Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases

PURPOSE

In 1998 Guillonneau and Vallancien introduced laparoscopic radical prostatectomy with primary access to the seminal vesicle. In 1999 we developed a different laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus on early results and the learning curve of the procedure in the first 180 patients.

MATERIALS AND METHODS

A transperitoneal approach is used with immediate access to Retzius' space. After the dorsal vein complex is endoscopically sutured, the urethra is incised and distal pedicles of the prostate with or without the neurovascular bundle transected. The apex is then pulled ventrally followed with incision at the bladder neck, and transvesical access to vas deferens and seminal vesicle. After completing the posterior wall of the urethrovesical anastomosis with 5 interrupted endoscopic sutures, the Foley catheter is placed, bladder neck closed and specimen extracted via the umbilical incision. From March 1999 to December 2000 we have performed 180 procedures, including 3 for stage pT1 tumor, 88 pT2, 82 pT3 and 7 pT4. Mean preoperative PSA was 13.3 ng./ml. (range 1.4 to 148), mean specimen weight 37.4 gm. (10 to 125) and median Gleason score 6 (3 to 9). For evaluation of the learning curve a separate analysis of 3 groups with 60 patients in each was done. Differences between groups 1 (first 60 patients) and 3 (last 60) were analyzed for statistically significant differences.

RESULTS

Mean operating time was 271 minutes (range 150 to 500) and transfusion rate 31%. The reintervention rate was 4.4% and complication rate 18.8%. Of the patients 92% did not require any analgesia on postoperative day 2. Positive margins were found in 16% of the patients. The rate of positive margins in pT2 tumors was 2.3%, pT3a 15% and pT3b 34%. After a median followup of 12 months (range 3 to 23) in 9 (5%) patients a prostate specific antigen relapse was observed. The anastomosis was tight after removal of the catheter in 83% of patients, with a median time of 7 days (range 5 to 30). An anastomotic stricture had to be treated with laser incision in 3.3% of patients. On discharge from the hospital 33% of patients were continent, after 6 months 74% and after 12 months 97%. Analysis of the learning curve revealed significant differences in operating time (324 versus 265 minutes), conversion rate to open surgery (8.1% versus 1.7%), complication rate (23.3% versus 11.7%) and rate of prolonged catheterization (31.6% versus 10%, respectively), whereas the percentage of positive margins and continence rates showed no influence.

CONCLUSIONS

Laparoscopic radical prostatectomy requires significant laparoscopic expertise with an ongoing learning curve. Morbidity is low, oncological control similar to results of open surgery and functional results are promising. The procedure should be performed only at dedicated centers with adequate training and expertise.

Proteinase-3 mRNA expressed by glomerular epithelial cells correlates with crescent formation in Wegener's granulomatosis

BACKGROUND

Wegener's granulomatosis (WG) is characterized by systemic vasculitis with crescentic glomerulonephritis (CGN) and circulating autoantibodies directed against neutrophil cytoplasmic antigens (ANCA). Proteinase 3 (PR-3), a neutral serine proteinase in neutrophils implicated in the growth control of myeloid cells, has been identified as the target antigen for ANCA in WG. Since the kidneys are frequently involved in WG, we studied the in situ expression of PR-3 by renal parenchymal cells.

METHODS

We assessed the expression of PR-3 in kidney biopsies of 15 patients with WG by immunohistochemistry (IHC) and in situ hybridization (ISH). Normal kidney tissue served as the control.

RESULTS

We detected PR-3 mRNA and PR-3 protein in distal tubular epithelial cells (TECs) and glomerular epithelial cells (GECs) in normal kidney tissue and in CGN. Furthermore, a strong glomerular PR-3mRNA expression restricted to the site of cellular crescents was detected in patients with WG. The analysis of 144 glomeruli with cellular or sclerotic crescents revealed a positive correlation of glomerular PR-3mRNA expression with the percentage of cellular crescents per glomerulus. The capability of human TECs and GECs to synthesize PR-3 was confirmed by Northern blot and ISH on cultured cells.

CONCLUSION

These data provide evidence that nonhematopoetic renal parenchymal cells express PR-3 and that glomerular expression of PR-3 is associated with crescent formation in WG. Our findings suggest that renal parenchymal cells may directly be involved in the pathogenesis of CGN in WG.

Thrombotic microangiopathy with renal failure in two patients undergoing gemcitabine chemotherapy

Described here are 2 patients who developed thrombotic microangiopathy of the kidneys after receiving high cumulative doses of the new anticancer drug gemcitabine. The first patient, who received gemcitabine for treatment of a carcinoma of the pancreas, required hemodialysis for 6 months. In the second case, a woman suffering from a cholangiocellular carcinoma, end-stage renal disease was irreversible. Clinical awareness, timely detection and discontinuation of gemcitabine are mandatory to prevent this rare but disastrous complication of gemcitabine therapy.

