In sickness and in health: The functional role of extracellular vesicles in physiology and pathology in vivo: Part II: Pathology: Part II: Pathology

It is clear from Part I of this series that extracellular vesicles (EVs) play a critical role in maintaining the homeostasis of most, if not all, normal physiological systems. However, the majority of our knowledge about EV signalling has come from studying them in disease. Indeed, EVs have consistently been associated with propagating disease pathophysiology. The analysis of EVs in biofluids, obtained in the clinic, has been an essential of the work to improve our understanding of their role in disease. However, to interfere with EV signalling for therapeutic gain, a more fundamental understanding of the mechanisms by which they contribute to pathogenic processes is required. Only by discovering how the EV populations in different biofluids change-size, number, and physicochemical composition-in clinical samples, may we then begin to unravel their functional roles in translational models in vitro and in vivo, which can then feedback to the clinic. In Part II of this review series, the functional role of EVs in pathology and disease will be discussed, with a focus on in vivo evidence and their potential to be used as both biomarkers and points of therapeutic intervention.

Effects of secondary biological treatment plant effluent administration, as drinking water, to rats' urogenital system in relation to cadmium and lead accumulation

The aim of this study was to examine the effect of the secondary biological treatment plant effluent administration on the kidneys, urinary bladder, and testis of Wistar rats in relation to lead (Pb) and cadmium (Cd) accumulation, since such an effluent is used for irrigation of edible plants. Male Wistar rats, randomly assigned into 5 groups, were treated with domestic sewage effluent (DSE) for 24 months. Cadmium and lead concentrations in the DSE, rats' tissues, and urine were estimated by means of atomic spectroscopy. Lead was rapidly accumulated in high amounts in rats' kidney and to a lesser extent in the testis whereas Cd concentration was raised in all tissues examined. Deposition of Cd and Pd in the kidney of the rats resulted in profound damage over time. The results showed that long-term administration to DSE as drinking water exposes living organisms to urogenital stress related to heavy metal concentration and pH of the effluent.

Chlamydia trachomatis bacterial load, estimated by Cq values, in urogenital samples from men and women visiting the general practice, hospital or STI clinic

Background

The bacterial load of Chlamydia trachomatis (CT) is assumed to play a role in transmission and sequelae. We assessed urogenital CT cycle quantification (Cq) values, as an indicator for CT load, of men and women diagnosed by general practitioners (GPs), hospital physicians and the STI clinic.

Methods

Urogenital CT-positive samples (n = 2,055 vaginal swabs, n = 77 cervical swabs, n = 1,519 urine samples and n = 19 urethral swabs) diagnosed by GPs, hospital physicians and the STI clinic from the Maastricht Medical Microbiology Laboratory were included (2012–2016). The outcome measure ‘urogenital Cq values’ was used as an inversely proportional measure for CT load. Among all patients, multivariate linear regression analyses were used to assess primary determinants for mean urogenital Cq values, stratified by sex. Additional clinical determinants were assessed among STI clinic patients.

Results

In men, mean urogenital Cq values were similar between GPs, hospital physicians and the STI clinic (32.7 and 33.5 vs. 32.7; p>0.05). Women visiting the GP had lower urogenital Cq values than women visiting the STI clinic (30.2 vs. 30.9; p = <0.001). Women visiting the hospital had higher urogenital Cq values than women visiting the STI clinic (32.4 vs. 30.9; p = <0.001). Among STI clinic women, urogenital Cq values were lower in women with concurrent anorectal CT and in rectally untested women compared to anorectal CT-negative women (30.7 and 30.6 vs. 33.9; p = <0.001).

Conclusion

Men visiting different STI care providers had similar urogenital Cq values, which could be an indicator for similar CT loads. The lower Cq values of women visiting the GP compared to women visiting the STI clinic could be an indicator for higher CT loads and likely higher transmission potential. Notably, urogenital Cq values of STI clinic women were much lower (>3 Cq) when STI clinic women also had anorectal CT. This finding could indicate higher urogenital CT loads and likely higher chances of transmission and sequelae.

Klebsiella Pneumoniae Visceral Organ Abscesses - Clinical Characteristics

INTRODUCTION

In recent years, Klebsiella pneumonia (KP) has emerged as the predominant cause of pyogenic liver abscess in Asia. KP - as the causative microorganism in other visceral organ abscesses-is less described. In this study, we seeked to describe the clinical characteristics of KP visceral organ abscesses in our institution and evaluated the prescription practices of physicians with regard to antibiotic therapy.

MATERIALS AND METHODS

A retrospective analysis of patients with culture positive (blood or abscess aspirate) KP visceral organ abscesses from May 2014 to April 2016 requiring hospitalisation in Changi General Hospital was conducted.

RESULTS

A total of 140 adult patients with KP visceral organ abscesses were identified. The commonest site of involvement was the liver (77.9%), followed by genitourinary tract (20.7%). Diabetic patients were more likely to have liver abscesses, genitourinary abscesses, abscesses in 2 or more organs, genitourinary disease with abscess formation outside of the genitourinary tract, and endovascular infection. Patients with extended spectrum beta-lactamase producing KP, were more likely to have an obstructive lesion related to the site of the abscess. Overall mortality rate was 7.1%. Amongst survivors, the mean total duration of parenteral antimicrobial therapy was 2.5 weeks before switching to oral antimicrobial agents.

CONCLUSION

Genitourinary tract is the commonest extra-hepatic site for visceral organ abscess in KP infections. Parenteral to oral switch of antimicrobial agents appears to be a safe and effective treatment option.

New Insights Into Marburg Virus Disease Pathogenesis in the Rhesus Macaque Model

Previously, several studies have been performed to delineate the development and progression of Marburg virus infection in nonhuman primates (NHPs), primarily to clarify the mechanisms of severe (fatal) disease. After the 2013-2016 Ebola virus disease (EVD) epidemic in Western Africa, there has been a reassessment of the available filovirus animal models and the utility of these to faithfully recapitulate human disease. The high lethality of the NHP models has raised doubts as to their ability to provide meaningful data for the full spectrum of disease observed in humans. Of particular interest are the etiologic and pathophysiologic mechanisms underlying postconvalescent sequelae observed in human survivors of EVD and Marburg virus disease (MVD). In the current study, we evaluated the lesions of MVD in NHPs; however, in contrast to previous studies, we focused on the potential for development of sequelae similar to those reported in human survivors of MVD and EVD. We found that during acute MVD in the macaque model, there is frequent inflammation of peripheral nerves, autonomic ganglia, and the iris of the eye. Furthermore, we demonstrate viral infection of the ocular ciliary body and retina, testis, epididymis, ovary, oviduct, uterine endometrium, prostate, and mammary gland. These findings are relevant for both development of postconvalescent sequelae and the natural transmission of virus.

[MORPHOLOGICAL CHANGES OF THE UROGENITAL SYSTEM INTERNAL STRUCTURE AT MODELING OF PORTAL HYPERTENSION IN RATS]

Portal hypertension is a constant companion of numerous diseases in gastroenterology, vascular surgery, cardiology, and hematology with grave consequences for the health and life of patients. The development of portal hypertension leads to significant violations of hemodynamics in the liver vessels and the development of arterial and venous hypertrophy, stasis of blood in the vessels of the portal tract. In the experiment on rats, portal hypertension was simulated in an original way with the following study of the peculiarities of morphological changes in the internal structure of the kidneys and gonads in males as a manifestation of a violation of systemic hemodynamics. The decrease of the renal artery throughput in portal hypertension, dystrophic changes in the epithelium against the background of venous congestion, paravazal polymorphocytic infiltration and proliferation of the connective tissue have been identified.

