Effects of intravesical onabotulinumtoxinA on bladder dysfunction and autonomic dysreflexia after spinal cord injury: role of nerve growth factor

Study Type – Aetiology (case control) Level of Evidence 3c What's known on the subject? and What does the study add? Neurogenic detrusor overactivity (NDO) and autonomic dysreflexia (AD) are common outcomes following spinal cord injury (SCI). In this study, we showed that onabotulinumtoxinA controlled NDO and AD in rats with T4‐SCI, and also provided a mechanism for the control of AS.

OBJECTIVE

• ? To assess the significance of onabotulinumtoxinA (onabotA) intravesical administration in blocking autonomic dysreflexia (AD) response induced by cystometrogram (CMG) after T4 spinal cord transection (SCT).

MATERIALS AND METHODS

• ? Female rats were stratified into three groups: a sham group; a SCT‐only group; and a SCT with onabotA treatment group. Each group was further subdivided into two subgroups: AD assessment, or nerve growth factor (NGF) assessment via enzyme‐linked immunosorbent assay (ELISA).
• ? Three weeks after T4‐SCT, all groups were assessed. Arterial pressure and heart rate were measured during and after CMG.
• ? NGF was also extracted from the bladder and the dorsal root ganglia (DRG) of the T4 root and quantified by ELISA. In the onabotA‐treated group, 48 h before assessment, onabotA (1 mL, 20 U/mL in saline) was given using a urethral tube and was left indwelling for 30 min.
• ? Univariate anova was used to analyse the data and statistical significance was set at P < 0.05.

RESULTS

• ? The maximum voiding pressure and the number of uninhibited contractions were significantly lower in the group treated with intravesical onabotA than in the SCT‐only group.
• ? Intravesical onabotA significantly blocked the dysreflexia response (high arterial pressure with bradycardia) induced by CMG after SCT.
• ? Intravesical onabotA also significantly lowered NGF concentrations in the bladder and the T4 DRG segment.

CONCLUSIONS

• ? The results of the present study showed that intravesical onabotA controls neurogenic detrusor overactivity and AD after SCT.
• ? The findings shed light on the potential benefits of intravesical onabotA treatment in patients with spinal cord injury, and also provide a novel mechanism for the control of AD via a minimally invasive treatment modality.

     

Enhanced S100 calcium‐binding protein P expression sensitizes human bladder cancer cells to cisplatin

What’s known on the subject? and What does the study add? So far, several molecules have been reported to be involved in cisplatin resistance. This study revealed that a decreased expression of S100P is implicated in cisplatin resistance. In addition, S100P overexpression rendered bladder cancer cells sensitive to cisplatin.

OBJECTIVE

• ? To investigate the role of S100 calcium‐binding protein P (S100P) in the gain of cis‐diamminedichloroplatinum (II) (cisplatin) resistance in bladder cancer, having previously found, with cDNA microarrays using two pairs of parental (T24, KK47) and their cisplatin‐resistant bladder cancer cell lines (T24/DDP10, KK47/DDP20), that S100P mRNA expression was significantly reduced in cisplatin‐resistant cells.

MATERIALS AND METHODS

• ? S100P mRNA and protein expression levels were investigated by northern and western blot analyses, respectively.
• ? Intracellular S100P localization was examined by immunocytochemistry and immunohistochemistry.
• ? S100P over‐expression, obtained by transfection with S100P expression plasmid, was used to investigate whether or not S100P affected cellular resistance to cisplatin.

RESULTS

• ? S100P mRNA showed increased expression by cisplatin stimulation in parental cell lines.
• ? On the other hand, S100P mRNA and protein expression levels were markedly reduced in cisplatin‐resistant cells.
• ? The over‐expression of S100P in resistant cells resulted in an increased sensitivity to cisplatin.

CONCLUSIONS

• ? In bladder cancer cells, S100P was expressed and localized mainly in the nucleus.
• ? S100P expression was also involved in cisplatin sensitivity.
• ? S100P might thus represent a molecular marker predicting cisplatin sensitivity and a molecular therapeutic target for cisplatin‐based chemotherapy.

     

IL-23 gene therapy for mouse bladder tumour cell lines

OBJECTIVES

• ? To evaluate the antitumour effects of IL‐23 gene transfer into mouse bladder carcinoma (MBT2) cells.
• ? To investigate the mechanisms underlying the subsequent constitutive secrection of IL‐23 by the MBT2 cells

MATERIALS AND METHODS

• ? An expression vector containing IL‐23 gene was introduced into MBT2 cells by liposome‐mediated gene transfer, and secretion of IL‐23 was confirmed by ELISA.
• ? The in vivo antitumour effect of IL‐23‐secreting MBT2 cells (MBT2/IL‐23) was examined by injecting the cells into syngeneic C3H mice.
• ? A tumour vaccination study using mitomycin C (MMC)‐treated IL‐23‐secreting MBT2 cells was carried out, and the usefulness of in vivo CD25 depletion for an additional vaccine effect was also investigated.
• ? The mechanisms underlying the antitumour effects were investigated by antibody depletion of CD8 or CD4 T cells, or natural killer cells, and cells infiltrating the tumour sites in vivo were assessed using immunohistochemistry.

