Correlation between urodynamic function and 3D cat scan anatomy in neobladders: does it exist?

INTRODUCTION: We compared the functional and anatomical differences among three different orthotopic neobladders, utilizing video urodynamics and 3D CT to determine what parameters, if any, correlate to function. MATERIALS AND METHODS: Thirty-four patients were able to participate in the evaluation of their neobladder by 3D CT and video urodynamics. Three different orthotopic neobladders were identified (12 ileal, 7 ileocecal, 15 sigmoid). Multiple measurements, observations and functional data have been obtained. Statistical analysis for this study employed a linear regression test and an odds ratio calculation (using StatSoft V. 5.1). RESULTS: In comparing three different neobladders, no significant differences were noted. Looking at the entire population, the following association was statistically significant in linear correlation: the maximal capacity and the neobladder volume; the pressure at the maximal capacity and the distance from the symphysis, the pressure at maximal flow and both the distance from the symphysis and the thickness of the neobladder. The distance from the left femoral head was directly correlated with the post void residual and inversely correlated with the maximal flow. The Odds ratio calculation revealed (with significant P < 0.05) that the further the center of the neobladder is from the right femoral head, the higher risk of incontinence. CONCLUSIONS: The study seems to show no significant anatomical or functional difference among the three different types of neobladders. A possible correlation between the position of the neobladder and urinary incontinence is suggested, recognizing further study in a larger population is required.

Identification of H-ras mutations in urine sediments complements cytology in the detection of bladder tumors.

BACKGROUND: Urinary cytology has long been used as a noninvasive screen for the detection of urinary tract cancer but is limited by the generation of false positive and false negative results. More recently, molecular changes associated with urothelial neoplastic progression have been identified in DNA from urine sediments, demonstrating an alternative approach for identifying neoplastic change in the bladder. PURPOSE: The purpose of this prospective study was to determine the value of detection of H-ras (also known as HRAS) mutations in urine sediment DNA as a clinical indicator of tumor presence, recurrence, and/or progression. METHODS: Urine sediments were collected from 100 patients presenting with bladder tumors, with follow-up samples collected from 19 patients. DNA extracted from urine sediments was analyzed for changes in exon 1 of the H-ras gene, using single-strand conformation polymorphism (SSCP) analysis. A representative number of aberrant H-ras/SSCP migrating bands were excised and sequenced to confirm the presence of a mutation. Human bladder specimens were obtained from patients (93 of the 100 patients initially and 18 of the 19 patients studied by follow-up) and histologically evaluated for tumor content and grade. RESULTS: Mutations in exon 1 of the H-ras gene were detected in urine sediments from 44% (44 of 100) of the patients; concordant results were obtained by cytologic analysis, where 33% (31 of 93) of the patients displayed positive cytology. Analysis of the distribution of abnormalities with tumor grade revealed greater detection of low-grade (1-2) lesions using ras analysis (47%) compared with cytology (16%). In contrast, cytology was more effective in identifying the presence of carcinoma in situ. Combined results from these two approaches substantially increased the sensitivity of tumor detection, resulting in the identification of tumors in 60% of patients. CONCLUSIONS: Identification of H-ras mutations in DNA from urine sediments facilitates the detection of low-grade bladder tumors and, in combination with cytology, increases the overall tumor detection from 33% to 60%. Preliminary results in patient follow-up suggest that detection of H-ras mutations may have some clinical utility in detecting the presence of abnormal cells in the absence of an overt lesion following cystoscopy or positive cytology.

Elevated expression of pp60c-src in low grade human bladder carcinoma.

The results presented in this report demonstrate that the tyrosine-specific protein kinase activity of pp60c-src is elevated over that recorded in normal bladder mucosa in a subset of human bladder carcinomas. Increased kinase activity was observed mainly in low grade bladder lesions and was associated, at least in part, with elevated levels of pp60c-src expression. Extension of this analysis to a panel of human bladder carcinoma cell lines confirmed previous observations of low pp60c-src kinase activity in three lines established from high grade (GIII) bladder tumors and revealed increased kinase activity in three alternative bladder lines derived from GI or GII tumors. Use of an anti-phosphotyrosine antibody in Western blot analysis revealed the presence of novel phosphotyrosyl cellular substrates in human bladder cell lines and tumors displaying elevated pp60c-src kinase activity. These observations suggest an association for the src protooncogene in urothelial cell differentiation events.

