Update of the results of the Spanish branch of the European Randomized Study on Screening for Prostate Cancer (ERSPC)

OBJECTIVE

The role of prostate cancer (PC) screening is currently being questioned. The objective of the European Randomized Study of Screening for Prostate Cancer (ERSPC) was to demonstrate whether PC screening reduced mortality from this disease. The results from the Spanish branch of this study are presented: all-cause and cancer-specific mortality, the characteristics of the detected tumors, primary treatments and progression to advanced disease.

MATERIAL AND METHODS

A total of 18,612 men, between the ages of 45 and 70, were invited to participate in the study, excluding those with a life expectancy of less than 10 years. The men were randomized to the screening arm (serum prostate-specific antigen [PSA] reading) or the control arm (no diagnostic tests). Randomized transrectal ultrasound-guided sextant prostate biopsies were indicated for the men in the screening arm with PSA levels ≥3ng/ml. The detected PCs were identified (stage and primary treatment), as well as the deaths that occurred (date and cause of death).

RESULTS

The study was performed with 4276 men (2415 in the screening arm and 1861 in the control arm). The median age and serum PSA level were 57 years and 0.90ng/mL, respectively. The median follow-up time was 15.8 years. A total of 242 PCs were diagnosed, 162 (6.7%) in the screening arm and 80 (4.3%) in the control arm (P<.001). Of these, 214 (88.4%) had an organ-confined clinical stage at onset (91.4% in the screening arm vs. 82.5% in the control arm; P=.024). A total of 112 patients (46.3%) underwent radical prostatectomy, 53 (21.9%) underwent prostate radiation therapy, 24 (9.9%) underwent hormone therapy and 47 (19.4%) were kept under observation. A total of 18 PCs progressed to advanced disease (M+ or PSA levels >100ng/mL), with no differences between the study arms (P=.938). A total of 618 (14.5%) patients died during follow-up: 340 (14.1%) in the screening arm and 278 (14.9%) in the control arm, with no differences between the arms in terms of cancer-specific (P=.907) or all-cause (P=.399) mortality. The main causes of death were neoplasia (54.0%), cardiovascular (17.6%), respiratory (8.7%) and gastrointestinal (4.0%), with no difference between study arms. Of the 334 patients who died from neoplasia, only 12 (3.6%) died from PC.

CONCLUSIONS

PC screening results in a shifting of the diagnosis towards earlier stages. Nevertheless, we have not demonstrated a benefit in terms of overall or cancer-specific survival after more than 15 years of follow-up. The low mortality from this disease in our community could be one of the main factors that explain these results.

Miniperc and retrograde intrarenal surgery: when and how?

CONTEXT

Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) are consolidated procedures for the treatment of kidney stones; however, their primary weak points are the lower efficacy of ESWL, especially for lower calyx stones, and the morbidity of PCNL resulting from the creation and dilation of the percutaneous trajectory. The increasing miniaturization of percutaneous surgery instrumentation and the development of retrograde intrarenal surgery (RIRS) are recent innovations.

ACQUISITION OF EVIDENCE

A structured nonsystematic review was conducted through a literature search of articles published between 1997 and 2013, using the terms kidney stones, miniperc, mini-PCNL, RIRS and flexible ureteroscopy in the PubMed, Google Scholar and Scopus databases.

SUMMARY OF THE EVIDENCE

RIRS requires greater surgical time, several procedures for voluminous stones and higher hospital costs, due in part to the relative fragility of the instruments. On the other hand, miniperc requires a longer hospital stay, an increased need for postoperative analgesia and a greater reduction in hemoglobin levels, although these do not translate into an increased rate of transfusions.

CONCLUSIONS

The current treatment of kidney stones uses minimally invasive procedures such as miniperc and RIRS. The 2 procedures are equivalent in terms of efficacy (stone clearance) and are associated with minimal complications. Comparative prospective studies are necessary to determine the position of each of these techniques in the treatment of kidney stones. In our experience, the 2 techniques are complementary and should be part of the current urological therapeutic arsenal.

Laser transurethral resection of the prostate: Safety study of a novel system of photoselective vaporization with high power diode laser in prostates larger than 80mL

OBJECTIVE

To present the feasibility of photoselective vaporization of the prostate (PVP) with of a new diode laser-resection system. Surgical treatment of benign prostatic hyperplasia (BPH) is constantly evolving. Laser techniques are increasingly used in prostates of large size.

METHODS

A prospective study was performed to evaluate operative data and patient outcomes with PVP using high-power diode laser (HPD) and a novel quartz-head fiber with shovel shape in patients with prostate>80mL. Demographic data, operative time, hemoglobin loss, operative results (IPSS, quality of life (QoL), Qmax, post void residue (PVR), IIEF-5 and micturition diary) and complications following Clavien-Dindo classification are described.

