Netrin-1: A new promising diagnostic marker for muscle invasion in bladder cancer

BACKGROUND

Bladder cancer is the most common urological malignancy with a high tendency for progression and recurrence. So far, no reliable diagnostic marker is present with 100% sensitivity and specificity. Netrins are related to laminin proteins, and were first discovered to be involved in neural development. After that, they were found in other organs of the body and several studies stated that they have implicated in cancer progression.

PURPOSE

This study aimed at investigating the netrin-1 gene expression in bladder cancer tissues, in addition to the possibility of using urinary netrin-1 as a marker for muscle invasion diagnosis in bladder cancer cases.

METHODS

Netrin-1 gene expression in bladder cancer tissue was detected in this study by real-time polymerase chain reaction. Moreover, netrin-1 protein was measured in tissue and urinary deposit samples by western blotting.

RESULTS

The results of this study revealed that netrin-1 is expressed in bladder cancer and control tissues, with a strong positive correlation between netrin-1 in tissues and urinary netrin-1 (rs = 0.762, P < 0.0005). Receiver operating characteristic curve analysis confirmed the muscle-invasion diagnostic value of urinary netrin-1 with bladder cancer cases, providing an area under the curve equals to 0.758 (95% confidence interval, 0.630-0.886, P < 0.0005), with 96% sensitivity and 67% specificity. Bladder cancer patients had been included to examine risk factors for local recurrence, distant metastasis, and death. Cox regression models showed that netrin-1 gene expression, tumor size, and age are positive predictor markers for local tumor recurrence. Age is a predictor for distant metastasis, and tumor stage is a predictor for death.

CONCLUSION

Urinary netrin-1 can be used as a promising biomarker for diagnosis of muscle invasion, which may help in the follow up of non-invasive tumors. In addition, tissue netrin-1 expression may serve as a predictor of local tumor recurrence.

A correlation study between macro- and micro-analysis of pediatric urinary calculi

OBJECTIVE

The aim was investigate the relationship between macro- and micro-compositions of pediatric urinary stones by using two combined analytical techniques: Fourier transform infrared spectroscopy (FT-IR) and inductively coupled plasma-optical emission spectrometry (ICP-OES).

MATERIALS AND METHODS

A total of 74 consecutive urinary calculi were collected from children. Each stone was divided into two equal portions. One part was analyzed by FT-IR to determine mineralogical composition. The second part underwent analysis by ICP-OES to determine the heavy metals and trace elements contents. The association between mineralogical components and elemental contents was evaluated.

RESULTS

The percentages of mineralogical components of the stones were 78.3% calcium oxalate monohydrate, 63.5% calcium oxalate dihydrate, 24.3% ammonium urate, 13.5% uric acid, 10.9% dahllite, 12.1% brushite, 8.1% ammonium calcium phosphate, 8.1% struvite, 4.5% cysteine, and 2.7% were xanthine. There were seven elements with significant different high concentrations; magnesium, sulfur, strontium, lead, chromium, calcium, and phosphorous. High calcium-containing stones had significant higher contents of magnesium, lead, strontium, and zinc (p<0.05) than low calcium-containing stones. Phosphate stones had significant contents of magnesium, strontium, zinc and chromium when compared to other stones (p<0.05).

CONCLUSIONS

Pediatric urinary stones have variable biochemical structures. The stones contained many significant heavy metals and trace elements in different concentrations, and phosphate stones enclosed most of the heavy and trace elements.

Quantitative Evaluation of Heavy Metals and Trace Elements in the Urinary Bladder: Comparison Between Cancerous, Adjacent Non-cancerous and Normal Cadaveric Tissue

