False-positive screening results in the Finnish prostate cancer screening trial

BACKGROUND

There is evidence that prostate cancer (PC) screening with prostate-specific antigen (PSA) serum test decreases PC mortality, but screening has adverse effects, such as a high false-positive (FP) rate. We investigated the proportion of FPs in a population-based randomised screening trial in Finland.

METHODS

Finland is the largest centre in the European Randomized Study of Screening for Prostate Cancer. We have completed three screening rounds with a 4-year screening interval (mean follow-up time 9.2 years) using a PSA cutoff level of 4.0 ng ml(-1); in addition, men with PSA 3.0-3.9 and a positive auxiliary test were referred. An FP result was defined as a positive screening result without cancer in biopsy within 1 year from the screening test.

RESULTS

The proportion of FP screening results varied from 3.3 to 12.1% per round. Of the screened men, 12.5% had at least one FP during three rounds. The risk of next-round PC following an FP result was 12.3-19.7 vs 1.4-3.7% following a screen-negative result (depending on the screening round), risk ratio 3.6-9.9. More than half of the men with one FP result had another one at a subsequent screen. Men with an FP result were 1.5 to 2.0 times more likely to not participate in subsequent rounds compared with men with a normal screening result (21.6-29.6 vs 14.0-16.7%).

CONCLUSION

An FP result is a common adverse effect of PC screening and affects at least every eighth man screened repeatedly, even when using a relatively high cutoff level. False-positive men constitute a special group that receives unnecessary interventions but may harbour missed cancers. New strategies are needed for risk stratification in PC screening to minimise the proportion of FP men.

Specificity of serum prostate-specific antigen determination in the Finnish prostate cancer screening trial

Specificity constitutes a component of validity for a screening test. The number of false-positive (FP) results has been regarded as one of major shortcomings in prostate cancer screening. We estimated the specificity of serum prostate-specific antigen (PSA) determination in prostate cancer screening using data from a randomised, controlled screening trial conducted in Finland with 32 000 men in the screening arm. We calculated the specificity as the proportion of men with negative findings (screen negatives, SN) relative to those with negative and FP results (SN/(SN+FP)). A SN finding was defined as either PSA</=4 ng ml(-1) or PSA 3.0-3.9 ng ml(-1) combined with a negative ancillary test (digital rectal examination, DRE or free/total, F/T PSA ratio). False positives were those with positive screening test followed by a negative diagnostic examination. Of the 30 194 eligible men, 20 794 (69%) attended the first screening round and 1968 (9.5%) had a screen-positive finding. A total of 508 prostate cancers were detected at screening (2.4%). Hence, the number of SN findings was 18 825 and the number of FP results 1358. Specificity was estimated as 0.933 (18 825 out of 20 183) with 95% confidence interval (CI) 0.929-0.936. Specificity decreased with age. Digital rectal examination as ancillary examination had similar or higher specificity than F/T PSA. In the second screening round, specificity was slightly lower (0.912, 95% CI 0.908-0.916). The specificity of PSA screening in the Finnish screening trial is acceptable. Further improvement in specificity could, however, improve acceptability of screening and decrease screening costs.

Bladder management in persons with spinal cord lesion

STUDY DESIGN

Cross-sectional clinical descriptive prevalence study.

OBJECTIVE

To evaluate the methods of self-reported bladder management, the frequency of urinary tract infection (UTI) and subjective disturbance of bladder problems of all those individuals with traumatic spinal cord lesion (SCL) living in Helsinki area.

SETTING

: Helsinki, Finland.

METHODS

A total of 152 persons with SCL were found in the Helsinki area (546 000 inhabitants). A structured questionnaire was sent to all subjects and they were invited to a clinical visit.

RESULTS

The final study-group consisted of 129 (85%) subjects. They were defined into seven specific subgroups of bladder management: 14 (11%) subjects in the normal voiding group, 15 (12%) in the controlled voiding group, 16 (12%) in the clean intermittent catheterization (CIC) group, 30 (23%) in the mixed group, 31 (24%) in the suprapubic tapping group, 16 (12%) in the compression or straining group and seven (5%) in the catheter or conduit group. The frequency of UTI was highest in the mixed group. The bladder management was a biggest bother to the subjects in the compression or straining group.

CONCLUSIONS

This prevalence study assesses the self-reported bladder management methods in all the persons with traumatic SCL in the Helsinki area. The subjects who used CIC and other methods for bladder management had more problems than others. These subjects might manage better by using either CIC or suprapubic tapping as the only method for bladder emptying.

A randomized trial of choice of treatment in prostate cancer: the effect of intervention on the treatment chosen

OBJECTIVE

To determine whether different approaches in the choice of treatment affect the treatment chosen by the patient for prostate cancer.

PATIENTS AND METHODS

We conducted a randomized trial with 210 men who had a histologically confirmed diagnosis of prostate cancer in 1993-94 at four major hospitals in Finland. After obtaining informed consent the men were randomized either to an intervention arm, in which there was greater patient participation in the choice of treatment following a structured procedure, or a control arm in which the standard approach, i.e. a standardized treatment protocol, was used. The main outcome measure of the analysis was the primary treatment chosen for prostate cancer.

RESULTS

In the enhanced participation arm patients not eligible for radical prostatectomy chose orchidectomy less frequently and favoured nonsurgical endocrine treatment than in the treatment protocol arm. Radical prostatectomy was the most commonly chosen treatment option in both arms among men with operable cancer. The way treatment options were presented affected the treatment chosen for prostate cancer.

CONCLUSION

Patients with prostate cancer are willing and able to take an active role in making decisions. The preferences of patients with prostate cancer in the choice of treatment may differ from the priorities of the physicians.

The effect of photodynamic therapy on rat urinary bladder with orthotopic urothelial carcinoma

OBJECTIVE

To assess the effect of whole-bladder photodynamic therapy (PDT) on a rat model with orthotopic superficial bladder cancer, as PDT is an alternative intravesical therapy for treating superficial bladder cancer, based on an interaction between a photosensitizer and light energy to induce oxygen radicals that destroy tissue by lipid peroxidation.

MATERIALS AND METHODS

In all, 76 female Fischer F344 rats were inoculated intravesically with AY-27 tumour cells. After establishing superficial tumour, 24 rats were treated with PDT using aminolaevulinic acid (ALA)-induced protoporphyrin IX as a photosensitizer, and a continuous-wave argon pumped-dye laser (638 nm). At 4 h after intravenous (300 mg/kg) or intravesical (100 mg/mL) administration of ALA the bladders were intravesically exposed to a 40 J/cm(2) light dose; 12 rats received no ALA but were exposed to the same light dose. Before administering ALA, urine cytology samples were taken for analysis. At 3 or 21 days the treated rats were killed and morphological changes in the bladder walls analysed by light microscopy. Forty rats served as controls to examine the presence of tumour.