RESULTS

Thirty-one patients were included in the study. Sixteen (51.6%) were on active antiplatelet treatment and 12 (38.7%) had received anticoagulants before surgery. All cases were followed at least 6mo. No intraoperative or postoperative major complications occurred. Three patients (9.7%) had minor complications according to Clavien-Dindo classification. Twenty-seven (87.1%) were discharged on postoperative day one without catheter. There were significant improvements in IPSS, QoL, Qmax and PVR, both at 3 and 6mo (P<.0001), but sexual function according to IIEF-5 showed no differences. Urgency (any grade) increased at 3mo (48.4%; P=.002) and considerably decreased at 6mo (9.7%; P<.0001).

CONCLUSION

This pilot experience with shovel shape fiber and HPD is encouraging. It shows that laser-resection is a safe procedure, achieving excellent results in terms of IPSS, QoL and Qmax in large prostates even in high-risk patients. Longer follow-up, comparative and randomized controlled studies are needed to widespread these results.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages.

PATIENT AND METHOD

We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision.

RESULTS

After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications.

CONCLUSIONS

Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

DNA repair genes and prognosis in sporadic forms of urothelial carcinoma of the upper urinary tract

INTRODUCTION

Lynch syndrome or hereditary nonpolyposis colorectal cancer is caused by mutations in DNA repair genes, known as mismatch repair (MMR) genes, and is associated with microsatellite instability. Urothelial carcinoma of the renal pelvis is also associated with this syndrome. These genetic abnormalities have been described in sporadic forms of upper tract urothelial carcinoma (UTUC).

MATERIAL AND METHOD

This was a descriptive study and survival analysis of a series of 80 patients with sporadic UTUC with no metastases at diagnosis (N0/Nx M0) treated exclusively with nephroureterectomy. We evaluated the expression of MMR genes (hMLH1, hPMS2, hMSH2 and hMSH6) in sections performed with tissue microarray (TMA) and their association with clinical-pathological parameters. We analyzed the prognostic value of the loss of expression of these genes in UTUC.

RESULTS

We detected no loss of MSH2 or of MSH6, but there was a loss of MLH1 in 11 cases (13.8%) and of PMS2 in 21 cases (26.3%). The expression of hMLH1 and hPMS2 were strongly associated (P<.0001), and this phenotype expression entails significant clinical implications. The loss of MLH1 was associated with a low grade (P=.02). Loss of PMS2 was associated with a lower stage (P=.05), a pushing pattern with no invasive edges (P=.008) and less angiogenesis (P=.008). The inactivation of hPMS2 or hMLH1 is an independent protective factor (HR, 0.309) and, along with the histologic grade (HR, 5.561), defines the patients' prognosis.

CONCLUSION

In our experience, the inactivation of hPMS2 or hMLH1 is an independent marker of good prognosis and occurs in a quarter of sporadic UTUC cases. The immunohistochemical study of these patients can be used to assess the screening of hidden forms of Lynch syndrome.

Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones

OBJECTIVE

Retrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS.

MATERIAL AND METHODS

From September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1-3cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures.

RESULTS

The patients underwent RIRS (n=12) or microperc (n=8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P=1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120min (111.2-148.7) and 120 (88.7-167.5) min for RIRS and microperc (P=.8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1-2) and 1.5 days (1-3.5) for RIRS and microperc (P=.33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P=.54).

CONCLUSIONS

Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position.

Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft

INTRODUCTION

Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique.

MATERIAL AND METHODS

This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation.

RESULTS

A total of 14 patients (median age, 64+13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45+26.5mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were was 177+76min and 1.5+1 day, respectively. The preoperative Qmax and PVRV values were 4.5+4.45mL/sec and 212.5+130 cc, respectively. The postoperative values were 15.15+7.2mL/sec and 6+21.5cc, respectively (P<.01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was no required.

CONCLUSION

The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

Impact of p53, MIB-1 and PECAM-1 expression on the prognosis of urothelial carcinoma of the renal pelvis

OBJECTIVE

Determine whether the overexpression p53, MIB-1 and PECAM-1 of protein levels is of interest in predicting the prognosis of transitional cell carcinoma of the upper urinary tract (TCC-UUT) with the primary seat in the renal pelvis.

MATERIAL AND METHOD

A univariate and multivariate analysis was conducted for prognosis prediction in a series of 82 patients with TCC-UUT of the renal pelvis who had no metastases at diagnosis (N0/Nx M0) and were treated exclusively with nephroureterectomy. We assessed clinicopathological parameters (age, gender, tumor grade and extent, histological variety, growth pattern, vascular invasion, infiltration of the renal parenchyma, tumor necrosis) and the immunohistochemical expression of p53, MIB-1 (ki-67) and PECAM-1 (CD31) in sections performed with tissue microarray (TMA).

