Laparoscopic removal of multicystic dysplastic pelvic kidney.

A patient presented to us with a symptomatic, polycystic, nonfunctioning, pelvic kidney, which was removed laparoscopically. Laparoscopic removal of multicystic pelvic kidney has not been reported in an adult. The technique we adopted is described, and the relevant literature is reviewed.

PSK, a novel STE20-like kinase derived from prostatic carcinoma that activates the c-Jun N-terminal kinase mitogen-activated protein kinase pathway and regulates actin cytoskeletal organization.

Degenerate polymerase chain reaction against conserved kinase catalytic subdomains identified 15 tyrosine and serine-threonine kinases expressed in surgically removed prostatic carcinoma tissues, including six receptor kinases (PDGFBR, IGF1-R, VEGFR2, MET, RYK, and EPH-A1), six non-receptor kinases (ABL, JAK1, JAK2, TYK2, PLK-1, and EMK), and three novel kinases. Several of these kinases are oncogenic, and may function in the development of prostate cancer. One of the novel kinases is a new member of the sterile 20 (STE20) family of serine-threonine kinases which we have called prostate-derived STE20-like kinase (PSK) and characterized functionally. PSK encodes an open reading frame of 3705 nucleotides and contains an N-terminal kinase domain. Immunoprecipitated PSK phosphorylates myelin basic protein and transfected PSK stimulates MKK4 and MKK7 and activates the c-Jun N-terminal kinase mitogen-activated protein kinase pathway. Microinjection of PSK into cells results in localization of PSK to a vesicular compartment and causes a marked reduction in actin stress fibers. In contrast, C-terminally truncated PSK (1-349) did not localize to this compartment or induce a decrease in stress fibers demonstrating a requirement for the C terminus. Kinase-defective PSK (K57A) was unable to reduce stress fibers. PSK is the first member of the STE20 family lacking a Cdc42/Rac binding domain that has been shown to regulate both the c-Jun N-terminal kinase mitogen-activated protein kinase pathway and the actin cytoskeleton.

Influence of investigative and operative procedures on serum prostate-specific antigen concentration.

We determined the effect of cystoscopy (flexible and rigid), transrectal ultrasonography (with and without needle biopsy of the prostate) and transurethral resection of the prostate or bladder tumour on the serum prostate-specific antigen (PSA) concentration. Samples were taken from 60 men before and up to 14 days following these procedures. Flexible cystoscopy did not result in a significant increase in serum PSA concentration, with a median increase of 0.1 microgram/L (P > 0.05). Small but statistically significant increases in serum PSA levels 1 day post-procedure were observed following rigid cystoscopy and transrectal ultrasound without biopsy. The median increase in serum PSA concentration following rigid cystoscopy was 0.15 microgram/L (P = 0.04) and following transrectal ultrasound was 0.3 microgram/L (P = 0.01). In both cases the serum PSA level had normalized by 2 days post-procedure. Transurethral resection of bladder tumours resulted in a variable rise in serum PSA, with a median increase of 2.6 micrograms/L after 1 day, which returned to normal over 7-14 days. Ultrasound-guided needle biopsy of the prostate and transurethral resection of the prostate produced significant increases in serum PSA levels, which took up to fourteen days to return to normal. The median increase in serum PSA following needle biopsy was 6.0 micrograms/L and following transurethral resection of the prostate (TURP) was 13 micrograms/L. Samples for PSA measurement may safely be taken within 24-48 h of flexible cystoscopy and transrectal ultrasonography (TRUS) providing prostatic biopsy is not carried out. For other procedures it is necessary to wait for at least 14 days to ensure that false positive PSA results are not obtained.

Intravesical chemotherapy with epirubicin: a dose response study.

PURPOSE: We determined the difference in response to high and standard doses of intravesical epirubicin for treatment of superficial bladder cancer. MATERIALS AND METHODS: A total of 122 patients were entered into a randomized trial to compare the response of a marker tumor at 3 months, time to first recurrence and recurrence rates for 2 years after intravesical chemotherapy for superficial (pTa/pT1) bladder cancer. Patients were randomized to receive treatment for 1 hour with 1 (standard dose) or 2 mg./ml. (high dose) epirubicin (50 or 100 mg./50 ml. solution). RESULTS: There was no difference in the marker tumor response rate in 24 of 52 patients treated with the standard dose compared with 21 of 50 treated with the higher dose of epirubicin (p = 0.67). Similarly, the higher dose was not superior in regard to time to first recurrence, with a hazard ratio of 1.46 (p = 0.14, 95% confidence intervals 0.88 to 2.42). Considering the upper end of the confidence interval, we can reliably exclude an absolute difference of greater than 4% at 1 year for time to first recurrence in favor of higher dose chemotherapy. CONCLUSIONS: Epirubicin at double the standard dose for intravesical chemotherapy of superficial bladder cancer is not superior in regard to marker tumor response, time to first recurrence or recurrence rate.

