The psychiatrist as philosopher: an appreciation of Dr Séamus Mac Suibhne (Sweeney) (1978-2019).

Dr Séamus Mac Suibhne (Sweeney), consultant psychiatrist and writer, who died on 8 September 2019, was a unique, much admired figure in Irish psychiatry. His interests ranged from clinical care to philosophy, from medical education to history, from innovative technology to the natural world. He was a dedicated family man as well as a doctor, scholar and writer who moved between academic fields with ease and erudition. As a clinician, he consistently placed compassion at the centre of care. Séamus's work appeared in the Lancet, BMJ, British Journal of Psychiatry, International Journal of Social Psychiatry and Irish Journal of Psychological Medicine, among other publications. He also wrote for the Guardian, Spectator, Scotsman and Times Literary Supplement. Séamus had a particular passion for better acknowledgement and treatment of mental illness among psychiatrists, and his compelling advocacy on this theme is one of his lasting legacies.

Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy.

BACKGROUND: The age-adjusted rate of radical prostatectomy, the most common treatment of early (nonmetastatic) prostate cancer, increased almost sixfold between 1984 and 1990. This increase was due in part to reported improvements in postoperative sexual potency after the use of newly developed "nerve-sparing" procedures. However, published estimates from physicians of impotence following various types of radical prostatectomy may be low, since not all patients may report treatment-related complications accurately and completely to their doctors. In contrast, direct surveys of patients indicate much higher rates of postoperative sexual and urinary dysfunction. One problem with most physician and patient surveys is that they have been performed retrospectively, and pretreatment impotence and incontinence prevalent in older men cannot be assessed accurately in retrospective studies. PURPOSE: This study was initiated in a cohort of men before they underwent radical prostatectomy to assess treatment-related effects on impotence and incontinence. METHODS: The study population consisted of 94 men enrolled in a cohort study of treatment for early prostate cancer. The patients completed questionnaires about sexual and urinary functions before surgery and at 3 and 12 months after surgery and had adequate information to assess the type of surgical technique used (non-nerve-sparing, unilateral nerve-sparing, or bilateral nerve-sparing). Because items assessing sexual function were inadvertently omitted from the questionnaire in the initial months of the study, information on sexual function for all time periods was available for only 49 men. RESULTS: Compared with men who had not been treated with a nerve-sparing procedure, men who underwent nerve-sparing radical prostatectomy, particularly of the bilateral type, were younger and had better prognostic features, indicating less advanced cancers. Before surgery, nine (75%) of 12 men not treated with a nerve-sparing procedure reported erections that were usually inadequate for sexual intercourse compared with six (33%) of 18 men and one (5%) of 19 men who underwent unilateral and bilateral nerve-sparing prostatectomies, respectively. At 12 months after surgery, most men reported inadequate erections, including 15 (79%) of the 19 men who had bilateral nerve-sparing surgery; unilateral nerve preservation provided no apparent benefit. In general, nerve-sparing surgery was associated with more use of absorbent pads at 3 and 12 months following treatment, and this approach was associated with substantial urinary incontinence at 3 months but not at 12 months following surgery. CONCLUSIONS: Nerve-sparing prostatectomy, particularly when performed unilaterally, improves postoperative sexual function to a lesser extent than previously reported. Because men with preoperative impotence and more advanced cancers receive nerve-sparing surgery less often, some of the previously reported benefit of nerve preservation may be the result of patient selection and not of the technique per se.

Increased incidence of matrix metalloproteinases in urine of cancer patients.

Matrix metalloproteinases (MMPs) have been implicated in mechanisms of metastasis in experimental cancer models and in human malignancies. In this study, we used substrate gel electrophoresis (zymography) to determine the frequency of detection of MMPs in urine of patients with a variety of cancers. Three molecular weight classes of urinary MMPs, Mr 72,000, Mr 92,000, and high molecular weight (Mr > or = 150,000) species, were detected reproducibly and correlated with disease status. The Mr 72,000 and Mr 92,000 species were identified as MMP-2 and MMP-9, respectively, by Western blot analysis. The presence of biologically active MMP-2 (P < 0.001) or MMP-9 (P = 0.002) was an independent predictor of organ-confined cancer, and the high molecular weight species (P < 0.001) was an independent predictor of metastatic cancer. This is the first study to demonstrate that analysis of urinary MMPs may be useful in determining disease status in a variety of human cancers, both within and outside of the urinary tract.

