A Supravital Cytodiagnostic Stain

for Urinary Sediments

Richard Sternheimer, MD

A mixture of aqueous solutions of National fast blue, a copper-phthal- in their size and form.
ocyanine dye, and pyronin B, a red xanthene dye, when added to fresh uri- Modified techniques of ordinary
nary sediment, supravitally stains benign or malignant cells and the various light microscopy,2 phase-contrast mi¬
types of casts and their inclusions. The stain facilitates identification of the croscopy,'-' interference microsco¬
formed elements and particularly aids in the differentiation of polymorpho- py,"7 and fluorescence microscopy""
nuclear leukocytes from lymphocytes, histiocytes, plasma cells, and renal have offered but limited assistance in
tubular cells. A variable staining of casts and their inclusions has been ob- solving these problems and have not
served. Tumor cells may be recognized by nuclear abnormalities or, in case obviated the need for staining meth¬
of hyperchromatic tendency, by a very rapid and early uptake of dye preced- ods. Where a more detailed structural
ing that of the surrounding cells. analysis of cells becomes crucial, as in
The staining method is rapid and simple enough for routine urinalysis and the diagnosis of bladder tumors,1" of
screening procedures. tubular necrosis, or of rejection of
(JAMA 231:826-832, 1975) renal transplants,1112 staining of air-
dried and fixed sediments has re¬
mained the method of choice. Unfor¬
(
tunately, these laboratory procedures
EVALUATION of microscopic uri¬ dergo changes in size, structure, and not infrequently entail the loss of cel¬
nary findings rests on adequate rec¬ transparency that add to the already lular elements during preparation
ognition of cellular elements and existing cytodiagnostic uncertainties and are too time-consuming for rou¬
casts. This has always been a difficult created by the poor optical contrast tine use. In contrast, wet stains offer
task since the cells may originate between cells and the liquid medium. readily available results. Separate
from diverse tissues such as epithelial Thus, differentiation, particularly supravital stains have been devised
layers of the urinary and genital of the small cells (like those cast off for red blood cells (RBCs),12 for white
tracts, blood and connective tissue from renal tubules, the deeper muco- blood cells (WBCs),141s for tumor
sources, or tumors, and are likely to sal layers, or the prostate) from cells,1"17 and for casts.18 Some stains
show variable degrees of degenera¬ polymorphonuclear leukocytes, lym¬ that facilitate recognition of a larger
tion, viability, permeability, and den¬ phocytes, histiocytes, plasma cells, or range of formed elements have been
sity when shed into the urine. Subse¬ tumor cells, has remained a frustrat¬ used more widely,19-20 but "none has
quently, by being exposed for varying ing and largely unsolved problem in supplanted the direct examination of
periods of time to different os- ordinary light microscopy.1 Obviously, the unstained sediment for routine
molarities, to fluctuations of pH, and the same predicament exists in the use."21
to enzymatic, toxic, or possibly bacte¬ identification of cellular elements and It is safe to say, therefore, that
rial agents in the urine, they also un- their decomposition products that are there exists a need for a procedure
enmeshed in urinary casts. Finally, suitable for routine urinalysis that
From the departments of medicine and pa-
the casts themselves are often diffi¬ aids in the differentiation of cells, be¬
thology,Michael Reese Hospital and Medical cult to visualize on account of the nign or atypical, as well as in the rec¬
Center, Chicago. variable optical and chemical charac¬ ognition of casts and in the character¬
Reprint requests to Michael Reese Hospital teristics of the cast matrix—hyaline ization of their inclusions. This article
and Medical Center, 2900 S Ellis Ave, Chicago,
IL 60616 (Dr. Sternheimer). vs waxy casts—and the wide variety reports such a staining method.

