Aggressive management of elderly patients with muscle-invasive bladder cancer.
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Aged↗
Biomedical subjects
Alon Z Weizer
Publications and source records attributed to Alon Z Weizer.
Use of negative-pressure dressings and split-thickness skin grafts following penile shaft reduction and reduction scrotoplasty in the management of penoscrotal elephantiasis.
From 1988 to 2005, 8 men who presented with penoscrotal elephantiasis underwent penile shaft degloving and reduction scrotoplasty, followed by transplantation of a split-thickness skin graft (STSG) to the penile shaft. The etiology of elephantiasis in these patients included self-injection of viscous fluid and postsurgical obstructive lymphedema. In the 6 most recent cases, negative-pressure dressings were applied over the STSG to promote graft take, and STSG take rate was 100%. The results of our series corroborate those of a previous report, which showed circumferential negative-pressure dressings to be safe and efficacious in bolstering STSGs to the penile shaft. Furthermore, these results suggest that the use of negative-pressure dressings may improve graft take in this patient population.
Bandages↗
Ureteroscopic management of renal calculi in anomalous kidneys.
OBJECTIVES: To review our experience with ureteroscopy in treating patients with renal calculi in anomalous kidneys and to evaluate the efficacy of this approach. METHODS: Eight patients with renal calculi in anomalous kidneys who were managed by ureteroscopic procedures were identified. Demographic information, preoperative stone burden, operative information (ureteroscope size, lithotrite used, instruments used, duration of surgery, complications, stenting), follow-up imaging, and complications were obtained from the medical record. This information was analyzed to determine the most frequently used instruments and stone-free rates. RESULTS: Our cohort consisted of 4 patients with horseshoe kidneys (HSK) and 4 patients with pelvic kidneys (PK) (6 male, 2 female, mean age, 50.6 years). The average preoperative stone burden of the 11 treated calculi was 1.4 cm, with 5 stones located in the renal pelvis, 2 in the upper pole, and 4 in lower pole calyces. A 7.5F flexible ureteroscope, holmium laser lithotripsy, and nitinol baskets and graspers were used in all patients. Six patients had complete clearance of the stone on postoperative imaging (75% HSK, 75% PK), with 88% of patients asymptomatic after their procedure. No patients required additional surgical intervention. CONCLUSIONS: Flexible ureteroscopy with holmium laser lithotripsy and the use of nitinol baskets and graspers provides a reasonable alternative to shock wave lithotripsy in the management of patients harboring renal calculi in anomalous kidneys. In addition, ureteroscopy can be considered a primary option for managing select patients with symptomatic stones in PKs before a percutaneous surgical approach.
Adult↗
Complications after percutaneous radiofrequency ablation of renal tumors.
OBJECTIVES: To evaluate our experience with percutaneous radiofrequency ablation (pRFA) to determine common characteristics of patients with complications, to elucidate possible relative contraindications to therapy. METHODS: Medical records of all patients undergoing pRFA were reviewed for demographic data, medical and surgical history, indication, tumor characteristics, and treatment information (complications and management). The group of patients with complications was analyzed for common characteristics. RESULTS: From January 2000 to September 2003, 24 patients (mean age 61 years, 5:1 male/female) with 32 renal tumors were treated with pRFA. Indications for pRFA included prior renal surgery and/or chronic renal insufficiency, significant medical disease, patient choice, von Hippel-Lindau disease, and treatment of a metastasis. Average pretreatment tumor size was 2.4 cm (range 0.5-8.6 cm). Of the 5 patients experiencing complications from pRFA treatment, 2 developed perinephric hematomas, 1 had a persistent urinoma and proximal ureteral stricture, and 2 had colonic injuries. Among patients with complications, 3 of 5 had undergone prior partial nephrectomy on the pRFA-treated kidney. Two of four patients treated for multiple tumors and 57% of patients (4 of 7) with anteriorly located tumors experienced complications. CONCLUSIONS: Early experience with pRFA for renal tumor seems promising, but patient selection criteria are evolving. On the basis of our limited experience, we recommend caution when using renal pRFA in patients with prior partial nephrectomy, multiple tumors treated in the same setting, and tumors located anteriorly or centrally. Further clinical experience will help establish guidelines for the use of this powerful technology in the management of renal tumors.
Aged↗
Twenty-five years of shockwave lithotripsy: back to the future?
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Humans↗
Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience.
