- Email: [email protected]
Pediatrics (II)
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482 ADULT ADIPOSE DERIVED STEM CELLS FOR RECONSTRUCTION OF THE ATROPHIC FEMALE URETHRA: TISSUE ENGINEERING TECHNIQUES FOR TREATMENT OF SUI Fernando De Almeida, Zeni Alfonso, Brian Strem, Larissa V Rodriguez», Los Angeles, CA INTRODUCTION AND OBJECTIVE: The spongy tissue of the urethra consists of smooth musculature (SM) essential in maintaining continence. Current treatments of SUI involve injection of bulking agents into periurethral tissues to provide support and resistance to flow. This approach is problematic due to issues of biocompatibility and durability related to rejection, migration, and absorption of these materials. We are studying the use of adult adipose derived stem cells (ADSC) for the reconstruction of functional urethral SM. The procurement process is simpler than other sources of stem cells and the ability of these cells to form SM could provide a long lasting biocompatible treatment for SUI. METHODS: Human liposuction samples were processed with saline washes and collagenase digestion to obtain a stromal vascular fraction (SVF). A fibroblastlike cell population was obtained. The cells were seeded in 100mm dishes and allowed to grow to 70% confluence. The cells were resuspended in Hank's Balance Salt Solution at a concentration of I X 108/ml. 20ILI of this cell suspension was injected into bladder walls of immunodeficient scm mice. The bladders were harvested at 4,6,8, and 12 wks. Three different labeling techniques were used: (1) Incorporation of LacZ reporter gene (2) Incorporation of 5' -bromodeoxyuridine (BrdU), and (3) Alu. Cells transduced with the LacZ gene were identified by l3-galactosidase activity. BrdU was incorporated in mitotically active cells and was identified by immunohistochemistry. The human origin of the cells was confirmed with in situ hybridization of the Alu DNA sequence. RESULTS: There was an even distribution of ADSCs throughout the muscle layer of the bladder at the injection site. The cells were morphologically identical to surrounding SM cells. Many ADSCs were identified at all time points by identification of BrdU and lacZ containing cells. In addition, the cells were shown to be of human origin by the presence of Alu. CONCLUSIONS: This study serves as proof of concept of the use of human ADSCs for lower urinary reconstruction and treatment of SUI. The cells were shown to survive in the smooth musculature of the urinary tract. Given that the procurement process is simple, with minimal morbidity, and one familiar to urologists, this is an attractive source of stem cells. In addition, the ability of these cells to differentiate into multiple tissue types including skeletal, SM, and neural cells, makes them attractive for development of functional tissues of the lower urinary tract. Source of Funding: American Geriatrics Society; Council on Research of the Academic Senate of the Los Angeles Divison of the University of California.
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fecal leakage was seen. We reoperated on 7 patients (outlet substitution using the appendix in 3 and Monti tube in one; conversion to Mainz pouch II in one and to a Bricker conduit in other; revision of a colon stoma stenosis at skin level in one). End results in terms of continence showed only 2 patients incontinent (one refused surgery, other with Bricker), 2 partial continent (up to 2hs) and 1 remained with a stenotic stoma (lost follow-up). Alltogether continence rate> 4hs was 91,6 % and> 2hs was 95%. The reoperation rate in this series was of 12,9% per patient (7/54) or 11,6% per stoma (7/60). The reoperation rate of the CCUR was 13 % (6/46). Mean follow-up was 26 months. CONCLUSIONS: The results found with this alternative approach are equivalent to other reported series. We believe that continent catheterizable reservoirs are easier to perform than augmentation plus incorporation of the appendix or Monti tube. This strategy has also the advantage to spare the appendix for an eventual operative revision of the outlet channel. Source of Funding: None.
484 LOCAL AND SYSTEMIC EFFECTS OF ENGINEERED BLADDER TISSUE Tae Gyun Kwon*, James J Yoo, Anthony Atala, Boston, MA INTRODUCTION AND OBJECTIVE: The use of engineered bladders has become a potential treatment option in urologic surgery. Although the engineered bladder tissues demonstrate adequate anatomical and functional parameters, studies regarding the host response and overall safety have not been extensively pursued. This study aimed to determine the local and systemic host tissue effects from engineered bladders in a canine cystoplasty model. METHODS: Seven beagles underwent trigone-sparing cystectomies. Autologous urothelial and smooth muscle cells were grown and seeded on prefabricated polymer (PGA) molds and used for bladder augmentation. Serial urodynamic studies, cystograrns, PB smears, urinalysis, serum chemistry, CBC and electrolytes were obtained at pre-determined time points postoperatively. The bladder tissues, local and distant organs were retrieved 6 months after surgery for histologic and immunologic analyses. RESULTS: The capacity and compliance of the engineered bladders reached near normal levels by 3 months and normal levels by 6 months. The engineered bladders showed a similar tissue composition as the normal bladders. There was no evidence of immune cells, and infiltration of inflammatory cells was minimal. An increase in total systemic leukocyte count and bacteriuria were evident initially at 1 week, and returned to normal levels by 1 month postoperatively. Other systemic parameters remained within normal levels at all time points. There was no evidence of abnormal findings in any of the local and distant organs. CONCLUSIONS: Implantation of bladder molds with cells does not exhibit significant local or systemic toxicity. This study demonstrates that the engineered bladders, composed of autologous cells and polymer scaffolds, are safe and effective for their use in reconstructive surgery. Source of Funding: Departmental.
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483 CONTINENT CATHETERIZABLE STOMAS: SHOULD WE CHANGE? Antonio Macedo*, Gilmar Garrone, Mauricio Hachul, Riberto Liguori, Sergio Otoni, Sao Paulo, Brazil; Ubirajara Barroso, Sao Paulo; Miguel Srougi, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Experience with urinary and colonic continent stomas suggest the use of the appendix as first choice efferent channel for Mitrofanoff and Malone principles. Differently to this strategy, we use the appendix primarily only for the cases where there is no need for bladder augmentation and secondarily in case of revision of leaking or stenotic catheterizable stomas. We evaluated our experience with catheterizable stomas to support our strategy. METHODS: Between June 1996 and September 2002 we constructed 60 catheterizable stomas by 54 patients. There were 7 appendicovesicostomies (AV), 46 continent catheterizable urinary reservoirs (CCUR) and 7 left-colon stomas (LCS) for antegrade bowel wash-outs. All but one patient with left-colon stoma underwent this procedure in association with a CCUR. The indications for urinary reconstruction were mainly complex urethral strictures by the AV group (417) and end-stage bladder diseases by the CCUR patients (neurogenic bladder, bladder exstrophy, PUV, rhabdomyossarcoma and others). The age ranged from 2 to 62 years, mean 19. The continent urinary reservoirs were made from the ileum (45/46) and colon transversus in only one case. RESULTS: There were no complications by the primary AV patients. We found stoma stenosis in 4 patients (3 CCUR, I LCS), urinary fistula in one (bladder exstrophy), total stoma incontinence in 4 and leakage after 2 hours in 2 cases. No
URETEROCYSTOPLASTY: HOW GOOD IS IT?
Douglas A Husmann*, Rochester, MN; Warren Snodgrass, Dallas, TX; Stephen A Kramer, Rochester, MN
INTRODUCTION AND OBJECTIVE: The ability to assess the efficacy of ureterocystoplasty in the current literature is fraught with problems. Frequently there is no mention if preoperative urodynamic evaluations were performed in the presence or absence of a refluxing megaureter and urodynamic end points are not standardized between the publications. Although the original reports regarding this operation were extremely favorable, as our own personal experience with ureterocytoplasty has grown we became concerned with the frequent need to reaugment these pts. This report clarifies the complications of this procedure that heretofore have not been elucidated. METHODS: Pts undergoing ureterocystoplasty from 1987- 2002 were reviewed. All pts included in the study were incontinent of urine preoperatively. The pre and post operative end fill bladder capacity defined as the volume in cc reached when the detrusor pressure reaches 40 ern of water or when the patient becomes intolerant of additional bladder was recorded. The onset of urinary continence, the need for reaugmentation and the association of any associated urologic complications were noted. RESULTS: A total of 22 ureterocystoplasties were performed. The etiology for bladder noncompliance or instability was neurogenic in etiology in 18 and due to urethral valvular disease in 4. Augmentation was performed with a single system intact ureter and pelvis in 20 pts and with bilateral ureters and renal pelvis in 2 pts, prior to renal transplantation. Fourteen pts had refluxing megaureters, preoperatively, with 8 having nonrefluxing megaureters. End fill bladder capacity in pts with single system augments increased by a median of 2.5 fold, range 0.8 to 4. End fill bladder capacity with bilateral system augments increased by a 3 and 4.5 fold margin. Clinically, 2/22 pts (9%) became continent and were voiding,
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2/22(9%) were continent on anticholinergics and voiding, 5/22 (23%) were continent but required CIC to empty, 3/22 (13%) were continent on anticholinergics and CIC, 10/22 (45 %) remained incontinent and required reaugmentation witb a gastrointestinal segment. It is notewortby tbat one pt with a double system augment dry on CIC perforated his augment 6 montbs after renal transplant and died of overwhelming sepsis. CONCLUSIONS: Ureterocystoplasty is not a panacea and may on occasion (45%) be inadequate to provide continence resulting in the need for reaugmentation. In addition it is not free from tbe morbidity associated with delayed spontaneous bladder perforations. Source of Funding: None.
