The Asia-Pacific AMS800 artificial urinary sphincter consensus statement

This Asia-Pacific (AP) AMS 800™ artificial urinary sphincter (AUS) consensus statement aims to provide a set of practical recommendations to assist surgeons with the AMS 800 device surgery. The AP consensus committee consisted of key opinion leaders with extensive experience with AMS 800 surgery across several AP countries. The panel reviewed and discussed relevant findings with emphasis on locoregional and specific clinical challenges relevant to the AP region. Recommendations were made in key areas namely (1) patient selection and informed consent process; (2) preoperative assessment; (3) dealing with co-existing urological disorders; (4) surgical principles and intraoperative troubleshooting; (5) postoperative care; (6) special populations; and (7) cost analysis and comparative review. The AMS 800 device should be offered to males with moderate to severe stress urinary incontinence (SUI). Full informed consent should be undertaken, and emphasis is placed on surgical contraindications and high-risk candidates. The presence of a surgical mentor or referral to experts is recommended in complex AUS candidates. Preoperative cystoscopy with or without multichannel urodynamic study is necessary and patients with pre-existing urological disorders should be treated adequately and clinically stable before surgery. Adherence to strict patient selection and safe surgical principles are critical to ensure excellent clinical outcomes and minimize complications. Given that InhibiZone-coated device is not available in many AP countries, the use of prophylactic antibiotics pre-and post-operatively are recommended. The AMS 800 device should be prepared according to the manufacturer's guidelines and remains a cost-effective treatment for male SUI. The AMS 800 device remains the surgical benchmark for male SUI but is associated with certain mechanical limitations and a unique set of complications.

Effectiveness of antimuscarinics and a beta-3 adrenoceptor agonist in patients with overactive bladder in a real-world setting

Both antimuscarinics and beta-3 adrenoceptor agonists are generally used as first-line pharmacotherapy for overactive bladder (OAB). This study aimed to investigate the differences in clinical characteristics and manifestations between different medication groups using real-world data. In this retrospective study, we recruited all patients aged > 18 years diagnosed with OAB at our institute from March 2010 to December 2017. They were allocated into three groups, the antimuscarinics (group A), beta-3 adrenoceptor agonist (group B), and discontinued (group C) treatment groups, and they completed OAB symptom score and quality of life questionnaires before and after treatment. In addition, the Clinical Global Impression was recorded for treatment outcomes. A premedication urodynamic study was also applied. A total of 215 patients were analyzed (group A: 43, B: 35, C: 137). Group B was significantly older (mean age 77.4 years) than group A (69.2 years, p = 0.012) and group C (68.6 years, p = 0.001). However, there were no significant differences in sex or underlying diseases among the groups. Before treatment, there were no significant differences in the questionnaire results among all groups. The cystometric capacity of group A (mean ± SD, 257.3 ± 135.1 cm³) was significantly larger than that of group B (125.8 ± 46.0 cm³, p = 0.002) and group C (170.5 ± 99.2 cm³, p = 0.001). After treatment, there were no significant differences between group A and group B in any of the questionnaire scores; however, their scores were better than those of group C. The OAB patients who adhered to antimuscarinics tended to be younger and have larger cystometric bladder capacity in the urodynamic study. However, there were no significant differences in effectiveness between the patients who took antimuscarinics and those who took a beta-3 adrenoceptor agonist.

Role of urodynamics in management of urethral diverticulum in females

BACKGROUND

Few studies have focused on the urodynamic findings of urethral diverticula (UD). We characterized the symptoms and urodynamic findings in women with UD.

METHODS

A retrospective review of all women in a single center having surgical treatment for symptomatic UD between May 2004 and September 2014 was done. Lower urinary tract symptoms were evaluated with International Prostate Symptom Score and Overactive Bladder Symptom Score questionnaires. All patients underwent magnetic resonance imaging and videourodynamic study (VUDS) prior to surgery, and postoperative evaluation with VUDS.