OBJECTIVES: To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer. METHODS: A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs. RESULTS: The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs. CONCLUSIONS: RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.
Adult↗
Bilateral renal calculi: assessment of staged v synchronous percutaneous nephrolithotomy.
BACKGROUND AND PURPOSE: Percutaneous stone removal has replaced open renal surgery and has become the treatment of choice for large or complex renal calculi. However, patients with large bilateral stone burdens still present a challenge. Simultaneous bilateral percutaneous nephrolithotomy (PCNL) has been demonstrated to be a well-tolerated, safe, cost-effective, and expeditious treatment. We present what is, to our knowledge, the first large retrospective series comparing synchronous and asynchronous bilateral PCNL. PATIENTS AND METHODS: A chart review was performed on 26 patients undergoing 57 PCNLs for bilateral renal calculi over a 7-year period. Seven patients received synchronous PCNL (same anesthesia; Group 1), and 19 patients underwent asynchronous PNL (procedures separated by 1-3 months; Group 2). Complete surgical and hospital records were available on all patients. The average stone burden for Group 1 was 8.03 cm(2) on the left and 9.18 cm(2) on the right v 10.1 cm(2) on the left and 14.23 cm(2) on the right for Group 2 (P> 0.05). Variables of interest included anesthesia time, operative time, blood loss, transfusion rates, length of hospital stay, and complication rates. Each variable was evaluated per operation and per renal unit. Follow-up imaging with stone assessment was available on 20 patients. RESULTS: Group 1 required 1.14 access tracts per renal unit to attempt complete clearance of the targeted stones v 1.88 tracts per renal unit in Group 2 (P> 0.05). The average operative time per renal unit was significantly less in Group 1 (83 minutes) than in Group 2 (168.5 minutes) (P< 0.0001), as was blood loss (178.5 mL v 307.4 mL, respectively; P= 0.02). However, blood loss per operation was similar at 357 mL in Group 1 and 282 mL in Group 2. Comparable transfusion rates of 28.6% and 36.8%, respectively, were noted. Forty percent of the patients in Group 1 were completely stone free compared with 36% of the patients in Group 2; however, an additional 50% and 57%, respectively, had residual stone burden <4 mm (P> 0.05). Complications occurred in 2 of 7 operations (28%) in Group 1 and 8 of 42 operations (19%) in Group 2. The total length of hospital stay was nearly doubled for patients undergoing staged PCNL (P= 0.0005). CONCLUSIONS: These results demonstrate similar stone-free rates, blood loss per operation, and transfusion rates for simultaneous and staged bilateral PCNL. The reduced total operative time, hospital stay, and total blood loss, along with the requirement for only one anesthesia, makes synchronous bilateral PCNL an attractive option for select individuals. However, in patients with larger, less easily accessible stones, excessive bleeding may be encountered more frequently on the first side, thereby delaying management of the second side to a later date. Synchronous bilateral PCNL should be considered in patients in whom the first stage of stone removal is accomplished quickly and safely.
Adolescent↗
When to diagnose and how to treat prostate cancer in the "not too fit" elderly.
The appropriate management of elderly patients diagnosed with prostate cancer remains controversial. In order to provide guidelines as to when aggressive local treatment may be indicated, we provide estimates of the long-term probability of death from prostate cancer and other competing causes in patients of 70 years of age or older, who underwent radical surgery in the form of radical perineal prostatectomy for clinically non-metastatic disease. In this study, a total of 484 patients with an age of 70 or above who underwent radical perineal prostatectomy between 1970 and 2000 comprised a retrospective cohort of patients with clinically organ confined prostate cancer. Of these patients, 461 patients (95.3%) had a minimum follow-up of half a year and were included in the analysis. The median age was 73 years (range 70-81 years) and the median follow-up was 5.4 years. Overall 115 men died during the follow-up period with 49.6% of deaths attributable to prostate cancer. The median time to cancer-associated death was 17.5 years and the median time to death of any cause 11.6 years. When the likelihood of death from prostate cancer as a function of Gleason score was estimated, the 10-year cancer-associated death rates of patients with Gleason scores of 2-6, 7 and 8-10, were 15.2, 25.2 and 40.2%, respectively. In the subset of patient with margin positive disease the estimated likelihood of a cancer-associated death was 45.3% after 10 years. While the median time to cancer-associated death for margin positive patients with a Gleason score of 2-6 was not reached, patients with a Gleason score of 7 and 8-10 experienced median cancer-associated survival times of 9.6 and 7.6 years, respectively. In conclusion, Gleason score is a strong predictor of the likelihood of prostate cancer related death in elderly patients. Patients with a given Gleason score and a projected life expectancy of at least 10 years may be at similar risk of dying of prostate cancer as younger patients.