RESULTS

The tumour established in 33 of 40 rats (83%) in the controls, but after PDT with intravesical ALA there was carcinoma in only in one of 12 (P < 0.001, Pearson's chi(2) test). After PDT with intravenous ALA there was carcinoma in five of 11 rats (P = 0.063, Pearson's chi2 test). In the control group of 12 rats receiving only light energy there was carcinoma in three (P = 0.001, Pearson's chi(2) test). Histologically, at 3 days after PDT there was only mild superficial damage in all six rats treated intravesically. Bladder wall destruction reached the muscular layer, with an abscess in one of six rats treated intravenously. After 3 weeks of PDT there was muscular necrosis with perforation and abscess from catheterization two of six rats treated intravesically and in three the bladder wall totally recovered. In the intravenous group the bladder walls were normal or had only mild superficial damage. Cytology of the urine sediment failed to detect half the tumours in the treatment groups.

CONCLUSION

These results support the use of PDT with intravesical ALA-induced protoporphyrin X for treating superficial bladder carcinoma. Intravesical was better than intravenous ALA in eradicating bladder carcinoma with PDT.

A randomized trial of the choice of treatment in prostate cancer: design and baseline characteristics

OBJECTIVE

To assess the effects of different approaches to decision-making on the treatment chosen for prostate cancer and on the patients' quality of life in prostate cancer.

PATIENTS AND METHODS

A multicentre randomized trial was conducted, including all histologically confirmed cases of prostate cancer diagnosed between September 1993 and November 1994 in four Finnish hospitals. In the intervention group, the role of the patient in the choice of treatment was actively emphasized. In the control group, the treatment was chosen using standardized treatment protocols. The first intermediate endpoint was the patient's participation in decision-making and the next will be the treatment chosen in the intervention and control groups. The main outcome will be the quality of life. Clinical data on prognostic factors including age, tumour grade, stage, functional status and serum prostate-specific antigen (PSA) concentration was collected for comparison between the arms, and between those enrolled or not.

RESULTS

In all, 210 of 251 eligible patients were randomized into the two arms. Patients were randomized before obtaining informed consent, which led to four patients already randomized refusing to participate. The 41 patients not enrolled were of similar age and grade distribution, but more frequently had extensive disease than had those enrolled in the trial. Three patients were unable to participate because of rapid deterioration in their general condition after randomization. There were no clear differences in baseline characteristics (including age, functional status, tumour grade and stage) of the patients between the arms. The distribution of PSA level differed slightly between the arms, which may require adjustment in the analyses. Patients in the intervention arm participated in decision-making more actively than those in the control arm.

CONCLUSION

Randomized studies on ethical issues such as the patient's role in choosing treatment are feasible and likely to provide important information.

Two-year follow-up results of a prospective randomized trial comparing hybrid laser prostatectomy with TURP in the treatment of big benign prostates

OBJECTIVE

We compared conventional transurethral electroresection of the prostate (TURP) and hybrid laser treatment in patients with symptomatic bladder outflow obstruction caused by a benign prostate bigger than 40 ml.

MATERIAL AND METHODS

Forty-six patients with symptomatic urodynamically confirmed outflow obstruction caused by benign prostate hyperplasia bigger than 40 ml were accepted to the prospective trial and were randomized to receive hybrid laser treatment or TURP. The hybrid laser technique involved initial non-contact Nd:YAG coagulation followed by contact Nd:YAG vaporization to open the prostatic urethra. Patients were re-assessed after 3, 6, 12 and 24 months.

RESULTS

Of the 46 patients, 37 (80%) were available at the 24-month follow-up. The re-operation rate was 14.3% in the hybrid laser group and 8.3% in the TURP group. The decrease in DanPSS-1 symptom score from baseline at 24 months was 51.0% in the hybrid laser group (p<0.01) and 80.0% in the TURP group (p<0.001), with no statistically significant differences between the groups. Early improvement in objective urinary parameters of peak urinary flow rate and residual urinary volume showed deterioration in hybrid laser group during longer follow-up, whereas in TURP group the improvement of these variables was sustained. Comparison between groups showed TURP to be superior in peak urinary flow rate (p < 0.001) and residual urinary volume (p < 0.01) at the 24-month follow-up visit.

CONCLUSIONS

Both hybrid laser treatment and TURP give good symptomatic relief lasting at least 2 years in the treatment of big obstructing prostates, but hybrid laser treatment is associated with a higher re-operation rate because of inadequate initial prostate tissue removal and with inferior outcome in objective urinary parameters compared with TURP.

Effect of photodynamic therapy on urinary bladder function: an experimental study with rats

Photodynamic therapy (PDT) produces localized necrosis with light after prior administration of a photosensitizing drug. The problems with laser light dosimetry and complications relating to bladder function appear to be important limiting factors of PDT in urology. Photodynamic therapy on urinary bladder with normal epithelium of rats was performed using an argon ion laser as an energy source, with aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) photosensitizer. Four hours after ALA intravenous administration, the bladders were intravesically radiated with light doses 20, 40, or 80 J/cm2. Animals in the control group did not receive ALA and were radiated with 20 J/cm2 light dose. Three weeks prior to PDT, the bladder capacity and pressure changes during filling cystometry were assessed. Cystometrics were repeated 1, 3, 7, or 21 days after laser therapy. The light dose 20 J/cm2 and 40 J/cm2 together with the used ALA dose caused no reduction in bladder capacity, whereas 80 J/cm2 light dose produced up to 50% reduction in the capacity at 3 weeks postoperatively. In control group without ALA, the animals did not regain more than 34% of the capacity of their control values at 3 weeks. The light dose of 20 J/cm2 and 40 J/cm2 with ALA induced functional changes that subsided after day 1. Our results indicate that with proper dosing of photosensitizing drug and light energy, the functional impairment of urinary bladder may be reduced as transient. These findings support the use of PDT as safe therapy of superficial bladder cancer.

The effect of transurethral needle ablation on symptoms of chronic pelvic pain syndrome--a pilot study

OBJECTIVE

We evaluated the effects of transurethral needle ablation (TUNA) in chronic pelvic pain syndrome (CPPS).