The release of free prostate specific antigen into the circulation during transurethral resection of the prostate: kinetics and interaction with serum protease inhibitors.

OBJECTIVE: To determine the nature and extent of the release of prostate specific antigen (PSA) and its interaction with its plasma protein-derived inhibitors after transurethral resection of the prostate (TURP). MATERIALS AND METHODS: Twenty-three consecutive patients undergoing routine TURP for benign prostatic hyperplasia had blood samples taken pre-operatively and then post-operatively at 8-hourly intervals for 24 h. Further samples were obtained at 48 and 72 h post-operatively. Serum free and total PSA were determined by immunofluorometric assay. The major plasma protein inhibitors for PSA were also determined by immunoassay. RESULTS: The mean free and total PSA fractions increased significantly post-operatively with levels greatest immediately after surgery. There was also a gradual increase in the complexed PSA fraction, reaching a peak at 48 h. The concentration of the major serum inhibitors of PSA (alpha-1-antichymotrypsin and alpha-2-macroglobulin) also declined immediately after surgery. CONCLUSION: Increases of serum total PSA in patients after TURP are caused by increases in the free PSA fraction. The exponential decline in free PSA concentrations is consistent with the complexing of PSA with its protease inhibitors present in the plasma. The formation of this complex suggests that the free PSA released into the circulation at the time of TURP is the enzymatically active form.

The role of surgery in the multimodality treatment of bladder cancer.

There has been little change in bladder cancer survival for more than 40 years, although earlier diagnosis is now detecting more cases at an early, potentially curable stage. Radical cystectomy remains the most effective single treatment, although in the past the morbidity and mortality of treatment and the age of patients made it less favoured as primary treatment. Progress in continent bladder reconstruction is changing attitudes. However, because tissue damage from preoperative radiation, particularly when combined with chemotherapy, makes such operations less safe in patients with advanced disease, reconstruction is primarily of value in high risk superficial and early invasive cancers, though there remains a need for randomized trials or immediate vs deferred use of these operations to establish when they give most benefit. With new knowledge about the role of trauma released tissue repair cytokines and immunosuppressive effect of prolonged anaesthesia on increasing tumour recurrence after surgery, new approaches such as treatment with TNFA, anti-EGF antibody or neoadjuvant chemo/immunotherapy before TURBT to improve on the benefits of surgery need to be explored in randomized trials in both advanced invasive and early superficial disease. With progress in vaccine and gene therapy on the horizon, the central role of the urologist in both harvesting tumours for molecular diagnosis and monitoring response of local disease to treatment is undisputed. The relative underusage and value of bladder washings cytology to provide cells for such studies is also highlighted.

Ischemic damage to the prostate during cardiac surgery: a clinical model.

BACKGROUND: To determine if altered tissue perfusion during cardiac surgery results in ischemic tissue damage to the prostate, as suggested by a rise in prostatic-specific antigen (PSA). METHODS: Twenty-nine male patients undergoing elective coronary artery bypass grafting were studied. Ten male patients undergoing elective gastrointestinal surgery served as controls. PSA levels were determined preoperatively and six hourly intervals postoperatively for 48 hr. All patients underwent urethral catheterization at induction of anesthesia. RESULTS: All patients (100%) who had undergone cardiac bypass surgery showed rises in serum PSA during 48 hr of postoperative follow-up. At the 6-hr postoperative interval, the mean PSA was significantly different from the mean baseline value (paired two tailed Student's t test, P < 0.001) in 27 of the 29 (93%) patients. In contrast, the PSA values in the 10 gastroenterological controls did not change at 6 hr (P > 0.2) or during the next 48 hr. One patient in the cardiac group showed a very marked elevation in serum PSA of greater than 50 times normal preoperative levels. CONCLUSIONS: Statistically significant rises in PSA levels are seen following coronary bypass surgery. This rise may be caused by ischemic nontrauma related damage to the prostate and suggests a possible pathophysiological mechanism for the clinically episodic symptoms of prostatism seen in elderly men.

Assessment of alternative tissue approximation techniques for laparoscopy.

