[Laparoscopic cystectomy and ileal conduit urinary diversion for neurogenic bladders and related conditions. Morbidity and better quality of life]

OBJECTIVES

To assess morbidity and functional consequences of laparoscopic cystectomy with ileal conduit urinary diversion: in neurologic patients.

MATERIALS

We reviewed the records of forty-two patients (ten men and thirty-two women) who underwent surgery between August 2007 and October 2013. The median age of the patient was 54 years old (range between 21-79 years). A laparoscopic cystectomy was performed followed by a short laparotomy to perform the ileal conduit urinary diversion. Records were reviewed to retrieve the indications and describe the postoperative and functional course. Patients and GPs were interviewed during phone calls to appreciate the quality of life by the PGII scale in order to assess the functional outcome.

RESULTS

The operation was performed on 42 patients, of whom 18 had multiple sclerosis, nine a post-traumatic neurogenic bladder. Among the total population, 10 patients (23.81%) required a transfusion of at least one packed red blood cells (1-7). The overall rate of early complications was 35.71%. Belated complications were seen in 52.38% of the population. The median duration of hospital stay was 16 days (range between 9-70 days). The median follow up was 34 months (range between 1-76 months). For patients, the PGII scale rating had a median value of 6 (2-7). All referring physicians described a better functional status.

CONCLUSION

The laparoscopic cystectomy can make postoperative course smoother for the neurological patients. However, the surgeon must weigh individually the benefit of performing the operation.

[Atypical metastatic site of lung adenocarcinoma]

The case concerns a 40 years old smoker male, treated for an adenocarcinoma of the left upper lobe, metastatic in muscle extended to the right femur cortex. The patient had first a surgical excision of the mass of the thigh, an intramedullary femoral nailing, and six courses of chemotherapy (cisplatin-vinorelbine) with concurrent thoracic radiotherapy. This treatment led to disease stability. One year later, hematuria revealed a bladder tumor. Cystoscopy with biopsy concluded to an adenocarcinoma pulmonary origin. The PET-scanner showed an uptake of the bladder mass, a hypermetabolic right adrenal gland and subcutaneous left shoulder nodule. The patient had a partial cystectomy associated with enterocystoplasty and left ureteral reimplantation, plus excision of the subcutaneous nodule located in the left shoulder and a right adrenalectomy during the same time. All of the sites were metastasis from adenocarcinoma of pulmonary origin. A salvage chemotherapy was initiated. In the vast majority of cases, bladder metastasis as primary bladder tumours is revealed by hematuria, cystitis or sometimes vague pelvic pain. Our case is a very unusual bladder metastatic site from lung cancer. We will discuss the different procedures and the therapeutic strategies on the basis of the published data.

LIM-class homeobox gene Lim1, a novel oncogene in human renal cell carcinoma

Human clear cell renal cell carcinoma (CCC) remains resistant to therapies. The transcription factor LIM-class homeobox gene Lim1 is required for normal organogenesis, including nephrogenesis, by regulating cell movements, differentiation and growth. Its expression is controlled partly by the sonic hedgehog-Gli signaling pathway, which we have recently shown to be reactivated in human CCC. So far, no study has assessed whether Lim1 may be associated with tumorigenesis. Using a panel of human CCC cell lines expressing or not the von Hippel-Lindau tumor suppressor gene and 44 tumor/normal tissues pairs, we found that Lim1 is constitutively and exclusively reexpressed in tumors. Through Lim1 silencing or overexpressing, we show that Lim1 is a growth and survival factor in human CCC, at least through the activation of oncogenic pathways including the phosphoinositide kinase-3/Akt and nuclear factor-kappaB pathways. More importantly, in nude mice bearing human CCC tumors, Lim1 silencing abolished tumor growth through the same mechanism as in vitro. In Lim1-depleted cells and tumors, cell movements were substantially impaired because of the inhibition of expression of various proteins involved in metastatic spread, such as paxillin or tenascin-C. These findings establish that the developmental marker Lim1 acts as an oncogene in cancer cells and targeting Lim1 may constitute an innovative therapeutic intervention in human CCC.

