Intravesical Administration of Xenogeneic Porcine Urothelial Cells Attenuates Cyclophosphamide-Induced Cystitis in Mice

The urothelium of the bladder, renal pelvis, ureter and urethra is maintained through the regulated proliferation and differentiation of urothelial stem and progenitor cells. These cells provide a rich source of a novel urothelial cell therapy approach that could be used to protect, regenerate, repair and restore a damaged urothelium. Urothelial injury caused by physical, chemical and microbial stress is the pathological basis of cystitis (bladder inflammation). The loss of urothelial integrity triggers a series of inflammatory events, resulting in pain and hematuria such as hemorrhage cystitis and interstitial cystitis. Here we investigate a novel cell therapy strategy to treat cystitis by protecting the urothelium from detrimental stresses through intravesically instilling porcine urothelial cells (PUCs) into the bladder. Using a chemical-induced urothelial injury mouse model of cyclophosphamide (CPP)-induced hemorrhagic cystitis, we determined how the intravesical instillation of PUCs could protect the urothelium from toxic attack from CPP metabolites. We show that intravesical PUC instillation protected the bladder from toxic chemical attack in mice receiving CPP with reduced inflammation and edema. Compared with the vehicle control mice, the proliferative response to chemical injury and apoptotic cells within the bladder tissues were reduced by intravesical PUC treatment. Furthermore, the urothelium integrity was maintained in the intravesical PUC-treated group. After xenogeneic PUCs were introduced and adhered to the mouse urothelium, immunological rejection responses were observed with increased neutrophil infiltration in the lamina propria and higher immune-related gene expression. Our findings provide an innovative and promising intravesical PUC cell therapy for cystitis with urothelial injury by protecting the urothelium from noxious agents.

Cytomegalovirus Hemorrhagic Cystitis in a Malignant Glioma Patient Treated with Temozolomide

Temozolomide, a key drug in the treatment of malignant glioma, can cause profound lymphopenia and various opportunistic infectious diseases. A 79-year-old woman with anaplastic oligodendroglioma developed a fever and gross hematuria after 8 weeks of standard radiotherapy with concomitant temozolomide treatment. A cytomegalovirus (CMV) antigen test for pp65 antigenemia was positive (137 cells per 75,800 leukocytes), and the findings from a urine cytology test were consistent with CMV-induced hemorrhagic cystitis. She was treated with ganciclovir, and her condition improved. CMV monitoring is needed when patients develop symptoms related to opportunistic infections during temozolomide treatment for malignant glioma.

Complete reversal of the clinical symptoms and image morphology of ketamine cystitis after intravesical hyaluronic acid instillation: A case report

RATIONALE

Ketamine abuse is an emerging issue in many countries, and ketamine cystitis (KC) is a growing disease which more and more urologists may encounter with. There was no gold standard diagnostic criteria of ketamine cystits established yet, but well-accepted with the positive substance abuse history and clinical symptoms. The clinical presentation of ketamine cystitis varies and may mimic those presented in interstitial cystitis (IC), such as voiding frequency, urgency with urge incontinence, dysuria, nocturia, burning sensation during urination, post urination pain, painful hematuria, and small bladder capacity, but there are still differences that KC presented with more urgency, hematuria, pyuria and upper urinary tract involvement such as ureteral stenosis, vesico-ureteric reflux, hydronephrosis and renal function impairment.

PATIENT CONCERNS

We presented an interesting case with a 36-year-old man who's symptoms mimic acute prostatitis but there was no positive pathogen been cultured. The computed tomography (CT) findings revealed asymmetrical bladder wall thickening, which misleading us to the impression of bladder cancer. After the cystoscopy with bladder biopsy, the pathology revealed severe inflammation without malignancy. After that, we prescribed anticholinergic agent, beta-3 agonist and nonsteroidal anti-inflammatory drug (NSAID) for him, but in vain.

DIAGNOSES

Erosive cystitis with prominent infiltration by eosinophils, lymphocytes, neutrophils and plasma cells.

INTERVENTIONS

Then we introduced hyaluronic acid (HA) instillation, once a week for total 10 times.

OUTCOMES

After the treatment, his urgency, frequency, nocturia improved and his bladder capacity increased from less than 100ml to 350mL per urination. The following magnetic resonance imaging (MRI) and bladder biopsy result revealed complete reversal.

LESSONS

To our literature review, this is the first case of ketamine cystitis presented with asymmetrical bladder wall thickening, which may be considered as an irreversible change, but turns out complete reversal of the clinical symptoms and image morphology after merely intravesical hyaluronic acid instillation.

Efficacy of Cidofovir in Treatment of BK Virus-Induced Hemorrhagic Cystitis in Allogeneic Hematopoietic Cell Transplant Recipients

BK virus-associated hemorrhagic cystitis (BK-HC) is a common complication after allogeneic hematopoietic stem cell transplantation (allo-HCT), with incidences up to 70%. Cidofovir is an antiviral agent with growing evidence as a therapeutic intervention. To assess the safety profile and efficacy of intravenous and intravesical cidofovir in allo-HCT patients with BK-HC, a retrospective study was undertaken of the allo-HCT cohort who received cidofovir for symptomatic BK-HC (hematuria with BK viruria or viremia) from January 2010 until March 2017 in a single transplant center in Ontario, Canada. The primary outcome measure was a reduction in BK-HC severity (graded from 1 to 4); secondary outcomes included overall survival, BK virus titers, and the onset of acute kidney injury. Twelve allo-HCT patients received cidofovir for BK-HC, with pretreatment clinical severity of 3 (50%) or 4 (50%). Cidofovir was administered via intravenous (33%), intravesical (58%), or both modalities (8%). After a median cumulative dose of 10 mg/kg (range, 1 to 37), mean BK-HC grade decreased significantly by 1.8 (3.5 precidofovir, 1.7 postcidofovir, P < .01). Sixty-six percent of patients had at least partial response to cidofovir, with similar response rates between intravenous (66%) and intravesical (62%) administration. Sixty-seven percent of patients died, and 33% of patients experienced renal toxicity, including 2 patients receiving intravesical therapy. In this retrospective series, there was a significant reduction in BK-HC severity after cidofovir administration; most patients achieved at least partial response after cidofovir administration. Even with intravesical instillation, acute kidney injury remains a potential complication of cidofovir. Although cidofovir may be an efficacious therapy for BK-HC, albeit with potential demonstrated toxicities, further prospective trials are needed.

Clinical Outcome of Augmentation Enterocystoplasty for Patients with Ketamine-induced Cystitis

BACKGROUND

Ketamine abuse has become a global phenomenon in recent years. Ketamine-induced cystitis (KC) is a new clinical syndrome which can result in severely inflamed bladder and intractable bladder pain. Currently there is no guideline for managing patients with KC.

OBJECTIVES

To analyze the clinical outcome of patients with KC managed with augmentation enterocystoplasty (AE).

STUDY DESIGN

Retrospective interventional study.

SETTING

A tertiary teaching hospital, Hualien Tzu Chi Hospital.

METHODS

We retrospectively collected and analyzed the medical records and video-urodynamic (VUD) test results of 26 patients who underwent AE as treatment for refractory KC during the period 2009 - 2014. All of these patients abused ketamine with nasal snorting, at least 3 grams per dose, twice per week for 6 months. Data from VUD studies performed before AE and 3 - 6 months after surgery that were analyzed in this study included cystometric bladder capacity (CBC), post-void residual (PVR) urine volume, maximum urinary flow rate (Qmax), voided volume, and bladder compliance. A self-report questionnaire was used to assess patient satisfaction with AE.

