Emphysematous cystitis

We present a case of emphysematous cystitis in a diabetic patient with a poor glycemic control in the context of alcoholic chronic pancreatitis. A 62-year-old woman was admitted to the emergency department after being found on floor with confusion and vomiting. The clinical examination was unremarkable except she was undernourished, agitated and presented an hepatomegaly. Urine contained 5.104 leukocytes/mm3 and culture grew Escherichia coli, 10(7) Colony Forming Unit/ml. Abdominal plain film showed gas shadows along the wall of urinary bladder. CT scan of the pelvis confirmed the presence of gas, and diffuse thickening of the urinary bladder wall. A Foley catheter was placed and the patient was treated with antibiotics for 6 weeks. She was also treated with insulin, rehydratation, vitamin B1 and B6, and pancreatic enzyme replacement. Emphysematous cystitis is defined by the presence of gas in the urinary bladder wall. It complicates urinary tract infections especially in diabetic patients but other disabled general medical conditions may be present. Because this relatively uncommon disease may present with fairly nonspecific findings, the diagnosis is often made incidentally on X-rays. However, as early diagnosis and treatment improve the outcome, a high index of suspicion for unusual presentations is warranted. Every diabetic patient with a urinary tract infection who seems to be severely ill should have an abdominal X-ray as a minimal screening tool to detect emphysematous complications.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

In vitro biocompatibility assessment of naturally derived and synthetic biomaterials using normal human urothelial cells

The reconstruction of urinary tissues often employs various types of biomaterials, and adequate material biocompatibility is essential for the successful reconstruction of urinary tissues. In this study we utilized a primary normal human urothelial cell culture system to evaluate the in vitro biocompatibility of a number of naturally derived biomaterials [i.e., bladder submucosa, small intestinal submucosa, collagen, and alginate] and polymeric biomaterials [i.e., poly(glycolic acid), poly(L-lactic acid), poly(lactic-co-glycolic acid), and silicone] that are either experimentally or clinically used in urinary reconstructive surgery. To determine the cytotoxic and bioactive effects of these biomaterials, the cell viability, metabolic activity, apoptotic properties, and DNA-synthesis activity were measured with four types of assays [Neutral Red, 3-(4,5-dimethylthiazol-2-yl)-2,5diphenyl tetrazolium bromide, apoptotic activity, and tritiated thymidine incorporation assays] using extract and direct contact methods. Most of the biomaterials tested did not induce significant cytotoxic effects and exhibited normal metabolic function and cell growth in vitro. This normal primary human urothelial cell culture model is suitable for in vitro biocompatibility assessments and is able to provide information on the cell-biomaterial interactions and the ability of biomaterials to support bioactive cell functions.

In vitro immunization of patient T cells with autologous bone marrow antigen presenting cells pulsed with tumor lysates

Presentation of cell-associated antigen to T cells is a critical event in the initiation of an anti-tumor immune response but it appears to often be deficient or limiting. Here we report an experimental system for stimulation of human T lymphocytes using autologous antigen presenting cells (APCs) and autologous tumor cells. Two types of APCs were prepared from human bone marrow: MC and DC. MC were produced by using GM-CSF and SCF. DC were obtained with the same cytokines plus IL-4. DC and MC were generated in parallel from the same patients and their phenotypes and capacities to prime T lymphocytes were analyzed and compared. MC were CD14+, CD1a-, CD33+ and HLA-DR+. Two populations of DC were defined: immature DC were uniformly CD1a-; mature DC expressed CD1a, CD80, CD86, HLA-DR, CD54 and CD58 but lacked surface CD14. Stimulation of autologous T lymphocytes was studied by measuring their proliferation and cytotoxic function. In more than 80% of our experiments the proliferation of autologous T lymphocytes cocultured with APC pulsed or not with tumor cell lysates was higher than that of T cells cultured alone. DC were more effective than MC in stimulating proliferation of lymphocytes. The capacity of a patient's autologous bone marrow-derived APC to stimulate T cells when exposed to autologous tumor cell lysates suggest that such antigen-exposed APC may be useful in specific anti-tumor immunotherapy protocols.

Cytotoxicity assessment of latex urinary catheters on cultured human urothelial cells

PURPOSE

To study the toxicity of latex urinary catheters on cultured human urothelial cells (HUC).

MATERIALS AND METHODS

We exposed monolayers of HUC (well characterized for their proliferation, qualitative evaluation and quantitative measurement of cytokeratins) to either pure or diluted liquid latex extracts, obtained under standard conditions or by direct contact with materials.

