Integrated drug profiling and CRISPR screening identify BCR::ABL1-independent vulnerabilities in chronic myeloid leukemia

BCR::ABL1-independent pathways contribute to primary resistance to tyrosine kinase inhibitor (TKI) treatment in chronic myeloid leukemia (CML) and play a role in leukemic stem cell persistence. Here, we perform ex vivo drug screening of CML CD34+ leukemic stem/progenitor cells using 100 single drugs and TKI-drug combinations and identify sensitivities to Wee1, MDM2, and BCL2 inhibitors. These agents effectively inhibit primitive CD34+CD38- CML cells and demonstrate potent synergies when combined with TKIs. Flow-cytometry-based drug screening identifies mepacrine to induce differentiation of CD34+CD38- cells. We employ genome-wide CRISPR-Cas9 screening for six drugs, and mediator complex, apoptosis, and erythroid-lineage-related genes are identified as key resistance hits for TKIs, whereas the Wee1 inhibitor AZD1775 and mepacrine exhibit distinct resistance profiles. KCTD5, a consistent TKI-resistance-conferring gene, is found to mediate TKI-induced BCR::ABL1 ubiquitination. In summary, we delineate potential mechanisms for primary TKI resistance and non-BCR::ABL1-targeting drugs, offering insights for optimizing CML treatment.

Aggressive natural killer-cell leukemia mutational landscape and drug profiling highlight JAK-STAT signaling as therapeutic target

Aggressive natural killer-cell (NK-cell) leukemia (ANKL) is an extremely aggressive malignancy with dismal prognosis and lack of targeted therapies. Here, we elucidate the molecular pathogenesis of ANKL using a combination of genomic and drug sensitivity profiling. We study 14 ANKL patients using whole-exome sequencing (WES) and identify mutations in STAT3 (21%) and RAS-MAPK pathway genes (21%) as well as in DDX3X (29%) and epigenetic modifiers (50%). Additional alterations include JAK-STAT copy gains and tyrosine phosphatase mutations, which we show recurrent also in extranodal NK/T-cell lymphoma, nasal type (NKTCL) through integration of public genomic data. Drug sensitivity profiling further demonstrates the role of the JAK-STAT pathway in the pathogenesis of NK-cell malignancies, identifying NK cells to be highly sensitive to JAK and BCL2 inhibition compared to other hematopoietic cell lineages. Our results provide insight into ANKL genetics and a framework for application of targeted therapies in NK-cell malignancies.

Aggressive natural killer-cell leukemia (ANKL) has few targeted therapies. Here ANKL patients are reported to harbor STAT3, RAS-MAPK pathway, DDX3X and epigenetic modifier mutations; and drug sensitivity profiling uncovers the importance of the JAK-STAT pathway, revealing potential ANKL therapeutic targets.

Immunophenotypic Characterization of Cytogenetic Subgroups in Egyptian Pediatric Patients With B-Cell Acute Lymphoblastic Leukemia

BACKGROUND

Identification of prognostic factors in acute lymphoblastic leukemia (ALL) patients is important for stratifying patients into risk groups and tailoring treatment accordingly. Molecular and cytogenetic abnormalities are the most important prognostic factors. Minimal residual disease (MRD) is also an important predictor of relapse in ALL. However, the correlation of both prognostic variables has not been thoroughly studied.

METHODS

We investigated the correlation between defined cytogenetic abnormalities and selected new MRD markers (CD79b, CD123, and CD200) in 56 newly diagnosed Egyptian pediatric B-cell ALL patients.

RESULTS

CD123 found to be expressed in 45% of patients, CD200 in 80.3%, and CD79b in 67.9%. MRD analysis during treatment showed stable expression patterns of CD200. There was significant association of CD123 expression with the hyperdiploid ALL group (P = .017). Another association (P = .029) was found between CD79b negativity and the t(12;21) group. CD200 was widely expressed in all groups.

CONCLUSION

There is a significant correlation between some markers, and certain ALL recurrent cytogenetic subgroups (CD123 and hyperdiploidy, CD79b negativity, and ETV-RUNX1 group) have good prognostic value. CD200 can be used as MRD markers in ALL patients and can also can serve as therapy targets.

Crosstalk between tongue carcinoma cells, extracellular vesicles, and immune cells in in vitro and in vivo models

The crosstalk between immune cells, cancer cells, and extracellular vesicles (EVs) secreted by cancer cells remains poorly understood. We created three-dimensional (3D) cell culture models using human leiomyoma discs and Myogel to study the effects of immune cells on highly (HSC-3) and less (SCC-25) invasive oral tongue squamous cell carcinoma (OTSCC) cell lines. Additionally, we studied the effects of EVs isolated from these cell lines on the cytotoxicity of CD8⁺ T and NK cells isolated from three healthy donors. Our analysis included the effects of these EVs on innate immunity in zebrafish larvae. Activated immune cells significantly decreased the proliferation of both OTSCC cell lines and associated with a diminished invasion area of HSC-3 cells. In general, EVs from SCC-25 increased the cytotoxic activity of CD8⁺ T and NK cells more than those from HSC-3 cells. However, this effect varied depending on the source and the immune and cancer cell subgroups. In zebrafish, the amount of IL-13 mRNA was decreased by SCC-25 EVs. This study describes promising in vitro and in vivo models to investigate interactions between immune cells, cancer cells, and EVs.

