Prostate-specific amplification of expanded polyglutamine expression: a novel approach for cancer gene therapy

For cancer gene therapy, it is of primary importance to develop a system to sufficiently and selectively express therapeutic genes in cancer cells. In this study, we showed that an approximately 5.3-kb promoter region of the prostate-specific antigen (PSA) gene can replicate the endogenous expression pattern, although its expression is very weak. We then developed a novel two-step transcriptional activation system in which the PSA promoter drives an artificial transcriptional activator, GAL4-VP16 fusion protein, and it in turn activates transgene expressions under the control of GAL4-responsive elements. By using this system, transgene expressions can be greatly augmented while maintaining prostate-specific expression. Finally, we applied this system to drive an expanded polyglutamine, a potent proapoptotic molecule, to induce apoptosis selectively in PSA-positive prostate cancer cells. This novel system would provide an ideal approach for cancer gene therapy applicable not only to prostate cancer but to other cancers as well.

Detection of tumor-derived DNA in exfoliated cells of urine sediments with a novel quantitative PCR method based on allele-specific PCR

We have established a novel quantitative method based on the allele-specific PCR, which uses the linearly amplified fragment of the PCR products as the internal control. The improved characteristics of the procedure are the high sensitivity for quantitation of the mutant alleles at ratios of up to 1:10000 and the reduced necessity of the optimization of the PCR conditions for each mutation. Using this modified allele-specific PCR, we could quantify the tumor alleles in the urine sediments of three patients with urothelial cancers that harbored different p53 gene mutations. This method can be applied to other genetic targets that have other types of alterations, such as deletions or insertions.

[Intravesical bacillus Calmette-Guerin instillation for patients over 80 years old]

To study the efficacy and the safety of intravesical bacillus Calmette-Guerin (BCG) therapy for very elderly patients with superficial bladder cancer, we retrospectively compared patients over 80 years old who had received BCG therapy at our department between 1991 and 1996 (Group A; 10 patients 11 courses), with those below 80 years old (Group B, 17 patients 18 courses). In these patients, skin test reactivity to purified protein derivative showed a significant negative correlation with age (p = 0.016). No irreversible complications were observed in any patient. Persistence of acid-fast bacilli for more than one month after the termination of the course was observed in two patients in group A, and one in group B. A comparison of the cases undergoing eradicational BCG therapy in the two groups, grade 2 transitional cell carcinoma (TCC) was significantly more predominant than grade 3 TCC in group A (p = 0.004). (None of the tumors in group A were of grade 3) The disease-free rate was significantly lower in group A (p < 0.05), but 5 of the 10 patients in this group were finally disease-free. From these results, we conclude that intravesical BCG instillation therapy can be performed in patients over 80 years old, although a relatively lower disease-free rate is expected and special attention should be taken with regard to persistent BCG infection. The lower disease-free rate could be attributable to either diminished cellular immunity or a difference in tumor grade, although a definite conclusion could not be obtained here.

[Combination therapy of daily intramuscular injection of interferon-alpha and oral administration of fluorouracil for advanced renal cell carcinoma]

BACKGROUND

To achieve optimum drug delivery of Interferon-alpha in treatment of renal cell carcinoma, a regimen consisting of its daily intramuscular administration, in combination with oral fluorouracil, was designed and carried out. Its efficacy is examined retrospectively.

METHODS

In our department 7 patients with disseminated renal cell carcinoma were treated with daily intramuscular injection of interferon-alpha (3 x 10(6) IU) and daily oral administration of fluorouracil. All patient was nehprectomized before initiation of the regimen.

RESULTS

Two patients achieved complete, and three patients achieved partial response radiographically (Overall response rate 71%). Metastatic sites of responders were lung (4) and pleura (2). The time required until response was 3.9 (median 5.4) months. In two responders, new lesions appeared in other organs despite durable response in initial pulmonary metastatic sites. There were two no-responders, one patient is alive with stable disease and the other patient died for progression of the disease. In all, two patients died of disease, one died for other cause, one surviving without evidence of disease, and three are surviving with disease. No significant side effect was noted in these seven patients.

CONCLUSIONS

This regimen can be carried out on outpatient basis and considerable response can be expected for pulmonary and pleural lesions.

