Treatment-induced neuroendocrine prostate cancer and de novo neuroendocrine prostate cancer: Identification, prognosis and survival, genetic and epigenetic factors

Neuroendocrine prostate cancer (NEPC) shows an aggressive behavior compared to prostate cancer (PCa), also known as prostate adenocarcinoma. Scanty foci in PCa can harbor genetic alternation that can arise in a heterogeneity of prostate cancer. NEPC may arise de novo or develop following androgen deprivation therapy (ADT). NEPC that arise following ADT has the nomenclature “treatment-emerging/induced NEPC (t-NEPC)”. t-NEPC would be anticipated in castration resistant prostate cancer (CRPC) and metastatic PCa. t-NEPC is characterized by low or absent androgen receptor (AR) expression, independence of AR signaling, and gain of neuroendocrine phenotype. t-NEPC is an aggressive metastatic tumor, develops from PCa in response to drug induced ADT, and shows very short response to conventional therapy. t-NEPC occurs in 10%-17% of patients with CRPC. De novo NEPC is rare and is accounting for less than 2% of all PCa. The molecular mechanisms underlying the trans-differentiation from CRPC to t-NEPC are not fully elucidated. Sphingosine kinase 1 plays a significant role in t-NEPC development. Although neuroendocrine markers: Synaptophysin, chromogranin A, and insulinoma associated protein 1 (INSM1) are expressed in t-NEPC, they are non-specific for diagnosis, prognosis, and follow-up of therapy. t-NEPC shows enriched genomic alteration in tumor protein P53 (TP53) and retinoblastoma 1 (RB1). There are evidences suggest that t-NEPC might develop through epigenetic evolution. There are genomic, epigenetic, and transcriptional alterations that are reported to be involved in development of t-NEPC. Knock-outs of TP53 and RB1 were found to contribute in development of t-NEPC. PCa is resistant to immunotherapy, and at present there are running trials to approach immunotherapy for PCa, CRPC, and t-NEPC.

Erdafitinib and checkpoint inhibitors for first-line and second-line immunotherapy of hepatic, gastrointestinal, and urinary bladder carcinomas: Recent concept

Cancer immunotherapy is administered for first-line, second-line, neoadjuvant, or adjuvant treatment of advanced, metastatic, and recurrent cancer in the liver, gastrointestinal tract, and genitourinary tract, and other solid tumors. Erdafitinib is a fibroblast growth factor receptor (FGFR) inhibitor, and it is an adenosine triphosphate competitive inhibitor of FGFR1, FGFR2, FGFR3, and FGFR4. Immune checkpoint inhibitors are monoclonal antibodies that block programmed cell death protein 1 (PD-1) and its ligand that exert intrinsic antitumor mechanisms. The promising results of first-line treatment of advanced and metastatic urothelial carcinoma with PD-1 blockades with single or combined agents, indicate a new concept in the treatment of advanced, metastatic, and recurrent hepatic and gastrointestinal carcinomas. Cancer immunotherapy as first-line treatment will improve overall survival and provide better quality of life. Debate is arising as to whether to apply the cancer immunotherapy as first-line treatment in invasive carcinomas, or as second-line treatment in recurrent or metastatic carcinoma following the standard chemotherapy. The literature in the field is not definite, and so far, there has been no consensus on the best approach in this situation. At present, as it is described in this editorial, the decision is applied on a case-by-case basis.

Is bladder outlet obstruction rat model to induce overactive bladder (OAB) has similarity to human OAB? Research on the events in smooth muscle, collagen, interstitial cell and telocyte distribution

BACKGROUND

Cellular and cytoskeletal events of overactive bladder (OAB) have not been sufficiently explored in human bladder due to different limitations. Bladder outlet obstruction (BOO) had been induced in different animal models with different methods to induce (OAB). Similarity of the animal models of BOO to the human OAB is postulated but has not been confirmed. The interstitial cells of Cajal (ICCs), and telocytes (TCs) are an important players in smooth muscles conductivity, they had not been well investigated in the previous BOO models. Objectives are to investigate the morphological pattern of cellular, cytoskeleton and telocytes distribution in BOO rat model and to match the events in two time periods and compare it to the findings in real-world human OAB.

METHODS

Female Sprague-Dawley rats (Rattus norvegicus) were randomly divided into: sham (n = 10), BOO 6 W (n = 10), BOO 8 W (n = 10). Operative procedure to Induce BOO was done under anesthesia with intraperitoneal Ketamine administration. The Effect of induction of BOO was evaluated after 6 and 8 weeks. The rats were anesthetized, and the urinary bladder was removed, while the rat was unconscious under anaesthesia it was transferred to the inhalation anaesthesia cage for euthanasia, rats were sacrificed under light anesthesia using isoflurane. Care of animals, surgical procedure, and euthanasia adhered to Guide for the Care and Use of Laboratory Animals, and AVMA Guidelines for the Euthanasia of Animals. The retrieved bladder was processed for examination with histopathology, immunohistochemistry (IHC), and transmission electron microscopy (EM).

