Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions

PURPOSE

An abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult.

METHODS

The indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up.

RESULTS

Of 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4).

CONCLUSION

The mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

Delayed symptomatic renal arteriovenous fistula in a 24 years old male following renal biopsy

We report a case of a 24-year-old male with a history of kidney biopsy at young age due to chronic renal dysfunction and challenging hypertension, who presented with flank pain and hematuria. Initial imaging suggested renal pelvis enlargement, but MRI revealed a massive renal arteriovenous malformation (AVM). Angiographic embolization was abandoned due to extensive effluent flow, followed by successful surgical resection preserving healthy kidney tissue. This case underscores the importance of considering renal AVMs in the differential diagnosis of young patients with gross hematuria or refractory hypertension to prevent complications and improve patient outcomes.

Xpert bladder cancer monitor to predict the need for a second TURB (MoniTURB trial)

To determine whether Xpert bladder cancer monitor, a noninvasive PCR-based biomarker test, can predict the need for 2nd transurethral resection of the bladder (TURB) better than clinical assessment. Patients scheduled for TURB were prospectively screened. After initial TURB, patients were assigned to 2nd TURB or follow-up cystoscopy at 3 months (FU) by clinicians' discretion. Central urine cytology and Xpert monitor tests were performed prior to the 1st TURB and 2nd TURB or FU, respectively. Statistical analysis to compare clinical assessment and Xpert monitor comprised sensitivity (SENS), specificity (SPEC), NPV and PPV. Of 756 screened patients, 171 were included (114 with 2nd TURB, 57 with FU). Residual tumors were detected in 34 patients who underwent 2nd TURB, and recurrent tumors were detected in 2 patients with FU. SENS and SPEC of Xpert monitor were 83.3% and 53.0%, respectively, PPV was 32.6% and NPV was 92.1%. Clinical risk assessment outperformed Xpert monitor. In patients with pTa disease at initial TURB, Xpert monitor revealed a NPV of 96%. Xpert monitor was not superior than clinical assessment in predicting the need for 2nd TURB. It might be an option to omit 2nd TURB for selected patients with pTa disease.

[Current recommendations for surveillance, risk reduction and therapy in Lynch syndrome patients]

INTRODUCTION

 Lynch syndrome (LS) is the most common hereditary colorectal cancer syndrome and accounts for ~3 % of all CRCs. This autosomal dominant disorder is caused by germline mutations in DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2, and EPCAM). One in 300 individuals of the general population are considered to be mutation carriers (300 000 individuals/Germany). Mutation carriers are at a high CRC risk of 15-46 % till the age of 75 years. LS also includes a variety of extracolonic malignancies such as endometrial, small bowel, gastric, urothelial, and other cancers.

METHODS

 The German Consortium for Familial Intestinal Cancer consists of 14 university centers in Germany. The aim of the consortium is to develop and evaluate surveillance programs and to further translate the results in clinical care. We have revisited and updated the clinical management guidelines for LS patients in Germany.

RESULTS

 A surveillance colonoscopy should be performed every 12-24 months starting at the age of 25 years. At diagnosis of first colorectal cancer, an oncological resection is advised, an extended resection (colectomy with ileorectal anastomosis) has to be discussed with the patient. The lifetime risk for gastric cancer is 0.2-13 %. Gastric cancers detected during surveillance have a lower tumor stage compared to symptom-driven detection. The lifetime risk for small bowel cancer is 4-8 %. About half of small bowel cancer is located in the duodenum and occurs before the age of 35 years in 10 % of all cases. Accordingly, patients are advised to undergo an esophagogastroduodenoscopy every 12-36 months starting by the age of 25 years.

CONCLUSION

 LS colonic and extracolonic clinical management, surveillance and therapy are complex and several aspects remain unclear. In the future, surveillance and clinical management need to be more tailored to gene and gender. Future prospective trials are needed.

[Long-term follow up of the serosa-lined and tapered Ileum as an efferent segment of various urinary diversion reservoirs ("Fulda-nipple")]

BACKGROUND

 In 2008, Kälble et al. presented the "serosa-lined and tapered ileum" ("Fulda nipple") as a new continence mechanism of the modified MAINZ-Pouch-I. In accordance with the principle of Abol-Enein, a tapered ileum segment is embedded into a serosa-lined tunnel consisting of a second "U"-shaped ileum segment. Thus a combination of continence mechanism and pouch augmentation - which can be applied to all forms of pouches - was established.

PATIENTS AND METHODS

 We report on 21 patients who received a serosa-lined and tapered ileum at the Department of Urology of the University Hospital of Bonn for different indications. The aim of this study was to evaluate this technique, especially with regard to stenosis and incontinence rates in the long-term follow up.  RESULTS:  At a mean follow-up period of 37 months, stoma stenosis occurred in 33 % of the cases. Incontinence was observed in 21 % (n = 4) of the cases. Remarkably, two of these patients suffered from incontinence due to the phenomenon of "nipple gliding".

CONCLUSION

 The long-term analysis shows similar stenosis and incontinence rates compared to the two best-established techniques - submucosally embedded appendix and intussuscepted ileum. Despite limitations due to the small number of cases, the Fulda nipple is at least a safe alternative as a "second-line technique" in cases where the initial method has failed.

Fungaemia caused by obstructive renal candida bezoars leads to bilateral chorioretinitis: a case report

BACKGROUND

Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia.

CASE PRESENTATION

Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous "nephrolitholapaxy". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth.

CONCLUSION

To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

Kidney sparing surgery for urothelial carcinoma of the pyelocalyceal system: is there a role for open techniques? Results from a small series

PURPOSE

To evaluate individually tailored open nephron-sparing surgical techniques for urothelial carcinoma of the pyelocalyceal system (UCPCS).

