Frequent PD-L1 expression in testicular germ cell tumors

BACKGROUND

Many testicular germ cell cancers are curable despite metastatic disease, but about 10-15% of patients fail cisplatin-based first-line treatment. Immunotherapy is considered as additional treatment approach for these patients. Inhibition of the interaction between Programmed Death Receptor 1 (PD-1) and Programmed Death Receptor Ligand 1 (PD-L1) enhances T-cell responses in vitro and mediates clinical antitumour activity. We analysed the expression of PD-L1 in testicular germ cell tumours to evaluate its potential as target for immunotherapeutic strategies.

METHODS

Immunohistochemistry was performed in 479 formalin-fixed paraffin-embedded specimens using a rabbit monoclonal antibody (E1L3N). The tissue microarray consisted of 208 pure seminomas, 121 non-seminomas, 20 intratubular germ cell neoplasia unclassified (IGCNU) and 20 specimens of non-neoplastic testicular tissue.

RESULTS

Programmed Death Receptor Ligand-1 expression was found in 73% of all seminomas and in 64% of all non-seminomas. None of 20 IGCNU and none of 20 normal tissue specimens exhibited PD-L1 expression. PD-L1 positive stromal cells were only detected in seminomas, but not in non-seminomas. The anti PD-L1 antibody showed a pre-dominantly membranous staining pattern in testicular tumour cells, as well as expression in stromal cells.

CONCLUSIONS

This frequent expression of PD-L1 in human testicular germ cell tumours suggests that patients with testicular germ cell tumours could profit from immunotherapeutic strategies using anti-PD1 and anti-PDL1 antibodies.

[Urological treatment of renal calculi]

As a disease, nephrolithiasis can not only be exceedingly bothersome for the respective patients, it is also very expensive for our public health system. Indications for an active treatment of renal calculi go mainly according to the stone size as well as the clinical symptoms. The goal of modern nephrolithiasis treatment is the complete removal of all stones from the pelvi-calyceal system with the lowest possible morbidity. Extracorporeal shockwave lithotripsy, percutaneous nephrolitholapaxy and flexible ureterorenoscopy are the main options for treatment. According to the stonesize, -localisation and -composition these options are given different priorities. However, due to significant technical progress in the field of endourology there is a clear trend towards flexible ureterorenoscopy, which is a promising modality for the treatment of kidney stones for a number of reasons.

Primitive Neuroectodermal Tumor of the Kidney with Hyaline Cells

Primitive neuroectodermal tumor (PNET) of the kidney is a rare disease with high malignant potential. It affects young adults and has the tendency towards early metastasis. Relying on recently available immunohistochemistry and cytogenetic investigations, today most authors define PNET as part of the same nosologic entity as Ewing's sarcoma. We present the case of a 22-year-old man with a PNET arising from the kidney with, to our knowledge, a previously undescribed finding of hyaline cells within the tumor.

Transurethral injection therapy with dextranomer/hyaluronic acid copolymer (Deflux) for treatment of secondary vesicoureteral reflux after renal transplantation

BACKGROUND AND PURPOSE

Secondary vesicoureteral reflux (SVUR) after renal transplantation may cause recurrent urinary-tract infections (UTI) and loss of renal function. There are only a few reports on the endoscopic treatment of SVUR by transurethral injection therapy. This is the first report of transurethral injection of dextranomer/hyaluronic acid copolymer (Deflux; Q-Med Scandinavia, Uppsala, Sweden) to relieve SVUR after renal transplantation.

PATIENTS AND METHODS

Between November 2003 and October 2005, four women were treated for SVUR with transurethral injections of dextranomer/hyaluronic acid copolymer. All patients had deterioration of renal function attributable to SVUR, recurrent UTI, or both. The mean follow-up was 29 months (range 16-38 months).

RESULTS

Initially, SVUR was corrected in all patients. Recurrent SVUR made a second treatment necessary in two patients. Three patients had no signs of SVUR 15, 27, and 36 months after the treatment. Renal function remained stable in these patients, and two were free of UTI. One of the patients who received two Deflux injections developed a filiform stenosis of the distal ureter, which was corrected by ureteropyeloplasty with the native ureter.

CONCLUSION

Transurethral injection therapy with Deflux is a minimally invasive treatment option for patients with SVUR after renal transplantation. A second treatment seems to be necessary in some cases. Complications such as ureteral obstruction may occur.

