Biomarker analysis of the phase II JO25567 study comparing erlotinib with or without bevacizumab in first-line advanced EGFR+non-small-cell lung cancer

Background

Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs), such as erlotinib, are standard-of-care for patients with EGFR mutation-positive non-small-cell lung cancer (NSCLC), but most patients progress within 1 year. Previously, we demonstrated that erlotinib plus bevacizumab (EB) improved progression-free survival (PFS) in patients with EGFR-positive non-squamous NSCLC in the randomized JO25567 study. To understand this effect, we conducted comprehensive exploratory biomarker analyses.

Methods

Using blood and tissue specimens from patients enrolled in the JO25567 study, angiogenesis-related serum factors, plasma vascular endothelial growth factor-A (pVEGFA), angiogenesis-related gene polymorphisms, and messenger RNAs (mRNAs) in tumor tissue were analyzed. Interactions between potential predictors and treatment effect on PFS were analyzed in a Cox model. Continuous variable predictors were evaluated by multivariate fractional polynomial interaction methodology and subpopulation treatment effect pattern plotting (STEPP).

Results

Overall, 152 patients treated with EB or erlotinib alone (E) were included in the analysis. Among 26 factors analyzed in 134 baseline serum samples, high follistatin and low leptin were identified as potential biomarkers for worse and better outcomes with EB, with interaction P values of 0.0168 and 0.0049, respectively. Serum concentrations of 12 angiogenic factors were significantly higher in patients with high follistatin. Low pVEGFA levels related to better outcomes with EB, interaction P=0.033. VEGF-A165a was the only predictive tissue mRNA, showing a similar trend to pVEGFA. No valid results were obtained in 13 polymorphisms of eight genes.

Conclusions

EB treatment showed better treatment outcomes in patients with low pVEGFA and serum leptin, and limited efficacy in patients with high serum follistatin.

Bladder pain induced by prolonged peripheral alpha 1A adrenoceptor stimulation involves the enhancement of transient receptor potential vanilloid 1 activity and an increase of urothelial adenosine triphosphate release

AIM

Pathophysiological mechanisms of chronic visceral pain (CVP) are unknown. This study explores the association between the sympathetic system and bladder nociceptors activity by testing the effect of a prolonged adrenergic stimulation on transient receptor potential vanilloid 1 (TRPV1) activity and on urothelial adenosine triphosphate (ATP) release.

METHODS

Female Wistar rats received saline, phenylephrine (PHE), PHE + silodosin, PHE + naftopidil or PHE + prazosin. TRPV1 knockout and wild-type mice received saline or PHE. Visceral pain behaviour tests were performed before and after treatment. Cystometry was performed, during saline and capsaicin infusion. Fos immunoreactivity was assessed in L6 spinal cord segment. Human urothelial ATP release induced by mechanical and thermal stimulation was evaluated.

RESULTS

Subcutaneous, but not intrathecal, PHE administration induced pain, which was reversed by silodosin, a selective alpha 1A adrenoceptor antagonist, but not by naftopidil, a relatively selective antagonist for alpha 1D adrenoceptor. Silodosin also reversed PHE-induced bladder hyperactivity and L6 spinal cord Fos expression. Thus, in subsequent experiments, only silodosin was used. Wild-type, but not TRPV1 knockout, mice exhibited phenylephrine-induced pain. Capsaicin induced a greater increase in voiding contractions in PHE-treated rats than in control animals, and silodosin reversed this effect. When treated with PHE, ATP release from human urothelial cells was enhanced either by mechanical stimulation or by lowering the thermal threshold of urothelial TRPV1, which becomes abnormally responsive at body temperature.

CONCLUSION

This study suggests that the activation of peripheral alpha 1A adrenoceptors induces CVP, probably through its interaction with TRPV1 and ATP release.

Antigen-dependent internalization is related to rapid elimination from plasma of humanized anti-HM1.24 monoclonal antibody

Anti-HM1.24 monoclonal antibody (AHM) is a humanized anti-HM1.24 monoclonal antibody that binds to the HM1.24 antigen, a protein that is highly expressed in multiple myeloma cells. The pharmacokinetics of AHM was determined in experiments in which AHM was administered intravenously to cynomolgus monkeys. The area under the plasma concentration-time curve increased by more than the dose ratio between 2 and 20 mg/kg, and nonlinear pharmacokinetics was observed. The elimination half-life of AHM from the plasma was 7.56 h at 2 mg/kg and 28.6 h at 20 mg/kg, which was shorter than that observed for other therapeutic humanized monoclonal antibodies, such as trastuzumab and bevacizumab. Although antibodies to AHM were detected in all monkeys on or after 10 days of administration, there was a temporal disassociation between the rapid elimination of AHM and the appearance of anti-AHM antibodies. HM1.24 antigen-dependent internalization and intracellular metabolism of AHM were investigated in peripheral blood mononuclear, KPMM2, and U937 cells. In all cases, AHM was rapidly internalized from the cell surface; this internalization was significantly prevented by phenylarsine oxide in KPMM2 cells, an inhibitor of receptor-mediated endocytosis, and the internalized AHM was subsequently degraded within the cells. Furthermore, immunofluorescence microscopy revealed that the internalized AHM is delivered to and degraded in late endosomes/lysosomes. Taken together, our results suggest that the rapid elimination of AHM from plasma in monkey is due to HM1.24 antigen-dependent internalization followed by delivery to the lysosomes.

The safety, tolerability, pharmacokinetics, and pharmacodynamics of single oral doses of CH4987655 in healthy volunteers: target suppression using a biomarker

PURPOSE

CH4987655 (RO4987655) is an orally active and highly selective small-molecule MEK inhibitor. It potently inhibits mitogen-activated protein kinase signaling pathway activation and tumor cell growth, with an in vitro IC(50) of 5.2 nmol/L for inhibition of MEK1/2. Single-agent oral administration of CH4987655 resulted in complete tumor regressions in xenograft models.

EXPERIMENTAL DESIGN

All 40 subjects received a single oral dose followed by 72 hrs of pharmacokinetic, pharmacodynamic, and safety/tolerability assessments. The pharmacodynamics were measured by changes in phosphorylated extracellular signal-regulated kinase (pERK) levels in a surrogate tissue peripheral blood mononuclear cells ex vivo stimulated by PMA.