RESULTS

Histological examination of the bladder shows thinner urothelium, condensation of collagen between muscle bundles. IHC with c-kit shows the excess distribution of ICCs between smooth muscle bundles. EM shows frequent distribution of TCs that were situated between collagen fibers. Finings in BOO 6 W group and BOO 8 W group were comparable.

CONCLUSION

The animal model study demonstrated increased collagen/ smooth muscle ratio, high intensity of ICCs and presence of TCs. Findings show that a minimally invasive procedure to induce BOO in rats had resulted in an OAB that has morphological changes that were stable in 6 & 8 weeks. We demonstrated the distribution of TCs and ICCs in the rat animal model and defined them. The population of TCs in the BOO rat model is described for the first time, suggests that the TCs and ICCs may contribute to the pathophysiology of OAB. Similarity of animal model to human events OAB was demonstrated. These findings warrant further study to define the role of TCs in OAB.

CLINICAL TRIAL REGISTRY

The study does not require a clinical trial registration; it is an experimental animal study in basic science and does not include human subjects.

Concerns about stone free rate and procedure events of percutaneous nephrolithotripsy (PCNL) for 2-4 cm kidney stones by standard-PCNL vs mini-PCNL- comparative randomised study

BACKGROUND

To compare the efficacy and safety of standard percutaneous nephrolithotomy (PCNL) with mini- PCNL for kidney stones 2-4 cm.

METHODS

Eighty patients were enrolled in a comparative study, they were randomly divided into mini-PCNL group (n = 40) and standard-PCNL (n = 40). Demographic characteristics, perioperative events, complications, stone free rate (SFR) were reported.

RESULTS

Both groups showed no significant difference in clinical data about age, stone location, back pressure changes, and body mass index. The mean operative time was (95 ± 17.9 min) in mini-PCNL, and (72.1 ± 14.9 min). Stone free rate were 80% and 85% in mini-PCNL and standard-PCNL respectively. Intra-operative complications, post-operative need for analgesia, hospital stay were significantly higher in standard-PCNL compared to mini-PCNL (85% vs. 80%). The study followed CONSORT 2010 guidelines for reporting parallel group randomization.

CONCLUSION

Mini-PCNL is an effective and safe treatment of kidney stones 2-4 cm, it has the advantage over standard-PCNL being has less intra-operative events, less post-operative analgesia, shorter hospital stay, while operative time and stone free rate are comparable when considering multiplicity, hardness, and site of stones.

Telocytes and ezrin expression in normal-appearing tissues adjacent to urothelial bladder carcinoma as predictors of invasiveness and recurrence

Recurrence and progression rates vary widely among different histological subtypes of bladder cancer (BC). Normal-appearing mucosa in non-muscle invasive bladder cancer and muscle-invasive bladder cancer in cystoscopy and histopathology is a factor in staging and treatment. Telocytes (TCs) are spindle-shaped cells that connect with other cell types allowing communication though cytoskeletal signaling. They are involved in tissue regeneration and pathogenesis of diseases and cancer. In this study, 12 normal-appearing tissues from urinary bladder with BC, both invasive and non-invasive were evaluated in patients who had either trans-urethral resection of bladder tumor or cystectomy. In each case, cystoscopy, intraoperative inspection, and histopathology all confirmed the absence of cancerous elements. Five patients with neurogenic bladder were used as a control group. Immunohistochemistry revealed that c-Kit + cells were intensively distributed in bladder layers from BC samples, while they were seldom detected in the control group. Ultrastructural examination of reprocessed tissue showed an intense distribution of TCs and telopodes in the submucosa and between smooth muscle cells in BC. Telopodes were numerous, arborizing, and intercommunicating. Whereas TCs and telopodes were scarce in the neurogenic bladder. Also, cancerous tissue had the highest expression level of ezrin protein, and this level gradually decreased as we moved away from the tumor. Our finding of TCs number in normal-appearing tissues in conjunction with ezrin expression may compete invasiveness and possibly a trail to reduce recurrence rates.

Multidisciplinary basic and clinical research of acute kidney injury with COVID-19: Pathophysiology, mechanisms, incidence, management and kidney transplantation

Acute kidney injury (AKI) linked to coronavirus disease 2019 (COVID-19) has been identified in the course of the disease. AKI can be mild or severe and that is dependent on the presence of comorbidities and the severity of COVID-19. Among patients who had been hospitalized with COVID-19, some were admitted to intensive care unit. The etiology of AKI associated with COVID-19 is multifactorial. Prevention of severe AKI is the prime task in patients with COVID-19 that necessitates a battery of measurements and precautions in management. Patients with AKI who have needed dialysis are in an increased risk to develop chronic kidney disease (CKD) or a progression of their existing CKD. Kidney transplantation patients with COVID-19 are in need of special management to adjust the doses of immunosuppression drugs and corticosteroids to guard against graft rejection but not to suppress the immune system to place the patient at risk of developing a COVID-19 infection. Immunosuppression drugs and corticosteroids for patients who have had a kidney transplant has to be adjusted based on laboratory results and is individualized aiming at the protection of the transplanted from rejection.

