British Journal of Urology International July 2005 - Vol

British Journal of Urology International July 2005 - Vol. 96 Issue 1 Page i-205

i Editor's comment Online publication date: 17-Jun-2005 Comments 1 Beyond marketing: the real value of robotic radical prostatectomy

Anthony J. Costello

Online publication date: 17-Jun-2005 2 Prolonging survival in prostate cancer: chemotherapy will have an important role

Chris Parker, Mark Emberton

Online publication date: 17-Jun-2005 3 -acylmethyl co-enzyme A racemase: a tumour marker for the 21st century?

Debashis Das, Prokar Dasgupta, Asish Chandra

Online publication date: 17-Jun-2005 4 The 'flare' phenomenon: should we be concerned?

Ramesh Thurairaja, Rajendra Persad, John Peters, Amit Bahl

Online publication date: 17-Jun-2005 Mini-reviews 7 Molecular staging of bladder cancer

Anirban P. Mitra, Ram H. Datar, Richard J. Cote

Online publication date: 17-Jun-2005

13 The role of hand-assisted laparoscopy in urology: a critical appraisal

Abhay Rane, J. Stuart Wolf

Online publication date: 17-Jun-2005 17 The role of photodynamic diagnosis in the contemporary management of superficial bladder cancer

Sunjay Jain, Roger C. Kockelbergh

Online publication date: 17-Jun-2005 22 Nonsurgical factors in the success of hypospadias repair

Christopher R.J. Woodhouse, Deborah Christie

Online publication date: 17-Jun-2005 Urological Oncology 29 Racial differences in serum prostate-specific antigen (PSA) doubling time, histopathological variables and long-term PSA recurrence between African-American and white American men undergoing radical prostatectomy for clinically localized prostate cancer

Ashutosh Tewari, Wolfgang Horninger, Ketan K. Badani, Mazen Hasan, Steven Coon, E. David Crawford, Eduard J. Gamito, John Wei, David Taub, James Montie, Chris Porter, George W. Divine, Georg Bartsch, Mani Menon

Online publication date: 17-Jun-2005 34 Installation of telerobotic surgery and initial experience with telerobotic radical prostatectomy

Anthony J. Costello, Hodo Haxhimolla, Helen Crowe, Justin S. Peters

Online publication date: 17-Jun-2005 39 Robot-assisted vs pure laparoscopic radical prostatectomy: are there any differences?

Jean V. Joseph, Ivelisse Vicente, Ralph Madeb, Erdal Erturk, Hitendra R.H. Patel

Online publication date: 17-Jun-2005

43 Radical prostatectomy versus high-dose rate brachytherapy for prostate cancer: effects on health-related quality of life

Yoshimasa Jo, Hiratsuka Junichi, Fujii Tomohiro, Imajo Yoshinari, Fujisawa Masato

Online publication date: 17-Jun-2005 48 Does neoadjuvant hormone therapy for early prostate cancer affect cognition? Results from a pilot study

Valerie A. Jenkins, David J. Bloomfield, Valerie M. Shilling, Trudi L. Edginton

Online publication date: 17-Jun-2005 54 Surgical treatment of stage pT3b renal cell carcinoma in solitary kidneys: a case series

Shomik Sengupta, Horst Zincke, Bradley C. Leibovich, Michael L. Blute

Online publication date: 17-Jun-2005 58 A description of radical nephrectomy practice and outcomes in England: 1995 2002

Martin Nuttall, Paul Cathcart, Jan van der Meulen, David Gillatt, Gregor McIntosh, Mark Emberton

Online publication date: 17-Jun-2005 62 The relationship between angiogenesis and cyclooxygenase-2 expression in prostate cancer

Rono Mukherjee, Joanne Edwards, Mark A. Underwood, John M.S. Bartlett

Online publication date: 17-Jun-2005 67 Testicular-sparing microsurgery for suspected testicular masses

Giovanni Maria Colpi, Luca Carmignani, Franco Nerva, Piediferro Guido, Franco Gadda, Fabrizio Castiglioni

Online publication date: 17-Jun-2005

Lower Urinary Tract 71 Extracorporeal application of high-intensity focused ultrasound for prostatic tissue ablation

Axel Häcker, Kai Uwe Köhrmann, Walter Back, Oliver Kraut, Ernst Marlinghaus, Peter Alken, Maurice Stephan Michel

Online publication date: 17-Jun-2005 77 Association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symptoms in older American men: findings from the third National Health And Nutrition Examination Survey

Sabine Rohrmann, Carlos J. Crespo, Jason R. Weber, Ellen Smit, Edward Giovannucci, Elizabeth A. Platz

Online publication date: 17-Jun-2005 83 Relevance and variability of the severity of incontinence, and increased daytime and night-time voiding frequency, associated with quality of life in men with lower urinary tract symptoms

Johannes Haltbakk, Berit R. Hanestad, Steinar Hunskaar

Online publication date: 17-Jun-2005 88 The prevalence and correlates of urinary tract symptoms in Norwegian men: The HUNT Study

Arnfinn Seim, Cathrine Hoyo, Truls Østbye, Lars Vatten

Online publication date: 17-Jun-2005 93 A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self-catheterization in men with chronic urinary retention

Ibrahim Fathi Ghalayini, Mohammed A. Al-Ghazo, Robert S. Pickard

Online publication date: 17-Jun-2005

98 Preoperative administration of chlormadinone acetate reduces blood loss associated with transurethral resection of the prostate: a prospective randomized study

