Radiographic Evaluation of the Urethral Kock Ileal Bladder Substitute

Fifty male patients who had undergone bladder substitution with a urethral Kock pouch after radical cystectomy for bladder cancer, were evaluated in the immediate postoperative period by retrograde pyelography and pouch cystography, and at later follow-up by pouch cystography. Other radiologic procedures (urography, ultrasonography, CT, etc.) were not part of a routine program, but were used when clinically indicated. In 12% a ureteroileal anastomotic leakage was found; the leaks resolved with continued ureteral stenting. Extravasation at the anastomosis between the pouch and the urethra was seen in 55% at the first cystography. It resolved within one month in all cases by simply leaving a catheter in the bladder. On the late cystograms reflux was observed in 6% of patients, whereas stone formation in the pouch was not encountered. A careful radiologic follow-up of patients with urinary diversions is essential to minimize postoperative complications.

Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work

BACKGROUND

Widening access to medicine in the UK is a recalcitrant problem of increasing political importance, with associated strong social justice arguments but without clear evidence of impact on service delivery. Evidence from the United States suggests that widening access may enhance care to underserved communities. Additionally, rural origin has been demonstrated to be the factor most strongly associated with rural practice. However the evidence regarding socio-economic and rural background and subsequent practice locations in the UK has not been explored. The aim of this study was to investigate the association between general practitioners' (GPs) socio-economic and rural background at application to medical school and demographic characteristics of their current practice.

METHOD

The study design was a cross-sectional email survey of general practitioners practising in Scotland. Socio-economic status of GPs at application to medical school was assessed using the self-coded National Statistics Socio-Economic Classification. UK postcode at application was used to define urban-rural location. Current practice deprivation and remoteness was measured using NHS Scotland defined measures based on registered patients' postcodes.

RESULTS

A survey was sent to 2050 Scottish GPs with a valid accessible email address, with 801 (41.5 %) responding. GPs whose parents had semi-routine or routine occupations had 4.3 times the odds of working in a deprived practice compared to those with parents from managerial and professional occupations (95 % CI 1.8-10.2, p = 0.001). GPs from remote and rural Scottish backgrounds were more likely to work in remote Scottish practices, as were GPs originating from other UK countries.

CONCLUSION

This study showed that childhood background is associated with the population GPs subsequently serve, implying that widening access may positively affect service delivery in addition to any social justice rationale. Longitudinal research is needed to explore this association and the impact of widening access on service delivery more broadly.

The functional and psychosocial status of patients with disseminated bladder cancer

This study describes self-reported functional and psychological status of patients using The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) and relates this to the prognosis. Patients with incurable locally advanced or metastatic transitional cell cancer of the urothelial tract were prospectively included in a study of self-reported functional and psychosocial status. The study included 25 patients; 19 patients completed one or more Quality of Life Questionnaires. The median survival was 5.2 months, and there was a significant relation between functional, emotional, and social status and survival. The self-assessment of functional status was a better prognostic factor for survival than performance status evaluated by the clinician. The value of the global quality of life scale did not relate to survival after recurrence. Functional, emotional, and quality of life scales declined during the progression of the disease. The study suggests that evaluation with self-reporting questionnaires may provide the physician with useful information, and it may aid in making treatment decisions in patients with metastatic bladder cancer.

A case with severe diarrhoea and Strongyloides stercoralis infection

A case with severe diarrhoea and Strongyloides stercoralis infection is described. Further examination showed that the patient also had abnormal colonization of the duodenum with Hafnia alvei and that this disappeared when the Strongyloides infection was treated with mebendazole. Symptoms such as abdominal pain, diarrhoea, "skin rash" and malabsorption in association with blood eosinophilia should arouse suspicion of strongyloidiasis.

The RCP's 'Three Key Questions' for asthma: review of practical use

Assessment tools are a vital component of chronic disease management. The Royal College of Physicians has developed a patient-focused outcome measure for the treatment of asthma, the 'Three Key Questions'. However, in a study investigating the goals of people with asthma, several issues related to the tool emerged. Forty-seven adults of a range of ages and asthma severity but with no significant co-morbidity were interviewed. It emerged that the outcome measure may be subject to recall bias. Also, symptom reports may be conflated if daytime symptoms also occur with activity. 'Interference with activity' is a subjective term the interpretation of which varies considerably. Changes in the level of activity undertaken may be reported rather than changes in symptom severity. The 'Three Key Questions' are not fully patient-centred because they assess the presence of symptoms rather than their importance to the individual. The use of the 'Three Key Questions' as an outcome measure may not allow valid comparisons to be made between settings.

Asthma care by nurse practitioners in the United States

PURPOSE

To survey nurse practitioners (NPs) in the United States on their level of input to asthma care prior to enrolling in The National Asthma and Respiratory Training Centre (NARTC) specialist asthma education program in the UK.

DATA SOURCES

Responses of 134 (66%) of the 202 NPs who self-selected for enrollment in the NARTC program on a preliminary questionnaire.

CONCLUSIONS

Nearly all (133 or 99%) currently work with asthmatics and 122 (91%) prescribe asthma drugs. Only 92 (69%) measure peak flow(PF), 84 (63%) check inhaler technique, 76 (57%) teach use of a home PF meter and diary, and 63 (47%) provide written self-management plans on any regular basis. Many have not established follow-up procedures (56 or 42%), or evaluated their asthma management practices (55 or 41%).

IMPLICATIONS FOR PRACTICE

Successful asthma management requires correct medication, systematic follow-up, patient education, and self-management. Specialist asthma training should encourage practitioners to combine effective drug usage with a long-term preventative approach.

Reconstructive urology in the nordic countries--a hospital questionnaire survey

A hospital survey of adult reconstructive urologic surgery in the Nordic countries is presented. The response rate was 80% and included most general hospitals and university clinics. Despite similarities between the healthcare systems of the various countries several differences were found. Cystectomy was performed in a large number of institutions in all countries except Denmark. The annual number of orthotopic bladder substitutions per institution was calculated as three to four (range of medians for each country) and the number of continent cutaneous diversions as two to seven. Open urethral procedures were performed more frequently in Sweden than in the other countries. Surgery for penile curvature and implantation of three-component prostheses for erectile dysfunction was more commonly performed in Denmark and Iceland compared to Sweden.

