Characteristics and clinical significance of bacterial colonization of ureteral double-J stents in children.

OBJECTIVE: To determine the frequency, type of pathogen and clinical significance of bacterial colonization of double-J stents after pyeloplasty in children. PATIENTS AND METHODS: The medical files of 82 consecutive children (22 girls, 60 boys) who underwent pyeloplasty at a tertiary pediatric medical center in 2000-2007 were reviewed. Additional inclusion criteria were sterile urine preoperatively and placement of an indwelling double-J stent during surgery. Intravenous gentamicin was administered prior to pyeloplasty and stent removal; cephalexin was administered postoperatively until discharge. Children with a postoperative urinary tract infection (UTI) received full-dose antimicrobial treatment followed by prophylaxis until stent removal. RESULTS: Median patient age at surgery was 11 months (1 month-17.5 years). Forty-nine stents were inserted on the left side, 32 on the right, and one bilaterally. Cultures showed bacterial colonization in 58 cases (70.7%); 15 (25.8%) grew Staphylococcus (coagulase negative and positive). Eight children had febrile UTI postoperatively; in four the stent was colonized by Enterococci and in one by Proteus; three were sterile. There was no statistically significant association between positive stent culture and febrile UTI, patient age or sex, or stent laterality. The study was potentially limited by its observational design, small sample size, and the selective antibiotic treatment of patients with UTI which may have affected stent bacterial resistance. CONCLUSION: Bacterial colonization is not uncommon in double-J stents retained for several weeks after pyeloplasty, but is usually not clinically significant. Enterococcus is the most frequent pathogen.

Early initiation of aspirin after prostate and transurethral bladder surgeries is not associated with increased incidence of postoperative bleeding: a prospective, randomized trial.

PURPOSE: Lower urinary tract operations are being increasingly performed in elderly patients, in whom aspirin intake is common for preventing cardiovascular disease. We determined the safety of early aspirin re-initiation after lower urinary tract surgeries. MATERIALS AND METHODS: A randomized, open label clinical trial was done. The study cohort included patients referred for transurethral prostatectomy, open prostatectomy and transurethral resection of bladder tumor while receiving aspirin prophylaxis. After controlling for surgical modality patients were randomized into 2 arms, including aspirin treatment initiation 24 hours after discontinuing of bladder irrigation (early treatment group) and aspirin treatment initiation 3 weeks after surgery (late treatment group). Primary end points were pre-discharge hematuria necessitating the restoration of bladder irrigation or the cessation of aspirin treatment and late hematuria treated in an urgent care setting, requiring hospital admission or compelling the cessation of aspirin treatment. RESULTS: A total of 120 patients were enrolled, including 60 per treatment group. There were no significant differences between the groups in surgery related factors that could have affected postoperative bleeding. Primary end points were attained by 16 of the 120 patients (13.6%), including 10 of the 60 (16.7%) in the early treatment group and 6 (10%) in the late treatment group (p = 0.28). Time to catheter removal and persistent hematuria duration were similar in the 2 groups. Cardiovascular morbidity was noted in 3 of 120 patients, of whom all were assigned to the early treatment group. CONCLUSIONS: Early aspirin initiation after lower urinary tract surgeries does not appear to carry an increased risk of postoperative bleeding. Thus, it may be considered in patients at high risk for cardiovascular morbidity.

Retrograde intrarenal surgery as second-line therapy yields a lower success rate.

BACKGROUND AND PURPOSE: Retrograde intrarenal surgery (RIRS) is a recent addition to the treatment options for renal calculi. Therefore, the indications, as well as the predictors of success, are still being studied. Herein, we report a retrospective comparison of RIRS performed as the primary treatment and as second-line therapy, mostly after shockwave lithotripsy (SWL) failure. PATIENTS AND METHODS: Between October 2001 and August 2004, 93 patients underwent RIRS (11% of all ureteroscopies), all by the same surgeon. Patients were divided into two groups: group 1 (n = 42) consisted of patients undergoing RIRS as a first-line modality and group 2 (n = 51) of those having RIRS as secondline therapy. The indications for RIRS in group 1 were renal calculi with prior placement of a double-J stent (30%), renal + ureteral stone (25%), pushback of ureteral stone during ureteroscopy (22%), a radiolucent stone (8%), coagulopathy, and abnormal renal anatomy. In group 2, the patients were initially treated by SWL (92%) or percutaneous nephrolithotomy. The groups did not differ significantly in demographic characteristics, mean stone size (9.5 and 8.7 mm, respectively), or stone location (in both 60% in the lower pole). The variables analyzed were operating time, complications, length of hospitalization, and stone-free rate. RESULTS: The overall stone-free rate was 73%. However, the stone-free rate was significantly higher in group 1 than in group 2: 80% v 67%, respectively. A higher complication rate and longer hospitalization were noted in group 2, although the difference was not statistically significant. CONCLUSIONS: When RIRS is performed after failed SWL, it has a lower success rate and may be associated with a higher morbidity rate than if it is performed as first-line therapy. These results suggest that the success rate of RIRS may be influenced by the same negative factors that reduce SWL success. Therefore, if a patient fails SWL, careful consideration should be given to the best second-line therapy comparing RIRS with percutaneous stone removal.

