Hämaturie und Spontanruptur der Niere (Aneurysma der A. renalis) während der Behandlung einer meningealen und renalen Tuberkulose mit Streptomycin

Ohne ZusammenfassungMit 8 Textabbildungen.     

Distal nephron carcinoma: a rare kidney tumor

Bellini's duct carcinoma is a very rare tumor originating from the collecting tubules of the kidney. It should be part of differential diagnosis in cases with gross hematuria, failed diagnostic proof of a tumor within the collecting system and a centrally located hypovascular mass. Analysis of the cytoskeleton by means of cytokeratin patterns enables classification as a tumor of urothelial origin.     

Alteration of the LRP1B gene region is associated with high grade of urothelial cancer

We have delineated regions of interest at chromosome 2q21.2, 2q36.3, and 2q37.1 by deletion mapping of 114 urothelial cancers (UC). Altogether, 17%, 18%, and 63% of the G1, G2, and G3 tumors displayed loss of heterozygosity at chromosome 2q, respectively, The region at 2q21.2 was narrowed down to the LRP1B gene (NT_005129.6). Hemi- and homozygous deletion at the LRP1B gene region was seen in 31 of 114 UCs. Only 8% of the UCs with G1 and none with G2 tumors showed loss of heterozygosity at the LRP1B gene, whereas 49% of the G3 UCs had allelic loss at this region. RT-PCR analysis of the LRP1B gene showed the lack of expression of several exons in 2 of 9 cases analyzed. Our analysis suggests that the LRP1B gene is a candidate tumor suppressor gene in UCs.     

The effect of single shock waves on the vascular system of artificially perfused rabbit kidneys

Extracorporeally-perfused rabbit kidneys were exposed to five shock waves at 14 kV on the XL1 Dornier experimental lithotripter (Dornier Medical Systems, Inc., Germering, Germany). While the perfusion flow rate was kept constant, the arterial perfusion pressure was recorded to assess changes in vascular resistance. Immediately after shock wave application, perfusion pressure decreased by 20%-30%, followed by a short, relative pressure rise that did not reach pretreatment values. Fifteen-twenty minutes later, arterial perfusion pressure reattained pretreatment values. Subsequent to treatment, urine flow decreased by greater than 50%. The observed pressure rise was also induced in nontreated kidneys by perfusion with the effluent of treated kidneys indicating that this is based on a humoral mechanism. On the other hand, shock wave application to formalin fixed kidneys only caused a marked decrease in arterial perfusion pressure, suggesting that this effect is due to a pure mechanical interaction of the shock wave also found with denaturated kidneys. The observed decrease of urine flow is probably caused by a decreased filtration rate. Since this was not the case in nontreated kidneys being perfused with the effluent of treated kidneys, the reduction of urine flow after extracorporeal shock wave lithotripsy does not appear to be mediated by a humoral factor, but is more likely a result of the mechanically-induced vasodilation with consecutive decline of the glomerular filtration rate.     

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors: Indications and Limitations

Purpose

We describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups.

Materials and Methods

The patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag.

Results

The procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients.Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease.

Conclusions

Our preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).     

Volumetrie der Harnblase mittels implantierbaren Ultraschallsensoren

Experimental studies revealed that the contractile response of the urinary bladder to sacral anterior root stimulation depends on the actual bladder volume. Furthermore, no clinical relevant technique is available for continuous monitoring of the bladder wall distension respectively bladder volume in paraplegic patients. The presented study investigates the reliability of especially developed implantable ultrasound sensors as a sensoric system for continuous monitoring of the bladder volume. In six anaesthesized pigs two ultrasound sensors, one transmitter and one receiver, were implanted on the bladder wall at different locations (latero-lateral, dorsal-ventral, rostral-caudal). After closing the abdominal wall, the bladder was filled in 50 ml steps up to 250 ml. After each filling step the running time of the ultrasound signal was measured. In all experiments reproducible results and a high correlation of the measured running times with bladder volume were observed. The latero-lateral configuration of the sensors seemed to be most confidential. The presented study indicates that bladder volumetry with implantable ultrasound sensors is possible with minimal technical prerequisites. This promising technique for continuous bladder volumetry could play an important role in the development of an intelligent and autoadaptive neurostimulator of the urinary bladder in paraplegic patients.     

Feedback activities of instructors during a trauma surgery course

Background

The aim of this study was to examine the quality and quantity of feedback and instruction from faculty members during an acute trauma surgery team training using a newly designed observational feedback instrument.

Methods

During the training, 11 operating teams, each consisting of 1 instructor coaching 2 trainees, were videotaped and audiotaped. Forty-five minutes of identical operating scenarios were reviewed and analyzed. Using a new observational feedback instrument, feedback and instruction, containing different levels of specific information related to technical and nontechnical skills, were noted.

Results

Instructors more often provided instruction (25.8 ± 10.6 times) than feedback (4.4 ± 3.5 times). Most feedback and instruction contained either nonspecific or less specific information and referred to technical skills. Instructors addressed communication skills more specifically.

Conclusions

Coaching by faculty members predominantly contained unspecific instructions regarding technical skills. The observational feedback instrument enabled scoring of the coaching activities.     

High intensity focused ultrasound as noninvasive therapy for multilocal renal cell carcinoma: case study and review of the literature

PURPOSE: Noninvasive tumor ablation can be achieved by extracorporeally induced high intensity focused ultrasound. Clinical high intensity focused ultrasound performed to date for renal tumors have only been experimental in nature. We present specific details on a patient with renal cell carcinoma who underwent high intensity focused ultrasound with curative intent and long-term followup examinations. MATERIALS AND METHODS: Ultrasound waves were generated by a cylindrical piezoelectric element focused by a paraboloid reflector. High intensity focused ultrasound was applied to 3 tumors in 3 sessions with the patient under general anesthesia or sedation analgesia, followed by magnetic resonance imaging for 6 months. RESULTS: After treatment magnetic resonance imaging showed necrosis in the 2 tumors in the lower kidney pole within 17 and 48 days, respectively. The necrotic tumor area shrank thereafter within 6 months. The tumor in the upper pole was not affected by treatment due to absorption of the ultrasound energy by the interposed ribs. General anesthesia was required to apply high energy levels of focused ultrasound. Absorption of high intensity focused ultrasound in the tissue induced sharply demarcated thermonecrosis. For 50 years patients have been treated with high intensity focused ultrasound for different indications, focusing on the brain, eyes, prostate, liver and bladder. For the kidney experimental but only few clinical studies indicate sufficient tissue ablation. CONCLUSIONS: In our case contactless noninvasive application of high intensity focused ultrasound to 2 renal carcinomas achieved thermal ablation. When high intensity focused ultrasound energy was coupled correctly, no lesions occurred outside of the target area. Successful high intensity focused ultrasound application depended on optimum energy coupling, a sufficiently high ultrasound energy level and general anesthesia.