Electrovaporization using a rollerball electrode for flat or small papillary tumors of the bladder: basic study in dogs.

PURPOSE: We investigated electrovaporization of flat bladder tumors with a rollerball electrode 3 mm in diameter as a substitute for conventional transurethral resection with a cutting loop. MATERIALS AND METHODS: A basic study of the action of electrovaporization was performed in dogs. The bladder was exposed under general anesthesia in three mongrel dogs. The rollerball electrode was attached to the resectoscope and inserted into the bladder via a cystostomy. Then electrovaporization was performed with a low or high pressure on the electrode tip and a speed of about 1 cm/sec using a Force 40 generator. The cutting mode power was set at 100 W or 200 W. The effects of the rollerball and cutting loop electrodes were also examined in the coagulation mode (45 W) as a control. RESULTS: A deeper vaporization zone was obtained by using a power of 200 W in the cutting mode than with a power of 100 W, and a desiccation zone was found below the vaporization zone (VZ). The VZ was thicker with a high contact pressure than with a low contact pressure. This VZ was deeper than the tissue defect and heat-affected zone obtained using a rollerball electrode or cutting loop electrode in the 45 W coagulation mode. CONCLUSION: Although caution is required because the VZ can become too deep with excessive pressure, the rollerball electrode seems to be safer and more useful than the cutting loop electrode for resection of flat or small papillary bladder tumors.

Cytokines accumulated in acquired renal cysts in long-term hemodialysis patients.

BACKGROUND: Cytokines play a pivotal role in growth, differentiation, and apoptosis. In this study, we measured cytokine content in the renal cyst fluid of patients with acquired cystic disease of the kidney (ACDK) in order to elucidate the possibility that cytokines are related to the development of ACDK. PATIENTS AND METHODS: All or some of 15 cytokines, IL-1a, -1b, -2, -4, -5, -6, -8, -10, IFN-alpha, -gamma, G-, M-, GM-CSF, TNF-alpha, and vascular endothelial growth factor (VEGF) were analyzed in cyst fluid and serum of 12 patients on hemodialysis (HD) including 8 with ACDK and 8 with normally functioning kidneys by sandwich enzyme-linked immunosorbent assay. RESULTS: Out of these cytokines, only IL-6, -8, M-CSF, and VEGF were detected in the cyst fluid of patients with ACDK. Moreover, IL-6, -8, and VEGF showed significantly higher concentrations in the cyst fluid than in the blood (194.9 +/- 90.9 vs. 0.0 +/- 0.0 pg/ml, 2,377. 5 +/- 602.9 vs. 0.0 +/- 0.0 pg/ml, 5,167.8 +/- 1,316.9 vs. 41.1 +/- 14.7 pg/ml, respectively), while M-CSF showed comparable concentrations in the cyst fluid with those in the blood (3,519.4 +/- 730.0 vs. 3,250.3 +/- 319.1 pg/ml, p = 0.69). Additionally, IL-6, -8, and VEGF accumulated more abundantly in the cyst fluid of patients with ACDK than in that of patients with other cystic nephropathies including ADPKD patients on HD (194.9 +/- 90.0 vs. 4.6 +/- 3.2 pg/ml, 2,377.5 +/- 602.9 vs. 76.8 +/- 46.5 pg/ml, 5,167.8 +/- 1,316.9 vs. 131.1 +/- 63.1 pg/ml, respectively). However, there was no significant correlation between the intracystic concentrations of these cytokines and the corresponding cyst diameters. CONCLUSION: These results showed that in ACDK patients a local environment exists in which production or accumulation of certain cytokines is selectively enhanced compared with patients with other cystic nephropathies. They imply that these cytokines are closely related to pathogenesis particular to ACDK.

[Renal angiomyolipoma with a tumor thrombus extending into the right atrium--a case report].

We present a case of spontaneous rupture of renal angiomyolipoma with a tumor thrombus extending from the right renal vein and inferior vena cava to the right atrium. A 41-year-old woman, previously in good health, was referred to our hospital with right flank pain. Computed tomography showed fat densities in both tumor and thrombus. Other imaging examinations also demonstrated a large right renal mass (18 cm in diameter), a long tumor thrombus (13 cm in length) and a small left renal tumor (1.5 cm in diameter). Right nephrectomy and en-bloc removal of the intra caval and intracardiac tumor thrombus were performed on cardiopulmonary bypass. It was pathologically diagnosed as an angiomyolipoma without tuberous sclerosis. At present, three years after surgery the patient is doing well, showing neither metastasis nor increase of the left renal angiomyolipoma. To our knowledge, our case seems to be the 3rd case report of renal angiomyolipoma with a tumor thrombus extending to the right atrium. We conclude that renal angiomyolipoma even with an intra cardiac tumor thrombus can be resected safely and successfully.

