Identification of a gene frequently mutated in prostate tumors.

Although prostate cancer is the second leading cause of cancer death for men in the United States, the genetics of tumor development are poorly understood. Several expressed sequence tagged genes (ESTs) that are expressed predominantly in the prostate have recently been identified, although their role in the development and maintenance of the prostate is unknown. Here, we demonstrate that the gene identified as UNIGENE cluster Hs. 104215, which codes for a message found predominantly in the prostate, may be important in tumor development. We name this gene PCan1 for Prostate Cancer gene 1. Northern blot experiments were performed using RNA isolated from tumor-derived cell lines and human prostate to determine the expression pattern of the gene. DNA sequencing was used to identify mutations that occurred in tumor tissue. By Northern blot analysis, this gene product was not detectable in LNCaP, DU 145, or PC-3 prostate cancer cell lines, although it was readily observed in RNA isolated from total prostate and from dissected central and peripheral regions of prostate. Sequence analysis of genomic DNA from LNCaP, DU 145, or PC-3 cells demonstrated a G/A polymorphism at position 193. Analysis of matched tumor-derived DNA and blood-derived DNA samples from 11 of 13 patients who had undergone a radical prostatectomy and who were homozygous for A in blood-derived DNA demonstrated mutation of position 193 in matched tumor samples resulting in G/A polymorphism. Sixteen additional patient samples were G/A polymorphic in both blood-derived DNA and tumor-derived DNA and two samples were GG in both blood-derived and tumor-derived DNA. Our results suggest that this gene may be a hot spot for mutation in prostate cancer, especially because our radiation hybrid mapping located this gene within a region identified in linkage mapping studies of affected families with prostate cancer. Loss of heterozygosity in prostate tumors has also been reported at the location of PCan1. Further studies to determine the functional role of this candidate tumor suppressor gene are warranted.

Acute lobar nephronia of renal transplant allograft.

Acute lobar nephronia (acute focal bacterial nephritis) has recently been recognized as an infectious process of the kidney. It is a radiologic diagnosis characterized as a nonliquifiable inflammatory renal mass associated with signs and symptoms of bacterial pyelonephritis. We present the successful management of a renal allograft recipient who had radiologic evidence of acute lobar nephronia within the graft six weeks after placement of an internalized ureteral stent.

Hypospadias repair in elderly patients.

Although surgical repair of hypospadias has been performed for decades, some older men with this anomaly have never been treated or even referred. Age alone should not be a contraindication for surgery. Rather, the physician needs to consider the degree of urethral stricture and voiding impairment caused by the disorder and the extent those factors affect the patient's quality of life.

Fatal transitional cell carcinoma of bladder in renal transplant recipient.

The risk of development of a malignancy as a consequence of long-term immunosuppression is well documented. Herein, we report the course of a renal allograft recipient in whom a fatal transitional cell carcinoma of the bladder developed eighteen years following transplantation.

Modified cruciate incision for transabdominal radical nephrectomy.

Experience with multiple organ harvesting procedures as well as orthotopic liver transplantation has provided for excellent extensive upper abdominal surgical exposure. We report use of a modified cruciate incision for transabdominal radical nephrectomy.

Electromagnetic induced shock wave therapy of ureteral calculi.

Between March 1989 and July 1990, 86 patients with ureteral stones were treated with electromagnetic induced extracorporeal shock wave lithotripsy at our facility, of which 77 were available for follow-up. Sixty-one of the patients were male, 16 were female, and the average age was 53.8 +/- 16.0 (11-84). Seventy-four of the patients were treated with intravenous sedation. One patient required general anesthesia and two other patients requested no sedation. Sixty-four of 77 (83%) patients were stone free after therapy, 59 of 77 (77%) after a single treatment, and 5 of 9 (56%) after a second treatment. Thirteen patients were hospitalized post therapy, however, 6 had been hospitalized pretreatment because of pain or obstruction. Four major complications were encountered: hematoma (1), ureteral stricture (1), urinary extravasation (1), and proximal stent migration (1). There were no statistically significant differences between stone free and non-stone free patients when comparing for sex, age, stone size, number of shocks, maximum kilovoltage, or duration of symptoms pretreatment. The patients who had unsuccessful treatment, however, were noted to have a significantly greater incidence of distal stones (69% v 39%) (P less than .05).