Subchronic administration of (R,S)-ketamine induces ketamine ring hydroxylation in Wistar rats.

Subchronic administration of (R,S)-ketamine, (R,S)-Ket, is used in the treatment of neuropathic pain, in particular Complex Regional Pain Syndrome, but the effect of this protocol on the metabolism of (R,S)-Ket is unknown. In this study, daily administration of a low dose of (R,S)-Ket for 14-days to Wistar rats was conducted to determine the impact of sub-chronic dosing on the pharmacokinetics of (R,S)-Ket and its major metabolites. The data indicate that, relative to a single administration of (R,S)-Ket, subchronic administration resulted in increased clearance of (R,S)-Ket and the N-demethylated metabolite norketamine measured as elimination half-life (t1/2) and decreased plasma concentrations of these compounds. Subchronic administration produced a slight decrease in t1/2 and an increase in plasma concentration of the major metabolite, (2S,6S;2R,6R)-hydroxynorketamine, and produced significant increases in the plasma concentrations of the (2S,6R;2R,6S)-hydroxynorketamine and (2S,4R;2R,4S)-hydroxynorketamine metabolites. The metabolism of (R,S)-Ket predominately occurs via two microsomal enzyme-mediated pathways: (R,S)-Ket⇒(R,S)-norketamine⇒(2S,6S;2R,6R)-hydroxynorketamine and (2S,4R;2R,4S)-hydroxynorketamine and the (R,S)-Ket⇒(2S,6R;2R,6S)-hydroxyketamine⇒(2S,6R;2R,6S)-hydroxynorketamine and (2S,6S;2R,6R)-hydroxynorketamine. The results indicate that the activity of both metabolic pathways are increased by subchronic administration of (R,S)-Ket producing new metabolite patterns and potential differences in clinical effects.

Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study.

PURPOSE: To assess complications of therapy for early (nonmetastatic) prostate cancer. PATIENTS AND METHODS: A prospective study of a cohort of 279 men who sought treatment advice and completed required pretreatment forms. The measures were self-reported patient symptoms and other measures of quality of life before therapy and at 3 and 12 months afterward. RESULTS: Bowel and bladder symptoms were uncommon pretreatment. Patients frequently reported irritative bowel and bladder symptoms at 3 months after radiotherapy, although these subsided somewhat at 12 months. Substantial ("a lot") urinary incontinence and wearing of absorptive pads were reported by 11% and 35% at 12 months after surgery and varied little by age. Incontinence occurred after radiotherapy infrequently, and only in men more than 65 years old. Inadequate erections, present in one third of men pretreatment, were nearly universal at 3 months after surgery, although some improvement, primarily in men under 65 years of age, was evident at 12 months. Sexual dysfunction after radiotherapy increased less but continually through 12 months, suggesting that observed treatment-related differences would decline with further follow-up. CONCLUSION: External-beam radiotherapy of early prostate cancer is followed by bowel and bladder irritability, by increasingly severe sexual dysfunction and, in men aged more than 65 years, occasional urinary incontinence. Greater sexual dysfunction and urinary incontinence occur in the year following radical prostatectomy. These postsurgical complication rates from patient questionnaires are greater than have been reported in other treatment series and confirm the results of two retrospective studies of patient-reported complications.

Calculated prostate cancer volume greater than 4.0 cm3 identifies patients with localized prostate cancer who have a poor prognosis following radical prostatectomy or external-beam radiation therapy.

PURPOSE: Patients with palpable extraprostatic disease (T3) have a poor prostate-specific antigen (PSA) failure-free (bNED) survival rate after radical prostatectomy (RP) or external-beam radiation therapy (RT). This study was performed to validate or refute the prognostic value of the previously defined calculated prostate cancer volume (cV(Ca)). PATIENTS AND METHODS: For patients with clinically localized disease (T1c,2), a Cox regression multivariable analysis was used to assess the ability of the cV(Ca) value to predict time to posttherapy PSA failure following RP or RT. RESULTS: The cV(Ca) value was a significant predictor (P < or = .0005) of time to posttherapy PSA failure in both an RP and RT data set independent of the one used to derive the cV(Ca)-based clinical staging system. In both RP- and RT-managed patients, estimates of 3-year bNED survival were not statistically different for patients with either T1c,2 disease and a cV(Ca) greater than 4.0 cm3 (RP, 27%; RT, 18%) or T3 disease (RP, 37%; RT, 34%). Despite pathologic T2 disease, the 3-year estimate of bNED survival was at most 51% in RP-managed patients with T1c,2 disease and cV(Ca) greater than 4.0 cm3. CONCLUSION: A cV(Ca) greater than 4.0 cm3 identified patients with T1c.2 disease whose bNED survival was poor after RT or RP despite pathologic T2 disease that suggests the presence of occult micrometastatic disease in many of these patients. Prospective randomized trials to evaluate the impact on survival of adjuvant systemic therapy in these high-risk patients are justified.

