Comparison of human telomerase reverse transcriptase messenger RNA and telomerase activity as urine markers for diagnosis of bladder carcinoma

BACKGROUND

Human telomerase reverse transcriptase (hTERT) has been identified as the catalytic subunit of telomerase ribonucleoprotein complex known to be required for cellular immortality and oncogenesis. Although human telomerase activity (hTA) is considered as a general marker for malignancy based on its presence in most malignant tumors including bladder cancer, its detection in urine is affected by many factors. The objective of this study was to compare the clinical utility of detecting urine hTERT messenger RNA (mRNA) by multiplex hTERT/GAPDH RT-PCR and urine hTA by telomerase repeat amplification protocol (TRAP) in the diagnosis of bladder cancer.

METHODS AND RESULTS

Cystoscopy urine samples or bladder washes prospectively collected from 35 patients with confirmed (35) or clinically suspected (5) transitional cell carcinoma (TCC) of the bladder were examined by TRAP, hTERT/GAPDH RT-PCR, and urine cytology. The control group comprised 21 healthy volunteers and 3 patients without TCC. The hTERT/GAPDH RT-PCR test showed significantly higher diagnostic sensitivity than TRAP assay (94.3% vs 48.6%, P <.001) and urine cytology (95.2% vs 61.9%, P =.008) for confirmed TCCs. In particular, for superficial TCCs low grade (I-II), the hTERT/GAPDH RT-PCR test outperformed TRAP (90% vs 25%, P <.001) and urine cytology (91.7% vs 58.3%, P =.46). The overall specificity of the hTERT/GAPDH RT-PCR, TRAP and urine cytology was 92% (22/24), 100% (24/24), and 100% (3/3), respectively. A positive hTERT mRNA expression was also detected in urologic specimens from 3 patients with previous history of TCC, 3 to 6 months before cystoscopic evidence of cancer.

CONCLUSION

In this pilot study, the hTERT mRNA expression in urine sediments is a more sensitive marker for diagnosis of TCC of the bladder than hTA and cytology. However, there is a higher false-positive rate.

Treatment of caliceal diverticular stones: transdiverticular percutaneous nephrolithotomy with creation of a neoinfundibulum

PURPOSE

To evaluate transdiverticular percutaneous nephrolithotomy (TDPN) with creation of a neoinfundibulum in the treatment of caliceal diverticular stones.

PATIENTS AND METHODS

Between 1990 and 1998, 18 patients with symptomatic calculi in caliceal diverticula underwent TDPN. Transdiverticular puncture into the renal collecting system with creation of a neoinfundibulum was used, eliminating the need for prolonged probing with a wire for the neck of the diverticulum. Eight diverticula were upper polar, six were interpolar, and four were in the lower pole. Stones were endoscopically treated with use of Lithoclast (Electromedical Systems, Lausanne, Switzerland), graspers, ultrasound, or a combination of these methods.

RESULTS

Sixteen kidneys (89%) were rendered stone-free at discharge. Two kidneys (11%) were left with stone fragments of 5 mm or smaller. Hospital stay ranged from 3 to 15 days (average, 7 days). Procedure time ranged from 45 to 169 minutes (average, 87 minutes). One patient developed a left renal-pleural fistula, which closed 1 week after chest tube drainage. No other complications were encountered for an overall complication rate of 6%.

CONCLUSION

TDPN is a safe and effective method for treating caliceal diverticular stones, with a complication rate comparable to other methods.

Microwave thermotherapy for benign prostatic hyperplasia with the Dornier Urowave: results of a randomized, double-blind, multicenter, sham-controlled trial

OBJECTIVES

To study the efficacy and safety of a new transurethral microwave thermotherapy device (the Urowave) in the treatment of men with clinical benign prostatic hyperplasia (BPH) in a randomized, double-blind, sham-controlled trial.

METHODS

A total of 220 patients (mean age 66.2 years) with clinical BPH, an American Urological Association symptom index (AUA SI) of 13 points or more, and a peak flow rate of 12 mL/s or less were enrolled and randomized 2:1 for active versus sham treatment. All treatments were conducted as an outpatient procedure under local anesthesia, with oral sedation and analgesia only. Patients were followed up at 1 week and 1, 3, and 6 months after treatment.

RESULTS

The treatments were well tolerated, and no patient received general or spinal anesthesia. The AUA SI dropped from 23.6 to 12.7 points at 6 months (P < 0.05) in the active group and from 23.9 to 18.0 points in the sham-treated group (P < 0.05, between-group difference). Statistically significant improvements were also noted for peak flow rate (7.7 to 10.7 mL/s at 6 months for active treatment, 8.1 to 9.8 mL/s for sham treatment, P < 0.05, between-group difference) and for average flow rate. A decrease in AUA SI of more than 30% was achieved in 72% versus 38% of patients (active versus sham treatment, respectively) and more than 50% in 50% versus 19% of patients. In general, active Urowave-treated patients perceived "a lot" of improvement, whereas sham-treated patients perceived "a little" to "some" improvement. More of the actively treated patients had dysuria and urgency after treatment, and ejaculatory dysfunction (e.g., hematospermia) was more common in actively treated patients as well. Secondary urinary retention after removal of the catheter occurred in 8 patients (5.4%).