RESULTS

A total of 20 female patients were enrolled into the study. 12 (60%) UD patients presented with symptoms of stress urinary incontinence (SUI). However, there were merely 3 (15%) patients diagnosed as urodynamic SUI. 15 (75%) patients exhibited low catheter-free uroflow. Detrusor overactivity was demonstrated in 4 (20%) patients. Bladder outlet obstruction (BOO) was diagnosed in 8 (40%) cases. Postoperative VUDS revealed persistent BOO in 50% of patients with preoperative BOO. Of these, residual diverticulum was noted by VUDS in one patient.

CONCLUSION

For UD patients with urinary incontinence or voiding dysfunction, VUDS is helpful in accurately characterizing these symptoms.

Activation of the mTOR dependent signaling pathway underlies ketamine-induced uropathy

AIMS

To investigate the pathogenic role of activation of the mammalian target of the rapamycin (mTOR) in the ketamine induced microvascular injury.

METHODS

Twenty-three patients with ketamine-induced cystitis (KC) and 16 control volunteers were recruited. Bladder tissues were obtained from both groups by cystoscopic biopsies. Phospho-S6 ribosomal protein (p-S6RP), an end product of the mTOR pathway, was stained in the urinary bladder from both groups. Endothelial cells of the urinary bladder (HBdMECs) were examined to investigate the in vitro activation of the mTOR pathway and the co-expression of the endothelial marker (cluster of differentiation 31 [CD31]) and the mesenchymal marker (fibroblast-specific protein 1 [FSP-1]).

RESULTS

Expression of p-S6RP increased significantly after ketamine exposure, especially in the vesical microvessels of KC patients. In HBdMECs treated with 100 µM Ketamine, time-dependent activation of the mTOR pathway occurred, with significantly increased levels of the phosphorylated forms of mTOR at 30 min and of S6RP and p70S6 kinase (p70S6K) at 6 h. The increased level of p-S6RP returned to baseline within 2 days after ketamine exposure. The co-expression of CD31 and FSP-1 implied that EndMT was present in HBdMECs at 7 days after ketamine treatment, while TGF-β1 facilitated significant up-regulation of FSP-1 at 1 day after treatment. Furthermore, when the mTOR inhibitor rapamycin was administered with ketamine to the HBdMECs, the expression of FSP-1 decreased significantly.

CONCLUSIONS

Ketamine induces activation of the mTOR pathway and subsequent mesenchymal phenotypic expression (FSP1) in HBdMECs.

Patients with Urinary Incontinence Appear More Likely to Develop Upper Urinary Tract Stones: A Nationwide, Population-Based Study with 8-Year Follow-Up

This study aimed to investigate associations between primary urinary incontinence and development of upper urinary tract stones in a nationwide population in Taiwan. Data of 1,777 adults with primary urinary incontinence and 26,655 controls (groups A, B, and C) without urinary incontinence at study inception were retrieved from the National Health Insurance System database in Taiwan and were analyzed retrospectively. No enrolled subjects had previous diagnosis of upper urinary tract stones or spinal cord injury. All subjects were followed through end of 2009, with a minimum follow-up of 8 years. A greater percentage of study subjects (334/1777, 18.8%) developed upper urinary tract stones than that of control groups A (865/8885, 9.7%) and B (888/8885, 10%), and C (930/8885, 10.5%) (all p-values < 0.0001). Urinary incontinence was associated with significantly increased risk of developing urinary tract stones (HR 1.99, 95% CI, 1.70-2.34, p < 0.001). Age and metabolic syndrome status were both associated with developing upper urinary tract stones (both p-values < 0.0001). After adjusting for metabolic syndrome, regression analysis showed that urinary incontinence was still associated with a significantly increased risk of developing upper urinary tract stones (HR 1.99, 95% CI = 1.76-2.26, p < 0.0001). Long-term follow-up of Taiwanese patients with primary urinary incontinence suggests that urinary incontinence is associated with a significantly increased risk of developing upper urinary tract stones. Study findings suggest that physicians treating patients with urinary incontinence should give attention to early detection of upper urinary tract stones.