Clinical implication of routine stone culture in percutaneous nephrolithotomy--a prospective study.

OBJECTIVES: To evaluate the correlation between preoperative urine culture (UC) and intraoperative stone culture (SC) and the impact of SC findings on clinical decisions. METHODS: UC and intraoperative fragmented SC were prospectively obtained in all patients undergoing percutaneous nephrolithotomy between January 2004 and March 2005. Patients with a positive UC received a full course of antibiotics before surgery. All postoperative systemic inflammatory response syndrome (SIRS) events were recorded, as was the antibiotic regimen used and any changes in antibiotic treatment secondary to the SC results. RESULTS: The study group consisted of 75 consecutive patients. Of these 75 patients, 33 (49%) had sterile UC and SC results. Both urine and renal stones were colonized in 17 patients (24%); in 6 of them, the UC and SC showed different pathogens. A colonized SC associated with a sterile UC was found in 19 patients (25%). The calculated UC sensitivity, specificity, and positive and negative predictive value for the detection of stone colonization was 30%, 94%, and 84% and 58%, respectively. Seventeen patients (22%) had postoperative SIRS. In 13 of them, a change in antibiotic treatment was made according to the SC findings. On univariate analysis, the incidence of SIRS was not related to the length of the operation, stone-free rate, or supracostal or infracostal access. The relative risk of SIRS when the SC was positive was 3.6. CONCLUSIONS: Renal calculi pathogens are one of the predisposing factors for infectious events; however, preoperative UC often fails to grow stone-colonizing bacteria. Intraoperative SC may be essential in directing the antibiotic regimen postoperatively and should be routinely used.

Evaluation of a progressive treatment program for erectile dysfunction in patients with diabetes mellitus.

The aim was to evaluate the effectiveness of a progressive program, starting with simple methods and, when not effective, moving to more complex methods, to treat erectile dysfunction (ED) in patients with diabetes mellitus. A total of 284 diabetic patients with ED entered into a 6-phase program starting with sildenafil citrate (Viagra). Those with contraindications, side effects, or negative response (erection insufficient for vaginal penetration) were switched to the vacuum erection device (VED), and then progressively (for failures) to intracavernous injection (ICI), sildenafil citrate+ICI, ICI+VED, and penile prosthesis. Patients were followed for 2 y. Of the 284 patients 276 patients were eligible for sildenafil citrate and 147 (53.3%) responded positively, but 25 (9.1%) patients stopped it soon due to adverse effects. Of 162 patients (129 nonresponders, eight noneligible for the sildenafil and 25 patients who dropped out due to adverse effects), treated with VED, 114 (70.4%) responded well, however, only 19 (11.7%) patients agreed to continue its use. Of the remaining 143 patients (nonresponders, noneligible for the previously mentioned treatments and patients who dropped out due to adverse effects), 103/143 (72%) responded to ICI, 27/40 (67.5%) to sildenafil+ICI, and 9/13 (69.2%) to ICI+VED. Four patients received a penile implant. At the 2 y follow-up, 81 of 284 patients who entered the study (28.5%) were still responding to sildenafil, seven (2.5%) to VED, 113 (39.8%) to ICI, 24 (8.5%) to sildenafil+ICI, two (0.7%) to ICI+VED; 15 (5.3%) had a penile implant. In all 17 (6%) patients reported spontaneous erections, 11 (3.9%) stopped the treatment due to family reasons and 14 (4.9%) failed the treatment. In conclusion, the progressive treatment program for ED seems to be very effective for diabetic patients, yielded a complete response for short-term and 91.2% rate of success at the end of 2 y follow-up.

