The significance of calprotectin, CD147, APOA4 and DJ-1 in non-invasive detection of urinary bladder carcinoma

Aim of the study is to define the diagnostic accuracy of selected urinary protein biomarkers in the non-invasive detection of primary and recurrent urothelial carcinoma of the urinary bladder. The urinary levels of calprotectin, CD147, APOA4 and protein deglycase DJ-1 were examined in 255 individuals, including 60 controls with non-malignant urological disease, 61 patients with a history of urinary bladder cancer with negative cytology and negative cystoscopy and 134 patients with urinary bladder cancer. Urinary concentrations of biomarkers were determined by Enzyme-Linked Immunosorbent Assay (ELISA). During the follow-up of patients with non-muscle invasive bladder cancer (NMIBC), a group of 44 patients with cancer recurrence was compared to the group of 61 patients with a history of NMIBC but with no evidence of disease. Urinary concentrations of the evaluated markers did not reveal any significant difference between these groups. During the primary diagnosis, a group of 90 patients with primary bladder cancer and 60 subjects with benign disease were compared. Urinary levels of CD147 were not significantly higher in patients with tumors. The greatest diagnostic accuracy was observed in APOA4 (sensitivity 55.6, specificity 83.3, AUC 0.75), and lesser in calprotectin (sensitivity 39.4, specificity 87.7, AUC 0.66) and in DJ-1 (sensitivity 61.1, specificity 66.7, AUC 0.64), respectively. Apolipoprotein A4 may be used potentially as a supplemental urinary marker in the diagnosis of primary bladder cancer.

MicroRNAs in urine supernatant as potential non-invasive markers for bladder cancer detection

Urinary bladder carcinoma contributes to 4% of newly diagnosed oncological diseases in the Czech Republic. Biomarkers for its early non-invasive detection are therefore highly desirable. Urine seems to be an ideal source of such biomarkers due to the content of cell-free nucleic acids, especially microRNAs (miRNAs).To find potential biomarkers among miRNAs in urine supernatant, we examined in total 109 individuals (36 controls and 73 bladder cancer patients) in three phases. In the first - discovery - phase, microarray cards with 381 miRNAs were used for miRNA analysis of 13 controls and 46 bladder cancer patients. In the second - verification - phase, the results of this first phase were verified on the same groups of subjects by single-target qPCR assays for the selected miRNAs. For the third - validation - phase, new independent samples of urine supernatant (23 controls and 27 bladder cancer patients) were analyzed using single-target qPCR assays for 13 verified in the previous phase. The results of all phases were normalized to miR-191, miR-28-3p, and miR-200b, which were selected as suitable for our study by the qBase+®.We found that miR-125b, miR-30b, miR-204, miR-99a, and miR-532-3p are significantly down-regulated in patients' urine supernatant. In our experiments, the analysis of miR-125 levels provided the highest AUC (0.801) with 95.65% specificity and 59.26% sensitivity, the analysis of miR-99a lead to AUC (0.738) with 82.61% specificity and 74.07% sensitivity. We demonstrate that levels of these miRNAs could potentially serve as promising diagnostic markers for the non-invasive diagnostics of bladder cancer.

The importance of serum osteopontin and stanniocalcin-1 in renal cell carcinoma

A total of 56 RCC patients with staging ≥ pT1b were enrolled in a prospective study to assess the prognostic importance of serum levels of osteopontin (OP), stanniocalcin-1 (SC), FGF-23, alpha Klotho and 25-OH-D at the time of diagnosis in renal cell carcinoma (RCC) patients. The relationship between the serum level of the analyzed parameters and recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) was examined, and our control group consisted of 20 patients without cancer. The levels of osteopontin, stanniocalcin-1, FGF-23 and alpha Klotho were determined by Enzyme-Linked Immunosorbent Assay (ELISA) and 25-OH-D by chemiluminiscence immunoanalysis (CLIA). The follow-up period median was 46 months. Renal cell carcinoma recurred in 9 patients and 20 patients died during follow-up; 12 of them from RCC. The level of osteopontin and stanniocalcin-1 varied between the control group and RCC patients (at p=0.02 and p=0.0003). Higher levels of stanniocalcin-1 were detected in the metastatic RCC group than in the localized RCC group (p=0.003). Only the stanniocalcin-1 level at the time of surgery was associated with RFS (p=0.0004). Both OS and CCS were associated with the osteopontin, stanniocalcin-1 and FGF preoperative level. Patients with stanniocalcin-1 level over 1,277 pg/ml and osteopontin level over 100 ng/ml had 17.8 times higher and 7.9 times higher risk of dying from RCC progression, respectively (p<0.001 and p=0.002). High levels of osteopontin, stanniocalcin-1 and FGF 23 at the time of surgery are important prognostic factors related to CSS and OS. Patients with high stanniocalcin-1 level were at risk of tumor recurrence.