Microvascular Injury in Ketamine-Induced Bladder Dysfunction

The pathogenesis of ketamine-induced cystitis (KC) remains unclear. In this study, bladder microvascular injury was investigated as a possible contributing mechanism. A total of 36 KC patients with exposure to ketamine for more than 6 months, and 9 control subjects, were prospectively recruited. All participants completed questionnaires, including the O'Leary-Sant interstitial cystitis symptom index (ICSI) and the interstitial cystitis problem index (ICPI). All KC patients received a urodynamic study and radiological exams. Bladder tissues were obtained from cystoscopic biopsies in the control group and after hydrodistention in the KC group. Double-immunofluorescence staining of N-methyl-d-aspartate receptor subunit 1 (NMDAR1) and the endothelial marker, cluster of differentiation 31 (CD31), was performed to reveal the existence of NMDAR1 on the endothelium. Electron microscopy (EM) was applied to assess the microvascular change in the urinary bladder and to measure the thickening of the basement membrane (BM). A proximity ligation assay (PLA) was used to quantify the co-localization of the endothelial CD31 receptor and the mesenchymal marker [fibroblast-specific protein 1 (FSP-1)]. The Mann-Whitney U test and Spearman's correlation coefficient were used for statistical analysis. The mean ICSI [14.38 (± 4.16)] and ICPI [12.67 (± 3.54)] scores of the KC group were significantly higher than those (0 and 0, respectively) of the control group (both p < 0.001). The KC patients had decreasing cystometric bladder capacity (CBC) with a mean volume of 65.38 (± 48.67) mL. NMDAR1 was expressed on endothelial cells in both groups under immunofluorescence staining. Moreover, KC patients had significant BM duplication of microvessels in the mucosa of the urinary bladder under EM. The co-expression of the endothelial marker CD31 and mesenchymal marker FSP1 was significantly stained and calculated under PLA. In conclusion, microvascular injury and mesenchymal phenotypic alteration of endothelial cells can potentially contribute to KC-induced bladder dysfunction.

Efficacy, Safety and Tolerability of Fesoterodine in Asian Patients with Overactive Bladder

OBJECTIVES

To assess the efficacy, safety, and tolerability of fesoterodine 4 and 8 mg once daily (QD) compared with placebo in Asian subjects with overactive bladder (OAB) after 12 weeks of treatment.

METHODS

This phase II, dose-finding study consisted of a 2-week placebo run-in period followed by a 12-week, randomized, double-blind, placebo-controlled, treatment period. Eligible subjects were aged ≥20 years with ≥8 micturitions per 24 h and ≥1 urgency urinary incontinence (UUI) episodes per 24 h reported in a 3-day diary. The subjects were randomized to receive placebo, fesoterodine 4 mg, or fesoterodine 8 mg QD for 12 weeks.

RESULTS

Of 1232 subjects who entered the placebo run-in period, 951 received double-blind treatment. The mean number of UUI episodes per 24 h at baseline was 2.2 among the three treatment groups. The two fesoterodine groups showed statistically significant decreases from baseline in the mean number of UUI episodes per 24 h at week 12 (primary endpoint) compared with placebo. Most all-causality adverse events (e.g. dry mouth and constipation) were mild or moderate. The percentage of subjects with severe adverse events was low and similar among the treatment groups (placebo, 1.3%; fesoterodine 4 mg, 1.9%; fesoterodine 8 mg, 1.0%).

CONCLUSION

Fesoterodine 4 and 8 mg QD were significantly better than placebo in improving OAB symptoms. Overall, the two fesoterodine dosing regimens were well tolerated. These results suggest that fesoterodine 4 and 8 mg QD are effective and well-tolerated treatments for OAB in Asian subjects.