Telocytes, c-Kit positive cells, Smooth muscles, and collagen in the ureter of pediatric patients with congenital primary obstructive megaureter: elucidation of etiopathology

Congenital primary obstructive megaureter (POM) is an uncommon pediatric anomaly that is due to obstructive distal ureter leading to the loss of peristalsis with consequent ureterohydronephrosis causing loss of kidney function. The objectives are to elucidate the etiology of POM by demonstrating the presence of interstitial cells of Cajal (ICC), telocytes, smooth muscles, and collage in the obstructive and dilated ureteral segments. The study was carried out on 15 surgical specimens of congenital POM in pediatric patients, age range was 4 to 24 months, they were operated upon by excision of the obstructed segment, tailoring the dilated ureter, and anastomosing it to the bladder. Specimens included the obstructed ureteral segment and part of the dilated ureter. Specimens were examined with hematoxylin and eosin (H&E) stain, Modified Gomori trichrome stain, immunohistochemistry (IHC) with α-muscle actin, and c-kit (CD117), and transmission electron microscopy (TEM). Obstructed segment showed excess collagen intervening between smooth muscles, excess c-Kit positive cells, and presence of telocytes. The dilated segment of the ureteral wall is formed of smooth muscle bundles with scanty collagen. Staining with c-Kit did not demonstrate positive cells. TEM showed myofibroblasts and close adherence of smooth muscle cells to each other with absence of telocytes. The pathophysiology of POM is multifactorial. Loss of interstitial cells and rarity of collagen result in loss of elasticity of dilated segment leading to massive dilatation. While the obstructed segment had no muscle conductivity due to excess collagen irrespective of presence of telocytes.

Lower urinary tract dysfunction in pediatrics progress to kidney disease in adolescents: Toward precision medicine in treatment

Newborn infants who had neurogenic bladder dysfunction (NBD) have a normal upper urinary tract at birth. Most of them will develop deterioration of renal function and chronic kidney disease if they do not receive proper management. Children with NBD can develop renal damage at adolescence or earlier, which is due to high detrusor pressures resulted from poor compliance of the bladder, detrusor overactivity against a closed sphincter or detrusor sphincter dyssynergia. To preserve renal function and prevent deterioration of the kidneys, NBD must be treated immediately after being diagnosed. Over the last few years there was great progress in the treatment of children with the NBD. We searched PubMed and the Cochrane Library for peer-reviewed articles published in any language up to March 10, 2021, using the search term “neurogenic bladder children.” Our search excluded diagnosis, pathophysiology, surgical treatment of spinal cord injury and spina bifida. The research identified the effectiveness of treatment regimens targeting prevention of chronic kidney disease and the indications of kidney transplantation. The results of the research showed that NBD in children should be diagnosed early in life, and the child should receive the proper management. The literature search concluded that the management of NBD in children would be personalized for every case and could be changed according to response to treatment, side effects, child compliance, availability of treatment modality and costs of treatment. The objectives of the study are to present the different options of management of NBD in children and the selection of the proper method in a personalized manner.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series

Introduction

Hypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap.

Material and methods

From March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS).

Results

The results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported 'very satisfactory' (98.2%) and 'satisfactory' (1.8%).

Conclusions

The described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator's and parent's perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Genital-Sparing Cystectomy versus Standard Urethral-Sparing Cystectomy Followed with Orthotopic Neobladder in Women with Bladder Cancer: Incidence and Causes of Hypercontinence with an Ultrastructure Study of Urethral Smooth Muscles

BACKGROUND:

Bladder cancer in women is an indication for radical cystectomy (RC) when the tumour is confined muscle-invasive bladder cancer (MIBC) of T2 N0M0, or high risk progressive non-muscle invasive bladder cancer (NMIBC). Radical cystectomy is either genital-sparing cystectomy (GSC) or standard urethra-sparing cystectomy (USC) that is followed with orthotopic ileal neobladder (ONB). Post-operative chronic retention “Hypercontinence” had been reported in different series following URS or GSC and ONB. In long-term follow-up, we evaluated the functional outcome of women who developed hypercontinence after USC or GSC and ONB.

AIM:

An ultrastructure study of female urethral smooth muscle was done to elucidate the underlying causes of hypercontinence.

MATERIAL AND METHODS:

Retrospective study was conducted on 71 women who underwent RC and ONB, 45women had undergone USC, and 26 women had GSC, follow-up ranged from 5 to 15 years. Ultrastructure studies were done on 5 urethral biopsy specimens from 5 women who had hypercontinence, and 4 biopsies were from a normal control.

RESULTS:

Follow-up showed that women who had undergone USC and ONB, 28.88% developed hypercontinence, where in the series of GSC and ONB three women out of 26 developed hypercontinence (7.80%). Three women who had hypercontinence following USC and ONB, they developed stones in the ileal pouch. Ultrastructure study of urethral smooth muscles in women who had hypercontinence showed organized collagen fibrils, absent myelin sheath, and non-detected lymphatic vessels. Normal urethra showed collagen fibrils within the interstitial matrix, preserved myelin sheath of nerve fibres, the presence of lymphatic vessels in the matrix.