MATERIAL AND METHODS

CPPS patients were subjected to TUNA (n = 21) or sham therapy (urethrocystoscopy) (n = 6). Digital rectal examination and transrectal ultrasound were performed. Prostate-specific antigen and urine were analysed before and 1 month after treatment. Symptoms, the DAN-PSS-1 questionnaire, urine flow, residual urine volume, medication and a subjective estimation of the effect of treatment were evaluated during a follow-up period of 12 months.

RESULTS

In both groups the maximal urine flow increased and the DAN-PSS-1 score decreased, but the decrease in the DAN-PSS-1 score was significant (p = 0.002) only in the TUNA group. The total symptom score decreased from 14 to 8.3 points in the TUNA group, and from 12.6 to 8.0 points in sham patients. TUNA relieved pain significantly. In the TUNA group symptoms were ameliorated in patients with small (< or = 20 ml; p = 0.002) and large prostates (> 20 ml; p = 0.04). Similarly, patients with both mild (p = 0.004) and severe (p = 0.02) symptoms at baseline benefitted from TUNA. Of the TUNA patients, 72% felt better at 1-year follow-up, although 57% still had symptoms and 38% needed medication. The figures in the sham group were 50%, 66% and 50%, respectively.

CONCLUSIONS

TUNA relieved symptoms in CPPS patients for at least 12 months. The need for medication and the presence of symptoms were reduced, and the fraction of patients satisfied with treatment was higher in the TUNA group than in the sham group. However, these differences between the groups were not statistically significant. To assess the clinical value of TUNA in CPPS a prospective double-blind study with a large number of patients is needed to confirm the results of this pilot study.

Expression and prognostic value of CD44 standard and variant v3 and v6 isoforms in prostate cancer

BACKGROUND

The adhesion molecule CD44 standard (CD44s), and its variant isoforms v3 and v6 are associated with cell-to-cell adhesion. The down-regulation of CD44 standard and its variant isoform CD44v6 is linked with early cancer cell dissemination, but the relationship between CD44v3 and malignant features of prostate cancer (PC) has not been established previously.

METHODS

The expression of CD44s and its CD44v3 and CD44v6 isoforms was analysed by immunohistochemistry in 209 archival PC biopsy specimens to establish their prognostic value.

RESULTS

Down-regulation of CD44s and CD44v6 was related to high T classification, metastasis, high Gleason score, DNA aneuploidy, high S-phase fraction, high mitotic index, perineural growth and dense amount of tumour infiltrating lymphocytes (p < 0.03 for all). Down-regulation of CD44s and CD44v6 was related to poor survival in the entire cohort (p < 0.0001), in M0 tumours (p < 0.001) and in T1-2M0 tumours (p < 0.05). In needle biopsies and TURP specimens, the prognostic impact of the investigated parameters was similar. In the multivariate analysis, T classification (p = 0.0009), presence of metastases (p < 0.0001), Gleason score (p = 0.0060) and CD44v6 (p = 0.0220) expression were independent prognostic factors. In M0 tumours, T classification (p < 0.0001) and CD44v6 (p = 0.003) independently predicted survival.

CONCLUSION

Down-regulation of CD44s and its CD44v6 isoform is related to tumour malignancy and unfavourable prognosis in PC.

Human complement factor H related protein test for monitoring bladder cancer

PURPOSE

The BTA stat test is a rapid, noninvasive, qualitative urine test that detects bladder tumor associated antigen (human complement factor H related protein) in urine. We compared BTA stat test to voided urine cytology in patients monitored for bladder cancer in a prospective trial, and determined whether this test is effective in detection of recurrence not seen by regular cystoscopy.

MATERIALS AND METHODS

A total of 445 consecutive patients with bladder cancer were studied. A voided urine sample was obtained before cystoscopy and divided for culture, cytology and BTA stat testing. In cases of a positive BTA stat test but negative cystoscopy, excretory urography or renal ultrasound, random biopsies and collected ureteral urine samples for ureteral cytology were obtained. The overall sensitivity and specificity as well as positive and negative predictive values for BTA stat test, cytology and their combination were calculated.

RESULTS

Of the 445 patients 118 (26.5%) had bladder cancer recurrence on cystoscopy, which was detected by BTA stat test and cytology in 63 (53.4%) and 21 (17.8%), respectively. Of the remaining 327 patients not having recurrent tumor on cystoscopy 81 (24.8%) had a positive BTA stat test. Excretory urography or renal ultrasound and random biopsies in 48 (59.3%) of these patients revealed 7 recurrences, making the total number of recurrent tumors 125 of 412 (30.3%). The overall sensitivities and specificities for the BTA stat test, cytology and their combination were 56.0%, 19.2%, 60.0% and 85.7%, 98.3% and 85.0%, respectively.

CONCLUSIONS

The sensitivity for detection of recurrent tumor on BTA stat test is superior to that of voided urine cytology in all bladder cancer categories, whereas the specificity of voided urine cytology is higher than that for BTA stat test. However, a sixth of the patients with apparent false-positive BTA stat test results chosen for further investigation had recurrent tumors that were not found on routine cystoscopy. Although the sensitivity and specificity were highest when both tests were used, the differences were not significant overall. Therefore, the BTA stat test could potentially replace urine cytology for followup of superficial bladder cancer.

MR urography in evaluation of acute flank pain: T2-weighted sequences and gadolinium-enhanced three-dimensional FLASH compared with urography. Fast low-angle shot

OBJECTIVE

The aim of this study was to compare the usefulness of breath-hold heavily T2-weighted sequences with gadolinium-enhanced three-dimensional fast low-angle shot (3D FLASH) MR urography in the evaluation of patients with acute flank pain.

SUBJECTS AND METHODS

Forty consecutive patients with symptoms of acute flank pain underwent MR urography followed immediately by excretory urography. Heavily T2-weighted (combined thin-slice half-Fourier acquisition single-shot turbo spin-echo [HASTE] and thick-slab single-shot turbo spin-echo) and 3D FLASH sequences were evaluated separately and independently by two experienced radiologists for the presence, cause, level, and degree of obstruction. Interobserver agreement was calculated using the kappa statistic. Excretory urography and the final clinical diagnosis were used as reference.

