Multi-ancestry genome-wide association study of kidney cancer identifies 63 susceptibility regions

Here, in a multi-ancestry genome-wide association study meta-analysis of kidney cancer (29,020 cases and 835,670 controls), we identified 63 susceptibility regions (50 novel) containing 108 independent risk loci. In analyses stratified by subtype, 52 regions (78 loci) were associated with clear cell renal cell carcinoma (RCC) and 6 regions (7 loci) with papillary RCC. Notably, we report a variant common in African ancestry individuals ( rs7629500 ) in the 3' untranslated region of VHL, nearly tripling clear cell RCC risk (odds ratio 2.72, 95% confidence interval 2.23-3.30). In cis-expression quantitative trait locus analyses, 48 variants from 34 regions point toward 83 candidate genes. Enrichment of hypoxia-inducible factor-binding sites underscores the importance of hypoxia-related mechanisms in kidney cancer. Our results advance understanding of the genetic architecture of kidney cancer, provide clues for functional investigation and enable generation of a validated polygenic risk score with an estimated area under the curve of 0.65 (0.74 including risk factors) among European ancestry individuals.

Pan-cancer genomic analysis shows hemizygous PTEN loss tumors are associated with immune evasion and poor outcome

In tumors, somatic mutations of the PTEN suppressor gene are associated with advanced disease, chemotherapy resistance, and poor survival. PTEN loss of function may occur by inactivating mutation, by deletion, either affecting one copy (hemizygous loss) leading to reduced gene expression or loss of both copies (homozygous) with expression absent. Various murine models have shown that minor reductions in PTEN protein levels strongly influence tumorigenesis. Most PTEN biomarker assays dichotomize PTEN (i.e. presence vs. absence) ignoring the role of one copy loss. We performed a PTEN copy number analysis of 9793 TCGA cases from 30 different tumor types. There were 419 (4.28%) homozygous and 2484 (25.37%) hemizygous PTEN losses. Hemizygous deletions led to reduced PTEN gene expression, accompanied by increased levels of instability and aneuploidy across tumor genomes. Outcome analysis of the pan-cancer cohort showed that losing one copy of PTEN reduced survival to comparable levels as complete loss, and was associated with transcriptomic changes controlling immune response and the tumor microenvironment. Immune cell abundances were significantly altered for PTEN loss, with changes in head and neck, cervix, stomach, prostate, brain, and colon more evident in hemizygous loss tumors. These data suggest that reduced expression of PTEN in tumors with hemizygous loss leads to tumor progression and influences anticancer immune response pathways.

What is the impact of dynamic contrast-enhancement sequence in the Vesical Imaging, Reporting and Data System (VI-RADS)? A subgroup analysis

Background

A scoring system focusing on the risk of muscle layer invasion by Bladder cancer (BCa) has been released, Vesical Imaging - Radiological and Data System (VI-RADS), with a growing interest in evaluating its diagnostic accuracy.

Our goal was to assess the accuracy and reproducibility of the VI-RADS score for assessment of the vesical muscular layer with (multiparametric-mp) and without (biparametric-bp) a dynamic-contrast enhancement (DCE) sequence.

Methods

Retrospective study conducted from July 2018 to July 2020. All patients had suspicions of BCa and underwent Magnetic Resonance Imaging (MRI) before any intervention. MRI was interpreted by two radiologists with different levels of experience, and a VI-RADS score assigned in two different sessions (3 months apart) without and with DCE. After exclusions, 44 patients with 50 lesions were enrolled. The standard of reference was transurethral resection in 18 patients (40.9%) and cystectomy in 26 patients (59.1%).

Results

Twenty-five lesions (50%) were muscle-invasive. There was no significant difference between the two groups for gender and presence of a stalk, but mean age of NMIBCa group was significantly higher (p = 0.01). The sizes of lesions were significantly different between groups for both readers at 2.42+/− 1.58 vs. 5.70+/− 2.67 cm for reader 1 (p < 0.0001) and 2.37+/− 1.50 vs. 5.44 +/− 2.90 cm for reader 2 (p = 0.001). The area under the curve (AUC) for muscle invasion with mpVI-RADS, considering all lesions, was 0.885 +/− 0.04 (95% CI-0.79-0.98) for reader 1 and 0.924 +/− 0.04 (0.84–0.99) for reader 2, and for bpVI-RADS was 0.879+/− 0.05 and 0.916 +/− 0.04 (0.85–0.99), respectively, both differences not statistically significant (p = 0.24 and 0.07, respectively). When considering only small lesions (< 3.0 cm), the accuracy for mpVI-RADS was 0.795 +/− 0.11 (0.57–1.0) for reader1, and 0.80 +/− 0.11(0.57–1.0) for reader 2, a non-significant difference (p = 0.56) and for bpVI-RADS was 0.747 +/− 0.12 (0.50–0.99) for reader 1 and 0.80 +/− 0.11(0.57–1.0) for reader 2, a significant difference (p = 0.04). The intraclass correlation coefficient for the final score was 0.81 (0.60–1.0) for mpVI-RADS and 0.85 (0.63–1.0) for bpVI-RADS.

Conclusion

The VI-RADS system was accurate in demonstrating muscle-invasive BCa, for both experienced and less experienced reader, regardless of the use of a DCE sequence. However, when only small lesions were assessed the difference between the two readers was significant only for the biparametric analysis. The reproducibility was similar between multiparametric and biparametric approach.

Implications of Regionalizing Care in the Developing World: Impact of Distance to Referral Center on Compliance to Biopsy Recommendations in a Brazilian Prostate Cancer Screening Cohort

Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004-2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135-718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.

Risk Stratification of Prostate Cancer Through Quantitative Assessment of PTEN Loss (qPTEN)

BACKGROUND

Phosphatase and tensin homolog (PTEN) loss has long been associated with adverse findings in early prostate cancer. Studies to date have yet to employ quantitative methods (qPTEN) for measuring of prognostically relevant amounts of PTEN loss in postsurgical settings and demonstrate its clinical application.

METHODS

PTEN protein levels were measured by immunohistochemistry in radical prostatectomy samples from training (n = 410) and validation (n = 272) cohorts. PTEN loss was quantified per cancer cell and per tissue microarray core. Thresholds for identifying clinically relevant PTEN loss were determined using log-rank statistics in the training cohort. Univariate (Kaplan-Meier) and multivariate (Cox proportional hazards) analyses on various subpopulations were performed to assess biochemical recurrence-free survival (BRFS) and were independently validated. All statistical tests were two-sided.