486 NEPHRON-SPARING SURGERY FOR BILATERAL WILMS TUMOR (BWT): A 15 YEARS REVIEW AT A SINGLE INSTITUTION Wladimir Alfer*, Sergio Moreno, Paulo Chapchap, Maria Lucia Pinho, Beatriz De Camargo, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Bilateral disease occurs in 4-8% of patients with Wilms tumor. Nephron-sparing surgery is a challenging procedure currently recommended for BWT. We reviewed our results with these procedures. METHODS: Retrospectively analysis of 15-year at the Pediatric Department was performed. Twelve children, ten with synchronous BWT and 2 with metachronous disease were treated. Mean age was 28,5 months (range from 8 to 60 months), 7 were girls and 2 had congenital abnormalities. Among the synchronous cases initial approach was biopsy in 6 (4 open, 2 percutaneous), 2 preoperative chemotherapy witbout biopsy, and 2 had been submitted to unilateral nephrectomy elsewhere. All children received chemotherapy 8 to 34 weeks (median 13 weeks). Surgical procedure on 20 renal units was: 13 enucleation, 4 partial nephrectomies and 3 complete nephrectomies. Pathology findings regarding margins on 18 renal units was: 7 microscopic positive margins, 8 negative and 8 not evaluated. Only one case had positive lymph nodes. There were 3 local relapses, 2 on negative microscopic margins and 1 with positive microscopic margins. Definitive surgical procedures: 12 enucleations, 4 partial nephrectomies and 4 complete nephrectomies. Only one case had unfavorable histology (anaplasia in both kidneys) with compromised microscopic margins, this child is alive 10 years after treatment. Among the 2 metachronous tumors, enucleation was possible in one, this child is alive without disease 11 years after. RESULTS: Final bilateral renal preservation rate was 80%. Nine out of 10 children with synchronous tumors and lout of 2 with metachronous tumors are alive without disease. CONCLUSIONS: Microscopic residual disease may not have a major impact in either local recurrence or survival. Bilateral nephron sparing surgery is possible without compromising outcome. Multidisciplinary team is essential. Source of Funding: None.
487 INITIAL RESULTS OF DEFLUX INJECTION FOR VESICOURETERAL REFLUX: THE DALLAS EXPERIENCE James M Elmore*, David H Ewalt, Warren T Snodgrass, Dallas, TX INTRODUCTION AND OBJECTIVE: Following recent FDA approval of dextranomerlhyaluronic acid copolymer (DEFLUX®), endoscopic injection has become another option for the management of vesicoureteral reflux (VUR) in the U.S. Herein we report our intial experience with the technique. METHODS: We reviewed the charts of all patients undergoing Deflux injection for VUR at our institutions. After treatment, patients were maintained on antibiotic prophylaxis pending follow-up voiding cystourethrogram (VCUG). For this study, results were determined after only 1 Deflux injection. Success was defined as complete resolution of reflux on postoperative VCUG. RESULTS: Since December 2001,70 girls and 5 boys (117 renal units) with a mean age of 5.5 years (range 7 months to 15 years) underwent a single Deflux injection for treatment of VUR. Indications were persistent reflux on observation, breakthrough pyelonephritis, or parental preference as primary therapy at diagnosis. Follow-up VCUG, performed at a mean 14 weeks after treatement (range 8 to 20 weeks), is currently available for 35 patients (54 renal units) including 2 patients with neurogenic bladder (NGB) and 3 patients with ureteral duplication. Preoperative reflux in the 54 treated ureters was grade I in 3, grade II in 32, grade III in 16, grade IV in 2, and grade V in 1. One Deflux injection completely resolved reflux in 22 of 35 patients (63%) and in 38 of 54 ureters (70%). Therapy was successful in 2 of 3 patients with duplex ureters, all ureters with grade 4 or 5 reflux, and in botb patients with NGB. Complications included de novo contralateral relux in 2 patients and ureteral obstruction in 1. CONCLUSIONS: In our initial experience, a single Deflux injection resolved reflux in 70% of ureters. As in open surgery, contralateral reflux can occur in untreated ureters, and may be of greater concern when injection is done as primary therapy after only I VCUG. To our knowlegde, our patient with asymptomatic ureteral obstruction is tbe first with tbis complication after Deflux injection. Source of Funding: None. *Presenting author.
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488 OUTCOME OF LAPAROSCOPY FOLLOWING NONDIAGNOSTIC OPEN EXPLORATION FOR CRYPTORCHIDISM Christopher S Cooper", Iowa City, IA; John V Kryger, Madison, WI; Steven G Docimo, Pittsburgh, PA; Sean P Hedican, Madison, WI INTRODUCTION AND OBJECTIVE: Adequate surgical evaluation of a non-palpable testicle (NPT) requires either positive identification of a testicle (or testicular nubbin) attached to the spermatic cord vasculature, or demonstration of ipsilateral blind ending testicular vessels. Any procedure that does not achieve one of these two results should be considered non-diagnostic. The danger of not pursuing further evaluation and potential treatment results from the increased potential risk of 1) testicular atrophy with loss of spermatogenesis and androgen production, 2) malignancy and the inability to effectively screen the intraabdominal testicle, and 3) a delayed torsion event. We investigated the use of laparoscopy in evaluating and treating the inadequately explored NPT. METHODS: A total of 7 children aged 18 months to 10 yrs (mean 3 yrs 11 months) and one adult male (age 20 yrs) were evaluated for a NPT tbat had undergone a previous non-diagnostic open exploration. Six patients had been explored tbrough a standard inguinal incision, 1 had a bilateral abdominal exploration through a Pfannenstiel during which only one testicle was identified, and 1 underwent a successful first stage of a Fowler-Stephens repair but during the second stage no testicle or cord structures were identified. Six patients had been explored by a general urologist, one by a pediatric surgeon, and in one case this information was not available. A review of the initial operative notes or personal communications with the operative surgeons revealed that blind ending vessels were not identified in each case. RESULTS: Laparoscopic exploration was performed in all 8 patients and an intra-abdominal testicle was identified in 5 patients, blind ending vessels in 2, and vessels exiting the internal ring with an attached testicular nubbin in 1. In the patients with a testicle identified, a single stage laparoscopic Fowler-Stephens orchiopexy was then performed in 2, a pure laparoscopic orchiopexy in 1, open orchiopexy in 1, orchiectomy in 1, and nubbinectomy in 1. Time from open exploration to laparoscopic exploration ranged from 2 months to 16 yrs (mean 38 months). CONCLUSIONS: Laparoscopy provided 100% diagnostic accuracy in our series of patients with NPT who had undergone a previous non-diagnostic open exploration with an intra-abdominal testicle identified 63% of the time. Source of Funding: None.
489 LAPAROSCOPIC BILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IS ASSOCIATED WITH SUPERIOR POSTOPERATIVE VOIDING EFFICIENCY· FIVE YEARS RESULTS Brett M Carswell*, Sergio D Fefer, Worcester, MA; Leo C Fung, Minneapolis, MN INTRODUCTION AND OBJECTIVE: Application of bilateral extravesical ureteral reimplantation has been hindered by concerns over post-operative urinary retention, reported by multiple series to range from 4 to 22%. In performing extravesical ureteral reimplantations by the laparoscopic approach, there is minimal peri-vesical mobilization compared to the open procedures. In addition, the detrusor dissection is limited to an inverted-Y shape, mobilizing only the anterior and lateral aspects of the UVJ while preserving the distal trigonal attachment. In this technique, the ureterovesical junction (UVJ) remains at the original position with no dissection distal to the UVl. The objective of this study was to assess the five years results of the laparoscopic approach on voiding efficiency following bilateral extravesical ureteral reimplantations. METHODS: Over the past five years, 49 bilateral extravesical ureteral reimplantations (98 ureters) were performed for primary vesicoureteral reflux, using the inverted-Y detrusor dissection, through a laparoscopic approach. Patient age ranged from 4 to 18 (mean 8.7) years. All patients were monitored prospectively. Voiding efficiency was assessed by uroflowmetry and ultrasound post-void residual volume measurements at 1 to 2 days, 2 weeks and 2 months post-operatively. Upper tract imaging and voiding cystourethrogram were obtained 2 months post-operatively, and renal ultrasonography was performed at 1 year. RESULTS: Urethral catheters were removed the day of discharge home, with a mean post-operative stay of 25 hours. None of the laparoscopic patients were identified to have post-operative urinary retention (0%), which compares favorably to reported series (4 to 22%) (p
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effective as traditional open bilateral extravesical ureteral reimplantation, but is associated with superior post-operative voiding efficiency. Source of Funding: None.
