Vol. 173, No.
4, Supplement, Tuesday, May 24, 2005
fragmentation with less renal tissue injury in comparison to a constant or a
decreasing output voltage by optimizing the stress wave and cavitation erosion
forces.
METHODS: BegoStone® phantoms were implanted in the renal pelvis of 13
swine and administered lithotripsy at a repetition rate of I Hz. Animals in the
increasing strategy group (n=4) were subjected to 18, 20 and 22kV for 600, 600,
and 800 shocks, respectively. The second group (n =4) received a decreasing
strategy of 22, 20, and 18kV for 800, 600, and 600 shocks, respectively. The third
group (n=5) received all 2000 shocks at 20kV, mimicking the clinical setting. To
examine the effects of treatment strategy on renal tissue injury, these studies were
repeated in 12 animals (n=4/protocol) that did not undergo stone implantation.
RESULTS: The mean comminution efficiency, or percentage of fragments<
2mm, was improved to 96.5::!:1.4% by using the increasing strategy (p=O.Ol). A
decreasing strategy or constant output voltage produced a mean comminution of
89.0::!:3.3% and 80.7::!:9.8%, respectively. The mean volume percentage of renal
tissue injury was reduced to 2.5::!:0.8% when using the increasing strategy
(p<O.Ol). By comparison, a decreasing strategy or constant output voltage
produced a mean volume of 3.5::!: 1.0% and 5.2::!:0.7%, respectively.
CONCLUSIONS: A progressive increase in lithotripter output voltage can
produce greater stone comminution efficiency and reduce renal tissue injury in
comparison to SWL protocols employing a constant or decreasing output voltage.
Source of Funding: Howard Hughes Medical Institute
1109
EFFECT OF HIGH AND LOW CALCIUM DIET DURING
LIBERAL OXALATE INTAKE: IMPACT ON STONE FORMING
RISK Edward D Matsumoto*, Hamilton, ON, Canada; Howard J Heller,
Linda J Brinkley, Beverly Adams-Huet, Charles Y C Pak, Margaret S Pearle,
Dallas, TX
INTRODUCTION AND OBJECTIVE: A recent metabolic study showed that
the apparent protective effect of a high calcium intake observed in epidemiological
studies may be due to concurrent intake of protective dietary factors, and the rise
in urinary oxalate attributed to a low calcium diet can be averted by oxalate
restriction. Our objective was to compare the effect of a high and low calcium diet
on the relative saturation ratio (RSR) of CaOx during liberal oxalate intake.
METHODS: We enrolled 10 healthy subjects (5 male, 5 female) in a 2-phase,
randomized crossover study comparing high (1000 gm daily) and low (400
mglday) calcium intake. During each phase, subjects followed an instructed diet for
3 days then were maintained on a controlled metabolic diet (200 mg/day of oxalate)
for the last 4 days. Serum and 24-hr urine specimens were collected on the last 2
days of each phase for measurement of stone risk factors and calculation of RSR
CaOx.
RESULTS: Urinary calcium was higher (170::!:64 SD vs 124::!:49 SD mglday,
p=0.002) and urinary oxalate was lower (25::!:4.8 SD vs 27::!:4 SD mg/day,
p=0.02) on the high vs low calcium diet. Overall, the RSR of calcium oxalate was
higher on the high calcium compared with the low calcium diet (3.3 versus 2.5,
p<O.OOOI). Even after adjusting for confounding variables, urinary saturation of
CaOx was 18% higher on the high calcium diet.
CONCLUSIONS: In normal subjects, a high calcium diet in the setting of
liberal oxalate intake increased urinary saturation of CaOx because the decline in
urinary oxalate was unable to overcome the effect of increased urinary calcium. A
high calcium diet during liberal oxalate intake may pose an increased risk for CaOx
stone formation.
Source of Funding: GCRC GRANT #M01-RR00633 from NIHINCRR-CR
1110
INCREASED INTERCALATED VERSUS PRINCIPAL CELLS IN
INNER MEDULLARY COLLECTING DUCTS IN HUMAN
STONE FORMERS Chung Kuang Su, Jonathan N Rubenstein*, Affonso
H LA Camargo, Stephen L Gluck, Marshall L Stoller, San Francisco, CA
INTRODUCTION AND OBJECTIVE: The inner medullary collecting duct
(IMCD) is thought to play a vital role in urinary acidification. In vitro studies with
IMCD cell lines of rats have shown that exocytosis of vacuolar H+ -ATPase
mediates H+ secretion. Translocation of H+ pumps can only be accomplished with
an intact cytoskeleton and appropriate intracellular calcium concentration. This
modulation of urinary pH has a potential implication in the development of urinary
stone disease. No similar study however has been demonstrated with human renal
tissue. Our study examines the distribution of H+·ATPase in IMCD from retrieved
human papilla in patients with and without urinary stone disease.
