A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction

OBJECTIVE

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients.

METHODS

A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm.

RESULTS

A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.

CONCLUSION

A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

Antibiotic use, best practice statement adherence, and UTI rate for intradetrusor onabotulinumtoxin-A injection for overactive bladder: A multi-institutional collaboration from the SUFU Research Network (SURN)

INTRODUCTION

Onabotulinumtoxin A (BTX-A) is a well-established treatment for overactive bladder (OAB). The American Urological Association (AUA) 2008 Antibiotic Best Practice Statement (BPS) recommended trimethoprim-sulfamethoxazole or fluoroquinolone for cystoscopy with manipulation. The aim of the study was to evaluate concordance with antibiotic best practices at the time of BTX-A injection and urinary tract infection (UTI) rates based on antibiotic regimen.

METHODS

Men and women undergoing first-time BTX-A injection for idiopathic OAB with 100 units in 2016, within the SUFU Research Network (SURN) multi-institutional retrospective database were included. Patients on suppressive antibiotics were excluded. The primary outcome was concordance of periprocedural antibiotic use with the AUA 2008 BPS antimicrobials of choice for "cystoscopy with manipulation." As a secondary outcome we compared the incidence of UTI among women within 30 days after BTX-A administration. Each outcome was further stratified by procedure setting (office vs. operating room; OR).

RESULTS

Of the cohort of 216 subjects (175 women, 41 men) undergoing BTX-A, 24 different periprocedural antibiotic regimens were utilized, and 98 (45%) underwent BTX-A injections in the OR setting while 118 (55%) underwent BTX-A injection in the office. Antibiotics were given to 86% of patients in the OR versus 77% in office, and 8.3% of subjects received BPS concordant antibiotics in the OR versus 82% in office. UTI rates did not vary significantly among the 141 subjects who received antibiotics and had 30-day follow-up (8% BPS-concordant vs. 16% BPS-discordant, CI -2.4% to 19%, p = 0.13). A sensitivity analysis of UTI rates based on procedure setting (office vs. OR) did not demonstrate any difference in UTI rates (p = 0.14).

CONCLUSIONS

This retrospective multi-institutional study demonstrates that antibiotic regimens and adherence to the 2008 AUA BPS were highly variable among providers with lower rates of BPS concordant antibiotic use in the OR setting. UTI rates at 30 days following BTX-A did not vary significantly based on concordance with the BPS or procedure setting.

Engaging and Empowering Female Urologists in Academic Publishing and Peer Review

N/A.

Apelin as a new therapeutic target for COVID-19 treatment

BACKGROUND

Apelin is an endogenous neuropeptide that binds to the G-protein-coupled receptor (APJ) and participates in a variety of physiological processes in the heart, lungs and other peripheral organs. Intriguingly, [Pyr1]-Apelin-13, a highly potent pyroglutamic form of apelin, has the potential to bind to and be degraded by angiotensin-converting enzyme 2 (ACE2). ACE2 is known to operate as a viral receptor in the early stages of severe acute respiratory coronavirus (SARS-CoV-2) infection.

AIM

This study aimed to determine if apelin protects against SARS-CoV-2 infection by inhibiting ACE2 binding to SARS-CoV-2 spike protein.

DESIGN AND METHODS

To determine whether [Pyr1]-Apelin-13 inhibits ACE2 binding to the SARS-CoV-2 spike protein (S protein), we performed a cell-to-cell fusion assay using ACE2-expressing cells and S protein-expressing cells and a pseudovirus-based inhibition assay. We then analyzed publicly available transcriptome data while focusing on the beneficial effects of apelin on the lungs.

RESULTS

We found that [Pyr1]-Apelin-13 inhibits cell-to-cell fusion mediated by ACE2 binding to the S protein. In this experiment, [Pyr1]-Apelin-13 protected human bronchial epithelial cells, infected with pseudo-typed lentivirus-producing S protein, against viral infection. In the presence of [Pyr1]-Apelin-13, the level of viral spike protein expression was also reduced in a concentration-dependent manner. Transcriptome analysis revealed that apelin may control inflammatory responses to viral infection by inhibiting the nuclear factor kappa B pathway.