RESULTS

A total of 47.6% of the patients had high-grade lesions according to the USIP-WHO classification. The growth pattern was flat in 15.85%. The distribution by T category was: 3.7% pTa, 51.2% pT1, 11% pT2, 29.3% pT3 and 4.9% pT4. The mean follow-up was 46.8+38.5 (range, 4-172) months. The median survival was reached at 57 (95% CI 44-63) months. The univariate analysis revealed that survival in these patients is associated with tumor size (P=.028), histological variety (P<.0001), growth pattern (P<.0001), grade (P<.0001), pT (P=.01), vascular invasion (P=.025), necrosis (P=.004) and overexpression of p53 (P=.0006), PECAM-1 (P=.0036) and MIB-1 (P=.0038). The Cox regression model showed that high-grade (HR, 4.2; 95% CI 1.28-13.79; P=.018), flat growth pattern (HR, 2.52; 95% CI 1.05-6.03; P=.038) and p53 overexpression (HR, 2.8; 95% CI 1.22-6.44; P=.015) were independent predictors.

CONCLUSION

Histological grade, tumor growth pattern and p53 overexpression were established as the primary predictors of prognosis for primary TCC-UUT of the renal pelvis. The independent value of MIB-1 observed in other studies was not reproduced in this study.

Virtual reality simulator for training on photoselective vaporization of the prostate with 980 nm diode laser and learning curve of the technique

OBJECTIVE

The utility of a virtual reality simulator for training of the photoselective vaporization of the prostate with diode laser was studied.

MATERIAL AND METHOD

Two experiments were performed with a simulator (VirtaMed AG, Zürich, Switzerland) with software for specific training in prostate vaporization in contact mode with Twister fiber (Biolitec AG, Jena, German). Eighteen surgeons performed ablation of the prostate (55 cc) twice and compared the score obtained (190 points efficacy and 80 safety) in the second one of them by experience groups (medical students, residents, specialists). They also performed a spatial orientation test with scores of 0 to 6. After, six of these surgeons repeated 15 ablations of the prostate (55 and 70 ml). Improvement of the parameters obtained was evaluated to define the learning curve and how experience, spatial orientation skills and type of sequences performed affects them.

RESULTS

Global efficacy and safety score was different according to the grade of experience (P=.005). When compared by pairs, specialist-student differences were detected (p=0.004), but not specialist-resident (P=.12) or resident-student (P=.2). Regarding efficacy of the procedure, specialist-student (p=0.0026) and resident-student (P=.08) differences were detected. The different partial indicators in terms of efficacy were rate of ablation (P=.01), procedure time (P=.03) and amount of unexposed capsule (p=0.03). Differences were not observed between groups in safety (P=.5). Regarding the learning curve, percentage median on the total score exceeded 90% after performing 4 procedures for prostates of 55 ml and 10 procedures for prostate glands of 70 ml. This course was not modified by previous experience (resident-specialist; P=.6). However, it was modified according to the repetition sequence (progressive-random; P=.007). Surgeons whose spatial orientation was less than the median of the group (value 2.5) did not surpass 90% of the score in spite of repetition of the procedure.

CONCLUSION

Simulation for ablation of the prostate with contact diode laser is a good learning model with discriminative validity, as it correlates the metric results with levels of experience and sills. The sequential repetition of the procedure on growing levels of difficulty favors learning.

Effects of resveratrol and other wine polyphenols on the proliferation, apoptosis and androgen receptor expression in LNCaP cells

PURPOSE

To address the effect of resveratrol and other red wine polyphenols on cell proliferation, apoptosis and androgen receptor (AR) expression in human prostate cancer LNCaP cells.

MATERIALS AND METHODS

LNCaP cells (5 × 102) were cultured in microtiter plate modules and treated with gallic acid, tannic acid and quercetin (1, 5 and 10 μM), rutin and morin (25, 50 and 75 μM) and resveratrol (5, 10 and 25 μM). To address the extent of proliferation at 24, 48, 72 and 96 hours, a colorimetric immunoassay method was used. An activity caspase 3/7 detection assay was used to disclose apoptosis at 24, 48 and 72 hours. AR mARN levels were determined by real time RT-PCR.

RESULTS

All polyphenols studied significantly inhibited (P<.05) cell proliferation compared to control. However, there were moderate differences between them. Resveratrol was the strongest inhibitor at different times and doses. Also, caspase-3 and caspase-7 activity was significantly higher (P<.05) than control in the presence of all the compounds, but the earlier response was achieved by resveratrol. Resveratrol, quercetin and morin were the only nutrients that significantly inhibited AR mRNA expression. Again resveratrol produced the highest inhibition (90-250 times less than control), followed by morin (67-100 times) and quercetin (55-91 times).

CONCLUSIONS

All polyphenols studied showed important antiproliferative effects and induced apoptosis when added to LNCaP cells culture. We confirm that resveratrol, morin and quercetin may achieve such effect through reduced expression of AR. The synergistic effects of these compounds and their potential to prevent progression of hormone-dependent prostate cancer merit further study.

Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones

OBJECTIVE

Retrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS.

MATERIAL AND METHODS

From September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1-3cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures.

RESULTS

The patients underwent RIRS (n=12) or microperc (n=8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P=1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120min (111.2-148.7) and 120 (88.7-167.5) min for RIRS and microperc (P=.8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1-2) and 1.5 days (1-3.5) for RIRS and microperc (P=.33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P=.54).