MATERIALS AND METHODS

Four patients underwent nephron-sparing surgery for UCPCS including, open partial resection of the pyelon with peritoneal reconstruction, partial nephrectomy, open partial resection of the pyelon with kidney autotransplantation, combined open resection and calicoscopic laser coagulation.

RESULTS

Recurrence-free survival was 24 months without any impairment of kidney function in all patients.

CONCLUSION

Open nephron-sparing surgery for UCPCS should be taken into consideration for selected cases.

Continent ileovesicostomy after bladder neck closure as salvage procedure for intractable incontinence

INTRODUCTION

We evaluated the success rate of continent vesicostomy using an ileal segment with seroserosally embedded, tapered ileum for bladder augmentation with continent stoma following bladder neck closure (BNC) for severely damaged bladders or persistent urinary incontinence.

MATERIAL AND METHODS

A total of 15 patients were treated for persistent urinary incontinence or non-reconstructible bladder outlet between 2003 and 2012. Underlying diagnosis included post-prostatectomy incontinence (n = 5), recurrent bladder neck stenosis (n = 5), neurogenic bladder (n = 3), urethral tumor recurrence following orthotopic neobladder (n = 1) and post-TVT and colposuspension incontinence (n = 1). All patients underwent open BNC, omental interposition and continent vesicoileostomy. The continent outlet was placed in the lower abdomen using a circumferential subcutaneous and skin plasty to avoid retraction. Data collected included age, underlying diagnosis, stoma site, time to complications and need for subsequent surgical revisions. All patients received a standardized questionnaire at the time of data acquisition and were personally interviewed.

RESULTS

Median follow-up was 24 months (range: 2-111). Primary BNC was successful in all patients and primary continence rate was 86.7%. Two patients (13.3%) suffered from failure of the continence mechanism, caused by stoma stenosis at skin level and insufficiency of the bladder augmentation and stoma due to local infection. One additional patient developed a mild stomal incontinence without need for further reconstruction. Regardless of the number of revisions, at the last follow-up 93.3% of patients had a functional channel. All complications occurred within the first postoperative year.

CONCLUSIONS

This technique is an effective last resort treatment for patients with non-reconstructible bladder outlet.

Serum DNA hypermethylation in patients with kidney cancer: results of a prospective study

AIM

No reliable biomarker for renal cell carcinoma (RCC) exists. The purpose of this study was to analyze the value of CpG island hypermethylation of cell-free (cf) circulating serum DNA in patients with RCC as a potential biomarker.

PATIENTS AND METHODS

In total 35 patients with RCC and 54 healthy individuals were enrolled in this study. Cell-free DNA (cFDNA) in serum was isolated and digested with methylation-sensitive restriction enzymes (Bsh1236I, HpaII and HinP1I) to quantify the amount of methylated Adenomatosis-poliposis-coli gene (APC), Gluthation-a-transferase-protein 1 gene (GSTP1), ARF tumor suppressor protein gene (p14(ARF)), cyclin-dependent kinase inhibitor 2A (p16), Retinoid-acid-receptor-beta gene (RAR-B), RAS-association domain family-1 gene (RASSF1), Tissue inhibitor of metalloproteinase-gene (TIMP3) and Prostaglandin-endoperoxid synthase 2 (PTGS2) DNA fragments.

RESULTS

In 30 of 35 investigated patients with RCC, at least one gene was methylated within the serum cfDNA. The methylation frequency ranged from 14.3% for p14(ARF) to 54.3% for APC. All genes, except p16 and TIMP3, were significantly more frequently methylated in patients with RCC compared to healthy individuals. Receiver operator characteristic analysis showed a high specificity for serum cfDNA methylation [between 85.2% for RAR-B and 100% for p14(ARF)], but the sensitivity was low in single-gene analysis [range-14.3% for p14(ARF) to 54.3% for APC]. The combined analysis of multiple genes increased the diagnostic sensitivity (i.e. APC, PTGS2 and GSTP1, 62.9%) at a high specificity (87%). DNA hypermethylation of APC was correlated with advanced tumor stage.

CONCLUSION

The detection of hypermethylated cfDNA in serum may be helpful for the identification of RCC; the combinatorial analysis of multiple genes may increase the diagnostic accuracy.

Diagnostic meaning of urodynamic studies in pouch incontinence: results of a small series

INTRODUCTION

To evaluate the meaning of urodynamic parameters in patients with pouch incontinence.

MATERIALS AND METHODS

Thirteen urodynamic studies in patients with an ileal nipple as the efferent segment of an ileocecal pouch or ileum/ileocecal-augmented bladder were performed. The recorded parameters included pouch capacity, leak point pressure/volume, maximum pouch pressure, compliance, static and dynamic closure pressure, and functional length. Three patients suffered from urinary incontinence.

RESULTS

In all cases of incontinent patients, no functional length or static or dynamic closure pressure could be revealed. In 8 of 10 cases of continent patients, a positive functional length as well as static and/or dynamic closure pressure were measured (mean value in continent patients: 15.9 mm, 14.5 cm H2O and 26.5 cm H2O, respectively). In 2 of 3 cases of incontinent patients, the pouch compliance was restricted (21 and 37 ml/cm H2O). The pouch capacity of continent patients was greater than the capacity of incontinent patients (377.4 vs. 185.7 ml).

CONCLUSIONS

Positive functional length, static and dynamic closure pressures, and a high pouch capacity with an unrestricted compliance are predictive for pouch continence. They may individually not determine continence, but combining them can. However, the meaning of urodynamic studies in pouch incontinence is not the same as with the urinary bladder.