RESULTS

• ? Stable transformants transduced with MBT2/IL‐23 secreted IL‐23 into the culture supernatant.
• ? Genetically engineered IL‐23‐secreting MBT2 cells were rejected in syngeneic mice.
• ? MBT2/IL‐23‐vaccinated mice inhibited the tumour growth of parental MBT2 cells injected at a distant site and this vaccine effect was enhanced by combination with in vivo CD25 depletion by an antibody.
• ? The main effector cells for the direct antitumour effect of MBT2/IL‐23 were CD8 T cells, which was shown by in vivo depletion and immunohistochemical study.

CONCLUSIONS

• ? IL‐23‐secreting MBT2 cells were rejected in syngeneic mice by the activation of CD8 T cells.
• ? MMC‐treated MBT2/IL‐23 can have a tumour vaccine effect for parental MBT2 cells, and this effect was enhanced by combination with in vivo CD25 depletion.

     

Use of fluorescein isothiocyanate-human serum albumin for the intravesical photodiagnosis of non-muscle-invasive bladder cancer: an in vitro study using multicellular spheroids composed of normal human urothelial and urothelial cell carcinoma cell lines

OBJECTIVE

• ? To evaluate human serum albumin (HSA), fluorescently labelled with fluorescein isothiocyanate (FITC), as a potential intravesical photodiagnostic method for the early detection of non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? By using multicellular spheroids prepared from normal human urothelial (NHU) cells and from different urothelial cell carcinoma (UCC) cell lines (T24, J82), we simulated three‐dimensionally the normal urothelium and non‐muscle‐invasive UCCs present in the bladder of patients.
• ? The distribution of FITC‐HSA in these spheroids was investigated.

RESULTS

• ? Our data showed that fluorescently labelled albumin is quite evenly dispersed throughout the spheroids. However, in the case of the 10 mg/mL incubations, the fluorescence intensity seems to increase slightly towards the spheroid core.
• ? Using 1 mg/mL, the penetration of FITC‐HSA in T24 differed significantly from the penetration in NHU spheroids, but this was not the case for J82 spheroids.
• ? When the concentration of FITC‐HSA was increased 10‐fold, all UCC spheroids exhibited a significantly different accumulation of FITC‐HSA.

CONCLUSIONS

• ? As spheroids represent a suitable in vitro model for predicting the in vivo behaviour of compounds, our data suggest that FITC‐HSA could be used for the early detection of non‐muscle‐invasive bladder cancer.
• ? Human serum albumin conjugates of new or already available intravesical drugs could be generated to create alternative bladder cancer therapies with increased selectivity.

     

Evans blue as a selective dye marker for white-light diagnosis of non-muscle-invasive bladder cancer: an in vitro study

What's known on the subject? and What does the study add? We found that Evans blue preferentially accumulate in spheroids prepared from urothelial cell carcinoma (UCC) cells as compared to spheroids composed of normal human urothelial (NHU) cells. The present findings could be important for future developments in clinical diagnostics for early bladder cancer detection staging and grading involving white light cystocopy.

OBJECTIVE

• ? To develop a diagnostic method relying on the preferential accumulation of a dye in non‐muscle‐invasive bladder cancer (NMIBC) that is visible in conjunction with white‐light cystoscopy (WLC).

MATERIALS AND METHODS

• ? We investigated in detail the permeation of Evans blue in urothelial cell carcinoma (UCC) spheroids prepared from T24, J82 and RT‐112 human cell lines and spheroids composed of normal human urothelial (NHU) cells.
• ? To gain more insight into the differential accumulation, all spheroids were investigated ultrastructurally using transmission electron microscopy (TEM).

RESULTS

• ? We found that, after exposure to Evans blue for 2 h, UCC spheroids accumulated dramatically more dye than spheroids composed of NHU cells.
• ? Using TEM it was found that the malignant spheroids contain similar ultrastructural characteristics, i.e. a wide intercellular space and a decreased number of desmosome‐like cell attachments, to those from clinical samples of non‐papillary carcinoma in situ of the bladder.

CONCLUSION

• ? We believe the present findings could be important for future developments in clinical diagnostics for early bladder cancer detection, staging and grading involving WLC.

     

Secondary bladder cancer after upper tract urothelial carcinoma in the US population

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? It is known that a certain percentage of patients treated for upper tract urothelial carcinoma (UTUC) will go on to develop a secondary bladder cancer; however, the risk factors for developing a secondary bladder tumour have not been studied in a population‐based setting. Given the large changes in how UTUC has been diagnosed and managed in recent years, this study aimed to evaluate the natural history of UTUC in the US population over a 30‐year period, with a particular emphasis on the development of secondary bladder cancer.