RESULTS

Twenty-six patients were found to have unilateral obstruction caused by ureteral stones. Both MR urography methods were excellent for detecting obstruction. In the detection of stones 3D FLASH was superior, with a sensitivity of 96.2% and 100% and specificity of 100% and 100% for observers A and B, respectively, compared with a sensitivity of 57.7% and 53.8% and a specificity of 100% and 100%, respectively, for T2-weighted sequences. The best degree of obstruction was seen with 3D FLASH, and the interobserver agreement was excellent for stone detection (kappa = 0.97).

CONCLUSION

T2-weighted sequences alone are not sufficient for examining patients with acute flank pain. However, the combined use of both T2-weighted and 3D FLASH sequences will ensure better confidence in the evaluation of acute suspected renal colic. MR urography can replace conventional excretory urography when the latter is contraindicated or undesirable.

Prognostic value of CD44 standard, variant isoforms 3 and 6 and -catenin expression in local prostate cancer treated by radical prostatectomy

OBJECTIVE

The clinical and histological data of prostate cancer patients were compared with the expression of CD44 standard (CD44s), variant isoforms CD44v3, CD44v6 and alpha-catenin. The prognostic value of these adhesion molecules was also analysed.

PATIENTS AND METHODS

We analysed the clinical and histological data of 87 prostate cancer patients treated by radical prostatectomy in two Finnish hospitals. The mean (SD) age of the patients at diagnosis was 64 years (6) and the mean follow-up was 3 years (8). Immunohistochemistry was used to detect the expression of CD44s and its v3 (CD44v3) and v6 (CD44v6) isoforms and alpha-catenin.

RESULTS

The mean (SD) fractions of positively stained cancer cells were 38 (38), 10 (22), 56 (41) and 93% (17) for CD44s, CD44v3, CD44v6 and alpha-catenin, respectively. Low fractions of CD44s- and CD44v6-positive cancer cells were related to high preoperative prostate-specific antigen (PSA) levels (p<0.05 for both). Low fraction of CD44s positive cancer cells was linked with presence of seminal vesicle invasion (p = 0.07), surgical margin positivity (p = 0.09), high Gleason score (p = 0.04) and high mitotic index (p = 0. 02). Low fraction of CD44v3-positive cancer cells was related to positive surgical margins (p = 0.05), high Gleason score (p = 0.04), presence of perineural infiltration (p = 0.02) and absence of tumour-infiltrating lymphocytes (p = 0.02). Low fraction of CD44v6-positive cancer cells was related to high pT classification (p = 0.07), capsule invasion (p = 0.03), positive surgical margins (p = 0.05), high Gleason score (p = 0.008), perineural infiltration (p = 0.0001) and high mitotic index (p = 0.001). alpha-Catenin expression was not related to any of the clinicopathological variables included in this study. Gleason score (p = 0.001), pT classification (p = 0.007), perineural infiltration (p = 0.01) and the fraction of CD44v3-positive cancer cells (p = 0.04) were predictors of PSA failure in univariate analysis. pT category (p = 0. 012), Gleason score (p = 0.02) and expression of CD44v3 (p = 0.0003) were independent predictors of PSA failure.

CONCLUSIONS

The expression of CD44s, CD44v3 and CD44v6 is related to tumour differentiation. The expression of CD44v3 independently predicts PSA failure in addition to Gleason score and pT category during a short-term follow-up.

The morphological, in situ effects of a self-reinforced bioabsorbable polylactide (SR-PLA 96) ureteric stent; an experimental study

PURPOSE

The present study was done to evaluate the biocompatibility of a new biodegradable double helical spiral self-reinforced poly-L, D-lactide copolymer (L/D ratio 96/4, SR-PLA96) ureteric stent.

MATERIALS AND METHODS

In sixteen dogs, the right ureter was cut transversally, sutured and stented with a 50 mm. long SR-PLA 96 stent. In eight dogs, left ureter was similarly operated and stented with a double-J pigtail stent (C-Flex, Cook Urological Inc.), while eight remaining ureters served as plain controls. Urine was analyzed for signs of infection. The dogs were terminated at 6, 12 and 24 weeks postoperatively and the ureters dissected to find persistent SR-PLA 96 particles or local ureteric changes. Histologic samples were taken at three levels of dissected ureters in contact with the stent.

RESULTS

C-Flex and SR-PLA 96 materials were well tolerated. Both of these induced only minimal ureteral wall edema, epithelial hyperplasia, epithelial destruction and inflammatory cell reaction. In SR-PLA 96 stented ureters the tissue reaction subsided after the degradation of the device.

CONCLUSIONS

SR-PLA 96 spiral stent is regarded highly compatible and SR-PLA 96 might be a suitable material for a partial ureteric stent. Biodegradation of a SR-PLA 96 stent makes stent removal unnecessary.

Evaluation of p21WAF1/CIP1 and cyclin D1 expression in the progression of superficial bladder cancer. Finbladder Group

Immunoreactivity of p21WAF1/CIP1 and cyclin D1 proteins was assessed in a cohort of 207 patients with superficial (pTa-pT1) bladder cancer followed up for a mean of 4.9 years. The results of the immunostainings were compared with T category, WHO grade, tumor cell proliferation rate (MIB-1 score), the expressions of p53 and bcl-2 as well as survival. Sixty-eight percent and 75% of the tumors were p21WAF1/CIP1 positive (> or = 5% of cells positive) and cyclin D1 positive (> or = 10% of cells positive), respectively. The p21WAF1/CIP1 expression was related to cyclin D1 immunolabelling (P < 0.001) but not to the other variables studied. The expression of cyclin D1 was inversely associated with T category (P = 0.001), WHO grade (P = 0.006), MIB-1 score (P = 0.014), p53 expression (P = 0.001), and bcl-2 (P = 0.011) immunoreactivity. In univariate analysis, T category (P = 0.0001), WHO grade (P < 0.0001), MIB-1 score (P < 0.0001), bcl-2 (P = 0.0092), p53 (P = 0.0016) and p21WAF1/CIP1 (P = 0.009) expressions were significant prognostic factors with regard to tumor progression, whereas cyclin D1 was without any prognostic significance (P = 0.1). Out of 123 p21 positive tumors 21 progressed, whereas only 2 out of 58 p21 negative tumors progressed. In multivariate analysis, the MIB-1 score was the only independent predictor of cancer-specific survival (P = 0.03), whereas tumor grade (P = 0.002) and cyclin D1 expression (P = 0.04) were independent predictors of tumor recurrence. Only the WHO grade (P = 0.04) retained its prognostic value indicating the risk of progression. We suggest that in superficial bladder cancer p21WAF1/CIP1 and cyclin D1 immunohistochemistry provide no additional prognostic information compared with already established prognostic factors for predicting the risk of progressive disease.