490 JUVENILE GRANULOSA CELL TUMOR OF THE TESTIS: CONTEMPORARY CLINICAL MANAGEMENT AND PATHOLOGICAL DIAGNOSIS Aseem R Shukla", Huff S Dale. Philadelphia, PA; R B Filmer, Wilmington, DE; Douglas A Canning, Howard M Snyder, Michael C Carr, Philadelphia, PA INTRODUCTION AND OBJECTIVE: The juvenile granulosa cell tumor of the testis is a rarely diagnosed subset of stromal testis tumors. Although this variant of testis stromal tumors is predominantly a benign entity in prepubertal patients, limited experience has precluded complete understanding of its clinical presentation and pathological diagnosis. We combined the cumulative experience at two large children's hospitals with juvenile granulosa cell tumors to further the understanding of this neoplasm. METHODS: Retrospective review of testis tumors at our institution identified 74 tumors of which 8 (II %) of the tumors were stromal tumors. This group of stromal tumors consisted of juvenile granulosa cell tumors (3), Leydig cell tumors (2), mixed stromal tumors (2) and not otherwise specified (1). Additionally, we reviewed the clinical histories and pathological specimens for 2 juvenile granulosa cell tumors from another institution and included them in our study to form a cohort of 5 patients with JGCT. RESULTS: Four patients presented at birth and 1 infant was first examined at 3 months of age. All patients presented with a finn testicular mass; sonography revealed a multi-septated hypoechoic mass. While 4 of the 5 patients underwent a radical orchiectomy, a testis-sparing excision was performed in 1 patient with an atrophic contralateral testis. Gross examination of the tumors revealed intratesticular masses with cystic spaces on the cut surface. Immunostaining with inhibin, WT-l and vimentin were positive, while PLAP and AFP were negative for all specimens. At mean followup of7.5 years on the 3 patients from one institution, no metastatic or local tumor recurrence have been diagnosed. CONCLUSIONS: The JGCT of the testis should be suspected in neonates presenting at birth with a complex, cystic mass of the testis. Absence of tumor recurrence or metastasis, including the 1 patient with a testis-sparing mass excision, suggests a role for conservative management in certain cases. When routine histology is not diagnostic, immunohistochemical staining can distinguish this neoplasm from the yolk-sac tumor. Source of Funding: None.
491 CLINICAL OUTCOME AND QUALITY OF LIFE (QOL) ASSESSMENT OF LIVE DONORS AFTER LAPAROSCOPIC (LD) VS OPEN (OD) DONOR NEPHRECTOMY FOR PEDIATRIC RENAL TRANSPLANTATION (PED-KTX) William K Johnston III*, Jonathan L Pierce, John P McVicar, Richard V Perez, Christoph Troppmann, Sacramento, CA INTRODUCTION AND OBJECTIVE: Kidneys for adult-to-child living donor KTX are increasingly procured laparoscopically. While the laparoscopic approach was shown to be beneficial for the donor in adult KTX, there is little data concerning the impact on QOL and family dynamics of those donating a laparoscopic kidney to a child. We reviewed our initial experience by comparing donor clinical outcome and QOL of LD vs OD for PED-KTX. METHODS: We compared 14 consecutive LD (4/97-6/02) with 15 consecutive OD (12/91-3/97) who gave a kidney to a pediatric «18yr) recipient (mean age 9.9 yr). Twenty-six (90%) of 29 kidneys were donated by a biologic parent of the recipient (2, stepmother; 1 uncle). Graft and patient survival was calculated according to Kaplan-Meier. All donors were mailed a structured questionnaire regarding preop decision-making, periop care, QOL, and concerns, and a standardized Medical Outcome Study Health Survey (SF-36). RESULTS: Mean age of LD (34 yr) vs OD (31 yr) was not significantly different. Graft survival at 1 and 3 yr was 100% for LD PED-KTX; and 93% and 85% for OD PED-KTX, respectively. Recipient survival at 1 and 3 yr was 100% for LD PED-KTX, and 100% and 92% for OD PED-KTX respectively. For LD, median postop length of stay was significantly shorter (3 vs 5 d for OD, P=0.02). One LD was converted to open nephrectomy. No LD or OD required blood transfusion, reoperation, or readmission. Ten LD (71%) and 9 OD (60%) responded to our QOL questionnaires. Of those that responded, all LD (100%) felt that the availability of the laparoscopic technique had not affected their decision to donate. Upon returning home, 60% LD and 56% OD provided their care for themselves. By one month, 60% LD vs 10% OD were back to their normal activity, but at 6 months no LD perceived residual pain or other problems; 1 OD complained of incisional numbness. All donors would make the same decision today and would recommend it to others.
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CONCLUSIONS: While LD nephrectomy has contributed to the significant increase of adult live donor KTX, our data suggest that the parent-to-child bond supersedes any potential concern about the procurement mode in this unique population and does not influence the decision to donate. Nevertheless, the shorter hospital stay and more rapid convalescence makes LD particularly advantageous for the typical parental donor in PED-KTX who is frequently responsible for his own in addition to other family and work obligations. Source of Funding: None.
492 DYNAMIC CONTRAST ENHANCED MAGNETIC RESONANCE UROGRAPHY IN THE EVALUATION OF HYDRONEPHROSIS IN CHILDREN: PELVIC TRANSIT TIME PREDICTS PRESENCE OF OBSTRUCTION Marcos R Perez-Brayfield", Damien Grattan-Smith, Hal Scherz, Richard Jones, Andrew J Kirsch, Atlanta, GA INTRODUCTION AND OBJECTIVE: A combination of nuclear medicine techniques, ultrasound, and voiding cystourethrography (VCUG) are typically used to investigate hydronephrosis in children. In order to make appropriate clinical decisions regarding intervention, urologists need to be able to distinguish the dilated, poorly draining non-obstructed system from the system that is actually obstructed. One of the major problems is that there is no gold standard to assess obstruction.The objective of our study is to evaluate the utility of dynamic contrast enhanced MR urography in the investigation of children with hydronephrosis, to define urinary tract anatomy, to calculate differential renal function and to assess urinary tract obstruction. METHODS: Dynamic contrast enhanced MR imaging was performed in 51 children. There were 21 girls and 30 boys with mean age 4 years. The information from traditional imaging modalities (renal ultrasound, renal scintigraphy, and VCUG) was compared to the information obtained from the MR study. RESULTS: The final diagnoses by MR urography were 9 children with UPJ obstruction, 4 with primary UVJ obstruction, 7 with dilated but not obstructed systems, 7 with duplex systems , 2 with multicystic dysplastic kidneys, 1 with unilateral small, scarred kidney, 2 with acute pyelonephritis, 1 renal mass, 1 bilateral policystic kidneys, 1 dysplastic horseshoe kidney and 16 children with normal study MR urography. The anatomic imaging with MR was equivalent to ultrasound in detecting and classifying hydronephrosis but was far superior at delineating ureteric anatomy. The split rena! function as calculated by both nuclear and MRI scans were compared and the correlation coefficient was excellent (r=0.91) Pelvic Transit Time (PTT) >450 sec predicted obstruction in all DTPA obstructed systems. PTT for non obstructed systems was < 250 sec regardless of degree of dilation. Four cases were equivocal with PTT between 250 sec and 450 sec. CONCLUSIONS: Dynamic contrast enhanced MR Urography provides superior anatomic and equivalent functional infonnation when compared with ultrasound and diuretic renal scintigraphy. Pelvic Transit Time predicted the presence of obstruction in all DTPA obstructed systems. It is likely that MR urography will replace renal scintigraphy in the evaluation of hydronephrosis in children. Source of Funding: None.
493 EVALUATION OF TC-99M DIMERCAPTOSUCCINIC ACID (DMSA) SCINTIGRAPHY AND ITS ABILITY TO PREDICT OCCURRENCE OF A SECOND FEBRILE URINARY TRACT INFECTION (UTI) IN CHILDREN UNDER TWO YEARS OF AGE Matthew P Rutman", Evan J Kass, Royal Oak, MI INTRODUCTION AND OBJECTIVE: To evaluate DMSA renal scintigraphy in children less than two years old with a first hospitalized febrile UTI. In addition, to determine if the DMSA result predicts the occurrence of a second febrile UTI in those children with normal voiding cystourethrogram (VCUG) and ultrasound (U/S). METHODS: A total of 233 DMSA scans performed between August 1997 and December 200 I on children under two years old, for an indication of first hospitalized febrile UTI, were reviewed. The VCUG and UIS for those children were also reviewed. Patients were then divided into two groups: the first with all normal studies; the second with abnormal DMSA, and normal VCUG and U/S. The groups were then evaluated for occurrence of a second febrile UTI. RESULTS: Of the 233 patients, 155 (66.5%) had abnormal DMSA scans, of whom 83 (53.5%) had reflux. Of the 155 patients with abnormal DMSA studies. 56 (36.1%) had norma! VCUG and UIS studies. One of the 56 (1.78%) presented with a second febrile UTI, with a mean follow-up of 29.6 months. Of the 233 patients, 78 (33.5%) had normal DMSA scans, of whom 54 (69.2%) had normal VCUG and UlS studies. None of those patients presented with a second febrile UTI, with a mean follow-up of 24.2 months. CONCLUSIONS: This study indicates that children with normal VCUG and UIS studies are unlikely to develop a second febrile UTI regardless of DMSA
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result. Of those patients with normal DMSA, VCUG and UIS, none developed a second febrile UTI. Of those patients with an abnormal DMSA, normal VCUG and UlS, only one developed a second febrile UTI. In children less than two years old, with normal studies (VCUG and U/S), it appears DMSA has little predictive value in the occurrence of a second febrile UTI. Source of Funding: None.
