Surgery in the management of bladder cancer.
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Humans↗
Biomedical subjects
J A Freeman
Publications and source records attributed to J A Freeman.
Accumulation of nuclear p53 and tumor progression in bladder cancer.
BACKGROUND: We have previously demonstrated a strong association between nuclear accumulation of p53 protein, as determined by immunohistochemical analysis, and mutations in the p53 gene. The purpose of this study was to determine the relation between nuclear accumulation of p53 and tumor progression in transitional-cell carcinoma of the bladder. METHODS: Histologic specimens of transitional-cell carcinoma of the bladder (stages Pa, noninvasive disease, to P4, disease with direct extension into adjacent organs or structures) from 243 patients who were treated by radical cystectomy were examined for the immunohistochemical detection of p53 protein. Nuclear p53 reactivity was then analyzed in relation to time to recurrence and overall survival. RESULTS: The detection of nuclear p53 was significantly associated with an increased risk of recurrence of bladder cancer (P < 0.001) and with decreased overall survival (P < 0.001). In patients with cancer confined to the bladder, the rates of recurrence for stage P1, P2, and P3a tumors that had no detectable nuclear p53 reactivity at five years were 7, 12, and 11 percent, respectively, as compared with 62, 56, and 80 percent, respectively, for tumors that had p53 immunoreactivity. Similar results were obtained when the presence or absence of p53 in the nuclei of the tumor cells was studied in relation to overall survival. In a multivariable analysis stratified according to grade, pathological stage, and lymph-node status, nuclear p53 status was an independent predictor (and in cancer confined to the bladder, the only independent predictor) of recurrence and overall survival (P < 0.001). CONCLUSIONS: In patients with transitional-cell carcinoma confined to the bladder, an accumulation of p53 in the tumor-cell nuclei detected by immunohistochemical methods predicts a significantly increased risk of recurrence and death, independently of tumor grade, stage, and lymph-node status. Patients with transitional-cell carcinoma confirmed to the bladder that demonstrates nuclear p53 reactivity should be considered for protocols of adjuvant treatment.
Aged↗
Gas-phase ion-molecule reactions: a model for the determination of biologically reactive electrophilic contaminants in the environment.
A promising instrumental technique has been investigated to rapidly screen complex environmental samples for chemical contaminants having the propensity to covalently bond to biomacromolecules such as DNA. Radical molecular ions of pyridine, a model compound for nucleophilic bases of DNA, were mass-selected and allowed to react with electrophilic environmental contaminants in the collision cell of a triple quadrupole mass spectrometer. Analytes were introduced into the collision cell via a gas chromatographic column. Reactive chemicals are then characterized by scanning Q3 to identify associative reaction products. A good qualitative correlation was observed for the gas-phase reactivity of a series of electrophilic reagents with both their alkylating reactivity in solution (4-(4-nitrobenzyl)pyridine) and AMES test mutagenicity which had been previously published. Femtomole limits of detection for specific associative reaction products were demonstrated. Gas-phase reactions of ions of environmental contaminants (introduced into the source) with neutral pyridine (in the collision cell) were also investigated. Reactions of the radical molecular ion of the allyl reagents with neutral pyridine were similar to results from the mass-selected reaction of the pyridine radical molecular ion with neutral allylic reagents.
Alkylation↗
Modification of cysteine residues within G(o) and other neuronal proteins by exposure to nitric oxide.
Nitric oxide (NO), a free-radical gas produced endogenously by some neurons, functions as a diffusible intercellular messenger and appears to play a role in activity-dependent modification of synaptic efficacy in the mammalian CNS. The molecular targets and mechanisms of action of NO in neurons remain largely uncharacterized. Employing in vitro brain slices and isolated synaptosomes, we show here that exposure to exogenous or endogenously generated NO results in the modification of cysteine residues within neuronal proteins, as revealed by reduced binding of agents which react with cysteine sulfhydryls. In particular, exposure of synaptosomes to NO inhibits subsequent thiol-linked ADP-ribosylation of the heterotrimeric G-protein, G(o), by pertussis toxin. Our results demonstrate directly that NO may exert its neuronal effects through modification of protein cysteine thiols, and identify G(o) as a potential synaptic target of NO.