The role of heavy metals and trace elements (HMTE) in the development of some cancers has been previously reported. Bladder carcinoma is a frequent malignancy of the urinary tract. The most common risk factors for bladder cancer are exposure to industrial carcinogens, cigarette smoking, gender, and possibly diet. The aim of this study was to evaluate HTME concentrations in the cancerous and adjacent non-cancerous tissues and compare them with those of normal cadaveric bladder. This prospective study included 102 paired samples of full-thickness cancer and adjacent non-cancerous bladder tissues of radical cystectomy (RC) specimens that were histologically proven as invasive bladder cancer (MIBC). We used 17 matched controls of non-malignant bladder tissue samples from cadavers. All samples were processed and evaluated for the concentration of 22 HMTE by using Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). Outcome analysis was made by the Mann-Whitney U, chi-square, Kruskal-Wallis, and Wilcoxon signed ranks tests. When compared with cadaveric control or cancerous, the adjacent non-cancerous tissue had higher levels of six elements (arsenic, lead, selenium, strontium, zinc, and aluminum), and when compared with the control alone, it had a higher concentration of calcium, cadmium, chromium, potassium, magnesium, and nickel. The cancerous tissue had a higher concentration of cadmium, lead, chromium, calcium, potassium, phosphorous, magnesium, nickel, selenium, strontium, and zinc than cadaveric control. Boron level was higher in cadaveric control than cancerous and adjacent non-cancerous tissue. Cadmium level was higher in cancerous tissue with node-positive than node-negative cases. The high concentrations of cadmium, lead, chromium, nickel, and zinc, in the cancerous together with arsenic in the adjacent non-cancerous tissues of RC specimens suggest a pathogenic role of these elements in BC. However, further work-up is needed to support this conclusion by the application of these HMTE on BC cell lines.

Diagnostic performance and predictive capacity of early urine cytology after transurethral resection of nonmuscle invasive bladder cancer: A prospective study

OBJECTIVES

To prospectively evaluate the value of early urine cytology (EUC) after the primary transurethral resection of bladder tumor (TURBT) of nonmuscle invasive bladder cancer (NMIBC) for the prediction of positive biopsy findings on repeat TURBT.

METHODS

After approval of institutional review board, patients who underwent TURBT for NMIBC between February 2014 and July 2018 were included in the study. Patients with concomitant Carcinoma in Situ (CIS), upper tract urothelial tumors, biopsy proven muscle invasion, or low-risk NMIBC (single, primary, Ta, and G1 tumor) were excluded. Forty-eight hours after primary TURBT, EUC was retrieved and patients were scheduled for repeat TURBT 2 to 6 weeks later according to the predetermined protocol. The primary outcome was to determine the role of positive EUC to predict positive biopsy findings on repeat TURBT.

RESULTS

During the study period, 198 patients fulfilled the study inclusion criteria of which 49 (25%) had recurrent NMIBC. Primary TURBT pathology results showed T1 stage in 195 (98.5%) patients and high-grade malignancy in 158 (79.8%). Intermediate- and high-risk NMIBC were defined in 49 (25%) and 149 (75%) patients, respectively. EUC was positive in 114 patients; of whom 78 (68.4%) showed positive biopsy findings on repeat TURBT (P = 0.001). The sensitivity, specificity, negative, and positive predictive values of EUC for biopsy findings at repeat TURBT were 90% (95%CI: 87-94), 75% (95%CI: 71-79), 89% (95%CI: 85-94), and 68% (95%CI: 62-74), respectively. On mean (±SD) follow-up of 42(±13) months, tumor recurrence was encountered in 101 (53%) patients. On multivariate Cox regression analysis, EUC was significantly associated with tumor recurrence (HR = 4.6, 95%CI: 2.37-8.9, P < 0.001).

CONCLUSIONS

Positive EUC after primary TURBT for NMIBC is significantly associated with positive repeat TURBT for malignancy. EUC is an independent predictor of tumor recurrence. EUC might be implemented after primary TURBT to help refining indications of repeat biopsy and planning of further intervention.

A magnetic device for increasing the urethral resistance to flow: an experimental study in female dogs

OBJECTIVE

To test a new magnetic device for increasing the urethral resistance to flow in a dog model, and thus provide a potential mechanical device for the treatment of incontinence in women.