OBJECTIVE

• ? To assess the natural history of upper tract urothelial carcinoma (UTUC) and the development of lower tract secondary cancer.

PATIENTS AND METHODS

• ? Patients diagnosed with UTUC between 1975 and 2005 were identified within nine Surveillance, Epidemiology and End Results registries.
• ? Baseline characteristics of patients with and without secondary bladder cancer were compared.
• ? A multivariate logistic regression model was fitted to test if the year of diagnosis predicted the likelihood of developing a secondary bladder cancer.

RESULTS

• ? Of the 5212 patients with UTUC, 242 (4.6%) had a secondary bladder cancer (range: 1.7–8.2%).
• ? There was a mean interval of 26.5 (95% CI: 22.2–30.8) months between cancer diagnoses.
• ? Compared with those without secondary tumours, patients with secondary bladder malignancy were more likely to present with larger tumours (4.2 vs 3.1 cm, P < 0.001) and with tumours located in the ureter (P < 0.001).
• ? Year of diagnosis was not a predictor of the likelihood of having a secondary bladder malignancy in a multivariate analysis controlling for demographic and tumour characteristics (odds ratio: 0.99; 95% CI: 0.95–1.03)

CONCLUSIONS

• ? Patients with larger urothelial tumours located in the ureter were those most likely to develop a secondary lower tract tumour.
• ? No longitudinal changes in the rate of secondary bladder cancer were noted among patients with UTUC over the 30‐year study period.

     

Reported use of intravesical therapy for non-muscle-invasive bladder cancer (NMIBC): results from the Bladder Cancer Advocacy Network (BCAN) survey

Study Type – Therapy (patterns of practice) Level of Evidence 2b What's known on the subject? and What does the study add? Claims‐based analyses suggest unexplained and potentially problematic variation in treatment intensity adherence to guidelines‐recommended care in NMIBC. Previous physician surveys prior to the contemporary Clinical Practice Guidelines (CPGs) reported associations between variation in NMIBC care and practice type, years in practice, and other physician‐related factors. In the largest physician survey addressing the management of NMIBC, and the first to examine these questions after the promulgation of contemporary CPGs, US urologists report grade‐specific utilization consistent with CPG recommendations, at rates higher than suggested by recent claims‐based analyses. As with prior studies, practice type and years in practice were significantly associated with variation in practices. Further research is needed to reconcile these findings with administrative claims data.

OBJECTIVES

• ? To determine self‐reported practices of use of intravesical chemo‐ and immunotherapy for patients with non‐muscle‐invasive bladder cancer (NMIBC)
• ? To evaluate the extent to which respondent characteristics were associated with any observed variation. Guidelines recommend intravesical therapy (IVT) in the management of NMIBC, but recent claims‐based analyses suggest exceedingly low rates of use of some of these therapies.

MATERIALS AND METHODS

• ? An electronic survey was developed by members of the Bladder Cancer Advocacy Network (BCAN) to elicit self‐reported use of management strategies for NMIBC.
• ? The survey was circulated to urologists via the American Urological Association, Society for Urologic Oncology and Large Urology Group Practice Association distribution lists.
• ? In all, 512 respondents completed the survey.

RESULTS

• ? In all, 63% reported routine perioperative mitomycin‐c (MMC) after transurethral resection of bladder tumour (80% academic vs 54% private practice, P < 0.001).
• ? Whereas 5% of respondents reported routine induction therapy with all new low‐grade (LG) diagnoses, 99% reported routinely doing so in new high‐grade (HG) cases; most commonly with single‐agent bacille Calmette‐Guérin (BCG) (94% vs 9% BCG/interferon and 5% MMC).
• ? Reported induction therapy was higher in the setting of high‐volume (77%) or frequently recurrent (44%) LG disease.
• ? In all, 89% reported routinely using maintenance therapy for HG vs 29% for LG disease.
• ? Routine biopsy after BCG, even with normal cystoscopy, was endorsed by 28% (39% academic vs 22% private practice, P < 0.001).

CONCLUSIONS

• ? Urologists report grade‐specific use of IVT for NMIBC, at rates higher than suggested in some claims‐based analyses.
• ? Further study is needed to corroborate these self‐reported patterns of care with lower rates of use suggested by claims‐based analyses.