Reluctance Over Right-Sided Retroperitoneoscopic Living Donor Nephrectomy: Justified or Not?

We retrospectively compared perioperative donor outcomes and early complication rate of right- and left-sided retroperitoneoscopic living donor nephrectomy (RLDN).

METHODS

From November 2001 to April 2006, we performed 118 RLDN. Including 24% (n = 28) right-sided RLDN and 76% (n = 90) left-sided RLDN. Perioperative results and the rate of adverse events were compared for both sides.

RESULTS

We observed no significant difference in operation time, blood loss, warm ischemia time, or postoperative creatinine levels between right- and left-sided kidney donors. RLDN was successfully performed in 116 of 118 donors. One donor in each group had to be converted to an open approach. We observed one graft loss due to renal artery kinking in one recipient after left-sided RLDN. Two right donations needed a saphenous venous patch due to a short right renal vein (<2 cm). Overall, intraoperative and postoperative complications were comparable between the two donor groups.

CONCLUSION

Right-sided RLDN provides comparable perioperative and postoperative results to those of left-sided RLDN. Our results demonstrated that groups with significant experience in RLDN can perform right living donor nephrectomy safely and efficiently with minimal invasiveness.

Surgical management of renal cell carcinoma during the second trimester of pregnancy

Renal cell carcinoma is rarely diagnosed during pregnancy and its management represents a real challenge. Pregnancy demands special consideration in terms of diagnostic evaluation and management, particularly during the second trimester. We report a patient undergoing left radical nephrectomy using a thoracoretroperitoneal approach at 22 weeks' gestation. Histological analysis revealed a pT2R0G2 chromophobic renal cell carcinoma. Furthermore, we review the sparse literature available.

Photoselektive Vaporisation der Prostata

BACKGROUND

We report about our experiences with photoselective vaporization of the prostate (PVP) in patients with symptomatic benign prostatic hyperplasia (BPH) and total prostate volume larger than 80 cm(3).

PATIENTS AND METHODS

The study included 201 patients with BPH: 51 (25.4%) patients had a prostate volume larger than 80 cm(3) and 150 (74.6%) patients had a volume smaller than 80 cm(3) in the preoperative transrectal ultrasound.

RESULTS

The mean operation time for patients with large prostates was 79 min. Neither TUR syndrome nor severe bleeding was observed. In patients with large adenomas peak urinary flow increased by 135, 136, and 132% after 6, 12, and 24 months, respectively. The overall complication rate was comparable in both groups.

CONCLUSION

PVP is characterized by excellent perioperative safety and significant improvement of voiding parameters. PVP is feasible in patients with large prostates.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction (UPJO): Solving the Technical Difficulties

OBJECTIVES

To evaluate our current practice in retroperitoneoscopic pyeloplasty in patients with ureteropelvic junction obstruction (UPJO). Special interest was paid to technical difficulties associated with the retroperitoneoscopic approach.

METHODS

Our retroperitoneoscopic approach for pyeloplasty is explained step for step including the most technically challenging part: the ureteropelvic anastomosis.

RESULTS

Within 49 months a total of 47 retroperitoneoscopic pyeloplasties we performed at our institution. Before pyeloplasty an endopyelotomy had failed in five patients (11%). We did not necessarily perform a ventral transposition of the anastomosis in cases with a crossing vessel. Two (4%) conversions to open surgery were required because of scarring after previous endopyelotomy and massive obesity resulting in a limited working space. There were no intraoperative complications. A recurrence of UPJO was observed in 2% (n = 1).

CONCLUSION

Functional results after retroperitoneoscopic pyeloplasty are excellent and comparable to those of open surgery. However, special knowledge of retroperitoneoscopy is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.

Does the Prostate Really Need Androgens to Grow? Transurethral Resection of the Prostate in a Male-to-Female Transsexual 25 Years after Sex-Changing Operation

We present the case of a male-to-female transsexual presenting with obstructive voiding symptoms due to benign prostatic hyperplasia 25 years after sex-changing operation and under continuous estrogen therapy.