Animals↗
Recurrent lymphoma resulting in Kock pouch incontinence.
Incontinence following the Kock pouch continent cutaneous urinary diversion currently occurs in < 20 percent of patients undergoing the operation. Various causes of cutaneous incontinence have been identified, including efferent nipple prolapse, incompetent valve, pinhole fistula, parastomal herniation, and Marlex mesh erosion into the efferent nipple mechanism. We report the first case of a patient with recurrent lymphoma involving the small bowel utilized for the efferent continence nipple valve mechanism resulting in incontinence.
Carcinoma, Transitional Cell↗
Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience.
Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.
Adult↗
Undiversion in men following prior cystoprostatectomy and cutaneous diversion. Is it practical?
This report discusses the feasibility and functional outcome of conversion to an orthotopic Kock neobladder in 11 men (average age 58 years) who underwent cystoprostatectomy and cutaneous urinary diversion an average of 7.3 years previously are discussed. Cystectomy had been performed for bladder cancer in 9 men and for multiple failed bladder reconstructions in 2. No patient had any evidence of recurrent cancer. The reasons for conversion to a Kock neobladder included complications with the current form of diversion (stomal stenosis, leakage and so forth) and dislike of a cutaneous stoma. Average followup since neobladder conversion was 36 months. The exactness of the anastomosis to the urethra and the presence of a retained apex of the prostate were major factors in the technical success of the operation, degree of continence and satisfaction of the patients. All 4 patients who had some portion of retained prostate enjoy excellent continence without anastomotic stricture. In 2 of the early undiversion patients with direct membranous urethral anastomoses anastomotic strictures occurred and they subsequently chose to resume continent cutaneous diversion. The other 5 patients with anastomoses to the membranous urethral stump did well but 2 required an artificial urinary sphincter for continence. These latter 5 patients had more extensive pelvic mobilization of the urethra for more exact anastomoses. The satisfaction level of all 9 continuing neobladder patients, even if an artificial urinary sphincter was necessary, has been exceptional.
Adult↗
Stenosis of the afferent antireflux valve in the Kock pouch continent urinary diversion: diagnosis and management.
Between August 1982 and May 1988, 503 patients underwent construction of a continent ileal reservoir (Kock pouch) for cutaneous urinary diversion at our university. Stenosis of the afferent antireflux valve resulted in upper urinary tract obstruction in 11 patients (2%). In addition, 2 patients underwent Kock pouch diversion elsewhere and upon referral to our institution they had afferent valve stenosis. To date 13 patients have been identified with this problem. Hydronephrosis was present in 100% of the functional kidneys in these patients. Radiographs of the Kock pouch were uniformly normal without evidence of reflux or other pathological condition. The most common presenting symptom was flank pain in 7 patients (54%) and the most common presenting sign was creatinine elevation above baseline in 7 (54%). Infections recurred with or without sepsis in 5 patients (38%). Ureteroileal anastomotic strictures were not present in any patient. The interval from creation of the Kock pouch to the diagnosis of stenosis ranged from 2 to 75 months (mean 39). All patients underwent endoscopic evaluation of the Kock pouch confirming stenosis of the afferent antireflux valve, and subsequent mechanical dilation of the stenotic valve. Dilation procedures were repeated in 6 patients (46%), 4 of whom subsequently required open surgical revision of the afferent valve. Of these patients 3 are clinically stable and 1 died of the primary malignancy. The remaining 2 patients are clinically and radiographically stable after multiple dilations. Of the 7 patients (54%) requiring only a single dilation 6 are clinically stable and 1 died of the primary malignancy. Stenosis of the afferent antireflux valve of the Kock pouch, previously unreported to our knowledge, is a rare late complication leading to flank pain, hydronephrosis, recurrent infection and elevation of serum creatinine levels. Approximately 50% of the patients respond to a single dilation of the nipple valve. However, most patients who require repeat dilation will need open surgical revision.
