Advanced Renal Cell Carcinoma (RCC) cannot be cured by surgery alone. Its resillience to irradiation and chemotherapy demands a new approach to the management of this disease. This book provides an overview of the scientific and clinical developments of RCC, and clarifies the fields ofimmunotherapy and immunobiology. The book contains a compilation of approaches that will enhance the effectiveness of the management of advancedRCC, even in the absence of definitive pre-clinical data. These require additional study and will stimulate the reassessment of preliminary results.Furthermore, preliminary results of already implemented clinical trials withbiological modifiers are presented. Of special interest are the current achievements in the field of immunotherapy using topically and subcutaneously low dosage combinations of cytokines. This concise volume will benefit those seeking a thorough review of the research and the clinical aspects of RCC simultaneously.

The management of advanced renal cell carcinoma is still problematic. Surgery, although the therapy of choice for locally advanced renal tumors, is still controversial as the treatment for metastases. The role of surgery in the management of patients with pulmonary, bony, and liver metastasis is one of the subject matters discussed in this book. Our results with series of patients undergoing resection of metastases from the lung, bone, and liver show that surgery may be appropriate in selected patients with a good performance status, although most of them certainly cannot be cured by this procedure alone, i.e., in the absence of effective adjuvant therapies. As recent developments show, new strategies for immunotherapy of renal cell carcinoma represent a modest advance over traditional approaches in the treatment of this cancer, such as chemo- and radiotherapy. Clinical trials employing recombinant interferon-a and interleukin 2 produced response rates in up to 30% of patients treated, as evidenced by the European Immunotherapy Trials Program. The adverse reactions and the lack of efficacy in the majority of patients warrants the search for new immunotherapeutic approaches.

In February 1980 the Royal College of Radiologists, London, held its Second Symposium on Clinical Oncology. The subject was Prostatic Cancer and this publication is based on the presen tations at this meeting by leading authorities in the United Kingdom. The principal objective of these Symposia is to promote multi disciplinary collaboration for the benefit of cancer patients. Awareness and understanding of advances in a broad range of subjects are essential to ensure the timely and effective appli cation of new techniques in the prevention and treatment of all forms of cancer. Communication of this kind may also stimulate the creation of new ideas that may prove to be of more fundamental relevance to cancer research. Prostatic cancer has been afforded too little attention in the past, and its importance in Clinical Oncology has not been adequately recognised. And yet over the last 10 years consid erable progress has been recorded in our understanding of this disease and in its assessment and management. These achieve ments are well documented in this collection of papers and the outstanding problems are also clearly indicated. It is acknowl edged that the early diagnosis of prostatic cancer presents a continuing challenge, associated with the uncertainties that concern the clinical significance of 'latent' cancer of the prostate. The accurate assessment of the incidence and preva lence of the disease is extremely difficult and together these problems complicate the evaluation of the management of early or localised prostatic cancer."

Presented by recognised experts around the world this reference book helps identify the role of medical and surgical therapies in the treatment of Benign Prostate Hyperplasia (BPH), prostate cancer and prostasis. By combining the latest epidemiological data with detailed comment on management and treatment, the book is a unique up-to-date and fully referenced resource on the subject.

The use oflasers in clinical practice is increasing rapidly, both in the definitive treatment of disease and in the palliation of symp toms. Consequently, this sixth contribution to the Bloomsbury Series in Clinical Science is particularly timely. It opens with an introduction to the basic physics of lasers and then focuses on the current use of lasers in urological practice, and concludes by reflecting on their potential for the future. Edited, and with several contributions by Tom McNicholas, the book also contains contributions from a number of workers at the National Medical Laser Centre in University College Hos pital. London. Given their ever widening application, there can be little doubt that lasers will be a subject the series will return to again. To date, the series has been concerned with a wide range of topics of fundamental importance in clinical science. It has now gained momentum and future titles continue to reflect its wide sphere of interest. As Series Editor, I would welcome suggestions from readers of topics and issues that could usefully be addressed in the series.