A Vitex agnus-castus extract inhibits cell growth and induces apoptosis in prostate epithelial cell lines

Extracts of Vitex agnus-castus fruits (VACF) are described to have beneficial effects on disorders related to hyperprolactinemia (cycle disorders, premenstrual syndrome). A VACF extract has recently been shown to exhibit antitumor activities in different human cancer cell lines. In the present study, we explored the antiproliferative effects of a VACF extract with a particular focus on apoptosis-inducing and potential cytotoxic effects. Three different human prostate epithelial cell lines (BPH-1, LNCaP, PC-3) representing different disease stages and androgen responsiveness were chosen. The action of VACF on cell viability was assessed using the WST-8-tetrazolium assay. Cell proliferation in cells receiving VACF alone or in combination with a pan-caspase inhibitor (Z-VAD-fmk) was quantified using a Crystal Violet assay. Flow cytometric cell cycle analysis and measurement of DNA fragmentation using an ELISA method were used for studying the induction of apoptosis. Lactate dehydrogenase (LDH) activity was determined as a marker of cytotoxicity. The extract inhibited proliferation of all three cell lines in a concentration-dependent manner with IC (50) values below 10 microg/mL after treatment for 48 h. Cell cycle analysis and DNA fragmentation assays suggest that part of the cells were undergoing apoptosis. The VACF-induced decrease in cell number was partially inhibited by Z-VAD-fmk, indicating a caspase-dependent apoptotic cell death. However, the concentration-dependent LDH activity of VACF treated cells indicated cytotoxic effects as well. These data suggest that VACF contains components that inhibit proliferation and induce apoptosis in human prostate epithelial cell lines. The extract may be useful for the prevention and/or treatment not only of benign prostatic hyperplasia but also of human prostate cancer.

Retroperitoneoscopic nephropexy for symptomatic nephroptosis using a modified three-point fixation technique

INTRODUCTION

Laparoscopy has been reported as a minimally invasive approach for performing nephropexy in patients with nephroptosis. We evaluated our results after retroperitoneoscopic nephropexy using a modified three-point fixation technique.

TECHNICAL CONSIDERATIONS

Twelve women presenting with flank pain and radiologically documented nephroptosis underwent retroperitoneoscopic nephropexy. After complete dissection of the perirenal fat from the kidney, three nonabsorbable (Ethibond-0) sutures were placed on the posterior renal capsule between the upper pole, middle part, and lower pole of the kidney and the psoas muscle. The average operative time was 91 minutes (range 50 to 180), and the mean estimated blood loss was less than 50 mL in all patients. Postoperative urography revealed complete resolution of nephroptosis in all cases. On a comparative pain analog score patients had 84% improvement (range 0% to 100%). Nine patients had complete resolution of their pain, and two had improvement of 70% to 80%. One patient did not have any improvement. The mean follow-up time was 3.4 years (range 0.5 to 5.5).

CONCLUSIONS

Retroperitoneosopic nephropexy with a modified three-point fixation technique of the upper posterior pole, middle part, and lower pole of the kidney to the psoas muscle is a rapid and effective minimally invasive procedure for treating symptomatic nephroptosis with excellent intermediate-term results.

[Mixed epithelial and stromal tumor of the kidney]

We describe a case of mixed epithelial and stromal tumor of the kidney. The tumor was identified in a 63 years old woman and retroperitoneoscopically resected. Immunohistochemistry, electron microscopy and fluorescence in situ hybridization were performed. Grossly, the tumor was well-circumscribed with a diameter of 8 cm and consisted of solid and cystic components. Microscopically, the spindle cell component ranged in appearance from scar-like fibrous tissue to leiomyoma-like fascicles. Epithelial elements were composed of tubules with variable lining. The tubules were focally transformed into large cysts. Estrogen and progesteron receptors were detected in the nuclei of the spindle cells. Electron microscopy confirmed a smooth-muscle differentiation of the spindle cells. Previously, such tumors were published as adult mesoblastic nephroma or cystic hamartoma of the renal pelvis. Its predominance in females with a history of long-term estrogen replacement or the history of long-term sex-steroid use in a male patient, combined with the expression of estrogen und progesteron receptors in the spindle cells suggest that hormonal influence is relevant for the development of these tumors.

Retroperitoneoscopic Living Donor Nephrectomy: A Comparison With the Open Approach in Respect of Early Postoperative Pain Management

INTRODUCTION

We retrospectively compared perioperative donor outcomes and early postoperative pain control after retroperitoneoscopic (RLDN) and standard open (OLDN) living donor nephrectomy.

