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BACKGROUND: Traditional single-marker and multimarker molecular profiling approaches in bladder cancer do not account for major risk factors and their influence on clinical outcome. This study examined the prognostic value of molecular alterations across all disease stages after accounting for clinicopathological factors and smoking, the most common risk factor for bladder cancer in the developed world, in a population-based cohort. METHODS: Primary bladder tumors from 212 cancer registry patients (median follow-up, 13.2 years) were immunohistochemically profiled for Bax, caspase-3, apoptotic protease-activating factor 1 (Apaf-1), Bcl-2, p53, p21, cyclooxygenase-2, vascular endothelial growth factor, and E-cadherin alterations. “Smoking intensity” quantified the impact of duration and daily frequency of smoking. RESULTS: Age, pathological stage, surgical modality, and adjuvant therapy administration were significantly associated with survival. Increasing smoking intensity was independently associated with worse outcome (P < .001). Apaf-1, E-cadherin, and p53 were prognostic for outcome (P = .005, .014, and .032, respectively); E-cadherin remained prognostic following multivariable analysis (P = .040). Combined alterations in all 9 biomarkers were prognostic by univariable (P < .001) and multivariable (P = .006) analysis. A multivariable model that included all 9 biomarkers and smoking intensity had greater accuracy in predicting prognosis than models composed of standard clinicopathological covariates without or with smoking intensity (P < .001 and P = .018, respectively). CONCLUSIONS: Apaf-1, E-cadherin, and p53 alterations individually predicted survival in bladder cancer patients. Increasing number of biomarker alterations was significantly associated with worsening survival, although markers comprising the panel were not necessarily prognostic individually. Predictive value of the 9-biomarker panel with smoking intensity was significantly higher than that of routine clinicopathological parameters alone. Cancer 2013. © 2013 American Cancer Society.

Since 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993.Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence was individually evaluated via a detailed patient questionnaire.The pouch related early and late complication rates were 7.2 and 11.6%, respectively, and pouch related abdominal reoperation rates were 0.0 and 1.4%, respectively. Analysis of late pouch related complications revealed 4.1% stone formation and 2.4% afferent nipple stenosis rates, and only 1 case (0.3%) of ileal urethral anastomotic stricture. Of the patients 87 and 86% reported good or satisfactory daytime and nighttime continence, respectively. With regard to age, while overall continence was similar, a significantly greater percentage of patients younger than 70 years experience good daytime and nighttime continence relative to the older counterparts. Of the patients 5% perform regular intermittent catheterization and 2.7% required an artificial urinary sphincter due to unacceptable continence.The Kock orthotopic ileal neobladder can be constructed with minimal morbidity and extraordinary functional results. We strongly advocate its use when possible.

We report a rare case of a 24-year-old woman who presented during her second trimester of pregnancy with a presumptive diagnosis of right-sided xanthogranulomatous pyelonephritis (XGP). Despite attempted conservative management, the patient ultimately required a right nephrectomy without complications to either the patient or fetus. Pathology confirmed the diagnosis of XGP of the right kidney. Herein, we present a case report and a review of the literature concerning XGP and pregnancy.

A case of a traumatic pyeloduodenal fistula secondary to a gunshot wound is reported. After initial conservative management failed, the fistula tract was surgically excised without removal of the involved kidney. Previous treatments of pyeloduodenal fistulas secondary to gunshot wounds have involved nephrectomy. We present the first case of a pyeloduodenal fistula secondary to gunshot wound managed without nephrectomy along with a review of the literature regarding traumatic pyeloduodenal fistula.

Surgical repair of an abdominal aortic aneurysm in conjunction with radical cystectomy and orthotopic urinary diversion can be safely performed without morbidity secondary to excessive blood loss, operative time, or vascular graft infection. The techniques required for this combined procedure and a case report are discussed.