CONCLUSION

Apelin is a potential therapeutic candidate against SARS-CoV-2 infection.

Changes in patient reported outcome measures after treatment for female urethral stricture

INTRODUCTION

There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture.

METHODS

American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed.

RESULTS

Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01).

CONCLUSION

Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Two-year outcomes of the ARTISAN-SNM study for the treatment of urinary urgency incontinence using the Axonics rechargeable sacral neuromodulation system

AIMS

Sacral neuromodulation (SNM) is a guideline-recommended treatment with proven therapeutic benefit for urinary urgency incontinence (UUI) patients. The Axonics® System is the first Food and Drug Administration-approved rechargeable SNM system and is designed to deliver therapy for a minimum of 15 years. The ARTISAN-SNM study was designed to evaluate UUI participants treated with the Axonics System. Two-year follow-up results are presented.

METHODS

One hundred and twenty-nine UUI participants underwent implantation with the Axonics System. Therapeutic response rate, participant quality of life (QoL), and satisfaction were determined using 3-day voiding diaries, ICIQ-OABqol, and satisfaction questionnaires. Participants were considered responders if they had a 50% or greater reduction in UUI episodes post-treatment. As-treated and Completers analyses are presented.

RESULTS

At 2 years, 93% of the participants (n = 121 Completers at 2 years) were therapy responders, of which 82% achieved ≥ 75% reduction in UUI episodes and 37% were dry (100% reduction). Daily UUI episodes reduced from 5.6 ± 0.3 at baseline to 1.0 ± 0.2 at 2 years. Statistically significant improvements in ICIQ-OABqol were reported. All participants were able to recharge their device and 94% of participants reported that the recharging frequency and duration were acceptable. Participant demographics nor condition severity were correlated with clinical outcomes or recharging experience. No unanticipated or serious device-related adverse events occurred.

CONCLUSIONS

At 2 years, participants treated with the Axonics System demonstrated sustained safety and efficacy, high levels of satisfaction with therapy and recharging. Participant-related factors were not associated with efficacy or recharging outcomes, indicating the reported results are applicable to a diverse population.

One-year outcomes of the ARTISAN-SNM study with the Axonics System for the treatment of urinary urgency incontinence

Aims

Sacral neuromodulation (SNM) is a guideline‐recommended treatment for voiding dysfunction including urgency, urge incontinence, and nonobstructive retention as well as fecal incontinence. The Axonics® System is a miniaturized, rechargeable SNM system designed to provide therapy for at least 15 years, which is expected to significantly reduce revision surgeries as it will not require replacement as frequently as the non‐rechargeable SNM system. The ARTISAN‐SNM study is a pivotal study designed to treat patients with urinary urgency incontinence (UUI). Clinical results at 1‐year are presented.

Methods

A total of 129 eligible UUI patients were treated. All participants were implanted with a quadripolar tined lead and neurostimulator in a single procedure. Efficacy data were collected using a 3‐day bladder diary, a validated quality of life questionnaire (ICIQ‐OABqol), and a participant satisfaction questionnaire. Therapy responders were defined as participants with ≥50% reduction in UUI episodes compared to baseline. Data were analyzed on all 129 participants.

Results

At 1 year, 89% of the participants were therapy responders. The average UUI episodes per day reduced from 5.6 ± 0.3 at baseline to 1.4 ± 0.2. Participants experienced an overall clinically meaningful improvement of 34 points on the ICIQ‐OABqol questionnaire. All study participants (100%) were able to recharge their device at 1 year, and 96% of participants reported that the frequency and duration of recharging was acceptable. There were no serious device‐related adverse events.

Conclusions

The Axonics System is safe and effective at 1 year, with 89% of participants experiencing clinically and statistically significant improvements in UUI symptoms.

