Simultaneous Upper and Lower Urinary Tract Obstruction Associated with Severe Genital Prolapse: Diagnosis and Evaluation with Magnetic Resonance Imaging

Genital prolapse causing both urethral and ureteral obstruction is an infrequent occurrence, especially in the absence of uterine prolapse. We report on a patient with massive genital prolapse causing both urethral and ureteral obstruction in whom magnetic resonance imaging demonstrated the level of obstructive uropathy and, after surgical repair of the prolapse, confirmed restoration of the normal pelvic and upper urinary tract anatomy.

Nocturia: current concepts and future perspectives

Nocturia is a prevalent highly bothersome urinary symptom that may significantly detriment the health and well-being of sufferers. It is characterized by waking at night to void, each void preceded and followed by sleep, hence leading to fragmentation of sleep and day-time tiredness. This may result in reduced productivity in the workplace, which contributes to the significant burden to the wider society that nocturia incurs. Nocturia was traditionally viewed as one of the many urinary tract symptoms that occur due to lower urinary tract dysfunction. However, recently it has been recognized that due to its multi-factorial aetio-pathogenesis, nocturia should be viewed as distinct clinical condition in its own right. Careful assessment of the nocturic patient is essential so that treatment strategies are guided by the likely causes. Much research is currently being undertaken into the underlying causes and the optimal management approaches. This review will explore the contemporary status of research on nocturia with a focus on the current and newly available pharmacotherapies.

Urinary incontinence: classification and pharmacological therapy

Pharmacological therapy has been developed which can have significant impact in the management of many forms of urinary incontinence and voiding dysfunction. In general the clinical laboratory studies which have supported or challenged the efficacy of many of the commonly prescribed drugs for voiding dysfunction are often difficult to interpret and contradictory. The available clinical studies often do not demonstrate a lack of bias. Nor do they include an adequate number of subjects, use appropriate and sensitive methods of evaluation, employ double-blind placebo-controlled design, or appear statistically valid. Although the contribution of laboratory research has been of unquestionable value in the development of our current knowledge of lower urinary tract pharmacology it is difficult to interpret the results of in vitro pharmacological studies because of the array of experimental models used and the need to extrapolate to in vivo activity. This paper utilizes a functional scheme which classifies agents by their effects on urinary storage and emptying. The purpose of this review is to promote discussion of the application of uropharmacological investigation to the development of newer, more efficacious forms of drug therapy.

Radiofrequency Ablation of Small Renal Cell Carcinomas Using Multitined Expandable Electrodes: Preliminary Experience

PURPOSE

Radiofrequency ablation is a minimally invasive, nephron-sparing option for renal cell carcinoma (RCC) in poor surgical candidates. We report our contemporary experience with RCC radiofrequency ablation using multitined expandable electrodes along with an aggressive treatment strategy to displace adjacent viscera away from probe tines. Involution of the treatment zone was assessed over time.

MATERIALS AND METHODS

Over a 36-month period, a quality-assurance database identified 22 patients with 26 sporadic RCC who underwent 43 ablations during 27 radiofrequency ablation sessions. The mean age of the cohort was 71 years (range, 47-89 y). Mean RCC diameter was 2.2 cm (range, 1-4 cm). Twenty-six of radiofrequency ablation sessions were performed using multitined expandable electrodes. All ablations used CT guidance with moderate sedation. Adjunctive techniques used during ablation were recorded, as were instances in which ablation mandated penetration of tines beyond the kidney margin. Post-treatment ablation zones were measured from CT/MR images to evaluate serial involution and treatment response.

RESULTS

Technical success in targeting and ablation was 100%. Follow-up periods ranged from 1 to 31 months (mean, 11.2). During this period, one patient presented with marginal local recurrence and underwent repeat radiofrequency ablation. Adjunctive techniques in four patients included water injection for displacement of the tail of the pancreas (n = 1) or descending colon (n = 3). Deliberate penetration of tines beyond the margins of the kidney was performed in 41% of cases; no hemorrhage occurred in these cases. No major complications occurred. Minor complications occurred in 17% of patients, including asymptomatic pneumothorax, perirenal hematomas, subcutaneous hematoma, and subcutaneous abscess. After 6 months, mean involution of the ablation zone was 15% from baseline volume per year.

CONCLUSION

Multitined expandable radiofrequency electrodes produce a high rate of local control for small RCCs with a low complication rate, even when tine penetration of the kidney is required for an adequate tumor treatment margin. Adjacent organs can be protected with adjunctive percutaneous maneuvers.

Transitional cell carcinoma of the fossa navicularis in a man with preexisting adenocarcinoma of the prostate

In this report we present a patient with a history of prostatic adenocarcinoma who was found to have a low-grade/low-stage transitional cell carcinoma of the fossa navicularis. The patient underwent transurethral resection and at approximately 2 years of follow-up he has no evidence of tumor recurrence. Very limited follow-up data exist on which to base management decisions, and this report lends support to the use of transurethral resection alone as a means to treat low-grade/low-stage lesions.

Renal angiomyolipoma: long-term results after arterial embolization

PURPOSE

Selective arterial embolization of renal angiomyolipomas (AMLs) was performed to prevent hemorrhage in patients with AMLs larger than 4 cm. This study was conducted to evaluate the long-term efficacy of AML embolization.

MATERIALS AND METHODS

Nineteen patients underwent embolization for 30 renal AMLs between July 1991 and June 2002. Of these, 10 patients had tuberous sclerosis (TS) with multiple AMLs and nine patients had a solitary sporadic AML. Embolization was performed with use of ethanol mixed with iodized oil (Ethiodol) in 29 tumors; coils were used in addition to the ethanol/Ethiodol mixture in one case. All tumors were completely embolized according to angiographic criteria including vascular stasis and absence of arterial feeders. The efficacy of embolization was determined over a mean follow-up period of 51.5 months (range, 6-132 months). Recurrence was defined as an increase in tumor size of greater than 2 cm on follow-up imaging and/or recurrent symptoms that required repeat embolization. An institutional review board exemption was obtained to perform this retrospective study.

RESULTS

Embolization of the renal AMLs was technically successful in all 19 patients and for all 30 lesions. AML recurrence was noted in 31.6% of patients (n = 19) and for 30% of lesions overall (n = 9). Six of 10 patients in the TS group had AML recurrences. No recurrences occurred in the patients with sporadic AML. In the TS group of 10 patients, there was a total of 21 AMLs and the overall tumor recurrence rate was 42.9% (nine of 21). Six lesions in four patients had to be reembolized because of recurrent symptoms, including one hemorrhage, and three lesions in two patients required repeat embolization because of a greater than 2 cm increase in size. The median time interval from embolization to recurrence was 78.7 months (range, 13-132 months). Statistical testing with use of the Fisher exact test demonstrated that patients with TS were significantly more likely to develop recurrence than those without TS (P = .01).

CONCLUSIONS

Transarterial embolization is effective in preventing hemorrhage in patients with renal AMLs. However, long-term follow-up revealed a high AML recurrence rate in patients with TS. Lifelong surveillance for recurrence after AML embolization is essential in patients with TS.