Acute renal failure complicating non-fulminant hepatitis A

Hepatitis, A is usually a mild and self-limiting infection of the liver. Whereas the clinical course is usually benign in children, complications such as prolonged cholestasis and fulminant liver failure have been reported in adults. Acute functional renal failure is an uncommon event in the absence of fulminating liver disease. So far, only cases of acute hepatitis A with biopsy-proven interstitial renal disease or tubular necrosis have been reported [Geltner et al. 1992. Kramer et al. 1986]. We present the case of a 35-year-old, previously healthy male with non-fulminant cholestatic viral hepatitis A, who developed progressive oliguric renal failure requiring dialysis therapy. Kidney biopsy ruled out glomerular disease and tubular necrosis. In the absence of bleeding and other causes of fluid depletion this case may be another variant of hepatorenal syndrome whose etiopathogenesis is only poorly understood.

Localized amyloid in the menisci of the knee joint

This is, to the best of our knowledge, the first report on amyloid deposits in menisci. Fragments of menisci gained by arthroscopy from 316 patients between 20 and 80 years of age were examined. Amyloid was found in 70% of the cases from male, as well as female patients. The amyloid amount found was always very small, but the deposits seemed to increase with age. Patients more than 50 years of age all had menisceal amyloid. Two types of deposits were observed: a)stroma-deposits in the deep central portions of the menisci (tiny dots of intensely stained amyloid and/or ill defined patches of low staining intensity) and b) surface associated deposits: band-like amyloid imbibition of the collagenous stroma immediately beneath the surface of the menisci but not deeper than 0.2 mm. In all cases, amyloid was resistant when pretreated by KMn04 and immunohistologically antisera against amyloid types AA, AB and AF were negative. 3/25 cases showed a reaction with an amyloid-lambda-antibody. We assume, that amyloid in menisci is a further type of localized senile amyloidosis.

Recurrent hematuria: a novel clinical presentation of hereditary complete complement C4 deficiency

A 10-year-old boy suffered from recurrent attacks of fever, vomiting, and hematuria. During disease flares, circulating immune complexes were detected in the serum. Elevated levels of Bb, Ba, and C3a indicated complement activation through the alternative pathway. Complement C4 was undetectable. C4 phenotyping by agarose gel electrophoresis showed complete C4 deficiency. Restriction fragment length polymorphism (RFLP) studies showed a homozygous deletion of the C4B and 21-hydroxylase A genes. A mild mesangioproliferative glomerulonephritis with mesangial deposits of immunoglobulin (1g) G, IgM, IgA, Clq, C3, properdin, and terminal complement complex was probably caused by immune complex deposition and alternative complement pathway activation. Treatment with low-dose prednisolone substantially reduced the frequency of further episodes.

[Cystic degeneration of the adventitia of the popliteal artery as a possible sequela of entrapment syndrome]

We report two cases of cystic adventitial degeneration of the popliteal artery in young sportsmen. The pathogenetic role of microtrauma is suggested by the localisation of the adventitial cysts, the clinical symptoms, as well as the immunohistochemical demonstration of foamy macrophages instead of endothelial cells in the wall of the cysts. In one case the cause of the intermittent claudication could be verified by duplex sonography and comparison of the arterial pressure of both legs with a Doppler method only after physical exercise. As expected, an angiodilatation has only a temporary effect. Therefore a surgical resection of the cyst or of the involved arterial segment had be performed.

Malignant rhabdoid tumor in the gastric wall of an aged orangutan (Pongo pygmaeus)

A 34-year-old female orangutan (Pongo pygmaeus) developed renal failure and became uremic. At necropsy, large gastric masses were present around the cardia and in the corpus. Abdominal metastases occurred in the liver, pancreas, and right ovary. Light microscopic examination of the tumor revealed polygonal cells with vesicular nuclei and prominent nucleoli. The growth pattern was predominantly solid. Focal areas contained excentric cytoplasmic intermediate filament inclusions, as identified by immunohistochemistry and electron microscopy. Immunohistochemical procedures demonstrated mainly the vimentin type of intermediate filaments. Except for occasional cytokeratin, other intermediate filament markers and neural, lymphocytic, and histiocytic markers stained negative. The morphologic and ultrastructural characteristics are typical for a malignant rhabdoid tumor, a term used in human pathology to describe a rare and extremely aggressive malignancy of uncertain histogenesis. Although usually located in the infant kidney, a few reports have documented the occurrence of similar lesions in extrarenal sites of adults. In human tumors, vimentin is often combined with the expression of cytokeratins. The sparsity of the cytokeratin filaments in this case might be due to species-specific variations and/or may reflect the hypothesis of a phenotypic concept encompassing a spectrum of histogenetic diversity.