The orthotopic Kock ileal neobladder: functional results, urodynamic features, complications and survival in 166 men

PURPOSE

We report our experience with 166 patients who underwent radical cystectomy and orthotopic bladder substitution with the ileal Kock neobladder between February 1990 and January 1999.

MATERIALS AND METHODS

We classified complications as early (3 months or less postoperatively) and late. Continence was assessed by patient interview, the need to use protective devices and provocative incontinence testing. Neobladder function was evaluated by uroflowmetry, post-void residual urine volume measurement and enterocystometry, and renal function was assessed by 51creatinine ethylenediaminetetraacetic acid clearance.

RESULTS

There were no perioperative deaths. However, 52 early complications developed in 39 patients (23.5%) and 73 late complications in 62 (37.4%). The rate of early and late complications associated with the urinary tract was 11.5% and 23.5% with abdominal reoperation rates of 1.8% and 2.4%, respectively, due to these complications. At 3 and 5 years the risk of stone formation on the metallic staples was 18% and 34%, and the risk of B12 deficiency was 30% and 33%, respectively. One patient (0.6%) underwent reoperation for ureteral anastomotic stricture. Anterior urethral stricture in 5 cases (3%) was caused by recurrence in 1 and urethral anastomotic stricture in 1 also resulted from recurrent disease. Daytime continence was reported by 97% and 100% of our patients at 1 and 5 years, respectively. Provocative incontinence testing confirmed this level of daytime continence. Overall 75% of patients reported nighttime continence at 1 year and 94% at 5 years. The need for a nighttime protective device decreased with time. At 1 versus 3 years 39.8% versus 45.9% of patients used no protection, 29.7% versus 39.2% used a sanitary pad and 30.5% versus 14.9% used a condom device. Enterocystometric capacity and subtracted maximum reservoir pressure remained remarkably uniform at 456 versus 411 ml. and 47 versus 50 cm. water 6 months and 5 years postoperatively, respectively. Nevertheless, median post-void residual urine volume increased from 20 ml. at 6 months to 40 ml. at 5 years with an increased prevalence of patients requiring intermittent catheterization due to post-void residual urine greater than 100 ml. from 16% at 6 months to 44% at 5 years. 51Creatinine ethylenediaminetetraacetic acid clearance remained unchanged. There was a substantial 5-year survival advantage for the subpopulation with stage pT3a or less, pN0 tumors (94% versus 51%, p <0.001).

CONCLUSIONS

Radical cystectomy and orthotopic bladder substitution with the Kock ileal neobladder may be performed with an acceptable complication rate and good functional results. The probability of survival was considerably higher for patients with tumor confined to the bladder. Consequently we believe that early aggressive treatment should be considered in those with invasive disease, and reconstruction with orthotopic bladder substitution may encourage patients to accept radical surgery.

Stone risk after bladder substitution with the ileal-urethral Kock reservoir

OBJECTIVE

The study was carried out to compare urinary biochemical and physicochemical environments in patients who had undergone bladder substitution with the ileal-urethral Kock reservoir, and who had no actual urinary infection, with those of healthy subjects.

MATERIAL AND METHODS

The participants were 23 male patients who had undergone bladder substitution with the ileal-urethral Kock reservoir and 25 healthy men. All subjects had sterile urine at the time of urine collection. Concentrations of calcium, magnesium, phosphorus, creatinine, citrate, oxalate, and ammonia in 24-h urine samples were measured. Estimates of ion activity products of calcium oxalate (CaOx), calcium phosphate (CaP), brushite (Bru), and magnesium ammonium phosphate (MAP) in urine were calculated according to Tiselius.

RESULTS

There was no significant difference in 24-h urinary volume between patients with a bladder substitute and the healthy controls. For most of the other measured values the results for patients differed significantly from those for controls. The most striking findings were markedly lower urinary excretion rates of citrate (p < 0.0001) and higher urine pH (p < 0.0001) in patients compared with controls. These findings were reflected in significantly higher levels of urinary supersaturation with respect to CaOx (p < 0.0001), CaP (p <0.0001), Bru (p < 0.0001) and MAP (stuvite) (p < 0.0001) in patients with a bladder substitute compared with healthy subjects.

CONCLUSIONS

Hypocitraturia seems to be the main risk factor for calcium stone formation in non-infected Kock reservoir patients, and citrate supplementation appears to be the most obvious choice for stone prophylaxis in patients with intestinal urinary diversion and recurrent renal stone formation.

Assessment of patients with metastatic transitional cell carcinoma of the urinary tract

PURPOSE

We propose an appropriate assessment of patients with disseminated transitional cell carcinoma of the urothelial tract, and investigate the pattern of metastases relative to pathological features and primary tumor treatment.

MATERIALS AND METHODS

A total of 156 consecutive patients with recurrent locally advanced (nonresectable, radioresistant) and/or metastatic transitional cell carcinoma of the urothelial tract were evaluated with blood tests, chest x-ray, bone scintigraphy, bone marrow biopsy, and abdominal and brain computerized tomography.

RESULTS

Distant metastases were evident in 86% of the patients, with lymph nodes and bones being the most frequent sites. Bone metastases were mostly in the pelvis or lower spine and were asymptomatic in 19% of patients. Bone marrow metastases were noted in 14% of these patients. However, most of them also had radiological bone metastases and bone marrow biopsy is not recommended for routine evaluation. Approximately 2% of patients had brain metastases without symptoms at recurrence. Elevated lactate dehydrogenase was predictive of disseminated disease. Patients receiving radical radiotherapy as primary treatment had an increased rate of recurrent locally advanced disease but the same frequency of distant metastases compared to those undergoing cystectomy. Primary tumor features did not relate to the pattern of metastases.

CONCLUSIONS

We recommend chest x-ray, whole abdominal computerized tomography and routine blood tests, including lactate dehydrogenase, for patients with recurrent locally advanced or metastatic disease. Skeletal symptoms should be examined radiologically, while asymptomatic patients with recurrence in sites other than bone should be evaluated with bone scintigraphy.

Radical cystectomy: extending the limits of pelvic lymph node dissection improves survival for patients with bladder cancer confined to the bladder wall

PURPOSE

We assess the influence of the limits of pelvic lymph node dissection on survival following radical cystectomy for bladder cancer.