Pharmacologic management of urinary incontinence in the female

Pharmacotherapy combined with behavioral therapy is often used for the initial therapy of urinary incontinence (UI) in the female. Although there are multiple central and peripheral sites and mechanisms that can potentially influence bladder and urethral function, the pharmacological manipulation of only a select few are clinically useful. The problems are: 1) how to affect bladder function without interfering with the function of other organ systems (uroselectivity); and, 2) how to eliminate UI without disturbing normal micturition. Multiple categories of drug therapies are potentially useful to treat UI. It is clear that the ideal agent for this indication has not yet been identified. Although significant improvement can be seen with several different agents for the treatment of various types of incontinence, complete cure is rarely seen with pharmacological therapy of UI. However, several new pharmacologic treatments including some with novel approaches to drug delivery and/or mechanisms of action have emerged in clinical development over the last few years. In initial studies, some of the agents appear to compare favorably to existing therapies. Whether these promising results will hold up when subjected to large scale, well controlled clinical trials is unclear.

Association of prostate cancer family history with histopathological and clinical characteristics of prostate tumors

Genetic factors may be used not only to assess risk of prostate cancer development but also to evaluate prostate cancer outcomes including clinical prognosis, treatment methods, and treatment response. To assess the role of family history on prostate cancer outcomes, we evaluated tumor characteristics, diagnostic precursors and biochemical (prostate specific antigen) relapse-free survival in men with and without a family history of prostate cancer. A total of 684 prostate cancer cases unselected for family history were identified from an ongoing hospital based prostate cancer case-control study between 1995 and 2002. Self-reported family history was grouped within the following categories: none, any, moderate (one affected first or second degree relative) and high (2 or more affected first or second degree relatives). We further considered groups defined by early (before age 60) and late (after age 60) age at diagnosis. Overall, tumor stage was not significantly associated with any (odds ratio [OR] = 1.43 95% confidence interval [CI] = 1.00-2.05) or moderate (OR = 1.48, 95% CI = 1.0-2.19) family histories. Men diagnosed before age 60, however, had higher tumor stages if they had any (OR = 2.19, 95% CI = 1.28-3.75) or moderate (OR = 2.15, 95% CI = 1.2-3.9) family histories. Men diagnosed after age 60 with any family history were significantly more likely to experience biochemical (PSA) failure (Hazard ratio [HR] = 2.60, 95%CI = 1.08-6.25). Men with any and moderate family histories were at significantly increased risk of biochemical failure (HR = 2.49, 95%CI = 1.25-4.95 and HR = 2.46, 95% CI = 1.17-5.16, respectively). Moderate family history increased probability of seminal vesicle invasion (OR = 2.14, 95%CI = 1.06-4.34). Our results suggest that a family history of prostate cancer may be associated with predictors of clinical outcome in prostate cancer cases unselected for a family history of prostate cancer.

A pilot clinical trial of oral pentosan polysulfate and oral hydroxyzine in patients with interstitial cystitis

PURPOSE

This pilot study was designed to evaluate the feasibility of a multicenter, randomized, clinical trial in interstitial cystitis (IC). Secondary objectives were to evaluate the safety and efficacy of oral pentosan polysulfate sodium (PPS), hydroxyzine, and the combination to consider their use in a larger randomized clinical trial.

MATERIALS AND METHODS

A 2 x 2 factorial study design was used to evaluate PPS and hydroxyzine. Participants met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC and reported at least moderate pain and frequency for a minimum of 6 months before study entry. The primary end point was a patient reported global response assessment. Secondary end points included validated symptom indexes and patient reports of pain, urgency and frequency. The target sample size was 136 participants recruited during 10 months.

RESULTS

A total of 121 (89% of goal) participants were randomized over 18 months and 79% provided complete followup data. The response rate for hydroxyzine was 31% for those treated and 20% for those not treated (p = 0.26). A nonsignificant trend was seen in the PPS treatment groups (34%) as compared to no PPS (18%, p = 0.064). There were no treatment differences for any of the secondary end points. Adverse events were mostly minor and similar to those in previous reports.

CONCLUSIONS

The low global response rates for PPS and hydroxyzine suggest that neither provided benefit for the majority of patients with IC. This trial demonstrated the feasibility of conducting a multicenter randomized clinical trial in IC using uniform procedures and outcomes. However, slow recruitment underscored the difficulties of evaluating commonly available IC drugs.

Prevalence and burden of overactive bladder in the United States

CONTEXT

the National Overactive BLadder Evaluation (NOBLE) Program was initiated to better understand the prevalence and burden of overactive bladder in a broad spectrum of the United States population.

OBJECTIVE

to estimate the prevalence of overactive bladder with and without urge incontinence in the US, assess variation in prevalence by sex and other factors, and measure individual burden.

DESIGN

US national telephone survey using a clinically validated interview and a follow-up nested study comparing overactive bladder cases to sex- and age-matched controls.

SETTING

noninstitutionalized US adult population.

PARTICIPANTS

a sample of 5,204 adults >/=18 years of age and representative of the US population by sex, age, and geographical region.

MAIN OUTCOME MEASURES

prevalence of overactive bladder with and without urge incontinence and risk factors for overactive bladder in the US. In the nested case-control study, SF-36, CES-D, and MOS sleep scores were used to assess impact.

RESULTS

the overall prevalence of overactive bladder was similar between men (16.0%) and women (16.9%), but sex-specific prevalence differed substantially by severity of symptoms. In women, prevalence of urge incontinence increased with age from 2.0% to 19% with a marked increase after 44 years of age, and in men, increased with age from 0.3% to 8.9% with a marked increase after 64 years of age. Across all age groups, overactive bladder without urge incontinence was more common in men than in women. Overactive bladder with and without urge incontinence was associated with clinically and significantly lower SF-36 quality-of-life scores, higher CES-D depression scores, and poorer quality of sleep than matched controls.

CONCLUSIONS

the NOBLE studies do not support the commonly held notion that women are considerably more likely than men to have urgency-related bladder control problems. The overall prevalence of overactive bladder does not differ by sex; however, the severity and nature of symptom expression does differ. Sex-specific anatomic differences may increase the probability that overactive bladder is expressed as urge incontinence among women compared with men. Nonetheless, overactive bladder, with and without incontinence, has a clinically significant impact on quality-of-life, quality-of-sleep, and mental health, in both men and women.

Increased contractility of diabetic rabbit corpora smooth muscle in response to endothelin is mediated via Rho-kinase beta

Corpus cavernosum smooth muscle (CCSM) from rabbits made diabetic for 6 months as a result of alloxan injection exhibited increased sensitivity (3vs 9 nM EC(50)) and generated 20-50% greater force to endothelin-1 (ET-1) compared to CCSM from normal rabbits. In contrast, the force produced by the CCSM in response to KCl and phenylephrine was not significantly altered in diabetic CCSM. The increased ET-1 sensitivity is associated with a two to three-fold upregulation of ET receptor A at both mRNA and protein levels in diabetic CCSM. ET-1-induced CCSM contraction is largely dependent upon Rho-kinase (ROK), since it is almost completely blocked by Y-27632 (a highly selective ROK inhibitor). Furthermore, expression of ROKbeta isoform is selectively upregulated in CCSM from diabetic rabbits. Thus, an increased CCSM tone, modulated by sensitization of the endothelin-mediated contractile pathway via ROK, may be a key component of the molecular mechanism of diabetes-induced erectile dysfunction.

Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder

OBJECTIVES

To compare the efficacy of tolterodine plus simplified bladder training (BT) with tolterodine alone in patients with an overactive bladder.

PATIENTS AND METHODS

In a multicentre, single-blind study at 51 Scandinavian centres, 505 patients aged >or= 18 years with symptoms of urinary frequency (>or= 8 micturitions/24 h) and urgency, with or without urge incontinence, were randomized to oral treatment with either tolterodine 2 mg twice daily plus simplified BT or tolterodine alone. Changes in voiding diary variables were evaluated after 2, 12 and 24 weeks of treatment. The patients' perceptions of their bladder symptoms and tolerability (adverse events) were also determined.

RESULTS

In all, 501 patients (75% women) were evaluable on an intention-to-treat basis (244 on tolterodine + BT and 257 on tolterodine alone). Tolterodine significantly reduced the voiding frequency and increased the volume voided per void at all sample times; these effects were significantly increased by adding BT. At the end of the study the median percentage reduction in voiding frequency was greater with tolterodine + BT than with tolterodine alone (33% vs 25%, P < 0.001), while the median percentage increase in volume voided per void was 31% with tolterodine + BT and 20% with tolterodine alone (P < 0.001). There was a median of 81% fewer incontinence episodes than at baseline with tolterodine alone, which was not significantly different from that with tolterodine + BT (- 87%). The two groups had comparable median percentage reductions in urgency episodes. Some 76% of patients on tolterodine + BT reported an improvement in their bladder symptoms relative to baseline, compared with 71% on tolterodine alone. Tolterodine was well tolerated; the most common adverse event was mild dry mouth.

CONCLUSION

Tolterodine 2 mg twice daily is an effective and well tolerated treatment for an overactive bladder, the effectiveness of which can be augmented by a simplified BT regimen.

Osteopontin gene expression and immunolocalization in the rabbit urinary tract

PURPOSE

Osteopontin is a highly phosphorylated, calcium binding sialoprotein characterized by a conserved arginine-glycine-aspartate sequence. Vitronectin receptor (alphavbeta3 integrin) and hyaluronan receptor (CD44) are documented as receptors for osteopontin and their expression has been established in the bladder. Based on that finding and the fact that osteopontin protein is present in urine we hypothesized that osteopontin is expressed in the lower urinary tract.

MATERIALS AND METHODS

Osteopontin messenger (m)RNA and protein were analyzed in 5 adult urinary tracts and 5 neonatal bladders of New Zealand White rabbits using reverse transcriptase-polymerase chain reaction and immunohistochemical testing. Analysis of mRNA expression and localization of osteopontin receptors, alphavbeta3 integrin and CD44 were also performed in adult bladders and primary cultures of detrusor myocytes.

RESULTS

Adult renal pelvis, ureter, bladder and urethra, and neonatal bladders contained significant levels of osteopontin mRNA. Immunohistochemical staining revealed osteopontin expression in all layers of the transitional epithelium of the bladder, co-localizing with alphavbeta3 integrin mainly in the superficial layers and with CD44 mainly in the basal layers. Osteopontin was detected within the cytoplasm of smooth muscle cells, while alphavbeta3 integrin was located closer to the plasmalemma. Furthermore, primary cultured detrusor myocytes expressed osteopontin mRNA in stable fashion for up to 4 passages. Treating bladder myocyte cultures with insulin-like growth factor-1 and 17beta-estradiol resulted in up-regulation and down-regulation of osteopontin mRNA, respectively.

CONCLUSIONS

Adult and neonatal rabbit detrusors are a prominent source of osteopontin in vivo and in vitro. Epithelial osteopontin may be a source of osteopontin in urine. The co-localization of osteopontin in the bladder epithelium with alphavbeta3 integrin and CD44 suggests a role in maintaining the integrity of the transitional epithelium by providing the sealing and adhesiveness needed for the impermeable state of the bladder.

Using the receiver operating characteristic curve to select pretreatment and pathologic predictors for early and late postprostatectomy PSA failure

OBJECTIVES

Pretreatment prostate-specific antigen (PSA), prostatectomy Gleason score, margin status, and pathologic T stage are known explanatory variables for the postprostatectomy PSA outcome. We used the receiver operating characteristic (ROC) curve to select those factors that were optimal for predicting early and late postoperative PSA failure.

METHODS

We designed and implemented a clinical outcome prediction expert that performs, assesses, and optimizes the actuarial prediction on individual cases. A postprostatectomy database of 1022 patients was divided into 60% for training and 40% for validation. The ROC areas of the predictors were calculated over a range of cutoff time from 24 to 60 months.

RESULTS

Multivariate pathologic T stage/prostatectomy Gleason score/margin status had the highest ROC area of 0.900. Patients with Stage T disease less than T3, negative surgical margins, and Gleason score of 6 or less had a 90% probability to be PSA failure free at 4 years versus 36% otherwise. The pathologic T stage/margin status accurately predicted PSA failure at 24 months or less after prostatectomy with an ROC area of 0.800. Lower risk patients (less than Stage T3, negative surgical margins) had a 94% probability to be PSA failure free at 2 years versus 46% otherwise.

CONCLUSIONS

A combination of actuarial analysis and ROC optimization accurately identified the individual patients at high risk of early and late postprostatectomy PSA failure.

Effects of Bowman-Birk inhibitor concentrate (BBIC) in patients with benign prostatic hyperplasia

BACKGROUND

The Bowman-Birk inhibitor is a soybean-derived protease inhibitor that has anti-inflammatory and anticarcinogenic activities.

METHODS

A Phase I trial of Bowman-Birk inhibitor concentrate (BBIC) in 19 male subjects with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) has been performed.

RESULTS

The results of the trial indicated that there was no dose-limiting toxicity of BBIC. There was a statistically significant decrease in serum PSA levels in all BBIC-treated patients. Some BBIC-treated patients exhibited a relatively large reduction in serum PSA levels, ranging up to a 43% reduction. There was also a statistically significant decrease in serum triglyceride levels and a decrease in prostate volume in the treated patients. The scores recorded in response to a urinary symptom questionnaire indicated improved urinary activities in the BBIC-treated patients; however, the control subjects exhibited similar improvements in urinary activities during the course of the trial.

CONCLUSIONS

The data obtained in this trial, particularly the data suggesting that BBIC treatment may lead to reduced serum PSA levels and reduced prostate volumes, suggest that a Phase II clinical trial of BBIC for the therapy of BPH is warranted.

How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study

OBJECTIVE

To determine the prevalence of chronic and debilitating symptoms of the overactive bladder, defined here as the presence of chronic frequency, urgency and urge incontinence (either alone or in any combination), and presumed to be caused by involuntary detrusor contractions. Subjects and methods Data were collected using a population-based survey (conducted by telephone or direct interview) of men and women aged >/= 40 years, selected from the general population in France, Germany, Italy, Spain, Sweden and the United Kingdom, using a random stratified approach. The main outcome measures were: prevalence of urinary frequency (> 8 micturitions/24 h), urgency and urge incontinence; the proportion of participants who had sought medical advice for symptoms of an overactive bladder; and current or previous therapy received for these symptoms.