METHODS: Normal appearing human renal papillary tissue was harvested
from stone and non-stone forming surgically retrieved kidneys for a variety of
reasons. The tissues were immersed in 10% formaldehyde with 6% mercuric
chloride and 1.25% sodium acetate for over night fixation. This tissue was
embedded in paraffin for 5-8 !Lm sections. The avidin-biotin peroxidase procedure
THE JOURNAL OF UROLOGY® 301
was applied for immunohistochemistry. Murine monoclonal anti-H+·ATPase was
used as the primary antibody and visualized with 3,3' -diaminobenzidine (DBA).
Staining accuracy was confirmed by peptide competition immunohistochemistry.
RESULTS: Two distinct staining patterns of H+ -ATPase were observed along
IMCD. Stone former tissue revealed increased numbers of H+ -ATPase-rich cells.
The H+ -ATPase within the intercalated cells was consistently stained in an
asymmetric fashion with the vast majority staining at the luminal border. This polar
pattern of staining was seen in both stone and non-stone former tissues.
CONCLUSIONS: This is the first study of human papillary tissue to
demonstrate differences in intercalated and principal cells in the IMCD between
normal and stone forming tissues. This has unique implication in the micro-
environmental pH in the renal papilla. Such findings may direct future therapy for
patients with urinary stone disease.
Source of Funding: None
Bladder Cancer: Invasive
Podium
Tuesday, May 24, 2005 10:00 am - 12:00 pm
1111
THE EFFECT OF BODY MASS INDEX (BMI) ON THE QUALITY
AND MORBIDITY OF RADICAL CYSTECTOMY FOR
BLADDER CANCER. Karim Touijer*, Daniel Cho, Bernard H Bochner,
Harry W Herr, Guido Dalbagni, S Machele Donat, New York, NY
INTRODUCTION AND OBJECTIVE: Nodal counts and the extent of nodal
dissection (LND) have been shown to effect survival outcomes in patients
undergoing radical cystectomy for bladder cancer. We evaluated the effect of BMI
on the quality and morbidity of surgery in patients undergoing radical cystectomy
for bladder cancer.
METHODS: A prospective evaluation of 141 patients undergoing radical
cystectomy with either a standard (54) or extended (87) LND for invasive bladder
cancer between June 2001 and April2003 was performed. Standard World Health
Organization definition of BMI was utilized ( <25kg/m2 = normal, 25-29.9=
overweight, 2:30=obesity). Clinical and surgical parameters evaluated were age,
sex, clinical and pathologic stage, extent of node dissection, nodal count, ratio of
positive nodes, margin status, local recurrence rate, operative (OR) time, blood loss
(EBL), complication type and frequency, BMI, and morbidity indices.
RESULTS: BMI was assessable in 141 patients with 27% normal weight, 40%
overweight 33% morbidly obese. All patients were followed median of 20 months
postoperatively. Median BMI was 28, range 16-48. Pathologic stage was organ
confined in ( <pT3a) 57%, with II% surgical margins and 22% nodes positive. The
quality of surgery in terms of extent of node dissection (p= .52), nodal ratio
(positive/total, p=.68), or the number of nodes obtained (p=.84, median 18
normal, 18 overweight, 19 obese) was not significantly affected by BMI. Although
positive surgical margin rates decreased significantly with increasing BMI (p=.05,
normal 18.4%, overweight 12.5%, obese 2.2%), this did not translate into lower
local recurrence rates (p=.77). There was a trend towards greater perioperative
complications with advancing BMI. Obese patients were more likely to have
urinary (p= .006) complications, or require a return to the OR (p= .03). OR times
were longer with increasing BMI (p=.04), but there were no significant differences
in EBL (p=.48) or transfusion rates (p=.87).
CONCLUSIONS: BMI did not affect the quality of surgery performed as
measured by median nodal count, nodal ratio, extent of dissection or local
recurrence rates and therefore obese patients should not be excluded from clinical
trials based on weight alone. An increased BMI was associated with a higher but
acceptable surgical morbidity in overweight and obese patients undergoing radical
cystectomy.
Source of Funding: None
1112
DEVELOPMENT OF AN INTERNATIONAL BLADDER
CANCER SPECIFIC NOMOGRAM PREDICTING SURVIVAL
FOLLOWING RADICAL CYSTECTOMY International Bladder
Cancer Nomogram Consortium; Bernard H Bochner*, New York, NY
INTRODUCTION AND OBJECTIVE: Outcomes following radical
cystectomy (RC) vary greatly based on a variety of clinical and pathologic
variables. Nomograms are devices derived from statistical or mathematical models
which are used to predict outcomes for an individual patient. In this study, we used
an international database of bladder cancer patients to develop a nomogram that
predicts survival following radical cystectomy.