Predictors of erectile function improvement in obstructive sleep apnea patients with long-term CPAP treatment.

The long-term effect of treatment with continuous positive airway pressure (CPAP) on erectile function was assessed in 60 patients with obstructive sleep apnea syndrome (OSAS). Severity of OSAS was evaluated by respiratory disturbance index (RDI) and minimal oxygen saturation (OxiMin). Severity of erectile dysfunction (ED) was assessed with the five question International Index of Erectile Function (IIEF-5) before and after CPAP treatment. Subjects were categorized into three groups on the basis of the change in IIEF-5 score: Group 1, no change (n=37); Group 2, improvement from 10+/-5.65 to 19.1+/-5.7, P<0.01 (n=12); Group 3, worsening from 19.9+/-4.7 to 9.5+/-7.8, P<0.01 (n=11). Group 2 had significantly higher RDI and lower OxiMin than the other groups, and was also more compliant and satisfied with CPAP. Change in IIEF-5 with CPAP treatment was negatively correlated (Pearson coefficient) with OxiMin (r=-0.374), and positively correlated with adherence to CPAP treatment (r=0.689). In conclusion, in selected patients, CPAP treatment for OSAS may by itself have a positive effect on erectile function by improving respiration during sleep. Predictors of erectile improvement include high RDI, low OxiMin, and CPAP compliance.

Urinary diversion in children with pelvic tumors.

PURPOSE: The aim of this study was to investigate children presenting with malignant pelvic tumors obstructing the upper urinary tract. METHODS: Seventeen children with upper urinary tract obstruction by a malignant tumor were reviewed. A nephrostomy tube or Double J (DJ) stent was inserted into each obstructed urinary system and removed after tumor shrinkage and/or hydronephrosis regression. RESULTS: There were 9 boys and 8 girls in the study; the mean age and median follow-up were 5.7 years and 2.5 years, respectively. The most common obstructing tumor was rhabdomyosarcoma. Twelve children underwent diversion by nephrostomy tubes and 3 by DJ stents; 2 patients underwent resection of the tumors with ureteroureterostomy. Complications after the insertion of the stents included febrile urinary tract infections (UTI) or pyelonephritis in 4 of the children with DJ stents. In the nephrostomy group, febrile UTI developed in 3 and the tube fell out in 1, and was blocked in another. Of the 17 children, 9 have no evidence of disease, 2 are currently under treatment, and 6 died of cancer. CONCLUSIONS: The prognosis of children with malignant pelvic tumor obstructing the upper urinary system justifies urgent and optimal upper tract diversion, enabling chemotherapy to be started immediately.

DCC protein expression in clear cell renal cell carcinoma.

OBJECTIVES: To investigate whether the expression of protein from the "deleted in colorectal cancer" (DCC) gene, which predicts a poor outcome for patients with colorectal carcinoma, can also serve as a prognostic factor in renal cell carcinoma (RCC). PATIENTS AND METHODS: The expression of DCC was evaluated immunohistochemically in 94 paraffin-embedded tumour samples from patients with stage T1, T2, and T3 clear cell RCC. The mean follow-up was 52.3 months. The endpoints of the study were recurrence of disease and death from disease. RESULTS: The under-expression of DCC protein was detected in 63% of patients who died from the disease and in 36% with no evidence of disease. DCC protein under-expression was detected in all patients with T1 tumours who died from the disease, in half the T2 tumours and in two-thirds of T3 tumours. CONCLUSION: DCC protein under-expression correlated with more aggressive tumour behaviour and a greater risk of death from RCC. However, a larger cohort of patients should be assessed before drawing definitive conclusions.

Abdominal compartment syndrome: urological aspects.

ACS is prevalent in various surgical conditions and in a large percentage of critically ill patients. Measuring the IAP is important in the early diagnosis of ACS and can be easily done by measuring the intravesical pressure. ACS adversely affects many organ systems; the pathogenesis of renal dysfunction is probably multifactorial, from a combination of reduced cardiac output, reduced GFR mediated by secretion of renin and angiotensin, aldosterone-mediated water reabsorption, increased renal parenchymal pressure and direct compression of the renal vein. Successful treatment requires a high index of suspicion, prompt recognition and early surgical abdominal decompression.