Changing concepts in surgical management of renovascular hypertension.

As newer surgical techniques and concepts have emerged, including revascularization of the totally occluded renal artery and alternatives to aortorenal bypass (hepatic, splenic, or iliac artery to renal artery grafts), our patient population has changed. Patients with diffuse atherosclerotic disease, bilateral renal artery stenosis, totally occluded renal arteries, and azotemia are being referred for renal revascularization, thereby changing the indications for operation and the results that can be anticipated. Although our results in patients operated on solely for uncontrollable hypertension or renal failure have been successful, much work needs to be done to improve the results obtained when patients have a combination of uncontrollable hypertension and renal failure.

Decreased insulin requirement in acute renal failure in diabetic nephropathy.

Twelve of 13 diabetics with azotemic nephropathy experienced exacerbation of renal failure and decreased insulin requirement after coronary angiography utilizing radiographic contrast material. The single patient who did not develop acute renal failure had no evidence of decreased insulin requirement. Eleven of 12 patients had decreased insulin requirement: mean decrement in insulin dose, 40%; mean decrement in fasting blood glucose level, 33%; mean decrement in peak blood glucose level, 42%. The 12th patient underwent peritoneal dialysis against hypertonic glucose without need of an increased insulin dose. Eight of 11 patients experienced a total of 19 insulin reactions; one patient was hypoglycemic continuously, despite infusion of glucose and discontinuation of insulin. The decrement of insulin requirement was not proportional to the rise in either serum creatinine or potassium concentrations. We suggest that when acute renal failure occurs in diabetics, decreased insulin requirement should be anticipated and the insulin dose lowered.

Improving survival after renal transplantation for diabetic patients with severe coronary artery disease.

After successful renal transplantation, seven diabetic renal failure patients with severe coronary artery disease returned to productive employment. Despite the requirement for additional peripheral vascular or ophthalmologic surgery in four patients, their renal function remained adequate. Following transplantation, diabetic complications included angina in three, myocardial infarction in three, and cerebrovascular accident in two patients. Two patients with adequate renal function died suddenly at 29 and 62 mo. Despite severe coronary artery disease, an increasing number of diabetic dialysis patients may be able to return to work after a successful kidney transplant.

Expression of classic cadherins type I in urothelial neoplastic progression.

Loss or reduced expression of E-cadherin has been shown to be associated with poor survival in patients with bladder cancer. In numerous cases, loss of E-cadherin expression in bladder tumors has been accompanied by continued association of catenins with the membrane, suggestive of the expression of an alternative cadherin member. In this study we examined 75 bladder tumors using immunohistochemistry for the expression of E-, P-cadherin, and alpha-, beta-, and gamma-catenins. As reported previously, loss or reduced E-cadherin expression is a frequent event in late stage bladder cancer, accompanied by less frequent alterations associated with different catenin family members. Analysis of 51 tumors for expression of E-, P-, and N-cadherin showed P-cadherin localized to the basal cell layers of normal urothelium, with retention of expression in the majority of tumors. In low-grade tumors P-cadherin was found localized to an expanded basal cell compartment, contrasting with the more extensive staining observed in late stage tumors. Membranous P-cadherin staining was often found in the absence of E-cadherin staining. N-cadherin is not expressed in normal bladder mucosa, but detection of this cadherin member was recorded in 39% (20/51) of bladder tumors. Unlike P-cadherin, membranous N-cadherin was detected in focal regions within tumors, representing novel expression in urothelial neoplastic progression. Although focal N-cadherin staining was observed in 3 noninvasive lesions, the majority of tumors expressing N-cadherin were invasive (17/20). Coexpression of E-, P-, and N-cadherin was recorded in 5 grade 2 bladder tumors. Expression of P-cadherin is maintained throughout bladder tumorigenesis, accompanied by aberrant expression of N-cadherin. Clearly, neither P- nor N-cadherin act in an invasive-suppressor mode in bladder cancer, but whether they have a primary role to play in urothelial neoplastic progression has yet to be established.

Resection of cavoatrial renal cell carcinoma employing total circulatory arrest.

