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Purpose: We investigated the ability of the fusion protein granulocyte-macrophage colony-stimulating factor and carbonic anhydrase IX (GMCA-9)(1) to induce an immune response in vitro and in vivo for the development of a GMCA-9-based kidney cancer vaccine., Experimental Design: Human dendritic cells (DCs) were transduced with a recombinant adenovirus containing the GMCA-9 gene and tested for their capacity to induce CA9-specific cytotoxic T lymphocytes in vitro. Tumor growth was studied in severe compromised immunodeficiency disease (SCID) mice s.c. injected with R11-GMCA-9, a human renal cell carcinoma cell line stably transfected with the GMCA-9 gene. Involvement of natural killer (NK) cells in the antitumor activity of GMCA-9 was determined in SCID mice treated with the NK-blocking agent anti-asialoGM-1., Results: DC and R11 cells transduced with GMCA-9 produced a GMCA-9 protein that is targeted to the cell membrane and partially processed to granulocyte macrophage colony-stimulating factor- and CA9-like products. Furthermore, GMCA-9 was capable of inducing DC maturation, as well as CA9-specific cytotoxic lymphocytes in vitro. Tumor growth of R11 cells in SCID mice was significantly inhibited after transfection with the GMCA-9 fusion gene (P < 0.01). In mice treated with anti-asialoGM-1, R11-GMCA-9 tumors grew significantly faster than those of control mice (P < 0.05), suggesting an involvement of NK cells., Conclusions: Our results suggest that the fusion protein GMCA-9 is capable of generating an immune response both in vitro and in vivo. Additional studies will confirm the utility of ex vivo GMCA-9-transduced DCs as a kidney cancer vaccine.

Background and Objectives: Cervical epidural block is useful in the management of a variety of acute, chronic, and cancer-related pain syndromes involving the head, face, neck, and upper extremities. Knowledge of the depth from the skin to the cervical epidural space (DSES) may be helpful when performing cervical epidural block and may reduce the possibility of complications. We studied DSES in adults and its relationship with patient age, height, weight, and neck circumference., Methods: The study included 816 patients. Cervical epidural block was performed at the C5-6, C6-7, and C7-T1 intervertebral space by a midline approach under fluoroscopic guidance. The depth to the epidural space from the skin was measured., Results: DSES at C5-6, C6-7, and C7-T1 was 4.7 +/- 0.6 cm, 5.1 +/- 0.6 cm, 5.6 +/- 0.8 cm in males and 4.0 +/- 0.6 cm, 4.6 +/- 0.6 cm, 5.0 +/- 0.6 cm in females (mean +/- SD). Linear regression analysis revealed significant correlations between DSES and weight, neck circumference, and body mass index., Conclusion: DSES varies with cervical intervertebral space. DSES increases as one moves caudally. The greatest DSES was noted at C7-T1 in men, and the least was at C5-6 in women. DSES had a significant relationship with weight, neck circumference, and body mass index in both genders.

Purpose: Upper pole tumors with direct extension into the adrenal gland are currently staged as pT3a tumors in the 1997 TNM staging system. To determine whether the clinical behavior of pT3a adrenal tumors differs from that of tumors with perinephric fat invasion (also stage pT3a) a retrospective analysis was performed., Materials and Methods: Of 1,087 patients who underwent nephrectomy 27 were identified with direct adrenal involvement and 187 were identified with perinephric fat or renal sinus involvement. Variables and outcomes analyzed in each group included the percent of patients with metastatic disease at presentation, lymph node involvement, Eastern Cooperative Oncology Group score, response to immunotherapy, and median and overall survival using Kaplan-Meier curves., Results: Median survival for patients with pT3a disease and perinephric or renal sinus fat involvement was 36 months with a 36% 5-year cancer specific survival rate. In contrast, patients with adrenal gland invasion had significantly worse survival at a median of 12.5 months and a 0% 5-year cancer specific survival rate (p <0.001), which was similar to median survival of those with stage pT4 disease (11 months)., Conclusions: Upper pole tumors with direct extension into the adrenal gland predict significantly worse survival than similarly staged tumors with fat invasion and they have a prognosis similar to that of stage pT4 disease. While these data await external validation, consideration should be given to re-categorizing tumors with direct adrenal gland involvement as stage pT4 or in a subcategory such as pT4a.

Objectives: To perform a retrospective study to determine whether survival and immunotherapy response are related to the site of metastases (lung versus bone) and to the number of organ sites involved (one versus multiple). The most common sites of metastatic renal cell carcinoma (mRCC) are the lung and bone., Methods: The records of 434 patients with mRCC were reviewed. Patients with pathologic evidence of nodal involvement were excluded, leaving 120 patients with mRCC to lung only, 33 patients to bone only, and 144 patients with multiple organ involvement. The response rates to immunotherapy and overall survival were compared. The variables evaluated in statistical analyses included Eastern Cooperative Oncology Group score, grade, 1997 tumor stage, and multiple organ involvement., Results: The median survival for patients with lung only and bone only mRCC was 27 months; patients with multiple organ involvement had a median survival of 11 months. In patients who underwent nephrectomy followed by immunotherapy, the median survival time was 31, 31, and 13 months in the lung, bone, and multiple sites groups, respectively. The response rate to immunotherapy after nephrectomy was 44%, 20%, and 14% in the lung, bone, and multiple organ groups, respectively. Multivariate analysis confirmed that metastatic disease to more than one organ site was associated with poor prognosis (2.05 risk ratio, P <0.001)., Conclusions: Patients with mRCC to only one organ site fared significantly better than patients who had evidence of disease in multiple organs. Survival in patients with disease limited to the lung was similar to that of patients whose disease was limited to bone.