MATERIALS AND METHODS

From January 1990 to September 1997, 194 patients underwent radical cystectomy without prior treatment. Between March 1993 and September 1997, 126 consecutive patients underwent radical cystectomy with extended pelvic lymph node dissection beginning at the bifurcation of the aorta, including the common and external iliac vessels, presacral nodes and obturator fossa. Between January 1990 and March 1993, 68 consecutive patients underwent radical cystectomy, with limited pelvic lymph node dissection beginning at the bifurcation of the common iliac vessels, including the external iliac vessels and obturator fossa. The cystectomy procedure remained unchanged throughout this period and 1 surgeon performed all procedures.

RESULTS

A total of 117 patients had tumors confined to the bladder wall (stage pT3a or less) and 77 had tumors penetrating beyond the bladder into perivesical fat or adjacent structures (stage pT3b or greater). The prevalence of patients with tumors penetrating the bladder was higher in the extended dissection group (42.9 versus 33.8% limited dissection). The incidence of lymphatic involvement was 26.2% and slightly higher in the extended than the limited dissection group. There was a modest improvement in the 5-year recurrence-free survival for the extended dissection group (62 versus 56% limited dissection, p = 0.33), and a substantial improvement for the subgroups with tumors confined to the bladder wall (tumor stage pT3a or less) (85 versus 64%, p <0.02) and without lymph node metastasis (stage pT3a or less, pN0) (90 versus 71%, p <0.02). Accordingly, extended pelvic lymph node dissection reduced the 5-year probabilities for pelvic and distant metastasis (2 versus 7% limited dissection, p = 0.17 and 10 versus 21%, p = 0.15, respectively) for patients with tumors confined to the bladder wall (stage pT3a or less). Survival was similar for patients with pT3b or greater tumor.

CONCLUSIONS

This retrospective analysis suggests that extending the limits of pelvic lymph node dissection from the bifurcation of the common iliac vessels to the bifurcation of the aorta improves the recurrence-free survival rate for patients undergoing radical cystectomy for bladder cancer confined to the bladder wall (stage pT3a or less).

Sexological problems after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire study of male patients

A questionnaire study was carried out to compare the postoperative sexological problems after cystectomy and bladder substitution using the urethral Kock reservoir or the ileocecal reservoir with that following ileal conduit diversion. A total of 76 male patients with bladder cancer completed the questionnaire: 49 patients had a bladder substitution and 27 an ileal conduit diversion. Median follow-up was 1.3 years (range 0.5-6.4) and 4.8 years (range 2.4-14.7), respectively. Only 9% of all patients could achieve an erection at least every second time, in comparison to 82% preoperatively. Thirty-eight percent of all patients were able to achieve orgasm, and 26% were coitally active to some degree. Reasons for decrease or cessation of coitus were loss of potency among 77% and 96% respectively (p = 0.04), while those reporting decreased libido (29%), partner refusal (13%), and feeling less sexually attractive (20%) showed no between-group differences. Regression analysis showed no influence of type of operation, while age above 68 years influenced orgasmic ability and coital activity, and radiation treatment influenced whether the patient felt less sexually attractive than before surgery.

The influence of the level of lamina propria invasion and the prevalence of p53 nuclear accumulation on survival in stage T1 transitional cell bladder cancer

PURPOSE

We assessed the influence of the level of lamina propria invasion and the prevalence of p53 nuclear immunoreactivity on the survival of patients with stage T1 transitional cell bladder cancer.

MATERIALS AND METHODS

All patients presenting with stage T1 bladder cancer were prospectively and routinely grouped according to the level of lamina propria invasion. Invasion of the tumor stalk was defined as stage T1a, invasion of the lamina propria proper superficial to the level of muscularis mucosa as stage T1b and into or deeper than the muscularis mucosa as stage T1c. The p53 nuclear immunoreactivity was determined with antibody PAB 1801.

RESULTS

The study comprised 143 patients including 31 (22%) with stage T1a disease, 60 (42%) with stage T1b and 52 (36%) with stage T1c. Mean patient age was 67 years (range 38 to 92) and mean followup was 4.7 years (range 2.4 to 9.7). Tumor grade related to the depth of lamina propria invasion (p < 0.05) and the prevalence of dysplasia in random mucosal biopsies was higher in stage T1b and T1c tumors than in stage T1a. Of all tumors 42% expressed p53 nuclear reactivity which correlated with tumor grade (p < 0.05). Also the prevalence of nuclear p53 was higher in stages T1b and T1c compared with T1a disease. Of the patients 115 were treated with transurethral resection alone and 28 underwent radical cystectomy. Overall survival was 60.1%. Age was the only independent predictor of survival in patients older than 75 years. For patients up to 75 years old survival related to age, level of lamina propria invasion and presence of p53 nuclear accumulation. For this subpopulation overall survival was 67%, and 79% for stage T1a, 70% for stage T1b and 57% for stage T1c (p < 0.05). Survival was higher in patients with p53 negative (73%) than in those with p53 positive (61%) tumors (p < 0.05). A multivariate analysis of the influence of lamina propria invasion and nuclear p53 status on survival histology was found to be the only independent predictor of survival.

CONCLUSIONS

Immediate radical cystectomy should be considered for patients with stage T1c tumors and for some patients with stage T1b disease, particularly those with tumors expressing p53 nuclear reactivity and with dysplasia in the random mucosal biopsies.

p53 nuclear immunoreactivity as a predictor of response and outcome following chemotherapy for metastatic bladder cancer

p53 nuclear immunoreactivity was determined in primary bladder tumours from 50 patients who developed metastatic bladder cancer. We investigated the relationship between p53 nuclear immunoreactivity and the response and outcome following chemotherapy. p53 nuclear accumulation was detected in 48% of the primary tumours using the PAb1801 antibody in archival paraffin-embedded tissue sections. All patients received platinum-based combination chemotherapy including methotrexate for metastatic disease. The response to chemotherapy did not relate to the prevalence of p53 nuclear overexpression: 50% of the patients expressing p53 nuclear reactivity achieved a response compared to 27% of those without p53 expression (P = 0.14); overall, 38% of the patients responded. The median survival after chemotherapy was 5.9 months; 8.4 months for patients with p53 nuclear reactivity compared to 5.2 months for those without (P = 0.38). Multivariate analysis showed that performance status but not p53 nuclear status was an independent prognostic factor for survival following chemotherapy. The results indicate that patients with p53 nuclear immunoreactivity in the primary bladder tumour do not have a lower response rate or poorer outcome following chemotherapy for metastatic disease than do patients without p53 nuclear reactivity.