Pathological findings in the red fox (Vulpes vulpes), stone marten (Martes foina) and raccoon dog (Nyctereutes procyonoides), with special emphasis on infectious and zoonotic agents in Northern Germany

Anthropogenic landscape changes contributed to the reduction of availability of habitats to wild animals. Hence, the presence of wild terrestrial carnivores in urban and peri-urban sites has increased considerably over the years implying an increased risk of interspecies spillover of infectious diseases and the transmission of zoonoses. The present study provides a detailed characterisation of the health status of the red fox (Vulpes vulpes), stone marten (Martes foina) and raccoon dog (Nyctereutes procyonoides) in their natural rural and peri-urban habitats in Schleswig-Holstein, Germany between November 2013 and January 2016 with focus on zoonoses and infectious diseases that are potentially threatening to other wildlife or domestic animal species. 79 red foxes, 17 stone martens and 10 raccoon dogs were collected from traps or hunts. In order to detect morphological changes and potential infectious diseases, necropsy and pathohistological work-up was performed. Additionally, in selected animals immunohistochemistry (influenza A virus, parvovirus, feline leukemia virus, Borna disease virus, tick-borne encephalitis, canine adenovirus, Neospora caninum, Toxoplasma gondii and Listeria monocytogenes), next-generation sequencing, polymerase chain reaction (fox circovirus) and serum-neutralisation analysis (canine distemper virus) were performed. Furthermore, all animals were screened for fox rabies virus (immunofluorescence), canine distemper virus (immunohistochemistry) and Aujeszky's disease (virus cultivation). The most important findings included encephalitis (n = 16) and pneumonia (n = 20). None of the investigations revealed a specific cause for the observed morphological alterations except for one animal with an elevated serum titer of 1:160 for canine distemper. Animals displayed macroscopically and/or histopathologically detectable infections with parasites, including Taenia sp., Toxocara sp. and Alaria alata. In summary, wildlife predators carry zoonotic parasitic disease and suffer from inflammatory diseases of yet unknown etiology, possibly bearing infectious potential for other animal species and humans. This study highlights the value of monitoring terrestrial wildlife following the "One Health" notion, to estimate the incidence and the possible spread of zoonotic pathogens and to avoid animal to animal spillover as well as transmission to humans.

Genital invasion or perigenital spread may pose a risk of marginal misses for Intensity Modulated Radiotherapy (IMRT) in anal cancer

BACKGROUND

While intensity modulated radiotherapy (IMRT) in anal cancer is feasible and improves high-dose conformality, the current RTOG/AGITG contouring atlas and planning guidelines lack specific instructions on how to proceed with external genitalia. Meanwhile, the RTOG-Protocol 0529 explicitly recommends genital sparing on the basis of specific genital dose constraints. Recent pattern-of-relapse studies based on conventional techniques suggest that marginal miss might be a potential consequence of genital sparing. Our goal is to outline the potential scope and increase the awareness for this clinical issue.

METHODS

We present and discuss four patients with perigenital spread in anal cancer in both early and advanced stages (three at time of first diagnosis and one in form of relapse). Genital/perigenital spread was observed once as direct genital infiltration and thrice in form of perigenital lymphatic spread.

RESULTS

We review the available data regarding the potential consequences of genital sparing in anal cancer. Pattern-of-relapse studies in anal cancer after conventional radiotherapy and the current use of IMRT in anal cancer are equivocal but suggest that genital sparing may occasionally result in marginal miss. An obvious hypothesis suggested by our report is that perigenital lymphovascular invasion might be associated with manifest inguinal N+ disease.

CONCLUSIONS

Local failure has low salvage rates in recent anal cancer treatment series. Perigenital spread may pose a risk of marginal misses in IMRT in anal cancer. To prevent marginal misses, meticulous pattern-of-relapse analyses of controlled IMRT-series are warranted. Until their publication, genital sparing should be applied with caution, PET/CT should be used when possible and meeting genital dose constraints should not be prioritized over CTV coverage, especially (but not only) in stage T3/4 and N+ disease.

Differential Activity of Nivolumab, Pembrolizumab and MPDL3280A according to the Tumor Expression of Programmed Death-Ligand-1 (PD-L1): Sensitivity Analysis of Trials in Melanoma, Lung and Genitourinary Cancers

Background

The potential predictive role of programmed death-ligand-1 (PD-L1) expression on tumor cells in the context of solid tumor treated with checkpoint inhibitors targeting the PD-1 pathway represents an issue for clinical research.

Methods

Overall response rate (ORR) was extracted from phase I-III trials investigating nivolumab, pembrolizumab and MPDL3280A for advanced melanoma, non-small cell lung cancer (NSCLC) and genitourinary cancer, and cumulated by adopting a fixed and random-effect model with 95% confidence interval (CI). Interaction test according to tumor PD-L1 was accomplished. A sensitivity analysis according to adopted drug, tumor type, PD-L1 cut-off and treatment line was performed.

Results

Twenty trials (1,475 patients) were identified. A significant interaction (p<0.0001) according to tumor PD-L1 expression was found in the overall sample with an ORR of 34.1% (95% CI 27.6-41.3%) in the PD-L1 positive and 19.9% (95% CI 15.4-25.3%) in the PD-L1 negative population. ORR was significantly higher in PD-L1 positive in comparison to PD-L1 negative patients for nivolumab and pembrolizumab, with an absolute difference of 16.4% and 19.5%, respectively. A significant difference in activity of 22.8% and 8.7% according to PD-L1 was found for melanoma and NSCLC, respectively, with no significant difference for genitourinary cancer.

Conclusion

Overall, the three antibodies provide a significant differential effect in terms of activity according to PD-L1 expression on tumor cells. The predictive value of PD-L1 on tumor cells seems to be more robust for anti-PD-1 antibody (nivolumab and pembrolizumab), and in the context of advanced melanoma and NSCLC.

[The species variety of microflora in samples from urogenital tract of female patients of large network laboratory and its dependence of content of lactobaccilli]

The evaluation of content of DNA of lactobaccilli and particular types of aerobic anaerobic opportunistic bacteria in sampling of scrapes from urogenital tract offemale patients of the network laboratory INVITRO was implemented. The technique of polymerase chain reaction in real-time was implemented. It is demonstrated that decreasing of content of lactobaccilli in total bacterial mass isfollowed by increasing of occurrence, concentration and relative content of all types of opportunistic pathogens except ureaplasmna. These changes are expressed in different degree for different types of opportunistic pathogens. The increasing of varieties of types of microflora of urogenital tract under decreasing of content of lactobaccilli is noted.

[The comparative characteristic of immune status of males with bacterial inflammatory urogenital pathology of different etiology in the city of Orenburg]

The article discusses presence of typical characteristics of parameters of system immunity under gonococcal and nonspecific uretroprostatitis and diagnostic value of these indicators. The reliable differences of immunologic indicators in patients with gonorrhea are established as compared to patients with nonspecific bacterial uretroprostatitis. The study established in peripheral blood the reliable decrease of level of leukocytes, relative amount of monocytes, phagocyte index, functional reserve of leukocytes at the expense of spontaneous and stimulated NBT test, IgA, sIgA. On the contrary, the study detected increasing of level of IgM and lactoferrin in patients with gonorrhea as compared to corresponding indicators in patients nonspecific infections. Under gonorrhea, the largest deviation of indicators from standard values was established for lactoferrin. The detected differences of immunologic parameters can be used as differentiating markers of nonspecific and gonococcal uretroprostatitis and criteria of effectiveness of immune correction.

[Comparative analysis of informative-diagnostic properties of mucosa immune-reactivity parameters]

AIM

Study the features of immune-reactivity expression in mucosa depending on their topicity and etiopathogenesis of the pathological process.