Ethanol injection therapy of the prostate for benign prostatic hyperplasia: preliminary report on application of a new technique.

PURPOSE: We evaluate the efficacy of a new technique of minimally invasive treatment for benign prostatic hyperplasia involving direct injection of dehydrated ethanol. MATERIALS AND METHODS: Dehydrated ethanol was injected transurethrally with lumbar or sacral and urethral anesthesia in 10 patients with prostatic hyperplasia. Endoscopic injection was performed at 4 to 8 sites in the prostate and 3.5 to 12.0 ml. ethanol were used. RESULTS: There were no intraoperative complications but postoperative urinary retention occurred transiently in all patients which required catheterization for a mean of 8.8 days. Mean symptom score plus or minus standard deviation was 12.2+/-5.8 at 3 months postoperatively, which was significantly improved from 23.1+/-7.0 preoperatively (p<0.01). Mean quality of life score also improved significantly from 5.1+/-0.6 preoperatively to 3.2+/-1.5 at 3 months postoperatively (p<0.01), mean peak urinary flow rate increased from 8.0+/-2.2 (9 patients) to 13.1+/-3.6 ml. per second (p<0.05) and mean residual urine volume decreased from 129.1+/-55.3 (9 patients) to 49.3+/-34.7 ml. (p<0.05). There was no significant change in prostate volume. Acute epididymitis and chronic prostatitis occurred in 1 patient each. CONCLUSIONS: This technique can be performed as an outpatient procedure and appears to be safe and cost-effective. Retrograde ejaculation can be avoided.

Analysis of prognostic factors related to primary superficial bladder cancer tumor recurrence in prophylactic intravesical epirubicin therapy.

PURPOSE: The aims of the present study were to examine the effects of intravesical instillation of epirubicin on tumor recurrence and to identify tumors that are at a high risk of recurrence. METHODS: Forty-five patients with primary superficial bladder cancer were treated with prophylactic intravesical epirubicin following transurethral resection of the bladder tumor (TUR-BT). Epirubicin (20 mg) was administered intravesically every second week for 4 months and then once a month or every 2 weeks for next 8 months. Patients were analyzed with respect to prognostic factors related to tumor recurrence. RESULTS: The overall recurrence-free rate, calculated using the Kaplan-Meier method, was 76.1 and 52.3% at 2 and 5 years after operation, respectively. These results were better than those reported for patients treated with TUR-BT alone. A univariate analysis demonstrated that high-grade, T1, sessile, large (> or = 2 cm) and multiple tumors were a significantly high risk for recurrence. A multivariate analysis performed by using the Cox proportional hazard model with stepwise selection showed that morphologic features (pedunculated or sessile) were the most prognostic factors for recurrence. This was followed by age and tumor size. The remaining four factors were not found to contribute significantly to recurrence. CONCLUSIONS: Epirubicin appears to be effective in preventing the recurrence of superficial bladder cancer. Morphologic features, patient age and size of the tumor were considered independent risk factors. The risk of recurrence for each tumor should be taken into consideration when the intravesical adjuvant therapy protocol is being selected.

[A case of sudden death by pulmonary embolism after angio-embolization of renal cell carcinoma extending into the inferior vena cava].

We report a 42-year-old renal-transplanted man with renal cell carcinoma (RCC) in the native kidney. He was admitted with gross hematuria and general fatigue as the chief complaint. Ultrasonography, computed tomography, magnetic resonance imaging and angiography, revealed a right RCC with intracaval tumor thrombus extending to the level of hepatic veins. Since selective renal angiography demonstrated a hypervascular tumor, angio-embolization was performed preoperatively. However, he died suddenly the next morning despite aggressive resuscitative measures. Autopsy revealed bilateral pulmonary arteries obstructed by the tumor thrombus. Renal arterial embolization is useful for advanced RCC, and side effects are mostly transient and well tolerated by the patients. However, indications for angio-embolization should be selected carefully with such a fatal case as this patient kept in mind.

