Laparoscopic radical prostatectomy: preliminary results

OBJECTIVES

To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures.

METHODS

Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site.

RESULTS

Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse.

CONCLUSIONS

Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery.

Laparoscopic radical prostatectomy. The Créteil experience

OBJECTIVES

In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency.

METHODS

200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogeneous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi-circumferential or a single circumferential running suture.

RESULTS

All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night.

CONCLUSIONS

Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.

Apolipoprotein E Regulates Amyloid Formation within Endosomes of Pigment Cells

Accumulation of toxic amyloid oligomers is a key feature in the pathogenesis of amyloid-related diseases. Formation of mature amyloid fibrils is one defense mechanism to neutralize toxic prefibrillar oligomers. This mechanism is notably influenced by apolipoprotein E variants. Cells that produce mature amyloid fibrils to serve physiological functions must exploit specific mechanisms to avoid potential accumulation of toxic species. Pigment cells have tuned their endosomes to maximize the formation of functional amyloid from the protein PMEL. Here, we show that ApoE is associated with intraluminal vesicles (ILV) within endosomes and remain associated with ILVs when they are secreted as exosomes. ApoE functions in the ESCRT-independent sorting mechanism of PMEL onto ILVs and regulates the endosomal formation of PMEL amyloid fibrils in vitro and in vivo. This process secures the physiological formation of amyloid fibrils by exploiting ILVs as amyloid nucleating platforms.

Laparoscopic radical prostatectomy with a remote controlled robot

PURPOSE

Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci* robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen.

RESULTS

The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins.

CONCLUSIONS

Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Vesicourethral anastomosis during laparoscopic radical prostatectomy: the running suture method

Vesicourethral reconstruction is the most critical and time-consuming step of laparoscopic radical prostatectomy. We describe the use of two hemicircumferential running sutures that has significantly simplified the procedure in our last 30 patients. The vesicourethral reconstruction took 31 minutes on average. Six months postoperatively, 84% of the patients were fully continent, and no bladder neck stenosis had occurred. The economy of intracorporeal suturing provided by this novel method, together with geometric factors such as the optimal position of the trocars, contributes to the improvement of ergonomy, allowing the surgeon to decrease operating times.

Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy

OBJECTIVE

To evaluate the complication rate and clinical follow-up of patients treated for T1 renal cancer by open or laparoscopic nephrectomy at the same institution, as this approach appears to be attractive for treating small renal cancers.

PATIENTS AND METHODS

Between 1995 and 2002, 39 patients underwent retroperitoneal laparoscopic and 26 transperitoneal open radical nephrectomy for T1 renal cancer (TNM 1997). Variables before during and after surgery, e.g. cancer recurrence, were compared between the groups.

RESULTS

There were no differences between the laparoscopic and open groups in age, sex ratio, weight, height, fitness score, operative duration (134 vs 133 min), minor or major complications, tumour diameter, Fuhrman grade or length of follow-up. Patients who underwent laparoscopic surgery had less blood loss (133 vs 357 mL, P < 0.001), less need for transfusion (none vs 150 mL, P = 0.04), a lower consumption of analgesia drugs, and shorter hospitalization (5.5 vs 8.8 days, P < 0.001). With a mean follow-up of 20.4 months there was no recurrence or tumour progression.

CONCLUSION

Laparoscopic radical nephrectomy for patients with T1 renal cancer is a safe, reliable procedure that decreases hospitalization time and bleeding, and ensures the same cancer control as open nephrectomy.

Prospective patient-reported continence after laparoscopic radical prostatectomy

OBJECTIVES

To perform a prospective study using confidential patient-completed questionnaires about their urinary habits before and after laparoscopic radical prostatectomy. Published reports on urinary continence after radical prostatectomy vary depending on the definitions of urinary continence and methods of data collection.

METHODS

From May 1998 to February 2000, 228 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer. The patients were given questionnaires before surgery and at 1, 3, 6, and 12 months postoperatively.