Neonatal nurse practitioner role satisfaction

The article reports a descriptive study utilizing a triangulated approach to explore the role satisfaction of a nationwide random sample of 315 neonatal nurse practitioners (NNPs). Role satisfaction was found to be high, and practice philosophy tended toward a medical orientation. Those NNPs who were master's prepared and who reported to and were evaluated and paid by departments of nursing were more likely to have a nursing practice philosophy. Intrinisic factors related to satisfaction included autonomy, patient management, relationships with colleagues and families, role diversity, and a sense of accomplishment. Implications for administrators and NNPs are discussed.

Long-term efficacy of intravesical bacillus Calmette-Guerin for carcinoma in situ: relationship of progression to histological response and p53 nuclear accumulation

PURPOSE

We assessed the influence of the histological response to intravesical bacillus Calmette-Guerin (BCG) and the prevalence of p53 nuclear accumulation on the clinical behavior of patients with carcinoma in situ.

MATERIALS AND METHODS

Of 60 patients with Bergquist grade 3 carcinoma in situ 13 had primary and 47 had secondary carcinoma in situ. Patients received 6 weekly instillations and nonresponders received an additional 6 instillations at 2-week intervals. No maintenance was administered. Median followup was 48 months. The p53 nuclear accumulation was detected by immunohistochemical analysis with antibody PAb 1801.

RESULTS

The complete histological response rate to BCG therapy was 64%, which decreased to 52% at 4 years. BCG was more effective for treatment of primary than secondary carcinoma in situ (complete response rate 85 versus 57%, respectively). The 45% progression rate was related to the initial histological response occurring in 26% of patients with a complete versus 77% with a partial and no response. Consequently, the progression rate was only 8% for primary versus 57% for secondary carcinoma in situ. Of the patients receiving only 1 course of BCG 40% had progression compared to 62% of those who received 2 courses. Patients in whom both courses failed had a progression rate of 89%. Intravesical BCG converted the p53 nuclear immunoreactivity from positive to negative in 73% of the 26 patients expressing reactivity before treatment, of whom 68% also had a complete response. The progression rate was related to the prevalence of p53 nuclear reactivity after but not before treatment (90% of patients with versus 37% without p53 nuclear accumulation had progression). All 3 complete responders with p53 nuclear reactivity after BCG had progression, which suggests that molecular genetic change may precede histological change. Complete responders without p53 nuclear accumulation after BCG treatment experienced the lowest progression rate (21%).

CONCLUSIONS

Our results suggest that patients with a persistent complete histological response and without p53 nuclear accumulation after BCG treatment can be followed conservatively. Cystectomy should be considered in all other patients.

A questionnaire study of sexological problems following urinary diversion in the female patient

A questionnaire study was conducted to evaluate the sexological problems after urinary diversion, using the continent Kock reservoir or the ileal conduit diversion. Thirty-seven female patients completed the questionnaire: 17 patients had a continent and 20 an ileal conduit diversion, with a median follow-up of 0.8 year (range 0.5-4.4) and 4.6 years (range 2.8-12.0), respectively. Data from only 33 patients were eligible for analysis, but no significant between-group differences were found. Coital frequency remained unchanged or increased among 44% of patients with a continent reservoir and among 18% of ileal conduit patients (p = 0.11). Among those reporting other than unchanged/increased activity almost one-third gave physical problems or decreased desire as the reason, and 30% felt less sexually attractive, with cystectomized patients reporting a higher percentage than others. A higher frequency of dyspareunia among patients with a continent reservoir was an unexpected finding (p = 0.06), and merits further investigation in a larger sample. Here it may be due to the shorter follow-up of these patients. Thirty per cent of all patients would have like more sexological counselling.

Bone metabolism following bladder substitution with the ileal urethral Kock reservoir

OBJECTIVES

To assess bone metabolism following bladder substitution with the ileal Kock reservoir.

PATIENTS, SUBJECTS AND METHODS

The investigation comprised two separate studies, one with baseline measurements before and after surgery, and the second after surgery only, of bone mass, made using single-photon absorptiometry and dual-energy X-ray absorptiometry, biochemical variables of bone turnover, plasma analyses and measurements of renal calcium and phosphate excretion. After inclusion, both groups of patients were observed longitudinally for 2 years. The post-surgery study included 25 patients who had undergone bladder substitution (median age 67 years, range 44-75), with a median post-operative follow-up of 1.0 year (range 0.3-3.7), and 16 control subjects (either healthy or with other minor urological complaints; median age 62 years, range 34-80), and the pre-surgery study comprised seven patients who had undergone bladder substitution (median age 57 years, range 42-68).

RESULTS

Total body, forearm and spinal bone mineral contents were similar in patients with an ileal bladder substitute measured 1 year after surgery and in control subjects. There were equivalent significant changes in both the patients and control subjects during the 2-year observation period, with a 2-3% decrease in total body and forearm bone mineral content. The values were similar in patients with and without a mild metabolic acidosis. Plasma calcium, phosphate, total alkaline phosphatase, intact parathyroid hormone, vitamin D and osteocalcin were normal in both patients and control subjects. Renal excretion of calcium and phosphate was also similar in patients and in control subjects.

CONCLUSIONS

Ileal urethral Kock bladder substitution does not lead to accelerated bone mineral loss in elderly men, despite a mild metabolic acidosis in half of the patients.

Evidence for two tumor suppressor loci associated with proximal chromosome 9p to q and distal chromosome 9q in bladder cancer and the initial screening for GAS1 and PTC mutations