RESULTS

In all, 16 776 interviews were conducted in the six European countries. The overall prevalence of overactive bladder symptoms in individuals aged >/= 40 years was 16.6%. Frequency (85%) was the most commonly reported symptom, followed by urgency (54%) and urge incontinence (36%). The prevalence of overactive bladder symptoms increased with advancing age. Overall, 60% of respondents with symptoms had consulted a doctor but only 27% were currently receiving treatment. Conclusion Symptoms of an overactive bladder, of which frequency and urgency are as bothersome as urge incontinence, are highly prevalent in the general population. However, only a few affected individuals currently receive treatment. Taken together, such findings indicate that there is considerable scope for improvement in terms of how physicians diagnose and treat this condition.

Heterogeneity of bladder myocytes in vitro: modulation of myosin isoform expression

We studied the expression of myosin heavy chain isoforms differing at the N-terminal (SM-A, SM-B) and the C-terminal (SM1, SM2) regions and non-muscle myosin heavy chain II-A and II-B (NMMHC II-A and B) in newborn and adult rabbit bladder smooth muscle cells (SMCs) and in cultures of enzymatically dissociated neonatal detrusor. RT-PCR analyses revealed that 94.5+/-3.27% of MHC transcripts of the adult bladder SMCs contained the 21-nucleotide insert (SM-B) compared with 83.8+/-3.2% in the newborn bladder, with the remainder of the mRNA being non-inserted (SM-A). In 3, 7, and 10 days of primary culture (proliferating, confluent, and post-confluent, respectively) and up to 4 subculture passages, bladder myocytes expressed predominantly SM-A. Immunofluorescence microscopy revealed heterogeneity in cultured myocytes, i.e. SM-B positive cells coexisting with negatively stained cells. In adult bladder, the C-terminal isoforms SM1 and SM2 represented, 43.1+/-4.3% and 56.89 + 4.3% of the mRNA, respectively, while newborn bladders expressed 72.5+/-7% SM1 and 27.5+/-7% SM2. Upon culturing, cells predominantly expressed SM1 at both the mRNA and protein levels. NMMHC II-A was expressed by both adult and newborn bladders and in culture, whereas NMMHC II-B was expressed at low levels only in newborn bladders, but upregulated in culture. These data indicate that bladder myocytes in vitro undergo modulation with relative overexpression of SM-A and SM1 and upregulation of NMMHC II-B. Information on the mechanisms responsible for this modulation in vitro might provide an understanding of the nature of altered myosin isoform expression associated with smooth muscle dysfunction in certain bladder diseases.

Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women

OBJECTIVES

Accurate determination of the size and extent of urethral diverticula can be important in planning operative reconstruction and repair. Voiding cystourethrography (VCUG) is currently the most commonly used study in the preoperative evaluation of urethral diverticula. We reviewed our experience with the use of endoluminal (endorectal or endovaginal) magnetic resonance imaging (eMRI) in these patients as an adjunctive study to VCUG to evaluate whether the MRI provided anatomically important information that was not apparent on VCUG.

METHODS

A retrospective analysis of all patients with a clinical diagnosis of urethral diverticula undergoing MRI at a single institution was performed. Patients were evaluated with history, physical examination, cystoscopy, VCUG, and eMRI. Endoluminal MRI was retrospectively compared to VCUG with respect to size, extent, and location found at operative exploration.

RESULTS

Twenty-seven consecutive patients underwent endorectal or endovaginal coil MRI in the evaluation of suspected urethral diverticula. Twenty patients subsequently had attempted transvaginal operative repair of the diverticulum. In 2 patients, eMRI demonstrated a urethral diverticulum, whereas VCUG did not. Operative exploration in these patients revealed a urethral diverticulum. In 14 of 27 patients, the VCUG underestimated the size and complexity of the urethral diverticulum as compared to eMRI and operative exploration. In 13 of 27 patients, the size, location, and extent of the urethral diverticulum on VCUG correlated well with the eMRI and/or operative findings.

CONCLUSIONS

We have found endorectal and endovaginal coil MRI to be extremely accurate in determining the size and extent of urethral diverticula as compared to VCUG. This information can be critical when planning the approach, dissection, and reconstruction of these sometimes complex cases.

Estrogen modulates the expression of myosin heavy chain in detrusor smooth muscle

The effect of low serum estrogen levels on urinary bladder function remains poorly understood. Using a rabbit model, we analyzed the effects of estrogen on the expression of the isoforms of myosin, the molecular motor for muscle contraction, in detrusor smooth muscle. Expression of myosin heavy chain (MHC) isoforms, which differ in the COOH-terminal (SM1 and SM2) and the NH(2)-terminal (SM-A and SM-B) regions as a result of alternative splicing of the mRNA at either the 3'- or 5'-ends, was analyzed in age-matched female rabbits that were sham operated, ovariectomized (Ovx), and given estrogen after ovariectomy (4 rabbits/group). Ovx rabbits showed a significant decrease in the overall MHC content per gram of wet detrusor smooth muscle compared with controls (P < 0.04), which was reversed by estrogen replacement (P < 0.02). MHC content, as a proportion of total milligram of protein in the bladder tissue extracted, was also increased in estrogen-treated Ovx rabbits. Quantitative competitive RT-PCR revealed 1.72-, 2.63-, and 5.82 x 10(6) copies of MHC mRNA/100 ng total mRNA in Ovx, control, and estrogen-treated rabbits, respectively (P < 0.01). RT-PCR analysis using oligonucleotides specific for the region containing the SM1/SM2 MHC alternative splice sites indicated a lower SM2-to-SM1 ratio in estrogen-treated compared with control and Ovx rabbits (P < 0.05). Similarly, SDS-PAGE analysis of extracted myosin from estrogen-treated rabbits revealed a significantly lower SM2-to-SM1 isoform ratio compared with control and Ovx rabbits (P < 0.05). Expression of the SM-A and SM-B isoforms was not affected. These results indicate that myosin content is increased upon estrogen replacement in Ovx rabbits and that the abundance of SM1 relative to SM2 is greater in estrogen-treated rabbits compared with normal and Ovx rabbits. These data suggest that estrogen affects alternative splicing at the 3'-end of the MHC pre-mRNA to increase the proportion of SM1 vs. SM2.

Significance of hematuria in patients with interstitial cystitis: review of radiographic and endoscopic findings

OBJECTIVES

Hematuria may be found in up to 30% of patients with interstitial cystitis (IC). However, few studies have described its etiology based on the findings of a complete evaluation. We reviewed the clinical significance of hematuria in the setting of IC.

METHODS

We retrospectively reviewed the records of 148 patients fulfilling the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases inclusion criteria for IC. Patients with gross or microscopic hematuria were identified. Evaluation consisted of urine culture and cytology, cystoscopy, and intravenous urography (or retrograde pyelography plus renal ultrasound). Patients with urinary tract infections were excluded.

