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Background: Following our hypothesis that oxidative stress might play a primary role in renal ischemia/reperfusion injury (RIRI), we investigated if ethyl pyruvate (EPy) with potent antioxidant activity might prevent or alleviate RIRI induced in rats. Methods: Sprague-Dawley rats were randomly divided into four groups: (A) Sham, (B) renal ischemia/reperfusion (RIR), (C) RIR with EPy supplement (RIR+EPy), and (D) RIR with Mann supplement (RIR+Mann). Mannitol (Mann), a preoperative agent being clinically used, was tested for comparison with EPy. Rats were subjected to 40-min ischemia, followed by 24-h reperfusion. Either EPy or Mann was given to rats 30 min prior to ischemia and immediately before the reperfusion period. Results: The RIR and RIR+Mann groups showed palpable kidney injuries with the ~5-fold elevated blood urea nitrogen (BUN) and creatinine (Cr) levels, indicating renal dysfunction. However, the kidneys in the RIR+EPy group appeared merely normal (similar to the Sham’s) with the basal BUN/Cr levels, indicating normal renal function. No effects on histology, BUN or Cr were yet seen with Mann. Moreover, specific kidney injury markers were up-regulated and oxidative stress was also ~2.1-fold severer in the RIR group, whereas little changes in those markers and oxidative stress were seen with EPy supplement (RIR+EPy). Conclusions: Although oxidative stress feasibly plays a key role in RIRI, EPy with antioxidant activity is capable of protecting the kidneys from such an assault. Thus, EPy (not Mann) should be considered as an effective perioperative renoprotective agent that could be used clinically.

INTRODUCTION AND OBJECTIVE:Patients with ureteral tumors managed endoscopically often benefit from adjuvant immuno-chemotherapy and require interval upper tract surveillance with ureteroscopy. Howe...

Introduction: The widespread use of diagnostic and therapeutic ionizing radiation raises concerns regarding excessive occupational and patient exposure. In this study, we test a novel fluo...

OBJECTIVE To assess interviewing applicant perceptions of a virtual urology residency interview in the setting of changes mandated by COVID-19 and to determine applicant preference for virtual or in person interviews. Applicant perceptions of multiple interview components were queried to identify program specific and interview modality specific strengths or weaknesses in the 2020 to 2021 Urology Match. METHODS A 12 question multiple choice and free text survey was emailed to 66 virtually interviewed applicants for open residency positions at a metropolitan training program after conclusion of interviews. Items of interest included interview type preference, overall interview impression, and recommendations for improvement. RESULTS A total of 50 of 66 (76%) applicants completed the survey corresponding to approximately 11% of the 2020 national urology applicant pool. A total of 49 of 50 (96%) respondents assessed faculty interaction and the virtual platform positively. A total of 38 of 50 (76%) was satisfied with their resident interaction and 32 of 50 (64%) applicants stated they were able to satisfactorily evaluate the site and program. Ultimately, 39 of 50 (78%) respondents would have preferred an in person interview to our virtual interview. Respondents cited challenges in assessing program culture and program physical site virtually. CONCLUSION The majority of survey respondents indicated a preference for in person interviews. A smaller proportion of applicants preferred virtual interviews citing their convenience and lower cost. Efforts to improve the virtual interview experience may focus on improving applicant-resident interaction and remote site assessment.

Objective To characterize the rates of endovascular stapler complications during hilar ligation in minimally invasive radical nephrectomy over the last 10 years. Material and Methods We reviewed the Food and Drug Administration Manufacturer and User Facility Device Experience database from January 1, 2009 to August 1, 2019. Staplers were categorized according to type, namely Ethicon Inc. endocutters (Johnson & Johnson, New Brunswick NJ); Endo-GIA (Medtronic, Minneapolis MN); and Endo-TA (Medtronic, Minneapolis MN). Results There were 383 cases of complications involving staplers, 63% with Ethicon endocutters; 28% with GIA; and 9% with TA. 22 deaths (5.7% of total complications) were attributed to staplers. No deaths or reoperations occurred due to TA staplers. TA staplers were also associated with a reduced incidence of conversion to open as compared to Ethicon and GIA staplers. Apart from one device, manufacturer evaluation of returned devices either showed no abnormalities or attributed fault to improper use of staplers. Discussion We characterized stapler complications during a 10-year period for minimally invasive radical nephrectomy. No deaths or reoperations occurred due to TA staplers, perhaps due to cutting and stapling occurring in separate steps. Based on manufacturer evaluation attributing stapling malfunctions to human errors, training of operating room staff on proper use of these devices is critical to prevent potentially significant complications from occurring.