CONCLUSIONS

The Dornier Urowave transurethral microwave thermotherapy device for treatment of clinical BPH is effective in decreasing symptoms and bother and improving quality of life and flow rate and is superior to sham treatment. Patients perceive a great deal of improvement, independent of their baseline symptom severity. Adverse events are in general transient and mild in nature. Extended follow-up is necessary to document long-term durability of improvements.

Eutectic mixture of local anaesthetics is not effective for extracorporeal shock wave lithotripsy

PURPOSE

Eutectic mixture of local anaesthetics (EMLA) produces cutaneous analgesia. This randomized, double blind, placebo controlled study evaluated the efficacy of EMLA cream during extracorporeal shock wave lithotripsy (ESWL) using the Dornier MFL 5000 lithotripter.

METHODS

Patients scheduled to undergo lithotripsy of renal or pelviureteric junction stones were randomized to receive either 30 g EMLA cream (E) or placebo (P) over the kidney area 60-90 min before the procedure. During lithotripsy all patients received alfentanil via a PCA machine (dose--10 mu.kg-1, lockout time--three minutes, no basal infusion). Additional bolus doses of 5 micrograms.kg-1 alfentanil were administered by the anaesthetist if analgesia was inadequate. Visual analogue scores (VAS) for pain were documented prior to application of the cream. On arrival in the post anaesthesia care unit VAS pain scores were documented for maximum pain and average pain felt during the procedure as well as for satisfaction of the analgesic technique used. Total time spent in the PACU and the Aldrete scores on arrival were compared.

RESULTS

Eighty-three patients completed the study. Demographic data were similar between the two groups. Also, VAS for maximal pain, average pain and satisfaction and the total number of shock waves were similar although the EMLA group received more shock waves at the lower energy level (kV) (P < 0.0001). Total dose of alfentanil, dose as boluses, rate of alfentanil use, total number of PCA attempts and missed attempts were similar. The incidence of adverse events such as bradypnoea, airway obstruction, transient hypoxaemia, pruritus and nausea were small and similar. There was a slightly higher incidence of inadequate analgesia documented by the anaesthetist in the EMLA group. There was no difference between the groups with regards to duration of stay in the PACU, incidence of nausea or Aldrete scores on admission to PACU.

CONCLUSIONS

During lithotripsy EMLA cream does not modify the pain perceived nor does it have any opioid sparing effect. It does not facilitate early discharge from the PACU.

Prognostic value of angiogenesis and vascular invasion in muscle-invasive bladder cancer

Angiogenesis is important in the pathogenesis of tumors and correlates with clinical outcome in certain malignancies. Recent advances in staining techniques have raised doubts about the prognostic value of vascular invasion in muscle-invasive bladder cancer, for which relatively few predictors for survival exist. Twenty-one radical cystectomy specimens from patients with stage pT2-3NOMO transitional cell tumors were examined by staining with Hematoxylin and Eosin (H&E). Factor VIII-related antigen (FVIII RAG) which is specific for vascular endothelium, and MOVAT which highlights large vessels. Angiogenesis, estimated by microvessel density, and presence of vascular invasion were then correlated with survival in the follow-up period which ranged from 3 to 141 months. Six of 21 patients survived disease-free with follow-up ranging from 47 to 141 months. Twelve patients had lower microvessel density than 178/mm2 and five of these survived, whereas only one of nine patients having higher microvessel density survived. Twelve of 21 patients had vascular invasion and three survived whereas three of nine patients without vascular invasion survived. There was no correlation found between vascular invasion and survival in this study. Analysis by Kaplan-Meir survival curves demonstrated trends which were not statistically significant between high and low angiogenesis groups. The preliminary data suggest that further assessment of the prognostic role of angiogenesis and vascular invasion in muscle-invasive bladder cancer is indicated.

Management of urinary calculi during pregnancy

Renal calculous disease is an infrequent but not insignificant occurrence during pregnancy. In 50 to 80% of the cases conservative management is appropriate and the stone will pass spontaneously. Should intervention be required, recent advances in stone management and techniques for urinary tract drainage may be successfully applied to the obstetric population. Concerns regarding surgical and anesthetic risks, and the potential hazards of radiation exposure during pregnancy favor a minimally invasive approach with definitive treatment late in pregnancy or post partum. We review our experience during a 5-year period in managing 29 patients with urinary calculous disease during pregnancy. Based on our experience and review of the literature an algorithm for treatment of urolithiasis during pregnancy is proposed.