Serum DNA hypermethylation in patients with bladder cancer: results of a prospective multicenter study

BACKGROUND

Cell-free serum DNA levels are increased in patients with cancer, and at least partially, these DNA fragments are derived from cancer cells. A few reports indicated that methylated serum DNA in patients with bladder cancer (BCA) is a useful non-invasive biomarker. The purpose of this prospective multicenter study was to validate earlier studies.

MATERIALS AND METHODS

In total, 227 consecutive participants (non-muscle invasive BCA, n=75; muscle-invasive BCA, n=20; transurethral bladder resection (TURB) without BCA, n=48; benign disease, n=31; healthy individuals, n=53), were recruited for this study. Cell-free serum DNA was isolated and digested with methylation-sensitive restriction-enzymes (Bsh1236I, HpaII and HinP1I) to quantify the amount of methylated (TIMP3, APC, RARB, TIG1, GSTP1, p14, p16, PTGS2 and RASSF1A) DNA fragments.

RESULTS

The amount of methylated DNA was usually small (<10%), and the methylation frequencies varied for different genes (e.g. frequent: TIMP3; moderate: APC, RARB, TIG1; infrequent: p16, PTGS2, p14, RASSF1A, GSTP1). Methylation levels at each gene site and the number of methylated genes were increased in BCA compared to healthy individuals, but were similar in BCA and patients with non-malignant disease. The number of methylated genes allowed for discrimination (62% sensitivity, 89% specificity) of BCA patients from healthy individuals. DNA hypermethylation was not correlated with advanced stage or grade in patients with BCA.

CONCLUSION

The detection of hypermethylated DNA in serum allows for discrimination of patients with BCA and healthy individuals, but there is no difference between patients with BCA and those with non-malignant disease, thereby limiting its value as a non-invasive biomarker.

Spindle cell rhabdomyosarcoma of the prostate

The spindle cell rhabdomyosarcoma is a rare variant of the embryonal rhabdomyosarcoma, mostly occurring in childhood. Only a few cases are described in adults. To date, no case of the spindle cell subtype of the prostatic embryonal rhabdomyosarcoma has been published. We report on a 23-year-old man, initially presenting with obstructive micturition problems, perineal pain and night sweat. After diagnosis by transrectal biopsy of the prostate, radiochemotherapy within the CWS 2002 P study was applied: nine cycles of vincristine, doxorubicin, actinomycin D, ifosfamide, and fractionated radiotherapy of the tumor and suspect lymph nodes (final dose 50.4 Gy). The tumor initially shrank, but an early local recurrence arose. Second-line chemotherapy was applied, followed by a salvage radical cytoprostatectomy. The patient died of disseminated disease 14 months after diagnosis.

Cell-free serum DNA in patients with bladder cancer: results of a prospective multicenter study

BACKGROUND/AIM

Cell-free DNA may serve as a biomarker for patients with cancer; we designed our study to determine its potential in patients with bladder cancer (BCA).

MATERIALS AND METHODS

Short β-actin (ACTB)-106 and large ACTB-384 fragments were quantified using real time PCR (RT-PCR); the ratio of ACTB-384/ACTB-106 was defined as DNA integrity. We analyzed the serum from 95 patients with and from 132 without BCA.

RESULTS

Patients with BCA had increased ACTB-106 levels and lower DNA integrity compared to patients without cancer. However, patients undergoing transurethral bladder resection (TURB) with histological exclusion of BCA had a similar ACTB-106 level and DNA integrity, as patients with BCA. Cell-free DNA was not correlated with smoker status, pT stage, grade or lymph node metastasis, or DNA integrity. There was a weak inverse correlation of age with DNA integrity in patients with BCA.

CONCLUSION

Analysis of serum cell-free DNA levels and fragmentation patterns are of limited value regarding the identification of patients with BCA.

Global histone H4K20 trimethylation predicts cancer-specific survival in patients with muscle-invasive bladder cancer

OBJECTIVE

•To determine the role of global histone methylation as a prognostic parameter in patients with bladder cancer.

PATIENTS AND METHODS

•We used a tissue microarray with samples from patients with non-muscle-invasive bladder cancer (NMIBC; n= 161), muscle-invasive bladder cancer (MIBC, n= 127), normal urothelium (NU; n= 31) and bladder cancer metastases (METS; n= 31) to determine global histone methylation (me) levels at histone H3 lysine 4 (H3K4) and H4K20.

RESULTS

•Global histone modification levels (H3K4me1, H3K4me3, H4K20me1, H4K20me2, and H4K20me3) were lower in bladder cancer samples than in NU tissue •Global levels of H3K4me1, H4K20me1, H4K20me2 and H4K20me3 were decreasing from NU over NMIBC and MIBC to METS. •H4K20me1 levels were increased in patients with NMIBC with advanced pTstage and less differentiated bladder cancer. •In patients with MIBC, pTstage was negatively correlated with H3K4me1, H4K20me1 and H4K20me2 levels. •H4K20me3 levels were significantly correlated in a univariate and multivariate model with bladder cancer-specific mortality after radical cystectomy in patients with MIBC.

CONCLUSION

•Global histone methylation levels may help to identify patients with bladder cancer with poor prognosis after radical cystectomy.

Evoluting the invaginated--one step closer to the perfect valve? Modified serosal lined tapered ileum (Kälble's procedure) as a continence mechanism for catheterizable pouches

INTRODUCTION

A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal 'U' according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions.

METHODS

All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months.

RESULTS

All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively.

CONCLUSIONS

Subject to our short follow-up, Kälble's technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

Randomized phase III trial of 2nd line gemcitabine and paclitaxel chemotherapy in patients with advanced bladder cancer: short-term versus prolonged treatment [German Association of Urological Oncology (AUO) trial AB 20/99]

BACKGROUND

The second-line chemotherapeutic treatment for metastatic urothelial cancer (UC) after failure of cisplatin-based first-line therapy needs to be improved. Based on encouraging phase II data of gemcitabine and paclitaxel (Taxol) (GP), this trial was designed to compare a short-term (arm A) versus a prolonged (arm B) second-line combination chemotherapy of GP.