RESULTS

Before surgery, no patient reported incontinence. At 1, 3, 6, and 12 months postoperatively, perfect diurnal urinary control (no pads, no leakage at all) was reported in 9.9%, 28.6%, 57.4%, and 56.8% of patients, respectively. No pads were used in 18.8%, 58.4%, 68.9%, and 78.4% at 1, 3, 6, and 12 months, respectively. No patient reported use of more than 1 pad daily at 6 months of follow-up.

CONCLUSIONS

Continence after laparoscopic radical prostatectomy is comparable to the results after traditional radical retropubic prostatectomy. Ongoing use of the laparoscopic route for treating clinically localized prostate cancer is warranted.

Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases

OBJECTIVES

To assess the feasibility and results of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction.

METHODS

From September 1996 to January 1999, 15 patients underwent extraperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. Aberrant vessels were noted in 4 patients. Dismembered pyeloplasty was performed in 7 patients and nondismembered Fenger plasty in 7 patients. Pyeloplasty was not possible in 1 patient.

RESULTS

Fourteen of the 15 procedures were successfully completed. The procedure was not possible in 1 patient who had already undergone endopyelotomy repair. The mean operating time was 178 minutes (range 100 to 250), and the mean postoperative hospital stay was 4.8 days (range 1 to 14). Postoperative complications occurred in 3 patients (two hematomas and one urinoma). Radiographic assessment by intravenous urography 3 months after the procedure showed good results.

CONCLUSIONS

Retroperitoneoscopy, by providing easy and rapid access to the retroperitoneal space, seems to be a valuable alternative treatment for ureteropelvic junction obstruction.

Results of retroperitoneal laparoscopic radical nephrectomy

PURPOSE

To analyze the retroperitoneal approach to laparoscopic radical nephrectomy in terms of feasibility, safety, morbidity, and cancer control.

PATIENTS AND METHODS

We reviewed the records of 50 consecutive patients with renal cancer underwent radical nephrectomy via the retroperitoneal laparoscopic approach from 1995 through 1999.

RESULTS

The mean operative time was 139 minutes (range 60-330 minutes) with a mean of 149.78-mL operative blood loss (0-1500 mL). The mean renal size was 100 mm (70-150 mm) with a mean tumor size of 38.6 mm (20-90 mm). The postoperative hospital was 6 days (2-13 days). Three open conversions were necessary: one for laparoscopically uncontrolled bleeding and two because obesity interfered with surgery. We noted two major complication and two minor complications. Two disease progression have been noted to date. One patient with a pT3 grade 2 renal-cell carcinoma had a local recurrence with liver metastasis 9 months after the procedure and died 19.7 months after radical nephrectomy. Another patient with a pT3aN+M+ cancer died 23.1 months after the procedure.

CONCLUSION

Retroperitoneal laparoscopic nephrectomy for kidney cancer requires further assessment. It seems to have several advantages over open radical nephrectomy and to be effective and safe for small (<50-mm) renal tumors.

Retroperitoneal laparoscopic living-donor nephrectomy. Preliminary results

PURPOSE

Living-donor nephrectomy is performed via a standard flank approach during open surgery in contrast to laparoscopy where kidneys are procured transperitoneally. Being more familiar with retroperitoneal laparoscopy for the surgery of the upper urinary tract, we investigated the feasibility of live donor nephrectomy by this approach.

MATERIAL AND METHODS

We performed laparoscopic retroperitoneal left-sided nephrectomy in 3 living donors. The patients were placed in lumbotomy position. The retroperitoneal space was developed with blunt finger dissection, through a 2-cm mini-lumbotomy under the 12th rib in the posterior axillary line. 5 trocars were inserted. After primary access to the renal artery and vein, these were dissected to their junctions with the aorta and inferior vena cava, respectively, before freeing the kidney of its perinephric attachments. The kidney was delivered manually, through the slightly enlarged initial subcostal incision.

RESULTS

The average duration of surgery was 83 min; warm ischemia time less than 5 min. Average blood loss was 120 cm(3). Donors did not present any postoperative morbidity and were discharged after an average of 2.3 days. Mean analgesic requirement was 5 mg morphine sulphate equivalent (0-15). Average convalescence was 13.3 days (10-18). All 3 kidneys harvested laparoscopically had immediate function with urine production after graft revascularization; serum creatinine levels returned to normal within 1 week. The first patient presented ureteral stenosis 2 months after surgery. He underwent ureteropyeloplasty using his native ureter.

