- [Show abstract] [Hide abstract] ABSTRACT: Durasphere is gaining popularity as a bulking agent for treating women with stress urinary incontinence. We present a series of patients with periurethral mass formation following Durasphere injection. The charts of 135 women with a mean age of 69.4 years (range 46 to 83) who underwent Durasphere periurethral injections were retrospectively reviewed. Patients who had a periurethral mass were identified and their clinical data were collected and analyzed. Four patients (2.9%) were diagnosed with periurethral mass formation 12 to 18 months (average 14.7) following a Durasphere injection. Clinical presentation varied, including irritative voiding symptoms, pelvic pain and urinary incontinence. All patients were found to have a tender and tense periurethral mass. A radiopaque mass was revealed during videourodynamic study in 1 patient. Incision, and transvaginal and endoscopic drainage or transvaginal excision were used to treat these masses. Intraoperative and pathological findings as well as operative outcomes are presented. Irritative or obstructing voiding symptoms, pelvic pain or a periurethral mass in patients with a history of Durasphere or other periurethral bulking agent injection should alert the physician to the possibility of periurethral mass formation. The true incidence of this late complication remains to be determined.
- [Show abstract] [Hide abstract] ABSTRACT: Midurethal sling procedures are gaining popularity as the treatment of choice for stress urinary incontinence. Complications that were described include bladder perforation, urinary retention, pelvic hematoma and suprapubic wound infection. Sling erosion and pelvic abscess are rare complications of midurethral slings. We report the first case of an abscess formed within the wall of the urinary bladder, 7 months following a midurethral sling procedure.
- [Show abstract] [Hide abstract] ABSTRACT: Prostate cancer is the most common male malignancy and the second leading cause of male cancer death; therefore, there is urgent necessity for noninvasive assays for early detection of prostate cancer. Obtaining prostate tumor samples surgically is problematic because the malignancy is heterogeneous and multifocal and early-stage tumors are nonpalpable. In contrast, exfoliated cells represent the cancer status of the entire gland better due to the general tendency of cancer cells to exfoliate into biological fluids. The purpose of this study was to clarify whether quantitative analysis of telomerase activity in exfoliated cells in urine could serve as a reliable molecular marker of prostate malignancy. We analyzed prospectively post-prostatic examination-exfoliated cells from the urine of 56 patients undergoing routine prostate screening. Epithelial cells were isolated and enriched by immunomagnetic separation. Telomerase activity was analyzed by quantitative real-time PCR telomeric-repeat amplification protocol assay using Opticon MJ research instrument. We report now that all prostate cancer patients revealed high levels of telomerase activity thereby showing 100% of the assay sensitivity. In contrast, the majority of patients with clinically confirmed benign prostatic hyperplasia (BPH) did not express any telomerase activity (70% of all BPH patients), most likely presenting cancer-free cases, or expressed low levels of activity (18%). However, about 12% of BPH patients revealed high levels of telomerase activity that potentially can reflect hidden prostate cancer. We suggest that the quantitative analysis of telomerase activity can be useful for the selection of prostate cancer and cancer-free cases.
- [Show abstract] [Hide abstract] ABSTRACT: Urinary calculus formation following renal transplantation is an uncommon phenomenon. As a result of the growing number of renal transplants performed and the greater graft survival, there has been increased awareness of transplant-related complications, one of which is calculus formation. We report our experience in the management of bladder calculi after renal transplantation. We retrospectively reviewed the charts of 500 consecutive renal transplant patients from 1992 through 2002 and encountered 7 who had bladder calculi postoperatively. Ureteroneocystostomy had been performed using polyglactic acid suture. Bladder calculi were treated endoscopically by litholapaxy, electrohydraulic lithotripsy (EHL), or holmium:YAG laser lithotripsy. Three calculi were found incidentally at the time of stent removal, and the others were associated with hematuria (43%), urinary tract infection (14%), or irritative voiding symptoms (14%). Eighty-six percent of the calculi were close to the allograft ureteral orifice. While various forms of lithotripsy were employed in treating bladder calculi, Hol:YAG laser lithotripsy appeared to be both efficacious and safe. Both EHL and litholapaxy were complicated by mucosal bleeding necessitating Bugbee fulguration. Holmium:YAG laser lithotripsy was not associated with mucosal bleeding, and fulguration was not required near the allograft ureteral orifice. In addition, ureteral stenting is not required. Bladder calculi may form over both absorbable and nonabsorbable suture material, and the ideal suture for the ureteroneocystostomy has yet to be found. Until then, the Hol:YAG laser should be the lithotrite of choice for bladder calculi following renal transplantation.