CONCLUSION:

The present study shoes that GSC with ONB leads to the minimal incidence of hypercontinence (7.80%), while standard USC lead to higher incidence (28.88%). Ultrastructure changes of the female urethra who had hypercontinence were fibrotic changes, loss of myelin sheath and minimal vascularity, their findings explains the underlying cause of hypercontinence and support the technique of GSC rather than the standard USC.

Upregulation of Twist2 in Non-Muscle Invasive Urothelial Carcinoma of the Bladder Correlate with Response to Treatment and Progression

BACKGROUND:

Twist2 is a transcription factor and an epithelial-to-mesenchymal transition that plays an important role in cell polarity, cell adhesion, and has a role in tumour invasion and metastases.

AIM:

In this study, we examined the expression of Twist2 in non-muscle invasive bladder carcinoma (NMIBC) and correlated the expression with response to treatment and tumour progression.

METHODS:

Data of 305 patients with NMIBC of Ta, T1 were retrieved from hospitals archives. Twist2 expression was examined in tissue samples by immunohistochemistry at initial diagnosis and final follow-up, normal control was 10 normal urothelium, 10 patients with muscle-invasive bladder cancer (MIBC) were a positive control. Treatment of NMIBC was implemented according to the European Association of Urology guidelines on NMIBC. The descriptive statistical analysis included means, standard deviation, p-value; Univariate and multivariate Cox regression analyses.

RESULTS:

Twist2 expression score was identified as negative, low (1-15%); medium (15-40%); and high (40-100%). Patients who had low or low medium scores at the initial diagnosis had a good response and a favourable prognosis. Expression of a high score of Twist2 in patients having high-grade T1 tumours showed non-responsiveness to repeated courses of intravesical bacillus Calmette Guerin (BCG) therapy and was upstaged to MIBC.

CONCLUSION:

Twist2 expression in tissue samples of NMIBC would indicate the tumour response to therapy, upgrading and upstaging in the follow up after intravesical BCG therapy.

TWIST2 EXPRESSIONS IN PATIENTS WITH SQUAMOUS CELL CARCINOMA OF THE URINARY BLADDER SHOWED DOWN REGULATION CORRELATED WITH GOOD SURVIVAL AND LOW INCIDENCE OF DISTANT METASTASIS

This study evaluated the association between expression of Twist2 monogenic, with pathological features and clinical outcomes of squamous cell carcinoma of the urinary bladder (SCCUB) following radical cystectomy (RC). Immunohistochemical staining Twist2 was performed on tissue archival samples comprising normal urothelium from ten controls, cystectomy specimens from 87, patients with T2 NO MO and T3-4a NO MO of bladder squamous cell carcinoma (SCC).all patients with T2-4 SCC undergone radical cystectomy and urinary diversion, follow up was for 5-10 years to assess overall survival (OS) and disease free survival (DFS). Specimens from 10 muscle-invasive urothelial carcinoma patients were reassessed for Twist2 expression to represent over- expression of Twist2. All ten controls had normal status of biomarkers which was negative. Negative or, low, and medium expression of Twist2 was noted in SCC of the urinary bladder of local pathological status with no lymph node metastasis or distant metastasis, clinicopathologic characteristics of the cohort were pT2NO MO (n=659 and pT3-4a NO MO (n= 22). Twist2 negative expression was in 36 case, weak expression (n=33), medium expression (n=16), there were no strong expression. Twist2 low-regulation with combination of tomor stage in SCC of the urinary bladder werel independently associated with overall survival and free disease survival, 7.7 and 5 years survival in pT2 NO MO(n=65) were 89% and 13% respectively, 7.7 and 5 years survival in pT3-4a NO MO(n=22) were 72.7% and 22.7% respectively.

AMBULANT FLEXIBLE CYSTOSCOPY FOR FOLLOW-UP OF Ta-TI UROTHELIAL CARCINOMA OF THE URINARY BLADDER: PAIN PERCEPTION AND COST EFFECTIVE