CONCLUSIONS

Laparoscopic living-related-donor nephrectomy become a new standard for organ harvesting. Our data suggest that retroperitoneal laparoscopic donor nephrectomy may represent a reasonable option in centers in which more extensive experience has been accumulated with retroperitoneal than with transperitoneal laparoscopy for the surgery of the upper urinary tract.

Outcome and complications of radical prostatectomy in patients with PSA <10 ng/ml: comparison between the retropubic, perineal and laparoscopic approach

The objective of this work was to evaluate the oncological outcomes and complications of prostate cancer patients with prostate specific antigen (PSA)<10 ng/ml after radical prostatectomy by retropubic, perineal and laparoscopic approach. From 1988 to 2001, 306 patients with PSA<10 ng/ml underwent radical prostatectomy by the retropubic, perineal or laparoscopic approach. Mean operative time, complication rates, length of hospital stay, catheterization time and pathological results were reviewed. Kaplan-Meier analysis was used to evaluate the likelihood of biochemical PSA recurrence. There were no statistical differences between the three groups in terms of preoperative characteristics except for PSA levels (5.5, 6.5 and 6.6 ng/ml for the retropubic, perineal, and laparoscopic approach, respectively, P<0.05) and for the T1c stage prevalence (50%, 43.1% and 68.4%, P<0.05). Operating time was significatively longer in the laparoscopic approach (266 min), whereas transfusion rate (22.1%), bladder catetherization (12.1 days), and length of hospital stay (12.1 days) were higher in the retropubic group (P<0.05). The percentage of medical and surgical complications were 6.9%, 3.1% and 3.4% (P<0.05) and 18.6%, 16.9% and 11.6% (P<0.05) for the retropubic, perineal, and laparoscopic approach, respectively. Pathological staging revealed pT2 in 76.7%, 78.4% and 81.3% for retropubic, perineal and laparoscopic approach, respectively (P<0.05). Positive surgical positive margins were noted in 20.9%, 18.4% and 20.6% (P>0.05). The actuarial 3-year recurrence-free survival rate was 89.3%, 89.2% and 86.2% (P>0.05) for retropubic, perineal and laparoscopic approach, respectively. It can be concluded that in patients with preoperative PSA<10 ng/ml, clinical outcome and complication rates were similar, regardless of the choice of surgical approach.

Carcinological risks and retroperitoneal laparoscopy

PURPOSE

To determine the incidence of trocar site spillage, local recurrence, and metastatic disease associated with retroperitoneal laparoscopic tumor resection.

METHODS

From 1994 to 1999, 228 retroperitoneal laparoscopic procedures were performed at our institution. Fifty-six procedures (24.6%) were for malignancies and comprised 41 radical nephrectomies and 8 partial nephrectomies for renal tumors, and 7 nephro-ureterectomies for renal pelvis tumors. The pathological stage and the status of surgical margins were noted according to the 1997 TNM classification. Postoperative follow-up data were obtained by means of physical and radiological examinations after 1 and 3 months, and then half-yearly. Trocar site seeding, local recurrence and metastatic disease were recorded. Kaplan-Meier actuarial analysis was used to determine the disease-free survival likelihood.

RESULTS

The mean follow-up was 24.9+/-13.85 months. All the patients had tumor-free surgical margins. No laparoscopic trocar site recurrences were identified. For laparoscopic radical nephrectomy: one patient had a local recurrence with hepatic metastasis of a pT(3)G(2) tumor after 9 months and died 19.7 months after the procedure. One patient with a pT(3a)G(3)M+ tumor died 23.1 months after radical nephrectomy without any sign of local recurrence. For laparoscopic nephro-ureterectomy: one patient with a pT(3)G(3) tumor had a local recurrence 12.1 months after the procedure and died 26.6 months after surgery. One patient with a pT(1)G(2) renal pelvis tumor had bone metastasis at 9 months and died 29 months after the procedure. The Kaplan-Meier actuarial disease-free survival rate was 91% at 54 months for radical nephrectomy, 61% at 30 months for nephro-ureterectomy and 100% at 49 months for partial nephrectomy.

