Amos Shapiro

Intravesical Bacillus Calmette-Guerin Therapy for Superficial Bladder Cancer: Effect of Bacillus Calmette-Guerin Viability on Treatment Results

We treated 40 patients with superficial bladder cancer via intravesical bacillus Calmette-Guerin for 1) prophylaxis against tumor recurrence, 2) residual carcinoma or 3) flat carcinoma in situ. A single course of intravesical bacillus Calmette-Guerin therapy was successful in 6 of 11 patients (55 per cent) treated for residual carcinoma and 6 of 12 (50 per cent) treated for carcinoma in situ. Of 17 patients receiving a single course of bacillus Calmette-Guerin for prophylaxis 11 remained free of tumor during short-term followup. A second course of therapy was administered to failures in each treatment category, which resulted in favorable responses in 5 of 6 patients treated for prophylaxis, 2 of 5 treated for residual tumor and 3 of 6 treated for carcinoma in situ. Over-all complete responses were achieved in 16 of 17 patients (94 per cent) treated for prophylaxis, 8 of 11 (73 per cent) for residual carcinoma and 8 of 12 (66 per cent) for carcinoma in situ, with a mean followup from the final treatment of 9.3, 12.3 and 7.9 months, respectively. Favorable results occurred more frequently among patients who exhibited a granulomatous inflammatory response in the bladder and delayed hypersensitivity skin test response to purified protein derivative. Marked variability in viability of bacillus Calmette-Guerin organisms was observed among different lots of bacillus Calmette-Guerin, and a direct relationship was observed between bacillus Calmette-Guerin vaccine viability and therapeutic efficacy. Most patients who failed initial therapy with a low viability lot of bacillus Calmette-Guerin responded favorably to re-treatment with a higher viability lot. The results suggest that the level of viability of each lot of bacillus Calmette-Guerin vaccine should be verified before clinical use.

Lateral Decubitus Position for Percutaneous Nephrolithotripsy in the Morbidly Obese or Kyphotic Patient

BACKGROUND AND PURPOSEnMorbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty.nnnPATIENTS AND METHODSnTwo morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position.nnnRESULTSnAn attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously.nnnCONCLUSIONnWe highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

Diagnosis and management of renal angiomyolipoma

Renal angiomyolipoma (hamartoma) is an uncommon benign tumor of the kidney. Although about 400 cases of renal angiomyolipoma have been reported, it still causes difficulties in diagnosis and treatment. Until a few years ago it was almost impossible to arrive at a correct diagnosis preoperatively, and most of the cases underwent nephrectomy with the wrong diagnosis of renal carcinoma. More recently, abdominal computerized tomography and renal sonography have made it possible to reach the correct preoperative diagnosis in many cases, and thus to avoid unnecessary nephrectomies. We report on our experience with 13 cases of renal angiomyolipoma, and our conservative approach in a number of cases, which has enabled us to preserve renal tissue and function.

Renal Cell Carcinoma: Evaluation of the 1997 TNM System and Recommendations for Follow–Up after Surgery

Objective: We evaluated the tumor recurrence pattern after radical or nephron–sparing surgery for localized renal cell carcinoma. Based on this pattern, we suggest a surveillance protocol after surgery. Methods: The outcome of 200 consecutive patients with localized renal cell carcinoma (RCC) that were operated on between January 1982 and December 1997 was evaluated retrospectively. Radical nephrectomy was performed in 155 patients (77.5%), and nephron–sparing surgery in 45 patients (22.5%). The timing and site of disease recurrence were correlated with parameters of the primary tumor. Results: One hundred and twenty–four patients (62%) had pathological stage T1, 26 (13%) had stage T2, and 50 (25%) had stage T3 (41 stage T3a, 8 stage T3b, and 1 stage T3c). The mean follow–up was 47 months (range 6–169 months). Four patients (3.2%) with stage T1, 6 patients (23%) with T2, and 13 patients (26%) with T3 developed recurrent disease. None of the patients with a stage T1 tumor, smaller than 4 cm, had tumor recurrence. There were no recurrences after nephron–sparing surgery compared to 23 recurrences (14.8%) among patients after radical nephrectomy (p = 0.01). Only 1 patient who underwent pulmonary lobectomy for asymptomatic metastases smaller than 2.5 cm, found by routine chest CT, attained long–term survival. Conclusions: The prognosis of patients after radical nephrectomy for renal cell carcinoma, smaller than 4 cm, is excellent and they do not need radiological follow–up. Patients with larger T1 tumors, 4–7 cm in diameter, or a higher stage should be followed with CT of the chest and abdomen done every 6 months for 5 years and then annually. Following partial nephrectomy of small renal tumors periodic renal ultrasonography should be done to rule out local recurrence in the operated kidney.

SEGMENTAL TESTICULAR INFARCTION DUE TO SICKLE CELL DISEASE

Testicular infarction not associated with torsion is rare and segmental infarction is even more rare. The causes of testicular infarction in adults include trauma, sequela of epididymo-orchitis, polycythemia, hypersensitive angiitis, intimal fibroplasia of the spermatic artery and idiopathic etiology.l.2 In most reported cases the diagnosis of testicular infarction was made several days after the onset of symptoms, and the testis was removed to rule out malignancy. We report a case of segmental infarction of a testis presenting as an acute scrotum in a patient with sickle cell anemia. The clinical and sonographic findings that developed during 18 hours of observation allowed insight into the pathogenesis of large vessel occlusion in patients with sickle cell anemia. CASE REPORT A 27-year-old man with homozygous sickle cell anemia presented to the emergency department with severe pain in the left testicle 6 hours in duration. Previous complications of sickle cell disease included acute chest crisis, splenic infarction, osteomyelitis of the left foot and recurrent hemolytic crises. However, the patient had been free of painful crises for the last 9 years. He was married and the father of l-yearold twins who were born after successful in vitro fertilization. The pain was not accompanied by urinary or gastrointestinal symptoms and there was no history of trauma to the testicles. Physical examination revealed a severely distressed patient with normal vital signs. The left hemiscrotum was slightly swollen, red and tender. It was difficult to differentiate the epididymis from the testis. Urinalysis showed 10 to 20 red blood cells per high power field, hemoglobin was 7.7 gm. (normal 14 to 18) and white blood count was 16,500/mm.3 (normal 4,000 to 10,000). Working diagnosis was testicular torsion and color Doppler ultrasonography was done. Both testes appeared normal in echo texture and arterial blood flow. Analgesics, oxygen supplementation and hydration were administered.