Absence of p53 overexpression and favorable response to cisplatin-based neoadjuvant chemotherapy in urothelial carcinomas

It has been controversial whether cancer cells harboring loss or inactivation of the tumor suppressor p53 are resistant or sensitive to DNA-damaging agents including cisplatin and doxorubicin. Overexpression of mdm2 oncoprotein, a negative regulator of p53, is assumed to be an alternative to p53 dysfunction. Archival urothelial carcinoma specimens obtained from 60 patients prior to cisplatin-based chemotherapy were immunohistochemically studied for overexpression of p53 and mdm2. Thirty-two patients (group I) were treated with chemotherapy in the neoadjuvant setting, while 28 patients (group II) underwent chemotherapy for distant metastases or inoperable locoregional tumors. In group I, the responsiveness was correlated with staining status of p53 (P=0.0225) and the combination of p53 and mdm2 (P=0.0497). Negative staining of p53 and negative for both p53 and mdm2 could have predicted favorable response to chemotherapy in 16 of 18 (88.9%) and in 12 of 13 (92.3%) tumors, respectively. On the other hand, p53-positive and p53 and/or mdm2-positive staining could have predicted poor response only in 7 of 14 (50.0%) and 8 of 19 (42.1%) tumors, respectively. Disease-specific survival of the p53-negative group was significantly superior to that of the p53-positive group (P=0.0086). Difference in survival did not become more significant when overexpression of mdm2 was taken into consideration (P=0.0456). In contrast, in group II, there was no correlation of responsiveness to chemotherapy or survival with p53- or p53/mdm2-staining status. The patients with urothelial carcinomas negative for overexpression of p53 will benefit from neoadjuvant chemotherapy. From clinical viewpoint, however, p53 status alone or the combination of p53 and mdm2 status is not enough to identify those patients who will not benefit from the treatment.

Low frequency of positive telomerase activity in a chromophobe subtype of renal cell carcinoma

PURPOSE

In malignant tumors, telomerase reactivation plays an important role in the acquisition of cellular immortality. We evaluated the telomerase activity in renal cell carcinomas (RCCs) with special reference to their clinicopathologic features.

MATERIALS AND METHODS

Telomerase activity was examined in 47 RCCs and 9 RCC cell lines by telomeric repeat amplification protocol assay (TRAP). The telomere lengths were assessed by Southern analysis of terminal restriction fragments (TRFs) generated by Hinfl-digested DNA.

RESULTS

Thirty-six (77%) of the 47 RCCs and all 9 RCC cell lines showed telomerase activity, whereas no activity was detected in any of 30 normal kidneys. When the tumors were histopathologically classified, only one (17%) of the 6 chromophobe cell carcinomas was telomerase-positive. This frequency was significantly low (p < 0.001) when compared with those in clear cell RCCs (93%; 26/28). In 40 of the 47 patients, DNA from the tumor tissues and the paired normal kidneys was available for analysis of the TRF lengths. No tumor showed elongated TRF length compared to its paired normal kidney. Regarding the relationship between telomere length and telomerase activity, 23 (74%) of the 31 telomerase-positive RCC and 6 (67%) of the 9 telomerase-negative RCC exhibited reduced TRF. There was no significant correlation between the telomere reduction and telomerase activity.

CONCLUSION

The mechanism for preventing telomere shortening may differ according to RCC subtype. Alternatively, telomerase-negative tumors may have yet to reach the immortal stage when they progress to clinical cancer. The telomerase activity status may contribute to the biological potential and the prognosis of RCCs.

Multifactorial involvement of multidrug resistance-associated [correction of resistance] protein, DNA topoisomerase II and glutathione/glutathione-S-transferase in nonP-glycoprotein-mediated multidrug resistance in human bladder cancer cells

BACKGROUND

Multiple mechanisms are important in multidrug resistance in urothelial cancers. We investigated the acquisition of a multidrug resistance phenotype in human bladder cancer cells exposed to doxorubicin.

METHODS

Human bladder cancer cell line 5637 and 2 doxorubicin drug-resistant sublines (5637/DR5.5 and 5637/DR50) were used. Measurements were made of the steady state mRNA levels of the multidrug resistance gene (mdr1), multidrug resistance-associated protein (MRP), glutathione-S-transferase-pi and DNA topoisomerase II (topo II) genes, P-glycoprotein (PgP) and MRP expression, glutathione (GSH) and GSH enzyme activity, and topo II catalytic activity. The pharmacokinetics were compared between the parent and the drug-resistant sublines.