Trefoil factor family (TFF) proteins as potential serum biomarkers in patients with metastatic colorectal cancer

Trefoil factor family (TFF) is composed of three secretory proteins (TFF1, TFF2 and TFF3) that play an important role in mucosal protection of gastrointestinal tract. Their overexpression in colorectal tumors seems to be associated with more aggressive disease. We collected serum samples from 79 healthy controls and 97 patients with metastatic colorectal cancer at the time of diagnosis or at progression. Serum levels of TTF1-3, CEA and CA19-9 were measured by ELISA. Serum TFF1 and TFF3 levels were significantly higher in patients with colorectal cancer compared to healthy controls (p < 0.0001). Moreover, serum levels of TFF3 correlated with extent of liver involvement in patient without pulmonary metastases and patients with higher TFF3 levels had significantly worse outcome (p < 0.0001). Compared to CEA and CA19-9, TFF3 had higher sensitivity and the same specificity. Our results indicate that TFF3 is an effective biomarker in patients with metastatic colorectal cancer with higher sensitivity than CEA a CA19-9. TFF3 levels strongly correlate with extension of liver disease and seem to have prognostic value.

[Current state of diagnostics and treatment of overactive bladder in the Czech Republic - five years ago and today]

INTRODUCTION

Overactive bladder (OAB) presents one of the most frequent medical problems among the current adult population, with a significant impact on the quality of life of the affected patients. A questionnaire survey was carried out in 2006, with the aim to assess the level of knowledge regarding the problem of OAB among gynaecologists and urologists in the Czech republic, as well as to evaluate the currently applied methods of OAB diagnostics and treatment. The aim of this work was to perform a repeated survey after five years, and to evaluate, whether there have been any changes achieved in the monitored parameters.

MATERIALS AND METHODS

A total of 290 respondents (181 gynaecologists, 109 urologists) were included in the survey in 2006; the study group in 2011 included a total of 285 respondents (180 gynaecologists, 105 urologists). The questionnaire used for the survey in 2011 was identical to the document utilized in the initial survey performed five years ago, with minimal changes. The anonymous questionnaire was designed as "multiple-choice", i.e. with a possible selection from proposed answers; the questions were targeted at the topics of definition, diagnostics and therapy of OAB. The obtained results were processed with the methods of descriptive statistics; the concordance of proportions was evaluated with the Fishers exact test.

RESULTS

A total of 114 gynaecologists (63.3%), and 65 urologists (61.9%) were able to determine the correct definition of OAB, which presents a significant increase when compared to 2006 (p<0.0001). The most frequently applied methods of OAB diagnostics were patient history (gynaecologists: 97.8% in 2011 vs. 96.5% in 2006, urologists: 99.0% in 2011 vs. 99.0% in 2006), local examination (gynaecologists: 57.8% vs. 76.4%, urologists: 86.7% vs. 87.2%), bladder diaries (gynaecologists: 62.8% vs. 40.3%, urologists: 79.0% vs. 60.5%), and urine examination (gynaecologists: 71.1% vs. 82.3%, urologists: 96.2% vs. 97.1%). Anticholinergic medication is the first-choice in the OAB treatment in our conditions, which has been confirmed by 146 (81.1%) gynaecologists, and 89 (84.4%) urologists. In cases when the physicians use anticholinergic medication for the treatment of OAB, the first-choice medication is trospium, among both gynaecologists and urologists. In case of failure of the first-choice treatment, twenty-six (14.4%) gynaecologists from the addressed respondents try to continue with a treatment according to their own decision, 154 (85.6%) gynaecologists refer the patient to a specialist. Similarly, a total of 90 (85.7%) urologists try to manage the further course of treatment by their own means, 15 urologists (14.3%) refer the patient to a specialist.

CONCLUSION

The level of understanding and awareness about the problem of OAB among the Czech gynaecologists and urologists has significantly improved during the past five years. The applied diagnostic and treatment methods for OAB are being harmonized with the International Continence Society (ICS) recommendations. Taking into consideration the prevalence of OAB among the population, it is desirable to increase the number of clinical departments who deal with the problem of OAB in a complex manner. The remaining significant task lies in the improvement of foreknowledge about the current possibilities and effectiveness of the OAB treatment among the patient population.

[Prevalence of women with overactive bladders in the Czech Republic]

INTRODUCTION

The term OAB (overactive bladder) was introduced in praxis in the year 2002 by Abrams. This term includes symptoms of urgency, with or without urgent incontinence, and it is generally accompanied by urinary frequency and nocturia. OAB is widespread among our female population. Approximately 20% of women suffer from this problem, but the frequency of the syndrome has not been assessed more precisely by means of questionnaires. The aim of our study was to assess the prevalence of OAB among patients who visited gynecologists in the first line and completed the Bladder Control Self Assessment Questionnaire (BCSAQ).

MATERIAL AND METHODS

Five gynecologists in the first line questioned 492 consecutive patients as to whether they suffered from urgency, frequency, nocturia and urgent incontinence, and their answers were later evaluated. The BCSA questionnaires completed by the patients in the waiting room before seeing the doctor were subsequently also evaluated.

RESULTS

Due to inquiries made by the gynecologist, 320 patients took the BCSA questionnaires in the waiting room before seeing the doctor, and 314 completed them; 14 patients completed the questionnaires after seeing the doctor who questioned them about problems with urgency. The patients then handed the completed questionnaires to the nurse, i.e. the total of 328 questionnaires were assessed. 159 patients suffered from urgency, and 35% of these patients had problems with leakage of urine. In reply to the question: Is it difficult to hold urine when you have the urge to go? 22% of patients from the whole group of patients (n = 492) answered yes. 24% of patients had problems with frequency, 32% with nocturia and 14% with urgent incontinence.