RESULTS

Of 148 patients, 60 (41%) were found to have had at least one episode of hematuria during a mean follow-up of 18 months. Of 56 patients who agreed to be evaluated, 8 (14%) had positive urologic findings. Of these, none were highly significant; five were simple renal cysts (8.9%), one was a renal stone (1.8%), one was reflux nephropathy (1.8%), and one was medullary sponge kidney (1.8%). Cystoscopy, cytology, and bladder biopsy did not demonstrate malignancy in any patient. No statistically significant differences were found in age (49.9 versus 46.7 years), sex (90% versus 91% female), bladder capacity (792 versus 808 mL), and the presence of Hunner's ulcers (5% versus 2.4%), glomerulations (60% versus 59.9%), or detrusor mastocytosis (55% versus 47.6%) between patients with hematuria and those without (P >0.05).

CONCLUSIONS

The incidence of hematuria in patients with IC may be higher than previously reported. Nevertheless, although many of these patients present with pelvic pain and irritative voiding symptoms, the hematuria evaluation is unlikely to reveal a life-threatening urologic condition.

Regional variation in myosin isoforms and phosphorylation at the resting tone in urinary bladder smooth muscle

Urinary bladder filling and emptying requires coordinated control of bladder body and urethral smooth muscles. Bladder dome, midbladder, base, and urethra showed significant differences in the percentage of 20-kDa myosin light chain (LC20) phosphorylation (35.45 +/- 4.6, 24.7 +/- 2.2, 13.6+/- 2.1, and 12.8 +/- 2.7%, respectively) in resting muscle. Agonist-mediated force was associated with a rise in LC20 phosphorylation, but the extent of phosphorylation at all levels of force was less for urethral than for bladder body smooth muscle. RT-PCR and quantitative competitive RT-PCR analyses of total RNA from bladder body and urethral smooth muscles revealed only a slight difference in myosin heavy chain mRNA copy number per total RNA, whereas mRNA copy numbers for NH2-terminal isoforms SM-B (inserted) and SM-A (noninserted) in these muscles showed a significant difference (2.28 x 10(8) vs. 1.68 x 10(8) for SM-B and 0.12 x 10(8) vs. 0.42 x 10(8) for SM-A, respectively), which was also evident at the protein level. The ratio of COOH-terminal isoforms SM2:SM1 in the urethra was moderately but significantly lower than that in other regions of the bladder body. A high degree of LC20 phosphorylation and SM-B in the bladder body may help to facilitate fast cross-bridge cycling and force generation required for rapid emptying, whereas a lower level of LC20 phosphorylation and the presence of a higher amount of SM-A in urethral smooth muscle may help to maintain the high basal tone of urethra, required for urinary continence.

ROC optimization may improve risk stratification of prostate cancer patients

OBJECTIVES

Rational treatment decision requires accurate projection of the clinical course of a patient. Current methods in clinical outcome analysis mostly focus on population data. We investigated the applicability and optimization of the widely used actuarial method to project individual clinical outcomes.

METHODS

We designed and implemented a Clinical Outcome Prediction Expert (COPE) that performs, assesses, and optimizes actuarial prediction on individual cases. We analyzed a post-prostatectomy database, consisting of 1043 patients. Sixty percent of the database was used for training and 40% for validation. Stratified actuarial curves are used to project individual outcomes. The prostate-specific antigen (PSA) level, the Gleason score, and the clinical American Joint Commission on Cancer Staging T-stage before treatment were used as predictors. The area under the receiver operator characteristic (ROC) curve was used to measure predictive performance.

RESULTS

We obtained simple optimized stratification of pretreatment PSA level of 10 ng/mL or less, or more than 10 ng/mL; Gleason score of 6 or lower, or higher than 6; and clinical AJCC T-stage of T2a or lower, or higher. The optimized univariate risk scores were used to generate a multivariate score. After optimization, we found the higher risk group consisted of patients with PSA more than 10 ng/mL, or with PSA of 10 ng/mL or less and Gleason score higher than 6 and clinical AJCC T-stage higher than T2a. The optimized multivariate risk score has the highest ROC area of 0.77 among all predictors.

CONCLUSIONS

The best conditions to perform actuarial prediction on individual cases are not known a priori and require optimization. This study shows that ROC optimization simplifies risk stratification and may improve the accuracy of clinical outcome prediction.

Pharmacological agents for the treatment of urinary incontinence due to overactive bladder

Although the exact aetiology of overactive bladder is unknown to date, pharmacological therapy has been targeted to both the central and peripheral nervous systems. Potential CNS targets include GABA, opioid, serotonin (5-HT), dopamine and glutaminergic receptors as well as the alpha-adrenoceptors. Potential PNS targets include muscarinic receptors, calcium and potassium channels and alpha- and beta-adrenergic receptors. Since acetylcholine is the primary excitatory neurotransmitter involved in bladder (detrusor) contraction and emptying, anticholinergic agents are the primary compounds used clinically to decrease involuntary detrusor contractions. Anticholinergic therapy has a stabilising effect on the bladder (detrusor muscle); increases bladder capacity; decreases frequency of involuntary detrusor contractions; and delays the initial urge to void, but does not affect warning time. However, the clinical utility of antimuscarinic therapy is limited by the lack of receptor selectivity, resulting in the classic anticholinergic side effects of dry mouth, blurred vision, constipation and potentially, CNS effects such as somnolence and impaired cognitive function. These unwanted side effects often result in premature discontinuation of therapy and poor compliance. Previous attempts to develop uroselective alpha-adrenergic receptor antagonists have not been successful and although research continues, the hope that this class of agents would be viable alternatives to the anticholinergics remains to be proven in the clinical setting. The recent demise of several potassium channel openers does not augur well for the future of this class of agent. The reasons for the discontinuation of trials with these agents have not been fully elucidated, but one must assume that they were not uroselective and the cardiovascular side effects rendered them less than useful clinically. The serotonin re-uptake inhibitors appear to be promising novel therapeutic agents aimed at controlling bladder over-activity through specific CNS pathways. The sensory side of the micturition reflex is a potential therapeutic target. Agents to desensitise afferent nerve endings involved in C-fibre afferent reflexes include capsaicin and resiniferatoxin. Their clinical applicability is currently being evaluated. Finally, the recent findings related to the role of the P2X3 receptor in the sensory aspects of bladder filling have created new interest in the future development of agents that will improve the management of this prevalent and debilitating condition.

Treatments used in women with interstitial cystitis: the interstitial cystitis data base (ICDB) study experience. The Interstitial Cystitis Data Base Study Group

OBJECTIVES

To evaluate the frequency and types of treatments reported at baseline in women who entered the Interstitial Cystitis Data Base (ICDB) cohort study.

METHODS

From 1993 to 1997, 581 women were enrolled and followed in the ICDB. All treatments reported at study entry, including those prescribed for interstitial cystitis (IC) and concomitant medications, were reviewed. The number and types of treatments were evaluated with respect to baseline factors such as prior diagnosis of IC and symptom severity.

RESULTS

One hundred five (18%) women were receiving no therapy at baseline. Single-mode therapy was reported by 195 (34%) women, and a combination of two treatments was reported by 119 (21%) women. Three or more treatments were reported in 162 (28%) women. A total of 183 different types of therapies were recorded. The five most commonly used therapies for IC symptoms were cystoscopy and hydrodistention, amitriptyline, phenazopyridine, special diet, and intravesical heparin. Because most patients entered the ICDB before the approval of oral pentosan polysulfate sodium (PPS), only 6% of women reported oral PPS use at baseline. There were statistically significant associations between the number and types of treatments and clinical center, a prior diagnosis of IC, and symptom severity.