Surgery for Anterior Compartment Vaginal Prolapse: Suture-Based Repair

Native tissue anterior compartment prolapse repair remains an important surgical procedure for pelvic prolapse. Native tissue repair has been well-studied and is successful in relieving vaginal bulge symptoms and reducing prolapse within the vagina. Native tissue cystocele repair has been performed safely since the advent to modern vaginal surgery for prolapse. Reoperation rates are low and the contribution of apical support in the durability of vaginal wall defect repair surgery has been well-established. Native tissue cystocele repair addresses symptom relief for women, and should continue to be a part of pelvic floor reconstructive surgery.

EMG characteristics of the external anal sphincter guarding reflex and effects of a unilateral ventral root avulsion injury in rhesus macaques ( Macaca mulatta)

The external anal sphincter (EAS) is important for the maintenance of bowel continence and may be compromised by a variety of neuropathic conditions. However, large animal models for the study of EAS functions have been sparse. The EAS guarding reflex was examined by electromyography (EMG) in neurologically intact rhesus macaques ( n = 6) and at 4-6 wk after a unilateral EAS denervation from an L6-S3 ventral root avulsion (VRA) injury ( n = 6). Baseline EAS EMG recordings were quiescent in all subjects, and evoked responses showed an initial large-amplitude EMG activity, which gradually returned to baseline within 1-2 min. At 4-6 wk postoperatively, the EAS guarding reflex showed a significantly reduced EMG response duration of 47 ± 15 s and area under the curve (AUC) of 0.198 ± 0.097 mV·s compared with the corresponding evoked EAS EMG duration of 102 ± 19 s and AUC of 0.803 ± 0.225 mV·s ( P < 0.05) in the control group. Detailed time- and frequency-domain analysis of the evoked EAS EMG responses for the first 40 s showed no difference between groups for the maximum amplitude but a significant decrease for the mean amplitude across the study period and an early AUC reduction for the first 10 s in the VRA injury group. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrower midrange of frequencies in the VRA injury group. We conclude that the EAS guarding reflex in rhesus macaques shows characteristic EMG features in control subjects and signs of partial target denervation after a unilateral L6-S3 VRA injury. NEW & NOTEWORTHY The external anal sphincter guarding reflex showed initial large-amplitude peaks and a gradual return to a quiescent baseline after a rectal probe stimulus in rhesus macaques. At 4-6 wk after a unilateral ventral root avulsion (VRA) injury, the electromyography duration, mean amplitude, and area under the curve measurements were decreased. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrowed midrange of frequencies in the VRA injury cohort.

Serious hunger games: Increasing awareness about food security in Canada through digital games

Digital games are becoming increasingly common knowledge transfer media. So-called "serious games" or "games for good" have attracted academic, industry, and mainstream attention through the proliferation of conferences, journals, blogs, and online communities. They offer what few other educational resources can in a single medium: interactive, user-led learning experiences based on discovery and experimentation, explorations of complex systems through skill development and decision making, and a personal connection with the content through role-playing (Bogost, 2007; Dahya, 2009; Gee, 2003; Kee & Bachynski 2009). As digital games move out of the home and into public education, sharing experienced-based insights on how to navigate this new terrain is important and necessary to efficiently create media that is both informative and engaging. This field report reflects on the process of developing the educational game Food Quest, from conception to completion, including the challenges, surprises and lessons learned. After detailing the gameplay of Food Quest, we provide a chronological report on the design and development process, including origins and exploratory phases of the project, concerns around digital game-based learning, and the unanticipated obstacles that contributed to a lengthy development process. The report also provides preliminary evaluations and recommendations for others interested in create a similar digital resource to spread awareness about food security.

Cost-effectiveness analysis of tension-free vaginal tape vs burch colposuspension for female stress urinary incontinence in the USA

OBJECTIVE

To compare the cost-effectiveness (CE) of tension-free vaginal tape (TVT) with that of burch colposuspension (BC) for the treatment of female stress urinary incontinence (SUI).