MATERIALS AND METHODS

Data from 30 clinically healthy children and 77 children with acute and recurrent diseases of respiratory tract: 51--with acute and 15--with chronic bronchitis; as well as 132 women: 41--with active stage of acute urogenital chlamydia infection, 29--with recurrent chronic process, 30--with non-recurrent form and 32 clinically healthy women were analyzed. Saline and urogenital tract mucosa discharge was analyzed for IgG, sIgA and secretory component, IL-1beta, 4, 6, 8, 9, 10, 12, IFNgamma, TNFalpha and GM-CSF, TLR-2, TLR-3, TLR-4, TLR-8 gene expression levels as well as content of lysozyme, total protein and leucocytes.

RESULTS

Solidity, universality and practically single-stage triggering of mucosa immune reaction mechanisms to intervention by foreign agents regardless of their localization was confirmed. A dependence of immune-reactivity expression on the form of pathologic process, its localization and qualitative and quantitative characteristics of the infectious agents was clearly seen. The highest level of clinical-laboratory and immunological parameters is inherent for patients with acute processes in urogenital tract (cervical canal and urethra), especially cause by mixed infections.

CONCLUSION

Immune diagnostic parameters of mucosa among which TLR system is especially notable have high information properties allowing not only diagnostics of inflammatory process but also differentiating its form and character our course.

Urogenital Prolapse and Atrophy at Menopause: A Prevalence Study

For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.

GSK-3β function in bone regulates skeletal development, whole-body metabolism, and male life span

Glycogen synthase kinase 3 β (GSK-3β) is an essential negative regulator or "brake" on many anabolic-signaling pathways including Wnt and insulin. Global deletion of GSK-3β results in perinatal lethality and various skeletal defects. The goal of our research was to determine GSK-3β cell-autonomous effects and postnatal roles in the skeleton. We used the 3.6-kb Col1a1 promoter to inactivate the Gsk3b gene (Col1a1-Gsk3b knockout) in skeletal cells. Mutant mice exhibit decreased body fat and postnatal bone growth, as well as delayed development of several skeletal elements. Surprisingly, the mutant mice display decreased circulating glucose and insulin levels despite normal expression of GSK-3β in metabolic tissues. We showed that these effects are due to an increase in global insulin sensitivity. Most of the male mutant mice died after weaning. Prior to death, blood glucose changed from low to high, suggesting a possible switch from insulin sensitivity to resistance. These male mice die with extremely large bladders that are preceded by damage to the urogenital tract, defects that are also seen type 2 diabetes. Our data suggest that skeletal-specific deletion of GSK-3β affects global metabolism and sensitizes male mice to developing type 2 diabetes.

[The characteristic of biocenosis of urogenital tract in women]

The article deals with the study of characteristics of biocenosis of urogenital tract in women of reproductive age with using of "Femoflor" test. The scrapings of posterolateral wall of vagina were analyzed using the technique of real-time polymerase chain reaction using the reagents "Femoflor". The complex evaluation of urogenital biota identified three main types of biocenosis of vagina: type I--normocenosis (n = 50 or 11.5%): type II--mild dysbiosis (n = 88 or 21%); type III--marked dysbiosis (n = 133 or 30.6%). In the structure of alterations of biocenosis of urogenital tract the main role play the anaerobic bacteria with involvement of candida, ureoplasma and mcoplasma.

[The antibiotics sensitivity of strains of Corinebacterium non diphtheriae circulating in Rostov-on-Don and Rostov oblast]

The article deals with the results of study of sensitivity of strains of Corinebacterium non diphtheriae circulating in Rostov-on-Don and Rostov oblast to antibacterial preparations. The strains of Corinebacterium non diphtheriae isolated from urogenital tract (C. xerosis, C. pseudotuberculosis. C. amycolatum, C. striatum) are analyzed. The sample of 41 strains of C. non diphtheriae was used to detect the sensitivity to 9 antibacterial preparations. The technique of serial dilutions in liquid growth medium was applied. The range of variations (minimal suppressive concentration) of preparations as related to C. non diphtheriae made up 0.003-20.0 mkg/ ml. The results demonstrated that C. non diphtheriae are: highly sensitive to gentamycin, vancomycin and cefotaxime: sensitive to rifampicinum; and resistant to lincomicyn. In all analyzed strains of Corinebacterium non diphtheriae the greatest indicators of minimal suppressive concentration are detected in lincomicyn and at that the maximal indicator was for C. striatum and consisted 11.52 +/- 2.26 mkg/ml.

Chlamydia trachomatis infection during pregnancy: known unknowns

Genital Chlamydia trachomatis infection is the commonest bacterial sexually transmitted infection worldwide. Infection prevalence peaks in young women aged between 18-25 years. Infection in women has been associated with reproductive tract pathology, infertility, and adverse pregnancy outcomes including miscarriage, early membrane rupture, pre-term labor, and postpartum endometritis. However, the evidence base varies with the population studied and the methods used to detect infection. There may be differential consequences for pathology associated with primary or recurrent infection during pregnancy. These differences may be potentiated by physiological differences in the host response to infection in the pregnant state. Such changes have particular relevance for infections of the reproductive tract. Cost effectiveness estimates for screening during pregnancy require basic knowledge of the natural history of infection and the host response to calculate associated risks. Our level of knowledge is hampered by the lack of good experimental models for human pregnancy. To make rational decisions about screening of pregnant women there is a need for case control studies that compare detection of infection by nucleic acid amplification tests with evaluation of immunity to the infection.

Efficacy of vaginal use of topical estriol in postmenopausal women with urogenital atrophy

OBJECTIVE

This study evaluates the effect of intravaginal estriol on urogenital atrophy, Pap smear parameters, colposcopy parameters and discomfort during gynecological examination.

METHODS

31 postmenopausal women who had not used hormone therapy in the previous six months were studied. All women used intravaginal estriol, 1 mg/day for 21 days. The following variables were analyzed before and after treatment: complaints of urogenital atrophy; cytological parameters, colposcopic parameters, and subjective evaluation of discomfort during gynecologic examination.

RESULTS

All urogenital atrophy complaints improved after treatment. At the first visit, 45.2% of women presented a predominance of profound cells, 51.6% with predominance of intermediate cells, and 3.2% with predominance of superficial cells. At the second visit, these rates were 35.5%, 64.5%, and 0%, respectively. Evaluation of the maturation index showed that 83.9% of women had atrophic Pap smears, and 16.1% showed good estrogenic level before treatment. At the second visit, atrophic smears occurred in 12.9%, and 87.1% of women exhibited good estrogenic level (chi2 = 20.045; p = 0.000). Colposcopy showed that 71% of women had atrophic colpitis and/or petequiae before treatment, while atrophy after therapy was present in only 6.4%. The evaluation of other colposcopic parameters also improved after treatment. Great discomfort was reported by 19.4% before and by 0% after treatment.

CONCLUSION

Intravaginal estriol 1 mg/day for a period of 21 days was efficient in improving urogenital atrophy, Pap smear parameters and colposcopic evaluation in postmenopausal women.

Maternal exposure to a brominated flame retardant and genitourinary conditions in male offspring

BACKGROUND

The upward trend in industrial nations in the incidence of male genitourinary (GU) conditions may be attributed to increased exposure to endocrine disruptors. Polybrominated biphenyl (PBB), a brominated flame retardant, is one such suspected endocrine disruptor.

OBJECTIVE

We investigated the relationship between maternal serum levels of PBBs and GU conditions among male offspring exposed in utero.

METHODS

In this cohort study of sons born to women accidentally exposed to PBBs during 1973-1974, we examined self-reported data on GU conditions among male offspring in relation to maternal serum PBB levels. We used generalized estimating equations to calculate odds ratios (ORs), controlling for gestational age at birth.