Ambulant flexible cystoscopy is the standard procedure in the urological practice for follow-up of Ta-T1 urothelial carcinoma (UC) due to its ability to survey the bladder for a variety of indications. It is the principal means of diagnosis and surveillance of bladder tumors. The follow-up of patients treated for Ta-T1 UC is of great importance because of the high incidence of recurrence and progression of the disease, whereby patients with Ta-T1 UC undergo cystoscopy every three months. The aim of this study to evaluate the procedure of ambulant flexible cystoscopy in proper diagnostic follow-up of Ta-T1 UC, patient's acceptance in regard to pain tolerance, non-hospital stay and expenses. Twenty one patients (18 male and 3 female) were diagnosed before as Ta-T1 UC by rigid cystoscopy and transuretheral resection of bladder (TURB) lesion scheduled for follow up by flexible cystoscopy under local anesthesia using 20 ml 2% lidocain gel on an ambulatory bases. Comparison was done using a cohort of 32 patients who underwent the procedure of follow-up of Ta-T1 cystoscopy and TURB using rigid cystoscopy and resectoscope. Seventeen patients 80.9% (16 male and 2 female) proved to be bladder free from recurrent lesion, 4 patients {19.1 %} (3 males and one female) which revealed recurrent lesions in spite of that the urinary bladder was free in pelvic ultrasonography. Cold cup biopsy from the lesions sent for histopathological examination which revealed recurrence of the tumor in 3 patients (two patients with Ta and one patient T1. TURB was done to have complete resection in 4 patients, the histopathological examination revealed ulcerating mucosa and free lamina propria in 3 specimens, and T2 in the fourth specimen. Comparison between the 2 groups revealed more patient's acceptance for the flexible cystoscopy group as regard pain tolerance, non-hospital stay and expenses. Ambulatory flexible cystoscopy with 20 ml of 2% lidocaine gel anesthesia is tolerated well by patients, with advantage of no hospital stay in the regular follow up of Ta-T1 tumors, pain perception was accepted by all patient provided delayed cystoscopy after lidocaine-gel instillation.

COMPUTED TOMOGRAPHY VERSUS PLAIN RADIOGRAM IN EVALUATION OF RESIDUAL STONES AFTER PERCUTANEOUS NEPHROLITHOTOMY OR PYELONEPHROLITHOTOMY FOR COMPLEX MULTIPLE AND BRANCHED KIDNEY STONES

This study compared the efficacy of computed tomography of the urinary tract (CT urography) versus plain X-ray of the urinary tract (KUB) in detection and evaluation of the significance of residual stone after percutaneous nephrolithotripsy (PCNL) or surgical pyelonephrolithotomy (SPNL) for complex branching or multiple stones in the kidney. A retrospective prospective archival cohort of 168 patients underwent PCNL or SPNL for large stag horn or multiple stones in the kidney were evaluated, they were 113 patients who underwent SPNL, and 55 patients underwent PCNL. In all patients they had KUB second day of the operation, those who had multiple kidney punctures in the PCNL procedure for multiple stones, or multiple nephrotomies in the SPNL procedure, or had a radiolucent stones had an additional imaging with CT urography. Indications for the CT urography were cases of radiolucent stones and multiple small calyceal stones detected pre-operatively. The study was conducted between March 2010 and December 2014, data weie retrospectively analyzed. Preoperatively multiple or branching stones were diagnosed with intravenous urography and CT urography. Stone size and location were mapped pre-operatively on a real-size drawing, and three dimensional computed construction images in multiple planes. All patients were informed about the advantages, disadvantages and probable complications of both PCNL and SPNL before the selection of the procedure. Patients decided the type of the surgery type by themselves and written informed consent was obtained from all patients prior to the surgery. Patients were in two groups according to the patient's preference of surgery type. Group 1 consisted of 113 patients who underwent SPNL and Group 2 consisted of 55 patients treated with PCNL. Detection of residual stones stone postoperatively using KUB and CT urography was evaluated in both groups. There was statistical significance between the two imaging methodology in detection of residual stones after PCNL and/or SPNL. CT urography detected stones of 2 mm and up to 5mm which was not visualized with KUB. CT urography was statistically significant and precise in detecting the radiolucent stones of uric acid, urate, and phostate stones which were not detected by KUB.

Detour technique, Dipping technique, or Ileal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder

Background:

Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated.

Design and Participants:

From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder.

Surgical procedures:

Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter.

Results:

Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J.

Conclusion:

After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

Superiority of fluorescent in situ hybridization over immunohistochemistry in detection of HER2 gene in carcinoma of the urinary bladder associated with and without schistosomiasis

HER2 is an oncogene encoding a type 1 tyrosine kinase growth factor receptor and the role of HER2 in the development of numerous types of human cancer is still understood and correlates with clinical outcome, poor prognosis, it is a predictor factor for poor response to chemotherapy. HER2 overexpression is associated with reduced disease free and overall survival. Patients who have HER2 negative expression have a poor prognosis. The aim of the present study is to explore the accuracy of detection of expression of HER2 protein by two different techniques of immunohistochemistry (IHC) and gene amplification by fluorescent in situ hybridization (FISH). The two techniques were applied to sixty two patients that included different cell types of carcinoma of the bladder, benign bilharzial lesions and control. Characteristics of the 62 patients are: 10 chronic cystitis, 19 squamous cell carcinoma (SCC) with schistosomiasis, 33 urothelial carcinoma (UC) schistosomal and non-schistosomal, ten healthy individuals without schistosomiasis served as controls. Gene amplification of HER2 was done using FISH and protein expression of HER2 by IHC. The study was applied on archival data of formalin-fixed paraffin embedded tissues and patient clinical data and follow up for 5 years. Overexpression of HER2 protein was found in 30/52 (57.7%). Fourteen cases had score of 2+, and sixteen cases had score of 3+. Using FISH technique it showed more accurate detection of HER2 gene as those fourteen cases who had score of 2+ had been found to be 5 out of 14 were positive for gene over expression, the other sixteen who had score of 3+ all were positive for gene amplification. HER2 protein and gene was found to be significantly overexpressed in carcinoma of the bladder in both cell types SCC and UC with or without schistosomiasis compared to the benign lesions and control groups (P <0.01) by both techniques. There is significant increase in expression of HER2 protein and gene in SCC compared to UC (P< 0.01). In UC overexpression of HER2 protein and gene was evident in all stages Ta, T1, T2-4. HER2 protein and gene overexpressed in different grades of UC. In SCC HER2 protein and gene had overexpression in different stages and grades.