RESULTS

PTEN loss in more than 65% cancer cells was most clinically relevant and had statistically significant association with reduced BRFS in training (hazard ratio [HR] = 2.48, 95% confidence interval [CI] = 1.59 to 3.87; P < .001) and validation cohorts (HR = 4.22, 95% CI = 2.01 to 8.83; P < .001). The qPTEN scoring method identified patients who recurred within 5.4 years after surgery (P < .001). In men with favorable risk of biochemical recurrence (Cancer of the Prostate Risk Assessment - Postsurgical scores <5 and no adverse pathological features), qPTEN identified a subset of patients with shorter BRFS (HR = 5.52, 95% CI = 2.36 to 12.90; P < .001) who may be considered for intensified monitoring and/or adjuvant therapy.

CONCLUSIONS

Compared with previous qualitative approaches, qPTEN improves risk stratification of postradical prostatectomy patients and may be considered as a complementary tool to guide disease management after surgery.

Independent external validation of nomogram to predict extracapsular extension in patients with prostate cancer

INTRODUCTION

The objective of this study was to perform an independent external validation of the Giganti-Coppola nomogram (GCN), which uses clinical and radiological parameters to predict prostate extracapsular extension (ECE) on the final pathology of patients undergoing radical prostatectomy (RP).

MATERIAL AND METHODS

Seventy-two patients diagnosed with prostate cancer (PCa), who were RP candidates from two institutions, were prospectively included. All patients underwent preoperative multi-parametric magnetic resonance imaging (mpMRI) at 1.5 T, without the use of an endorectal coil, with multiplanar images in T1WI, T2WI, DWI, and DCE. The AUC and a calibration graph were used to validate the nomogram, using the regression coefficients of the Giganti-Coppola study.

RESULTS

The original nomogram had an AUC of 0.90 (p = 0.001), with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%, 5.1%, 47.1%, 100%, and 48%, respectively. The calibration graph showed an overestimation of the nomogram for ECE.

CONCLUSION

The GCN has an adequate ability in predicting ECE; however, in our sample, it showed limited accuracy and overestimated likelihood of ECE in the final pathology of patients with PCa submitted to RP.

KEY POINTS

• Knowledge of preoperative local staging of prostate cancer is essential for surgical treatment. Extracapsular extension increases the chance of positive surgical margins. • Imaging modalities such as mpMRI alone does not have suitable accuracy in local staging. • Giganti-Coppola's nomogram achieved an adequate ability in predicting ECE.

Diagnostic accuracy of signal loss in in-phase gradient-echo images for differentiation between small renal cell carcinoma and lipid-poor angiomyolipomas

OBJECTIVES

To assess the diagnostic accuracy of signal loss on in-phase (IP) gradient-echo (GRE) images for differentiation between renal cell carcinomas (RCCs) and lipid-poor angiomyolipomas (lpAMLs).

METHODS

We retrospectively searched our institutional database for histologically proven small RCCs (<5.0 cm) and AMLs without visible macroscopic fat (lpAMLs). Two experienced radiologists assessed MRIs qualitatively, to depict signal loss foci on IP GRE images. A third radiologist drew regions of interest (ROIs) on the same lesions, on IP and out-of-phase (OP) images to calculate the ratio of signal loss. Diagnostic accuracy parameters were calculated for both techniques and the inter-reader agreement for the qualitative analysis was evaluated using the κ test.

RESULTS

15 (38.4%) RCCs lost their signal on IP images, with a sensitivity of 38.5% (95% CI = 23.4-55.4), a specificity of 100% (71.1-100), a positive predictive value (PPV) of 100% (73.4-100), a negative predictive value (NPV) of 31.4% (26.3-37.0), and an overall accuracy of 52% (37.4-66.3%). In terms of the quantitative analysis, the signal intensity index (SII= [(SI_IP - SI_OP) / SI_OP] x 100) for RCCs was -0.132 ± 0.05, while for AMLs it was -0.031 ± 0.02, p = 0.26. The AUC was 0.414 ± -0.09 (0.237-0.592). Using 19% of signal loss as the threshold, sensitivity was 16% and specificity was 100%. The κappa value for subjective analysis was 0.63.

CONCLUSION

Signal loss in "IP" images, assessed subjectively, was highly specific for distinction between RCCs and lpAMLs, although with low sensitivity. The findings can be used to improve the preoperative diagnostic accuracy of MRI for renal masses.

ADVANCES IN KNOWLEDGE

Signal loss on "IP" GRE images is a reliable sign for differentiation between RCC and lpAMLs.

Predicting Adherent Perinephric Fat Using Preoperative Clinical and Radiological Factors in Patients Undergoing Partial Nephrectomy

BACKGROUND

The decision to perform a partial nephrectomy (PN) relies largely upon the complexity of the renal mass and its surrounding anatomy. The presence of adherent perinephric fat (APF) can increase surgical complexity and extend operative times. The accurate prediction of APF may improve surgical planning and aid in decision making for the surgical approach.

OBJECTIVE

We sought to develop and externally validate a score that predicts APF based on preoperative clinical and radiological prognostic factors.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed 495 consecutive patients who underwent open or minimally invasive PN. APF was defined as the presence of "dense," "adherent," or "sticky" perinephric fat at the time of dissection by the surgeon, and this did not require subcapsular dissection. Additionally, we analyzed an independent cohort of 285 patients for external validation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A score model was developed using multivariate logistic regression analysis. Calibration of the fitted model was assessed graphically with a plot of the predicted versus the actual probability of APF, and discrimination was assessed by calculating the area under the receiver operating characteristic curve.

RESULTS AND LIMITATIONS

Of the 495 patients, 95 (19%) had APF. Patients with APF had longer operative (p=0.02) and arterial clamp (p=0.01) times than non-APF patients. On multivariate analyses, diabetes mellitus (p=0.009), posterior perinephric fat thickness (p<0.001), and perinephric stranding (p<0.001) were predictors of encountering APF in PN. A risk score ranging from 0 to 4 was developed based on these three variables to predict APF. The scoring system demonstrated good discrimination of 0.82 and 0.84 for the development and external validation cohorts, respectively.

CONCLUSIONS

The APF score can accurately predict the presence of APF in patients with a small renal mass who are planning to undergo PN. This score could aid in pre- and intraoperative planning and impact the surgical approach.