Intracaval extension of renal cell carcinoma to the right atrium is a life-threatening presentation that may result in fatal tricuspid valve obstruction or pulmonary embolization. From 1981 to 1989 we treated 10 patients with such extension of tumor, the last 7 of whom underwent resection in which hypothermic circulatory arrest was used. No postoperative deaths, myocardial infarctions, or strokes occurred. Four patients were alive with no evidence of disease at 4, 10, 16, and 39 months after resection, and 1 patient was alive with pulmonary and spine metastases at 34 months after resection. Two patients died of metastatic disease at 7 and 12 months. In the absence of diffuse metastatic disease, lymph-node involvement, or invasion of contiguous organs, radical resection of cavoatrial hypernephroma may result in excellent palliation and possibly a cure.

Resection of atriocaval adrenal carcinoma using hypothermic circulatory arrest.

Carcinoma of the adrenal cortex may occasionally extend through the inferior vena cava to the right atrium without actually invading the vascular endothelium. Surgical resection may result in excellent palliation and the potential for prolonged survival when no other signs of advanced disease are present. Extrapolating from our experience with renal cell carcinoma extending to the right atrium, we resected a similar adrenocortical carcinoma using hypothermic circulatory arrest.

Ultrasound in diagnosis and evaluation of lymphoceles after renal transplantation.

Three cases of lymphoceles after renal transplantation are described. The value of ultrasound is stressed in making the diagnosis, totally delineating the size, following the progression, evaluating the transplanted kidney for secondary hydronephrosis, and localizing the lymphocele for aspiration. Ultrasound is, therefore, believed to be a valuable diagnostic study in the evaluation of patients with a transplanted kidney with an unexplained reduction in renal function, leg edema, or a suspicion of a pelvic mass.

Ureteral reconstruction in renal transplantation.

The complications associated with ureteral reconstruction in renal transplantation produce significant morbiditiy and mortality rates. We have evolved a combined intravesical-extravesical nonstented ureteroneocystostomy and have used it in 100 consecutive transplants, 50 of which were in high-risk diabetic recipients. No instances of urinary extravasation, fistula formation, disruption of the ureterovesical anastomosis, ureteral solughing, or ureterovesical obstruction have occurred in this series. The lack of urologic complications utilizing this technique offers reduced morbidity and mortality to transplant recipients.

Reversal of hypercoagulable state by bilateral nephrectomy.

The hypercoagulable state associated with select cases of glomerulonephritis is difficult to diagnose by standard laboratory techniques but is clinically manifested by recurrent shunt and fistula thrombosis which may be refractory to anticoagulant therapy. Bilateral nephrectomy reversed this hypercoagulable state. After renal allograft, however, the patient experienced hyperacute rejection, and transplant nephrectomy was required to cure the recurrent hypercoagulable state. The mechanism of this previously unreported phenomenon and its implications with regard to renal transplantation are discussed.

Is magnetic resonance imaging alone accurate enough in staging renal cell carcinoma?

A patient with renal cell carcinoma extending into the inferior vena cava presented to our institution. Magnetic resonance imaging demonstrated the superior extent of the thrombus to be at the level of the hepatic veins. Preoperative venacavography showed extension into the right atrium. The need for both studies in evaluating patients with Stage 3A disease is reviewed.

Neurocutaneous syndromes and retroperitoneal tumors.

A patient with multiple basal cell carcinoma syndrome, a symptom complex characteristized by nevoid basal cell carcinomas of the skin, jaw cysts, skeletal abnormalities, and hyporesponsiveness to parathormone is presented. In addition, the patient had a retroperitoneal lymphagiomyoma, a hamartomatous lesion, causing ureteral obstruction. The association of neuroectodermic syndromes and retroperitoneal and intra-abdominal tumors is reviewed.

The laparoscope as a teaching aid in open pelvic surgery.

Laparoscopic imaging equipment is useful in open surgical procedures, especially in the deep male pelvis. The magnification and brilliant illumination provided by these unobtrusive instruments increase visibility, facilitating both dissection and reconstruction. The application of this technique for surgical education is discussed.

Is the neodymium:YAG laser effective therapy for invasive bladder cancer?