MATERIALS AND METHODS

The study comprised 12 female mongrel dogs; three dogs were used to study the effect on urethral resistance of inserting a vaginal magnet (control experiment) and five were assessed in a urodynamic study. With the animals under general anaesthesia, the bladder and the urethra were exposed by a low midline incision. One magnet, embedded in a silicon layer, was placed on the anterior side of the urethra 3 cm distal to the bladder neck and fixed with a few sutures. To increase the urethral resistance as required, a second magnet was inserted into the vagina and the device activated. Urethral pressure profiles and leak-point pressures were recorded in the anaesthetized animals under resting conditions and after the urethra was compressed between the magnets. Recordings were also made after pharmacological blockade of the urethral musculature. In four additional dogs, chronic experiments were conducted to evaluate the effect of continuous compression of the urethra and the vaginal wall for 14 days.

RESULTS

Urethral compression between the magnets resulted in a doubling of the maximal pressure in the proximal urethra and in a threefold increase of the leak-point pressure. After pharmacological denervation of the urethra the differences between the control pressures and those after activating the device were even greater, although not significantly so. After 2 weeks of continuous compression of the vaginal wall and the urethra between the magnets there was no detectable tissue damage.

CONCLUSION

These results suggest that the magnetic device can efficiently increase urethral pressure and that prolonged compression caused no apparent damage to the urethra or vagina. It may therefore be a useful potential method of providing urinary continence in women.

Characteristics of long-term live-donor renal allograft survivors

BACKGROUND/AIMS

Despite the high rate of rejection, allograft failure and patient mortality in the early years of renal allotransplantation, some patients have done-remarkably well. We report here on 62 renal transplant recipients out of 144 patients (43%) who had functioning grafts for more than 15 years (range 15-24 years).

MATERIALS

Demographic and follow-up data for patients fulfilling the criteria were reviewed. These patients include 43 males and 19 females, with a mean age at transplantation of 27.5 +/- 6.6 years (range 9-43 years), and mean donor age of 30 +/- 8.6 years. The donor source was 8 parents, 49 siblings and 5 unrelated. The main causes of end-stage renal disease were chronic pyelonephritis and chronic glomerulonephritis. Twenty-nine patients were treated with cyclosporine (CsA) while 33 patients were primarily immunosuppressed by steroids and azathioprine.

RESULTS

Acute rejection episodes occurred in 40 patients (64.3%), out of them 19 patients experienced two or more acute rejection episodes. Univariate analysis showed that recipient and donor age, HLA-DR matching, pre- and post-transplant hypertension, ATN, delayed diuresis and chronic allograft nephropathy are significant risk factors; while recipient age, delayed diuresis and post-transplant hypertension were still significant by multivariate analysis.

CONCLUSIONS

We concluded that renal transplantation, even in its earliest years and despite the numerous complications, has provided 15 or more years of near-normal life to patients with end-stage renal disease. Certain characteristics of long-term renal allograft survivors include young donor/recipient pairs, good DR matching with less pre- and post-transplantation prevalence of hypertension.

Validation of the Arabic version of the Functional Assessment of Cancer Therapy-Bladder questionnaire in Egyptian patients with bladder cancer

Objectives

To validate the Arabic version of the Functional Assessment of Cancer Therapy-Bladder (FACT-Bl) questionnaire in Egyptian patients who underwent radical cystectomy (RC) and orthotopic neobladder (ONB) construction.

Patients, subjects and methods

The English version of the FACT-Bl was translated into the Arabic language using multi-step process by two urologist and two independent translators. The Arabic version was validated by inviting 90 patients who underwent RC and ONB and 72 normal individuals to complete the questionnaire. The reliability of the questionnaire was tested for internal consistency using the Cronbach’s α test. Inter-domain association was tested by Spearman’s correlation coefficient. The discrimination validity was measured by comparing the scores in RC patients and in normal individuals using the Mann–Whitney U-test and independent sample t-test.

Results

Internal consistency was high for all domains. There was high correlation between all domains. This high internal consistency and good correlation was maintained when assessment included patients with <7.5 and those with ≥7.5 years follow-up. Discrimination validation was confirmed by the statistically significant lower scores of all domains in the studied patients in comparison to the controls.

Conclusion

The Arabic version of the FACT-Bl is a reliable and validated instrument that can be used to evaluate health-related quality of life in patients after RC and ONB.

Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney

OBJECTIVE

To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney.