Enhanced antioxidant capacity of dental pulp-derived iPSC-differentiated hepatocytes and liver regeneration by injectable HGF-releasing hydrogel in fulminant hepatic failure

Acute hepatic failure (AHF) is a severe liver injury leading to sustained damage and complications. Induced pluripotent stem cells (iPSCs) may be an alternative option for the treatment of AHF. In this study, we reprogrammed human dental pulp-derived fibroblasts into iPSCs, which exhibited pluripotency and the capacity to differentiate into tridermal lineages, including hepatocyte-like cells (iPSC-Heps). These iPSC-Heps resembled human embryonic stem cell-derived hepatocyte-like cells in gene signature and hepatic markers/functions. To improve iPSC-Heps engraftment, we next developed an injectable carboxymethyl-hexanoyl chitosan hydrogel (CHC) with sustained hepatocyte growth factor (HGF) release (HGF-CHC) and investigated the hepatoprotective activity of HGF-CHC-delivered iPSC-Heps in vitro and in an immunocompromised AHF mouse model induced by thioacetamide (TAA). Intrahepatic delivery of HGF-CHC-iPSC-Heps reduced the TAA-induced hepatic necrotic area and rescued liver function and recipient viability. Compared with PBS-delivered iPSC-Heps, the HGF-CHC-delivered iPSC-Heps exhibited higher antioxidant and antiapoptotic activities that reduced hepatic necrotic area. Importantly, these HGF-CHC-mediated responses could be abolished by administering anti-HGF neutralizing antibodies. In conclusion, our findings demonstrated that HGF mediated the enhancement of iPSC-Hep antioxidant/antiapoptotic capacities and hepatoprotection and that HGF-CHC is as an excellent vehicle for iPSC-Hep engraftment in iPSC-based therapy against AHF.

Bladder outlet obstruction due to labial agglutination

Here, we report the case of a 63-year-old female patient who presented with emptying symptoms and was subsequently diagnosed with delayed labial agglutination. The adhered labia minora were divided by blunt dissection, and a topical estrogen ointment was applied after surgery. The patient's voiding symptoms were completely resolved and no recurrence of labial agglutination was noted 3 months after surgery. Labial agglutination is rare but often manifests with nonspecific emptying symptoms. Nevertheless, it can be easily diagnosed on physical examination and successfully treated by surgical intervention and the application of a local estrogen ointment. We present this rare case in order to emphasize the importance of physical examination.

Non-inferiority of silodosin to tamsulosin in treating patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH)

What's known on the subject? and What does the study add? Silodosin administered by 4 mg twice daily is as effective as tamsulosin 0.2 mg daily in treating patients with LUTS associated with BPH. Relative to tamsulosin, silodosin has less cardiovascular side effects as judged by the minimal changes of blood pressure and pulse rats after treatment.

OBJECTIVE

• To test the hypothesis that the efficacy of silodosin would not be inferior to tamsulosin in treating patients with lower urinary tract symptoms associated with benign prostate hyperplasia (BPH).

PATIENTS AND METHODS

• At nine medical centres, 209 patients with an International Prostate Symptom Score (IPSS) of ≥13 were randomized to silodosin (4 mg twice daily) or tamsulosin (0.2 mg once daily) for 12 weeks. • The primary efficacy measure was the mean change from baseline to endpoint in IPSS. • The non-inferiority margin of the IPSS change was set at 1.0. • Secondary efficacy measures included change in maximal urinary flow rate (Q(max)) and health-related quality of life (HRQL) score.

RESULTS

• Of the 170 (81.3%) patients who completed the study, 86.2% in the silodosin group vs 81.9% in the tamsulosin group achieved a ≥25% decrease in IPSS (P= 0.53). • The mean difference (silodosin minus tamsulosin) in IPSS change from baseline was -0.60 (95% confidence interval -2.15, 0.95), inferring the non-inferiority of silodosin to tamsulosin. • The mean changes in the Q(max) and HRQL score from baseline were comparable between the groups (both, P > 0.05). Although patients receiving silodosin had a significantly higher incidence of abnormal ejaculation (9.7% vs tamsulosin 1.0%, P= 0.009), only 1.9% discontinued treatment. • Tamsulosin treatment resulted in a significant reduction in mean systolic blood pressure (-4.2 mmHg, within-group P= 0.004) relative to the negligible change of silodosin (-0.1 mmHg, within-group P= 0.96)

CONCLUSION

• The trial shows the non-inferiority of silodosin 4 mg twice daily to tamsulosin 0.2 mg once daily in patients with symptoms of BPH.