[Adenomatous neoplasia of the middle ear]

Adenomatous neoplasm occurring in the middle ear is rare. The clinical findings are non-specific and include otological symptoms as well as sometimes functional deficits of the lower cranial nerves. The final diagnosis will be made only after elaborate histological examinations because of the inconsistent radiological and clinical findings. DNA analysis yields some information on the prognosis of this tumour. We report on a case where a primary adenomatous neoplasm developed in the middle ear, and discuss our concept of therapy.

Autosomal dominant polycystic kidney disease--in vitro culture of cyst-lining epithelial cells

The major form of autosomal dominant polycystic kidney disease (ADPKD) in humans is linked to the PKD1 gene on chromosome 16p. The identity of the gene and the underlying pathogenetic mechanisms are not yet defined. Cyst-lining epithelial cells derived from a polycystic kidney were successfully grown in culture and designated MZ-PKD-1 cells. By linkage analysis, the related pedigree of the nephrectomized patient could be linked to the PKD1 gene on chromosome 16p. Thus, these cells exhibit the genotype of a mutated PKD1 gene and represent an in vitro culture model for ADPKD involving chromosome 16p. The antigenic phenotype was characterized immunohistologically by epithelial differentiation antigens and markers of individual nephron segments. An essentially identical antigenic pattern of proximal tubular cells was observed both in vitro and in fresh frozen tissue. Electron microscopy showed the formation of a microvillous-like coating. During growth phases in vitro successive changes in the cell shape were observed. MZ-PKD-1 cells exhibited a limited lifespan ending in replicative senescence. Northern blot analysis of kidney-growth-related genes, c-myc, TGF-alpha, TGF-beta 1, and EGF receptor revealed abundant expression of all of these genes in MZ-PKD-1 cells.

Dissection following balloon angioplasty of aortic coarctation: review of the literature

Balloon angioplasty of the coarctation of the aorta can result in intimal or medial or even adventitial dissections as demonstrated by in vitro studies and animal experiments. As a typical sign of stretching of the aortic wall, patients complain of pain during the angioplasty procedure. In the literature, aortic wall rupture and ventricular fibrillation during the procedure are reported. Additional sudden deaths can occur within 40 hours after the procedure. Mortality ranges from 0.1% to 2.5%. By transesophageal echocardiography, monitoring of balloon angioplasty, control of the positioning of the balloon, and control of the results and detection of complications are possible. Intimal as well as medial dissections can be detected with observed healing for intimal but also medial dissections. In order to avoid the patient's discomfort, intraaortic ultrasound will be used in the future, when major methodological improvements are done. Computed tomography demonstrates medial dissections but is not able to visualize intimal dissections. Using computed tomography and magnetic resonance after angioplasty of the coarctation of the aorta, irregularities are described in up to 17% of the patients. For angiography, a low detection rate of medial dissections has to be expected, when not biplane angiographies of the whole thoracic aorta are performed. Medial dissections can be seen, but intimal dissections are missed. In conclusion, a review of the literature demonstrates a high incidence of intimal and medial dissections after angioplasty of the coarctation of the aorta with spontaneous healing in most patients. As is the way with coronary angioplasty, aortic wall ruptures are rare, but stand-by surgery is necessary.

[Secondary achalasia in non-Hodgkin's lymphoma of low malignancy and leiomyomatosis of the cardia]

A 28-year-old man had been dysphagic for 9 months with a weight loss of 4 kg. A preliminary diagnosis of primary achalasia was made on the basis of typical radiological and manometric findings. Despite balloon dilatation of the cardia the symptoms did not improve and further diagnostic tests were performed. Ultrasound demonstrated a 4 cm tumour below the cardia. But its type and possible malignancy remained uncertain even at laparotomy. But as a malignant tumour was suspected a gastrectomy and omentectomy with removal of the local and regional lymph nodes were performed. After this the symptoms regressed and postoperative food intake was without problem. Histological examination of the surgical specimen revealed leiomyomatosis of the cardia and the gastric fundus, combined with a low-malignant B-cell lymphoma of the mucosa-associated lymphatic tissue. Oesophagus manometry 4 months postoperatively gave normal results. The patient has been free of symptoms and without evidence of recurrence for by now 18 months postoperatively.

