Conditional inactivation of the mouse von Hippel-Lindau tumor suppressor gene results in wide-spread hyperplastic, inflammatory and fibrotic lesions in the kidney.

Mutations of the tumor suppressor gene von Hippel-Lindau (VHL) can lead to benign and malignant tumors, including clear-cell renal cell carcinoma (ccRCC). To understand the progression of ccRCC, we generated a novel mouse Vhlh conditional knockout, using Hoxb7-driven Cre that is specific for the collecting ducts and a subset of distal tubules. These mice exhibited wide-spread epithelial disruption and interstitial inflammation as early as 2 months of age with high penetrance. Lesions are cystic, show severe fibrosis and display significant hyperplasia. An abundance of infiltrating macrophages and lymphocytes was detected. Interestingly, the Vhlh mutant lesions could be rescued when Hif-1α, but not Hif-2α, was also knocked out. In addition, administration of a JAK1/2 kinase inhibitor alleviated the Vhlh knockout phenotypes. Taken together, these results suggest that HIF-1α-dependent inflammation and fibrosis may be an early event in the development of ccRCC.

Role of the insulin/Tor signaling network in starvation-induced programmed cell death in Drosophila oogenesis.

Amino-acid starvation leads to an inhibition of cellular proliferation and the induction of programmed cell death (PCD) in the Drosophila ovary. Disruption of insulin signaling has been shown to inhibit the progression of oogenesis, but it is unclear whether this phenotype mimics starvation. Here, we investigate whether the insulin-mediated phosphoinositide kinase-3 pathway regulates PCD in mid oogenesis. We reasoned that under well-fed conditions, disruption of positive components of the insulin signaling pathway within the germline would mimic starvation and produce degenerating egg chambers. Surprisingly, mutants did not mimic starvation but instead produced many abnormal egg chambers in which the somatic follicle cells disappeared and the germline persisted. These abnormal egg chambers did not show an induction of caspases and lysosomes like that observed in wild-type (WT) degenerating egg chambers. Egg chambers from insulin signaling mutants were resistant to starvation-induced PCD, indicating that a complete block in insulin-signaling prevents the proper response to starvation. However, target of rapamycin (Tor) mutants did show a phenotype that mimicked WT starvation-induced PCD, indicating an insulin independent regulation of PCD via Tor signaling. These results suggest that inhibition of the insulin signaling pathway is not sufficient to regulate starvation-induced PCD in mid oogenesis. Furthermore, starvation-induced PCD is regulated by Tor signaling converging with the canonical insulin signaling pathway.

Adenocarcinoma of the testicular adnexa presenting with metastatic disease.

Primary epididymal adenocarcinoma is a rare malignancy with fewer than 30 documented cases. We report a case of a 57-year-old patient with a paratesticular mass in the presence of retroperitoneal metastatic disease. Histology confirmed the presence of primary paratesticular adenocarcinoma. In this report we review the index case, the pertinent literature and discuss adjuvant therapy.

Mechanical reliability, surgical complications, and patient and partner satisfaction of the modern three-piece inflatable penile prosthesis.

OBJECTIVES: The modern three-piece inflatable penile prosthesis (IPP) has undergone multiple revisions since its introduction in 1973. We reviewed devices placed since the last major revision by American Medical Systems (AMS) in 1987. METHODS: A retrospective chart review was refined with data from an independent patient and partner survey. RESULTS: Two hundred twelve consecutive penile prosthetic devices placed by a single surgeon over an 8-year period are reviewed. One hundred sixty-nine of the devices were three-piece inflatables with 146 being primary implants. The average device has been in place 36.5 months (range 9 to 102). The infection rate in 146 primary three-piece devices was 2.1%. The infection rate in 46 secondary implants or revisions was 6.5%, excluding seven salvage attempts. Mechanical failure in 122 primary AMS devices placed was 4.1%. Mechanical failure in 24 Mentor devices was 4.2% if one discounts connector failures that were revised in 1990. A surgical complication and revision rate of 1.4% was noted in the 146 primary implants. An independent telephone survey achieved a 57% and 24% response rate in patients and partners with three-piece devices placed. In the group of 86 patients with a primary three-piece device placed and complete follow-up, the probability of having a normally functioning device placed in a single operative procedure was 90.6% at 3 years. On a 1 to 10 scale looking at all primary devices, secondary devices, revisions, and infections, the average and median satisfaction rate was as follows: 8.2, 8.5; 8.4, 9.0; 7.7, 7.75 for the Ultrex patients, CX 700 and Mentor patients, and all partners, respectively. CONCLUSIONS: The modern three-piece IPP is an excellent surgical option offering a very safe, reliable return to sexual activity for our patients.