MATERIALS AND METHODS

A Markov-chain decision model was created to simulate treatment of SUI with TVT or BC using Treeage Pro 2011 software (Treeage Software Inc., Williamstown, MA, USA). Costing data were obtained from the Medicare Resource-Based Relative Value Scale. Data regarding the success of TVT vs BC were obtained from the peer-reviewed literature, as were corresponding utilities for different continence states. The CE of each procedure was calculated and compared, and sensitivity analyses were performed.

RESULTS

At 10-year follow-up, TVT was more cost-effective (CE = $1495/quality-adjusted life year [QALY]) than BC (CE = $1824/QALY). Sensitivity analysis showed that TVT was more cost-effective than BC if the cost of the TVT device was <$3220. If the probability of success after TVT was <42%, then BC became the more cost-effective strategy (CE = $1827/QALY).

CONCLUSION

Our study showed that TVT was more cost-effective than BC as a treatment for female SUI. Both cost of TVT device and efficacy of the procedure affect the CE analysis.

Association of hypomagnesemia with inferior survival in a phase III, randomized study of cetuximab plus best supportive care versus best supportive care alone: NCIC CTG/AGITG CO.17

BACKGROUND

Cetuximab-induced hypomagnesemia has been associated with improved clinical outcomes in advanced colorectal cancer (CRC). We explored this relationship from a randomized clinical trial of cetuximab plus best supportive care (BSC) versus BSC alone in patients with pretreated advanced CRC.

PATIENTS AND METHODS

Day 28 hypomagnesemia grade (0 versus ≥1) and percent reduction (<20% versus ≥20%) of Mg from baseline was correlated with outcome.

RESULTS

The median percentage Mg reduction at day 28 was 10% (-42.4% to 63.0%) for cetuximab (N = 260) versus 0% (-21.1% to 25%) for BSC (N = 251) [P < 0.0001]. Grade ≥1 hypomagnesemia and ≥20% reduction from baseline at day 28 were associated with worse overall survival (OS) [hazard ratio, HR 1.61 (95% CI 1.12-2.33), P = 0.01 and 2.08 (95% CI 1.32-3.29), P = 0.002, respectively] in multivariate analysis including grade of rash (0-1 versus 2+). Dyspnea (grade ≥3) was more common in patients with ≥20% versus < 20% Mg reduction (68% versus 45%; P = 0.02) and grade 3/4 anorexia were higher in patients with grade ≥1 hypomagnesemia (81% versus 63%; P = 0.02).

CONCLUSIONS

In contrast to prior reports, cetuximab-induced hypomagnesemia was associated with poor OS, even after adjustment for grade of rash.

ε-Acetamidocaproic acid pharmacokinetics in rats with gastric ulcer or small bowel inflammation

The pharmacokinetics of ϵ-acetamidocaproic acid (AACA) were evaluated after the intravenous and oral administration of an antiulcer agent, zinc acexamate (ZAC) at a dose of 20 mg kg⁻¹ (ion pairing between zinc and AACA) in rats with indomethacin-induced acute gastric ulcer (IAGU) or indomethacin-induced small bowel inflammation (ISBI). In IAGU rats, the area under the curves (AUCs) of AACA were significantly smaller after both the intravenous (551 versus 1270 μg min ml⁻¹) and oral (397 versus 562 μg min ml⁻¹) administration of ZAC than controls, possible due to the significantly faster CL(R) of AACA. In ISBI rats, however, the AUCs of AACA were comparable with controls after both the intravenous and oral administration of ZAC. In IAGU rats, the significantly smaller AUCs of AACA were due to the significantly faster CL(R) (due to the decreased urinary pH by indomethacin treatment) than controls. AACA has a basic secondary amine group. On the other hand, the comparable AUCs of AACA in ISBI rats were due to the comparable CL(R)s between ISBI and control rats. AACA was excreted in the urine via active renal tubular secretion in all rats studied.

