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Poletajew S, Brzózka MM, Krajewski W, Kamecki H, Nyk Ł, Kryst P. Glycosaminoglycan Replacement Therapy with Intravesical Instillations of Combined Hyaluronic Acid and Chondroitin Sulfate in Patients with Recurrent Cystitis, Post-radiation Cystitis and Bladder Pain Syndrome: A Narrative Review. Pain Ther 2024; 13:1-22. [PMID: 37917298 PMCID: PMC10796878 DOI: 10.1007/s40122-023-00559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023] Open
Abstract
Defects in the glycosaminoglycan layer (GAG) of the bladder mucosa have been identified as a significant contributor to the pathogenesis and clinical progression of chronic inflammatory diseases of the bladder, such as post-radiation cystitis, bladder pain syndrome and recurrent urinary tract infections. This narrative review aims to explore the contemporary evidence on the role of GAG reconstitution with intravesical installations of hyaluronic acid and chondroitin sulfate in the management of those patients, with a goal to provide valuable insights for clinical practice. The reviewed studies consistently demonstrate that GAG reconstitution can result in varying degrees of clinical improvement in patients with post-radiation cystitis, bladder pain syndrome and recurrent urinary tract infections, and is associated with a very favorable safety profile. While the available evidence is growing, its level is still limited, mainly by relatively low number of randomized controlled trials, with small sample sizes. Further research with larger, well-designed trials is needed to solidify the findings and optimize the clinical application of GAG reconstitution.
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Affiliation(s)
- Sławomir Poletajew
- Second Department of Urology, Medical Centre of Postgraduate Education, Warsaw, Poland.
| | | | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Hubert Kamecki
- Second Department of Urology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Łukasz Nyk
- Second Department of Urology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Piotr Kryst
- Second Department of Urology, Medical Centre of Postgraduate Education, Warsaw, Poland
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King GK, Goodes LM, Hartshorn C, Thavaseelan J, Jonescu S, Watts A, Rawlins M, Woodland P, Synnott EL, Barrett T, Hayne D, Boan P, Dunlop SA. Intravesical hyaluronic acid with chondroitin sulphate to prevent urinary tract infection after spinal cord injury. J Spinal Cord Med 2023; 46:830-836. [PMID: 35792831 PMCID: PMC10446783 DOI: 10.1080/10790268.2022.2089816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
CONTEXT/OBJECTIVE Prevention of urinary tract infection (UTI) after spinal cord injury is an important goal. Intravesical hyaluronic acid with chondroitin sulphate (HA+CS) has been effective in preventing UTI in other settings. We aimed to demonstrate safety and feasibility of a standard treatment course of 7 intravesical HA+CS instillations over 12 weeks, in patients with acute (Arm A) and chronic (Arm B) spinal cord injury (SCI). DESIGN Follow-up of adverse events, quality of life bladder management difficulty (BMD) and bladder complication (BC) T-scores at baseline (Arm B only), 12 and 24 weeks, and symptomatic urinary tract infection (UTI). RESULTS Of 33 and 14 individuals screened, 2 and 8 participants were recruited to the study for Arm A and Arm B respectively. Of the 10 participants, 8 completed all 7 instillations. HA+CS commonly caused cloudy urine with urinary sediment which was mild and short-lived. In Arm B, a mean reduction in BMD and BC T-scores was observed from baseline (57.3 and 54.4 respectively), of 6.8 and 4.3 at 12 weeks and 1.6 and 2.8 at 24 weeks, respectively. Four participants with a history of frequent UTI in the prior 12 months did not have UTI in the 24 weeks of the study. CONCLUSIONS HA+CS was well tolerated. Recruitment was more difficult in early acute SCI; participants with chronic SCI were highly motivated to reduce UTI and manage self-administration without difficulty. Larger case-control or randomized controlled trials in patients with neurogenic bladder from SCI are warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03945110.
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Affiliation(s)
- Gabrielle K. King
- School of Biological Sciences, The University of Western Australia, Crawley, WA, Australia
| | - Louise M. Goodes
- School of Biological Sciences, The University of Western Australia, Crawley, WA, Australia
| | | | - Jeffery Thavaseelan
- Perth Urology Clinic, Murdoch, WA, Australia
- Department of Urology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Sheryl Jonescu
- Department of Trauma, Royal Perth Hospital, Perth, WA, Australia
| | - Anne Watts
- State Rehabilitation Service, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Matthew Rawlins
- Department of Pharmacy, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Peter Woodland
- Department of Spinal Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Emma-Leigh Synnott
- State Rehabilitation Service, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Trent Barrett
- Department of Urology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Dickon Hayne
- Department of Urology, Fiona Stanley Hospital, Murdoch, WA, Australia
- UWA Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
- Department of Microbiology, Fiona Stanley Hospital, PathWest Laboratory Medicine WA, Murdoch, WA, Australia
| | - Sarah A. Dunlop
- School of Biological Sciences, The University of Western Australia, Crawley, WA, Australia
- Minderoo Foundation, Perth, WA, Australia
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Wang Y, Zhu Y, Xu X. Advances in the management of radiation-induced cystitis in patients with pelvic malignancies. Int J Radiat Biol 2023; 99:1307-1319. [PMID: 36940182 DOI: 10.1080/09553002.2023.2181996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Radiotherapy plays a vital role as a treatment for malignant pelvic tumors, in which the bladder represents a significant organ at risk involved during tumor radiotherapy. Exposing the bladder wall to high doses of ionizing radiation is unavoidable and will lead to radiation cystitis (RC) because of its central position in the pelvic cavity. Radiation cystitis will result in several complications (e.g. frequent micturition, urgent urination, and nocturia) that can significantly reduce the patient's quality of life and in very severe cases become life-threatening. METHODS Existing studies on the pathophysiology, prevention, and management of radiation-induced cystitis from January 1990 to December 2021 were reviewed. PubMed was used as the main search engine. Besides the reviewed studies, citations to those studies were also included. RESULTS AND DISCUSSIONS In this review, the symptoms of radiation cystitis and the mainstream grading scales employed in clinical situations are presented. Next, preclinical and clinical research on preventing and treating radiation cystitis are summarized, and an overview of currently available prevention and treatment strategies as guidelines for clinicians is provided. Treatment options involve symptomatic treatment, vascular interventional therapy, surgery, hyperbaric oxygen therapy (HBOT), bladder irrigation, and electrocoagulation. Prevention includes filling up the bladder to remove it from the radiation field and delivering radiation based on helical tomotherapy and CT-guided 3D intracavitary brachytherapy techniques.
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Affiliation(s)
- Yimin Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yan Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoting Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Functionalised penetrating peptide-chondroitin sulphate‑gold nanoparticles: Synthesis, characterization, and applications as an anti-Alzheimer's disease drug. Int J Biol Macromol 2023; 230:123125. [PMID: 36603725 DOI: 10.1016/j.ijbiomac.2022.123125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
The purpose of this study was to construct a transmembrane peptide-chondroitin sulphate‑gold nanoparticle (TAT-CS@Au) delivery system and investigate its activity as an anti-Alzheimer's disease (AD) drug. We successfully prepared TAT-CS@Au nanoparticles, investigated their anti-AD effects, and explored the possible mechanisms in in vitro models. TAT-CS@Au exhibited excellent cellular uptake and transport capacity, effectively inhibited the accumulation of Aβ1-40, and significantly reduced Aβ1-40-induced apoptosis in SH-SY5Y cells. Furthermore, TAT-CS@Au significantly reduced oxidative stress damage and cholinergic injury induced by Aβ1-40 by regulating intracellular concentrations of reactive oxygen species (ROS), malondialdehyde (MDA), glutathione peroxidase (GSH-Px), and acetylcholine (ACh). Western blotting results demonstrated that TAT-CS@Au inhibited aberrant tau phosphorylation (Ser199, Thr205, Ser404, and Ser396) through GSK3β inactivation. TAT-CS@Au decreased the levels of inflammatory factors, specifically TNF-α, IL-6, and IL-1β, by inhibiting NF-κB nuclear translocation by activating MAPK signalling pathways. Overall, these results indicate that TAT-CS@Au exhibits excellent transmembrane ability, inhibits Aβ1-40 accumulation, antagonises oxidative stress, reduces aberrant tau phosphorylation, and suppresses the expression of inflammatory factors. TAT-CS@Au may be a multi-target anti-AD drug with good cell permeability, providing new insights into the design and research of anti-AD therapeutics.