Detrusor resistive index evaluated by Doppler ultrasonography as a potential indicator of bladder outlet obstruction.

OBJECTIVES: To appraise detrusor blood flow by Doppler ultrasonography in men with suspected bladder outlet obstruction (BOO) to determine whether this imaging technique provides useful information for the assessment of BOO. Experimental studies have shown that BOO is associated with reduced blood flow to the detrusor. METHODS: Twenty-nine consecutive men with lower urinary tract symptoms were prospectively enrolled. A urodynamic pressure-flow study was performed by the urologist to determine BOO, and Doppler ultrasonography was subsequently performed by the radiologist. The physicians were unaware of the other's results. Scanning was performed on a filled and empty bladder. Arterial blood flow was measured at three distinct sites, the two lateral walls and the trigone, and the resistive index (RI) of each site was calculated (RI = (V(MAX) - V(MIN))/V(MAX)). For each patient, the arithmetic average of the three RIs was defined as the detrusor RI. The findings were compared between patients with and without evidence of BOO. A logistic regression model tested the predictive value of the RI. RESULTS: According to the pressure-flow study results, 22 (75%) and 7 (25%) of the 29 patients were diagnosed as having or not having BOO, respectively. A statistically significant difference was found between the detrusor RI in the obstructed versus nonobstructed patients in both full (P <0.001) and empty (P <0.03) bladder states (0.79 versus 0.68 and 0.74 versus 0.66, respectively). Our logistic regression model predicted BOO with an overall accuracy of 86%, positive predictive value of 95%, and negative predictive value of 57%. CONCLUSIONS: The RI of arterial blood flow in the detrusor measured by Doppler ultrasonography provides important predictive information for the presence of BOO. Additional studies are warranted to validate our results and explore the role of Doppler ultrasonography in the management paradigms of patients with suspected BOO.

Human DNA topoisomerase-IIalpha expression as a prognostic factor for transitional cell carcinoma of the urinary bladder.

OBJECTIVE: To investigate the immunohistochemical expression of topoisomerase II-alpha (TII-alpha, a nuclear enzyme, the expression of which increases rapidly at the end of the S to G2/M phase and declines when mitosis ends) in bladder urothelial neoplasms (transitional cell carcinoma), and its correlation with grade, stage and survival. PATIENTS AND METHODS: Histological sections from 57 urothelial neoplasms were stained immunohistochemically for TII-alpha expression; the percentage of positive cells in the area of greatest staining was recorded as the TII-alpha index. RESULTS: TII-alpha nuclear staining was positive in all the samples except one. The mean (sd) TII-alpha index was 10.7 (5.9) in urothelial neoplasms of low malignant potential (grade 1), 15.5 (5.0) in low-grade (grade 2) and 42.1 (13.4) in high-grade urothelial carcinoma (grade 3). The mean TII-alpha index was 10.7 (5.9), 26.3 (14.8) and 44 (19) in stages pTa, pT1 and pT2, respectively. The TII-alpha index was significant for predicting death from cancer, independently of the stage or grade of the disease (P = 0.019, hazard ratio 1.1). CONCLUSIONS: A higher TII-alpha index indicates a greater probability of recurrence of disease and lower overall survival. Therefore TII-alpha expression has prognostic value in bladder carcinoma.

Intracavernous injections for erectile dysfunction in patients with cardiovascular diseases and failure or contraindications for sildenafil citrate.

The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of erectile dysfunction in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option. The study population included 106 patients selected from 267 with cardiovascular disease. The intracavernous injection program consisted of three protocols of increasingly complex combinations of vasoactive drugs, papaverine, phentolamine, prostaglandin E1 and atropine sulfate. Patients who failed the first protocol were switched to the second, and those who failed the second were switched to the third. A positive response was defined as an erection sufficient for vaginal penetration. A positive response was achieved on protocol I in 61 of the 106 patients (57.5%); protocol II in 32 of the remaining 45 patients (71.1%); and protocol III in seven of the remaining 13 patients (53.8%); the total success rate was 94.3%. These 100 patients were included in the 1-year follow-up, and 90 reported successful coitus at the end of that period: 79 patients (87.8%) with intracavernous injection and 11 (12.2%) without injection. The remaining 10 patients (10%) dropped out of the program, seven (7.0%) for health or marital reasons and three (3.0%) because of treatment failure. We conclude that a progressive program of intracavernous injections of vasoactive drugs may be a good alternative for the treatment of erectile dysfunction in patients with cardiovascular disease.