The morphological changes in rat bladder after photodynamic therapy with 5-aminolaevulinic acid-induced protoporphyrin IX

OBJECTIVE

To assess the optimum light energy needed to induce only superficial bladder wall damage during photodynamic therapy (PDT) as a treatment for bladder cancer. Materials and methods The urinary bladder (with normal epithelium) of 64 female rats was treated with PDT using a continuous-wave argon-ion laser as an energy source and aminolaevulinic acid (ALA)-induced protoporphyrin IX photosensitizer. Four hours after the intravenous administration of ALA (300 mg/kg) the bladders were intravesically exposed to light fluences of 20-80 J/cm2. The control rats received no ALA and were exposed to 20 J/cm2 light. After 1, 3, 7 and 21 days the animals were killed and the morphological changes in bladder wall analysed both macroscopically and using light and scanning electron microscopy.

RESULTS

At the dose of ALA given, a fluence of 20-40 J/cm2 caused mainly superficial damage, whereas 80 J/cm2 produced full-thickness injuries to the bladder wall. The maximum effect of PDT occurred after 1 and 3 days of irradiation. After 3 weeks of PDT the histology showed few full-thickness injuries and only in those treated with 80 J/cm2 light.

CONCLUSION

These results indicate that PDT can be used to safely induce a selective superficial removal of bladder mucosa with no fibrotic effects on detrusor musculature, when optimum photosensitizing drug and fluences are used. These findings support the use of PDT in the therapy of superficial bladder cancer.

Expression of activator protein 2 in prostate cancer is related to tumor differentiation and cell proliferation

OBJECTIVES

Activator protein 2 (AP-2) is a DNA-binding transcription factor that can activate the expression of p21 (waf1/cip1), which in turn causes growth arrest of cells through inhibition of cyclin-dependent kinases required in G1-S progression. The aims of the present study were to analyze the expression of AP-2 in prostate cancer and to relate the results of AP-2 immunohistochemistry to other known prognostic factors and patient survival.

METHODS

AP-2alpha was demonstrated by an immunohistochemical method in 215 prostate cancer cases, and the results of immunohistochemistry were related to other known prognostic factors and patient survival.

RESULTS

The expression of AP-2alpha in carcinomas was usually weak and cytoplasmic, similar to normal prostatic epithelium adjacent to tumors. In 6% of the tumors, the expression was strong, and in 15% no staining signal was detected. Nuclear expression was detected in 22% of cases. Low fraction of AP-2-expressing cells was related to high mitotic index, Ki67 labeling and high expression of p21 (waf1/cip1). Nuclear expression of AP-2 was related to high Gleason score, advanced T category, DNA aneuploidy and high S-phase fraction. Nuclear expression was an indicator of unfavorable disease outcome, but in multivariate analysis, expression of AP-2 had no prognostic value.

CONCLUSIONS

Cytoplasmic expression of AP-2alpha is reduced in poorly differentiated prostate carcinomas. The rare nuclear expression occurs in a small proportion of tumors which are aneuploid, have a high T category and high Gleason score. The expression of AP-2 seems to have no prognostic value in prostate cancer.

BTA test is superior to voided urine cytology in detecting malignant bladder tumours

BACKGROUND AND AIMS

In a prospective study, Bard BTA (bladder tumour antigen) test was compared to voided urine cytology (VUC) in detecting primary and recurrent bladder cancer (BC).

MATERIALS AND METHODS

407 control cystoscopies, BTA test and VUC were performed on 150 patients, of which 96 (23.6%) recurrent tumours were found, and 43 patients with a new BC were noticed.

RESULTS

BTA test was superior to VUC in detecting superficial Ta (23% vs. 3%, p < 0.001) and grade 1 (16% vs. 0%, p < 0.001) as well as grade 2 (35% vs. 11%, p < 0.01) tumours. In Tis and T2-T4 tumours as well as in grade 3 tumours both tests performed similarly. The sensitivity of BTA test compared to VUC in detecting recurrent tumours was higher (24 % vs. 9%, p < 0.01), but VUC had more specificity than BTA test (99% vs. 80%, p < 0.001).

CONCLUSIONS

BTA test was superior to VUC in detecting BC and its recurrence. The simultaneous use of the BTA test and VUC did not add any information in detecting tumour growth in the bladder as compared to the BTA test alone.

Expression of cyclins A and D and p21(waf1/cip1) proteins in renal cell cancer and their relation to clinicopathological variables and patient survival

We have studied 118 renal cell carcinomas to analyse the expressions of cyclins A and D1 and p21(waf1/cip1), and their relationship to clinical and histopathological parameters as well as to clinical outcome. Cyclins A and D1 and cyclin-dependent kinase inhibitor p21 (waf1/cip1) were not expressed in normal renal tissue. Staining signals of cyclin D1 and p21(waf1/cip1) were always nuclear but cyclin A was also expressed in the cytoplasm of the tumour cells. The mean (range) fractions of cyclin A, cyclin D1 and p21(waf1/cip1)-positive tumour cells were 2.2% (range 0-20%), 23.3% (range 0-90%) and 6.8% (range 0-70%) respectively. The expression of cyclin A was related to venous invasion, high nuclear grade, high mitotic rate, high Ki-67 and high PCNA expressions (P < or = 0.006 for all). The expression of cyclin D1 was linked with age over 65 years, low nuclear grade and high p53 expression (P < or = 0.05 for all). An inverse correlation was present between p21(waf1/cip1) and cyclin D1 (P = 0.011). Cyclin A predicted survival in the entire study group (P = 0.0014), in T1-4/N0-2/M0 (P = 0.0007) and in T1-2/N0/M0 tumours (P = 0.0007). Cyclin A was also a powerful predictor of disease-free survival in T1-4/N0/M0 (P = 0.0027) tumours (P = 0.0007). Cyclin D1 and p21(waf1/cip1) were not significantly related to survival or disease-free survival in any of the groups. In the entire material the independent prognostic factors were the presence of distant metastases (relative risk (RR) 5.16, P < 0.001), T category (RR 2.68, P < 0.001), Ki-67 expression (RR 1.02, P = 0.026) and cyclin A expression (RR 1.12, P = 0.001). The independent predictors in T1-4/N0/M0 tumours were T-category (RR 2.67, P = 0.001) and cyclin A (RR 1.21, P < 0.001), and in T1-2/N0/M0 tumours the only significant predictor was cyclin A (RR 1.19, P = 0.0002). In renal cell carcinoma, cyclin A is a powerful and independent prognostic factor in all clinical stages of the disease, whereas cyclin D1 and p21(waf1/cip1) have no prognostic value.