PATIENT SUMMARY

The presence of "sticky" fat surrounding the kidney in patients undergoing partial nephrectomy has previously been linked to longer operative times, intraoperative complications, and surgical conversion. In our study, we found that this feature is more often presented in patients with diabetes mellitus, and thicker and more inflammatory fat on renal imaging. Based on these findings, we developed a risk score that can accurately predict this feature before surgery, in order to improve surgical planning and better counsel the patients.

PTEN-deficient prostate cancer is associated with an immunosuppressive tumor microenvironment mediated by increased expression of IDO1 and infiltrating FoxP3+ T regulatory cells

BACKGROUND

Accumulating evidence shows that tumor cell-specific genomic changes can influence the cross talk between cancer cells and the surrounding tumor microenvironment (TME). Loss of the PTEN tumor suppressor gene is observed in 20% to 30% of prostate cancers (PCa) when first detected and the rate increases with PCa progression and advanced disease. Recent findings implicate a role for PTEN in cellular type I interferon response and immunosuppression in PCa. However, the way that PTEN inactivation alters antitumor immune response in PCa is poorly understood.

MATERIALS AND METHODS

To investigate the changes associated with PTEN loss and an immunosuppressive TME in PCa, we used CIBERSORT to estimate the relative abundance of 22 immune-cell types from 741 primary and 96 metastatic tumors. Our in silico findings were then validated by immunohistochemical analysis of immune cells and IDO1 and PDL1 checkpoint proteins in a cohort of 94 radical prostatectomy specimens.

RESULTS

FoxP3+ T regulatory cells (Tregs) were significantly increased in PTEN-deficient PCa in all three public domain cohorts. Loss of PTEN in bone metastases was associated with lower CD8+ T-cell abundance, but in liver metastasis, FoxP3+ Tregs were present at higher levels. PTEN-deficient lymph node metastasis had a distinct profile, with high levels of CD8+ T cells. Moreover, we found that metastatic PCa presents higher abundance of FoxP3+ Treg when compared to primary lesions. Since PTEN-deficient tumors are likely to be immunosuppressed as a consequence of increased FoxP3+ Tregs, we then evaluated the localization and expression of IDO1, PDL1 immune checkpoints, and the corresponding density of FoxP3+ Treg and CD8+ T cells using our validation cohort (n = 94). We found that IDO1 protein expression and FoxP3+ Treg density were higher in neoplastic glands compared with benign adjacent tissue. Moreover, higher densities of FoxP3+ Treg cells in both stromal (P = 0.04) and tumor (P = 0.006) compartments were observed in PTEN-deficient tumors compared to tumors that retained PTEN activity. Similarly, IDO1 protein expression was significantly increased in the tumor glands of PTEN-deficient PCa (P < 0.0001). Spearman correlation analysis showed that IDO1 expression was significantly associated with FoxP3+ Treg and CD8+ T-cell density (P < 0.01).

CONCLUSIONS

Our findings imply that PTEN deficiency is linked to an immunosuppressive state in PCa with distinct changes in the frequency of immune cell types in tumors from different metastatic sites. Our data suggest that determining PTEN status may also help guide the selection of patients for future immunotherapy trials in localized and metastatic PCa.

Effects of treatment of preweaning dairy calves with recombinant bovine somatotropin on immune responses and somatotropic axis

Weaning may be associated with negative energy balance and body weight loss when calves are still immunologically immature, predisposing them to infectious diseases. The aim of the present experiment was to investigate the effects of treatment of preweaning dairy calves with recombinant bovine somatotropin (rbST) on the somatotropic axis, selected immune parameters, and hematology of calves around weaning. Thirty-six Holstein female calves were randomly assigned to receive 1.5 to 1.8 mg of rbST (Posilac, Elanco Animal Health, Greenfield, IN) per kilogram of body weight or to receive injections of saline (saline solution 0.9%, Valley Vet Supply, Marysville, KS) every 7 d from 21 to 63 d of life. Calves were fed milk replacer ad libitum from birth to 38 d of age (d -11), when progressive weaning started, and calves were weaned at 49 d of age (d 0). Calves were weighed at birth and weekly from 21 to 63 d of age, when wither height also was measured. Calves were vaccinated with 0.5 mg of ovalbumin on study d -28 and -7. Blood samples were collected on d -28, -25, -21, -11, 0, 3, 7, and 14. Polymorphonuclear leukocytes were isolated and challenged ex vivo with Escherichia coli to determine phagocytosis and oxidative burst capacity. Additionally, expression of cluster of differentiation (CD)62L and CD18 by granulocyte, lymphocyte, and CD14+ monocyte were determined. Blood samples were also used to determine hematological parameters and concentrations of growth hormone, insulin-like growth factor-1, insulin, glucose, fatty acids, β-hydroxybutyrate, haptoglobin, and anti-ovalbumin IgG. Calves treated with rbST had greater concentrations of growth hormone and insulin-like growth factor-1 from d -25 to 14 than control calves, whereas insulin, fatty acid, and β-hydroxybutyrate concentrations did not differ. On d -11, glucose concentration was greater for rbST-treated calves. Treatment did not affect polymorphonuclear lymphocyte phagocytosis and oxidative burst, but intensity of expression of CD62L and CD18 by granulocytes tended to be increased by rbST treatment. Treatment did not affect the concentration of anti-ovalbumin IgG in serum. Haptoglobin concentration was reduced in rbST treated calves on d 3 and we noted a tendency for hematocrit to be lower in rbST-treated calves. Treatment did not affect body weight, wither height, and average daily gain, despite the fact that rbST-treated calves had lower daily milk replacer intake. The relatively minor improvements in immune responses resulting from rbST treatment of weaning calves may not be sufficient to reduce the incidence of infectious diseases.