[Metastatic renal cell carcinoma: pretherapeutic approach before antiangiogenic treatment. A case report]

Antiangiogenic treatment initiation justifies a clinical and biological pretherapeutic assessment and a close follow-up of side effects according to each drug. Because of potential healing complications, a deadline of 4 weeks after surgery is recommended before starting antiangiogenic treatment. The optimal sequence and the potential role of neo-adjuvant therapies remain to define. In the absence of prospective data, nephrectomy is still recommended in renal cell carcinoma management.

[Fluorescence diagnosis in patients with non-muscle invasive bladder cancer: results of a metaanalysis]

PURPOSE

Heterogeneous results of single studies with photodynamic diagnosis (PDD) in bladder cancer have been reported. A metaanalysis of prospective studies has now been performed.

MATERIAL AND METHODS

The effect of PDD in addition to WLC on a) the diagnosis and b) the therapeutic outcome of primary or recurrent non-muscle invasive bladder cancer (NMIBC) investigated by cystoscopy or transurethral resection was analysed. An electronic database search was performed. Trials were included if they prospectively compared WLC with PDD in bladder cancer. Primary endpoints were additional detection rate, residual tumour at second resection and recurrence-free survival.

RESULTS

Significantly more tumour-positive patients were detected with PDD in all patients with non-muscle invasive tumours (= 20 %) [95 % confidence interval (CI): 8 to 35 %] and in CIS patients (= 39 %) (CI: 23 to 57 %). Residual tumour was significantly less often found after PDD (odds ratio 0.28, CI: 0.15 to 0.52, p < 0.0001). Recurrence-free survival was significantly higher at 12 and 24 months in the PDD groups than in WLC only groups.

CONCLUSIONS

More bladder tumour-positive patients are detected by PDD. Best results were found in CIS patients. Diagnosis with PDD results in a more complete resection and a longer recurrence-free survival.

[The role of introital ultrasonography in treating low urinary tract symptoms complicating sub-urethral tape placement]

OBJECTIVE

To assess the role of the introital ultrasound in the evaluation of patients with low urinary tract symptoms after sling placement.

MATERIAL AND METHOD

From 2000 till 2007, a total of 31 patients underwent sub-urethral tape placement for a stress urinary incontinence and developed thereafter a low urinary tract symptoms. The urological evaluation consisted of a detailed medical history, a urogynecologic examination, a complete urodynamic exam, a measurement of the postvoiding residue and a introital ultrasound. All patients filled the mesure du handicap urinaire (MHU) questionnaire. These patients had a transvaginal tape lysis under local anesthesia. We correlated the ultrasound findings with postoperative clinical success and failure.

RESULTS

Thirty-one patients with low urinary tract symptoms secondary to sling placement underwent a tape lysis. Median age was 63.1+/-10.9 years, the median time between the anti-incontinence surgery and the tape lysis was 21.5+/-16.2 months. Seven patients had only obstructive symptoms, 15 patients had obstructive and bladder overactivity symptoms and nine patients had bladder overactivity symptoms. Introital ultrasound revealed an abnormality of the tape in 26 patients. Ten patients had a position abnormality of the tape, five patients had urethral angulation abnormality and 11 patients had the previous two abnormalities. After tape lysis, the obstructive symptoms disappeared in 19 out of 22 patients (86%), the bladder overactivity symptoms disappeared in 16 out of 24 patients (66%). In case of introital ultrasound abnormalities, the tape lysis was efficient in 23 out of 26 patients (89%), while in the absence of ultrasound abnormalities (five patients), the tape lysis was not useful in treating LUTS in all patients.

CONCLUSION

Ultrasonography is a useful tool in investigating postoperative low urinary tract symptoms and in the selection of patients who will benefit from tape lysis.

[Can candidates for reimplantation of suburethral sling after sling removal due to chronic obstruction be identified intraoperatively?]

OBJECTIVE

To intraoperatively identify candidates for immediate reimplantation of a suburethral sling after sling removal due to chronic obstruction.

MATERIAL AND METHOD

Clinical study of 22 women, operated by suburethral sling for stress urinary incontinence between 2000 and 2007, who subsequently developed lower urinary tract obstructive symptoms. The suburethral sling was removed in all patients under local anaesthesia and fentanyl/midazolam sedation. Immediate replacement of the suburethral sling was performed in patients with cough incontinence demonstrated intraoperatively after sling removal. The measure of handicap urinary (MHU) questionnaire, UDI-6/IIQ-7 score and uroflowmetry with determination of the post-voiding residual volume were performed before and three months after the operation.