RESULTS

5637/DR5.5 and 5637/DR50 cells were 7.6- and 16.2-fold more resistant to doxorubicin and 16.7- and 48.3-fold more resistant to etoposide, respectively, compared with 5637 cells. A dose escalation of doxorubicin increased the MRP expression, GSH levels and glutathione-S-transferase (GST) activity, although no PgP expression was observed in any cell line. Resistance was brought about by decreased drug accumulation through drug efflux, although intracellular daunorubicin concentrations were similar between DR5.5 and DR50 cells. Topo II catalytic activity was undetectable in DR50 cells, but maintained in both the parent and DR5.5 cells.

CONCLUSION

Reduced drug accumulation in doxorubicin-resistant cells was mediated by MRP instead of PgP indicating that MRP-mediated drug efflux functions in a limited manner for drug resistance. An increase in drug efflux via MRP, reduced topo II activity, and increased GSH levels/GSH-related enzyme activities may play major roles in nonPgP-mediated multidrug resistance in urothelial cancers treated with anthracyclines.

A high prevalence of functional inactivation by methylation modification of p16INK4A/CDKN2/MTS1 gene in primary urothelial cancers

We analyzed the genetic and epigenetic alterations of p16INK4A/CDKN2/MTS1 gene (MTS1 gene) in 38 primary urothelial cancers. Genetic alterations of the MTS1 gene consisted of one base substitution mutation in exon 2 (2.6%) and 6 homozygous deletions (16.2%). Hypermethylation of the 5' CpG island in exon 1 of the MTS1 gene was observed in 12 tumors (37.5%). Consequently, 19 of 38 tumors (50%) showed genetic alterations or epigenetic hypermethylation of the MTS1 gene. Retention of hypermethylated MTS1 gene(s) in 36% of the tumors showing loss of heterozygosity at the critical region indicates that the methylation modification could be an initial event followed by genomic rearrangements associated with total loss of MTS1 gene function. Immunohistochemical analysis of MTS1 expression revealed that all the tumors with genetic alterations of the MTS1 gene and 9 of 12 highly methylated tumors displayed an absence of MTS1 nuclear antigen. Genetic and epigenetic changes of the MTS1 gene were not correlated with the grade and stage of tumors, indicating that these alterations are early events in urothelial carcinogenesis, in which functional inactivation by hypermethylation is a predominant mechanism.

Association of in vitro growth potential of urinary exfoliated cells with tumor localization and intraluminal recurrence rates of urothelial cancers

PURPOSE

One problem in the treatment of urothelial cancers, in particular of upper urinary tract cancers, is multifocal synchronous and/or metachronous tumor development in the heterotopic urothelium. We investigated the abilities of exfoliated cells in the urine of patients with urothelial cancers to colonize and proliferate in vitro.

MATERIALS AND METHODS

Short-term cultures of 129 urine samples obtained from patients with urothelial cancers and 53 samples from healthy volunteers were compared as to the growth potential of urinary-exfoliated cells and clinico-pathological features, in particular tumor localization and evidence of intraluminal tumor recurrence.

RESULTS

Primary cell outgrowth occurred in 112 (86.8%) of the 129 cell cultures from the patients and in 29 (54.7%) of the 53 from the healthy volunteers (p < 0.0001). "Sufficient cell growth" (more than 10(5) cells per flask) was obtained for 77 (59.7%) of the 129 cultures from patients and 7 (13.2%) of the 53 from the healthy volunteers (p < 0.0001). In terms of tumor localization, the rate of sufficient cell growth was significantly higher for patients with upper urinary tract tumor (21/25, 84.0%) than for those with bladder tumor (56/104, 53.8%) (p = 0.0062). Proportional hazard regression analysis showed that only the growth potential of the urinary-exfoliated cells was significantly predictive of intravesical tumor recurrence in patients with superficial bladder tumors (p = 0.011).

CONCLUSIONS

The potentials for the colonization and proliferation of urinary-exfoliated cells are associated with intraluminal multifocal tumor recurrence of urothelial cancers.