RESULTS

Of 464 sons, 33 reported any GU condition (13 hernias, 10 hydroceles, 9 cryptorchidism, 5 hypospadias, and 1 varicocele). Four reported both hernia and hydrocele, and one both hernia and cryptorchidism. After adjustment for gestational age at birth, sons of highly exposed women (> 5 ppb) were twice as likely to report any GU condition compared with sons of the least exposed women [< or =1 ppb; OR = 2.0; 95% confidence interval (CI), 0.8-5.1]. This risk was increased when we excluded sons born after the exposure but before the mother's serum PBB measurement (OR = 3.1; 95% CI, 1.0-9.1). We found evidence of a 3-fold increase in reported hernia or hydrocele among sons with higher PBB exposure (test of trend p-value = 0.04). Neither hypospadias nor cryptorchidism was individually associated with PBB exposure.

CONCLUSIONS

Although cryptorchidism and hypospadias were not associated with in utero PBB exposure, this study suggests that other GU conditions may be associated with exposure to endocrine-disrupting chemicals during development.

The unilateral urogenital anomalies (UUA) rat: a new mutant strain associated with unilateral renal agenesis, cryptorchidism, and malformations of reproductive organs restricted to the left side

We established an inbred rat strain with unilateral urogenital anomalies from an incidentally identified male rat with unilateral renal agenesis and an undescended left testis. These rats were characterized by unilateral renal agenesis in both sexes, undescended testes with agenesis and hypoplasia of the accessory sex organs in male rats, and complete and partial agenesis of the uterine horn in female rats. All of these urogenital anomalies were unilateral and restricted to the left side; we named this phenotype unilateral urogenital anomalies (UUA). Breeding tests showed that these abnormalities were inherited as polygenic traits. The weight of right kidneys of affected rats was 1.7-fold higher than that of normal rats; histologically, glomerulosclerosis, tubular dilations, and tubular casts were detected at 30 wk of age. These alterations may have resulted from compensatory renal adaptation to the lack of 1 kidney. The cryptorchid left testes of affected male rats showed atrophy of seminiferous tubules and degeneration of spermatocytes and spermatids. These results indicate that the UUA rat may be a good model to study the etiology of unilateral renal agenesis accompanied by agenesis of the reproductive tract and to study compensatory alterations resulting from the congenital loss of 1 kidney.

[Evaluation of patients with urogenital trauma managed in a urology clinic]

BACKGROUND

Ten percent of all traumas, responsible for 14% of all deaths, involve the urogenital system. We retrospectively evaluated the patients with genitourinary trauma who underwent any kind of management modality in our clinics.

METHODS

We retrospectively evaluated 108 patients (92 males, 16 females; mean age 35.8+/-17.5 years; range 6 to 87 years) with urogenital trauma between 2003 and 2007 according to age, gender, type of trauma, affected organ, grade of trauma, accompanying other-organ injuries, radiological imaging techniques, and treatment.

RESULTS

Sixty-eight patients (63%) had blunt, 25 (24%) had penetrating, and 12 (11%) had iatrogenic trauma, and 3 patients (3%) had spontaneous organ injury. When we considered the affected organ, renal trauma was determined in 34 patients (32%), ureteral trauma in 11 (10%), bladder injuries in 18 (17%), urethral trauma in 27 (25%), testicular trauma in 6 (6%), and penile trauma in 12 (10%) patients. Seventeen patients (50%) had grade 3, 11 (32%) had grade 4 and 6 (18%) had grade 5 renal injury; 6 patients of these cases underwent surgical treatment.

CONCLUSION

Our results were parallel to those available in the literature. Due to the lack of sufficient information about urogenital trauma rates in our country, it would be highly useful for reference centers to evaluate and publish their own data.

Extracolonic findings in an asymptomatic screening population undergoing intravenous contrast-enhanced computed tomography colonography

BACKGROUND AND AIM

The purpose of this study was to evaluate extracolonic findings that could be encountered with computed tomography colonography (CTC) using intravenous (IV) contrast material in an asymptomatic screening population.

METHODS

Intravenous contrast medium-enhanced CTC was performed in 2230 asymptomatic adults (mean age, 57.5 years). Axial images were prospectively examined for extracolonic lesions. These findings were classified into three categories: potentially important findings, likely unimportant findings, and clinically unimportant findings. Potentially important extracolonic findings were defined as those which required immediate further diagnostic studies and treatment. Clinical and radiologic follow up, missed lesions and clinical outcomes were assessed using medical records (mean duration of follow up, 1.6 years).

RESULTS

A total of 115 new potentially important findings in 5.2% of subjects (115/2230) were found. Subsequent medical or surgical intervention was performed in 2.0% (45/2230). New extracolonic cancer was detected in 0.5% (12/2230), and the majority of them (83.3%) were not metastasized. Computed tomography colonography missed eight potentially important extracolonic findings in eight subjects (0.4%, 8/2230): 0.8-cm early-stage prostatic cancer, six adrenal mass and one intraductal papillary mucinous tumor. There were no severe life-threatening complications related to contrast medium.

CONCLUSION

Intravenous contrast-enhanced CTC could safely detect asymptomatic early-stage extracolonic malignant diseases without an unreasonable number of additional work-ups, thus reducing their morbidity or mortality.

Myeloperoxidase binds to non-vital spermatozoa on phosphatidylserine epitopes

The heme protein myeloperoxidase is released from stimulated polymorphonuclear leukocytes, a cell species found in increasing amounts in the male and female genital tract of patients with genital tract inflammations. Myeloperoxidase binds only to a fraction of freshly prepared human spermatozoa. The number of spermatozoa able to bind myeloperoxidase raised considerably in samples containing pre-damaged cells or in acrosome-reacted samples. In addition, myeloperoxidase released from zymosan-stimulated polymorphonuclear leukocytes was also able to bind to pre-damaged spermatozoa. The ability of spermatozoa to bind myeloperoxidase coincided with the binding of annexin V to externalized phosphatidylserine epitopes indicating the loss of plasma membrane integrity and with the incorporation of ethidium homodimer I. Myeloperoxidase did not interact with intact spermatozoa. Annexin V and myeloperoxidase bind to the same binding sites as verified by double fluorescence techniques, flowcytometry analyses as well as competition experiments. We demonstrated also that myeloperoxidase is eluted together with pure phosphatidylserine liposomes or liposomes composed of phosphatidylserine and phosphatidylcholine in gel filtration, but not with pure phosphatidylcholine liposomes. In conclusion, myeloperoxidase interacts with apoptotic spermatozoa via binding to externalized phosphatidylserine indicating a yet unknown role of this protein in recognition and removal of apoptotic cells during inflammation.

Urogenital involvement in the Klippel-Trenaunay-Weber syndrome. Treatment options and results

OBJECTIVE

Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital condition characterized by vascular malformations of the capillary, venous and lymphatic systems associated to soft tissue and bone hypertrophy in the affected areas. This syndrome may involve bladder, kidney, urethra, ureter and genitals. We report the treatment of 7 KTWS patients with urogenital involvement.

MATERIALS AND METHODS

From 1995 to 2005, 7 patients with KTWS were evaluated and the charts of these patients were reviewed.

RESULTS

Patients' median age was 19-years (range 4 to 46-years) and only 1 was female. The clinical presentation included genital deformities in 3 cases, hematuria in 2 and urethrorragia in 2, one of which associated with cryptorchidism and phimosis. Three patients had an association of pelvic and genital malformations, including 2 patients with hematuria due to vesical lesions and 1 patient with left ureterohydronephrosis due to a pelvic mass. Two patients had urethral lesions. Treatment included endoscopic laser coagulation for 1 patient with recurrent hematuria and 1 patient with urethrorrhagia, pelvic radiotherapy for 1 patient with hematuria and circumcision in 2 patients with genital deformities. One patient required placement of a double-J catheter to relieve obstruction. Hematuria and urethrorragia were safely and effectively controlled with laser applications. Circumcision was also effective. The patient treated with radiotherapy developed a contracted bladder and required a continent urinary diversion.