Osamu Ukimura, Akihiro Kawauchi, Motohiro Kanazawa, Hiroaki Miyashita, Kimihiko Yoneda, Munekado Kojima, Tsuneyuki nakanouchi, Tsuneharu Miki, for the Benign Prostatic Hyperplasia Study Group of Kyoto Prefectural University of Medicine

Online publication date: 17-Jun-2005 103 Porcine small intestinal submucosa as a percutaneous mid- urethral sling: 2-year results

J. Stephen Jones, Raymond R. Rackley, Ryan Berglund, Joseph B. Abdelmalak, Gerard Deorco, Sandip P. Vasavada

Online publication date: 17-Jun-2005 Hyperbaric oxygen therapy for radiation-induced 107 haemorrhagic cystitis

Amos Neheman, Ofer Nativ, Boaz Moskovitz, Yehuda Melamed, Avi Stein

Online publication date: 17-Jun-2005 Upper Urinary Tract 111 Magnetic resonance imaging as a sole method for the morphological and functional evaluation of live kidney donors

Tarek A. El-Diasty, Mohamed E. Abo El-Ghar, Ahmed A. Shokeir, Hossam M. Gad, Ehab W. Wafa, Mohamed E. El- Azab, Ahmed B. Shehab El-Din, Mohamed A. Ghoneim

Online publication date: 17-Jun-2005 117 Vitamin E therapy prevents hyperoxaluria-induced calcium oxalate crystal deposition in the kidney by improving renal tissue antioxidant status

Sivagnanam Thamilselvan, Mani Menon

Online publication date: 17-Jun-2005

Reconstructive Urology 127 Treatment of pelvic fracture-related urethral trauma: a survey of current practice in the UK

Daniela E. Andrich, Tamsin J. Greenwell, Anthony R. Mundy

Online publication date: 17-Jun-2005 Paediatric Urology 131 Upper and lower urinary tract outcome after surgical repair of cloacal malformations: a three-decade experience

Richard C. Rink, C.D. Anthony Herndon, Mark P. Cain, Martin Kaefer, Andrew M. Dussinger, Shelly J. King, Anthony J. Casale

Online publication date: 17-Jun-2005 135 An objective assessment of the results of hypospadias surgery

Moschos Ververidis, Alan P. Dickson, David C.S. Gough

Online publication date: 17-Jun-2005 140 Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

Philippos A. Androulakakis, Dimitrios K. Karamanolakis, Georgios Tsahouridis, Antonios A. Stefanidis, Ilias Palaeodimos

Online publication date: 17-Jun-2005 Investigative Urology 146 Expression of Ki-67 in squamous cell carcinoma of the penis

Navid Berdjis, Axel Meye, Johannes Nippgen, Dag Dittert, Oliver Hakenberg, Gustavo B. Baretton, Manfred P. Wirth

Online publication date: 17-Jun-2005 149 Accuracy of the routine detection of mutation in mismatch repair genes in patients with susceptibility to hereditary upper urinary tract transitional cell carcinoma

Morgan Rouprêt, Florence Coulet, Abdel-Rahmène Azzouzi, Gaëlle Fromont, Olivier Cussenot

Online publication date: 17-Jun-2005

152 Mesenchymal cells infiltrating a bladder acellular matrix gradually lose smooth muscle characteristics in intraperitoneally regenerated urothelial lining tissue in rats

Kimihiko Moriya, Hidehiro Kakizaki, Satoshi Watanabe, Hiroshi Sano, Katsuya Nonomura

Online publication date: 17-Jun-2005 158 Apoptosis: a key effector mechanism of lymphocyte action in human nonseminomatous testicular carcinoma?

Hans U. Schmelz, Matthias Port, Ekkehard W. Hauck, Michael J. Schwerer, Wolfgang Weidner, Christoph Sparwasser, Michael Abend

Online publication date: 17-Jun-2005 164 In vivo and in vitro response of corpus cavernosum to phosphodiesterase-5 inhibition in the hypercholesterolaemic rabbit

Farzeen Firoozi, Penelope A. Longhurst, Mark D. White

Online publication date: 17-Jun-2005 169 Effect of bladder ischaemia/reperfusion on superoxide dismutase activity and contraction

Erim Erdem, Robert Leggett, Brian Dicks, Barry A. Kogan, Robert M. Levin

Online publication date: 17-Jun-2005 175 Allopurinol provides long-term protection for experimentally induced testicular torsion in a rabbit model

Elijah O. Kehinde, Jehoram T. Anim, Olusegun A. Mojiminiyi, Farida Al-Awadi, Aida Shihab-Eldeen, Alexander E. Omu, Tunde Fatinikun, Asha Prasad, Mathew Abraham

Online publication date: 17-Jun-2005 Pharmaceutical review 181 The era of ESSTIs is slowly approaching?