Aged↗
Durability of the medical management of cystinuria.
PURPOSE: Cystinuria is an autosomal recessive disorder of dibasic amino acid transport in the kidney that leads to an abundance of cystine in the urine. This molecule is poorly soluble in urine and it is prone to crystallization and stone formation at concentrations above 300 mg./l. Medical treatment in these patients has incorporated increasing urine volumes, alkalinization and thiol medications that decrease the availability of free cystine in urine. Despite a reasonable prognosis for reduced stone formation we and others have noted difficulties in patients complying with medical management recommendations. Therefore, we evaluated the durability of treatment success in our patients with cystinuria. MATERIALS AND METHODS: A retrospective chart review was performed in all patients with cystinuria referred to the comprehensive kidney stone center at our institution for an 8-year period. Medical therapy, stone recurrence rates, compliance with medications and scheduled followup, and the results of metabolic evaluations via 24-hour urine collections were reviewed. The average concentrations of urinary cystine in initial and followup 24-hour samples were compared in patients compliant and noncompliant with medical treatment. In addition, each patient was mailed a 1-page questionnaire to assess the self-perception of medical compliance. RESULTS: We identified 26 patients with a mean age of 32 years at referral (range 13 to 67) who were followed an average of 38.2 months (range 6 to 83). Females represented 58% of those with cystinuria. Overall compliance with medical recommendations was poor with a short duration of success. Of the 26 patients followed at our stone center only 4 (15%) achieved and maintained therapeutic success, as defined by urine cystine less than 300 mg./l. An additional 11 patients (42%) achieved therapeutic success but subsequently had failure at an average of 16 months (range 6 to 27). Of these patients 7 (64%) regained therapeutic success at an average of 9.4 months (range 4 to 20). Five patients (19%) never achieved therapeutic success, while an additional 6 (23%) failed to present to followup appointments or provide subsequent 24-hour urine studies despite referral to a tertiary care center. Patient self-assessment of medical compliance was uniformly high regardless of physician perceptions or treatment results. CONCLUSIONS The durability of medically treating patients with cystinuria is limited with only a small percent able to achieve and maintain the goal of decreasing cystine below the saturation concentration. Greater physician vigilance in these complicated stone formers is required to achieve successful prophylactic management. Furthermore, these patients require better insight into the own disease to improve compliance.
Adolescent↗
Assessment of stricture formation with the ureteral access sheath.
OBJECTIVES: To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether the device might cause significant ureteral trauma. METHODS: Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureterotomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and 70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days (range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients. RESULTS: The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The access sheath did not appear to be a contributing factor. CONCLUSIONS: The results of our series indicate that the ureteral access sheath is safe and beneficial for routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered. We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac vessels.
Adolescent↗
Prospective evaluation of pain medication requirements and recovery after radical perineal prostatectomy.
OBJECTIVES: To perform a study to quantify the variables relating to postoperative pain, activity, and gastrointestinal function after radical perineal prostatectomy to allow comparisons with alternative treatments. METHODS: Ninety-eight consecutive radical perineal prostatectomy candidates between January 2001 and December 2001 with clinically localized prostate cancer were prospectively evaluated. The time to tolerate solid food, time to unassisted ambulation, postoperative pain levels (analog pain scale of 1 to 10), and perioperative analgesic requirements (in morphine equivalents) were selected as the analysis endpoints and correlated with preoperative (age, American Society of Anesthesiology class, body mass index, and serum prostate-specific antigen level), intraoperative (node dissection, operating room time, and estimated blood loss), and postoperative (Gleason score, tumor stage, and lower extremity neurapraxia) patient variables. RESULTS: The mean time to tolerate solid food and unassisted ambulation was 21.2 +/- 1.4 and 22.4 +/- 0.8 hours, respectively; 25.5% of patients experienced transient lower extremity neurapraxia, which was associated with longer operative times (P = 0.001). In a multivariate regression analysis, lymph node dissection correlated with both a prolonged time to tolerate solid food (P = 0.002) and unassisted ambulation (P = 0.001) and neurapraxia with an extended time to unassisted ambulation (P = 0.018). The narcotic requirements were greatest on postoperative day 1, totaling 31.7 +/- 3.0 morphine equivalents, of which 90.5% +/- 3.1% were met with oral analgesics. The average maximal pain scores were highest the first week after discharge (4.7 +/- 0.3), yet approached baseline levels by 4 weeks (1.7 +/- 0.2) after surgery at which time no patient required any pain medication. CONCLUSIONS: Modern radical perineal prostatectomy offers a favorable outcome profile with early patient recovery and low narcotic requirements. A future prospective study should directly compare radical perineal, retropubic, and laparoscopic prostatectomy to document whether the latter offers any advantages with respect to these outcome parameters.