RESULTS

Patients included 14 women and 12 men aged 20 - 43 years (mean age, 28.5 years) with an average duration of ketamine abuse of 4.7 years (range, 1 - 10 years). All patients had contracted bladder, 9 had hydronephrosis, and 10 had vesicoureteral reflux (VUR). There was significant improvement in CBC (52.7 ± 29.7 v 327 ± 69.4 mL, P < 0.0001), Qmax (6.94 ± 4.32 v 13.7 ± 4.96 mL/s, P < 0.0001), PVR (8.08 ± 19.2 v 82.6 ± 91.5 mL, P < 0.0001), voided volume (44.1 ± 28.3 v 250.7 ± 133.4 mL, P < 0.0001), and bladder compliance (11.1 ± 11.9 v 54 ± 43, P < 0.0001) after AE. Hydronephrosis resolved in 7 patients after AE and VUR resolved in all patients who underwent AE with ureteral reimplantation. All patients who stopped using ketamine were free of bladder pain postoperatively. However, 10 patients who reused ketamine had recurrent bladder pain and recurrent urinary tract infection.

LIMITATIONS

Small number of patients limits scope of study.

CONCLUSIONS

AE is effective at treating KC-induced bladder pain and restoring normal lower urinary tract function. However, absolute cessation of ketamine is the key to success in KC treatment.Key words: Ketamine-induced cystitis, augmentation enterocystoplasty, bladder pain, contracted bladder, inflammation, surgery.

Clinical Assessment of Urinary Tract Damage during Sustained-Release Estrogen Supplementation in Mice

Estrogen supplementation is a key component of numerous mouse research models but can adversely affect the urinary system. The goal of this study was to develop a clinical scoring system and identify biomarkers of occult urinary tract lesions prior to the development of systemic illness in mice. Ovariectomized or sham-surgery SCID mice were implanted subcutaneously with a placebo pellet or one containing sustained-release estradiol (0.18 mg 60-d release 17β-estradiol). Mice were assessed twice weekly for 4 to 6 wk by using a clinical scoring system that included body condition, general activity, posture, hair coat, hydration, abdominal distension, urine staining of coat and skin, and ability to urinate. Samples were collected weekly for urinalysis, BUN, creatinine, and serum estradiol levels. Terminal samples were analyzed for histopathologic lesions. Compared with placebo controls, estradiolsupplemented mice had higher serum estradiol levels at weeks 2 and 3; significant differences in total clinical scores by the 3-wk time point; and in body condition, general activity, posture, hair coat, and urine staining scores by the 6-wk terminal time point. Urinary tract lesions included hydronephrosis, pyelonephritis, cystitis, and urolithiasis. All mice with urolithiasis had crystalluria, and 5 of the 6 mice with pyelonephritis or hydroureter had dilute urine (that is, specific gravity less than 1.030). However, these findings were not specific to mice with lesions. A total clinical score of 3.5 (maximum, 24) identified estradiol-supplemented mice with 83% specificity and 50% sensitivity, but no single clinical parameter, biomarker, or the total clinical score accurately predicted occult urinary tract lesions. Considering the lesions we observed, prudence is warranted when using pelleted sustained-release estradiol in mice, and important parameters to monitor for animal health include urine staining, body condition score, urine sediment, and urine specific gravity.

Histone deacetylase inhibitors mediate DNA damage repair in ameliorating hemorrhagic cystitis

Hemorrhagic cystitis is an inflammatory and ulcerative bladder condition associated with systemic chemotherapeutics, like cyclophosphomide. Earlier, we reported reactive oxygen species resulting from cyclophosphamide metabolite, acrolein, causes global methylation followed by silencing of DNA damage repair genes. Ogg1 (8-oxoguanine DNA glycosylase) is one such silenced base excision repair enzyme that can restore DNA integrity. The accumulation of DNA damage results in subsequent inflammation associated with pyroptotic death of bladder smooth muscle cells. We hypothesized that reversing inflammasome-induced imprinting in the bladder smooth muscle could prevent the inflammatory phenotype. Elevated recruitment of Dnmt1 and Dnmt3b to the Ogg1 promoter in acrolein treated bladder muscle cells was validated by the pattern of CpG methylation revealed by bisulfite sequencing. Knockout of Ogg1 in detrusor cells resulted in accumulation of reactive oxygen mediated 8-Oxo-dG and spontaneous pyroptotic signaling. Histone deacetylase (HDAC) inhibitor, suberoylanilide hydroxamic acid (SAHA), restored Ogg1 expression in cells treated with acrolein and mice treated with cyclophosphamide superior to the standard of care, mesna or nicotinamide-induced DNA demethylation. SAHA restored cyclophosphamide-induced bladder pathology to that of untreated control mice. The observed epigenetic imprinting induced by inflammation suggests a new therapeutic target for the treatment of hemorrhagic cystitis.

Protective Effect of Intravesical Platelet-Rich Plasma on Cyclophosphamide-Induced Hemorrhagic Cystitis

PURPOSE

Hemorrhagic cystitis (HC) is the most common urotoxic side effect of cyclophosphamide (CYP). Platelet rich plasma (PRP) plays an important role in wound healing and inflammatory responses. The aim of this study was to investigate the efficacy of intravesical PRP at treatment of interstitial cystitis (IC).

MATERIAL-METHODS

Female rats (n=24) were used. IC was induced by intraperitoneal injection of cyclophosphamide (CYP). Rats were randomly allocated to one of four groups (n = 6 per group): a control group; a sham group with saline (75 mg/kg; i.p.) instead of CYP on day 1; a IC group, which was injected with CYP (150 mg/kg; i.p.) on day 1; and, a intravesical PRP‑treated group which was injected with CYP (150 mg/kg; i.p.) on day 1. On day 2, the rats in each group were sacrificed under anesthesia.

RESULTS

Histological evaluation showed that bladder inflammation in CYP‑treated rats was not suppressed by PRP. CYP administration induced severe IC with marked edema, hemorrhage and inflammation in CYP and CYP+PRP groups, but PRP was not found to be effective to decrease these effects.

CONCLUSION

The application of PRP could not reverse the histopathological changes in rats that had interstitial cystitis due to the cyclophosphamide injection.

Mesenchymal stem cells protect against the tissue fibrosis of ketamine-induced cystitis in rat bladder

Abuse of the hallucinogenic drug ketamine promotes the development of lower urinary tract symptoms that resemble interstitial cystitis. The pathophysiology of ketamine-induced cystitis (KC) is largely unknown and effective therapies are lacking. Here, using a KC rat model, we show the therapeutic effects of human umbilical cord-blood (UCB)-derived mesenchymal stem cells (MSCs). Daily injection of ketamine to Sprague-Dawley rats for 2-weeks resulted in defective bladder function, indicated by irregular voiding frequency, increased maximum contraction pressure, and decreased intercontraction intervals and bladder capacity. KC bladders were characterized by severe mast-cell infiltration, tissue fibrosis, apoptosis, upregulation of transforming growth factor-β signaling related genes, and phosphorylation of Smad2 and Smad3 proteins. A single administration of MSCs (1 × 10(6)) into bladder tissue not only significantly ameliorated the aforementioned bladder voiding parameters, but also reversed the characteristic histological and gene-expression alterations of KC bladder. Treatment with the antifibrotic compound N-acetylcysteine also alleviated the symptoms and pathological characteristics of KC bladder, indicating that the antifibrotic capacity of MSC therapy underlies its benefits. Thus, this study for the first-time shows that MSC therapy might help to cure KC by protecting against tissue fibrosis in a KC animal model and provides a foundation for clinical trials of MSC therapy.