A novel class of somatic mutations in blood detected preferentially in CD8+ cells

Somatic mutations have a central role in cancer but their role in other diseases such as autoimmune disorders is poorly understood. Earlier work has provided indirect evidence of rare somatic mutations in autoreactive T-lymphocytes in multiple sclerosis (MS) patients but such mutations have not been identified thus far. We analysed somatic mutations in blood in 16 patients with relapsing MS and 4 with other neurological autoimmune disease. To facilitate the detection of somatic mutations CD4+, CD8+, CD19+ and CD4-/CD8-/CD19- cell subpopulations were separated. We performed next-generation DNA sequencing targeting 986 immune-related genes. Somatic mutations were called by comparing the sequence data of each cell subpopulation to other subpopulations of the same patient and validated by amplicon sequencing. We found non-synonymous somatic mutations in 12 (60%) patients (10 MS, 1 myasthenia gravis, 1 narcolepsy). There were 27 mutations, all different and mostly novel (67%). They were discovered at subpopulation-wise allelic fractions of 0.2%-4.6% (median 0.95%). Multiple mutations were found in 8 patients. The mutations were enriched in CD8+ cells (85% of mutations). In follow-up after a median time of 2.3years, 96% of the mutations were still detectable. These results unravel a novel class of persistent somatic mutations, many of which were in genes that may play a role in autoimmunity (ATM, BTK, CD46, CD180, CLIP2, HMMR, IKFZF3, ITGB3, KIR3DL2, MAPK10, CD56/NCAM1, RBM6, RORA, RPA1 and STAT3). Whether some of this class of mutations plays a role in disease is currently unclear, but these results define an interesting hitherto unknown research target for future studies.

Assessment of bone marrow lymphocytic status during tyrosine kinase inhibitor therapy and its relation to therapy response in chronic myeloid leukaemia

PURPOSE

Tyrosine kinase inhibitors (TKIs) used in the treatment of chronic myeloid leukaemia have been reported to induce immunomodulatory effects. We aimed to assess peripheral blood (PB) and bone marrow (BM) lymphocyte status at the diagnosis and during different TKI therapies and correlate it with treatment responses.

METHODS

BM and PB samples were acquired from 105 first-line TKI-treated patients. Relative number of BM lymphocytes was evaluated from MGG-stained BM aspirates, and immunophenotypic analyses were performed with multicolour flow cytometry.

RESULTS

Early 3-month expansion of BM lymphocytes was found during all different TKIs (imatinib n = 71, 20 %; dasatinib n = 25, 21 %; nilotinib n = 9, 22 %; healthy controls n = 14, 12 %, p < 0.0001). Increased PB lymphocyte count was only observed during dasatinib therapy. The BM lymphocyte expansion was associated with early molecular response; patients with 3-month BCR-ABL1 <10 % showed higher lymphocyte counts than patients with BCR-ABL1 >10 % (23 vs. 17 %, p < 0.05). Detailed phenotypic analysis showed that BM lymphocyte expansion consisted of various lymphocyte subclasses, but especially the proportion of CD19+ B cells and CD3negCD16/56+ NK cells increased from diagnostic values. During dasatinib treatment, the lymphocyte balance in both BM and PB was shifted more to cytotoxic direction (increased CD8+CD57+ and CD8+HLA-DR+ cells, and low T regulatory cells), whereas no major immunophenotypic differences were observed between imatinib and nilotinib patients.

CONCLUSIONS

Early BM lymphocytosis occurs with all current first-line TKIs and is associated with better treatment responses. PB and BM immunoprofile during dasatinib treatment markedly differs from both imatinib- and nilotinib-treated patients.

Long-term results and complications of augmentation ileocystoplasty for idiopathic urge incontinence in women

OBJECTIVE

To assess the long-term (3-9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients' satisfaction with the outcome.

PATIENTS AND METHODS

The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information.

RESULTS

Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred.

CONCLUSION

Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.

Anthraquinones from the polar fractions of Galium sinaicum

The new anthraquinones, 6,7-dimethoxy xanthopurpurin, 6-hydroxy-7-methoxy rubiadin, 5-hydroxy-6-hydroxymethyl anthragallol 1, 3-dimethyl ether, 7-carboxy anthragallol 1,3-dimethyl ether, anthragallol 1-methyl ether 3-O-beta-D-glucopyranoside, anthragallol 1-methyl ether 3-O-rutinoside, anthragallol 3-O-rutinoside and alizarin 1-methyl ether 2-O-primeveroside were isolated from the CH2Cl2 and n-BuOH extracts of Galium sinaicum roots and their structures were established by various spectroscopic techniques. In addition, two known anthraquinones were also isolated and fully characterized.

Cystitis associated with tiaprofenic acid

Ten patients with cystitis associated with tiaprofenic acid were reviewed. All patients displayed similar cystoscopic and histological features, and all failed a variety of initial therapies but achieved a dramatic improvement or resolution of symptoms with discontinuation of the tiaprofenic acid. Drug-induced cystitis may be more common than previously recognized.

Long-term results of combined interstitial gold seed implantation plus external beam irradiation in localised carcinoma of the prostate

Carcinoma of the prostate is one of the leading causes of death in men. Patients with localised disease can be treated with radiotherapy, but controversy still exists regarding the most effective therapeutic technique. We report 180 patients with surgical stage A2-C prostate cancer treated between 1976 and 1986 by pelvic lymphadenectomy and radioactive gold seed implantation followed by external irradiation. Annual post-treatment biopsies were performed up to 5 years in most patients. Regular follow-up included a digital rectal examination, prostatic acid phosphatase and bone scan. One hundred and sixty-four patients had complete follow-up data at the end-point of data collection (December 1991). The actuarial 10-year cancer-free survival rates were 83.0% and 91.3% for stages A2 and B1 respectively. The incidence of positive biopsy at 2 and 5 years was 13% and 17.1% respectively for the whole series. A firm correlation was defined between biopsy result and subsequent development of local progression, distant metastases and overall survival. Combined interstitial gold seed implantation plus external beam irradiation represent a valid option for the treatment of patients with localised prostatic cancer.