INTRODUCTION AND OBJECTIVE:With the advent of minimally invasive surgery, ligation of major renal vessels during radical nephrectomy is accomplished using endovascular staples as opposed to sutures...

Background: Secondary malignancies of the ureter are uncommon. We report the diagnosis and management of metastatic colon cancer to the bifurcation of a bifid ureter. Case Presentation: A 59-year-old man presented with diffuse metastasis with right hydronephrosis in both renal moieties of a partially duplicated system and an enhancing lesion within the proximal common ureter. Ureteral biopsy was positive for colorectal adenocarcinoma. The patient was subsequently started on palliative chemoradiation. Conclusion: The ureter is a rare location for hematogenous/lymphatic metastases. When a ureteral mass is present on imaging, ureteroscopy should be performed to characterize the extent of tumor and to rule out secondary malignancy.

Percutaneous nephrolithotomy (PCNL) is an established technique for removal of large stones from the upper urinary tract. It is a complex multistep procedure requiring several classes of instruments that are subject to operator misuse and device malfunction. We report device-related adverse events during PCNL from the Manufacturer and User Facility Device Experience (MAUDE) database using a recently developed standardized classification system.The MAUDE database was queried for "percutaneous nephrolithotomy" from 2006 to 2016. The circumstances and patient complications associated with classes of devices used during PCNL were identified. We then utilized a novel MAUDE classification system to categorize clinical events. Logistic regression analysis was performed to identify associations between device classes and severe adverse events.A total of 218 device-related events were reported. The most common classes included: lithotripter 53 (24.3%), wires 43 (19.7%), balloon dilators 30 (13.8%), and occlusion balloons 28 (12.8%). Reported patient complications included need for a second procedure 12 (28.6%), bleeding 8 (19.0%), retained fragments 7 (16.7%), prolonged procedure 4 (9.5%), ureteral injury 2 (4.8%), and conversion to an open procedure 3 (7.1%). Using a MAUDE classification system, 176 complications (81%) were Level I (mild/none), 26 (12%) were Level II (moderate), 15 (7%) were Level III (severe), and 1 (0.5%) was Level IV (life threatening). On univariate analysis, balloon dilators had the highest risk of Level II-IV complications compared with the other device classes [odds ratio: 4.33, confidence interval: 1.978, 9.493, p 0.001]. The device was evaluated by the manufacturer in 93 (42.7%) cases, with 54.8% of reviewed cases listing the source of malfunction as misuse by the operator.PCNL is subject to a wide range of device-related adverse events. A MAUDE classification system is useful for standardized, clinically-relevant reporting of events. Our findings highlight the importance of proper surgeon training with devices to maximize efficiency and decrease harm.

Triplication of the ureter is a rare urologic finding that has been well described in the literature. Patients can present with urinary tract infections, incontinence, and calculi. We present the case of a patient with extensive stone burden with right trifid and left bifid collecting systems. Stone management was performed with a multimodal approach using a combination of endoscopic and percutaneous approaches. Our systematic and staged approach highlights a method for efficacious stone treatment in a complex endourologic case.

Background: Hypothesizing that oxidative stress (OXS) could be a key pathogenic factor for the incidence of chronic kidney disease (CKD), we investigated if the Poria mushroom extract, PE, with possible antioxidant activity, would prevent the incidence of CKD in rats. Materials and Methods: Antioxidant activity of PE was examined against OXS induced by hydrogen peroxide (H2O2) in renal LLC-PK1 cells. Whether PE could prevent the development of CKD in the rat kidneys, mediated through adenine (ADN)-induced OXS, was also examined. After 2 weeks, blood and kidney specimens were collected from rats for blood, histopathologic, and biochemical analyses. Results: Although H2O2-induced OXS led to a significant cell viability reduction in LLC-PK1 cells, PE significantly diminished OXS and sustained high (~70%) cell viability. In rats, ADN-given rats showed typical renal dysfunction with palpable kidney damage; however, PE supplement improved renal function with better histology. A ~2.2-fold increased OXS level was also seen in ADN-given rats but it was reduced by ~27% with PE supplement. Moreover, analysis of kidney injury biomarkers further confirmed extended kidney damage by ADN. Nevertheless, PE effectively maintained the natural status of those markers, protecting the rat kidneys. Conclusions: OXS is indeed harmful to renal cells in vitro and could even lead to ADN-induced CKD in vivo. However, PE appears to have antioxidant activity capable of protecting renal cells and the rat kidneys from such detrimental OXS. Therefore, it is rather possible that PE could be a natural antioxidant with prophylactic effect against OXS-induced CKD.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of