Urinary kidney injury molecule-1 (KIM-1) excretion in rats with experimental cystitis induced by oxazaphosphorines

INTRODUCTION

Oxazaphosphorine agents (cyclophosphamide - CP, ifosfamide - IF) are causative factors of cystitis and also exert a characteristic nephrotoxic effect, clinically manifested by a broad spectrum of disturbances. The aim of the study was to estimate the toxic effect of the abovementioned oxazaphosphorines on the renal tubules by assessment of diuresis and urinary concentration and daily urinary excretion of the kidney injury molecule-1 (KIM-1) in rats with induced and histologically confirmed cystitis.

MATERIAL AND METHODS

The study involved 60 rats (equal amounts of ♀ and ♂), including animals treated with CP, administrated four times at the dose 75 mg/kg (group 1; n=10) and treated with IF, administrated four times at the dose 50 mg/kg IF (group 2; n=10) with the suitable control group A (group 3; n = 10), as well as animals receiving either a single dose 150 mg/kg of CP (group 4) or IF (group 5), with an appropriate control group B (group 6).

RESULTS

In both groups 1 and 4, a significant increase in the daily diuresis and decrease of the urinary pH were revealed, compared to the appropriate control group A (group 3) and B (group 6), while IF-treated animals, regardless of the applied doses (groups 2 and 5), were characterized by a urinary pH decrease. KIM-1 urinary concentration in rats from group 1 and 4 was almost three times higher compared to the appropriate control groups A or B, respectively, and the difference was statistically significant. In animals with chronic (group 2) and acute (group 5) ifosfamide- induced cystitis, no statistically significant difference concerning KIM- 1 urinary concentration compared to a control A and B groups was revealed, although a clear tendency of increase of the parameter was observed in the IF-treaded animals. Analysis of daily KIM-1 urinary excretion showed a statistically significant, almost six-fold increase in group 1 and almost two-fold increase in group 2. In the groups with acute model of cystitis, the highest, nearly eight-fold, daily KIM-1 urinary excretion, was revealed in animals treated with single CP dose, compared to the respective control B group, while rats treated with a single IF dose were characterized by a daily urinary KIM -1 excretion, comparable to animals with IF-induced chronic cystitis. The histopathological analysis confirmed cystitis in all animals treated with either CP or IF (groups 1,2,4,5), while no altered kidney microscopic morphology, compared to respective control groups A and B, was observed in those rats.

CONCLUSIONS

The study confirmed the proximal tubular dysfunction in rats with both cyclophosphamide- and ifosfamide-induced cystitis, which was reflected by an increased urinary KIM-1 excretion. The disturbance was more emphasized in CP-treated animals, especially in those ones treated with the single, high CP dose. The functional tubulopathy was not accompanied by a structural kidney damage in rats treated with either CP or IF.

Urinary uroplakin expression in cyclophosphamide-induced rat cystitis model

Cyclophosphamide (CYP) induces urothelial injury and causes excretion of cellular exudates at 24 h, followed by rapid restoration at 72 h. We investigated the role of urinary uroplakin II (UPII) levels in a CYP-induced cystitis model. For the purpose of this study, 10 controls and 26 CYP-injected female Sprague Dawley rats were killed at 24 h and 72 h postinjection. The vesical weight, severity of hematuria, and expression of UPII in the urinary bladder and urine were measured. CYP decreased the level of vesical UPII messenger RNA at 24 h, followed by rapid recovery at 72 h. Contrary to the negligible levels of urinary UPII and hematuria in controls, CYP treatment abruptly increased the excretion of urinary UPII at 24 h. The excretion had subsided at 72 h. Similarly, severe hematuria was observed at 24 h, with improvement at 72 h. However, some rats still exhibited hematuria at 72 h. CYP caused increase in vesical weight. The vesical weight at 24 h after CYP injection was negatively correlated with the vesical UPII level. Rats with significant hematuria demonstrated higher urinary UPII levels than those with insignificant hematuria. Vesical UPII could be an important barrier for early CYP-related injury, while the levels of urinary UPII may be associated with the severity of hematuria during dynamic periods in the urothelium.

The Quinovic Acid Glycosides Purified Fraction from Uncaria tomentosa Protects against Hemorrhagic Cystitis Induced by Cyclophosphamide in Mice

Uncaria tomentosa is widely used in folk medicine for the treatment of numerous diseases, such as urinary tract disease. Hemorrhagic cystitis (HE) is an inflammatory condition of the bladder associated with the use of anticancer drugs such as cyclophosphamide (CYP). Sodium 2-mercaptoethanesulfonate (Mesna) has been used to prevent the occurrence of HE, although this compound is not effective in established lesions. It has been demonstrated that the purinergic system is involved in several pathophysiological events. Among purinergic receptors, P2X7 deserves attention because it is involved in HE induced by CYP and, therefore, can be considered a therapeutic target. The objective of this study was to investigate the potential therapeutic effect of the quinovic acid glycosides purified fraction (QAPF) from U. tomentosa in the mouse model of CYP-induced HE. Pretreatment with QAPF not only had a protective effect on HE-induced urothelial damage (edema, hemorrhage and bladder wet weight) but was also able to control visceral pain, decrease IL-1β levels and down-regulates P2X7 receptors, most likely by inhibit the neutrophils migration to the bladder. This research clearly demonstrates the promising anti-inflammatory properties of QAPF, supporting its use as complementary therapy. QAPF represents a promising therapeutic option for this pathological condition.

Detrusor myocyte autophagy protects the bladder function via inhibiting the inflammation in cyclophosphamide-induced cystitis in rats

Autophagy, a highly conserved homeostatic cellular process that removes and recycles damaged proteins and organelles in response to cellular stress, is believed to play a crucial role in the immune response and inflammation. The role of autophagy in bladder cystitis, however, has not well been clarified. Here we investigate the role of detrusor myocytes autophagy (DMA) in cyclophosphamide-induced cystitis animal model. 164 female Sprague-Dawley rats were randomized into three experimental groups and compared to three control groups, respectively. The expressions of microtubule-associated protein 1 light chain 3 (LC3), p-p70s6k (the phosphorylated form of ribosomal protein S6), SOD2 (superoxide dismutase 2) in the bladder muscular layer were measured using western blot. The co-location of LC3, alpha-smooth muscle actin (α-SMA), and autophagic vacuoles were investigated with double-labeled immunofluorescence and transmission electron microscopy (TEM). The expression of lL-1β, IL-6, IL-8, malondialdehyde (MDA), and glutathione (GSH) in the detrusor layer were analyzed using ELISA. The bladder inflammation and the number of mast cells in the muscular layer were analyzed by histology. The bladder function was evaluated using cystometry. In cyclophosphamide-induced cystitis, autophagy was detected in detrusor myocytes by increased LC3, p-p70s6k expression, and autophagosomes. However, the presence of enhanced inflammation and oxidative stress in the cyclophosphamide-treated group suggest autophagy of detrusor myocytes may not be sufficiently activated. Inflammation and oxidative stress were significantly decreased and the bladder histology and micturition function were significantly improved with rapamycin (RAPA, autophagy agonist) pre-treatment. In contrast, inflammation and oxidative stress were dramatically increased and the bladder histology and function were negatively affected with chloroquine (CQ, autophagy blocker) pre-treated. These findings preferentially provide evidence of the association between DMA and cyclophosphamide-induced cystitis in rats. The autophagy agonist RAPA significantly decreased the inflammation and protected the bladder function, which might be considered as a potential treatment for interstitial cystitis.