The pathophysiology of contractile activity in the chronic decentralized feline bladder

Autonomous wave activity occurs in the decentralized bladder and may contribute to upper tract damage and incontinence. In order to clarify the poorly understood pathophysiology and neuropharmacology of autonomous waves, cats were prepared with L7-S3 ventrodorsal rhizotomy alone or with L7-S3 ventral rhizotomy with and without total sympathectomy. The incidence of autonomous waves was < 15% 12 weeks after ventral or ventrodorsal rhizotomy, but acute sympathectomy at 13 weeks increased the incidence to 58% in these groups. With chronic sympathectomy the incidence was 100%. This suggests that the waves arise locally via a mechanism which is independent of L7-S3 dorsal roots, due to lack of a suppressive sympathetic pathway. Autonomous waves were inhibited by atropine after acute sympathectomy and by prazosin after chronic sympathectomy, but increased inhibition occurred after both drugs in either case. Adrenergic neuron depletion with 6-hydroxydopamine enhanced wave activity, which was incompletely inhibited by subsequent atropine. This implies that the peripheral reflex pathway has facilitatory alpha 1-adrenergic, muscarinic and also noncholinergic nonadrenergic elements. Clinically, sensory or sympathetic damage caused incontinence, but sympathectomy also caused high pressure waves, which may cause upper tract damage and treatment resistant incontinence in patients.

Control of detrusor stiffness in the chronic decentralized feline bladder

The neuropharmacology of increased bladder stiffness, which may contribute to upper tract damage and incontinence, was investigated in 76 cats. beta-blockade increased but combined alpha 1-adrenergic with muscarinic blockade decreased filling phase stiffness in normal cats. Bladder wall stiffness during the early filling phase was unaffected by chronic S2 ventrodorsal rhizotomy or L7-S3 ventral rhizotomy, but was decreased when L7-S3 dorsal rhizotomy or total sympathectomy was combined with the ventral root lesion, implying that sacral dorsal roots and sympathetic efferents maintain normal detrusor stiffness. Acute sympathectomy increased stiffness in all the former 3 chronic groups, implying that a tonic or reflex sympathetic inhibition operates independently of the L7-S3 dorsal roots. Stiffness during early filling phase decreased with acute ventral rhizotomy. This change persisted with chronic sympathectomy but returned to normal if sympathetic nerves were left intact. These results suggest that bladder stiffness is modulated by tonic or reflexic sympathetic activity, which is influenced by L7-S3 afferents. Detrusor stiffness during the later stages of filling, which was decreased by acute sympathectomy in chronic groups but increased by chronic sympathectomy, was reduced by interference with adrenergic or muscarinic mechanisms after either lesion. Therefore, a peripheral pathway with facilitatory alpha 1-adrenergic and muscarinic receptors is involved in the production of increased late stage stiffness after chronic sympathetic damage. We propose that the increased bladder stiffness seen in congenital sacral lesions may be analogous to the stiffness during late stages of filling reported here. Our results also imply that the presence of this increased stiffness is closely associated with chronic sympathetic damage. Whether the increased stiffness in congenital and traumatic neural lesions in humans arises from sympathetic damage remains to be determined.

Idiopathic reduced bladder storage versus interstitial cystitis

Idiopathic reduced bladder storage is a term we used to describe a group of patients who have subjective and objective evidence (by cystometrogram) of diminished bladder capacity without a demonstrable cause. We performed a prospective study comparing this condition with interstitial cystitis. We studied the clinical, urodynamic and histological features, and response to therapy in these 2 groups of patients. No statistical difference was found between the incidence of irritative bladder symptoms and/or suprapubic pain. Only minor differences were noted in the maximum cystometric capacity and incidence of bladder instability. Histological and immunofluorescent features were analogous. Also, the reduced bladder storage and interstitial cystitis patients responded similarly to bladder dilation and pharmacological therapy. Augmentation ileocystoplasty used in patients refractory to medical treatment produced comparable results in the short term. Based upon similar findings, it is likely that these 2 conditions represent the same disease entity with the only difference being the cystoscopic findings.

Final diagnosis and therapeutic implications of mixed symptoms of urinary incontinence in women

The final diagnosis of 244 females who presented with mixed symptoms of stress incontinence (SI) and urge incontinence (UI) was made based on clinical, urodynamic, and cystoscopic findings. The UD studies consisted of cystometrogram, uroflow and urethral pressure profiles in the supine and standing positions. Diagnosis of genuine stress urinary incontinence (GSI) in 72 patients (30%) was based on the presence of positive Marshall test result or maximum urethral closure pressure 40 cm of water or less, in addition to the symptoms of stress incontinence. Diagnosis of reduced bladder storage (RBS) in 36 patients (15%) was based on MCC 300 mL or less, or the findings of bladder instability on cystometrogram in addition to the symptoms of urge incontinence. Ninety-five patients (39%) with the criteria of both GSI and RBS were classified as the mixed group. The diagnosis of interstitial cystitis in 19 patients (8%) was made according to the criteria outlined by Messing. Urethral stenosis was diagnosed in 6 patients (2%) based on a reduced maximal flow rate by at least 2 S.D. and a tight urethra to F16 calibration at cystoscopy. Sixteen patients (7%) with inconclusive diagnosis had symptoms only of SI and UI but no objective findings. The clinical and urodynamic findings in each group and the results of the surgical and medical treatment are compared.