Michael G. Wyllie

Online publication date: 17-Jun-2005

Points of Technique 183 Laparoscopic O'Conor's repair for vesico-vaginal and vesico- uterine fistulae

Percy Jal Chibber, Hemendra Navinchandra Shah, Pritesh Jain

Online publication date: 17-Jun-2005 187 Tied and tested: a cheap and simple method for transurethral resection

Amrith Raj Rao, John D. Beatty, Frederick C.L. Banks, Charles Hudd

Online publication date: 17-Jun-2005 Book reviews 189 Basic and advanced techniques in prostate brachytherapy

Stephen Langley

Online publication date: 17-Jun-2005 189 Transurethral resection

DC Dangerfield, E McLarty, RA Gardiner

Online publication date: 17-Jun-2005 Letters 190 Technical characterization of an ultrasound source for noninvasive thermoablation by high-intensity focused ultrasound

STORZ Medical, Switzerland

Online publication date: 17-Jun-2005 190 Conventional and alternative methods for providing analgesia in renal colic

Amrith Raj Rao, Roger O. Plail

Online publication date: 17-Jun-2005 191 High-intensity focused ultrasound (HIFU) for treating prostate cancer

Suril Patel, Shashi Kommu, Raj Persad

Online publication date: 17-Jun-2005

192 Managing patients with an overactive bladder and glaucoma: a questionnaire survey of Japanese urologists on the use of anticholinergics

David Goh, Jin Chan, Suresh Vasudevan, Jennifer L.Y. Yip, Paul J Foster

Online publication date: 17-Jun-2005 192 Vesico-vaginal fistula

Nagesh Kamat

Online publication date: 17-Jun-2005 Surgery Illustrated 195 Surgical Atlas Transureteroureterostomy

John M. Barry

Online publication date: 17-Jun-2005 202 Corrigendum Online publication date: 17-Jun-2005 203 Abbreviations Online publication date: 17-Jun-2005 204 Diary Online publication date: 17-Jun-2005

I am introducing a new section in the August issue of the Journal entitled ‘Great Drug Classes’ and it will be a full description of drug classes by internationally known writers

I have mentioned before in this column my In keeping with this ideal, I am introducing belief that, especially with the modern a new section which will have its ﬁrst multidisciplinary approach to treating appearance in the August issue of the Journal. urological cancer, we must listen carefully to The Pharmaceutical Review section, which what our colleagues in medical and radiation appears towards the end of each issue of the oncology have to say. Journal and written by Mike Wyllie, has received very positive reviews, and it allows In this way we can resolve some of the readers to see what is happening to drug misunderstandings which sometimes exist development in many areas of urological between our disciplines, and we can offer our interest. The new section will be entitled patients the best treatment for their ‘Great Drug Classes’ and will be a full condition. To allow us to hear the views of description of drug classes by internationally these colleagues, and to see what new drugs known writers, which will appear roughly are being used in oncology, we will be twice annually. This new concept will receive a publishing several mini-reviews and original formal introduction in this column next articles from leading authors which will month by Mike Wyllie and myself, but I felt it outline new therapeutic strategies, and which was such an important innovation that I will, I am certain, be of interest to the readers would announce it in an informal way this of the BJU International. month.

This multidisciplinary approach is not I hope you will let me know your views on the confined to just urological oncology. We must new section, as well as on the oncology listen also to the views of many allied papers, and indeed on any other aspect of the specialists in virtually every other field of Journal which you feel strongly about. I also urological interest. This view is reflected in the very much hope you enjoy the innovations types of papers published in the other which I try to introduce on a regular basis. sections of the Journal, and in the number of non-urologists on the Editorial Board of the Journal, and in the sections which have their own Editorial Boards, such as Sexual Medicine and Investigative Urology. It is only in this way that we can advance our knowledge in JOHN M. FITZPATRICK urology in general. Editor - in - Chief

COSTELLO

INTRODUCTION BEYOND MARKETING: THE REAL VALUE OF ROBOTIC RADICAL PROSTATECTOMY ANTHONY J. COSTELLO – Department of Urology, The Royal The recent paper by Smith [1] is timely and provocative. Dr Smith proposes that the Melbourne Hospital, Division of Surgery, University of Melbourne, Australia minimally invasive surgical (MIS) approach to radical retropubic prostatectomy (RRP) via robotics does not deliver the distinct reduction of the twin major morbidities of [3] show that there are several variations of advantages of MIS. The advantages of RRP, i.e. erectile dysfunction and urinary the anatomical relationship of the cavernosal reduced pain and early return to normal incontinence. nerve to the urethra at this point. In a dry activity found in other surgery, e.g. surgical field with the magnification available laparoscopic nephrectomy and Despite much better understanding of the via robotics, there is conceptually and cholecystectomy, are clear. The assertion is anatomy of the neurovascular bundle (NVB) practically less chance of nerve damage at made by Dr Smith that this is not so in open [2], sexual dysfunction remains the key this location. The same authors also describe RRP compared with laparoscopic RRP, despite malady associated with RRP. Robotics the branch from the NVB to the urethral the technology of robotics delivering a three- provides three significant advantages over sphincter at this point. dimensional view, ×10 magnification, 540° open surgery which may translate into ‘wristing’, motion scaling, tremor elimination, improved sexual outcomes after robotic RRP. Ahlering et al. [4] recently described a robotic seven degrees of freedom and ergonomic Indeed, Dr Smith reports his impression in his technique to reduce the pT2 positive-margin comfort. series of an earlier return to erectile function rate at the apex. Robotic dissection and after telerobotic radical prostatectomy. visualization of the NVB and apical tissue In his institution and his personal series, Dr allowed a reduction in the positive apical rate Smith achieved equivalence in the outcomes The pneumoperitoneum provides haemostatic from 36% to 16.7% in their series. of blood loss, pain control and early discharge tamponade, allowing a better visualization of with open RRP compared with laparoscopic the NVB unobscured by bleeding. The ×10 In conclusion, according to Smith, the robotic RRP. His contends that a lower midline magnification certainly improves visualization advantages in robotic RRP lie not in its MIS subumbilical incision is not painful, as the here. The robotic dissection of the NVB in an character but in its improved precision, linea alba is split and there is no muscle antegrade fashion from bladder neck to apex, visualization and haemostatic tamponade. cutting. However, it may be that the muscle with less traction on the NVB, which is clearly These technical enhancements may in turn retraction provided by the self-retaining visually identifiable, provides a surgical lead to robotics providing better outcomes in instrument causes much postoperative pain advantage. Will this improved recognition and cancer control, erectile function and return to not seen after a laparoscopic approach. dissection provide robotics with a compelling complete urinary continence. Certainly, modern surgical advance? I agree with this marketing of robotic services has Most other centres, certainly those outside view and in my series, erectile function seems concentrated more on the former advantages North America, are unable to provide such a to improve earlier. than the latter. We await reports from other comfortable journey after surgery for their robotic centres for verification of Dr Smith’s patients treated with open RRP. I think that Urinary incontinence after RRP remains an postulate. I would contend that another the patients’ expectation of early discharge in issue in ≈8% of patients and 1–2% need an advantage not mentioned by Smith is the the USA, because of the very significant artificial sphincter implanted surgically. The easy transfer of MIS laparoscopic skills to hospital-stay costs, contributes to a greater absolute control of bleeding from a dorsal the untrained laparoscopic surgeon via acceptance of discomfort at the time of vein complex at robotics permits an robotics. hospital discharge. The hospital stay at my astonishingly precise dissection of the institution for open RRP is 5 days, compared sphincter musculature at the prostatic apex. Finally, cost issues also need to be considered. with 2 days for robotic RRP. This makes apical dissection much more The high capital and disposable cost of the refined (a site commonly associated with Da Vinci robotic system creates a ‘have and If the advantage of this ‘high-tech, new-tech’ positive margins) and facilitates preservation have not’ environment. As with computers, computer robotic approach is not in its MIS of the sphincter. It is here also that the television sets and mobile telephones, role, Dr Smith suggests it may be in the cavernosal nerves can be damaged if they are robotics will be cheaper over time. Maybe the delivery of improved cancer control and the not clearly visible. Recent studies from Japan time has come to acknowledge that putting a

