Cardiovascular Complications in Pheochromocytoma and Paraganglioma: Does Phenotype Matter?

BACKGROUND

Adrenaline-producing tumors are mostly characterized by a sudden release of catecholamines with episodic symptoms. Noradrenergic ones are usually less symptomatic and characterized by a continuous overproduction of catecholamines that are released into the bloodstream. Their effects on the cardiovascular system can thus be different. The aim of this study was to determine the prevalence of cardiovascular complications by catecholamine phenotype.

METHODS

We retrospectively analyzed data on the prevalence of cardiovascular events in 341 consecutive patients with pheochromocytoma and paraganglioma treated from 1995 to 2023. Biochemical catecholamine phenotype was determined based on plasma or urinary catecholamines and metanephrines.

RESULTS

According to the phenotype, 153 patients had noradrenergic pheochromocytoma and paraganglioma and 188 had adrenergic pheochromocytoma and paraganglioma. In the whole sample, the incidence of serious cardiovascular complications was 28% (95 patients), with no difference between the phenotypes or sexes. The noradrenergic phenotype had significantly more atherosclerotic complications (composite end point of type 1 myocardial infarction and symptomatic peripheral artery disease; odds ratio, 3.58 [95% CI, 1.59-8.83]; P=0.003), while the adrenergic phenotype more often had type 2 myocardial infarction and takotsubo-like cardiomyopathy (OR, 0.24 [95% CI, 0.09-0.57]; P=0.002). These changes remained even after adjustment for conventional risk factors of atherosclerosis.

CONCLUSIONS

We found a 28% incidence of cardiovascular complications in a consecutive group of patients with pheochromocytoma and paraganglioma. Patients presenting with a noradrenergic phenotype have a higher incidence of atherosclerotic complications, while the adrenergic phenotype is associated with a higher incidence of acute myocardial damage due to takotsubo-like cardiomyopathy.

Gene Profile of Adipose Tissue of Patients with Pheochromocytoma/Paraganglioma

Background: Brown adipose tissue (BAT) is a therapeutic target to combat obesity and related disorders. Pheochromocytoma and functional paraganglioma (PPGL) are associated with activated BAT due to catecholamine excess. Our aim was to evaluate BAT activity by gene profile and assess its relation to clinical characteristics and overproduced catecholamine. Methods: mRNA expression of 15 genes in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) was measured via RT-PCR in 25 patients with PPGL and 14 controls undergoing cholecystectomy. Results: We found in VAT of PPGL higher expression of UCP1 (p < 0.001), CEBPB, PPARGC1A (both p < 0.001), PRDM16 (p = 0.069) and DIO2 (p = 0.005). UCP1 expression correlated only with norepinephrine levels and its metabolite. UCP1 expression, among others, correlated negatively with BMI, age and positively with HDLc levels. Dominance of BAT or BeAT markers was not assessed in PPGL. In SAT of PPGL, we found higher expression of ADRB3, CIDEA (both p < 0.05), and PPARGC1A (p = 0.001), but not UCP1. Conclusion: We demonstrate signs of UCP1-dependent norepinephrine-induced thermogenesis connected with higher expression of DIO2, PPARGC1A, CEBPB and PRDM16 in retroperitoneal VAT of PPGL and its relations to circulating HDLc and triglycerides levels. However, no direct relationship with increased basal energy metabolism measured by calorimetry was found.

Effect of adrenalectomy on remission of subclinical left ventricular dysfunction in patients with pheochromocytoma: a speckle-tracking echocardiography study

BACKGROUND

Pheochromocytomas (PHEO) are tumours with the ability to produce, metabolize and secrete catecholamines. Catecholamines overproduction leads to the decrease of longitudinal function of the left ventricle (LV) measured by speckle-tracking echocardiography. Patients with PHEO have a lower magnitude of global longitudinal strain (GLS) than patients with essential hypertension. GLS normalization is expected after resolution of catecholamine overproduction.

METHODS

Twenty-four patients (14 females and 10 males) with a recent diagnosis of PHEO have been examined before and 1 year after adrenalectomy. An echocardiographic examination including speckle-tracking analysis with the evaluation of GLS and regional longitudinal strain (LS) in defined groups of LV segments (basal, mid-ventricular and apical) was performed.

RESULTS

One year after adrenalectomy, the magnitude of GLS increased (-14.3 ± 1.8 to -17.7 ± 1.6%; P < 0.001). When evaluating the regional LS, the most significant increase in the differences was evident in the apical segment compared to mid-ventricular and basal segments of LV (-5.4 ± 5.0 vs -1.9 ± 2.7 vs -1.6 ± 3.8; P < 0.01).

CONCLUSIONS

In patients with PHEO, adrenalectomy leads to an improvement of subclinical LV dysfunction represented by the increasing magnitude of GLS, which is the most noticeable in apical segments of LV.

Postoperative adrenal insufficiency in Conn's syndrome-does it occur frequently?