The human prostate gland is of undoubted importance in reproductive physiology and is one of the commonest causes of clinical urological problems in the male patient. Despite the wealth of published lit erature relating to the prostate gland surprisingly little is understood about its neural innervation, the influence of pharmacological factors and its precise physiological functions. Indeed, benign disorders of the prostate gland including benign prostatic hyperplasia, bladder neck dyssynergia and inflammatory disorders of the prostate (prostatitis, prostatodynia) although well recognised clinically, are as yet poorly characterised and understood. It was not until the late 1960s that the subject of urodynamics, which for the first time allowed scientific assessment of the function of the lower urinary tract, was introduced. The first section of this book considers recent advances in our understanding of the innervation of the bladder and prostate gland and the changes in bladder function which accompany prostate medi ated bladder outflow obstruction. The clinical consequence of benign prostatic hyperplasia in many patients is bladder outflow obstruction and although the traditional treatment of these conditions is by the use of ablative surgery, in recent years a number of new modalities have been investigated and are reviewed in the second section of the book.

Urinary incontinence is a humiliating disability and a common problem in gynaecological clinics. In some centres specialised facilities are avail able for its investigation and treatment but in most hospitals the general gynaecologist has to manage this difficult condition. For both generalist and subspecialist it is timely to summarise advances in our knowledge of normal and abnormal micturition. Since 1973 the Royal College of Obstetrician's and Gynaecologists, through its Scientific Advisory Committee, has convened Study Groups on important growth areas in our specialty. The College invites an international panel of leading researchers to participate in a workshop, allowing time for in-depth discussion as well as the presentation of papers. It is hoped that this will produce not only an up-to-date sum mary of current knowledge but also a useful interaction between indi viduals and between specialties. This book is the result of the 21st Study Group, which was held in October 1989. The participants included urological and colorectal surgeons and a neurologist, as well as scientists and gynaecologists. The meeting began with sessions on basic science and advances in the investigation of the lower urinary tract, then covered voiding diffi culties, genuine stress incontinence and detrusor instability, before a final session on the relationship between urinary incontinence and ali mentary tract problems. The discussions formed an essential part of the meeting, and it is hoped that the lightly edited versions reproduced here will convey to the reader the stimulating atmosphere of the Study Group.

The introduction of lasers into operative medicine and advances in fiberoptic technology have made a significant contribution to minimally invasive surgery. This book was written to raise awareness of the capabilities and advant ages of lasers in urological surgery and to make this tech nology more widely accessible. The book reflects the cumulative experience of 25 years of laser research and clinical application, starting in 1972 with studies on laser tissue interactions, endoscopic studies with fiberoptic "sutures;' and the first clinical use of lasers in 1975 and 1976. These early efforts were followed by the develop ment oflaser lithotripsy in the early 1980 s and a Lubeck based research program leading to the development of a "smart" laser lithotriptor (Lithognost) in the late 1980s. There have been recent advances in the field of photo dynamic diagnosis based on the use of locally adminis tered photo sensitizers, a development that will redefine the role of the Nd:YAG laser in the treatment of bladder cancer. Perhaps the most interesting concept is the inter stitiallaser therapy of prostatic hyperplasia and, perhaps one day, certain forms of prostatic cancer. We have also developed a technique, first described in 1986, for the laser treatment of schistosomal bladder lesions. I dedicate this book to the many pioneers oflaser medi cine and to all the colleagues and research assistants who accompanied me on this journey. I cannot name them all; their names can be found in more than 300 publications.