Purpose: Metastatic renal cell carcinoma (RCC) has a poor prognosis and an unpredictable course. To date, there are no molecular markers which can reliably predict RCC outcome. We investigated whether a novel kidney cancer marker, carbonic anhydrase IX (CAIX), is associated with progression and survival., Experimental Design: Immunohistochemical analysis using a CAIX monoclonal antibody was performed on tissue microarrays constructed from paraffin-embedded specimens from patients (N = 321) treated by nephrectomy for clear cell RCC. CAIX staining was correlated with response to treatment, clinical factors, pathologic features, and survival., Results: CAIX staining was present in 94% of clear cell RCCs. Survival tree analysis determined that a cutoff of 85% CAIX staining provided the most accurate prediction of survival. Low CAIX (

Background: Positron emission tomography (PET) is an emerging imaging modality that is being investigated for use in urologic oncology. PET scanning using the radioactive glucose analog FDG has proven to be a highly accurate imaging test for diagnosing and staging a variety of non-urologic cancer types. This review was performed to determine the role of PET imaging in genitourinary malignancies., Methods: A review of the literature focusing on PET and urologic oncology was performed. The role of PET imaging was reviewed in prostate, bladder, renal, and testicular cancer., Results: In testicular cancer, PET has a higher diagnostic accuracy than computed tomography (CT) for both staging and re-staging and should be the test of choice for the assessment of a CT-visualized residual mass following chemotherapy. In prostate, renal, and bladder cancer, the current role of PET is still being defined, but it has a high positive predictive value and can be used for problem solving in patients with indeterminate findings on conventional imaging. Its role in the diagnosis and staging of prostate cancer is hampered by the generally low glycolytic rate of most prostate tumors and their metastases. It has shown promise for staging and re-staging patients with advanced-stage disease and aggressive tumors suspected by a high tumor grade and high prostate-specific antigen velocity. PET has also demonstrated success when applied to renal cell carcinoma in classifying indeterminate renal masses as well as residual renal fossa masses following nephrectomy, gauging response to therapy, and staging and re-staging patients with a known diagnosis of renal cell carcinoma., Conclusions: PET imaging has demonstrated great potential in certain applications, but further investigations are necessary to determine its eventual place as an imaging modality in genitourinary malignancies.

Objectives: To review the incidence and the impact of pulmonary seed migration after prostate brachytherapy on lung function. Isolated reports of seed migration to the lungs after prostate brachytherapy have been published; however, the clinical consequences of this pulmonary migration have not been adequately evaluated., Methods: We performed a retrospective review of patients undergoing prostate brachytherapy from 1998 to 2000. Pulmonary imaging with chest x-ray was performed 15 to 90 days (median 45) after the procedure. The chest radiographs were reviewed by a single radiologist (V.S.D.), and patients with seed migration to the lungs were evaluated by a single pulmonologist (A.M.H.) using a questionnaire, chest radiography, and pulmonary function tests. Computed tomography of the prostate after seed implantation was performed to check seed position and dosimetry. Odds ratio, confidence intervals, chi-square tests, and logistic regression analysis were performed to evaluate the relationship between the type and number of seeds used, the incidence of pulmonary migration, and the effects on pulmonary function., Results: A total of 83 patients underwent prostate brachytherapy during the study period and 58 patients underwent chest radiography. Seed migration occurred in 21 (36.2%) of 58 patients (95% confidence interval 23.8% to 48.6%). Thirty-four (0.71%) of 4755 seeds used migrated to the lungs. Nine patients had single seed migration to the right lung and three to the left lung. Nine patients had multiple (maximum of 4) and bilateral seed migration. No consistent relationship was found between seed migration and the type of seeds used (P = 0.24). Borderline statistical significance suggested an increased incidence of seed migration with an increasing number of implanted seeds (P = 0.054). Repeat chest radiography in 21 patients revealed no delayed migration at a median follow-up of 16 months. Clinical and pulmonary function testing revealed no consistent abnormality attributable to seed migration., Conclusions: Radioactive seed migration occurred in 36.2% of brachytherapy patients who had chest radiographs done in our series. Pulmonary seed migration may be influenced by the number of implanted seeds and does not appear to be influenced by the seed type. Additional study of this observed phenomenon is required. A thorough pulmonary workup failed to reveal any short-term harmful side effects; however, long-term follow-up is needed. Healthcare providers should discuss the possibility of pulmonary seed migration with patients with prostate cancer considering prostate brachytherapy.