Alpha-catenin expression has prognostic value in local and locally advanced prostate cancer

Normally functioning cell-cell adhesion plays an important role in the maintenance of tissue architecture and cell cohesion. E-cadherin is an important adhesion molecule of epithelial cells. In many types of cancer the expression of E-cadherin is reduced leading to increased risk of disease progression. alpha-Catenin is one of the intracellular elements of the E-cadherin-catenin complex. The abnormalities in the expression of alpha-catenin seem to associate with malignant cellular features and disease progression in prostate cancer. To further analyse the significance of alpha-catenin expression, we studied 215 cases of prostate cancer by immunohistochemistry and the results were related to other known prognostic factors and patient survival during a mean follow-up period of 13 years. alpha-Catenin expression was down-regulated in 19% of the cases and 3% of the tumours were totally alpha-catenin-negative. The abnormal alpha-catenin expression and cytoplasmic signal were significantly linked with high T-category, metastatic disease, high Gleason score, perineural growth, high mitotic rate, high S phase fraction and DNA aneuploidy (P < 0.05 for all). In the survival analysis, reduced alpha-catenin expression (P = 0.06) and cytoplasmic signal (P = 0.04) were related to unfavourable patient outcome. In the multivariate analysis, including TM-classification and Gleason score, alpha-catenin expression had independent prognostic value in T1-2 M0 tumors. In the M0 tumours, abnormal alpha-catenin signal was independently associated with recurrence-free survival as well. The results indicate that down-regulation of alpha-catenin is related to several malignant cellular features, and it seems to have prognostic significance in the early phases of cancer progression. We suggest that alpha-catenin expression can provide prognostic information in early prostate cancer.

Prognostic value and expression of p21(waf1/cip1) protein in prostate cancer

BACKGROUND

p21(waf1/cip1) protein is a cyclin-dependent kinase inhibitor able to arrest the cell cycle at the G1 phase by inhibiting DNA replication. The expression of p21(waf1/cip1) and its prognostic value in prostate cancer are largely unexplored.

METHODS

We used immunohistochemistry to analyze the expression of p21(waf1/cip1) in 213 prostate cancer cases, and the results were related to other known prognostic factors and patient survival during a long-term follow-up.

RESULTS

The expression of p21 (waf1/cip1) protein was significantly associated with high Gleason score (P = 0.001), DNA aneuploidy (P = 0.013), high S-phase fraction (P = 0.019), and expression of Ki-67 (P = 0.021) and bcl-2 (P = 0.001) as well as cyclin A (P = 0.035) and D proteins (P<0.001). In univariate survival analysis the signal of p21(waf1/cip1) was significantly related to unfavorable prognosis (P = 0.010) both in the entire cohort and in local tumors (P = 0.034). In multivariate analysis, M-category, clinical T-category, Gleason score, and patient age were independent prognostic factors. In local tumors the expression of p21(waf1/cip1) together with clinical T-category and S-phase fraction were significant independent predictors of cancer related survival.

CONCLUSIONS

The results suggest that the expression of p21(waf1/cip1) protein is associated both with cell proliferation and patient survival in prostate cancer.

New bioabsorbable polylactide ureteral stent in the treatment of ureteral lesions: an experimental study

OBJECTIVE

To evaluate the suitability of a new biodegradable double-helical spiral self-reinforced poly-L,D-lactide copolymer (SR-PLA 96; L/D ratio 96/4) stent as a device for ureteral stenting in respect to changes in kidney function during the biodegradation process.

MATERIALS AND METHODS

Sixteen dogs were used as experimental animals and were subdivided into two groups of eight. In Group A, both ureters were cut transversally, sutured, and stented. The right ureter was stented using an SR-PLA 96 stent, whereas a double-J C-Flex stent was used on the left side. Cystotomy was performed at 6 weeks to remove the double-J stents. In Group B, the right ureter of each dog was cut and stented in similar manner using an SR-PLA 96 stent, whereas the left ureters served as untreated controls, and cystotomy was not performed. Serum creatinine and nitrogen values were measured, urine was analyzed for signs of infection, and renal function was evaluated by urography and renography examinations preoperatively and at 6, 12, and 24 weeks postoperatively, at which time points, the dogs were euthanized and the ureters dissected to find persistent SR-PLA 96 particles and macroscopic local changes. There were no urinary tract infections found during the study.

RESULTS

In the SR-PLA 96-stented ureters, obstructive hydronephrosis and stricture formation were observed in two cases (11%), with distal displacement of the SR-PLA 96 stent in another case (5.5%). In two additional renal units, a temporary prolongation in the kidney washout time was observed at 6-week renogram examinations. In the C-Flex-stented ureters, temporary changes in renography studies were observed in three cases (37.5%) at 6 weeks. Kidney washout times were protracted at 6 weeks in the pigtail-stented ureters in Group A as a sign of a pressure rise in the renal pelvis secondary to the direct connection between the renal pelvis and bladder, whereas pressure remained normal in SR-PLA 96-stented ureters. In Group B, renal function remained normal after ureteral repair in SR-PLA 96-stented ureters compared with the controls.

CONCLUSIONS

The double-helical apical stent design offers some advantages over a double-J design. The risk of pressure-induced kidney damage is lowered, because there is no direct connection between the bladder and renal pelvis, and the risk of upper urinary tract infections is reduced. The biodegradation of the device necessitates the removal of the stent. These preliminary results suggest that a biodegradable SR-PLA 96 stent with more effective expansion capacity can be used for stenting after a ureteral repair.

Contact laser prostatectomy compared to TURP in prostatic hyperplasia smaller than 40 ml. Six-month follow-up with complex urodynamic assessment

OBJECTIVE

To compare the efficacy and safety of contact laser vaporization (CLV) of the prostate and transurethral resection of the prostate (TURP).

MATERIAL AND METHODS

Fifty patients with symptomatic prostatic hyperplasia with prostate volumes less than 40 ml were randomized to CLV or TURP treatment. All patients had infravesical obstruction confirmed preoperatively by pressure-flow studies.