The effects of acute and chronic psychological stress on bladder function in a rodent model

OBJECTIVE

Psychological stress plays a role in the exacerbation of functional lower urinary tract disorders, such as painful bladder syndrome and overactive bladder. To better understand the mechanism underlying this relationship, we characterized changes in micturition, anxiety-related behavior, and bladder pathology in rats exposed to repeated water avoidance (WA) stress.

METHODS

Twenty-four Wistar rats were subjected to WA stress or sham. Immediately after acute (day 1) and chronic (day 10) stress or sham, rats were placed in a metabolic cage for a 2-hour voiding behavior assessment. Voiding parameters were compared with baseline values obtained before stress. Four animals from each group were sacrificed on day 10 and bladders harvested for histologic and gene expression studies. The remaining 8 animals per group underwent repeated voiding assessment every 3 days for 1 month followed by 10 days of repeat WA stress or sham. Bladder histology and gene expression were studied.

RESULTS

Rats exposed to WA stress developed a significant increase in micturition frequency and decrease in latency to void, voiding interval, and volume of first void compared with sham and baseline. Alterations in micturition persisted for approximately 1 month. Stressed rats showed increased fecal pellet excretion and anxiety-like behavior. In addition, bladder specimens from stressed animals revealed increased angiogenesis, and increased total and activated mast cells.

CONCLUSION

In rats, repeated psychological stress results in lasting alterations in micturition frequency, interval, and volume. This rodent model may represent a valid tool for studying syndromes characterized by increased urinary frequency.

Women's experience with severe overactive bladder symptoms and treatment: insight revealed from patient focus groups

AIMS

Research has focused on treatment of overactive bladder (OAB) symptoms in women with the goal of cure. The objective of this study was to assess women's perceptions of their OAB symptoms, treatment experience, and outcomes by conducting patient focus groups.

METHODS

Women seen in our academic center female urology referral clinics were identified by ICD-9 codes for OAB symptoms and recruited to participate in one of five focus groups, totaling 33 patients. Non-clinician moderators conducted the focus group sessions incorporating topics related to patients' perceptions of OAB symptoms, treatments, and outcomes. Data analysis was performed using grounded theory methodology.

RESULTS

Qualitative analysis yielded several preliminary themes: impact of OAB on quality of life, strategies to control wetness, medications and side effects, and triggers. The majority of focus group participants reported only a partial response to medication and other physician-recommended treatments for OAB. Therefore, they developed self-reliant personalized strategies to improve their quality of life. These strategies included fluid restriction, preventive toileting, and, most importantly, the use of incontinence pads.

CONCLUSIONS

The majority of the women who participated in the focus groups reported only a partial response to medical and other treatments for OAB. As a result, they developed personalized self-management strategies to improve their quality of life. Although most studies addressing the treatment of OAB aim at curing the condition, such a strategy may be unrealistic. Applying a chronic care model that uses a patient-centered symptom-management approach to OAB may optimize patient outcomes and improve quality of life.

Emerging concepts for pelvic organ prolapse surgery: What is cure?

The objective of this review is to discuss emerging concepts in pelvic organ prolapse, in particular, "What is cure?" In a post-trial data analysis of the CARE (Colpopexy and Urinary Reduction Efforts) trial, treatment success varied tremendously depending on the definition used (19.2%-97.2%). Definitions that included the absence of vaginal bulge symptoms had the strongest relationships with the patients' assessment of overall improvement and treatment success. As demonstrated by this study, there are several challenges in defining cure in prolapse surgery. Additionally, the symptoms of prolapse are variable. The degree of prolapse does not correlate directly with symptoms. There are many surgical approaches to pelvic organ prolapse. Multiple ways to quantify prolapse are used. There is a lack of standardized definition of cure. The data on prolapse surgery outcomes are heterogeneous. The goal of surgical repair is to return the pelvic organs to their original anatomic positions. Ideally, we have four main goals: no anatomic prolapse, no functional symptoms, patient satisfaction, and the avoidance of complications. The impact of transvaginal mesh requires thoughtful investigation. The driving force should be patient symptoms in defining cure of prolapse.