Priapism is well documented as a potential side effect of psychotropic medications. To date, there have been no reports of risperidone-induced priapism in the urologic literature. We report a case of risperidone-induced priapism requiring surgical treatment.

Several urine markers have been and are currently being investigated for the diagnosis and prognostication of bladder malignancies. While cystoscopy and urine cytology remain the gold standard in the detection of bladder cancer, cystoscopy is invasive and cytology yields low sensitivities in low-grade disease. The availability of a non-invasive, accurate, office-based test would be ideal. In this review, we discuss markers that are useful in the prevention and detection of transitional cell carcinoma of the bladder. In general, each of the markers has better sensitivities than cytology, but lower specificities. Furthermore, each of these markers must still be used in adjunct with cystoscopy.

Renal cell carcinoma is the most common cancer in the kidney, affecting nearly 30,000 Americans every year and is associated with over 12,000 deaths annually. If detected early, renal cell carcinomas can be cured surgically. However, once metastatic disease develops the prognosis for long-term survival is poor. Unfortunately, one-third of patients have metastatic disease at the time of diagnosis and approximately 50% of the patients undergoing surgical resection for less advanced disease eventually relapse. This review examines the clinical and molecular prognostic tools currently available or under investigation for kidney cancer.

Metastatic cancer presenting as an oral lesion is exceedingly uncommon. To the best of our knowledge this is the first reported instance of renal cell carcinoma presenting initially as an oral lesion.

Blunt trauma to the penis is an uncommon injury in young children. We present two cases of blunt penile trauma secondary to mechanical compression from a toilet seat.

Lymph node mapping has become an integral part of the management of melanoma and breast cancer with regard to both staging and treatment. We report our technique for lymphatic mapping and intraoperative lymphoscintigraphy applied to a patient with penile melanoma. This technique may improve the sensitivity of identifying the sentinel lymph node in patients with malignant penile lesions.

Purpose: Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion., Materials and Methods: Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months., Results: Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia., Conclusions: Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.

Purpose: Prostate cancer foci have a characteristic appearance on endorectal magnetic resonance imaging (MRI) which might be useful for prostate cancer detection. In this pilot study the ability of endorectal MRI to detect prostate cancer foci prospectively in men at risk for a malignant prostatic neoplasm is assessed., Materials and Methods: Endorectal MRI was performed in 33 consecutive men with 1 or more prior negative prostatic biopsies. All studies were read by 2 MRI dedicated study radiologists in consensus before and after receiving patient clinical data. Areas of interest on endorectal MRI were mapped as low, moderate or high suspicion for carcinoma on a prostate model. Directed needle biopsy cores of the prostate were obtained based on this model, and the histopathological findings were compared with MRI results., Results: Carcinoma was detected in 7 of 33 men (21.2%) on post-MRI biopsy, including 1 of 18 (5.6%) with low, 1 of 8 (12.5%) with moderate and 5 of 7 (71.4%) with high suspicion MRI. The site of positive biopsy correlated correctly with the area of suspicion on MRI in 85.7% of cases. Overall, endorectal MRI had 40% positive predictive value (moderate or high suspicion), 94.4% negative predictive value (low suspicion) and 69.7% accuracy. On multivariate analysis positive endorectal MRI was associated with an 11.3-fold risk of positive biopsy., Conclusions: Endorectal MRI may effectively stratify patients with prior negative prostatic biopsy into low, moderate and high risk groups for a malignant prostatic neoplasm, and may improve our ability to identify prostatic tumor foci prospectively.

We describe the first case of an ureteroarterial fistula developing after orthotopic neobladder substitution and its minimally invasive management using endovascular stent grafting. We outline the risk factors for the development of ureteroarterial fistulae and trace the evolution of diagnostic and therapeutic modalities used in the management of these life-threatening complications. Minimally invasive management with endovascular stent grafting and exclusion of two pseudoaneurysms in the iliac artery system was performed successfully. After successful endovascular exclusion of two pseudoaneurysms, the patient's hematuria resolved and he recovered fully. Three-dimensional computed tomography performed 3 months later documented a patent aortoiliac arterial system without evidence of pseudoaneurysm or endovascular leak. Ureteroarterial fistula after orthotopic bladder substitution was managed with an endovascular stent graft without the need for extra-anatomical vascular bypass. Early recognition, stabilization, and angiographic evaluation followed by this minimally invasive technique may avoid open operative repair and attendant morbidity.

Werdnig-Hoffman Disease (WHD) is a rare type of spinal muscular atrophy which causes progressive deterioration of the lower motor neurons of the spinal cord and the brainstem. To our knowledge we report the first case of neurogenic bladder documented on urodynamic studies of a patient with WHD.

We report a case of blunt trauma causing both a pseudoaneurysm and an arteriocalyceal fistula. These 2 lesions have not previously been reported occurring simultaneously as a complication of renal trauma. Pathophysiology, clinical presentation, and management options are discussed. Angiography in this case was both diagnostic and therapeutic. Selective and superselective gelfoam embolization led to immediate resolution of both injuries.