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Rahnama’i MS, Javan Balegh Marand A, Röschmann-Doose K, Steffens L, Arendsen HJ. The efficacy and safety of intravesical chondroitin sulphate solution in recurrent urinary tract infections. BMC Urol 2022; 22:188. [PMID: 36424583 PMCID: PMC9685912 DOI: 10.1186/s12894-022-01149-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Urinary tract infections are among the most common indications for antibiotic therapy. The emergence of resistant uropathogens indicates the need for treatment alternatives. Replenishment of the glycosaminoglycan layer of the bladder, achieved by intravesical instillation of e.g. chondroitin sulphate (CS), is described to be a cornerstone in the therapy of cystitis. To retrospectively evaluate the efficacy of a therapy with 0.2% CS in patients suffering recurrent urinary tract infections (rUTI) in comparison to a treatment with low-dose long-term antibiotics (LDLTAB) and a combination of both. METHODS A total of 151 patients with recurrent UTI who underwent intravesical therapy at Diaconesse hospital in Leiden, The Netherlands were included. 50 patients had been treated with CS, 51 patients had received LDLTAB, and 50 patients had received a combination therapy (LDLTABCS). Data recorded for baseline, after 6, and 12 months of treatment were evaluated. Descriptive statistics were calculated. Exploratory comparisons between groups and within groups were performed by using one-tailed and paired t-tests. Patients filled in a standardized quality of life questionnaire (EQ-5D). RESULTS We found a statistically significant reduction of number of infections from 7.10 ± 0.50 SEM to 0.45 ± 0.07 SEM after 12 months therapy with CS compared to 12 months therapy with LDLTAB (from 7.04 ± 0.47 SEM to 1.8 ± 0.15 SEM). The number of visits to the urologist significantly decreased in the CS group from 7.46 ± 0.80 SEM to 1.28 ± 0.11 SEM and from 4.10 ± 0.29 SEM to 1.35 ± 0.11 SEM in the LDLTABCS group. In addition, a significant increase in Quality of life (QoL) was seen in the CS-group (from 58.2 ± 0.82 SEM to 80.43 ± 0.82 SEM) and in the LDLTABCS group (from 62.4 ± 0.97 SEM to 76.73 ± 1.06 SEM). There was no improvement in QoL with LDLTAB (from 58.24 ± 1.08 SEM to 58.96 ± 1.19 SEM). Evaluation's evidence is limited due to its retrospective character. CONCLUSIONS Retrospective analysis of data from patients that underwent therapy for rUTIs confirms the safety and efficacy of CS and indicate a superiority to antibiotic treatment of rUTIs.
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Affiliation(s)
- M. S. Rahnama’i
- grid.416373.40000 0004 0472 8381St. Elizabeth- Tweesteden Hospital, Tilburg, The Netherlands ,Society of Urological Research and Education (SURE), Heerlen, The Netherlands
| | - A. Javan Balegh Marand
- Society of Urological Research and Education (SURE), Heerlen, The Netherlands ,grid.412966.e0000 0004 0480 1382Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | | | - L. Steffens
- grid.476374.5G. Pohl-Boskamp GmbH & Co. KG, Hohenlockstedt, Germany
| | - H. J. Arendsen
- Andros Clinics, Bladdercenter, The Hague, The Netherlands
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Pabjańczyk-Wlazło EK, Puszkarz AK, Bednarowicz A, Tarzyńska N, Sztajnowski S. The Influence of Surface Modification with Biopolymers on the Structure of Melt-Blown and Spun-Bonded Poly(lactic acid) Nonwovens. MATERIALS (BASEL, SWITZERLAND) 2022; 15:7097. [PMID: 36295163 PMCID: PMC9605061 DOI: 10.3390/ma15207097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
The article presents the continuation of the research on modification of fibrous carriers based on poly(lactic acid) using the electrophoretic deposition (EPD) method by the two types of biocompatible polymers-sodium hyaluronate and sodium alginate. Such modified nonwovens, differing in the structural parameters due to different manufacturing methods, could be potentially used in different biomedical applications. The results of the analysis indicate that the EPD process significantly changes the structural characteristics of the carrier in terms of thickness and porosity, which not always can be beneficial in terms of the final application. The varying structure of both carriers significantly influences the mode of deposition of the layer, the efficiency of the deposition process as well as the structural characteristics of the carrier after deposition. Microtomographic and SEM studies were employed to analyze the structure of deposits, and FTIR analysis allowed for confirmation of the occurrence of the polymer layers and its chemical structure.
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Alipoor R, Ayan M, Hamblin MR, Ranjbar R, Rashki S. Hyaluronic Acid-Based Nanomaterials as a New Approach to the Treatment and Prevention of Bacterial Infections. Front Bioeng Biotechnol 2022; 10:913912. [PMID: 35757807 PMCID: PMC9213665 DOI: 10.3389/fbioe.2022.913912] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/16/2022] [Indexed: 12/21/2022] Open
Abstract
Bacterial contamination of medical devices is a great concern for public health and an increasing risk for hospital-acquired infections. The ongoing increase in antibiotic-resistant bacterial strains highlights the urgent need to find new effective alternatives to antibiotics. Hyaluronic acid (HA) is a valuable polymer in biomedical applications, partly due to its bactericidal effects on different platforms such as contact lenses, cleaning solutions, wound dressings, cosmetic formulations, etc. Because the pure form of HA is rapidly hydrolyzed, nanotechnology-based approaches have been investigated to improve its clinical utility. Moreover, a combination of HA with other bactericidal molecules could improve the antibacterial effects on drug-resistant bacterial strains, and improve the management of hard-to-heal wound infections. This review summarizes the structure, production, and properties of HA, and its various platforms as a carrier in drug delivery. Herein, we discuss recent works on numerous types of HA-based nanoparticles to overcome the limitations of traditional antibiotics in the treatment of bacterial infections. Advances in the fabrication of controlled release of antimicrobial agents from HA-based nanosystems can allow the complete eradication of pathogenic microorganisms.
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Affiliation(s)
- Reza Alipoor
- Student Research Committee, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | | | - Michael R Hamblin
- Laser Research Centre, Faculty of Health Science, University of Johannesburg, Doornfontein, South Africa
| | - Reza Ranjbar
- Molecular Biology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Somaye Rashki
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran.,Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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Jafari NV, Rohn JL. The urothelium: a multi-faceted barrier against a harsh environment. Mucosal Immunol 2022; 15:1127-1142. [PMID: 36180582 PMCID: PMC9705259 DOI: 10.1038/s41385-022-00565-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/18/2022] [Accepted: 08/28/2022] [Indexed: 02/04/2023]
Abstract
All mucosal surfaces must deal with the challenge of exposure to the outside world. The urothelium is a highly specialized layer of stratified epithelial cells lining the inner surface of the urinary bladder, a gruelling environment involving significant stretch forces, osmotic and hydrostatic pressures, toxic substances, and microbial invasion. The urinary bladder plays an important barrier role and allows the accommodation and expulsion of large volumes of urine without permitting urine components to diffuse across. The urothelium is made up of three cell types, basal, intermediate, and umbrella cells, whose specialized functions aid in the bladder's mission. In this review, we summarize the recent insights into urothelial structure, function, development, regeneration, and in particular the role of umbrella cells in barrier formation and maintenance. We briefly review diseases which involve the bladder and discuss current human urothelial in vitro models as a complement to traditional animal studies.