494 CLITORAL SENSITIVITY AND VIABILITY FOLLOWING A MODIFIED REDUCTION CLITOROPLASTY WITH FOLLOWUP TESTING IN 21 PATIENTS Dix Poppas, Maher M El Chaar*, Cathy Kelly, Maria New, New York, NY INTRODUCTION AND OBJECTIVE: Enlargement of the clitoris is a prominent manifestation of virilizing congenital adrenal hyperplasia (CAH) and other disease states resulting in ambiguous genitalia. Controversy persists as to the viability and sensitivity of the clitoris following reduction clitoroplasty. To date, no single large group study using a single technique has been evaluated for postsurgical clitoral viability and sensitivity. We report on a modified technique for reduction clitoroplasty based on the understanding of the female clitoral anatomy that results in outstanding cosmetic appearance with reliable viability and sensation. METHODS: 21 patients underwent reduction clitoroplasty from 1996 to 2002 using the same technique by a single surgeon. The youngest was 5 months and the oldest 24 years with a mean age of 6 years. 18 patients had CAH. One patient was a 46 XX true hermaphrodite and two patients were 46 XY and underwent sex reassignment surgery. Simple modifications to the conventional technique include: total mobilization of the neurovascular bundles (NVB) through parallel ventral midline incisions of Buck's fascia, no reduction or excision of the glans clitoris, irrigation of the NVB with papaverine and subtotal excision of the corpus cavernosal tissue. All patients were evaluated post-operatively for clitoral viability by gross examination and capillary perfusion testing. Of the 21 patients, 7 patients were above 5 years of age and considered candidates for clitoral sensory testing (CST). CST was performed using a cotton-tip stimulator. On a scale of 0 to 5, the patient was asked to report the degree of sensation at various points of the genitalia and inner thigh. Mean follow-up time of these patients was 2 years. RESULTS: Our results in the 21 patients that underwent reduction clitoroplasty have been excellent. No postoperative complications have been reported. All patients had a viable clitoris with normal capillary perfusion. Of the 7 patients that were evaluated with CST, all reported a degree of sensation of 3/5 at the inner thighs, 4/5 at the labia minora and 515 at the clitoris. CONCLUSIONS: The modified reduction clitoroplasty provides a safe, reliable approach to managing the enlarged clitoris. The positive viability and sensation outcomes in the older patients suggest this technique will be successful in the younger children undergoing the procedure. This data supports the belief that clitoral reconstructive surgery using this technique does not result in loss of sensation or viability. Source of Funding: Weill Medical College of Cornell University-Center for Pediatric Urology.
Bladder Cancer: Basic Research (I) Discussed Poster Monday, April 28, 2003
8:00 AM-12:00 PM
495 PROTEA SOME INHIBITOR PS-341 SENSITIZES DRUGREFRACTORY HUMAN TRANSITIONAL CELL TUMORS TO GEMCITABINE Ashish M Kamat*, Takashi Karashima, Darren Davis, Colin Dinney, David J McConkey, Houston, TX INTRODUCTION AND OBJECTIVE: Recent studies have implicated the transcription factor nuclear factor kappa B (NF-KB) in cancer progression, angiogenesis, metastasis, and therapeutic resistance. Our previous studies indicated that NF-KB activity was elevated in a metastatic variant of the human 253J transitional cell carcinoma (TCC) line (253J-BV) relative to isogenic nonmetastatic controls. The 26S proteasome regulates NF-KB activity by degrading its physiological inhibitor, IkappaBalpha (IKBO'). We therefore tested the effects ofthe proteasome inhibitor PS-341 on NF-KB activity and apoptosis in 253J-BV cells grown in vitro and as tumor xenografts in vivo. METHODS: The apoptotic effect of PS-341 alone, gemcitabine alone and the combination was assessed in vitro by propidium iodide staining and flow cytometry. The ability of PS-341 to inhibit inducible NF-KB activity was assessed *Presenting author.
using the luciferase reporter gene assay and the electrophoretic mobility shift assay. We also implanted 253J-BV cells into the subcutis of athyrnic nude mice using 2 x 106 cells in 200 ,.,,1 of Matrigel or orthotopically into the bladder wall of the mice using 0.5 x 106 cells in 40 ,.,,1 of Hanks balanced salt solution. One week after implantation, treatment was started using saline (control), PS-341 (I mg/kg), gemcitabine (12.5 or 50 mg/kg) or both (n=12, each group). Mice received intraperitoneal injections every Monday and Thursday for 4 weeks at which point the animals were sacrificed. RESULTS: PS-341 induced apoptosis in the 253J-BV cells in vitro and increased the levels of apoptosis induced by gemcitabine. PS-341 also inhibited the production of several pro-angiogenic factors (intedeukin-8 (IL-8), matrix metalloproteinase-9 (MMP-9) and vascular endothelial cell growth factor (VEGF)) by 253J-BV cells in vitro, effects that were associated with reduced NF-KB DNA binding activity. Combination therapy with PS-341 plus gemcitabine also significantly (p<0.05) inhibited the growth of ectopic (subcutaneous) and orthotopic 253J-BV tumors grown as xenografts in nude mice, effects that were associated with reductions in tumor IL-8, MMP-9, and VEGF expression. CONCLUSIONS: Proteasome inhibition with PS-341 blocks inducible NF-KB activity, leading to enhanced apoptosis and augmenting the chemosensitivity to gemcitabine. This is accompanied by downregulation of IL-8, MMP-9 and VEGF. Together, our data demonstrate that PS-341-based combination chemotherapy has the potential to overcome therapeutic resistance in bladder cancer. Source of Funding: Grant IP50CA91846-01 (Bladder Cancer SPORE).
496 RECOMBINANT BCG EXPRESSING IL-18 (IL·18 RBCG) ENHANCES MACROPHAGE CYTOTOXICITY AGAINST MOUSE BLADDER CANCER CELL LINE MBT-2 IN VITRO Yi Luo*, Hiroshi Yamada, Xiaohong Chen, Michael A Odonnell, Iowa City, IA INTRODUCTION AND OBJECTIVE: The role of macrophages in BCG immunotherapy of bladder cancer has been barely explored. This study was undertaken to investigate if macrophages exhibit a direct cytolytic activity on bladder cancer cells upon BCG stimulation. Since IL-18 is known to be a potent activator for macrophages, our newly developed IL-18 rBCG was evaluated for its induction of macrophage cytotoxicity. METHODS: Macrophages were induced by intraperitoneal injection of thioglycollate in C3H1HeJ mice for 3 days. Peritoneal exudate cells (PEC) were then harvested and cultured in the presence of either control wild-type BCG or IL-18 rBCG at a ratio of 1:1 of PEC to BCG. For comparison IL-2 rBCG and GMCSF rBCG were included. After 24 hour incubation 51Cr-Iabeled MBT-2 cells were added at several E:T ratios and the mixture cultures were incubated for 20 hours before counting the supernatants for cell lysis evaluation. Supernatants from a panel of parallel mixture cultures of PEC and BCG were harvested at different time points for cytokine production assays. Neutralizing antibodies to IFN--y, TNF-O', IL-12, and IL-18 were used to evaluate the role of each of these cytokines in BCG-induced macrophage cytotoxicity. RESULTS: Macrophages prepared without BCG stimulation showed weak cytotoxicity against MBT2 cells (less than 10% lysis at E:T=20:1). Enhanced cytotoxicity (20-30% lysis at E:T=20: I) in a dose-dependent manner was observed upon wild-type BCG stimulation. IL-18 rBCG showed about 2-fold higher (3060% lysis at E:T=20:1) cytolytic activity than that induced by wild-type BCG. These increased cytolytic levels were comparable with those induced by wild-type BCG plus exogenous IL-18. Such increased lysis was also observed when IL-2 rBCG and GMCSF rBCG were used for stimulation. Although all neutralizing antibodies (Ab) tested showed an inhibitory effect on BCG-induced macrophage cytotoxicity, anti-TNF-O' Ab exhibited a nearly complete inhibition (95-99%), indicating that TNF-O' plays a major role in macrophage-mediated killing of MBT-2 cells. Consistent with cytolytic activity, cytokine analysis for supernatants of macrophage-BCG mixture cultures demonstrated higher levels of IFN--y and TNF-O'in IL-18 rBCG cultures than those in wild-type BCG cultures. CONCLUSIONS: BCG efficiently induces macrophage cytotoxicity against MBT-2 cells in vitro. IL-18 rBCG is superior to wild-type BCG for induction of this cytotoxicity and thus may serve as a better agent for bladder cancer immunotherapy. Source of Funding: None.