Obstetric fistula is as old as mankind. While the incidence has diminished progressively with better health care in Western societies, the situation has changed little in many developing countries. Fistulae of pelvic organs, often monstrous defects, still are a major complication of child-birth causing misery to uncounted young women, and if they cannot find help in one of the very few hospitals with trained specialists, they became urological cripples losing everything: family, home and job. The magnitude of the problem is illustrated by some figures given by Reginald and Catherine Hamlin-about 700 fistula patients treated each year-a total of over 10,000 cases operated upon in their fistula hospital in Addis Ababa, Ethio pia. Most of these injuries could be prevented by better health care at the village level as some studies have shown conclusively. The incidence of fistula is an indicator of the standard of health and obstetrical care. The author of this book-Obstetric Fistula-is an internationally known Australian gynaecologist who for many years has been interested in all aspects of gynaecological urology, especially urinary stress inconti nence, other forms of involuntary loss of urine, and associated gynaeco logical conditions. He has devised a number of new operations to treat pelvic defects. Robert Zacharin's interest in obstetric fistula was a con sequence of his surgical activity in developing countries."

For doctors and students who wish to learn ultrasonography concisely yet comprehensively. The authors present the subject both systematically and practically, and with the facility of quick reference in mind, making generous use of flow-charts, tables and teaching-points. All general aspects of diagnostic ultrasound are covered, concentrating on those disorders encountered in the daily routine of scanning, but also referring to rarer conditions which need to be considered in differential diagnosis.

The aim of this series is to bring the reader up-to-date data and opinions on the practice of urological surgery. The ten titles published since 1982 have all been concerned with adult urology, with reference to paediatric problems included in some relevant chapters. The addition of this title on paediatric urology is especially welcome because it brings together the important components of the sub-specialty. This book has developed from one of the first of the annual courses in urological sub-specialties provided for trainees in the UK as part of their higher surgical training. But that audience is not the only one at which this book is aimed. In his Preface, Robert Whitaker emphasises the changes over the past ten to fifteen years: this means that any urologist over the age of 45 is already out of date in much of his or her knowledge of paediatric urology - unless there has been a genuine attempt at continuing medical education. Attendance and discussions at meetings and reading of current literature are useful methods of updating our knowledge. However, this book provides a much-needed link with the paediatric urology course and is a splendid reference source for all urologists. Robert Whitaker has gathered together four eminent co-authors to present their material on the main issues in paediatric urology. In keeping with the aims of this series, the data are up to date, the perspectives are contemporary and in every way this is an excellent addition to Clinical Practice in Urology.

The anticipation of seeing and having to manage patients suffering from sensory disorders of the urinary tract brings dismay and foreboding to the urologist. This stems from his experience of the time that these patients take up, both at the stage of initial interview and subsequently during numerous consultations over periods of months and years. This and the largely unsatisfactory response to various forms of therapy in the past are reason enough for this bold attempt to define with objectivity the notoriously subjective disorders of interstitial cystitis, urethral syndrome and prostatodynia. In writing this book the principal aim of the authors has been to define these three entities concisely and to describe the investiga tional methods which are required to establish the diagnosis in each case. The importance of this cannot be overestimated since, when the label of one or other of these conditions is attached to a patient, further objective consideration of the case is-endangered. The casual attribution of these sensory diagnoses to inappropriate cases is already on record as having dulled clinical awareness and led to oversight of progressive disease and its sometimes avoidable conse quences."

The handbook on lithiasis edited by Kurt Boshamer and originally brought out in 1961 was for more than two decades the standard work in this field for researchers and clinicians alike. However, our knowl edge of urolithiasis has been increased so enormously - by worldwide interdisciplinary research into the genesis of urinary calculi, by the new treatment possibilities opened up principally by advances in tech nology, and by the success achieved in prevention of recurrence - that it is almost impossible to take in all the relevant journal articles, books chapters, monographs, and proceedings. It was therefore our aim in this, the first of two independent vol umes, to provide a concise but comprehensive summary of current knowledge concerning the morphology and composition of calculi, epidemiology, pathogenesis, and diagnostic techniques. The most re cent developments are described, and nothing in the world literature is ignored. A second volume will cover medical therapy, operative, in strumental and noninvasive treatment, and prophylaxis. To have any chance of success, treatment and prophylaxis must be based on knowledge of calculus formation. Study of the composition of calculi has yielded important information regarding the conditions for formation, and this underlines once again the great value of analy sis of urinary concretions. Evaluation of epidemiological data has im portant consequences for the individual patient."