Pharmacokinetic interaction between itraconazole and metformin in rats: competitive inhibition of metabolism of each drug by each other via hepatic and intestinal CYP3A1/2

BACKGROUND AND PURPOSE

Fungal infection is prevalent in patients with diabetes mellitus. Thus, we investigated whether a pharmacokinetic interaction occurs between the anti-fungal agent itraconazole and the anti-glycaemic drug metformin, as both drugs are commonly administered together to diabetic patients and are metabolized via hepatic CYP3A subfamily in rats.

EXPERIMENTAL APPROACH

Itraconazole (20 mg·kg(-1)) and metformin (100 mg·kg(-1)) were simultaneously administered i.v. and p.o. to rats. Concentrations (I) of each drug in the liver and intestine, maximum velocity (V(max)), Michaelis-Menten constant (K(m)) and intrinsic clearance (CL(int) ) for the disappearance of each drug, apparent inhibition constant (K(i) ) and [I]/K(i) ratios of each drug in the liver and intestine were determined. Also the metabolism of each drug in rat and human CYPs was measured in vitro.

KEY RESULTS

After simultaneous administration of both drugs, either i.v. or p.o., the total area under the plasma concentration-time curve from time zero to infinity (AUC)s of itraconazole and metformin were significantly greater than that of either drug administered alone. The metabolism of itraconazole and metformin was significantly inhibited by each other via CYP3A1 and 3A2 in rat and 3A4 in human microsomes.

CONCLUSIONS AND IMPLICATIONS

The significantly greater AUCs of itraconazole and metformin after i.v. administration of both drugs are probably due to competitive inhibition of the metabolism of each drug by each other via hepatic CYP3A1/2. Whereas after oral administration of both drugs, the significantly greater AUCs of each drug administered together than that of either drug alone is mainly due to competitive inhibition of intestinal metabolism of each drug by each other via intestinal CYP3A1/2.

A phase II study of sunitinib in patients with recurrent epithelial ovarian and primary peritoneal carcinoma: an NCIC Clinical Trials Group Study

PURPOSE

Sunitinib is a multitargeted receptor tyrosine kinase inhibitor. We conducted a two-stage phase II study to evaluate the objective response rate of oral sunitinib in recurrent epithelial ovarian cancer.

PATIENTS AND METHODS

Eligibility required measurable disease and one or two prior chemotherapies, at least one platinum based. Platinum-sensitive or -resistant disease was allowed. Initial dose schedule was sunitinib 50 mg daily, 4 of 6 weeks. Observation of fluid accumulations during off-treatment periods resulted in adoption of continuous 37.5 mg daily dosing in the second stage of accrual.

RESULTS

Of 30 eligible patients, most had serous histology (67%), were platinum sensitive (73%) and had two prior chemotherapies (60%). One partial response (3.3%) and three CA125 responses (10%) were observed, all in platinum-sensitive patients using intermittent dosing. Sixteen (53%) had stable disease. Five had >30% decrease in measurable disease. Overall median progression-free survival was 4.1 months. Common adverse events included fatigue, gastrointestinal symptoms, hand-foot syndrome and hypertension. No gastrointestinal perforation occurred.

CONCLUSIONS

Single-agent sunitinib has modest activity in recurrent platinum-sensitive ovarian cancer, but only at the 50 mg intermittent dose schedule, suggesting that dose and schedule may be vital considerations in further evaluation of sunitinib in this cancer setting.

Laparoscopic partial nephrectomy for tumour in the presence of nephrolithiasis or pelvi-ureteric junction obstruction

OBJECTIVE

To report on patients with a small renal mass and concomitant calculus or pelvi-ureteric junction obstruction (PUJO), and to propose an algorithm for minimally invasive management when these conditions coexist, as the success of laparoscopic partial nephrectomy (LPN) depends greatly on the absence after surgery of ureteric obstruction.

