Leaf trait modification in European beech trees in response to climatic and edaphic drought

Leaf morphological and physiological traits control the carbon and water relations of mature trees and are determinants of drought tolerance, but it is not well understood how they are modified in response to water deficits. We analysed five sun-canopy leaf traits (mean leaf size (LS), specific leaf area (SLA), Huber value (HV), water potential at turgor loss point (Ψ_tlp ) and foliar carbon isotope signature (δ¹³ C)) in European beech (Fagus sylvatica L.) across three precipitation gradients sampled in moist (2010), dry (2019) and very dry (2018) summers, and tested their response to short-term water deficits (climatic water balance (CWB) preceding sample collection) and long-term water availability (mean annual precipitation (MAP), plant-available soil water capacity (AWC) and neighbourhood competition). Across the 34 sites, LS varied seven-fold (3.9-27.0 cm² ), SLA four-fold (77.1-306.9 cm²·g^-1 ) and HV six-fold (1.0-6.65 cm² ·m^-2 ). In the 2018 dataset, LS showed a negative and HV a positive relationship to MAP, which contradicts relations found in multi-species samples. Average Ψ_tlp ranged from -1.90 to -2.62 MPa and decreased across the sites with decreasing CWB in the month prior to measurement, as well as with decreasing MAP and AWC in 2019. Studied leaf traits varied considerably between years, suggesting that mast fruiting and the severe 2018 drought caused the formation of smaller leaves. We conclude that sun-canopy leaf traits of European beech exhibit considerable plasticity in response to climatic and edaphic aridity, and that osmotic adjustment may be an important element in the drought response strategy of this anisohydric tree species.

218 Compliance With the British Society for Surgery of the Hand (BSSH) Guidelines on the Management of Open Hand Fractures Audit

Aim

British Society of Surgery of the Hand (BSSH) have defined standards for managing open hand fractures. We intended to ascertain our and referring peripheral units’ adherence with BSSH’s standards of care in managing open hand fractures and determine the associated morbidity.

Method

We performed a 6-month prospective audit reviewing clinical records of patients referred to our department with open hand fractures, to determine whether: antibiotic prophylaxis had been started, and discontinued at definitive closure; wound washout and closure had been performed within 24 hours of injury; patients had continued rehabilitation with hand therapists.

Results

25 patients sustained open hand fractures in this period. All patients, except 1 who declined, received antibiotic prophylaxis. 19 (76%) had a wound washout and closure within 24 hours of injury.

Antibiotic prophylaxis was discontinued at time of definitive closure in theatre in 3 (12%) patients. The remaining 21 patients continued antibiotic prophylaxis beyond 72 hours. 3 (12%) patients developed a wound infection, 2 (6%) of these requiring debridement and irrigation in theatre. Both patients had proximal interphalangeal joint fracture dislocations who underwent a wound debridement within 24 hours of injury, 1 of which was secondary to an animal bite. 22 (88%) patients attended their hand therapy appointment.

Conclusions

The incidence of deep infection requiring subsequent operative debridement remains low in open hand fractures, despite the substandard adherence to BSSH’s recommendations.

Educating colleagues will improve the adherence to guidance. The BSSH hand injury triage app fulfils this purpose. We intend to raise awareness and encourage its use.

368 Challenges Moving to a Fully Electronic System: An Audit

Aim

In October 2020, our hospital moved to an all-online clinical record keeping system, resulting in clinicians becoming responsible for electronically requesting follow up appointments at the time of each clinical encounter. We aimed to ensure that with the introduction of the new computing system, appropriate follow up was booked and all members of staff were proficient in utilising this new system.

Method

Operative notes were reviewed to obtain the requirements for follow up, specifically for wound assessment clinic (WAC), hand therapy (HT) and outpatient clinic (OPC). Patient charts were then reviewed to ascertain if planned follow up happened, was booked, or was requested. We re-audited this 4 months later, following departmental education.

Results

In the first week of using the new electronic system, 100% of required WAC (24/24) and HT (13/13) follow up appointments were completed, however 14% (4/27) of required OPC appointments had not been requested.

Following departmental education, the re-audit found similar results, however the 12% (4/31) of cases where OPC follow up was not requested, it was not specified in the operation note whether or not this was required.

Conclusions

When introducing new clinical systems there is potential for unfamiliarity with use to impact on patient care, even after trust-wide training. It is important to bear this in mind and continue to audit and educate staff, implementing appropriate safety netting systems. Detailing the follow up plan in operation notes, including when follow up is not required, improves communication between staff and ensures required follow up is not lost.