Primary aldosteronism (PA) is the most frequent form of endocrine hypertension. Recently, frequent clinically significant adrenal insufficiency after adrenalectomy in subjects with PA has been reported, which may make the early postsurgical management difficult. We retrospectively searched for possible adrenal insufficiency in subjects who underwent adrenalectomy for PA and have measured cortisol in the early postoperative course. We included subjects with confirmed diagnosis of PA who underwent either posture testing (blood draw at 06:00 and 08:00) and/or adrenal venous sampling (AVS) (blood draw between 08:00 and 09:00) and have also measured cortisol after surgery (cortisol measured approximately at 07:00). Cortisol was measured by immunoassay. In this study, we identified 150 subjects (age 48.5 ± 10.3 years) with available cortisol values in the early postoperative course (median [25th percentile, 75th percentile]) 6 [5,6] days. Postoperative cortisol values (551 ± 148 nmol/l) were normal and significantly higher, compared to preoperative standing cortisol values (404 ± 150 nmol/l; (P < 0.001) and AVS cortisol values (493 ± 198 nmol/l; P = 0.009), and did not significantly differ from preoperative supine cortisol values. Postsurgical cortisol values were not different among subjects with or without abnormal dexamethasone suppression test or elevated urinary free cortisol pre-surgery, and were significantly higher in subjects with abnormal diurnal cortisol variability compared with subjects with normal diurnal variability. No patient presented with adrenocortical crisis in the later follow-up. In conclusion, postoperative cortisol values did not indicate any suspicion of possible adrenal insufficiency. To exclude possible adrenal insufficiency, it may be sufficient to measure morning cortisol in the early postoperative course.

Pheochromocytoma With Adrenergic Biochemical Phenotype Shows Decreased GLP-1 Secretion and Impaired Glucose Tolerance

CONTEXT

Impaired glucose homeostasis is a common finding in pheochromocytoma (PHEO), especially with adrenergic phenotype. The possible contribution of incretin dysfunction to dysglycemia in PHEO patients has not been studied.

OBJECTIVE

To compare changes in pancreatic endocrine function and gut hormones' production during a liquid meal test before and 1 year after adrenalectomy.

METHODS

In a prospective study, we included 18 patients with PHEO (13 females) with adrenergic biochemical phenotype. A liquid meal test with predefined isocaloric enteral nutrition was performed to evaluate dynamic changes in pancreatic hormones and incretins.

RESULTS

During the meal test, insulin levels were significantly lower before adrenalectomy only in the early phase of insulin secretion, but changes in area under the curve (AUC) did not reach statistical significance (AUC = 0.07). Plasma glucagon (AUC < 0.01) and pancreatic polypeptide levels (AUC < 0.01) were suppressed in comparison with the postoperative state. Impaired response to the meal was found preoperatively for glucagon-like peptide-1 (GLP-1; AUC P < 0.05), but not glucose-dependent insulinotropic polypepide (GIP; AUC P = 0.21). No significant changes in insulin resistance indices were found, except for the homeostatic model assessment-beta index, an indicator of the function of islet β cells, which negatively correlated with plasma metanephrine (R = -0.66, P < 0.01).

CONCLUSIONS

Our study shows suppression of pancreatic α and β cell function and impaired GLP-1 secretion during a dynamic meal test in patients with PHEO, which is improved after its surgical treatment. These data demonstrate a novel and potentially significant interconnection between excessive catecholamine production and the secretion of glucoregulatory hormones.

Blood Pressure Profile, Catecholamine Phenotype, and Target Organ Damage in Pheochromocytoma/Paraganglioma

CONTEXT

Impaired diurnal blood pressure (BP) variability is related to higher cardiovascular risk.

OBJECTIVE

To assess diurnal variability of BP and its relation to target organ damage (TOD) and catecholamine phenotype in a consecutive sample of pheochromocytoma/paraganglioma (PPGL).

DESIGN

We included 179 patients with PPGL All patients underwent 24 hours of ambulatory BP monitoring to determine dipping status. Differences in plasma metanephrine or urine adrenaline were used to distinguish catecholamine biochemical phenotype. To evaluate TOD, renal functions, presence of left ventricle hypertrophy (LVH), and the subgroup (n = 111) carotid-femoral pulse wave velocity (PWV) were assessed. Structural equation modeling was used to find the relationship among nocturnal dipping, catecholamine phenotype, and TOD parameters.

RESULTS

According to the nocturnal dipping, patients were divided into the three groups: dippers (28%), nondippers (40%), and reverse dippers (32%). Reverse dippers were older (P < 0.05), with a higher proportion of noradrenergic (NA) phenotype (P < 0.05), a higher prevalence of diabetes mellitus (P < 0.05), and sustained arterial hypertension (P < 0.01) and its duration (P < 0.05), as opposed to the other groups. All parameters of TOD were more pronounced only in reverse dippers compared with nondippers and dippers. The presence of NA phenotype (=absence of adrenaline production) was associated with reverse dipping and TOD (LVH and PWV).

CONCLUSIONS

Patients with reverse dipping had more substantial TOD compared with other groups. The NA phenotype plays an important role, not only in impaired diurnal BP variability but also independently from dipping status in more pronounced TOD of heart and vessels.