PATIENTS AND METHODS

Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome.

RESULTS

Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted.

CONCLUSION

Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m2 is considered relative contraindication.

Bladder perforation as a complication of transurethral resection of bladder tumors: the predictors, management, and its impact in a series of 1570 at a tertiary urology institute

OBJECTIVES

To report the incidence, predictors, the impact of bladder perforation (BP), and our protocol of management in patients who underwent trans-urethral resection of bladder tumor (TURBT).

METHODS

This is a retrospective study, between 2006 and 2020, on patients who underwent TURBT for non-muscle-invasive bladder cancer (NMIBC). Bladder perforation was defined as any full thickness resection of the bladder wall. Bladder perforations were managed based on their severity and type. Small BP with no or mild symptoms were managed with prolongation of urethral catheters. Those with significant extraperitoneal extravasations were managed by insertion of a tube drain (TD). Abdominal exploration was done for extensive BP and all intraperitoneal extravasations.

RESULTS

Our study included 1,570 patients, the mean age was 58 ± 11 years and 86% were males. Bladder perforation was recorded in 10% (n = 158) of the patients. The perforation was extraperitoneal in 95%, and in 86%, the perforation was associated with no symptoms, mild symptoms, or mild fluid extravasation that required only prolongation of the urethral catheter. On the other hand, active intervention was required for the 21 remaining patients (14%) with TD being the most frequent management. History of previous TURBT (p = 0.001) and obturator jerk (p = 0.0001) were the only predictors for BP.

CONCLUSIONS

The overall incidence of bladder perforation is 10%; however, 86% required only prolongation of urethral catheter. Bladder perforation did not affect the probability for tumor recurrence, tumor progression nor radical cystectomy.

Outcome of Live-Donor Renal Transplants With Incidentally Diagnosed Renal Angiomyolipoma in the Donor

INTRODUCTION

Accepting donors with renal lesion amenable for pre-transplant management with no suspected long-term harm seems to expand the live-donor pool. We aimed to assess the long-term outcome of live-donor renal transplantation with incidentally discovered renal angiomyolipoma (AML) during routine evaluation of donors.

PATIENTS AND METHODS

A retrospective evaluation of incidentally discovered AML, during live-related-donor evaluation, was performed. The tumor criteria were retrieved. In cases with exophytic tumor, a back-table, partial nephrectomy was done with frozen section to exclude malignancy. Endophytic lesions were kept in situ and transplanted. Both donor and recipient were followed up by periodic imaging.

RESULTS

Among 2925 cases, 6 AML with a median volume of 0.96 (range, 0.5-2) cm² were identified. The median recipients' age was 21 (range, 10-38) years and the median donors' age was 48 (range, 45-50). Two AML were exophytic and back-table partial nephrectomy was performed, while 4 were endophytic and kept in situ, and the kidney was transplanted. After a median follow-up of 82 (range, 25-150) months, 4 patients were alive with functioning grafts and 2 resumed hemodialysis 5 and 7 years after transplantation. There was no evidence of increase in the AML size or newly developed AML in the grafts. All donors were alive with normal renal function (mean ± standard deviation, serum creatinine was 0.9 ± 0.2 mg/dL) and none developed new AML in the remaining kidney.

CONCLUSION

Incidentally discovered AML during live-donor evaluation is not a contraindication of donation after proper counseling of the couples and regular, periodic follow-up.

Weekly intravesical bacillus Calmette-Guerin (BCG) alternating with epirubicin in Ta and T1 urothelial bladder cancer: An approach to decrease BCG toxicity

CONTEXT

Bacillus Calmette-Guerin (BCG) therapy is the standard treatment for nonmuscle-invasive bladder cancer (NMIBC). However, its toxicity is a major concern.

AIM

If we reduce the number of BCG doses by half and replace the second half with epirubicin, we may have a lower toxicity while maintaining the same efficacy of BCG. To test this hypothesis, we conducted this study as an update of our previous report.

SETTING AND DESIGN

The study included 607 patients with Ta and T1 NMIBC between January 1994 and December 2008.