     

Maintenance therapy with bacillus Calmette-Guérin Connaught strain clearly prolongs recurrence-free survival following transurethral resection of bladder tumour for non-muscle-invasive bladder cancer

Study Type – Therapy (RCT) Level of Evidence 1b

OBJECTIVE

• ? To confirm the recurrence‐preventing efficacy and safety of 18‐month bacillus Calmette‐Guérin (BCG) maintenance therapy for non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? The enrolled patients had been diagnosed with recurrent or multiple non‐muscle‐invasive bladder cancer (stage Ta or T1) after complete transurethral resection of bladder tumours (TURBT).
• ? The patients were randomized into three treatment groups: a maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks as induction therapy, followed by three once‐weekly instillations at 3, 6, 12 and 18 months after initiation of the induction therapy), a non‐maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks) and an epirubicin group (epirubicin, 40 mg, intravesically instilled nine times). The primary endpoint was recurrence‐free survival (RFS).

RESULTS

• ? Efficacy analysis was performed for 115 of the full‐analysis‐set population of 116 eligible patients, including 41 maintenance group patients, 42 non‐maintenance group patients and 32 epirubicin group patients.
• ? At the 2‐year median point of the overall actual follow‐up period, the final cumulative RFS rates in the maintenance, non‐maintenance and epirubicin groups were 84.6%, 65.4% and 27.7%, respectively.
• ? The RFS following TURBT was significantly prolonged in the maintenance group compared with the non‐maintenance group (generalized Wilcoxon test, P= 0.0190).

CONCLUSION

• ? BCG maintenance therapy significantly prolonged the post‐TURBT RFS compared with BCG induction therapy alone or epirubicin intravesical therapy.

     

Nerve growth factor level in the prostatic fluid of patients with chronic prostatitis/chronic pelvic pain syndrome is correlated with symptom severity and response to treatment

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To explore whether levels of nerve growth factor (NGF) in expressed prostatic secretions (EPS) are correlated with symptom severity in chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

PATIENTS AND METHODS

• ? All patients with CP/CPPS underwent a complete history and physical examination, and were scored according to the National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI).
• ? Expressed prostatic secretion samples from 20 patients with CP/CPPS and from four asymptomatic control patients were collected and frozen, and NGF levels in EPS were measured by enzyme‐linked immunosorbent assay.
• ? Patients were asked to complete NIH‐CPSI questionnaires at baseline and 8 weeks after treatment and patients with at least a 25% decrease in total NIH‐CPSI score from the baseline values were classified as responders to treatment.

RESULTS

• ? The mean (±sd ) NGF levels in EPS of patients with CP/CPPS and asymptomatic control patients were 7409 (±3788) pg/mL and 4174 (±1349) pg/mL, respectively. The NGF level in patients with CP/CPPS correlated directly with pain severity (P= 0.014, r= 0.541).
• ? There were no significant differences between NGF levels in EPS before and after treatment. However, successful treatment significantly decreased NGF levels in responders (P= 0.001).

CONCLUSION

• ? Nerve growth factor might contribute to the pathophysiology of CP/CPPS as changes in NGF level in EPS occurred in proportion to pain severity. Therefore, these results suggest that NGF could be used as a new biomarker to evaluate the symptoms of CP/CPPS and the effects of treatment.

     

Role of Rho-kinase and protein kinase C during contraction of hypertrophic detrusor in mice with partial urinary bladder outlet obstruction

What's known on the subject? and What does the study add? Intracellular signaling via Rho‐kinase and protein kinase C modulate contraction of urinary bladder smooth muscle. These systems can be involved in the bladder overactivity and may constitute pharmalogical targets for treatment of OAB. This study describes the integrated action of these two cellular pathways in BOO and normal bladders, using a mouse model. It is also shown that the activation via membrane depolarization could specifically be inhibited in BOO bladders using Rho‐kinase blockers.

OBJECTIVE

• ? To study muscarinic/purinergic receptor activation and Rho‐kinase/protein kinase C (PKC) signalling during smooth muscle contraction in normal and hypertrophic mouse urinary bladders.

METHODS

• ? Partial urinary outflow obstruction was induced in adult female (10–12 weeks) C57Bl/6 mice and comparisons were made with sham‐operated controls.
• ? Bladder preparations were examined in vitro.
• ? Expression of signalling proteins was examined using Western blot analysis.

RESULTS

• ? Obstructed bladders increased more than threefold in weight and were found to have enhanced muscarinic and attenuated purinergic components during nerve‐induced contractions.
• ? The contractile response to carbachol was shifted towards lower concentrations of carbachol for the peak response and had a markedly enhanced sustained component. The amplitude of the α,β‐methylene ATP‐induced responses was lowered. Rho‐kinase inhibitor Y27632 (10 µm ) inhibited peak and sustained contractile responses to carbachol in control bladders (peak by 38%; plateau 57%) and obstructed bladders (peak 37% plateau 47%).
• ? PKC inhibitor GF109203X (1 µm ) inhibited carbachol contractions in controls (peak by 29%; plateau 29%) and obstructed bladders (peak 17%; plateau 12%). Inhibition by a similar extent was observed after nerve stimulation.
• ? Sensitivity to Ca²⁺ in high‐K⁺ depolarized intact tissues increased in obstructed bladders. This increased receptor‐independent Ca²⁺‐sensitivity was abolished by Y27632.
• ? Tissue contents of the myosin‐binding phosphatase subunit MYPT‐1 and catalytic phosphatase subunit PP1β, were decreased and the contents of RhoGDI, RhoA and CPI‐17 increased. A decrease in the Rho‐kinase isoform ROCK‐1 was observed.