Pubovaginal slings using fascia lata for the treatment of intrinsic sphincter deficiency.

PURPOSE: Various materials and techniques have been used to construct a pubovaginal sling. We believe that fascia lata has several advantages and report our experience. MATERIALS AND METHODS: A total of 32 female patients with urodynamically proved intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata. An unscarred fascial strip 24 to 28 x 2 cm. was attached to itself over a 3 to 4 cm. bridge of abdominal wall fascia. Results were tabulated by chart review and an independent patient survey. RESULTS: Chart review revealed that 28 of 32 patients (87%) required no pads, and 3 improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of 30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small pads per day. Of the patients 80% would undergo the procedure again. CONCLUSIONS: Excellent results can be obtained with fascia lata for the treatment of intrinsic sphincter deficiency. A long, wide strip of fascia attached to itself allows for precise tensioning and good urethral closure, and minimizes the risk of obstruction.

Capillary gel electrophoresis separation of high-mannose type oligosaccharides derivatized by 1-aminopyrene-3,6,8-trisulfonic acid.

In this paper we report the capillary gel electrophoresis separation of 1-aminopyrene-3,6,8-trisulfonic acid (APTS) labeled oligosaccharides, released enzymatically from bovine pancreatic ribonuclease B. The released and labeled high-mannose structures were identified by spiking the separated peaks with the appropriate commercially available individual oligosaccharides. Baseline separation of the three positional isomers of the mannose-7 and mannose-8 oligosaccharides was attained. Comparison of the electrophoretic mobilities of the high-mannose type branched carbohydrates to the linear molecules of maltooligosaccharides (glucose oligomers) have been shown using different gel concentrations in the running buffer system. We observed that increasing gel concentration in the running buffer causes an increase in the relative mobility values of the high-mannose type carbohydrate molecules compared to the linear glucose oligomers. Analysis of our data indicated that this increase in relative migration time was not due to sieving, but seemed to be related to the mannose content and hydrodynamic volume of the branched glycans as well as to the viscosity of the separation medium.

Timing of penile color flow duplex ultrasonography using a triple drug mixture.

Duplex ultrasonography is an accepted method to assess noninvasively arterial inflow to the penis. Optimal pharmacological agents as well as timing of the scan and stimulation during the scan continue to be debated. In an effort to achieve a more complete smooth muscle relaxation and capture what we perceived was a wide variation in interval to maximum arterial velocity, we revised our duplex protocol in January 1991. We report on 280 consecutive patients evaluated in this manner. Patients received 0.25 or 0.5 cc of a triple drug mixture containing 22.5 mg./cc papaverine, 0.83 mg./cc phentolamine and 8.33 micrograms/cc prostaglandin E1. Scans were performed at 0, 5, 15 and 30 minutes after injection in all patients. Any patient not having a full erection at 15 minutes performed private self-stimulation while in the standing position for at least 5 minutes before the 30-minute scan. If we conservatively define normal arterial inflow as a peak Doppler velocity of 25 cm. per second or greater in the best artery, only 35% of our patients achieved this velocity at 5 minutes. Of the remainder 26% and 22% did not reach normal velocity values until 15 and 30 minutes, respectively, after the injection. By delaying initial measurements of velocity until 5 minutes, could the highest inflow velocity be missed and patients diagnosed incorrectly? The group at risk would be those who had good tumescence at 5 minutes and who had presumably already decreased the inflow velocities. Of the 280 patients 74 (26%) had greater than 10% tumescence at 5 minutes. Only 6 of these 74 patients did not reach velocities of 25 cm. per second or more in the best artery at some time during their study. In conclusion, our study clearly supports delaying the initial scan until 5 minutes, since only 6 of our 280 patients (2.1%) may have been incorrectly diagnosed. The study also strongly argues for additional scans until 30 minutes and self-stimulation when necessary.