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Affiliation(s)
- Nazila V Jafari
- Department of Renal Medicine, Division of Medicine, University College London, Royal Free Hospital Campus, London, UK
| | - Jennifer L Rohn
- Department of Renal Medicine, Division of Medicine, University College London, Royal Free Hospital Campus, London, UK.
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Exploring the application and mechanism of sodium hyaluronate in cryopreservation of red blood cells. Mater Today Bio 2021; 12:100156. [PMID: 34825160 PMCID: PMC8603211 DOI: 10.1016/j.mtbio.2021.100156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/02/2023] Open
Abstract
The cryopreservation of red blood cells (RBCs) is essential for transfusion therapy and maintaining the inventory of RBCs units. The existing cryoprotectants (CPAs) have many defects, and the search for novel CPAs is becoming a research hotspot. Sodium hyaluronate (SH) is polymerized from sodium glucuronate and N-acetylglucosamine, which has good water binding capacity and biocompatibility. Herein, we reported for the first time that under the action of medium molecular weight sodium hyaluronate (MSH), the thawed RBCs recovery increased from 33.1 ± 5.8% to 63.2 ± 3.5%. In addition, RBCs functions and properties were maintained normally, and the residual MSH could be removed by direct washing. When MSH was used with a very low concentration (5% v/v) of glycerol (Gly), the thawed RBCs recovery could be increased to 92.3 ± 4.6%. In general, 40% v/v Gly was required to achieve similar efficiency. A mathematical model was used to compare the performance of MSH, PVA and trehalose in cryopreservation, and MSH showed the best efficiency. It was found that MSH could periodically regulate the content of intracellular water through the “reservoir effect” to reduce the damages during freezing and thawing. Moreover, MSH could inhibit ice recrystallization when combined with RBCs. The high viscosity and strong water binding capacity of MSH was also conducive to reducing the content of ice. This works points out a new direction for cryopreservation of RBCs and may promote transfusion therapy in clinic. MSH improved the RBCs recovery in cryopreservation. MSH can be removed directly after thawing. The properties and functions of RBCs were protected by MSH. High RBCs recovery is found using MSH with 5% v/v glycerol. The mathematical model is studied for the cryopreservation. The mechanism is proposed for cryopreservation using MSH.
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Dalghi MG, Montalbetti N, Carattino MD, Apodaca G. The Urothelium: Life in a Liquid Environment. Physiol Rev 2020; 100:1621-1705. [PMID: 32191559 PMCID: PMC7717127 DOI: 10.1152/physrev.00041.2019] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 02/08/2023] Open
Abstract
The urothelium, which lines the renal pelvis, ureters, urinary bladder, and proximal urethra, forms a high-resistance but adaptable barrier that surveils its mechanochemical environment and communicates changes to underlying tissues including afferent nerve fibers and the smooth muscle. The goal of this review is to summarize new insights into urothelial biology and function that have occurred in the past decade. After familiarizing the reader with key aspects of urothelial histology, we describe new insights into urothelial development and regeneration. This is followed by an extended discussion of urothelial barrier function, including information about the roles of the glycocalyx, ion and water transport, tight junctions, and the cellular and tissue shape changes and other adaptations that accompany expansion and contraction of the lower urinary tract. We also explore evidence that the urothelium can alter the water and solute composition of urine during normal physiology and in response to overdistension. We complete the review by providing an overview of our current knowledge about the urothelial environment, discussing the sensor and transducer functions of the urothelium, exploring the role of circadian rhythms in urothelial gene expression, and describing novel research tools that are likely to further advance our understanding of urothelial biology.
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Affiliation(s)
- Marianela G Dalghi
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicolas Montalbetti
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marcelo D Carattino
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gerard Apodaca
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Towner RA, Smith N, Saunders D, Lerner M, Greenwood-Van Meerveld B, Hurst RE. Assessing bladder hyper-permeability biomarkers in vivo using molecularly-targeted MRI. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2020; 10:57-65. [PMID: 32211219 PMCID: PMC7076299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/21/2020] [Indexed: 06/10/2023]
Abstract
The objective was to investigate if some of the key molecular players associated with bladder hyper-permeability in interstitial cystitis/bladder pain syndrome (IC/BPS) could be visualized with molecularly-targeted magnetic resonance imaging (mt-MRI) in vivo. IC/BPS is a chronic, painful condition of the bladder that affects primarily women. It has been demonstrated over the past several decades that permeability plays a substantial role in IC/BPS. There are several key molecular markers that have been associated with permeability, including glycolsaminoglycan (GAG), biglycan, chondroitin sulfate, decorin, E-cadherin, keratin 20, uroplakin, vascular endothelial growth factor receptor 1 (VEGF-R1), claudin-2 and zonula occludens-1 (ZO-1). We used in vivo molecularly-targeted MRI (mt-MRI) to assess specific urothelial biomarkers (decorin, VEGF-R1, and claudin-2) associated with bladder hyper-permeability in a protamine sulfate (PS)-induced rat model. The mt-MRI probes consisted of an antibody against either VEGF-R1, decorin or claudin-2 conjugated to albumin that had also Gd-DTPA (gadolinium diethylene triamine penta acetic acid) and biotin attached. mt-MRI- and histologically-detectable levels of decorin and VEGF-R1 were both found to decrease following PS-induced bladder urothelial hyper-permeability, whereas claudin-2, was found to increase in the rat PS model. Verification of the presence of the mt-MRI probes were done by targeting the biotin moiety for each respective probe with streptavidin-hose radish peroxidase (HRP). Levels of protein expression for VEGF-R1, decorin and claudin-2 were confirmed with immunohistochemistry. In vivo molecularly-targeted MRI (mt-MRI) was found to successfully detect alterations in the expression of decorin, VEGFR1 and claudin-2 in a PS-induced rat bladder permeability model. This in vivo molecularly-targeted imaging approach has the potential to provide invaluable information to enhance our understanding of bladder urothelium hyper-permeability in IC/BPS patients, and perhaps be used to assist in developing novel therapeutic strategies.
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Affiliation(s)
- Rheal A Towner
- Advanced Magnetic Resonance Center, Oklahoma Medical Research FoundationOklahoma, OK, USA
- Department of Pathology, University of Oklahoma Health Sciences CenterOklahoma, OK, USA
| | - Nataliya Smith
- Advanced Magnetic Resonance Center, Oklahoma Medical Research FoundationOklahoma, OK, USA
| | - Debra Saunders
- Advanced Magnetic Resonance Center, Oklahoma Medical Research FoundationOklahoma, OK, USA
| | - Megan Lerner
- Department of Surgery Research Laboratory, University of Oklahoma Health Sciences CenterOklahoma, OK, USA
| | | | - Robert E Hurst
- Department of Urology, University of Oklahoma Health Sciences CenterOklahoma, OK, USA
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El-Batal AI, Nasser HA, Mosallam FM. Fabrication and characterization of cobalt hyaluronic acid nanostructure via gamma irradiation for improving biomedical applications. Int J Biol Macromol 2019; 147:1328-1342. [PMID: 31770562 DOI: 10.1016/j.ijbiomac.2019.10.097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 01/28/2023]
Abstract
Aqueous dispersed cobalt hyaluronic acid nanostructure (CoHANs) was synthesized using cobalt ion (Co+2) as precursor and natural polysaccharide hyaluronic acid (HA) as stabilizing agent and gamma irradiation as reducing agent. The synthesized CoHANs are characterized by UV-Vis. spectroscopy, Dynamic light scattering (DLS), X-ray diffraction (XRD) and Fourier Transform Infrared spectroscopy (FT-IR). The morphology and surface appearance of CoHANs has been observed by SEM images. The particles size and shape of CoHANs were estimated by TEM images and was found to be 12.0 nm. XRD analysis of the CoHANs confirmed the formation of crystalline nanoparticles. The nucleation and growth mechanism of CoHANs was also discussed. The size of nanoparticles was found to be influenced by certain parameters such as the choice of stabilizer and cobalt ion concentration and the absorbed dose. The results indicated the CoHANs possesses high activity than cobalt ion and HA. The present study explored the positive role of CoHANs as an antitumor agent on different cell carcinoma in vitro. Excellent bactericidal spatially against pathogenic bacteria and fungicidal activity was shown by the CoHANs.