PATIENTS AND METHODS

Of 102 randomized patients, 96 were eligible for analysis. Primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), objective response rates (ORR) and toxicity.

RESULTS

Neither OS [arm A: 7.8 (95% CI: 4.2-11.4), arm B: 8.0 (95% CI: 4.9-11.1) months] and PFS [arm A: 4.0 (95% CI: 0-8.0), arm B: 3.1 (95% CI: 1.9-4.2) months] nor ORR (arm A: 37.5%, arm B: 41.5%) were significantly different. On prolonged treatment, more patients experienced severe anemia (arm A: 6.7% versus arm B: 26.7% grade III/IV anemia; P = 0.011). In six patients, treatment was stopped during the first cycle due to disease progression or toxicity. Two patients died due to treatment-related toxic effects.

CONCLUSION

Due to rapid tumor progression and toxicity at this dosage and schedule in a multicenter setting, it was not feasible to deliver a prolonged regimen. However, a high response rate of ∼40% makes GP a promising second-line treatment option for patients with metastatic UC.

Cell-free circulating DNA: Diagnostic value in patients with renal cell cancer

OBJECTIVES

To analyse the diagnostic and prognostic value of cell-free DNA in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Cell-free DNA was measured in 35 patients with RCC and 54 healthy individuals using quantitative real-time PCR. ACTB-106 detects fragmented cell-free DNA due to apoptosis and ACTB-384 detects long DNA fragments by necrosis. DNA-Integrity (ACTB-384/ACTB-106 ratio) served as measure of DNA fragmentation.

RESULTS

Levels of both DNA fragments were increased in RCC patients compared to healthy individuals (ACTB-384: 1.77 vs. 0.61ng/ml, p=0.0003; ACTB-106: 1.31ng/ml vs. 0.77 ng/ml p=0.003). Receiver operator characteristic analysis (ROC) showed at a threshold level of 1.03 ng/ml for ACTB-106 68.6%, sensitivity and 70.4% specificity (AUC: 0.69). ROC analysis showed at a threshold level of 1.70 ng/ml for ACTB-384 57.1%, sensitivity and 81.5% specificity (AUC: 0.73). DNA integrity was increased in RCC (1.07 vs. 0.72 p=0.04). In vascular invasion the DNA integrity was reduced (p=0.003).

CONCLUSION

Cell-free-DNA levels are increased in RCC. The DNA integrity indicates mostly necrotic origin in RCC.

[Urethral reconstructive surgery]

There is no technique which can be used in all types and localizations of urethral strictures. Urethral strictures occur in the majority of cases in the bulbar urethra. The success rate of urethroplasty is above 80% and results are much better compared to DVIU. Dorsal onlay shows a significantly better success rate than ventral onlay. If the graft bed has poor vascularization a flap should be used or a staged approach should be considered.

Modified spectrometry (O2C device) of intraoperative microperfusion predicts organ function after kidney transplantation: a pilot study

BACKGROUND

Delayed graft function (DGF) is defined as posttransplantation dialysis within 1 week, which might be associated with impaired long-term graft survival. The aim of our pilot study was to establish the ability of intraoperative spectrometry of allograft microperfusion to predict DGF.

METHODS

Twenty human kidney allografts transplanted from deceased donors were evaluated intraoperatively after reperfusion using modified organ spectrometry (O2C device). We examined hemoglobin oxygen saturation, intravascular amount of hemoglobin, and microperfusion flow/velocity.

RESULTS

Retrospectively, 10/20 (50%) allografts with measurable impairment of cortical hemoglobin oxygen saturation and microperfusion flow/velocity developed DGF. Retrospectively, we found that if the intravascular amount of hemoglobin was increased upon intraoperative measurement, the kidney was prone to develop DGF.

CONCLUSIONS

Spectrometry data predicted DGF. Our results supported the thesis that impaired microperfusion is the key to DGF and might be related to postcapillary endothelial damage or intravascular sludge.

[Autotransplantation--a forgotten option?]

Renal autotransplantation should be considered as an individual treatment in a number of renal or ureteral pathologies, such as ureteral strictures or transitional cell carcinomas of the upper urinary tract. Pyelovesicostomy offers the possibility of a complete ureteral resection and provides the opportunity for a follow-up cystopyeloscopy. In cases of careful patient selection and experience in vascular surgery autotransplantation should not become a forgotten option.

Rapamycin inhibits in vitro growth and release of angiogenetic factors in human bladder cancer

OBJECTIVES

To evaluate the in vitro effects of rapamycin in human transitional cell carcinoma and to clarify the possible rapamycin-hypoxia interactions.

METHODS

Monolayer cultures of RT112 (G1), RT4 (G1-2), T24 (G3), and SUP (G4) cells were incubated in medium with or without rapamycin (10 microM, 100 microM) in different gaseous conditions (1% oxygen plus 5% carbon dioxide plus 94% nitrogen or 95% oxygen plus 5% carbon dioxide or 21% oxygen plus 78% nitrogen). Cell vitality and proliferation were determined using the microculture tetrazolium assay. Apoptotic cells were quantified by flow cytometry. Enzyme-linked immunosorbent assay was used to visualize inhibition of the mammalian target of rapamycin (mTOR) by rapamycin and synthesis of vascular endothelial growth factor.

RESULTS

Rapamycin delayed proliferation of cancer cell lines but did not induce apoptosis. No direct hypoxia interactions of rapamycin were found. Enzyme-linked immunosorbent assay gave evidence of mTOR inhibition in all cell lines and a significant decrease of hypoxia-induced vascular endothelial growth factor synthesis.