RESULTS

CLV lasted longer (51 +/- 13 min versus 34 +/- 12 min; p < 0.001), caused less bleeding (57 +/- 49 ml versus 175 +/- 133 ml; p < 0.001) and required longer bladder drainage time (4.3 +/- 6.1 versus 1.7 +/- 0.8 days; p < 0.01) than TURP. At 6-month follow-up, both treatments had improved objective urinary parameters and effectively reduced subjective symptoms. There were no significant differences between the study groups in symptoms scores (DanPSS-1), peak urinary flow rates (Qmax) and post-void residuals (PVR). Six months after treatment the detrusor pressure at peak urinary flow rate (PdetQmax) was 38.3 +/- 9.7 cm H2O in CLV patients and 31.3 +/- 9.9 cm H2O in TURP patients (NS). CLV treatment caused less retrograde ejaculation than TURP (1/16 potent CLV men versus 13/16 potent TURP men; p < 0.001).

CONCLUSIONS

Contact laser prostatectomy proved to be a safe procedure which improved subjective and objective urinary parameters during 6-month follow-up as effectively as TURP in the treatment of symptomatic infravesical obstruction caused by minimal or moderate benign prostate enlargement.

Expression of CD44 standard and variant-v6 proteins in transitional cell bladder tumours and their relation to prognosis during a long-term follow-up

The expression of the standard CD44 (CD44s) and its v6 isoform (CD44v6) was analysed immunohistochemically in 173 cases of transitional cell bladder cancer. The results of immunohistochemical analyses were related to established prognostic factors and clinical follow-up data. The expression intensity of CD44s in non-basal tumour cells was significantly related to TN classification, S-phase fraction (SPF), mitotic index, grade, density of tumour infiltrating lymphocytes. The expression intensity of CD44v6 in non-basal tumour cells was inversely related to DNA ploidy, SPF, and mitotic index. The expression intensity of CD44v6 in basal tumour cells was also inversely related to T-category, grade, papillary status, DNA ploidy, SPF, and mitotic index. Strong expression of CD44s in non-basal tumour cells was related to unfavourable outcome in univariate analysis (p = 0.008), whereas the strong expression of CD44v6 in both non-basal cells (p = 0.005) and basal cells (p = 0.0008) was related to high survival probability. In multivariate survival analysis, the expression intensity of CD44v6 was independently related to favourable outcome in muscle invasive tumours, while in superficial tumours, CD44s was an independent prognostic factor. The results suggest that the expression of CD44s and CD44v6 is associated with malignant features and prognosis in bladder cancer.

Expression of p21(waf1/cip1) protein in transitional cell bladder tumours and its prognostic value

OBJECTIVES

p21(waf1/cip1) protein is a cyclin-dependent kinase inhibitor able to arrest the cell at the G1 phase by inhibiting DNA replication through interaction with proliferating cell nuclear antigen (PCNA). Experimental analyses of human bladder cancer cell lines show that p21 might be considered a tumour suppressor gene since it is able to induce apoptosis like p53. The prognostic value and expression of p21(waf1/cip1) is incompletely studied in bladder cancer at present.

METHODS

The expression of p21 protein was immunohistochemically analysed in paraffin-embedded specimens of 186 patients with primary transitional cell bladder tumours. The results of immunohistochemical analysis were related to known prognostic factors and complete long clinical follow-up data (over 11 years).

RESULTS

The expression of p21(waf1/cip1) protein was significantly related to DNA ploidy, S phase fraction, mitotic index, apoptotic index, morphometric nuclear factors, and the expression of p53 and PCNA proteins, whereas it was unrelated to grade or TNM classification. In univariate survival analysis, the expression of p21(waf1/cip1) protein was not significantly related to prognosis. Independent prognostic factors were T category, papillary status and mitotic index.

CONCLUSION

The results indicate that although the expression of p21(waf1/cip1) protein is related to indicators of cell proliferation, apoptosis and p53 expression, it has no better prognostic value than already established prognostic factors in bladder cancer.

Value of Ki-67 immunolabelling as a prognostic factor in prostate cancer

OBJECTIVE(S)

The aim of the study was to analyze the results of Ki-67 immunostaining in prostatic adenocarcinoma and to assess its prognostic value.

METHODS

Clinical follow-up data was reviewed in 190 prostatic adenocarcinomas and the results of Ki-67 immunolabelling were correlated to standard prognostic factors and survival data of the patients. All stage and grade categories were included.

RESULTS

Ki-67 expression correlated significantly with histological differentiation of tumors, indicators of cell proliferation, perineural growth, density of tumor-infiltrating lymphocytes and TM classification. In survival analysis, Ki-67 expression was able to discriminate patients into different prognostic groups (p = 0.0035). In a separate analysis including T1-2M0 tumors, Ki-67 immunolabelling was a significant predictor of survival (p = 0.0258). In Cox's multivariate analysis Ki-67 was an independent prognostic factor in the entire cohort.

CONCLUSIONS

The results show that Ki-67 expression is a potentially useful prognostic factor in prostatic adenocarcinoma and it could be used as an additional criterion in defining a correct prognostic category in this malignancy.

Prognostic value of Ki-67 expression in renal cell carcinomas

OBJECTIVE

The aim of the study was to determine the prognostic power of Ki-67 immunostaining in renal cell carcinomas (RCC).

METHODS

Clinical follow-up data were reviewed in 111 RCC and the results of Ki-67 immunolabelling were correlated to standard prognostic factors and survival data of the patients.

RESULTS

Ki-67 expression correlated with tumor grade (p < 0.0001) and mitotic activity (p < 0.0001). In survival analysis Ki-67 expression could be used to divide patients into different prognostic groups (p = 0.0003). In separate analysis with M0 tumors Ki-67 immunolabelling was a powerful predictor of survival (p = 0.0016) as well as disease-free survival (DFS; p = 0.0067). In T1-2N0M0 tumors Ki-67 immunolabelling was superior (p = 0.0005) to other prognostic factors in survival analysis as well as in predicting DFS (p = 0.0006). Grade-2 tumors could be separated into distinct prognostic groups according to Ki-67 labelling (p = 0.0098). In Cox's multivariate analysis Ki-67 was an independent prognostic factor in all three subgroups of RCC.

CONCLUSIONS

The results show that Ki-67 expression is an independent prognostic factor in renal adenocarcinoma and could be applied in defining proper therapy for patients suffering from this malignancy.

A primary carcinoid tumor of the kidney: a case report and review of the literature

BACKGROUND

Primary carcinoids are found mostly in the gastrointestinal tract. Primary carcinoid tumor of the kidney is rare; only 28 patients have been reported. Because of the rarity of the lesion, its radiological and clinicopathological features are not well characterized. At the same time, its prognosis and histogenesis is unknown.