The use of internalised ureteric stents in renal transplant recipients.

Since 1982, we have used internal indwelling ureteric stents for the management and prevention of ureteric reconstruction complications in 28 renal allograft recipients. A total of 30 stents were placed in 18 patients either diagnostically or therapeutically in the management of allograft ureteric obstruction. In 16 patients internal stents were placed at the time of reconstruction for primary ureteropyelostomy (3), secondary ureteropyelostomy (8), repeat reimplant (3) and repair of ureteric or pelviureteric junction injury (2). Complications included 3 episodes of transplant pyelonephritis, proximal stent migration (1), persistent bacteriuria (1) and prolonged healing of a ureteropyelostomy (1). Internalised ureteric stenting is a safe and effective means of managing or preventing ureteric reconstruction complications in renal transplant recipients.

Augmentation of the bladder in preparation for renal transplantation.

Although loop urinary diversion has been used successfully with renal allograft recipients, the potential and real morbidity of these diversions has led us to avoid this type of reconstruction in favor of the reconstructed bladder (3). Many of our first patients had undergone reconstruction or undiversion prior to the establishment of renal insufficiency and had a variety of augmentations (two ileocecal and three sigmoid). One additional patient underwent ileal patch augmentation three years after transplantation. However, many patients are now being seen in preparation for renal transplantation who have urinary diversions or require reconstruction and have such poor renal reserve that renal replacement therapy is inevitable. It is this latter group of patients who have prompted us to define what is the most suitable form of reconstruction of the bladder when subsequent transplantation is planned. Many forms of reconstruction and undiversion are available and appear to be equally satisfactory in the management of patients with lower urinary tract dysfunction. However, patients who are to undergo renal transplantation subsequently should be given consideration regarding the technical feasibility of the transplant operation. Accordingly, we believe that simple augmentation of the sigmoid colon as described herein prevents dissection of either iliac fossa, which greatly facilitates implantation of the allograft. As there currently appears to be no superior segment of both the large and small intestine or configuration for augmentation, augmentation of the sigmoid colon is at least as effective as other modes of reconstruction and, therefore, should be strongly considered in this population of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Needle biopsy of renal allografts: comparison of two techniques.

Two techniques for renal allograft biopsy were retrospectively evaluated to compare relative safety and efficacy. After ultrasound (US) localization of the kidney and biopsy with a hand-held 14-gauge cutting needle, an adequate specimen was obtained in 74 of 77 cases (96%). Major complications occurred in six of these 77 cases (8%). One hundred four biopsies were performed by using a smaller 18-gauge cutting needle with a spring-loaded biopsy "gun" and real-time US guidance. With this newer technique, specimens adequate for diagnosis were obtained in 99 biopsies (95%). There was a single major complication with this technique (1%). The 18-gauge needle with real-time US guidance yields comparably adequate specimens with a lower frequency of complications.

Secondary hyperparathyroidism. The role of surgery.

A retrospective analysis was undertaken to better define the clinical presentation and therapy of patients with secondary hyperparathyroidism and the timing of surgical removal of the parathyroid glands in secondary hyperparathyroidism. Sixty-eight patients with end-stage renal disease (ESRD) underwent 74 parathyroid procedures over a 10-year period. There were 38 per cent women and 62 per cent men in this population--the same proportion of men and women with ESRD. These proportions are reversed when compared with patients with primary hyperparathyroidism. The mean time between initiation of dialytic therapy and parathyroidectomy was 5.4 years. Preoperative mean serum calcium and phosphorus levels were 10.1 +/- 0.2 and 6.1 +/- 0.2 mg/dl, respectively. All patients were symptomatic and 60 per cent of the patients had at least two symptoms before surgery. Renal osteodystrophy was the most common symptom (74%), whereas pruritus was noted in 65 per cent of this population. Patients underwent either subtotal (88%) or total (12%) parathyroidectomy with autotransplantation. Six patients required reoperation: five for recurrent disease (2 to 5 years after the initial surgery) and one for persistent disease. All patients were symptomatically improved after the surgery. Complications included the following: transient hoarseness (7%), hypocalcemia requiring calcium, and/or vitamin D therapy (32%) for 6 months after surgery. This analysis demonstrates that although the initial therapy of secondary hyperparathyroidism is medical, surgical therapy should be instituted before multiple symptoms develop in the ESRD population.