Expression of hepatic genes related to energy metabolism during the transition period of Holstein and F1 Holstein-Gir cows

The aim of this study was to investigate the expression of genes encoding enzymes and other factors involved with carbohydrate and lipid metabolism in the liver of 2 genetic groups of dairy cows during the transition period. We analyzed the expression of glucose-6-phosphatase (G6PC), cytosolic phosphoenolpyruvate carboxykinase (PEPCK-C), methylmalonyl-CoA mutase (MUT), β-hydroxybutyrate dehydrogenase-2 (BDH2), acetyl-CoA carboxylase (ACC), carnitine palmitoyltransferase-2 (CPT2), 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), glucose transporter-2 (SLC2A2), and the transcription factor peroxisome proliferator-activated receptor α (PPARA). Blood concentrations of glucose, nonesterified fatty acids, and β-hydroxybutyrate were also determined. Liver biopsies and blood samples were taken at d 15 prepartum and at d 6, 21, 36, 51, and 66 postpartum from Holsteins (n = 6) and F₁ Holstein-Gir (n = 6) cows. Cows were kept under the same prepartum and postpartum management conditions. The results showed that the expression of G6PC, PEPCK-C, BDH2, ACC, CPT2, HMGCR, SLC2A2, and PPARA genes did not differ between genetic groups. Except for PEPCK-C, no interaction between genetic groups and the experimental period was observed. Within both groups of cows, G6PC and PEPCK-C gene expression decreased when comparing prepartum gene expression with 21 and 36 DIM, and increased in d 51 postpartum. MUT mRNA levels differed between the 2 genetic groups and displayed a significant increase after d 36 postpartum, whereas mRNA levels of HMGCR tended to increase when comparing d 21 and 36 to d 51 postpartum. Glucose concentrations also differed between genetic groups, being significantly higher in the plasma of F₁ Holstein-Gir cows than in Holstein cows, but no differences were found within each group during the analysis period. β-Hydroxybutyrate and nonesterified fatty acid concentrations did not differ between genetic groups, but displayed increased levels from prepartum to d 6 and 21 postpartum. Our results indicated that expression in the liver of genes involved with glucose and fatty acid metabolism were similar in both groups of cows and significant differences were observed between the 2 groups in the expression of MUT, a gene involved in propionate metabolism.

Multiparametric MRI of the prostate: diagnostic performance and interreader agreement of two scoring systems

OBJECTIVE

To compare the diagnostic accuracies and interreader agreements of the Prostate Imaging Reporting and Data System (PI-RADS) v. 2 and University of California San Francisco (UCSF) multiparametric prostate MRI scale for diagnosing clinically significant prostate cancer.

METHODS

This institutional review board-approved retrospective study included 49 males who had 1.5 T endorectal MRI and prostatectomy. Two radiologists scored suspicious lesions on MRI using PI-RADS v. 2 and the UCSF scale. Percent agreement, 2 × 2 tables and the area under the receiver operating characteristic curves (Az) were used to assess and compare the individual and overall scores of these scales. Interreader agreements were estimated with kappa statistics.

RESULTS

Reader 1 (R1) detected 78 lesions, and Reader 2 (R2) detected 80 lesions. Both identified 52 of 65 significant cancers. The Az for PI-RADS v. 2 and UCSF scale for R1 were 0.68 and 0.69 [T2 weighted imaging (T2WI)], 0.75 and 0.68 [diffusion-weighted imaging (DWI)] and 0.64 and 0.72 (overall score), respectively, and were 0.72 and 0.75 (T2WI), 0.73 and 0.67 (DWI) and 0.66 and 0.75 (overall score) for R2. The dynamic contrast-enhanced percent agreements between scales were 100% (R1) and 95% (R2). PI-RADS v. 2 DWI of R1 performed better than UCSF DWI (Az = 0.75 vs Az = 0.68; p = 0.05); no other differences were found. The interreader agreements were higher for PI-RADS v. 2 (T2WI: 0.56 vs 0.42; DWI: 0.60 vs 0.46; overall: 0.61 vs 0.42). The UCSF approach to derive the overall PI-RADS v. 2 scores increased the Az for the identification of significant cancer (R1 to 0.76, p < 0.05; R2 to 0.71, p = 0.35).

CONCLUSION

Although PI-RADS v. 2 DWI score may have a higher discriminatory performance than the UCSF scale counterpart to diagnose clinically significant cancer, the utilization of the UCSF scale weighing system for the integration of PI-RADS v. 2 individual parameter scores improved the accuracy its overall score.

ADVANCES IN KNOWLEDGE

PI-RADS v. 2 is moderately accurate for the identification of clinically significant prostate cancer, but the utilization of alternative approaches to derive the overall PI-RADS v. 2 score, including the one used by the UCSF system, may improve its diagnostic accuracy.

Predicting adherent perinephric fat with preoperative clinical and radiological factors in partial nephrectomy: Development and validation of a risk score

497

Background: The decision to perform a partial nephrectomy (PN) relies largely upon the complexity of the renal mass and its surrounding anatomy. An often encountered intraoperative challenge in PN is the adherent perinephric fat (APF). The anticipation of this feature may improve preoperative risk assessment and aid in decision-making for the surgical approach. We sought to develop and externally validate a score that predicts for APF based on preoperative clinical and radiological prognostic factors. Methods: We retrospectively analyzed 495 consecutive patients that underwent open or minimally invasive PN. APF was defined as the presence of “dense”, “adherent”, or “sticky” perinephric fat at time of dissection by the surgeon and this did not required subcapsular dissection for tumor isolation. A score model was developed using multivariate logistic regression analysis. This score was further validated using an external data set with 285 patients. Discrimination and calibration were assessed by calculating the area under the receiver operating characteristic curve (AUC) and the Hosmer–Lemeshow statistic, respectively. Results: Among the 495 patients, 95 (19%) patients presented with APF. On multivariate analyses, diabetes mellitus (p = 0.009), perinephric fat thickness (p < 0.001) and perinephric stranding (p < 0.001) were predictors of encountering APF in PN. A risk score ranging from 0 to 4, was developed based on these three variables to predict for APF. Among the 285 patients in the validation cohort, 41(14.3%) presented with APF. The score demonstrated good discrimination of 0.82 and 0.84 for the development and validation cohort, respectively. The model did not show a statistically significant lack of calibration (p-values = 0.98, 0.35). Moreover, predicted probabilities of APF based on a 0.5 threshold yielded a specificity of 92.3 and 92.2 in the development and validation cohorts, respectively. Conclusions: The score can accurately predict the presence of APF in patients with small renal mass planning to undergo PN. This score could aid current algorithms of preoperative risk assessment and impact surgical approach.