CONCLUSIONS

Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position.

The role of matrix metalloproteinase MMP-9 and TIMP-2 tissue inhibitor of metalloproteinases as serum markers of bladder cancer

INTRODUCTION

The diagnosis and molecular staging of bladder cancer based on the detection of gelatinases mRNA (MMP-2 and MMP-9) in peripheral blood circulating and mononuclear cells have shown promising results. We analyze if the determination of the corresponding protein synthesis products makes it possible to diagnose and characterize patients with bladder cancer.

MATERIAL AND METHOD

Quantification of the serum levels of MMP-2, MMP-9 and TIMP-2 in a series of 42 individuals (31 patients with bladder cancer in different stages and 11 healthy controls) using the ELISA technique was carried out. The determinations were compared between cases and controls (Mann-Whitney U) and between different groups of tumors (Mann-Whitney U or Kruskal-Wallis), according to the clinical-pathological characteristics (age, gender, T category, M category or grade). Diagnostic yield of these markers was evaluated by analysis of the ROC curves.

RESULTS

There is a correlation between the determinations of MMP-2 and TIMP-2 (R=.699; P>.0001) and MMP-9 and TIMP-2 (R=.305; P=.049). Patients with bladder cancer have higher levels of MMP-9 (p<0.0001) and TIMP-2 (P=.047) than the controls. Furthermore, the MMP-9/TIMP-2 ratio is also superior in cancer patients (P<.001). Differences were not detected between cancer and controls regarding age (P=.64) or gender (P=.64). Differences were also not detected regarding MMP-2 (P=.35) or MMP-2/TIMP-2 rate (P=.45). Within the cancer patient population, the MMP-2 and MMP-9 values differ according to T category (P=.022 and P=.038, respectively) and those of the TIMP-2 according to M category (P=.036). ROC curve analysis showed that both MMP-9 and the MMP-9/TIMP-2 ratio discriminate patients with cancer and controls, with equivalent diagnostic accuracy (ABC 0.953) and cut offs of 3.93 ng/mL (S 90%; Sp 81%) and 0.053 ng/mL (S 96%; Sp 84%), respectively.

CONCLUSIONS

The results obtained suggest that both serum MMP-9 and TIMP-2 would have an application in the prediction of the development and progression of bladder cancer, and a potential utility as clinical markers of the disease. Multicenter, prospective studies that confirm their preliminary results are necessary.

Evaluation of risk of muscle invasion, perivesical and/or lymph node affectation by diffusion-weighted magnetic nuclear resonance in the patient who is a candidate for radical cystectomy

INTRODUCTION

Preoperative staging of bladder cancer using imaging methods has serious limitations. The accuracy of the abdominal diffusion-weighted magnetic resonance (DW-MRI) to predict residual muscle invasion, perivesical and/or lymph node affectation in the cystectomy specimen is evaluated.

MATERIAL AND METHODS

A prospective study was performed on 20 patients with high grade muscle invasive bladder cancer who received transurethral resection of the bladder (TURB) in a period of <1 month. The DW-MRI was performed before the radical cystectomy and the radiologist predicted muscle invasion, extravesical affectation and lymph node affectation, being blind to the histopathological study. Sensitivity (S), specificity (sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Ac) of the test were analyzed. The medians of the apparent diffusion coefficient (ADC) value (Mann-Whitney) were compared and the ROC curves study for DW-MRI and ADC was carried out.

RESULTS

Distribution by categories was: pT0 1(5%), pT1 6(30%), pT2 2(10%), pT3 8(40%) and pT4 3(15%). There was agreement in the T-pT assignment in 17(85%). In 7(35%) there was lymph node affectation (pN1-2). Consistency of the DW-MRI for muscle affectation was k=.89 (CI .67-1; S=1.0, Sp=,86, PPV=.93, NPV=1.0, Ac=.95), for perivesical fat affectation k=.6 (CI .25-.95; S=.8, Sp=.8, PPV=.8, NPV=.8, Ac=.8) and for lymph node affectation k=.89 (CI .67-1; S=.86, Sp=1.0, PPV=1.0, NPV=.93, Ac=.95). Mean value of ADC was greater in G2 tumors (OMS1987) compared to G3 (p=.08). Evaluation of DW-MRI imaging and ADC numerical value showed equivalent areas under the curve for muscle (.93 and .9; Z=.7), fat (.8 and .91; Z=.31) and lymph node (.93 and .97; Z=.36) affectation, respectively.

CONCLUSIONS

DW-MRI allows for good pre-operative evaluation of the patient who is a candidate for cystectomy, especially for the prediction of muscle (<pT2 vs ≥pT2) and/or lymph node (N0 vs N1-2) affectation. Both are key points to choice the therapeutic attitude after the bladder TURB. Furthermore, the ADC coefficient also predicts tumor differentiation grade.

The study of DNA methylation in urological cancer: present and future

OBJECTIVES

We have synthesized the principal advances in the field of the study of epigenetics and specifically DNA methylation regarding the diagnosis of urological neoplasms.