Adult↗
Papillary adenocarcinoma of the rete testis: a case report and review of the literature.
Adenocarcinoma of the rete testis is a rare neoplasm with 40 reported cases in the world literature to our knowledge. Although the natural history of this tumor is not well known, it appears highly malignant even in localized forms. Adenocarcinoma of the rete testis is highly resistant to adjuvant radiotherapy and any known chemotherapeutic regimen. We recommend radical orchiectomy followed by a retroperitoneal lymphadenectomy as the treatment for clinically localized Stage A tumors and minimal or microscopic Stage B disease. We report a case of adenocarcinoma of the rete testis and review the world literature.
Adenocarcinoma, Papillary↗
Blunt renal trauma in the pediatric population: indications for radiographic evaluation.
OBJECTIVES: The purpose of this study was to define more clearly the clinical indications for radiographic evaluation of blunt renal injury in the pediatric population. METHODS: Children evaluated for blunt abdominal trauma at the Children's Hospital of Los Angeles and Los Angeles County/University of Southern California Medical Center undergo routine physical examination, laboratory analysis, and computed tomography (CT) scan of the abdomen and pelvis regardless of urinalysis results. We retrospectively evaluated the abdominal and pelvic CT scans of 412 children sustaining blunt abdominal trauma between June 1985 and June 1990. A total of 48 children, ages 6 months to 14 years (mean 5.6 years), with CT-documented renal injuries secondary to blunt trauma were identified. The radiographic findings were correlated with clinical presentation in this group of patients. RESULTS: Of the 48 children sustaining renal injuries (12% of the group), 23 (48%) had renal contusions and 25 children (52%) sustained more serious (significant) renal injuries. Of the children with significant renal injuries, 17 (68%) had minor renal lacerations and 8 (32%) had major renal lacerations. No child sustained a renal pedicle injury. All 25 children sustaining significant renal injuries presented with hematuria: 17 (68%) had microscopic (more than 3 red blood cells per high-power field) and 8 (32%) had gross hematuria. In the 23 children with renal contusions, 4 (17%) had no hematuria, 13 (57%) had microscopic hematuria, and 6 (26%) presented with gross hematuria. Hypotension occurred in 2 of the 25 children with significant renal injuries and in 2 of 23 children with renal contusions. Fifteen of the 25 patients (60%) with significant renal injuries had associated organ injuries, and 17 of the 23 children (74%) with renal contusions had associated organ injuries. CONCLUSIONS: In adults, gross hematuria and microscopic hematuria with hypertension following blunt trauma have been correlated with significant renal injuries requiring radiographic investigation. We conclude that these clinical criteria proposed to guide the radiographic evaluation of the adult population with blunt trauma do not apply to children. In our study, the degree of hematuria did not correlate with the degree of renal injury, and significant renal injury did occur with microhematuria in the absence of hypotension. We suggest that any child with a history of blunt abdominal trauma and any evidence of hematuria should undergo abdominal and pelvic CT scanning for the proper diagnosis and staging of renal and other associated intra-abdominal injuries.
Abdominal Injuries↗
Metastatic renal cell carcinoma to the contralateral ureter.
Renal cell carcinoma uncommonly metastasizes to the ureter, with only rare reports of metastatic lesions developing in the contralateral side. Recently at our institution, two patients presented with contralateral ureteral metastases from a primary renal adenocarcinoma; one was synchronous and the second metachronous. Following extensive metastatic evaluations, both lesions were believed to be solitary metastases. The involved ureters were managed with total ureterectomy and construction of an ileal ureter. We report these two cases and review the literature.