CONCLUSION

OAB syndrome is widespread in our population; it constitutes a major problem which must be treated. Awareness of this problem has now improved; patients feel less embarrassed to discuss about problem, and increasingly they seek treatment, while at the same time gynecologists have improved their knowledge about the diagnosis and treatment of OAB. This means that the quality of life for these patients can be improved.

[Principal value of surgical therapy in the renal cell cancer, chances of the biological treatment]

Renal cell cancer belongs to the most malignant tumours in urology; the incidence in the Czech Republic is highest world. Surgical treatment is the first method of choice both in localized and metastatic renal cell cancer due to its chemo and radioresistance. Cytoreductive nephrectomy in case of metastatic renal cell cancer can prolong the overall survival. Lymfogenic propagation is rare, but involvement of lymphatic retroperitoneal nodes is the most unfavourable risk factor. Patients with vein tumour thrombus profit from the radical surgical treatment; the most important thing is the removal of whole tumour thrombus. Miniinvasive methods in treatment of renal cell cancer are getting more and more popular nowadays. Partial nephrectomy is a method of choice in the treatment of small suitable localised renal cell cancers. Adjuvant therapy is not indicated in localised renal cell cancer. Immunotherapy was the most convenient method of treatment generalised renal cell cancer in the last decade of 20th century. Understanding of signalling pathways for growth factors in angiogenesis was the cue for targeted therapy. This method pushes back immunotherapy. Unfortunately targeted therapy fails to cure patients with generalized renal cell cancer; it can only stabilize disease and prolong the overall survival.

Life-threatening arrhythmia caused by primary aldosteronism

BACKGROUND

Arrhythmias are one of the typical complications of primary aldosteronism (PA), is commonly characterized by hypertension and hypokalemia.

CASE REPORT

In this report, we present 3 cases of subjects in whom primary aldosteronism manifested with life-threatening arrhythmias. In 2 subjects, after excluding organic heart disease, an implantable cardioverter defibrillator was inserted and, only after the second episode of polymorphic ventricular tachycardia accompanied with low plasma potassium levels, the diagnosis of primary aldosteronism was made.

CONCLUSIONS

It is important to include diagnosis of primary aldosteronism in the diagnostic work-up of hypertensive subjects without any structural cardiovascular impairment who present with malignant arrhythmia and hypokalemia. Appropriate treatment of primary aldosteronism may avoid insertion of an implantable cardioverter defibrillator.

Statistical analysis of symptoms, endoscopy and urothelial morphology in 58 female bladder pain syndrome/interstitial cystitis patients

INTRODUCTION

The goal of the study was to assess the course of painful syndrome in patients with bladder pain syndrome/interstitial cystitis and to assess the changes in endoscopic and histopathological findings in relation to the type of treatment.

PATIENTS AND METHODS

We included a total of 58 patients with histologically diagnosed interstitial cystitis. Out of these, 31 patients were treated with oral pharmacotherapy and 27 patients were treated by intravesical application of heparin. The patients were followed from time of diagnosis for 6.9 +/- 2.5 and 6.6 +/- 2.7 years, respectively.

RESULTS

Treatment - irrespective of its type - had a clear demonstrable effect on the monitored parameters; intravesical treatment was more effective than oral. Statistically significant (p < 0.05) changes could be observed in both groups (with two exceptions). When evaluating the relationship between subjective symptoms and objective criteria, and patients' age and time to diagnosis, it is clear that the higher the age and the longer the time from symptoms to diagnosis, the more severe the symptoms.

CONCLUSIONS

When evaluating the monitored parameters, we found significant correlations (both positive and negative). However, these relationships cannot be used to simplify the evaluation algorithm (according to ESSIC) and the initial criteria cannot predict the course of the disease.

[Primary synovial sarcoma of the kidney]

The authors present two cases of primary synovial sarcoma of the kidney. Both patients had a tumor mass in the kidney with vascular invasion of the inferior vena cava and right atrium of the heart in case no. 1. In case no. 2 retroperitoneal lymph node metastasis and multiple metastases to both lungs were observed. Radical nephrectomies were performed in both patients. Histologically, the tumor in case no. 1 was monophasic and in case no. 2 poorly differentiated. Immunohistochemically, vimentin was diffusely positive and a few tumor cells were positive for epithelial membrane antigen. The tumor cells were negative for keratins, S- 100 protein, CD 34, smooth muscle actin, and desmin. In both cases, reverse transcription-polymerase chain reaction using ribonucleic acid extracted from formalin-fixed, paraffin-embedded tissues detected SYT-SSX 1 fusion gene transcripts, which are characteristic molecular findings of synovial sarcoma.

[Cystectomy in the treatment of bladder cancer]

Radical cystectomy with pelvic lymphadenectomy and urinary diversion is an important component in the treatment of bladder cancer. It is considered the most important method in the therapy for muscle invasive and selected high-risk non-muscle invasive tumours with excellent local control and high complete remission rate. It consists of complete removal of tumour tissue in the bladder, small pelvis and regional lymph nodes. In males, urinary bladder and prostate are routinely removed; in females, bladder, uterus and anterior vaginal wall are removed. Urethrectomy is indicated only in selected situations. An integral part of the operation is the bilateral pelvic lymphadenectomy. Extravesical disease extension and lymph node positivity are unfavourable prognostic factors. Better prognosis is expected in patients with less than 5 positive nodes. Important prognostic factor is also the number of removed lymph nodes, which is a strong argument for meticulous bilateral pelvic lymphadenectomy. Lymph node density (number of positive nodes/ number of removed nodes) is considered as very important prognostic factor. Better prognosis can be expected in patients with less positive and more removed nodes.