The neodymium:YAG (yttrium-aluminum-garnet) laser can cause transmural coagulation necrosis of bladder tumor or bladder wall. Pathologic specimens of 18 patients prospectively treated with the neodymium:YAG laser before radical cystectomy were reviewed to compare the initial clinical stage of bladder tumor with the final pathologic stage and to assess the destructive tissue effects of neodymium:YAG laser therapy. Eleven of 18 patients were unchanged pathologically in stage of tumor or had tumor progression. Seven patients had a lower pathologic tumor stage; 3 of these patients had pathologic Stage T0 with no residual tumor, with the remainder of patients showing superficial disease. One asymptomatic small bowel injury was discovered at operation. Healing lesions showed marked granulation tissue, coagulation necrosis, and persistent ulceration.

Pathologic review of consecutive radical prostatectomy specimens. Nerve sparing versus nonnerve sparing.

Retrospective pathologic analysis was conducted of specimens from 88 radical retropubic prostatectomy operations performed between 1982 and 1987 inclusive. The median age of patients was sixty years (range, 46 to 73 years). Of the 88 radical prostatectomies performed, 51 were nerve-sparing (40 bilateral) and 37 were nonnerve-sparing (11 unilateral) procedures. Preoperative clinical staging was similar in both groups. Thirty-five of 37 patients (95%) in nonnerve-staging group and 51 of 51 patients (100%) in nerve-sparing group had clinical Stage B2 disease or less. Pathologic staging in both groups was also similar. In 26 of 37 patients (70%) in nonnerve-sparing group and in 35 of 51 patients (69%) in nerve-sparing group, disease remained localized to the prostate. Both groups were analyzed retrospectively to determine whether or not the incidences of microinvasion of capsule and of extraprostatic disease differed. Review of the apical and lateral margins of the specimens revealed no statistically significant difference in either the degree of microinvasion of capsule or the incidence of extraprostatic disease between the groups.

Radiolabeled monoclonal antibody indium 111-labeled CYT-356 localizes extraprostatic recurrent carcinoma after prostatectomy.

OBJECTIVES: The sites of recurrent carcinoma of the prostate were localized with radiolabeled monoclonal antibody, and these sites were correlated with the response of patients treated with pelvic radiation after prostatectomy. METHODS: Radionuclide scans were performed with indium 111-labeled CYT-356, a monoclonal antibody that binds to prostate epithelial cells, in 48 men diagnosed with recurrent carcinoma detected by prostate-specific antigen (PSA) screening after radical retropubic prostatectomy. RESULTS: In 48 patients with recurrent carcinoma detected by PSA screening following radical retropubic prostatectomy, 73% had monoclonal antibody activity beyond the prostatic fossa, and only 3 patients (6%) had activity in the prostatic fossa alone; 65% had monoclonal antibody activity in pelvic lymph nodes despite the fact that lymph node dissections were pathologically negative at the time of prostatectomy in 90% of the patients; and 23% of patients had monoclonal antibody activity in abdominal and extrapelvic retroperitoneal nodes. Of 48 patients, 13 underwent external beam radiation therapy after monoclonal antibody scans. Six patients had scans showing activity beyond the field of radiation, and radiation therapy failed in 4 of these patients. Seven patients had scans with no activity beyond the field of radiation therapy, and radiation therapy failed in only 2 of these patients. CONCLUSIONS: The scans frequently show monoclonal antibody uptake in pelvic, abdominal, and extrapelvic retroperitoneal sites beyond the region of limited obturator node dissections and may account for the understaging and subsequent failure of radical prostatectomy in some patients. The monoclonal antibody scan seems to be a good predictor of which patients will respond to radiation therapy after radical prostatectomy, but because these patients often have nodal activity beyond the radiated field, this initial response may not be curative.

Renal angiomyolipoma in adult-type polycystic disease.

Two adults with renal angiomyolipomas and polycystic disease are presented with emphasis on the angiographic manifestations of the coexisting lesions. One patient had multiple episodes of gross hematuria and a perinephric abscess which resulted in bilateral nephrectomies; the second presented with hypertension and underwent unilateral nephrectomy to treat a hypervascular tumor. The clinical and radiographic diagnoses of the combined lesions are discussed and suggestions for management offered.

Elevated alpha-fetoprotein secondary to Hodgkin's lymphoma.

We describe the case of a 26-year-old man with an elevated level of alpha-fetoprotein who had no evidence of intragonadal or extragonadal germ cell tumor. The patient was found to have Hodgkin's lymphoma within an anterior mediastinal mass. We review the significance of elevated alpha-fetoprotein levels and discuss the clinical relevance of this unusual presentation of a possible primary Hodgkin's lymphoma.