secretion is stimulated by endothelin, a recently discovered peptide with strong vasoconstrictive properties and stimulating effects on renin secretion. Endothelin is relevant in the development of hypertension and acute renal failure.*Dornier Medical Systems, Inc., Marietta, Georgia.Materials and Methods: In a prospective study of 48 normotensive patients undergoing ESWL for renal stones the influence of high energy shock waves on plasma endothelin and active renin was analyzed. These substances are secreted by renal cells in response to hemodynamic alterations, and inflammatory and traumatic processes. Peripheral blood samples were analyzed for active renin and endothelin before, and immediately, 1, 3 and 5 days after ESWL. Blood pressure was measured before, an...

During the last few years, there has been relevant progress in both understanding and managing urolithiasis. Our knowledge of stone formation has changed; although the importance of urine biochemistry was questioned by several investigators years ago, the decisive role of cellular processes (induced by oxidative stress) and the renal papilla has only recently been generally accepted as the most important step in stone formation. For calcium oxalate urolithiasis, the formation of papillary calcifications plays a key role and is of prognostic relevance. Further research has to concentrate on these aspects of preventing urolithiasis. Stone prevention (metaphylaxis) is a major issue when considering the burden it places on healthcare systems. An effective metaphylaxis could lower the cost of stone therapy significantly. For uric acid urolithiasis, so far there is only preliminary information available showing that papillary plaques are not as important as they are in calcium oxalate urolithiasis. Concerning stone management, endourology has improved stone therapy significantly during the last few years. Morbidity decreased and success (stone-free) rates increased. Therefore, the indications for extracorporeal shockwave lithotripsy (ESWL) narrowed. ESWL, however, still has its place in stone therapy. There is not one single treatment modality that is equally effective for all situations. It is important to observe the differential indications for different stones depending on size, localization, and composition.

Introduction. Several studies showed an association of overweight and obesity with calcium oxalate stone disease (CaOx). However, there are no sufficient data on the influence of body weight on the course of the disease and the recurrence rate.Patients and Methods.N=100consecutive stone formers with pure CaOx were studied. Different parameters were investigated. According to the BMI, patients were divided into three groups: (1)BMI≤25; (2) BMI 25.1–30; (3)BMI>30.Results.N=32patients showed aBMI≤25,n=42patients showed a BMI of 25.1–30 andn=26patients showed aBMI≥30. The groups differed significantly concerning BMI (by definition), urine pH, and urine citrate. The recurrence rate was not significantly different.Discussion. Our study demonstrated that body weight negatively influences single risk factors in CaOx, but obesity is not a predictor for the risk of recurrence in CaOx.

Background: Citrate is one of the most important inhibitors in urolithiasis. Hypocitraturia is a common risk factor in stone formers. Citrate excretion is regulated – amongst others – by acidosis and protein intake. A considerable number of stone formers, however, show hypocitraturia in the presence of normal urine pH levels. This is potentially due to defects in the renal tubular citrate carriers (NaDC 1 and 3) which may be genetically determined. Patients and Methods: 350 consecutive stone formers were examined. Exclusion criteria were urinary tract infection, hypokalemia, and steatorrhea. The following parameters were measured: serum: creatinine, calcium, potassium, and uric acid; urine: pH profiles, citrate, calcium, uric acid, ammonia, urea, and creatinine. Results: 83/350 patients were hypocitraturic (48 males, 35 females). 14/83 had low urine pH (≤6), 69/83 showed normal levels (>6). In the latter group there was a significantly higher recurrence rate (23 vs. 9%). The two groups were not different in serum parameters apart from uric acid. In urine, only pH and calcium (males) were significantly lower in the first group. Citrate did not correlate with urine pH and creatinine in the hypocitraturia-normal pH group, only with calcium in both sexes and urea and ammonia in females. In the hypocitraturia-low pH patients, there was no significant correlation between citrate and any other parameter tested. Conclusions: Hypocitraturia with normal urine pH is an entity indicating a high risk for recurrence. Since there was no correlation between citrate and pH, urea and ammonia, respectively, citrate excretion is not regulated in these patients as usual. There may be a link to calcium excretion. Potentially, these patients have defects in the renal tubular citrate carriers which may be genetically determined. Genetic examinations should be performed to elucidate a potential genetic disorder in hypocitraturia-normal pH stone formers.

Previous results on the peripheral blood immune status of renal cell carcinoma had indicated immunosuppression in metastatic disease, possibly mediated by prostaglandin E2 (PGE2). In the present study the immunologic effects of inhibition of PG synthesis by piroxicam in combination with interleukin 2 (IL 2) + lymphokine-activated killer (LAK) cell therapy were tested by immunomonitoring. In addition to peripheral blood parameters (lymphocyte subpopulations, neopterin, beta 2-microglobulin, TNF, IL 1, IFN gamma) we recorded in vitro cellular activity by incubating the patients' peripheral blood mononuclear cells (PBMC) in media containing fetal calf serum (FCS) or autologous serum, and either IL 2 or buffer. After 24 h of incubation we measured PGE2 and cytokine levels in supernatants. Systemic application of IL 2 induced in vivo lymphocyte proliferation and clearly influenced the serum levels of neopterin, beta 2-microglobulin and TNF. There was minor affection of IFN gamma and none of IL 1. PBMC in vitro produced high amounts of PGE2, IL 1 and TNF pretherapeutically, during therapy in vitro synthesis of these parameters decreased. Consistent production of IFN gamma was detected in supernatants only when FCS and IL 2 were added to the medium. Lack of affection of IFN gamma production in the autologous system during therapy indicated impaired cellular activity, which could neither be improved by therapy of the patient using IL 2 nor by adding IL 2 to the culture medium. Immunosuppression seems to interfere in a complex way with immunotherapy. Therapeutical influence of immunosuppression based on the results of immunomonitoring, however, seems to be a promising strategy for improving the still limited clinical results of immunotherapy.