Evaluation of prostate volume by transabdominal ultrasonography with modified ellipsoid formula at different stages of benign prostatic hyperplasia

The aim of the study was to propose an eccentricity parameter (EP)-based correction to the ellipsoid formula to improve the evaluation of the prostate volume defined by transabdominal ultrasonography (TAUS) at different stages of benign prostatic hyperplasia (BPH). All 202 adult male volunteers underwent the prostate volume evaluations with TAUS and computerized tomography (CT). Based on the EP index, three clearly different stages of BPH were also deduced by analytical analysis. By applying the correction formula, the mean prostate volume differences of TAUS with CT were improved from 28.1%, -25.4% and -0.6% to 7.6%, -3.5% and -0.6% for EP < 0.055, 0.055 < EP < 0.14 and EP > 0.14, respectively. Hence, for EP > 0.14, representing the advanced stage of BPH, TAUS with the ellipsoid formula can be regarded as an effective tool for computing volume, whereas for EP < 0.14, the correction formula is recommended to improve the volume estimation based on TAUS.

Duloxetine versus placebo for the treatment of women with stress predominant urinary incontinence in Taiwan: a double-blind, randomized, placebo-controlled trial

BACKGROUND

This manuscript compares the efficacy and safety of duloxetine with placebo in Taiwanese women with SUI.

METHODS

Taiwanese women with SUI were were randomly assigned to placebo (n = 61) or duloxetine 80 mg/day (n = 60) in this double-blind, 8-week, placebo-controlled study. Outcome variables included: incontinence episode frequency (IEF), Incontinence Quality of Life questionnaire (I-QOL) scores, and Patient Global Impression of Improvement rating (PGI-I).

RESULTS

Decrease in IEF was significantly greater in duloxetine-treated than placebo-treated women (69.98% vs 42.56%, P < .001). No treatment differences in I-QOL scores were significant. There were significant differences in PGI-I rating. Treatment-emergent adverse events (TEAEs) were experienced by more duloxetine-treated than placebo-treated women (80.0% vs 44.3%; P < .001). Discontinuations due to adverse events were significantly greater for duloxetine-treated than placebo-treated women (26.7% vs 6.6%; P = .003).

CONCLUSION

Data provide evidence for the safety and efficacy of duloxetine for the treatment for Taiwanese women with SUI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00475358.

Urgency is the Core Symptom of Female Overactive Bladder Syndrome, as Demonstrated by a Statistical Analysis

PURPOSE

We determined overactive bladder symptoms in combination with other lower urinary tract symptoms and illustrated their relationships using a statistical analysis. Furthermore, we also describe the potential contributory factors and adaptation strategies in patients that are associated with overactive bladder subtypes.

MATERIALS AND METHODS

A total of 1,930 women with a mean age +/- SD of 46 +/- 15 years (range 15 to 91) with troubling lower urinary tract symptoms were successfully interviewed with a validated questionnaire at the urology and urogynecology clinics at 14 medical centers in Taiwan. The questionnaire was constructed to evaluate 6 lower urinary tract symptoms and 7 adaptation strategies. A log linear statistical model and multiple logistic regression analysis were used to assess the associations among lower urinary tract symptoms and the potential overactive bladder contributory factors, respectively.

RESULTS

No single or isolated symptom presented in patients with overactive bladder. Most patients reported a combination with other lower urinary tract symptoms. These female patients can be categorized into 3 groups, including 1 is associated with dry symptoms (urgency, frequency and nocturia), 1 associated with wet symptoms (urgency, urge incontinence and mixed stress incontinence) and a small group that may have overactive bladder symptoms combined with voiding difficulty symptoms. in contrast to patients with dry overactive bladder (urgency associated with frequency and/or nocturia without urge incontinence), after multiple logistic regression analysis patients with wet overactive bladder (urgency with urge incontinence) had a greater average age and higher body mass index, and made more adaptation efforts (p <0.05).