Duplex Doppler US of renal allografts: causes of elevated resistive index.

The authors retrospectively investigated the utility of the resistive index (RI) in evaluating the major causes of renal allograft dysfunction. Three hundred fourteen duplex US studies in 162 patients with 150 episodes of renal allograft dysfunction within a 17-month period were reviewed. Histologic findings were available in 69 cases. Three patients had hyperacute rejection with a mean RI of 0.85 +/- 0.049. There were 37 episodes of acute rejection (mean RI, 0.76 +/- 0.054) and 22 instances of chronic rejection (mean RI, 0.71 +/- 0.065). Ureteral obstruction (nine cases; mean RI, 0.72 +/- 0.026) was the only cause of allograft dysfunction other than rejection with a mean RI greater than 0.70. Mean RI values associated with rejection were significantly elevated above those in the 88 cases of dysfunction without rejection (mean, 0.64 +/- 0.064) and in baseline examinations (mean, 0.63 +/- 0.066). The results identified two causes of increased RI values in addition to acute rejection: chronic rejection and ureteral obstruction.

Posterior urethral valves in siblings.

The etiology and incidence of posterior urethral valves is unknown. We report on a pair of non-twin siblings with identical pathology stemming from type I posterior urethral valves as well as discordance in a pair of monozygotic twins. Familial posterior urethral valves have been reported before in both twin and non-twin siblings. The occurrence of identical pathology in non-twin siblings suggests the possibility of an inherited trait as does its occurrence in identical twins. However, non-identical clinical manifestation is as common as is identical presentation in both groups. There are also instances of discordance in monozygotic twins suggesting the possibility of a random mutation. As such, we recommend urologic evaluation of the male siblings of affected patients with posterior urethral valves. Further prospective and retrospective analyses are needed to define the genetic etiology of valves.

Renal transplantation into the reconstructed bladder.

In our experience with 821 renal transplants performed between 1974 and October 1987 we used the native or reconstructed bladder of the patient in all but 2 instances. Seven patients have undergone enterocystoplasty and subsequent renal transplantation, while 1 underwent bladder augmentation after transplantation. Of these 8 patients 4 have functioning grafts 6 months to 7 years after transplant or reconstruction. Renal transplantation coupled with enterocystoplasty in properly selected patients has acceptable morbidity and should be considered as an alternative to other forms of urinary diversion in allograft recipients.

Renal transplantation in a patient with an artificial urinary sphincter device.

Use of the artificial urinary sphincter device has become widespread. We describe the successful transplantation of a renal allograft into a recipient with an artificial urinary sphincter. Pretransplant placement of a sphincter, intraoperative avoidance of the prosthetic device and proper urinary drainage perioperatively make the artificial urinary sphincter device a feasible means to provide continence in a renal transplant recipient.

Infectious complications of penile prosthetic implants.

An infectious complication involving placement of a penile prosthesis is a disastrous event. A review of more than 300 devices placed between 1979 and 1984 at this center reveals an infectious complication rate of 8.3 per cent. Perioperative risk factors predisposing to infection included reoperation for technical failures, inadequate antibiotic coverage (specifically for Staphylococcus epidermidis), failure to perform a circumcision at the time of placement in uncircumcised patients and simultaneous placement with an artificial urinary sphincter device. No group of patients nor type of prosthesis was more susceptible to the development of a postoperative infection.

Parapelvic lymph cyst in a renal allograft mimicking hydronephrosis: CT diagnosis.

Lymphoceles are common complications of renal transplantation and usually arise between the bladder and the transplant kidney. A rare case of a parapelvic lymphocyst in a renal allograft is presented that sonographically mimicked hydronephrosis but was correctly diagnosed by CT.