METHODS

A 62-year-old patient presented with a carcinoid tumor on the isthmus of the horseshoe kidney. Radiological, clinicopathological, and immunohistochemical tests were performed. The tumor was resected.

RESULTS

Two years later, metastasis were observed in the liver. The metastasis were treated with percutaneous ethanol sclerotherapy (PET).

CONCLUSIONS

To our knowledge, this is the first case of primary renal carcinoid tumor present on the isthmus of the horseshoe kidney and the first case of carcinoid liver metastasis to be treated with PET.

A prognostic score for prostatic adenocarcinoma based on clinical, histological, biochemical and cytometric data from the primary tumour

The aim of this study was to create a multivariate prognostic score for prostatic adenocarcinoma. A retrospective analysis of clinical, histological and cytometric prognostic factors in 325 cases of prostatic adenocarcinoma followed up on average over 13 years was performed. A multivariate prognostic score was built by using the independent prognostic factors. M-category, T-category, Gleason score and patient age were independent prognostic factors in the entire cohort. In MO tumors T-category, density of tumor infiltrating lymphocytes, the presence of apoptotic cells, and patient age were independent prognostic factors. In T1-2MO tumors the density of tumour infiltrating lymphocytes, mitotic index, standard deviation of maximum nuclear diameter and the serum level of acidic phosphatase were independent prognostic factors. By combining the coefficients of the regression model, a prognostic score was built for each of the tumour categories. The subsequent survival analysis based on the prognostic score indicated that it is a highly significant prognostic factor superior to individual prognostic parameters. The results show that the combination of prognostic data is a valuable tool in assessing the correct prognostic category for prostatic adenocarcinoma.

Concentrations of cadmium and lead in renal cell cancer

The incidence of renal cancer increased during the 1980's in Finland. The influence of environmental factors on carcinogenesis has been discussed in recent years. We determined the concentrations of cadmium and lead in renal tissue in 13 renal cancer patients. The mean concentration of cadmium for women was 9430 micrograms/kg (range 3437-13,962 micrograms/kg) and for male patients 14,702 micrograms/kg (range 3263-21,272 micrograms/kg). The mean concentration of lead for women was 73 micrograms/kg (range 41-105 micrograms/kg) and for male patients 96 micrograms/kg (range 34-106 micrograms/kg). Our results showed that the mean concentrations of cadmium and lead were-low in the renal cortex of renal cell cancer patients.

A new system for descriptive classification of stones in the upper urinary tract

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Effect of oral clodronate on bone pain. A controlled study in patients with metastic prostatic cancer

Although osteosclerotic metastases are characteristic of prostatic carcinoma, bone resorption is also accelerated. Since clodronate inhibits bone resorption and relieves bone pain, we have given it to patients with painful bone disease from prostatic cancer after failure of hormonal therapy. All patients received estramustine phosphate orally. Simultaneously they were randomly allocated to clodronate (36) and placebo (39) groups. Clodronate was given by mouth. The dose was 3.2 g for the first month, thereafter 1.6 g. Pain relief was more distinct in the clodronate group where one third of patients were totally free of bone pain. The use of analgesics stopped in 38% of patients on clodronate and in 18% on placebo which effect probably belongs to estramustine phosphate. Serum calcium concentration decreased more markedly in the clodronate group. Clodronate dose of 3.2 g seemed to be more potent than that of 1.6 g. Side effects were uncommon and occurred equally in both groups. No significant differences were seen in median survival or survival rates between the groups.

Orchiectomy versus oestrogen in the treatment of advanced prostatic cancer

The primary clinical efficacy of orchiectomy and the combination therapy of intramuscular polyoestradiol phosphate 80 mg monthly and oral ethinyl oestradiol 0.15 mg daily was evaluated by progression and cancer mortality rates in a series of 277 prostatic cancer patients representing part of the Finnprostate study. After a follow-up of 5 years there was a significant difference between the groups in terms of progression rate and prostatic cancer deaths. The oestrogen combination was more effective in delaying progression of the disease. The overall mortality rate was similar in both groups. About one-third of the patients were alive after 5 years.

Diagnostic problems associated with cystinuria

To elucidate the role of the urinary cystine concentration for the formation of urinary stones, 190 stone-formers were evaluated in this prospective study. Seven patients (3.8%) were heterozygous and one patient (0.5%) was homozygous for cystinuria; only two (1%) of them were cystine stone-formers. Two patients with calcium stones were heterozygous for cystinuria. This study confirms the observation that elevated concentrations of urine cystine are relatively infrequent among patients with urinary stones.

Unprocessed bran and intermittent thiazide therapy in prevention of recurrent urinary calcium stones

Both urinary calcium excretion and renal stone episodes are increased during the summer in Finland. Since thiazide and unprocessed bran are known to decrease urinary calcium excretion, we treated 73 patients with recurrent urinary stone formation by giving them unprocessed bran and intermittent thiazide. Of the patients, 32 had absorptive hypercalciuria and 41 had normal urinary calcium values. All patients were on a low-calcium and low-oxalate diet and took 40 g bran daily. Fourteen of the hypercalciuric and 14 of the normocalciuric patients were randomly allocated to use hydrochlorothiazide 50 mg b.i.d. from May to September. Reduction of stone formation was seen in all groups. The combination of thiazide + bran was superior to the bran on its own in inhibition of stone formation. Only 3/11 (27%) stones passed through during the summer in the thiazide + bran group as compared with the 11/17 (65%) in the bran group.

Five years of experience with selective therapy in recurrent calcium nephrolithiasis

We evaluated the efficacy of selective treatment in 126 patients with recurrent calcium urolithiasis who were chosen on the basis of ability to correct underlying physiochemical disturbances. Patients with hyperparathyroidism underwent an operation. Patients with renal hypercalciuria were treated with thiazide and those with absorptive hypercalciuria were given a low calcium, low oxalate diet with or without thiazide. The only treatment for normocalciuric patients was high fluid intake, which was suggested also to the other groups. A significant individual mean reduction in stone formation was observed in all groups after 5 years of treatment. However, only 48 per cent of the normocalciuric patients were in remission after 5 years of high fluid intake therapy and 45 per cent of those with absorptive hypercalciuria were free of recurrence with diet only. Thiazide treatment seemed to be effective despite the type of hypercalciuria. The effect of the treatment on stone formation was mediated through reduction of risk factors in the urine. Conversely, a high level of risk factors commonly predicted stone recurrence.