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 GENERAL CONSIDERATIONS
The stain used is a mixture of a
copper-phthalocyanine dye, National
fast blue, and a xanthene dye, pyro-
nin B. The choice of the dye mixture
was made on the basis of the follow¬
ing data:
The copper-phthalocyanines used in
histology, National fast blue, alcian
blue, and astrablau, are dyes of high
molecular weights-990, 1,341, and
1,267, respectively. They differ from
each other mainly in the side chains
attached to the copper-phthalocya¬
nine chromophore (dimethylhydrazine
for National fast blue, isothiouronium
for alcian blue, and acetate for
astrablau). All appear to be high¬
ly aggregated in aqueous solutions
(dimers, trimers, or polymers). They
are strongly basic dyes, but are dis¬
tinct from other cationic dyes (1) by
being precipitated and irreversibly
adsorbed to the living outer cell mem¬
brane (as observed in ^Imoeoa),22 (2)
by diffusing slowly through gels and
matrices and by staining tissues
slowly,23 (3) by displaying no tend¬
ency to avid staining of nucleic
acids,2425 and (4) by prominently
staining acid mucopolysaccharides.
In contrast, pyronin B is a basic
dye of low molecular weight (359) and
relatively faster diffusion rate that
interacts strongly with polynucleo-
tides, particularly ribonucleic acids.24
These contrasting characteristics
were believed to be advantageous in a
supravital stain, where differences in
the rate of permeation by the two
dyes could be observed directly and
possibly correlated with membrane
permeability, the physicochemical
state of cellular matrices, and the via¬
bility of cells. It also appeared likely
that the remarkably low affinity of
the phthalocyanine dye for cytoplas-
mic ribonucleic structures2526 would
favor their preferential staining by
pyronin. This in turn might contrast
with nuclear staining by the blue dye,
which even under conditions of low
pH has been found as "hard to pre-
vent."26-27 Finally, the marked sensi¬
tivity of acid mucopolysaccharides to
the copper-phthalocyanine suggested
the use of this dye for the staining of
casts, based on the demonstration
that Tamm-Horsfall protein, a sial-
ic-acid-containing glycoprotein, was
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prominently represented in the
matrix of casts.28-2"
It was realized that these consid¬
erations, some of which were derived
from observations on fixed tissues un¬
der controlled conditions of pH,
might have only limited validity for
supravital staining. The approach had
to be empirical and the tentative in¬
terpretations presumptive, or at best
inferred with a "confidence mitigated
by prudence" (Lison).30
PREPARATION OF THE STAIN
As the copper-phthalocyanine dye,
National fast blue was preferred, be¬
cause it has greater potency per unit
of weight, offers greater color con¬
trast, and proved to be quite stable.
1. National fast blue (Allied Chem¬
ical Corp, No. 1946 P) was prepared in
a 2% aqueous solution.
2. Pyronin B (Matheson Coleman &
Bell No. Pbl7). In view of the great
variations in dye content of the com¬
mercially available pyronin, which
may vary from lot to lot, it appeared
advisable to purify the dye by alcohol
extraction, whereby dextrin and salts
are removed.31 After evaporation of
the alcohol, dye crystals separated
from the gummy residue were dis¬
solved to form a 1.5% aqueous solution
of relatively constant staining capac¬
ity.
3. Both solutions were filtered and
equal parts of each dye solution were
mixed and the resulting mixture kept
in a dropper bottle. The dispensing
capillary consisted of the lower end of
a Pasteur pipette fitted into the rub¬
ber bulb of the bottle cap. Individual
batches of dye solutions and the mix¬
ture appeared stable for many
months.
If alcian blue or astrablau is used as
an alternate dye for National fast
blue, a stronger concentration of the
blue dye is required in the stain mix¬
ture to achieve comparable contrasts.
Depending on the purity and the man¬
ufacturing source of the blue dye,32
its ratio in percent weight per volume
to that of the red dye may vary be¬
tween 2:1 and 4:1. High concentration
ratios of blue dye to red dye tend to
produce a more violet staining of the
cellular cytoplasm. On the other hand,
a proportionately high pyronin con¬
centration in the mixture should be
avoided, since pyronin has a moderate
affinity to Tamm-Horsfall protein
and in sufficiently high concentration
may compete with the blue dye in the
staining of hyaline casts.
The following spectrophotometric
data may serve as a more precise
guideline. The stain mixture should
be made up to meet the following cri¬
teria: When 0.1 ml of the stain is di¬
luted to 100 ml deionized water, the
absorbance (from pyronin B) at ap¬
proximately 553 nm is 1.81±10%. The
ratio of the absorbance at approxi¬
mately 553 nm to the absorbance
(from the blue dye, alcian blue or as¬
trablau) at approximately 622 nm is
between 2:1 and 4:1.
Such a stain mixture, when tested
on a sediment of a urine with low
protein content, should stain hyaline
casts bright blue and the cytoplasm of
the epithelial cells in a pink color.
STAINING THE SEDIMENT
Sediment samples were prepared in
the usual manner, by centrifuging a
10- to 15-ml sample of urine in a stan¬
dard centrifuge tube at 1,500 to 2,000
rpm for five minutes and discarding
the supernatant, leaving only about 1
to 2 drops of it to mix the sediment
by agitation or finger flipping. Via
a rubber-topped Pasteur pipette, 2
drops of the sediment mixture were
transferred into a small tube and 1
drop of stain added. After shaking,
1 drop of the stained sediment was
placed on a glass slide and mounted
by a cover glass for immediate micro¬
scopic examination.
Staining started promptly and in¬
creased in intensity particularly dur¬
ing the first five to ten minutes; from
then on, progression of staining was
slow and diminishing. Observation
during the initial staining period,
however, proved extremely valuable
since the rate of staining of individ¬
ual cells appeared related to their via¬
bility or, as in some malignant cells,
to a tendency towards hyperchroma-
sia. Overstaining of ordinary cell
components occurred infrequently,
and the stained sediment mixture
could be viewed after standing for
many hours. The effects of differing
protein and electrolyte concentra¬
tions in the urine and of the vari¬
ations in cell content of the sediment
 Fig 1.—Finely and coarsely granular cast; Fig 2.—Variable staining of WBCs, "glitter Fig 3—Histiocytes, WBC in late
"glitter cells" with dye precipitated on cells," and round cells (original pyelonephritis (original magnification
their surface (original magnification X400). magnification x 400). x 400).