Treatment of complete staghorn calculi by extracorporeal shock wave lithotripsy monotherapy with special reference to internal stenting

Extracorporeal shock wave lithotripsy monotherapy was used to treat 41 patients with complete staghorn calculi. In 20 patients polyethylene angiographic pigtail catheters were inserted prophylactically as ureteral stents and the other 21 patients did not receive stents. Prophylactic stenting reduced the incidence of complications and the need for percutaneous nephrostomy tubes to relieve subsequent ureteral obstruction. Internal stenting maintained the sterility of the urinary tract and reduced the average hospital stay by a third. Residual stone fragments representing less than 5 per cent of the original stone mass remained in 56 per cent of the patients, particularly in those with hydronephrotic kidneys. We suggest that extracorporeal shock wave lithotripsy monotherapy with prophylactic stenting is the preferred treatment for noninfected complete staghorn calculi.

Inhibition of murine bladder tumor growth by bacille Calmette-Guerin: Lack of a role of natural killer cells

Intravesical instillation of bacille Calmette Guerin (BCG) currently is considered the most effective treatment for recurrent superficial bladder cancer, but little is known about the mechanism of action. We have adapted a model in which the mouse bladder tumor, MBT-2, is implanted directly into the bladder to examine the mechanism by which BCG inhibits tumor growth. The intravesical administration of BCG inhibited MBT-2 implantation in a dose-dependent manner. Concomitantly, natural killer (NK) activity was augmented in a dose-dependent manner. Conversely, BCG doses which did not augment NK activity lacked antitumor activity. Linear regression analysis showed a significant correlation between the antitumor activity of BCG and modulation of NK activity (correlation coefficient, 0.991). Additional studies were performed in which NK activity was abrogated by administration of anti-asialo-GM1 serum. NK activity was depressed in spleens and lymph nodes of both normal and BCG-treated mice. Abrogation of NK activity did not alter the efficacy of BCG therapy suggesting that NK cells are not a major contributor to the antitumor activity of BCG.

Is radical cystectomy mandatory in every patient with variant histology of bladder cancer.

Urothelial carcinomas have an established propensity for divergent differentiation. Most of these variant tumors are muscle invasive but not all. The response of non muscle invasive variant tumors to intravesical immunotherapy with BCG is not established in the literature, and is reported here. Between June 1995 and December 2007, 760 patients (mean age of 67.5 years) underwent transurethral resection of first time bladder tumors in our institution. Histologically variant tumors were found in 79 patients (10.4%). Of these 57 patients (72%) of them had muscle-invasive disease or extensive non-muscle invasive tumors and remaining 22 patients (28%) were treated with BCG immunotherapy. These included 7 patients with squamous differentiation, 4 with glandular, 6 with nested, 4 with micropapillary and 1 patient with sarcomatoid variant. The response of these patients to immunotherapy was compared with that of 144 patients having high-grade conventional urothelial carcinomas. Median follow-up was 46 months. The 2 and 5-year progression (muscle-invasion) free survival rates were 92% and 84.24% for patients with conventional carcinoma compared to 81.06% and 63.16% for patients with variant disease (P=0.02). The 2 and 5-year disease specific survival rates were 97% and 91.43% for patients with conventional carcinoma compared to 94.74 % and 82% for patients with variant disease (P=0.33). 5 patients (22.7%) of variant group and 13 patients (9.03%) of conventional group underwent cystectomy during follow-up (P=0.068). Patients with non-muscle invasive variants of bladder cancers can be managed with intravesical immunotherapy if tumor is not bulky (>4 cm). Although progression to muscle invasive disease is more common than in conventional group and occurs in about 40% of the patients, life expectancy is similar to patients with conventional high-grade urothelial carcinomas provided that follow-up is meticulous.

Traumatic avulsion of the female urethra: case report.

Complete rupture of the female urethra is rare. We found only 30 such cases described in the literature, 19 of which were in children. In most of these patients, the proximal urethra and bladder neck were injured. Herein we report on the complete rupture of the distal part of the urethra in a female child with a pelvic fracture. This diagnosis should be considered in such cases with deep vaginal lacerations, inability to void, and with unsuccessful catheterization.

Role of immunotherapy in the prevention of recurrence and invasion of urothelial bladder tumors: a review

SummaryAlthough many different chemotherapeutic regimens for the treatment of superficial bladder cancer have been used, none are considered ideal. This has stimulated investigations of alternative forms of therapy, including immunotherapy. Contained within this therapeutic category are bacterial agents such as Bacille Calmette-Guerin, Corynebacterium parvum and a streptococcal preparation, OK-432, as well as the interferon inducer polyriboinosinic acid-polyribocytidylic and passive immunotherapy with sensitized pig lymphocytes. With the exception of BCG, most forms of immunotherapy have not been been effective in the treatment of superficial bladder carcinoma. This paper reviews immunotherapy with emphasis on the studies of BCG as prophylaxis against and treatment for superficial transitional cell carcinoma of the bladder.