Breast cancer resistance protein (BCRP/MXR/ABCG2) in acute myeloid leukemia: discordance between expression and function.

Data on breast cancer resistance protein (BCRP, MXR, ABCG2) expression in acute myeloid leukemia (AML) have been inconsistent, possibly due to use of different assays in different studies. BCRP mRNA was studied by the reverse-transcription polymerase chain reaction and BCRP protein expression (BXP-21, BXP-34 or anti-ABCG2 antibody, with anti-CD34 and anti-CD33) and function (fumitremorgin C modulation of mitoxantrone retention) by flow cytometry in eight cell lines and in pretreatment blasts from 31 AML patients. BCRP mRNA levels, antibody staining and function correlated strongly in cell lines (Pearson r values, 0.73-0.97), but not in AML samples. AML sample BCRP mRNA levels were between those in parental 8226 and 35-fold mitoxantrone-resistant 8226/MR20 cells in all but one case, and BCRP mRNA had the wild-type sequence at codon 482 in all. In AML, unlike in cell lines, BCRP protein expression or function, when present, was only detected in small subpopulations. BCRP mRNA and protein expression did not correlate, nor did staining with different BCRP antibodies, and function did not correlate with mRNA nor protein expression. Presence of BCRP only in subpopulations and discordance among BCRP measurements suggest complex biology of BCRP in AML and incomplete modeling by cell lines.

Determination of tissue distribution of an intramuscular plasmid vaccine using PCR and in situ DNA hybridization.

The increasing use of nucleic acid-based therapeutics has created a need for new methods of determining tissue distribution and levels. Radiolabel methods may not always be appropriate because nucleic acids are easily degraded. Quantitation using the polymerase chain reaction (PCR) has the advantage that only continuous stretches of DNA will be amplified. In situ hybridization allows detection of specific sequences in histological preparations. We have used quantitative PCR and in situ hybridization techniques to study the pharmacokinetics and distribution of PGagPol (a potential anti-HIV plasmid vaccine) in rabbits. Samples were obtained 4 hr, 24 hr, 7 days, and 28 days after intramuscular injection of 100 micrograms or 400 micrograms of plasmid. A simplified procedure for collecting and processing tissues for PCR that minimizes the risk of contamination was developed. Using PCR, plasmid was found principally in the skin and muscle of the injection site and in blood plasma. At 4 hr after dosing with 400 micrograms, the plasmid was detected at the injection site with mean copy numbers of 10(6) (in muscle) and 4 x 10(4) (in skin) per microgram of tissue. Plasmid copy number declined rapidly in muscle during the first 24 hr and was undetectable at 7 and 28 days after injection. The decline was slower in the skin, and the plasmid was still detectable at 28 days. With in situ hybridization, plasmid was detected in muscle, mainly in the perimysium and to a lesser degree in the endomysium and within the muscle fibers. These data indicate that quantitative PCR and in situ hybridization are sensitive methods for examining tissue distribution of DNA used for gene therapy.

Amphiregulin is coordinately expressed with heparin-binding epidermal growth factor-like growth factor in the interstitial smooth muscle of the human prostate.