The most common genetic alteration identified to date in bladder cancer is loss of heterozygosity (LOH) of chromosome 9, suggesting the presence of possible tumor suppressor genes on this chromosome. We attempted to map the location of these genes by analyzing 69 primary transitional cell carcinomas of the bladder with a panel of microsatellite markers for LOH on chromosome 9. Monosomy 9 (defined by LOH of all informative markers analyzed on 9p and 9q) was detected in 26 of 69 (38%) tumors, and 22 of 69 (32%) tumors showed subchromosomal deletions. Twelve tumors (17%) demonstrated partial LOH of chromosome 9 and indicated two distinct regions of LOH. Eight tumors showed distal allelic loss of 9q with a minimal region of common deletion flanked proximally by marker GSN on 9q33. Six tumors showed proximal allelic loss of 9p and 9q with a minimal area of common deletion flanked by markers D9S970 on 9p12 and D9S283 on 9q21. Two tumors showed loss of both the distal region of 9q and the proximal region of 9p and 9q, which were separated by a possible 6-44 cM of retained genetic material. The proximal minimal area of common deletion excluded 9q22.3-q31 to where two putative tumor suppressor genes, the nevoid basal cell carcinoma syndrome and multiple self-healing squamous epithelioma (ESS1) genes, have been mapped. The growth arrest-specific gene (GAS1), a candidate tumor suppressor gene, was included within the proximal minimal region. We evaluated the GAS1 gene for its potential role in bladder cancer using single-strand conformational polymorphism to screen for mutations in GAS1 in 10 bladder cancer cell lines and 14 primary bladder tumors. A polymorphism at codon 88 was noted in one primary bladder tumor, but no other abnormalities were found, suggesting that another potential tumor suppressor gene important to bladder cancer resides in these minimally deleted regions. Because the nevoid basal cell carcinoma syndrome gene has long been speculated to be a putative tumor suppressor gene in bladder cancer and this gene has recently been characterized as the human homologue of the Drosophila patched gene (PTC), 20 primary bladder tumors with chromosome 9q LOH were screened for mutations in PTC using single-strand conformational polymorphism and heteroduplex analysis. No alterations were found in any of the samples analyzed. Furthermore, 4 of 37 noninvasive papillary (Ta) tumors demonstrated loss of all 9q markers with retention of 9p, whereas no Ta tumor showed loss of 9p with retention of all 9q markers, suggesting that LOH of 9q is the earlier event in bladder tumorigenesis. In summary, our results indicate two tumor suppressor loci associated with proximal chromosome 9p to q and distal chromosome 9q that may be important in bladder cancer. GAS1 and PTC do not seem to be frequently mutated in bladder cancer.

Acid-base metabolism after bladder substitution with the ileal urethral Kock reservoir

OBJECTIVES

To assess acid-base metabolism after bladder substitution with the ileal Kock reservoir, using capillary blood-gas analysis, measurement of the renal excretion of ammonium and titratable acid and the evaluation of renal function by plasma clearance of 51Cr-labelled ethyl-enediamine tetra-acetic acid (51Cr-EDTA).

PATIENTS, SUBJECTS AND METHODS

The investigation comprised both a cross-sectional study, with initial measurements after surgery, and a longitudinal study, with pre-operative measurements, both groups of patients being followed for 2 years after inclusion. The cross-sectional study included 26 patients (median age 66 years, range 44-75), with a median post-operative follow-up of 1.2 years (range 0.3-3.7), and 16 control subjects (median age 62 years, range 34-80), and the longitudinal study comprised seven patients (median age 57 years, range 42-68).

RESULTS

The median values for capillary blood pH, carbon dioxide pressure, standard bicarbonate and standard base excess were significantly lower in patients with a bladder substitute than in the control subjects. An acid-base chart showed that the values for 44% of patients and none of the controls were within the area representing mild metabolic acidosis. This difference could not be attributed to differences in renal function because the 51Cr-EDTA clearance was normal and similar in the two groups of patients and among patients and controls. Nevertheless, the median values for each of the variables measured by blood-gas analysis were within the reference interval of the normal population. Net acid excretion was similar in patients with a bladder substitute and control subjects, but urinary pH was significantly higher in the patients. Accordingly, the renal excretion of ammonium was significantly higher and the excretion of titratable acid significantly lower in patients after ileal bladder substitution.

CONCLUSIONS

The results are consistent with the hypothesis that bladder substitution with the ileal Koch reservoir results in an acid load to the body, caused mainly by ammonium reabsorption in the reservoir. The acid load is compensated by an increased renal excretion of ammonium but causes a mild metabolic acidosis in about half the patients.

[Extensive rectal cancer--preserved intestinal and urinary continence after en-block rectal resection and radical cystectomy]

A patient with rectal cancer and invasion of the urinary bladder without extra-pelvic spread underwent total pelvic exenteration with rectal resection and bladder substitution with the urethro-ileal Kock reservoir. The patient has normal bowel and voiding functions and is without recurrence after two years.

Mosaicism in human epithelium: macroscopic monoclonal patches cover the urothelium

Previous studies of chimeric animals and human tissues have shown the clonal nature of organ development, giving clues as to the normal development of organs and also to abnormal developments, such as atheromatous plaques. The clonal nature of bladder cancer in female patients has been demonstrated, but little has been known of the clonal development of the normal urothelium. Using an X chromosome inactivation analysis of cells microdissected from histologic slides from the female human bladder, macroscopic urothelial patches of monoclonality were detected. These patches are about 120 mm.2 in size, contain about 2 x 10(6) cells each and reflect the presence of coherent cellular families composed of stem cells and their differentiated derivatives. The large size of these patches was surprising when compared with previously reported patch sizes in other organ systems. The patches most probably are composed of the descendants of the original founder cells, which would suggest that only 200 to 300 cells participated in the formation of the urothelium. The limited number of stem cells, each giving rise to millions of cells may provide an explanation for the "field defect" that is often referred to in the pathogenesis of bladder cancer, as different cell patches may possess different predispositions to tumorigenesis.

Implantation metastasis after laparoscopic biopsy of bladder cancer

We report a case of tumor implantation in the abdominal wall following laparoscopic biopsy of a transitional cell tumor. Tumor seeding is a known risk in patients with transitional cell carcinoma and we recommend that laparoscopic biopsy of urothelial tumors be avoided.

Health-related quality of life after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire survey

OBJECTIVE

To compare the health-related quality of life after bladder substitution with that following ileal conduit diversion.

PATIENTS AND METHODS

Sixty-seven male patients with bladder cancer completed the questionnaire; 38 had undergone bladder substitution and 29 ileal conduit diversion; the median follow-up was 1.0 year (range 0.5-3.0) and 4.8 years (range 1.1-15.2), respectively. Semi-structured qualitative interviews were conducted and analysed, and the questionnaire was developed based upon these results.

RESULTS

Both day- and night-time urinary leakage occurred more frequently following bladder substitution (18% against 10%, and 21% against 3%). Nevertheless, urinary leakage affected conduit patients more severely and they scored higher on a leakage distress scale. Furthermore, 58% of the ileal conduit but only 21% of the bladder substitution patients gave urinary leakage as their main concern (P = 0.04). Ileal conduit patients did not retain their body image as well as those with bladder substitution. The frequency of both sexual and non-sexual physical contacts decreased in the majority of the conduit patients but only in a minority of the bladder substitute patients. Global satisfaction was high and similar in both groups.

