Successful treatment of disseminated extragonadal germ cell cancer with intensive conventional chemotherapy after first-line high-dose chemotherapy.

High-dose chemotherapy (HDCT) with peripheral blood stem cell (PBSC) support has been investigated as a first-line treatment in patients with poor risk germ cell cancer. However, effective management of patients with residual cancer after HDCT has not been well addressed, and the outcome in such patients is poor. Here, we report a case of disseminated germ cell cancer successfully treated with intensive conventional chemotherapy after HDCT. A 31-year-old man presented with a bulky mass at the retroperitoneum, which had invaded the lumbar and sacral vertebra, and multiple lung and liver metastases. The patient's serum beta subunit of human chorionic gonadotrophin (beta-hCG) was elevated to 2600 IU (cut-off value <0.1 IU). At the time of diagnosis of poor risk germ cell cancer of extragonadal origin, he underwent two cycles of BEP (bleomycin, etoposide, and cisplatin) chemotherapy and PBSC harvest followed by three cycles of HDCT with PBSC transplantation. The liver metastases disappeared. The retroperitoneal bulky mass and multiple lung metastases shrank but were still present, and the serum beta-hCG level was not completely normalized. An additional three courses of BEP and five courses of VIP (cisplatin, ifosfamide, etoposide) normalized the beta-hCG level. Pathological evaluation of the residual masses revealed no viable cancer cells at either site. The patient is alive without disease recurrence 5 years after completion of chemotherapy.

Diagnostic potential in bladder cancer of a panel of tumor markers (calreticulin, gamma -synuclein, and catechol-o-methyltransferase) identified by proteomic analysis.

Using proteomic analysis, we previously identified calreticulin (CRT) as a potentially useful urinary marker for bladder cancer. Now, we have also identified gamma -synuclein (SNCG) and a soluble isoform of catechol-o-methyltransferase (s-COMT) as novel candidates for tumor markers in bladder cancer, by means of proteomic analysis. In the process of establishing a superior tumor marker system, we investigated the diagnostic value of a combination assay of these three proteins. Voided urine samples were obtained from 112 bladder cancer and 230 control patients. Urinary CRT, SNCG, and s-COMT were measured as a combined marker by quantitative western blot analysis. Relative concentration of each protein was calculated and the diagnostic value of a concomitant examination of these markers was evaluated by receiver operator characteristic analysis. With the best diagnostic cutoff, the overall sensitivity of the combined markers was 76.8% (95% confidence interval, 69-81%) with a specificity of 77.4% (72-80%), while those of a single use of CRT were 71.4% and 77.8%, respectively. When evaluated in relation to tumor characteristics, such as grade, stage, size, and outcome of urinary cytology, the diagnostic capacity of the combined markers was equal to or better than that of CRT in all categories. Concomitant use of CRT, SNCG, and s-COMT had higher sensitivity for detection of bladder cancer than did single use of CRT. Our study suggests that use of this panel of markers will improve the diagnosis of bladder cancer and may allow the development of a protein microarray assay or multi-channel enzyme-linked immunosorbent assay.

[Neurogenic voiding dysfunction after sacrococcygeal teratoma resection].

A 6-year-old girl was referred to our department due to pyelonephritis. Voiding cystourethrogram (VCUG) revealed grade 4 vesicoureteral reflux (VUR) and urethral deformity (stenosis and lateral deviation). She had a history of sacrococcygeal teratoma resection in the newborn. Urodynamic study revealed a large-capacity hypotonic bladder and poor bladder emptying. Magnetic Resonance Imaging of the spine demonstrated no abnormal findings. Despite conservative therapy, there were no improvement of VUR. Then, urethral dilation and anti-reflux-surgery were performed. Six months after the operation, VCUG showed no VUR. However, she has persistent residual urine due to neurogenic voiding dysfunction, and is being treated with a regimen of frequent timed voiding to reduce urinary residual and urinary tract infection.

Renal hypothermia using ice slush for retroperitoneal laparoscopic partial nephrectomy.

Renal hypothermia using ice slush for retroperitoneal laparoscopic partial nephrectomy was performed in 2 patients. A cylindrical device was secured in the enlarged port site. Through the device, ice slush was introduced and placed around the kidney. The nadir renal temperature under renal ischemia in the 2 patients was 18.4 degrees C and 25.8 degrees C.

Retroperitoneal lymph node dissection in patients with interaortocaval lymph node metastases of transitional cell carcinoma of the urinary tract.

Three patients suffered from renal pelvic, ureteral and bladder cancers that were treated with both standard surgical treatments and two adjuvant cycles of cisplatin-based combination chemotherapy. Metastases of interaortocaval lymph nodes were detected in all patients between 9 and 33 months from the surgery for primary lesions. All patients received three cycles of cisplatin-based combination chemotherapy and retroperitoneal lymph node dissection (RPLND). The chemotherapy achieved partial response (62-98%). Two patients with viable cancer cells died with hepatic metastases; the first 15 months and the second 25 months from the date of diagnosis of distant lymph node metastasis. The third patient, who had no viable cancer cells, remains alive and disease-free 36 months later. Therefore, RPLND after chemotherapy provides prognostic information that helps to define patients who might benefit from additional systemic chemotherapy.

Identification by proteomic analysis of calreticulin as a marker for bladder cancer and evaluation of the diagnostic accuracy of its detection in urine.