Alport-type glomerulopathy: evidence for diminished capillary loop size

Hereditary nephropathy of the Alport type is morphologically characterized by a specific and diagnostic thinning and splitting lesion of the glomerular basement membranes, which can be recognized only by electron microscopy. The light microscopical aspect has not been considered to be characteristic until now. This paper describes a light microscopical constellation of glomerular alterations by which ATGP can be recognized with high probability. Three histological features are of importance: 1. ATGP glomeruli in patients older than 10 years of age mostly have smaller capillary loops than age-matched controls. However, during the first 10 years of life no difference in glomerular capillary loop size was noticed. 2. ATGP loops often stain less intensely with basement membrane stains. 3. Presence of fetal-like glomeruli. Using this triad of light microscopic parameters as a screening tool, ATGP-cases were found without knowledge of any clinical data among other glomerulopathies with a sensitivity of 72% and a specificity of 93%. The definitive diagnosis, however, depends on electron microscopy.

Fibrosing alveolitis responsive to corticosteroids following Legionnaires' disease pneumonia

Two male patients ages 54 and 58 years had persisting pneumonia with dry cough, dyspnea, weight loss, and fever up to 39 degrees C that did not respond to erythromycin treatment. There was extensive restrictive impairment of ventilation and loss of diffusing capacity for carbon monoxide. Histologic examination of the basal pulmonary infiltrates showed fibrosing alveolitis. Serologic titers indicated that the patients had suffered from Legionella pneumophila infection. We believe that Legionella had caused the fibrosing alveolitis since there was absence of any other causative agents or factors. Both patients responded to corticosteroid treatment with rapid clinical improvement but delayed radiologic regression.

[Obstructive jaundice: its histological diagnosis by percutaneous endoluminal bile duct biopsy]

32 forceps biopsies were performed in 30 patients with obstructive jaundice during percutaneous transhepatic biliary drainage procedures. In one patient an adequate specimen could not be obtained. In 25 of the remaining 31 cases diagnosis was confirmed histologically (malignant tumours: n = 22, benign stricture: n = 3). In 6 patients false-negative results were obtained. Transluminal biopsy is an easily performed adjunct to percutaneous transhepatic diagnostic interventions with minimal additional discomfort for the patient. In many cases percutaneous needle biopsy can be avoided. Forceps biopsy enables nonoperative histological diagnosis of small carcinomas of the bile ducts.

Bellini duct carcinoma: further evidence for this rare variant of renal cell carcinoma

Bellini duct carcinomas have recently been identified as a new entity in the spectrum of renal cell carcinomas and 10 cases have now been reported. The present paper adds detailed clinical and morphological data on six new cases. In addition, immunohistological and electronmicroscopical results support the origin of these tumours from the renal collecting ducts, especially the papillary ducts (Bellini ducts). A set of immunohistological reactions, including reactions to cytokeratins 13 and 19, vimentin and UEA-1 was found to facilitate the differential diagnosis of Bellini duct carcinomas from other renal cell carcinomas and infiltrating urothelial carcinomas of renal pelvis.

[An association of arterial occlusive disease with cyclosporine therapy after kidney transplantation]

Renal transplantation followed by immunosuppression with cyclosporine (whole-blood levels 200-300 micrograms/l) and methylprednisolone (4 mg daily) was performed in a 54-year-old man with chronic glomerulonephritis. Three years later rapidly progressive arterial obstructive disease (peripheral type) developed. Parenteral treatment with prostaglandins, calcium antagonists and nitrates, as well as a lumbar sympathectomy, was unsuccessful so that, in rapid succession, several amputations on upper and lower limbs became necessary. The disease progression was arrested only when azathioprine replaced cyclosporine. Raynaud's phenomenon, present at the time, also disappeared and analgesics were no longer required. Histological examination revealed severe Mönckeberg arteriosclerosis and thromboembolic occlusion of the affected vessels. The cyclosporine treatment, especially the hypercoagulability induced by it, and the Mönckeberg arteriosclerosis were thought to be significant factors in the pathogenesis of the rapidly progressive arterial disease. It is concluded that, in the presence of progressive arterial obstructive disease occurring under cyclosporine treatment, the replacement by other immunosuppressive agents should be considered.

Pulmonary histiocytosis X cells phagocytize Staphylococcus aureus in vitro

The broncho-alveolar lavage from an 18-year-old girl with proven histiocytosis X of the lung has been cocultivated with Staphylococcus aureus. Electron microscopy revealed that the bacteria adhere to the membrane of HX cells and become ingested afterwards.

[Classification of renal cell carcinoma/tumors and their relationship to the nephron-collecting tubules system]

After a controversial phase of nomenclature (including--among others--the terms "hypernephroma" and "hypernephroid carcinoma") a cytomorphologically defined subtyping of renal cell tumours (adenomas, carcinomas, oncocytomas) is offered, based on new electron microscopical and histochemical observations. These data are in part supported by cytogenetical findings reported in the literature. Phenotypical/histogenetical relations to different parts or cell types, respectively, of the nephron-collecting duct system could be demonstrated. Chromophobe cell carcinoma and oncocytoma exhibit features of the intercalated cells.