Prostatitis continues to be a major clinical enigma. In this book, all modern aspects of etiology, pathogenesis, diagnosis and therapy are critically evaluated. Of special interest to the readers will be the modern diagnostic management of chronic prostatitis and the debatable therapeutic approach to chronic nonbacterial prostatitis. From the contents: Radical Transurethral Prostatectomy for Chronic Bacterial Prostatitis; Etiology, Pathogenesis, and Inflammatory Reactions in Chronic Bacterial Prostatitis; Therapy of Nonbacterial Prostatitis; Ultrasonographic Features of Prostatitis.

Die grundlegend aktualisierte 2. Auflage bietet einen einzigartigen und fachA1/4bergreifenden Aoeberblick zu den Grundlagen, urologischen und orthopAdischen Details sowie psychosozialen und juristischen Aspekten der Spina bifida. Fallbeispiele machen das Buch besonders fA1/4r Studenten, praxisnah arbeitende A"rzte und auch Physiotherapeuten attraktiv. komplett A1/4berarbeitete und ergAnzte 2. Auflage praxisnah und aktuell neu gestaltete Abbildungen

After the positive response which followed the first edition of this book 6 years ago, the editors were encouraged to prepare a completely reworked second edition that includes the modern advances in this field. There has been a complete change of diagnostic procedure in the detection of renal tumors, which is now based on sonography, computed tomography, and nuclear magnetic resonance imaging, pushing intravenous urography and angiography completely into the background. Also, new methods of treat ment with radionuclides using embolisation are incorporated. The description of morphological structures forms the basis for under standing and recognising pathology of the kidneys and adrenals. The con tents of pathological morphology could be extended, as we are of the opinion that the detection and therapy of renal and adrenal tumors are derived from different areas of diagnostic science. We are indebted to Springer-Verlag for the excellent book production. On behalf of all the authors, we would like to thank our colleagues and associates for their cooperation in the realisation of this project. The editors hope that this volume will be of interest to radiologists, pa thologists, urologists, pediatrists, and also radiotherapists. Essen, April 1987 EBERHARD LOHR LUTZ-DIETRICH LEDER Table of Contents Pathology of Renal and Adrenal Neoplasms LEDER, L.-D., RICHTER, H.l.

The first edition of "Testosterone: Action, Deficiency, Substitu tion" was published in 1990. Since then our understanding of the hormone that turns males into men has tremendously increased. Therefore, the editors felt that a second extended edition of the book is warranted in order to summarize established and recent findings in the field and to present the reader with an up-to-date is reflected by the textbook. The increased mass of knowledge growth of the volume from 14 to 20 chapters. In the updated edition the biochemistry and metabolism of androgens have been complemented by extensive information on the molecular biology of the androgen receptor and its disorders. The key role of testosterone in spermatogenesis is now better de fined. We have a more complete understanding of the psychotro pic effects of testosterone and know so much about the different target organs and functions that individual chapters deal with testosterone and the prostate, lipids and the cardiovascular sys tem, hair, bones and muscles. The general chapter on pharmacol ogy and clinical uses of testosterone, in particular in male hypo gonadism, is extended by pharmacokinetic studies on testoster one preparations and individual substitution modalities using testosterone esters as well as implants and advanced trans dermal applications. The physiologic basis and possible clinical applica tions of testosterone in non-gonadal diseases, in male senes cence, in hormonal male contraception and in transsexuals are discussed. The last chapter describes the role of "investigative" steroid biochemistry applied to tracking anabolic steroid abuse."