[Detection of prostate cancer by ultrasonographically-guided transrectal prostate biopsies at the Department of Urology of the First Faculty of Medicine, Charles University and General Teaching Hospital in Prague, analysis of 1464 cases]

BACKGROUND

Early diagnostics of prostate cancer is still the most important factor in tumor-specific survival of patients harbouring this malignant disease. Without better understanding of the etiology and without relevant markers of the disease progression, only the early diagnostics of organ-confined disease can save the patient's life.

METHODS AND RESULTS

Throughout 7 consecutive years, 1464 transrectal prostate biopsies in 1302 patients were performed. In all cases, the age, DRE (positive or negative), prostatic volume (ccm), total PSA in peripheral blood (ng/ml) were assigned, as well as free/total PSA ratio (%) in most of them. Apart from previously used linear regression, we applied logistic regression, since only age grows linear and DRE is determined only as positive or negative. The surrogate endpoint was ROC, which determines the area applying to the relations of sensitivity and specificity of any marker. Multifactorial logistic regression then reached best results at values over 0.8 in all tested age categories with maximal deviation of 8%, which had not been achieved before.

CONCLUSIONS

Despite hundreds of papers published on this topic, the question of when and how the patient is indicated to the biopsy of the prostate has not been solved. A computer driven model based on 1464 documented examinations on the relatively homogeneous population is presented. On the basis of the combination of biological and statistical methods, the model can give correct predictions in 9 out of 10 cases.

[Radical cystectomy in the treatment for bladder carcinoma: results of 125 operated patients]

BACKGROUND

Radical cystectomy with pelvic lymphadenectomy and urinary diversion is standard treatment in patients with muscle-invasive and selected high-risk superficial bladder cancers. The aim of our study was to evaluate oncological results and correlate prognosis with the extent of the disease.

METHODS AND RESULTS

Data of 125 patients (33 females and 92 males) with mean age of 59.8 years were analysed. Histological diagnosis was urothelial carcinoma in 114, squamous cell carcinoma in 8 and small-cell carcinoma in 3 patients respectively. During the mean follow-up of 22.4 months the disease-free survival (DFS) and disease-specific survival (DSS) were evaluated according to the extent of the disease. Tumours were classified as pTa, pT1, pTis in 31 (24.8%), as pT2 in 39 (31.2%), as pT3 in 24 (19.2%) and pT4 in 20 (16%) patients respectively. There was no tumour detected in the specimen in 11 (8.8%) of cases (pT0). Lymph node metastases were confirmed in 36 (28.8%) of patients. Three-year DFS and DSS were 100% and 100% in pT0, 76% and 87.1% in pTa, pT1, pTis, 69.2% and 82.9% in pT2, 32.9% and 62.4% in pT3 and 39.5% and 36.8% in pT4 tumours respectively (p = 0.0001, p = 0.0004). Three-year DFS and DSS reached 69.4% and 51.8% in patients with negative lymph nodes and 51.8% and 44.8% in patients with lymph node involvement (p = 0.0008, p < 0.0001).

CONCLUSIONS

DFS and DSS after radical cystectomy depend from the local extent of the tumour and from lymph node status, which is a strong argument for its timely indication.

[Painful bladder syndrome in interstitial cystitis: relation between symptoms, endoscopy and biopsia results and the treatment effects]

BACKGROUND

Interstitial cystitis/Painful Bladder Syndrome (IC) is a chronic abacterial inflammatory disease of the bladder wall. It is accompanied by predominant neuropathic pain. Typical symptoms of IC include: suprapubic pain, bladder pain even between voiding, urgency, short intervals between micturition with frequency and nocturia. The objective of the study was to find a correlation between a symptom score and endoscopy together with histopathologic findings from the detrusor biopsy and a correlation between symptoms before and after the intravesical treatment.

METHODS AND RESULTS

We have evaluated a group of 30 patients with newly diagnosed IC prospectively. These patients were in the group 1. Control group 2 consisted of 10 patients with asymptomatic bacteriuria. Group 3 consisted of 15 patients with no voiding symptoms. Validated questionnaire (O'Leary-Sant Symptom (ICSI) and Problem Index (ICPI) was used to objectify subjective symptoms. The diagnosis of IC was based on the clinical assessment of subjective symptoms, urodynamic results, endoscopy and histology. The efficacy of therapy was found statistically significant only in the intravesical therapy. In the patients with immunohistochemically identified increased numbers of mast cells per one microscopic field, the correlation with ICSI and ICPI score was statistically significant.

CONCLUSIONS

Differences in symptom score in the patients before and after the treatment were found significantly higher after the intravesical (with heparin) treatment then after peroral therapy. Significant differences in the correlations of ICSI and ICPI score values with the histopathologic finding (i.e. number of mast cells) were found.

[Analysis of results of percutaneous nephrolithotomies]

BACKGROUND

Percutaneous nephrolithotomy is an effective less invasive method for the treatment of nephrolithiasis. Authors retrospectively analysed results of this procedure performed in a single centre (Department of Urology, General University Hospital, Prague) from January 2005 till June 2007.