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Affiliation(s)
- Ahmed I El-Batal
- Drug Radiation Research Department, Biotechnology Division, National Center for Radiation Research and Technology (NCRRT), Atomic Energy Authority, Egypt
| | - Hebatallah A Nasser
- Microbilogy and Public Health Department, Faculty of Pharmacy, Heliopolis University, Egypt
| | - Farag M Mosallam
- Drug Radiation Research Department, Biotechnology Division, National Center for Radiation Research and Technology (NCRRT), Atomic Energy Authority, Egypt.
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Scarneciu I, Bungau S, Lupu AM, Scarneciu CC, Bratu OG, Martha O, Tit DM, Aleya L, Lupu S. Efficacy of instillation treatment with hyaluronic acid in relieving symptoms in patients with BPS/IC and uncomplicated recurrent urinary tract infections - Long-term results of a multicenter study. Eur J Pharm Sci 2019; 139:105067. [DOI: 10.1016/j.ejps.2019.105067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 12/27/2022]
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Sherif H, Sebay A, Kandeel W, Othman T, Fathi A, Mohey A, Eshazly A. Safety and efficacy of Intravesical hyaluronic acid/chondroitin sulfate in the treatment of refractory painful bladder syndrome. Turk J Urol 2019; 45:296-301. [PMID: 30475699 PMCID: PMC6619837 DOI: 10.5152/tud.2018.63600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/22/2018] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of intravesical instillation of hyaluronic acid/chondroitin sulfate in the treatment of refractory painful bladder syndrome. MATERIAL AND METHODS Forty patients were subjected to intravesical instillations of hyaluronic acid/chondroitin sulfate weekly for 4 weeks and at 6., 8., 12. and 16. weeks, afterwards. Then we evaluated the efficacy of this treatment modality by determining the mean changes in visual analogue scale (VAS) pain score, the pelvic pain and urgency/frequency questionnaire, the O'Leary-Sant interstitial cystitis symptoms index/problems index and 3 day-voiding diary results including daily number of voids and mean voided volume at 2 weeks, 3, and 9 months after the last dose (4th month) and urodynamic studies including cystometric capacity, 1st sensation of urination, and Q-max at 9 months after the last dose. RESULTS Thirty-seven patients (6 males 16.2%, 31 females 83.8%) completed the entire follow-up protocol of this study. Age of the patients ranged from 22 to 37 years (mean, 30.7±4.18 years) and their body mass indexes (BMIs) ranged between 29 and 37 kg/m2 (mean, 33.5±2.58 kg/m2). An initial response to treatment in all parameters at variable degrees was noticed at 2 weeks after the last instillation when compared to the baseline, and these changes were statistically significant (p<0.001). Progressive improvement in all test parameters was noticed at 3 months after treatment, and this improvement was statistically significant compared with baseline and 2 weeks after treatment, respectively (p<0.001). CONCLUSION Intravesical instillation with both hyaluronic acid/chondroitin sulfate in the treatment of refractory painful bladder syndrome is safe, effective and well tolerated by all patients with no recorded side effects.
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Affiliation(s)
| | - Ahmed Sebay
- Department of Urology, Benha University, Benha, Egypt
| | - Wael Kandeel
- Department of Urology, Benha University, Benha, Egypt
| | - Tarek Othman
- Department of Urology, Benha University, Benha, Egypt
| | | | - Ahmed Mohey
- Department of Urology, Benha University, Benha, Egypt
| | - Ali Eshazly
- Department of Urology, Benha University, Benha, Egypt
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Goddard JC, Janssen DAW. Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and meta-analysis. Int Urogynecol J 2018; 29:933-942. [PMID: 29181550 PMCID: PMC6004275 DOI: 10.1007/s00192-017-3508-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/01/2017] [Indexed: 12/02/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to assess the efficacy of intravesical hyaluronic acid (HA) and chondroitin sulfate (CS), alone or in combination, for recurrent urinary tract infections (RUTIs) in adult female patients using a systematic review and meta-analysis. METHODS English-language articles were obtained from the MEDLINE, Embase, and Cochrane databases through November 2016, by manual searching and cross-referencing. Randomized and nonrandomized trials of adult female patients with a documented history of RUTIs who received HA, CS or HA plus CS were included. The random effects model was applied to all pooled analyses. Risk of bias was assessed for individual studies and across studies. RESULTS Two randomized (n = 85) and six nonrandomized (n = 715) studies met the inclusion criteria. These studies assessed HA ± CS; studies of CS alone were not identified in the search. HA ± CS decreased the UTI rate per patient-year (pooled mean difference [MD] -2.56; 95% confidence interval [CI] -3.86, -1.26; p < 0.001) and increased the time to first UTI recurrence (pooled MD 130.05 days; 95% CI 5.84, 254.26; p = 0.04). There was heterogeneity in most outcomes considered, and publication bias in many studies. The standard of trial reporting was low. The patient population size, and the number of studies included, were small. CONCLUSIONS HA ± CS appears to reduce the rate of UTI and increase the time to recurrence in women with RUTI. As randomized controlled studies are available only for HA plus CS, the quality of evidence is higher for the combination than for HA alone.
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Affiliation(s)
| | - Dick A W Janssen
- Department of Urology, Radboud University Medical Center, Geert Grootteplein Zuid 10, 6525, Nijmegen, GA, Netherlands.
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Guelfi G, Stefanetti V, Zampini D, Oommen OP, Brecchia G, Dall'Aglio C, Arcelli R, Cochetti G, Boni A, Mearini E. Gold nanoparticles approach to detect chondroitin sulphate and hyaluronic acid urothelial coating. Sci Rep 2017; 7:10355. [PMID: 28871206 PMCID: PMC5583281 DOI: 10.1038/s41598-017-09872-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023] Open
Abstract
This study investigated the location of hyaluronic acid (HA)- and chondroitin sulphate (CS)-coated gold nanoparticles in rabbit bladder and evaluated gene expression of CD44, RHAMM and ICAM-1 receptors involved in HA and CS transport into the cell. Gold nanoparticles were synthesised by reduction of gold salts with HA or CS to form HA-AuNPs and CS-AuNPs. Bladder samples were incubated with CS-AuNPs and HA-AuNPs or without glycosaminoglycans. Transmission electron microscopy, optic microscopy and scanning electron microscopy were used to determine the location of the synthesised AuNPs. Real-time PCR was used to analyse expression of urothelial cell receptors CD44, RHAMM, ICAM-1, after ex vivo administration of CS-AuNPs and HA-AuNPs. We showed that HA-AuNPs and CS-AuNPs were located in the cytoplasm and tight junctions of urothelial umbrella cells; this appearance was absent in untreated bladders. There were no significant differences in gene expression levels for CD44, RHAMM and ICAM-1 receptors in treated versus control bladder tissues. In conclusion, we clearly showed the presence of exogenous GAGs in the bladder surface and the tight junctions between umbrella cells, which is important in the regeneration pathway of the urothelium. The GAGs-AuNPs offer a promising approach to understanding the biophysical properties and imaging of urothelial tissue.