RESULTS

Doses of 0.5, 1, 2, 3, and 4 mg were safe and well tolerated. No clinically significant safety event was observed. A total of 26 adverse events (n = 15) were reported: 21 mild, 5 moderate, and none severe. Moderate adverse events were experienced by one subject at 1 mg (autonomic nervous system imbalance) and three subjects at 4 mg (diarrhea, abdominal pain, autonomic nervous system and acne). CH4987655 was rapidly absorbed with a t(max) of approximately 1 h. Exposures were dose proportional from 0.5 to 4 mg. The disposition was biphasic with a terminal t(1/2) of approximately 25 hr. Intersubject variability was low, 9% to 23% for C(max) and 14% to 25% for area-under-the-curve (AUC). pERK inhibition was exposure dependent and was greater than 80% inhibition at higher doses. The pharmacokinetic-pharmacodynamic relationship was characterized by an inhibitory E(max) model (E(max) approximately 100%; IC(50) 40.6 ng/mL) using nonlinear mixed-effect modeling.

CONCLUSIONS

A significant extent of pERK inhibition was achieved for a single dose that was considered to be safe and well tolerated in healthy volunteers.

The role of capsaicin-sensitive afferents in autonomic dysreflexia in patients with spinal cord injury

OBJECTIVES

To determine whether capsaicin-sensitive nerves in the bladder form the afferent limb involved in autonomic dysreflexia (AD) in patients with spinal cord injury (SCI).

PATIENTS AND METHODS

Seven men with SCI (five cervical cord, two thoracic cord) with AD and detrusor hyper-reflexia (DH) were enrolled. Under general anaesthesia, capsaicin solution (100 mL of 2 mmol/L in 10% ethanol) was instilled in the bladder and retained for 30 min. The patients were assessed by medium-fill cystometry (CMG) just before and 50 min after the capsaicin treatment. Intra-arterial blood pressure (BP) and heart rate were monitored continuously throughout the procedure; 10% ethanol was instilled before capsaicin treatment in four patients as a control. Serum catecholamines were measured during bladder filling and capsaicin treatment, and the blood ethanol concentration also measured after instillation in all patients. The CMG with concomitant monitoring of BP and heart rate was repeated 1 week, 1, 3, 6, 12 and 24 months after instillation. In two patients the instillations were repeated 5 and 12 months after the first because of recurrence of DH. Urodynamic variables assessed were maximum cystometric capacity (MCC), maximum amplitude of uninhibited detrusor contraction (UICmax), the bladder capacity at 40 cmH2O detrusor pressure (Cdp40) and a systolic BP of> 140 mmHg or diastolic BP of> 90 mmHg (C(HT)).

RESULTS

There was an increase in BP and a decrease in heart rate in all patients during bladder filling before capsaicin treatment. Instillation of capsaicin produced a significant increase in both systolic and diastolic BP and a significant decrease in heart rate. The maximum cardiovascular effects were at 5-10 min after instillation and gradually returned to baseline within 40 min. The vehicle had negligible effects on either BP or heart rate. After capsaicin treatment, the responses of BP and heart rate to bladder distension were significantly reduced. Both serum catecholamine values and the blood ethanol concentration remained within normal limits. The mean (range) follow-up after the first treatment was 15 (6-30) months. One month after treatment all seven patients became continent and their episodes of AD became negligible and well tolerable between catheterizations (for 3-4 h); the effects lasted for >or= 3 months in all. MCC was significantly increased at 4 weeks and 3 months, and UICmax significantly decreased at 4 weeks after treatment. Both mean Cdp40 and C(HT) increased 1 week, 1 and 3 months after treatment. Two patients received a second instillation, and have been continent with no symptomatic AD for 6 and 24 months. The remaining five patients have been continent with no symptomatic AD for 6-12 months.

CONCLUSION

These results indicate that intravesical capsaicin, but not the vehicle, acutely triggers AD in patients with SCI, suggesting involvement of bladder capsaicin- sensitive afferents in AD in these patients. The results also suggest that intravesical capsaicin may be a promising therapy for both AD and DH in such patients. Further long-term follow-up studies are needed to evaluate the duration of its effect.

[Significance of PSA-density: analysis in PSA gray zone cases]

We studied the sensitivity and specificity of digital examination and prostate specific antigen (PSA) density to detect prostatic cancer in those patients whose PSA values are in a range of 4 to 10 ng/ml or in a gray zone. Sextant prostate biopsy revealed 14 cases (17.2%) of prostatic cancer out of 81 PSA gray zone cases. The sensitivity of digital examination was 38.5%, and the specificity was 73.0%. If we use 0.29 as a PSA density cut-off value, the sensitivity was 70.0%, and the specificity was 70.0%. At a PSA density cut off value of 0.22, we could obtain 90% sensitivity, which was considered applicable for detection of cancer in PSA gray zone cases.

The serous-lined tunnel principle for urinary reconstruction: a more rational method

OBJECTIVE

To examine the feasibility of using the serous-lined-tunnel principle for orthotopic neobladder, continent cutaneous diversion and ureteric replacement by an intestinal segment. Patients and methods We created: (i) an orthotopic ileal neobladder using the serous-lined technique for antirefluxing ureteric implantation in 16 patients; (ii) a continent ileal pouch, adopting the principle for continent-valve construction and for ureteric implantation, in 10 patients (another patient with a failed continent valve underwent revision using an adaptation of this principle; and (iii) by applying the same principle an ileal ureter with a proximal antirefluxing mechanism was constructed in two patients (with lower ureteric cancer), and total replacement of the ureter by a tubular segment of the colon in association with a continent transverse colon pouch in one irradiated patient.

RESULTS

In all, 52 ureters implanted into ileal neobladders or continent pouches functioned well, with neither obstruction nor reflux; 11 continent valves functioned well with no incontinence. Two patients with ileal ureters showed no ileo-ureteric reflux and had less hydronephrosis than before surgery. The tubularized ureter provided a unidirectional flow into the pouch. Conclusion Ureteric reimplantation and continent valve formation achieved by adopting the serous-lined tunnel principle provided satisfactory results. The versatility of the principle is apparent in the present experience and the creative application of the serous-lined tunnel principle should be possible in urinary reconstruction.