METHODS

One hundred donors included fifty after RLDN (37 women/13 men) and 50 after OLDN (35 women/15 men) were retrospectively analyzed for basic analgesics, for opioid consumption, and for visual analog scale (VAS) to verify the experienced pain. The donors were questioned in the morning and evening of the first through fifth postoperative days.

RESULTS

The mean age of both groups was equal. The mean operating time was 149.7 +/- 48.2 minutes (60 to 270) for RLDN and 164.1 +/- 30.3 minutes (60 to 240) for OLDN (P = NS). The mean warm ischemia time was 120 +/- 36 seconds (50 to 240) and 114 +/- 31 seconds (60 to 190) for the RLDN and OLDN groups, respectively (P = NS). The mean evening VAS for RLDN versus OLDN on postoperative days 1 to 5 was: 2.1 versus 2.2 (P = NS), 0.9 versus 1.8 (P = .009), 0.5 versus 1.3 (P = .016), 0.1 versus 0.7 (P = .013), and 0.1 versus 0.7 (P = .013), respectively. In both groups there was a tendency toward a higher VAS score in the morning than in the evening. RLDN donors showed significantly earlier period free of pain (VAS = 0) than those after OLDN. There was a significant difference of being free from any opiate between both groups after surgery.

CONCLUSIONS

After RLDN donors experienced less postoperative pain than after OLDN over the early postoperative days. Therefore, postoperative regional anesthesia is not necessary for donors operated by a retroperitoneoscopic approach.

Curative surgery for solitary adrenal metastasis of pT1 G3 transitional cell carcinoma of the bladder

A preoperative computed tomography scan in a patient undergoing radical cystectomy for pT1N0 grade 3 transitional cell carcinoma revealed a tumor in the adrenal gland. Biopsy was negative, but 2 years later computed tomography showed progression, and adrenalectomy was performed, revealing transitional cell carcinoma. Four years after cystectomy, the patient had no evidence of other metastases. We discuss surgery for solitary metastasis of transitional cell carcinoma as a curative treatment option.

First case of lymphangioma of the bladder in an adult

Lymphangioma is a congenital malformation consisting of a developmental or primary defect of the lymphatic channels. We report the first case of lymphangioma of the bladder in an adult and review the literature. In our case a 49-year-old man presented with irritative voiding symptoms, cystoscopy showed a non-papillary tumor between the two orifices within the trigone, and transurethral resection was performed. Three months after operation the irritative voiding symptoms had improved and cystoscopy showed no residual tumor.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction

BACKGROUND AND PURPOSE

Retroperitoneoscopy is an established procedure for renal surgery. We evaluated our results with retroperitoneoscopic pyeloplasty for ureteropelvic junction (UPJ) obstruction.

PATIENTS AND METHODS

In 14 female and 10 male patients, a retroperitoneoscopic pyeloplasty was performed (13 right/11 left). Four patients had previously had an endopyelotomy. The operation was performed using standard retroperitoneoscopic technique with the patient in a flank position. After preparation of the ureter and renal pelvis, the UPJ was resected in 22 patients in an Anderson-Hynes pyeloplasty. Twenty of these patients had a crossing vessel. The other two patients, who had small renal pelves, were operated on with a Fenger pyeloplasty. In all patients a 7F double-J stent was placed.

RESULTS

The mean operative time was 189 minutes (range 70-360 minutes), and the average blood loss was 110 mL (range 50-400 mL). There were no intraoperative complications, although one patient with adhesions and scarring after previous endopyelotomy had to be converted to open surgery. The transurethral catheter was left for 7 days in the first 10 cases and for 4 days in the 14 subsequent patients. The hospitalization time was 9.7 and 7.5 days, respectively. The only postoperative complication was a urinoma, which was punctured. The double-J catheter was removed after an average of 4.6 weeks (range 4-8 weeks). Intravenous urography 6 weeks later showed no obstruction. The mean follow-up time was 11.5 months (range 1-24 months) with no signs of obstruction on ultrasonography.

CONCLUSIONS

Retroperitoneoscopic pyeloplasty for UPJ obstruction is a safe and effective procedure. Our short-term results are similar to those of open pyeloplasty with the advantage of a minimally invasive approach.

Die 80-Watt-Kalium-Titanyl-Phosphat- (KTP-)Laservaporisation der Prostata

BACKGROUND

Despite good efficacy, even in our days, TURP remains a potentially difficult procedure to perform and is associated with significant risks for the patient. Several alternatives have been tried to reduce the known perioperative morbidity. We report our first experiences with 80 W potassium titanyl phosphate (KTP) laser vaporization of the prostate in patients with symptomatic BPH.