CONCLUSIONS

Because proliferation in bladder cancer cells was delayed, but no apoptosis was induced, cell cycle arrest caused by rapamycin was feasible. Rapamycin decreased hypoxia-induced synthesis of vascular endothelial growth factor. These findings should be substantiated in an animal model to verify the antiangiogenetic effects of rapamycin.

Impairment of long-term graft function after kidney transplantation by intraoperative vascular complications

OBJECTIVE

Surgical complications in kidney transplantation often demand reoperation and therefore may severely affect graft survival. Major complications can be divided into ureteral and vascular related. Reoperation for ureteral complications is supposed to worsen graft survival, but vascular complications or anastomosis technique has not been evaluated for this issue.

PATIENTS AND METHODS

Between 1994 and 2004 260 patients underwent kidney transplantation. All ureterovesical junctions were performed in extravesical technique with ureteral stenting in 132/260 (50.7%) patients. Arterial end-to-side anastomosis was performed routinely except for 13/260 (5%) with end-to-end anastomosis. Mean follow-up was 43 months (0-121) including serum creatinine and ultrasound inter alia.

RESULTS

Graft failure rate was 8.1% 12 months and 12.7% 60 months postoperatively. Of the patients, 29/260 (11.5%) underwent reoperation within 30 days after transplantation (stenosis or leakage of the ureterovesical junction: n = 8; vascular complications: n = 10; thrombectomy for graft vein thrombosis: n = 1; evacuation of hematoma: n = 6; nephrectomy for complete graft ischemia: n = 4). Reoperation for vascular-related complications significantly enhances the risk of graft failure (P < 0.05, Cox proportional hazard) compared to urological complications. Arterial end-to-end anastomosis was also found to have a negative impact on graft survival. No correlation between routine ureteral stenting and ureteral stenosis or leakage was found.

CONCLUSION

Our data emphasize the importance of vascular complications compared to ureteral ones in kidney transplantation. Resolving 'non-urological' problems successfully, kidney transplantation is a safe procedure in urological hands.

[The role of superselective transcatheter arterial embolisation in management of complications after kidney surgery]

PURPOSE

Transcatheter arterial embolisation (TAE) is replacing open procedures in terms of vascular malformations or traumatic haemorrhage. Furthermore, the role of TAE is established in post-surgery bleeding complications. We report on a number of patients with severe haemorrhage after kidney surgery and successful management by TAE.

MATERIALS AND METHODS

Gross renal haemorrhage was observed after pyelocalicolithotomy and open kidney-sparing surgery. One patient developed a large arteriovenous fistula after kidney transplantation preceded by open biopsy. Technique of TAE: In all cases the bleeding vessel was located by transfemoral arteriography. Embolisation was performed by dropping platinum coils or gelfoam pellets.

RESULTS

TAE stopped the haemorrhage in all patients and occluded the arteriovenous fistula in the renal allograft. No complications were observed.

CONCLUSION

TAE can be considered as the treatment of choice for a widespread range of complications after kidney surgery. It should always be taken into consideration before open surgical revision.

First report of an unexpected blind-ending duplication of the ureter as a rare pitfall in kidney transplantation

We report on the case of an unexpected blind-ending ureter in a kidney transplant. To our knowledge, this is the first report of a blind-ending ureter in kidney transplantation. The recipient was a 60-year-old woman, with a 6-year history of chronic haemodialysis. During the performance of ureterocystostomy, the ureteric stent could not be placed in the renal pelvis as the ureter, surprisingly, was found as blind-ending in the ureteral sheath. Dissecting the ureteral sheath a second shorter ureter was found and used for ureterocystostomy. The histology reported a normal ureter, which led to a thread of connective tissue. The patient had an uneventful recovery; the creatinine was 1.07 mg/dl at discharge from the hospital. It is mandatory for the transplanting surgeon to be aware of the ureteral variations and the surgeon should be trained in the surgical management of these variations. Accuracy should be ensured when exploring the exact anatomy of the donor organ.

Renal autotransplantation combined with direct pyelocystostomy for a doubled renal artery aneurysm of a stone forming kidney

A 35-yr-old female patient presented with recurrent left-sided calcium oxalate nephrolithiasis in combination with equilateral doubled renal artery aneurysm. Approximately two-thirds of the cumulative renal function were scintigraphically calculated in favour of the affected kidney. After a left-sided nephrectomy, "workbench surgery" with resection of both aneurysms was performed. The renal artery was reconstructed with contralateral internal-iliac artery graft. To allow passage of renal calculi, the kidney was transplanted in the right iliac fossa combined with a wide pyelocystostomy. The patient recovered uneventfully and presented with good physical health and regular serum creatinine 1 yr postoperatively.

Evaluation of hypoxia-mediated growth factors in a novel bladder cancer animal model

BACKGROUND AND AIM

The outcome of advanced transitional cell carcinoma (TCC) is poor. Changes taking place in the tumor microenvironment are receiving increased scrutiny. Hypoxia is the key to increased expression of HIF-1alpha (hypoxia-inducible factor 1alpha) resulting in increased expression of growth factors (e.g. vascular endothelial growth factor (VEGF), epidermal growth factor (EGF)). The aim of our study was to establish an animal model with modulatable tumor hypoxia. Resulting tumor growth and growth factors were assessed.

MATERIALS AND METHODS

Low Hb levels were induced in rats by total body irradiation (5 Gy). Twenty animals received EPO erythropoietin (EPO), 1000 IE/kg/week subcutaneously). After subcutaneous injection of NBT-II cells a weekly determination of Hb concentration, leukocyte counts and tumor volume were performed. Serum VEGF levels were quantified and oxygen Hb saturation in healthy tissue and tumors were measured by percutaneous laser spectroscopy. HIF-1alpha and VEGF were examined immunohistochemically.