PATIENTS AND METHODS

Fifteen (3%) of 548 patients undergoing LPN (November 1999 to May 2005) had concomitant calculus/PUJO; the calculus/PUJO was treated in six, either before (one), during (three) or after (two) LPN, depending on the presence of obstruction. The remaining nine patients were monitored as they had a punctate and unobstructing stone burden. RESULTS; The mean (range) tumour size was 2.7 (1.4-4) cm, the operative duration 3.8 (2-6) h, the warm ischaemia time 34.8 (22-53) min, and blood loss 237 (50-600) mL. Two patients with concomitant PUJO had a single-session dismembered Anderson-Hynes pyeloplasty and LPN. Three patients with smaller stones (5-12 mm) had extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy or or ureteroscopic removal before (one) or after (two) LPN. One patient with a larger 1.6 cm obstructing renal pelvic calculus had laparoscopic flexible pyeloscopy, but the stone was not visualized. At the end of all treatments, the 6-month tumour-free and stone-free rates were 15/15 and 11/13, respectively.

CONCLUSION

Patients with a concomitant small renal mass and calculus/PUJO can be successfully managed in a simultaneous or staged manner using minimally invasive techniques. A management algorithm is presented.

Bladder and urethral function in pelvic organ prolapsed lysyl oxidase like-1 knockout mice

OBJECTIVES

To examine bladder and urethral function in pelvic organ prolapsed lysyl oxidase like-1 (LOXL1) knockout mice.

MATERIALS AND METHODS

Female parous Loxl1 (-/-) mice in the stable phase of prolapse, and age-matched wild type (WT) mice (six each) had conscious cystometry, leak-point pressure (LPP) testing, and contractile responses assessed of their bladder muscle strips to KCl, electrical-field stimulation, ATP, and carbachol.

RESULTS

Loxl1 (-/-) mice voided more frequently and had lower mean (sem) bladder capacity, at 0.10 (0.01) vs 0.20 (0.01) mL, and voiding pressure, at 25.0 (1.90) vs 36.6 (4.04) cmH(2)O, respectively, during cystometry than had WT mice. The LPP was not significantly different between WT and Loxl1 (-/-) mice, at 7.05 (0.81) vs 5.22 (1.23) cmH(2)O, respectively. There were no significant differences between bladder strips from Loxl1 (-/-) mice and WT mice in their responsiveness to various stimuli.

CONCLUSIONS

Loxl1 (-/-) knockout mice had lower urinary tract dysfunction, most likely due to urethral dysfunction. Loxl1 (-/-) knockout mice can be used as an animal model for pelvic floor disorders. Further studies are needed to characterize the morphological and molecular alterations of the bladder and urethra.

Phase II multicenter open-label study of carboplatin and pegylated liposomal doxorubicin in uterine and cervical malignancies

The results of a multicenter phase II study investigating carboplatin and pegylated liposomal doxorubicin (PLD) in patients with recurrent/metastatic uterine and cervical malignancies (UCM) are presented here. Fifty-three subjects with measurable, untreated, advanced UCM were enrolled. Fifty-one were evaluable for response. Prior combined-modality treatment was permitted if a component of primary therapy. Patients received carboplatin AUC = 5 with PLD 35 mg/m(2) intravenously once every 4 weeks. Overall response rate was 33% (35% stable disease). Overall survival (OS) at six months was 86% (95% CI 76%-96%). Six-month progression-free survival (PFS) was 43% (95% CI 30%-57%). Median PFS was 22.9 weeks (range 16.0-35.3) and median OS was 49.1 weeks (range 41.4-75.1). The most frequent grade 3-4 nonhematological adverse events were: abdominal pain (n = 7), fatigue (4), vomiting (4), nausea (3), and shortness of breath (3). There was 1 report of grade 3 hand-foot syndrome and none of grade 4. Twelve patients had first infusion reactions with only 1 discontinuing treatment. Grade 3-4 neutropenia occurred in 26/230 cycles (11.3%). There were no treatment-related deaths. The combination of carboplatin and PLD is well tolerated with sufficient activity to justify additional evaluation in clinical trials and might be suited to the addition of a taxane.