Radioimmunoassay of chromogranin A and free metanephrines in diagnosis of pheochromocytoma

This work discusses the clinical performance of chromogranin A, free metanephrine and normetanephrine determination in plasma using a radioimmunoanalytical methods for the diagnosis of pheochromocytoma and paraganglioma. Blood samples were collected from 55 patients (46 pheochromocytomas, 9 paragangliomas). A sampling of biological materials was performed preoperatively and about one week, six months and one year after adrenal gland surgery. The comparative group without a diagnosis of pheochromocytoma/paraganglioma consisted of 36 pheochromocytoma/paraganglioma patients more than 4 months after adrenal gland surgery, and of 87 patients, 16 of them with multiple endocrine neoplasia, 9 with medullary and 5 with parafolicullar carcinoma of the thyroid gland. The rest were patients with various adrenal gland disorders. Chromogranin A, metanephrine and normetanephrine were determined in the EDTA-plasma using a radioimmunoassay kits Cisbio Bioassays, France and IBL International GmbH, Germany. Clinical sensitivity was 96 % for the combination of metanephrine and normetanephrine, and 93 % for chromogranin A. Clinical specificity was 100 % for the combination metanephrine and normetanephrine, and 96 % for chromogranin A. Falsely elevated levels of chromogranin A were observed in 1 patient with chronic renal insufficiency and 9 analyses were influenced by the administration of proton pump inhibitors. These results were excluded of CGA specificity. Both the combination of plasma free metanephrine, normetanephrine and chromogranin A as determined by radioimmunoassays, which are simple without the necessity of special laboratory material, are effective markers of pheochromocytoma or paraganglioma. Chromogranin A exerts association to malignity and all markers are associated with tumor mass.

Biochemical Testing After Pheochromocytoma Removal: How Early?

Pheochromocytomas are catecholamine-producing tumors with typical clinical presentation. Tumor resection is considered as an appropriate treatment strategy. Due to its unpredictable clinical behavior, biochemical testing is mandatory to confirm the success of tumor removal after surgery. The aim of the study was to investigate the feasibility of a shorter interval of postoperative testing (earlier than the recommended 2-4 weeks according to recently published Guidelines). We investigated 81 patients with pheochromocytoma before and after surgery. Postoperative examination was performed of stable subjects after their transport from the surgical to the internal ward (7.1±2.2 days after surgery). Plasma metanephrines were used for the diagnosis of pheochromocytoma and confirmation of successful tumor removal. All subjects with pheochromocytoma had markedly elevated plasma metanephrines before surgery. No correlation between postoperative interval (the shortest being 3 days) and plasma metanephrine levels was found. Postoperative plasma metanephrine levels did not differ significantly from those taken at the one-year follow-up. In conclusion, we have shown that early postoperative diagnostic workup of subjects with pheochromocytoma is possible and may thus simplify early postoperative management of this clinical condition.

High incidence of cardiovascular complications in pheochromocytoma

Excess of catecholamines in pheochromocytoma is usually accompanied with classical symptoms and signs. In some cases, severe cardiovascular complications (e. g., heart failure, myocardial infarction) may occur. We performed a retrospective analysis focused on the incidence of cardiovascular complications (classified as follows: arrhythmias, myocardial involvement or ischemia and atherosclerosis, cerebrovascular impairment) before the establishment of diagnosis of pheochromocytoma among 145 subjects treated in our hospital. Cardiovascular complications occurred in 28 subjects, but these subjects did not differ significantly from subjects without complications in age, gender, body mass index, paroxysmal symptoms, symptom duration, tumor dimension, catecholamine secretory phenotype, and incidence of hypertension or diabetes mellitus. Arrhythmias occurred in 15 subjects (2 arrhythmia types in 2 subjects): atrial fibrillation in 9 subjects, supraventricular tachycardia in 3 cases, and ventricular tachycardia in 2 patients. Significant bradycardia was noted in 3 cases. Five subjects presented with heart failure with decreased systolic function (takotsubo-like cardiomyopathy found in 2 cases). One subject suffered from hypertrophic obstructive cardiomyopathy. Seven subjects presented with non-ST-segment elevation myocardial infarction, 2 patients with ST-segment myocardial infarction, and 1 subject underwent coronary artery bypass grafting. Two subjects suffered from significant peripheral atherosclerosis. Among cerebrovascular complications, transient ischemic attack was found in 3 cases, 2 subjects suffered from stroke, and subarachnoidal bleeding occurred in 1 patient. One subject suffered from diffuse neurological impairment due to multiple ischemic white matter lesions. These data show relatively high incidence of cardiovascular complications (19.3%) in subjects with pheochromocytoma. Early diagnosis is mandatory to prevent severe complications in pheochromocytoma.

Intrapancreatic accessory spleen

Intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately 1% to 2%. Accessory spleen itself is found in approximately 7% to 15% of the population. Our findings show a case of an intrapancreatic accessory spleen suspected for a malignancy in the pancreatic tail. A 63-year-old man admitted for cholecystitis was incidentally diagnosed with a tumor at the pancreatic tail. On hyperintense magnetic resonance imaging, a solid mass of 1.5 cm in diameter in the pancreatic tail was seen, which contrasted as hyperdense in T2-weighted imaging. Because of inhomogeneous enhancement on the early vascular phase, the diagnosis of a endocrine pancreatic tail carcinoma was suspected. Intraoperatively, an accessory spleen was found in the pancreatic tail. An oncologic left pancreatectomy was performed because of a malignant tumor. Histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. In conclusion, intrapancreatic accessory spleen is a rare cause of unnecessary laparotomy, but the absence of reliable diagnostics for this entity make histologic ascertainment of a benign tumor indispensable. Therefore, we still needed an oncologic tumor resection.

[Intrapancreatic accessory spleen]

BACKGROUND

Intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and in about 1-2% located in the pancreatic tail. Accessory spleens itself are found in about 10-15% of the population. Our findings show a case of an intrapancreatic accessory spleen suspected for a malignancy in the pancreatic tail.