Peptide growth factors have been proposed as mediators of smooth muscle-epithelial cell interactions in the human prostate; however, the identity of these molecules has not been established. In this study, we compared expression levels of messenger RNAs (mRNAs) encoding the epidermal growth factor (EGF) receptor-related receptor tyrosine kinases (ErbB1 through 4), the six EGF receptor ligands, EGF, transforming growth factor (TGF)-alpha, amphiregulin (ARG), HB-EGF, betacellulin, and epiregulin, and the related molecule heregulin-alpha, in a series of 10 prostate tissue specimens. Only EGF showed a disease-specific association, with increased mRNA levels in four of five PCa specimens in comparison to matched normal tissue from the same subject. In contrast, ARG and HB-EGF mRNAs showed a coordinate pattern of expression in 7/10 specimens that was distinct from all other growth factor or receptor genes examined and from mRNAs for prostate specific antigen, the androgen receptor and GAPDH, a house-keeping enzyme. Analysis of an additional series of benign prostatic hyperplasia and prostate cancer specimens from 60 individuals confirmed that ARG and HB-EGF mRNA levels varied in a highly coordinate manner (r = 0.93; P < 0.0001) but showed no association with disease. ARG was immunolocalized largely to interstitial smooth muscle cells (SMC), previously identified as the site of synthesis of HB-EGF in the prostate, while the cognate ARG and HB-EGF receptor, ErbB1, was localized exclusively to ductal epithelial cells and carcinoma cells. Although ARG was a relatively poor mitogen for Balb/c3T3 cells in comparison to HB-EGF, it was similar in potency to HB-EGF in stimulating human prostate epithelial cell growth, suggesting that prostate epithelia may be a physiologic target for ARG in vivo. Expression of both ARG and HB-EGF mRNAs was induced in cultured prostate SMC by fibroblast growth factor-2, a human prostate SMC mitogen linked to prostate disease. These findings indicate that ARG and HB-EGF are likely to be key mediators of directional signaling between SMC and epithelial cells in the human prostate and appear to be coordinately regulated.

Gonadotropin determinations in times 3-hour urine collections during the menstrual cycle and LHRH testing.

The usefulness of timed 3-hour urine collections as a substitute for serum gonadotropin (LH and FSH) determinations during the menstrual cycle and during LHRH testing was examined. The timing of the 3-hour urine collection is not important in mature individuals, since no significant temporal trend was found when aliquots were collected every 3 hours throughout two 24-hour periods in one mature woman. Good correlation was found between serum LH and FSH concentrations and the quantity of LH and FSH in timed 3-hour urine specimens throughout normal, ovulatory menstrual cycles in two women. Studies before and during 51 LHRH stimulation tests in normal men, children, and women during different phases of the menstrual cycle and in patients with a variety of hypothalamic-pituitary-gonadal axis disorders were performed. There was good correlation between the quantity of the gonadotropins in time 3-hour urine collections and the mean serum LH and FSH concentrations before and during the LHRH test. The "response area" for serum LH and FSH also correlated well with the amounts of LH and FSH in the urine collected during this period. Therefore, the timed 3-hour urine collection for gonadotropin estimation provides a simple, accurate method for the integration of fluctuating serum concentrations of LH and FSH during such instances of physiologic variability as the menstrual cycle and LHRH stimulation tests.

Analysis of biological and immunological activities in the two pools of LH released during constant infusion of luteinizing hormone-releasing hormone (LHRH) in men.

In response to constant infusion of a submaximal dose of LHRH (0.2 microgram/min for 4 hours), luteinizing hormone (LH) was released in a biphasic pattern in 6 normal men. When the in vitro biologic activity of plasma LH was compared to the immunologic activity throughout the response to LHRH, the B/I ratio remained unchanged (3.6 +/- 0.5, mean +/- SE). Thus, in men the biologic activity of stored LH (acutely releasable) is not different from the presumably newly synthesized hormone that is released as the second pool during prolonged LHRH infusion.

Immunoreactive luteinizing hormone, follicle stimulating hormone and their subunits in human urine following gel filtration.

Urine collected from postmenopausal women, normal men, women and children was prepared by vacuum dialysis and kaolin extraction prior to chromatography on Sephadex G-100. Specific radioimmunoassays for LH, alpha subunit, LHbeta, FSH and FSHbeta were utilized to define the elution patterns of the urinary filtrates, extracts, 2nd IRP-HMG and postmenopausal serum. The following findings were obtained: 1) FSH eluted as a distinct immunoreactive peak whereas LH eluted more diffusely, 2) free alpha subunit was present in all urinary preparations, the 2nd IRP-HMG and postmenopausal serum, 3) free FSHbeta but not LHbeta was detectable in postmenopausal urine, and 4) an LHbeta immunoreactive fragment with an approximate molecular weight of 5000 daltons was present in all urinary preparations and the 2nd IRP-HMG but not in postmenopausal serum.