CONCLUSION

These results show that the health-related quality of life is retained to a higher degree after bladder substitution and supports the use of this procedure as the standard method of diversion after cystectomy for bladder cancer.

Single stage pancreaticoduodenectomy (Whipple's procedure), radical cystectomy and bladder substitution with the urethral Kock reservoir. Case report

Single stage radical cystectomy and pancreaticoduodenectomy (Whipple's procedure) was carried out in a 59-year old man for a benign pancreatic tumour (ancient schwannoma) and multifocal invasive bladder cancer. Urinary diversion was carried out using the urethral Kock reservoir.

The in vitro cytotoxicity of urine from patients with interstitial cystitis

Urine from patients with interstitial cystitis has been reported to be more cytotoxic than urine from healthy subjects when tested in vitro against cells from a normal urothelial cell line. The purpose of the present study was to develop a method to measure urinary cytotoxicity and so make it possible to estimate the toxicity of urine from interstitial cystitis patients. The study included 10 women with interstitial cystitis and 10 healthy controls. Urine specimens were obtained from both groups and urine cytotoxicity was measured by a modified 51Cr-release assay: A range of urine dilutions was added to suspensions of target cells with intracellular bound 51Cr, and cellular death was recorded by measuring the 51Cr-release from the target cells. The transitional cell bladder cell lines T24 and Hu609 and the erythroleukemia K562 cell line were used as target cells. There was no difference in urine cytotoxicity between interstitial cystitis patients and healthy controls. Urine cytotoxicity was increased by dilution in both groups.

Microsatellite instability in bladder cancer

Somatic instability at microsatellite repeats was detected in 6 of 200 transitional cell carcinomas of the bladder. Instabilities were apparent as changes in (GT)n repeat lengths on human chromosome 9 for four tumors and as alterations in a (CAG)n repeat in the androgen receptor gene on the X chromosome for three tumors. Single locus alterations were detected in three tumors, while three other tumors revealed changes in two or more loci. In one tumor we found microsatellite instability in all five loci analyzed on chromosome 9. The alterations detected were either minor 2-base pair changes or larger (> 2 base pairs) alterations in repeat length. All six tumors were low stage (Ta-T1), suggesting that these alterations can occur early in bladder tumorigenesis.

Intravesical Bacillus Calmette-Guérin with the Danish strain for treatment of carcinoma in situ of the bladder

We report our experience of the treatment of carcinoma in situ (CIS) using intravesical therapy with the Danish Bacillus Calmette-Guérin (BCG) strain 331 (SSI). Forty-two patients received treatment, 11 had primary and 31 secondary CIS. The median follow-up period was 26 months (range 3-68). Patients received 6 weekly instillations (1 course) and non-responders an additional 6 instillations at 2-week intervals (2 courses). The complete response rate was 59% for 1-course patients, 33% for the 2-course patients and 68% for the entire series. Patients were considered treatment failures if they suffered progression to invasive cancer, metastasis or died from transitional cell carcinoma. BCG treatment was more effective in primary than in secondary CIS, with a complete response rate of 80% versus 65% and with no failures versus 35%. Patients with persistent CIS after the first course of BCG had a greater risk of failure than responders: 50% versus 17%. Patients with persistent CIS after the second course had a 75% failure rate. This suggests that cystectomy should be considered for non-responders following a 6-week course and recommended to those not responding to 2 courses. Ten patients had CIS in the prostatic urethra. All responded to BCG treatment; 2 suffered from recurrent CIS 1 associated with invasive urethral tumour. The incidence and severity of side effects were similar to those reported with other strains of BCG. One patient with primary CIS failed to complete the treatment owing to "BCG-itis".

p53 nuclear protein accumulation correlates with mutations in the p53 gene, tumor grade, and stage in bladder cancer

Seventy-three transitional cell carcinomas of the bladder were analyzed by immunohistochemistry for p53 nuclear accumulation, and the results were compared to mutations detected in the p53 gene by single strand conformational polymorphism analysis (SSCP) and DNA sequence analysis. Immunohistochemical studies were performed on formalin-fixed, paraffin-embedded tissue sections. A highly significant association between the presence of p53 mutations and p53 nuclear reactivity as detected by immunohistochemistry was found (P = 0.0001). Of 32 tumors that demonstrated p53 mutations by SSCP, 27 (84%) showed p53 nuclear reactivity. Of the five cases that did not demonstrate p53 nuclear reactivity, four had mutations in exon 5. However, of 41 tumors with no evidence of p53 mutation by molecular analysis, 12 (29%) showed p53 immunoreactivity. This indicates that immunohistochemical methods may be more sensitive than SSCP in detecting p53 mutations or that discordant cases represent tumors with accumulation of wild type p53 protein, without mutations at the p53 locus. Of the 15 tumors that were found to have mutations at exon 8, 13 demonstrated high-intensity homogeneous p53 nuclear reactivity by immunohistochemistry, and all mutations located at codon 280 demonstrated high-intensity homogeneous immunoreactivity. However, three of three tumors with exon 6 mutations demonstrated low-level p53 immunoreactivity, and four of six tumors with mutations in exon 5 showed no detectable p53 nuclear reactivity. This indicates that the heterogeneity of immunoreactivity observed when analyzing p53 nuclear accumulation may be related to the site of the p53 gene mutation. Information on tumor grade, stage, lymph node status, disease-free interval, and overall survival were available in 54 patients who had undergone cystectomy. A significant association was observed between p53 alterations (detected by immunohistochemistry and SSCP) and histological tumor grade (P = 0.003) and stage (P = 0.01). We conclude that the immunohistochemical detection of p53 nuclear accumulation in formalin-fixed, paraffin-embedded tissue is highly associated with mutations in the p53 gene; this association has now been demonstrated in a large number of tumors. The heterogeneity of p53 nuclear reactivity seems to be related to the site of mutation in the p53 gene. A small proportion of tumors with a p53 gene mutation do not demonstrate immunohistochemically detectable p53 nuclear accumulation. Furthermore, a small but substantial proportion of tumors demonstrate p53 nuclear reactivity but do not show detectable mutations in the p53 gene by SSCP. Finally, both grade and stage of bladder cancer are related to p53 alterations, detected by immunohistochemistry or molecular methods.(ABSTRACT TRUNCATED AT 400 WORDS)