- [Show abstract] [Hide abstract] ABSTRACT: The presence of tumor infiltrating lymphocytes (TIL) has been attributed to the host cell mediated immune response against the evolving malignancy. However, due to specific evasive and escape mechanisms, the immune competent cells are rendered ineffective. One such mechanism may be the production of immune suppressor substance(s), inhibiting lymphocyte proliferation, and subsequently, their transformation into effector cells. To evaluate a possible impact of RCC extract on lectin and alloantigen-induced proliferation of TIL and peripheral blood lymphocytes (PBL) from renal cell carcinoma (RCC) patients and from healthy control human subjects. Tumor extract and TIL were derived from 13 patients with RCC undergoing radical nephrectomy. Tumor infiltrating lymphocytes and PBL from these patients were activated with Concanavalin A (Con-A), Phytohemoglutinine (PHA) or Pokeweed (PW) and the rate of blastogenesis was measured by (3)H Thymidine incorporation. The same procedure was used in assay with PBL from control healthy blood donors. There was a significant reduction (88.6%) in the proliferative response to ConA of TIL compared to PBL from the same patients (P = 0.007). A similar decrease was seen following stimulation by PHA (85.8%, P = 0.01) and PW mitogen (78.5%, P = 0.001). A 79.5% decrease in response level of TIL to alloantigens compared to PBL from RCC patients (P = 0.021), was observed. Lectin induced proliferative response of RCC patients was significantly lower in the presence of RCC extract (82.9%) compared to normal kidney extract (P = 0.008). Alloantigenic stimulation of healthy individual PBL was also decreased significantly in the presence of RCC extract (92.9%, P = 0.0001) compared to normal kidney extract. Similarly, lectin induced stimulation of healthy control PBL in the presence of RCC extract was significantly lower (83.2%, P = 0.003). Our data suggest that RCC extract contains an immune suppressive substance(s), capable of inhibiting lymphocyte proliferative response of tumor infiltrating lymphocytes as well as of PBL from patients and healthy individuals alike. This may be one of the mechanisms by which the tumor evades the transformation of lymphocytes into effector killer cells, and thus affects the biological inter-relationship between tumor and host. Identification of this substance and its gene may provide an effective anti-tumoral treatment modality.
- [Show abstract] [Hide abstract] ABSTRACT: As manifested by the presence of immune competent cells, failure to control the progression of renal cell carcinoma by a local immune response attests to impaired local cell mediated immunity. To test this hypothesis we compared the expression of T-cell activation markers in renal cell carcinoma infiltrating lymphocytes with the expression of activation markers of peripheral blood lymphocytes in the same patients. Tumor infiltrating lymphocytes were harvested from a patient with renal cell carcinoma undergoing radical nephrectomy. Peripheral blood was obtained before surgery. Tumor infiltrating and peripheral blood lymphocytes were incubated with monoclonal antibodies defining specific differentiation and activation markers on the cell surface, and analyzed by flow cytometry. Cell subsets are expressed as a fraction of the total number of mononuclear cells. The T-cell subset level was significantly higher in peripheral blood than in renal cell carcinoma tissue of the same patient. However, the level of activated T-cell subset expressing HLA-DR was significantly higher in renal cell carcinoma tissue than in peripheral blood. The levels of interleukin-2 receptor and transferrin receptors expressing T-cell subsets were also significantly higher in carcinoma tissue than in peripheral blood. Natural killer cells were found in significantly higher proportions in renal cell carcinoma than in peripheral blood. These results point to significant activation of T, B and natural killer tumor infiltrating lymphocytes. The inability of tumor infiltrating lymphocytes to mount an effective immune response to renal cell carcinoma may be secondary to the presence of suppressive factors in the tumor that prevent tumor infiltrating lymphocytes from transforming into effector cells. These factors may be particularly valuable for the further study of renal cell carcinoma-host interactivity.
- [Show abstract] [Hide abstract] ABSTRACT: In 219 renal allograft transplants performed at the University Hospital, State University of New York at Stony Brook, 24 urological complications were encountered (10.8%). There were 12 episodes of ureteral obstruction and 8 of ureteral fistulas with extravasation. Four patients had bladder fistulas. In all patients, early surgical corrective procedures were employed. No graft or patient losses occurred as a result of these complications or of their treatment (0% mortality; 0% graft loss). Based on this as well as others' experience (1-24), it appears that early aggressive diagnosis and surgical treatment, combined with urological expertise, are a central requirement for the avoidance of graft loss or mortality following urological complications.
- [Show abstract] [Hide abstract] ABSTRACT: The effects of increasing in vitro cyclosporine concentrations (0, 50 100 or 200 ng./ml.) on lymphocyte blastogenesis, measured by incorporation of tritiated thymidine and induced by varying levels of concanavalin A (0, 0.25, 1.0 or 5.0 ng./ml.), were studied in regard to mean serum level of cyclosporine in 26 renal allograft recipients. Results were compared to similar data obtained in healthy controls. Patients were divided into group 1 (13 patients, mean serum cyclosporine trough level less than 150 ng./ml.) and group 2 (13 patients, cyclosporine level greater than 150 ng./ml.). With no cyclosporine added to the assay proliferation of lymphocytes obtained from all patients inversely correlated to the mean serum trough cyclosporine level at all stimulatory levels of concanavalin A (0.25 ng./ml., p less than 0.01; 1.0 ng./ml., p less than 0.001 and 5.0 ng./ml., p less than 0.001) and was significantly lower than in controls (p less than 0.0002). Whereas increasing in vitro cyclosporine concentrations has produced the expected increase in suppression of blastogenesis in controls and group 1, a paradoxical effect became evident in group 2. Under stronger stimulatory conditions (concanavalin A 1.0 or 5.0 ng./ml.) increasing in vitro cyclosporine concentrations were associated with significantly decreased suppression of blastogenesis (p less than 0.01) compared to group 1. These results confirm previous reports and suggest that the duality of effect of cyclosporine in this in vitro model may be related to its functional relationship to the calcium ion (Ca++)/calmodulin complex and to its cellular concentration/solubility curve. These considerations may be of importance in adjusting cyclosporine dosage based on serum trough levels of cyclosporine.