Survival up to 5-15 years in young women following genital sparing radical cystectomy and neobladder: oncological outcome and quality of life. Single-surgeon and single-institution experience

Introduction

This is an observational retrospective study utilising long term patient follow–up for 15 years to determine the survival and quality of life in women (age range 20–54 years) after having been treated for carcinoma of the bladder by radical cystectomy with preservation of genital organs.

Material and methods

The study included 13 female patients with urothelial carcinoma of the bladder treated with genital sparing radical cystectomy during the period of 1995 until 2006. They had orthotopic ileal neobladder. Follow–up included recurrence–free survival, metastases–free survival, overall survival, continence, and sexual function.

Results

Genital sparing cystectomy was done in 13 women. Seven women were between the ages of 20–37, and 6 women were aged 38–54. Overall survival of 10–15 years was 61.53%, survival from 5 to 9 years was 38.46%. The procedure was done in 9 women with a muscle–invasive tumor of stage T2– T3a. Non–muscle invasive T1 tumor was present in four patients. Quality of life was assessed by continence, which was good in 10/13 patients. Three women needed CIC. Sexual function was tested by female sexual function index >20–30 and was scored at 84.61%.

Conclusions

The study provides evidence of safety and efficacy of radical cystectomy with sparing of genital organs in women aged 20 to 54 with urothelial carcinoma of the bladder. Oncological outcome for 5–15 years was good; continence and sexual function were good. This procedure should be considered when surgical approach appears to be feasible. The limitation of our findings is the small sample size of this case series.

Urothelial carcinoma of the urinary bladder mixed with squamous differentiation or squamous cell carcinoma in areas with schistosomiasis is showing high risk of recurrence and poor survival

In schistosomiasis haematobium areas endemic, bladder cancer is the first cause of malignancy in men and fourth in women. The chronic schistosomiasis would lead to variant histologic patterns which manifest in squamous cell carcinoma (SCC) or squamous differentiation (SqD). This study evaluated the clinical outcome after radical cystectomy (RC) in patients with urothelial carcinoma (UC) mixed with SCC or SqD, Comparison was done with two arms of pure UC and pure SCC, indication for RC was muscle-invasive-disease, and evaluation included recurrence, metastases, and overall survival. The data of patients treated with RC for muscle-invasive-disease, selection was revised for 127 patients with urothelial carcinoma mixed with SCC/SqD, two comparative arms were 100 patients with pure UC, and 100 patients had pure SCC. Follow up was on 8 months, 3 years, and 5 years to detect recurrence, metastasis, and overall survival in the three groups. The results showed that by comparison of disease aggressiveness in the three groups regarding recurrence, metastasis, and overall survival was analysed. Overall survival with mixed tumours was significantly lower than pure UC or SCC, recurrence and metastases were higher in mixed tumour which was an independent factor for poor prognosis and low survival.

Impact of density of schistosomal antigen expression in urinary bladder tissue on the stratification, cell type, and staging, and prognosis of carcinoma of the bladder in Egyptian patients

BACKGROUND

Infection with urinary schistosomiasis and its severity are oncogenic factors for developing carcinoma of the bladder, whether it is urothelial carcinoma (UC) of a transitional cell type (TCC) or non-urothelial of squamous cell carcinoma (SCC). In UC it is not defined whether it is schistosomal or not. This led to controversial results in expression of tumour markers, tumour prognosis, and response to therapy.

OBJECTIVES

We assessed the application by immunohistochemistry method (IHC) for detection of schistosomal antigen in bladder cancer tissue samples to differentiate UC associated with or without schistosomiasis. Urothelial carcinoma stage, grade, and progression were correlated with the density, intensity, and index of schistosomal antigen expression. Follow up was done for 2-5 years.

DESIGN AND PARTICIPANTS

Archival tissue samples of 575 patients were studied: 515 urothelial carcinoma, 30 patients with SCC associated with schistosomiasis, and a control group of 30 patients without schistosomiasis.

MEASUREMENTS

Expression of schistosomal antigen in tissue was done by IHC using monoclonal antibodies (MAbs) against schistosomal antigens (SA). Correlation of intensity of antigen expression to clinical and pathological data was analysed.