Since June 1990, 21 women aged from 31 to 78 years (mean, 62 years) have undergone lower urinary tract reconstruction by means of an orthotopic Kock ileal reservoir following cystectomy. The indication for cystectomy included 15 patients with transitional-cell carcinoma of the bladder, 2 patients with urachal adenocarcinoma, 1 patient with cervical carcinoma, 1 patient with a mesenchymal tumor of endometrial origin, 1 patient with interstitial cystitis, and 1 patient with a fibrotic irradiated bladder. A total of four complications (two early and two late) have occurred in this group of patients. Excellent continence has been achieved during the day and night in 95% and 89% of the patients, respectively. In all, 16 of 20 patients void volitionally per urethra without a residual urine volume, whereas 4 patients require intermittent catheterization to empty the neobladder. All patients are completely satisfied. One patient died of metastatic transitional-cell carcinoma without a pelvic recurrence. Of the remaining 20 patients, 18 are currently alive without evidence of recurrent disease. Tumor recurrence has occurred in two patients: one patient with an extensive mesenchymal tumor developed a sigmoid recurrence necessitating conversion to a continent cutaneous diversion, and one patient developed a right iliac recurrence. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results, and we feel that the option of orthotopic reconstruction following cystectomy can safely be offered to selected female patients.

Emphysematous pyelonephritis is a rare, rapidly progressive, life-threatening infection of the renal parenchyma. It most commonly is unilateral, is found almost exclusively in diabetics, is associated with gas-forming coliform bacteria, and is characterized by the presence of gas within the renal parenchyma. Early aggressive therapy (combined medical and surgical) is the hallmark of successful treatment. A high index of suspicion coupled with radiographic imaging is essential to make a timely diagnosis and guide therapeutic intervention. Bilateral emphysematous pyelonephritis is an even more rare phenomena, with only 14 reported cases in the English literature and is associated with a high patient mortality. We herein present an additional case and review the literature as it pertains to bilateral emphysematous pyelonephritis. Appropriate care requires aggressive combined medical and surgical therapy in an attempt to preserve renal function without increased mortality.

Introduction Retrospective studies suggest that p53 alteration is prognostic for recurrence in patients with urothelial bladder cancer and predictive for benefit from combination methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) adjuvant chemotherapy. Patients and Methods Patients with pT1/T2N0M0 disease whose tumors demonstrated ≥ 10% nuclear reactivity on centrally performed immunohistochemistry for p53 were offered random assignment to three cycles of adjuvant MVAC versus observation; p53-negative patients were observed. By using a log-rank test with one-sided α = .05 and β = .10, 190 p53-positive patients were planned to be randomly assigned to detect an absolute improvement in probability of recurring by 3 years from 0.50 to 0.30. Results A total of 521 patients were registered, 499 underwent p53 assessment, 272 (55%) were positive, and 114 (42%) were randomly assigned. Accrual was halted on the basis of the data and safety monitoring board review of a futility analysis. Overall 5-year probability of recurring was 0.20 (95% CI, 0.16 to 0.24) with no difference on the basis of p53 status. Only 67% of patients randomly assigned to MVAC received all three cycles with 12 patients receiving no treatment. There was no difference in recurrence in the randomly assigned patients (hazard ratio, 0.78; 95% CI, 0.29 to 2.08; P = .62). Conclusion Neither the prognostic value of p53 nor the benefit of MVAC chemotherapy in patients with p53-positive tumors was confirmed, but the high patient refusal rate, lower than expected event rate, and failures to receive assigned therapy severely compromised study power.

4575 Background: Urothelial carcinoma of the bladder (UCB) is a disease of alterations in several cellular pathways. Routine molecular profiling studies do not account for smoking, a well established risk factor for UCB, and its influence on outcome. This study assessed the prognostic potential of a multi-pathway protein panel across all UCB stages in a population-based cohort after accounting for clinicopathologic factors and smoking history. Methods: 212 UCB patients from the LA CSP, part of the NCI/SEER cancer registry, were included. "Smoking intensity" analyzed biologic and molecular impact of smoking by combining smoking status, duration of smoking and number of cigarettes smoked daily into a composite covariate. Tumors were profiled for Bax, caspase-3, Apaf-1, Bcl-2, p53, p21, COX2, VEGF and E-cadherin alterations by IHC. Univariate analyses and multivariable modeling examined associations with outcome. Results: Median follow up was 13.2 years. Age, pathologic stage, adjuvant therapy (all p< 0.001) and surgical modality (p = 0.05) were associated with survival. Increasing smoking intensity was associated with worse outcome (P < 0.001). Apaf-1 (p = 0.005), E-cadherin (p = 0.014) and p53 (p = 0.032) were univariately prognostic; E-cadherin remained prognostic after multivariate analysis (p = 0.04). Combined alterations in all 9 biomarkers were prognostic by univariate (p < 0.001) and multivariate (p = 0.006) analysis. A multivariate model that included all 9 biomarkers and smoking intensity was more accurate in predicting prognosis than models comprising of standard clinicopathologic covariates without (p < 0.001) or with (p = 0.018) smoking intensity. Conclusions: The study confirms detrimental effects of smoking on UCB prognosis. Apaf-1, E-cadherin and p53 individually predicted UCB survival. Increasing number of biomarker alterations was significantly associated with worsening survival, although markers contained in the panel were not necessarily prognostic individually. Predictive value of the nine-biomarker panel with smoking intensity was significantly higher than that of routine clinicopathologic parameters alone.