CONCLUSIONS

Urogenital involvement in patients with KTWS is not rare and must be suspected in the presence of hematuria or significant cutaneous deformity of the external genitalia. Surgical treatment may be warranted in selected cases.

Pathological Findings in Harbour Seals ( Phoca vitulina ): 1996–2005

Between 1996 and 2005 the carcasses of 355 harbour seals originating from the coast of Schleswig-Holstein, Germany, were investigated for pathological changes. The animals were collected before (n=280) and after (n=75) the second phocine distemper virus (PDV) epizootic in 2002. The seals were either found dead or were killed due to severe illness. Necropsy was performed in each case, in addition to histopathological, immunohistochemical, microbiological and parasitological examinations. Throughout the period of study, the respiratory and alimentary tracts were the organ systems most consistently affected by pathological change. The most common cause of death was bronchopneumonia caused by parasitic and/or bacterial infection of the lung. Less frequently identified changes included: trauma, gastroenteritis, uterine torsion or dystocia, polyarthritis/polymyositis, intestinal torsion, septicaemia, dermatitis, and keratitis. The most frequent causes of bronchopneumonia, gastroenteritis, polyarthritis, dermatitis and septicaemia were infections with alpha/beta-haemolytic streptococci, Escherichia coli and Clostridium perfringens. A number of changes were more frequently identified after 2002. These included the presence of parasites in the lung, stomach and intestine; bronchopneumonia, gastritis, enteritis, septicaemia and perinatal death. The increased prevalence of these changes may have been related to the preceding PDV epidemic.

Clinical impact of second pathology opinion: A longitudinal study of central genitourinary pathology review before prostate brachytherapy

PURPOSE

To evaluate the clinical impact of pathology review before prostate brachytherapy.

METHODS AND MATERIALS

Original and reviewing pathologists' reports were retrospectively collected from 1323 men treated with prostate brachytherapy between July 1998 and October 2005 at one institution. Statistical analysis was performed pre- and post-January 2002. The clinical impact of pathology review was evaluated.

RESULTS

Gleason Score (GS) change (GS(Delta)) occurred in 25.2% (334) of cases; GS increased in 21.6%, decreased in 2.4%, and diagnosed malignancy in 1.2% of cases. Post-2002, concordance in attributed GS improved, with GS(Delta) of 31.9-20.6%, respectively (p<0.001), and a reduction in the average GS(Delta) (p<0.001). The clinical impact was substantial with management changing in 14.8% of cases.

CONCLUSION

Concordance between the original and reviewing pathologists' GS has improved during the study period. Nevertheless, discordance persists in one of five cases. Pathology review remains essential, if treatment decisions hinge on GS.

Malakoplakia Outside the Urinary Tract

Context.—Malakoplakia is a rare granulomatous disease that occurs commonly in the urinary tract. Histologically, it is defined by sheets of histiocytes (Hansemann cells) with accumulation of granular basophilic periodic acid-Schiff– positive, diastase-resistant inclusions and calcified Michaelis-Gutmann bodies, which are pathognomonic but not necessary for diagnosis. In addition to the urinary tract, malakoplakia has been reported in other organs, including the gastrointestinal tract, central nervous system, female genital tract, and the tongue.

Objectives.—To review the literature of reported sites of malakoplakia outside the urinary tract and their variable clinical presentations, and to discuss the main diagnostic features and differential diagnoses of malakoplakia. The pathogenesis and possible etiologic factors are also presented.

Data Sources.—Data for this work were collected from the published literature, textbooks, and the Internet.

Conclusions.—It is important to be aware of the existence of this entity in abnormal locations. In many situations, malignancy can be mimicked, especially when the lesion is ulcerated and is accompanied by lymph node involvement. Misinterpreting large, rapidly growing nodules of malakoplakia as tumor might lead to overstaging. Pathologists should be also aware of the possibility of malakoplakia coexisting with other lesions, such as tuberculosis and carcinoma, in the same specimen.

[Psychophysiologic disturbances in early postmenopause in women after physiological and surgical menopause]

BACKGROUND/AIM

The most common secondary manifestations of menopause are clinical manifestations of estrogen deficiency. They could be early and late. The aim of this study was to compare manifestations of somatic disturbances in early postmenopause in women after physiological and surgical menopause.

METHODS

This prospective study included 60 women, age 41-55 years, divided into two groups: physiological (30 of them) and surgically induced menopause. For every subject a special evidence list, consisting of the disease history questions, physical and gynecology examination as well as dates about physiological variables (arterial tension, height, weight, and body-mass index) and laboratory examination was formed. The values of arteriol blood pressure, body height, body mass, body mass index (BMI), and lipid status were determined and gynecological examinations were performed in each patient.

RESULTS

The most frequent symptoms in both groups were vasomotor ones. Headache was the more intensive sign in the group after induced menopause. Extrasistolyc heart excursion was a common symptom in both study groups. Arterial tension, regardless of the type of menopause, was in the physiological range. The frequent organic signs of menopause, more intensive in the group after induced menopause, were genitourinary and skin atrophy. An analysis of the BMI showed that the women in both groups were obese (BMI > 25). The lipids analysis confirmed the predomination of hyperlipoproteinemia type IIa in the group with physiologic menopause and type IIb after induced menopause.

CONCLUSION

The dominant signs of menopausal syndrome were vasomotor and bone-joint symptoms, more frequent in the group after induced menopause. There were no statistically significant differences between the study groups according to the genitourinary atrophy and other signs of aging. Menopausal hormonal changes, regardless of the way of menopause developing, increase the risk for hyperlipoproteinemia. The frequency of somatic signs in early post menopause is typically higher after induced menopause. More intensive follow-up in patients after surgical removing of the ovaria is necessary in order to improve the quality of life in these patients.

Oxymorphone Hydrochloride, a Potent Opioid Analgesic, Is Not Carcinogenic in Rats or Mice

Despite their long history of chronic use, little information is available regarding the carcinogenicity of opioid analgesics. Oxymorphone is a potent morphinan-type mu-opioid analgesic used for treatment of moderate-to-severe pain. Oxymorphone was tested for carcinogenicity in Crl:CD IGS BR rats and CD-1 mice. Oxymorphone hydrochloride was administered orally once daily for 2 years to rats at doses of 2.5, 5 and 10 mg/kg/day (males) and 5, 10 and 25 mg/kg/day (females), and mice at 10, 25, 75 and 150 mg/kg/day (65 animals per sex per group; 100 animals per sex in controls). In rats, survival was generally higher than controls in oxymorphone-treated groups, attributable to lower body weight gain. In mice, survival was generally higher than controls in females at all doses and males given < or = 25 mg/kg/day but lower in males given > or = 75 mg/kg/day due to a high incidence of obstructive uropathy. Opioid-related clinical signs and reduced body weight gain occurred in both species throughout the study. Nonneoplastic findings associated with oxymorphone pharmacology included ocular and pulmonary changes in rats considered secondary to inhibition of blinking and mydriasis, and antitussive activity, respectively, and urinary tract and renal findings in mice considered secondary to urinary retention. There was no target organ toxicity, and no increase in any neoplastic lesions attributed to oxymorphone. Plasma oxymorphone levels achieved in these studies exceeded those in patients taking high therapeutic doses of oxymorphone (Area under the curve [AUC(0-24 h)] values up to 5.6-fold and 64-fold in rats and mice, respectively). Oxymorphone is not considered to be carcinogenic in rats or mice under the conditions of these studies.

Imaging of the neonatal genito-urinary tract

OBJECTIVE

To describe imaging of typical conditions and diseases in the neonatal genito-urinary (GU) tract.