Introduction and Objectives: Multiple surgical therapies for benign prostatic hyperplasia (BPH) have been developed to decrease complications and increase provider efficiency. We investigated contemporary BPH treatment device-related adverse events by searching a publicly available database. Materials and Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for contemporary BPH treatments. All devices were evaluated for malfunction, patient complications, and manufacturer review. The MAUDE adverse event classification system was used to standardize complications. Univariate analysis was performed to identify associations between BPH devices and adverse events. Results: A total of 2567 reports were identified: transurethral resection of the prostate (TURP) 197 (7.67%), holmium laser enucleation of the prostate (HoLEP) 39 (1.52%), GreenLight™ 2315 (90.2%), and UroLift(®) 16 (0.62%). The most common deviations for each modality included cutting loop detachment during TURP 116 (58.9%), morcellator dysfunction for HoLEP 23 (58.9%), tip fracture/detachment for GreenLight (68.8%), and failure to deploy during UroLift 10 (62.5%). Only 18 (0.7%) patients required medical/surgical management (MAUDE II–IV) due to a device complication. No significant relationship was seen between each modality and complications; however, morcellator use (27.8%) was observed in higher grade complications. Manufacturer review occurred in 61.7% of cases, with 41.3% of reviewed cases finding the operator the cause of the malfunction. Conclusion: Each BPH modality investigated had minimal patient harm with over 99% of patients experiencing no complication after device malfunction. Of note, great care should be taken with morcellator use during HoLEP as it had the greatest number of MAUDE II to IV complications among all devices. Manufacturer review revealed that over 40% of cases were due to misuse by the user. Therefore, urologists should select the modalities they are most familiar with to decrease patient harm and prevent device malfunctions.

INTRODUCTION AND OBJECTIVES:Ureteroscopy for renal and ureteral stone disease is a low-risk procedure with minimal risks of serious complications, however, the rate of postoperative sepsis can be a...

Background: The pathogenesis of nephrolithiasis (kidney stone) remains elusive, while several therapeutic options are available but not effective as we expected. Accumulating data yet suggest that oxidative stress (generation of oxygen free radicals) may play a primary role in its occurrence. Particularly, calcium oxalate (CaOx) is a key element in the most common form (> 75%) of kidney stones, and its crystal form known as CaOx monohydrate (COM) has been shown to exert oxidative stress, facilitating CaOx stone formation. Hence, diminishing oxidative stress with certain antioxidants could be a potential strategic approach. We are interested in a bioactive extract of Poria mushroom, PE, which has been shown to have antioxidant and renoprotective activities. Accordingly, we investigated if PE might have antioxidant activity that would have implication in prevention of kidney stone formation. Methods: Renal epithelial LLC-PK 1 cells were employed and exposed to COM or hydrogen peroxide (H 2 O 2 ) as a positive control capable of exerting oxidative stress. Possible antioxidant and protective effects of PE against oxidative stress (exerted by COM or H 2 O 2 ) were assessed by cell viability test and lipid peroxidation (LPO) assay. To explore its protective mechanism, two glycolytic parameters, hexokinase (HK) activity and ATP synthesis, were examined and cell cycle analysis was also performed. Results: Both H 2 O 2 and COM led to a significant (P < 0.05) reduction in cell viability, accompanied by severe oxidative stress assessed by LPO assay. Such oxidative stress also caused the significant decline in HK activity and cellular ATP level, indicating the inhibition of glycolysis. Cell cycle analysis further indicated that oxidative stress interfered with cell cycle, inducing a G 1 cell cycle arrest that presumably results in the cessation of cell proliferation. However, PE was capable of significantly preventing or diminishing all these cellular effects mediated through oxidative stress (exerted by H 2 O 2 and COM). Conclusions: The present study shows that the mushroom extract PE appears to have antioxidant and renoprotective effects against oxidative stress exerted by COM in renal cells. Therefore, PE with antioxidant activity is considered a promising natural agent that may have clinical implications in prevention of nephrolithiasis primarily induced by oxidative stress. J Clin Med Res. 2016;8(12):908-915 doi: http://dx.doi.org/10.14740/jocmr2781w

INTRODUCTION AND OBJECTIVE:The standard of care for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy; however, certain patient populations such patients with significant medica...

