Intravesical bacillus Calmette-Guérin therapy prevents tumor progression and death from superficial bladder cancer: ten-year follow-up of a prospective randomized trial.

PURPOSE: Superficial bladder tumors (stage Ta, T1, and Tis) may progress to invade the bladder muscle and cause death from metastatic cancer. Transurethral tumor resection (TURB) is the standard therapy for such tumors, but surgery alone may not prevent tumor progression. Intravesical therapy is widely used as an adjunct to TURB. Bacillus Calmette-Guérin (BCG) is the most active intravesical agent, but whether BCG prevents tumor progression and death from bladder cancer is unknown. PATIENTS AND METHODS: Between 1978 and 1981, 86 high-risk patients with superficial bladder cancer were randomly assigned to receive either TURB (n = 43) or TURB plus BCG (n = 43). Adverse tumor features for progression were equally distributed between the two groups. BCG was administered weekly for 6 weeks. Patients were evaluated every 3 to 6 months thereafter for progression to muscle invasion or metastasis. Control (TURB) patients with recurrent superficial tumors were eligible for crossover to the BCG arm. All patients have been monitored until event or for a minimum of 10 years (range, 10 to 14). RESULTS: The 10-year progression-free rate was 61.9% (95% confidence interval [CI], 47.2% to 76.7%) for patients treated with BCG and 37% (95% CI, 22.9% to 53.1%) for control patients. The median progression-free interval was not reached for the BCG group and was 46 months for the control group (P = .0063). Of 18 control patients crossed over to BCG (median, 29 months), 15 did not show tumor progression. TURB plus BCG resulted in a 10-year disease-specific survival rate of 75%, compared with 55% with TURB alone (P = .03). CONCLUSION: This study shows that intravesical therapy with BCG delays tumor progression and death from tumor in patients who present with superficial bladder cancer.

Maintenance intravesical bacillus calmette-guerin for superficial transitional cell carcinoma of bladder. A retrospective study.

Eighteen patients with recurrent and/or multifocal superficial transitional cell carcinoma of the bladder who were rendered tumor-free by transurethral resection and were then treated with either a single or second six-week course of induction Bacillus Calmette-Guerin (BCG) therapy, followed by maintenance therapy, were retrospectively reviewed. A 73 percent complete response rate was achieved in those patients treated prophylactically, while a 70 percent complete response rate was observed in patients treated for carcinoma in situ (CIS) with an average follow-up of twenty-nine months. Maintenance therapy may be warranted in those patients able to tolerate it without significant side effects.

Application of microwave tissue coagulation in partial nephrectomy.

Microwave tissue coagulation was used during partial nephrectomy in 10 mongrel dogs, without clamping the renal artery. There were no major complications, such as retroperitoneal hematoma, abscess formation, or macroscopic infarction of the kidney tissue related to this new procedure. The advantages of microwave coagulation are reduced blood loss, shorter operative time, and minimal risk of vascular injury.

Techniques to negotiate the tortuous ureter.

A tortuous ureter can prevent successful retrograde ureteral access. Forceful attempts at catheterizing a ureteral kink may result in perforation and urinary extravasation. We review the currently recommended techniques to negotiate the tortuous ureter and present an additional endourological maneuver to bypass those kinks refractory to conventional methods.

Morphological and physiological changes in the urinary tract associated with ureteral dilation and ureteropyeloscopy: an experimental study.

The gross and microscopic effects of four common modes of ureteral dilation and ureteroscopy were examined in 26 renoureteral units in 13 minipigs. Acutely, ureters subjected to mechanical (bougie, Teflon, or balloon) ureteral dilation and ureteropyeloscopy (UPS) demonstrated active mucosal bleeding with multiple sites of perforation, whereas ureters subjected to hydraulic dilation and UPS were significantly less traumatized. Two weeks after mechanical ureteral dilation and UPS, 3 of 6 ureters were obstructed radiographically, whereas all 7 hydraulically dilated ureters were unobstructed. By 6 weeks, all radiographic evidence of obstruction had resolved in the mechanically dilated group. While 5 of 6 mechanically dilated ureters showed extensive scarring with muscle loss 4 to 6 weeks after dilation, no scarring was seen in those ureters dilated hydraulically. Renal pelvic pressure (RPP) was measured continuously with a nephrostomy catheter in vivo during (bougie, Teflon, balloon and hydraulic) ureteral dilation and UPS. Renal pelvic pressure during rigid ureteroscopy approximated the resting pelvic pressure plus the irrigant height above the kidney or set pressure on a hydraulic pump, plus a "scope effect" which was characterized by a 20 to 25 mm. Hg increase in RPP produced by moving the endoscope in the ureter without flow. The effects on RPP of continuous bladder drainage with a uretheral catheter and renal pelvic decompression with an open-ended ureteral catheter passed into the renal pelvis through the ureteroscope working channel were also examined. The maximum RPP was evaluated in vitro in a separate group of 16 freshly harvested pig kidneys of similar weight examined immediately after sacrifice and was found to be 439 mm. Hg. We also studied the immediate and long-term effects of low (< 120 cm. H2O or 90 mm. Hg) versus high (> 200 cm. H2O or 150 mm. Hg) RPP on renal histology. Acutely, high pressure caused diffuse denudation and flattening of the caliceal urothelium, submucosal edema and congestion not seen in calyces subjected to low irrigant pressure. Four to six weeks later, there was a higher incidence of columnar metaplasia, subepithelial nests and pericalyceal vasculitis in calyces subjected to high pressure as compared with those subjected to low irrigant pressure. Acutely, renal tubules subjected to high irrigant pressure demonstrated marked vacuolization and degeneration, whereas tubules subjected to low pressure appeared normal. At 4 to 6 weeks, focal scarring was seen in 5 of 7 kidneys subjected to high irrigant pressure, whereas no scarring was noted in all 6 kidneys subjected to low irrigant pressure.(ABSTRACT TRUNCATED AT 400 WORDS)