Gene expression study related with the intrinsic pathway of apoptosis in bladder cancer by real-time PCR technique

We examined the expression of anti-apoptotic genes (XIAP and Bcl-2) and apoptotic genes (cytochrome c, caspase-9, Apaf-1) in tissue samples of patients with superficial bladder cancer. Thirty-two bladder cancer tissue samples (8 papillary urothelial neoplasm of low malignant potential, 10 low-grade, and 14 high-grade) and 8 normal bladder tissue samples from necropsy were used for the study of gene expression by real-time PCR analysis. Analysis of the expression of apoptotic gene constituents of an apoptosome demonstrated an increase in Apaf-1 expression in the three tumor grades when compared with the control (P < 0.01, P < 0.05, and P < 0.01), low expression of caspase-9 in all groups (P < 0.05), and an increase in cytochrome c expression in all tumor grades in relation to the control, although without statistically significant difference. The expression of anti-apoptotic genes revealed an increase in XIAP expression in all tumor grades in relation to the control, although without statistically significant difference, and low expression of Bcl-2 in all tumor grades and the control (P < 0.05). The results proved that there is low evidence of apoptotic activity by the intrinsic pathway, demonstrated by the low expression of caspase-9 and considerable increase in XIAP expression, which may render these genes potential therapeutic targets in bladder cancer treatment.

Association between family history of prostate cancer and positive biopsies in a Brazilian screening program

PURPOSE

To test the association between family history of prostate cancer (FH) and prostate cancer (PCa) risk in a large screening program in Brazil, as no conclusive study has yet investigated this.

METHODS

Between 2004 and 2007, 17,569 men were screened in 231 small municipalities using mobile screening units. Positive FH was defined as any relative having PCa among screened men. Men were biopsied if they had digital rectal examination suggestive of PCa or PSA >4.0 ng/mL or PSA of 2.5-4 ng/mL with percent free PSA ≤ 15 %. We analyzed the association between FH and PCa using multivariable logistic regression in the first screening round of the program.

RESULTS

Positive FH was present in 735 men (4.2 % of total), and they were younger, better educated and more likely to have had previous PCa screening (41.5 vs. 28.5 %; P < 0.001) compared to men with negative FH. FH status did not affect compliance rates in men recommended to undergo biopsy (P = 0.94). In first round, PCa was detected in 3.1 % of screened men (n = 552). In multivariable analysis, positive FH was associated with increased PCa risk (OR = 1.79; 95 % CI, 1.21-2.65; P = 0.003). However, Gleason scores (P = 0.78) or percent of positive cores (P = 0.32) among men with positive biopsies were similar, regardless of FH status.

CONCLUSIONS

In Brazil, men with positive FH were at increased PCa risk, which could not be explained by differential biopsy rates. This finding suggests that FH is also a true PCa risk factor in Brazil, a country with highly diverse population in terms of race, ethnicity, culture and socioeconomic status.

Using Mitrofanoff's principle and Monti's technique as a surgical option for bladder augmentation with a continent stoma: a case report

Introduction

Hydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients.

Case presentation

A 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H₂O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel.

After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel.

Conclusion

The unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).

Histologic study of urethral extracellular matrix and collagen from aging and long-term alloxan-induced diabetic male rats

OBJECTIVES

To evaluate the histological alterations of extracellular matrix in long-term alloxan-induced diabetes and aging urethras of male rats with descriptions of total connective tissue, muscle layer and collagen types I and III relative amounts.

METHODS

Histologic evaluations were performed in 3 animal groups: group 1, 8 weeks old; group 2, 44 weeks old; and group 3, 44 weeks old with alloxan-induced diabetes. The muscle layer thickness, extracellular matrix fibrosis, and collagen were quantified on digital images of the urethral samples.

RESULTS

A higher total thickness and muscle layer thickness and higher connective tissue and collagen content were observed in the urethras of group 3. No changes in the collagen type III/I ratio were found in the urethra of groups 2 and 3.

CONCLUSIONS

Our results suggest that the morphologic alterations of the urethra should also be considered in long-term studies of diabetic lower urinary tract dysfunction. These morphologic alterations due to diabetes differ from the changes induced by aging itself and could represent a final stage in decompensate urethras. Further studies are necessary to establish the real influence of the urethral morphologic changes on lower urinary tract diabetes dysfunction.

Therapeutic option for infected urinary tract fistulas in renal transplantation

BACKGROUND

Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge.

OBJECTIVE

To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair.

PATIENTS AND METHODS

The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis).

RESULTS

Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%.

CONCLUSION

Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

THE IMPACT OF TUMOR STAGE ON PROGNOSIS IN CHILDREN WITH ADRENOCORTICAL CARCINOMA

PURPOSE

We evaluated treatment outcomes in children with adrenocortical carcinoma.

MATERIALS AND METHODS

We studied 34 children with a median age of 3 years. In 27 of 28 patients without intracaval extension complete surgical excision was accomplished, while tumor resection combined with thrombectomy was carried out in 5 of 6 children with vascular invasion. In 2 children with cavoatrial thrombus the thrombectomy required cardiopulmonary bypass with deep hypothermia and circulatory arrest. Children with incomplete excision of the tumor and/or stage IV disease received adjuvant chemotherapy.

RESULTS

Ultrasonography, computerized tomography and magnetic resonance imaging exhibited specificity of 100% in the diagnosis of vascular invasion, and sensitivity of 50%, 66% and 100%, respectively. Patient age, tumor stage or size and vascular invasion were associated with survival in univariate analysis. Tumor stage was the only independent factor associated with survival in multivariate analysis. The overall 5-year survival rates according to tumor stage were 100% in stage I, 85% in stage II, 40% in stage III and 0% in stage IV. Of 11 children with local recurrence only 2 were alive without disease at 96 and 204 months after reoperation with complete tumor excision. Only 2 of 6 patients with vascular invasion were disease-free at 17 and 50 months. A total of 10 children with stage IV disease treated with chemotherapy died within a median of 6 months.

CONCLUSIONS

Tumor stage was the most relevant prognostic factor for children with adrenocortical carcinoma. Reoperation for local tumor recurrence and thrombectomy for inferior vena caval tumor invasion should be attempted whenever possible.