PATIENTS AND METHODS

In 70 patients 80 W KTP laser vaporization was performed successfully. Mean age was 70.5 years (46-93 years) and mean transrectal prostate volume was 48.1 ml (10-250 ml).

RESULTS

Mean operating time was 41 min ( n=22), 64 min ( n=33), and 80 min ( n=15) for a 26 ml, 46 ml, and a 91 ml prostate, respectively. At time of discharge, after 1 month, and 6 months the urinary peak flow increased by 75.4%, 166.8%, and 168.6%, respectively.

CONCLUSION

The 80 W KTP laser vaporization of the prostate combines the tissue-debulking properties of transurethral resection of the prostate with the known good hemostatic properties of other laser procedures. It is a safe procedure for the patient and provides a virtually bloodless operation and immediate improvement of voiding.

Second Transurethral Resection of Superficial Transitional Cell Carcinoma of the Bladder: A Must Even for Experienced Urologists

INTRODUCTION

As even experienced urologists have a high percentage of persisting carcinoma after transurethral bladder tumour resection (TUR-B) the importance of a routine second resection in the management of transitional cell carcinoma (TCC) of the bladder is defined.

PATIENTS AND METHODS

The medical records of all patients treated with TUR-B at our institution between January 1989 and September 2000 were reviewed. 214 patients with pTa and pT1 carcinoma undergoing a second resection 4-6 weeks later were included in the analysis. The rate of persisting carcinoma in the second resection was compared to the actual tumour stage and grade, the patient's age, sex and the experience of the urologist performing the resection.

RESULTS

Of the 214 patients 99 had pTa and 115 pT1 carcinoma. The rate of persisting tumour in the second resection was 27% in pTa and 37% in pT1 carcinoma. This rate was independent of the patient's age and sex. Urologists in training had an equally low rate of persisting carcinoma in the second resection compared to senior urologists (p = 0.08).

CONCLUSIONS

Routine second resection of superficial transitional cell carcinoma of the bladder should be part of the treatment even in larger operative experience.

[Manually-assisted laparoscopic donor nephrectomy]

The number of patients suffering from terminal renal failure awaiting kidney transplantation has continued to increase. Since the number of available cadaver donor kidneys has largely remained unchanged, a special publicity campaign achieved that almost one-half of the kidneys transplanted in Basle come from live donors. We performed a laparoscopic live donor nephrectomy in 14 patients between March 1998 and August 1999. Despite good experience regarding transplant function and patient satisfaction, the hand-assisted technique was introduced in 1999 because of the long average operating time of 230 min (200-270) and warm ischemia time of 7.5 min (4-9). In the 33 operations performed up to now, the average operating time and warm ischemia time could be significantly reduced to 185 min (135-240) and 2.4 min (1.5-4), respectively. Most recently, the technique of retroperitoneoscopic live donor nephrectomy was successfully employed in 4 patients and could possibly represent the method of choice for the future.

Treatment of varicocele: a prospective randomized comparison of laparoscopy versus antegrade sclerotherapy

OBJECTIVES

To compare the therapeutic success, the morbidity and the costs of antegrade sclerotherapy versus laparoscopic varicocelectomy.

METHODS

Seventy-six consecutive varicocele patients were randomly assigned to two treatment arms. Preoperative and 3 month postoperative sperm density, motility and morphology were analysed. The diagnosis of the varicocele was established clinically and with Doppler ultrasonography.

RESULTS

Fifty-eight patients treated by either of the two methods were followed up. The recurrence rate increased progressively with the size of the varicocele in both groups. The postoperative incidence of complications particularly hydrocele formation was significantly higher in the laparoscopic group. The costs of the disposable material for laparoscopic varicocelectomy was twice as high as for sclerotherapy.

CONCLUSIONS

Antegrade sclerotherapy is the less invasive treatment method of male varicocele with lower costs and better outcome and should therefore be the preferred treatment method for male varicocele.