MATERIALS AND METHODS

After transurethral resection of bladder tumor (TURBT), the patients received weekly doses of 120 mg BCG alternating with 50 mg epirubicin for six weeks (three weekly doses of each). Maintenance was given. Recurrence, progression rates, and toxicity were assessed. End points were progression, recurrence, and cancer-specific survival.

RESULTS

A total of 532 patients were eligible for evaluation (mean age: 58 years; median follow-up: 45 months). Of these, 291 (55%) were free, 157 (29.5%) showed recurrence, and 84 (15.8%) showed muscle-invasive progression. Toxicity developed in 221 patients. These were mild in the majority (167), whereas 10 developed hematuria, 30 severe cystitis, and five systemic complications. The rate of permanent therapy discontinuation was 3.8%.

STATISTICAL ANALYSIS USED

SPSS package version 16 and Kaplan-Meier curves were used to evaluate survival.

CONCLUSIONS

Reducing the frequency of BCG instillations by half and replacing the second half with epirubicin results in a similar efficacy and a lower toxicity compared with historical cases receiving BCG alone. However, further trials are required to support these results.

Micro-elemental analysis and characterization of major heavy metals and trace elements in the urinary stones collected from patients living in diverse geographical regions

In the process of urinary stone formation, several heavy metals and trace elements (HMTE) have been identified among the major constituents of the calculi. The micro-elements within the stones cannot be identified by ordinary laboratory analytical techniques, the latter can only detect the major crystalline component. The objective of the present study was to evaluate the different types of HMTE (no. 22) and their concentrations within the urinary stones. The stone samples were obtained from patients living in different geographical locations (10 countries: 5 Western and 5 non-Western). The number of retrieved stones after open or endoscopic procedures was 1177. The concentrations of the 22 HMTE in the stones were assessed by inductively coupled plasma optical emission spectrometry (ICP-OES). The statistical data were analyzed using Kruskal-Wallis, one-way ANOVA, and SPSS software (version 20). The biochemical stone analysis showed that calcium oxalate was present as a major component in 650 patients (55.2%), calcium phosphate in 317 (26.9%), and uric acid and cystine stones in 210 (17.8%). The analyzed stones showed the presence of HMTE in different concentrations. Significantly higher concentrations of 17 elements (Al, As, Ba, B, Ca, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, S, Se, Sr, and Zn) were noted in all stones. Seven elements (Al, As, Se, Sr, Fe, Zn, and Ni) were present in higher concentrations in calcium-based stones. In comparison, eight elements (Mg, B, Ba, Cd, Se, Pb, Sr, and Zn) in higher concentrations were associated with phosphate-based stones. Both uric acid and cystine stones had a higher concentration of sulfur. The concentrations of HMTE in calcium phosphate stones were higher than in calcium oxalate and uric acid stones. Calculi obtained from patients living in western countries contained higher levels of 13 HMTE (B, Ba, Ca, Cd, Co, Cu, Fe, K, Mg, Mo, P, Pb, and Se) than those in non-western countries. The age of calculi-forming patients from non-western countries was younger than those living in western countries. These results may indicate the role of many significant heavy metals and trace elements in the pathogenesis of urinary stone formation. The types and contents of HMTE within urinary stones differ from one country to another. The conventional stone analysis techniques cannot either identify the stone micro-elements or the concentrations of HMTE, so a specific and additional instrument such as the ICP-OES is necessary. Further research work on the urinary stone micro-elemental structure could lead to a new strategy for the prevention of stone formation and recurrence.

The short-term effects of tolterodine on nocturnal incontinence after ileal orthotopic neobladder: a randomised crossover placebo-controlled study

OBJECTIVES

To assess the effect of tolterodine in the treatment of nocturnal urinary incontinence (NUI) after ileal orthotopic neobladder (ONB).

PATIENTS AND METHODS

This is a prospective randomised placebo-controlled crossover study (clinicaltrials.gov: NCT02877901). Patients with NUI after ONB were randomly allocated into two equal groups. Group T received 4 mg extended-release tolterodine at bed-time and Group P received placebo for 4 weeks followed by 2 weeks of washout, then crossed over to the alternate therapy for 4 weeks. Patients were assessed by the number of pads used per night (PPN) and with the Arabic version of the International Consultation on Incontinence Modular Questionnaire-Short Form (ICIQ-SF) at both phases of the study. The outcomes were the rate of NUI improvement and medication adverse events.