Spectral heart rate variability in rats with cyclophosphamide-induced hemorrhagic cystitis treated with cyclooxygenase inhibitors

The pathogenesis of cyclophosphamide-induced hemorrhagic cystitis (CP-HC) is complex, involving the im- pact of many systemically and locally released agents on autonomic nervous system (ANS) activity, that affects bladder functioning. The purpose of our study was to provide an indirect evaluation of ANS functional status in experimental CP-HC model, involving prostaglandin synthesis block resulting from administration of cyclooxygenase inhibitors. The ANS activity was estimated through the spectral analysis of heart rate variability (HRV) in CP-HC rats divided into three study groups: 1-control, 2-treated with meloxicam (MLX) that preferentially blocks COX-2, and 3-treated with piroxicam (PRX) that inhibits COX1 and 2 activity. In animals treated either with MLX or PRX, the percent distribution of the spectrum in relation to components of very low (VLF) and low (LF) frequency was not different from the control group. PRX-treated group displayed nearly two times lower percent share of the high frequency (HF) component compared to the control. Moreover, an increase of the normalized LF (nLF) value with simultaneous reduction of the normalized HF (nHF) value were noted in PRX-treated rat with no change of these parameters for MLX-treated rats. The HRV analysis in CP-HC rats receiving PRX, indicated a functional reorganization manifested by reduced parasym- pathetic activity and increased sympathetic tonus. A partial prostaglandin synthesis block caused by COX-2 inhibitor (meloxicam) caused no significant changes of evaluated HRV parameters compared to the control. Assessing functional changes of the ANS caused by prostaglandin synthesis block it should be stated that prostaglandins synthesized by the constitutive COX-1 isoform seem to maintain the parasympathetic activity, which may be associated with the cholinergic anti-inflammatory pathway and resolution of inflammation in course of cyclophosphamide-induced cystitis.

Suppression of the PI3K pathway in vivo reduces cystitis-induced bladder hypertrophy and restores bladder capacity examined by magnetic resonance imaging

This study utilized magnetic resonance imaging (MRI) to monitor the real-time status of the urinary bladder in normal and diseased states following cyclophosphamide (CYP)-induced cystitis, and also examined the role of the phosphoinositide 3-kinase (PI3K) pathway in the regulation of urinary bladder hypertrophy in vivo. Our results showed that under MRI visualization the urinary bladder wall was significantly thickened at 8 h and 48 h post CYP injection. The intravesical volume of the urinary bladder was also markedly reduced. Treatment of the cystitis animals with a specific PI3K inhibitor LY294002 reduced cystitis-induced bladder wall thickening and enlarged the intravesical volumes. To confirm the MRI results, we performed H&E stain postmortem and examined the levels of type I collagen by real-time PCR and western blot. Inhibition of the PI3K in vivo reduced the levels of type I collagen mRNA and protein in the urinary bladder ultimately attenuating cystitis-induced bladder hypertrophy. The bladder mass calculated according to MRI data was consistent to the bladder weight measured ex vivo under each drug treatment. MRI results also showed that the urinary bladder from animals with cystitis demonstrated high magnetic signal intensity indicating considerable inflammation of the urinary bladder when compared to normal animals. This was confirmed by examination of the pro-inflammatory factors showing that interleukin (IL)-1α, IL-6 and tumor necrosis factor (TNF)α levels in the urinary bladder were increased with cystitis. Our results suggest that MRI can be a useful technique in tracing bladder anatomy and examining bladder hypertrophy in vivo during disease development and the PI3K pathway has a critical role in regulating bladder hypertrophy during cystitis.

The influence of prostaglandin PGE1 and PGF2alpha analogues on autonomic nervous system activity, estimated with heart rate variability, in cyclophosphamide-induced hemorrhagic cystitis in rats

The cyclophosphamide-induced hemorrhagic cystitis (CP-HC) is a common consequence of cyclophosphamide treatment with complex pathophysiology involving several inflammatory mechanisms and autonomic nervous system dysregulation.

THE AIM OF THIS STUDY

To determine effects of prostaglandin PGE1 and PGF2alpha analogues on the activity of the autonomic nervous system (ANS), estimatedindirectly on the basis of heart rate variability (HRV), in an experimental model of cyclophosphamide-induced hemorrhagic cystitis (CP-HC). Moreover we verified if potential changes in autonomic regulation can contribute to uroprotective role of prostaglandins.

MATERIAL AND METHODS

The study included three groups of rats with experimentally induced CP-HC. The animals from group 2 and 3 were administered PGE1 and PGF2a analogues, respectively, and the rats from group 1 (controls) did not receive any treatment. The HRV of animals from all the groups was analyzed after seven days of the experiment.

RESULTS

Administration of both PGF2alpha and PGE1 was associated with an increase in the power of VLF component and total power on frequency-domain analysis. Moreover, a significant increase in the power of non-normalized components, LH and HF, and two parameters of time-domain analysis, SDN-N and rMSSD, was documented in PGF2alpha-administered animals. Both prostaglandin-treated groups did not differ significantly from the controls in terms of the values of normalized parameters, nLF and nHF.

CONCLUSIONS

The analyzed prostaglandin analogues increased total autonomic activity but did not induced preferential changes in sympathetic or parasympathetic activity. Nevertheless, the VLF changes documented on HRV analysis may reflect a decrease in the level of certain pro-inflammatory mediators, thus pointing to, previously postulated in literature, potential beneficial uroprotective effect of prostaglandins in CP-HC.

Protective effect of palmitoylethanolamide in a rat model of cystitis

PURPOSE

PEA is an endogenous mediator released together with the endocannabinoid anandamide from membrane phospholipids. It is a plant derived compound with analgesic and anti-inflammatory properties. We verified whether the pathophysiology of experimental cystitis involves changes in the levels of PEA and of some of its targets, ie CB1 and CB2 receptors, and PPARα. We also determined whether exogenously administered PEA could be proposed as a preventive measure for cystitis.

MATERIALS AND METHODS

Cystitis was induced by cyclophosphamide in female rats. Nociceptive responses, voiding episodes, gross damage, myeloperoxidase activity, bladder weight, bladder PEA and endocannabinoid levels (measured by liquid chromatography-mass spectrometry) and the expression of PEA targets (measured by quantitative reverse transcriptase-polymerase chain reaction) were recorded.

RESULTS

Cyclophosphamide induced pain behavior, bladder inflammation and voiding dysfunction associated with increased bladder levels of PEA, up-regulation of CB1 receptor mRNA expression, down-regulation of PPARα mRNA and no change in CB2 receptor mRNA expression. Exogenously administered, ultramicronized PEA attenuated pain behavior, voids and bladder gross damage. The CB1 antagonist rimonabant and the PPARα antagonist GW6471 counteracted the beneficial effect of PEA on gross damage. Also, GW6471 further decreased voiding episodes in rats treated with PEA.

CONCLUSIONS

The current study provides strong evidence for a protective role of PEA as well as an alteration in bladder levels of PEA and of some of its targets in cyclophosphamide induced cystitis.

Prevention of cyclophosphamide-induced hemorrhagic cystitis by resveratrol: a comparative experimental study with mesna

PURPOSE

Hemorrhagic cystitis (HC) is the most common urotoxic side effect of cyclophosphamide (CP). The aim of this study was to compare the classical efficacy of mesna (2-mercaptoethane sulfonate sodium) with three different doses of resveratrol (RES) on cyclophosphamide-induced HC in rats.

METHODS

Forty-six male Sprague-Dawley rats were divided into six groups. Group 1 served as a negative control (sham). Five groups received a single dose of cyclophosphamide (150 mg/kg) intraperitoneally at the same time. Groups 2, 3, 4, 5, and 6 received only CP, CP + 20 mg/kg RES, CP + 40 mg/kg RES, CP + 80 mg/kg RES, and CP + classical protocol of three doses of mesna (30 mg/kg three times), respectively. Antioxidants, cytokines, and malondialdehyde levels were measured in all groups. In addition, histopathological alterations in tissues were examined.