[Persisting alveolitis after Legionella pneumonia]

Pneumonia was diagnosed radiologically in three patients (43, 54 and 58 years old, respectively), presenting with temperatures between 39 degrees and 40 degrees C, cough and weight loss. These signs persisted for 6, 7 and 13 weeks, respectively, but the pathogens could not be cultivated. Lung function analysis showed partial respiratory insufficiency with extensive restrictive impairment of ventilation. Samples of lung tissue were obtained in all three cases and histology revealed fibrosing alveolitis. In two patients serology yielded antibody titres of 1:512 and in one patient of 1:128, against Legionella pneumophila. Treatment with 1 g erythromycin three times daily was unsuccessful. Therefore, the patients were given prednisone at an initial dosage of 50-100 mg which was subsequently reduced. Lung function normalised during this treatment course, radiological findings and antibody titres receded. Hence, treatment with corticosteroids should be attempted if there is an urgent suspicion of fibrosing alveolitis caused by Legionella pneumophila, after having excluded a florid infectious pneumonia and after failure of erythromycin treatment.

[Phagocytosis of Staphylococcus aureus and Pseudomonas aeruginosa by pulmonary neutrophilic granulocytes]

The elimination of Staphylococcus aureus (S. a.) and Pseudomonas aeruginosa (P. a.) by pulmonary neutrophilic granulocytes was investigated in vitro. The elimination rate of P. a. is appreciably smaller than that of S. a.. The reason for this is apparently a reduced degree of phagocytosis of P. a. in consequence of the slight adherence to the granulocyte membrane. The liberation of oxidants differs only to a negligible degree.

Surgical correction of a severely obstructed pulmonary artery bifurcation in Takayasu's arteritis

A young male patient (NYHA III) presented with a severe pulmonary artery bifurcation stenosis of unknown origin. He underwent successful radical resection and endarterectomy of abundant endoluminal and perivascular inflammatory tissue. Surgery was performed with extracorporeal circulation (ECC) without transection of the aorta and the pulmonary artery bifurcation was enlarged with a patch. Right ventricular to peripheral pulmonary artery pressure gradient fell from 80 mmHg preoperatively to 25 mmHg 18 months postoperatively. The patient is fully rehabilitated and working (NYHA I). Histological examination confirmed Takayasu's arteritis as the underlying disease and medium-term follow-up angiography showed an almost normal pulmonary artery bifurcation. We conclude that the radical surgical approach is a valuable palliation in this disease.

Peritonitis and massive granulocytic infiltration of the spleen in adult Still's disease

A case of adult Still's disease is described which, in addition to the more common manifestations, also included abdominal discomfort. Upon laparoscopy, peritonitis was disclosed; a biopsy showed massive granulocytic infiltration of the spleen which could not be attributed to an infectious disease. The patient did not improve on conventional therapeutic modalities but required intensive combination therapy consisting of high dose acetylsalicylic acid, prednisone, and slow-reacting substances before entering remission.

Chromophobe cell renal carcinoma and its variants--a report on 32 cases

This paper reports on 32 chromophobe cell renal carcinomas observed in 697 renal cell cancers (RCC) of adults (peak in the sixth decade of life). The chromophobe cell-type differs from other types of RCC macroscopically, the cut-surface being predominantly of grey-beige colour. Histologically, there are two variants: one is the typical (light) variant (n = 22) and the other is eosinophilic (n = 10). Both variants have in common (a) reaction of the cytoplasm with Hale's acid iron colloid; (b) electron microscopic detection of cytoplasmic microvesicles (150-300 nm), frequently with 'inner vesicles', and (c) low glycogen content in comparison with the clear cell carcinoma. Immunocytochemical investigations on the intermediate filaments show a positive reaction for cytokeratins No. 18 (uniformly) and Nos. 7 and 19 (to varying extents) for both variants, whereas vimentin was not found in any of these carcinomas, in contrast to the clear-cell type. The cytomorphological grading revealed predominantly G II tumours. A lymph node metastasis was found in one patient. On the basis of the mortality curves determined, the prognosis for patients with chromophobe cell carcinomas is more favourable than that of the clear-cell type. In terms of differential diagnosis, on the one hand, the typical (light) variant of the chromophobe cell RCC must be delimited from the clear-cell RCC, and on the other hand, the eosinophilic variant must be distinguished from the chromophilic or 'granular' RCC. Microscopic, histological, histochemical, electron microscopic, and intermediate filament analysis results document that the chromophobe cell type of RCC is a distinct entity. The implications for the nomenclature of RCC, especially with regard to the 'granular' type, are discussed.