Objectives. A retrospective analysis of the results of an aggressive multimodalapproach combining radical prostatectomy with adjuvant radiation, chemotherapy, or androgen deprivation therapy for patients with pathologic Stage D 1 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. Llnivariate 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 D l prostate carcinoma by a combination of radical prostatectomy and radiation therapy without the need for routine androgen deprivation therapy.

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.

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.

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.

69-year-old woman of the Jehovah’s Witness faith was found to have a mass on a computed tomography bone density scan done for osteoporosis. Computed tomography demonstrated a 10-cm right renal mass with a tumor thrombus extending to the level of the hepatic veins (Fig. 1). Both the computed tomography and magnetic resonance imaging scans demonstrated fat within the tumor, consistent with an angiomyolipoma or a liposarcoma (Fig. 2). No metastatic disease was evident. A right radical nephrectomy was performed with a retroperitoneal lymphadenectomy and level II thrombectomy using a thoracoabdominal approach 1 (Fig. 3). Erythropoietin was given preoperatively, and her starting hematocrit was 50%. Vascular control was obtained intraoperatively by mobilizing the liver off the inferior vena

INTRODUCTION: Urothelial carcinoma of the bladder develops through multiple cellular alterations. Traditional single-marker and multimarker molecular profiling approaches in bladder cancer do not account for risk factors and their influence on clinical outcome. Cigarette smoking is the most well established risk factor for bladder cancer in the western world. This study sought to examine the prognostic value of molecular alterations across all disease stages after stratifying for clinicopathologic factors and smoking in a population-based cohort. METHODS: 212 patients from the Los Angeles County Cancer Surveillance Program, a NCI/SEER cancer registry, were included. To analyze the biologic and molecular impact of smoking, we introduced a novel “smoking intensity” variable that took into account a patient's smoking status, duration of smoking and number of cigarettes smoked daily to quantify the impact of exposure to cigarette smoke. Primary bladder tumors were immunohistochemically profiled for Bax, caspase-3, Apaf-1, Bcl-2, p53, p21, cyclooxygenase-2, vascular endothelial growth factor, and E-cadherin alterations. Univariate analyses and multivariable modeling were used to examine associations with outcome. RESULTS: Median follow up was 13.2 years. For smokers (n=184), median age to start smoking was 17 years (range, 12-40 years), and median smoking duration was 35 years (range, 0.5-50 years). Median number of cigarettes smoked daily was 25 (range, 2-100). Increasing pathologic stage and smoking intensity were independently associated with worsening survival (P CONCLUSION: The study confirms detrimental effects of smoking on bladder cancer prognosis. Apaf-1, E-cadherin and p53 can individually predict survival in bladder cancer patients, with Apaf-1 being the most prognostic individual marker. The nine-biomarker panel can significantly predict outcome independent of stage and smoking history. Increasing biomarker alterations was significantly associated with worsening survival, although markers comprising the panel were not necessarily prognostic individually. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2258. doi:10.1158/1538-7445.AM2011-2258

Cyclophosphamide has been used to treat a variety of malignant and nonmalignant diseases. The association of this agent with the development of urothelial tumors has been well documented. Although most bladder cancers associated with prior cyclophosphamide therapy are transitional cell carcinoma, to our knowledge there have been 6 reports of cyclophosphamide-induced squamous cell carcinoma of the bladder. We report 2 additional cases of squamous cell carcinoma of the bladder that occurred in patients after cyclophosphamide treatment for Wegener’s granulomatosis. Any patient with a history of prolonged cyclophosphamide ingestion needs careful long-term monitoring of the lower urinary tract, since there is at least a 9-fold increase in the incidence of lower urinary tract malignancy in such patients.