[A rare cause of nephrotic syndrome in a young woman with flank pain, milky urine and leukocyturia]

A 27 year old patient presented with a sudden acute illness showing right flank pain, milky urine, nephrotic range proteinuria, erythrocyturia and leukocyturia in the urinary sediment with a negative leukocyte test stick. The proof of a pronounced hypertriglyceriduria led to the diagnosis of Chyluria. The lymphangiogram confirmed the presence of a retroperitoneal lymphatic dysplasia with evidence of communication with the right renal pelvis on the CT-lymphogram. Chyluria is generally the result of parasitic infection and is extremely rare in Europe. In the presence of symptoms including milky urine, proteinuria and leukocyturia in the urinary sediment and a negative urine leukocyte stick test and absence of infectious signs, chyluria must be suspected. The diagnosis should be substantiated through proof of hypertriglyceriduria and confirmed by lymphangiography.

[Results of comprehensive data collection concerning urologic laparoscopy]

To evaluate the current status of laparoscopy, the "Working Group Laparoscopy" of the German Urological Association performed a questionnaire among urologists in Germany. Of 300 questionnaires 183 were returned and analyzed (61%): 54% of the departments already performed laparoscopy and another 50% are planning to introduce this technique. The major concerns are economical (70%), long learning curve (92%), investment (53%), and lack of scientific data (76%). Simple nephrectomy, cryptorchism, and varicoceles are treated by 66, 59, and 58 of the 96 departments laparoscopically (of 183 resp.). Laparoscopic surgery for radical prostatectomy and tumor nephrectomy is done by 32 and 34 of 96 departments. Only a minority of the centers performs more than 40 laparoscopies per year and indication. Compared to a survey conducted in 1995, the acceptance level of this technique has increased (100% vs 48%). Only a minority of the departments performs more than 40 laparoscopic interventions per year for one indication.

Noninflammatory chronic pelvic pain syndrome: immunological study in blood, ejaculate and prostate tissue

OBJECTIVES

The aim of this prospective study was to observe immunophenotypic patterns in patients with noninflammatory chronic pelvic pain syndrome (Cat IIIB CPPS) for further description and as possible surrogate markers for diagnosis and treatment.

METHODS

Eighty-eight patients with a referral diagnosis of chronic prostatitis underwent fractionated urinary cultures including expressed prostate secretion (EPS) and ejaculate analysis twice on two occasions. Monthly serum analyses included C3c, C4, IL-1alpha, sIL-2R, and IL-6. One hundred samples from healthy individuals were used as the control group for serum analysis. Monthly ejaculate testing was done for IgG, IgA, IgM, IL-1alpha, sIL-2R, and IL-6. The control group for ejaculate analysis was composed of 96 normal ejaculates (according to the WHO criteria). Immunohistochemical detection of CD3 cells (T lymphocytes) and CD20 cells (B lymphocytes) was performed in 71 biopsy cylinders of Cat IIIB CPPS patients and in 25 prostate biopsy cylinders of men without symptoms or obstruction.

RESULTS

Complete sampling of urinary, serum and ejaculate specimens was achieved in 50/88 (57%) patients. Cat IIIB CPPS was observed in 44/50 (88%) patients. Intra-acinar T-lymphocytic infiltrates were dominated by T cytotoxic cells (p = 0.05). Immunohistochemical studies showed inflammatory expression in serum complement, serum interleukin, and ejaculate interleukin concentrations in relation to the presence of large numbers of T cells (all p values < or =0.01). No difference was found in the proportion of B lymphocytes in patients with Cat IIIB CPPS compared to the control group. Serum and ejaculate IL-6 and ejaculate IgA increased significantly and dropped again, correlating with a release of clinical symptoms.

CONCLUSIONS

Interleukin, complement and immunoglobulin determinations in serum and ejaculate reveal an inflammatory process even in Cat IIIB CPPS. The findings of intra-acinar T-cell-rich infiltrates and the associated inflammatory reaction may be a significant advance in defining Cat IIIB CPPS caused by a possible autoimmune component. Serum and ejaculate IL-6 and ejaculate IgA are possible surrogate markers for the diagnosis and treatment of Cat IIIB CPPS.

Primary erectile dysfunction in combination with congenital malformation of the cavernous bodies

Primary erectile dysfunction in combination with congenital malformation of the cavernous bodies has only rarely been reported. We report on 2 young patients with different congenital malformations. To our knowledge this is the first time partial aplasia of the distal part of the cavernous bodies is described, whilst complete isolation of the cavernous bodies in combination with veno-occlusive dysfunction has yet been described in 3 cases. After complete examination, including penile angiography and cavernosometry, a surgical correction with a fully satisfying result was achieved in the patient with distal aplasia. In case of isolated cavernous bodies with severe veno-occlusive dysfunction, the implantation of a penile prosthesis remains the treatment of choice.