PATIENT

A 63-year-old man admitted for Cholezystitis was incidencially diagnosed with a tumor at the pancreatic tail. On MRI a hyperintense solid mass of 1.5 cm in diameter in the pancreatic tail was seen, which contrasted hyperdense in T2-weighted imaging. Due to inhomogenous enhancement on the early vascular phase the diagnosis of a endocrine pancreatic tail Carcinoma was suspected.

RESULTS

Intraoperative an accessory spleen was found in the pancreatic tail. An oncological left pancreatectomy was performed suspecting a malignant tumor. Histology showed an intrapancreatic accessory spleen in the pancreatic tail excluding presence of cancer.

CONCLUSION

Intrapancreatic accessory spleen is a rare cause of unnecessary laparotomy but the absence of reliable diagnostics for this entity make histological ascertainment of a benign tumor indispensable. Therefore we still need an oncological tumor resection.

[Laparoscopic pyeloplasty in adults--mid-term results in 32 laparoscopic pyeloplasties during 2003-2008]

Pyeloureteric iunction obstruction is the most common inborn error of the upper urinary pathways. In the time of routine prenatal ultrasound examination, this disease is discovered in the child's age, when it is treated most frequently. Publication summarizes the results of modern laparoscopic management in the adults, who had not been diagnosed previously and symptoms occurred many years after their birthdate. The surgical treatment has been changed in the approach, but not the goal of desobtruction. The results in the adults are influenced not only by the operation technique, but also by the length of time the obstruction lasted and by the number and severity of the inflammatory changes.

[Neurinoma of the recurrent nerve]

AIMS

Neurinoma of the recurrent nerve presented a rare diagnosis in thyroid gland surgery.

METHODS

A case report is presented and the result of the neurinoma of the recurrent nerve extirpation--nerve paresis--is discussed with the rare results in literature.

RESULTS

The preoperative diagnosis is difficult and intraoperative histological diagnosis was not correct. The postoperative paresis of the nerve was clinical only very light.

CONCLUSION

The problematical neuromonitoring by isolated nodes in parathyroideal regions and after their exstirpation must lead to the suspicion of a recurrent nerve neurinoma.

[Mid-term outcomes and survival rates in patients with radical retropubic prostatectomy (RRP) under current Czech healthcare system]

The mid-term results (5 yr) after radical retropubic prostatectomy (RRP) are outlined and compared with pre- and postoperative parameters of patients. While 5 years survival could be expected in as many as 92.4%, relatively higher age (majority over 65) brings a higher risk of complications with it, though fully comparable with international standards. No perioperative mortality was recorded (0%), obstructive symptoms post-operatively developed in 13.4% patients, who were subsequently managed successfully endoscopically. Continence with maximum one pad per 24 hours was recorded in 77.2%, the severe incontinence was only in 3.3%. Spontaneous erection was reported in 4.3%, but except for higher age, the other objective factors were involved.

[Outcomes of transperitoneal laparoscopic nephrectomy for renal adenocarcinoma]

Laparoscopic radical nephrectomy (LRN) is method of choice in malignant renal tumors (RCC) stage T1-3. Procedure has proved to be technically safe with low post-operative morbidity and standard oncological results, provided the patients are secondaries free in the time of surgery, and there was no positive margin in resected tissue. There was no recurrence even after 6 years of follow-up. The most influential variables regarding the survival of patients postoperatively were: presence of metastases in the time of surgery p <0.0001, pathological grade p < 0.001, stage p < 0.018 and p < 0.046, respectively, if the tumors were 4 cm and bigger. It could be concluded, that laparoscopic way of removing the tumor with the kidney has proved the same oncological results even in the mid-term follow-up, if compared with classical open surgery done lege artis.

Visualization of symbiotic tissue in intact root nodules of Vicia tetrasperma using GFP-marked Rhizobium leguminosarum bv. viciae

In rhizobial symbiosis with legume plant hosts, the symbiotic tissue in the root nodules of indeterminate type is localized to the basal part of the nodule where the symbiotic zones contain infected cells (IC) interspersed with uninfected cells (UC) that are devoid of rhizobia. Although IC are easily distinguished in nodule sections using standard histochemical techniques, their observation in intact nodules is hampered by nodule tissue characteristics. Tagging of Rhizobium leguminosarum bv. viciae strain 128C30 with a constitutively expressed gene for green fluorescent protein (nonshifted mutant form cycle3) in combination with the advantages of the tiny nodules formed by Vicia tetrasperma (L.) SCHREB . allowed for vital observation of symbiotic tissue using fluorescence microscopy. Separation of a red-shifted background channel and digital image stacking along z-axis enabled us to construct a nodule image in a classical fluorescence microscopy of nodules exceeding 1 mm in diameter. In parallel, visualization of nodule bacteria inside the symbiotic tissue by confocal microscopy at the excitation wavelength 488 nm clearly distinguished IC/UC pattern in the nodule virtual sections and revealed red-shifted fluorescence of nonrhizobial origin. This signal was located on the periphery of IC and increased with their degradation, thus suggesting accumulation of secondary metabolites, presumably flavonoids. The simultaneous detection of bacteria and secondary metabolites can be used for monitoring changes to intact nodule physiology in the model legumes. The advantage of V. tetrasperma as a suggested laboratory model for pea cross-inoculation group has been demonstrated.

[Detection of prostate cancer by ultrasonographically-guided transrectal prostate biopsies at the Department of Urology of the First Faculty of Medicine, Charles University and General Teaching Hospital in Prague, analysis of 1464 cases]

BACKGROUND

Early diagnostics of prostate cancer is still the most important factor in tumor-specific survival of patients harbouring this malignant disease. Without better understanding of the etiology and without relevant markers of the disease progression, only the early diagnostics of organ-confined disease can save the patient's life.