Fig 4—Plasma cells (oil immersion). Fig 5.—Epithelial cell casts. Fungi. (Septic Fig 6.—Hyaline cast with enmeshed or
arthritis, diabetes mellitus, antibiotic attached tubular cells (original
therapy) (original magnification x400). magnification x400).

Fig 7—Cast containing tubular epithelial Fig 8.—Renal tubular cell cast. Nephrotic Fig 9.—Renal tubular cast. Nephrotic
cells. Renal amyloid (oil immersion). syndrome (oil immersion). syndrome (oil immersion).

Fig 10.—Squash preparation from Fig 11.—Epithelial cells. Note variable Fig 12.—Caudate transitional epithelial
prostate, obtained at autopsy, supravitally sizes and staining of nuclei (original cells. Note nuclear chromatin (oil
stained (original magnification x400). magnification x400). immersion).

Fig 13.—Bladder epithelial cells, obtained Fig 14.—Bladder epithelial cells, Fig 15.—Degenerative epithelial cell
by catheterization, following surgery of catheterized specimen (original inclusions; atypical transitional epithelial
ureteral stricture (original magnification magnification x400). cell (original magnification x400).
x 400).

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 Fig 16.—Multinucleated giant epithelial Fig 17.—Hyaline casts, short, long, spiral Fig 18.—Hyaline casts (original
cell(oil immersion). forms (original magnification x100). magnification x400).