Transperitoneal laparoscopic adrenalectomy: experience in 100 patients

Between July 1992 and October 1996, 100 transperitoneal laparoscopic adrenalectomies were performed on 99 patients at our hospital and affiliated hospitals. The clinical diagnoses were primary aldosteronism (41 patients), Cushing's syndrome (15), pre-Cushing's syndrome (6), pheochromocytoma (7; 8 adrenal glands), adrenal cancer (2), nonfunctioning adenoma (22), myelolipoma (3), and complicated adrenal cyst (3). Ninety-seven glands were removed laparoscopically. The mean operative time was 240 +/- 76 (SD) minutes and the mean blood loss 68 +/- 80 mL for the series. The mean blood was 77 +/- 113 mL when the three operations that were converted to open surgery are included. The mean times for the return to a normal diet and unassisted ambulation were 1.3 +/- 0.6 and 1.4 +/- 0.8 days, respectively. The mean duration of the use of analgesics was 1.5 +/- 1.3 days, including the day of surgery. In contrast, in the latest 10 open adrenalectomies done at Kyoto University Hospital, the mean operative time was 186 +/- 53 minutes and the mean blood loss 220 +/- 170 mL. The mean times for return to a normal diet and for unassisted ambulation and the mean duration of the use of analgesics were 1.9 +/- 0.3, 2.9 +/- 1.1, and 2.9 +/- 1.7 days, respectively. Thirty-six operations, excluding one converted to open surgery, performed at Kyoto University Hospital were selected to look at the learning curve for transperitoneal laparoscopic adrenalectomy and evaluated for operative time and blood loss. The mean operative time and mean blood loss in the first 10 procedures performed at Kyoto University Hospital were 256 +/- 63 minutes and 89 +/- 57 mL; however, these values were reduced to 177 +/- 39 minutes and 48 +/- 32 mL in the next 10 procedures at the same hospital. Laparoscopic adrenalectomy via the transperitoneal anterior approach can be equivalent to open adrenalectomy in efficiency with a shorter convalescence.

[Renal artery embolism treated by selective intra-arterial infusion of tissue plasminogen activator: report of 2 cases]

Two cases of renal artery embolism treated by selective intra-arterial infusion of tissue plasminogen activator (t-PA) are reported. A 74-year-old woman with atrial fibrillation presented with left flank pain of 54-hour duration. Selective renal angiography revealed embolic obstruction of multiple segmental arteries in the left kidney. She was treated by one-shot intra-arterial t-PA infusion (8,000,000 units) and intravenous heparinization (25,000 units/3 days). Although fibrinolysis was successful except for most distal arterial branches, complete recovery of renal function was not obtained. A 66-year-old man presented with complete obstruction of left main renal artery. He had hyperthyroidism and atrial fibrillation. At 75 hours after onset of left flank pain, he was treated by one-shot intra-arterial t-PA infusion (18,000,000 units) and intravenous heparinization (4,000 units/24 hours). His renal function was recovered completely. Selective intraarterial t-PA infusion is considered an effective treatment for renal artery embolism.

Strong correlation of basement membrane degradation with p53 inactivation and/or MDM2 overexpression in superficial urothelial carcinomas

PURPOSES

We investigated the relationships between the degradation of basement membrane underlying superficial urothelial carcinomas, including carcinoma in situ and the functional p53 loss caused by inactivation of p53 and the overexpression of mdm2 oncoprotein.

MATERIALS AND METHODS

Nuclear accumulations of p53 and mdm2 were examined immunohistochemically for 60 transitional cell carcinomas (primary lesions) and 13 accompanying (concomitant) carcinoma in situ lesions. Degradation of the basement membrane was defined as the reduction or total loss of type IV collagen expression. Whether there was up-regulation of MMP-1, MMP-2, and MMP-9 was analyzed immunohistochemically.

RESULTS

The frequency of the degradation of basement membrane underlying grade 1 pTa tumors was 0%, grade 2-3 pTa tumors 57.1%, and primary CIS lesions 83.3%. Nuclear over-accumulation of p53 was found in 48.3% and of mdm2 in 23.3% of the primary tumors. In pTa-pT1 carcinomas, nuclear staining of p53, mdm2, or both was highly correlated with degradation of the basement membrane underlying carcinomas (p = 0.00002). In the CIS lesions, the association of p53 nuclear staining with the destruction of type IV collagen expression was of borderline significance (p = 0.03). When mdm2 overexpression was considered as a molecular abnormality together with p53 inactivation, the correlation with the degradation of the basement membrane was highly significant (p = 0.00006). Moreover, the functional p53 loss was strongly associated with the up-regulation of matrix metalloproteinases (MMPs) (p = 0.0005). This finding was well correlated with the strong association of basement membrane degradation with up-regulation of MMPs (p = 0.000004).