Effects of corn particle size and source on performance of lactating cows fed direct-cut grass-legume forage

We conducted two experiments to evaluate the effects of corn supplementation, source of corn, and corn particle size on performance and nutrient utilization of lactating dairy cows. In experiment 1, treatments were 1) direct-cut grass-legume forage without supplement, 2) direct-cut forage plus 10 kg DM of ground dry shelled corn-based concentrate, and 3) direct-cut forage plus 10 kg DM of coarsely ground high moisture ear corn-based concentrate. In experiment 2, treatments were 1) direct-cut grass-legume forage plus 10 kg DM of ground dry shelled corn-based concentrate, 2) direct-cut forage plus 10 kg DM of coarsely ground high moisture ear corn-based concentrate, and 3) direct-cut forage plus 10 kg of DM finely ground high moisture ear corn-based concentrate. Both experiments were designed as 3 x 3 Latin squares replicated three times. In experiment 1, yields of milk and milk protein increased with concentrate supplementation, but were not affected by source of corn. Solids-corrected milk yield tended to increase with grain supplementation. Dry matter intake increased with concentrate supplementation, but was not affected by source of corn or corn particle size. Corn supplements decreased ruminal pH and acetate to propionate ratio and increased ruminal propionate concentration. Grain supplements reduced ruminal ammonia concentration, increased concentration of urine allantoin, and increased the urinary allantoin to creatinine ratio. In the second study, fine grinding of high moisture corn reduced fecal starch plus free glucose levels and tended to increase its apparent digestibility. In both experiments, starch plus free glucose intake was higher on the diets with dry corn, but its utilization was not affected by source of corn.

Effect of coarse or fine grinding on utilization of dry or ensiled corn by lactating dairy cows

This study evaluated the effect of coarse or fine grinding of three forms of corn on the performance of lactating cows. Six diets, fed as total mixed rations, were identical except for the corn portion of the diet. Corn treatments were dry shelled corn, high moisture ensiled ear corn, and high moisture ensiled shelled corn, either coarsely or finely ground. The experimental design was a 6 x 6 Latin square with 36 cows. Eighteen cows were assigned to the six different treatments and were fed once daily. Within this group of 18 cows, six had a ruminal cannula and were used to evaluate nutrient digestibilities and ruminal fermentation. The remaining 18 cows, six of which were ruminally cannulated, were similarly assigned, except they were fed twice daily. In the group fed once daily, milk production and composition were not affected by treatment. Starch digestibility was greater with the high moisture and with the finely ground corn treatments. In addition, the high moisture ensiled corn treatments had reduced ruminal ammonia concentrations. In the group that was fed twice daily, milk production and protein yield were greatest for the finely ground high moisture ensiled shelled corn treatment. Starch utilization was improved by fine grinding. Lower ruminal ammonia concentrations were obtained with the high moisture ensiled corn treatments, and there was a tendency for reduced ammonia concentration with fine grinding. Results indicate that high moisture ensiled corn as well as fine grinding improved nitrogen and starch utilization.

Effects of increasing levels of grain supplementation on rumen environment and lactation performance of dairy cows grazing grass-legume pasture

The impact of supplemental energy on nutrient utilization, fiber digestion, rumen fermentation, and lactation performance was evaluated in dairy cows grazing pastures composed of brome, orchardgrass, red clover, and alfalfa. Three amounts [0, 5, and 10 kg dry matter (DM)/d] of ground dry shelled corn-based concentrate were supplemented to nine rumen cannulated Holstein cows in a 3 x 3 Latin square replicated three times. Cows were on average 84+/-13 d in milk and producing 41.6+/-5.9 kg of milk/d at the beginning of the study. An increase in amounts of concentrate in the diets was associated with an increase in milk production, solids-corrected milk, and concentrations of milk protein and SNF. Milk fat percentage and milk urea nitrogen concentration decreased linearly with supplementation. Milk production and protein percentage were 21.8, 26.8, and 30.4 kg/d, and 2.85, 2.95, and 3.05% for the increasing levels of concentrate, respectively. Intake and digestibility of DM and organic matter (OM) increased as grain supplementation increased. Ruminal pH and total volatile fatty acid concentration (VFA) were not affected by supplementation or the amount of concentrate. Ruminal ammonia concentration was reduced by supplementation, presumably due to a decrease in N intake and greater use of ammonia-N for rumen microbial protein synthesis. Rumen fermentation varied throughout the day, with lower mean pH and higher VFA concentrations at night. Supplementation increased total OM intake, decreased forage OM intake, and increased the proportion of OM that was digested in the intestines. Total DM intake by grazing dairy cows can be increased using ground dry shelled corn-based concentrate without causing negative effects on forage digestion.

Effects of corn processing and supplemental hay on rumen environment and lactation performance of dairy cows grazing grass-legume pasture

The effect of corn processing (9 kg of dry matter/d of ground dry shelled or 9 kg of dry matter/d of steam rolled) and supplemental hay (0 or 3.2 kg of dry matter/d of alfalfa hay) on milk yield and composition, rumen environment, and starch utilization by lactating cows grazing grass-legume pasture was studied. Twelve rumen cannulated, multiparous Holstein cows in early lactation (95 d in milk), were assigned to a 4 x 4 Latin square design replicated three times. Treatments were ground shelled corn-based concentrate, ground shelled corn-based concentrate plus alfalfa hay, steam-rolled, corn-based concentrate, or steam-rolled, corn-based concentrate plus alfalfa hay. Supplements were fed in equal proportions twice daily. Cows fed steam-rolled corn tended to have higher percentage of milk protein and lower milk urea nitrogen concentrations than cows fed shelled corn. Milk yield was not affected by corn processing or hay supplementation. Intake of pasture forage but not total dry matter intake was reduced by hay supplementation. Starch plus free glucose digestibility in the total tract was not affected by grain processing; however, starch plus free glucose digestibility tended to increase with hay supplementation. Supplemental hay increased starch plus free glucose digestibility through changes in rumen digestion kinetics. Hay supplementation reduced the liquid rate of passage, and tended to reduce particulate turnover. Rumen degradability of pasture forage organic matter tended to be higher for cows fed supplemental hay. Supplemental hay in these diets had a greater impact on starch utilization than corn processing.

Detrusor contraction duration may predict response to alpha-blocker therapy for lower urinary tract symptoms

OBJECTIVES

Baseline pressure/flow parameters have not correlated well with response to medical therapy for lower urinary tract symptoms (LUTS). This open-label, nonrandomized retrospective study was designed to evaluate whether the urodynamic parameter duration (in seconds) of the detrusor contraction (DCD) correlates better with alpha-blocker response than previously described urodynamic parameters.

METHODS

93 men (mean age 62.6+/-8.5) with LUTS underwent urodynamic evaluation prior to initiating therapy with doxazosin titrated to 8 mg and followed for 6 months. Parameters of evaluation included the AUA symptom score (AUASx), peak urinary flow rate (Q(max)), maximal detrusor pressure (P(max)), detrusor pressure at maximal flow (P(det)) and DCD. The correlation and predictive value of therapeutic response and baseline urodynamic parameters were assessed.