Role of dopamine D1 and D2 receptors in the micturition reflex in conscious rats

To clarify the role of dopamine D1 and D2 receptors in the volume-induced micturition reflex, conscious, female rats were investigated cystometrically before and after intravenous administration of SKF 38393 (a selective D1 receptor agonist), SCH 23390 (a selective D1 receptor antagonist), quinpirole (a selective D2 receptor agonist), and remoxipride (a selective D2 receptor antagonist). The effect of quinpirole was also investigated in the presence of remoxipride. Intravenous administration of SKF 38393 (0.01-3.0 mg/kg) did not affect any cystometric parameters investigated. On the other hand, SCH 23390 (0.1-1.0 mg/kg i.v.) reduced bladder capacity and micturition volumes and increased the micturition pressure in a dose-dependent manner. Quinpirole (0.01-0.1 mg/kg) given intravenously, dose-dependently decreased bladder capacity and micturition volumes. Pre-treatment with remoxipride (1.0 mg/kg i.v.) significantly attenuated the effect of quinpirole (0.1 mg/kg i.v.). Remoxipride (0.1-1.0 mg i.v.) itself did not cause any significant changes in the cystometric parameters. These results suggest that in conscious rats, D1 receptors tonically inhibit the micturition reflex and that D2 receptors are involved in facilitation of the micturition reflex. It may be speculated that detrusor hyperreflexia associated with Parkinson's disease results from activation failure of D1 receptors and that administration of D2 receptor agonists might worsen the condition.

A rat model for investigation of bladder dysfunction associated with demyelinating disease resembling multiple sclerosis

Myelin basic protein (MBP) can be used as an antigen for inducing experimental allergic encephalomyelitis (EAE). In various studies, EAE animals have been used as an experimental model of demyelinating diseases. The aim of this study was to determine whether EAE, induced by MBP in rats, can be useful for investigation of bladder dysfunction associated with demyelinating disease. Female Lewis rats were used. In Study 1, the time course of behavioral and cystometric changes were observed consecutively after MBP sensitization. In Study 2, the correlations between behavioral, cystometric, and histologic abnormalities were studied. The degree of paralysis and histologic findings were evaluated. In Study 1, transient hind limb paralysis was observed in all rats. Cystometric findings were characterized by three different patterns: 1) detrusor areflexia (DA), 2) detrusor hyperactivity (DH), and 3) normal. Ten (77%) of the 13 rats given MBP showed bladder dysfunction, including DA (seven), DA/DH (two) and DH (one). Study 2 showed DA in 10 rats, DH in one, and normal findings in nine animals. The difference in degree of paralysis between the DA and the cystometrically normal animals was statistically significant (P<0.01). The mean value of the degree of inflammation in the spinal cord (L6-S1) in the DA group was significantly (P<0.05) higher than that in the cystometrically normal group. The degrees of paralysis and spinal inflammation were weakly correlated (R = 0.47, P = 0.05). The present rat model seems useful for studies of bladder dysfunction associated with spinal myelitis/demyelinating diseases.

[Laparoscopic adrenalectomy at Shinshu University School of Medicine]

We report our experience with transperitoneal laparoscopic adrenalectomy in 26 cases (mean age 45 years). We experienced primary aldosteronism in 19 cases, Cushing syndrome in 6 cases and non-functioning tumor in one case. There was no significant difference in the operation time between right and left, men and women, primary aldosteronism and Cushing syndrome. The blood loss decreased with training. There were no severe complications during and after the operation. The weight of the resected adrenal glands increased. The blood loss decreased significantly compared with the open surgery. Transperitoneal laparoscopic adrenalectomy is becoming the safe and standard surgery for the adrenal gland tumor, and the number of suitable cases for this procedure is expected to increase in the future.

Relaxant effects of isoproterenol and selective beta3-adrenoceptor agonists on normal, low compliant and hyperreflexic human bladders

PURPOSE

We compared the relaxant effects of the stimulation of beta-adrenoceptors with isoproterenol and of drugs selective for beta-adrenoceptor subtypes in detrusor preparations from patients with normal and neurogenic bladder, respectively.

MATERIALS AND METHODS

We studied in vitro preparations of a cystometrically normal, low compliant and hyperreflexic bladder from 45, 26 and 7 patients, respectively.

RESULTS

Isoproterenol relaxed concentration dependently and with the same potency as detrusor preparations obtained from normal and neurogenic bladders. In 37 normal detrusor, 25 low compliant and 7 hyperreflexic cases pD2 values were 6.36, 6. 25 and 6.38, respectively. Maximal relaxation did not differ significantly among the 3 groups (about 80% of 10-5 M. forskolin induced relaxation). Neither the beta1-/beta2-adrenoceptor agonist dobutamine nor the beta2-adrenoceptor agonist procaterol produced any significant relaxation of preparations from the 3 groups at a concentration of up to 10-5 M. At a concentration of 10-4 M. the preparations were relaxed but neither of these effects reached a maximum. BRL37344A and CL316243, selective beta3-adrenoceptor agonists and CGP-12177A (a selective beta3-adrenoceptor partial agonist and beta1-/beta2-adrenoceptor antagonist) relaxed detrusor preparations from the normal, low compliant and hyperreflexic groups when applied at concentrations greater than 10-6 M. For each agonist the pD2 value did not differ significantly among the 3 groups.

CONCLUSIONS

beta-adrenoceptor stimulation is an effective way of relaxing the human detrusor and the effect is similar in normal and neurogenic bladders. A major portion of the relaxant effect of isoproterenol is mediated via beta3-adrenoceptor stimulation. Clinical trials may reveal whether this method is useful for treating bladder overactivity.