Fig 19.—Variably stained casts. Late Fig 20.—Waxy cast. End-stage Fig 21 .—Hemoglobin cast, rust-brown;
pyelonephritis (original magnification pyelonephritis (original magnification angular cast with RBC: acute glomer-
x 400). X100). ulonephritis (original magnification X400).

Fig 22.—Red blood cell cast. Chronic Fig 23.—Oval fat body (oil immersion). Fig 24.—Bacteria (original magnification
glomerulonephritis (original magnification X400).
x 400).

Fig 25.—Suspected tumor cells, found in Fig 26.—Same patient, following cystos- Fig 27.—Tumor cells, RBCs, same patient
routine urine specimen (original copy: transitional cell carcinoma of blad¬ (oil immersion).
magnification x400). der. Tumor cells, RBCs (oil immersion).

Fig 28—Transitional cell carcinoma of Fig 29—Papillary transitional cell Fig 30.—Tumor cells, same patient (oil
bladder (original magnification x 400). carcinoma of bladder. "Tadpole" cell; immersion).
degenerative inclusion cells (oil
immersion).

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 mixture on the rate of staining
seemed to be minimized by the rela¬
tively high dye concentrations used.
The description of the staining
characteristics is based on observa¬
tions and photographic records of the
urinary sediments of 230 patients.
The sediment samples were chosen
from routine laboratory urine speci¬
mens whenever increased cellular or
cast contents were found on ordinary
examination. Clinical records of pa¬
tients were made available for corre¬
lation. The observations extended
over a 2%-year period. In a number of
cases, follow-up examinations were
performed at intervals. Many normal
sediment samples were examined as
controls. The pH of the urine speci¬
mens varied between 5.0 and 6.5; os-
molarity, generally between 200 and
450 mOsm/liter; and albuminuria,
from trace to 4 +.
RESULTS
The dyes of the mixture have a
tendency to combine selectively with
the various structural components of
the cells. Preferential staining of the
cytoplasm by pyronin is quite ob¬
vious. Cell nuclei are predominantly
stained by the blue dye, but red stain¬
ing of the nucleus can also be ob¬
served. These differences in nuclear
staining are most obvious in the vari¬
able staining of urinary leukocytes; it
was this observation that offered a
clue to the mode of action of the dyes.
Immediately after addition of the
dye mixture to the sediment, leuko¬
cytes may appear unstained and re¬
sist permeation by either dye for a
prolonged period. This is especially
true for the oversized, swollen "glit¬
ter cells." When they begin to stain
subsequently, the red dye always pre¬
cedes the blue and the blue will fol¬
low after a varying interval, trans¬
forming the red nuclear staining into
blue, while leaving the cytoplasm red.
One reason for the delayed entry of
the phthalocyanine dye may be its
visible initial clumpy precipitation on
the leukocytic cell surface, which is
analogous to the precipitation ob¬
served in Amoeba (Fig 1).
In other instances, both nuclei and
cytoplasm are immediately dyed by
pyronin only, and this appearance
may remain unchanged for many
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hours thereafter, or there may be
gradual shift to a blue staining of the
nuclei, which is then irreversible. On
other occasions deep blue nuclear and
red cytoplasmic staining are present
from the outset and will remain so in¬
definitely. The three stages of stain¬
ing may be found on different leuko¬
cytes in the same microscopic field,
indicating that the variable nuclear
staining reflects progressive degrees
of individual cellular damage rather
than changes in the composition of
the urine (Fig 2). A simple experi¬
ment supports this concept: If the
buffy coat of blood treated with cit¬
rate is stained wet, the WBCs will
show diffuse staining by pyronin
alone. If, however, a smear is made of
the same buffy coat and stained after
drying, the cell nuclei will appear
sharply outlined in deep blue, the
cytoplasm red.
The results of the cell-dye inter¬
action are remarkably different for