ACQUISITION OF EVIDENCE

Review of the literature (PubMed, MEDLINE and Cochrane) on the study of DNA methylation in urological neoplasms (prostate cancer, bladder cancer, renal cancer and testicular cancer), considering all the studies published up to January 2013.

SYNTHESIS OF EVIDENCE

It was possible to determine the state of methylation of many genes in our tumor samples. When these were compared with healthy tissue samples, it was possible to define the specific aberrant methylation patterns for each type of tumor. The study and definition of specific abnormal methylation patterns of each type of tumor is a tool having potential utility for diagnosis, evaluation, prediction of prognosis and treatment of the different forms of genitourinary cancer. The analysis of gene methylation in urine after micturition or post-prostatic massage urine, semen, in the wash plasma or fluid from prostatic biopsies may allow early detection of bladder, prostate, renal and testicular cancer. In each one of the neoplasms, an epigenetic signature that may be detected in the DNA has been identified, obtained from very scarce or not at all invasive specimens, with potential in the diagnosis and evaluation of prognosis. Validation of these studies will confirm the accuracy, effectiveness and reproducibility of the results available up to now. Criteria have still not been developed that determine if a gene panel provides sufficient information in the health care practice to guide an unequivocal diagnosis or therapeutic conduct. More studies are needed to compare sensitivity, specificity, positive and negative predictive value of the test in each case. Multicenter studies analyzing the real reproducibility of these results in a clinical setting also do not exist.

CONCLUSIONS

The study of aberrant DNA methylation in biological specimens of patients has an enormous potential for the early diagnosis and screening of genitourinary neoplasms. A larger number of studies is needed to be able to define the series of genes that would mean unequivocal signatures of malignancy. This methodology also has potential when defining prognostic groups and potential of response to different therapies.

[Onset of a training program for single-port laparoscopic urology]

OBJECTIVES

To describe the onset of a single port laparoendoscopic program to carry out oncology surgery in a Urology Service. We present the initial experience in the laboratory and in the Animal Facility with rigid precurved instruments and KeyPort reusable access element (Richard Wolf).

MATERIAL AND METHODS

Two surgeons experienced in laparoscopic surgery and with the help of four assistants performed a training program based on predetermined tasks performed in simulation boxes (pelvitrainer) and porcine model following the requirements of the Regional Community of Madrid to handle experimental animals.

RESULTS

The participants in this program were initially divided into pairs made up of an experienced surgery and assistant for the predetermined multiple tasks in simulator box in order to become familiarized with the instruments. After, 20 animal sessions were conducted in which the following were performed: (retroperitoneal or pelvic) lymph node dissections (n = 20), nephrectomies (n = 40), cystorrhaphy with suture (n = 20) and uterine-vesical anastomosis (n = 20). Times needed to perform the exercises and the principal errors perceived during the performance of each one of the tasks were recorded. The tasks, of growing complexity, were performed with the instruments described in increasingly less time and with less difficulty. An accessory trocar of 3.5 mm was required to perform the in vivo sutures.

CONCLUSIONS

The KeyPort approach has potential application in different urological applications. Standardized training allows the acquirement of skills and makes the successful implementation possible of a laparoendoscopic surgery program in humans.

[Clinical versatility of the inflammatory pseudotumor in urology]

OBJECTIVE

The inflammatory pseudotumor is a rare lesion, having benign behavior and some histological heterogeneity that appears in the genitourinary tract. A series of urogenital inflammatory pseudotumors are reviewed with emphasis on their clinicopathological and immunohistochemical characteristics.

MATERIAL AND METHODS

A retrospective study the causistics treated between January 1981 in December 2010 was performed. It identified the cases of inflammatory pseudotumor with urogenital localization. The variables age, gender, symptoms, topography, treatment and anatomopathological and immunohistochemical characteristics of each case were analyzed.

RESULTS

A total of 8 cases of the urogenital-located inflammatory pseudotumor are described. Of these, 6 were located in the bladder, one in the kidney and one in the epididymis. Mean age of the patients was 46.75 (± 19.84) years. Tumor presentation symptoms were macroscopic hematuria, single symptom or accompanied by symptoms of the lower urinary tract and inguinoscrotal mass. In regards to treatment in the cases of bladder localization, transuretheral ± cystectomy were performed. In the case of kidney localization, treatment was made by means of pyelotomy and exeresis, and in the case of epididymis localization, simple exeresis was performed. The anatomopathological study showed inflammatory pseudotumor in every cases, having a mesenchymal and myxoid appearance, with fusiform cells of eosinophil cytoplasm, with presence of frequent inflammatory cells. The most common immunohistochemical pattern shows positivity for the muscle-specific actin (HHF-35), vimentin and negativity for protein S-100. ALK-1 was positive and 87.5% of the cases.

CONCLUSION

The inflammatory pseudotumor is a condition having good prognosis which, when there is a good histopathological and immunohistochemical diagnosis, every urologist should recognize and distinguish in order to carry out as conservative a surgical treatment as possible.