RESULTS

Reduced O2 supply promoted expression of HIF-1alpha and VEGF. Low oxygen availability was essential for tumor growth. EPO improved the O2 supply and decreased expression of growth factors but did not reduce tumor volumes.

CONCLUSION

Based on these studies, treatment of low Hb levels appears reasonable in TCC. O2 supply is improved and expression of tumor growth factors is decreased. Tumor volumes did not differ between the groups, causatively adverse effects of EPO overtreatment might negatively affect microcirculation. Restoring low Hb levels and improvement in the O2 supply resulted in tumor shrinkage.

Health-related quality of life (QoL) in patients with seminoma stage I treated with either adjuvant radiotherapy (RT) or two cycles of carboplatinum chemotherapy (CT): Results of a randomized phase III trial of the German Interdisciplinary Working Party on Testicular Cancer

5050

Background: RT and CT are efficient adjuvant therapies in seminoma stage I and were compared in this trial. Clinical results will be reported elsewhere. Secondary endpoint was to assess QoL. Materials and Methods: Pts were randomized to receive RT (5x2 Gy/wk, 26–30 Gy total dose) or carboplatinum (300–460 mg/m2, 1 h iv d 1, 29). The QLQ C30 vs. 2.0 (15 QoL dimensions) and the Testicular Tumour Questionnaire (TTQ, 16 domains) were completed at randomization (0) and 1, 4, and 12 months (m) after trial entry. QoL was compared over time within the two arms (Wilcoxon) and between treatments (Mann-Whitney) by intent-to-treat. Results: 807 pts were randomized. Questionnaire compliance was 72% at 0, 75% at 1, 69% at 4 and 70% at 12m. Sign. variation (p<0.05) in QoL over time in both treatment arms (no. of Qol domains with deterioration over time): QLQ C30: RT: m1 vs 0 9, m4 vs 0 2, m12 vs 0 0 , CT: m1 vs 0 6, m4 vs 0 3, m12 vs 0 1; TTQ: RT: m1 vs 0 4, m4 vs 0 2, m12 vs 0 3, CT: m1 vs 0 1, m4 vs 0 2, m12 vs 0 1. (¼ improvement over time): QLQ C30: RT: m1 vs 0 0, m4 vs 0 6, m12 vs 0 8, CT: m1 vs 0 2, m4 vs 0 6, m12 vs 0 10; TTQ: RT: m1 vs 0 1, m4 vs 0 2, m12 vs 0 3, CT: m1 vs 0 2, m4 vs 0 4, m12 vs 0 6. Sign. variation in QoL comparing treatment modalities: QLQ C30: Better QoL in RT: at m1 in 0, at m4 in 0 and at m12 in 0 domains, Better QoL in CT: at m1 in 11, at m4 in 2 and at m12 in 5 domains; TTQ: Better QoL in RT: at m1 in 4, at m4 in 1 and at m12 in 0 domains, Better QoL in CT: at m1 in 3, at m4 in 0 and at m12 in 2 domains. Discussion and Conclusions: Adjuvant RT has a more negative impact on self-reported QoL of seminoma pts than CT, as determined by two instruments over a period of one year. RT negatively affects more dimensions of QoL as compared to CT, especially during the early phase. Pts rapidly adapt to QoL impairment, with little change persisting at m12. Not all observed differences are clinically relevant. Potential bias and methodological limitations will be discussed. Given the presumed clinical equivalence of both modalities, pts should be aware of the more negative impact of RT on the well-being. Treatment recommendation should be based on objective outcome parameters, toxicity, logistics and QoL considerations.

No significant financial relationships to disclose.

Reducing recurrence and costs in superficial bladder cancer: preclinical evaluation of osmotic cytolysis by distilled water vs. mitomycin

Transurethral resection followed by instillation of chemotherapeutic agents such as mitomycin is considered as standard therapy in recurrent superficial bladder cancer. However, incidence of bladder cancer is increasing, and contrariwise resources to finance the health care systems are decreasing. Therefore, effective alternatives to expensive chemotherapeutics are necessary. Recurrence of bladder cancer after transurethral resection is mostly promoted by reimplantation of dissolved tumour cells which are therapeutical purpose of any intravesically instillated agent. Monolayer cultures of human RT112, RT4, T24 and TCC SUP bladder cancer cells were incubated and exposed to mitomycin or distilled water. Cell survival was determined by microculture tetrazolium assay. Distilled water led to significant cytolysis in all tumour cells. This effect was comparable to exposition to mitomycin. Distilled water and mitomycin have comparable in vitro effects in bladder cancer cells. These findings have to be substantiated by an animal model emphasising the aspect of larger tumour cell compounds or possible damage to healthy bladder tissue.

Small intestine submucosa in urethral stricture repair in a consecutive series

OBJECTIVES

To define the feasibility of acellular porcine small intestine submucosa (SIS) as a xenograft implant. SIS is commercially available and approved for use in humans.

METHODS

Five patients underwent open surgery for urethral stricture repair using SIS and a four-layer SIS graft. Two patients had a bulbar stricture and three had a combined penile-bulbar stricture. The median stricture length was 9 cm (range 3.5 to 10). All patients underwent at least one internal urethrotomy. The urethral stricture repair was performed as an onlay urethroplasty. SIS was used to augment the urethral caliber at the stricture site. A catheter and percutaneous cystostomy for drainage were placed. The catheter was removed 10 days after surgery. Three weeks postoperatively, voiding cystourethrography and retrograde urethrography were performed.