CONCLUSIONS

The diversity of IC therapies underscores the lack of understanding about the treatment of this syndrome. Further research in IC is essential to develop and to evaluate rational therapies and treatment algorithms. These algorithms should be "evidence based" and should be revised as the underlying etiology and pathophysiology of IC is delineated.

The glutathione S-transferase-mu and -theta genotypes in the etiology of prostate cancer: genotype-environment interactions with smoking

It has been reported that individuals who express GSTT1, the gene coding for the theta class of the glutathione S-transferases (GSTs), have an elevated risk of prostate cancer (CaP). This result is supported by studies that show glutathione conjugation of some xenobiotics by the GSTs can produce mutagenic intermediates. However, the potential role of environmental factors in modifying the risk of CaP conferred by GSTT1 is not known. We investigated whether there was an interaction between smoking and the non-deleted genotypes of the mu (GSTM1) and theta (GSTT1) GST genes using a clinic-based study of 276 CaP cases and 499 controls. We observed no main effect of smoking (odds ratio, 0.95; confidence interval, 0.69-1.29) or GSTM1 (odds ratio, 1.00; confidence interval, 0.73-1.36) with CaP, but did observe a statistically significant main effect of GSTT1 with CaP (odds ratio, 1.61; confidence interval, 1.14-2.28) as reported previously. No interaction between smoking and GSTM1 was observed. A significant increase in the probability of having CaP was observed in men who were both smokers and carried a non-deleted GSTT1 genotype compared with men who had neither or only one of these risk factors (P = 0.049). Approximately 30.9% of CaP cases in this study could be attributed to the smoking x GSTT1 interaction. Whereas the mechanism of this interaction is not known, it is plausible that the metabolism of carcinogenic intermediates or the response to chronic inflammation associated with smoking may be modulated by the GSTT1 genotype and may modify CaP risk.

Injected periurethral collagen for postprostatectomy urinary incontinence: MR and CT appearance

BACKGROUND

Urinary incontinence, a disturbing complication of radical prostatectomy, is often treated with periurethral collagen injections to increase urethral closure and resistance to urinary outflow.

METHODS

Using magnetic resonance imaging and computed tomography, we studied the appearance of glutaraldehyde cross-lined bovine collagen endoscopically injected into the periurethral tissues in four men who developed urinary incontinence after radical prostatectomy. Collagen was also scanned in vitro to verify its magnetic resonance appearance.

RESULTS

Collagen deposits appear as well-circumscribed nodules of low to intermediate signal intensity on both T1- and T2-weighted images in the periurethral tissues or in the base of the subjacent penile bulb (base of corpus spongiosum). On contrast-enhanced computed tomography, collagen appears as a hypoattenuating nodular-filling defect within the penile bulb.

CONCLUSION

These imaging characteristics should allow differentiation of collagen from locally recurrent prostate carcinoma and avoid inappropriate work-up of benign findings.

Lower urinary tract physiology and pharmacology

This review focuses on what we consider to be the most important findings of the last year relating to the smooth muscle of the lower urogenital system and the different levels of regulation that control its contraction and relaxation. One level is through modulation of the smooth muscle itself or its environment. Recent findings examining myosin isoform composition and collagen content as well as mechanisms that appear to be involved in inducing hyperplasia/hypertrophy of smooth muscle are described. Another method of regulation is via calcium-dependent phosphorylation of the regulatory light chain of myosin, which increases its activity. Interesting results indicating an uncoupling of force from calcium in the bladder are discussed. A third level of regulation is pharmacologic. Thus, the most recent findings related to receptor subtypes, including muscarinic, endothelin, alpha-adrenergic and nicotinic receptors, are presented. In addition, the effects of diabetes, incontinence, and partial bladder outlet obstruction on these modes of contractile regulation are also discussed.

Association of HPC2/ELAC2 genotypes and prostate cancer

HPC2/ELAC2 has been identified as a prostate cancer (CaP) susceptibility gene. Two common missense variants in HPC2/ELAC2 have been identified: a Ser-->Leu change at amino acid 217, and an Ala-->Thr change at amino acid 541. Tavtigian et al. reported that these variants were associated with CaP in a sample of men drawn from families with hereditary CaP. To confirm this report in a sample unselected for family history, we studied 359 incident CaP case subjects and 266 male control subjects that were frequency matched for age and race and were identified from a large health-system population. Among control subjects, the Thr541 frequency was 2.9%, and the Leu217 frequency was 31.6%, with no significant differences in frequency across racial groups. Thr541 was only observed in men who also carried Leu217. The probability of having CaP was increased in men who carried the Leu217/Thr541 variants (odds ratio = 2.37; 95% CI 1.06-5.29). This risk did not differ significantly by family history or race. Genotypes at HPC2/ELAC2 were estimated to cause 5% of CaP in the general population of inference. These results suggest that common variants at HPC2/ELAC2 are associated with CaP risk in a sample unselected for family history or other factors associated with CaP risk.

Noninvasive outcome measures of urinary incontinence and lower urinary tract symptoms: a multicenter study of micturition diary and pad tests

PURPOSE

We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms.

MATERIALS AND METHODS

We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lin's concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability.

RESULTS

Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance.

CONCLUSIONS

The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.

Erectile function and quality of life after interstitial radiation therapy for prostate cancer

Few studies have evaluated erectile function after interstitial radiation therapy for localized prostate cancer. Using a validated quality of life questionnaire, we assessed post-treatment erectile function and its relationship to treatment satisfaction and quality of life. We retrospectively reviewed the records of 171 consecutive patients who underwent Pd-103 or I-125 brachytherapy for prostate cancer between December 1992 and June 1998. Seventy percent of patients received neoadjuvant androgen deprivation therapy. All patients were mailed a validated questionnaire assessing sexual function and overall quality of life (UCLA Prostate Cancer Index and SF-36). Sixty-seven percent of all questionnaires were available for evaluation (114/171). The mean age was 69.1 y with a mean follow-up of 23 months (range 4-72, median 24). Seventy-one percent of patients (81/114) had pre-treatment erections sufficient for sustained vaginal penetration. Of these patients, potency was maintained in 49% of men (40/81). An additional 26% had erections firm enough for foreplay but not penetration (21/81). Erectile dysfunction rates were significantly lower in younger patients (48%) vs older patients (55%). There was no difference in post-treatment potency between men who received neoadjuvant hormonal therapy and those who did not (P>0.05). In addition, there were no differences in physical function (86, scale 0-100), general health perception (78), emotional well-being (83), energy/fatigue (74), and overall satisfaction (84) between men with erectile dysfunction and those without. In summary, two years following brachytherapy 25% of patients complained of complete (20/81) or partial (26%, 21/81) erectile dysfunction, for an overall rate of 51% (41/81). Short-term neoadjuvant hormonal therapy (<3-6 months) did not increase the likelihood of post-treatment erectile dysfunction. Interestingly, overall satisfaction rates among brachytherapy patients were high (84/100) and surprisingly did not correlate with post-treatment sexual function.