METHODS AND RESULTS

Patients were acquired by an analysis of operating reports performed over a period January 2005 till June 2007 and subsequently a retrospective analysis of electronic and paper patient's records was carried out. Percutaneous nephrolithotomy was performed in 150 patients. Of those, 117 (78%) patients underwent primary and 33 (21.3%) secondary procedure. Analysed group consisted of 85 (56.7%) men and 65 (43.3%) women. Right-sided procedure was performed in 46% (69 times) and left-sided in 54% (81 times) of cases. Mean patient's age was 52.9 years (SD +/- 16.3). Mean stone size was 18.3 (SD +/- 9.5) mm. Staghorn calculi were present in 19 (12.7%) patients and 77 (51.3%) patients had more than 1 stone. Intracorporeal lithotripsy was necessary in 82 (54.7%) cases. Seventy eight (52.9%) patients were stone free after the procedure. There were 24 (16%) patients with an anatomic abnormality of upper urinary tract. The most common (in 64.3%) component in analysed stones was a calcium oxalate.

CONCLUSIONS

The amount of stone free patients is rather lower compared to the literature results. However, definitive results are always affected by auxiliary procedures (mainly extracorporeal shock wave lithotripsy), which are not included in the analysis.

[Possibilities of the laboratory diagnostic of metabolic skeletal changes]

Skeletal disorders represent ever-rising problem. Such diseases are of the highly heterogenous origin and for their verification the laboratory diagnostic of metabolic skeletal changes cannot be omitted. Increasing knowledge on the physiology and pathophysiology of the bone tissue metabolism and the use of new laboratory methods can improve the diagnosis and treatment of such critical states. The article gives an overview of contemporary possibilities of the laboratory diagnostic of metabolic skeletal changes. The significance, advantages, disadvantages and possible risks in evaluation of individual osteomarkers are presented.

[Intermittent catheterization of urinary bladder--indications, technique, complications]

The intermittent catheterization technique is considered at present to be one of pillars of the therapy of lower urinary tract dysfunction. The technique gradually became used also in the treatment of some non-neurogenic voiding dysfunctions. There are many ways, how the intermittent catheterization could be performed (methodology, catheter material and type, lubrication type and method, catheterization frequency). Authors provide an overview of present indications to use the treatment; they describe individual techniques and draw attention to the possible complications and their solution. Next they emphasize the necessity of individual approach to intermittent catheterization technique in individual patients in the broader context of general concept of treatment.

[Renal artery embolism]

Renal artery embolism (RAE) is a rare disease. Urgent treatment is necessary, as ischaemia can cause irreversible kidney damage in 60 to 90 minutes. RAE frequently clinically manifests as a pain similar to renal colic. Source of embolus is predominantly the heart at atrial fibrillation. Laboratory findings are unspecific. Ultrasonography with color Doppler imaging is essential. Kidney perfusion is low and upper urinary tract is undilated. Renal function can be recognized by intravenous urography and at renal scintigraphy. In angiography, renal artery is closed with thromboembolus. With no delay, transcatheter clot aspiration should be performed and fibrinolytic agents (tissue plasminogen activator) should be topically administered. Continual heparinisation and later warfarinisation should follow. In spite of successful revascularisation, parameters of kidney function can almost never reach that prior the RAE and shrinkage of kidney becomes a frequent consequence. Treatment can be successful even in patients with renal occlusion lasting over 90 minutes, since occlusion is often incomplete or significant collateral blood supply exists. In conclusion, renal artery embolism must be considered in cases of flank pain in patients with certain risk actors (especially atrial fibrillation). Ultrasonography with color Doppler imaging and urgent angiography of the renal artery are necessary in these cases. Thromboembolus can be then aspirated, and kidney perfused with fibrinolytic agent.

Rectourethral fistulas

A recent review of the literature shows an increasing number of studies on this subject, most of which are retrospective and presented solely from a clinical point of view. Some of them are no more than case-reports. There is a lack of valid epidemiologic data about the incidence of rectourethral fistulas. According to the literature, these fistulas result from many different causes. Rectourethral fistulas may have a congenital or acquired origin. Acquired cases include inflammatory, neoplastic, or traumatic etiologies. The diagnostic algorithm is clear and very classical. The new diagnostic approach represents an MRI investigation of the male urethra. It is important to recognize this diversity of etiology because each type requires a different surgical strategy. The aim of the surgical approach is the closure of all types of fistulas. Spontaneous closure of the recto-urethral fistulas after double diversion or by means of a one-stage procedure is possible only in a few cases. In most cases, the treatment proceeds in three stages (double diversion-urinary and bowel, closure technique, undiversion). An endoscopic approach using biological sealants seems to be promising. Few urologists and general surgeons have attained wide experience in the management of rectourethral fistulas. No single procedure has been proven most effective or even universally applicable.

Causes and treatment of residual urine volume after orthotopic bladder replacement in women

OBJECTIVES

Intact innervation of the female urethra is conditional for normal urination. In the past, urethrectomy was performed as part of cystectomy. After intense anatomical studies of the female pelvis, urethral-function-sparing cystectomy was developed.

METHODS

Our clinical group consists of 41 female patients who were operated from 1993 to 1998 for bladder cancer, utilizing cystectomy with orthotopic bladder replacement.

RESULTS

In 28 patients, complete daytime continence was restored and in 13 patients, daytime continence was socially satisfactory (1-2 pads were used due to mild stress incontinence). The drawback of orthotopic replacements in females is the frequent development of serious residual volume, which was seen in one third of the 41 patients. The functional results of orthotopic neobladders and therapy of residual urine volume were documented using urodynamic studies.