Detection and quantification of soluble intercellular adhesion molecule-1 (sICAM-1) in the serum and urine of patients with bladder cancer.

BACKGROUND: A possible role for intercellular adhesion molecules in tumor progression and metastasis has been strongly suggested. To investigate the effect of soluble intercellular adhesion molecule-1 (sICAM-1) on bladder cancer, sICAM-1 serum and urinary concentrations were measured in patients with superficial or invasive bladder cancer and in patients with prostatic hypertrophy. METHODS: Serum and urine samples were obtained from 26 patients with transitional cell carcinoma of the bladder (mean age, 66.8 years) and 14 patients with benign prostatic hypertrophy (BPH; mean age, 70.5 years). Fifteen healthy volunteers served as control patients. Samples were collected before surgery and 5 days after surgery. The serum and urinary slCAM-1 levels were measured by an ELISA. RESULTS: The preoperative serum concentration of sICAM-1 was significantly higher in patients with invasive bladder cancer (351.8+/-158.0 ng/mL) than in the healthy controls (233.1+/-96.1 ng/mL; P< 0.05) or BPH patients (224.7+/-80.5 ng/mL; P< 0.05). In addition, serum sICAM-1 levels were significantly higher in patients with tumors greater than 3 cm in size (412.7+/-147.6 ng/mL) than in patients with smaller tumors (246.6+/-101.2 ng/mL; P<0.05). Urinary sICAM-1 levels in patients with invasive bladder cancer were also significantly higher than in the patients with superficial cancer prior to surgery. CONCLUSION: Our results suggested that sICAM-1 may play an important role in the progression of bladder cancer, and that elevated serum sICAM-1 levels may be related to tumor size.

[Study on urinary levels of interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha in patients with renal cell carcinoma].

We examined the preoperative and postoperative, urinary levels of the cytokines, interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) in 14 patients with renal cell carcinoma (RCC), and 9 patients who underwent nephrectomy as donors (controls). Although urinary IL-1 beta was measurable in every subject, both IL-6 and TNF-alpha were undetectable in 12 of the 14 patients. None of the urinary cytokines showed levels significantly different from the controls preoperatively. Urinary levels of IL-1 beta showed no correlation with clinical stage or histological grade. Only urinary IL-1 beta was significantly elevated after nephrectomy, when compared with the controls (P < 0.05). However, urinary IL-1 beta showed no correlation with operative blood loss or postoperative infection. These findings suggest that measurement of urinary cytokines is not useful for diagnosis or monitoring of therapy in RCC patients.

[A case of retroperitoneal pseudotumor (xanthogranuloma)].

A 57-year-old male patient was admitted to our hospital for left flank pain and a slight increase in serum creatinine. He had left hydronephrosis and extrinsic stenosis of left lower ureter shown by intravenous and retrograde pyelography. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a mass along the bilateral lower ureters, the left side of which was larger (5 x 3 x 4 cm). After surgical exploration and biopsy of the tumor the patient was diagnosed as having xanthogranulomatous inflammatory pseudotumor. No malignant findings were observed. Tumor size spontaneously decreased to 20% of the original size at 2 weeks after laparotomy. The patient underwent ureterolysis because of prolonged left hydronephrosis. Approximately 3 years after development of disease, hydronephrosis has improved and the pelvic tumor has almost diminished.

[Mitrofanoff procedure with bladder-sparing urethrectomy in female urethral carcinoma: report of a case].

A 60-year-old woman with urethral carcinoma treated by bladder sparing surgery is reported. A tumor of Grabstald's clinical stage C2 arose from the anterior urethra infiltrated into the distal wall of vagina with invasion of vaginal mucosa. Pathological findings revealed poorly differentiated squamous cell carcinoma. She underwent a wide local excision of the urethra and the anterior vaginal wall with preserving the bladder. An appendicovesicostomy (Mitrofanoff procedure was selected for the urinary diversion. This technique provided a small stoma, appropriate continence, normal bladder sensation and preseving renal function. Bladder-sparing urethrectomy could be an alternative treatment for female urethral tumors.

[Utility of prostate specific antigen (PSA) density in detecting prostate cancer in men showing gray zone serum PSA levels].