CONCLUSIONS

Degradation of basement membranes underlying superficial carcinomas or CIS of the urothelium was significantly related to p53 inactivation, mdm2 overexpression, or both. The expression status of mdm2 should provide better information about the progression of superficial urothelial carcinomas than the status of p53 alone.

Detection of telomerase activity in exfoliated cells in urine from patients with bladder cancer

BACKGROUND

Telomeres are specific structures located at the ends of chromosomes that help maintain chromosome stability. In most tissues, telomeres become shorter as cells divide, a phenomenon thought to be associated with limitations on normal cell proliferation. Almost all types of cancer cells, including bladder cancer cells, express the enzyme telomerase, which can maintain or extend telomere length.

PURPOSE

We examined telomerase activity in tumor specimens from a cohort of patients with bladder cancer and determined whether telomerase could be detected in exfoliated cancer cells present in urine from these patients.

METHODS

Spontaneously voided urine specimens and bladder-washing fluids (obtained by propelling normal saline into the bladder through a catheter and then withdrawing the liquid contents) were taken from 45 patients before they underwent surgery. Telomerase activity was examined by means of the TRAP (telomeric repeat amplification protocol) assay on extracts of tumor samples from 42 patients and extracts of exfoliated cells in urine and bladder-washing fluid from 42 and 43 patients, respectively. Standard cytologic examination (Pap staining) of urine specimens was also used to detect exfoliated cancer cells.

RESULTS

Telomerase activity was found in 41 (98%; 95% confidence interval [CI] = 87%-100%) of the 42 tumor samples examined. In contrast, it was not detected in normal bladder tissue from two autopsied individuals who were free of bladder cancer and five of six individuals who had bladder cancer. Telomerase was detected in exfoliated cells in 23 (55%; 95% CI = 39%-70%) of the 42 spontaneously voided urine specimens and in 36 (84%; 95% CI = 69%-93%) of the 43 bladder-washing fluids examined. Considering voided urine specimens and bladder-washing fluids together, telomerase was detected in exfoliated cells from 40 (89%; 95% CI = 76%-96%) of the 45 patients. Telomerase activity was not detected in bladder-washing fluids from 12 cancer-free individuals. Cancer cells were detected by means of standard cytologic examination in the urine of 19 (42%; 95% CI = 28%-58%) of the 45 patients. Urine cytologic examination detected cancer cells in one (8%; 95% CI = 0%-38%) of 12 patients with grade 1 tumors and in 13 (46%; 95% CI = 28%-66%) of 28 patients with grade 2 tumors. In contrast, telomerase activity was detected in exfoliated cells (in voided urine or bladder-washing fluids) from nine (75%; 95% CI = 43%-95%) of 12 patients with grade 1 tumors and from 27 (96%; 95% CI = 82%-100%) of 28 patients with grade 2 tumors.

CONCLUSION AND IMPLICATION

Telomerase activity can be detected in exfoliated cells in urine from patients with bladder cancer, and measurement of this activity appears to be more sensitive in detecting the presence of cancer than standard urine cytologic examination. These findings suggest that measuring telomerase activity in exfoliated cells would be useful in the diagnosis and follow-up of patients with bladder cancer, a possibility that warrants further study.

Laparoscopic adrenalectomy for bilateral pheochromocytoma: a case report

We report a case of bilateral (2.4-cm left and 6.5-cm right) adrenal pheochromocytoma in a 27-year-old man that was treated by laparoscopic adrenalectomy. The patient had no evidence of multiple endocrine neoplasia, type II. The left adrenalectomy was performed first, with the patient in a semilateral position, and then the patient was turned before the procedure was begun on the right side. His postoperative convalescence was uneventful, and he continues corticosteroid replacement therapy. Transperitoneal laparoscopic adrenalectomy can be a safe procedure for bilateral pheochromocytoma, if the patients are carefully selected and the procedures are performed by experienced laparoscopists.