Tumours in Urology is an up-to-date review of the advances in clinical management, clinical science, and basic science aspects of urological oncology. The text is divided into four parts for ease of reference: In these sections the molecular biology and biochemistry of bladder cancer, prostate cancer, and renal cell cancer are examined. There are authoritative reviews of the risk factors in superficial bladder cancer, the role of chemotherapy and bladder reconstruction in invasive cancer, along with comparative views of conservative treatment and the role of radical surgery in prostate cancer. Current methods of hormonal manipulation are also discussed. Conservative surgery for renal cancer, the use of interleukins, and the use of radical lymphadenectomy for testis cancer are comprehensively set out for the reader. A unique feature is the review at the beginning of each section of the controversial areas within each major topic. This gives the reader an excellent overview of recent advances in the field.

The preface to Urodynamics - Upper and Lower Urinary Tract edited by LUTZEYER and MELCHIOR (Springer-Verlag 1973) mentions the self-evidence of using functional examinations in other medical de partments: "It is self-evident that the cardiologist uses the EeG not just routinely, but continuously in an intensive-care unit, where it is computerized and always on call. It is self-evident, too, in gastro enterology and pulmology that a functional analysis is based on readings of different electronic probes. In urology, however, we tend to rely on optical control by cystoscopy, static data in order to reach a functional interpretation that is based on this information alone. " Referring to the preface mentioned above, especially the upper uri nary tract is said to be assessed mainly from an anatomic-morpho logic point of view in the clinical routine, though in this case we are also mainly concerned with an active transport system. 1971, which the Twelve years after the urodynamic meeting in above-mentioned volume was based on, a second urodynamic meet ing took place in Aachen that was called and also dealt with "Re-: viewing the Aachen 1971 Meeting. " Its purpose was to review which of the statements that had been made more than a decade before were still valuable, what had to be added or revised, and which ex perimental tests and results could be clinically applied."

The most recent experimental work in urology is presented in this volume. Itcontinues the biennial publication of the reports given at the internationalsymposia for experimental urological research; the tenth symposium was held in Munich in June, 1990. The wide range of subjects covers renal cell cancer and adenoma, bladder cancer, urinary diversion, uro- dynamics, renal pathophysiology and transplantation as well as the pathogenesis and treatment of urolithiasis.

The 1992 International Yearbook of Nephrology is the 4th in a successful series of yearly books updating practising nephrologists and nephrologists-in-training on rapidly changing areas of nephrology. We were encouraged to proceed in our editorial venture by reviews of the previous issues which have appeared in various Nephrology Journals. These reviews have pointed to the successful use of the International Editorial Board, the broad range of topics of current interest which have been covered and the comprehensive and practical nature of the reviews. The principal aim of the Yearbook remains to provide reviews which are more current than those which appear in Nephrology textbooks and which can be in the hands of the readers a few months after the authors have completed the manuscripts. The appointed authors are always experts in the field, who are asked to give an objective review of the topic, up-dating the readers on the world-wide literature and providing them with a complete, accurate and up-ta-date list of important recent references. We have decided to maintain the successful format of the first three issues. Thus, the volume will continue to be divided into sections; each section will continue to have a different primary focus every year, depending upon what is of greatest interest at the time.

Technical improvements over the past twenty years have made endos copy the procedure of choice for examination of the hollow organs of the genitourinary and gastrointestinal tracts. The development of electro surgical techniques, laser technology, injection therapy, and a wide variety of other modalities now allow the endoscopist to treat many problems that in the past required open surgery. The simultaneous development of transcutaneous abdominal sonography has had an equally dramatic impact on the practice of gastrointestinal and geni tourinary surgery. The marriage of these proven technologies, known as endoscopic sonography, provides an exciting new modality that promises to further revolutionize the diagnosis and management of many intraabdominal diseases. Endoscopic sonography opens new frontiers by overcoming the primary limitations of its parent technologies. Fiberoptic endoscopy is limited by the inability to see beyond the luminal surface, this is particularly important when considering neoplastic disease because depth of wall invasion is a key factor in determining treatment. The limiting factor in transcutaneous sonography is the distance between the transducer and the target organ. With endoscopic sonography, the transducer is placed in close proximity to the target organ. This allows the use of high frequency waves (greater than 5 MHz), which provide better tissue resolution and eliminates the image distortion caused by overlying structures.