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computer squarely between the surgeon bundle and cavernous nerves. BJU Int 0.70–0.99; P = 0.03), with a trend favouring and patient is the way of the new surgical 2004; 94: 1071–6 treatment at 3-weekly intervals rather than world. 3 Takenaka A, Murakami G, Matsubara A, weekly. Importantly in this study, treatment Han SH, Fujisawa M. Variation in course with docetaxel was also associated with a CONFLICT OF INTEREST of cavernous nerve with special reference significant advantage in both pain response to details of topographic relationships and quality of life, while the toxicity of None declared. Source of funding: near prostatic apex: Histologic study docetaxel chemotherapy was comparable to A.J. Costello received funding from his using male cadavers. J Urol 2005; 65: that of mitoxantrone. In the second trial, by department. 136–42 the South-west Oncology Group in >700 4 Ahlering TE, Eichel L, Edwards RA, patients, the combination of docetaxel REFERENCES Lee DI, Starecky DW. Robotic radical plus estramustine was compared with prostatectomy: a technique to reduce pT2 mitoxantrone plus prednisolone [6]. There was 1 Smith JA. Robotically assisted positive margins. Urology 2004; 64: a significant survival advantage for the laparoscopic prostatectomy: An 1224–8 docetaxel/estramustine combination (median assessment of its contemporary role in 18 vs 16 months, hazard ratio 0.80, 95% CI the surgical management of localized Correspondence: Anthony J. Costello, Director 0.67–0.97l P = 0.01) but at the cost of greater prostate cancer. Am J Surg 2004; 188 of Urology, The Royal Melbourne Hospital, toxicity. Taken together, these two trials show (Suppl. 1): 63–7 Grattan Street, Parkville, Victoria 3050, that docetaxel is more effective than 2 Costello AJ, Brooks M, Cole OJ. Australia. mitoxantrone, and suggest that adding Anatomical studies of the neurovascular e-mail: [email protected] estramustine increases the toxicity, but not [email protected] 2005 961 the efficacy, of docetaxel-based