Correlation of the cystoscopic appearance and functional integrity of the female urethral sphincteric mechanism.

OBJECTIVES: Urologists in the past, and many today, rely on the cystoscopic appearance of the female urethra as a guide to its functional integrity. To assess the accuracy of this approach better, we compared the cystoscopic appearance of the bladder neck and proximal urethra to the functional integrity of this mechanism during videourodynamic studies. METHODS: One hundred consecutive videourodynamic studies were reviewed on female patients with more complex types of urinary incontinence. Reports of their cystoscopic examinations were reviewed and results compared. RESULTS: Significant dysfunction of the intrinsic mechanism was noted in 36% of the patients (26% moderate dysfunction and 10% severe dysfunction) on video studies. Cystoscopy underestimated these deficits 74% and 44% of the time, respectively, in the moderate and severe dysfunction groups. CONCLUSIONS: We conclude that the cystoscopic appearance of the bladder neck proximal urethra cannot predict the functional integrity of this mechanism.

Experience with triple-drug therapy in a pharmacological erection program.

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Surgical management of traumatic posterior urethral strictures in children.

We review our recent experience with the treatment of traumatic strictures of the posterior urethra in children. Five males, ages six to seventeen years with dense posterior urethral strictures, have required open reconstructive procedures. Four patients had injury secondary to pelvic fractures, and 1 patient had an iatrogenic injury from surgery for imperforate anus. Two patients were repaired perineally, 2 with a combination retropubic-perineal approach, and 1 patient required a transpubic approach. Excision and direct anastomosis was achieved in 3 patients, and a foreskin interposition tube graft was used in 2 patients. Excellent results were achieved with return of urethral voiding and preservation of continence in all patients. Complications were seen in 3 patients. One secondary internal urethrotomy was required. Erectile capability was preserved in all patients who were potent before surgery. Posterior urethral strictures in children can be successfully managed with a variety of surgical approaches. This experience demonstrates that the surgical procedure must be individualized depending on the anatomy of the injury.

A transportable, remote sensing, infrared air-monitoring system.

A transportable, remote sensing instrument has been built that is capable of performing real-time quantitative analysis of gas and vapor contaminants of workplace air. The emphasis in this system is on simplicity and sensitivity for use over pathlengths of up to 40 m. A method was developed to overcome the effect of nonanalyte species present in the background spectrum on the quantitation of analytes in the sample spectrum. In addition, results demonstrated that instrument response was proportional to the beam pathlength under homogeneous concentration conditions. The application of software capable of qualitative analysis was also demonstrated.

Primary adenocarcinoma of bladder.

Between April 1983 and December 1987, we have treated and followed 16 patients at the University of Southern California for adenocarcinoma of the bladder. In 10 patients, the cancer originated from a nonurachal source; all underwent radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion. The other 6 patients had an apparent urachal origin of their cancer. Half of these patients were treated with radical cystectomy and urinary diversion and half were treated initially with segmental cystectomy. Presenting characteristics (age, sex ratio, and symptoms) were similar for both groups. Three-year adjusted acturial tumor-free survival rates for the two groups were 48 percent and 31 percent, respectively. We advocate an aggressive approach of radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion for all invasive adenocarcinoma of the bladder, regardless of location.

Pulsed dye laser fragmentation of ureteral calculi: a review of the first 50 cases performed at Virginia Mason Medical Center.

During the preceding 2 1/2 years 50 patients have undergone laser fragmentation of ureteral calculi at our medical center. Of these 50 patients 48 (96%) became free of stones without the need for an open operation: 44 (88%) were managed in 1 setting and 4 required adjunctive extracorporeal shock wave or ultrasonic lithotripsy, or a repeat session with the laser. Two patients (4%) eventually required an open operation: 1 required ureterolithotomy for a large impacted stone overlying the bony pelvis after a ureteroscope could not be advanced to this level and 1 had a good initial result with the laser but a persistent ureteral stricture developed and he required ureteroureterostomy 4 months later. Both open procedures were necessitated by mid ureteral stones, and the ureteral stricture was believed to be related to ureteroscopy and the impacted nature of the stone, rather than any damage by the laser probe.

Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival.

In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.

4-O-acetyl-N-acetylneuraminic acid in the N-linked carbohydrate structures of equine and guinea pig alpha 2-macroglobulins, potent inhibitors of influenza virus infection.