INTRODUCTION: Urothelial carcinoma (UC) of the bladder develops through alterations in several cellular processes. Previous UC multimarker studies do not account for risk factor exposure that can influence clinical outcome. Cigarette smoking is the most well established risk factor for UC in the U.S. This study sought to identify molecular alterations associated with smoking and their prognostic value in a population-based cohort. METHODS: 212 UC patients from the Los Angeles County Cancer Surveillance Program, a NCI/SEER cancer registry, were included. Median follow up was 13.2 years. To analyze the biologic and molecular impact of smoking, we introduced novel variables - “smoke exposure” considered smoker status and duration of smoking, and “smoking intensity” considered number of cigarettes smoked daily in addition to the above smoking parameters. For ex-smokers, the “relative cessation measure” considered duration of smoking cessation until diagnosis and duration of smoking. Bax, caspase-3, Apaf-1, Bcl-2, p53, p21, COX-2, VEGF, and ECAD immunohistochemical expressions were analyzed on archival UC sections. Covariate and clinical outcome (overall survival) associations were examined. RESULTS: Stage was associated with p53 (P CONCLUSION: The study confirms the detrimental effect of smoking on UC prognosis and identifies key molecules that are deregulated by the carcinogenic exposure. Apaf-1, ECAD and p53 were important individual predictors of outcome, with Apaf-1 being prognostic after stratifying for stage and/or smoking. Number of altered markers was the most robust outcome predictor, independent of standard clinicopathologic and epidemiologic criteria, and can be used as a tool to identify patients who are in need of more aggressive treatment. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4702.

In the search for donor tissue for massive craniofacial defects, the transplantation of somatic tissue allografts was explored. Four young, out-bred cynomolgus monkeys were the recipients of orthotopic hemimandibular allotransplants from nonrelated cynomolgus monkeys. The transplant consisted of one-half of the mandible with attached muscle, skin, and mucosa. Cyclosporine 15 mg/kg/day was given subcutaneously each day. The 4 monkeys were observed for 13, 27, 63, and 65 days, respectively. All transplants showed primary wound healing and hair growth. The 2 longest survivors chewed, ate a normal diet, and gained weight. Two allografts showed severe rejection signs at 2 to 3 weeks, and the monkeys were euthanized. One monkey had a second episode of rejection that could not be reversed, and it was killed. The fourth monkey died of undetermined causes.

We recently reported our initial clinical experience with a novel form of urinary diversion, that is the T pouch. 1 The T pouch incorporates a unique antireflux mechanism and eliminates the complications associated with an intussuscepted nipple valve. We describe the application of this concept with conversion of a ureterosigmoidostomy into a new ileo-anal reservoir with an antireflux mechanism. Others have reported followup of as long as 40 years. 2 To our knowledge 61 years is the longest interval to be reported between construction of a ureterosigmoidostomy and its revision. CASE HISTORY P. K., a 64-year-old woman with a history of bladder exstrophy, underwent cystectomy and ureterosigmoidostomy at age 3 years. At 18 years she underwent right nephrectomy for intractable pyelonephritis, and was well until she was 55 years old and had recurrent episodes of pyelonephritis, which necessitated suppressive antibiotic therapy. Multiple drug allergies developed, and she was ultimately hospitalized for urosepsis. Renal ultrasound demonstrated moderate to severe left hydroureteronephrosis. A furosemide nuclear scan was consistent with obstruction. Creatinine was 1.6 mg./dl. (normal 0.3 to 0.9) and blood chemistry study revealed severe hyperchloremic metabolic acidosis. Colonoscopy showed no evidence of malignancy. The patient was satisfied with the voiding pattern and declined any form of external urinary diversion. Conversion of the ureterosigmoidostomy to an ileoanal reservoir incorporating the T pouch antireflux mechanism to the sigmoid colon was performed. At the time of surgery a 24F Medina tube was placed into the anus and, after copious irrigation with a diluted povidone-iodine solution, sutured in place. The Medina tube served as a tactile cue for proper placement of the proctostomy. The colon was mobilized and the previous ureterocolostomy was excised at its junction and sent for frozen section to rule out neoplastic degeneration. A 15 cm. proctostomy was then made at the tip of the Medina tube 10 cm. proximal to the transition zone between the rectum and anus. A portion of sigmoid colon was isolated 4 to 6 cm. proximal to the proctostomy and intussuscepted to prevent urine reflux into the proximal colon. A T pouch was then constructed using techniques previously described. 1 A 20 cm. segment of distal ileum was placed in an inverted V configuration with each limb of the V measuring 10 cm. A more proximal 10 cm. segment of ileum was isolated as the afferent limb. Adhering to the principles outlined for the T pouch, the antireflux mechanism was created by anchoring the distal 3 to 4 cm. of afferent limb into a serosal lined trough. This trough was constructed by maintaining the windows of Deaver to the afferent limb, which allowed for permanent fixation to the serosa of the ileal pouch. The ileal trough was then closed by over sewing the adjacent ileal flaps that are created when the bowel is detubularized (part A of figure). The ileum was left open to be laid onto the rectum as a pouch