Comment Article chemotherapy. comment PROLONGING SURVIVAL IN PROSTATEPARKER AND EMBERTONCANCER: CHEMOTHERAPY What are the implications of these new CHRIS PARKER and WILL HAVE AN IMPORTANT ROLE findings? Certainly, docetaxel given at 3- MARK EMBERTON* – Academic Unit of Radiotherapy & Oncology, The Institute of Cancer weekly intervals combined with a low-dose Research and Royal Marsden NHS Foundation Trust, Sutton, Surrey and *University College steroid should be the new standard of care for chemotherapy in patients with progressive, London, London, UK symptomatic castration-resistant prostate cancer. However, in the past many UK clinicians took the view that the benefits of INTRODUCTION prednisolone 10 mg daily with or without treatment with mitoxantrone were not large mitoxantrone (12 mg/m2) at 3-week intervals. enough to justify its widespread use. The key The management of advanced prostate cancer There was a significant advantage for the use question now is whether the proven survival has changed relatively little in the 60 years of chemotherapy in terms of the pain relief advantage, in addition to a further since the therapeutic role of castration was response (29% vs 12%, P = 0.01). This was the improvement in quality of life, alters the identified by Huggins and Hodges [1]. first of two randomized trials which showed balance of harm and benefit to a point where Androgen suppression, currently using an that adding mitoxantrone chemotherapy it will become the norm for men with LHRH agonist (medical castration), remains could improve symptom palliation in castration-resistant prostate cancer to receive the mainstay of treatment. Castration- castration-resistant prostate cancer [3,4]. chemotherapy. Some may still argue that a ‘2- resistant disease progression is inevitable and However, the use of chemotherapy in these month survival benefit’ is a poor return for the while further hormonal manipulations, using trials had no apparent effect on overall effort and expense associated with up to 10 androgen receptor antagonists, oestrogens or survival. cycles of chemotherapy. However, the modest corticosteroids, can be of some benefit, none difference in median survival does not of these agents has been shown to prolong The role of prostate cancer chemotherapy is adequately describe the benefit that patients overall survival. Some 9000 men die from now set to change significantly, with the stand to gain from docetaxel. First, in prostate cancer every year in the UK, which is recent publication of two large randomized comparison with mitoxantrone, 3-weekly the equivalent of one death every hour. studies, which for the first time show that docetaxel was associated with a 24% chemotherapy can improve overall survival. reduction in the hazard of death. Second, the Prostate cancer was once considered to be a In the TAX 327 trial, 1006 patients with benefits in terms of pain control and quality relatively chemo-resistant disease. A review of castration-resistant disease received of life are at least as important as any survival 17 prostate cancer chemotherapy trials before prednisolone 5 mg twice daily and were benefit, if not more so. 1985 found a disappointing overall response entered into a three-way randomization rate of <5% [2]. A clinical role for prostate between weekly docetaxel, 3-weekly Prostate cancer should no longer be cancer chemotherapy was first confirmed by docetaxel, and standard chemotherapy with considered a chemo-resistant disease. There the landmark trial reported in 1996 by mitoxantrone [5]. There was a significant are ≈10 000 new cases of castration-resistant Tannock et al. [3]; 161 men with progressive, overall survival advantage for docetaxel prostate cancer in the UK every year. If half of symptomatic castration-resistant metastatic chemotherapy (median survival 18.2 vs them were to receive chemotherapy for an prostate cancer were randomized to receive 16.4 months, hazard ratio 0.83, 95% CI average of 4 months each, this would

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translate into 33 patients on prostate cancer resistant prostate cancer. Cancer 1993; advanced prostate cancer. N Engl J Med chemotherapy at any one time in each of 50 71 (Suppl. 3): 1098–109 2004; 351: 1502–12 cancer centres. This would represent a major 3 Tannock IF, Osoba D, Stockler MR et al. 6 Petrylak DP, Tangen CM, Hussain MH additional pressure on already stretched Chemotherapy with mitroxantrone plus et al. Docetaxel and estramustine resources. prednisone or prednisone along for compared with mitoxantrone and symptomatic hormone-resistant prostate prednisone for advanced refractory Docetaxel is the ﬁrst drug that has been cancer: a Canadian Randomised Trial with prostate cancer. N Engl J Med 2004; 351: shown to improve survival for men with Palliative End Points. J Clin Oncol 1996; 1513–20 castration-resistant prostate cancer. By 14: 1756–64 7 Savage P, Bates C, Abel P, Waxman J. analogy with other solid cancers, the survival 4 Kantoff PW, Halabi S, Conaway M British urological surgery practice: 1. beneﬁt of chemotherapy may be greater if et al. Hydrocortisone with or without Prostate cancer. Br J Urol 1997; 79: 749– used earlier in the natural history of the mitoxantrone in men with hormone- 55 disease. The Medical Research Council refractory prostate cancer. results STAMPEDE trial is important in this regard, of the cancer and leukemia group Correspondence: Chris Parker, Academic Unit and aims to recruit >3000 patients starting B 9182 study. J Clin Oncol 1999; 17: of Radiotherapy & Oncology, The Institute of long-term androgen suppression for locally 2506–13 Cancer Research and Royal Marsden NHS advanced or metastatic disease, to test the 5 Tannock IF, de Wit R, Berry WR Foundation Trust, Downs Road, Sutton, Surrey effect of adding docetaxel chemotherapy, et al. Docetaxel plus prednisone or SM2 5PT, UK. either with or without zoledronate and mitoxantrone plus prednisone for e-mail: [email protected] [email protected] 2005 celecoxib, on overall survival. 961