RESULT

Twelve patients (group 1) underwent removal and reimplantation of a new sling and 10 patients (group 2) underwent simple sling removal. The two groups were comparable. In each group, a significant difference was observed between preoperative and postoperative post-voiding residual volume, peak flow rate and MHU score and a non-significant difference was observed for the UDI-6/IIQ-7 score in group 2, in contrast to group 1. The urinary continence rate was 100% in both groups. The success rate, defined urodynamically, was 75% in group 1 and 80% in group 2. The success rate, defined by resolution of the initial urinary symptoms and improvement of the questionnaire score, was 75% in group 1 and 90% in group 2.

CONCLUSION

Candidates for immediate replacement of suburethral sling after sling removal due to obstructive symptoms can be identified intraoperatively. The cough test under local anaesthesia and fentanyl/midazolam sedation allows selection of these patients. Immediate sling replacement is accompanied by good results on continence without inducing a new obstruction.

Pharmacokinetics (PK) and immunologic responses in a phase I/II study of a sustained release formulation of IL-2 in renal cell carcinoma (RCC) patients

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Background: The utility of interleukin-2 (IL-2) in treating RCC is limited by its significant toxicity, expense, and limited efficacy. Formulations that reduce post-injection peak concentration (Cmax) and support sustained therapeutic levels may improve efficacy and tolerability of IL-2 therapy. In preclinical studies, IL-2 formulated with Medusa (IL-2XL), a novel sustained drug delivery system, reduces Cmax and supports controlled release of IL-2 for up to 6 days. Methods: The open-label Phase I/II study was designed to accrue 12 patients (pts), with a goal of 10 evaluable pts. Pts aged 18–85 at high risk of recurrence after surgical resection of histologically confirmed RCC, and without CNS metastases, other malignancy, autoimmune disorders were eligible. Pts received one single subcutaneous (SC) injection of 10.6 MIU naked IL-2 (IL-2N) or IL-2XL. At least two weeks later, patients were crossed over to receive a single SC administration of 10.6 MIU of the other agent. Safety, PK, biological activity and immunological responses were assessed. Results: 8 patients have accrued and results from 6 pts evaluable to date show a 4-fold reduction in Cmax following IL-2XL injection compared with IL-2N. IL-2 was detectable in serum 7 days after IL-2XL treatment, compared with 2 days for IL-2N. Relative bioavailability of IL-2XL was approximately 150% of IL-2N, and Tmax was appoximately 48 hrs compared with 2–4 hrs. T50 also was higher following IL-2XL administration compared with IL-2N (48 vs. 8 hrs). Soluble CD25 and neopterine, markers of IL-2 activity, had much higher Cmax (159 vs. 63 pg/ml and 14 vs. 6 pM for sCD25 and neopterin) and AUC (14,749 vs. 7,701 pg/ml/hrs and 1,569 vs. 665 pM/hrs for sCD25 and neopterin) following IL-2XL treatment compared with IL-2N. Compared to IL-2N immunoflowcytometry showed an increase in percentage and activation of lymphocytes (CD3+/CD45+; CD8+/CD25+ and CD4+/CD25+). Conclusions: Weekly dosing of IL-2XL reduces Cmax, increases induction of IL-2 biomarkers and improves immunologic responses compared with IL-2N. Data support the development of IL-2-XL used on a weekly schedule for treating cancer and viral disease such as HIV.

No significant financial relationships to disclose.

Unfaithfulness and promiscuity of a mutant androgen receptor in a hormone-refractory prostate cancer

Missense mutations in the androgen receptor (AR) contribute to the failure of hormonal therapy for prostate cancer (PCa), but the underlying molecular bases remain uncharacterized. Here, we describe a new AR variant found in a hormone-refractory metastatic PCa, in which threonine 575 in the DNA binding domain, and threonine 877 in the ligand-binding domain, were both replaced by an alanine. Using gene reporter assays, we demonstrate that the T575A mutation weakened transcriptional activity from promoters containing AR-specific responsive elements, while activity from promoters with AR-non-specific elements was enhanced. Data from gel shift experiments revealed a preferential binding of the T575A mutant to AR-non-specific motifs. We demonstrate that the two mutations T575A and T877A cooperate to confer new functional properties on the AR, and that the mutant AR functions simultaneously as a promiscuous AR due to the T877A mutation, and an unfaithful AR due to the T575A mutation.