- [Show abstract] [Hide abstract] ABSTRACT: We report a case of refractory bladder fistula in a diabetic renal allograft recipient that recurred shortly after conventional operative repair without any detectable external cause. After reoperation and use of a vascularized rectus muscle flap the fistula closed and the patient has retained excellent graft function. It is suggested that this technique should be considered as the primary repair modality for bladder fistulas in diabetic recipients, when wound healing is impaired seriously as a consequence of the combined effects of diabetic microangiopathy and steroid therapy.
- [Show abstract] [Hide abstract] ABSTRACT: The role of humoral immune factors in graft destruction is not fully understood. With immunofluorescence techniques the possibility of a specific pattern and/or clustering of immune complex or complement deposits was analyzed in 140 percutaneous kidney needle biopsies performed in 73 patients with renal allograft dysfunction. The results were correlated with concomitant alterations in renal blood flow as measured by cortical and global perfusion indexes and graft survival. The deposition of IgG, IgM, C3 and C4 correlated significantly with acute rejection confirmed by biopsy (p less than 0.05, less than 0.001, less than 0.02 and less than 0.001, respectively). Subsequent graft survival was compromised when IgA, IgG, IgM, C3, C4 and properdin were present together in biopsy specimens (p less than 0.05). There was a significant clustering of IgA with C3, of IgG with C3 and C4, and of IgM with C1, C3 and C4 (p less than 0.001). There also was a significant association among alterations in renal blood flow, deposition of IgA (p less than 0.05) and C4 (p less than 0.02), and graft outcome. Higher perfusion indexes, indicative of decreased blood flow, showed significant associations (p less than 0.007 and less than 0.04 for the cortical and global perfusion indexes, respectively) with a greater risk of graft loss. Although it primarily is a cellular event, the data suggest that acute rejection is associated with a deposition of various humoral factors that may mediate alterations in renal blood flow. The latter may affect graft function and structural integrity, and, thus, may show a direct correlation with the outcome of a graft.
- [Show abstract] [Hide abstract] ABSTRACT: Studies in the canine model indicate that effective in situ flush cooling (ISFC) depends on the maintenance of flush pressures (FP) of at least 70 mm Hg. Low FP of 30 mm Hg (currently used during ISFC) produces reactive vasospasm leading to poor core cooling and inadequate expulsion of blood from the renal microvasculature. In an attempt to deliver the necessary flush pressure and flow rate to cadaver donor kidneys, a new ISFC tube - Anaise Organ Procurement Tube (AOPT) (Sheridan Corporation, Argyle, New York) - was developed. A prospective study was designed to compare the effectiveness of ISFC at high FP of 70 mm Hg with the results of low FP of 30 mm Hg. This preliminary report suggests that ISFC at an adequate FP produces improved graft function after transplantation, and highlights the need to deliver and monitor adequate levels (70 mm Hg) of FP during ISFC.
- [Show abstract] [Hide abstract] ABSTRACT: The cancer family syndrome is an unusual hereditary disease rarely associated with transitional cell carcinoma of the urinary tract. We describe the occurrence of this syndrome in a patient with bilateral transitional cell malignancies.
- [Show abstract] [Hide abstract] ABSTRACT: The authors evaluated a method of detecting urinary tract bleeding using Tc-99m sulfur colloid in a canine model.
- [Show abstract] [Hide abstract] ABSTRACT: The authors describe a case report of a squamous cell carcinoma in a horseshoe kidney and summarize the literature.
- [Show abstract] [Hide abstract] ABSTRACT: The complications of bleeding in patients with Waldenström's macroglobulinaemia (WM) are relatively well described. The pathophysiology of such a haemorrhagic diathesis is complex and involves the inhibition and depression of coagulation factors as well as qualitative and quantitative platelet abnormalities. Treatment of WM must be targeted at the underlying lymphocellular malignancy, but amelioration of the hyperviscous state and component transfusion(s) to correct abnormal coagulation parameters will decrease the incidence of bleeding. A case of WM with E. coli urinary tract infection and subsequent retroperitoneal haemorrhage with abscess formation and sepsis is presented. The pathophysiology and management of such patients is described.
State University of New YorkNew York City, New York, United States
Stony Brook University
Stony Brook, NY, United States
- Department of Surgery