[Reconstructive treatment of female urethral estenosis secondary to erosion by suburethral tape]

INTRODUCTION

Female urethral stricture secondary to erosión by suburethral sling is an unfrequent problem of difficult solution. Ventral vaginal rotation flaps or buccal mucosa dorsal grafts are not useful because this type of stricture is very proximal (close to the bladder neck) and the vagina is thinned. We present our experience to manage this problem using excision of disease urethral tract, associated to bladder mucosa flap and vaginal sling using transverse vaginal flap to repair the weakened vaginal wall.

MATERIAL AND METHODS

Three females with urethral stricture secondary to urethral erosion of their sling were treated with a technique of combined urethroplasty with bladder flap and vaginal reinforcement with pediculated vaginal flap transferred in a mini-sling fashion. Two of the patients suffered chronic urinary retention and preoperative placement of urethral catheter was not possible. The patients were evaluated 12, 36 and 55 months after surgery, respectively.

RESULTS

Surgery was performed without complications. Results were satisfactory in all the patients, reaching good micturition postoperative caliber and being without incontinence at follow-up.

CONCLUSION

Patients with suburethral erosion by a synthetic sling and secondary severe urethral stricture need total extirpation of the mesh and complete reconstruction of the urethro-vaginal septum. Tension-free urethral suture and use of vaginal sling with the technique here described are two useful technical tips for this problem.

African swine fever virus structural protein pE120R is essential for virus transport from assembly sites to plasma membrane but not for infectivity

This report examines the role of African swine fever virus (ASFV) structural protein pE120R in virus replication. Immunoelectron microscopy revealed that protein pE120R localizes at the surface of the intracellular virions. Consistent with this, coimmunoprecipitation assays showed that protein pE120R binds to the major capsid protein p72. Moreover, it was found that, in cells infected with an ASFV recombinant that inducibly expresses protein p72, the incorporation of pE120R into the virus particle is dependent on p72 expression. Protein pE120R was also studied using an ASFV recombinant in which E120R gene expression is regulated by the Escherichia coli lac repressor-operator system. In the absence of inducer, pE120R expression was reduced about 100-fold compared to that obtained with the parental virus or the recombinant virus grown under permissive conditions. One-step virus growth curves showed that, under conditions that repress pE120R expression, the titer of intracellular progeny was similar to the total virus yield obtained under permissive conditions, whereas the extracellular virus yield was about 100-fold lower than in control infections. Immunofluorescence and electron microscopy demonstrated that, under restrictive conditions, intracellular mature virions are properly assembled but remain confined to the replication areas. Altogether, these results indicate that pE120R is necessary for virus dissemination but not for virus infectivity. The data also suggest that protein pE120R might be involved in the microtubule-mediated transport of ASFV particles from the viral factories to the plasma membrane.

African swine fever virus protease, a new viral member of the SUMO-1-specific protease family

African swine fever virus (ASFV) is a complex DNA virus that employs polyprotein processing at Gly-Gly-Xaa sites as a strategy to produce several major core components of the viral particle. The virus gene S273R encodes a 31-kDa protein that contains a "core domain" with the conserved catalytic residues characteristic of SUMO-1-specific proteases and the adenovirus protease. Using a COS cell expression system, it was found that protein pS273R is capable of cleaving the viral polyproteins pp62 and pp220 in a specific way giving rise to the same intermediates and mature products as those produced in ASFV-infected cells. Furthermore, protein pS273R, like adenovirus protease and SUMO-1-specific enzymes, is a cysteine protease, because its activity is abolished by mutation of the predicted catalytic histidine and cysteine residues and is inhibited by sulfhydryl-blocking reagents. Protein pS273R is expressed late after infection and is localized in the cytoplasmic viral factories, where it is found associated with virus precursors and mature virions. In the virions, the protein is present in the core shell, a domain where the products of the viral polyproteins are also located. The identification of the ASFV protease will allow a better understanding of the role of polyprotein processing in virus assembly and may contribute to our knowledge of the emerging family of SUMO-1-specific proteases.

The African swine fever virus prenyltransferase is an integral membrane trans-geranylgeranyl-diphosphate synthase

In a previous study, it was shown that the protein encoded by the gene B318L of African swine fever virus (ASFV) is a trans-prenyltransferase that catalyzes in vitro the condensation of farnesyl diphosphate and isopentenyl diphosphate to synthesize geranylgeranyl diphosphate and longer chain prenyl diphosphates (Alejo, A., Yáñez, R. J., Rodríguez, J. M., Viñuela, E., and Salas, M. L. (1997) J. Biol. Chem. 272, 9417-9423). To investigate the in vivo function of the viral enzyme, we have determined, in this work, its subcellular localization and activity in cell extracts. Two systems were used in these studies: cells infected with ASFV and cells infected with a recombinant pseudo-Sindbis virus carrying the complete B318L gene. In this latter system, the trans-prenyltransferase was found to colocalize with the endoplasmic reticulum marker protein-disulfide isomerase, whereas in cells infected with ASFV, the viral enzyme was present in cytoplasmic viral assembly sites, associated with precursor viral membranes derived from the endoplasmic reticulum. In addition, after subcellular fractionation, the viral enzyme partitioned into the membrane fraction. Extraction of membrane proteins with alkaline carbonate and Triton X-114 indicated that the ASFV enzyme behaved as an integral membrane protein. The membrane enzyme synthesized predominantly all-trans-geranylgeranyl diphosphate from farnesyl diphosphate and isopentenyl diphosphate. These results indicate that the viral B318L protein is a trans-geranylgeranyl-diphosphate synthase, being the only enzyme of this type that is known to have a membrane localization.