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Affiliation(s)
- Gabriella Guelfi
- Department of Veterinary Medicine, University of Perugia, Perugia, PG, Italy.
| | | | - Danilo Zampini
- Department of Veterinary Medicine, University of Perugia, Perugia, PG, Italy
| | - Oommen P Oommen
- Faculty of Biomedical Sciences and Engineering & BioMediTech Institute, Bioengineering and Nanomedicine Lab, Tampere University of Technology, 33520, Tampere, Finland
| | - Gabriele Brecchia
- Department of Veterinary Medicine, University of Perugia, Perugia, PG, Italy
| | - Cecilia Dall'Aglio
- Department of Veterinary Medicine, University of Perugia, Perugia, PG, Italy
| | - Rolando Arcelli
- Department of Veterinary Medicine, University of Perugia, Perugia, PG, Italy
| | - Giovanni Cochetti
- Department of Surgical and Biomedical Sciences, Section of Urological, Andrological and Minimally invasive techniques, University of Perugia, Piazza Lucio Severi 1, 06132, Perugia, PG, Italy
| | - Andrea Boni
- Department of Surgical and Biomedical Sciences, Section of Urological, Andrological and Minimally invasive techniques, University of Perugia, Piazza Lucio Severi 1, 06132, Perugia, PG, Italy
| | - Ettore Mearini
- Department of Surgical and Biomedical Sciences, Section of Urological, Andrological and Minimally invasive techniques, University of Perugia, Piazza Lucio Severi 1, 06132, Perugia, PG, Italy
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Romanò C, De Vecchi E, Bortolin M, Morelli I, Drago L. Hyaluronic Acid and Its Composites as a Local Antimicrobial/Antiadhesive Barrier. J Bone Jt Infect 2017; 2:63-72. [PMID: 28529865 PMCID: PMC5423572 DOI: 10.7150/jbji.17705] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Living in biofilms is probably the most common condition for bacteria and fungi and biofilm-related infections account for the majority of bacterial infectious diseases worldwide. Among others biofilm-related infections, those associated with implanted biomaterials have an enormous and still largely underestimated impact in orthopaedics and trauma, cardio-surgery and several other surgical disciplines. Given the limited efficacy of existing antibiotics in the prevention and treatment of bacterial biofilms, new strategies are needed to protect implants and host tissues, overcoming the striking ability of the microorganisms to adhere on different surfaces and to immediately protect themselves by forming the biofilm matrix. Adhesion is a necessary first step in microbial colonization and pathogenesis and provides a potential target for new preventive and treatment approach. Among various polymers, tested as antibacterial coatings, hyaluronic acid and some of its composites do offer a well-established long-term safety profile and a proven ability to reduce bacterial adhesion and biofilm formation. Aim of the present review is to summarize the available evidence concerning the antiadhesion/antibiofilm activity of hyaluronic acid and some of its derivatives to reduce/prevent bacterial adhesion and biofilm formation in various experimental and clinical settings.
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Affiliation(s)
- C.L. Romanò
- Department of Reconstructive Surgery of Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milano, Italy
| | - E. De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
| | - M. Bortolin
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
| | - I. Morelli
- Department of Reconstructive Surgery of Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milano, Italy
| | - L. Drago
- Laboratory of Technical Sciences for Laboratory Medicine, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
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Schwalenberg T, Berger FP, Horn LC, Thi PH, Stolzenburg JU, Neuhaus J. Intravesical Glycosaminoglycan Replacement with Chondroitin Sulphate (Gepan(®) instill) in Patients with Chronic Radiotherapy- or Chemotherapy-Associated Cystitis. Clin Drug Investig 2016; 35:505-12. [PMID: 26175064 PMCID: PMC4519582 DOI: 10.1007/s40261-015-0306-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and Objective Intravesical instillation of glycosaminoglycans is a promising option for the treatment of chronic cystitis, as it supports the regeneration of the damaged urothelial layer. We investigated the efficacy of short-term intravesical chondroitin sulphate treatment (six courses of instillation) in patients with chronic radiotherapy- or chemotherapy-associated cystitis. Methods This prospective, observational study included patients with chronic radiotherapy- or chemotherapy-associated cystitis, who received six once-weekly intravesical instillations of 0.2 % chondroitin sulphate 40 mL. Every week, patients recorded their symptoms and their benefits and tolerance of treatment, using a self-completed questionnaire. Results The study included 16 patients (mean age 68.5 years; 50 % male). During the study, a reduction in all evaluated parameters was observed. After one dose of chondroitin sulphate, symptom improvement was observed in 38 % of patients, and after the second dose, an additional 31 % of patients showed improvement. At week 6, 80 % of patients had either improved or were symptom free, and significant improvements in urinary urgency (p = 0.0082), pollakisuria (p = 0.0022), urge frequency (p = 0.0033) and lower abdominal pain (p = 0.0449) were observed. Haematuria, present in 9 of the 16 patients at baseline, was completely resolved in all cases after 6 weeks. The majority of patients (93 %) evaluated the tolerance of chondroitin sulphate as ‘good’ or ‘very good’. No treatment-related adverse events were reported. Conclusion Intravesical administration of chondroitin sulphate was effective for the treatment of radiotherapy- or chemotherapy-associated cystitis. Even short-term treatment appears to be effective in reducing symptoms and improving the quality of life of patients.
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Affiliation(s)
- Thilo Schwalenberg
- Department of Urology, Universitätsklinik Leipzig AöR (Leipzig University Hospital), Liebigstraße 20, 04103, Leipzig, Germany
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The effects of intravesical therapy with hyaluronic acid for painful bladder syndrome: Preliminary Chinese experience and systematic review. Taiwan J Obstet Gynecol 2016; 54:240-7. [PMID: 26166334 DOI: 10.1016/j.tjog.2014.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To present the preliminary results of treating a series of Chinese patients with painful bladder syndrome/interstitial cystitis (PBS/IC) using intravesical hyaluronic acid (HA). MATERIALS AND METHODS A series of 13 patients with PBS/IC received first-line therapy followed by HA once-a-week for 4 weeks and then once monthly for 4 months. Outcomes measured included O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ISPI) scores, voiding frequency, and bladder capacity. RESULTS ISPI and ICSI scores were significantly (p < 0.001) decreased after treatment [median change (interquartile range): ISPI = 2 (2-3); ICSI = 3 (2-3)]. Voiding frequency and functional bladder capacity were significantly (p < 0.001) decreased [median change: 7 (6-8) times/d] and increased [median change: 190 (116-233) mL], respectively after treatment. CONCLUSION Our case series supports the efficacy of intravesical HA in the treatment of PBS/IC.