BACKGROUND: New methods for detection of bladder cancer are needed because cystoscopy is both invasive and expensive and urine cytology has low sensitivity. We screened proteins as tumor markers for bladder cancer by proteomic analysis of cancerous and healthy tissues and investigated the diagnostic accuracy of one such marker in urine. METHODS: Three specimens of bladder cancer and healthy urothelium, respectively, were used for proteome differential display using narrow-pH-range two-dimensional electrophoresis. To evaluate the presence of calreticulin (CRT) as detected by Western blotting, we obtained 22 cancerous and 10 noncancerous surgical specimens from transurethral resection or radical cystectomy. To evaluate urinary CRT, we collected 70 and 181 urine samples from patients with and without bladder cancer, respectively. Anti-CRT COOH-terminus antibody was used to detect CRT in tissue and urine. RESULTS: Proteomic analysis revealed increased CRT (55 kDa; pI 4.3) in cancer tissue. Quantitative Western blot analysis showed that CRT was increased in cancer tissue (P = 0.0003). Urinary CRT had a sensitivity of 73% (95% confidence interval, 62-83%) at a specificity of 86% (80-91%) for bladder cancer in the samples tested. CONCLUSIONS: Proteomic analysis is useful in searching for candidate proteins as biomarkers and led to the identification of urinary CRT. The diagnostic accuracy of urinary CRT for bladder cancer appears comparable to that of Food and Drug Administration-cleared urinary markers, but further studies are needed to determine its diagnostic role.

[Urinary continence after radical retropubic prostatectomy: a modification in the technique of apical dissection].

Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.

A simple technique for facilitating kidney entrapment using a laparoscopic sack during retroperitoneal laparoscopic radical nephrectomy.

The mouth of a LapSac was opened horizontally using a guidewire and, thereafter, the kidney was moved onto the center of the mouth. Forceps lifted the mouth and the specimen entered into the sack automatically under its own weight. Use of this technique facilitated kidney entrapment.

Developmental expression of glial cell-line derived neurotrophic factor, neurturin, and their receptor mRNA in the rat urinary bladder.

AIMS: Glial cell-line derived neurotrophic factor (GDNF) and related factors neurturin (NRTN), artemin, and persephin are members of the GDNF family of neurotrophic factors. GDNF and NRTN bind to the tyrosine kinase receptor Ret and the receptors GFRalpha1 and GFRalpha2. The objective was to examine the developmental expression of GDNF, NRTN, and their receptors within the rat urinary bladder. METHODS: Rat bladders dissected from embryonic day (E) 15, postnatal day (P) 0, P14, P28, and adult rats (P60) were investigated by semiquantitative reverse transcriptase polymerase chain reaction. Embryos (E15, E16, and E17) were immunohistochemically stained for neurofilament. RESULTS: GDNF and Ret mRNA levels at E15 were the highest of all the stages we examined and then immediately decreased. In contrast, NRTN mRNA levels did not change between E15 and postnatal day 14; thereafter, they gradually but insignificantly increased. GFRalpha1 and GFRalpha2 mRNA levels were high at E15, after which their signal intensities decreased. In whole-mounted specimens, neurofilament-positive axons were first detected in the bladder at E16. CONCLUSIONS: Our results suggest that GDNF and NRTN may act as trophic factors for neural in-growth to the bladder and/or for the maintenance of mature neurons innervating the bladder. These factors might also be involved in bladder morphogenesis.

Transitional cell carcinoma in a single ectopic ureter opening into the ejaculatory duct.

The incidence of an ectopic ureter in male patients is low. The ectopic ureter in men often ends at the seminal tract in association with renal dysgenesis. Malignant transformation of this closed, nonfunctional urothelial system has been reported only once. To our knowledge, we report the first case of primary transitional cell carcinoma in a single ectopic ureter with a dysplastic kidney that terminated in the ejaculatory duct.

[Initial failure in open pyeloplasty for ureteropelvic junction obstruction].

We retrospectively reviewed the records of 23 patients (25 kidneys) who underwent open pyeloplasty for ureteropelvic junction obstruction (UPJO) between 1980 and 2001, focusing on failures. The patients included 17 men and 6 women, ranging from 3 months to 69 years old (mean 15.9 years). The followup period was 6 months to 19 years (mean 8.6 years). Anderson-Hynes pyeloplasty, Y-V plasty, Hëllstrom's operation and simple pelvi-ureterostomy were performed in 22, 1, 1 and 1 kidney, respectively. We successfully repaired 21 of 25 renal units (success rate 84.0%). Of the four patients (4 kidneys) with persistent UPJO occurring in this primary pyeloplasty series, repeat pyeloplasty was performed on 2 patients, nephrectomy on 1 patient and balloon dilatation on 1 patient. Infection and prolonged urinary drainage seem to result in fibrosis of periureteral tissues. Inadequate stitches may cause granuloma in the lumen of the anastomosis. The techniques and complications associated with open pyeloplasty are discussed.

Torsion of spermatocele: a rare manifestation.

Torsion of a spermatocele on its pedicle is an extremely rare clinical condition that mimics acute testicular torsion. This rare condition has not been well characterized. Here, we report a case of torsion of a spermatocele. The present case is the 5th case of torsion of a spermatocele and the first report in a patient with a history of scrotal trauma. A tender cystic mass adjacent to the normally appearing testicle in the scrotum is highly significant for the differentiation from other types of acute scrotum. Torsion of a spermatocele should be considered a differential diagnosis of acute scrotum in adolescents and adults.