METHODS AND RESULTS

Throughout 7 consecutive years, 1464 transrectal prostate biopsies in 1302 patients were performed. In all cases, the age, DRE (positive or negative), prostatic volume (ccm), total PSA in peripheral blood (ng/ml) were assigned, as well as free/total PSA ratio (%) in most of them. Apart from previously used linear regression, we applied logistic regression, since only age grows linear and DRE is determined only as positive or negative. The surrogate endpoint was ROC, which determines the area applying to the relations of sensitivity and specificity of any marker. Multifactorial logistic regression then reached best results at values over 0.8 in all tested age categories with maximal deviation of 8%, which had not been achieved before.

CONCLUSIONS

Despite hundreds of papers published on this topic, the question of when and how the patient is indicated to the biopsy of the prostate has not been solved. A computer driven model based on 1464 documented examinations on the relatively homogeneous population is presented. On the basis of the combination of biological and statistical methods, the model can give correct predictions in 9 out of 10 cases.

[Analysis of results of percutaneous nephrolithotomies]

BACKGROUND

Percutaneous nephrolithotomy is an effective less invasive method for the treatment of nephrolithiasis. Authors retrospectively analysed results of this procedure performed in a single centre (Department of Urology, General University Hospital, Prague) from January 2005 till June 2007.

METHODS AND RESULTS

Patients were acquired by an analysis of operating reports performed over a period January 2005 till June 2007 and subsequently a retrospective analysis of electronic and paper patient's records was carried out. Percutaneous nephrolithotomy was performed in 150 patients. Of those, 117 (78%) patients underwent primary and 33 (21.3%) secondary procedure. Analysed group consisted of 85 (56.7%) men and 65 (43.3%) women. Right-sided procedure was performed in 46% (69 times) and left-sided in 54% (81 times) of cases. Mean patient's age was 52.9 years (SD +/- 16.3). Mean stone size was 18.3 (SD +/- 9.5) mm. Staghorn calculi were present in 19 (12.7%) patients and 77 (51.3%) patients had more than 1 stone. Intracorporeal lithotripsy was necessary in 82 (54.7%) cases. Seventy eight (52.9%) patients were stone free after the procedure. There were 24 (16%) patients with an anatomic abnormality of upper urinary tract. The most common (in 64.3%) component in analysed stones was a calcium oxalate.

CONCLUSIONS

The amount of stone free patients is rather lower compared to the literature results. However, definitive results are always affected by auxiliary procedures (mainly extracorporeal shock wave lithotripsy), which are not included in the analysis.

[Progress of laparoscopic surgery in adults at the Department of Urology of the First Faculty of Medicine and General Teaching Hospital]

Laparoscopy is the most modern operative technique, the main advantage of which is the least invasivity. In urology, the laparoscopy has won its yield only in nineties of 20th century, but it was in urology, where the robots were launched as first, and nowadays using them it is possible to perform ablative/reconstructive surgery in a tiny intracorporeal space. The price of laparoscopic operations is high and has been the only limit up to now, but technical approaches and indications have already been fixed.

[Conservative treatment of the traumatic neurogenic bladder dysfunction]

The goal of the conservative treatment of neurogenic bladder dysfunction is preservation of upper urinary tract and improving continence. The multifactorial approach is needed in the decision and the treatment must be individualized according to the results and side effects, patients and his family compliace. The therapy facilitating urine storage is focused on inhibiting bladder contractility, decreasing sensory input and increasing bladder capacity or increasing outlet resistance. The therapy facilitating voiding is focused except clean intermittent (auto)catheterization on increasing bladder contractility and decreasing outlet resistance. The combination of different approaches is frequent.

[Inovative techniques in partial laparoscopic resection of the kidney for adenocarcinoma]

Authors present the first case of laparoscopic partial resection of the kidney for RCC using modern technique of tissue sealing with FloSeal, which was used in this indication for the first time in the Czech Republic. The other most useful innovative point was the usage of tail-clipped sutures from resorbable material "Lahodny", which are suitable for suturing in renal parenchyma. Despite the relatively long time of warm ischemia, the function of rest of the kidney is more than satislying.

Visualization of nodulation gene activity on the early stages of Rhizobium leguminosarum bv. viciae symbiosis

A technique was optimized for the in situ detection of nodulation (nod) gene activity in Rhizobium leguminosarum bv. viciae symbiosis with compatible plant hosts Vicia tetrasperma (L.) SCHREB. and Pisum sativum L. The transcription of nodABC-lacZ fusion was visualized as beta-galactosidase (beta-Gal) activity after reaction with the chromogenic substrate X-Gal and subsequent light microscopy, while the background of the indigenous beta-Gal activity of rhizobia and the host plant was eliminated by glutaraldehyde treatment. V. tetrasperma was suggested as a suitable model plant for pea cross-inoculation group due to its advantages over the common model of V. hirsuta (L.) S.F. GRAY: compactness of the plant, extremely small seeds, fast development and stable nodulation under laboratory conditions. In the roots of both plants, a certain extent of nod gene activity was detectable in all rhizobia colonizing the rhizoplane. In pea 1 d after inoculation (d.a.i.), the maximum was localized in the region of emerging root hairs (RH) later (3 and 6 d.a.i.) shifting upwards from the root tip. Nodulation genes sustained full expression even in the infection threads inside the RH and the root cortex, independently of their association with nodule primordia. Comparison of two pea symbiotic mutant lines, Risnod25 and Risnod27, with the wild type did not reveal any differences in the RH formation, RH curling response and rhizoplane colonization. Both mutants appeared to be blocked at the infection thread initiation stage and in nodule initiation, consistent with the phenotype caused by other mutant alleles in the pea sym8 locus. Judging from the nod gene expression level and pattern in the rhizoplane, flavonoid response upon inoculation is preserved in both pea mutants, being independent of infection thread and nodule initiation.