CONCLUSIONS

Postvoiding residual volume may be caused by isolated dysfunction of the urethra and can be treated with clean intermittent self-catheterization or with alpha-blockers, which improve evacuation of the neobladder.

[Urinary continence after radical retropubic prostatectomy]

Urinary incontinence following radical retropubic prostatectomy is a serious medical and psychological complication with a major negative impact on quality of life in patients with localized prostate cancer. The overall incidence of this complication is higher than 2% regardless whether the surgery has been done by the retropubic or perineal approach. The correct diagnosis of incontinence is based on urodynamic investigations. Two main causes of incontinence are detrusor hyperactivity and sphincteric insufficiency. The best prevention for postoperative incontinence of urine is meticulous surgery. Treatment options of incontinence are pharmacological or surgical (injections of collagen, autologous fat or implantation of artificial urinary sphincters).

[Injuries of the ureter treated at the General Medical School Hospital in Prague during the last 5 years]

Injury of the ureter is the most frequent trauma in urological practice. The most important deal concerning a patient's expectancy is early diagnosis and adequate treatment. During 1994-1998 the authors have treated 65 patients with diagnosis an injury of the ureter. The most frequent cause was the iatrogenic injury. Timing of surgery was 5-6 weeks. A percutaneous nephrostomy was the most frequent method of initial treatment (38 patients). Ureterorhaphy (32 patients), ureterocystoneostomy (12 patients) and Boari's flap operation (5 patients) was the most frequent definitive method of the treatment.

[Reconstruction of the lower urinary tract in women after cystectomy]

BACKGROUND

The first extirpation of the urinary bladder on account of malignant papilomatosis was carried out by Karel Pawlik in 1889 as the first one in the world. At present cystectomy is indicated usually because of an infiltrating carcinoma of the urinary bladder. The objective of the present paper is, based on anatomical investigations, elaboration of a surgical technique of creating a orthotopic neovesica following cystectomy sparing a functional female urethra.

METHODS AND RESULTS

In 1993-1998 32 women were operated within the age bracket of 32-72 years with a confirmed infiltration carcinoma of the urinary bladder. The authors describe in detail their own surgical technique. Day continence was achieved in 20 patients. Twelve patients suffer from stress incontinence. Eight patients have a post-micturition residue of 250-300 ml calling for a combination of medicamentous treatment and autocatheterization. The capacity of the neovesicle is the cause of nycturia: 21 patients must micturate once or twice during the night. Urodynamic studies did not reveal significant differences between patients with chronic post-miction residues and without residues. Also the mean functional length of the urethra was in both groups similar (27 mm in patients with a residue and 26.2 mm in patients without a residue).

CONCLUSIONS

The elaborated surgical technique of cystectomy and creation of a neovesica makes a good quality of the patients' life possible.

[Kidney sparing surgery]

From 1988 to 1998 107 nephron sparing surgery have been done for localised renal cell tumor. The age was between 21 to 75. Nephron sparing surgery means removal of tumor consumed part of renal tissue with oncology clean border in healthy renal tissue. Elective indication for nephron sparing surgery is renal cell carcinoma on single kidney or on bilateral function disabled kidneys. In the last years indication for nephron sparing surgery have spread also to patients with both kidneys, who have single extrarenal growing renal cell carcinoma to the diameter 4.5 cm. In our group of follow up patients, within the interval 3 to 96 months from operation we have 96.26% survival without evidence of recurrent renal cell carcinoma.

[Ureterocystoplasty--ureteral augmentation of the urinary bladder]

The method of choice in the surgical treatment of neurogenic dysfunctions of the lower urinary pathways is to use the ureteral wall for augmentation of the urinary bladder. The advantage of the method is that it rules out risks and complications encountered in techniques using an excluded intestinal or gastric segment (mucus formation, metabolic disorders, malignant transformation, uroinfection, urolithiasis). The author presents the case-history of a 28-year-old man with a neurogenic bladder due to surgery of meningomyelocele during childhood.

[Small-cell carcinoma of the prostate]

Small cell carcinoma of the prostate (SCCP) is a rare entity. A literature review disclosed less than 150 cases. SCCP has an aggressive course and both local and distant failure is common. The optimal treatment method has not been clearly established. We review our experience with 7 patients paying attention to clinical and pathological details. Three patients had mixed tumors of both SCCP and adenocarcinoma, three had pure adenocarcinomas that occurred as small cell carcinoma and one patient had pure small cell carcinoma. All patients progressed locally and developed distant metastasis. We recommend the use of hormonal manipulation and combination of chemotherapy, as well as surgery and/or radiation therapy of the prostate for local control and we emphasize that histologic entity is important for proper treatment.

[Treatment of localized carcinoma of the prostate]

Review of the treatment of localized prostate cancer. The major attention is devoted to the surgical treatment. The radical retropubic prostatectomy is used most frequently. Problems of the indication, anatomical foundations and the technique of the surgery are discussed. The radical perineal prostatectomy is used less frequently. The radiation therapy is an alternative to the surgical treatment. The radiation therapy is recommended by urologists in patients, for whom is this treatment considered as more advantageous.