Characterization of beta-adrenoceptor subtypes in the ferret urinary bladder in vitro and in vivo

In the present study, the beta-adrenoceptor subtypes distributed in the detrusor of the ferret were investigated in functional experiments in vitro and in vivo using a variety of beta-adrenoceptor agonists and antagonists. All the beta-adrenoceptor agonists tested relaxed the isolated detrusor strip, the rank order of potency being (+/-)-(R*, R*)-[4-[2-[[2-(3-chlorophenyl)-2-hydroxyethyl]-amino]propyl]phenoxy]- acetic acid sodium (BRL 37344A)>(+/-)-4-(3-t-butylamino-2-hydroxypropoxy) benzimidazol-2-one (CGP-12177A), isoprenaline and (R, R)-5-[2-[[2-(3-chlorophenyl)-2-hydroxyethylamino]propyl]-1, 3-benzodioxole-2,2-dicarboxylate (CL 316,243)>dobutamine and procaterol. In antagonist experiment, 3-(2-allylphenoxy)-1-[(1S)-1,2, 3,4-tetrahydro-naphth-1-ylamino]-(2S)-2-propanol hydrochloride (SR 58894A), but neither 2-hydroxy-5(2-((2-hydroxy-3-(4-((1-methyl-4-trifluoromethyl)1H-imidaz ole-2-yl)-phenoxy)propyl)amino)ethoxy)-benzamide monomethane sulphonate (CGP-20712A) nor erythro-(+/-)-1-(7-methylindan-4-yloxy)-3-isopropylaminob utan-2-ol hydrochloride (ICI-118,551), caused a rightward shift of the concentration-relaxation curve for isoprenaline. In in vivo experiments, isoprenaline and CL 316,243 each reduced bladder pressure in a dose-dependent manner. CL 316,243 was the only drug that did not produce any significant influences on blood pressure and heart rate at doses that reduced bladder pressure. The present functional study provides the first evidence that relaxation of the ferret detrusor by beta-adrenoceptor activation is mediated mainly via the beta(3)-adrenoceptor, as in the human detrusor.

Improvement of urological-management abilities in individuals with tetraplegia by reconstructive hand surgery

OBJECTIVE

To evaluate whether reconstructive hand surgery could improve the ability of tetraplegic patients to perform clean intermittent self-catheterization (CIC).

MATERIALS AND METHODS

The subjects were patients with complete traumatic tetraplegia admitted to the Nagano Rehabilitation Center between 1977 and 1996. A total of 63 subjects were included in this study with an age range of 18-73 years (mean 38.2 years). Reconstructive hand surgery was performed on 44 hands (28 cases). Current urological conditions were assessed by interview or mail questionnaire.

RESULTS

Fifty-one per cent (22/43) of the patients with C6 level of tetraplegia and 86% (12/14) of those with C7 or C8 neurological level of injury could perform CIC independently and only one subject needed assisted CIC.

CONCLUSION

CIC is the preferred option for people with tetraplegia. Reconstructive hand surgery is thus recommended to make urological management more independent for a selected group of people with tetraplegia.

Continent ileal pouch using the serous-lined principle

OBJECTIVES

The flap valve principle is not easily applicable to an ileal pouch since a submucosal tunnel is difficult to create. We attempted to construct an ileal pouch with an umbilical stoma applying the serous-lined principle for both ureteral implantation and construction of a continent valve.

METHODS

In 9 patients, a continent pouch with an umbilical stoma was created entirely from an ileal segment. Adopting the serous-lined principle, a continent valve was created by appendix in 2 cases, tapered ileum in 3 cases, and reconfigured ileum in 4 cases. These were implanted into the anterior suture line of the pouch and embedded into the serous-lined tunnel formed by the pouch wall.

RESULTS

Patients can catheterize the pouch easily with a 14-Fr catheter. Postoperatively, pouch capacity is over 400 ml with complete continence.

CONCLUSION

This technique can provide a simple and effective continent ileal pouch facilitating umbilical anastomosis. As a continent valve, the reconfigured ileal segment seems most useful for application of the serous-lined principle.

Role of the beta(3)-adrenoceptor in urine storage in the rat: comparison between the selective beta(3)-adrenoceptor agonist, CL316, 243, and various smooth muscle relaxants

The objective of this study was to compare the effects of a beta(3)-adrenoceptor (beta(3)-AR) agonist on bladder function and cardiovascular parameters in rats with those of several drugs that act on smooth muscle. CL316,243 (beta(3)-AR agonist), isoproterenol (nonselective beta-AR agonist), procaterol (beta(2)-AR agonist), verapamil (Ca(2+) antagonist), and papaverine (antispastic drug) each evoked a concentration-dependent relaxation of the detrusor in vitro. They also reduced bladder pressure in anesthetized rats, the beta-AR agonists apparently being more potent than the other drugs. Atropine (muscarinic antagonist) neither relaxed detrusor strips nor reduced bladder pressure. In anesthetized rats, CL316,243 and atropine each had only a slight influence on blood pressure and heart rate, but isoproterenol, procaterol, verapamil, and papaverine significantly affected cardiovascular function at the same dose range as that required to reduce bladder pressure. In cystometry experiments, CL316,243 (10 microg/kg i.v.), verapamil (1 mg/kg i.v.), and papaverine (1 mg/kg i.v.) all significantly prolonged micturition interval and increased bladder capacity, but did not change the residual urine volume after a micturition contraction. Procaterol (100 microg/kg i.v.) prolonged the micturition interval and increased both bladder capacity and residual urine volume (all significantly). Atropine (100 microg/kg i.v.) reduced micturition pressure and increased residual urine volume (both significantly). Because the human detrusor, like the rat detrusor, relaxes on beta(3)-AR stimulation, we conclude that this beta(3)-AR agonist may have potential in pollakiuria (frequent urination) as a therapeutic agent without cardiovascular side effects.

Role of supraspinal tachykinins for micturition in conscious rats with and without bladder outlet obstruction

In order to clarify the role of supraspinal tachykinins in volume-induced micturition and in bladder hyperactivity secondary to bladder outlet obstruction, conscious, normal, female Sprague-Dawley rats were investigated cystometrically before and after intracerebroventricular administration of RP 67,580, a selective antagonist of neurokinin (NK)-1 receptors and/or SR 48,968, a selective antagonist of NK-2 receptors. In normal rats, RP 67,580 or SR 48,968, at a dose of 2 nmol, caused no marked changes in cystometric parameters. Higher doses (up to 20 nmol) caused dose-dependent decreases in micturition pressure and increased bladder capacity, micturition volume and residual urine. A combination of the two drugs, each at a dose of 2 nmol, significantly decreased micturition pressure and increased bladder capacity. In rats with bladder outlet obstruction, the antagonists suppressed micturition dose-dependently, producing urinary retention in two out of eight rats already at a dose of 2 nmol. At a dose of 20 nmol, dribbling incontinence, due to urinary retention, was seen in five out of ten rats. A combination of the two drugs (2 nmol of each drug) caused urinary retention in three out of nine animals and significantly increased bladder capacity, micturition volume and residual volume. The results suggest that outflow obstruction in rats increases the effects of tachykinins in supraspinal structures involved in micturition, and that antagonism of supraspinal NK-receptors may depress the micturition reflex. Whether or not this implies that supraspinal NK-receptors can be targets for drugs aimed for inhibiting bladder hyperactivity in humans should be explored.