[Treatment of the lower pole nephrolithiasis]

BACKGROUND

The purpose of the study was to compare the efficacy of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for lower pole nephrolithiasis.

METHODS AND RESULTS

We retrospectively analyzed results of lower pole nephrolithiasis treatment in 396 patients (221 treated by extracorporeal shock wave lithotripsy and 175 by percutaneuos nephrolithotomy). We evaluated results of the treatment in the 3 months interval after the procedure in groups classified according to the stone size: <10 mm, 10-20 mm, >20 mm. Stone free status was achieved in these groups after 96 (66%), 43 (38 %) and 2 (25%) shock wave lithotripsies and 48 (84%), 75 (76%) and 25 (74%) percutaneous nepholithotomies. The efficacy irrespective of insignificant residual fragments (< 4 mm) was in 176 (66%) lithotripsies and 156 (82%) single percutaneuos nephrolithotomies.

CONCLUSIONS

Percutaneous nephrolithotomy is more effective methods in the treatment for lower pole nephrolithiasis than extracorporeal shock wave lithotripsy especially for stone size >10 mm.

[Reconstruction surgical procedures for iatrogenic injuries to the ureter. Examples of uncommon, however successful approaches to their management]

The authors present several less usual reconstructions of ureters after the primary iatrogenic lesions. The appropriate ureteric capacity to drain the urine after previous injury is quite demanding and hence before the definitive decision is made the wholesome health status of the patient is to be considered and all possible solutions should be weighted. The efficient primary urinary diversion above the lesion is unavoidable. The genuine reconstruction could be deferred by several weeks or months in the view that in some cases the least invasive (endourologic) methods can completely avoid the need of open surgery in difficult adhesions after previous major surgery.

[Role of laparoscopy in uro-oncology]

The article reviews problems of laparoscopic surgery in uro-oncology. Examples supporting and opposing the laparoscopic alternative are given. Original objections against the use of the method for the treatment of malignancies are discussed from the retrospective position. According to the predominant views it looks that laparoscopic treatment by a highly educated team with good technical background, respecting oncologic and functional aspects, does not have worse short-term and long-lasting results. The improving diagnostics and possibility to identify malignancies in early stage of development will enable wider use of the laparoscopic surgery.

[Echinococcus cysts (hydatids)]

INTRODUCTION AND MATERIAL

This work is based on rich experience of the first-stated author. During a three-year expertise in Botswana he operated 80 patients with hydatic cysts and he took part in treatment of other patients affected by the Echinococcus granulosus infection. In 59 cases the infectious focus was located in the liver, in 18 cases in the lungs, in 2 cases in the spleen and in one case the foci were multiple peritoneal.

METHODOLOGY

During the expertise period, the patients were observed prospectively, throughout the diagnostic decision-making and the treatment. Prior to the surgical procedure, they had been, in a long-run, treated with albendazole. In 18 cases out of the total number of the liver cysts, the experts chose a two-step procedure followed by a secondary plombage of the reduced cavity of the cyst with the omentum. The rest of the cysts were removed. Miniinvasive methods were not applied. However, the authors discuss their risks.

RESULTS

None of the patients exited, in 3 cases a peroperational anaphylactic reaction was managed. Throughout the expertise, no cases of the echinococcus dissemination in the operated subjects were recorded. The team even managed to treat the hydatic cysts in patients who were HIV/AIDS positive and who were, originally, in a serious state of immunodeficiency. Five cases are presented in the form of brief case reviews.

CONCLUSIONS

Benefits of the long-term preparation with albendazole--plombage operations are beneficial to be conducted in two steps, Betadin is the most suitable lavage solution, miniinvasive surgical procedures (PAIR) may bring on specific complications.

[Benefits and risks of urologic laparoscopic surgery in adult patients]

The paper describes the advantages and disadvantages of the laparoscopic operations, the number of which steadily rises in urology. The laparoscopic surgery is considered to be a benefit regarding the short postoperative hospital stay, painless postoperative course, and virtually non-existing postoperative paralytic ileus. As disadvantage are deemed the long learning curve for the operating personal, and high economical costs, which could be cut down only if short off-work period in productive population is included. In the paper, the pathophysiological guidelines are outlined and emphasized during the laparoscopic operation, which the surgical and anesthesiological teams have to have in mind. On the own cohort of patients, the numbers and types of operations are described, which have been done at our department.

[HIV/AIDS positive patients in surgery. Part I: Epidemiologic situation]

INTRODUCTION AND MATERIAL

The paper is mostly based on materials and experience of the first author, who took part in an expert action, together with an international team of surgeons, treated more than 6000 HIV-positive patients in Botswana and performed more than 3,200 interventions himself. The co-authors corrected the African experience by a brief survey of experience in this country and reviewed the presently valid legislation.