Adult↗
In vitro analysis of stone fragmentation ability of the FREDDY laser.
BACKGROUND AND PURPOSE: The Frequency-Doubled Double-Pulse Nd:Yag) (FREDDY) laser (World of Medicine, Berlin Germany) is a short-pulsed, double-frequency solid-state laser with wavelengths of 532 and 1064 nm. This low-power, low-cost laser was developed for intracorporeal lithotripsy. We designed an experimental set-up to test its fragmentation efficiency at different energy and frequency settings. MATERIALS AND METHODS: Forty previously weighed plaster-of-Paris stone phantoms were divided into four groups in order to test fragmentation at 5 and 10 Hz for 2 and 4 minutes. A hands-off underwater laboratory set-up including a holder to keep the stone phantom in contact with the quartz laser fiber was utilized. The 280-microm laser fiber was cleaved and stripped between runs to ensure optimal energy delivery. After fragmentation was completed, all of the stone fragments remaining within the holder were allowed to desiccate for 48 hours and reweighed. Fragmentation was measured as the percentage weight loss. RESULTS: Stone phantoms fragmented at 5 Hz for 2 minutes sustained a mean 24% loss of weight, whereas the 4-minute treatment at 5 Hz reduced stone weight by 54%. Treatment at 10 Hz for 2 minutes demonstrated results similar to those of stones treated for 4 minutes at 5 Hz, reducing stone weight by 51%. Fragmentation at 10 Hz for 4 minutes revealed a 64% loss of mass, less than expected for these power settings. Fiber deterioration observed at the higher energy settings may be the cause of the reduced stone-fragmentation efficiency. CONCLUSIONS: Fragmentation with the FREDDY laser in the 5 Hz, 4 minutes and 10 Hz, 2 minutes protocols is comparable, suggesting that stone fragmentation correlates well with the total energy delivered to the stone. The slight drop in fragmentation efficiency at 10 Hz, 4 minutes is most likely explained by fiber damage occurring consistently at these higher energy settings. The safety profile and low investment and running costs of this laser are advantages that suggest the laser warrants further clinical trials.
In Vitro Techniques↗
A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy.
PURPOSE: Recent studies have suggested an increased incidence of fecal incontinence following radical perineal prostatectomy. We provide a prospective and longitudinal assessment of bowel related symptoms of patients undergoing radical perineal prostatectomy. MATERIALS AND METHODS: A total of 78 patients who underwent radical perineal prostatectomy between January 1 and December 31, 2001 and had a minimal followup of 6 months were included in the analysis. Patient information was obtained from the chart and the bowel domain specific questions of a validated quality of life questionnaire, the Expanded Prostate Cancer Index Composite. The questionnaire was administered to the candidates preoperatively, at 4 weeks following surgery and subsequently at 3-months intervals. A mean bowel function, bother and summary health related quality of life score was calculated at each interval. The duration of new or worsened symptoms with respect to baseline was evaluated using Kaplan-Meier analysis. RESULTS: Symptoms of involuntary stool leakage and rectal urgency were reported by 11.5% (9 of 78) and 19.2% (15) of patients preoperatively. While all bowel related symptoms transiently increased following surgery, rectal urgency was the most persistent symptom, yet normalized in more than 90% of patients within 9 1/2 months. Compared to individual baseline 15.4%, 7.7%, 5.1% and 3.9% of patients reported worsened symptoms of fecal incontinence after 3, 6, 9 and 12 months, respectively. In the subset of 69 patients who denied preoperative fecal incontinence the incidence of involuntary stool leakage was 2.9% by 12 months following radical perineal prostatectomy. Of 10 patients 9 recovered individual health related quality of life score by 6 months after prostatectomy. CONCLUSIONS: Longitudinal assessment of self-reported questionnaire data suggests that fecal incontinence and bowel related symptoms are more prevalent following radical perineal prostatectomy compared to baseline, yet resolve in the majority of patients with time in the early postoperative period.