Lower body mass index is associated with a higher prostate cancer detection rate and less favorable pathological features in a biopsy population

PURPOSE

Body mass index (BMI), calculated as weight in kg divided by the square of height in m, is used as an indicator of obesity. We assessed the relationship between BMI, and prostate cancer detection rates and biopsy features in a referral based biopsy population.

MATERIALS AND METHODS

A total of 787 consecutive patients referred for abnormal digital rectal examination and/or prostate specific antigen (PSA) greater than 4 ng/ml underwent systematic prostate biopsy. Three standard categories of BMI were considered, namely normal-less than 25, overweight-25 to 29.9 and obese-30 or greater kg/m. The presence or absence of cancer, percent of core involvement and tumor grade were correlated with BMI. Additional analyses controlled for patient age, PSA and prostate volume.

RESULTS

For the entire population detection rates were highest in the normal BMI group compared to the overweight or obese group (52% vs 37% vs 42%, p = 0.0026). When stratified by age, this observation was true for men younger than 70 years (49% vs 32% vs 37%, p = 0.0042) but not for men 70 years or older. When only patients with PSA 10 ng/ml or less were considered, detection rates were highest in the normal BMI group (44% vs 28% vs 36%, p = 0.0061). This observation also persisted in patients younger than 70 years with PSA 10 ng/ml or less, or when only patients younger than 70 years with a total prostate volume of less than 50 cc were included. Of patients with cancer those with a normal BMI had a greater length of needle core involvement on biopsy.

CONCLUSIONS

Normal BMI correlates with a higher cancer detection rate and larger cancers in men undergoing prostate biopsy.

Growth of human squamous cell carcinoma xenografts in mice is inhibited by local angiostatin gene therapy

The possibility of inhibiting tumor growth by blocking the formation of new tumor vessels has recently received attention. Antiangiogenic tumor therapies have recently attracted intense interest because of their direct endothelial targeting and the absence of drug resistance. Local antiangiogenic gene therapy for cancer offers a potential way to achieve sustained therapeutic release of antiangiogenic substances. As a step toward this goal, we used liposomes complexed to angiostatin cDNA and targeted to human squamous cell carcinoma cell lines in vivo. Tumor cells expressing angiostatin after local gene transfer showed markedly reduced vascularity and contained many apoptotic tumor cells. These results demonstrate the potential utility of liposome-derived angiostatin for adjuvant therapy of oral cancer in humans.

Broad bean wilt virus Causes Necrotic Symptoms and Generates Defective RNAs in Capsicum annuum

ABSTRACT A virus was isolated from hot pepper (Capsicum annuum cv. Hyang Chon) growing in Korea and displaying necrotic spots or streaks on leaves and stems followed by stunting and death of plants. Morphological and host range analyses of extracts from infected plants suggested that the causal agent of disease was a Broad bean wilt virus (BBWV), and the virus was tentatively named a Korean isolate of BBWV (BBWV-K). When the isolate was back-inoculated onto hot pepper plants, it induced symptoms similar to those of naturally infected hot pepper in the field. Two coat proteins (CPs) of 44 and 22 kDa, corresponding to a large CP and a small CP, respectively, were identified from the virus, and both reacted specifically with polyclonal antibody to BBWV 2. The complete nucleotide sequences of RNA 1 and RNA 2 of the isolate were determined from cDNA clones. The deduced amino acid sequence data from the putative proteins encoded by RNA 1 and 2 of the BBWV-K indicated a closer relationship with the isolates of BBWV 2 than BBWV 1. However, sequence comparison of the 5' noncoding regions of the viruses differentiates BBWV-K from other BBWV 2 isolates. Another distinctive feature of the BBWV-K is that it generates defective RNAs in hot pepper exhibiting necrotic symptoms, which is the first report of defective RNAs in the Fabavirus genera of BBWVs.