METHODS

The first two parts deal with literature knowledge on HIV/AIDS and confront it with the author's experience over three years of his expert stay in a hospital in Gabarone. The first part deal with epidemiological situation in the place of study and the second part analyzes in a general aspect the problems of surgical intervention in HIV-positive patients and the occupational risk. This part also includes a corresponding description of conditions in the Czech Republic including Czech legislation. The third, principal, part of the contribution is a prospective study where the author, under limited local conditions, investigated 3,200 HIV-positive patients undergoing surgery. The relation between HIC and tuberculosis is also analyzed from various other minor aspects and there are mainly the levels of CD4+ T lymphocytes followed from the standpoint of course of therapy and prognosis of the patients. The fourth part of the paper describes briefly twelve cases confirming and illustrating the results.

RESULTS

HIC-positive individuals with the CD4 value below 200/mm3 represent the critically endangered patients. The values between 200 and 499 represent a distinct risk, which may be overcome, and values between 500 and 799 represent a minimum risk, whereas the value over 800 is exceptionally favorable. Tuberculosis is a very frequent opportune infection in African conditions (over 53% in the cohort under study), but rather than to influence the prognosis itself it act in relation to the values of CD4+ T lymphocytes. The main risk for surgical patients related to decreased immunity is not due to complications in the wounds and anastomoses, but in severe opportune infections.

CONCLUSIONS

This most comprehensive surgical survey on HIV/AIDS, worked out by Czech authors, is very well applicable in conditions of the Czech Republic.

[Mesenteric venous thrombosis--a shift in therapeutic strategy?]

The authors present a group of nine patients suffering from mesenteric venous thrombosis, which were treated in three hospitals with participation of the first author. Basic principles of diagnostic and therapeutic procedure are summarized and a shift in the treatment strategy over the last 10 years is pointed out. The patient after a very radical intestinal resection may expect to survive and entertain an acceptable quality of life, provided the surgery is followed by an extensive team care in the post-operation period, later accompanied by the care of specialists in modern ways of nutrition.

Allelic relationships of pea nodulation mutants

Thirteen stable nonnodulating mutant lines of pea (Pisum sativum L.) originating from cv. Finale were tested for allelism in pairwise crosses. The F(1) plants were evaluated for the symbiotic phenotype under controlled growth conditions against the nodule bacterium Rhizobium leguminosarum bv. viciae strain 248. All mutations were found to be recessive and the lines were classified into eight complementation groups comprising Risnod1-Risnod23, Risnod8, Risnod9-Risnod22, Risnod14, Risnod19-Risnod25, Risnod20, Risnod24-Risnod26, and Risnod32. Position of Risnod21 was not firmly established, leaving the possibility of allelism both with Risnod19-Risnod25 and Risnod20. The results were partially consistent with the previous reports on the allelism of these lines. Additional crosses confirmed the correspondence of Risnod14 with the locus sym7 and of Risnod19-Risnod25 with sym8. The high number of eight complementation groups formed by 13 mutants provides an indication of additional nodulation loci in pea to those already reported and confirms the complexity of the genetic control of the early stages of nodulation.

Effect of exogenous flavonoids on nodulation of pea (Pisum sativum L.)

Selected flavonoids that are known as inducers and a suppressor of nodulation (nod) genes of the symbiotic bacterium Rhizobium leguminosarum bv. viciae were tested for their effect on symbiosis formation with garden pea as the host. A solid substrate was omitted from the hydroponic growing system in order to prevent losses of flavonoids due to adsorption and degradation. The presumed interaction of the tested flavonoids with nod genes has been verified for the genetic background of strain 128C30. A stimulatory effect of a nod gene inducer naringenin on symbiotic nodule number formed per plant 14 d after inoculation was detected at concentrations of 0.1 and 1 micro g ml(-1) nutrient solution. At 10 micro g ml(-1), the highest concentration tested, naringenin was already inhibitory. By contrast, nodulation was negatively affected by a nod gene suppressor, quercetin, at concentrations above 1 micro g ml(-1), as well as by another tested nod gene inducer, hesperetin. The deleterious effect of hesperetin might be due to its toxicity or to the toxicity of its degradation product(s) as indicated by the inhibition of root growth. Both the stimulatory effect of naringenin and the inhibitory effect of quercetin on nodule number were more pronounced at earlier stages of nodule development as revealed with specific staining of initial nodules. The lessening of the flavonoid impact during nodule development was ascribed to the plant autoregulatory mechanisms. Feedback regulation of nodule metabolism might also be responsible for the fact that the naringenin-conditioned increase in nodule number was not accompanied by any increase in nitrogenase activity. By contrast, the inhibitory action of quercetin and hesperetin on nodule number was associated with decreases in total nitrogenase activity. Naringenin also stimulated root hair curling (RHC) as one of the earliest nodulation responses at concentrations of 1 and 10 microg ml(-1), however, the same effect was exerted by the nod gene suppressor, quercetin, suggesting that feedback regulatory mechanisms control RHC in the range of nodulation-inhibiting high flavonoid concentrations. The comparison of the effect of the tested flavonoids in planta with nod gene activity response showed a two orders of magnitude shift to higher concentrations. This shift is explained by the absorption and degradation of flavonoids by both the symbionts during 3 d intervals between hydroponic solution changes. The losses were 99, 96.4, and 90% of the initial concentration of 10 micro g ml(-1) for naringenin, hesperetin, and quercetin, respectively.