Analysis of imaging modalities, staging systems, and prognostic indicators for renal cell carcinoma

A retrospective analysis of 314 patients with renal cell carcinoma was done focusing mainly on imaging modalities and prognostic significance of tumor stage using both the Robson and TNM systems. Computerized tomography (CT) scan proved to be the most effective modality for staging. Overall staging accuracy was 62 and 68 percent for TNM and Robson staging, respectively, and understaging was more frequent than overstaging. The actuarial five-year survival using the Robson system was 73 percent for Stage A, 68 percent Stage B, 51 percent Stage C, and 20 percent Stage D. The main limitation of the Robson system is the heterogeneity of the Stage C group which includes patients with renal vein and those with nodal involvement with a significant difference in survival. The survival by the TNM system showed no difference in those with T1, T2, T3a and T3b disease but a significant difference in those with T3c or T4a. One hundred sixteen patients (37%) presented with metastatic disease with a median survival of seventeen months (range 2-204) for those with solitary metastasis and six months (range 1-132) for those with multiple metastases (the difference was not statistically significant). Except for anecdotal cases, nephrectomy with or without treatment of the metastases did not seem to affect survival significantly. The presence of spindle cell, alone or in association with clear or granular cell, affected the prognosis adversely. Thirty-one patients had their tumors identified incidentally. Their stage at diagnosis was earlier than the symptomatic group (Stage T1-T2: 77% vs 34%), and there was a significant difference in the disease-free survival at fifty-four months between the two groups (79% vs 57%, respectively).

Urethral function after chronic cauda equina lesions in cats. I. The contribution of mechanical factors and sympathetic innervation to proximal sphincter dysfunction

We investigated the contribution of mechanical and sympathetic neural factors to proximal urethral sphincter dysfunction in the cat after chronic sacral rhizotomy. Concomitant vesicostomy prevented a decrease in the urethral pressure profile measured three months post-rhizotomy. Sympathetic influences on basal urethral perfusion pressure were the same in neurally-intact and chronic rhizotomised cats. A significant prazosin-sensitive component of basal urethral perfusion pressure remained after section of all extrinsic urethral innervation in both neurally-intact and chronic cats. Local intra-arterial 6-hydroxydopamine also abolished this component. After rhizotomy, noradrenaline content in the proximal urethra was significantly increased but there was no change in sensitivity to sympathetic stimulation. A small (5% of control) atropine-sensitive and prazosin-resistant constriction was seen only after chronic sacral rhizotomy. We conclude that a mechanical factor associated with bladder expression and not an alteration in sympathetic control is the major factor leading to diminished proximal urethral closure after vesicourethral lower motor neuron lesion. Furthermore, short adrenergic neurons have an important role in the maintenance of urethral pressure in the normal state and after lower motor neuron lesion.

Urethral function after chronic cauda equina lesion in cats. II. The role of autonomically-innervated smooth and striated muscle in distal sphincter dysfunction

We investigated the possibility that distal sphincter dysfunction after chronic sacral rhizotomy in the cat might be due to altered sympathetic influences on smooth and striated muscle. Three months after rhizotomy, sympathetic influences on basal perfusion pressure in the distal sphincteric urethra were significantly decreased. A prazosin-sensitive component of basal perfusion pressure remained after section of all extrinsic urethral innervation in both control and chronic cats. Local intra-arterial 6-hydroxydopamine also abolished this component. After rhizotomy, noradrenaline content in the distal sphincteric urethra was significantly increased but there was no evidence of a change in sensitivity to sympathetic stimulation. A novel prazosin- and atropine-resistant component of the response to hypogastric nerve stimulation was seen in the rhabdosphincteric urethra of chronic cats. This component was abolished by atracurium or hexamethonium. It was significantly greater in cats with S1-3 as compared to S2-3 lesions and was never seen in control cats. It is concluded that autonomic activation of the rhabdosphincter could be a factor in distal sphincter obstruction.

Selective transsacral nerve root blocks

This study compares the effectiveness and extent of spread of two different volumes, 1 ml and 2 ml, of a local anesthetic/radiopaque dye combination (referred to here as the injectate) in selective sacral nerve root blocks. With 1 ml of injectate, a selective sacral nerve root block was obtained in seven of nine patients, and with 2 ml of injectate, in eight of nine patients, as measured by urodynamic testing or scoring of pain relief. The three patients who did not have a successful block in this study were effectively blocked at another sacral nerve on a later date (outside of the study) when injected with 1 ml of injectate. The group that received 2 ml of injectate had significantly larger spread of injectate than the 1 ml group. One milliliter of injectate can produce a selective sacral nerve root block. Increasing the volume of injectate increases the spread and thus the possibility of involving other nerve roots. This could then cause difficulty in the interpretation of the results of the block.

Liver transplantation: intraoperative changes in coagulation factors in 100 first transplants

Six intraoperative blood samples were obtained at intervals from each of 100 individuals undergoing their first liver transplants. The patients fell into the following diagnostic categories: postnecrotic cirrhosis 28, primary biliary cirrhosis 20, sclerosing cholangitis 19, miscellaneous diseases 14, carcinoma/neoplasia 12 and fulminant hepatitis 7. Coagulation factor values in the initial (baseline) blood samples varied by patient diagnosis. In general, all factor levels were reduced except factor VIII:C, which was increased to almost twice normal. The slight intraoperative changes in factors II, VII, IX, X, XI and XII suggested that a steady-state relationship existed between depletion (consumption/bleeding) and repletion (transfusion, transit from extra- to intravascular space), even in the anhepatic state. In contrast, there were rapid and very significant falls in factor VIII and fibrinogen and a less pronounced decrease in factor V, all reaching their nadirs in early to mid-Stage III. The cause of these coagulation changes appears to be activation of the fibrinolytic system.