497 SYNERGISTIC ANTITUMOR EFFECT OF INTRA VESICAL LIPOSOME·MEDIATED INTERLEUKIN-2 GENE THERAPY PLUS BCG IN ORTHOTOPIC MURINE BLADDER CANCER Masafumi Oyama*, Warren D Heston, Cleveland, OH; Yutaka Horiguchi, Toru Nishiyama, Masaru Murai, Tokyo, Japan; Andrew C Novick, Cleveland, OH; William A Larchian, Elyria, OH INTRODUCTION AND OBJECTIVE: Bladder cancer is one of common cancers in the United States. Bacillus Calmette-Guerin(BCG) is considered to be the most effective agent for the treatment andlor prophylaxis of the bladder
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482 ADULT ADIPOSE DERIVED STEM CELLS FOR RECONSTRUCTION OF THE ATROPHIC FEMALE URETHRA: TISSUE ENGINEERING TECHNIQUES FOR TREATMENT OF SUI Fernando De Almeida, Zeni Alfonso, Brian Strem, Larissa V Rodriguez», Los Angeles, CA INTRODUCTION AND OBJECTIVE: The spongy tissue of the urethra consists of smooth musculature (SM) essential in maintaining continence. Current treatments of SUI involve injection of bulking agents into periurethral tissues to provide support and resistance to flow. This approach is problematic due to issues of biocompatibility and durability related to rejection, migration, and absorption of these materials. We are studying the use of adult adipose derived stem cells (ADSC) for the reconstruction of functional urethral SM. The procurement process is simpler than other sources of stem cells and the ability of these cells to form SM could provide a long lasting biocompatible treatment for SUI. METHODS: Human liposuction samples were processed with saline washes and collagenase digestion to obtain a stromal vascular fraction (SVF). A fibroblastlike cell population was obtained. The cells were seeded in 100mm dishes and allowed to grow to 70% confluence. The cells were resuspended in Hank's Balance Salt Solution at a concentration of I X 108/ml. 20ILI of this cell suspension was injected into bladder walls of immunodeficient scm mice. The bladders were harvested at 4,6,8, and 12 wks. Three different labeling techniques were used: (1) Incorporation of LacZ reporter gene (2) Incorporation of 5' -bromodeoxyuridine (BrdU), and (3) Alu. Cells transduced with the LacZ gene were identified by l3-galactosidase activity. BrdU was incorporated in mitotically active cells and was identified by immunohistochemistry. The human origin of the cells was confirmed with in situ hybridization of the Alu DNA sequence. RESULTS: There was an even distribution of ADSCs throughout the muscle layer of the bladder at the injection site. The cells were morphologically identical to surrounding SM cells. Many ADSCs were identified at all time points by identification of BrdU and lacZ containing cells. In addition, the cells were shown to be of human origin by the presence of Alu. CONCLUSIONS: This study serves as proof of concept of the use of human ADSCs for lower urinary reconstruction and treatment of SUI. The cells were shown to survive in the smooth musculature of the urinary tract. Given that the procurement process is simple, with minimal morbidity, and one familiar to urologists, this is an attractive source of stem cells. In addition, the ability of these cells to differentiate into multiple tissue types including skeletal, SM, and neural cells, makes them attractive for development of functional tissues of the lower urinary tract. Source of Funding: American Geriatrics Society; Council on Research of the Academic Senate of the Los Angeles Divison of the University of California.
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fecal leakage was seen. We reoperated on 7 patients (outlet substitution using the appendix in 3 and Monti tube in one; conversion to Mainz pouch II in one and to a Bricker conduit in other; revision of a colon stoma stenosis at skin level in one). End results in terms of continence showed only 2 patients incontinent (one refused surgery, other with Bricker), 2 partial continent (up to 2hs) and 1 remained with a stenotic stoma (lost follow-up). Alltogether continence rate> 4hs was 91,6 % and> 2hs was 95%. The reoperation rate in this series was of 12,9% per patient (7/54) or 11,6% per stoma (7/60). The reoperation rate of the CCUR was 13 % (6/46). Mean follow-up was 26 months. CONCLUSIONS: The results found with this alternative approach are equivalent to other reported series. We believe that continent catheterizable reservoirs are easier to perform than augmentation plus incorporation of the appendix or Monti tube. This strategy has also the advantage to spare the appendix for an eventual operative revision of the outlet channel. Source of Funding: None.
484 LOCAL AND SYSTEMIC EFFECTS OF ENGINEERED BLADDER TISSUE Tae Gyun Kwon*, James J Yoo, Anthony Atala, Boston, MA INTRODUCTION AND OBJECTIVE: The use of engineered bladders has become a potential treatment option in urologic surgery. Although the engineered bladder tissues demonstrate adequate anatomical and functional parameters, studies regarding the host response and overall safety have not been extensively pursued. This study aimed to determine the local and systemic host tissue effects from engineered bladders in a canine cystoplasty model. METHODS: Seven beagles underwent trigone-sparing cystectomies. Autologous urothelial and smooth muscle cells were grown and seeded on prefabricated polymer (PGA) molds and used for bladder augmentation. Serial urodynamic studies, cystograrns, PB smears, urinalysis, serum chemistry, CBC and electrolytes were obtained at pre-determined time points postoperatively. The bladder tissues, local and distant organs were retrieved 6 months after surgery for histologic and immunologic analyses. RESULTS: The capacity and compliance of the engineered bladders reached near normal levels by 3 months and normal levels by 6 months. The engineered bladders showed a similar tissue composition as the normal bladders. There was no evidence of immune cells, and infiltration of inflammatory cells was minimal. An increase in total systemic leukocyte count and bacteriuria were evident initially at 1 week, and returned to normal levels by 1 month postoperatively. Other systemic parameters remained within normal levels at all time points. There was no evidence of abnormal findings in any of the local and distant organs. CONCLUSIONS: Implantation of bladder molds with cells does not exhibit significant local or systemic toxicity. This study demonstrates that the engineered bladders, composed of autologous cells and polymer scaffolds, are safe and effective for their use in reconstructive surgery. Source of Funding: Departmental.
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483 CONTINENT CATHETERIZABLE STOMAS: SHOULD WE CHANGE? Antonio Macedo*, Gilmar Garrone, Mauricio Hachul, Riberto Liguori, Sergio Otoni, Sao Paulo, Brazil; Ubirajara Barroso, Sao Paulo; Miguel Srougi, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Experience with urinary and colonic continent stomas suggest the use of the appendix as first choice efferent channel for Mitrofanoff and Malone principles. Differently to this strategy, we use the appendix primarily only for the cases where there is no need for bladder augmentation and secondarily in case of revision of leaking or stenotic catheterizable stomas. We evaluated our experience with catheterizable stomas to support our strategy. METHODS: Between June 1996 and September 2002 we constructed 60 catheterizable stomas by 54 patients. There were 7 appendicovesicostomies (AV), 46 continent catheterizable urinary reservoirs (CCUR) and 7 left-colon stomas (LCS) for antegrade bowel wash-outs. All but one patient with left-colon stoma underwent this procedure in association with a CCUR. The indications for urinary reconstruction were mainly complex urethral strictures by the AV group (417) and end-stage bladder diseases by the CCUR patients (neurogenic bladder, bladder exstrophy, PUV, rhabdomyossarcoma and others). The age ranged from 2 to 62 years, mean 19. The continent urinary reservoirs were made from the ileum (45/46) and colon transversus in only one case. RESULTS: There were no complications by the primary AV patients. We found stoma stenosis in 4 patients (3 CCUR, I LCS), urinary fistula in one (bladder exstrophy), total stoma incontinence in 4 and leakage after 2 hours in 2 cases. No
URETEROCYSTOPLASTY: HOW GOOD IS IT?
Douglas A Husmann*, Rochester, MN; Warren Snodgrass, Dallas, TX; Stephen A Kramer, Rochester, MN
INTRODUCTION AND OBJECTIVE: The ability to assess the efficacy of ureterocystoplasty in the current literature is fraught with problems. Frequently there is no mention if preoperative urodynamic evaluations were performed in the presence or absence of a refluxing megaureter and urodynamic end points are not standardized between the publications. Although the original reports regarding this operation were extremely favorable, as our own personal experience with ureterocytoplasty has grown we became concerned with the frequent need to reaugment these pts. This report clarifies the complications of this procedure that heretofore have not been elucidated. METHODS: Pts undergoing ureterocystoplasty from 1987- 2002 were reviewed. All pts included in the study were incontinent of urine preoperatively. The pre and post operative end fill bladder capacity defined as the volume in cc reached when the detrusor pressure reaches 40 ern of water or when the patient becomes intolerant of additional bladder was recorded. The onset of urinary continence, the need for reaugmentation and the association of any associated urologic complications were noted. RESULTS: A total of 22 ureterocystoplasties were performed. The etiology for bladder noncompliance or instability was neurogenic in etiology in 18 and due to urethral valvular disease in 4. Augmentation was performed with a single system intact ureter and pelvis in 20 pts and with bilateral ureters and renal pelvis in 2 pts, prior to renal transplantation. Fourteen pts had refluxing megaureters, preoperatively, with 8 having nonrefluxing megaureters. End fill bladder capacity in pts with single system augments increased by a median of 2.5 fold, range 0.8 to 4. End fill bladder capacity with bilateral system augments increased by a 3 and 4.5 fold margin. Clinically, 2/22 pts (9%) became continent and were voiding,
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2/22(9%) were continent on anticholinergics and voiding, 5/22 (23%) were continent but required CIC to empty, 3/22 (13%) were continent on anticholinergics and CIC, 10/22 (45 %) remained incontinent and required reaugmentation witb a gastrointestinal segment. It is notewortby tbat one pt with a double system augment dry on CIC perforated his augment 6 montbs after renal transplant and died of overwhelming sepsis. CONCLUSIONS: Ureterocystoplasty is not a panacea and may on occasion (45%) be inadequate to provide continence resulting in the need for reaugmentation. In addition it is not free from tbe morbidity associated with delayed spontaneous bladder perforations. Source of Funding: None.