Mycetoma of the renal pelvis caused by Fusarium species.

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.

Predicting the success of retrograde stenting for managing ureteral obstruction.

PURPOSE: Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. MATERIALS AND METHODS: Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. RESULTS: The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. CONCLUSIONS: Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.

Comparative evaluation of treatments for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy.

OBJECTIVE: To assess the effectiveness of a progressive local treatment protocol for erectile dysfunction (ED) in patients after undergoing radical retropubic prostatectomy (RRP) for prostate cancer. PATIENTS AND METHODS: The study included 85 patients (mean age 59.5 years, range 50--75) with ED after RRP. Treatment was offered in four progressive phases, with patients passing to the next phase only if they failed the previous one: in phase I patients used a vacuum erection device; in phase II, sildenafil; in phase III, intracorporal injection; and in phase IV, intracorporal injection plus the vacuum erection device. The patients were followed for 1 year. RESULTS: Of the 85 patients, 78 (92%) responded to the vacuum erection device (with an erection sufficient for vaginal penetration), but only 11 (14%) agreed to continue with it at home. Of the remaining 74 patients, 69 with no contraindications were given sildenafil and 14 (20%) had a positive response. Sixty patients were then treated with intracorporal injection and 51 (85%) had a positive response; four of the nine failures in phase III responded to intracorporal injection plus vacuum therapy. Five patients failed all four protocols. After 1 year of follow-up, 76 of the 80 patients were successfully continuing treatment at home; seven (9%) used the vacuum erection device, 11 (14%) sildenafil, 54 (71%) intracorporal injection and four (5%) intracorporal injection plus the vacuum erection device. CONCLUSION: Overall, this progressive treatment method gave a positive response in 80 of the 85 patients (94%). After 1 year of follow-up, 76 of the 80 patients (95%) continued to respond well. Of all the methods used, intracorporal injection was the most effective for ED after RRP.

The effect of cholinergic enhancement during filling cystometry: can edrophonium chloride be used as a provocative test for overactive bladder?

PURPOSE: Overactive bladder, a highly prevalent disorder, is suspected of having a low detection rate due to the lack of sensitive diagnostic tools. Recent studies imply the involvement of the cholinergic system in the pathophysiological mechanism underlying overactive bladder. We determined whether in vivo enhancement of cholinergic activity with edrophonium chloride, a potent cholinesterase inhibitor, would serve as a provocative maneuver to increase the sensitivity of filling cystometry. MATERIALS AND METHODS: A total of 27 patients underwent a multichannel video urodynamic evaluation, followed by filling cystometry with the intravenous administration of 10 mg. edrophonium chloride. The response to edrophonium was defined as a significant change in sensation and decreased bladder capacity, the induction or amplification of involuntary detrusor contractions, or significantly decreased detrusor compliance. Findings were compared in responders and nonresponders. RESULTS: We identified 11 responders and 16 nonresponders. A response was noted in 78% of the patients with the symptomatology of overactive bladder but in none with no specific complaints suggesting bladder overactivity. In 7 of the 12 responders (64%) baseline cystometry was interpreted as normal. In 6 of the 11 responders (54%) uninhibited urinary leakage was observed in response to edrophonium. There were no serious adverse reactions to the drug. CONCLUSIONS: This preliminary study implies that edrophonium may serve as a novel, practical and safe drug for provocative cystometry. By significantly increasing cystometry sensitivity the drug would facilitate the identification of the subset of patients with overactive bladder who are currently classified with sensory urgency.

Three-year outcome of a progressive treatment program for erectile dysfunction with intracavernous injections of vasoactive drugs.