[Relevance of histopathologic grading in colonic cancer]

The histopathological grading exerted a significant influence on prognosis in patients with colonic carcinoma. More than half of the well differentiated tumors were found in early stage pT1-3 N0 M0 compared to 25% of the G2- and 10% of the G3-tumors. The percentage of incurable cases in G2-tumors was twice as high and in G3-tumors three times as high as in patients with well differentiated carcinomas. The recurrence rate increased significantly with decreasing tumor differentiation from 21% to 51%. Despite the correlation with tumor stage the histopathological grading could be established as an independent prognostic variable and had an influence on the recurrence rate especially within tumor stage pT1-3 N0 M0.

[Morphology of the coronary arteries following percutaneous transluminal coronary angioplasty with hemopericardium]

Autopsy findings in a patient with cardiac tamponade following percutaneous transluminal coronary angioplasty (PTCA) are reported. Angiography during PTCA demonstrated coronary dissection without extravasation of contrast medium at the site of angioplasty. Histologic examination of the dilated coronary segment revealed longitudinal splitting of intima and media as well as circumferential subintimal and submedial dissection. Hemorrhage into plaque, intima, media, adventitia and dissection lumina was found. Disruption of the adventitia was not present. Cardiac tamponade may occur transadventitially without complete disruption of the coronary artery and without extravasation of contrast medium.

Acute human pyelonephritis: leukocytic infiltration of tubules and localization of bacteria

The fine structural details of how leukocytes appear in the lumen of tubules and the localization of bacteria in the tubulo-interstitial space were studied by light and electronmicroscopy in renal cortical biopsy specimens from three patients with acute pyelonephritis. The cells of interstitial infiltrates infiltrated and sometimes disrupted the cortical collecting tubules preferentially, while inflammatory infiltration of the proximal and distal convoluted tubules occurred more rarely. Since the emigration of tubular wall-localized individual leukocytes into the lumen was not observed even in long series of thin sections, focal inflammatory disruption of the uriniferous ducts was considered to be the morphological basis of the intratubular accumulation of leukocytes. The structural simplicity of the collecting tubular cells is suggested to be the reason for their preferential involvement in the drainage of the interstitial suppuration, although a role for specific carbohydrate receptors cannot be excluded. The bacteria were usually found within the neutrophilic granulocytes and macrophages of the interstitial infiltrates, and within and among the cells of leukocyte casts. Additionally, pure bacterial colonies were noticed in the lumen of a few collecting tubules. The problem of the adherence of the bacteria to the surface of the tubular cells is discussed.

Alterations of glomerular podocytic processes in immunologically mediated glomerular disorders

The importance of the relationship between the alteration of podocytic processes (PP) and proteinuria has been controversial for almost 30 years. In spite of several morphometric studies the range of PP alterations in different proteinuric conditions has gone unnoticed. Thus, we studied the distribution of abnormally broadened PP in different glomerulopathies and in normal controls (children and adults). We found a highly variable mean PP-width in all proteinuric patients, values that were, however, always clearly distinct from normal controls in children and adults. A correlation between the extent of PP alteration and the amount of proteinuria was not found (r = 0.09) for the group as a whole or for the different clinico-pathological entities. In proteinuric patients 15 to 50% of all PP were broadened and covered 40 to 60% of the total length of the peripheral capillary loop. We conclude that the alteration of PP in various proteinuric conditions is variable and does not correlate with the level of proteinuria. These studies further suggest that other mechanisms, possible hemodynamic adaptation in response to the capillary wall injury, might play a role in the permeability changes observed in these patients.

Alport's syndrome: specificity and pathogenesis of glomerular basement membrane alterations

In Alport's syndrome (AS) thinning and splitting of the glomerular basement membrane (GBM) are assumed to be characteristic ultrastructural alterations. Both lesions are, however, non-specific because they can occur in other glomerulopathies. In addition, splitting may be found in non-glomerular structures. It should be emphasized that the characteristic lesion in AS is a result of the widespread combination of thin and split GBM in the same biopsy specimen. In our opinion the basic lesion is the thin GBM, which is characterized by a lamina densa (measuring 50-150 nm in thickness) which may begin to split as a result of focal detachment of podocyte pedicles (spacing) and repeated subepithelial deposition of new lamina densa layers. Splitting thus appears to be a secondary lesion. Thinning of GBM may represent a persistent embryonal status of the lamina densa and may thus be the result of a development defect. This assumption is supported by the findings of fetal-like glomeruli and small capillary loops in AS.

