To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain.The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed.The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively.LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.
Physicochemical properties of urine do not explain the formation of urinary stones. Clinical findings and results of animal experiments suggest that alteration to the renal tubular cell plays a key role in the initiation of urinary stone formation. It is not clear whether this is a primarily intracellular alteration of metabolic origin which, after lysis of the renal tubular cell in the lumen, presents a nucleus for the formation of concretions, or whether in the lumen it is tubular cell damage induced by crystalluria that triggers the formation of urinary stones.Using Madin-Darby canine kidney cells, the influence of crystalluria on the renal tubular cell was tested in cell cultures. The influence of parathyroid hormone, vitamin D(3), oxalate and calcium concentrations and the extent to which these processes can be inhibited by allopurinol and selenium were investigated.Calcium oxalate monohydrate crystals produced reproducible damage to the renal tubular cell which was independent of parathyroid hormone and vitamin D(3). The crystalluria-induced effects were unrelated to the oxalate and calcium concentration or the pH. Allopurinol and selenium were able to inhibit the processes.The results indicate secondary involvement of the renal tubular cell in lithogenesis as a result of luminal alteration caused by calcium oxalate crystals. Mechanical damage and interaction between crystal and tubular cell lead to the apposition of crystals. The nephroprotective effect of allopurinol and selenium as antioxidants might explain the benefit of allopurinol found clinically in terms of stone metaphylaxis.
In a retrospective study we analyzed patients undergoing open stone removal in the Department of Urology of the University of Tübingen. In 2.7% of all urinary calculi, open stone surgery was necessary. Open operation was performed on all patients with complete staghorn calculi as well as on patients with renal pelvic stones and simultaneous morphological obstruction. Partial staghorn calculi were operated on only after endoscopic treatment had failed. Small renal pelvic stones and ureteral stones were surgically removed only after extracorporeal shock wave lithotripsy (ESWL) and endoscopic surgery had been unsuccessful. The treatment of choice for ureteral calculi is ESWL. If ESWL is impossible, an endoscopic approach is advisable. Open operations of ureteral calculi only have to be performed if endoscopic therapy has failed or if there is a simultaneous morphological obstruction. Meta-analysis of publications from 1981 to 1995 confirmed our approach regarding indications for open stone removal. Comparison of the results reported in the literature is very difficult because of the missing, but generally accepted definition of stone free. In addition different examination techniques to determine the status Ê»stone free' make it difficult to compare the various studies.