RESULTS

CP administration induced severe HC with marked edema, hemorrhage, and inflammation in group 2. RES 20 mg/kg showed meaningful protection against bladder damage compared to the control group. It was seen that RES 40 mg/kg gave weaker protection but RES 80 mg/kg was not found to be effective.

CONCLUSION

In conclusion, marked bladder protection was found in 20 and 40 mg/kg RES applications compared to the control group, but this protection was weaker than with mesna.

Evidence-Based Practice Recommendations for Hydration in Children and Adolescents With Cancer Receiving Intravenous Cyclophosphamide

Hemorrhagic cystitis is a known complication of cyclophosphamide, an antineoplastic agent used to treat a variety of oncologic diseases in children. Hydration can prevent hemorrhagic cystitis; however, use varies in clinical practice. A team was assembled to develop evidence-based practice recommendations to address the following question: in a population of children with cancer, what is the appropriate pre- and posthydration for the administration of different dose levels of intravenous cyclophosphamide to prevent bladder toxicity? The purpose was to identify the appropriate rate, duration, and route of hydration to prevent bladder toxicity with low, intermediate, and high dose cyclophosphamide. After a systematic search of the literature, 15 pieces of evidence were evaluated and used. There is a moderate level of quality evidence related to hydration for high dose cyclophosphamide and very low quality evidence related to intermediate or low dose cyclophosphamide. Three general recommendations were made for hydration associated with cyclophosphamide. There is a need for further research related to the prevention of bladder toxicity in children with cancer receiving cyclophosphamide.

The influence of piroxicam, a non-selective cyclooxygenase inhibitor, on autonomic nervous system activity in experimental cyclophosphamide-induced hemorrhagic cystitis and bladder outlet obstruction in rats

Signs and symptoms of secondary overactive bladder (OAB) are observed both in course of infravesical obstruction of urine outflow in patients with benign prostatic hyperplasia, and as a result of development of hemorrhagic cystitis (HC) following administration of cyclophosphamide (CP). Non-steroidal antiinflammatory drugs (NSAIDs) alleviate symptoms of bladder overactivity reducing local synthesis of prostaglandins (PGs), but precise effects of those agents on functions of the autonomic nervous system (ANS) in course of OAB remain unknown. The purpose of this study was to evaluate the effect of piroxicam-induced prostaglandins (PGs) synthesis block on activity of the ANS in two experimental models of secondary OAB: bladder outlet obstruction (BOO) and cyclophosphamide-induced HC (CP-HC), by heart rate variability analysis (HRV). The experiment was performed on a group of rats with surgically induced 2-week BOO, and on a group of rats that were administered CP five times, with corresponding control groups. Study animals were given piroxicam (PRX) i.p. in two doses: 2 and 10 mg/kg b.w. In the BOO model, PRX in both doses revealed a trend for reduction of value of all non-normalized components of HRV. The lower PRX dose caused an increased nHF value, and PRX administered in the dose of 10 mg/kg b.w. caused an increase of the nLF value. In the CP-HC model, the lower PRX dose caused a trend for an increase of values of all non-normalized components, and the higher dose--for their decrease. Both doses of PRX in that model caused increase of the nLF value. Inhibition of PGs synthesis caused changes of ANS function in both models of OAB. Both in BOO and in CP-HC, PGs seem to be ANS-activating factors, responsible for maintenance of a high parasympathetic activity. In both models, inhibition of PGs synthesis with PRX administered at the dose of 10 mg/kg b.w. lead to functional reconstruction of ANS, with marked sympathetic predominance. That may contribute to reduction of the bladder contractile action and improvement of its compliance in the filling period, which was demonstrated by other authors in urodynamic tests for NSAIDs.

Comparison of intravesical application of chondroitin sulphate and colchicine in rat protamine/lipopolysaccharide induced cystitis model

PURPOSE

To investigate beneficial effect of the readily available colchicine through its intravesical application on protamine/lipopolysaccharide induced interstitial cystitis model in rat and to compare its efficacy to the chondroitin sulphate available for clinical use.

MATERIALS AND METHODS

Twenty-four Wistar female rats were assigned to control (C), interstitial cystitis (IC), chondroitin sulphate (CS) and colchicine (Col) groups. IC, CS and Col groups received protamine sulphate and lipopolysaccharide (PS/LPS) instillation. Testing agents CS and Col were administered a day after PS/LPS inoculation into the bladders. Rats in Group C received saline solution. CS and Col groups received 1 mL CS (0.2%) and 1 mL Col (0.05 mg/mL). The treatment agents were left in bladders for one hour's duration. Animals were sacrificed 5 days after the inoculation and the bladder tissues were examined histologically to evaluate the amount of extravasated leucocytes, mast cell concentration (by counting total number of cells per 10 high power field (hpf; 1 hpf = ×400 magnification) as well as interstitial tissue edema for each bladder.

RESULTS

Intravesical application of CS reduced significantly the leucocyte and mast cell infiltration as well as interstitial edema compared to group C . The level of reduction in leucocyte and mast cell infiltration in Col group was comparable to that of CS, although the interstitial edema was not resolved.

CONCLUSION

Intravesical administration of Col decreased leucocyte and mast cell infiltration to the same extent of CS in PS/LPS induced bladder inflammation in rat. Col may be an alternative to other treatment modalities for painful bladder conditions such as IC.

[Morphological changes in bladder tissue after submucosal injection of mitomycin-C solution in experiment]

The article presents the results of morphological examination of bladder tissue reactions on the submucosal injection of mitomycin-C solution in different (0.1, 0.05, 0.025, and 0.0125%) concentrations. The experiments were conducted using dogs weighing 13-15 kg. Tissue sampling for histological evaluation were performed at 1, 2 and 3 hours, and on Day 7, 14, and 30. Maximum expression of the inflammatory response in the submucosa (edema, foci of lymphohistiocytic infiltration, increased microvascular lumen, diffuse leukocyte infiltration around the vessels of connective tissue between muscle fibers) was developed early after injection of 0.1% mitomycin-C, and it was minimal 3 hours after injection of 0.0125 % solution.

Chemical- and radiation-induced haemorrhagic cystitis: current treatments and challenges

To review the published data on predisposing risk factors for cancer treatment-induced haemorrhagic cystitis (HC) and the evidence for the different preventive and therapeutic measures that have been used in order to help clinicians optimally define and manage this potentially serious condition.

Despite recognition that HC can be a significant complication of cancer treatment, there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.

A systematic literature review was undertaken to evaluate the evidence for preventative measures and treatment options in the management of cancer treatment-induced HC.

There is a wide range of reported incidence due to several factors including variability in study design and quality, the type of causal agent, the grading of bleeding, and discrepancies in definition criteria.

The most frequently reported causal factors are radiotherapy to the pelvic area, where HC has been reported in up to 20% of patients, and treatment with cyclophosphamide and bacillus Calmette-Guérin, where the incidence has been reported as up to 30%.

Mesna (2-mercaptoethane sodium sulphonate), hyperhydration and bladder irrigation have been the most frequently used prophylactic measures to prevent treatment-related cystitis, but are not always effective.

Cranberry juice is widely cited as a preventative measure and sodium pentosanpolysulphate as a treatment, although the evidence for both is very limited.

The best evidence exists for intravesical hyaluronic acid as an effective preventative and active treatment, and for hyperbaric oxygen as an equally effective treatment option.