RESULTS

The latex urinary catheter appears to be highly toxic since cell viability and metabolic activity were about 10% of those of negative controls for original extracts. Concerning direct contact, latex reduced cell viability, metabolic activity and cell proliferation of HUC on days 1, 3 and 8.

CONCLUSION

The high toxicity of latex on HUC is confirmed for extracts and direct contact. Therefore, it should no longer be used for urinary catheters.

Analytical and prospective evaluation of urinary cytokeratin 19 fragment in bladder cancer

PURPOSE

We evaluated CYFRA 21-1, an immunoradiometric assay, developed to detect soluble cytokaratin 19 fragment, for its diagnostic performance in bladder transitional cell carcinoma as well as its analytical performance.

MATERIALS AND METHODS

We assessed CYFRA 21-1 in the serum and urine of 182 patients, including 66 with bladder transitional cell carcinoma (group 1), 66 with another urological pathology (group 2) and 50 free of urothelial disease (group 3). The power of urinary CYFRA as a diagnostic test for bladder transitional cell carcinoma was evaluated by receiver operating characteristics curve analysis. Analytical performance was assessed by determining intra-assay and interassay precision, and accuracy by dilution testing and recovery of supplemented analyte.

RESULTS

Mean urinary CYFRA plus or minus standard deviation was 154.39+/-49.00, 22.6+/-8.9 and 2.40+/-0.14 ng./ml. in groups 1 to 3, respectively (significantly different). Receiver operating characteristics curve analysis revealed optimal 96.9% sensitivity and 67.2% specificity for a threshold value of 4 ng./ml. Analytical determination showed that intra-assay and interassay precision provides a satisfactory coefficient of variation. The assay for accuracy had acceptable recovery in diluted samples as well as in those with supplemented analyte.

CONCLUSIONS

The urinary immunoradiometric CYFRA 21-1 assay performs well analytically. Urinary CYFRA 21-1 is a useful marker for diagnosing transitional cell carcinoma and provides sensitivity in low grade disease.

Cultured differentiated human urothelial cells in the biomaterials field

To review the use of normal cultured differentiated human urothelial cells in the biomaterials field, we checked the literature for human urothelial cells in culture (HUC) both for their use in biocompatibility assessment and as bioartificial devices. The in vitro culture of differentiated human urothelium is now a simple and reliable procedure. These techniques provide new tools for biocompatibility assessment of urinary biomaterials, because for the rational design of a testing procedure, it is preferable that the particular cell culture models selected should be closely related to the end-use application. The emerging use of HUC culture should lead to the development of bioartificial tissue for urinary tract reconstruction. Tissue engineering techniques require urothelial cells and cell delivery matrices. The cytocompatibility of novel artificial delivery matrices should be assessed in vitro before implantation using cultured HUC to find the best material available.

Dilatation of the collecting system during pregnancy: physiologic vs obstructive dilatation

Dilatation of the collecting system is a classical phenomenon during pregnancy, due to hormonal and extrinsic compressive factors. Imaging has to differentiate a physiological dilatation and a pathological obstruction due to urolithiasis. Presently, sonography, using both, B-mode and color Doppler, has the potential to demonstrate the physiological compression of ureters at the level of the pelvic brim. A pathological obstruction is considered either when a stone is detected above the usual site of compression or when the ureter appears dilated beyond. Color Doppler helps in localizing the site of ureteral compression against the vessels and in differentiating ureters from veins. Magnetic resonance urography, with strongly T2-weighted sequences, also may show the site and type of obstruction without contrast agent administration. These two non-radiating techniques make it possible to avoid the use of X-rays in most cases for management of these patients. The type of treatment is based mostly on the level of pain and the presence or absence of stone.

[Gynecomastia]

Gynaecomastia is the least rare manifestation of the male breast disease. Urologists must therefore be able to distinguish the various forms of gynaecomastia, eliminate a testicular tumour and identify the main causes by performing a simple but complete assessment. Medical treatment is fairly disappointing. Surgical treatment is required in patients presenting with complications or when persistent gynaecomastia is aesthetically bothersome.