Optimization of orthotopic colonic bladder: implantation of tubularized mucosal flap from colonic segment into demucosalized urethra

If the urethral mucosa of a female could be replaced by another mucosa, one could augment the indication for orthotopic reconstruction of the bladder. A mucosal replacement technique for the female urethra is reported. A colonic mucosal flap formed from a colonic bladder was used in a patient with bladder cancer for whom cystectomy was indicated. For 3 years after the surgery, the patient has maintained satisfactory voiding and urethral function. There has been no evidence of a recurrence. The orthotopic bladder with the mucosal replacement technique can be applied to female patients who have a bladder cancer with a high risk of urethral recurrence.

Role of supraspinal tachykinins for volume- and L-dopa-induced bladder activity in normal conscious rats

To clarify the roles of tachykinins in volume-induced micturition and in bladder hyperactivity, presumed to originate from supraspinal structures, normal, female Sprague-Dawley rats were investigated cystometrically before and after intracerebroventricular (i.c.v) administration of RP 67,580, a selective antagonist of NK-1 receptors, and/or SR 48,968, a selective antagonist of NK-2 receptors. The effects of RP 67,580 and SR 48,968 on intra-peritoneal (i.p.) L-dopa-induced bladder hyperactivity were also investigated. I.c.v. administration of RP 67,580 (20 nmol) SR 48,968 (20 nmol) suppressed micturition. Combination of i.c.v. RP 67, 580 (2 nmol) and SR 48,968 (2 nmol) significantly decreased micturition pressure (18%), and increased bladder capacity (26%), micturition volume (18%), and residual volume (223%). In rats pretreated with i.p. carbidopa 50 mg/kg, i.p. L-dopa 50 mg/kg caused bladder hyperactivity that was attenuated by the combination of i.c. v. RP 67,580 (2 nmol) and SR 48,968 (2 nmol). The results suggest that tachykinins, via stimulation of NK receptors in supraspinal structures, are involved in both volume and L-dopa-induced stimulation of bladder activity. This may imply that tachykinins can influence both the supraspinal and spinal control of the urinary bladder. It also implies that supraspinal NK receptors are a possible target for drugs aimed for elimination of bladder hyperactivity mediated via these pathways. Neurourol. Urodynam. 19:101-109, 2000.

Role of supraspinal tachykinins for volume- and L-dopa-induced bladder activity in normal conscious rats

To clarify the roles of tachykinins in volume-induced micturition and in bladder hyperactivity, presumed to originate from supraspinal structures, normal, female Sprague-Dawley rats were investigated cystometrically before and after intracerebroventricular (i.c.v) administration of RP 67,580, a selective antagonist of NK-1 receptors, and/or SR 48,968, a selective antagonist of NK-2 receptors. The effects of RP 67,580 and SR 48,968 on intra-peritoneal (i.p.) L-dopa-induced bladder hyperactivity were also investigated. I.c.v. administration of RP 67,580 (20 nmol) SR 48,968 (20 nmol) suppressed micturition. Combination of i.c.v. RP 67, 580 (2 nmol) and SR 48,968 (2 nmol) significantly decreased micturition pressure (18%), and increased bladder capacity (26%), micturition volume (18%), and residual volume (223%). In rats pretreated with i.p. carbidopa 50 mg/kg, i.p. L-dopa 50 mg/kg caused bladder hyperactivity that was attenuated by the combination of i.c. v. RP 67,580 (2 nmol) and SR 48,968 (2 nmol). The results suggest that tachykinins, via stimulation of NK receptors in supraspinal structures, are involved in both volume and L-dopa-induced stimulation of bladder activity. This may imply that tachykinins can influence both the supraspinal and spinal control of the urinary bladder. It also implies that supraspinal NK receptors are a possible target for drugs aimed for elimination of bladder hyperactivity mediated via these pathways. Neurourol. Urodynam. 19:101-109, 2000.

Functional electrical stimulation for detrusor instability

The clinical efficacy of functional electrical stimulation (FES) for female detrusor instability (DI) is reviewed. Various types of FES methods (including anogenital long-term stimulation, short-term maximal stimulation, implantable stimulation and transcutaneous stimulation) have been reported. The therapeutic effects of these approaches were similar: the percentage of patients improved has been reported to be in the range 50%-90%. FES for female DI is a non-destructive procedure with a curative effect and very few side effects. This curative effect (re-education) is a major benefit of FES.

[A case of transitional cell carcinoma presenting as rupture of a renal arteriovenous malformation]

A 76-year-old man was seen at this hospital for the treatment of asymptomatic gross hematuria. Retrograde pyelography revealed a filling defect in the left lower calyx. The diagnosis was left renal pelvic carcinoma by urinary cytology. The patient underwent left nephrouretectomy with partial cystectomy. Hemosiderin accumulation on histological examination demonstrated an arteriovenous malformation in the left lower calyx. Transitional cell carcinoma was confirmed apart from the arteriovenous malformation, and no relation between the two was seen. These findings suggest the coexistence of a renal arteriovenous malformation with a renal pelvic and ureteral carcinoma. Hematuria was due probably to rupture of the renal arteriovenous malformation.

Simple anti-reflux uretero-ileal anastomosis: an experimental study in dogs

PURPOSE

To develop more simple and effective anti-reflux techniques applicable to the ileal reservoir, we examined the usefulness of a novel anti-reflux uretero-ileal anastomosis creating a flap valve mechanism.

MATERIALS AND METHODS

Five dogs were used. A 4 cm. long ileal segment was isolated and its oral part (2.5 cm.) was detubularized. The detubularized ileal plate was anastomosed to the dome of the bladder. The left ureter was cut and its proximal end was spatulated and anastomosed end-to-side to the ileal plate. The end of the 1.5 cm. long afferent limb (non-detubularized part of the ileal segment) was closed and fixed down to the ileal plate to create an extramural tunnel. In this way, the reimplanted ureter was covered by the afferent limb. The dogs were evaluated between 3 and 4 months postoperatively.

RESULTS

None of the 5 dogs used showed vesico-ureteral reflux or hydronephrosis. Histological examination showed an intact ureter enclosed with a normal ileal wall.