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Gacci M, Saleh O, Giannessi C, Detti B, Livi L, Monteleone Pasquetti E, Masoni T, Finazzi Agro E, Li Marzi V, Minervini A, Carini M, Gravas S, Oelke M, Serni S. Sodium hyaluronate and chondroitin sulfate replenishment therapy can improve nocturia in men with post-radiation cystitis: results of a prospective pilot study. BMC Urol 2015; 15:65. [PMID: 26148853 PMCID: PMC4493946 DOI: 10.1186/s12894-015-0046-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 06/02/2015] [Indexed: 12/25/2022] Open
Abstract
Background Radiotherapy is one of the treatment options for prostate cancer (PCa) but up to 25 % of men report about severe nocturia (nocturnal voiding). The combination of hyaluronic acid (HA) and chondroitin sulfate (CS) resembles glycosaminoglycan (GAG) replenishment therapy. The aim of our study was to evaluate the impact of HA and CS on nocturia, in men with nocturia after PCa radiotherapy. Methods Twenty-three consecutive patients with symptomatic cystitis after external radiotherapy for PCa were enrolled. Patients underwent bladder instillation therapy with HA and CS weekly for the first month and, afterwards, on week 6, 8 and 12. Nocturnal voiding frequency was assessed by item 3 (Q3) of the Interstitial Cystitis Symptoms Index (ICSI) and item 2 (Q2) of the Interstitial Cystitis Problem Index (ICPI). Data were analyzed with paired-samples T-test and adjusted for age. Results Eighteen patients (78 %) reported about nocturia. Pre- and post-treatment ICSI-Q3 was 2.13 ± 0.28 and 1.61 ± 0.21 (−24.4 %, p = 0.001). With logistic regression analysis, both age and baseline ICSI-Q3 had a significant impact on nocturnal voiding frequency (r = 0.293, p = 0.011 and r = 0.970, p < 0.001). Pre- and post-treatment ICPI-Q2 was 1.87 ± 0.26 and 1.30 ± 0.25 (−30.5 %, p = 0.016); logistic regression analysis was without significant findings. Conclusion Bladder instillation treatment with a combination of HA and CS was effective in reducing nocturnal voiding frequency in men with post-radiation bladder pain for PCa. Randomized, controlled trials with sham treatment are needed to confirm our result.
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Affiliation(s)
- Mauro Gacci
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Omar Saleh
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Claudia Giannessi
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Beatrice Detti
- Department of Radiation Therapy, University of Florence, Careggi Hospital, Largo Brambilla 3, Florence, Italy.
| | - Lorenzo Livi
- Department of Radiation Therapy, University of Florence, Careggi Hospital, Largo Brambilla 3, Florence, Italy.
| | | | - Tatiana Masoni
- Department of Radiation Therapy, University of Florence, Careggi Hospital, Largo Brambilla 3, Florence, Italy.
| | - Enrico Finazzi Agro
- Department of Urology, Tor Vergata University, Via di Tor Vergata, Rome, Italy.
| | - Vincenzo Li Marzi
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Andrea Minervini
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Marco Carini
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
| | - Stavros Gravas
- Department of Urology, University Hospital of Larissa, Larissa, Greece.
| | - Matthias Oelke
- Department of Urology, Hannover Medical School, Hannover, Germany.
| | - Sergio Serni
- Department of Urology, University of Florence, Careggi Hospital, Largo Brambilla 3, Urologic Clinic San Luca, Florence, 50100, Italy.
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Kamalov AA, Khodyreva LA, Dudareva AA, Nizov AN. Risk factors causing the development of infection and inflammation of the lower urinary tract. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-2-63-67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Persistence as well as high survival rate and resistance of microorganisms belong to the key reasons promoting symptoms of lower urinary tract diseases. They can stay active for a long time and can substantially deteriorate the life quality of patients suffering from chronic infections and inflammations in the wall of the urinary bladder even after the eradication of the pathogen. Recent studies in the field of clinical microbiology reflect serious qualitative and quantitative changes in the infection incidence structure, which is mainly related to changes in the bacterial pathogenicity. Pathogenicity island genes control the synthesis of different adhesins, invasins, hemolysins and toxins (hemolysin, cytotoxic necrotizing factor type 1, etc.) as well as iron ion absorption system, which are essential for the pathogen propagation and activity in tissues. The determination of genetic determinants will provide a new insight into the bacterial evolution process and will help to understand the reason of prompt formation and propagation of virulent strains as well as fast development of the infection and inflammation in the lower urinary tract, which may explain different severity of the pathology and symptoms of the lower urinary tract.
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Cicione A, Cantiello F, Ucciero G, Salonia A, Torella M, De Sio M, Autorino R, Carbone A, Romancik M, Tomaskin R, Damiano R. Intravesical treatment with highly-concentrated hyaluronic acid and chondroitin sulphate in patients with recurrent urinary tract infections: Results from a multicentre survey. Can Urol Assoc J 2014; 8:E721-7. [PMID: 25408813 DOI: 10.5489/cuaj.1989] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We assess the effectiveness of intravesical instillation of hyaluronic acid (HA) and chondroitin sulphate (CS) as a non-antibiotic treatment option for prophylaxis of recurrent urinary tract infections (UTIs) in female patients. METHODS This was a retrospective cohort study involving 7 European institutions. We included patients with recurrent UTIs who received intravesical instillations of Ialuril (IBSA International) (50 mL HA 1.6% and CS 2% solution) between January 2010 and March 2012. Medication schedule, length of follow-up, recurrence infection time, number of UTIs/patients/year, patient quality of life, subjective symptoms score, and treatment-emergent side effects were recorded and analyzed. RESULTS In total, 157 women (mean age: 54.2 ± 4.1 years) were included in the analysis. All patients had at least 12 months follow-up. After 4 weekly and 5 monthly HA-CS bladder instillations, UTI episodes decreased from 4.13 ± 1.14 to 0.44 ± 0.50 (p = 0.01) at 12 months, while recurrent UTI time prolonged from 94.8 ± 25.1 days to 178.4 ± 37.3 days (p = 0.01) at 12 months. An improvement in symptoms and quality of life was achieved. A medium-depth pain after medication instillation was the most reported side effect. Regression model analysis showed significant risk factors in developing new UTI episodes: being more than 50 years old and having more than 4 UTI episodes per year (OR 3.41; CI 95%; 1.51-7.71, p = 0.003 and OR 3.31; CI 95% 1.51-7.22; p = 0.003, respectively). Retrospective design and lack of a control group represent two main limitations of the study. CONCLUSIONS Restoring glycosaminoglycans bladder layer therapy is a promising non-antibiotic therapy to prevent recurrent UTIs.
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Affiliation(s)
- Antonio Cicione
- Department of Urology & Research Doctorate Urology Program, Magna Graecia University, Catanzaro, Italy
| | - Francesco Cantiello
- Department of Urology & Research Doctorate Urology Program, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Ucciero
- Department of Urology & Research Doctorate Urology Program, Magna Graecia University, Catanzaro, Italy
| | - Andrea Salonia
- Department of Urology, University Vita-Salute San Raffaele, Milano, Italy
| | - Marco Torella
- Gynaecology Unit, Second University of Naples, Napoli, Italy
| | - Marco De Sio
- Urology Unit, Second University of Naples, Napoli, Italy
| | | | - Antonio Carbone
- Unit of Urology - ICOT, Sapienza University of Rome, Latina, Italy
| | - Martin Romancik
- Department of Urology, St. Cyril and Method University Hospital, Bratislava, Slovakia
| | - Roman Tomaskin
- Department of Urology, Faculty Hospital of Martin (MFN), Martin, Slovakia
| | - Rocco Damiano
- Department of Urology & Research Doctorate Urology Program, Magna Graecia University, Catanzaro, Italy
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Parsons CL. Diagnosing the bladder as the source of pelvic pain: successful treatment for adults and children. Pain Manag 2014; 4:293-301. [PMID: 25300387 DOI: 10.2217/pmt.14.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The key to successful therapy of interstitial cystitis (IC) is to correctly diagnose it. The significant majority of patients with IC have a dysfunctional bladder epithelium that allows urinary solutes (primarily potassium) to leak into the bladder wall, causing symptoms and tissue damage. Drugs that correct this dysfunction and suppress symptoms are important to achieve successful outcomes in patients. Today over 95% of females with IC are misdiagnosed as having gynecologic chronic pelvic pain, vulvodynia, vaginitis, endometriosis, overactive bladder or urinary tract infection. Men are misdiagnosed as having prostatitis. Often children are not diagnosed at all. Multimodal drug therapy may be required and can achieve successful resolution of IC in over 90% of patients. IC in children can be treated successfully with pentosan polysulfate.