[Merkel cell carcinoma of the upper eyelid]

Case report of a rare eyelid tumor in an 83-year-old woman. The excised lesion was classified as a neuroendocrine Merkel cell carcinoma on the basis of histologic, ultrastructural, and immunohistochemical examination. Detection of neurosecretory granules by electron microscopy and the characteristic cytokeratin and neurofilament pattern supported the diagnosis. The patient developed a local recurrence, which was successfully removed. There is no evidence of regional or distant metastases.

Urothelial leukoplakia: new aspects of etiology and therapy

We describe 3 women in 1 family who had systemic urothelial leukoplakia with no underlying pathological condition of the urinary tract. Irritative clinical symptoms resolved, and the macroscopic and microscopic appearance improved after 6 months of therapy with sodium pentosanpolysulfate. Electron microscopy showed special cells in the basal layer of the cornified squamous epithelium that also have been found in the trigone of women with so-called squamous metaplasia. Their similarity to Merkel's cells of the skin supports the theory that ectodermal cells are misplaced during embryogenesis. Genetic factors and sex hormones seem to influence the development of certain variants of squamous epithelium within the urinary tract.

Morphology of the coronary arteries after combined thrombolysis and percutaneous transluminal coronary angioplasty for acute myocardial infarction

Autopsy findings are reported for 6 patients who died early (8, 9, 12, 13 and 14 days) or late (52 days) after combined thrombolysis and percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction. Morphologic changes in the coronary arteries at the site of revascularization included injury to the inner portion of the arterial wall (intimal splitting, subintimal dissection, medial tears and submedial dissection) and necrosis of medial smooth muscle cells. Residual mural thrombi and thrombotic reocclusion were noted within the arterial lumen. There was a beginning neointima formation in all patients who died early and a reobstructing neointima proliferation in the patient who died late after PTCA. The results of this study support the suggestion that both rupture and dissection of the inner arterial wall and necrosis of the tunica media resulting from irreversible dilatation of the grossly intact outer layers are the most important mechanisms of PTCA. Response to arterial wall injury after PTCA is a neointima formation leading to covering of mural thrombi and thrombogenic intimal, medial and adventitial substances and smoothing of the luminal surface. Large residual mural thrombi and excessive neointimal proliferation may cause restenosis within a few weeks.

Histopathology and classification of renal cell tumors (adenomas, oncocytomas and carcinomas). The basic cytological and histopathological elements and their use for diagnostics

The term renal cell tumors (adenomas and carcinomas) subsumes the tumors deriving from the uriniferous tubule epithelium of the kidney. Precise analysis shows that the renal cell tumors display different cell types which build up the individual tumor alone or in combination with each other. Three categories of basic elements are distinguished in the characterization of renal cell tumors: Cytological elements = tumor cell types: Clear, chromophobe, chromophilic (basophilic, eosinophilic), oncocytic, spindle-shaped/pleomorphic. Histological elements = growth patterns: Compact, acinar (nest-like), tubulopapillary (tubular, papillary), cystic. Cytological grading of malignancy: G I, G II, G III; mainly based on the degrees of nuclear atypia. The cytological features are given priority compared to the histological growth forms for classification of renal cell tumors. However, the latter are not to be neglected in the overall evaluation of a tumor. A classification of renal cell tumors is suggested and the result of its application in 510 renal cell carcinomas and oncocytomas is presented. On this basis and in connection with the cytological grading, a more precise prognostic evaluation of the renal cell carcinomas is expected.

[Simplified procedure for cold preservation of human parathyroid gland tissue for replantation]

A simplified technique for cryopreservation of human parathyroid tissue is described. It allows to achieve the same quality of tissue than using the programmable expensive freezing method which is usually employed up to now. Cryovials are placed in a methanol bath. The temperature is decreased by -1 degree C/min down to -25 degrees C, thereafter by -10 degrees C/min down to -70 degrees C by repeated adding of cryo ice-cubes into the methanol. Thereafter the vials are stored in LN2. The temperature lowering is controlled by a stop watch and a thermometer in a reference vial. This simple and cheap technique may allow a more general application of cryopreservation in surgery of hyperparathyroidism.

The effect of cryopreservation on hormone secretion in vitro and morphology of human parathyroid tissue

The hormone secretion from human parathyroid tissue autografted after cryopreservation can fail frequently. In this study we examined the effects of the cryopreservation procedure on parathyroid hormone secretion in vitro and the viability of parathyroid cells to identify possible reasons for graft failure. Cryopreservation did not affect quantitative parathyroid hormone release from single-cell suspensions or its calcium-and magnesium-dependent regulatory mechanisms. However, morphometric analysis of thawed 1 mm3 graft particles showed various degrees of necrosis when compared with fresh grafts. Thus partial necrosis of cryopreserved tissue appears to contribute to poor transplantation results compared with immediate replantation of fresh parathyroid tissue. This limitation can be overcome by increasing the number of frozen graft particles used for autotransplantation. The percentage of viable cells should be accounted for by morphometric analysis and this factor used when calculating the number of graft particles employed.