The efficacy of prostate specific antigen density (PSAD) in diagnosing prostate cancer was assessed in 98 patients with serum prostate specific antigen (PSA) levels between 2 and 10 ng/ml who had a pathological diagnosis made by prostate biopsy or transurethral resection of the prostate. Of the 98 patients, 22 (22%) had prostate cancer. The PSA (based on a cut-off value of 4.5 ng/ml) had a sensitivity and positive predictive value (PPV) of 82% and 38%, respectively, for diagnosing prostate cancer, while the results for PSAD (based on a cut-off value of 0.13) were 91% and 61%. The PSAD was more efficient than the PSA levels and was also superior to digital rectal examination (DRE) combined with transrectal ultrasonography (TRUS), for which the sensitivity and PPV were 73% and 39%, respectively. Six (11%) out of 57 patients who were normal on DRE and TRUS had prostate cancer. In these 57 patients, the PSA (cut-off value: 4.5 ng/ml) had a sensitivity of 50% and PPV while the values for PSAD (cut-off value: 0.13) were 83% and 36% respectively. The PSAD could effectively detect even impalpable prostate cancer not visible on TRUS.

[A case of xanthogranuloma of the urinary bladder].

A case of xanthogranuloma of the urinary bladder is reported. A 68-year-old man was referred to our hospital for the evaluation of microscopic hematuria. At that time, he did not have an abdominal tumor and ultrasonography showed no abnormality of the kidneys and the bladder wall. Two months later, he was admitted with the chief complaints of perineal discomfort and non tender fist size mass was palpable in the lower abdomen. Ultrasonography, computed tomographic scan and magnetic resonance imaging MRI demonstrated a supravesical mass which was strongly suspected as urachal tumor. Total cystectomy with urachal resection was performed. The histological diagnosis was xanthogranuloma. The patient has been in good health without recurrence, 4 years after surgery. We discuss xanthogranuloma of the urinary bladder in the literature.

[A clinico-pathological study of renal cell carcinoma with a diameter of less than 5 cm].

To examine the indication of nephron sparing operations, we searched 31 nephrectomized kidneys with renal cell carcinoma for small associated lesions in the normal-appearing portion of these kidneys. The diameter of the predominant tumors was between 15 and 50 mm. The kidneys were serially sectioned at 5-mm intervals, and all sections were examined microscopically. Two of the 31 kidneys had a small renal cell carcinoma, and four had a small adenoma in the normal-appearing portion. We recommend that the nephron-sparing operation should be is performed limitedly and that radical nephrectomy is yet a standard operation in the presence of a normal contralateral kidney.

[Flow cytometric DNA analysis on renal cell carcinoma--a study of 116 cases on fresh surgical specimens].

DNA ploidy was investigated using flow cytometry on fresh surgical specimens from 116 cases with renal cell carcinoma. DNA diploid tumor was observed in 39 cases (33.6%) and aneuploid in 77 cases (66.4%). DNA aneuploid group was further classified into 3 subgroups by DNA index (D.I.); near-diploid group (D.I.: 0.8-1.2, 21.6%), near-tetraploid group (D.I.: 1.8-2.2, 12.9%) and other aneuploid group (31.9%). DNA ploidy pattern correlated with clinical stages and histological grading, indicating significantly a higher incidence of DNA diploid in cases in stage I and grade 1. DNA clonal heterogeneity was observed in 48.1%, and homogeneously diploid was in 28.6% of 77 cases who were analyzed more than 2 specimens. Incidences of DNA heterogeneity and homogeneous diploid correlated with the number of analyzed specimens and our results showed that more than 4 specimens were necessary to diagnose the DNA ploidy patterns. The near-tetraploid group was shown to have an extremely poor prognosis compared with the diploid group and the other aneuploid group. There were no significant difference between the diploid group and the aneuploid group in terms of the early prognosis, however, the incidence of disease recurrence was significantly higher in the aneuploid group. Our results demonstrated that DNA ploidy was an useful prognostic factor in the evaluation of patients with renal cell carcinoma.

A phase II study of prophylactic intravesical chemotherapy with epirubicin in the treatment of superficial bladder cancer. Tokyo Women's Medical College Bladder Cancer Collaborating Group.