the two dyes. Pyronin can be washed
away easily by distilled water, both
from the blood smear as well as from
the urinary sediment. In contrast, the
blue dye always remains irreversibly
bound. This difference can be ob¬
served directly on the stained sedi¬
ment under the microscope by adding
distilled water below the cover glass
to flood the preparation by capillary
action.
Polymorphonuclear leukocytes in
the urinary sediment were identified
with relative ease. More difficult was
the differentiation between mononu-
clear WBCs and the small round epi¬
thelial cells derived either from renal
tubules or from the lining epithelia of
the remainder of the urinary tract.
The size of these epithelial elements
varied not only by shrinking or swell¬
ing with changing urine osmolarities
but also in connection with fatty de¬
generation or as a result of inflam¬
matory changes. Nevertheless, cer¬
tain distinguishing features were
observed.
Cells
Lymphocytes, as a rule, appeared
comparatively smaller than renal
tubular cells or leukocytes and were
recognized by their densely blue nu¬
cleus surrounded by a small rim of
cytoplasm. Small- and medium-sized
histiocytes could be identified by their
eccentric, kidney-shaped nuclei and
their vacuolated cytoplasm (Fig 3).
Cells resembling plasma cells with
eccentrically located, oval-shaped nu¬
clei, whose chromatin was ar¬
ranged in a wheel-spoke pattern, and
where the cytoplasm exhibited one or
more pyronin-stained inclusions,
were (Fig 4).
also observed
However, recognition of renal tu¬
bular cells on morphological grounds
alone seemed to be a most difficult
task and fraught with uncertainty.
Their appearances and staining char¬
acteristics seemed to be not uniform;
one felt more certain of their identity
if they were found within casts (Fig 5
through 9). More often than not, the
cytoplasm of the renal tubular cells
was ovoid or polygonal rather than
round; their nuclei were either vesicu¬
lar and indistinct or sharply outlined
when stained dense blue. Fatty de¬
generation, if present, was clearly
visible. Not infrequently, the differ¬
entiation from the small round or
cuboidal cells of the deeper mucosal
layers of the urinary tract was tenta¬
tively made by taking into account
the milieu of the accompanying cellu¬
lar or formed elements. In these
doubtful situations, consultation of
the clinical records was helpful in try¬
ing to corroborate or weaken a pre¬
sumptive diagnosis. A strong support
for their renal origin, for instance,
was obtained by clinical data showing
a sudden rise in blood urea nitrogen
and creatinine levels, oliguria, and
symptoms suggesting tubular necro¬
sis. Conversely, in some instances, a
marked increase in presumably renal
epithelial cells in the sediment pre¬
ceded the ensuing azotemia and
served as an early warning to the
clinician. The advantage of such rap¬
idly obtainable information for both
clinician and morphologist is obvious.
Squash preparations were obtained
from autopsy material from kidney
cortex, medulla, and pelvis, as well
as from ureters and urinary blad¬
der, and supravitally stained with the
dye mixture for a direct comparison
of identically stained tissue and
sediment cells. Disregarding the
structural pattern of the cellular ar¬
rangements in the tissues, the differ¬
entiation by morphological appear-
 anees alone of individual small cells
exfoliated from the various sources
seemed uncertain. As shown in
Fig 10, the distinct columnar appear¬
ance of prostatic cells within the tis¬
sue structure cannot be recognized on
the separated individual cells. Small,
caudate transitional epithelial cells,
however, were identifiable both in the
preparations and in the urine.
The cytoplasm of the squamous epi¬
thelial cells from bladder, urethra, or
vagina found in the sediment stained
preferably with pyronin, but various
tinges of violet also occurred. The
dense pyknotic nuclei of the large su¬
perficial keratinized cells were always
stained blue, while the larger vesicu¬
lar nuclei appeared blue or red (Fig
