Ca 125 as a marker of tumor activity in advanced urothelial malignancy.

PURPOSE: The discovery of increased CA 125 in a patient with metastatic bladder carcinoma prompted a prospective study to screen those referred for consideration of adjuvant or palliative chemotherapy of advanced urothelial malignancy for high serum CA 125. Although CA 125 is a useful marker of ovarian cancer and, reportedly, is expressed by a few other tumors, to our knowledge no association with transitional cell malignancy of the urothelium has been previously described. MATERIALS AND METHODS: A group of 68 patients with nodal or metastatic disease was examined. A total of 60 patients had lower urinary tract tumors, 6 had renal or ureteral transitional cell carcinoma and 2 had both lesions. Of these patients 21 underwent surgery alone, 40 underwent both surgery and chemotherapy, and 5 were treated by chemotherapy only. There were 2 patients who received no treatment. Periodic serum CA 125 was obtained in cases found to be initially marker positive and with a change in clinical status. RESULTS: Of the 68 patients 48 (71%) had increased CA 125. Variation in the serum level with change in disease status was often dramatic (mean 516.3 units per dl.). Of 30 radiologically measurable disease progressions 16 were accompanied by increasing CA 125. Increases were seen in 80% of patients who had increased baseline levels. In 5 cases marker increases were seen in the absence of measurable progression but the clinical course indicated therapeutic failure. Decreasing CA 125 reflected 3 of 5 imaged regressions. Overall, a 42% decrease in median levels was seen after chemotherapy. Significantly more cases of metastatic or residual disease were marker positive. CONCLUSIONS: CA 125 appears to be a marker of disease activity in a patient subset with advanced urothelial malignancy. The clinical use of CA 125 in this population is worthy of further study.

Carcinogenesis. The fate of intestinal segments used in urinary reconstruction.

The actual mechanism for risk of developing cancer in intestinal segments used for urinary diversion remains uncertain. The clinical and laboratory experiences are reviewed in this article. The pathogenesis is multifaceted, involving initiators and promoters of carcinogenesis. Molecular genetic technology may provide the key to decoding the mechanisms involved.

Ileocecal valve resistance augmentation using glutaraldehyde cross-linked collagen: a canine model for endoscopic salvage of the leaking Indiana reservoir.

PURPOSE: Periurethral injection of glutaraldehyde cross-linked collagen is a well-established modality for the treatment of patients with incontinence caused by structural defects at the bladder outlet. Little is known about the potential usefulness of this approach to the nonfunctioning continence mechanism of a leaking continent urinary reservoir. An animal model of an incontinent Indiana reservoir was created using the naturally incompetent canine ileocecal valve. The effectiveness and feasibility of endoscopic submucosal injection of glutaraldehyde cross-linked collagen into the ileocecal valve to increase resistance were examined. MATERIALS AND METHODS: Seven beagle dogs underwent isolation of the ileocecal segment. The right colon and ileum were brought to the skin as 2 stomas. Baseline leak point pressures of the ileocecal valve were determined while infusing contrast material into the right colon. The leak point was observed fluoroscopically, and the pressure at which contrast material crossed the valve was measured. Glutaraldehyde cross-linked collagen, 4 to 10 ml., was injected endoscopically into the valve in a circumferential pattern. Leak point pressures were measured immediately, 1 month after injection and 3 months after injection. RESULTS: An average of 7.1 gm. (range, 4.1 to 10.1 gm.) was required to create an endoscopically "closed" ileocecal valve. Leak point pressure increased from a mean 3.8 mm. water (range, 2.5 to 6.0 mm. water) at baseline to mean 35.7 mm. water after injection (range, 22.0 to 57.0 mm. water). At 1 month, mean leak point pressure decreased slightly to 26.7 mm. water. This pressure stabilized at 3 months at 29.5 mm. water. CONCLUSIONS: Endoscopic delivery of glutaraldehyde cross-linked collagen into the ileocecal valve consistently enhanced resistance as measured by leak point pressure. This effect was durable over a 3-month period of observation. Admittedly, this period of observation is relatively short. Longer followup may have demonstrated significant diminution of collagen migration or resorption. However, this feasibility study demonstrates that collagen injections may provide a minimally invasive means of treating the incontinent continent urinary reservoir.

Regression of large pelvic desmoid tumor by tamoxifen and sulindac.

A 54-year-old man was evaluated for symptoms of bladder outlet obstruction. Evaluation revealed a 10 by 9.8-cm tumor composed of bland, fibroblastic, poorly cellular material adjacent to the prostate. Administration of a course of antiestrogen (tamoxifen) and a nonsteroidal anti-inflammatory agent (sulindac) resulted in prompt relief of symptoms and a slow decrease in the size of the tumor as measured by computed tomography. After 54 months of therapy, the tumor was undetectable clinically and dramatically reduced in size as seen on computed tomography. Data on the natural history of desmoid tumors and the efficacy of various therapeutic strategies are reviewed.

The laparoscope as a teaching aid in open pelvic surgery.

Laparoscopic imaging equipment is useful in open surgical procedures, especially in the deep male pelvis. The magnification and brilliant illumination provided by these unobtrusive instruments increase visibility, facilitating both dissection and reconstruction. The application of this technique for surgical education is discussed.

Corticosteroid-associated fatal mycobacterial sepsis occurring 3 years after instillation of intravesical bacillus Calmette-Guerin.

A case is reported of systemic Mycobacterium bovis infection that occurred 3 years after uneventful instillation of intravesical bacillus Calmette-Guerin (BCG) and after several months of oral prednisone therapy. The literature on delayed BCG infection and the systemic persistence of BCG after intravesical instillation is reviewed. We propose that rarely a reservoir of dormant M. bovis may become established after intravesical therapy. Reactivation infection may later develop in a manner that parallels the natural history of secondary tuberculosis.

Computerized tomographic appearance of hernias of the bladder.

Herniation of the bladder is not uncommon and it can occur with any type of hernia in the groin. Most bladder hernias are discovered unexpectedly during herniorrhaphy, and serious complications can result from intraoperative injury to the bladder. The appearance of hernias on excretory urography and cystography has been described extensively but experience with computerized tomography (CT) has been limited. We describe the appearance of 8 bladder hernias on CT: 2 incisional, 2 femoral, 3 small direct inguinal, and 1 massive direct inguinal hernia with bladder necrosis and perforation. Appearance on CT is characteristic, and this modality may be useful for preoperative evaluation.