Efficacy and acceptability of tadenan (Pygeum africanum extract) in the treatment of benign prostatic hyperplasia (BPH): a multicentre trial in central Europe

Pygeum africanum extract is available as Tadenan in many countries, including those in central and eastern Europe, for the treatment of mild to moderate BPH. Its efficacy and acceptability have been demonstrated in numerous open and placebo-controlled studies in large populations. The present open three-centre efficacy and safety study was conducted according to common protocol at urology clinics in the Czech and Slovak Republics and in Poland, in order to confirm the therapeutic profile of Pygeum africanum in conditions of daily practice, using International Prostate Symptom Score (IPSS) and flowmetry assessments. Men aged 50-75 years and in compliance with the selection criteria (including IPSS > or = 12, quality of life (QoL) score > or = 3, and maximum urinary flow < or = 15 ml/s) were first examined then recalled after two weeks during which no treatment was provided (washout and check of stability). If still compliant, they were entered at this point into a two-month period of treatment with Pygeum africanum extract 50 mg twice daily. There followed a further one-month period without treatment, the objective being to evaluate the persistence of any effects observed during the previous two months of Pygeum africanum administration. The primary efficacy parameter investigated was IPSS; the other efficacy parameters were QoL, nocturnal frequency, maximum urinary flow, average urinary flow, post-voiding residual volume and prostatic volume, after one and two months of Pygeum africanum treatment and one month after stopping treatment. A total of 85 patients were evenly distributed between the three centres and completed the entire study. At inclusion their mean IPSS was 16.17, QoL was 3.60 and nocturia was 2.6 times per night. The changes in subjective scores, IPSS and QoL after the two-month treatment period were highly statistically significant with mean improvements of 40% and 31%, respectively. Nocturnal frequency was reduced by 32% and the mean reduction was again highly statistically significant. Mean maximum urinary flow, average urinary flow and urine volume were also statistically significantly improved, but the modest improvement in post-voiding volume did not reach statistical significance. The improvements, which exceeded those observed with placebo in earlier studies, were maintained after one month without treatment indicating an interesting persistence of clinically useful activity. Prostatic volume and quality of sexual life remained unchanged throughout. No treatment-related adverse effects were observed. In conclusion, under conditions of daily practice, Pygeum africanum extract induces significant improvement in IPSS and uroflowmetry parameters. These positive effects are accompanied by a very satisfactory safety profile with the overall result of a substantial improvement in QoL.

[Partial replacement of the ureter with the appendix in Ormond disease --case report]

Surgical repair of a damaged portion of the ureter cannot always be resolved by mere ureterolysis or resection of the ureter and its "end to end" anastomosis, but it is not always resolved by complete replacement of the ureter by an ileal loop. The presented case-record describes the partial replacement of the abdominal portion of the ureter (9 cm) by an excluded appendix in a 59-year-old patient with a solitary right kidney, suffering from morbus Ormond.

[Simultaneous occurrence of pheochromocytoma of the adrenal gland and papillary carcinoma of the urinary bladder (case report)]

Simultaneous tumourous duplicity of an adrenal pheochromocytoma and papillocarcinoma of the urinary bladder is obviously more frequent than publications on the condition. It involves however a serious medical problem and calls for a non-standard therapeutic approach. The author presents the case-history of a 52-year-old male smoker.

[Seminal vesical abscess and ipsilateral agenesis of the kidney]

So far only about 20 cases were published on abscesses of the seminal vesicles and only two patients suffered also from agenesis of one kidney. The presented case-history pertains to a patient with a history of haemospermia and a cystically dilated formation in the region of the posterior urethra on ascendent urethrocytography. The solution was surgery-revision and extirpation.

[Renal oncocytoma]

Renal oncocytomas are infrequent solid tumours of the renal parenchyma. Usually they are diagnosed incidentally. As to treatment conservative surgery predominates. The authors submit their experience with the treatment of eight patients during the past two years where they performed five times transperitoneal nephrectomy and three times resection of the tumour.

[Profile of radical retropubic prostatectomy during a 5-year period]

The authors evaluated 165 radical retropubic prostatectomies, which have been performed at the Department of Urology of the 1st School of Medicine, the Charles University and the General Faculty Hospital in Prague, from January 1992 until half of April 1997. After more precise indication criteria have been implemented, even more per cent of patients are operated in clinical T1c stage (only in this year it was up to 45%). Out of all, in 56 patients PSA exceeded 20 ng/ml, in 46 patients, there was proved seminal vesicles invasion and in 29 patients, there have been disclosed regional lymph node involvement. The postoperative decline of PSA below the 4.0 ng/ml within three months was recorded in 80% of patients with seminal vesicles involvement, but only in 69.2% of patients with nodal invasion. It may indicate the worse prognosis of latter patients. Nowadays we perform the routine peroperative staging lymphadenectomy provided PSA exceeds 10 ng/ml preoperatively and in case of presence of cancerous cells in regional lymph nodes, we do not proceed in the operation and the patient is indicated to another therapeutical modality.

[Primitive neuroectodermal tumors of the minor pelvis in women--case report]

A primitive neuroectodermal tumour (PNET) of the minor pelvis is a rare malignant small-cell tumour developing from the neural groove. It metastatizes into the lungs, bones, liver and brain. Treatment involves radical surgical extirpation followed by chemotherapy and actinotherapy. The author presents the case-history of PNET of the pelvis minor in a 33-year-old woman.