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Marson F, Tienforte D, Kocjancic E. Post-Radiation Cystitis: Current Treatments. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0244-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sommariva M, Lazzeri M, Abrate A, Guazzoni G, Sandri S, Montorsi F. Intravesical Hyaluronic Acid and Chondroitin Sulphate Improve Symptoms and Quality of Life in Patients with Late Radiation Tissue Cystitis: An Investigative Pilot Study. EUR J INFLAMM 2014. [DOI: 10.1177/1721727x1401200117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intravesical hyaluronic acid (HA) and chondroitin sulphate (CS) instillation are effective for urinary tract infections (UTIs) and bladder pain syndrome. This study aimed to evaluate the tolerability, safety and efficacy of intravesical HA and CS instillation in patients with late radiation tissue cystitis (LRTC). In this pilot study, tolerability was reported as discontinuation or deviation of the protocol, safety as general or local side effects, efficacy as improvement of bladder capacity and frequency, quality of life (QoL) through the European Quality of Life 5-Dimensions (EQ-5D) (details at http://www.controlled-trials.com/ISRCTN37534393 ). Thirty-two patients with LRTC were enrolled. Twenty-seven patients (84.8%) received a mean of 12.2±0.3 months of instillation therapy. Only two patients (6.2%) developed a urinary tract infection from instillation, which required antibiotic treatment, nevertheless not compromising the therapy schedule. No male patient developed a urethral stricture. Intravesical instillation was associated with a significant increase (>50%) of bladder capacity from baseline (66.9ml) both at 3 months (101.9ml; p<0.001) and 12 months (174.4 ml; p<0.001). EQ-5D index significantly increased from baseline to both 3 and 12 months (0.26, 0.69 and 0.96, respectively; p<0.001). Intravesical co-administration of HA and CS improved bladder function, symptoms and QoL in patients with LRTC.
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Affiliation(s)
- M.L. Sommariva
- Department of Urology, G. Fornaroli Hospital, Magenta, Milan, Italy
| | - M. Lazzeri
- Department of Urology, Ospedale San Raffaele, San Raffaele Scientific Institute, Milan, Italy
| | - A. Abrate
- Department of Urology, Ospedale San Raffaele, San Raffaele Scientific Institute, Milan, Italy
| | - G. Guazzoni
- Department of Urology, Ospedale San Raffaele, San Raffaele Scientific Institute, Milan, Italy
| | - S. Sandri
- Department of Urology, G. Fornaroli Hospital, Magenta, Milan, Italy
| | - F. Montorsi
- Department of Urology, Ospedale San Raffaele, San Raffaele Scientific Institute, Milan, Italy
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Ablove T, Patankar M, Seo S. Prevention of recurrent urinary tract infections by intravesical administration of heparin: a pilot study. Ther Adv Urol 2013; 5:303-9. [PMID: 24294288 DOI: 10.1177/1756287213504804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To assess the effect of bladder instillations using heparin on the rate of urinary tract infections in women resistant to standard therapy. PATIENTS AND METHODS The medical records of all women who received bladder instillations between May 2009 and January of 2010 at the University of Wisconsin urogynecology clinic were reviewed. Eighteen women (mean age 67 years) with a history of recurrent urinary tract infections received intravesical instillations (heparin 40,000 U, 2% lidocaine 8 ml, sodium bicarbonate 4 ml) once weekly for 6 weeks. Patients were considered resistant to standard therapy if their condition failed to respond to chronic suppression antibiotic therapy; they had chronic infections and for this reason could not be placed on chronic suppression; or they were not candidates for chronic suppression due to drug allergies. The number of urinary tract infections was monitored during treatment and for 6 months after therapy. The urinary tract infection rates were compared with the rates of urinary tract infection in the 6 months before treatment. RESULTS Seventy-eight percent of patients responded to therapy. Subjects were thought to have responded to therapy if there was a greater than 50% reduction in the rate of urinary tract infection. Other variables reviewed included evidence of chronic infection, hormonal status, glomerular filtration rate, age, body mass index, antibiotic allergies, diabetes, hypertension, and chronic antibiotic therapy during bladder instillations. None of these variables were found to be statistically significant. CONCLUSION Bladder instillations decreased the rate of urinary tract infection in this pilot study; this effect persisted into the post-treatment period. More research is needed to confirm these preliminary findings.
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Affiliation(s)
- Tova Ablove
- Department of Obstetrics and Gynecology, University of Wisconsin, 600 Highland Avenue, H4/656 CSC, Madison, WI 53792, USA
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Tornero JI, Olarte H, Escudero F, Gómez G. Long-term experience with sodium chondroitin sulfate in patients with painful bladder syndrome. Actas Urol Esp 2013; 37:523-6. [PMID: 23769895 DOI: 10.1016/j.acuro.2013.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 01/18/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the response of patients diagnosed with painful bladder syndrome to treatment with instillations of sodium chondroitin sulfate. MATERIAL AND METHODS We present a series of cases of patients with painful bladder syndrome who followed a bladder instillation protocol with sodium chondroitin sulfate, according to our centre's regimen. The response to treatment was assessed with respect to pain, according to the Downie scale; urinary frequency, according to the voiding diary; and subjective improvement, according to the Patient Global Impression of Improvement (PGI-I) scale. RESULTS A total of 28 patients with a median age of 59 years (range 22-90) followed this protocol. From the medical histories, 19.4% had suffered an infection of the urinary tract, 3.8% had suffered urinary tuberculosis, 7.6% received pelvic radiation therapy and 26.9% had taken anticholinergic drugs for overactive bladder syndrome. We evaluated the response to treatment at 0, 3, 6 and 12 months and found that at the end of treatment 72.3% of the patients had improved bladder pain and 75% were significantly better. CONCLUSIONS Treatment with sodium chondroitin sulfate through endovesical instillation in painful bladder syndrome improves pain, voiding frequency and quality of life in the long term.
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Affiliation(s)
- J I Tornero
- Servicio de Urología, Hospital Universitario Virgen de La Arrixaca, Murcia, España.
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Schmidt TA, Sullivan DA, Knop E, Richards SM, Knop N, Liu S, Sahin A, Darabad RR, Morrison S, Kam WR, Sullivan BD. Transcription, translation, and function of lubricin, a boundary lubricant, at the ocular surface. JAMA Ophthalmol 2013; 131:766-76. [PMID: 23599181 DOI: 10.1001/jamaophthalmol.2013.2385] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Lubricin may be an important barrier to the development of corneal and conjunctival epitheliopathies that may occur in dry eye disease and contact lens wear. OBJECTIVE To test the hypotheses that lubricin (ie, proteoglycan 4 [PRG4 ]), a boundary lubricant, is produced by ocular surface epithelia and acts to protect the cornea and conjunctiva against significant shear forces generated during an eyelid blink and that lubricin deficiency increases shear stress on the ocular surface and promotes corneal damage. DESIGN, SETTING, AND PARTICIPANTS Human, porcine, and mouse tissues and cells were processed for molecular biological, immunohistochemical, and tribological studies, and wild-type and PRG4 knockout mice were evaluated for corneal damage. RESULTS Our findings demonstrate that lubricin is transcribed and translated by corneal and conjunctival epithelial cells. Lubricin messenger RNA is also present in lacrimal and meibomian glands, as well as in a number of other tissues. Absence of lubricin in PRG4 knockout mice is associated with a significant increase in corneal fluorescein staining. Our studies also show that lubricin functions as an effective friction-lowering boundary lubricant at the human cornea-eyelid interface. This effect is specific and cannot be duplicated by the use of hyaluronate or bovine serum albumin solutions. CONCLUSIONS AND RELEVANCE Our results show that lubricin is transcribed, translated, and expressed by ocular surface epithelia. Moreover, our findings demonstrate that lubricin presence significantly reduces friction between the cornea and conjunctiva and that lubricin deficiency may play a role in promoting corneal damage.