The significance of prior anti-incontinence surgery in women who present with urinary incontinence

In a series of 148 consecutive female patients with urinary incontinence 62 (group 1) had undergone 1 or more prior anti-incontinence operations and 86 (group 2) had none. After clinical and urodynamic assessment the incidence of detrusor instability in the 2 groups (44 and 51 per cent) was not significantly different but the incidence of stress incontinence in group 1 was significantly greater than in group 2 (58 and 38 per cent, p less than 0.05). Of the 69 patients with a final diagnosis of stress urinary incontinence 45 (24 in group 1) had surgery and were followed for a mean of 17 months postoperatively. Of the patients 43 (95 per cent) were cured or improved. A total of 17 patients (71 per cent) in group 1 and 3 (17 per cent) in group 2 had a fascial sling. Eight patients had symptomatic postoperative detrusor instability and all had a fascial sling. There also was a significant decrease in postoperative peak flow rate (p less than 0.01) in these patients. Neither the number of previous operations nor the presence of preoperative detrusor instability had a significant effect on the incidence of postoperative detrusor instability.

External sphincter dyssynergia: an abnormal continence reflex

Some of the characteristics of detrusor-external sphincter dyssynergia were examined in 14 patients with traumatic upper motor neuron lesions within 44 weeks of injury. The sacral evoked response latencies of the male patients were shortened at any time after injury. A continence reflex could be demonstrated in most patients at any time after injury. Comparing averaged values for the group at 4-week intervals, resting pressure at the external urethral sphincter and post-void residual volumes reached nadirs at 12 weeks while voiding efficiency peaked at this time. Thus, voiding function appears to be optimal 12 weeks after injury. During reflex detrusor activity, increases in external urethral sphincter electromyographic activity and external urethral sphincter pressure were associated clearly with a positive slope of the intravesical pressure trace, whereas decreases in both parameters were associated with a negative slope. Voiding occurred only during a negative slope. Although propantheline induced detrusor areflexia, episodic peaks in external urethral sphincter pressure and electromyographic activity continued to occur. We propose that external sphincter dyssynergia, which is independent of detrusor contraction, is the continence reflex exaggerated owing to the loss of supraspinal influences. We believe that the multiple patterns of dyssynergia described previously by others are variations, largely owing to technique, of the single pattern we have observed. The observation of synergic-like urethral responses in some patients during a negative slope of the intravesical pressure, even with complete suprasacral spinal lesions, implies existence of a pathway for synergic-like voiding in the spinal cord.

Conservative management of renal lacerations in blunt trauma

Controversy in the treatment of blunt renal trauma is largely focused on immediate surgery versus conservative management for parenchymal lacerations. A retrospective analysis of 133 cases of blunt renal trauma at the Victoria General Hospital in Halifax over a 10-year period revealed 26 cases of renal laceration. The conservative approach to radiologic diagnosis and treatment options is discussed. Our experience confirms a low rate of both nephrectomy and secondary complications using conservative management.

Oxybutynin versus propantheline in patients with multiple sclerosis and detrusor hyperreflexia

Hyperreflexia is the most common urological finding in patients with multiple sclerosis. A prospective randomized study was done to compare the effectiveness of 2 commonly used drugs, oxybutynin and propantheline. Of the 34 patients entered into the trial 19 were treated with oxybutynin and 15 with propantheline. The urological symptoms (frequency, nocturia, hesitancy, urgency and urge incontinence) were graded according to severity from 0 to 3. Patients with urinary infection were excluded. Urodynamic examination, consisting of cystometrography and electromyography, was performed in all patients before treatment. Both groups of patients had comparable neurological, urological and urodynamic status before treatment. In 4 patients (21 per cent) treated with oxybutynin and in 4 (27 per cent) treated with propantheline side effects were so severe that the treatment had to be discontinued. Symptomatic response to oxybutynin was good in 10 patients (67 per cent), fair in 2 (13 per cent) and poor in 3 (20 per cent). Propantheline produced good symptomatic results in 4 patients (36 per cent), fair in 1 (9 per cent) and poor in 6 (55 per cent). The mean increase in maximum cystometric capacity on cystometrography was significantly larger in the oxybutynin group than in the propantheline group (144 +/- 115 versus 35 +/- 101). Our results indicate that oxybutynin is more effective than propantheline in the treatment of detrusor hyperreflexia in patients with multiple sclerosis.

Bladder and urethral function and supersensitivity to subcutaneously administered bethanechol in cats with chronic cauda equina lesions

The failure of bethanechol chloride to induce voiding in patients with neurogenic bladder, despite a positive bethanechol test, is being reported more frequently. An experimental model was designed in the cat to study the response of the bladder and urethra to subcutaneous and intraarterial bethanechol after complete and partial sacral decentralization. Complete sacral rhizotomy abolished the micturition reflex. Basal urethral perfusion pressure was not affected by complete sacral rhizotomy and a significant part of this basal urethral pressure remained sympathetically mediated. However, the urethral constriction response to bladder filling was lost in half the cats with complete lesions. Bladder and urethral supersensitivity to bethanechol chloride in cats with complete lesions was characterized by a shift to the left of the i.a. dose-response curve, and by the presence of responses to doses of s.c. bethanechol chloride which are subthreshold in normal cats. The urethra also showed exaggerated constriction responses to i.a. and s.c. bethanechol. After complete lesions a part of the bladder and urethral responses to s.c. bethanechol was adrenergically mediated and exerted through the vesicourethral short neuron system. The rest of the response was due to stimulation of urethral muscarinic receptors. Partial sacral lesions were compatible with a micturition reflex and the urethra retained its reflex response to bladder distension. After partial decentralization the bladder and urethra also showed responses to subthreshold doses of s.c. bethanechol. While the bladder response to s.c. bethanechol did not show a significant adrenergic component in cats with partial lesions, most of the urethral response was sympathetically mediated. In conclusion, complete cauda equina lesions result in an areflexic detrusor with frequent loss of the urethral responsiveness to bladder filling. Urethral supersensitivity to s.c. bethanechol might be responsible for a non-voiding outcome after bethanechol injection in patients with complete cauda equina lesions, despite a positive bethanechol test. Because the detrusor reflex is preserved and the urethra is less supersensitive to bethanechol after partial cauda equina lesions, these may represent a better indication for bethanechol therapy than do complete ones.