As oxidative stress (OXS) has been shown to play a primary role in renal ischemia/reperfusion injury (RIRI), we investigated whether antioxidant such as ethyl pyruvate (EPy) might effectively prevent RIRI. Possible prophylactic effects of EPy and mannitol (Mann), one of perioperative agents often used, were tested against harmful OXS in vitro. Hydrogen peroxide (H2O2) was used to exert OXS on the renal proximal tubular MDCK cells. Severity of OXS and protective effects of EPy and Mann were assessed by lipid peroxidation assay and cell viability test, respectively. The cytotoxic mechanism of H2O2 was explored by examining the status of glycolysis, metabolic signaling pathways, cell cycle, and induction of apoptosis. Although H2O2 (500 µM) increased OXS by ~ 3.5 times of controls, EPy (1 mM) fully reduced it to the basal level. Cell viability declined to merely 10% by H2O2 was regained to > 90% with EPy. Hexokinase activity and ATP level also declined significantly by H2O2, but they sustained 80–90% with EPy. Additionally, H2O2 led to the modulations of metabolic signaling regulators, a G1 cell cycle arrest, and induction of apoptosis, which were yet prevented with EPy. Unlike EPy, Mann had virtually little effects. OXS can indeed lead to the significant cell viability reduction through its adverse cellular effects, ultimately resulting in RIRI. However, EPy appears to prevent these effects and protect MDCK cells, while Mann does not. Thus, EPy could be a more effective prophylactic renoprotective agent (than Mann) against oxidative renal cell injury including RIRI.

Surveillance is essential following endoscopic treatment for upper tract urothelial carcinoma. However unlike lower tract disease, surveillance cannot be performed in an outpatient basis. It is therefore critical to have a multidisciplinary approach to ensure follow-up. Conservative treatment which involves multiple invasive procedures can be cumbersome, for the patient and constant physician–patient dialogue must be maintained. We will outline the optimal approach in explaining to a patient and their families, what surveillance entails. Our surveillance protocol involves flexible cystoscopy, CT or MR urogram, and upper endoscopy in first 3 months. This is followed by repeat ureteroscopy, cytologies, cystoscopies, and imaging in 3–6 month intervals.

Ureteroscopic resection of upper tract is indicated by patient preference, medical comorbidities, and location/size of tumor. The literature on ureteral recurrence reports a recurrence rate of 48% for low grade and 60% for high grade, but the real recurrence rate is likely to be higher. Risk factors for recurrence include size >2 cm, grade, prior history of urothelial cell carcinoma and stage. The most important factor appears to be grade. Patients who failed conservative therapy and had a delayed radical nephroureterectomy had similar disease-specific survival and pathological stage to those who choose immediate radical nephroureterectomy. In our experience, ureteral tumors are best treated with ureteraoresectoscope. One must be careful with resecting near vessels such as the iliacs in the mid-ureter. In many cases, the resection will need to be staged secondary to the bulky nature of the tumor. If the lesion appears to be extensive or high grade, we instill Mitomycin C at the end of the procedure.

A survey of literature on UTUC shows a mix set of results on efficacy and outcome of conservative treatment. There are no standardized templates for ureteroscopic or percutaneous resection techniques nor the adjuvant treatment options. The assumptions of what institutes a diagnosis or success after treatment also remain unclear. The conservative management of UTUC is a work in progress requiring a multicenter prospective evaluation to provide more clear parameters to follow.

Endourologic management of upper tract urothelial carcinoma has become the preferred treatment in selected groups of patients. However, recurrence is high and there is a large interest in utilizing adjuvant topical agents as used in the lower tract. Many agents have been studied, but they are less efficacious than they are in the lower tract. This is likely due to incomplete staging, difficult delivery, and incomplete resection. There is evidence that primary BCG for isolated carcinoma in situ has some efficacy, but the evidence is not robust. There is mixed evidence for the use of adjuvant BCG, Mitomycin C, and Adriamycin. In our institution (ME), we utilize adjuvant Mitomycin C for a 6-week course in the office following resection. The future of adjuvant therapy likely lies in products such as MitoGel© that coat the upper tract.