Concomitant presence of p16/cyclin-dependent kinase 4 and cyclin D/cyclin-dependent kinase 4 complexes in LNCaP prostatic cancer cell line

The cyclin D/cyclin-dependent kinase (CDK)/CDK-inhibitory proteins/retinoblastoma protein (pRb) pathway is hypothesized to control the G1-S check point. The role of this pathway is reported to be different depending on the status of pRb. In the present study, we examined nine human urological tumor cell lines. Cells lacking functional pRb expressed p16, instead of forming cyclin D/ CDK4 complex. In the LNCaP prostatic cancer cell line, however, both p16/CDK4 and cyclin D/ CDK4 complexes were present independently, probably because of partial loss of pRb. In view of the concomitant presence of the incompatible complexes, LNCaP should provide us with a valuable model for the study of this pathway in cancer cells.

Clinical experience of orthotopic urinary reservoirs in male patients with bladder cancer

Between 1988 and 1996, 23 male patients with bladder cancer underwent bladder substitution after cystectomy, using either the hemi-Kock, Hautmann, and Reddy procedures. The mean postoperative follow-up period was 36 months, with a range of 3 to 85 months. There were no perioperative deaths, and early postoperative complications occurred in 7 patients (30%); transient urine leak from the pouch in 4, wound infection in 3 and pyelonephritis in 2 patients. Twenty-two of the 23 patients (96%) were continent during the day, while 7 (30%) had nocturnal incontinence. All 3 patients with the Reddy procedure had nocturnal incontinence. Complete continence was preserved in 70% of the patients. Dysuria was seen in 4 patients, including retention in 1 patient. Late complications included urethral stricture in 3, wound hernia in 2, metabolic acidosis in 1, stone in the pouch in 1, and gallbladder stone in 1 patient. However, reoperation was necessary in 1 patient for internal urethrotomy and 1 patient for removal of a stone in the neobladder. Mild degree of hydronephrosis and unilateral reflux were seen in 3 patients each, and followed up conservatively. No urethral recurrence has occurred and only 1 patient died of cancer. The need for reoperation was very low and the high reservoir capacity resulted in continence from the beginning in most patients. We considered the neobladder useful as an alternative form of urinary diversion in selected cases.

HLA-DRB1*0101 and *0405 as protective alleles in Japanese patients with renal cell carcinoma

A variety of malignancies have been linked to major histocompatibility complex genes, including the DRB1 alleles. The association of certain DRB1 antigens with renal cell carcinoma (RCC) has been both claimed and disclaimed. To determine whether HLA-DRB1 genotypes are associated with RCC, we used the modified PCR-RFLP method for the high-resolution HLA-DRB1 genotyping of 96 Japanese RCC patients. There were no significantly frequent HLA-DRB1 alleles, whereas the DRB1*0101 and *0405 alleles had significantly lower frequencies [P = 0.004, relative risk (RR) = 0.2 and P = 0.002, RR = 0.4) in the RCC patients than in the healthy Japanese controls (n = 1216). Moreover, patients with the HLA-DRB1 *0101 or *0405 allele tended to be in earlier stages and to have less aggressive tumors than patients with neither of these alleles. The corresponding serotyping subclassification, however, showed a significantly lower frequency only for DRB1-DR1 (P = 0.01, RR = 0.3). High-resolution genotyping is essential because the polymorphism of the peptide-binding domain of major histocompatibility complex class II molecules is more precisely determined by genotypes than serotypes. In addition, inherent technical difficulties and potential typing errors render serotyping inefficient. Our data suggest that HLA-DRB1*0101 and *0405 are protective alleles for both RCC development and tumor progression.

High-resolution HLA-DRB1 and DQB1 genotyping in Japanese patients with testicular germ cell carcinoma

We report for the first time the frequency distributions of HLA-DRB1 and -DQB1 genes in 55 patients with testicular germ cell carcinoma (TGC) using the modified PCR-RFLP method and compare the results with those for 1216 healthy Japanese control subjects. The modified PCR-RFLP method produced accurate, reproducible cleavage patterns that are easily discriminated. HLA-DRB1*0410 was the susceptibility allele (RR = 3.26, P = 0.006) and DQB1*0602 appears to be a candidate protective allele (RR = 0.26, P = 0.02) for TGC in the Japanese. None of the HLA-DRB1 and -DQB1 alleles showed a specific tendency for histological type or clinical stage of the tumours. Previous studies based on serotyping methods failed to show these allelic associations. High-resolution genotyping is essential because the peptide-binding domain of MHC class II molecules is determined more precisely by their genotypes than by their serotypes. In addition, inherent technical difficulties and typing errors of up to 25% make serotyping inefficient. Our results suggest that high-resolution genotyping is a useful genetic marker to determine risk for TGC.