CONCLUSION

Our proposed anti-reflux uretero-ileal anastomosis is simple and reliable. This technique may be suitable for applying to a urinary reservoir, especially as an alternative to the intussuscepted nipple valve.

A case of ileal ureter with proximal antireflux system

BACKGROUND

The initial experience of constructing a new antirefluxing valve at the uretero-ileal junction with ileal substitution is reported.

METHODS

A new antirefluxing valve was constructed at the uretero-ileal junction with ileal substitution by fixing the distal part of the ureter between the psoas muscle and ileal segment (the ileo-psoas tunnel technique).

DISCUSSION

The valve created by the technique has been working effectively for preventing the ileo-ureteral reflux. Pre-operative hydronephrosis was improved and the renal function has been well preserved.

CONCLUSION

The ileo-psoas tunnel technique is worthwhile when ileal substitution of the ureter is indicated.

Serous-lined extramural tunnel technique for uretero-ileal implantation in urinary diversion

PURPOSE

We present our initial experience of a serous-lined extramural tunnel technique for anti-refluxing uretero-ileal anastomosis in five cases of orthotopic ileal bladder and four cases of continent ileal pouch.

METHODS/RESULTS

Ureters were implanted into serous-lined tunnels formed from a detubularized W-configurated ileal segment. Neither upper tract dilatation nor reflux were observed in any patient postoperatively.

CONCLUSION

The technique can provide an effective uretero-ileal anastomosis for reflux prevention with minimal use of the ileal segment and without the use of any artificial materials.

Enhanced continent mechanism of tapered ileum by extramural support from pouch-abdominal wall: an experimental study in dogs

PURPOSE

To construct a reliable continent tube, which is easy to catheterize, we created and evaluated a new continent cutaneous diversion using a tapered ileum combined with extramural support from the pouch-abdominal wall.

MATERIALS AND METHODS

Six dogs underwent a procedure in which two ileal segments were tapered and anastomosed to the ileal pouch. One of the segments (continent) was placed between the back surface of the rectus muscle and the wall of the ileal pouch creating a continent tube. The other segment (control) was brought out into the abdominal skin directly without any support from the pouch-abdominal wall. Urodynamic and radiological studies were carried out postoperatively in all dogs.

RESULTS

In the continent tubes, the maximum closure pressure with a full pouch was significantly higher than those with an empty pouch (p<0.01). The maximum closure pressures of the continent tubes were significantly higher than those of the control tubes when the pouch was empty (p<0.01). The leak point pressures of the continent tubes were significantly higher than those of the control tubes (p<0.001). In all dogs, the retrograde radiogram of the continent tubes showed perfect canalization without stenosis.

CONCLUSION

This study suggests that the continent mechanism of tapered ileum can be greatly enhanced by fixing it between the abdominal and pouch walls, also allowing easy catheterization in contrast to the submucosal tunnel technique.

Functional and molecular biological evidence for a possible beta3-adrenoceptor in the human detrusor muscle

The possible existence of a beta3-adrenergic receptor (beta3-AR) in the human detrusor muscle was investigated by in vitro functional studies and analysis of mRNA expression. Isoprenaline, noradrenaline and adrenaline each produced a concentration-dependent relaxation of the human detrusor. The rank order for their relaxing potencies was isoprenaline (pD2 6.37+/-0.07) > or = noradrenaline (pD2 6.07+/-0.12) > or = adrenaline (pD2 5.88< or =0.11). Neither dobutamine (beta1- and beta2-AR agonist) nor procaterol (beta2-AR agonist) produced any significant relaxation at concentrations up to 10(-5) M. BRL37344A, CL316243 and CGP-12177A (beta3-AR agonists), relaxed the preparations significantly at concentrations higher than 10(-6) M. The pD2 values for BRL37344A, CL316243 and CGP-12177A were 6.42+/-0.25, 5.53+/-0.09 and 5.74+/-0.14, respectively. CGP-20712A (10(-7) - 10(-5) M), a beta1-AR antagonist, did not affect the isoprenaline-induced relaxation. On the other hand, ICI-118,551, a beta2-AR antagonist, produced a rightward parallel shift of the concentration-relaxation curve for isoprenaline only at the highest concentration used (10(-5) > M) and its pKB value was 5.71+/-0.19. Moreover, SR58894A (10(-7) - 10(-5) M), a beta3-AR antagonist, caused a rightward shift of the concentration-relaxation curve for isoprenaline in a concentration-dependent manner. The pA2 value and slope obtained from Schild plots were 6.24+/-0.20 and 0.68+/-0.31. The beta1-, beta2- and beta3-AR mRNAs were all positively expressed in detrusor smooth muscle preparations in a reverse transcription polymerase chain reaction assay. In conclusion, the present results provide the first evidence for the existence of the beta3-AR subtype in the human detrusor. They also suggest that the relaxation induced by adrenergic stimulation of the human detrusor is mediated mainly through beta3-AR activation.

Distribution of doxorubicin in the bladder wall and regional lymph nodes after bladder submucosal injection of liposomal doxorubicin in the dog

PURPOSE

Liposome-encapsulated doxorubicin (Lip-Dox) has increased therapeutic efficacy and reduced toxicity compared to free doxorubicin (Dox). To assess the utility of Lip-Dox for local control of bladder cancer, we examined the distribution of Dox in the bladder wall and the regional lymph nodes of dogs after bladder submucosal injection of Lip-Dox.

MATERIALS AND METHODS

In 8 dogs (group SM), Lip-Dox (2 mg.:1 ml.) was injected into the submucosal layer of each lateral bladder wall by using a flexible cystoscope. The other 8 dogs (group IV) underwent intravenous injection of free Dox (4 mg.). Both groups of animals were sacrificed at 1, 3, 5 or 7 days after the injections. The concentration of Dox was measured in both the mucosal and muscle layers of 5 bladder wall sites and also in the external iliac lymph nodes bilaterally.

RESULTS

The Dox-concentration in the lymph nodes of group SM was significantly higher (about 15-100 times) than that of group IV throughout the whole follow-up period. The Dox-concentration in the bladder wall for group SM was significantly higher than that in group IV (about 70-930 times at the lateral walls and 2-830 times at the other sites).