Comment Article comment The increased use of chemotherapy for DAS castration-resistant disease, and its potential et al. role earlier in the course of the disease, will have a significant impact on the way that a-ACYLMETHYL CO-ENZYME A RACEMASE: A TUMOUR MARKER patients with prostate cancer are managed in FOR THE 21ST CENTURY? DEBASHIS DAS, PROKAR DASGUPTA and the UK. At one time prostate cancer was ASISH CHANDRA* – Departments of Urology and *Histopathology, Guy’s and St. Thomas’ managed largely by urologists, with clinical oncologists providing palliative radiotherapy Hospitals and GKT School of Medicine, London, UK when required [7]. Prompted by the National Accepted for publication 3 February 2005 Health Service Cancer Plan, there has been recent progress towards multidisciplinary care. The new opportunities provided by docetaxel chemotherapy, together with INTRODUCTION highlighted its suitability in verifying the developments in radiation therapy, and the minute foci of prostate cancer often found in plethora of molecular-targeted agents under The end of the last century saw an the samples taken from needle-biopsies [4]. evaluation, mean that all patients with exponential growth in the screening of early prostate cancer should have access to carcinoma of the prostate, using serum PSA Previously available immunohistochemical specialist uro-oncological services levels. TRUS and needle-biopsy can then allow stains for high molecular weight cytokeratins throughout their cancer journey. This will pathologists to make a definite diagnosis, but (HMWCKs) and p63 highlight the absence of require both a significant cultural shift and a sadly up to 24% of specimens are ambiguous the basal-cell layer in the neoplastic prostate, major increase in the National Health Service and as a result, thousands of men have to and hence serve only as an indirect indicator resources devoted to uro-oncology. have expensive and time-consuming repeat of malignancy. False-positives can occur biopsies [1]. The recent article by Stamey et al. through artefact during specimen processing, CONFLICT OF INTEREST [2] further fuelled the controversy by or in certain benign conditions like adenosis, indicating that in the last 5 years, the use of which mimics invasive carcinoma in its Chris Parker and Mark Emberton have acted as serum PSA testing has mainly been related to architecture, cytology and occasional lack of medical advisors to Sanofi-Aventis. BPH, stating that the ‘PSA era’ for prostate demonstrable basal cells. cancer is over in the USA, and presenting the need for new serum markers. However, AAMCR indicates the presence of REFERENCES neoplastic epithelial cells and thus, for the α–Acylmethyl co-enzyme A racemase first time, provides direct evidence of 1 Huggins C, Hodges CV. The effect of (AAMCR) is a normally occurring prostatic neoplastic transformation. Moreover, it may castration, of estrogen and of androgen enzyme that has been widely shown to be also be used with, or even on the same section injection on serum phosphatases in significantly up-regulated in prostate cancer as, stains for HMWCK or p63. Such an metastatic carcinoma of the prostate. [3]. Initial reports showed that staining for ‘antibody cocktail’ would not only show the Cancer Res 1941; 1: 292 AAMCR could diagnose cancer in histological absence of the basal layer but also highlight 2 Yagoda A, Petrylak D. Cytotoxic specimens with up to 97% sensitivity and the presence of neoplastic epithelial cells, chemotherapy for advanced hormone- 100% specificity, and further studies simultaneously.

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However, AAMCR is not fool-proof, and most could act as a future serum or urinary marker 6 Jiang Z, Iczkowski KA, Woda BA, series show <100% accuracy [5]. Despite this, for any of these tumours. Indeed, many Tretiakova M, Yang XJ. P504S interest in the enzyme continues, and a more questions may remain unanswered for now, immunostaining boosts diagnostic specialized role is rapidly emerging, i.e. but the rapid advances in molecular resolution of ‘suspicious’ foci in prostatic to reach a definite diagnosis of cancer technology perhaps promise that an enzyme needle biopsy specimens. Am J Clin Path when traditional histopathology and that was once expected to be only a tumour 2004; 121: 99–107 immunohistochemistry have yielded only an marker for the 21st century might now 7 Zhou M, Aydin H, Kanane H, Epstein JI. ‘atypical’ diagnosis [6,7]. This alone could become one of its most important discoveries. How often does alpha-methylacyl-CoA- avoid both re-biopsy and a delay to any racemase contribute to resolving an required treatment for perhaps tens of atypical diagnosis on prostate needle thousands of men annually, but more REFERENCES biopsy beyond that provided by basal cell important still is the recent discovery that markers? Am J Surg Path 2004; 28: 239– AAMCR is an androgen-independent growth 1 Epstein JI, Potter SR. The pathological 43 modulator, the blockade of which in vitro can interpretation and significance of 8 Zha S, Ferdinandusse S, Denis S et al. successfully impair prostate cancer [8]. prostate needle biopsy findings: α–Methylacyl–CoA racemase as an implications and current controversies. androgen-independent growth modifier AAMCR functions to convert branched-chain J Urol 2001; 166: 402–10 in prostate cancer. Cancer Res 2003; 63: fatty acids into their stereo-isomers so that 2 Stamey TA, Caldwell M, McNeal JE, 7365–76 they can be oxidized and used as cellular Nolley R, Hemenez M, Downs J. The 9 Zhou M, Chinnaiyan AM, Kleer CG, energy sources. Relevant to the recent prostate specific antigen era in the United Lucas PC, Rubin MA. Alpha-methylacyl- interest in high-fat diets in the pathogenesis States is over for prostate cancer: what CoA racemase, a novel tumour marker of prostate cancer, and the postulated role of happened in the last 20 years? J Urol over-expressed in several human cancers oxidative damage in neoplasia, the main 2004; 172: 1297–301 and their precursor lesions. Am J Surg substrates AAMCR are dietary fats obtained 3 Jiang Z, Woda BA, Rock KL et al. P504S Path 2002; 26: 926–31 from dairy products and red meat, and its – a new molecular marker for the 10 Kuefer R, Varambally S, Zhou M et al. direct by-products are carcinogenic, pro- detection of prostate carcinoma. Am J α–Methylacyl–CoA racemase. Expression oxidant free radicals. Therefore there is little Surg Path 2001; 25: 1397–404 levels of this novel cancer biomarker surprise that colonic carcinoma, which has 4 Zhong J, Wu C, Woda BA et al. P504S/α– depend on tumor differentiation. Am J long-been associated with such factors, also methylacyl–CoA racemase. A useful Path 2002; 161: 841–8 has high levels of AAMCR expression [9]. marker for diagnosis of small foci of 11 Takahashi M, Yang XJ, Sugimura J et al. However, unlike colonic carcinoma, prostate prostatic carcinoma on needle biopsy. Am Molecular subclassification of kidney carcinoma has traditionally been regarded as J Surg Path 2002; 26: 1169–74 tumours and the discovery of new androgen-sensitive, and many of the 5 Magi-Galluzzi C, Luo J, Isaacs WB, diagnostic markers. Oncogene 2003; 22: contemporary conservative therapies rely on Hicks JL, De Marzo AM, Epstein JI. 6810–8 blocking these pathways, ultimately with α–Methylacyl–CoA racemase. A variably hormone escape. sensitive immunohistochemical marker Correspondence: Prokar Dasgupta, for the diagnosis of small prostate cancer Department of Urology, Guy’s Hospital, St. Other observations, e.g. the inversely foci on needle biopsy. Am J Surg Path Thomas Street, London SE1 9RT, UK. proportional staining of AAMCR in prostate 2003; 27: 1128–33 e-mail: [email protected] [email protected] 2005 cancers of differing tumour differentiation 961