CONCLUSION

Malignancies of the upper urinary tract can be managed by means of retroperitoneal laparoscopy. Short-term results suggest that this procedure is not associated with an increased risk of portsite or local recurrence, and that disease-free survival is equivalent to that obtained with open surgery.

The multidrug resistance half-transporter ABCG2 is purified as a tetramer upon selective extraction from membranes

ABCG2 is a human membrane ATP-binding cassette half-transporter that hydrolyzes ATP to efflux a large number of chemotherapeutic agents. Several oligomeric states of ABCG2 from homodimers to dodecamers have been reported depending on the overexpression systems and/or the protocols used for purification. Here, we compared the oligomeric state of His(6)-ABCG2 expressed in Sf9 insect cells and in human Flp-In-293/ABCG2 cells after solubilization in mild detergents. His(6)-ABCG2 was purified through a new approach involving its specific recognition onto a functionalized lipid layer containing a Ni-NTA lipid. This approach allowed the purification of His-ABCG2 in presence of all solubilized membrane components that might be involved in the stabilisation of native oligomers and without requiring any additional washing or concentration passages. ABCG2 purified onto the NiNTA lipid surfaces were directly analyzed by electron microscopy and by biochemical assays. Altogether, our data are consistent with a tetrameric organization of ABCG2 when expressed in either heterologous Sf9 insect cells or in human homologous cells.

Complete solo laparoscopic radical prostatectomy: initial experience

OBJECTIVES

To demonstrate the feasibility of "complete solo" (CS) laparoscopic radical prostatectomy (LRP) performed solely with robotic manipulation of the laparoscope and without any human assistant at all. A comparison was made between CS LRP and the standard technique to identify the advantages and drawbacks.

METHODS

Sixteen consecutive patients undergoing CS LRP were compared with the last 16 patients undergoing standard LRP. The standard procedure was performed with five trocars and one human assistant. Therefore, the surgeon had three instruments immediately available and could switch quickly from one to another, while the assistant held the laparoscope and a retractor. The CS method used a voice-controlled robotic arm to manipulate the laparoscope and a mechanical arm for the assisting instrument.

RESULTS

The mean operative time in the CS and standard groups was 324 and 347 minutes, respectively (P >0.5). An additional human assistant was required, for 1 hour, in 3 patients of each group. No significant difference was noted between the two groups in terms of catheterization time, hospital stay, positive margin rate, complications, short-term cancer control, or functional results. The CS method has been demonstrated to be highly cost-effective compared with the standard technique.

CONCLUSIONS

The CS LRP is feasible and compares favorably with the standard technique. It offers unique advantages in terms of direct control of the operative view, standardization of the assistance, and higher stability of the laparoscope, thus greatly enhancing the surgeon's comfort. The diminished need for human operative assistance provides significant economic and organizational benefits.

Experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma

PURPOSE

Although laparoscopic adrenalectomy has become the preferred surgical treatment of benign adrenal masses, for pheochromocytoma it is limited by concerns over hypertensive events related to early access to the adrenal vein. We report our experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

From January 1995 to December 1999, 21 retroperitoneal laparoscopic adrenalectomies (left 12 and right 9) were performed for symptomatic pheochromocytoma in 11 men and 9 women 17 to 68 years old (mean age 46). To our knowledge pheochromocytoma was always diagnosed by increased urinary catecholamine, computerized tomography, magnetic resonance imaging and 131iodine iobenguane scintigraphy.