METHOD

The use, the applications, and typical findings using standard imaging techniques (e.g., ultrasound, US, voiding cystourethrography, VCUG) are described, with emphasis on technical aspects, indications, and restrictions in neonatal queries. Only basic applications as used in routine clinical work are included, other more sophisticated and advanced imaging techniques such as scintigraphy, MR-urography, genitography or image-guided interventional procedures will only briefly be mentioned.

SUMMARY AND CONCLUSION

Conventional imaging methods are valuable and - particularly in the neonatal GU tract - sometimes irreplaceable. Skillfully used basic imaging techniques, particularly of US (including modern methods such as Doppler sonography, Harmonic imaging or contrast enhanced US), supplemented by fluoroscopy for VCUG can answer most acutely treatment relevant queries. Rarely early scintigraphic studies, genitography, or MRI may become indicated, usually not for establishing the diagnosis, but to collect additional (functional or anatomical) information necessary for deciding on further treatment, or even image guided interventional procedures may become necessary.

Histopathology and histomorphometry of the urogenital tract in 15-month old male and female rats treated neonatally with SERMs and estrogens

In this study, two selective estrogen receptor modulators (SERMs), tamoxifen (TAM) and toremifene (TOR) or two estrogens, ethinylestradiol (EE) and diethylstilbestrol (DES) were administered to newborn male and female Sprague-Dawley rats (days 1-5) to investigate the occurrence of developmental abnormalities in the adulthood. The compounds were dosed (s.c.) at an equimolar dose of 24.9 micromol/kg. During the follow-up period, mortality occurred mainly in DES-treated male rats (3/4), associated with obstructive urinary calculi and suppurative renal inflammation in 2/3 rats. Similar lesions were not evident in other groups. At the age of 15 months, the animals were necropsied and organs were collected for histopathology and histomorphometry. Treatment-related abnormalities were restricted to the reproductive organs. Chronic prostatitis and epithelial abnormalities in the vas deferens were observed in all treatment groups. The columnar epithelium of vas deferens showed hyperplasia and development of subepithelial glandular structures resembling epididymal cysts reported in humans exposed in utero to DES. Testicular atrophy was observed especially in estrogen-treated rats. Mainly in SERM-treated female rats, the uterus showed luminal dilation or obstruction, loss of endometrial glands and myometrium disorganization including foci of muscular disruption. TOR-treated female rats showed polyp-like nodules (incidence 4/15) and a high incidence (9/15) of a simple cuboidal epithelium in cervical regions normally occupied by multilayered epithelia. In conclusion, the vas deferens is a main target organ following neonatal administration of SERMs and estrogens. In addition, female rats were significantly more susceptible to SERM treatment than to treatment with estrogens.

Disseminated microsporidiosis due to Encephalitozoon hellem in an Egyptian fruit bat (Rousettus aegyptiacus)

Disseminated microsporidiosis was diagnosed in an adult female Egyptian fruit bat that died unexpectedly in a zoo. Gross findings, which were minimal, included poor body condition, bilateral renomegaly, and mottling of the liver. Histopathological lesions, which were particularly pronounced in the urogenital tract and liver, consisted primarily of inflammation associated with intracytoplasmic microsporidian spores. Polymerase chain reaction -based methods were used to establish the identity of the microsporidian as Encephalitozoon hellem. E. hellem is an emerging cause of human and avian disease, manifested mainly as opportunistic infection in immunosuppressed patients. This report describes the first documented case of E. hellem in a non-human mammalian species.

The effect of a soy-rich diet on urogenital atrophy: A randomized, cross-over trial

OBJECTIVE

To evaluate the effect of a soy-rich diet on urogenital symptoms, vaginal health index, and vaginal cytology in perimenopausal and postmenopausal women.

MATERIALS AND METHODS

Thirty-six perimenopausal and postmenopausal women (mean age 52.5+/-5.1 years) participated in a randomized, cross-over trial with two 12-week diet periods and two 4-week washout periods before and between treatments. The study diet consisted of a control diet (soy-free diet) and an isocaloric soy-rich diet (25 g soy protein in various forms of soy food containing more than 50 mg/day of isoflavones substituted for an equivalent amount of animal protein). Subjects were assessed for urogenital symptoms, vaginal health index, vaginal pH and vaginal cytology. The single physician and the single cytopathologist were blinded with regard to onset, period and randomization number. Statistical analyses were performed using paired t-test or Wilcoxon Signed Ranks Test, significance was set as P<0.05.

RESULTS

Good compliance to the diet was shown by the significant elevation of serum levels of daidzein and genistein during the soy-rich diet period. The symptoms of urge incontinence and vaginal dryness had significantly increased after 12-week of soy-free diet. All other urogenital symptoms did not change in both periods. The vaginal health index, the vaginal pH, the karyopyknotic index, and the maturation value were not significantly changed in both periods.

CONCLUSION

A soy-rich diet did not relieve the urogenital symptoms or restore the vaginal epithelium or improve the vaginal health in perimenopausal and postmenopausal Thai women.

Current practice of diagnosis and reporting of prostatic intraepithelial neoplasia and glandular atypia among genitourinary pathologists

The criteria for diagnosing prostatic intraepithelial neoplasia (PIN) and lesions suspicious for cancer are described in the literature. However, it is unknown how these are applied in practice by experts in genitourinary (GU) pathology. A questionnaire was sent to 93 GU pathologists in countries around the world with the purpose of surveying current practices. The response rate was 69% including 40 North American pathologists and 24 from other continents. For preneoplastic lesions, the term PIN was universally endorsed by the respondents. PIN was graded by 83%, usually as low/high-grade PIN (LGPIN/HGPIN) or as HGPIN only. Most respondents would usually not report lesions that may qualify for LGPIN. A majority (81%) did not specify architectural patterns of PIN. With both HGPIN and invasive cancer present, 69% would still mention HGPIN. Among the diagnostic criteria for HGPIN were any nucleoli visible (52%), or nucleoli seen in at least 10% of cells (33%). However, 56% would diagnose HGPIN in the absence of prominent nucleoli, most commonly based on prominent pleomorphism, marked hyperchromasia or mitotic figures. The number of cores involved with HGPIN was specified by 50%. Lesions suspicious for but not diagnostic of carcinoma were reported by 45% as atypia, atypical glands or suspicious for cancer and by 42% as atypical small acinar proliferation. The degree of suspicion was further defined by 41%. Our survey data may serve as a guideline to general pathologists on how to diagnose and report atypia and PIN in prostate biopsies.

Unknown ESUR cases 2004

The authors present 14 cases from the film interpretation session of the 11th annual meeting of the European Society of Urogenital Radiology presented in September, 2004. The cases demonstrate the imaging findings, differential diagnoses, and clinical relevance of a wide variety of genitourinary tract diseases. The cases include examples of benign and malignant urinary tract neoplasms, inflammatory processes, vascular diseases, traumatic injuries, and congenital anomalies.

Nephropathy and defective spermatogenesis in mice transgenic for a single isoform of the Wilms' tumour suppressor protein, WT1−KTS, together with one disruptedWt1 Allele

The Wilms' tumour suppressor protein, WT1, is a zinc finger protein essential for the development of several organs, including the kidney and gonads. In each of these tissues WT1 is required at multiple stages of development and its persistent expression in podocytes and Sertoli cells suggests WT1 may also have a role in the maintenance of kidney and testis function throughout adult life. Naturally occurring isoforms of WT1 are generated by alternative mRNA splicing. An altered ratio of the splice isoforms WT1-KTS and WT1 + KTS appears to be sufficient to account for the developmental abnormalities (pseudohermaphroditism and nephropathy) characteristic of Frasier syndrome. We show that mice with a transgene encoding WT1-KTS do not differ from their wild-type littermates unless they are also heterozygous for a null mutation at the endogenous Wt1 locus. Animals with both genetic modifications develop proteinuria, together with multiple glomerular cysts, and male infertility. These pathologic changes may be explained as a consequence of altering the WT1 isoform ratio in tissues that express WT1 during adulthood. The results suggest WT1 misexpression could contribute to human glomerulocystic kidney disease.