RESULTS

85 patients were evaluable at 6 months. For the entire group, AUASx decreased from 15.1+/-6.9 to 9.7+/-5.1 (-36%) and Q(max) increased from 9.3+/-3.7 to 11.9+/-5.7 ml/s (+28%). Baseline P(max) was 74.8+/-19.6 cm H(2)O, P(det) was 61.6+/-18.9 cm H(2)O and DCD was 107.6+/-28.6 s. There was weak correlation between either baseline P(max) or P(det) and therapeutic response (defined as a decrease in AUASx of 40% and an increase in Q(max) of 30%). Utilizing a baseline DCD of 90 s or more, there was a significant correlation to therapeutic response (r = 0.48, p = 0.002).

CONCLUSIONS

These preliminary data suggest that DCD may be a useful urodynamic parameter to predict and optimize therapy with a-blockade. The potential utility and cost-effectiveness of DCD remains to be determined.

Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction

OBJECTIVES

Sildenafil has been demonstrated to be safe and effective in the treatment of men with erectile dysfunction. The role of sildenafil in treating women with sexual dysfunction has heretofore not been reported. The purpose of this preliminary study was to ascertain the response of postmenopausal women with self-described sexual dysfunction treated with sildenafil for 3 months.

METHODS

Thirty-three consecutive postmenopausal women with sexual dysfunction based on history were entered in this open-label, nonrandomized study. All patients received 50 mg of sildenafil. Efficacy was assessed at weeks 4, 8, and 12 using a newly developed 9-item, self-administered Index of Female Sexual Function (IFSF) and a global efficacy question ([GEQ] Did treatment improve your sexual function?). The IFSF quantifies the domains of desire, quality of sexual intercourse, overall satisfaction with sexual function, orgasm, lubrication, and clitoral sensation.

RESULTS

Of the group, 30 women (91 %) completed the study and were available for follow-up at 3 months. Mean baseline IFSF score before therapy was 24.8+/-9.8. Mean usage of sildenafil was 3.1+/-1.4 times per week for the duration of the study. The IFSF score improved to 29.5+/-7.6, 30.3+/-8.5, and 31.4+/-10.4 at 4, 8, and 12 weeks, respectively (P = 0.25). Mean scores for questions 2 (lubrication), 8 (orgasm), and 9 (clitoral sensation) improved by 23.2%, 7.4%, and 31.3%, respectively, at 12 weeks. Seven women (21%) noted improvement on the GEQ. Overall, only 6 (18.1%) of 33 patients had a significant (more than 60% improvement in IFSF score) therapeutic response. Clitoral discomfort and "hypersensitivity" occurred in 7 women (21%), 3 of whom withdrew from the study. Other side effects, which did not result in withdrawal from the study, included headache (n = 5), dizziness (n = 4) and dyspepsia (n = 3).

CONCLUSIONS

The data suggest that sildenafil is well tolerated in postmenopausal women with sexual dysfunction. Overall sexual function did not improve significantly, although there were changes in vaginal lubrication and clitoral sensitivity. The role of sildenafil in treating sexual dysfunction in various cohorts of women remains to be determined.

Interstitial thermometry in men undergoing electrovaporization of the prostate

BACKGROUND AND OBJECTIVES

Transurethral electrovaporization of the prostate (TVP) has been utilized increasingly in the therapeutic management of benign prostatic hyperplasia (BPH). The temperature profile within both prostatic and periprostatic tissue has been presented as a parameter of safety in various preliminary studies. This prospective study measured interstitial temperature during TVP in both the prostate and the surrounding tissue of 18 men.

METHODS

These 18 men undergoing TVP had three interstitial thermocouple probes placed under ultrasound guidance. Probes were positioned in the rectal wall and at the 5 and 7 o'clock position of the prostate capsule. A fourth probe was placed within 1 mm of the area of vaporization to determine "lesion" temperature. Temperature was measured at baseline and at 15-minute intervals as TVP was performed utilizing the VaporTrode at 240 to 280 W with a Valley Lab Force 40 generator.

RESULTS

The maximum temperature variability was 1.9 degrees C. The temperature within 0.5 mm of the area of vaporization was >100 degrees C. These results were independent of the temperature of the irrigating solution.

CONCLUSIONS

These results provide compelling evidence that high vaporization temperatures do not affect surrounding prostatic tissue. In theory, the risk of injury to either the rectum or the neurovascular bundle during TVP should be extremely low.

Is the ratio of transition zone to total prostate volume higher in African-American men than in their Caucasian or Hispanic counterparts?

OBJECTIVE

To determine if the transition zone index (TZI, the ratio between transition zone volume, TZV, and total prostate volume, as estimated by transrectal ultrasonography, TRUS) differs among African-American (AA), Hispanic and Caucasian men.

PATIENTS AND METHODS

The study group consisted of 104 age-matched men (36 AA, 34 Hispanic and 34 Caucasian) with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH). A control group of 55 age-matched men, equally distributed among the three ethnic groups, but with no BPH (based on a digital rectal examination) were also evaluated. All men completed the International Prostate Symptom Score (IPSS) and a measurement of peak urinary flow rate (Qmax), prostate volume and TZV (by TRUS) and the TZI calculated.

RESULTS

In the control group, the mean prostate volume was 20.9, 18.2 and 19.8 mL, the TZV 6.9, 4.9, and 5.4 mL and the TZI 0.33, 0.27 and 0.25 for AA, Hispanic and Caucasian men, respectively. The TZI was significantly higher in AA than in either Hispanic or Caucasian men (P < 0.03). Although there were no differences in prostate volume among the three ethnic groups with BPH, the mean (SD) TZV and TZI were significantly higher in AA men than in either their Hispanic or Caucasian counterparts, at 15.8 (7.6) mL and 0.43, 12.7 (8.1) mL and 0.37, and 13.8 (6.7) mL and 0.37, respectively. For all groups, age correlated with the IPSS (r = 0.22, P < 0.04); the mean (SD) IPSS was 14.3 (5.7), 10.2 (2.9) and 10.6 (4.9) for AA, Hispanic and Caucasian men, respectively. There was no correlation between the IPSS and either prostate volume or TZV, but there was a strong correlation with the TZI (r = 0.29, P < 0.01), regardless of race.

CONCLUSIONS

These results suggest that AA men have a greater TZV and a higher TZI than their Caucasian or Hispanic counterparts, regardless of the presence of lower urinary tract symptoms. Studies are underway to determine if these differences are clinically significant and correlate with either subjective and/or objective parameters of BPH.