CONCLUSION

• ? Based on these results, one can speculate that Rho‐kinase inhibition would preferentially target the pathological phasic activity in the urinary bladder rather than inhibit the physiological receptor‐mediated bladder emptying.

     

Temporal diabetes and diuresis-induced alteration of nerves and vasculature of the urinary bladder in the rat

What’s known on the subject? and What does the study add? Diabetes mellitus seriously affects urinary bladder function. Diabetes induces time‐dependent bladder hypertrophy and altered tissue composition. However, the alterations of the density of nerves and vasculatures in bladder under diabetes remains poorly studied. Diabetes induced time‐dependent changes of density of the nerves and vasculatures in the bladder tissues. In addition, diabetes‐related polyuria plays an important role in this alteration.

OBJECTIVE

• ? To characterize the temporal changes of the nerves and vasculature of the bladder in diabetic rats.

MATERIALS AND METHODS

• ? A total of 36 Sprague–Dawley rats were divided into three groups: streptozotocin‐induced diabetics, 5% sucrose‐induced diuretics and age‐matched controls.
• ? The characteristics of the nerves and vasculature in the equatorial cross‐sectional areas of the bladder were examined by immunofluorescence staining of their specific markers, neurofilament 200 (NF200) and CD31, at 1, 9 or 20 weeks after induction.
• ? The distributions of the nerves and blood vessels were observed and the densities were quantified.

RESULTS

• ? Diabetes caused a significant reduction in body weight. Bladder weight increased in diabetic and diuretic rats, but not in controls.
• ? The total cross‐sectional wall area and detrusor muscle area at the equatorial midline were greater in bladders of diabetic and diuretic rats than in controls.
• ? Neurofilament 200‐immunoreactive (NF200‐IR) nerves were mainly distributed in the detrusor muscle. CD31‐immunoreactive blood vessels were mainly distributed in the mucosa/submucosa.
• ? There were no significant differences in the NF200‐IR nerve terminal area among control, diabetic and diuretic groups. However nerve density was decreased at 9 and 20 weeks in the muscle, and at 20 weeks in the mucosa/submucosa in diabetic and diuretic animals.
• ? Blood vessel density decreased in the diabetic and diuretic groups at 20 weeks in the muscle.

CONCLUSIONS

• ? Diabetes induced time‐dependent changes in the density of the nerves and vasculature in the bladder tissues.
• ? Diabetes‐related polyuria plays an important role in these changes.

     

Suberoylanilide hydroxamic acid (SAHA) combined with bortezomib inhibits renal cancer growth by enhancing histone acetylation and protein ubiquitination synergistically

What's known on the subject? and What does the study add? The treatment modality for advanced renal cancer is limited and new treatment approaches are urgently needed. Beneficial effects of bortezomib combined with SAHA have recently been reported. However, there are no previous reports of this combination being tested against renal cancer and its further mechanisms of action should be clarified. This study examined the combined effects of these two clinically feasible drugs and showed that the combination inhibits renal cancer cell proliferation by enhancing both protein ubiquitination and histone acetylation synergistically.

OBJECTIVE

• ? To investigate the combined effect of two clinically feasible drugs, the proteasome inhibitor bortezomib and the histone deacetylase (HDAC) inhibitor suberoylanilide hydroxamic acid (SAHA), on human renal cancer cells in vitro and in vivo.

MATERIALS AND METHODS

• ? The effectiveness of the combination of bortezomib (10–20 nm ) and SAHA (1–5 µm ) on renal cancer cells (Caki‐1, ACHN, A‐498, 786‐O, 769‐P) was assessed by MTS assay, colony formation assay, cell cycle analysis, and apoptosis assay.
• ? In vivo efficacy was evaluated using murine subcutaneous (s.c.) tumour models.
• ? Protein ubiquitination, unfolded protein response, histone acetylation, and changes in the expression of HDAC were evaluated by western blotting.

RESULTS

• ? The combination of SAHA and bortezomib induced apoptosis and inhibited cancer cell proliferation synergistically (combination indices <1) and colony formation significantly (P < 0.05).
• ? In s.c. tumour models a 10‐day treatment with a combination of SAHA (50 mg/kg) and bortezomib (60 µg/kg) inhibited tumour growth significantly (P < 0.05).
• ? Mechanistically, SAHA combined with bortezomib enhanced protein ubiquitination synergistically and enhanced histone acetylation by inhibiting the expression of HDACs.