Adult↗
Percutaneous management of calculi within horseshoe kidneys.
PURPOSE: Percutaneous treatment of patients with calculi in a horseshoe kidney can be challenging due to the altered anatomical relationship in the retroperitoneum. Therefore, we performed a multi-institutional review to assess the safety and efficacy of this minimally invasive technique. MATERIALS AND METHODS: Of 37 patients identified with calculi in a horseshoe kidney at 3 institutions 24 (65%) underwent percutaneous nephrolithotripsy as primary treatment. Average patient age was 48.4 years and 75% of the patients were male. In 3 patients with staghorn calculi mean stone size as measured by computed digitized stone surface area was 448 mm2. Mean followup was 5.8 months. The stone-free rate, complication rate, need for secondary intervention and stone composition were evaluated. RESULTS: Renal access was obtained through an upper pole calix in 63% of the cases, a lower calix in 25% and a middle calix in 4%. Access location was not documented in 1 patient (4%). Of the 24 patients 21 (87.5%) were rendered stone-free after primary or second look procedures. Flexible nephroscopy was used in 84% of cases. Minor complications occurred in 4 patients (16.7%), whereas 3 (12.5%) experienced major complications, including significant bleeding necessitating early cessation, nephropleural fistula and pneumothorax. No deaths occurred as a result of this treatment choice. Stone analysis was available for 21 cases (87.5%). Calcium stones predominated (87.5%), followed by uric acid (9.5%) and struvite (4.8%). CONCLUSIONS: Percutaneous treatment of patients with renal calculi in a horseshoe kidney is technically challenging, usually requiring upper pole access and flexible nephroscopy due to the altered anatomical relationships of the fused renal units. The success rate based on stone-free results and a relatively low incidence of major complications suggest that this minimally invasive management option is an effective means of stone management in this complex patient population.
Adult↗
Determining the incidence of horseshoe kidney from radiographic data at a single institution.
PURPOSE: An estimated 150,000 children are born with birth defects each year. One of the most frequent genitourinary abnormalities is horseshoe kidney (HSK). The incidence of HSK in the population is estimated to be 1/400 to 1,600 births based on autopsy data from the 1940s and 1950s. We prospectively evaluated the incidence of HSK based on radiographic studies to determine the contemporary incidence of HSK. MATERIALS AND METHODS: In a 6-month period patients undergoing abdominal computerized tomography, renal ultrasonography and excretory urography were screened for HSK. After identification medical charts were reviewed for demographics, history, study indication and findings. A literature review of 12 studies of 825 patients with HSK was compared with the current series with regard to common associated findings. RESULTS: From 15,320 radiographs 23 patients were identified with HSK for an overall incidence of 1/666. Computerized tomography, excretory urography and ultrasound identified 16, 5 and 2 patients, respectively, while 16 were male, 7 were female, 20 were adults and 3 were children. The most common concomitant urological disorder was nephrolithiasis in 9 patients (39%), prompting operative intervention in 4. The radiographic incidence of HSK closely matched data from autopsy series and yet it differed from that in current radiographic series using ultrasound in the perinatal period. CONCLUSIONS: Our radiographic evaluation of the HSK incidence closely matches past autopsy series. This finding suggests that the incidence of HSK remains stable despite an increasing number of birth defects. Moreover, it appears that radiographic studies can accurately estimate the incidence of congenital anatomical disorders. Our data suggest that HSK is a relatively benign condition with a low requirement for operative intervention in these incidentally identified patients.
Adolescent↗
Urinary continence and quality of life in the first year after radical perineal prostatectomy.