African swine fever virus is enveloped by a two-membraned collapsed cisterna derived from the endoplasmic reticulum

During the cytoplasmic maturation of African swine fever virus (ASFV) within the viral factories, the DNA-containing core becomes wrapped by two shells, an inner lipid envelope and an outer icosahedral capsid. We have previously shown that the inner envelope is derived from precursor membrane-like structures on which the capsid layer is progressively assembled. In the present work, we analyzed the origin of these viral membranes and the mechanism of envelopment of ASFV. Electron microscopy studies on permeabilized infected cells revealed the presence of two tightly apposed membranes within the precursor membranous structures as well as polyhedral assembling particles. Both membranes could be detached after digestion of intracellular virions with proteinase K. Importantly, membrane loop structures were observed at the ends of open intermediates, which suggests that the inner envelope is derived from a membrane cisterna. Ultraestructural and immunocytochemical analyses showed a close association and even direct continuities between the endoplasmic reticulum (ER) and assembling virus particles at the bordering areas of the viral factories. Such interactions become evident with an ASFV recombinant that inducibly expresses the major capsid protein p72. In the absence of the inducer, viral morphogenesis was arrested at a stage at which partially and fully collapsed ER cisternae enwrapped the core material. Together, these results indicate that ASFV, like the poxviruses, becomes engulfed by a two-membraned collapsed cisterna derived from the ER.

Inducible gene expression from African swine fever virus recombinants: analysis of the major capsid protein p72

A method to study the function of individual African swine fever virus (ASFV) gene products utilizing the Escherichia coli lac repressor-operator system has been developed. Recombinant viruses containing both the lacI gene encoding the lac repressor and a strong virus late promoter modified by the insertion of one or two copies of the lac operator sequence at various positions were constructed. The ability of each modified promoter to regulate expression of the firefly luciferase gene was assayed in the presence and in the absence of the inducer isopropyl beta-D-thiogalactoside (IPTG). Induction and repression of gene activity were dependent on the position(s) of the operator(s) with respect to the promoter and on the number of operators inserted. The ability of this system to regulate the expression of ASFV genes was analyzed by constructing a recombinant virus inducibly expressing the major capsid protein p72. Electron microscopy analysis revealed that under nonpermissive conditions, electron-dense membrane-like structures accumulated in the viral factories and capsid formation was inhibited. Induction of p72 expression allowed the progressive building of the capsid on these structures, leading to assembly of ASFV particles. The results of this report demonstrate that the transferred inducible expression system is a powerful tool for analyzing the function of ASFV genes.

Proteolytic processing in African swine fever virus: evidence for a new structural polyprotein, pp62

We have identified an open reading frame (ORF), CP530R, within the EcoRI C' fragment of the African swine fever virus (ASFV) genome that encodes a polyprotein of 62 kDa (pp62). Antisera raised against different regions of ORF CP530R recognized a polypeptide of 62 kDa in ASFV-infected cells during the late phase of virus replication, after the onset of viral DNA synthesis. Pulse-chase experiments showed that polyprotein pp62 is posttranslationally processed to give rise to two proteins of 35 kDa (p35) and 15 kDa (p15). This proteolytic processing was found to take place at the consensus sequence Gly-Gly-X through an ordered cascade of proteolytic cleavages like that which also occurs with ASFV polyprotein pp220 (C. Simón-Mateo, G. Andrés, and E. Viñuela, EMBO J. 12:2977-2987, 1993). Immunofluorescence studies showed that polyprotein pp62 is localized in the viral factories. In addition, immunoprecipitation analysis of purified virus particles showed that mature products p35 and p15 are major structural proteins. According to these results, polyprotein processing represents an essential strategy for the maturation of ASFV structural proteins.