Emphysematous pyelitis: findings in five patients

Emphysematous pyelitis (EP) is a benign entity. To our knowledge, it has not been reported frequently in the radiology literature. Previous articles have not focused on EP but rather have included other gas-forming entities (eg, emphysematous pyelonephritis [EPN]). The authors describe imaging findings in EP and distinguish them from findings in EPN in five cases. Computed tomography is the current method for demonstrating isolated gas production inside the urinary collecting system. The prognosis is excellent, with rapid complete recovery after medical treatment.

[Post-traumatic rupture in ureteropelvic junction obstruction syndrome: two case reports]

Post-traumatic rupture of UPJ obstruction is a rare event, with few reported cases in the literature. Diagnosis is suggested on imaging studies, especially US and CT findings. The presence of an anterior pelvic hematoma associated with thinning of kidney parenchyma, very distended pelvis and non dilated ureter is suggestive of pre-existing pathology.

Microscopic venous invasion: a prognostic factor in renal cell carcinoma

OBJECTIVE

Microscopic venous invasion (MVI) is characterized by local destruction of the endothelium by a tumor. The prognostic value of MVI in renal cell carcinoma (RCC) is not well established.

MATERIALS AND METHODS

From 1980 until 1990, 255 patients (169 men and 86 women), aged 16-87 (mean 60) years were treated by radical nephrectomy for N0M0 RCC. There were 9 pT1, 163 pT2, 30 pT3a, 34 pT3b, and 19 pT3ab (TNM 1992). The median follow-up time was 74 months. MVI was determined by a double-blind histological study with immunohistochemical staining.

RESULTS

MVI was noted in 74 patients (29%). MVI significantly increased metastatic progression (p = 0.003). Only stage and Fuhrman's grade were significant factors for metastatic progression in a multivariate analysis. MVI decreased the actuarial survival rates at 1 year (p = 0.01), but not significantly at 5 and 10 years. MVI and non-MVI survival curves were statistically different with the Peto/Wilcoxon (p = 0.04) and Gehan/Wilcoxon (p = 0.03) tests, but not with the log rank test (p = 0.06). MVI decreased survival in cases with a tumor size of 10 cm or more, capsular invasion, macroscopic venous invasion, stage pT3ab, sarcomatoid cell carcinoma and Fuhrman's grade IV. Only the stage was a significant factor for survival in a multivariate analysis.

CONCLUSION

In RCC, MVI is related to cancer progression and survival, but probably not as an independent prognostic factor.

Single stones of the lower pole of the kidney. Comparative results of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy

OBJECTIVE

To assess the effectiveness of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCN) as a treatment for stones of the lower pole of the kidney and to compare their morbidity according to the stone size.

METHODS

We retrospectively studied 739 patients treated for a single stone of the lower pole. Group I consisted of 666 patients treated by ESWL and group II consisted of 73 patients treated by PCN.

RESULTS

These were assessed at 3 months for 587 ESWL patients (88%) and at day 1 for all PCN patients on renal tomography or ultrasonography. Respectively in groups I and II, 335 patients (57%) and 53 patients (72.6%) were stone-free (p = 0.01). For medium-size (10-20 mm) stone patients, stone-free represented 102 patients (44%) and 29 patients (72.5%) in groups I and II respectively (p = 0.001). For smaller stones (< 10 mm), stone-free represented 231 patients (69%) and 21 patients (84%) in groups I and II respectively (p = 0.12). Morbidity rate was less with ESWL than with PCN.

CONCLUSIONS

PCN achieves better results than ESWL for single stone of the lower pole with statistical significance for middle-size stones but with higher morbidity.