To investigate the molecular basis of the differential ability of human, equine, and guinea pig alpha 2-macroglobulins to inhibit hemagglutination and infectivity of a human influenza virus, A/Memphis/102/72 (H3N2), the structures of oligosaccharides released from the three glycoproteins by hydrazinolysis were analyzed comparatively. Approximately seven to eight sugar chains were released from each subunit of two potent inhibitors (equine and guinea pig alpha 2-macroglobulins) and a weak inhibitor (human alpha 2-macroglobulin). More than 70% of the oligosaccharides contained sialic acids in all three cases. Structural analysis of these sialo-oligosaccharides revealed that all of the three glycoproteins contain biantennary oligosaccharides with one and two sialic acids as major sugar chains (70-80% of total sugar chains). Four percent of the biantennary oligosaccharides from equine sample, 10% of those from guinea pig, and 24% of those from human contain a fucosylated trimannosyl core. No triantennary oligosaccharide was detected in equine alpha 2-macroglobulin. However, human and guinea pig alpha 2-macroglobulins contain both fucosylated and nonfucosylated triantennary oligosaccharides. All sialic acid residues occur as the Sia alpha 2----6Gal group. The one unique feature of the carbohydrate groups of equine and guinea pig alpha 2-macroglobulins was the presence of 4-O-Ac-Neu5Ac as 30-50% of the total sialic acids, while human alpha 2-macroglobulin contained only Neu 5Ac. However, 4-O-Ac-Neu5Ac is not responsible for the potent inhibition of influenza virus infection and hemagglutination as will be described in the accompanying paper.

Basis for the potent inhibition of influenza virus infection by equine and guinea pig alpha 2-macroglobulin.

The unique properties of equine and guinea pig sera which make them potent inhibitors of influenza virus adsorption and infection have been investigated. The inhibitory activities of both sera are found to reside entirely in their respective alpha 2-macroglobulins, high molecular weight glycoproteins which bind to viral hemagglutinins via sialic acids of their N-linked carbohydrate groups. Structure analysis has shown that both proteins contain 4-O-acetyl-N-acetylneuraminic acid (4-O-Ac-NeuAc) (Hanaoka, K., Pritchett, T. J., Takasaki, S., Kochibe, N., Sabesan, S., Paulson, J.C., and Kobata, A. (1989) J. Biol. Chem. 264, 9842-9849). These 4-O-acetylated sialic acids have been found in few species, making their coincidence with high inhibitory potency in equine and guinea pig alpha 2-macroglobulin striking. However, 4-O-Ac-NeuAc does not appear to increase the avidity of interaction with influenza virus since isolated oligosaccharides of equine alpha 2-macroglobulin are no more potent inhibitors of adsorption than isolated oligosaccharides of human alpha 2-macroglobulin, which is a relatively poor inhibitor and contains only NeuAc. Since 4-O-Ac-NeuAc is resistant to cleavage by viral sialidase it may serve to protect the inhibitor from inactivation. These and supporting results suggest that the key property of equine and guinea pig alpha 2-macroglobulin which make them high potency inhibitors is a spatial arrangement of sialic acid containing oligosaccharide groups which allows optimal interaction with multiple hemagglutinins. The implications of these results for the design of low molecular weight inhibitors of influenza virus infection are discussed.

Mesenchymal-epithelial interactions between normal and transformed human bladder cells.

Epithelial cells obtained from normal human urothelium, a cell line derived from a papillary bladder carcinoma, and cells derived from an invasive carcinoma were grown in a serum-free fully defined medium. The interaction between these cell types and normal bladder stromal cells obtained by explant culture in serum were investigated in mixed cultures. These studies showed that normal urothelium was not responsive to the growth factors produced by cultured bladder fibroblasts and the cells did not grow at increased rates in association with living fibroblast layers. Cells derived from a papillary human bladder carcinoma cell line also did not associate well with fibroblast layers or show marked stimulation of growth by preformed layers of fibroblast cells. On the other hand, cells of the EJ carcinoma line, originally derived from a patient with highly invasive disease, easily infiltrated fibroblast layers and were strongly stimulated to grow by the presence of the stromal cells. This model system might therefore be used to determine key elements associated with malignant progression in human bladder carcinoma.