Urinary reconstruction using appendix as a urinary and catheterizable conduit in 12 patients

BACKGROUND

The appendix vermiformis can provide an excellent urinary conduit or a catheterizable outlet in continent urinary reservoirs in selected cases. We report our clinical experience using the appendix in urinary reconstruction in adult patients.

METHODS

A total of 12 patients underwent urinary reconstruction using the appendix. The indications were pelvic malignancies except for 1 patient with neurogenic bladder and difficulty in self-catheterization via urethra. The appendix was used as a catheterizable conduit in 8 patients, and as a urinary conduit in 4 patients. The in situ submucosally embedded method was used in 6 patients and the Mitrofanoff method was used in 2 patients. Follow-up ranged from 3 to 41 months (mean, 22).

RESULTS

Early complications occurred in 3 patients (wound infection, false passage and intestinal anasotomotic leak). Late complications occurred in 3 (slight hydronephrosis, ileus, stomal stenosis). Emergent colostomy and pouchstomy with resection of the appendix was performed in the patient with anastomotic leak. The isoperistaltic Kock nipple valve was reconstructed for continence in this case. Prolonged ileus in 1 patient was treated by open surgery. Other complications were managed conservatively. End results were excellent in 8 patients, good in 3, and poor in 1.

CONCLUSIONS

The appendix can be used advantageously as an outlet of continent urinary reservoirs or for a urinary conduit when the ureter is too short to reach the skin. Complete continence and easy catheterization can be obtained, and the appendix construction can be used as a urinary conduit instead of the ileal conduit in poor risk patients.

Quality of life survey of urinary diversion patients: comparison of continent urinary diversion versus ileal conduit

BACKGROUND

Continent urinary reservoirs (CUR) have become one of the major options for patients requiring urinary diversion to improve their quality of life (QOL). To assess whether CUR enhanced postoperative QOL, we surveyed patients with CUR and ileal conduit (IC) using a questionnaire sent by mail.

PATIENTS AND METHODS

The questionnaire consisted of 133 questions that covered physical and mental status, social life, sexual habits and symptoms related to urinary diversions. A total of 172 questionnaires were sent out, and 137 (80%) patients (74 CUR and 63 IC patients) responded.

RESULTS

Basic physical conditions were similar in the 2 groups, except for sleeping habits. Regarding social life, however, the CUR group showed better scores in bathing habits and frequency of overnight travel. Parastomal dermatitis was more frequent in the IC group and the patients were more hesitant to show their stoma to others. On the other hand, about half of the patients in the CUR group complained of troublesomeness in self-catheterization, especially at night. Overall, 74% and 41% of the patients in the CUR and IC group were satisfied with their urinary diversion. When the Kock pouch and Indiana pouch were compared, no statistically significant differences were found in average capacity, maximum capacity, or frequency of self-catheterization.

CONCLUSIONS

CUR recipients have enhanced QOL regarding the stoma, travel and sleeping habits as compared to ileal conduit. However, troublesomeness of night time self-catheterization was noted in the CUR group. Individualized selection of the type of urinary diversion with informed consent is essential.

Low toxicity of inhaled interferon-gamma in four patients with lung metastasis from renal cell carcinoma

Inhalation of interferon-gamma (IFN-gamma) was used in four patients with pulmonary metastasis from renal cell carcinoma. Three million JRU IFN-gamma were inhaled every day (3 patients) or 5 times per week (1 patient). One patient achieved no change after IFN-gamma inhalation and three patients had no response. No drug-related side effects were observed. These findings point to the clinical feasibility of inhalation of IFN-gamma. However, further studies are needed to establish the anti-tumor efficacy of IFN-gamma inhalation therapy.

Vitamin B12 deficiency in patients with urinary intestinal diversion

BACKGROUND

Because vitamin B12 is absorbed exclusively by the terminal ileum, we investigated vitamin B12 deficiency as a potential metabolic complication after urinary intestinal diversion.