CONCLUSIONS

We used statistical analysis to determine and suggest that urgency is the core symptom of female overactive bladder syndrome and there are 3 distinctive overactive bladder subtypes, which differ in their symptom combinations. Different symptom combinations and patient characteristics affect female adaptation to overactive bladder syndrome.

Hardness evaluation of penile prostheses

AIM

This work investigates the hardness and buckling force of penile prostheses to further understand the rigidity of penile prostheses before and after implantation.

METHODS

Evaluated herein are four prosthetic samples (three inflatable, one semi-rigid), five real prostheses (one inflatable, four semi-rigid), and one prosthesis after implantation. The hardness is measured with a Shore Durimeter by pressing the tester's indentor to the surface of the specimen. A volunteer with inflatable prosthesis implantation is evaluated with respect to penile hardness versus various numbers of pumping. The buckling force of the prosthesis is also determined by a push-pull gauge and a specially designed sampling table.

RESULTS

Results in this study demonstrate that although the inflatable prosthesis could only be pumped to a certain amount of hardness, hardness and buckling force correlate well with each other. After reaching the hardness limit, prostheses can even be pumped a further few times. However, continuous pumping only puts more tension on the prosthetic material without increasing hardness and could induce mechanical failure of the prosthesis. Results also indicate that the buckling force decreases with increasing length of the semirigid prostheses, and increases when the prosthesis has a larger diameter.

CONCLUSION

This mechanical measurement of rigidity in penile prostheses could provide more information to clinicians about the penile prosthesis before surgical implantation, and to patients about prosthesis usage after implantation.

Transurethral prostatic resection for acute urinary retention in patients with prostate cancer

BACKGROUND

Few studies have focused on clinical findings in prostate cancer patients receiving transurethral resection of the prostate (TURP) for acute urinary retention (AUR). We compared the clinical findings (preoperative characteristics, operative morbidities, and pathology results) of patients with diagnosed prostate cancer undergoing palliative TURP for AUR with those of patients undergoing TURP for AUR who were diagnosed with prostate cancer postoperatively.

METHODS

The charts of 25 patients with prostate cancer undergoing TURP for AUR between 1986 and 2003 were retrospectively reviewed. Fourteen patients underwent palliative TURP (group A) and the other 11 patients with newly diagnosed prostate cancer received TURP (group B). The data, including preoperative characteristics, operative morbidities, and pathology results were analyzed.

RESULTS

There were no significant differences between the 2 groups in parameters such as age at diagnosis and operation, operative time, hospitalization, and catheter duration. However, the Gleason score was higher in group A (7.6 +/- 1.7) than in group B (5.4 +/- 1.8) (p < 0.005). The mean resected weight was lower in group A (19.9 g) than in group B (39.5 g). Group A was more likely to receive recatheterization (33.3% vs 0%, p = 0.058) and repeat operation (28.6%), although the difference was not statistically significant. There were no complications such as transurethral resection syndrome or perioperative death in either group.

CONCLUSION

TURP can be performed safely for relief of AUR in patients with prostate cancer, no matter if the cancer was diagnosed before or after surgery. The higher Gleason score and more advanced cancer stage, as found in group A, may correlate to high recatheterization and reoperation rates due to preexisting tumor progression.

Primary urothelial carcinoma of the ureter: 11-year experience in Taipei Veterans General Hospital

BACKGROUND

Urothelial carcinoma of the upper urinary tract is relatively rare, occurring in 5% of all urothelial tumors. Ureteral urothelial carcinoma is even less common than that of the renal pelvis, accounting for about 25% of all upper urinary tract tumors. The aim of this study was to evaluate the clinical behavior, survival, recurrence and prognostic information of primary ureteral urothelial carcinoma from our 11 years of experience at the Taipei Veterans General Hospital.