RESULTS

There were no conversions to open surgery. The operating time ranged from 100 to 150 minutes (mean 116). Mean blood loss was 140 ml. (minimum 550), and none of the patients required transfusion. Hemorrhage due to adrenal vein injury occurred in 1 patient and was controlled intraoperatively. Average postoperative hospital stay was 3.4 days (range 1 to 12). The mean diameter of the excised masses was 38 mm. (range 15 to 70). Postoperative complications occurred in 4 cases, including hematoma in 1, trocar wound infections in 2 and eventration in 1 after 1 year. With a mean followup of 21.6 months (range 6 to 46), all patients had normal urinary catecholamine levels and 18 had normal blood pressure without treatment.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy can be safely performed for small (less than 5 cm. diameter) pheochromocytoma. Retroperitoneal laparoscopy is a direct approach that allows the surgeon to control the adrenal vein first, thereby avoiding hypertensive events.

Extracellular vesicles and co-isolated endogenous retroviruses from murine cancer cells differentially affect dendritic cells

Cells secrete extracellular vesicles (EVs) and non-vesicular extracellular (nano)particles (NVEPs or ENPs) that may play a role in intercellular communication. Tumor-derived EVs have been proposed to induce immune priming of antigen presenting cells or to be immuno-suppressive agents. We suspect that such disparate functions are due to variable compositions in EV subtypes and ENPs. We aimed to characterize the array of secreted EVs and ENPs of murine tumor cell lines. Unexpectedly, we identified virus-like particles (VLPs) from endogenous murine leukemia virus in preparations of EVs produced by many tumor cells. We established a protocol to separate small EVs from VLPs and ENPs. We compared their protein composition and analyzed their functional interaction with target dendritic cells. ENPs were poorly captured and did not affect dendritic cells. Small EVs specifically induced dendritic cell death. A mixed large/dense EV/VLP preparation was most efficient to induce dendritic cell maturation and antigen presentation. Our results call for systematic re-evaluation of the respective proportions and functions of non-viral EVs and VLPs produced by murine tumors and their contribution to tumor progression.

[Classification, favorable characteristics, prevention and treatment of adverse side-effects associated with Bacillus Calmette-Guerin in the treatment of superficial bladder cancer]

The efficacy of Bacillus Calmette-Guérin (BCG) in the treatment of superficial bladder cancer was first reported by Morales in 1976. Several authors have since demonstrated the efficacy of BCG in the prophylaxis and treatment of high-risk superficial bladder tumors (pT1G3, CIS). Although BCG is now recommended as an adjunctive treatment for superficial bladder tumors, the optimal treatment schedule remains to be defined. Results reported by Lamm suggest that an initial induction cycle of six weekly intravesical BCG instillations is suboptimal unless maintenance therapy (three consecutive weekly instillations) is given 3, 6, 12, 18, 24, 30 and 36 months later. However, the use of maintenance therapy is hindered by troublesome adverse reactions. This article reviews adverse reactions associated with BCG treatment, proposed a classification and discusses their prevention and treatment.

[Prostatic adenocarcinoma revealed by disseminated intravascular coagulation and fibrinolysis]

Disseminated intravascular coagulation (DIC) revealing a prostatic adenocarcinoma is rare. Most of the case are limited to biological abnormalities. We report a case of a 73 year old man with metastatic prostatic carcinoma and CIVD. The patient consulted for epistaxis and ecchymosis with thrombocytopenia and low coagulate factors. The prostatic specific antigen was 2200 ng/ml and fine needle aspiration of bone marrow biopsy detected metastatic cells. The patients received hormonotherapy, heparine and antithrombine III with a good follow up. About this case, we discuss the management of the patient with metastatic prostatic cancer and CIVD.

Exérèse laparoscopique d'une métastase ganglionnaire para-aortique d'un phéochromocytome malin

We report a laparoscopic lymph node resection of a patient who had malignant pheochromocytoma and underwent conventional transabdominal adrenalectomy for unilateral left malignant pheochromocytoma, followed by transperitoneal laparoscopic metastatic para-aortic lymph nodes six years later. The postoperative course was uneventful and the patient was cured of the metastasis. We believe that this procedure is minimally invasive, and metastatic extension can be diagnosed laparoscopic as well as ablation can be performed in most instances without recurrence.