RESULTS AND LIMITATIONS

We identified 3 parameters of antigen expression: density, intensity and index with 4 grades for each. SCC-group was 100% positive. UC was positive in 61.4% distributed as follows: Ta: 37.5%, T1: 62%, and muscle invasive T2-4 were 64%. Upstaging, metastases and recurrence were correlated with high index in T1 and T2-4 tumours.

CONCLUSION

Urothelial carcinoma associated with schistosomiasis was defined by the positive expression of schistosomal antigens in tissues detected by lHC using MAbs against schistosomal haematobium. Upstaging and progression of T1 and T2-4 were correlated with high density, intensity, and index of antigen expression. Non-schistosomal UC had negative expression for schistosomal antigen, which was detected in 36.5% of cases. These results would be of significance in differentiating schistosomal from non-schistosomal bladder cancer of UC and would predict the prognosis in T1, T2-3 tumours. Implementation of IHC using MAbs against SA in UC would help in planning the proper therapy. Schistosomiasis should be considered as an oncogene for UC in endemic areas.

Muscle-derived cells for treatment of iatrogenic sphincter damage and urinary incontinence in men

Introduction. Aim of this study was to assess the safety and efficacy of injection of autologous muscle-derived cells into the urinary sphincter for treatment of postprostatectomy urinary incontinence in men and to characterize the injected cells prior to transplantation. Methods. 222 male patients with stress urinary incontinence and sphincter damage after uroloical procedures were treated with transurethral injection of autologous muscle-derived cells. The transplanted cells were investigated after cultivation and prior to application by immunocytochemistry using different markers of myogenic differentiation. Feasibility and functionality assessment was achieved with a follow-up of at least 12 months. Results. Follow-up was at least 12 months. Of the 222 treated patients, 120 responded to therapy of whom 26 patients (12%) were continent, and 94 patients (42%) showed improvement. In 102 (46%) patients, the therapy was ineffective. Clinical improvement was observed on average 4.7 months after transplantation and continued in all improved patients. The cells injected into the sphincter were at least ~50% of myogenic origin and representative for early stages of muscle cell differentiation. Conclusions. Transurethral injection of muscle-derived cells into the damaged urethral sphincter of male patients is a safe procedure. Transplanted cells represent different phases of myogenic differentiation.

Bladder cancer documentation of causes: multilingual questionnaire, 'bladder cancer doc'

There is a considerable discrepancy between the number of identified occupational-related bladder cancer cases and the estimated numbers particularly in emerging nations or less developed countries where suitable approaches are less or even not known. Thus, within a project of the World Health Organisation Collaborating Centres in Occupational Health, a questionnaire of the Dortmund group, applied in different studies, was translated into more than 30 languages (Afrikaans, Arabic, Bengali, Chinese, Czech, Dutch, English, Finnish, French, Georgian, German, Greek, Hindi, Hungarian, Indonesian, Italian, Japanese, Kannada, Kazakh, Kirghiz, Korean, Latvian, Malay, Persian (Farsi), Polish, Portuguese, Portuguese/Brazilian, Romanian, Russian, Serbo-Croatian, Slovak, Spanish, Spanish/Mexican, Tamil, Telugu, Thai, Turkish, Urdu, Vietnamese). The bipartite questionnaire asks for relevant medical information in the physician's part and for the occupational history since leaving school in the patient's part. Furthermore, this questionnaire is asking for intensity and frequency of certain occupational and non-occupational risk factors. The literature regarding occupations like painter, hairdresser or miner and exposures like carcinogenic aromatic amines, azo dyes, or combustion products is highlighted. The questionnaire is available on www.ifado.de/BladderCancerDoc.

Evaluation of Biocompatibility of Alloplastic Materials: Development of a Tissue Culture In Vitro Test System

Optimized biocompatibility is a major requirement for alloplastic materials currently applied in surgical approaches for hernia, incontinence, and prolapse situations. Tissue ingrowth/adherence and formation of connective tissue seem to have important influence in mesh incorporation at the implant site. In an in vitro approach we randomly investigated 7 different mesh types currently used in surgeries with various indications with regard to their adherence performance. Using a tissue culture approach, meshes were incubated with tissue representative of fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. After 6 weeks, the meshes were assessed microscopically and a ranking of their adherence performance was established. Tissue culture was successful in 100% of the probes. We did not remark on interindividual differences concerning the growth and adherence performance after incubation with the different meshes in the investigated 10 patients. The ranking was consistent in all patients. In this test system, PVDF Dynamesh® (FEG Textiltechnik, Aachen, Germany) was the mesh with the best growth-in score. The test system was feasible and reproducible. Pore size seems to be a predictor of adherence performance. The test system may be a helpful tool for further investigations, and the predictive value should be assessed in further in vitro and in vivo experiments.