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Affiliation(s)
- Tannin A Schmidt
- Faculty of Kinesiology, Human Performance Laboratory Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
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Giberti C, Gallo F, Cortese P, Schenone M. Combined intravesical sodium hyaluronate/chondroitin sulfate therapy for interstitial cystitis/bladder pain syndrome: a prospective study. Ther Adv Urol 2013; 5:175-9. [PMID: 23904856 DOI: 10.1177/1756287213490052] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of this study was to verify the efficacy and safety of intravesical treatment combining sodium hyaluronate (HA) and chondroitin sulfate (CS) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS Between February 2010 and May 2011, 20 consecutive women with IC/BPS were treated with intravesical instillations containing sodium HA (1.6%; 800 mg/50 ml) and sodium CS (2%; 1 g/50 ml) weekly for the first month, biweekly for the second month, and then monthly for at least 3 months. Before and after treatment, all patients filled in the Interstitial Cystitis Symptom Index and Problem Index (ICSI/ICPI), the Patient Health Questionnaire 9 and the Pelvic Pain and Urgency/Frequency Patient Symptom Scale (PUF). Treatment efficacy was assessed by comparing the pre- and post-treatment mean scores of the three questionnaires using Student's t test (p value <0.05 was considered significant). RESULTS Statistically significant mean decreases in ICSI (from 13.0 to 9.3; p = 0.0003), ICPI (from 11.35 to 8.85; p = 0.0078) and PUF (from 20.0 to 15.75; p = 0.0007) questionnaire scores were seen. No cases of side effects or complications were observed. The mean follow up was 5 months. CONCLUSIONS Despite the limitations of this study, the outcomes confirmed the role of combination therapy with HA and CS as a safe and effective option for the treatment of IC/BPS. Further randomized controlled studies with a higher number of patients and a longer follow-up period are needed to confirm these results.
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Affiliation(s)
- Claudio Giberti
- Division of Urology, Department of Surgery, San Paolo Hospital, Savona, Italy
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Vedanayagam M, Brewin J, Briggs K, Salahia MG, Hammadeh MY. The role of hyaluronic acid in the management of uncomplicated recurrent female urinary tract infections: literature review and practical experience. JOURNAL OF CLINICAL UROLOGY 2013. [DOI: 10.1177/2051415813481027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: To assess the efficacy and safety of intravesical hyaluronic acid (HA) in the management of female patients with recurrent urinary tract infections (UTIs) in our hospital. Also to perform a literature review about the use of Glycosaminoglycan (GAGs) such as hyaluronic acid (HA) and chondroitin sulphate (CS) in the management of female recurrent UTI and compare our findings to the published evidence available. Method: We performed a literature review of studies using HA or CS for the management of recurrent UTIs. We retrospectively reviewed the outcome of 22 female patients who were treated at our district general hospital for recurrent UTIs refractory to first line management and compared our experience of using this treatment to the recently published literature. Results: Literature review showed growing evidence for the use of intravesical HA and HA-CS for the prevention of female recurrent UTIs including three recently published prospective randomised controlled trials (RCTs). These studies show a reduction in UTIs by over 70% in comparison to placebo and that intravesical treatment is more effective than low dose antibiotic prophylaxis. In our experience, intravesical HA was an effective second line treatment for females with recurrent UTIs. Of 22 patients with recurrent UTIs (aged 17 - 72 years), 64% (14 patients) remained recurrence free one year after treatment. In our experience, this treatment was tolerated well by the patients with minimal side effects. Conclusion: HA offers an effective management option for female patients with recurrent UTIs. It is a safe and effective second line treatment for female patients with recurrent urinary tract infections that may be refractory to first line management strategies.
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Affiliation(s)
| | - James Brewin
- Urology Department, Queen Elizabeth Hospital, London, UK
| | - Karen Briggs
- Urology Department, Queen Elizabeth Hospital, London, UK
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Damiano R, Cicione A. Editorial Comment to Intravesical hyaluronic acid and chondroitin sulfate alone and in combination for urinary tract infection: Assessment of protective effects in a rat model. Int J Urol 2012. [DOI: 10.1111/iju.12033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raymond I, Vasdev N, Ferguson J, Haskin M, Davis L, Hasan TS. The clinical effectiveness of intravesical sodium hyaluronate (cystistat®) in patients with interstitial cystitis/painful bladder syndrome and recurrent urinary tract infections. Curr Urol 2012; 6:93-8. [PMID: 24917721 DOI: 10.1159/000343517] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/10/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Painful bladder syndrome/interstitial cystitis (PBS/IC) and recurrent urinary tract infections (UTI) are clinically challenging conditions to manage in patients. We evaluate the clinical use of intravesical sodium hyaluronate (Cystistat®) in both these patient groups who have completed treatment. PATIENTS AND METHODS Thirteen patients with recurrent UTIs (Group I) and 8 patients with PBS/IC (Group II) received intravesical sodium hyaluronate (Cystistat®). Preinstallation demographic parameters were statically comparable in both groups. The mean age of presentation was 54.6 years in Group I and 57.5 years in Group II (p = 0.9). All 13 patients in Group I were on low dose antibiotics. The mean number of installations completed in both groups was 9 (range 4-21). RESULTS Data was collected prospectively using a standard pre- and post-treatment questioner with the pelvic pain and urinary/frequency patient symptom scale. At a mean follow-up of 21 months a significant improvement in bladder pain (p = 0.05), daytime frequency (p = 0.03) and quality of life (p = 0.02) was noted in patients in Group I. Two patients had breakthrough UTIs during treatment. Within Group I, 7 (53%) patients responded well to treatment. Patients in Group II had a significant improvement in bladder pain (p = 0.02), urgency (p = 0.01), nocturia (p = 0.01) and quality of life (p = 0.04). Within Group II, 6 patients (75%) responded to treatment. CONCLUSION Intravesical sodium hyaluronate (Cystistat®) can be used with minimal side effects and good compliance in both groups of patients with PBS and recurrent UTIs. Longer follow-up and larger patient numbers in both groups will be required to confirm the long-term efficacy of these two clinically challenging groups of patients.
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Affiliation(s)
- Ijabla Raymond
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Nikhil Vasdev
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jill Ferguson
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marion Haskin
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Liz Davis
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Tahseen S Hasan
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
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Tasdemir S, Tasdemir C, Vardi N, Yakupogullari Y, Duman Y, Parlakpinar H, Sagir M, Acet A. Intravesical hyaluronic acid and chondroitin sulfate alone and in combination for urinary tract infection: Assessment of protective effects in a rat model. Int J Urol 2012; 19:1108-12. [DOI: 10.1111/j.1442-2042.2012.03109.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gomelsky A, Dmochowski RR. GAG Layer Replenishment Therapy for Recurrent Infectious Bladder Dysfunction. CURRENT BLADDER DYSFUNCTION REPORTS 2012. [DOI: 10.1007/s11884-012-0121-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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