RESULTS

Out of 172 patients, 150 and 122 patients were evaluated at both phases of the study. The mean ICIQ-SF scores and PPN were significantly decreased in Group T compared to Group P in both study phases (P < 0.001). In Group T, 15 (10%) and 11 (9%) patients became dry after the first allocation and crossover, respectively. In Group T, 60 (77.9%) patients reported improvement vs four (5.5%) in Group P (P < 0.001) after the first allocation. Similarly, 46 (73%) and seven (11.9%) patients showed improvement in groups T and P after the crossover, respectively (P < 0.001). Dry mouth occurred in 31 (20.8%) patients.

CONCLUSIONS

Tolterodine seems to be a good choice for treatment of NUI after radical cystectomy and ONB. However, further studies are needed to delineate the long-term effects and the associated urodynamic characteristics.

The use of local anesthetic gel during retrograde urethrography: does it cause a false negative result?

PURPOSE

To investigate the implication of topical urethral anesthetic gel on the evaluation of retrograde urethrography (RGU) MATERIAL AND METHODS: In this prospective study, 20 patients with a mean age of 46 years were enrolled. All these patients were subjected to RGU because of suspecting a urethral stricture. Of these 13 had a history of open or endoscopic urethral manipulation, while seven had no such history. In all patients 10 ml of Gelicain gel 2% (lidocainhydrocloride) was used as local anesthetic gel at temperature of 22 degrees C. The injection was made gradually over 10 s. The first set of RGU was done without local anesthesia and the second image was taken after 10 min of instillation of 2% gelicain gel. All images were evaluated by the same radiologist. The diameter of the urethra was measured by capture screen during fluoroscopy immediately distal to the stricture site in case of urethral strictures and at the middle of the bulbous urethra in other cases.

RESULTS

In all patients, the mean diameter of the urethra at the selected site was 8.7 +/- 2.5 mm before and 9.4 +/- 2.9 mm after instillation of local anesthetic gel (P = 0.005). The stricture was diagnosed in 13 cases while seven patients had no stricture. The clinical diagnosis of a possible stricture was the same before and after instillation of the local agent in all patients.

CONCLUSION

Instillation of the local anesthetic gel before RGU produces a slight but statistically significant increase in the diameter of the urethra at the selected sites. However, neither the radiologic reading of RGU nor the clinical diagnosis of a possible stricture was changed because of this increment.

The previously common post-kidney transplant Kaposi sarcoma has become non-existent for a decade: an Egyptian experience

BACKGROUND

De novo malignancy is a worrying complication after kidney transplantation; the type of which may vary due to factors such as the prevalence of viral infection and race. Kaposi sarcoma used to be the most common malignancy among our patients constituting more than one-third of cancers. Nevertheless, we noticed that Kaposi sarcoma has not been observed for a long period. Therefore, we conducted this study to explore such observation.

METHODS

Data of all kidney transplant recipients were retrieved and retrospectively analyzed. Their total number was 3126 patients. Their mean age was 28.71 ± 10.97 years and of them, 823 (26.3%) were females. The pattern of Kaposi sarcoma throughout the last decade as well as the preceding three decades was studied. The possible relation between the disappearance of Kaposi sarcoma and three paradigm shifts in our practice, namely the use of mTOR inhibitors, steroid-free regimen and CMV prophylaxis was explored.

RESULTS

Since 2010, no new cases of Kaposi sarcoma have been observed. In addition, patients who have been transplanted after 2006 did not develop such malignancy. Patients who received CMV prophylaxis and/or were maintained on mTOR inhibitor or steroid-free regimens have not developed Kaposi sarcoma. Moreover, CMV prophylaxis had a statistically significant difference when compared to a homogenous group without CMV prophylaxis. However, Kaplan-Meier analysis of patients of the three policies and their counterpart groups showed comparable results.