PURPOSE: We attempt to characterize the return of urinary continence and urinary domain related quality of life objectively after radical perineal prostatectomy (RPP). MATERIALS AND METHODS: A total of 92 RPP candidates were prospectively enrolled in a quality of life (QOL) survey using a validated assessment tool and evaluated before surgery, and then after surgery at 1 month and subsequent 3-month intervals. The time to regain continence based on 3 different definitions and the time to recover baseline urinary domain related QOL was calculated. RESULTS: Median time to regain continence after RPP ranged from 3.0 to 3.3 months depending on the definition of continence. Median time for patients to regain continence depending on age (younger than 55, 55 to 64 and older than 64) and medical comorbidities (none, 1 and 2 or more) varied between 1.4 +/- 0.3, 3.0 +/- 0.9 and 3.3 +/- 0.4 months, respectively (p = 0.028), and 1.4 +/- 0.2, 3.3 +/- 0.2 and 3.5 +/- 2.6 months, respectively (p = 0.009). Twelve months after RPP 84%, 66% and 82% of patients regained individual baseline urinary summary, function and bother scores, respectively. Postoperative radiation (XRT) represented the only independent predictor of the time to recover baseline urinary domain summary scores in a multivariate analysis (p = 0.042) with a median delay in the XRT (10 patients) and nonXRT group (82 patients) of 8.0 and 6.7 months, respectively. CONCLUSIONS: Based on self-reported questionnaire data, a majority of patients regain urinary continence and urinary domain related QOL within 12 months after RPP. The time course of recovery from radical prostatectomy represents an important outcome criterion that should be shared with patients considering treatment options.
Adult↗
Enhanced induction of telomerase-specific CD4(+) T cells using dendritic cells transfected with RNA encoding a chimeric gene product.
Dendritic cells (DCs) transfected with mRNA encoding human telomerase reverse transcriptase (hTERT) have been shown to represent potent inducers of CTLs and antitumor immunity. However, it has become widely accepted that not only CTLs but also CD4(+) T helper cells are critical to the generation, as well as to the maintenance, of potent antitumor responses in vivo. In this study, we sought to determine whether human DCs transfected with mRNA encoding a chimeric hTERT/lysosome-associated membrane protein (LAMP-1) protein, carrying the endosomal/lysosomal sorting signal of the LAMP-1, are capable of stimulating concomitant hTERT-specific CD8(+) and CD4(+) T-cell responses in vitro. We show that processing of hTERT/LAMP-1 transcripts leads to enhanced stimulation of hTERT-specific CD4(+) T cells and does not negatively affect intracellular generation and subsequent presentation of MHC class I epitopes, hence, generating a CTL response. These findings provide a preclinical rationale of using DCs transfected with the chimeric hTERT/LAMP-1 RNA in vaccine trials to facilitate generation of antigen-specific CD4(+) T-cell responses that may be required to stimulate and maintain an optimal CD8(+) CTL response in vivo.
Antigens, CD↗
Techniques to maximize flexible ureteroscope longevity.
OBJECTIVES: To assess methods to improve the longevity and durability of flexible ureteroscopes by using the ureteral access sheath, 200-microm holmium laser fiber, and nitinol baskets or graspers during routine ureteroscopic procedures. Despite adequate advances in fiberoptics and endoscope design, the decreased size of currently available flexible ureteroscopes makes damage inevitable after repeated use. However, new auxiliary tools may be able to enhance ureteroscope durability. METHODS: The indications for performing flexible ureteroscopy were proximal ureteral stones (n = 32), renal calculi (n = 59), treatment of upper tract transitional cell carcinoma (n = 3), evaluation of hematuria or filling defect (n = 7), and treatment of ureteral strictures or ureteropelvic junction obstruction (n = 8). Using four new 7.5F flexible ureteroscopes, we prospectively evaluated the number of passes of each ureteroscope until more than 20 optical fibers were broken, more than a 25 degrees loss of deflection in either direction had occurred, or the instrument sustained injury requiring repair by the manufacturer. RESULTS: One hundred nine flexible ureteroscopic procedures (average 27.5 procedures per instrument; range 19 to 34) were performed with the four new flexible ureteroscopes before being sent for repair. Adjuncts to reduce scope damage during these procedures were the use of the ureteral access sheath (n = 109), nitinol devices allowing lower pole stone retrieval (n = 27), and the 200-microm holmium laser fiber for stone fragmentation, tumor ablation, and incision of ureteropelvic junction/ureteral stenoses (n = 91). The average number of passes until more than 20 optical fibers were broken was 15.3 (range 12 to 20), until more than a 25 degrees loss of deflection occurred was 50.3 (range 42 to 66), or until the scope required repair was 66.7 (range 46 to 82). CONCLUSIONS: Flexible ureteroscopy will be used increasingly to manage upper urinary tract pathologic findings. Historically, the number of procedures performed before a flexible ureteroscope requires repair averaged 6 to 15. By incorporating the new ureteroscopic accessories, such as nitinol devices, a ureteral access sheath, and the 200-microm holmium laser fiber into common practice, one can reduce the strain on these fragile 7.5F endoscopes, thereby maximizing their longevity.
Equipment Failure↗