From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come

PURPOSE

Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia.

METHODS

Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation.

RESULTS

Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting.

CONCLUSION

Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands.

A case report of cholinesterase inhibitor poisoning: cholinesterase activities and analytical methods for diagnosis and clinical decision making

Suicidal ingestion of organophosphorus (OP) or carbamate (CM) compounds challenges health care systems worldwide, particularly in Southeast Asia. The diagnosis and treatment of OP or CM poisoning is traditionally based on the clinical appearance of the typical cholinergic toxidrome, e.g. miosis, salivation and bradycardia. Yet, clinical signs might be inconclusive or even misleading. A current case report highlights the importance of enzymatic assays to provide rapid information and support clinicians in diagnosis and rational clinical decision making. Furthermore, the differentiation between OP and CM poisoning seems important, as an oxime therapy will most probably not provide benefit in CM poisoning, but—as every pharmaceutical product—it might result in adverse effects. The early identification of the causing agent and the amount taken up in the body are helpful in planning of the therapeutic regimen including experimental strategies, e.g. the use of human blood products to facilitate scavenging of the toxic agent. Furthermore, the analysis of biotransformation products and antidote levels provides additional insights into the pathophysiology of OP or CM poisoning. In conclusion, cholinesterase activities and modern analytical methods help to provide a more effective treatment and a thorough understanding of individual cases of OP or CM poisoning.

Abstract P5-05-01: Metabolic enzyme PFKFB4 activates transcriptional coactivator SRC-3 to drive aggressive metastatic breast cancer

Background: Metabolic rewiring is one of the central hallmarks of cancer progression and survival to support anabolic and energetic demands. Tumor cells constantly alter their metabolic state in response to oncogenic stimuli, nutrient availability, and interaction with immune cells however the precise regulation that precedes the metabolic alteration is poorly understood. Here we report a direct interaction of glycolytic enzyme PFKFB4 with transcriptional coregulator SRC-3. PFKFB4 functions as a critical regulator of Warburg effect and our study reveals that upon glucose stimulation PFKFB4 activates SRC-3 driving an invasive-metastatic breast cancer.

Methods: Molecular experiments were performed to understand the transcriptional activation of SRC-3 by PFKFB4 enzyme. Chromatin immunoprecipitation and gene expression studies were performed to investigate the functions of PFKFB4/SRC-3 crosstalk on transcriptional regulation. Metabolomics and isotope tracing studies were performed to identify the metabolic adaptations regulated by PFKFB4/SRC-3 in breast tumors. PFKFB4-knockout was established using CRISPR-Cas9 system and functional studies were carried out to define its role in tumor cell proliferation, invasion-migration, and breast to lung metastasis. Human breast tumor samples were evaluated to identify the clinical importance of PFKFB4/SRC-3 crosstalk in patients.

Results:Molecular studies revealed that PFKFB4 enzyme phosphorylates SRC-3 at serine 857 (S857) enhancing its transcriptional activity, whereas either suppression of PFKFB4 or ectopic expression of a phosphorylation-deficient SRC-3 mutant S857A (SRC-3S857A) significantly abolished SRC-3-mediated transcriptional output (p<0.000001). Functionally, PFKFB4-driven SRC-3 activation drives glucose flux towards the pentose phosphate pathway enabling purine synthesis by transcriptionally upregulating the expression of enzyme transketolase (TKT). Deletion of PFKFB4 by CRISPR-Cas9 system resulted in significantly reduced proliferation (p<0.05) and migration-invasion (p<0.001) compared to wildtype breast tumor cells. Ablation of SRC-3 or PFKFB4 suppressed in vivo breast tumor growth and prevents metastasis to the lung from an orthotopic setting (p<0.0001). PFKFB4 and phosphorylated SRC-3 levels are significantly increased in breast tumors (p=0.02), whereas, in patients with the basal subtype, PFKFB4 and SRC-3 drive a common protein signature that correlates with the poor survival of TNBC patients (p=0.03).

Conclusion:Our data suggest that the Warburg pathway enzyme PFKFB4 acts as a molecular fulcrum that couples sugar metabolism to transcriptional activation by stimulating SRC-3 to promote aggressive metastatic tumors. It also provides first evidence how Warburg pathway drives aggressive breast tumorigenesis by directly activating powerful oncogene SRC-3. Our work suggests that targeting the PFKFB4–SRC-3 axis may be therapeutically valuable in breast tumors that are notably dependent on glucose metabolism.