[Helical CT of urinary tract: clinical applications]

Helical CT is the most useful imaging modality to evaluate kidney diseases. Different imaging protocols are used to assess the correct diagnosis in each clinical situation. The nephrographic phase (between 90 and 100 s of delay after injection) is more accurate than the cortical phase (between 30 and 40 s of delay) to depict and characterise small renal masses. Multiplanar and 3D reconstruction are useful to plan partial kidney surgery or percutaneous surgery of lithiasis. In emergency, spiral CT, if available, is suitable to assess renal colic. Spiral CT is the best modality to evaluate traumatic kidney.

Three-month sustained-release form of triptorelin in patients with advanced prostatic adenocarcinoma: results of an open pharmacodynamic and pharmacokinetic multicenter study

The pharmacodynamics and the pharmacokinetic characteristics of a new longer-acting formulation containing 11.25 mg of triptorelin (Decapeptyl) to be administered every 3 months were evaluated in 14 patients with advanced prostate carcinoma. After one single injection, the mean time to reach the surgical castration testosterone range is 22 days, and this effective testosterone suppression is maintained for the 3-month therapy. After a first plasma surge (35.70 ng/ml) occurring 2.5 h after injection and a rise between day 17 and day 31 (maximum on day 24: 0.32 ng/ml), the mean triptorelin plasma level is stable (0.06 +/- 0.05 ng/ml) and maintained until day 91. This new formulation was well tolerated both locally and systemically.

Evaluation of microsatellite analysis in urine sediment for diagnosis of bladder cancer

Alterations at microsatellite DNA markers in cells exfoliated in urine have been correlated to the presence of bladder cancer. To check the feasibility of such noninvasive analysis to routinely diagnose bladder cancers, we have developed a highly sensitive method using fluorescent PCR to search for DNA microsatellite alterations in urine sediment compared with a blood paired sample. One hundred eighty-three patients were included in our study. This population comprised 103 bladder cancers (64 pTa stages), the complement representing controls and other benign or malignant diseases. Results of the analysis at 17 loci in a blinded study were compared with cystoscopy and/or pathology. The high reproducibility of this technique and the analysis of 26 control patients allowed us to determine for each microsatellite a cutoff characterizing a significant allelic imbalance. For bladder cancer detection, the overall sensitivity of the test was 84%. Using this procedure, we identified alterations in 81%, 84%, 91%, and 100% of pTa, pT1, pT2, and >pT2 stages, respectively. This corresponds to 79%, 82%, and 96% sensitivity for grades I, II, and III, respectively. Interestingly, for routine purposes, we observed an overall sensitivity of 80% (76% for pTa stages) when only the eight most rearranged microsatellites were considered. In conclusion, the noninvasive feature combined with the rapidity of this fluorescent and highly sensitive technique for the detection of early stages provides us with a useful help for the diagnosis of bladder cancer.

Histological and genetic analysis and risk assessment for chromosomal aberration after ICSI for patients presenting with CBAVD

Intracytoplasmic sperm injection (ICSI) has opened a new field in the treatment of male infertility, leading to a debate concerning its genetic safety. In this study we present an analysis of 11 patients presenting congenital bilateral absence of the vas deferens (CBAVD). In all 11 cases, genetic counselling, histological analysis of testicular biopsies, cystic fibrosis transmembrane conductance regulator (CFTR) mutation screenings of both partners and spermatozoa three-colour fluorescent in-situ hybridization (FISH) analysis were performed. A total of 31 CFTR mutations were screened and mutations were found in eight out of 11 cases, with DeltaF508 being the most common mutation found. Histological analyses showed that seven out of 11 patients had normal tubule/membrane/interstitium (TMI) and Johnsen scores, while the remaining four patients had mild impairment of testicular parenchyma. The average aneuploidy rate was 6.8 +/- 3.9% compared with two control subjects with 4.4 and 5.4% aneuploidy rates respectively, using FISH analysis. After ICSI, the fertilization and pregnancy rates were 66.2 and 22.7% respectively. Thus, in our case of CBAVD, the risk of chromosomal aberration following ICSI, in the absence of a CFTR mutation in the male patient and/or in his partner, was not higher than in normal fertile men. Furthermore, the pregnancy success rate following ICSI of these CBAVD patients was comparable to the general ICSI population, even when histological analysis showed limited spermatogenesis.