Role of endocytosis in cellular uptake of sex steroids

Androgens and estrogens are transported bound to the sex hormone binding globulin (SHBG). SHBG is believed to keep sex steroids inactive and to control the amount of free hormones that enter cells by passive diffusion. Contrary to the free hormone hypothesis, we demonstrate that megalin, an endocytic receptor in reproductive tissues, acts as a pathway for cellular uptake of biologically active androgens and estrogens bound to SHBG. In line with this function, lack of receptor expression in megalin knockout mice results in impaired descent of the testes into the scrotum in males and blockade of vagina opening in females. Both processes are critically dependent on sex-steroid signaling, and similar defects are seen in animals treated with androgen- or estrogen-receptor antagonists. Thus, our findings uncover the existence of endocytic pathways for protein bound androgens and estrogens and their crucial role in development of the reproductive organs.

Detection of acute tubulointerstitial rejection by proteomic analysis of urinary samples in renal transplant recipients

This study investigates proteomic analysis of urinary samples as a non-invasive method to detect acute rejection of renal allografts. Capillary electrophoresis coupled to mass spectrometry (CE-MS) was used to analyze urinary samples in 19 patients with different grades of subclinical or clinical acute rejection (BANFF Ia to IIb), 10 patients with urinary tract infection and 29 patients without evidence of rejection or infection. A distinct urinary polypeptide pattern identified 16 out of 17 cases of acute tubolointerstitial rejection, but was absent in two cases of vascular rejection. Urinary tract infection resulted in a different polypeptide pattern that allowed to differentiate between infection and acute rejection in all cases. Potentially confounding variables such as acute tubular lesions, tubular atrophy, tubulointerstitial fibrosis, calcineurin inhibitor toxicity, proteinuria, hematuria, allograft function and different immunosuppressive regimens did not interfere with test results. Blinded analysis of samples with and without rejection showed correct diagnosis by CE-MS in the majority of cases. Detection of acute rejection by CE-MS offers a promising non-invasive tool for the surveillance of renal allograft recipients. Further investigation is needed to establish polypeptide patterns in vascular rejection and to explore whether changes in the urinary proteome occur before the onset of histologically discernible rejection.

MAGNETIC RESONANCE IMAGING OF PELVIC MUSCULOSKELETAL AND GENITOURINARY ANATOMY IN PATIENTS BEFORE AND AFTER COMPLETE PRIMARY REPAIR OF BLADDER EXSTROPHY

PURPOSE

We characterize pelvic soft tissue and bony anatomy of patients before and after complete primary repair of exstrophy (CPRE).

MATERIALS AND METHODS

We evaluated 15 measurements on pelvic magnetic resonance imaging (MRI) in patients who underwent CPRE without osteotomy at our institution from 1996 to 2004. MRI protocols included axial, sagittal and coronal fast spin echo proton density sequences. Measurements were compared before and after CPRE using a paired t test, and between patients after CPRE, and age and gender matched controls using linear regression adjusting for the matched case-control groups. Patients older than 3 years with continent intervals longer than 3 hours after CPRE were compared to age and gender matched controls using linear regression.

RESULTS

A total of 29 MRIs in 18 patients with exstrophy were available for analysis. Median patient age at postoperative MRI was 25 months (range 4 to 36). The configuration of the post-CPRE pelvis was significantly different from that of controls in all parameters measured including wider symphyseal diastasis (34.5 mm vs less than 1 mm) and more obtuse iliac wing (121 degrees vs 98 degrees), puborectalis (94 degrees vs 49 degrees) and ileococcygeus angles (111 degrees vs 98 degrees ). The anatomy of continent patients after CPRE was not significantly different from that of controls in most parameters measured.

CONCLUSIONS

Comparison of the pelvic anatomy in patients before and after CPRE suggests that after CPRE patients have parameters that more closely approximate, but are still significantly different, from those of control patients. Patients with greater than 3-hour continent intervals after CPRE have anatomic parameters most similar to those of age matched controls.

A NEW MODEL USING NUMBER OF NEEDLES AND ANDROGEN DEPRIVATION TO PREDICT CHRONIC URINARY TOXICITY FOR HIGH OR LOW DOSE RATE PROSTATE BRACHYTHERAPY

PURPOSE

Prostate brachytherapy is an established treatment modality in early stage prostate cancer. We retrospectively reviewed our experience with low dose rate (LDR) and high dose rate (HDR) brachytherapy as a single treatment modality for early prostate cancer with emphasis on chronic toxicity.

MATERIALS AND METHODS

From June 1996 to August 2003, 253 patients with stage II prostate cancer, prostate specific antigen less than 12 and Gleason score less than 7 were treated with brachytherapy alone at our institution. A total of 92 patients underwent HDR brachytherapy with 192Ir, while 161 underwent LDR brachytherapy with 103Pd. HDR minimum prostate dose was 38 Gy, delivered in 4 fractions with a single implant during 36 hours. For HDR we used real-time dynamic 3-dimensional ultrasound base dosimetry. For 103Pd seed implants the dose was 120 Gy using selective peripheral weighted dose distribution. Treatment was given based on patient preference after pretreatment transrectal ultrasound. Toxicity was scored using the National Cancer Institute Common Toxicity Criteria 2.0. Median followup in all 253 cases was 2.9 years.

RESULTS

In all patients the rate of 3-year urinary toxicity grade 2 or greater and grade 3 or greater was 26% and 6.9%, which was not significantly different between HDR and LDR (p = 0.3 and 0.4, respectively). However, grade 1 urogenital toxicity was lower for HDR (p = 0.002). The 3-year grade 2 rectal toxicity rate was 0.8% with no grade 3 or greater events, which was and similar in the HDR and LDR groups (1% and 0.6%, respectively). No cancer related deaths occurred and 4-year overall survival was 99% for HDR and 96.4% for LDR (p = 0.4). The 3-year American Society for Therapeutic Radiology and Oncology biochemical control rate was 90% for LDR and 93% for HDR. Cox multivariate analysis for grade 2 or greater urinary toxicity was significant for the use of 14 or greater needles (HR 6.1, p = 0.02) and hormonal therapy (HR 2.2, p = 0.02). In the absence of risk factors the 4-year grade 2 or greater urinary toxicity rate was 7% vs 65% if the 2 risk factors were present (p <0.001). Impotence crude rates were 18.3% for HDR and 41.3% for LDR (p = 0.002).

CONCLUSIONS

HDR and LDR chronic urinary toxicity grade 2 or greater rates were equivalent. However, grade 1 was lower for HDR. The impotence rate was decrease by half with HDR. Neoadjuvant hormonal therapy and 14 or greater needles were significantly associated with increased chronic urinary toxicity on multivariate analysis.

COCCIDIOIDOMYCOSIS OF THE MALE GENITAL TRACT

PURPOSE

Symptomatic genital tract infection is a rare manifestation of disseminated coccidioidomycosis. We characterized the clinical presentation, diagnosis, management and outcome in male patients with genitourinary coccidioidomycosis.

MATERIALS AND METHODS

We reviewed all cases of genital tract coccidioidomycosis involving testes, epididymis or prostate at our institution between 1990 and 2000, and searched the medical literature for all reports since the first reported case in 1943.