RESULTS

Preoperatively, flow studies were available for 3 patients, in 1 patient voiding was not possible because of urinary retention, and in 1 patient the preoperative flow study was not available (surgery was performed on the basis of the preoperative urethrographic findings). The mean maximal flow rate was 4.2 mL/s (n = 3); the mean value of the mean flow rate was 2.6 mL/s (n = 3). Postoperatively, 1 patient had extravasation, which was treated by prolonged suprapubic drainage. One patient had severe urethritis and one urinary tract infection. Four patients had a recurrent stricture after a mean of 12.4 months (range 3.7 to 17.5). Two patients underwent open repair using buccal mucosa and two refused repeated surgery.

CONCLUSIONS

In 4 patients, the operation was not successful. Because of the poor results, we discontinued the use of SIS for open urethral stricture repair.

Sudden death due to giant cell coronary arteritis

An 89-year-old woman was found dead lying in her bed. Autopsy demonstrated a pronounced thickening of all coronary arteries except for the first 2-4 cm. Death was due to a recent myocardial infarction. Microscopically, the coronary arteries showed a substantial concentric thickening of all three layers with 90% narrowing. There was a dense transmural inflammatory infiltration with lymphocytes, macrophages, and numerous multinucleated giant cells. The CD68 positive giant cells were mostly located at the media-intima border in the vicinity of fragmented fibers of the lamina elastica interna. The aorta and its major branches including the carotid arteries, however, were free of inflammation and thickening. The findings were characteristic for giant cell arteritis, the equivalent of temporal Horton arteritis, but isolated involvement of the coronary arteries is exceptional.

Randomised phase II trial of gemcitabine and paclitaxel second-line chemotherapy in patients with transitional cell carcinoma (AUO Trial AB 20/99)

The objectives are to evaluate and compare the response and toxicity of a 3-weekly and a 2-weekly regimen of gemcitabine (Gem) and paclitaxel (Pac) second-line treatment in patients with transitional cell carcinoma (TCC). Between June 2000 and July 2001, 30 patients with progressive disease (PD) during first-line chemotherapy (n = 11) or relapse after adjuvant cisplatin-based chemotherapy of a metastatic or locally advanced TCC (n = 18) have been randomised to receive either six cycles (schedule A) of 3-weekly Gem (1000 mg/qm, days 1 and 8) and Pac (175 mg/qm, day 1) or 2-weekly treatment until disease progression (schedule B) with Gem (1250 mg/qm, day 1) and Pac (120 mg/qm, day 2). Restaging was performed after every 6 weeks by clinical imaging. Of 30 patients, one patient in schedule A and two patients in schedule B were not evaluable for response due to serious adverse events (SAEs) during the first cycle. The overall objective response (OR) was 44% (12 of 27) with eight complete remissions (CRs) and four partial remissions. Median time to progression (TTP) was 11 (3-41) months in schedule A and 6 (1-15+) months in schedule B. Median survival was 13 (5-46) months in schedule A and 9 (0-16) months in schedule B. Schedule A showed a significantly higher rate of CRs (7 vs. 1, p < 0.05). With a median number of six (1-6) cycles (A) and nine (1-23) cycles (B), TTP and survival were not significantly different. In schedule B, one patient had WHO grade IV anaemia and leucopenia. WHO grade III toxicities were seen in schedule A/B as follows: anaemia 3 (23%)/2 (16%) patients, leucopenia 5 (38%)/2 (16%), thrombocytopenia 0/2 (16%) and alopecia 10 (76%)/4 (32%). The combination of Gem and Pac is an effective second-line regimen in patients with mainly poor prognosis due to PD after cisplatin-based chemotherapy. Except for three SAEs (uncertainly therapy related), both regimens were tolerated well. The 3-weekly schedule with a nonsplit Pac dose showed a significantly higher complete response rate in our small study population and, thus, might be superior to the 2-weekly schedule.

Perforating colonic duplication as rare cause of renal abscess in children

Renal abscess is uncommon in children. In a few cases, ascending infection and/or hematogenous spread have been outlined as pathophysiologic mechanisms in published studies. We report on a 7-month-old female infant who was hospitalized with a high fever. Ultrasonography revealed a hypoechogenic mass in the left kidney. The diagnosis of a renal abscess was confirmed by computed tomography. Because antibiotic treatment had only a transient effect, an open operative procedure was performed. Intraoperatively, a perforating colonic duplication with broad contact to the kidney was found that had destroyed major parts of the kidney's parenchyma. After nephrectomy and complete resection of the colonic duplication, the patient recovered uneventfully.

Hyperoxia-induced improvement of the in vitro response to gemcitabine in transitional cell carcinoma

BACKGROUND

Anemic tissue hypoxia can decrease the effects of chemotherapy in bladder cancer. Hypoxia leads to overexpression of hypoxia-inducible factor (HIF) and increased synthesis of epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF). Tumor cell survival, invasion and angiogenesis thereby compromise treatment.

MATERIALS AND METHODS

Monolayer cultures of RT112, RT4, T24 and TCC SUP cells were incubated with or without gemcitabine and different gas mixtures (hypoxia, normoxia or hyperoxia). Cell proliferation (microculture tetrazolium assay), VEGF (enzyme-linked immunosorbent assay) and HIF-1alpha (Western blot analysis) were determined.

RESULTS

Hypoxia led to increased proliferation of transitional cell carcinoma (TCC) cells and elevated levels of HIF-1alpha and VEGF. Hyperoxia inhibited cell growth and lowered the concentration of VEGF. Treatment with gemcitabine was less effective under hypoxia.

CONCLUSION

Hypoxia enhances TCC growth and may intensify angiogenesis mediated by VEGF. Hypoxia compromises treatment with gemcitabine. Correction of anemia might provide advantages in chemotherapeutic strategies for TCC.