Effect of acute selective sacral rhizotomy in cats on bladder and urethral function and the response to bethanechol chloride

Bladder and urethral responses to filling and to subcutaneous bethanechol are dependent upon intact sacral innervation. Acute selective sectioning of nerve roots in chloralose anesthetized cats was used to compare the sacral innervation requirements for the support of these responses. The detrusor was found to require primarily intact S2 roots although an S2 root on one side could, alone, subserve a weak, unsustained detrusor reflex. The urethral reaction to bladder filling required an afferent sacral pathway through either S1 or S2 roots. The sustained bladder response to subcutaneous bethanechol required greater sacral innervation than the detrusor reflex inasmuch as the S2 segment could subserve this response in only half the cases, and unilateral rhizotomy L7-S3 eliminated the response in half the cases. Both treatments, however, were compatible with a preserved detrusor reflex. The urethral constriction response to subcutaneous bethanechol required an intact sacral afferent pathway through either the S1 or S2 segments. In conclusion, the detrusor and urethral reflex responses to bladder filling and subcutaneous bethanechol require a certain amount of intact sacral innervation through S1 and S2 which is least for the detrusor reflex and greatest for the bladder response to subcutaneous bethanechol.

Relationship between neurological and urological status in patients with multiple sclerosis

The relationship between neurological urinary symptoms and urodynamic findings in patients with multiple sclerosis was examined. The duration of multiple sclerosis was significantly longer in patients with urinary symptoms. The presence of urinary symptoms correlated with the severity of the pyramidal or sensory lesions and the total disability score. Cystometrograms revealed detrusor hyperreflexia in 67 per cent of the patients, areflexia in 21 per cent and a normal detrusor in 12 per cent. Somatic dyssynergia was found in 20 of the 39 patients whose examination revealed clear-cut results. Positive correlation was found between urge incontinence and detrusor hyperreflexia, and between hesitancy and detrusor areflexia but no relationship was found between urological symptoms and sphincter function. Analysis of the neurological lesions in relation to the cystometric findings revealed a positive correlation among pyramidal lesions, detrusor hyperreflexia and detrusor areflexia, and between cerebellar lesions and detrusor areflexia. The correlation between detrusor dysfunction and high total disability score disappeared when patients with high pyramidal scores were excluded. No correlation could be detected between somatic dyssynergia and the various neurological lesions.

Experimental evidence for a central nervous system site of action in the effect of alpha-adrenergic blockers on the external urinary sphincter

The present study was done to test the hypothesis that alpha-adrenoceptor blocking drugs (phentolamine and prazosin) could interfere with somatic control of the external sphincter through an action in the central nervous system. Stimulation of the hypogastric nerve in the chloralose-anesthetized cat caused a urethral constriction which could be antagonized by alpha-receptor blockers. However, the constriction produced by stimulation of the S1 or S2 ventral root was completely resistant to alpha blockade. The drugs therefore had the expected action against sympathetic stimulation of the urethra but had no peripheral effect on the somatic component. The central effect of these drugs was investigated by recording urethral perfusion pressure responses, or compound action potentials on the central cut end of the pudendal nerve, evoked by stimulation of the contralateral pudendal or pelvic nerve. The urethral constriction produced by stimulation of the central cut end of 1 pudendal nerve was antagonized by both prazosin and phentolamine. Action potentials evoked on the pudendal nerve by stimulation of the central cut end of the contralateral pudendal or pelvic nerve were substantially inhibited by prazosin. Phentolamine produced a more variable blockade of the pudendal-pudendal reflex. The results strongly indicate that these alpha-adrenoceptor antagonists and especially prazosin can influence pudendal nerve-dependent urethral responses through a central nervous system action and not through a peripheral mechanism.

Urethral response during bladder contraction induced by subcutaneous bethanechol chloride: elicitation of a sympathetic reflex urethral constriction

The responses of the urethra to bladder filling and to subcutaneous bethanechol were studied in a surgically separated bladder-urethra preparation in chloralose anesthetized cats. With the pudendal nerves cut or the neuromuscular junction blocked with gallamine, urethral closure pressure increased during bladder filling and the initial phase of the micturition contraction. It then fell spontaneously or in response to bladder emptying through a vent. With the bladder volume held constant subcutaneous bethanechol induced an increase in basal bladder pressure which culminated in a sustained (reflex) contraction. The urethral constrictor response resembled that seen during the cystometrogram; an increase during the rise in detrusor pressure and a fall during the latter part of the sustained (reflex) contraction. In both cases the urethral response was substantially depressed by hypogastric nerve transection or by intravenous prazosin, implying that the urethral responses were reflexly mediated through the sympathetic system. Intra-arterial bethanechol also produced a urethral constriction, but this response was abolished by atropine and not affected by hypogastric nerve section or prazosin. It is therefore concluded that although bethanechol can produce urethral constriction through a direct muscarinic action on the urethra, it does not do so after subcutaneous administration in a neurally intact cat. The urethral response seen after subcutaneous bethanechol administration is part of the micturition reflex complex and is sympathetically mediated.