Improved contractility of obstructed bladders after Tadenan treatment is associated with reversal of altered myosin isoform expression

PURPOSE

Tadenan is a plant extract from Pygeum africanum used in the treatment of benign prostatic hyperplasia, to protect the bladder from contractile dysfunction induced by partial bladder outlet obstruction (BOO). The aim of the present study was to determine whether the Tadenan-induced return of detrusor contractility affects the expression of myosin isoforms, which differ at the C-terminal (SM1 and SM2) and the N-terminal regions (SM-A and SM-B).

MATERIALS AND METHODS

Four groups of New Zealand White rabbits (3 to 5 kg., 4 to 6 rabbits per group) were either partially obstructed by ligation of the urethra (groups 1 and 2) or not obstructed (groups 3 and 4). After 2 weeks, rabbits from groups 2 and 4 received Tadenan in peanut oil (vehicle) orally at 100 mg. /kg./day for 3 weeks and rabbits in groups 1 and 3 received vehicle only. Rabbits were sacrificed and bladders were removed and weighed. Contractility studies were performed on isolated strips of detrusor and the remaining muscular layer from the bladder body was used to study the expression of myosin heavy chain (MHC) isoforms at mRNA (SM1, SM2, SM-A, and SM-B) and the protein (SM1 and SM2) levels by RT-PCR and SDS-PAGE analyses, respectively.

RESULTS

Tadenan significantly reduced the effect of BOO on bladder mass. The diminished contractile response to field stimulation and carbachol secondary to urethral obstruction was significantly reversed by Tadenan treatment. The relative ratios for MHC isoforms were altered at the mRNA (SM2:SM1 and SM-A:SM-B) and protein (SM2:SM1) levels in obstruction. Upon treatment with Tadenan, the ratio of these isoforms returned to normal, as shown at the mRNA levels. In addition, the altered relative ratio of SM2:SM1 at the protein level also returned to nearly normal values after treatment.

CONCLUSIONS

Improvement of obstruction-induced contractile dysfunction of the detrusor following treatment with Tadenan is associated with changes in the expression of myosin isoforms. The alteration in the expression of myosin isoforms associated with obstruction-induced hypertrophy is reversed close to normal in the detrusor smooth muscle from Tadenan-treated obstructed rabbits.

Efficacy of sildenafil in erectile dysfunction after radical prostatectomy

Radical retropubic prostatectomy (RRP) is an important cause of iatrogenic erectile dysfunction (ED). While sildenafil has been widely used since its introduction as a new treatment option for ED, its efficacy in post-RRP patients has not been extensively studied. We retrospectively compared the efficacy of sildenafil in post-RRP and non-surgical patients with ED (NSED) using a subset of questions from the International Index of Erectile Function (IIEF) and correlated results with their specific etiology of ED based on penile blood flow study (PBFS). A brief questionnaire regarding satisfaction with sildenafil was administered to 72 consecutive post-RRP patients (nerve sparing status unknown) and 32 consecutive NSED patients who had previously undergone PBFS with pharmacotesting as part of their evaluation for ED. PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) < 25 cm/sec; venogenic (CVOD) for PSV > or = 35 cm/sec, mixed vascular for PV > 25 but < 35 cm/sec and resistive index (RI) < 0.9; a vascular normal diagnosis (neurogenic impotence) required excellent rigidity sustained for 20 min. Differences in the IIEF subscores for the different groups of patients were assessed. Success with sildenafil was defined as moderate or excellent improvement (3/4 or 4/4) with ability for penetration. No differences were found among the different subgroups of RRP patients with respect to IIEF scores or success rates with sildenafil. NSED patients had both significantly higher post-treatment IIEF scores (3.6/3.4 vs 2.5/2.2; t=4.50, P<0.0001) and success rates (63% vs 31%; t=3.11, P < 0.01) with sildenafil treatment than RRP patients. We found that sildenafil is significantly less effective in impotent RRP patients than in age-matched patients with ED (31% vs 63%). We had postulated that sildenafil would be least effective among RRP patients with excellent sustained rigidity to PGE1, as this subgroup is likely to have neurogenic impotence. We found that sildenafil response rates among subgroups of RRP patients were statistically similar regardless of PBFS diagnosis. IIEF scores for the RRP subgroups were similar but statistically lower than in men with ED and no history of RRP. While individuals with normal vascular responses to PGE1 have an increased likelihood of having neurogenic impotence, in RRP patients, we were unable to demonstrate any difference in efficacy of sildenafil, regardless of the PBFS diagnosis.

Association of SRD5A2 genotype and pathological characteristics of prostate tumors

The enzyme product of SRD5A2, 5alpha-reductase type II, is responsible for converting testosterone to the more metabolically active dihydrotestosterone. Therefore, SRDSA2 may be involved in the development or growth of prostate tumors. To examine the effects of allelic variants in the gene SRDSA2 on the presentation of prostate tumors, we studied a sample, primarily Caucasian, of 265 men with incident prostate cancer who were treated by radical prostatectomy. We assessed the relationship of the A49T and V89L polymorphisms at SRD5A2 with clinical and pathological tumor characteristics of these patients. We found no association of V89L genotypes with any of the characteristics studied. The presence of the A49T variant was associated with a greater frequency of extracapsular disease [odds ratio (OR), 3.16; 95% confidence interval (CI), 1.03-9.68] and a higher pathological tumor-lymph node-metastasis (pTNM) stage (OR, 3.11; 95% CI, 1.01-9.65). In addition, the A49T variant was overrepresented in two poor prognostic groups, which have been correlated with reduced rates of biochemical disease-free survival. One group included men with at least two of the following poor prognostic variables: (a) stage T3 tumor; (b) PSA level >10; and/or (c) Gleason score, 7-10 (OR, 3.46; 95% CI, 1.04-11.49). The second group included men with positive margins and high Gleason score (OR, 6.28; 95% CI, 1.05-37.73). Our results suggest that the A49T mutation may influence the pathological characteristics of prostate cancers and, thus, may affect the prognosis of these patients.

Angiomyolipoma of the renal sinus: diagnosis by percutaneous biopsy

We report a case of angiomyolipoma of the renal sinus discovered incidentally during an evaluation for microscopic hematuria. Diagnosis was confirmed by percutaneous aspiration biopsy performed with magnetic resonance imaging control allowing differentiation of this entity from other fatty tumors of the renal sinus including liposarcoma, lipoma, and sinus lipomatosis.

Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome

PURPOSE

We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment.

MATERIALS AND METHODS

The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily.

RESULTS

Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily.

CONCLUSIONS

Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.

Ventral hernia of the urinary bladder with mixed urinary incontinence: treatment with herniorrhaphy and allograft fascial sling

Abdominal hernias are not rare in women with urinary incontinence, but incisional bladder hernia is uncommon. The presenting symptoms in the rare cases reported included suprapubic discomfort, irritative voiding symptoms, and urinary incontinence. We present a patient with bladder herniation and severe mixed urinary incontinence. The pathophysiology of the urinary symptoms and the surgical alternatives for the correction of this condition are discussed.