[Complications of urinary diversion after cystectomy in bladder carcinoma]

Urinary diversion following cystectomy on account of carcinoma of the bladder are pretentious surgical operations involving the risk of early and late complications. The authors made a retrospective analysis of 198 cases. Death during the early postoperative period was recorded in 3 patients (2x ileus and 1x pulmonary embolism). Other early complications were dehiscence of the intestinal anastomosis (3x), dehiscence of the skin would/3x) and pneumonia (3x). Clinically relevant late complications were ileus due to adhesions (4x), stenosis of the ureteroenteric anastomosis (21 ureteroenteric units and urolithiasis (6x). Metabolic acidosis was recorded frequently (19x). Complications were more frequent in patients with advanced disease and in a poor biological state.

[Iatrogenic lesions of the ureter in women]

The changing etiology of ureteral lesions is associated with the expanding spectrum of ureteroscopic, gynaecological, coloproctological and vascular operations. During 1989-1995 the authors treated 60 women with a ureteral lesion, mostly in conjunction with gynaecological operations (37 patients). The assessment of the diagnosis was sometimes delayed. The most frequent initial treatment was the establishment of percutaneous puncture nephrostomy (in 47 instances before delayed reconstruction). The authors discuss the time interval between the development of the ureteral lesion and its reconstruction. The most frequent treatment was ureterorhaphy, ureterocystoneoanastomosis or Boari's flap.

[Vesicovaginal and urethrovaginal fistulae]

The authors discuss treatment of vesicovaginal fistulae (VVF) in 36 patients and in six patients urethrovaginal fistulae treated in 1989-1995. The most frequent cause of VVF were iatrogenic lesions after hysterectomy. Occlusion of the fistula was performed 12x by the transvesical approach, nine times by a combined transperitoneal and vaginal approach, four times by a transvesical and transperitoneal approach, eight times by the vaginal route only and three times the authors had to make a continent derivation of urine of the sigma-rectum "pouch" type. Continence by primary operation was achieved in 86%, in urethrovaginal fistulae one reoperation was necessary. With the development of radical operations in the lesser pelvis in women the incidence of iatrogenic lesions is rising slightly, however when the technique of minimal invasive reconstruction urology is used, the prognosis of occlusion of fistulae is favourable.

[Pregnancy after urinary bladder augmentation]

Pregnancy after augmentation enterocystoplasty is an increasingly frequent phenomenon in women with congenital anomalies or a neurogenic urinary bladder. Possible complications during pregnancy and the period near delivery and their treatment is described by the authors, based on the case-history of a 22-year-old primipara after ileocoecal augmentation. The authors summarise the so far scarce data reported in the literature.

[An artificial urinary bladder sphincter for men]

Urinary incontinence is a condition with involuntary escape of urine and causes not only medical but also social and hygienic problems. One of the causes of incontinence is insufficiency of the urethral closure mechanism which in men is usually caused by previous prostatectomy or neurogenic dysfunction of the lower urinary pathways. The method of choice is the application of an artificial sphincter (model AMS 800) to the bulbar urethra or cervix. The authors applied an artificial sphincter in 1993-1996 to one boy and 14 men aged 11-72 years. The basic components of the artificial sphincter of the urethra-AMS 800 is a cuff, balloon and pump. The whole system is filled with isotonic solution Omnipaque 300, the cuff which is 45-80 mm long is placed either round the bulbar urethra from a perineal approach or round the cervix by a retropubic approach. The pump is placed beneath the skin of the scrotum and the balloon is in a perivesical position. All parts of the AMS are connected by tubes. Because of infectious complications the authors had to explant the sphincter in two patients. In one patient it was necessary to add another cuff. The perineal approach is simpler, but is associated with a higher risk of erosion of the urethra. Patients with a neurogenic bladder had more complications than those after prostatectomy. Despite the fact that the method and aid is expensive, the treatment is very effective and makes the patients independent on other aids for incontinent patients.

Female urethra-sparing cystectomy and orthotopic bladder replacement

OBJECTIVE

Orthotopic bladder replacement after cystoprostatectomy has long become the method of choice in the treatment of infiltrating bladder cancer in males. Very good quality of life in patients thus treated stimulated the work on a similar approach applicable to females.

METHODS

Twelve females were treated by urethra-sparing cystectomy. The surgical technique preserves not just the urethra itself but also the pelvic floor and relevant innervation.

RESULTS

Diurnal continence was achieved in 11 patients, 1 of whom had a so-called hypercontinence with a residual volume of 300 ml. The remaining patient suffered from stress incontinence.

CONCLUSION

The described urethra-sparing radical cystectomy in female patients with a urothelial tumor, with normal pelvic floor and with a low risk of secondary affection of the urethra, permits reconstructing a continent orthotopic neobladder from a detubularized intestinal segment.

[Interstitial cystitis]

Interstitial cystitis (IC) is a complex of painful mictional symptomatology of unknown etiology. Is occurs more frequently in women. By cystoscopy the ulcerative and non-ulcerative form is differentiated. A typical diagnosis symptom are glomerulations during cystoscopy under general anaesthesia. There are diagnostic criteria which rule out IC. Histopathologically the following are differentiated: classical IC with proliferation of mastocytes in the detrusor, detrusor myopathy and eosinophil cystitis. Treatment includes intervesical instillation of various substances, transurethral procedures or supratrifonal cystectomy, incl. enterocystoplasty.