[10] and its variable prevalence in both benign Comment Article comment tissue and the putative precursor lesions of THURAIRAJA prostate cancer, e.g. high-grade prostatic et al. intraepithelial neoplasia, lead to even more radical speculation. Will AAMCR be useful for THE ‘FLARE’ PHENOMENON: SHOULD WE BE CONCERNED? predicting progression to cancer in those RAMESH THURAIRAJA, RAJENDRA PERSAD, JOHN PETERS* and AMIT BAHL† – patients with such intense staining in Departments of Urology, Bristol Royal Infirmary, *Whipps Cross Hospital, London, and noncancerous lesions? If so, could they be †Oncology Unit, Bristol Oncology and Haematology Centre, Bristol, UK treated? Or, is it possible to predict which carcinomas are likely to become hormone- refractory by correlating patients’ present staining with expected tumour differentiation INTRODUCTION worsening clinical status after the initiation in the future? If so, again, could they be of tamoxifen therapy for advanced breast stopped? The ‘flare’ phenomenon was initially described cancer [1]. A similar phenomenon was seen over 20 years ago in patients with advanced when LHRH analogues were used for Notably, staining for AAMCR expression has breast cancer who were given hormonal androgen ablation therapy (ABT) in patients been detected in cases of both urothelial treatment. The term ‘tamoxifen flare’ was with advanced and metastatic prostate cancer carcinoma and papillary RCC [11]. Little else is designated for women who had a transient [2]. Steroidal and nonsteroidal antiandrogen known at present, including whether AAMCR but severe period of increased bone pain and drugs, when used in combination with LHRH

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analogues, are extremely potent in Patients at increased risk of the flare flare response has also yet to be identified obliterating the effects of the flare phenomenon, particularly clinical flare, are after recommencing treatment in patients on phenomenon [3]. Therefore, a combined men with metastatic prostate cancer (D1 and trials of intermittent ABT. More significantly, it androgen blockade (CAB) approach in the D2 disease). Studies show that 4–63% of this is still not clear if adding antiandrogens to form of an antiandrogen drug and an LHRH group of patients with prostate cancer have LHRH analogue therapy improves survival analogue is used frequently to treat patients the flare phenomenon [3,10]. The wide outcomes in patients with non-metastatic with prostate cancer requiring hormone variation in incidence may be the result of the prostate cancer. Although given for a deprivation. However, without antiandrogens, poor distinction between clinical and short period to cover a flare response, will all patients on LHRH analogues initially biochemical flare, and the subjective and antiandrogens are known to cause side- suffer the flare phenomenon, and is this objective aggravation of cancer-related effects which include: liver function effect always clinically deleterious? symptoms. However, for patients with abnormalities, hepatic encephalopathy, advanced but not metastatic prostate cancer diarrhoea and other gastrointestinal (D0 disease) commencing LHRH analogue disturbances (flutamide); pulmonary LHRH ANALOGUE therapy, the flare phenomenon is extremely toxicities, decreased light accommodation, rare. This assessment is important, particularly alcohol intolerance and rash (nilutamide); and Treatments for advanced and metastatic as the use of LHRH analogues for treating gynaecomastia, breast tenderness and prostate cancer require suppression of patients with prostate cancer has become cardiovascular complications (cyproterone testosterone in the form of surgical or more prevalent. Over the last decade, there acetate) [13]. Anti-androgen drugs add to the chemical castration. Historically, has been an increasing incidence of prostate total cost of CAB treatment and require orchidectomy was used to reduce cancer, with the advent of PSA testing, and biochemical monitoring of liver function, testosterone levels but because of the the increasing elderly population and public which is significant, particularly as there is profound psychological impact, patients awareness. Furthermore, with early hormone limited evidence about the appropriate time increasingly preferred chemical methods, e.g. deprivation in patients with advanced or of starting and duration of antiandrogen diethylstilbestrol, antiandrogens and LHRH asymptomatic metastatic prostate cancer administration before LHRH analogue analogues, in the treatment of their prostate being shown to delay disease progression, therapy. cancer [4]. As diethylstilbestrol increased the LHRH analogues are now being administered risk of cardiovascular side-effects in patients, in more men with prostate cancer [11]. This LHRH analogues have become the major has resulted in LHRH analogues being mainly CONCLUSION medical option for castration [5]. used to treat advanced rather than metastatic prostate cancer [8]. We are aware that antiandrogens are vital The sustained administration of LHRH in preventing the detrimental effects of analogues creates a blockade of the pituitary bone pain, cord compression and urinary and gonadal axis through the process of ANTI-ANDROGENS FOR obstruction secondary to the flare ‘down-regulation’ of LHRH receptors and NON-METASTATIC DISEASE phenomenon in patients with metastatic ‘desensitization’ of pituitary gonadotrophins, prostate cancer. However, there is no robust by reducing the synthesis and release of LH Conventionally, patients with locally evidence to support the almost routine use of and FSH [6]. Through the deprivation of LH advanced prostate cancer are started on initial antiandrogens to cover the flare and in turn testosterone, the growth and antiandrogens for a few days up to 2 weeks phenomenon for patients with non- proliferation of prostate cancer is halted. before and up to 2 weeks after their first metastatic disease starting LHRH analogues. However, LH and testosterone levels may injection with LHRH analogue. However, there Moreover, this may add to the costs and the transiently increase up to 10-fold and twice or is no robust evidence showing the incidence side-effects. Recently, LHRH antagonists have more, respectively, from 2–3 days and lasting of the flare phenomenon and the requirement proven to be effective and more convenient in up to 10–20 days after the initial injection of for antiandrogens in these patients. Most treating prostate cancer without causing the LHRH analogue [6,7]. This is known as a patients requiring ABT for adjuvant and flare phenomenon [6]. Further studies are ‘biochemical flare’ and is also characterized by neoadjuvant purposes are unlikely to have required to identify an ideal ABT for patients an increase in PSA levels [3,8]. It is now well prostatic bone metastases, and are therefore with prostate cancer. accepted that a rising PSA level is secondary not at risk of bone pain or spinal cord to tumour growth and reflects the compression secondary to the flare proliferation of prostate cancer. Therefore, in phenomenon after LHRH analogue treatment. REFERENCES some patients, the first 2–3 weeks of LHRH Similarly, at the time of diagnosis, if these analogue treatment may be associated with patients had not presented with LUTS 1 Ptlokin D, Lechner JJ, Jung WE, Rosen worsening clinical status in the form of related to an enlarged prostate, the initial PJ. Tamoxifen flare in advanced breast increasing bone pain, cord compression, BOO testosterone surge and tumour growth as a cancer. JAMA 1978; 240: 2644–6 and cardiovascular problems related to result of LHRH analogue therapy is unlikely to 2 Waxman J, Man A, Hendry W et al. increased hypercoagulability. This is described be significant enough to cause urinary Importance of early tumour exacerbation as a ‘clinical flare’. In addition, a scintigraphic obstruction. The lack of evidence of flare in patients treated with long acting flare has also been identified on bone scans of symptoms in these patients in previous trials analogues of gonadotrophin releasing patients started on monotherapy with LHRH might be because of the routine use of hormone for advanced prostate cancer. agonists [9]. antiandrogens with LHRH analogues [12]. The Br Med J 1985; 291: 1387–8