Endocrine studies during the refeeding of young women with nutritional amenorrhea and infertility.

Serial endocrine studies were performed during the refeeding of a group of nine young women who presented with amenorrhea associated with injudicious dieting. No significant psychopathology was disclosed by the Lanyon Psychological Screening Inventory in any of the patients, six of whom were single and three married and infertile. The mean weight before refeeding was 81.6% of the normal for height. The mean initial serum follicle-stimulating hormone concentration was within the limits of normal for young women of reproductive age, but the serum luteinizing hormone (LH) concentration and the vaginal maturation score were low. As weight was regained, the serum LH concentration increased (the pooled r for LH versus percent normal weight = 0.85) and the vaginal maturation score rose (the pooled r for vaginal maturation score versus percent normal weight = 0.93). When a mean weight of 96.6% of normal was reached after a mean of 5.3 (range, 2 to 11) months of refeeding, spontaneous menses occurred. The initial cycle was ovulatory in two instances and anovulatory in five, as determined by basal body temperature patterns, plasma progesterone concentrations, and endometrial biopsies. With continued weight gain, menstruation became regular and the three married patients conceived.

Virtual CT cystoscopy: color mapping of bladder wall thickness.

RATIONALE AND OBJECTIVES: To improve the conspicuity of bladder tumors in a virtual environment, we developed an algorithm for color mapping the thickness of the bladder wall. The purpose of this study was to demonstrate the feasibility of this algorithm as a component of virtual CT cystoscopy. METHODS: Five subjects with a history of superficial transitional-cell carcinoma of the bladder underwent helical CT scanning after insufflation of the bladder with air. Source images were transformed into three-dimensional models, and the thickness of the bladder wall was demarcated by using a new computer algorithm and a fixed color scale. Results were compared with those obtained by conventional cystoscopy. RESULTS: Three tumors, one site of benign wall thickening, and normal wall thickness were correctly identified by using axial source images and virtual cystoscopy with color mapping. CONCLUSIONS: Color mapping of bladder wall thickness is feasible and demonstrates both normal and thickened urothelium. Its value in identification of small or sessile tumors will require further trials.

A prospective, randomized trial for the prevention of mucositis in patients undergoing hematopoietic stem cell transplantation.

Oral mucositis is a complication common to many cancer therapies and produces considerable pain and morbidity. The present study reports a double-blind, prospective, randomized clinical trial testing the efficacy of a calcium phosphate mouth rinse (Caphosol) with fluoride treatments vs a standard regimen of fluoride rinsing and placebo tray treatments in 95 patients undergoing hematopoietic stem cell transplantation (HSCT). The days and severity of mucositis were prospectively evaluated. There were statistically significant decreases in days of mucositis (3.72 vs 7.22 P=0.001), duration of pain (2.86 vs 7.67, P=0.0001), dose of morphine (34.54 mg vs 122.78 mg), days of morphine (1.26 vs 4.02, P=0.0001) and days to the onset of engraftment ANC (absolute neurotrophil count)>200 mm(3) (11.12 vs 12.56) in the Caphosol and fluoride treatment group vs fluoride-rinse group, respectively. Caphosol, a neutral, supersaturated, Ca(2+)/PO(4)(3-) mouth rinse, used in combination with topical fluoride treatments, is superior to fluoride rinse alone in reducing the frequency, intensity and duration of oral mucositis in patients undergoing HSCT.

The utility of patient age in evaluating prostate cancer.

The utility of age in examining patients for prostate cancer was assessed. Of the 462 patients in the study, 138 had prostate cancer. The age distribution of the patients with cancer was similar to that found in patients with prostate cancer in the US population, and a correlation between age and the serum prostate-specific antigen (PSA) value was noted (r = .4, P < .002). Selection of reference intervals had a significant effect on test performance. Using an interval of 0 to 4.0 ng/mL, sensitivity of the PSA assay was 90% overall and varied from 78% (patients aged 50-59 years) to 94% (patients aged 70-79 years). In contrast, age-adjusted reference ranges yielded corresponding sensitivities of 84%, 78%, and 88%. With a single, fixed reference range, specificity decreased with advancing patient age (P < .001). This trend was eliminated by adjusting the cutoff in different age groups. In addition, age-adjusted reference ranges improved specificity by 10%, and by using the results of examination of a biopsy specimen as the "gold standard," the total number of patients classified correctly by PSA increased from 226 to 250 (49%-54%). For staging before treatment, patient age, clinical stage, and Gleason score were combined to yield a single probability estimate for organ-confined disease (P < .001). The use of age-adjusted reference ranges is supported by this study, which demonstrates that assay efficiency and specificity improve and sensitivity, although decreased overall, becomes more uniform across age groups. In this patient population, age was useful in determining the probability of organ-confined prostate cancer. Use of this model in clinical decision making should await evaluation in a prospective trial.