The management of clinically unconfirmed positive urinary cytology.

An aggressive evaluation of extravesical sites of disease in patients with clinically unconfirmed positive urinary cytology findings is indicated only in previously untreated asymptomatic or symptomatic patients (group 1) and in those with a complete response to intravesical therapy who are without evidence of disease for 1 year (group 4). Patients who have positive urinary cytology findings immediately after complete transurethral resection of bladder tumors or intravesical therapy will almost always have recurrent bladder transitional cell carcinoma and do not require aggressive extravesical evaluation initially. Transurethral resection prostate biopsy between the 5 and 7 o'clock positions along the entire length of the prostatic urethra is the technique of choice for detecting transitional cell carcinoma of the prostate, since other less invasive techniques frequently underestimate the extent of disease. In the absence of radiographic disease, bilateral ureteral lavage cytology is the technique of choice to identify the upper tract as the source of a positive urinary cytology result. Rigid and flexible ureteropyeloscopy should be performed only in the presence of radiographic or cytological evidence of upper tract transitional cell carcinoma, or in patients with a history of upper tract disease who have suspected relapse on the basis of a positive urinary cytology result.

Bilateral same session ureteroscopy.

During a period of 4 years we performed 15 bilateral 1-session ureteroscopic examinations in 13 patients. Indications included bilateral ureteral and/or renal calculi, unexplained hydronephrosis, hematuria or filling defects, and bilateral ureteral stent placement in situations when conventional retrograde methods of stent placement failed. Balloon or hydraulic intramural ureteral dilation was performed in all cases before rigid or flexible endoscopy. There were no major short-term or long-term complications resulting from bilateral 1-session ureteroscopy.

Combined penetrating rectal and genitourinary injuries: a challenge in management.

The standard management of penetrating rectal trauma consists of perioperative antibiotics, a diverting colostomy, and presacral drainage. While providing optimal results in isolated rectal trauma, this management scheme is inadequate in combined penetrating rectal and genitourinary (GU) tract injuries. A review of more than 200 cases of penetrating rectal trauma from our institution over a 13-year period identified 17 concomitant GU tract injuries (13 bladder, three urethral, and one ureteral injury). Complications consisted of pelvic, suprapubic, or subphrenic abscesses in 3 of 17 cases (18%), rectovesical or rectourethral fistulae in 24%, chronic urinary tract infections in 18%, bladder stones in 12%, and the development of urethral strictures in 12% of patients. Factors implicated in their pathogenesis included failure to perform presacral drainage, distal rectal washout, and rectal wound repair; prolonged suprapubic drainage; and failure to separate the rectal and GU tract wounds. Careful debridement of all necrotic tissue, urinary and fecal diversion, tension-free wound closure with well-vascularized tissue, and adequate drainage and separation of the injured sites with well-vascularized tissue such as omentum should reduce the high incidence of rectourethral and rectovesical fistulae from combined rectal-GU tract trauma. Therapeutic recommendations for individualized treatment are presented.

Expanding the role of the ureteroscope.

Although the rigid ureteroscope was designed exclusively for the diagnosis and treatment of pathological conditions of the ureter, its smaller diameter and extended length allow for its increased use in endoscopic procedures that cannot be performed successfully with a cystoscope. The indications can be divided into 3 categories: 1) difficult ureteral catheterizations, 2) augmented bladders and diverticula, and 3) narrow, strictured urethras and bladder necks. Several cases from each category are presented to illustrate the expanded role of the rigid ureteroscope in daily urological practice.

Identification of a new receptor subtype for tumor necrosis factor-alpha.

Two distinct receptors, which bind both tumor necrosis factor-alpha and tumor necrosis factor-beta (TNF-alpha and TNF-beta), have been previously identified and cloned from transformed cells. The present study identifies a novel receptor subtype in normal human liver which binds TNF-alpha but not TNF-beta. TNF-alpha but not TNF-beta competes for 125I-TNF-alpha binding and incorporation into affinity-labeled complexes in human liver plasma membranes (HLPM). Antisera to the cloned receptors competed for 125I-TNF-alpha binding to plasma membranes isolated from various transformed cell lines but not to HLPM. However, mRNAs corresponding in size to both known TNF receptors were detected in liver RNA, making it likely that post-transcriptional modifications account for the TNF-alpha specificity of HLPM. These observations suggest that the effects of TNF-alpha and TNF-beta on some normal tissues may be more distinct than previously realized.