CONCLUSION

• ? SAHA combined with bortezomib inhibits the proliferation of renal cancer cells in vitro and in vivo, and the effectiveness of the combination is due to its synergistic enhancement of histone acetylation and protein ubiquitination.

     

Detection of circulating tumour cells in peripheral blood of patients with advanced non‐metastatic bladder cancer

What’s known on the subject? and What does the study add? Circulating tumour cells (CTC) have prognostic relevance for patients with different metastatic carcinomas. Detection of CTC using the CellSearch system has also been reported in bladder cancer, but mainly in patients with metastatic disease. This is the largest report demonstrating that detection of CTC in non‐metastatic bladder cancer patients is feasible using the CellSearch system. Presence of CTC may be predictive for early systemic disease.

OBJECTIVE

• ? To prospectively detect and evaluate the biological significance of circulating tumour cells (CTC) in patients with bladder cancer, especially in those patients with non‐metastatic, advanced bladder cancer (NMABC).

PATIENTS AND METHODS

• ? Between July 2007 and January 2009, blood samples of 50 consecutive patients with localized bladder cancer and five patients with metastatic disease scheduled for cystectomy were prospectively investigated for CTC. Peripheral blood (7.5 ml) was drawn before cystectomy.
• ? Detection of CTC was performed using the USA Food and Drug Administration‐approved CellSearch^TM system. Data were compared with the clinical and histopathological findings.

RESULTS

• ? CTC were detected in 15 of 50 patients (30%) with non‐metastatic disease and five of five patients with metastatic disease. The overall mean number of CTC was 33.7 (range: 1–372; median: 2). In non‐metastatic patients, the mean number of CTC was 3.1 (range: 1–11; median: 1). Except for a univariate association between CTC with vessel infiltration (P= 0.047), all other common clinical and histopathological parameters did not reveal a significant correlation with CTC detection.
• ? A median 1‐year follow up was available for 53 patients (96.4%). Ten out of 19 preoperatively CTC‐positive patients died as a result of cancer progression.
• ? CTC‐positive patients showed significantly worse overall (P= 0.001), progression‐free (P < 0.001) and cancer specific survival (P < 0.001) compared to preoperatively CTC‐negative patients.

CONCLUSION

• ? This is the largest study demonstrating that detection of CTC in NMABC patients is feasible using the CellSearch^TM system. Our findings suggest that the presence of CTC may be predictive for early systemic disease.

     

Confocal laser endomicroscopy for the diagnosis of urothelial bladder neoplasia: a technology of the future?

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Bladder cancer is initially diagnosed by white light cystoscopy followed by histopathological evaluation after transurethral resection of tissue suspicious for cancer. Difficulties may occur especially in the assessment of flat lesions or in discrimination between CIS and inflammatory disease. Confocal endomicroscopy during diagnostic colonoscopy has been a valuable tool for in vivo microscopic visualization and detection of colonic neoplasias and has contributed to optimized detection rates of up to 99%. We evaluated resected bladder urothelium of 18 patients by confocal endomicroscopy and correlated microscopic findings with standard histopathology. Typical tumour growth patterns such as altered nuclear to cytoplasmic ratio, pseudopapillar tissue stratification and neoangiogenesis were readily visible. As nuclear and subnuclear architecture of healthy bladder tissue could be discriminated against neoplastic tissue, confocal endomicroscopy is a promising novel tool for the in vivo microscopic visualization of bladder cancer.

OBJECTIVE

• ? To evaluate bladder urothelium by confocal laser endomicroscopy (CLE) and correlate microscopic findings with standard histopathology.

PATIENTS AND METHODS

• ? Fresh bladder urothelium tissue specimens were topically stained with acriflavine for instantaneous microscopic imaging.
• ? A single‐line laser in a handheld CLE probe delivered an excitation wavelength of 488 nm providing a high resolution of 0.7 µm and an adjustable imaging depth of 0–250 µm.
• ? Resection specimens of 18 patients were investigated with 1000‐fold magnification and ex vivo findings were compared with targeted histopathology (haematoxylin and eosin staining).

RESULTS

• ? Typical tumour growth patterns such as altered nuclear to cytoplasmic ratio, pseudopapillar tissue stratification and neoangiogenesis were readily visible.
• ? Nuclear and subnuclear architecture of healthy bladder tissue could be discriminated against neoplastic tissue.

CONCLUSIONS

• ? In addition to white light cystoscopy, CLE is a promising novel tool for the in vivo microscopic visualization of bladder cancer; first results of the present study show its potential to define microscopic characteristics of bladder cancer tissue.
• ? Further in vivo studies are necessary to determine sensitivity and specificity of the technique.