15541 Background: To date there are no substantial series reported evaluating brain mets in TCC of the bladder. This makes therapeutic evidence-based decision making in this setting extremely difficult. Methods: We followed 1898 pts with TCC of the bladder treated with cystectomy from 1972–2004. Cohort analysis was undertaken for factors predisposing to and of factors that predict survival after brain mets. Results: With median follow-up of 3.6 yrs for this cohort, 545/1898 (28.7%) recurred, 30 (1.6%) with brain mets. Median time to brain mets development was 1.14 yrs, range 0.0710.92 yrs. Median time to first TCC recurrence in brain met pts was 0.86 yrs vs. 1.03 yrs for whole cohort (p=0.25). Median OS from cystectomy 1.36 yrs vs. 3.49 yrs for whole cohort (p No significant financial relationships to disclose.

Early radical cystectomy for a high-grade tumor invading the lamina propria (T1) remains controversial. In 1997, we cannot identify accurately which of these high-risk tumors will progress to muscle-invasive disease and metastases. In the near future, urologists may be able to use the presence of genetic alterations, such as p53 mutations, to help make therapeutic decisions. Previous reports on superficial bladder cancer treated with intravesical bacillus Calmette-Guerin immunotherapy have demonstrated a decrease in recurrence and progression. Unfortunately, there is no reliable method to predict which patients with a high-grade T1 tumor will fail to respond to intravesical therapy. Failure of intravesical therapy to control these aggressive tumors is associated with a significant rate of pathological upstaging and metastases. Radical cystectomy will cure a high percentage of these T1 tumors with acceptable morbidity and low mortality. In an era of nerve-sparing cystectomy and orthotopic neobladder reconstruction, early radical cystectomy is an alternative that should be discussed with the patient before instituting intravesical therapy.

Rb protein (pRb) expression was evaluated in 185 cases of transitional cell carcinoma of the bladder from patients that underwent radical cystectomy. Tumors were stratified into three categories based on the percentage of nuclei expressing pRb: (a) 0, 0% of tumor cells showing nuclear reactivity; (In \+, 1-50% of tumor cells showing nuclear reactivity; and (c)2+, >50% of tumor cells showing nuclear reactivity. Cases with undetectable (pRb 0) and high (pRb 2+) pRb reactivity had identical rates of recurrence. These cases had significantly higher recurrence (P = 0.0001) and lower survival rates i/' = 0.0002) compared to cases with moderate (pRb 1+ ) pRb reactivity, indicating that high levels of pRb expression may reflect a dysfunctional (altered) Rb pathway. The tumors were also examined for alterations in p53 expression; patients with tumors altered in both p53 and pRb had signifi cantly increased rates of recurrence (P < 0.0001) and survival (P < 0.0001) compared to patients with no alterations in either p53 or pRb; patients with alterations in only one of these proteins had intermediate rates of recurrence and survival. These results suggest that: (a) bladder cancers with high pRb expression do not show the tumor suppressor effects of the protein; and (In alteration in both p53 and pRb may act in cooperative or synergistic ways to promote tumor progression.

R. H., a 45-year-old woman with a history of stage B cervical carcinoma, underwent definitive treatment with 9,500 rad external beam radiation therapy. Six months later she presented to the gynecology service with right flank pain and was found to have right hydroureteronephrosis. A right percutaneous nephrostomy tube was placed and an antegrade nephrostogram demonstrated a 5 cm. distal ureteral stricture. At that time a wall stent was placed across the stricture into the distal ureter via a percutaneous approach and expanded to dilate the strictured portion of the ureter. The percutaneous nephrostomy tube was clamped and the patient was discharged home. She presented 2 weeks later with

4639 Background: Invasive bladder cancer has a 50% mortality rate. Adjuvant chemotherapy is used to try to improve survival, but is of unproven benefit. GC and MVAC have similar response rates and ...