The lack of robust data and variability in treatment strategies used highlights the need for further research, as well as best practice guidance and consensus on the management of HC.

[Function of bladder smooth muscle autophagy in cyclophosphamide-induced cystitis]

OBJECTIVE

To explore the existence of bladder smooth muscle autophagy and its function in cyclophosphamide (CYP) -induced cystitis.

METHODS

A total of 30 Sprague-Dawley rats were randomized into control (n = 6) and experimental groups (4 h, 48 h, 72 h, 96 h, n = 24) . The experimental group received a single intraperitoneal injection of 150 mg/kg CYP in 0.6 ml saline while the control group had the same volume of saline injection. The changes of microtubule-associated protein light chain 3 (LC3), interleukin-6 (IL-6), IL-1β and tumor necrosis factor-alpha (TNF-α) proteins in bladder muscular layer were measured with Western blot. Co-location of LC3 and alpha-small muscle action (α-SMA) was detected with double-labeled immunofluorescence. Autophagic vacuoles were observed with electron microscopy. The changes in bladder inflammation were measured by hematoxylin and eosin staining.

RESULTS

Autophagy was confirmed in detrusor myocytes with electron microscope, LC3 Western blot and double-labeled immunofluorescence. As compared with the control group, the expression level of LC3 in experimental groups decreased (0.08 ± 0.01 vs 0.13 ± 0.01, P < 0.05) at 4 h and increased 1.19, 0.75 and 0.20 fold (0.29 ± 0.04 vs 0.13 ± 0.01, P < 0.05; 0.23 ± 0.03 vs 0.13 ± 0.01, P < 0.05;0.16 ± 0.03 vs 0.13 ± 0.01, P > 0.05) at 48, 72 and 96 h respectively.Electron microscopy and double-labeled immunofluorescent also supported the above change of LC3 by Western blot.In addition, as compared with the control groups, IL-6, IL-1β and TNF-α and bladder histological scores of bladder muscular layer significantly increased in experimental groups (all P < 0.05) .

CONCLUSIONS

Autophagy exists in bladder smooth muscle. In cyclophosphamide-induced cystitis, bladder smooth muscle autophagy activation may not be sufficient to protect bladder muscle layer inflammation in rats.

The influence of oxazaphosphorines alkylating agents on autonomic nervous system activity in rat experimental cystitis model

The oxazaphosphorines alkylating agents (cyclophosphamide; CP and ifosfamide; IF) are often used in common clinical practice. However, treatment with CP/IF is burdened with the risk of many adverse drug reactions, especially including hemorrhagic cystitis (HC) that is associated with bladder overactivity symptoms (OAB). The HC pathophysiology is still not fully displayed; it seems that autonomic nervous system (ANS) functional abnormalities play important role in this disturbance. The aim of our study was to reveal the potential ANS differences in rat experimental HC model, evoked by CP and IF by an indirect ANS assessment--heart rate variability (HRV) study. We carried out our experimental research in three essential groups: control group (group 1), cyclophosphamide-induced HC (CP-HC; group 2) one and ifosfamide-induced HC (IF-HC; group 3) one. CP was i.p. administrated four times in dose of 75 mg/kg body weight while IF-treated rats received i.p. five drug doses; 50 mg/kg body weight. Control rats were administrated i.p. vehicle in appropriate volumes as CP/IF treated animals. HRV studies were performed the next day after the last oxazaphosphorines dose. Standard time- and spectral (frequency) domain parameters were estimated. We confirmed the HC development after both CP/IF in macroscopic assessment and bladder wet weight measurement; however, it was more aggravated in CP-HC group. Moreover, we demonstrated HRV disturbances, suggesting ANS impairment after both studied oxazaphosphorines, however, consistent with the findings mentioned above, the autonomic dysfunction was more emphasized after CP. CP treatment was also associated with changes of non-normalized HRV spectral components percentage distribution--a marked very low frequency--VLF [%] increase together with low frequency--LF [%] and high frequency--HF [%] decrease were observed. Taking into consideration the next findings, demonstrating the lack of both normalized power spectral components (nLF and nHF) values, the VLF percentage change seems to be of special meaning. IF produced smaller autonomic disturbances, and gentler bladders histological abnormalities comparing to CP. However, similar to CP, VLF [%] relative augmentation together with LF [%] and HF [%] drop accompanied the global ANS activity decrease. Additionally, in the case of IF treatment, a slight trend of nLF increase with nHF decrease was noted, suggesting the possible functional rearrangement between sympathetic (nLF) and parasympathetic (nHF) tension. It seems possible that the vagal withdrawal and--as a consequence--sympathetic overactivity, reflected by VLF [%] enlargement and HF and LF [%] diminishing (as well as LF and HF values decrease), may be an evidence of impaired anti-inflammatory cholinergic pathway, aggravating bladder inflammatory lesions. To sum up, our study showed ANS impairment in both CP- and IF-evoked experimental HC that was reflected in HRV recordings. HRV study, thus, may be considered to be a diagnostic tool for CP/IF treated patients, estimating autonomic abnormalities, associated with the HC development risk and its clinical course.

Crucial role of TRPC1 and TRPC4 in cystitis-induced neuronal sprouting and bladder overactivity

PURPOSE

During cystitis, increased innervation of the bladder by sensory nerves may contribute to bladder overactivity and pain. The mechanisms whereby cystitis leads to hyperinnervation of the bladder are, however, poorly understood. Since TRP channels have been implicated in the guidance of growth cones and survival of neurons, we investigated their involvement in the increases in bladder innervation and bladder activity in rodent models of cystitis.

MATERIALS AND METHODS

To induce bladder hyperactivity, we chronically injected cyclophosphamide in rats and mice. All experiments were performed a week later. We used quantitative transcriptional analysis and immunohistochemistry to determine TRP channel expression on retrolabelled bladder sensory neurons. To assess bladder function and referred hyperalgesia, urodynamic analysis, detrusor strip contractility and Von Frey filament experiments were done in wild type and knock-out mice.

RESULTS

Repeated cyclophosphamide injections induce a specific increase in the expression of TRPC1 and TRPC4 in bladder-innervating sensory neurons and the sprouting of sensory fibers in the bladder mucosa. Interestingly, cyclophosphamide-treated Trpc1/c4(-/-) mice no longer exhibited increased bladder innervations, and, concomitantly, the development of bladder overactivity was diminished in these mice. We did not observe a difference neither in bladder contraction features of double knock-out animals nor in cyclophosphamide-induced referred pain behavior.

CONCLUSIONS

Collectively, our data suggest that TRPC1 and TRPC4 are involved in the sprouting of sensory neurons following bladder cystitis, which leads to overactive bladder disease.

Effects of vitamin D analog on bladder function and sensory signaling in animal models of cystitis

OBJECTIVE

To measure the effects of nonhypercalcemic vitamin D receptor agonist elocalcitol on bladder function in rats with cyclophosphamide-induced cystitis and on bladder function and sensory nerve activity in a mouse with acetic acid-evoked bladder irritation.

MATERIALS AND METHODS

Female Wistar rats and male Balb/C mice were gavaged once daily with elocalcitol diluted in miglyol 812 (treatment group) or miglyol alone (control group). On experimental day 12, polyethylene tubing was implanted into the urinary bladder in all the animals. In the mice, a bipolar electrode was positioned under a single postganglionic bladder nerve. At 48 hours after surgery, bladder function was measured in awake, freely moving rats during bladder filling with 0.9% NaCl and both bladder function and sensory nerve activity was measured in awake, restrained mice during continuous intravesical infusion of 0.9% NaCl followed by 0.25% acetic acid.