Aged↗
Adjuvant radiation, chemotherapy, and androgen deprivation therapy for pathologic stage D1 adenocarcinoma of the prostate.
OBJECTIVES: A retrospective analysis of the results of an aggressive multimodal approach combining radical prostatectomy with adjuvant radiation, chemotherapy, or androgen deprivation therapy for patients with pathologic Stage D1 prostate carcinoma was performed to assess the impact of these therapies on survival, recurrence, local control, and morbidity. METHODS: Case records of 76 patients with pathologic Stage D1 tumors were reviewed. All had radical retropubic prostatectomy and were recommended adjuvant therapy based on the pathologic extent of the primary tumor and the number of involved lymph nodes. RESULTS: With a median follow-up of 7 years, overall survival was estimated to be 88% and 66% at 5 and 10 years, respectively, and equaled age- and race-matched controls. Prostate cancer-specific survival at 5 and 10 years was 88% and 74%, respectively. The probability of developing a clinically detectable recurrence (excluding prostate-specific antigen [PSA]) was 29% and 62% at 5 and 10 years, respectively. When PSA was added to the detection data, the probability of developing a recurrence increased to 58% and 78% at 5 and 10 years, respectively. Recurrence and cause-specific survival correlated with Gleason sum. Univariate analysis of the adjuvant therapies demonstrated no effect on survival, but adjuvant radiation alone and in combination with androgen deprivation increased the time to recurrence. Local control was excellent, surgical morbidity was equivalent to that of all patients undergoing prostatectomy during the same time period, and the morbidity of adjuvant therapy was minimal. CONCLUSIONS: Survival equivalent to age- and race-matched controls, with excellent control of the extensive primary tumor, can be achieved in patients with Stage D1 prostate carcinoma by a combination of radical prostatectomy and radiation therapy without the need for routine androgen deprivation therapy.
Acid Phosphatase↗
Pulmonary function tests before and after laparoscopic cholecystectomy.
Pulmonary function tests were performed in 22 patients undergoing laparoscopic cholecystectomy. Measurements were made before, 24 h after, and 6 weeks after operation (12 patients). At 24 h postoperatively there were significant decreases in forced expiratory volume in 1 s, vital capacity, functional residual capacity and total lung capacity to 75% (p < 0.001), 73% (p < 0.001), 92% (p = 0.002) and 83% (p < 0.001) of pre-operative values respectively. Inspiratory and expiratory mouth pressures decreased to 66% (p < 0.001) and 63% (p < 0.001) of the pre-operative pressures respectively. There was a reduction in PaO2 (p < 0.01) and an increase in alveolar-arterial gradient (p < 0.001) but no change in PaCO2 at 24 h. The pulmonary function tests measured in the patients who returned after 6 weeks had returned to pre-operative values.
Carbon Dioxide↗
Management of the patient with bladder cancer. Urethral recurrence.
Urethral recurrence develops in roughly 10% of patients following cystectomy for bladder cancer and appears to be another manifestation of the multicentric nature of TCC. By far the greatest risk factor for recurrence is tumor involvement of the prostate in the radical cystectomy specimen, with prostatic stromal invasion more ominous than either ductal or mucosal involvement. For patients in whom orthotopic diversion is contemplated, precystectomy screening of the prostate is recommended by means of deep transurethral biopsy. Surveillance of the urethra following cystectomy should be done by urethral wash cytology at 6-month to yearly intervals and must be continued for life. Management of documented urethral recurrence should be by total urethrectomy, including the meatus.
Carcinoma, Transitional Cell↗
Prolonged weakness and vecuronium.
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Drug Monitoring↗
Postreperfusion syndrome: hypotension after reperfusion of the transplanted liver.