OBJECTIVES: To perform a comparative evaluation and follow-up of patients with erectile dysfunction (ED) who were treated with intracavernous injection of vasoactive drugs, starting with simple drugs and advancing to complex combinations. METHODS: The study included 625 patients, 26 to 85 years old, with ED. Four intracavernous injection protocols were used: protocol 1, papaverine plus phentolamine; protocol 2, prostaglandin E(1); protocol 3, papaverine, phentolamine, and prostaglandin E(1); and protocol 4, atropine sulfate, papaverine, phentolamine, and prostaglandin E(1). A positive response was defined as an erection sufficient for penetration. Patients for whom the basic protocol failed were successively switched to the more advanced protocols until a positive response was achieved. RESULTS: A positive response was achieved by 415 (66.4%) of the 625 patients given protocol 1; 75 (36%) of the remaining 210 patients given protocol 2; 98 (72.6%) of the 135 patients given protocol 3; and 22 (59.5%) of 37 patients given protocol 4. All four protocols failed in only 15 patients (2. 4%). At the 3-year follow-up visit (n = 610), 349 had achieved coitus, 65 (10.6%) without an injection and 202 (33.1%) with an injection. Eighty-two patients sometimes performed coitus without an injection. Sixty-three patients (10.3%) abandoned the program because of marital or health problems; 198 asked to be switched to Viagra during the follow-up period, and 120 returned to the program. CONCLUSIONS: Overall, our progressive treatment yielded a high positive response rate (97.6%), with 57.2% achieving successful coitus on follow-up. The main advantage of the program is that it spares patients who are responsive earlier from using more complex, painful, and costly drugs.

Bladder neck involvement at radical prostatectomy: positive margins or advanced T4 disease?

OBJECTIVES: To assess the prognosis of patients with bladder neck (BN) involvement in radical prostatectomy specimens and compare it with patients with seminal vesicle invasion (SVI) presumed to have an inferior stage according to the TNM classification. METHODS: Two hundred eighty-six case files of consecutive radical prostatectomies were reviewed. The records of patients with pathologic BN involvement (pT4a) or SVI (pT3c) were thoroughly analyzed and compared. The mean and median follow-up periods were 30.8 and 35.5 months (range 9 to 40), respectively, for the patients with Stage pT4a and 40.8 and 44.1 months (range 8 to 86), respectively, for the patients with Stage pT3c. Particular attention was paid to the preoperative clinical and pathologic evaluation, the pathologic analysis of the prostatectomy specimen, and the postoperative follow-up data. Progression was defined as a prostate-specific antigen level of 0.2 ng/mL and rising. Adjuvant therapy was not initiated unless prostate-specific antigen failure had occurred. RESULTS: BN involvement was identified in 25 patients (8.7%) and SVI was found in 26 patients (9.1%). In 7 patients (2.4%), the BN was the only site of positive margins. Thirty-six percent of patients with BN involvement and 62% of patients with SVI demonstrated biochemical progression. Disease-free survival and metastasis-free survival rates were significantly better for the patients with Stage pT4a than for the patients with Stage pT3c at 24 and 36 months after surgery. Univariate analysis identified the prostate-specific antigen nadir to be the most significant predictor of prognosis. CONCLUSIONS: In this study, BN involvement in the surgical specimen carried a lower risk of progression than SVI. On the basis of our preliminary results and those in other studies, a conceivable downstaging of BN involvement in the TNM staging system should be considered. Possibly, additional modification of the TNM staging system should be contemplated on the basis of the results of pathologic analysis and prognosis. The significance of BN involvement and the role of adjuvant therapy in this group of patients need further evaluation.

Protein kinase C (PKC) isoenzymes immunohistochemistry in lymph node revealing solution-fixed, paraffin-embedded bladder tumors.

Protein kinase C (PKC) plays an important role in cellular differentiation and in the malignant process. In an earlier study, it was shown that the expression pattern of PKC isoenzymes is altered in some tumors compared to their corresponding normal tissue. In this study, we evaluated the pattern of PKC isoenzyme immunostaining in bladder transitional cell carcinoma (TCC) of different grades and stages and normal tissue. Twenty-seven TCC samples and six areas of normal bladder mucosa were stained with antibodies specific for the PKC isoenzymes: alpha, beta 1, beta 2, delta, and zeta. The sections were scored for intensity of staining, and the correlation with grade and stage of the tumors was computed. The PKC alpha and beta 2 immunostains were intense in normal urothelium and in all evaluated tumors. PKC beta 1 and delta stains were intense in normal and low-grade and -stage tumors and weak in high-grade and -stage tumors. The opposite trend was found for PKC zeta. PKC isoenzyme expression differs in invasive TCC compared to low-grade, low-stage TCC and normal urothelium. The value of these findings as a marker of tumor aggressiveness should be further assessed.