11). Under oil immersion the deep¬
ly blue stained strands of nuclear
chromatin were clearly visible (Fig
12). The well-described wide variation
in shape and size of the transitional
epithelial cells was distinctly visu¬
alized. They were pear-shaped or
spindle-shaped, caudate or polygonal,
and varied in size from small
mononuclear cells to very large mul-
tinuclear giant epithelial cells (Fig 12
through 16). Cells exhibiting spheri¬
cal, crescent-like, or bar-shaped pyro¬
nin-stained intracytoplasmic inclu¬
sions and containing either an intact
blue nucleus or disintegrating and ec¬
centrically located nuclear fragments
were found in low-grade bladder in¬
fections or in association with tumor
cells. Their appearance resembles
that of cells described as containing
eosinophilic cytoplasmic inclusions
(Fig 15).33-34
Casts
Casts stained promptly and in¬
tensely. Pure hyaline casts appeared
in bright blue colors; their great avid¬
ity for the phthalocyanine dye is in
keeping with the concept of the muco-
protein nature of the cast matrix.
Their characteristic shapes, either
short and plump, or long and narrow,
with rounded or straight ends, in tor¬
tuous or spiral forms, were distinctly
visualized (Fig 17 and 18). In finely
granular casts, the granular inclu¬
sions nearly always appeared bright
red within the blue matrix (Fig 1 and
19). Coarse granules within casts
tended to stain more in reddish-violet
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or blue-violet tinges. Most remark¬
able was a changein color and ap¬
pearance of the matrix of broad and
of waxy casts in instances of marked
proteinuria, especially nephrotic syn¬
dromes, mesangioproliferative glo-
merulonephritis, and in later stages
of pyelonephritis. These casts stained
reddish violet, showed markedly in¬
creased density and, at times, almost
complete loss of transparency (Fig 7
through 9 and 19, 20). Differences in
staining pattern and texture seen in
broad and waxy casts might well rep¬
resent changes within the cast matrix
itself, since it was noted in some but
not all of the casts in the same micro¬
scopic field. These findings offer an
interesting parallel to recent data,
obtained by immunofluorescent meth¬
ods, indicating differences in the
chemical composition of hyaline casts
and their granular inclusions35 and
also between hyaline casts, as pro¬
duced by certain diuretics, and the
casts excreted by patients'suffering
from renal disease.'" However, no
conclusions warranted before a
are
thorough comparative analysis of the
results obtained by the two methods
has been performed.
Hemoglobin casts appeared rust-
brown in color (Fig 21). Red blood cell
casts were easily identifiable (Fig 22).
Examples of the previously men¬
tioned wide variation in size and
staining appearance of renal tubular
cells, enmeshed in or adherent to the
casts, are given in Fig 5 through 9.
Fatty degeneration of these cells can
be recognized within and outside of
the casts. Fatty-degenerated "oval
fat bodies" were also clearly visual¬
ized (Fig 23).
Red blood cells are distinctly out¬
lined in various shades of pink, their
rims sometimes studded with tiny red
droplets. A tendency to agglutination
has been observed, and, in some
instances, hemolysis of individual
erythrocytes after prolonged observa¬
tion (15 to 20 minutes) of the stained
sediment. These are obviously lim¬
iting factors in the evaluation of
hematuria.
Microorganisms
Bacteria normally appeared
stained bright red; the stain has a
tendency to precipitate moving bac-
teria (Fig 24). Fungi remained un¬
stained (Fig 5); their differentiation
from RBCs presented no problem.
Trichomonas also seemed to resist
staining, or took on a slightly bluish
hue.
Amorphous Mucus
Amorphous mucus was stained in¬
tensely by the blue dye, which at
times was disturbing when it became
superimposed on the formed ele¬
ments. It did not, however, render
cellular differentiation impossible as
it would in an unstained sediment.
The occurrence of increased mucus
excretion was most notable in lower
urinary tract infection or following