Factors that influence the incidence of detrusor instability in women

Detrusor instability was examined in 108 women with urinary incontinence. The presence of instability correlated with the symptoms of urge incontinence in 81 of 99 patients. The technique of the cystometrogram also proved important and minor variations significantly altered the incidence. Finally, there seems to be a significant correlation between reduced urethral closure as measured by the urethral pressure profile and instability, suggestive of a causal relationship. An understanding of the factors that affect the incidence of detrusor instability will help to place it in the right perspective in terms of its diagnostic value and pathogenesis.

Behavioural treatment of urinary incontinence in geriatric patients

Urinary incontinence and a program to treat it were studied in a geriatric hospital. Of 161 men, 58 (36%) were incontinent. The most common probable causes were cerebrovascular accident and organic brain syndrome. Evaluation by cystometry (after treatment of infections) in 30 patients showed 24 (80%) to have detrusor hyperreflexia. Twenty patients with hyperreflexia completed a timed-voiding routine, which benefited 17 of them (85%).

Acute renal failure secondary to bilateral ureteric obstruction: review of 50 cases

The records of 50 patients with acute renal failure secondary to bilateral ureteric obstruction were reviewed. An underlying malignant disorder was the cause of the obstruction in 38 of the patients and had not previously been diagnosed in almost half of them. Carcinomas of the cervix and prostate were the most frequent malignant disorders, and aggressive management resulted in good survival rates. Similarly, the outcome for patients with benign bilateral ureteric obstruction, usually caused by retroperitoneal fibrosis, was good with proper management.

Dysfunction of the detrusor and urethra in multiple sclerosis: the role of drug therapy

Urinary tract disorders secondary to multiple sclerosis are common. In this series of 24 patients with multiple sclerosis, 5 had normal function of the detrusor, 3 had detrusor hypotonicity and 16 had detrusor hyperreflexia. The proximal urethra was evaluated using radiologic and electromyographic techniques. These studies showed that 5 patients had a normal urethra, 15 had some degree of somatic dyssynergia and 3 had sympathetic dyssynergia. Detrusor hyperreflexia with somatic dyssynergia was found in 11 patients and was the most common pattern. The therapeutic response to standard pharmacologic preparations was also evaluated. The regimen was based on the clinical and urodynamic findings for each patient. Dicyclomine hydrochloride was the drug of choice for detrusor hyperreflexia, bethanechol chloride for hypotonicity, dantrolene sodium for somatic dyssynergia and phenoxybenzamine hydrochloride for sympathetic dyssynergia. The authors found that most of their patients were amenable to drug therapy, the exception being those with advanced neurologic lesions.

The continence mechanisms: the effect of bladder filling on the urethra

We developed a surgical model in the cat, in which the bladder was completely separated from the urethra, in order to examine the changes in urethral resistance during bladder filling. An increase in urethral resistance occurred in two phases: an "initial" increase attributable to the activity of both the striated sphincter and the sympathetically innervated smooth muscle, and a "late" increase that is alpha-sympathetically mediated. The latter was secondary to trigonal distension. We concluded that the increased urethral activity during bladder filling is reflexly mediated and that the trigone plays a role in its control.

Response of the bladder to bethanechol after acute spinal cord transection in cats

Immediately after spinal cord transection, normal bladder reflex activity is lost and voiding contractions in response to cholinergic drugs can no longer be elicited. Intravesical pressure responses to s.c. and i.a. bethanechol were studied in male cats before and after spinal cord transection at T6 to T7. Bethanechol s.c. enhanced spontaneous bladder activity and produced a sustained bladder contraction. The sustained response was abolished by spinal transection. The response of the bladder to i.a. bethanechol consisted of two phases. The first, dose-related phase, which resembled the response to i.a. acetylcholine, was unchanged by spinal cord transection, rhizotomy (L7-S3) or by ganglion blockade with hexamethonium. The second sustained phase, like the s.c. response, was markedly reduced by all three treatments. Because the response to bethanechol in vitro did not differ in control and transected preparations, it is unlikely that the depressant effects are due to a persistent change in bladder muscle responsiveness. No contractions were observed regardless of s.c. injection site; hence, altered drug absorption and distribution are not sufficient to explain the diminished responses observed. Because interruption of pelvic parasympathetic reflex pathways by rhizotomy and ganglion blockade interfered with the responses to s.c. and i.a. bethanechol, we conclude that bethanechol requires intact pelvic reflex pathways in order to produce sustained contractions. The prolonged action of bethanechol is an important feature contributing to its effectiveness. Removal of reflex functions by spinal cord transection might explain the ineffectiveness of cholinergic drugs in both patients and experimental animals in the acute, areflexic stage after spinal cord transection.

Skin flap technique in formation of urinary conduit stoma

Stomal stenosis following ileal loop diversion is a significant complication to warrant attention. One of the predisposing factors remains the circular nature of the stoma itself, often in conjunction with chronic skin irritation. Surgical revisions predispose one not only to the usual hazards of operation, but also tend to be multiple or involve extensive surgical reconstruction. A skin flap technique in the initial formation of the stoma avoids the incidence of stenosis related to the circular nature of the stoma. The procedure is simple and does not increase the surgical time. No significant stomal complications developed in 28 patients who had urinary diversions, followed for a mean of 30.6 months.

Pharmacologic treatment of disorders of bladder and urethra: a review

The use of pharmacologic agents in treating disorders of the bladder and proximal urethra has expanded because of new knowledge gained in the past few years. A better understanding of the properties of these organs as they relate to drugs has contributed to this expansion. The authors present their experience with a number of drugs in treating disorders of the detrusor muscle and proximal urethra, and they briefly review the literature.