A case of Sjögren's syndrome with severe anemia due to myelitis

An unusual case of Sjögren's syndrome presenting with severe anemia as the predominant clinical feature is described. Histological examination of a bone marrow biopsy specimen demonstrated that the patient's anemia was caused by myelitis and vasculitis of the small intraosseous vessels. Our report might stimulate a more thorough investigation of bone marrow in patients with connective tissue diseases and anemia.

Epitheloid hemangioendothelioma of the scalp. A case report with immunohistochemical and ultrastructural study

A case of an epitheloid hemangioendothelioma of the skin and subcutaneous tissue of the scalp is described. Clinically and histologically a (metastatic) carcinoma had been considered in differential diagnosis. Of great help in recognition of the endothelial nature of this tumor was the immunohistochemical reaction with Factor-VIII associated antigen and Ulex europaeus antigen. Not only tumor cells in solid areas, but also intracytoplasmic vacuoles revealed positive staining. Thereby it could be shown, that this paranuclear vacuoles are actually compatible with developing capillary lumina. Only few tumor cells showed positive reaction with alpha-1-antichymotrypsin, pointing to a possible small histiocytic component of this tumor. Endothelial features of tumor cells and developing capillary lumina also could be demonstrated by electronmicroscopy.

[Significance of family studies and kidney biopsies in children with renal hematuria]

In children with renal hematuria the Alport syndrome could be diagnosed more frequently, if electronmicroscopic examination of the patients renal biopsy and a positive family history were obtained. In 16 children with renal hematuria, Alport syndrome was suspected by renal biopsy, physical examination or family history. Electronmicroscopic examination of the biopsy specimens of all 16 children revealed thinning together with a thickening and lamellation of the glomerular basement membrane (GBM), considered to be characteristic for Alport syndrome. In 11 of the children nephropathy, inner ear deafness or ocular changes were identified in 31 family members. In these families genetic information on the risk for other children is possible; furthermore ineffective medications such as steroids and cytotoxic drugs can be avoided, once the diagnosis has been established. In 5 children with characteristic renal lesions family history revealed no further support of Alport syndrome. In these cases with presence of characteristic lesions of GMB without positive family history the diagnosis Alport syndrome cannot be established with certainty, further examinations are necessary.

Myelolipoma of the adrenal gland. Review of diagnostic problems and surgical intervention

Myelolipoma is a benign, rare, and hormone-inactive tumor of the adrenal gland. Its characteristic appearance on sonography and computed tomography enables preoperative diagnosis with a high degree of safety and accuracy. Symptomatic or large tumors have to be removed since there is a high risk of spontaneous hemorrhage. Common findings in patients with myelolipoma are reviewed, especially in those with surgically removed tumors.

Human chromophobe cell renal carcinoma

Twelve renal cell carcinomas composed of "chromophobe" cells are described. This is the first report of renal chromophobe cell tumors in humans neoplasms of this cell type having been described previously only in experimentally induced adenomas in animals. By light microscopy chromophobe cells have slightly opaque or finely reticular cytoplasm when stained with haematoxylin and eosin. They may be distinguished from the clear cells of hypernephroid renal cell carcinomas by the strongly positive reaction of their cytoplasm with Hale's (1946) colloidal iron method and the weaker positive reaction with alcian blue. Vesicular structures, often containing internal vesicles, and possibly derived from the endoplasmic reticulum or from mitochondria are visible electronmicroscopically. Glycogen is present to a variable but slight extent so that it is usually detected only by electron microscopy. The twelve renal cell carcinomas described were composed entirely of chromophobe cells. They were derived from a series of more than 500 adult renal cell carcinomas giving a frequency of approximately 2%. To avoid confusion the descriptive term "light cell" should be discarded and replaced by either "clear cell" or "chromophobe cell" as appropriate, since it is assumed that chromophobe cell tumors have a different derivation from clear cell and other renal cell carcinomas. They may also have a different prognosis although this has not yet been established.

[Retroperitoneal cyst: a little known internal medicine problem]

Retroperitoneal cysts are often a differential diagnostic problem. The diagnosis is not infrequently made only by laparotomy. Our experience with a 33 year old patient with pain localized in the left upper part of the abdomen and "cyst of the spleen" confirms this rule. The diagnosis of a lymphatic cyst of the retroperitoneum was made after the surgical enucleation.