METHODS

We retrospectively reviewed 111 patients with ureteral urothelial carcinoma who had been treated in our hospital between January 1993 and December 2003. Tumor staging was according to the 2002 AJCC TNM classification and stage groupings. Patients with stage Oa and stage Ois were categorized as stage Oa/is, and patients with pathologic T stage pTa and pTis were categorized as pTa/is for statistical analysis. The Kaplan-Meier method was used for survival analysis.

RESULTS

There were 69 males and 42 females, with a mean age of 70.5 +/- 9.4 years at diagnosis. Of the 111 patients, 5 presented with stage Oa/is, 38 with stage I, 23 with stage II, 21 with stage III, and 24 with stage IV. Nephroureterectomy with bladder cuff excision was performed in 78 patients, 12 patients received segmental resection of the ureter, 4 received ureteroscopic laser coagulation, and 17 underwent chemotherapy or radiotherapy or both. Tumors were located on the left side in 53 patients, on the right in 53, and bilaterally in 5. The most frequent initial presenting symptom was gross hematuria (65%). The mean postoperative follow-up period was 49.3 months. Disease recurrence in the nephroureterectomy group occurred in 36 patients (46.2%), with 17 (21.8%) at the urinary bladder, 2 (2.6%) at the retroperitoneum, 1 (1.3%) at the contralateral ureter, 6 (7.7%) with distant metastases to the lung, bone, distant lymph nodes or liver, and 10 (12.8%) at multiple sites. The 5-year cancer-specific survival rate was 100% for pTa/is, 95.2% for pT1, 69.4% for pT2, and 43.8% for pT3. All 3 pT4 cases died of cancer in a median of 12 months. Significant prognostic factors for cancer-specific survival by univariate analysis were pT (p = 0.00001), stage (p = 0.00001), type of treatment (p = 0.00001) and grade (p = 0.0001). On multivariate analysis, only stage (p = 0.0001) and grade (p = 0.014) were significant for cancer-specific and overall survival. Stage (p = 0.0001), pT (p =0.0001) and grade (p = 0.026) were also significant prognostic factors of recurrence in multivariate analysis.

CONCLUSION

Our experience showed that patients with pTa/is and pT1 tumors treated with radical surgery have excellent prognoses. Tumor stage and grade are the only significant prognostic factors for both cancer-specific and overall survival.

Detrusor mitochondrial lipid peroxidation and superoxide dismutase activity in partial bladder outlet obstruction of rabbits

OBJECTIVES

Bladder outlet obstruction has shown to damage detrusor mitochondria with impaired detrusor contractility. One likely cause for mitochondrial injury is reactive oxygen species (ROS)-induced damages, including lipid peroxidation injury. We designed this study to examine this hypothesis.

MATERIALS AND METHODS

Placing a silicon ring around the bladder neck of male New Zealand rabbits induced bladder outlet obstruction. The bladders were removed 3 (N = 6), 7 (N = 6), and 14 days (N = 8) later. Sham operated animals (N = 6 for each time period) served as the controls. Contractile function of the bladder was assessed by the response of the detrusor strips to bethanechol and field stimulation. Detrusor mitochondrial superoxide dismutase (SOD) activity and mitochondrial content of malondialdehyde (MDA) were determined. Detrusor contents of phosphocreatine and adenine triphosphate (ATP) were assayed.

RESULTS

(1) Outlet obstruction induced an increase in the bladder weight and a decrease in the contractile function; (2) mitochondrial SOD activity significantly elevated in every time period of the obstruction, indicating a persistently increased ROS generation; (3) detrusor MDA level increased in 3-day obstruction animals. It returned to the control level in 7- and 14-day groups; (4) phosphocreatine content was significantly reduced in every time period of the obstruction; (5) ATP content was significantly decreased in 3- and 7-day groups; while 14-day obstruction group contained similar level as the sham-operated group.