[Place of chemotherapy in the treatment of invasive bladder tumors]

Urothelial bladder tumours are chemosensitive. Chemotherapy is indicated in the case of metastatic bladder cancer. The M-VAC protocol remains the reference treatment. The efficacy of this protocol is estimated to be about 18% in terms of complete responses and 20% of these responding patients achieve long-term survival. New combinations, comprising drugs such as ifosfamide, gallium nitrate, paclitaxel or gemcitabine, appear to be promising. Neoadjuvant and adjuvant chemotherapy cannot be considered to be standard treatment at the present time.

[Patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy]

OBJECTIVE

Evaluation of patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy (ESWL) using an EDAP LT01 lithotriptor.

STUDY DESIGN

Prospective clinical study.

PATIENTS

Fifty consecutive patients, ASA I or II, aged 18-65 years.

METHODS

Patients received 50 mg of propofol five minutes before ESWL, then they self-administered 50 mg bolus doses of propofol with a ten minutes lock-out interval. Pain (1-100 mm VAS) and sedation (four points scale) were assessed every five minutes. Patient satisfaction was recorded at the end of the procedure. Pharmacokinetic simulation was done with the Marsh's data set.

RESULTS

Three patients were excluded. Patients received a mean propofol dose of 147 +/- 68 mg during the procedure with a mean duration of 47 +/- 8 minutes. The median of the higher sedation scores was 2 (drowsy) and mean maximal VAS was 40 +/- 20 mm (10-70). No complications were recorded. Thirty-nine patients (83%) were satisfied or very satisfied by patient-controlled sedation.

CONCLUSION

Patient-controlled sedation with propofol is a safe and efficient mode of administration of an hypnotic agent for ESWL.

In vitro cytocompatibility of radio-opacifiers used in ureteral endoprosthesis

Ureteral endoprostheses are urinary catheters made of polymeric biomaterials made radio-opaque through the addition of X-ray absorbing additives such as barium, bismuth, tantale or tungsten. The aim of this work was to study the in vitro toxicity of solutions of these radio-opacifiers using two cell culture models. Primary-cultures of human urothelial cells (HUC) arising from normal adult urinary tract and permanent urothelial cell line were used. Solutions at different dilutions were placed into the wells containing monolayers of confluent cells. After 24 h incubation period, the solutions were removed and cell viability and cell metabolic activity tests were performed (Neutral Red assay and MTT assay). At a concentration lower than 1 mg l(-1) the different radio-opacifiers used showed no toxicity. From 1 to 3 mg l(-1) one can note a significant dose-dependent decrease of cell metabolic activity of solely HUC for barium chloride. At 3 mg l(-1) one can note a significant deleterious effect on HUC metabolic activity, with bismuth and tantale. For tungsten, there is no deleterious effect, but on the contrary a significant increase in HUC metabolic activity at a 0.5 mg l(-1) concentration. None of the solutions did provoke alterations in HUC viability for concentrations less than 3 mg l(-1). Interestingly, for permanent cell line one can note a solely significant decrease of cell viability at 3 mg l(-1) for tantale. All the other tested salts on permanent cell line were not significantly different from controls for cell viability as well as cell metabolic activity. HUC culture model may be of relevance for the screening of radio-opacifiers intended for ureteral endoprostheses.

Characterization of urinary calculi: in vitro study of "twinkling artifact" revealed by color-flow sonography

OBJECTIVE

The "twinkling artifact" is a color-flow sonographic artifact described behind calcifications and presenting as a random color encoding in the region where shadowing would be expected on gray-scale images. Our purpose was to study the relationship between this twinkling artifact seen behind urinary stones on color-flow sonography and the morphology or biochemical composition of these urinary stones.

MATERIALS AND METHODS

Forty-seven urinary stones were studied in vitro with color-flow sonography. Transmit frequency, color gain, velocity range, color filters, focal depth, and depth of field were changed during scanning. The twinkling artifact was graded 0 when absent, 1 when present but occupying a portion of acoustic shadowing, and 2 when occupying the entire acoustic shadowing. Stones were studied under a binocular magnifying glass to characterize the surface, and infrared spectrophotometry was used to determine the chemical composition.

RESULTS

Calculi of calcium oxalate dihydrate and calcium phosphate always produced a grade 1 or grade 2 twinkling artifact. Absence of artifact was noted only for calcium oxalate monohydrate and urate stones. In 100% of grade 0 calcium oxalate stones, the monohydrate compound was predominant (>93%). In 100% of grade 2 calcium oxalate stones, the dihydrate compound was predominant (>75%). For calcium oxalate stones, the surface pattern was correlated with their composition. Sensitivity and specificity for absence of artifact, as indicative of calcium oxalate monohydrate, were 60% and 83%, respectively, for all stones and 56% and 100%, respectively, only for radiopaque stones.