OBJECTIVE: To investigate the feasibility and results of applying alternative techniques of tissue approximation for experimental urothelial re-anastomosis in an open and laparoscopic setting. MATERIALS AND METHODS: The study was carried out in two phases; in phase 1, an open porcine ureteric re-anastomosis was performed using gelatin/resorcin/ formaldehyde (GRF) glue, fibrin glue or potassiumtitanyl-phosphate laser tissue-welding with a fluorescein-doped human albumin solder. The anastomoses were assessed both immediately, by leak pressure, and by the operating time, upper tract urodynamic studies and light and scanning electron microscopy, 6 weeks after surgery. In phase 2 the best technique from phase 1 was compared with sutured controls for porcine retroperitoneoscopic dismembered pyeloplasty, using the same assessment criteria. RESULTS: In phase 1, GRF glue produced adhesion which was insufficiently flexible to withstand rotation of the anastomosis and this technique was therefore abandoned. Fibrin-glued anastomoses withstood leak pressures equal to those from laser-welding (P = 0.91) and gave similar changes in maximum pressure with a Whitaker test at 6 weeks (P = 0.30), but were superior in requiring a shorter operating time (P = 0.02) and in their electron and light microscopic appearances. In phase 2, fibrin glue gave similar changes in maximum pressure with a Whitaker test to those from polyglactin 910 sutures (P = 0.51) but withstood higher leak pressures (P = 0.01), had a shorter operating time (P = 0.01) and had superior electron and light microscopic appearances. CONCLUSION: Fibrin glue produced effective experimental laparoscopic pelvi-ureteric anastomoses within less operating time than did sutured controls. Such anastomoses withstood supra-physiological pressures, with no evidence of functional obstruction and with a more favourable histological result after 6 weeks. Laparoscopic evaluation of this modality in a clinical setting is now justified.

[The future of laparoscopic surgery in urology]. / Die Zukunft der laparoskopischen Chirurgie in der Urologie.

Laparoscopy has followed the typical phases in the development of any new operative technique. We have now begun to realize its limitation and are beginning to standardize the procedures and specify their indications. Since laparoscopy predominantly reduces the trauma of access, the development of a total operative trauma score has assisted us in determining the impact of specific laparoscopic procedures compared to their open alternatives. Laparoscopy is responsible for less blood loss, less postoperative pain, a shorter hospital stay and a very small scar, all of which accounts for its popularity among patients. A rational combination of laparoscopy, endoscopy and open surgery to treat urological diseases should be developed in the future.

Randomized open labelled comparative study of the efficacy, safety and tolerability of leuprorelin acetate 1M and 3M depot in patients with advanced prostatic cancer.

OBJECTIVES: In a European, prospective, 1:2 randomized phase II multicentre study, 237 patients with advanced or metastatic prostate cancer were treated with either the 1M- (80 patients) or 3M-depot formulation (157 patients) of leuprorelin acetate for 9 months to compare efficacy and safety. METHODS: Standard clinical investigations and methods were employed in the study. Leuprorelin levels were determined using a specially modified RIA. RESULTS: The two formulations produced virtually identical effects with a pronounced fall in testosterone and gonadotropin serum levels and a marked reduction in PSA levels. After 9 months' treatment, PSA was normalized (< or = 4 ng/ml) in 65.2 and 66.1% of the 1M and 3M depot patients, respectively. The best response to 1M vs. 3M depot during the study was as follows: complete remission in 5 vs. 5.7%, partial remission in 36.3 vs. 33.8% and stabilization in 40.0 vs. 40.8%. The main side effects of both formulations were related to androgen deprivation. CONCLUSIONS: Comparable results were recorded for the two formulations of leuprorelin acetate in terms of clinical response, endocrine effects and tolerability. The newly developed leuprorelin acetate 3M depot, as a refinement of the established 1M depot, offers an opportunity to improve patient compliance and provides individualized and optimized, patient-orientated treatment by reducing the number of injections to four per year.

Overview of extraperitoneal laparoscopy.

Recent developments in extraperitoneal endoscopic techniques are causing a second wave of excitement amongst laparoscopic surgeons. In certain situations, there are definite advantages over an intraperitoneal alternative but the new interest of many surgeons for whom this has always been a more natural open route is also very welcome and timely. Many of the frustrating problems of access into the extraperitoneal space have been overcome by the introduction of an expanding dissecting balloon which both creates an adequate working space and tamponades potentially small haemorrhagic vessels torn in the dissection. Routine laparoscopic techniques can then take over using carbon dioxide for insufflation. The major advantage for the patient seems to be reduced post-operative pain but the major problem facing the surgeon is one of orientation in a space where there are no recognisable anatomical landmarks. This problem is being overcome with adjuvant radiological techniques.

Extraperitoneal pelvic and para-aortic lymphadenectomy.

Many laparoscopic surgeons, particularly in urology, have been performing a laparoscopic transperitoneal pelvic and para-aortic lymphadenectomy for prostatic and germ cell cancers respectively with great success. The transperitoneal route has been superceded by an extraperitoneal approach. Although the working space is sometimes a little more restricted and orientation more difficult, the ultimate result is a procedure associated with much less post-operative pain.

The future of laparoscopy in urology.

Laparoscopy has not changed urological techniques as radically as could be supposed, as only 17% of urological techniques are performed by laparoscopy instead of the predicted 70%. However, this limited proportion corresponds to 30% of urological operating time. The author proposes a combination of open surgery and laparoscopy in certain cases. Laparoscopy is responsible for lower blood loss, less postoperative pain, a shorter hospital stay and a very small scar which account for its popularity among patients. A rational combination of laparoscopy, endoscopy and open surgery to treat urological diseases should be developed in the future.