Combination therapy using oral alpha-blockers and intracavernosal injection in men with erectile dysfunction

OBJECTIVES

Intracavernosal injection with a combination of agents (ie, phentolamine plus papaverine or alprostadil) has been used in an effort to increase efficacy and reduce side effects compared with single agents. The purpose of this pilot study was to determine the potential role of oral alpha-blockers in combination with intracavernosal therapy in men with erectile dysfunction, for whom intracavernosal therapy alone failed.

METHODS

Thirty-eight consecutive men with moderate to severe erectile dysfunction on the basis of history and examination and with minimal or no therapeutic response to intracavernosal alprostadil injection therapy were evaluated. All patients received daily doxazosin titrated to 4 mg over 3 weeks in combination with intracavernosal therapy as needed for 12 weeks. Efficacy was assessed at 4, 8, and 12 weeks after doxazosin titration using the 1 5-item, self-administered International Index of Erectile Function (IIEF) and a global efficacy question (GEQ: Did treatment improve your erections?).

RESULTS

For the group, the mean baseline IIEF score before therapy was 29.7+/-9.8. After intracavernosal therapy (mean dose 34.7+/-7.3 microg), IIEF improved to 36.1+/-1 1.4 (17.7%). After addition of doxazosin, IIEF improved to 48.6+/-13.4, 46.4+/-10.9, and 51.5+/-14.3 at 4, 8, and 12 weeks, respectively (P < 0.01). The GEQ response improved from 25.7% at baseline to 81.4% at 12 weeks. Overall 22 (57.9%) of 38 patients with the combined regimen had a significant (more than 60% improvement in IIEF) therapeutic response.

CONCLUSIONS

The addition of an oral alpha-blocker may have a beneficial effect in patients with erectile dysfunction for whom intracavernosal therapy alone fails. The synergistic effects of vascular dilation and blockade of sympathetic inhibition may explain this response. The potential role of alpha-blockade in synergy with other agents designed to treat erectile dysfunction remains to be determined.

Intermittent alpha-blocker therapy in the treatment of men with lower urinary tract symptoms

OBJECTIVES

To determine the safety and efficacy of intermittent alpha-blocker therapy in men with lower urinary tract symptoms (LUTS) in a prospective study. Alpha-blockers have been demonstrated to be safe and effective in the treatment of men with LUTS. To date, the role of varying dosing regimens in responding patients has not been well studied.

METHODS

Men with LUTS were entered into this prospective open label, parallel, randomized trial. In phase 1, patients were treated with alfuzosin, 2.5 mg three times daily for 3 months. In phase 2, those patients who had a significant therapeutic response were randomized into one of the following three groups: (1) maintenance of alfuzosin; (2) alfuzosin every other day; and (3) discontinuation of alfuzosin (ie, no treatment). Patients were followed up for a total of 6 months. Parameters of evaluation included the International Prostate Symptom Score (IPSS), global satisfaction, peak urinary flow rate (Qmax), and adverse events.

RESULTS

At 3 months, there were 79 patients who were categorized as having obtained a therapeutic response: IPSS decreased to 7.6 +/- 3.2 and Qmax increased to 11.3 +/- 2.9 mL/s. After randomization, IPSS was 7.1 +/- 2.9 and 6.5 +/- 2.5 for group 1; 6.5 +/- 3.2 and 6.7 +/- 2.1 for group 2; and 11.4 +/- 4.8 and 12.3 +/- 4.9 for group 3 at 3 and 6 months, respectively. Qmax was 12.7 +/- 4.8 and 11.7 +/- 5.2 mL/s for group 1; 12.2 +/- 3.9 and 11.9 +/- 3.7 mL/s for group 2; and 9.7 +/- 2.5 and 9.3 +/- 2.1 mL/s for group 3 at 3 and 6 months, respectively. Global satisfaction at 6 months was the same for groups 1 and 2. There were no differences in adverse events among the three groups.

CONCLUSIONS

In men with LUTS who responded to alfuzosin, changing the dosing regimen from daily to once every other day resulted in similar efficacy and safety at 3 and 6 months. By contrast, complete cessation of alfuzosin resulted in recurrence of both symptoms and impaired urinary flow. These data provide evidence that in responding patients, intermittent alpha-blocker therapy may be a reasonable therapeutic regimen. The role of intermittent alpha-blocker therapy using other agents, as well as in a large cohort of men with LUTS, remains to be determined.

Significant correlation of the American Urological Association symptom score and a novel urodynamic parameter: detrusor contraction duration

PURPOSE

Various investigators have reported the lack of specificity of the American Urological Association (AUA) symptom score and its poor correlation with urodynamic parameters. A retrospective study was performed to ascertain the correlation of the AUA symptom score with various urodynamic parameters, including detrusor contraction duration.

MATERIALS AND METHODS

The urodynamic records of 120 consecutive patients with moderate (scores 8 to 19) or severe (scores greater than 19) symptoms were retrospectively analyzed to ascertain if the AUA symptom score correlated with the urodynamic parameters of maximum detrusor pressure, detrusor pressure at maximum flow, compliance, involuntary detrusor contractions and, a novel parameter, detrusor contraction duration.

RESULTS

There were 63 men (mean age 59.7 years) and 57 women (mean age 58.8 years). Mean AUA symptom score plus or minus standard deviation was 17.8 +/- 3.7 and 15.4 +/- 2.9, respectively. There was no correlation between any urodynamic parameter and symptoms in women. In men increasing symptoms were associated with worsening urodynamic parameters. The 2 parameters that had the greatest correlation with symptom severity were incidence of involuntary detrusor contractions (r = 0.56, p < 0.006) and detrusor contraction duration (r = 0.61, p < 0.003). Furthermore, increasing incidence of involuntary detrusor contractions was associated with increasing irritative symptoms, while increasing detrusor contraction duration was correlated with increasing obstructive symptoms. Detrusor contraction duration was correlated with symptom severity and urodynamic outlet obstruction in men.

CONCLUSIONS

These data demonstrated that the AUA symptom score correlates with certain urodynamic parameters. Furthermore, this correlation occurs in men in contrast to women despite similar AUA symptom scores. In addition, increasing detrusor contraction duration is associated with worsening symptoms and may herald worsening obstruction. Further prospective studies are underway to determine the prognostic value of these urodynamic parameters in altering ultimate outcomes of treatment.