Early orchiopexy: prepubertal intratubular germ cell neoplasia and fertility outcome

OBJECTIVES

To investigate the prepubertal prevalence of intratubular germ cell neoplasia of the unclassified type (ITGCNU) and its significance as a predictor of testicular cancer and to evaluate the effect of early orchiopexy (at younger than 2 years of age) on subsequent fertility of patients with bilateral cryptorchidism.

METHODS

Testicular biopsies (n = 660) from 440 prepubertal patients with cryptorchidism who underwent orchiopexy between January 1, 1970 and December 31, 1979 were evaluated for ITGCNU using placental-like alkaline phosphatase (PLAP) antibody. The clinical outcome in 15 patients with PLAP-positive germ cells was evaluated in 1997. In addition, the effect of age at surgery on the fertility of patients with bilateral cryptorchidism was assessed by clinical follow-up until 1997 and was correlated with the histologic data at orchiopexy.

RESULTS

PLAP-positive germ cells morphologically identical with adult ITGCNU were found in the biopsies of 22 patients (5%). After more than two decades, none of the 15 patients with successful follow-up developed testicular cancer. The fertility outcome in the patients with bilateral cryptorchidism correlated with the number of spermatogonia at orchiopexy (P = 0.018), but correlated inversely with age at orchiopexy (P = 0.021).

CONCLUSIONS

PLAP-positive germ cells in prepubertal testicular biopsy specimens are not necessarily precursors of testicular cancer after orchiopexy. In addition, our data support the idea that early orchiopexy may be beneficial in preventing infertility.

[Kidney and urinary tract diseases in pregnancy]

Management of urologic disorders in pregnant patients often increases the anxiety of all involved. Based on a thorough understanding of the physiologic changes seen in various organ systems the urologist has to assume the responsibility for the well-being of the mother and the fetus. Apart from the urinary tract infection, which occurs as frequent as in non-pregnant patients but has a significantly higher risk of acute bacterial pyelonephritis, it is mainly the pregnancy-associated symptomatic hydronephrosis and the urolithiasis which are complicating approximately 1 of every 1000-1500 pregnancies. Urinary tract infections should be treated in any case by antibiotics according to a antibiogram. High risk patients with history of vesicoureteral reflux or recurrent pyelonephritis should be treated prophylactically. Following parturition these patients should be investigated urologically to exclude structural abnormalities of the genitourinary system. In case of symptomatic hydronephrosis and calculous disease the first approach should be a watchful conservatism with symptomatic relief. If the symptoms persist insertion of a double-J-stent or in case of live-threatening situations (e.g. urosepsis) when urgent decompression and rapid evacuation is mandatory a percutaneous nephrostomy can be brought in place under sonographic monitoring completely thereby avoiding any radiation exposure.

[Ureteral stent placement in hydronephrosis during pregnancy]

In this study we describe 22 cases of retrograde ureteral stent placement in pregnant women with therapy-resistant flank pain due to hydronephrosis. Eleven were primiparous and one patient expected twins. Eight of 22 patients presented symptoms of pyelonephritis. In 21 cases the hydronephrosis was located on the right and in 4 cases it was bilateral. Maximal lower calix diameter was 12 mm (range 9-22 mm). With the exception of two cases, sonographically controlled stent placement was performed under local anesthesia without sedation. All patients were painfree within 6 days and were given prophylactic low doses of antibiotic until the day of delivery. Renal function remained within the normal limits. Double-J stent displacement occurred in 3 patients - of which one underwent nephrostomy. Postnatal examination demonstrated urolithiasis in 4 of 19 patients. This study provides evidence for effectiveness of retrograde ureteral Double-J stent placement as a therapeutic option in cases of severe symptomatic hydronephrosis during pregnancy with a low morbidity rate.

[Angiosarcoma of the kidney. Case report and review of the literature]

The primary renal angiosarcoma is a rarely seen highly malignant tumor. Making a diagnosis based on histology may prove difficult. Because of hematogenous formation of metastases and bad prognosis in most cases we recommend that the surgical intervention be followed by the well tolerated systemic chemotherapy with Doxorubicin and Ifosfamid.