486 NEPHRON-SPARING SURGERY FOR BILATERAL WILMS TUMOR (BWT): A 15 YEARS REVIEW AT A SINGLE INSTITUTION Wladimir Alfer*, Sergio Moreno, Paulo Chapchap, Maria Lucia Pinho, Beatriz De Camargo, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Bilateral disease occurs in 4-8% of patients with Wilms tumor. Nephron-sparing surgery is a challenging procedure currently recommended for BWT. We reviewed our results with these procedures. METHODS: Retrospectively analysis of 15-year at the Pediatric Department was performed. Twelve children, ten with synchronous BWT and 2 with metachronous disease were treated. Mean age was 28,5 months (range from 8 to 60 months), 7 were girls and 2 had congenital abnormalities. Among the synchronous cases initial approach was biopsy in 6 (4 open, 2 percutaneous), 2 preoperative chemotherapy witbout biopsy, and 2 had been submitted to unilateral nephrectomy elsewhere. All children received chemotherapy 8 to 34 weeks (median 13 weeks). Surgical procedure on 20 renal units was: 13 enucleation, 4 partial nephrectomies and 3 complete nephrectomies. Pathology findings regarding margins on 18 renal units was: 7 microscopic positive margins, 8 negative and 8 not evaluated. Only one case had positive lymph nodes. There were 3 local relapses, 2 on negative microscopic margins and 1 with positive microscopic margins. Definitive surgical procedures: 12 enucleations, 4 partial nephrectomies and 4 complete nephrectomies. Only one case had unfavorable histology (anaplasia in both kidneys) with compromised microscopic margins, this child is alive 10 years after treatment. Among the 2 metachronous tumors, enucleation was possible in one, this child is alive without disease 11 years after. RESULTS: Final bilateral renal preservation rate was 80%. Nine out of 10 children with synchronous tumors and lout of 2 with metachronous tumors are alive without disease. CONCLUSIONS: Microscopic residual disease may not have a major impact in either local recurrence or survival. Bilateral nephron sparing surgery is possible without compromising outcome. Multidisciplinary team is essential. Source of Funding: None.
487 INITIAL RESULTS OF DEFLUX INJECTION FOR VESICOURETERAL REFLUX: THE DALLAS EXPERIENCE James M Elmore*, David H Ewalt, Warren T Snodgrass, Dallas, TX INTRODUCTION AND OBJECTIVE: Following recent FDA approval of dextranomerlhyaluronic acid copolymer (DEFLUX®), endoscopic injection has become another option for the management of vesicoureteral reflux (VUR) in the U.S. Herein we report our intial experience with the technique. METHODS: We reviewed the charts of all patients undergoing Deflux injection for VUR at our institutions. After treatment, patients were maintained on antibiotic prophylaxis pending follow-up voiding cystourethrogram (VCUG). For this study, results were determined after only 1 Deflux injection. Success was defined as complete resolution of reflux on postoperative VCUG. RESULTS: Since December 2001,70 girls and 5 boys (117 renal units) with a mean age of 5.5 years (range 7 months to 15 years) underwent a single Deflux injection for treatment of VUR. Indications were persistent reflux on observation, breakthrough pyelonephritis, or parental preference as primary therapy at diagnosis. Follow-up VCUG, performed at a mean 14 weeks after treatement (range 8 to 20 weeks), is currently available for 35 patients (54 renal units) including 2 patients with neurogenic bladder (NGB) and 3 patients with ureteral duplication. Preoperative reflux in the 54 treated ureters was grade I in 3, grade II in 32, grade III in 16, grade IV in 2, and grade V in 1. One Deflux injection completely resolved reflux in 22 of 35 patients (63%) and in 38 of 54 ureters (70%). Therapy was successful in 2 of 3 patients with duplex ureters, all ureters with grade 4 or 5 reflux, and in botb patients with NGB. Complications included de novo contralateral relux in 2 patients and ureteral obstruction in 1. CONCLUSIONS: In our initial experience, a single Deflux injection resolved reflux in 70% of ureters. As in open surgery, contralateral reflux can occur in untreated ureters, and may be of greater concern when injection is done as primary therapy after only I VCUG. To our knowlegde, our patient with asymptomatic ureteral obstruction is tbe first with tbis complication after Deflux injection. Source of Funding: None. *Presenting author.
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488 OUTCOME OF LAPAROSCOPY FOLLOWING NONDIAGNOSTIC OPEN EXPLORATION FOR CRYPTORCHIDISM Christopher S Cooper", Iowa City, IA; John V Kryger, Madison, WI; Steven G Docimo, Pittsburgh, PA; Sean P Hedican, Madison, WI INTRODUCTION AND OBJECTIVE: Adequate surgical evaluation of a non-palpable testicle (NPT) requires either positive identification of a testicle (or testicular nubbin) attached to the spermatic cord vasculature, or demonstration of ipsilateral blind ending testicular vessels. Any procedure that does not achieve one of these two results should be considered non-diagnostic. The danger of not pursuing further evaluation and potential treatment results from the increased potential risk of 1) testicular atrophy with loss of spermatogenesis and androgen production, 2) malignancy and the inability to effectively screen the intraabdominal testicle, and 3) a delayed torsion event. We investigated the use of laparoscopy in evaluating and treating the inadequately explored NPT. METHODS: A total of 7 children aged 18 months to 10 yrs (mean 3 yrs 11 months) and one adult male (age 20 yrs) were evaluated for a NPT tbat had undergone a previous non-diagnostic open exploration. Six patients had been explored tbrough a standard inguinal incision, 1 had a bilateral abdominal exploration through a Pfannenstiel during which only one testicle was identified, and 1 underwent a successful first stage of a Fowler-Stephens repair but during the second stage no testicle or cord structures were identified. Six patients had been explored by a general urologist, one by a pediatric surgeon, and in one case this information was not available. A review of the initial operative notes or personal communications with the operative surgeons revealed that blind ending vessels were not identified in each case. RESULTS: Laparoscopic exploration was performed in all 8 patients and an intra-abdominal testicle was identified in 5 patients, blind ending vessels in 2, and vessels exiting the internal ring with an attached testicular nubbin in 1. In the patients with a testicle identified, a single stage laparoscopic Fowler-Stephens orchiopexy was then performed in 2, a pure laparoscopic orchiopexy in 1, open orchiopexy in 1, orchiectomy in 1, and nubbinectomy in 1. Time from open exploration to laparoscopic exploration ranged from 2 months to 16 yrs (mean 38 months). CONCLUSIONS: Laparoscopy provided 100% diagnostic accuracy in our series of patients with NPT who had undergone a previous non-diagnostic open exploration with an intra-abdominal testicle identified 63% of the time. Source of Funding: None.
489 LAPAROSCOPIC BILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IS ASSOCIATED WITH SUPERIOR POSTOPERATIVE VOIDING EFFICIENCY· FIVE YEARS RESULTS Brett M Carswell*, Sergio D Fefer, Worcester, MA; Leo C Fung, Minneapolis, MN INTRODUCTION AND OBJECTIVE: Application of bilateral extravesical ureteral reimplantation has been hindered by concerns over post-operative urinary retention, reported by multiple series to range from 4 to 22%. In performing extravesical ureteral reimplantations by the laparoscopic approach, there is minimal peri-vesical mobilization compared to the open procedures. In addition, the detrusor dissection is limited to an inverted-Y shape, mobilizing only the anterior and lateral aspects of the UVJ while preserving the distal trigonal attachment. In this technique, the ureterovesical junction (UVJ) remains at the original position with no dissection distal to the UVl. The objective of this study was to assess the five years results of the laparoscopic approach on voiding efficiency following bilateral extravesical ureteral reimplantations. METHODS: Over the past five years, 49 bilateral extravesical ureteral reimplantations (98 ureters) were performed for primary vesicoureteral reflux, using the inverted-Y detrusor dissection, through a laparoscopic approach. Patient age ranged from 4 to 18 (mean 8.7) years. All patients were monitored prospectively. Voiding efficiency was assessed by uroflowmetry and ultrasound post-void residual volume measurements at 1 to 2 days, 2 weeks and 2 months post-operatively. Upper tract imaging and voiding cystourethrogram were obtained 2 months post-operatively, and renal ultrasonography was performed at 1 year. RESULTS: Urethral catheters were removed the day of discharge home, with a mean post-operative stay of 25 hours. None of the laparoscopic patients were identified to have post-operative urinary retention (0%), which compares favorably to reported series (4 to 22%) (p
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effective as traditional open bilateral extravesical ureteral reimplantation, but is associated with superior post-operative voiding efficiency. Source of Funding: None.