This book is the product of long years of close collaboration between two physicians, a pediatric endocrinologist and a pediatric surgeon, who are interested in the complex field of human malformations. Their efforts have set a new standard in the treatment of children with intersexual or mal formed female genitalia. It is impossible to convey the details of complex surgical procedures without the help of meticulous illustrations. It is fortunate that happened to meet an academically trained artist, Mrs. Siri Mills, M.A., while visiting in the United States. Her excellent knowledge of anatomy, her remarkable skills as an artist and technical illustrator, and her readiness to include all details of interest to the surgeon have found their fruitful expression in the illustrations of this book. We express our thanks to Springer-Verlag and especially to Prof. Diet rich Goetze, at whose suggestion this book was written, for their amiable compliance with all our wishes, and particularly for their willingness to retain Mrs. Mills as our illustrator. Munich, May 1985 WALDEMAR HECKER Contents In trod ucti on 1 Part 1: Endocrinologic Diagnosis in Pediatric Patients with Genital Anomalies General Rules . . . . . . . . . . . 4 Endocrinology of Antenatal Sex Differentiation 6 Male Differentiation 6 Female Differentiation 7 Specific Endocrinologic Diagnosis and Therapy 8 Virilization of the Female External Genitalia 8 Congenital Adrenogenital Syndrome with a Defect of 21-Hydr- ylase . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Intersexual Genitals Due to Deficient Androgenization of the Male 11 Defects of Testosterone Biosynthesis 11 Androgen Receptor Defects . . ."

Malignancies originating from the urogenital tract account for about 20% of all solid neoplasias. The various tumor types, including carcinoma of the prostate, transitional cell carcinoma, renal cell carcinoma, and testicular germ cell tumors, differ widely in terms of biological features, in cidence and appearance, diagnostic work-up and manage ment. It is not surprising that this complexity of urologic oncology with its related problems has increasingly attracted both experimental investigators and clinical experts. Only time will tell whether the achievements that today are con sidered* as progress will turn out to be significant contribu tions towards the ultimate goal: the cure of the patients' life-threatening diseases with little or no side effects. How ever, many innovations and improvements have already taken place in the field of urologic oncology within recent years. The high pace of innovative development requires continuous, thorough, and critical updating of our kowledge so that persisting deficits can be defined: the basic require ment for posing new scientific questions. The following examples may serve to illustrate the recent developments and the resulting new problems and questions: Recently, it has become evident that carcinoma of the prostate must be detected earlier to enable us to cure more of the affected patients in the future than currently.

Such an important subject as urinary diversion is unlikely to remain unchanged and unchallenged for long. The problem is to determine when is an appropriate time to examine current clinical practice of this major urological procedure. Historically, urinary diversion began with attempts to resolve the distressing problems associated with ectopia vesicae; later, urinary diversion was extended to help those patients with neurological problems of bladder function and with malignant diseases of the lower urinary tract. A significant landmark in the development and use of these procedures came with the introduction of a uretero-ileostomy (ileal conduit) by Bricker. With this diversion, faecal and urinary streams were separated and the incidence of metabolic and infective problems dramatically reduced. The procedure was received with great enthusiasm and indeed the pendulum soon swung so far in its favour that some urologists would scarcely admit to carrying out an occasional ureterosigmoidostomy. The impact of change in a surgical technique can be slow to determine especially when, numerically, it is an uncommon procedure and when the follow-up is hoped to match normal life expectancy. Thus the impact of ileal conduits has taken some years to evaluate and only during the past decade have the data been sufficient to show the advantages and disadvantages. This book is a landmark in the literature on this subject. The editor has selected eminent contributors who have described the main clinical groups where urinary diversion is an important aspect of management.