RESULTS

In rats, the treatment group showed a significant increase in bladder capacity and decrease in number of nonvoiding bladder contractions. In mice, the filling pressure during saline infusion was similar in both groups; however, during acetic acid infusion, the average filling pressure was significantly increased (47%) in the control group but not in the elocalcitol treatment group. The firing rate at filling pressure for the treatment group was 3.6-fold and 2.7-fold lower than that in the control group during the saline and acetic acid infusion, respectively.

CONCLUSION

Oral treatment with elocalcitol suppressed signs of detrusor overactivity in both animal models and exerted strong suppressive effect on urinary bladder sensory signaling during filling in mice.

[Long-term oral low-dose cyclophosphamide-induced hemorragic cystitis which was successfully treated by ureterostomy: a case report]

An 80-year-old man presented to our hospital with macroscopic hematuria. Before coming to our hospital, he was treated for multiple myeloma with cyclophosphamide. We detected diffuse dilation of capillary on urinary bladder mucosa on cystoscopy, and diagnosed the patient with cyclophosphamide-induced hemorrhagic cystitis. Macroscopic hematuria once resolved by indwelling urethral catheter, but recurred and bladder tamponade developed. We performed transurethral electric coagulation. Macroscopic hematuria temporarily disappeared, but again relapsed. Then we performed intravesical instillation of aluminum hydroxide gel, but without a clear effect and the patient developed hemorrhagic shock. Eventually, we performed bilateral ureterostomy because the disease was unresponsive to less invasive therapies. Vesical bleeding disappeared and the patient was discharged 32 days after surgery. The treatment for multiple myeloma has been continued without cyclophosphamide since surgery.

Effect of silymarin on bladder overactivity in cyclophosphamide-induced cystitis rat model

The purpose of this study was to investigate the effects of silymarin, a phytotherapeutic agent, on bladder overactivity in a cyclophosphamide (CYP)-induced cystitis rat model. Female Wistar Albino rats received a single intraperitoneal injection of CYP (150 mg/kg) or saline and after 72 h, bladder function was evaluated by in vitro preparations of whole bladders and cystometry with continuous saline infusion under urethane anesthesia. Silymarin or a vehicle was orally given for 7 days in rats. CYP was injected on the 5th day of silymarin or vehicle treatment and then the animals were killed on the 8th day. CYP-treatment dramatically potentiated the basal spontaneous contractions of isolated whole bladders compared to control rats. In anesthetized rats, during continuous infusion cystometry, intercontraction interval (ICI) was significantly shorter, but bladder voiding pressure was not significantly changed in CYP-injected rats compared to control rats. In the CYP-injected group, silymarin treatment significantly decreased the amplitude, frequency (contractions/min) and area under the curve of spontaneous contractions, but failed to change carbachol-induced contraction in isolated whole bladder. Also, silymarin treatment significantly increased the ICI in comparison to the vehicle treatment. In the saline-injected group, no significant changes in the bladder function were observed between the silymarin and vehicle-treated groups. Histopathological examination showed that CYP-induced bladder inflammation tended to be lower in the silymarin+CYP-treated group. In conclusion, the oral administration of silymarin suppressed CYP-induced bladder overactivity. Silymarin may be considered as an attractive treatment for CYP-induced bladder overactivity.

Scutellaria baicalensis alleviates cantharidin-induced rat hemorrhagic cystitis through inhibition of cyclooxygenase-2 overexpression

Cantharidin, an active component in mylabris, is used in traditional Chinese medicine (TCM) to treat scabies and hepatoma, but accompanied by hemorrhagic cystitis. Evidence shows that cantharidin induces human bladder carcinoma cell death through COX-2 overexpression in vitro. In TCM, Scutellaria baicalensis is usually used to cure mylabris-induced hematuria. This work was undertaken to determine the mechanisms of cantharidin-induced rat hemorrhagic cystitis and explore the uroprotective effect of S. baicalensis. In vitro results showed cantharidin could induce cytotoxicity through prostaglandin (PG)E₂ overproduction of T24 cells. Boiling-water extract of S. baicalensis (SB-WE) could significantly inhibit PGE₂ production and COX-2 expression in lipo-polysaccharide-induced RAW 264.7 cells, indicating obvious anti-inflammatory abilities. In vivo results indicated that cantharidin caused rat hemorrhagic cystitis with hematuria via c-Fos and COX-2 overexpression. SB-WE was given orally to cantharidin-treated rats, whereby hematuria level, elevated PGE₂ and COX-2 protein overexpression were significantly and dose-dependently inhibited by SB-WE. The anti-inflammatory components of SB-WE are baicalin and wogonin, whose contents were 200.95 ± 2.00 and 31.93 ± 0.26 μg/mg, respectively. In conclusion, cantharidin induces rat cystitis through c-Fos and COX-2 over-expression and S. baicalensis can prevent the resulting hematuria because of its anti-inflammatory effects.

[Contemporary presentation of unusual adverse events during telmisartan therapy]

Man, 60 years old, in two weekly haemodialysis from 2009. From 2007 in treatment with once-daily telmisartan 40 mg for hypertension. From 2008 showed recurrent pharingitys. In June 2011 bacterial cystitis showed at the same time. The telmisartan was discontinued and both problems solved.

[Cystitis and ketamine associated bladder dysfunction]

OBJECTIVES

To analyze the prevalence of lower urinary tract symptoms (LUTS) in recreational ketamine users and evaluate its relationship with the consumption pattern.

MATERIAL AND METHODS

Evaluation of 13 ketamine users. The presence of LUTS, gross hematuria and lumbar spine pain was analyzed. The ketamine usage pattern was recorded: initiation, administration route, dose in the last month and frequency of usage.

RESULTS

Six patients (46%) reported LUTS, with daily mean micturations every 42 minutes and nighttime of 3 episodes, with dysuria (100%), urgency (100%), incontinence (20%), decreased flow (80%), hypogastric or perineal pain (80%), gross hematuria (80%) and bilateral lumbar spine pain (40%). Symptomatic patients described a mean intake of inhaled ketamine of 3g/day (SD 2), 80% with a daily frequency and the asymptomatic ones of 1.03 g/day (SD 0.92) limited to weekends. The mean consumption time to the appearance of the symptoms was 31 months (SD 16.29). Intensity of the symptoms was related with the ketamine dose and improved on increasing water intake.

CONCLUSIONS

There seems to be a relationship between the picture with the dose and frequency of consumption, there being factors that reinforce the hypothesis that this action of the drug is due to the harmful effect on the urothelium. The process to identify it on time should be known, since the only known effective measure is to stop the consumption in the initial phases.

Oral glutamine attenuates cyclophosphamide-induced oxidative stress in the bladder but does not prevent hemorrhagic cystitis in rats

Cyclophosphamide (CP) is widely used in the treatment of cancer and non-malignant disease states such as rheumatoid arthritis. Hemorrhagic cystitis is a major dose-limiting side effect of CP. The incidence of this side effect is related to the dosage and can be as high as 75%. Elimination of the side effects of CP can lead to better tolerance of the drug, and a more efficient therapy can be achieved for patients in need of CP treatment. Several studies have demonstrated that oxidative stress and neutrophil infiltration play important roles in CP-induced bladder damage. Glutamine is utilized under clinical conditions for preventing chemotherapeutic drug-induced side effects, based on its ability to attenuate oxidative stress. The aim of the study is to verify whether glutamine prevents CP-induced oxidative stress and bladder damage using a rat model. Adult male rats were administered 150 mg/kg body weight of CP intraperitoneally. Glutamine pretreated rats were administered 1 g/kg body weight of glutamine orally 2 h before the administration of CP. Vehicle/glutamine-treated rats served as controls. All the rats were killed 16 h after the dose of CP/vehicle. The urinary bladders were removed and used for light microscopic and biochemical studies. The markers of oxidative stress including malondialdehyde content, protein carbonyl content, protein thiol, and myeloperoxidase activity, a marker of neutrophil infiltration, were measured in bladder homogenates. CP treatment induced hemorrhagic cystitis in the rats. Pretreatment with glutamine significantly reduced CP-induced lipid peroxidation (p < 0.01), protein oxidation (p < 0.01), and increase in myeloperoxidase activity (p < 0.05). However, it did not prevent CP-induced bladder damage. The results of the present study show that glutamine pretreatment does not attenuate CP-induced hemorrhagic cystitis, although it prevents CP-induced oxidative stress and neutrophil infiltration significantly. It is therefore necessary to clarify the utility of glutamine as a chemoprotective agent before it is recommended in the market as a nutrient supplement.