Objectives: Endourological procedures as ureteroscopy require an advanced level of skills. To facilitate the training of the proper technique, simulators are helpful. Nonbiological models, useful to learn the basic steps, do not represent the clinical situation in an ideal way. We therefore looked for a biological but nevertheless easily available model. Methods: The complete urinary tract is dissected off the retroperitoneal organ package of freshly slaughtered pigs. Results: The porcine urinary tract model allows for training all aspects of diagnostic and therapeutic ureteroscopy including lithotripsy and stenting in a way which is almost identical to the clinical situation in humans. Conclusions: The porcine urinary tract model is an ideal ex vivo model. Concerning ‘tissue feeling’ and anatomic relations, it is superior to nonbiological simulators. Nevertheless, it is quite easily available and inexpensive. In training courses, we have used it with great success.

To study the pathogenesis of parathyroid-hormone-induced renal insufficiency and the influence of the new calcium channel antagonist Gö 6070 (Gödecke AG, Berlin, FRG) rats were assigned to three groups (n = 8 each): (1) control, (2) PTH, (3) PTH plus Gö 6070. PTH (30 micrograms/24 h, a nonhypercalcemic dose) was administered i.p. and Gö 6070 (1 mg/kg/24 h) p.o. for 6 days. PTH did not change plasma or urinary calcium and did not induce nephrocalcinosis. The glomerular filtration rate (GFR), however, was decreased (4.9 vs. 10.3 ml/min/kg). Concomitant administration of Gö 6070 attenuated the PTH-induced fall in GFR (6.2 ml/min/kg).

Assessing the peripheral blood immune status, we had found evidence of immunosuppression in metastatic renal cell carcinoma. Since immunosuppression might interfere with the outcome of immunotherapy, it was submitted to further investigation. Immunosuppression can be mediated by T suppressor cells, which for their part are inhibited by low-dose cyclophosphamide (Cy). We tested whether the immunomodulating effects of the biological response modifier keyhole limpet hemocyanine (KLH) on cellular and humoral immune parameters would be intensified by low-dose Cy. 10 patients were given 300 mg/m2 Cy i.v. 3 days before application of 1 mg KLH i.m. up to 8 times in 4-weekly intervals. Immune parameters were assayed twice pretherapeutically, and prior to and 1 day and 1 week after each KLH injection. In contrast to the results obtained with KLH-monoapplication, lymphocyte subsets – with the exception of T4 cell counts and the T4/T8 ratio – remained stable during the first 4 months of observation. There were increases in immunoglobulines and in the immunoactivation markers tumor necrosis factor, neopterin and Β2-microglobulin. The tendencies found here differed from those found in a previous study on patients who were given KLH alone, and were similar to those found in patients with nonmetastatic disease who received KLH alone. However, the increases of the activation markers during KLH + Cy application were at best half as much as in patients with nonmetastatic disease. In conclusion, immunosuppression was influenced, but not counterbalanced by low-dose Cy. Most probably other mediators of immunosuppression than T suppressor cells, for example prostaglan-din E2, must be considered as well. Treatment of immunosuppression, however, seems to be a promising concept for improving the clinical results of immunotherapy.

Several investigations have shown that shock wave lithotripsy (SWL) can impair renal tubule function. Recently, we established an in vitro model using cultured Madin Darby canine kidney (MDCK) cell...

Recently, hyperthermia has been used for treatment of benign prostatic hyperplasia. The preliminary results reported were promising. However, apart from patients with total urinary retention, objective voiding parameters have not been reported in detail for patients with prostatism. In a phase II study we treated 30 patients with benign prostatic hyperplasia by local microwave hyperthermia (915 MHz.). The prostate was heated transrectally to 42 to 43C, with the treatment consisting of 8 sessions of 60 minutes each given twice a week. To assess the results of treatment several parameters were determined before and 4 weeks after hyperthermia therapy, including transrectal ultrasound of the prostate with volumetry, urinary flow rate and residual volume. Of the patients 28 could be evaluated and only 2 showed a relevant improvement. Neither the voiding parameters nor the size of the prostate could be changed significantly by hyperthermia. The success rate of 7.1% is even lower than the spontaneous temporary regression rate of benign prostatic hyperplasia. Thus, we believe that hyperthermia cannot be regarded as an effective treatment for benign prostatic hyperplasia comparable to transurethral resection.

Shock wave lithotripsy (ESWL) has become an almost non-invasive standard treatment modality for urolithiasis. Several investigations, however, demonstrated that ESWL is not completely free of side effects. Among others alteration of renal tubular function has been reported. To study the effect of shock waves on tubular cells directly an in-vitro model with cultured Madin Darby Canine Kidney (MDCK) cells was established. Suspensions of MDCK cells (7 groups of 6 containers each) were exposed to 0, 16, 32, 64, 128, 256 shock waves (Dornier HM4, 18 kV). Before and 0, 1, 3, 6, 9, 12, 24 h after ESWL the following parameters were measured in the nutrient medium: lactate dehydroxygenase (LDH), glutamate oxalacetate transaminase (GOT), electrolytes. LDH and GOT increased depending on the number of shock waves indicating a membrane damage of MDCK cells. The MDCK model seems suitable for further studies on the effect of shock waves on renal tubular cells.