Assembly of African swine fever virus: role of polyprotein pp220

Polyprotein processing is a common strategy of gene expression in many positive-strand RNA viruses and retroviruses but not in DNA viruses. African swine fever virus (ASFV) is an exception because it encodes a polyprotein, named pp220, to produce several major components of the virus particle, proteins p150, p37, p34, and p14. In this study, we analyzed the assembly pathway of ASFV and the contribution of the polyprotein products to the virus structure. Electron microscopic studies revealed that virions assemble from membranous structures present in the viral factories. Viral membranes became polyhedral immature virions after capsid formation on their convex surface. Beneath the lipid envelope, two distinct domains appeared to assemble consecutively: first a thick protein layer that we refer to as core shell and then an electron-dense nucleoid, which was identified as the DNA-containing domain. Immunofluorescence studies showed that polyprotein pp220 is localized in the viral factories. At the electron microscopic level, antibodies to pp220 labeled all identifiable forms of the virus from the precursor viral membranes onward, thus indicating an early role of the polyprotein pp220 in ASFV assembly. The subviral localization of the polyprotein products, examined on purified virions, was found to be the core shell. In addition, quantitative studies showed that the polyprotein products are present in equimolar amounts in the virus particle and account for about one-fourth of its total protein content. Taken together, these results suggest that polyprotein pp220 may function as an internal protein scaffold which would mediate the interaction between the nucleoid and the outer layers similarly to the matrix proteins of other viruses.

Mapping and sequence of the gene encoding protein p17, a major African swine fever virus structural protein

The gene encoding protein p17, a major structural protein of African swine fever virus, has been mapped and sequenced. Protein p17 was purified from dissociated virus by reverse-phase HPLC and the amino acid sequence of a peptide obtained after digestion of protein p17 with cyanogen bromide was determined by automated Edman degradation. To map the gene encoding protein p17, a mixture of 17-mer oligonucleotides based upon a part of the amino acid sequence was hybridized to cloned African swine fever virus DNA restriction fragments. This allowed the location of the gene in the fragment EcoRI D of the viral genome. The nucleotide sequence of a Sa/l/KpnI fragment revealed an open reading frame designated D117R encoding a protein of 117 amino acids with a deduced molecular mass of about 13,000 Da. A transcriptional analysis revealed that the p17 gene is expressed late in the viral infection cycle.

Polyprotein processing in African swine fever virus: a novel gene expression strategy for a DNA virus

This report shows that African swine fever virus (ASFV)--a large DNA-containing virus--synthesizes a polyprotein to produce several of its structural proteins. By immunoprecipitation analysis, we have found that ASFV polyprotein is a 220 kDa myristoylated polypeptide (pp220) which, after proteolytic processing, gives rise to four major structural proteins: p150, p37, p34 and p14. Processing of the ASFV polyprotein takes place at the consensus sequence Gly-Gly-X and occurs through an ordered cascade of proteolytic cleavages. So far, polyprotein processing as a mechanism of gene expression had been found only in positive-strand RNA viruses and retroviruses. According to the results presented here, ASFV is the first example of a DNA virus that synthesizes a polyprotein as a strategy of gene expression.

Characterization of two African swine fever virus 220-kDa proteins: a precursor of the major structural protein p150 and an oligomer of phosphoprotein p32

Two kinds of unrelated African swine fever virus proteins of 220 kDa have been identified by means of two-dimensional gel electrophoresis and immunoprecipitation analysis. One species, named pp220 and identified as the precursor of the major structural protein p150, was found to be a moderately acidic protein (pl near 7) expressed after the replication of the viral DNA. The second species, a cluster of 220-kDa proteins with slightly different isoelectric points (pl ranging from 5 to 6), was found to be a homooligomeric complex formed by an early 32-kDa protein. This component was identified as the viral phosphoprotein p32, the most immunogenic early protein of African swine fever virus. A detailed characterization of its oligomeric structure is reported.

A structural model for the GroEL chaperonin

Individual particle analysis of end views from negatively stained specimens of purified GroEL from Escherichia coli showed the presence of two different particle populations, those with a six-fold symmetry and those with a seven-fold symmetry, when studied at pH 7.7 and 5.0. Image processing of particles from frozen-hydrated specimens revealed at both pH values a homogeneous population of particles with a strong seven-fold symmetry component and an average image with seven asymmetric units. Biochemical analysis of purified GroEL showed unequivocally the presence of a single polypeptide with the N-terminal sequence identical to that of GroEL. These results are compatible with a structural model of GroEL as an asymmetric aggregate built up by two rings of seven-fold and six-fold symmetries, respectively.

Transcriptional analysis of multigene family 110 of African swine fever virus

A transcriptional analysis of the 3.2-kb region of the African swine fever virus genome containing the five members of the multigene family 110 is presented. The mRNAs corresponding to the genes studied have short leader sequences with no intervening AUG codons before the translational start site, and their 3' ends map within a conserved sequence motif formed by a stretch of seven or more consecutive thymidylate residues. The possible role of this sequence as a signal for the 3'-end formation of African swine fever virus mRNAs is discussed. While four of the genes studied are actively transcribed from the beginning of the infection until the onset of virus DNA replication, the transcription of one of the members of the multigene family 110, the L270 gene, is silenced at an earlier time. A detailed analysis, including in vitro translation of mRNAs isolated from infected Vero cells, revealed that the L270 gene belongs to a small subset of early genes, designated immediate early, whose transcription is silenced before the onset of virus DNA replication. The transcriptional data obtained enabled us to generate the first detailed transcriptional map of a region of the African swine fever virus genome, thus opening the possibility of studying the cis-acting sequences involved in transcriptional control of the viral genes.