     

GreenLight laser prostatectomy: a safe and effective treatment for bladder outlet obstruction by prostate cancer

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Although looked on as standard of care there is little published data on the use of “channel TURP” . Those case series that have been published show significant morbidity (in particular stress incontinence) and relatively long hospitalization compared to standard TURP. The use of vaprorising lasers in this patient group has not been addressed. GreenLight laser is a safe and efficacious treatment for bladder outflow obstruction in men with prostate cancer. Hospitalization is minimal (most were day cases) which we feel is important in men who are often in their last few months. We had no serious complications apart from a few patients with stress incontinence. The stress incontinence rate was dramatically lower than that reported in previous reported series of channel TURP – we are not however able to offer any obvious explanation for that finding.

OBJECTIVE

• ? To present our experience on photoselective vaporization of the prostate (PVP) in a cohort of men with bladder outlet obstruction (BOO) by prostate cancer.

PATIENTS AND METHODS

• ? From 2003 to 2008 we identified 43 patients with prostate cancer treated with PVP.
• ? The patients’ hospital records were comprehensively reviewed to obtain preoperative, intra‐operative and postoperative data.
• ? Inclusion criteria were patients with BOO or urinary retention with a diagnosis of prostate cancer.

RESULTS

• ? Mean operating time was 42 min, mean post‐operative hospital stay was 9.6 h. 32 out of 43 patients were discharged home within 24 h. Twelve patients (28%) did not need post‐operative catheter. Mean and median catheter times were 22 and 21.5 h respectively.
• ? Complications were mild: 1 patient needed bladder irrigation, 3 failed initial TWOC, 1 had early stress incontinence. Three had clot retention.
• ? At 3 months post‐operatively, 41 of 42 evaluable patients were voiding without a catheter. The mean peak flow rate had increased by 80% and a mean residual volume decreased of 49%.
• ? Four patients underwent a second laser treatment. Three had developed further retention between 7 and 23 months post‐operatively and did not want further surgery. The local failure rate at a mean follow up of 22 months was 7 of 39 patients (18%).

CONCLUSION

• ? The present study is the first on PVP applied to patients with prostate cancer.
• ? It is shown that, for patients with CaP bothered by LUTS or retention, GreenLight laser prostatectomy is very safe and gives excellent relief from symptoms, with a good improvement in peak flow rate.

     

Reversing bladder outlet obstruction attenuates systemic and tissue oxidative stress

What's known on the subject? and What does the study add? Oxidative damage in bladder tissue and systemic oxidative biomarkers were both found to be increased in rabbits with partial bladder outlet obstruction. It is shown that the reversal of partial bladder outlet obstruction will attenuate the systemic oxidative stress.

OBJECTIVE

• ? To investigate whether partial bladder outlet obstruction (PBOO) increases systemic oxidative stress and whether relief of PBOO could attenuate this stress.

MATERIALS AND METHODS

• ? Surgically created PBOO in male New Zealand white rabbits was assessed after 4 weeks in one group of rabbits (n = 4), and was relieved in two additional groups of rabbits (n = 4 each) that were assessed at 4 and 8 weeks after relief of PBOO.
• ? Four sham‐operated rabbits served as controls. The assessed oxidative stress biomarkers included urinary and plasma 8‐hydroxy‐2′‐deoxyguanosine (8‐OHdG) and plasma malondialdehyde (MDA), total anti‐oxidant capacity (TAC) and glutathione (GSH).
• ? In addition, the copy number of mitochondrial DNA and the 8‐OHdG content in bladder tissues from these rabbits were also determined at the beginning and at indicated time points in the experiments.

RESULTS

• ? There were significant increases in both the 8‐OHdG levels of urine, plasma and bladder tissue and the plasma MDA after induction of PBOO.
• ? There were also significant decreases in the TAC, in GSH levels and in mitochondrial DNA copy number in bladder tissues after PBOO.
• ? Most importantly, all of the values returned toward the control levels after the PBOO was reversed at 8 weeks.

CONCLUSION

• ? PBOO increases systemic and oxidative stress and its reversal results in a progressive reduction of both systemic and tissue oxidative stress.

     

Mechanisms and urodynamic effects of a potent and selective EP4 receptor antagonist,MF191, on cyclophosphamide and prostaglandin E2‐induced bladder overactivity in rats

Study Type – Aetiology (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Recent evidence has suggested that up‐regulation of the prostaglandin E₂ (PGE₂) receptor subtype 4 (EP4) receptor in the bladder is involved in bladder overactivity. The present study found that MF191, a selective EP4 receptor antagonist, may have effects on the bladder urothelium and inflammatory cells and suppress CYP‐ or PGE₂‐induced bladder overactivity. Systemic or intravesical MF191 administration for the treatment of overactive bladder may merit clinical study.

OBJECTIVE

• ? To investigate the mechanisms and urodynamic effects of a potent and selective prostaglandin E₂ (PGE₂) receptor subtype 4 (EP4) antagonist, MF191, on cyclophosphamide (CYP) or PGE₂‐induced bladder overactivity in rats.