METHODS

We measured serum levels in patients with Kock pouches (n = 35); Indiana pouches (n = 27); and ileal conduits (n = 25). Serial determinations of serum B12 levels were obtained in 19 patients with kock pouches and 14 patients with Indiana pouches. The dual-isotope Schilling test was performed in 9 patients with Kock pouches and 6 patients with Indiana pouches.

RESULTS

No patient had an abnormally low serum B12 level (< 200 pg/mL). Mean (+/-SD) serum B12 levels in patients with the Kock pouch (506 +/- 202 pg/mL) and the Indiana pouch (536 +/- 249 pg/mL) were lower than that in patients with the ileal conduit (727 +/- 391 pg/mL). The mean serum B12 level was not significantly different between patients with and without preoperative irradiation. Serial determinations showed that serum B12 levels in some patients with continent urinary reservoirs were persistently near the lower normal limit, or became progressively lower. Three of the 9 patients (33%) with Kock pouches and 4 of the 6 patients (67%) with Indiana pouches were B12 malabsorbers, although no patients had megaloblastic anemia or neurologic symptoms.

CONCLUSIONS

Some patients with continent urinary reservoirs are at risk for vitamin B12 deficiency due to malabsorption. Routine evaluation of serum B12 levels is recommended for all patients with continent urinary reservoirs, and a Schilling test for those with subnormal serum B12 levels.

Mainz pouch with appendix-umbilical stoma using catheterizable conduit elongated with continuous cecal segment: a case report

The Mainz pouch with appendix-umbilical stoma is a very stable method for continent, self-catheterizable urinary reservoir in the presence of a healthy appendix. If the appendix is too short or an unexpected stenosis is seen at its distal portion, the elongation of the conduit using a part of the cecum and the implantation of the conduit to the pouch by the Mitrofanoff method can be a good alternative procedure. We herein report our experience in a 53-year-old male with high grade, invasive bladder tumor, who underwent cystourethrectomy and appendix Mainz pouch operation using the above technique.

Management of late complications of continent urinary diversion using the Kock pouch and the Indiana pouch procedures

BACKGROUND

Continent urinary diversion (CUD) is performed on patients after total cystourethrectomy due to invasive bladder cancer or other diseases requiring urinary diversion. Since 1984, we have performed CUD using either the Kock pouch procedure or a modified Indiana pouch method. During the long-term follow-up, increasing numbers of late complications occurred, especially after the Kock pouch procedure. We summarized the frequency of postoperative complications, their management, and outcome of CUD using these 2 methods.

METHODS

Between 1984 and 1995, CUD using the Kock pouch method was performed on 102 patients, and on 61 patients using the Indiana pouch method, with a mean follow-up period of 83 and 50 months, respectively. The patients were between 24 and 82 years old, with a mean age of 59 years. In most patients, the Kock pouch was constructed according to the original method, except for the use of a Dacron fabric collar, and the Indiana pouch was made using the ileal patch method.

RESULTS

Of 95 patients followed up for more than 3 months after CUD using the Kock pouch method, efferent and afferent nipple valve malfunction occurred in 21 (22%) and 26 (27%) patients, respectively. Efferent complications occurred during the first year after surgery, whereas afferent complications occurred several years after surgery. Open repair surgery (excluding ileus) was necessary for 36 (38%) patients. Of 59 patients followed for more than 3 months after CUD using the Indiana pouch method, 7 patients with stomal stenosis, 2 patients with stomal prolapse, and 1 patient with stricture at the ureterocolonic anastomosis were treated surgically. An hourglass-like deformity of the pouch was seen in 2 patients, on whom the original Indiana pouch method was performed. As a whole, 13 patients (22%) were retreated with open surgery. Urinary calculi occurred in 42 (44%) patients after CUD using the Kock pouch method and in 11 patients (19%) using the Indiana pouch method. The outcome was excellent, good, fair, and poor in 31, 37, 24, and 8% of the patients after CUD using the Kock pouch method, and in 36, 17, 42, and 5% of the patients after CUD using the Indiana pouch method.

CONCLUSIONS

We performed CUD using either the Kock pouch or the Indiana pouch method with a success rate of approximately 90%. The rates of revision, reoperation and stone formation were higher with the Kock pouch procedure than with the Indiana pouch procedure, while varying degrees of incomplete incontinence and difficulty in catheterization were seen more often in the latter.