Nitrative DNA damage and Oct3/4 expression in urinary bladder cancer with Schistosoma haematobium infection

To investigate whether mutant stem cells participate in inflammation-related carcinogenesis, we performed immunohistochemical analysis to examine nitrative and oxidative DNA lesions (8-nitroguanine and 8-oxodG) and a stem cell marker Oct3/4 in bladder tissues obtained from cystitis and bladder cancer patients infected with Schistosomahaematobium (S. haematobium). We also detected the expression of nuclear factor-κB (NF-κB) and inducible nitric oxide synthase (iNOS), which lead to 8-nitroguanine formation. The staining intensity of 8-nitroguanine and 8-oxodG was significantly higher in bladder cancer and cystitis tissues than in normal tissues. iNOS expression was colocalized with NF-κB in 8-nitroguanine-positive tumor cells from bladder cancer patients. Oct3/4 expression was significantly increased in cells from S. haematobium-associated bladder cancer tissues in comparison to normal bladder and cancer tissues without infection. Oct3/4 was also expressed in epithelial cells of cystitis patients. Moreover, 8-nitroguanine was formed in Oct3/4-positive stem cells in S. haematobium-associated cystitis and cancer tissues. In conclusion, inflammation by S.haematobium infection may increase the number of mutant stem cells, in which iNOS-dependent DNA damage occurs via NF-κB activation, leading to tumor development.

What happens if nothing happens?--History of an untreated urothelial carcinoma of the bladder

Bladder cancer is controllable when adequately diagnosed and treated according to current recommendations. Radical cystectomy with urinary diversion is the standard therapy for muscle invasive tumors. In patients unfit or unwilling to get radical surgery, external beam or combined chemo-radiotherapy display alternative treatment options and can be safely performed. Every therapy implies the patient's disposition to cooperate.

CASE PRESENTATION

This case report describes the clinical course over 31 months after initial diagnosis of a 56-years-old Caucasian, white man with an initial pT1G3 urothelial carcinoma of the bladder. The patient denied early radical cystectomy, radio-chemotherapy and almost all alternative treatment possibilities. He finally died 31 months after initial verification of the disease.

[Operative treatment of female urinary incontinence with particular consideration of sexuality according to anatomical findings]

An evaluation of surgical treatment modalities for urinary incontinence shows that loop plasties are easy to use and with good short-term results with regard to achievement of urinary continence. However, in the light of reports of serious complications and the lack of long-term results, this indication must be reconsidered. In the framework of prolapse surgery Burch's colposuspension with sarcopexy and, possibly, rectopexy represents the standard therapy. Laparoscopic procedures are currently being evaluated. Experimental concepts such as, for example, tissue engineering for the reconstruction of a damaged sphincter apparatus or the use of hyaluronic acid as a bulking agent are potential procedures for the treatment of stress incontinence that need investigation, especially since these methods will probably not have visible negative impacts of the female patient's sexual function. What we need is an interdisciplinary project like that currently practiced in the German Centre for Pelvic Surgery. Objectives are the preservation and reattainment for female sexuality in the course of operations to achieve urinary continence and other pelvic interventions.

Surgical treatment of disseminated peritoneal metastases from urological cancer: results from a prospective study

OBJECTIVE

To report a prospective phase II study of patients with disseminated peritoneal carcinomatosis and symptomatic disease, in whom the peritoneal metastases were resected.

PATIENTS AND METHODS

From 1995 to 1999, 32 patients (20 men and 12 women, median age 56 years, range 32-75) with peritoneal carcinomatosis were enrolled in the trial. Pain and ascites were determined according to the National Cancer Institute score/criteria, and performance scored according to the World Health Organisation criteria.

RESULTS

All patients had intraperitoneal disseminated malignancies with clinically evident ascites, and presented with abdominal pain. The median (range) operative duration was 2.9 (1-5.5) h and the hospital stay 25 (10-44) days, with no deaths at 30 days. The ascites was completely cured in 25 of the 32 patients, pain relieved in 28 and the performance score improved in 25. The median survival time was 1 year; the 1- and 2-year survival rates were 45% and 38%, respectively. Patients with residual metastases after incomplete resection had a significantly worse prognosis, but the prognosis was significantly better in those with a low tumour burden.

CONCLUSIONS

Peritoneal carcinomatosis is treatable; radical peritonectomy improves the performance score in selected patients with cancer-related ascites and/or pain, and is now the standard approach in the authors' Cancer Centre.

Association between HLA-A, B, C and DR antigens and clinical manifestations of Schistosoma haematobium in the bladder

This study is a search for the genetic susceptibility of Egyptians to Schistosoma haematobium infestation with its various bladder complications, including cancer. 80 bilharzial patients, 20 with simple bilharzial bladder cystitis, 30 with bilharzial bladder lesions, and 30 with bilharzial bladder cancer, as well as 35 normal Egyptian controls were studied. All patients were typed for HLA-A, B, C and DR antigens using the microlymphocytotoxicity test. HLA-A9 and its split Aw24 antigens were found to be negatively associated with the disease. As for the antigens with positive associations, HLA-B7 was significantly increased in the simple bilharzial cystitis group. In the bilharzial bladder cancer group, HLA-B16 and Cw2 antigens had positive associations. These findings might support the genetic control of the disease or the presence of an immune response and/or immune suppression genes which are in linkage disequilibrium with these HLA antigens and they control the susceptibility and pathological sequences of the disease.