The state of urethral musculature during the detrusor areflexia after spinal cord transection

The state of the urethral musculature was studied using the urethral pressure profile and electromyographic recording in periurethral striated muscle. In dogs under chloralose anesthesia a micturition reflex could be elicited by bladder distension and somatic reflexes could be elicited by various stimuli. Both the urethral profile and electromyographic activity could be recorded immediately after surgical transection of the spinal cord between T2 and T8 but the bladder remained areflexic for more than 12 hr. Pharmacologic analysis of the urethral pressure profile revealed a substantial contribution from both sympathetic and somatic components. The periurethral striated musculature usually responded to bladder filling in a similar manner both before and after transection, although there was no bladder contraction in the latter circumstance. It is concluded that the urethra does not experience the same depression of reflex activity as does the bladder in the acute stage after spinal cord transection.

Urethral pressure profile in female stress incontinence

The accuracy of the urethral pressure profile as a measure of sphincteric competence was examined in female subjects. Most profile measurements selected proved to be significantly different in patients with stress incontinence from those in controls. However, the measurement that seemed to have the highest potential for diagnostic accuracy was the maximum closure pressure in the continence zone, recorded with the bladder full and the patient standing. The concept of the continence zone and incorporating the effect of standing were believed to be the main reasons for this high accuracy. The second best measurement was the maximum closure pressure with the bladder full and the patient surpine. To lessen the chances of a diagnostic error it was recommended that both of these measurements should be obtained. The physiological implications of these findings and the clinical role of the urethral pressure profile examination in the assessment of female patients with urinary incontinence are discussed.

Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part I. Sphincteric incontinence

Phenylpropanolamine, an alpha receptor stimulant, was found effective in 11 of 13 female and 6 of 7 male patients with sphincteric incontinence. In all the male patients except 1, the incontinence has followed prostatectomy. Side effects occurred in only 1 patient. As a rule, the benficial response depended on the therapy being continued. The results are consistent with the distribution of alpha receptors and their effect in the proximal urethra.

Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part II. Urethral obstruction due to "sympathetic dyssynergia"

Lower urinary tract obstruction in patients with neurological lesions can be due to "sympathetic dyssynergia". The obstruction can be at the level of the external sphincter. Phentolamine (i.v.) used during the voiding cystourethrogram helps to make the diagnosis. Phenoxybenzamine therapy produced improvement in 10 of 18 patients. As a rule, patients had to continue on the drug to maintain their response.

Sympathetic dyssynergia in the region of the external sphincter: a possible source of lower urinary tract obstruction

Voiding cystourethrography demonstrated urethral constriction at the level of the external urinary sphincter in 10 patients with neurological dysfunctions. Ten mg. phentolamine mesylate intravenously alleviated this constriction, permitting better flow and reducing residual urine in 5 patients with a traumatic spinal injury, 2 with transverse myelitis and 1 who had had a cerebrovascular accident. Oral therapy with phenoxybenzamine hydrochloride, used in 7 of the 8 patients, reduced the post-void residual urine and produced improvement in hydronephrosis when present. These observations are consistent with the presence of a significant sympathetic component to obstruction at the region of the external sphincter in certain neurological disorders.

Antimuscarinic and noncompetitive antagonist properties of dicyclomine hydrochloride in isolated human and rabbit bladder muscle

In isolated strips of bladder neck (prostatic capsule) and detrusor of rabbit and man, dicyclomine had minimal effect on the resting tension. Competitive antimuscarinic activity against carbachol could be demonstrated at doses of dicyclomine less than or equal to 1 X 10(-6) M, whereas at higher doses a noncompetitive action against both carbachol and potassium was observed. The ratio of dissociation constants relating to the noncompetitive and competitive actions, respectively, was about 1200, approximately 100 times higher than that previously reported in ileum. Dicyclomine was only about 1/30 as potent as atropine in competitive antimuscarinic activity. Dicyclomine hydrochloride may be useful in the clinical management of "uninhibited bladder."

Carcinoma of the prostate: a critical look at staging

To stage accurately the extent of the disease comprehensive investigations were done on 75 patients with histologically documented carcinoma of the prostate. Estimation of bone marrow acid phosphatase appears to be the most sensitive test to detect blood-borne metastases. Serum acid phosphatase appears to be of little value in the detection of early blood spread and may have a role only in monitoring the effect of treatment on advanced disease. Bone scanning with technetium compounds has the disadvantage of non-specificity but has far greater sensitivity than a skeletal survey. Bone marrow cytology was not rewarding in the detection of early metastatic disease. Pedal lymphangiography is a highly inaccurate method to detect lymphatic spread of carcinoma of the prostate and pelvic lymphadenectomy, when indicated, remains the only truly adequate method to assess lymph node involvement. There was a 37 per cent incidence of metastatic lymph node pathology in 30 patients undergoing this procedure before either radical prostatectomy or deep x-ray therapy. A close correlation was found between stage and grade of disease and incidence of nodal pathology. There was some correlation between degree of nodal involvement and evidence of blood spread as detected by elevated bone marrow acid phosphatase levels. The significance of this finding remains unclear.

The treatment of the uninhibited bladder with dicyclomine

Symptomatic treatment of the uninhibited bladder has presented a challenge because of the lack of an effective, well tolerated smooth muscle relaxant for the bladder that can be used during an extended interval. In a preliminary study oral dicyclomine produced resolution or significant improvement of symptoms in 24 of 27 patients and an increase in bladder capacity by an average of 137 plus or minus 26 ml. (91 plus or minus 22 per cent) after 8 weeks of therapy. Additional controlled trials definitely are warranted.