(This work is funded by grants from Susan G. Komen and NCI to S.D.)

Citation Format: Dasgupta S, Anand V, John H, Sawant Dessai A, Katsuta E, Takabe K, O'Malley B. Metabolic enzyme PFKFB4 activates transcriptional coactivator SRC-3 to drive aggressive metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-05-01.

Pre-prostatic tissue removed in robotic assisted lymph node dissection for prostate cancer contains lymph nodes

Objective:

The on-going discussion about extent and best template for pelvic lymph dissection (PLND) motivated us to analyse pre-prostatic tissue (PPT) for lymph nodes and metastases.

Materials and Methods:

From December 2010 to August 2011 PPT was sent for histopathological evaluation during 80 robotic assisted radical prostatectomies (RARP) and one extended staging lymph node dissection. All patients had either a limited (lPLND, n = 44) or an extended lymph node dissection (ePLND, n = 36). Clinical data were retrospectively analyzed and compared to histopathological findings.

Results:

Lymph nodes were found in PPT in 10/80 (12.5%) patients after RARP and in the one patient after staging ePLND. Mean number of lymph nodes detected in PPT of them was 1.2 (range 1-3). Clinically no differences were found between patients with or without lymph nodes in PPT. In the standard template of either ePLND or lPLND the average number of lymph nodes was 13 (range 2-56). Herein metastases were found in 10 (12.5%) patients after RARP and in the patient after staging ePLND. A metastasis in PPT was only found after staging ePLND.

Conclusions:

Pre-prostatic tissue might contain lymph nodes that potentially harbour metastases. In the intention to perform the most accurate staging this tissue should be considered for histopathological evaluation.

[Technique of the urethral anastomosis in orthotopic neo-bladder following robot-assisted radical cystectomy (RARC)]

The urethral anastomosis in extracorporeally constructed orthotopic neo-bladder following robot-assisted radical cystectomy (RARC) remains a challenge. In principle either pre-posi-tioned single sutures or robotic continuous suture techniques can be applied. In the literature the different techniques are most often not described in detail. In the present work one example for each technique is given and the advantages and disadvantages of both methods are discussed.

[The urethral anastomosis in orthotopic neobladder following robot-assisted radical cystectomy (RARC) at German-speaking centres]

INTRODUCTION

Following robot-assisted radical cystectomy (RARC) and extracorporeal reconstruction, robotic continuous suture techniques and those using open or robotically pre-positioned single sutures are used for the urethroneovesical anastomosis.

METHODS

62 German-speaking robotic centres were asked in an online questionnaire whether they carried out RARC. Following an affirmative answer further questions were put to the form of the neobladder and the technique of the urethrovesical anastomosis.

RESULTS

80% of the online questionnaires were answered. 44% (n=22) of these centres perform the RARC. According to the answers, given all of the centres but one perform an extracorporeal construction of the neobladder [Studer bladder 73% (n=16), Hautmann bladder 18% (n=4), others 9% (n=2)]. After reconstruction 36% (n=8) of the teams perform a completely open surgical anastomosis with pre-positioned sutures, 24% (n=5) close the anastomosis in a single knot technique using robotically pre-positioned sutures and 40% (n=9) use continuous sutures during the intracorporeal reconstruction or after re-docking the robot.

CONCLUSION

According to this questionnaire to German-speaking centres the most common anastomotic technique following extracorporeal reconstruction, mostly a Studer bladder, is that of the pre-positioned single knot sutures. This offers the advantage that a re-docking of the robotic cart is unnecessary. In contrast, however, to robotically performed suturing, there must be enough space in the open procedure to surgically tie-off the sutures of the anastomosis.

Establishment of a protocol for large-scale gene expression analyses of laser capture microdissected bladder tissue

PURPOSE

Lower urinary tract symptoms (LUTS) can be caused by structural and functional changes in different compartments of the bladder. To enable extensive investigations of individual regions even in small bladder biopsies, we established a combination protocol consisting of three molecular techniques: laser capture microdissection microscopy (LCM), RNA preamplification and quantitative polymerase chain reaction (qPCR).

METHODS

Urinary bladders of ten mice were resected and frozen immediately or after a delay of 15 min. Cryosections were obtained and smooth muscle was isolated using the LCM technique. Then, RNA was extracted, including protocols with and without DNase digestion as well as with and without the addition of carrier RNA. Extracted RNA was either used for reverse transcriptase (RT)-PCR plus qPCR or for a combination of RNA preamplification and qPCR.

