Guido Fechner

Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia. Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous “nephrolitholapaxy”. After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth. To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

Purpose To evaluate surgical complications and functional results of deceased-donor renal transplantations (DDRT) in a small centre dependent on the surgeons level of experience and to derive a leaning-curve model for DDRT. Methods Three hundred and ninety-two recipients underwent DDRT at the Department of Urology, Bonn University. Operative procedures were performed by 18 various urological surgeons grouped in 5 levels of experience (LOE). Perioperative data, complications and graft survival after 12 months were recorded depending on LOEs. Results Operative time and warm ischaemia time significantly decreased after an experience of 40 DDRT. Complication rates and graft function after 12 months did not differ between all LOEs. Conclusions Kidney transplantation in a small centre is a safe and effective procedure even if performed by surgeons under education. As a crucial finding, a surgeon climbing his learning curve becomes faster but not necessarily better.

Indikation Zugangsweg Notwendige präoperative Diagnostik Spezielle Labordiagnostik Insbesondere bei jungen Patienten wird trotz sonografisch unauffälligem Hodenparenchym die präoperative Bestimmung der Hodentumormarker α-Fetoprotein (AFP) und β-HCG empfohlen. Sollten diese pathologisch erhöht sein, ist auch bei unauffälligem Parenchymbefund des Hodens ein inguinaler Zugangsweg sinnvoll. Die Versorgung der Hydrozele kann dann mit einer Probeexzision des Hodens kombiniert werden. Obligate bildgebende und Funktionsdiagnostik Die Diagnose einer Hydrozele wird sonografisch gestellt. Hierbei sollte eine Beurteilung der Parenchymqualität des Hodens erfolgen, da Hydrozelen in seltenen Fällen als „Begleithydrozele” eines Hodentumors auftreten können. Besteht der Verdacht auf einen Hodentumor, ist der inguinale Zugangsweg zum Skrotalfach zwingend. Patientenaufklärung und spezielle Risiken Spezielles Instrumentarium Nahtmaterial Postoperative Besonderheiten

Introduction: A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal ‘U’ according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions. Methods: All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months. Results: All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively. Conclusions: Subject to our short follow-up, Kälble’s technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

Renal autotransplantation should be considered as an individual treatment in a number of renal or ureteral pathologies, such as ureteral strictures or transitional cell carcinomas of the upper urinary tract. Pyelovesicostomy offers the possibility of a complete ureteral resection and provides the opportunity for a follow-up cystopyeloscopy. In cases of careful patient selection and experience in vascular surgery autotransplantation should not become a forgotten option.