Sixty-nine patients undergoing liver transplantation were evaluated to elucidate the relationship between hypotension and physiological changes seen on reperfusion of the grafted liver. Measured variables included hemodynamic profiles, core temperature, serum potassium, ionized calcium levels, arterial blood-gas tensions, and acid-base state. Measurements were taken 60 minutes after skin incision (baseline), 5 minutes before reperfusion, and 30 seconds and 5 minutes after reperfusion. On the basis of changes in mean arterial pressure (MAP) patients were divided in two groups. Group 1 (n = 49) maintained MAP greater than 70% and group 2 (n = 20) had MAP less than 70% of the baseline value for at least 1 minute within 5 minutes after reperfusion. On reperfusion, changes common to both groups were 27% increase in cardiac filling pressures, 23% base deficit, and 30% serum potassium level and a decrease of 16% in cardiac output and 9% in temperature. Compared with group 1, group 2 had greater decrease in systemic vascular resistance (SVR) (1097 +/- 868 and 741 +/- 399 dyn.s-1. cm-5, respectively, P < .05) and higher potassium level (4.5 +/- 0.8 and 5.3 +/- 0.8 mmol/L, P < .05). Collectively in both groups, there was no correlation between MAP and physiological variables; however, there was a poor correlation with SVR (r = .32, P < .01). Reperfusion hypotension seen in group 2 patients correlated only with a decrease in systemic vascular resistance (r = .5, P < .05). Acute hyperkalemia, hypothermia, and acidosis do not appear to be major causes of reperfusion hypotension.
Adult↗
Radical retropubic prostatectomy and postoperative adjuvant radiation for pathological stage C (PcN0) prostate cancer from 1976 to 1989: intermediate findings.
Between 1976 and 1989, 114 patients undergoing radical retropubic prostatectomy and bilateral pelvic lymph node dissection for prostatic adenocarcinoma were found to have stage PcN0 lesions. Postoperative adjuvant radiation therapy without hormonal treatment was given to 95 of these patients (83%): 26 (27%) with stage C1, 37 (39%) with stage C2 and 32 (34%) with stage C3 disease. The median radiation dose was 45 Gy. given at 180 cGy. daily. Median followup was 4.4 years (range 1.4 to 13.3). The overall 5 and 10-year actuarial rates for the patients were 94% and 70%, respectively. Disease-specific 5 and 10-year actuarial survival rates were 99% and 78%, respectively. At 5 and 10 years the chance of clinical recurrence was estimated as 6% and 13%, respectively, and the chance of recurrence (clinical or indicated by prostate specific antigen levels) was estimated to be 34% and 46%, respectively. Patients with high Gleason scores (8 to 10) and seminal vesicle involvement (stage C3) fared worst. There were 5 patients with clinical distant metastases, 1 with a clinical local recurrence and 1 with both conditions. Detectable elevation of prostate specific antigen without clinically evident recurrence was noted in 25 patients. Radiation therapy was well tolerated with minimal morbidity. Disease-specific survival and survival without clinical recurrence were improved over historical control in patients with stage PcN0 prostate cancer treated by radical prostatectomy alone. These data support a role for adjuvant radiation therapy in stage PcN0 prostate adenocarcinoma following radical prostatectomy.
Adenocarcinoma↗
Impairment of anesthesia task performance by laser protection goggles.
This study was designed to determine whether the wearing of colored goggles, commonly used during laser surgery, increased the time needed to perform simple tasks or the likelihood of medication errors. The Stromberg Dexterity Test and the Medication Sorting Task (MST), a test of our own design, were used to measure the speed and accuracy of identifying medications. Thirty anesthesia care providers performed the tests twice, once with colored goggles and once without. Ambient light during the test was controlled to approximate that in the operating room during laser surgery. Times required to complete the tests improved with repetition of the test. When colored goggles were worn, more time was needed to complete the tests. More errors, especially serious errors in medication sorting, occurred when goggles were worn than when they were not. The wearing of colored goggles in combination with low levels of illumination and stress due to time constraints, may increase the potential for medication errors.
Anesthesiology↗