CONCLUSIONS

This study shows that bladder outlet obstruction increases generation of ROS and enhances lipid peroxidation of detrusor mitochondria. The resulted mitochondrial damages might sustain, leading to persistently depressed energy production and impaired detrusor contractility.

Nocturnal enuresis in older adults

BACKGROUND

Nocturnal enuresis is uncommon in older adults. The paucity of literature about this problem prompts us to review our cases to determine the management strategy.

METHODS

Six older adults, including 2 females and 4 males, were evaluated for refractory nocturnal enuresis. Only 2 of them had minor daytime urge symptom. Most of them had failed in the treatment using anticholinergics and/or alpha-adrenergic blocker. Evaluation consisted of detailed medical history, voiding diary, and urodynamic studies. Clinical follow-up persisted for 12 months. We define nocturnal polyuria as nighttime urine amount being more than 35% of total daily urine amount. Bladder outlet obstruction in men was diagnosed based on the definition described by International Continence Society.

RESULTS

The average age was 71 years (range 61-84). The average duration of the symptom was 3.1 months (range 0.5-6). Two patients had bladder outlet obstruction. Four patients used hypnotics for insomnia, which might result in difficult awakening on bladder distension. Nocturnal polyuria was found in 3 patients. Most patients had multiple factors contributing to their nocturnal enuresis except 1, who was found to have an enlarged prostate with chronic bladder distension. Specific treatments were given based on the causes for each patient. Hypnotics were discontinued for a certain meanwhile in some patients. Nocturnal polyuria was managed with afternoon diuretic or bedtime desmopressin. Bedtime anticholinergic agent was used in patients with detrusor overactivity. The patient with enlarged prostate and urinary retention was managed with indwelling catheter followed by elective transurethral prostatectomy. All patients were dry in the night following the treatment.

CONCLUSIONS

Nocturnal enuresis in older adult is usually multi-factorial. Hypnotic usage and nocturnal polyuria are frequently overlooked. Detailed investigation is necessary to identify the causes. Tailored treatment may achieve satisfactory results.

The correlation between pretreatment serum hormone levels and treatment outcome for patients with prostatic cancer and bony metastasis

OBJECTIVE

To evaluate whether pretreatment serum hormone levels are a prognostic factor for prostatic cancer with bony metastasis under hormonal treatment.

PATIENTS AND METHODS

Between 1980 and 1994, 96 patients with prostate cancer and bony metastasis were included for an evaluation by a retrospective review of their charts. All 96 had received hormonal treatment after a diagnosis of metastatic prostatic carcinoma. Serum testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin were assessed before treatment. The patients were divided into two groups according to their response during the follow-up. Group 1 (good response) had no change or resolution of metastatic lesion(s) on the bone scan and a declining prostate-specific antigen (PSA) level. Group 2 had increased PSA or progression of metastatic lesion(s) on the bone scan. Tumours were graded as low (2-4), intermediate (5-7) and high (8-10) using the Gleason score.

RESULTS

There were 43 patients in group 1 and 53 in group 2; the overall mean (sd) age was 72.5 (6.8) years and the follow-up 29.5 (0.5) months. The respective mean (sd) levels of testosterone, LH, FSH and prolactin before treatment were 4.6 (1.6) ng/mL, 20.2 (13.3) mIU/mL, 19.6 (18.6) mIU/mL and 20.7 (12.1) ng/mL in group 1, and 2.6 (1.0) ng/mL, 27.3 (11.0) mIU/mL, 27.1 (9.8) mIU/mL and 41.3 (28.4) ng/mL in group 2. The level of testosterone was significantly higher in group 1 than in group 2, while LH, FSH and prolactin were significantly lower in group 1 than in group 2. When stratified by tumour grade, patients in group 1 still had significantly higher pretreatment testosterone and lower LH, FSH and prolactin than those in group 2.

CONCLUSION

Higher testosterone and lower LH, FSH and prolactin levels were good prognostic factors for patients with metastatic prostatic cancer under hormonal treatment, irrespective of tumour grading.