From the introduction of endoscopic approaches to genitourinary disease at the beginning of the nineteenth century to advances in 1970s that ushered in the current era of Endourology, the field has undergone continuous growth based on improved visualization, advances in scope design and instrument innovation. Currently available techniques offer access to the entire urinary tract via a retrograde ureteral or antegrade percutaneous approach for the inspection, biopsy, and treatment of the spectrum of benign and malignant pathology. While urine studies and cross-sectional imaging are utilized in the initial evaluation, direct visual inspection, and biopsy is required for the assessment of any abnormal findings. The current generation of digital flexible ureteroscopes are lighter and less cumbersome than their predecessors with better image quality. Instruments including forceps, baskets, and resection loops are available to maximize the diagnostic yield of endoscopic biopsy. Despite progress, it is critical to recognize that undergrading and understaging remain a significant concern even for experienced practitioners. This can best be tempered with a comprehensive evaluation of the entire urothelium, systematic approach to specimen collection and close clinical follow-up. In this chapter, we review basic endoscopic techniques for the biopsy of upper urinary tract lesions.

This chapter describes in details all the aspects of percutaneous management of renal pelvis tumors. These tumors are mostly low grade and bulky and the resection is with the intent of complete, curative and sometimes palliative purposes. Majority of these patients have compromised renal function or have significant co morbidities. The technical aspects of resection, follow up biopsy and surveillance are described with video samples of different stages. There will also be description of intracavitary treatment.

This chapter addresses the diagnostic and therapeutic urologic applications of ultrasound during pregnancy including assessment of hydronephrosis and renal colic, ultrasound-guided endoscopic procedures. 2D ultrasound is generally considered the safest and the first radiologic modality for evaluation of hydronephrosis during pregnancy. Although MRI is considered safe during pregnancy, its sensitivity for stone diagnosis is low.

This chapter will address the assessment of conditions associated with congenital pelvic and transplant kidneys utilizing ultrasound imaging. The diagnostic and interventional role of ultrasound in allografts will also be reviewed.

Because of a dismal prognosis for advanced renal-cell carcinoma (RCC), an alternative therapeutic approach, using vitamin K3 (VK3) and D-fraction (DF) was investigated. VK3 is a synthetic VK derivative and DF is a bioactive mushroom extract, and they have been shown to have antitumor activity. We examined if the combination of VK3 and DF would exhibit the improved anticancer effect on RCC in vitro.Human RCC, ACHN cell line, were treated with varying concentrations of VK3, DF, or a combination of the two. Cell viability was assessed at 72 hours by MTT assay. To explore the possible anticancer mechanism, studies on cell cycle, chromatin modifications, and apoptosis were conducted.VK3 alone led to a ~20% reduction in cell viability at 4 μM, while DF alone induced a 20% to 45% viability reduction at ≥ 500 μg/mL. A combination of VK3 (4 μM) and DF (300 μg/mL) led to a drastic90% viability reduction, however. Cell cycle analysis indicated that VK3/DF treatment induced a G1 cell cycle arrest, accompanied by the up-regulation of p21(WAF1) and p27(Kip1). Histone deacetylase (HDAC) was also significantly (~60%) inactivated, indicating chromatin modifications. In addition, Western blot analysis revealed that the up-regulation of Bax and activation of poly-(ADP-ribose)-polymerase (PARP) were seen in VK3/DF-treated cells, indicating induction of apoptosis.The combination of VK3 and DF can lead to a profound reduction in ACHN cell viability, through a p21(WAF1)-mediated G1 cell cycle arrest, and ultimately induces apoptosis. Therefore, the combination of VK3/DF may have clinical implications as an alternative, improved therapeutic modality for advanced RCC.

INTRODUCTION AND OBJECTIVES: Minimally invasive adrenalectomy (laparoscopic and robot-assisted) may offer lower postoperative morbidity and mortality. The purpose of this study is to analyze postoperative complications, readmission rates, and predictors of readmission in minimally invasive adrenalectomy (MIA) using a national outcomes database. METHODS: American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to analyze patients who underwent MIA in 2011 and 2012. Perioperative variables and Clavien complications were analyzed using multivariate regression analysis. P

Cold-knife retrograde endopyelotomy is a simple, safe, and effective therapeutic option for primary and secondary symptomatic ureteropelvic junction obstruction (UPJO). Our long-term success rate with negligible complications demonstrates its durability and safety. Retrograde endopyelotomy should be considered a viable first-line treatment option for the management of patients with UPJOs.

Reduced donor morbidity has been established after laparoscopic donor nephrectomy compared with open harvest, but differences in recipient outcomes remain less obvious. We compared the urologic complications in patients receiving kidneys procured by cadaveric, open, and laparoscopic harvest.A retrospective study of all the kidney transplantations performed between January 1998 and December 2003 was undertaken to extract 100 consecutive patients in each group. All urologic complications were obtained and grouped by the type of donor procurement.Overall, 48 of the 276 transplant patients (17%) had urologic complications: 14% of the cadaveric-donor recipients, 20% of the open-donor recipients, and 18% of the laparoscopic-donor recipients. There were no ureteral complications in the laparoscopic group.Laparoscopically procured donor kidneys were associated with significantly fewer recipient ureteral complications than open cadaver or live-donor procurement.