CONCLUSION

The present results demonstrate that Lip-Dox injected into the bladder submucosally distributes well, both in the whole bladder wall and in regional lymph nodes and remains at a high concentration in these tissues for at least one week after injection.

Bladder dysfunction after proximal urethrolysis in female dogs

BACKGROUND

Functional changes in the bladder after proximal urethrolysis are not recognized, despite the development of neuroanatomical studies of the female urethra or functional studies of the urethra after cystectomy. The aim of the present pilot study is to investigate possible functional changes in the bladder after proximal urethrolysis in female dogs.

METHODS

The bilateral nerve branches to the urethra were resected by separating the urethra from the anterior vaginal wall in 10 female dogs. Pre- and postoperative cystometrograms were recorded under anesthesia and the bladder capacity, threshold pressure for micturition and bladder stiffness (the inverse of compliance) were compared.

RESULTS

Fourteen days postoperatively, the bladder capacity significantly decreased and the threshold pressure and bladder stiffness significantly increased. Eight weeks after surgery, the threshold pressure and bladder stiffness remained high, but the bladder capacity tended to return to baseline values.

CONCLUSIONS

These results indicate that proximal urethrolysis with bilateral sections of the nerve branches to the urethra produces a low-compliant bladder in the early postoperative period and suggest that afferent stimuli from the urethra may participate in maintaining a compliant bladder during filling.

Effects of intravesical capsaicin and resiniferatoxin on distension-induced bladder contraction in conscious rats with and without chronic spinal cord injury

PURPOSE

To compare conscious, normal rats and rats with chronic spinal cord injury (CSI) in terms of the rhythmic bladder contractions (RBCs) induced by intravesical infusion of saline, and to determine how these contractions are influenced by intravesical capsaicin and resiniferatoxin.

MATERIALS AND METHODS

Female Sprague-Dawley rats, normal or with spinal transection at the level of Th8-Th9, were investigated cystometrically under isovolumetric conditions before and after intravesical administration of capsaicin or resiniferatoxin.

RESULTS

Spinal transection induced a significant increase in bladder weight. In both control and CSI animals, intravesical saline instillation induced reproducible RBCs that could be blocked by hexamethonium. Four weeks after the transection, the CSI animals had a significantly larger threshold volume than the controls, even after correction for bladder weight. The mean amplitude and duration of the RBCs did not differ between the two groups, but the frequency was significantly lower in CSI animals. Both capsaicin (0.1 and 1 mM) and resiniferatoxin (1 and 10 microM), instilled intravesically, were found to inhibit RBCs in both normal and CSI rats. There were no qualitative differences in the response to the drugs between the two groups. However, resiniferatoxin was approximately 100 times more potent than capsaicin.

CONCLUSION

Capsaicin and resiniferatoxin inhibited RBCs in both normal and CSI rats, suggesting that activity in sensory fibers (C and Adelta), which are sensitive to the action of these drugs, is initiated by bladder filling in both types of rat.

Effects of Glutamate Receptor Antagonists on Lower Urinary Tract Function in Conscious Unanesthetized Rats

OBJECTIVES

To study the effects of the intrathecal administered glutamate receptor antagonists on the bladder and urethral activities during isovolumetric bladder contraction in conscious normal and chronic spinal rats.

METHODS

Twenty-eight female Wistar rats with and without previous spinal cord transection were used. Before and after intrathecal administration of glutamate receptor antagonist, urodynamic parameters under isovolmetric condition of the bladder were analyzed.

RESULTS

In normal rats, MK-801 (noncompetitive N-methyl-D-aspartate [NMDA] receptor antagonist) and LY 293558 (competitive AMPA receptor antagonist) produced a decrease in bladder contraction pressure and urethral activity with dose dependent manner. In chronic spinal rats, detrusor-sphincter dyssynergia (DSD) was developed before drug administration. MK-801 and LY 293558 partially inhibited bladder contraction pressure, and markedly depressed urethral contraction concomitant with bladder contraction. LY 293558 produced urethral relaxation concomitant with bladder contraction.

CONCLUSIONS

In both normal rats and chronic spinal rats, two subtypes of glutamate receptors (NMDA and AMPA receptors) in the spinal cord were involved in the control of bladder and urethral activities. The AMPA receptor in the spinal cord seems to take an important role in the development of DSD.

[Posttraumatic priapism in a 6-year-old boy: a case report]

A 6-year-old boy showed priapism after blunt perineal trauma. We diagnosed him with venous priapism mainly based on clinical symptoms, although we could not deny an arterial type. In fear of possible erectile dysfunction as a late complication of the venous type, we performed a shunt operation. The shunt was created between glans penis and corporacavernosa, resulting in disappearance of priapism and preservation of erectile function. We also reviewed 14 cases reported previously.

Ileal pouch with an umbilical stoma: a continent mechanism created by the extramural tunnel technique

We present an initial experience of creating an extramural continent valve in the ileal pouch in 4 patients who required continent urinary diversion. Using the appendix or a tapered ileal segment, the continent valve was created by the extramural tunnel technique along the anterior suture line of the pouch to facilitate the umbilical anastomosis. All patients were continent postoperatively with easy catheterization. This technique can provide a simple and effective continent pouch formed entirely from the ileum.

Species differences in the distribution of beta-adrenoceptor subtypes in bladder smooth muscle

1. The beta-adrenoceptor (beta-AR) subtypes mediating relaxation of the rabbit, rat and canine detrusors were subjected to functional investigation using selective beta-AR agonists and antagonists. 2. In all three species, isoprenaline, noradrenaline and adrenaline each produced a concentration-dependent relaxation of the detrusor. The rank order for their relaxing potency was isoprenaline>adrenaline>noradrenaline in rabbits and rats, but isoprenaline>noradrenaline>adrenaline in dogs. 3. Dobutamine did not produce relaxation of the detrusors at concentrations that are selective for beta1-AR. The selective beta2-AR agonist, procaterol, had a more potent relaxing effect on rabbit and rat detrusors than on the canine detrusor. CGP-12177A, a selective beta3-AR agonist, was more effective in the rabbit than in the other two species. On the other hand, the relaxing effect of another beta3-AR agonist, CL316243, was more pronounced in dogs and rats than in rabbits. 4. CGP-20712A (10(-9) to 10(-7) M), a selective beta1-AR antagonist, caused a slight rightward shift of the concentration-relaxation response curve for isoprenaline in the canine detrusor (pA2 9.41), but not in the rabbit and rat detrusors. ICI-118,551, a selective beta2-AR antagonist, antagonized the isoprenaline-induced relaxation in rabbits (pA2 9.45) and rats (pA2 9.05), but not in dogs. Bupranolol, a non-selective beta-AR antagonist, caused a rightward shift of the concentration-relaxation curve for isoprenaline in the rabbit (pA2 9.32) and rat (pA2 8.98). However, higher concentrations (3 x 10(-8) to 10(-5) M) were needed to induce a rightward shift of the curve for isoprenaline in the dog (pA2 8.19) than in the other two species. 5. We have confirmed that the distribution of beta-AR subtypes in the detrusor muscle varies significantly from species to species and we provide here the first evidence of the presence of beta3-AR in the detrusor. It is suggested that the relaxation induced by adrenoceptor agonists in urinary bladder smooth muscle may be mediated mainly via beta2-AR in rabbits, via both beta2- and beta3-AR in rats, but mainly via beta3-AR in dogs.