CONCLUSION

An in vitro relationship exists between the twinkling artifact and the morphology of urinary stones. Color-flow sonography could play a role in detecting dense calcium oxalate monohydrate calculi, which in turn may help predict fragmentability.

An in vitro biocompatibility evaluation of double-J stents

OBJECTIVES

For several years, studies performed to estimate in vitro biocompatibility of urinary catheters have been carried out using permanent cell lines. However, for a rational design of the testing procedure, the cell culture model should depend on the material application. We assess the biocompatibility of 13 double-J stents using an in vitro model of normal human urothelial cells (HUC). This article aims to mimic in vitro, on HUC monolayers, the close contact existing in vivo between the urothelium and double-J stents and to evaluate the subsequent effect on these cells.

METHODS

Fragments of each stent were deposited into the wells containing confluent HUC, with close contact maintained between the material and the cells. The same procedure with either no material or fragments of latex catheter was undertaken to provide the negative and positive controls, respectively. The contact was maintained for 1, 3, and 8 days. At the end of the incubation period, fragments of stent were removed and cell activity tests were performed (neutral red assay, MTT assay, and cell proliferation).

RESULTS

One of the silicone stents is significantly deleterious on HUC as determined by three tests after 8 days of contact. For two copolymers, a tendency to increase cell proliferation was noted. Concerning polyurethanes, we observed significant decreases in HUC viability and cell metabolic activity for five stents after 8 days of contact. All seven polyurethane stents significantly inhibited cell proliferation.

CONCLUSIONS

The HUC culture model may be of relevance for the screening of materials intended for use as double-J stents.

First use of cultured human urothelial cells for biocompatibility assessment: application to urinary catheters

For several years, studies performed to estimate in vitro biocompatibility of urinary catheters have been carried out using permanent cell lines. But for a rational design of the testing procedure, the cell culture model should relate to the material application. This work presents the results of a probe study designed to obtain an in vitro model of normal human urothelial cells (HUC) and to test the relevance of this system in cytocompatibility experiments of urinary catheters currently used.A comparison is made with continuous cell lines, the use of which is recommended by normalization bodies. We exposed monolayers of HUC (well characterized for their proliferation, qualitative evaluation, and quantitative measurement of cytokeratins) and two continuous human cell lines to liquid extracts (either pure or diluted in the culture medium) of nine available catheters, including positive (latex) and negative controls, for a 24 h incubation. Then colorimetric assays (Neutral Red and MTT) were performed. The extracts of two polyurethanes provoked a significant toxic effect on HUC only, suggesting differences in sensitivity between the models used. This effect could be due to the presence of a great amount of barium (used as a radioopacifier) in extracts, as highlighted by results of absorption emission spectroscopy. A culture model of HUC may be of relevance for the screening of materials intended for urological practice.

[The biocompatibility of catheters and stents used in urology]

Biocompatibility can be interpreted as the optimal combination of a series of interactions occurring at the material-tissue interface as soon as these two systems are in contact. It is a multifactorial interface property which integrates all of the phenomena involved in a biological environment i.e. absence of toxicity of the material for the body and absence of degradation of the material by the body. Biocompatibility can be evaluated in a normative context by using in vivo techniques in animals or in vitro techniques using cell cultures allowing the study of cytotoxicity (related to a concept of safety) and cytocompatibility (related to biological acceptability) of a material. Because of their intimate contact with the urothelium throughout implantation, the biocompatibility of catheters and stents constitutes a major requirement. This review presents the current data reported in the literature concerning the evaluation of the biocompatibility of materials used in urology. The main problems encountered are alterations of the urothelium, such as erosions or, on the contrary, mucosal hyperplasia, and the existence of incrustations developing on these materials.

[Can the prostatic capsule be preserved during cystectomy for bladder tumors: a study of urethral and prostatic involvement in the cystectomy specimens]

OBJECTIVES

To evaluate the frequency of urethral and prostatic lesions on cystectomy specimens for bladder tumour.

MATERIAL AND METHODS

This retrospective histological study was based on 260 specimens: radical cystectomies performed in 7 operative sites. The prostate and urethra were analysed in 3 planes (upper, middle and lower thirds). The apex was studied separately. Urethral invasion was identified by continuity of the tumour or by the presence of vesical CIS.