Purpose: A retrospective review of preoperative three-dimensional (3D) CT and the operative findings during laparoscopic donor nephrectomy. Patients and Methods: Fifty-four consecutive patients underwent laparoscopic donor nephrectomy. Of these patients, 51 had preoperative 3D reconstructed CT scans. Each radiologic report was compared with the operative report. Results: The 3D CT correctly identified the arteries in 98% of the patients and the veins in 96%. Conclusions: Preoperative CT angiography can accurately identify the renal vasculature.

and 30 days following surgical removal of renal masses from 53 patients with presumed RCC. Samples were analyzed for immunosuppressive cell populations, including regulatory T cells, myeloid derived suppressor cells, inflammatory monocytes and exhausted T cells, and cytokines (IL-1 , IL-5, TNF ). Patients were compared to 10 age and gender matched healthy controls. RESULTS: Characteristics of patients with renal masses and controls are shown in Table 1. The percentage of regulatory T cells and exhausted T cells decreased after tumor removal in patients with clear cell RCC (p 0.01 and p 0.04). There was also an increased percentage of regulatory T cells and exhausted T cells in patients with clear cell RCC as compared to healthy controls (p 0.07 and p 0.007). Patients with stage T3 clear cell RCC had significantly higher levels of protumorigenic cytokines (IL-1 , IL-5 and TNF ) compared to stage T1 tumors (p 0.01, p 0.03 and p 0.02). CONCLUSIONS: Compared to healthy controls, patients with clear cell RCC had increased percentages of two immunosuppressive cell populations. After excision of the primary tumor, these cell populations decreased in number significantly. Serum concentrations of immunosuppressive cytokines were elevated in patients with increased tumor extent. Targeting these specific cell populations and/or cytokines in patients with clear cell RCC may represent a new therapeutic approach to treating advanced disease.

Hypothesis. Although several conventional therapeutic options for advanced renal cell carcinoma (RCC) are currently available, the unsatisfactory outcomes demand establishing more effective interventions. D-fraction (PDF), a bioactive proteoglucan of Maitake mushroom, demonstrates anticancer and immunomodulatory activities, which are also shown to be potentiated by vitamin C (VC). We thus hypothesized that a combination of PDF and VC (PDF + VC) could be an alternative approach to more effectively inhibit the growth of RCC. Study design. We examined the dose-dependent effects of PDF + VC on RCC cell viability and also performed biochemical assays to explore the growth regulatory mechanism. Methods. Human RCC, ACHN cell line, was employed and exposed to varying concentrations of PDF or VC and their combinations. Cell viability at specified times was determined by MTT assay. Lipid peroxidation assay, cell cycle analysis, and Western blot analysis were also performed. Results. PDF or VC alone led to the significant reduction in cell viability at 72 hours with PDF >500 µg/mL and VC ≥300 µM. When various combinations of PDF and VC were tested, the combination of the ineffective concentrations of PDF (300 µg/mL) and VC (200 µM) resulted in ~90% cell death in 24 hours. Lipid peroxidation assay then indicated significantly (~2.5 fold) elevated oxidative stress with this PDF + VC. Cell cycle analysis also indicated a G1 cell cycle arrest following a 6-hour PDF + VC treatment. Western blots further revealed a downregulation of Bcl2, an upregulation of Bax, and proteolytic activation of PARP (poly[ADP-ribose] polymerase) in PDF + VC-treated cells, indicating induction of apoptosis. Conclusion. The present study demonstrates that the combination of PDF and VC can become highly cytotoxic, inducing severe cell death in ACHN cells. This cytotoxic mechanism appears to be primarily attributed to oxidative stress, accompanied by a G1 cell cycle arrest. Such cell death induced by PDF + VC could be more likely linked to apoptosis, as indicated by the modulation of apoptosis regulators (Bcl2, Bax, and PARP). Therefore, as PDF and VC may work synergistically to induce apoptotic cell death, they may have clinical implications in an alternative, improved therapeutic modality for advanced RCC.

This chapter addresses the assessment of hydronephrosis and renal colic during pregnancy, as well as the assessment of conditions associated with congenital pelvic and transplant kidneys utilizing ultrasound imaging.