MATERIALS AND METHODS

• ? Experimental and control rats were injected with CYP (200 mg/kg i.p.) or saline on day 1. Continuous cystometrogram (CMGs) were performed on day 3.
• ? In group 1, MF191 (vehicle 0.1 and 1 mg/kg) was given i.v. The bladder was then harvested for histology and immunohistochemistry. Some bladders were harvested for analysis of EP4 expression by Western blotting without a CMG study.
• ? In group 2, MF191 (vehicle 10 nM, and 100 nM) was continuously infused into the bladder.
• ? In group 3, bladder overactivity was induced by intravesical instillation of PGE₂ (200 uM) and vehicle or MF191 (1 mg/kg) was given i.v.

RESULTS

• ? CYP induced bladder inflammation, overactivity and EP4 upregulation. The CYP effects were suppressed by MF191 (1 mg/kg i.v.; intercontraction interval [ICI]: 39.4% increase, and reduced inflammatory cells infiltration, and EP4 expression).
• ? Intravesical instillation of MF191 (100 nM) suppressed CYP‐induced bladder overactivity (ICI: 71.8% increase).
• ? PGE₂‐induced bladder overactivity was suppressed by MF191 (ICI: 43.2% increase).
• ? MF191 had no significant effects on other CMG variables or on control rats.

CONCLUSIONS

• ? MF191 might affect the bladder urothelium and inflammatory cells and suppresses CYP‐ or PGE₂‐induced bladder overactivity.
• ? Systemic or intravesical MF191 administration for the treatment of overactive bladder merits clinical study.

     

RADICAL CYSTECTOMY FOR BCG FAILURE: HAS THE TIMING IMPROVED IN RECENT YEARS?

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? High‐grade Ta‐T1‐carcinoma in situ bladder cancer is a heterogeneous group; long‐term studies have shown that intravesical BCG therapy can be inadequate in a substantial percentage. Despite concerns about delay in performing RC for patients failing one or more courses of BCG, in our study we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG.

OBJECTIVE

• ? To analyse if there is a trend in recent years towards performing radical cystectomy (RC) before muscle invasion or extravesical spread after failure of bacille Calmette–Guérin (BCG) for high grade Ta/T1 bladder cancer. Although BCG is indicated for prophylaxis after endoscopic tumour resection there is still a risk of progression.

PATIENTS AND METHODS

• ? A retrospective analysis of our RC database (1992–2008) was performed to identify patients who underwent RC after receiving BCG.
• ? Relevant clinical and pathological data for the patients with clinical stage Ta, T1 and/or Tis at initial transurethral resection of bladder tumour were analysed.
• ? Pathological stage and survival for patients undergoing RC from 2003 to 2007 (group 2) were compared with those for patients operated between 1992 and 2002 (group 1).

RESULTS

• ? A total of 152 patients were included (75 in group 2 and 77 in group 1). Both groups were similar in T‐stage before BCG initiation, number of BCG cycles received and time interval to RC.
• ? There was no change in the proportion of patients undergoing RC with ≥pT2 bladder cancer in recent years (P= 0.5).
• ? Fifty‐two percent of group 2 and 43% of group 1 had ≥pT2 BC. The 5‐year survival was similar.

CONCLUSIONS

• ? Despite concerns about delay in performing RC for patients failing one or more courses of BCG we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG.
• ? A high proportion of patients have muscle‐invasive bladder cancer; more than 10% have lymph node metastasis.

     

The use of estramustine phosphate in the modern management of advanced prostate cancer

What’s known on the subject? and What does the study add? Estramustine phosphate has anti‐tumour properties and it improves patient outcomes if combined with other chemotherapy agents such as doeetaxel. The efficacy of estramustine phosphate in selected patients and its safety profile, provided used with any low‐molecular‐weight heparin support its use as a second‐line treatment in hormone‐resistant prostate cancer.

OBJECTIVES

• ? Estramustine phosphate is a nitrogen mustard derivative of estradiol‐17β‐phosphate and has anti‐tumour properties.
• ? Interest in estramustine has been renewed because of the results of clinical studies showing improved patient outcomes if estramustine is combined with other chemotherapy agents such as docetaxel.

PATIENTS AND METHODS

• ? Relevant clinical studies using chemotherapy combinations including estramustine are discussed.
• ? Efficacy and safety outcomes are summarized.

RESULTS

• ? Combination therapy with estramustine and docetaxel can increase PSA response rates, improve quality of life and increase median patient survival compared with chemotherapy regimens that do not include estramustine.
• ? Although the overall tolerability of estramustine is favourable, its use can be associated with an increased risk of thromboembolic events.

CONCLUSIONS

• ? The identification of suitable patient groups and the effective management of the risk of thromboembolism with the adjunct of low‐molecular‐weight heparins support the use of estramustine as an effective second‐line treatment strategy in hormone‐resistant prostate cancer.
• ? These promising findings warrant further investigation in a randomized clinical trial.