RESULTS

A total of 30 male patients with a median age of 58 years who had coccidioidomycosis of the genital tract were identified, including 6 at our institution. Four patients (13%) had a simultaneous pulmonary infection and 63% (19) had a remote history of primary pulmonary coccidioidomycosis. The most commonly involved genital tract sites were the epididymis in 18 cases, prostate in 14 and testes in 6. Patients with prostatitis presented with urinary obstruction, prostatic enlargement, tenderness and palpable nodules. Most patients with epididymal infection presented with scrotal swelling, tenderness and induration. All 30 patients (100%) had histopathological evidence of granulomatous inflammation with fungal spherules. Urine fungal cultures were positive in 19 cases (63%). A total of 12 patients received combined medical and surgical treatment, and 18 underwent surgical excision only. Most immunocompetent patients with isolated genital coccidioidomycosis did well with surgical resection alone. Six deaths occurred in patients with multifocal, extragenital, disseminated disease.

CONCLUSIONS

Male genitourinary coccidioidomycosis is rare but it should be considered in the differential diagnosis of patients with exposure to the endemic area who present with prostatitis or epididymitis.

CD2-associated protein in human urogenital system and in adult kidney tumours

We studied expression of CD2-associated protein (CD2AP) in human urogenital system and in adult kidney tumours. In the cortex of normal kidney, CD2AP was expressed in all types of tubules and in the glomeruli. Labelling was more intense in cytokeratin 7- and in Tamm-Horsfall-positive tubules than in proximal tubules. In the medulla, expression was observed in the collecting ducts. Urothelium and the epithelium of prostatic acini, seminal vesicles, seminiferous tubules, epididymal ducts, Fallopian tube, endometrium and endocervix as well as granulosa cells showed moderate to strong CD2AP positivity. In syncytiotrophoblast, the expression was weaker than in cytotrophoblast. Endometrial stroma was negative, but decidualised stroma was weakly positive. Clear cell renal cell carcinoma (RCC) (n=63) showed a weak expression. Type-I papillary RCCs (n=4) and papillary adenomas (n=3) were negative. The epithelium lining the cysts in multilocular cystic RCCs (n=3) and in cystic nephroma (n=1) was strongly positive. Chromophobe RCCs (n=2), oncocytomas (n=3) and urothelial carcinomas (n=2) were moderately positive. The results show that CD2AP displays a specific expression pattern in human urogenital organs and that distinct expression is shown in several types of kidney tumours but not in type-I papillary RCCs or in papillary adenomas.

Early multipotential pituitary focal hyperplasia in the alpha-subunit of glycoprotein hormone-driven pituitary tumor-transforming gene transgenic mice

Pituitary tumor-transforming gene (PTTG), a securin protein isolated from pituitary tumor cell lines, is highly expressed in invasive tumors and exhibits characteristics of a transforming gene. To determine the role of PTTG in pituitary tumorigenesis, transgenic human PTTG1 was targeted to the mouse pituitary using the alpha-subunit of glycoprotein hormone. Males showed plurihormonal focal pituitary transgene expression with LH-, TSH-, and, unexpectedly, also GH-cell focal hyperplasia and adenoma, associated with increased serum LH, GH, testosterone, and/or IGF-I levels. MRI revealed both pituitary and prostate enlargement at 9-12 months. Urinary obstruction caused by prostatic hyperplasia and seminal vesicle hyperplasia, with renal tract inflammation, resulted in death by 10 months in some animals. Pituitary PTTG expression results in plurihormonal hyperplasia and hormone-secreting microadenomas with profound peripheral growth-stimulatory effects on the prostate and urinary tract. These results provide evidence for early pituitary plasticity, whereby PTTG overexpression results in a phenotype switch in early pituitary stem cells and promotes differentiated polyhormonal cell focal expansion.

Morphology and Innervation Pattern of the Feline Urogenital Junction

The feline urogenital junction is situated between the extratesticular rete and the spacious initial segments of the efferent ductules. The rete epithelium is cuboidal to low columnar. The rete cells forming the junction rest on a wavy basal lamina, display deep mutual invaginations, possess central nuclei with several infoldings and form a distinct border with the columnar epithelial cells of the initial segments of the ductuli efferentes. The epithelium of the initial segments is composed of ciliated cells and non-ciliated principal cells. The latter are the dominating type and characterized by an apical brush-border and a supranuclear endocytotic apparatus. The stroma of the extratesticular rete contains an abundance of collagen whereas contractile cells are here generally absent. In contrast, the initial segments of the efferent ductules are surrounded by elastic fibres and a layer of contractile cells. All nerves for the feline urogenital junction come from the nervus spermaticus superior. In the epididymal head, small nerve bundles deviate into the septa between the ductules. Single fibres establish a dense network within the muscular coat of the ductuli. At the transition to the extratesticular rete, this network ends abruptly. Nerve fibres in the confines of the rete are associated with blood vessels or proceed to the testicular interior, but establish no relationships with the rete epithelium or the myofibroblasts of the mediastinum. The nervous network in the walls of the efferent ductules and their initial segments is not only composed of sympathetic but also parasympathetic, non-myelinated fibres. Particularly noteworthy is the abundance of calcitonin gene-related peptide (CGRP)- and substance P (SP)-containing axons around the initial segments. Both neuroproteins are consistent markers for sensory neurones. Taken together, it can be assumed that the entry of seminal fluid and spermatozoa into the efferent ductules is controlled by a regulatory nervous chain provided with afferent and efferent components.

[Morphofunctional placental characteristics in pregnant women with chronic pyelonephritis and urogenital chlamydia infection]

Morphological features of the placenta were studied in women with chronic pyelonephritis and urogenital chlamydial infection. There was an appreciable amount of chaotic sclerotic villi and symplastic nephroses reflecting compensatory-adaptive processes. Morphometric study of the afterbirths has shown that placenta affected with urogenital infection has large area of the intervillous space and small area of chorionic villi involved in gas exchange, supply of nutrients and other components to the fetus.

Genitourinary phenotype in XX patients with distal 9p monosomy

Although testicular development has been shown to be variably impaired in XY patients with distal 9p monosomy, ovarian and other genitourinary phenotype has poorly been studied in XX patients monosomic for the distal 9p region. Thus, we studied a 13-month-old infant with 46,XX,der(9)t(9;10)(p23;p13) (case 1) and an 11-year-old girl with 46,XX,der(9)t(9;16)(p23;q22) (case 2). Case 1 had primary hypogonadism (basal serum follicle stimulating hormone [FSH], 40.0 mIU/mL; leteinizing hormone [LH], 1.2 mIU/mL; estradiol [E2], <10 pg/mL), whereas case 2 had age-appropriate pubertal development (breast, Tanner stage 4; pubic hair, Tanner stage 3; menarche 11.7 years of age) and hormone values (FSH, 7.3 mIU/mL; LH, 6.7 mIU/mL; E2, 47 pg/mL). In addition, case 1 had hypoplastic labia majora, short distance between the vaginal orifice and the anus, and five renal cysts, and case 2 had anal atresia, short distance between the vaginal orifice and the anus, bilateral hydronephrosis of grade 3 with probable ureteropelvic junction stenosis, and renal dysfunction (serum creatinine, 1.52 mg/dL; urea nitrogen, 34.5mg/dL). Fluorescence in situ hybridization analysis for five regions and microsatellite analysis for 10 loci on 9p confirmed hemizygosity for the distal 9p region with the breakpoints between IFNA and D9S285 in case 1 and between D9S168 and D9S286 in case 2. The results, in conjunction with the previous data in XX patients with molecularly defined distal 9p monosomy, are consistent with the presence of a gene(s) involved in the development of indifferent gonad or subsequent ovarian differentiation in a approximately 11 Mb region distal to D9S168. In addition, it is possible that a gene(s) for anoperineal and renal development also maps distal to D9S168 and that for external genital development maps distal to D9S285 at the position approximately 16 Mb from the 9p telomere.