RESULTS

Urethral involvement is frequent (30.6% cases) essentially due to contiguous invasion (43/80). CIS is the second pathological association (44 urethral CIS/75 bladder CIS). Prostatic adenocarcinoma was present in 17.8% of cases with a Gleason score > 6 for 30% of lesions.

CONCLUSION

The high frequency of urethral and prostatic involvement does not justify preservation of the prostate during cystectomy. A serial prospective study should define the precise criteria able to minimize the risk of conservative surgery.

[Renal angiomyolipoma with venous extension associated with complete duplication]

A case of venous extension de renal angiomyolipoma is reported. The diagnosis was established preoperatively by ultrasonography and renal CT. This tumour was treated conservatively by partial nephrectomy after selective embolization because of the presence of complete duplication.

Initial evaluation of CYFRA 21-1 diagnostic performances as a urinary marker in bladder transitional cell carcinoma

PURPOSE

CYFRA 21-1, an immunoradiometric assay developed for the detection of a soluble cytokeratin 19 fragment, is evaluated for its diagnostic performance in urine of patients with transitional cell carcinoma.

MATERIALS AND METHODS

CYFRA 21-1 was investigated in serum and urine of 128 patients, including 48 with bladder transitional cell carcinoma (group 1), 44 with other urological pathological conditions (group 2) and 36 free of urothelial disease (group 3). Urinary cytopathology was also performed.

RESULTS

Mean urinary CYFRA was 123.5 +/- 53, 11.9 +/- 4.8 and 2.3 +/- 0.2 ng./ml. for groups 1 to 3, respectively, and was significantly different. From the receiver operating characteristics curve, the optimal combination of 96% sensitivity and 74% specificity was determined for a threshold value of 4 ng./ml. while overall cytopathology sensitivity was 43%.

CONCLUSIONS

Urinary CYFRA 21-1 may be a useful marker for diagnosing transitional cell carcinoma.

[The value of transrectal MRI in the staging of localized prostate cancer]

OBJECTIVE

To determine the diagnostic value of transrectal magnetic resonance imaging (MRI) in the local staging of prostatic cancer.

METHOD

75 patients suffering from clinically localized prostatic cancer were included consecutively from December 1992 to September 1996. An MRI examination (1.5 Tesla, Siemens) with a transrectal coil was performed before radical prostatectomy. The results of this examination in terms of capsular invasion, seminal vesicle lesion and apical invasion were correlated with the results of histological examination of the operative specimen and the findings of digital rectal examination, transrectal ultrasonography, serum PSA level and biopsy mapping.

RESULTS

The best performance of transrectal MRI concerned elimination of seminal vesicle lesion with a specificity of 92%. The positive predictive value of transrectal MRI was 90% for the capsular invasion. The positive predictive value of transrectal MRI was 56% for the apex, the sensitivity was 40% and the specificity was 82%. When transrectal MRI did not reveal any extraprostatic involvement the risk of positive margins on radical prostatectomy was less than 6%.

CONCLUSION

In this study, transrectal MRI appeared to be satisfactory to improve the staging of localized prostate cancer, especially in terms of seminal vesicle lesion and apical invasion, but, most importantly, appeared to be very useful to predict negative resection margins.

[Conservative surgery in cancer of the kidney]

Partial nephrectomy is classically indicated in patients with renal cell cancer on a single kidney, although a certain amount of debate continues on surgical technique: simple enucleation or true partial nephrectomy. Incidence of multifocal tumours has been estimated at 6 to 19.6%. The crucial problem for the surgeon is to recognize satellite tumours pre- and peroperatively since it has been estimated that 4 to 10% of renal cell carcinomas contain a multifocal disease unrecognized during surgery. Is conservative nephrectomy acceptable for patients with a functional contralateral kidney? There are several arguments in favour of the technique: fortuitously discovered tumours are generally smaller and in a less advanced stage, morbidity after conservative surgery is low compared with total nephrectomy, nephron sparing improves long-term renal function and survival at 3 to 5 years is 95 to 100%. The fact that the risk of cancer on the contralateral kidney is small (1 to 2%) compared with the risk of local recurrence and the lack of sufficiently long follow-up in large series are negative arguments. Conservative nephrectomy must therefore be considered as the best solution when nephron sparing is essential. Total nephrectomy remains the reference treatment in other cases although the discussion remains open for cases with small (< 2.5 cm) tumours.