Binding, reconstitution and 2D crystallization of membrane or soluble proteins onto functionalized lipid layer observed in situ by reflected light microscopy

Monolayer of functionalized lipid spread at the air/water interface is used for the structural analysis of soluble and membrane proteins by electron crystallography and single particle analysis. This powerful approach lacks of a method for the screening of the binding of proteins to the surface of the lipid layer. Here, we described an optical method based on the use of reflected light microscopy to image, without the use of any labeling, the lipid layer at the surface of buffers in the Teflon wells used for 2D crystallization. Images revealed that the lipid layer was made of a monolayer coexisting with liposomes or aggregates of lipids floating at the surface. Protein binding led to an increase of the contrast and the decrease of the fluidity of the lipid surface, as demonstrated with the binding of soluble Shiga toxin B subunit, of purple membrane and of solubilized His-BmrA, a bacterial ABC transporter. Moreover the reconstitution of membrane proteins bound to the lipidic surface upon detergent removal can be followed through the appearance of large recognizable domains at the surface. Proteins binding and reconstitution were further confirmed by electron microcopy. Overall, this method provides a quick evaluation of the monolayer trials, a significant reduction in screening by transmission electron microscopy and new insights in the proteins binding and 2D crystallogenesis at the lipid surface.

Early removal of the catheter after laparoscopic radical prostatectomy

PURPOSE

We prospectively tested the safety of routine removal of the catheter as early as 2 to 4 days after laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Between March 1998 and March 2001, 228 patients underwent laparoscopic radical prostatectomy for clinically organ confined prostate cancer. The last 113 consecutive patients were included in a prospective study according to gravitational cystography performed 2 to 4 days postoperatively. If no leak was seen the catheter was removed. If a leak was apparent the catheter was left indwelling for another 6 days and cystography was repeated.

RESULTS

Cystography 2 to 4 days postoperatively showed an anastomosis without a leak in 96 (84.9%) patients who subsequently had the catheters removed. There were 28 patients who had the catheter removed on postoperative day 2, 28 day 3 and 40 day 4. In 17 (15.1%) patients an anastomotic leak was observed, and the catheter was not removed at that time. Of the 96 patients in whom the catheter was removed early 10 (10.4%) had urinary retention that necessitated re-catheterization. This procedure was performed without the need for cystoscopy. After the catheter was removed all patients were able to void 24 hours later. Median followup was 7 months (range 1 to 15) and showed continence rates greater than 93%. No anastomotic stricture, pelvic abscess or urinoma developed in any patient.

CONCLUSIONS

Patients who undergo laparoscopic radical prostatectomy can have the catheter safely removed 2 to 4 days postoperatively without a higher risk of incontinence, stricture or leak related problems.

[Mechanisms of action of BCG: towards a new individualized therapeutic approach?]

A better knowledge of antitumour immunity and the mechanisms allowing the tumour to overcome the host's immune surveillance has led to progress in the understanding of the mechanisms of action of Bacille Calmette-Guérin (BCG), as the local intravesical immune response is intimately related to the interaction of three systems: the host (the patient), the BCG (mycobacteria) and the tumour. This interaction gives rise to a cascade of immunological events, some of which are essential to the protective action of BCG against relapse and tumour progression. The immune response to BCG is currently considered to comprise three phases. First of all, the BCG adheres to the urothelium and is then phagocytosed by antigen-presenting cells. This phase corresponds to early release of so-called inflammatory cytokines (IL1, IL6, IL8). These cytokines could be responsible for certain adverse effects, but could also participate in cytotoxic phenomena. The second phase consists of recognition of bacterial antigens by helper CD4 lymphocytes, which mainly release IL2 and IFNg (Th1 response). This cellular activation leads to the third phase: amplification of cytotoxic populations capable of killing tumour cells: CD8, gd lymphocytes, macrophages, NK, LAK, BAK cells. All these cells also produce cytokines, which participate in regulation of the immune response. The understanding of these mechanisms of action, urinary cytokine assays, a better definition of cytotoxic cells and their role, molecular analysis of the tumour and probably certain genetic characteristics of the host will allow the elaboration of more effective immunization protocols by defining an individualized therapeutic approach.