490 JUVENILE GRANULOSA CELL TUMOR OF THE TESTIS: CONTEMPORARY CLINICAL MANAGEMENT AND PATHOLOGICAL DIAGNOSIS Aseem R Shukla", Huff S Dale. Philadelphia, PA; R B Filmer, Wilmington, DE; Douglas A Canning, Howard M Snyder, Michael C Carr, Philadelphia, PA INTRODUCTION AND OBJECTIVE: The juvenile granulosa cell tumor of the testis is a rarely diagnosed subset of stromal testis tumors. Although this variant of testis stromal tumors is predominantly a benign entity in prepubertal patients, limited experience has precluded complete understanding of its clinical presentation and pathological diagnosis. We combined the cumulative experience at two large children's hospitals with juvenile granulosa cell tumors to further the understanding of this neoplasm. METHODS: Retrospective review of testis tumors at our institution identified 74 tumors of which 8 (II %) of the tumors were stromal tumors. This group of stromal tumors consisted of juvenile granulosa cell tumors (3), Leydig cell tumors (2), mixed stromal tumors (2) and not otherwise specified (1). Additionally, we reviewed the clinical histories and pathological specimens for 2 juvenile granulosa cell tumors from another institution and included them in our study to form a cohort of 5 patients with JGCT. RESULTS: Four patients presented at birth and 1 infant was first examined at 3 months of age. All patients presented with a finn testicular mass; sonography revealed a multi-septated hypoechoic mass. While 4 of the 5 patients underwent a radical orchiectomy, a testis-sparing excision was performed in 1 patient with an atrophic contralateral testis. Gross examination of the tumors revealed intratesticular masses with cystic spaces on the cut surface. Immunostaining with inhibin, WT-l and vimentin were positive, while PLAP and AFP were negative for all specimens. At mean followup of7.5 years on the 3 patients from one institution, no metastatic or local tumor recurrence have been diagnosed. CONCLUSIONS: The JGCT of the testis should be suspected in neonates presenting at birth with a complex, cystic mass of the testis. Absence of tumor recurrence or metastasis, including the 1 patient with a testis-sparing mass excision, suggests a role for conservative management in certain cases. When routine histology is not diagnostic, immunohistochemical staining can distinguish this neoplasm from the yolk-sac tumor. Source of Funding: None.
491 CLINICAL OUTCOME AND QUALITY OF LIFE (QOL) ASSESSMENT OF LIVE DONORS AFTER LAPAROSCOPIC (LD) VS OPEN (OD) DONOR NEPHRECTOMY FOR PEDIATRIC RENAL TRANSPLANTATION (PED-KTX) William K Johnston III*, Jonathan L Pierce, John P McVicar, Richard V Perez, Christoph Troppmann, Sacramento, CA INTRODUCTION AND OBJECTIVE: Kidneys for adult-to-child living donor KTX are increasingly procured laparoscopically. While the laparoscopic approach was shown to be beneficial for the donor in adult KTX, there is little data concerning the impact on QOL and family dynamics of those donating a laparoscopic kidney to a child. We reviewed our initial experience by comparing donor clinical outcome and QOL of LD vs OD for PED-KTX. METHODS: We compared 14 consecutive LD (4/97-6/02) with 15 consecutive OD (12/91-3/97) who gave a kidney to a pediatric «18yr) recipient (mean age 9.9 yr). Twenty-six (90%) of 29 kidneys were donated by a biologic parent of the recipient (2, stepmother; 1 uncle). Graft and patient survival was calculated according to Kaplan-Meier. All donors were mailed a structured questionnaire regarding preop decision-making, periop care, QOL, and concerns, and a standardized Medical Outcome Study Health Survey (SF-36). RESULTS: Mean age of LD (34 yr) vs OD (31 yr) was not significantly different. Graft survival at 1 and 3 yr was 100% for LD PED-KTX; and 93% and 85% for OD PED-KTX, respectively. Recipient survival at 1 and 3 yr was 100% for LD PED-KTX, and 100% and 92% for OD PED-KTX respectively. For LD, median postop length of stay was significantly shorter (3 vs 5 d for OD, P=0.02). One LD was converted to open nephrectomy. No LD or OD required blood transfusion, reoperation, or readmission. Ten LD (71%) and 9 OD (60%) responded to our QOL questionnaires. Of those that responded, all LD (100%) felt that the availability of the laparoscopic technique had not affected their decision to donate. Upon returning home, 60% LD and 56% OD provided their care for themselves. By one month, 60% LD vs 10% OD were back to their normal activity, but at 6 months no LD perceived residual pain or other problems; 1 OD complained of incisional numbness. All donors would make the same decision today and would recommend it to others.
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CONCLUSIONS: While LD nephrectomy has contributed to the significant increase of adult live donor KTX, our data suggest that the parent-to-child bond supersedes any potential concern about the procurement mode in this unique population and does not influence the decision to donate. Nevertheless, the shorter hospital stay and more rapid convalescence makes LD particularly advantageous for the typical parental donor in PED-KTX who is frequently responsible for his own in addition to other family and work obligations. Source of Funding: None.
492 DYNAMIC CONTRAST ENHANCED MAGNETIC RESONANCE UROGRAPHY IN THE EVALUATION OF HYDRONEPHROSIS IN CHILDREN: PELVIC TRANSIT TIME PREDICTS PRESENCE OF OBSTRUCTION Marcos R Perez-Brayfield", Damien Grattan-Smith, Hal Scherz, Richard Jones, Andrew J Kirsch, Atlanta, GA INTRODUCTION AND OBJECTIVE: A combination of nuclear medicine techniques, ultrasound, and voiding cystourethrography (VCUG) are typically used to investigate hydronephrosis in children. In order to make appropriate clinical decisions regarding intervention, urologists need to be able to distinguish the dilated, poorly draining non-obstructed system from the system that is actually obstructed. One of the major problems is that there is no gold standard to assess obstruction.The objective of our study is to evaluate the utility of dynamic contrast enhanced MR urography in the investigation of children with hydronephrosis, to define urinary tract anatomy, to calculate differential renal function and to assess urinary tract obstruction. METHODS: Dynamic contrast enhanced MR imaging was performed in 51 children. There were 21 girls and 30 boys with mean age 4 years. The information from traditional imaging modalities (renal ultrasound, renal scintigraphy, and VCUG) was compared to the information obtained from the MR study. RESULTS: The final diagnoses by MR urography were 9 children with UPJ obstruction, 4 with primary UVJ obstruction, 7 with dilated but not obstructed systems, 7 with duplex systems , 2 with multicystic dysplastic kidneys, 1 with unilateral small, scarred kidney, 2 with acute pyelonephritis, 1 renal mass, 1 bilateral policystic kidneys, 1 dysplastic horseshoe kidney and 16 children with normal study MR urography. The anatomic imaging with MR was equivalent to ultrasound in detecting and classifying hydronephrosis but was far superior at delineating ureteric anatomy. The split rena! function as calculated by both nuclear and MRI scans were compared and the correlation coefficient was excellent (r=0.91) Pelvic Transit Time (PTT) >450 sec predicted obstruction in all DTPA obstructed systems. PTT for non obstructed systems was < 250 sec regardless of degree of dilation. Four cases were equivocal with PTT between 250 sec and 450 sec. CONCLUSIONS: Dynamic contrast enhanced MR Urography provides superior anatomic and equivalent functional infonnation when compared with ultrasound and diuretic renal scintigraphy. Pelvic Transit Time predicted the presence of obstruction in all DTPA obstructed systems. It is likely that MR urography will replace renal scintigraphy in the evaluation of hydronephrosis in children. Source of Funding: None.
493 EVALUATION OF TC-99M DIMERCAPTOSUCCINIC ACID (DMSA) SCINTIGRAPHY AND ITS ABILITY TO PREDICT OCCURRENCE OF A SECOND FEBRILE URINARY TRACT INFECTION (UTI) IN CHILDREN UNDER TWO YEARS OF AGE Matthew P Rutman", Evan J Kass, Royal Oak, MI INTRODUCTION AND OBJECTIVE: To evaluate DMSA renal scintigraphy in children less than two years old with a first hospitalized febrile UTI. In addition, to determine if the DMSA result predicts the occurrence of a second febrile UTI in those children with normal voiding cystourethrogram (VCUG) and ultrasound (U/S). METHODS: A total of 233 DMSA scans performed between August 1997 and December 200 I on children under two years old, for an indication of first hospitalized febrile UTI, were reviewed. The VCUG and UIS for those children were also reviewed. Patients were then divided into two groups: the first with all normal studies; the second with abnormal DMSA, and normal VCUG and U/S. The groups were then evaluated for occurrence of a second febrile UTI. RESULTS: Of the 233 patients, 155 (66.5%) had abnormal DMSA scans, of whom 83 (53.5%) had reflux. Of the 155 patients with abnormal DMSA studies. 56 (36.1%) had norma! VCUG and UIS studies. One of the 56 (1.78%) presented with a second febrile UTI, with a mean follow-up of 29.6 months. Of the 233 patients, 78 (33.5%) had normal DMSA scans, of whom 54 (69.2%) had normal VCUG and UlS studies. None of those patients presented with a second febrile UTI, with a mean follow-up of 24.2 months. CONCLUSIONS: This study indicates that children with normal VCUG and UIS studies are unlikely to develop a second febrile UTI regardless of DMSA
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THE JOURNAL OF UROLOGY®
Vol. 169, No.4, Supplement, Monday, April 28, 2003
result. Of those patients with normal DMSA, VCUG and UIS, none developed a second febrile UTI. Of those patients with an abnormal DMSA, normal VCUG and UlS, only one developed a second febrile UTI. In children less than two years old, with normal studies (VCUG and U/S), it appears DMSA has little predictive value in the occurrence of a second febrile UTI. Source of Funding: None.