[An AV aneurysm of a branch of the pulmonary artery associated with a pulmonary tumorlet]

The authors present a rare case of a relatively large A-V aneurysm of the branch of the pulmonary artery in the right upper pulmonary lobe. Successful and technically easy surgical treatment was preceded by a serious dilemma whether to select in a high risk patient another (less invasive) therapeutic method or even conservative treatment. The surgical finding and smooth postoperative course confirmed that the indication of surgery was correct. As a further pathological finding in the resected portion a pulmonary tumourlet was detected. The combination of the two rare findings is an extreme rarity.

[Laparoscopic transperitoneal adrenalectomy in hormonally-active adrenal tumors]

Laparoscopic adrenalectomy is considered the "gold standard" in adrenal surgery for benign functioning (and non-functioning) tumors. Laparoscopy meets criteria of miniinvasive surgery with minimal postoperative pain, short hospital stay and an outstanding cosmetic effect, the radicality of the procedure, open surgery and laparoscopy are equally effective. In cooperation with endocrinological department focused on detection of functioning adrenal tumors, the diagnostic and therapeutic procedure seems to be very efficient, so that the primary goal of rapid cure could be achieved. Patients after laparoscopic adrenalectomy mostly do not need chronic antihypertensive medication and only those after bilateral adrenalectomy (Cushing's disease) require life-long low dose hydrocortisone therapy. In pheochromocytomas, total excision of the tumor is considered to be a life-saving procedure, although up to 20% may recur as hereditary or as a part of von Hippel-Lindau's disease.

[Vesico-colonic fistulae in patients with chronic urinary tract infections]

The authors present their experience with diagnosis and treatment of colovesical fistula, which had been diagnosed due to chronic recurrent urinary tract infection. The underlying cause of the fistula was previously unrecognized diverticulosis with diverticulitis (3 out of 4 cases). The fistula was diagnosed primarily by a urologist, who performed cystoscopy, which proved to be the most contributing useful examination of all. On the other hand, coloscopy did not reveal the true diagnosis any time and its value is doubtful since insufflation of the inflamed bowel may be followed by intestinal rupture into the peritoneal cavity. Treatment of the fistulae was always surgical, during resection of the involved bowel and resection of the neighboring bladder was accomplished. In all cases one-staged procedure was done with restoration of bowel continuity and suturing of the bladder. Three patients were cured, one died on the 5th day due to complicated ischaemic heart disease.

Hydrocarbon deposition and soil microflora as affected by highway traffic

The proximity of a busy highway (90,000 vehicles/day) increased the amount of polycyclic aromatic hydrocarbons (PAHs) in soil at the depth of 5-15 cm from 106 ng/g as a grassland background to 3095 ng/g dry soil at the highway verge (a sum of 10 PAH species). The PAH concentration was related to the distance from the source and exhibited a biphasic character, which is interpreted in terms of bimodal distribution of the exhaust microparticles with different rates of deposition. Similarly, the tendency of benz(a)anthracene, chrysene, benzo(b)fluoranthene, benzo(k)fluoranthene, and indeno(1,2,3-cd)pyrene to decrease their proportion with distance from the highway, in contrast to phenanthrene, fluoranthene, pyrene, benzo(a)pyrene, and benzo(g,h,i)perylene, was attributed to their prevalent localisation on the heavier particle fraction. The abundance of bacteria (8.33 x background) and fungi (3.17 x background) close to the highway is thought to be a consequence of hydrocarbon deposition from the traffic that serves as a significant energetic input into the soil. The elevated concentrations of hydrocarbon substrates, as indicated by PAHs, increased both the absolute and relative numbers of the microbial degraders of diesel fuel, biphenyl, naphthalene, and pyrene. Their maximum numbers at 0.5-1.5 m from the pavement reached 1.3 x 10(4), 1.2 x 10(5), 1.1 x 10(4), and 6.6 x 10(3) colony-forming units (CFU) or infection units per gramme dry soil, respectively. On the other hand, the number of anthracene degraders (1.1 x 10(3) CFU per g dry soil) remained close to the detection limit of the enumeration technique used (0.1-0.2 x 10(3) per g dry soil), consistently with the absence of anthracene and higher linear PAHs in the investigated soil samples. The amounts of persisting PAHs justify artificial inoculation with effective degrader strains in the vicinity of motorways.

[Severe injury of the tracheal bifurcation]

The authors demonstrate a rare case of serious rupture in the area of the tracheal bifurcation with incomplete rupture of both bronchi which occurred after a severe multiple injury. The authors describe the difficult surgical solution, using temporary selective intubation of both main bronchi across the surgical field. The imperfect success of jet ventilation is ascribed to severe pulmonary contusion and major haemorrhage from the trachea which increased the risk of barotrauma. The authors emphasize the importance of peroperative and postoperative bronchoscopy.

Risk of lung resections in patients after inductive chemotherapy of non-small cell bronchogenic cancer

Results of 43 patients who were operated on after chemotherapy in the period 1986-1998 are presented. Authors evaluate the morbidity, mortality and survival. Relatively low mortality and good survival rate is considered to be success. In many patients, without the combination therapy their tumors would have been inoperable and quality of life would be poor.

Successful surgical treatment of the brachial plexus paresis in leiomyosarcoma of the subclavian artery

Described here is a unique case of surgical treatment of brachial plexus paresis in a 63-year-old female patient. The paretic condition was considerably improved by excision of a tumor in the upper mediastinum, growing from the left subclavian artery, and classified as leiomyosarcoma.