prostatic resections.
There is a marked tendency of the
stained mucus to aggregate. The
slightest pressure on the cover glass
or a shearing motion can produce
cast-like artifacts that, however, are
easily recognizable by their streak¬
like, regular, diagonal distribution
over the whole visual field. For this
reason, and as a standard precaution,
the cover glass should always be
dropped gently on the stained sedi¬
ment and no further corrections made
thereafter.
Malignant Cells
Inview of the great variability ob¬
served in form and structure of the
renal tubular cells, a cautious ap¬
proach to the interpretation of atypi¬
cal and especially of malignant cells
appeared indicated. Variations in size
and shape or alterations of the nu-
clear-cytoplasmic ratio of these cells,
therefore, were considered less sig¬
nificant than the evidence of irregu¬
lar nuclear outlines, of coarse clump¬
ing or strand formation of the
chromatin material within the nu¬
cleus, of condensation of chromatin
near the nuclear membrane, and of
hyperchromatic staining. Observation
of the sediment during the initial
staining period was especially valu¬
able in hyperchromatic cells because
they stained earlier than the remain¬
ing cells. Thus, they could be singled
out from the start in a search for fea¬
tures of malignancy. In order to ac¬
centuate the staining difference and
to prevent overstaining, the stain
mixture in these instances was some-
 times diluted by one third to one half
with distilled water.
Only 12 cases of clinically estab¬
lished bladder tumors have been ex¬
amined so far. In two, the diagnosis
was made initially from a routine
urine specimen with surgical confir¬
mation. The remaining ten urine
specimens stemmed from patients
with known bladder tumors. Exam¬
ples of malignant cells found in in¬
stances of carcinoma of the bladder
1. Kern WH: Epithelial cells in urine sedi-
ments. Am J Clin Pathol 56:67-72, 1971.
2. Kurtzman NH, Rogers PW: A Handbook of
Urinalysis and Urinary Sediment. Springfield,
Ill, Charles C Thomas Publisher, 1974.
3. Natusch R: Zur Sedimentuntersuchung des
Harns. Z Aerztl Fortbild 55:1018-1023, 1961.
4. Brody L, Webster MC, Clark RM: Identi-
fication of elements of urinary sediment with
phase-contrast microscopy: A simple method.
JAMA 206:1777-1781, 1968.
5. Michielsen P: L'examen du s\l=e'\dimenturi-
naire, in Actualit\l=e'\sNephrologigues Hopital
Necker. Paris, Editions M\l=e'\dicalesFlammarion,
1967, pp 249-269.
6. Ross KFA: Phase-Contrast and Interference
Microscopy for Cell Biologists. New York, St.
Martin's Press, 1967.
7. Haber MH: Interference contrast micros-
copy for identification of urinary sediments. Am
J Clin Pathol 57:316-319, 1972.
8. Derrick FC Jr: Fluorescence microscopy of
urinary sediment. J Urol 105:436-439, 1971.
9. Levy E, Jerusalem K: Experience with cyto-
logic examination of urines with the assistance
of multiple parallel methods with and without
clinical indication of tumor. Acta Cytol 17:121\x=req-\
124, 1973.
10. Esposti PL, Moberger G, Zajicek J: The
cytologic diagnosis of transitional cell tumors
of the urinary bladder and its histologic basis.
Acta Cytol 14:145-155, 1970.
11. Taft PD, Flax MH: Urinary cytology in re-
nal transplantation: Association of renal tubular
cells and graft rejection. Transplantation 4:194\x=req-\
204, 1966.
12. Kline TS, Craighead JE: Renal homotrans-
The cytology of the urine sediment.
plantation:
Am J Clin Pathol 47:802-806, 1967.
Downloaded From: http://jama.jamanetwork.com/ by a University of Chicago Libraries User on 08/27/2013
are given in Fig 25 to 30. Figure 25
is a reproduction of abnormal cells
found in a routine urine specimen of
a patient admitted for eye surgery.
The recommended cystoscopic exam¬
ination showed a transitional cell car¬
cinoma of the bladder. Following
cystoscopy an increased number of
malignant cells appeared in the sedi¬
ment (Fig 26 and 27).
While the staining procedure is
simple enough to suggest the use of
References
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