Appropriateness of prostate-specific antigen testing.

We established criteria for appropriate use of the prostate-specific antigen (PSA) assay and used them to evaluate PSA test utilization at 1 tertiary care institution. During a 6-month period, 2,330 PSA results were reported for outpatients and 95 for inpatients. We reviewed medical records for a random sample of 338 outpatient results (14.51%) and all 95 inpatient results, of which 21% (71/338) of outpatient and 17% (16/95) of inpatient results were inappropriate according to our test utilization criteria. Among outpatients, 52% of tests were done for screening and 19% for monitoring for cancer recurrence. For inpatients, workup for cancer (53/95 [56%]) was the most frequent indication for testing and screening the second (24/95 [25%]). Of tests failing the criteria, 66 (76%) of 87 resulted from excessively frequent and age-inappropriate screening. We assessed the potential effect on clinical outcome if these tests were not performed. Of the 87 tests considered inappropriate, only 1 test result influenced clinical management for patients younger than 75 years. By instituting simple limits on age and frequency, we estimate that 74% (64/87) of the inappropriate tests could have been eliminated.

Maximum diameter of prostatic carcinoma is a simple, inexpensive, and independent predictor of prostate-specific antigen failure in radical prostatectomy specimens. Validation in a cohort of 434 patients.

The amount of tumor in radical prostatectomy specimens can be determined with several techniques. Maximum tumor diameter correlates well with total tumor volume and can readily be obtained in incompletely submitted specimens. Initial results in a small series suggested that this measure also may predict for prostate-specific antigen (PSA) failure. We studied whether maximum tumor diameter was an independent predictor of PSA failure in a series of 434 men who underwent radical prostatectomy because of prostatic adenocarcinoma; 118 (27.2%) had PSA failure. Preoperative PSA, Gleason score, pathologic stage, margin status, and largest tumor diameter were determined, and multivariate logistic modeling was performed on the outcome of PSA failure. Maximum tumor diameter was an independent risk factor for PSA failure, along with preoperative serum PSA level, and Gleason score > or = 8. Only 15% of men with tumor with maximum diameter < 1 cm had PSA failure, compared with 73% of men with tumor with maximum diameter > 2. Maximum tumor diameter of prostatic carcinoma is a simple, inexpensive, and independent predictor of PSA failure that can be obtained readily from partially submitted radical prostatectomy specimens.

Urologic complications in 718 renal transplant patients.

Urologic complications occurred in 13.2% of the 718 patients who received renal transplants performed during a 26-year period at the Peter Bent Brigham Hospital. The complication rate remained constant over the quarter century period, whereas the rate of death caused by complications decreased significantly during the last decade. This was due, in part, to recent use of ultrasound techniques permitting earlier recognition of complications. The majority of urologic complications occurred during the first month after transplantation. Contributing factors included technical problems, ischemia, and perhaps allograft rejection. No correlation could be found between degree of HLA match or mismatch and likelihood of complication. Internal indwelling stents offered substantial advantages over nephrostomy tubes for temporary urinary diversion. The most serious complications encountered were calyceal-cutaneous fistulas associated with donor kidneys with multiple renal arteries. "Bench" operation has proved to be a major technical advance in the prevention of these fistulas.

Application of the flexible cystoscope to the excision of renal cell carcinoma with intracaval tumor thrombus.

Cardiopulmonary bypass, temporary cardiac arrest, and exsanguination have facilitated the surgical resection of renal tumors with intracaval thrombi that extend above the hepatic veins or into the atrium. The bloodless field provided by this approach enables the surgeon to utilize a flexible cystoscope to ensure that the caval thrombus has been removed entirely from the hepatic veins.