Severe cyclophosphamide-induced haemorrhagic cystitis treated with hyperbaric oxygen

AIM

Cyclophosphamide-induced haemorrhagic cystitis (CHC) is an uncommon but well-recognised condition caused by a metabolite, acrolein, which is toxic to the urothelium. Based on similarities in the histopathology of radiation- and chemotherapy-induced haemorrhagic cystitis, benefit from hyperbaric oxygen therapy (HBOT) has been proposed. HBOT produces an increased oxygen partial pressure diffusion gradient between the circulation and surrounding tissues, which enhances neutrophil function and fibroblast and macrophage migration into damaged hypoxic soft tissue, promoting collagen formation, fibroblast growth, angiogenesis and white-cell bacterial killing. There are only isolated case reports of HBOT for CHC, in the literature so we reviewed the New Zealand experience with HBOT in CHC.

METHOD

The case records of all patients with CHC referred to the three hyperbaric medicine units in New Zealand between 2000 and 2007 were reviewed retrospectively.

RESULTS

Six patients, with life-threatening haemorrhage at the time of referral for HBOT weeks or months after initial presentation with CHC, were identified. Cessation of bleeding occurred in all six patients after 14 to 40 HBOT, without complications. All patients remained clear of haematuria at 11 to 36 months follow-up.

CONCLUSIONS

We recommend the use of HBOT in the management of intractable cyclophosphamide-induced haemorrhagic cystitis as an effective and low-risk therapy.

Pharmacological modulation of the micturition pattern in normal and cyclophosphamide pre-treated conscious rats

In the current study, we wanted to assess the influence of muscarinic receptors, nitric oxide and purinoceptors on the micturition pattern of conscious normal and cyclophosphamide (CYP) pre-treated rats. The micturition parameters were assessed using a metabolic cage. Rats were pre-treated with either saline or CYP, to induce cystitis, followed by treatment with either the muscarinic M1/M3/M5 receptor antagonist 4-diphenylacetoxy-N-methylpiperidine (4-DAMP), the nitric oxide synthase blocker N(ω)-nitro-L-arginine methyl (L-NAME), the P2 purinoceptor antagonist pyridoxalphosphate-6-azophenyl-2',4'-disulfonic acid (PPADS) or a combination of 4-DAMP with PPADS or L-NAME. Voiding volumes per micturition event were significantly lower in CYP pre-treated than in saline pre-treated rats. Neither 4-DAMP nor L-NAME had any effect in the normal rats, whereas PPADS reduced the micturition volume per event. In CYP pre-treated rats, 4-DAMP and L-NAME significantly increased voiding volumes per event and micturition frequency, respectively. 4-DAMP dose-dependently reduced the differences in micturition activity between saline and CYP pre-treated rats. We show that cystitis changes the urodynamics in conscious rats and that this change seems to depend on the production of NO and on altered muscarinic receptor effects. The altered muscarinic receptor responses are likely to per se involve NO-mediated mechanisms.

Functional, histological structure and mastocytes alterations in rat urinary bladders following acute and [corrected] chronic cyclophosphamide treatment

Neurogenic inflammation is linked to urinary bladder overactivity development. Cyclophosphamide (CYP) damages all mucosal defence lines of urinary bladder and induces cystitis with overactivity. The aim of this study was to estimate the effect of CYP on rat urinary bladder function, histological structure and mastocytes numbers following acute and chronic CYP treatment. Fourty two female rats were divided into four groups: I (control), II (acute cystitis), III (chronic cystitis), IV (sham group). Acute and chronic cystitis were induced by CYP in single dose and four doses (1(st), 3(rd), 5(th), 7(th) day), respectively. In group I-III the cystometric evaluation was performed. Sections of the bladder were stained with HE and toluidine blue for the detection of mastocytes. The severity of inflammation was examined according to mucosal abrasion, haemorrhage, leukocyte infiltration and oedema. Acute and chronic CYP treatment caused inflammatory macroscopic and microscopic changes (mucosal abrasion, haemorrhage, oedema) and increased infiltration of inflammatory cells in urinary bladder. Acute treatment induced the infiltration of mastocytes within bladder wall contrary to chronic one decrement. Acute treatment caused more severe mucosal abrasion, whereas chronic one revealed more developed haemorrhage changes. Additionally, cystometric evaluation revealed urinary bladder overactivity development in both types of cystitis. Basal pressure and detrusor overactivity index after acute treatment increased considerably in comparison with the increase obtained after chronic one. Our results proved that acute model of CYP-induced cystitis in rats is more credible for further evaluation of neurogenic inflammation response in pathogenesis of overactive bladder as compared to chronic one.

Cyclooxygenase-2 contributes to functional changes seen on experimental hemorrhagic cystitis induced by ifosfamide in rat urinary bladder

PURPOSE

Ifosfamide (IFS) is often involved in the occurrence of hemorrhagic cystitis due to direct contact of its metabolite acrolein with uroepithelium. It has been shown that COX-2 is involved in this pathogenesis. Thus, we aimed to study the functional changes on the urinary bladder in the putative modifications induced by IFS, as well as the COX-2 role in this process.

MATERIALS AND METHODS

IFS-treated rats were evaluated by cystometrography in absence or presence of COX inhibitors indomethacin or etoricoxib or in the presence of mesna. Experiments with isolated strips of urinary bladder obtained from animals with IFS-induced cystitis, either treated or not treated with COX inhibitors or mesna, were performed. Histological analyses, immunohistochemistry for COX-2, and measurement of plasma PGE(2) were also performed.

RESULTS

IFS treatment caused severe inflammation of the bladder tissue. Cystometrography recordings of IFS-treated rats revealed bladder with increased micturition frequency and enhanced filling intravesical pressure. Contractility of the isolated smooth muscle from the rat's bladder with IFS-induced cystitis showed decreased force development in response to KCl and CCh. Almost all effects induced by IFS were ameliorated by the use of COX inhibitors or mesna. Enzyme expression in the urinary bladder tissue was positive, and plasma concentration of PGE(2) was increased in IFS-treated animals and decreased significantly in etoricoxib-treated animals.

CONCLUSIONS

IFS causes important changes in the micturition physiology in rats, and the inhibition of the isoenzyme COX-2 could be an important event that could prevent the detrimental effects elicited by IFS-induced hemorrhagic cystitis.

Eosinophilic cystitis following immediate post-resection intravesical instillation of mitomycin-C

We present a patient who developed severe lower urinary tract symptoms following resection of a Ta low grade bladder urothelial carcinoma with immediate post-resection instillation of mitomycin-C. Urine cultures were negative. Radiographic imaging demonstrated a bladder mass. On biopsy she was found to have eosinophilic cystitis. We report the clinical scenario and discuss treatment options. A review of reported cases in the English literature is provided.