Carcinoembryonic antigen positive adenocarcinoma of a female urethral diverticulum: case report and review of the literature

Paraurethral glands of the female urethra, which are assumed to be embryologically homologous to the male prostate gland, are possible origins for diverticular cancer of the urethra. A case of primary adenocarcinoma arising in a female urethral diverticulum is presented. Pathology revealed a columnar/mucinous type adenocarcinoma which stained positively for carcinoembryonic antigen (CEA) and negatively for PSA. Normal paraurethral ducts located near the urethra and normal urethral epithelium also stained positively for CEA. These findings suggest that the adenocarcinoma in our case originated from the paraurethral duct near the urethral lumen.

Transcutaneous electrical stimulation of thigh muscles in the treatment of detrusor overactivity

OBJECTIVE

To investigate the clinical effects on detrusor overactivity of a new method of transcutaneous reciprocal electrical stimulation of the thigh muscles.

PATIENTS AND METHODS

Nineteen patients with detrusor overactivity, comprising 14 with detrusor hyperreflexia (DH) and five with idiopathic detrusor instability (IDI), were studied. Electrical stimulation was applied alternately to the quadriceps and hamstring muscles of one or both legs through surface electrodes for 20 min. The treatment was given once a day for 14 days and then the patients were evaluated urodynamically.

RESULTS

All 19 patients tolerated the therapy well and none reported any adverse effects. The mean maximum cystometric capacity increased significantly (P < 0.05) after treatment. In 11 of the 19 patients, the maximum cystometric capacity was increased by > 50% of the pretreatment value; this occurred in eight of 14 of those with DH and in three of five of those with IDI. In six of the 11 who responded in this way, there was a clinical improvement in their urinary incontinence and frequency for several weeks to 3 months after the period of therapy. A second 14-day treatment was also effective in all four patients who underwent a repeat trial.

CONCLUSION

This method of transcutaneous electrical stimulation can inhibit DH as well as IDI with no adverse effects. The suppressive effect on detrusor overactivity may persist for several months and repeat trials appear to be effective. Thus, we believe that this new stimulation technique should be tried as an alternative to other types of electrical stimulation and augmentation cystoplasty.

Frequent recurrence of superficial bladder tumors in the periorificial region: possible predictor for delayed appearance of invasive intramural ureteric cancer

Two cases of invasive lower ureteric cancer developed following frequent recurrence of superficial bladder tumors in the region of the ureteral orifice. The cancer focus could not be identified in the intramural ureter prior to intravenous urography which revealed hydronephrosis. When bladder tumors repeatedly develop near the ureteric orifice, careful investigations such as ureteral catheterization with a small brush for cytology or ureteroscopy are necessary for the early detection of invasive disease.

Capsaicin-induced nitric-oxide-dependent relaxation in isolated dog urethra

Capsaicin (5 x 10[-8] to 5 x 10[-5] M) produced a non-adrenergic and non-cholinergic phasic relaxation in a concentration-dependent manner in isolated dog urethral preparations precontracted by noradrenaline. The mode of action of capsaicin was investigated with special reference to the possible involvement of endogenous nitric oxide (NO). A marked tachyphylaxis was observed in the responses to capsaicin. Pretreatment with NG-nitro-L-arginine-methyl-ester (L-NAME) prevented or markedly reduced the inhibitory effect of L-NAME. Methylene blue inhibited the capsaicin-induced relaxation. In preparations stored at 4 degrees C for 72 h, the reduction in the capsaicin-induced relaxation was significantly greater than that in the relaxation induced by either electrical field stimulation or by sodium nitroprusside. We conclude that capsaicin produces an endogenous-NO-dependent relaxation in the isolated dog urethra via mechanisms that deteriorate during cold storage of the preparations.

Incontinent ileal tube repaired by infolding with the ileal pouch wall

In a patient who had undergone construction of a continent ileal pouch we successfully repaired an incontinent ileal tube by infolding it in an imbricated portion of the ileal pouch wall. For 2 years postoperatively the patient has been urine continent and has catheterized the pouch easily. We believe this infolding technique is useful for reconstructing the continent mechanism in patients with incompetent ileal valves.

Cytotoxicity of sera from rats with puromycin aminonucleoside nephrosis

Administration of puromycin aminonucleoside (PAN) to rats induces acute nephrosis with hyperlipidemia, and, in some experimental conditions, it results in chronic focal glomerulosclerosis. In this study, we examined the cytotoxicity of serum from rats with PAN-induced nephrosis, since hypercholesterolemia is considered to cause injury to vascular walls in atherosclerosis, the mechanism of which is analogous to that of glomerulosclerosis. About half of the tested sera from nephrotic rats (9 out of 17) were cytotoxic to cultured aortic endothelial cells. The toxic substance(s) was heat-stable and was extracted in the lipid fraction. Serum levels of triglyceride and cholesterol were markedly higher in the group of rats with cytotoxic serum than in the group with noncytotoxic serum. No cytotoxicity was associated with sera from control rats or the corresponding lipid fractions. Cytotoxic sera were also effective against cultured glomerular epithelial and mesangial cells. These results indicate that cytotoxic lipid is produced in rats with PAN nephrosis and the results raise the possibility that the cytotoxic lipid in nephrotic serum might contribute to lipid-mediated glomerular injury which may induce glomerulosclerosis at a subsequent stage.