CONCLUSION

Kaposi sarcoma, which was previously the most common malignancy, is no longer observed for almost a decade among our kidney transplant recipients. m-TOR inhibitors, steroid-free regimen and CMV prophylaxis policy are possible contributing factors. Nevertheless, only CMV prophylaxis policy had a statistically significant relation to the disappearance of Kaposi sarcoma.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis

OBJECTIVE

To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract.

MATERIALS AND METHODS

A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract.

RESULTS

There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3).

CONCLUSION

Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

The alternating bidirectional versus the standard approach during shock wave lithotripsy for upper lumbar ureteric stones: a randomized controlled trial

PURPOSE

To compare the outcome of shock wave lithotripsy (SWL) for upper lumbar ureteric stones using the alternating bidirectional approach versus the standard approach during the first session.

METHODS

Our study was a randomized controlled trial including patients with single radio-opaque stone < 1 cm located in the upper lumbar ureter (from the ureteropelvic junction till the level medial to the lower margin of the kidney). SWL was conducted using electromagnetic Dornier Gemini Lithotripter. In group 1, patients were treated with the alternating under and over-table approach during the first session only and if other sessions were needed, the standard under-table approach was used. In group 2, patients were treated with the standard under-table approach during all sessions. Stone disintegration after the first session was assessed by kidney-ureter-bladder X-ray, renal ultrasonography and noncontrast computed tomography. Moreover, the incidence and severity of postoperative complications were evaluated.

RESULTS

Forty-eight patients in each group completed the study. Patient demographics and stone characteristics were comparable in both groups. Complete disintegration was achieved in 41.7% of patients in group 1 versus 18.8% in group 2 (P = 0.021). Stone-free rate (SFR) was 58.3% and 20.8% in group 1 and 2 respectively (P = 0.001). The mean session time was 56.42 min in group 1 versus 46.35 min in group 2 (P < 0.001). There was no significant difference in postoperative complications.

CONCLUSION

Stone disintegration and SFR after the first SWL session are higher when using the alternating bidirectional approach for upper lumbar ureteric stones at the expense of longer procedural duration.

TRIAL REGISTRATION

ClinicalTrials identifier (ID: NCT03243682), clinicaltrials.gov.

Functional MRI evaluation of blood oxygen dependent (BOLD) in renal allograft dysfunction: a prospective study

BACKGROUND

Blood oxygen level dependent-magnetic resonance imaging (BOLD-MRI) is a non-invasive functional imaging technique that can be used to assess renal allograft dysfunction.

PURPOSE

To evaluate the diagnostic performance of BOLD-MRI using a 3-T scanner in discriminating causes of renal allograft dysfunction in the post-transplant period.

MATERIAL AND METHODS

This prospective study was conducted on 112 live donor-renal allograft recipients: 53 with normal graft function, as controls; 18 with biopsy-proven acute rejection (AR); and 41 with biopsy-proven acute tubular necrosis (ATN). Multiple fast-field echo sequences were performed to obtain T2*-weighted images. Cortical R2* (CR2*) level, medullary R2* (MR2*) level, and medullary over cortical R2* ratio (MCR) were measured in all participants.

RESULTS

The mean MR2* level was significantly lower in the AR group (20.8 ± 2.8/s) compared to the normal group (24 ± 2.4/s, P <0.001) and ATN group (27.4 ± 1.7/s, P <0.001). The MCR was higher in ATN group (1.47 ± 0.18) compared to the AR group (1.18 ± 0.17) and normal functioning group (1.34 ± 0.2). Both MR2* (area under the curve [AUC] = 0.837, P <0.001) and MCR (AUC = 0.727, P = 0.003) can accurately discriminate ATN from AR, however CR2* (AUC = 0.590, P = 0.237) showed no significant difference between both groups.

CONCLUSION

In early post-transplant renal dysfunction, BOLD-MRI is a valuable non-invasive diagnostic technique that can differentiate between AR and ATN by measuring changes in intra-renal tissue oxygenation.

Stenting in extracorporeal shockwave lithotripsy; may enhance the passage of the fragments!