Intravesical instillation of epirubicin was carried out to investigate the efficacy of this treatment in preventing postoperative recurrence of superficial bladder cancer. The subjects were 100 patients who had been treated with transurethral resection (TUR) for superficial transitional-cell carcinoma of the bladder (classified as primary or recurrent superficial bladder cancer of pathological stage Tis, Ta, or T1 and histological grade G1, G2, or G3) at Tokyo Women's Medical College Hospital and its affiliated hospitals during the 2-year period ranging from April of 1990 through March of 1992. A solution of epirubicin was prepared by dissolving 20 mg in 30 ml physiological saline, and this was instilled into the bladder a total of 17 times during 1 year: once immediately after TUR, once every 2 weeks for the next 4 months, and then once per month for the following 8 months. Thereafter, the course of each patient was followed by performing urinary cytodiagnosis once each month and cystoscopy once every 3 months. Of the 100 patients, 83 were evaluable. The mean duration of follow-up was 461 +/- 222 days, and the recurrence rate was 30.1% (25/83 cases). The recurrence rate determined for primary cases was 19.7%, whereas that recorded for recurrent cases was 61.9%. Adverse effects occurred in 9.3% (9/97) of the patients, but these side effects were mild in severity and the instillation regimen did not have to be discontinued in any of the patients. Analysis of the risk factors for recurrence revealed significantly higher recurrence in the recurrent-patient group and the multiple-tumor group. On the basis of these findings, the authors surmised that when given in an intravesical instillation regimen, epirubicin causes few adverse effects, and its efficacy in the prophylaxis of recurrence of superficial bladder cancer is equivalent to that thus for reported for other drugs. At present, the authors are carrying out a controlled clinical study on epirubicin that takes into account the risk factors for recurrence of superficial bladder cancer.

Bellini's duct tumor associated with end stage renal disease: a case diagnosed by lectin immunohistochemistry.

We report a hemodialysis patient with an atypical renal neoplasm. The tumor cells were arranged in a two-cell pattern similar to that in the usual excretory duct systems. The histochemical staining pattern with some lectins and monoclonal antibody corresponded to the distal nephrons of normal kidney tissue. These findings enabled us to diagnose this patient as having so-called Bellini's duct tumor.

[The surgical management of renal cell carcinoma involving the right atrium].

Between January 1985 and November 1992, 12 patients with renal cell carcinoma involving the inferior vena cava were evaluated and treated at this hospital. In 4 of the 12 patients (33%), the tumors extended into the right atrium. These 4 patients underwent radical nephrectomy with tumor thrombus extraction. Of the 4 patients one had metastases to regional lymph nodes, but no patient had distant metastases. We used a cardiopulmonary bypass and a right atriotomy in all patients for the removal of thrombus under direct vision. We also performed in the intra-operative transesophageal ultrasonography for monitoring of intra-atrial thrombus. The average blood loss during operation was 10,430 ml. One of these patients died in the postoperative period and the other patient died from inferior vena caval emboli without long term sequelae. However, the remaining 2 patients of this group are free of disease, with a mean follow-up of 21 months. Although the numbers are small, these results suggest that patients with intra-atrial tumor thrombus had a worse prognosis than those with other types of vena cava tumor thrombus. One reason for this poor prognosis is due to the complicated surgical management and we believe that a complete removal of tumor thrombus and a complete vascular control are key points of this operation.

[Evaluation of complicated renal cyst: a comparison of CT and MR imaging].

We report 12 cases of renal cystic lesions that could not be diagnosed preoperatively. Sonography, computed tomography (CT), magnetic resonance (MR) imaging, and angiography were performed in all cases. Angiography was not helpful in evaluating cystic lesions, because all cystic lesions were hypovascular or avascular within the cystic mass. CT was useful in depicting the fine structural abnormalities, and especially bolus-contrast CT study was useful in the differentiation of cystic renal cell carcinoma from simple renal cyst. However, there were 5 false positive cases. MR imaging is superior to CT in distinguishing a hemorrhagic cyst or multiloculated cystic mass. In conclusion, CT is currently the primary imaging modality for evaluating complicated renal cysts, and surgical exploration is warranted for the undiagnosed cystic lesion by CT. However, MR imaging also has an important role in detecting the benign complicated cyst. Therefore if complicated cyst is thought to be benign by MR imaging, parenchyma-sparing surgery should be considered preoperatively.