Mechanical characteristics of tubular and detubularised bowel for bladder substitution: theory, urodynamics and clinical results

A theoretical analysis of the mechanics of tubular and detubularised bowel bladders is presented. The results are compared with clinical findings following bladder substitution with the tubular ileocaecal and the detubularised urethral Kock reservoir. The theoretical results are consistent with clinical observations showing that detubularisation increases reservoir capacity substantially, delays the onset and reduces the amplitude of the pressure rise produced by contractions. These findings account for the markedly improved nocturnal continence (80 versus 17% at 2 years), the longer voiding intervals (4 versus 2.5 h at 1 year) and the predisposition to urinary retention (25 versus 0% at 1 year) with detubularised bladder substitution. A simple equation is derived to calculate the capacities of both near-spherical and cylindrical reservoirs. The capacity of the U pouch is calculated to be less than that of the W-shaped, S-shaped and Kock reservoirs. Altering the shape of a reservoir from spherical to ellipsoid is calculated to have only a slight effect on its mechanical characteristics. Consequently the essence of detubularisation is to create a reservoir with high capacity, while shape is of secondary importance.

Distinct pattern of p53 mutations in bladder cancer: relationship to tobacco usage

A distinct mutational spectrum for the p53 tumor suppressor gene in bladder carcinomas was established in patients with known exposures to cigarette smoke. Single-strand conformational polymorphism analysis of exons 5 through 8 of the p53 gene showed inactivating mutations in 16 of 40 (40%) bladder tumors from smokers and 13 of 40 (33%) tumors from lifetime nonsmokers. Overall, 13 of the 50 (26%) total point mutations discovered in this and previous work were G:C-->C:G transversions, a relatively rare mutational type in human tumors. In six tumors, identical AGA (Arg)-->ACA (Thr) point mutations at codon 280 were observed, suggesting a mutational hotspot in these tumors. Comparison of the mutational spectra from smokers and nonsmokers revealed no obvious differences in the types or positions of inactivating mutations; however, 5 of 15 tumors containing point mutations from cigarette smokers had double mutations, four of which were tandem mutations on the same allele. No double mutations were found in tumors from nonsmoking patients. None of the mutations in smokers were G:C-->T:A transversions, which would be anticipated for exposure to the suspected cigarette smoke carcinogen 4-aminobiphenyl. The results suggest that, although cigarette smoke exposure may not significantly alter the kinds of mutations sustained in the p53 gene, it may act to increase the extent of DNA damage per mutagenic event.

Radiographic evaluation of the urethral Kock ileal bladder substitute

Fifty male patients who had undergone bladder substitution with a urethral Kock pouch after radical cystectomy for bladder cancer, were evaluated in the immediate postoperative period by retrograde pyelography and pouch cystography, and at later follow-up by pouch cystography. Other radiologic procedures (urography, ultrasonography, CT, etc.) were not part of a routine program, but were used when clinically indicated. In 12% a ureteroileal anastomotic leakage was found; the leaks resolved with continued ureteral stenting. Extravasation at the anastomosis between the pouch and the urethra was seen in 55% at the first cystography. It resolved within one month in all cases by simply leaving a catheter in the bladder. On the late cystograms reflux was observed in 6% of patients, whereas stone formation in the pouch was not encountered. A careful radiologic follow-up of patients with urinary diversions is essential to minimize postoperative complications.

Extraperitoneal pelvioscopy in staging of bladder carcinoma and detection of pelvic lymph node metastasis

This study was carried out to examine the efficacy of extraperitoneal pelvioscopy in detecting pelvic metastasis in patients scheduled to undergo radical cystectomy without preoperative chemo- or radiotherapy. The results of pelvioscopy were compared with those obtained by laparotomy. 54 consecutive patients underwent pelvioscopy without complications. Three were technically insufficient. Lymphatic tissue was biopsied in 29 (54%). Pelvioscopy demonstrated tumor dissemination in 5 patients (9.3%): 2 had pT4b tumor, 2 pelvic nodal metastases and 1 both. The remaining 49 patients with benign pelvioscopy were scheduled for laparotomy but 7 patients did not undergo the procedure: 3 had extrapelvic metastasis, 1 bronchial carcinoma, 1 aortic aneurysm, 1 refused surgery and 1 had pulmonary insufficiency. Accordingly, 42 patients underwent open exploration which demonstrated pelvic metastasis in 11: 9 had nodal metastasis, 1 a pT4b tumor and 1 both. Consequently the sensitivity of pelvioscopy in detecting pelvic metastasis was calculated at only 31%. This result indicates that extraperitoneal pelvioscopy should be considered a screening procedure rather than an accurate staging procedure for pelvic metastasis.

A model of the mechanics of smooth muscle reservoirs applied to the intestinal bladder

A model of the mechanics of smooth muscle reservoirs was derived from the stress-strain relation in smooth muscle strips. The model was applied to the intestinal bladder reservoir but may also be applied to natural reservoirs such as the bladder. The relation between reservoir volume and pressure was calculated at different values of smooth muscle tone and was found to accord with clinical results. The muscle tone of the bowel when measuring off the bowel to construct the reservoir was found to have a profound influence on its ultimate volume. Stiffening of a part of the reservoir wall as a result of edema or fibrosis will cause a substantial decrease in functional capacity, both directly as a result of a reduced expansion of the diseased part and indirectly by enhancing the stretching of the adjacent normal wall. The pressure rise produced by a slow peristaltic contraction was calculated to depend both upon the strength of contraction and on the degree of reservoir filling: Almost no pressure rise will occur in the near empty reservoir, while the highest pressure rise was calculated to occur at a volume of about 300 ml. If only a part of the reservoir contracts, more filling is needed before the pressure increases and the maximum pressure will be reached at a substantially higher volume. Localized contractions will stretch the resting reservoir wall and so activate stretch receptors, which may cause a desire to void, resulting in reduced functional capacity.

Treatment of metastatic renal cell carcinoma by continuous intravenous infusion of recombinant interleukin-2: a single-center phase II study

PURPOSE

A single-center phase II study was performed to evaluate the efficacy of recombinant interleukin-2 (rIL-2) administered by continuous infusion to patients with metastatic renal cell carcinoma (RCC).