Backstabbing?a report of an unusual case

A case of a 25-year-old male with a deep knife stab injury in the back is reported. The stab wound penetrated the left thorax and the left lung was injured, a thoracotomy was performed and the patient survived. The injured man could not remember what had happened, his bag was missing and the incident was therefore considered to be due to a robbery. Further results of the police investigations and the forensic pathology inspection revealed an extremely unusual accident constellation.

Fatal hepatic haemorrhage in a child-peliosis hepatis versus maltreatment

A 2.5-year-old boy with known myotubular myopathy (Spiro-Shy-Gonatas syndrome) and gonadorelin intake 9 months ante-mortem was found dead in his bed at home. At autopsy a ruptured subcapsular haematoma of the liver with resulting haemoperitoneum (600 ml) was found. Both lobes of the liver showed numerous circular blood foci <1 mm-2 cm in diameter. Signs of mechanical trauma such as bruising of the abdominal wall were absent. Histologically, the blood cysts were commonly connected to the sinusoids but did not have an endothelial lining and the reticular fibres showed ruptures. These pathomorphological findings are characteristic for peliosis hepatis and the cause of death was therefore determined to be exsanguination due to hepatic haemorrhage from peliosis hepatis instead of from mechanical trauma. To our knowledge this is the youngest casualty from peliosis reported so far.

Preclinical evaluation of a radiosensitizing effect of gemcitabine in p53 mutant and p53 wild type bladder cancer cells

OBJECTIVES

Despite clinical use, the radiosensitizing effect of gemcitabine (2'2'-difluorodeoxycytidine) in human transitional cell carcinoma (TCC) has not been shown to date. We investigated gemcitabine as a radiosensitizer for human TCC cells.

METHODS

Monolayer cultures of RT112 (G1, p53 wild type), RT4 (G1-G2, p53 wild type), T24 (G3, p53, mutant type), and SUP (G4, p53 mutant type) cells were incubated in medium with gemcitabine. Electron beam radiation was applied alone, simultaneous, or 3, 6, 12, and 24 hours after gemcitabine. Jurkat leukemia cells were used as controls for radiation toxicity. Cell survival was determined 6, 12, 24, 48, and 72 hours after radiation by microculture tetrazolium assay. DNA damage was evaluated by flow cytometric assessment of poly(ADP-ribose) polymerase, and apoptosis was determined by terminal-deoxynucleotidyltransferase-mediated dUTP nick-end labeling and flow cytometric assessment after annexin-V and propidium iodide labeling.

RESULTS

In all TCC cell lines, radiation alone caused only little and insignificant growth inhibitory effects at 10 Gy. Gemcitabine alone had a dose-dependent cytotoxic and apoptosis inducing effect on all TCC cell lines independent of p53 status. Assays combining radiation with gemcitabine in different dose and time schedules demonstrated no radiosensitizing effect in TCC cells.

CONCLUSIONS

Gemcitabine is effective in TCC cell lines independent of p53 status. A radiosensitizing effect could not be demonstrated. Again, p53 status was not predictive of the radioresponse in the bladder cancer cell lines. Clinical studies with gemcitabine and radiotherapy might nevertheless yield different results but should be performed with utmost caution.

Death due to intravenous application of enteral feed

A 6-month-old male infant was treated with intravenous infusions and enteral feed via a naso-gastric tube. Accidentally, enteral feed containing pureed carrots diluted with water was injected intravenously and the child died immediately. Carrot material could be found in the pulmonary blood vessels and in various organs of the systemic circulation.

Mycotic cerebral vasculitis in a paediatric cardiac transplant patient excludes misadventure

We present the case of a 10-year-old girl with cardiomyopathy who received a heart transplant. Due to organ rejection, the dosage of immunosuppressive agents was increased postoperatively. The patient complained of intermittent headaches in the following days and developed a haemorrhagic necrosis of the left thalamus. A week later, an oral dose of cyclosporin A was accidentally given intravenously, and 2 weeks later a recurrent subarachnoid haemorrhage of unknown origin was diagnosed. The clinical course was then characterised by progressive deterioration resulting in coma, fluctuating brain stem symptoms and the development of a massive cerebral oedema with subsequent brain death. A coroner's autopsy was instigated to investigate a claim of medical misadventure. Neuropathological investigations found a focal infiltration of fungal hyphae in the left posterior cerebral artery resulting in necrosis of the vascular wall and thus explaining the source of the recurrent subarachnoid haemorrhage which eventually resulted in the girl's death. Medical misadventure due to the administration of cyclosporin was not directly responsible for the death of this patient. This case illustrates that it is of paramount importance to copiously sample and investigate the basal cerebral arteries in cases of subarachnoid haemorrhage of unknown origin, in particular in a medico-legal context.

Proof of a gunshot wound and its delayed effects 54 years post injury

In 1945 a 6-year-old girl received a tangential gunshot injury to the left posterior inferior skull. After hospitalisation because of septicemia she was unable to walk for several months. Since 1967 she had been repeatedly applying for compensation because of pseudoneurasthenia and residual ataxia and many medical examinations were performed including X-ray, CT and MRI. Although certain objective findings (e. g. cerebellar atrophy) could be verified, a causal connection between the gunshot injury and the clinical findings could not be established. Therefore previous investigators concluded on a vascular origin of the disease. During the present re-examination of the patient, the authors found patch-like scars at the left posterior inferior skull base and behind the left ear, a cord-like scar formation in the subcutaneous tissue, connecting both skin scars, a gutter-like defect in the left occipital base of the skull and an indention of the left mastoid process, both again in line between the skin scars and a large defect of the left cerebellar hemisphere. It could be concluded with certainty that the anatomical findings and the clicinal symptoms were the direct result of a gunshot injury. Previous investigations had failed because of deficient investigations and techniques. In addition to an anatomical reconstruction, three dimensional reconstructions from CT scans proved most helpful.