OBJECTIVES

To prospectively evaluate the role of double J (DJ) stent in enhancing the passage of fragments in patients undergoing extracorporeal shockwave lithotripsy (SWL) for renal stones with diameters less than 2.5 cm.

METHODS

Between November 2005 and January 2007, 38 patients with an average age of 47.05 years (range 16-73) were included and underwent SWL for renal stones. The inclusion criteria were radio-opaque renal stone not located in the lower pole, complete disintegeration of the stone, normal renal function, no metabolic abnormalities, no major renal abnormalities and no symptomatic urinary tract infection. The patients were randomized to either a stented (11 patients) or stentless (27 patients) group. The average stone diameters in stentless and stented groups were 1.54 cm and 1.77 cm, respectively (p > 0.05). Double J stent was removed when there was no further passage of the fragments for 6 weeks after stone disintegration. All patients were given non-steroidal anti-inflammatory drugs for one week after ESWL treatment. Stone passage and the data of DJ were determined with plain X-ray of the urinary tract (UTP). The severity of lower urinary tract symptoms, loin pain and the need for intravenous or intramuscular analgesics were recorded.

RESULTS

The overall stone-free rate at 3 months was 92.1%. Two patients in the stented and one patient in the stentless group were partially free of stones. Steinstrasse were observed in two patients (5.3%); one patient in the stentless group and another one after the removal of DJ stent. Only one patient in the stented group had severe lower urinary tract symptoms which responded neither to oral nor to other forms of analgesics, and therefore DJ stent was removed. The remaining patients were in no need for analgesics other than the oral therapy.

CONCLUSION

Placement of DJ stent for the purpose of improving free stone rate or enhancing the passage of the fragments during SWL is unnecessary in renal stone with diameters less than 2.5 cm. However, further prospective trials should be designed to define the criteria for stented SWL.

Bladder cancer associated with elevated heavy metals: Investigation of probable carcinogenic pathways through mitochondrial dysfunction, oxidative stress and mitogen-activated protein kinase

OBJECTIVE

Carcinogenic mechanisms of heavy metals/ trace elements (HMTE) in bladder cancer (BC) are exactly unknown. Mitochondrial dysfunction (MD), oxidative stress (OS), and mitogen-activated protein kinases (MAPK) are probable carcinogenic mechanisms. The purpose is to investigate probable carcinogenic pathways of HMTE in BC using six MD genes, seven OS markers, and p38-MAPK.

METHODS

Study included 125 BC/radical cystectomy (RC) patients between October 2020 and October 2022, and 72 controls. Exclusion criteria included previous neoplasm, chemo- or radiotherapy. Two samples (cancer/noncancer) were taken from RC specimens. Tissues/plasma/urine cadmium (Cd), lead (Pb), cobalt (Co), nickel (Ni), strontium (Sr), aluminium (Al), zinc (Zn), boron (B) were measured by ICP-OES. Tissue MD genes (mt-CO3, mt-CYB, mt-ATP 6, mt-ATP8, mt-CO1, mt-ND1), and serum OS markers (8-OHdG, MDA, 3-NT, AGEs, AOPP, ROS, SOD2), p38-MAPK were assessed by RT-PCR, and ELISA, respectively.

RESULTS

BC and adjacent tissue showed higher (Al, Co, Pb, Ni, Zn, Cd,Sr), lower B concentrations, compared to controls. High tissue concentrations (Cd, Co, Pb, Ni, Sr) were associated with higher MD genes, OS, MAPK and lower SOD2 levels. The same differences were greater in 41 patients with concomitant elevation of two or more HMTE. Noninclusion of BC-related oncogenes (e.g. RAS) is a limitation.

CONCLUSIONS

Evidence suggests that high BC tissue (Cd, Co, Pb, Ni, Si) concentrations are associated with over-expressed MD genes, OS, p38-MAPK and low SOD2. These findings provide important understanding keys of probable carcinogenic pathways in BC associated with HMTE. So, efforts should be performed to minimize and counteract exposure to toxic HMTE.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women

OBJECTIVES

To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence.

MATERIAL AND METHODS

Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis.

RESULTS

The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%).

CONCLUSION

Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.