RESULTS

Our data showed that with RNA preamplification, 10 μg cDNA can be regularly generated from 2.5 ng RNA. Depending on expression levels, this is sufficient for hundreds of pPCR reactions. The efficiency of preamplification, however, was gene-dependent. DNase digestion before preamplification lead to lower threshold cycles in qPCR. The use of partly degraded RNA for RNA preamplification did not change the results of the following qPCR.

CONCLUSIONS

RNA preamplification strongly enlarges the spectrum of genes to be analyzed in distinct bladder compartments by qPCR. It is an easy and reliable method that can be realized with standard laboratory equipment. Our protocol may lead in near future to a better understanding of the pathomechanisms in LUTS.

Complications of a buried penis in an extremely obese patient

The buried penis syndrome in adults is a rare condition of different aetiologies. Today extreme obesity is considered as a major contributor. We present a case of a 30-year-old extremely obese patient (BMI 65 kg/m(2)) with purulent infection of the penile cavity, a phlegmon of the mons pubis and urinary retention due to a buried penis. Whereas acute complications of a buried penis in obese patients include local infection and urinary retention, chronic problems are undirected voiding, disturbed vaginal penetration and erectile dysfunction. Even though several surgical techniques are described, weight reduction should be primarily preferred.

[Robotic laparoscopic cystectomy: on the way to a standard procedure?]

INTRODUCTION

Radical cystectomy is considered the standard treatment for muscle-invasive bladder cancer. Minimally invasive techniques - especially robot-assisted techniques (RARC) - are being increasingly employed for this indication. Herein, we evaluate the current status of RARC and its acceptance in the urological community.

RESULTS

The field of RARC is steadily increasing particularly due to an extremely short learning curve for surgeons with previous experience in robot-assisted radical prostatectomy. Lymph node yield has been shown to be adequate in several independent studies, being comparable to that of the open approach. Urinary diversion is most frequently done extracorporeally while several groups have commited themselves to intracorporeal techniques and have already shown excellent results. The perioperative outcome data compare favourably to those of open cystectomy. Short-term and interim oncological data are promising while a final long-term assessment is still lacking.

CONCLUSIONS

RARC completed by appropriate urinary diversion is gaining relevance in academic institutions worldwide. The relatively wide availability of the robotic system will further add to this development. Secondary to the final assessment of its oncological efficacy RARC has the potential to become a standard treatment of muscle-invasive bladder cancer since its perioperative efficacy is excellent.

[Brucellosis as a differential diagnosis of cancer of the testes]

Brucellosis has become a rarity in industrialized countries. The manifestation as a granulomatous inflammation of the testes is described with an incidence of 5-40% in the literature and therefore is a relatively common complication of brucellosis. In cases of pain of the testes combined with B symptoms, a systemic inflammation with a local complication should also be considered besides cancer of the testes.

[Peyronie's disease-often a disabling disease for sexually active men]

Peyronie's disease is an acquired penile condition characterized by fibrous plaques between the tunica albuginea and the subtunical tissue of the corpora cavernosa. Plaques are considered responsible for the main symptoms: penile pain and deviation. Even though several risk factors and associations with other diseases are known its exact aetiology remains unclear. Most commonly discussed hypotheses are micro traumata, inflammatory and/or ischemic processes. Currently different treatment forms exist raging form systemic or local medical treatment, to physical applications and surgery. All treatment forms are symptom based and evidence based treatment remains difficult to establish. Because conservative treatment is of limited success in many patients especially with severe deviations surgery becomes necessary.

Eight years' experience of regional audit: an assessment of its value as a clinical governance tool

Strengthening clinical audit is crucial for improving the quality of healthcare provision. The West Midlands Rheumatology Service and Training Committee coordinates an innovative programme of regional audits and the experience of rheumatology healthcare professionals involved was surveyed. This was a questionnaire-based study in which respondents rated statements relating to regional audit on Likert scales. Out of 105 staff, 70 replied. There was consensus that results of regional audit have been robust, valid and reliable; regional audits benefit patients and units; provide educational opportunities for specialist registrars (SpRs); and are more efficient than local audit by allowing comparison between units. Opinion was divided about how well informed respondents were and how effective they are at closing the audit loop. Many units reported changes in practice. Regional audit is widely perceived to be a valuable clinical governance tool supporting significant changes to clinical practice, and an excellent training opportunity for SpRs. Recommendations for a successful regional audit scheme are described in this article.