PATIENTS AND METHODS

Thirty-one patients with RCC were entered onto the study. rIL-2 (Proleukin; Eurocetus Corp, Amsterdam, The Netherlands) was administered intravenously in a dose of 18 x 10(6) IU/m2 per 24 hours. A maximum of two induction cycles and four maintenance cycles were given. Each induction cycle consisted of two rIL-2 infusion periods of 120 hours and 108 hours duration, respectively; these were separated by a 6-day rest period. Each maintenance cycle consisted of a 120 hours rIL-2 infusion period.

RESULTS

Six of 30 assessable patients (20%) responded; two (7%) with a complete response (CR) and four (13%) with a partial response (PR). The response duration for patients with CR was 209 and 715+ days, and for those with PR 161, 197, 245, and 353 days. Seven patients had stable disease (SD) with a median duration of 261 days (range, 127 to 381 days). The overall median survival was 261 days (range, 13 to 905+ days). The most frequent toxicities requiring dose reductions of rIL-2 were: hypotension in 87% of patients, dyspnea in 32%, CNS toxicity in 55%, and an increase in serum creatinine levels in 48%. Septicemia occurred in 16% of patients. Toxicities usually reversed on interruption of rIL-2 infusion. One patient (3%) died as a result of the treatment from initial CNS toxicity followed by multiorgan failure.

CONCLUSIONS

The study confirmed the antitumor efficacy of rIL-2 administered by continuous infusion in patients with metastatic RCC. The response rate was similar to that obtained by high-dose bolus injections of rIL-2. Toxicity was substantial but manageable in a specialized oncology ward without routine use of an intensive care unit.

Recombinant interleukin-2 and lymphokine-activated killer cell treatment of advanced bladder cancer: clinical results and immunological effects

The purpose of this study was to evaluate the efficacy of treatment with recombinant interleukin-2 (rIL-2) and lymphokine-activated killer cells in patients with advanced bladder cancer and to study the induced changes in the distribution of leukocyte subsets in blood and tumor. Nine patients with metastatic transitional cell cancer of the bladder were treated with a continuous infusion of rIL-2 combined with lymphocytes stimulated in vitro with rIL-2. None of the patients responded to the therapy despite substantial changes observed in the immunological cells, both in tumor and blood. The rIL-2 infusion induced migration of leukocytes to the tumors, which was related to increased expression of the adhesion molecule VLA-1 on both peripheral blood mononuclear cells and the endothelial cells of small tumor vessels. Only T-cells, predominately expressing IL-2 receptors, and macrophages infiltrated the tumors. Natural killer cells remained few or absent in the tumors, even though the natural killer cells in peripheral blood were activated by the treatment. This study shows that the present technique of rIL-2 and lymphokine-activated killer cell therapy is able to induce substantial changes in the immune system of patients with metastatic bladder cancer. However, this treatment did not induce tumor regression, which may be due to the advanced stage of disease.

Intravesical BCG therapy in bladder carcinoma. Effect on cytotoxicity, IL-2 production and phenotype of peripheral blood mononuclear cells

The purpose of the study was to examine the effects of intravesical BCG treatment on the cytotoxicity, interleukin-2 (IL-2) production and distribution of the subsets of peripheral blood mononuclear cells (PBMC) in patients with carcinoma in situ of the bladder. Treatments were made in 6 patients during a conventional BCG treatment schedule. Four patients showed a complete response, one a partial response and one had a progressive disease after BCG treatment. Intravesical BCG did not induce significant changes in the cytotoxicity of PBMC. The distribution of NK-cells and T-cells also remained unchanged and so did the lectin induced production of IL-2. The results suggest that the effects of intravesical BCG on the immune system should be studied in lymphocytes isolated from the bladder.

Reduced LAK cytotoxicity of peripheral blood mononuclear cells in patients with bladder cancer: decreased LAK cytotoxicity caused by a low incidence of CD56+ and CD57+ mononuclear blood cells

The cytotoxicity of unstimulated peripheral blood mononuclear cells (US-PBMC), phytohemagglutinin (PHA)-stimulated PBMC (PS-PBMC) and interleukin-2 (IL-2)-activated PBMC (LAK cells) was assessed in patients with noninvasive and invasive transitional-cell bladder cancer and compared with those determined in healthy controls. The differences in the cytotoxicities were correlated with specific changes in the subsets of peripheral blood mononuclear cells (PBMC). PBMC from 37 patients and 13 healthy controls were tested against the bladder cancer cell line T24 in 51Cr-release assays. The PBMC subsets were analyzed using monoclonal antibodies against T cells, natural killer (NK) -cells, monocytes, and activation markers. The cytotoxicities of US-PBMC, PS-PBMC, and LAK cells were all significantly lower in the cancer patients than in the controls (P less than 0.05). The percentages of PBMC positive for the NK-cell markers CD56 and CD57 were lowest in the patients and were correlated to the decrease in cytotoxicity. Depletion of CD56+ or CD57+ cells from PBMC prior to or after 2 days stimulation with IL-2 demonstrated that these cells are the major source of LAK-cell cytotoxicity and showed that the reduced ability of bladder cancer patient PBMC to develop LAK-cell cytotoxicity is a result of a low incidence of CD56+ and CD57+ cells in the blood. These findings indicate that IL-2 therapy alone might not be a sufficient therapy of bladder cancer patients.

Low dose intravesical heparin as prophylaxis against recurrent noninvasive (stage Ta) bladder cancer

A controlled randomized clinical trial was conducted to examine the efficacy of topical low dose heparin (0.125 gm./l., 25,000 units per l.) as prophylaxis against recurrent noninvasive (stage Ta) transitional cell bladder cancer. Transurethral tumor resection was done with irrigation fluid containing either 1.5% glycine with heparin or glycine solution alone. Tumor recurrence was determined by cystoscopy 4 to 6 months later. There were 70 patients evaluated: 38 in the heparin and 32 in the control group, respectively. The recurrence rate (heparin 74%, control 66%) and the median number of recurrences (heparin 3, range 1 to 15 and control 3, range 1 to 30) were similar (p greater than 0.05) in the 2 groups of patients. These observations show that low dose heparin administered in the irrigation fluid during transurethral resection does not decrease the recurrence rate of noninvasive (stage Ta) bladder cancer.

[Epidermoid cyst of the testis]

We report a case of epidermoid cyst of the testis. The condition is rare and benign. Conservative surgical treatment is advocated when the diagnosis is confirmed by histological frozen sections.