Retrospective review of flow patterns following retropubic prostatectomy

AIM OF THIS STUDY

We retrospectively evaluated penile inflows in 103 previously potent individuals who underwent standard nerve sparing radical retropubic prostatectomy (RRP) for the treatment of prostate cancer. No effort to identify or spare the accessory pudendal artery (APA) was made in any case. Our goal was to investigate the role of the accessory internal pudendal artery (APA) in the maintenance of erections in this population. We hypothesize that if the APA is present in a significant number of men, and its ligation significantly contributes to post-RRP impotence, then there should be an increased incidence of asymmetry between R/L cavernous arterial flows among post RRP patients with vascular impotence.

MATERIALS AND METHODS

One hundred and three previously potent individuals complaining of persistent erectile dysfunction for at least six months after RRP were studied with color duplex Doppler, following age specific dosing of PGE1. Vascular assessment was performed before and after self-stimulation, measuring peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI). Erections were visually rated as inadequate (INA), adequate (ADE) for penetration, or excellent (EXC) with sustained rigidity for at least 20 min. Cavernous artery asymmetry (CAA) was defined as a >10 cm/s difference between right and left sided arterial flows.

RESULTS

Mean duration between surgery and Doppler study was 14.7 months. 27 out of 103 (26%) of patients developed excellent rigidity consistent with isolated neurogenic impotence (PSV=32.0 cm/s, mean RI=0.95); 24 out of 103 (23%) had adequate vascular responses making it impossible to infer presence or absences of neurogenic impotence; 52 out of 103 (51%) had inadequate rigidity consistent with vascular insufficiency (PSV=23.7 cm/s, mean RI=0.66). We noted that of patients with EXC response, 48% (13 out of 27) had CAA. Among patients with severe inflow disease (INA responders), CAA was seen in only 21% of cases (11 out of 52).

CONCLUSIONS

The incidence of APA has been reported as being from 4-70%, and its significance in the maintenance of erections has been questioned. Assuming that the APA provides significant inflow in some patients, we expected an increase in CAA in individuals in whom it was sacrificed. We found a higher incidence of CAA among post-RRP patients with normal vascular erectile responses to PGE1 (48%) compared to men with true vasculogenic impotence post-RRP (21%). These data do not support the importance of the APA in the maintenance of erections in the post-RRP patient.

Myosin light chain phosphorylation at resting level and the composition of myosin isoforms in the bladder body and urethra

Bladder filling depends upon the coordinated control of a storage chamber, the bladder body, and its outlet, the bladder base and urethra. Bladder emptying results from development of force in the bladder body and relaxation of the outlet. Muscle strips from bladder body reveal phasic characteristics, whereas the strips from urethral wall are tonic. To determine whether the compositions of myosin heavy chain (MHC) isoforms and the level of myosin light chain (MLC) phosphorylation contribute to the regional variation in the contractile states of the bladder smooth muscle, we analyzed the levels of MLC phosphorylation and the expression of myosin isoforms in smooth muscle tissues from different regions of the urinary bladder. Strips of bladder from the dome, mid body, base of the bladder and urethra were removed and analyzed for the levels of MLC phosphorylation at the resting tone. The expression of MHC isoforms that differ in the C-terminus (SM1 and SM2) and in the N-terminal region (SM-A and SM-B), formed by alternative splicing of the pre-mRNA at either the 3' end or the 5' end, respectively, was analyzed. The expression of these isoforms was characterized at the mRNA and protein levels using reverse transcriptase-polymerase chain reaction (RT-PCR), SDS-PAGE, and Western blotting. The levels of MLC phosphorylation were 35.5 +/- 4.6, 24.7 +/- 2.2, 13.6 +/- 2.1, and 12.8 +/- 2.7 for dome, mid bladder body, base and urethra respectively. Almost 100% of the MHC mRNA in the dome, mid bladder body, and base contains a 7-amino acid insert near the ATP-binding region, whereas the MHC in the urethral smooth muscle is only 81% inserted. Prior studies have shown that inserted myosin has a two-fold higher actin-activated ATPase activity compared to the myosin isoform that lacks the insert, and the maximum velocity of shortening of smooth muscle containing this insert is high compared to muscle that do not contain the insert. The expression of SM1 and SM2 were not significantly different. Our data suggests the presence of a high degree of inserted myosin and LC20 phosphorylation in the bladder dome and mid-body helps to facilitate rapid force development and emptying. Non-inserted myosin and the low level of MLC phosphorylation in the urethra may contribute to slowly or non-cycling myosin cross bridges and the maintenance of a tonic or contracted state during bladder filling.

Neoadjuvant androgen deprivation prior to transperineal prostate brachytherapy: smaller volumes, less morbidity

PURPOSE

Prostate brachytherapy is becoming increasingly utilized in the definitive treatment of men with early-stage prostate cancer. Others have reported a close relation between total dose to the gland and genitourinary and gastrointestinal toxicity. We tested the hypothesis that 3 months of hormone deprivation would decrease gland size and decrease radioactivity implanted, which would result in less morbidity. Here, we report the toxicity associated with this novel treatment strategy.

METHODS

One hundred fifty-five prostate cancer patients underwent ultrasound-guided transperineal implantation of palladium-103 at the Hospital of the University of Pennsylvania between January 1994 and July 1998. All men received at least 3 months of neoadjuvant luteinizing hormone-releasing hormone (LHRH) agonist therapy and were registered in the study. This group of men were compared with 55 men treated at the Hospital of the University of Pennsylvania with brachytherapy alone between December 1991 and December 1993.

RESULTS

Compared with men treated with implant alone, men who received LHRH agonist therapy had significantly smaller glands at the time of implant (27.7 cm3 vs 36.3 cm3), required fewer seeds (47.9 vs 83.2), and had significantly less radioactivity implanted (76.3 mCi vs 117 mCi). The genitourinary and gastrointestinal morbidity in the men receiving hormone deprivation was minimal, with long-term side effects occurring in only three patients. In addition, potency was preserved in 83% of men.

DISCUSSION

Three months or more of neoadjuvant LHRH agonist therapy before transperineal brachytherapy is safe, significantly reduces the amount of radioactivity implanted, and is associated with very low rates of genitourinary and gastrointestinal toxicity. In addition, potency preservation after combined-modality therapy is excellent and is similar to that of implantation alone. Further studies of this treatment approach are warranted.

Metabolic basis for contractile dysfunction following chronic partial bladder outlet obstruction in rabbits

Prior studies have shown that partial outlet obstruction of the rabbit bladder causes a progressive increase in bladder mass, a progressive decrease in the contractile response to different forms of stimulation, and a selective decrease in the activity of mitochondrial enzymes. In this investigation the contractile responses to field stimulation and bethanechol were directly correlated with the activity of citrate synthase as a function of both the duration of obstruction and the bladder mass. Partial bladder outlet obstruction was surgically induced in twenty New Zealand White rabbits. The bladders were then rapidly excised at 30, 40, 90, 105 or 150 days post obstruction. The contractile responses to field stimulation (32 Hz) and bethanechol (250 microM) were determined. The remainder of the bladders were frozen and used for citrate synthase activity determinations. The data were grouped for analysis both by the duration of obstruction and by the bladder mass. Chronic partial outlet obstruction caused a parallel decline in the activity of citrate synthase and in the response of the obstructed tissue to stimulation.