494 CLITORAL SENSITIVITY AND VIABILITY FOLLOWING A MODIFIED REDUCTION CLITOROPLASTY WITH FOLLOWUP TESTING IN 21 PATIENTS Dix Poppas, Maher M El Chaar*, Cathy Kelly, Maria New, New York, NY INTRODUCTION AND OBJECTIVE: Enlargement of the clitoris is a prominent manifestation of virilizing congenital adrenal hyperplasia (CAH) and other disease states resulting in ambiguous genitalia. Controversy persists as to the viability and sensitivity of the clitoris following reduction clitoroplasty. To date, no single large group study using a single technique has been evaluated for postsurgical clitoral viability and sensitivity. We report on a modified technique for reduction clitoroplasty based on the understanding of the female clitoral anatomy that results in outstanding cosmetic appearance with reliable viability and sensation. METHODS: 21 patients underwent reduction clitoroplasty from 1996 to 2002 using the same technique by a single surgeon. The youngest was 5 months and the oldest 24 years with a mean age of 6 years. 18 patients had CAH. One patient was a 46 XX true hermaphrodite and two patients were 46 XY and underwent sex reassignment surgery. Simple modifications to the conventional technique include: total mobilization of the neurovascular bundles (NVB) through parallel ventral midline incisions of Buck's fascia, no reduction or excision of the glans clitoris, irrigation of the NVB with papaverine and subtotal excision of the corpus cavernosal tissue. All patients were evaluated post-operatively for clitoral viability by gross examination and capillary perfusion testing. Of the 21 patients, 7 patients were above 5 years of age and considered candidates for clitoral sensory testing (CST). CST was performed using a cotton-tip stimulator. On a scale of 0 to 5, the patient was asked to report the degree of sensation at various points of the genitalia and inner thigh. Mean follow-up time of these patients was 2 years. RESULTS: Our results in the 21 patients that underwent reduction clitoroplasty have been excellent. No postoperative complications have been reported. All patients had a viable clitoris with normal capillary perfusion. Of the 7 patients that were evaluated with CST, all reported a degree of sensation of 3/5 at the inner thighs, 4/5 at the labia minora and 515 at the clitoris. CONCLUSIONS: The modified reduction clitoroplasty provides a safe, reliable approach to managing the enlarged clitoris. The positive viability and sensation outcomes in the older patients suggest this technique will be successful in the younger children undergoing the procedure. This data supports the belief that clitoral reconstructive surgery using this technique does not result in loss of sensation or viability. Source of Funding: Weill Medical College of Cornell University-Center for Pediatric Urology.
Bladder Cancer: Basic Research (I) Discussed Poster Monday, April 28, 2003
8:00 AM-12:00 PM
495 PROTEA SOME INHIBITOR PS-341 SENSITIZES DRUGREFRACTORY HUMAN TRANSITIONAL CELL TUMORS TO GEMCITABINE Ashish M Kamat*, Takashi Karashima, Darren Davis, Colin Dinney, David J McConkey, Houston, TX INTRODUCTION AND OBJECTIVE: Recent studies have implicated the transcription factor nuclear factor kappa B (NF-KB) in cancer progression, angiogenesis, metastasis, and therapeutic resistance. Our previous studies indicated that NF-KB activity was elevated in a metastatic variant of the human 253J transitional cell carcinoma (TCC) line (253J-BV) relative to isogenic nonmetastatic controls. The 26S proteasome regulates NF-KB activity by degrading its physiological inhibitor, IkappaBalpha (IKBO'). We therefore tested the effects ofthe proteasome inhibitor PS-341 on NF-KB activity and apoptosis in 253J-BV cells grown in vitro and as tumor xenografts in vivo. METHODS: The apoptotic effect of PS-341 alone, gemcitabine alone and the combination was assessed in vitro by propidium iodide staining and flow cytometry. The ability of PS-341 to inhibit inducible NF-KB activity was assessed *Presenting author.
using the luciferase reporter gene assay and the electrophoretic mobility shift assay. We also implanted 253J-BV cells into the subcutis of athyrnic nude mice using 2 x 106 cells in 200 ,.,,1 of Matrigel or orthotopically into the bladder wall of the mice using 0.5 x 106 cells in 40 ,.,,1 of Hanks balanced salt solution. One week after implantation, treatment was started using saline (control), PS-341 (I mg/kg), gemcitabine (12.5 or 50 mg/kg) or both (n=12, each group). Mice received intraperitoneal injections every Monday and Thursday for 4 weeks at which point the animals were sacrificed. RESULTS: PS-341 induced apoptosis in the 253J-BV cells in vitro and increased the levels of apoptosis induced by gemcitabine. PS-341 also inhibited the production of several pro-angiogenic factors (intedeukin-8 (IL-8), matrix metalloproteinase-9 (MMP-9) and vascular endothelial cell growth factor (VEGF)) by 253J-BV cells in vitro, effects that were associated with reduced NF-KB DNA binding activity. Combination therapy with PS-341 plus gemcitabine also significantly (p<0.05) inhibited the growth of ectopic (subcutaneous) and orthotopic 253J-BV tumors grown as xenografts in nude mice, effects that were associated with reductions in tumor IL-8, MMP-9, and VEGF expression. CONCLUSIONS: Proteasome inhibition with PS-341 blocks inducible NF-KB activity, leading to enhanced apoptosis and augmenting the chemosensitivity to gemcitabine. This is accompanied by downregulation of IL-8, MMP-9 and VEGF. Together, our data demonstrate that PS-341-based combination chemotherapy has the potential to overcome therapeutic resistance in bladder cancer. Source of Funding: Grant IP50CA91846-01 (Bladder Cancer SPORE).
496 RECOMBINANT BCG EXPRESSING IL-18 (IL·18 RBCG) ENHANCES MACROPHAGE CYTOTOXICITY AGAINST MOUSE BLADDER CANCER CELL LINE MBT-2 IN VITRO Yi Luo*, Hiroshi Yamada, Xiaohong Chen, Michael A Odonnell, Iowa City, IA INTRODUCTION AND OBJECTIVE: The role of macrophages in BCG immunotherapy of bladder cancer has been barely explored. This study was undertaken to investigate if macrophages exhibit a direct cytolytic activity on bladder cancer cells upon BCG stimulation. Since IL-18 is known to be a potent activator for macrophages, our newly developed IL-18 rBCG was evaluated for its induction of macrophage cytotoxicity. METHODS: Macrophages were induced by intraperitoneal injection of thioglycollate in C3H1HeJ mice for 3 days. Peritoneal exudate cells (PEC) were then harvested and cultured in the presence of either control wild-type BCG or IL-18 rBCG at a ratio of 1:1 of PEC to BCG. For comparison IL-2 rBCG and GMCSF rBCG were included. After 24 hour incubation 51Cr-Iabeled MBT-2 cells were added at several E:T ratios and the mixture cultures were incubated for 20 hours before counting the supernatants for cell lysis evaluation. Supernatants from a panel of parallel mixture cultures of PEC and BCG were harvested at different time points for cytokine production assays. Neutralizing antibodies to IFN--y, TNF-O', IL-12, and IL-18 were used to evaluate the role of each of these cytokines in BCG-induced macrophage cytotoxicity. RESULTS: Macrophages prepared without BCG stimulation showed weak cytotoxicity against MBT2 cells (less than 10% lysis at E:T=20:1). Enhanced cytotoxicity (20-30% lysis at E:T=20: I) in a dose-dependent manner was observed upon wild-type BCG stimulation. IL-18 rBCG showed about 2-fold higher (3060% lysis at E:T=20:1) cytolytic activity than that induced by wild-type BCG. These increased cytolytic levels were comparable with those induced by wild-type BCG plus exogenous IL-18. Such increased lysis was also observed when IL-2 rBCG and GMCSF rBCG were used for stimulation. Although all neutralizing antibodies (Ab) tested showed an inhibitory effect on BCG-induced macrophage cytotoxicity, anti-TNF-O' Ab exhibited a nearly complete inhibition (95-99%), indicating that TNF-O' plays a major role in macrophage-mediated killing of MBT-2 cells. Consistent with cytolytic activity, cytokine analysis for supernatants of macrophage-BCG mixture cultures demonstrated higher levels of IFN--y and TNF-O'in IL-18 rBCG cultures than those in wild-type BCG cultures. CONCLUSIONS: BCG efficiently induces macrophage cytotoxicity against MBT-2 cells in vitro. IL-18 rBCG is superior to wild-type BCG for induction of this cytotoxicity and thus may serve as a better agent for bladder cancer immunotherapy. Source of Funding: None.
497 SYNERGISTIC ANTITUMOR EFFECT OF INTRA VESICAL LIPOSOME·MEDIATED INTERLEUKIN-2 GENE THERAPY PLUS BCG IN ORTHOTOPIC MURINE BLADDER CANCER Masafumi Oyama*, Warren D Heston, Cleveland, OH; Yutaka Horiguchi, Toru Nishiyama, Masaru Murai, Tokyo, Japan; Andrew C Novick, Cleveland, OH; William A Larchian, Elyria, OH INTRODUCTION AND OBJECTIVE: Bladder cancer is one of common cancers in the United States. Bacillus Calmette-Guerin(BCG) is considered to be the most effective agent for the treatment andlor prophylaxis of the bladder