Regional survey of tuberculosis risk assessment in rheumatology outpatients commencing anti-TNF-alpha treatment in relation to British Thoracic Society guidelines

The aim of this study was to analyse tuberculosis (TB) risk assessment for rheumatology patients commencing anti-tumour necrosis factor-alpha (anti-TNF-alpha) therapy using the British Thoracic Society (BTS) guidelines. Data were obtained retrospectively on 856 outpatients regionally receiving anti-TNF-alpha. Prior to commencing treatment, patients had the following assessments documented: respiratory examination, 47.4%; chest X-ray, 84.5%; TB history, 92.9%; and advice about TB risk, 45.8%. Of the 856 patients, 94.3% were on immunosuppressives but 27% had a tuberculin test; 12.6% had > or =1 high-risk factors for TB. In total, 3.4% were referred to a TB specialist and of these, 24.1% had no risk factors for TB. Of patients with > or =1 risk factor, 76.9% were not referred. Only 4/28 patients at high risk for TB due to ethnicity or birthplace received chemoprophylaxis. Marked inter-unit variation was demonstrated and it was evident that patients require improved screening for TB. Greater awareness is necessary of patients with risk factors, particularly ethnicity, to facilitate more appropriate targeting of chemoprophylaxis. Multi-centre audit is a valuable clinical governance tool.

Cardiovascular risk factors and not disease activity, severity or therapy associate with renal dysfunction in patients with rheumatoid arthritis

OBJECTIVES

The present study aimed to evaluate the prevalence and associations of renal dysfunction in patients with rheumatoid arthritis (RA). It specifically addressed the hypotheses that renal dysfunction in these patients may associate with the presence of insulin resistance, dyslipidaemia, uric acid levels and/or current levels of systemic inflammation.

METHODS

Renal function was assessed by estimated glomerular filtration rate (GFR) using the modification of diet in renal disease equation in 400 consecutive RA patients for this cross-sectional, single-centre study. Risk factors for renal dysfunction were recorded/measured in all participants. Correlations between GFR and other variables were analysed by Pearson or Spearman test as appropriate. Linear regression was used to test the independence of the associations between GFR and other variables.

RESULTS

In this RA patient cohort, 67.75% of patients had a reduced GFR of less than 90 ml/minute per 1.73 m(2) and 12.75% had a GFR of less than 60 ml/minute per 1.73 m(2). Multivariable analysis revealed significant associations between GFR and age (beta = -0.370, p<0.001), female sex (beta = -0.181, p=0.002), total cholesterol (beta = -0.112, p=0.022), serum uric acid (SUA) (beta = -0.425, p<0.001) and the presence of extra-articular disease, apart from sicca and/or nodules (beta = -0.084, p=0.040).

CONCLUSIONS

Renal dysfunction in RA is quite common and associates with classic cardiovascular risk factors such as advanced age and dyslipidaemia, levels of SUA and the presence of extra-articular disease. Renal dysfunction was not related to other RA-related factors including disease activity and duration, disability and past or present use of nephrotoxic medications.

Hypertension in rheumatoid arthritis

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.

Prostatectomía radical extraperitoneal Da Vinci

OBJECTIVE

To report the outcomes of 100 robotically assisted laparoscopic radical prostatectomies (RALPs), a minimally invasive alternative for treating prostate cancer.

PATIENTS AND METHODS

In all patients was used RALP with an extraperitoneal approach assisted by the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Prospective data collection included quality-of-life questionnaires, basic demographics (height, weight and body mass index), prostate specific antigen (PSA) levels, clinical stage and Gleason grade. Variables assessed during RALP were operative duration, estimated blood loss (EBL) and complications, and after RALP were hospital stay, catheter time, pathology, PSA level, return of continence and potency.

RESULTS

The mean (range) duration of RALP was 180 (140-295) min; all procedures were successful, with no intraoperative transfusions or deaths. The mean EBL was 300 mL (40-1100); 97% of patients were discharged home on the first day after RALP with a mean haematocrit of 36%. The mean duration of catheterization was 7 (5-21) days. The positive margin rate was 14% for all patients. The overall biochemical recurrence free (PSA level < 0.1 ng/mL) survival was 95% at mean follow-up of 9.7 months. There was complete continence at 6 months in 95% of patients. At 1 year 78% of patients were potent (with or without the use of oral medications), 15% were not yet able to sustain erections capable of intercourse, and another 7% still required injection therapy.

CONCLUSION

RALP is a safe, feasible and minimally invasive alternative for treating prostate cancer. Our initial experience with the procedure shows promising short-term outcomes.

Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics

PURPOSE

In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs.

MATERIALS AND METHODS

A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment.

RESULTS

Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase.

CONCLUSIONS

Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Expression of Smoothelin in the Normal and the Overactive Human Bladder

PURPOSE

We established the expression pattern of smoothelin, a marker protein for contractile smooth muscle cells, in the human detrusor and investigated its possible impact on bladder overactivity.

MATERIALS AND METHODS

Detrusor samples of 13 overactive bladders (sensory urge and detrusor instability) were obtained before botulinum toxin injection and compared to those of 8 normally contractile, nonobstructed bladders obtained during radical cystectomy. Smoothelin mRNA expression patterns were investigated by Northern blot and variant specific reverse transcriptase-polymerase chain reaction as well as by quantitative reverse transcriptase-polymerase chain reaction on laser capture, microdissected smooth muscle. At the protein level smoothelin was investigated by standard and quantitative immunohistochemistry.

RESULTS

The bladder muscularis expressed vascular and visceral smoothelin isoforms, and 2 of the known splice variants. In the smooth muscle of patients with detrusor instability and sensory urge a significant 2.4 and 2.2-fold increase, respectively, in smoothelin variant 1 mRNA was observed in comparison to that of normal controls. Analyses at the smoothelin protein level confirmed significant up-regulation in these bladder dysfunctions by a factor of 2.3 and 1.8, respectively. No significant difference in smoothelin expression was observed between detrusor instability and sensory urge.

CONCLUSIONS

Increased expression of smoothelin in patients with detrusor instability and sensory urge implies that the etiology of these dysfunctions includes changes in myogenic parameters. In addition, our data support the new classification of the International Continence Society for overactive bladder proposing that sensory urge and detrusor instability represent a single clinical entity.

Diagnostische Abklärung der schmerzlosen Mikrohämaturie: Prospektive Studie zum Vergleich von Bildqualität, Beurteilbarkeit und diagnostischer Sicherheit von MDCT und IVU in einem Untersuchungsgang

PURPOSE

The purpose of this study is to prospectively compare intravenous pyelography (IVP) and combined unenhanced and excretory phase multidetector-row CT (MDCT) with respect to image quality, diagnostic certainty and diagnostic concordance with the final clinical diagnosis in patients with painless microhematuria.

MATERIALS AND METHODS

Unenhanced MDCT, IVP and excretory phase MDCT were performed in 59 consecutive patients (21 women, 38 men, mean age 56 +/- 19 years, range 23 - 83 years) with painless microhematuria of unknown origin during a single examination with a single contrast media application (100 ml, non-ionic iodinated contrast media). Images were assessed by two experienced urogenital radiologists in consensus for image quality, diagnostic certainty of stone detection, obstruction, parenchymal lesions and morphological distinctive features. Imaging diagnoses of MDCT and IVP were compared with the final clinical diagnoses. In case of failure to detect an relevant pathology, the final clinical diagnosis was established after a mean follow-up period of 18 +/- 6 months (10 months to 2 years). Costs and radiation exposure of IVP and MDCT were compared.

RESULTS

MDCT scan performed better than IVP in terms of image quality for all regarded variables. Image quality of MDCT was rated in all parameters as very good or good; the image quality of IVP differed in a wide range. MDCT and IVP reached a sensitivity of 100 % and 50 % for stone detection (n = 14, p = 0.008), respectively. Two bladder stones were not detected by IVU but correctly seen with MDCT. MDCT and IVP were unsatisfactory for detecting transitional cell carcinomas (n = 4, 2 of 4 detected with MDCT, 0 of 4 detected with IVU). One false positive transitional cell carcinoma was detected with IVP, none with MDCT. Additional relevant pathological changes (one teratoma, one abdominal aortic aneurysma and one abscess) were detected using MDCT but missed with IVP. In 38 of 59 patients (64 %) imaging and clinical follow-up over up to 24 months did not reveal any pathology to explain the microhematuria. The costs of the IVP (283 Euro) were lower compared with non-enhanced MDCT (380 Euro) or combined non-enhanced and contrast-enhanced MDCT (560 Euro). The radiation exposure was 23 - 27 mSv for MDCT and 2.3 mSv for IVP.

CONCLUSION

MDCT performed better regarding image quality, subjective diagnostic certainty and diagnostic results with respect to stone detection. Since urolithiasis is a frequent cause of painless microhematuria MDCT is recommended as the initial imaging modality rather than IVU.