3 Kuhn JM, Billebaud T, Navratil H et al. Steg A. Disease flare induced by D-Trp6- Initial results of the Medical Research Prevention of the transient adverse LHRH analogue in patients with Council Trial. Br J Urol 1997; 79: effects of a gonadotropin-releasing metastatic prostatic cancer. Lancet 1984; 235–46 hormone analogue (buserelin) in 1: 971–2 12 Bolla M, Gonzalez D, Warde P et al. metastatic prostatic carcinoma by 8 Bubley GJ. Is the flare phenomenon Improved survival in patients with locally administration of an antiandrogen clinically significant? Urology 2001; 58: advanced prostate cancer treated with (nilutamide). N Engl J Med 1989; 321: 5–9 radiotherapy and goserelin. N Engl J Med 413–8 9 Johns WD, Garnick MB, Kaplan WD. 1997; 337: 295–300 4 Drider R. The evolving role of hormone Leuprolide therapy for prostate cancer. An 13 Schroder FH, Whelan P, de Reijke TM therapy in advanced prostate cancer. association with scintigraphic ‘flare’ on et al. Metastatic prostate cancer treated Cleve Clin J Med 2000; 67: 720–6 bone scan. Clin Nucl Med 1990; 5: by flutamide versus cyproterone acetate. 5 Byer DP. Proceedings of the Veterans 485–7 Final analysis of the ‘European Administration Co-operative Urological 10 Peeling WB. Phase III studies to compare Organization for Research and Treatment Research Group studies of cancer goserelin (Zoladex) with orchiectomy and of Cancer’ (EORTC) Protocol 30892. Eur of the prostate. Cancer 1973; 32: with diethylstilbestrol in treatment of Urol 2004; 45: 457–64 1126–30 prostatic carcinoma. Urology 1989; 33: 6 Weckermann D, Harzmann R. Hormone 45–52 Correspondence: Ramesh Thurairaja, therapy in prostate cancer: LHRH 11 The Medical Research Council Prostate Department of Urology, Bristol Royal antagonists versus LHRH analogues. Eur Cancer Working Party Investigators Infirmary, Marlborough Street, Bristol BS2 Urol 2004; 46: 279–83 Group. Immediate versus deferred 8HW, UK. 7 Kahan A, Delreiu F, Amor B, Chiche R, treatment for advanced prostate cancer. e-mail: [email protected]

Attempts are being made in many Molecular staging of bladder cancer laboratories to find new biomarkers for and new methods of ANIRBAN P. MITRA, RAM H. DATAR and RICHARD J. COTE molecular staging of bladder Department of Pathology, University of Southern California Keck School of Medicine, Los Angeles, USA cancer. At the forefront of this are Accepted for publication 12 March 2005 the authors from Los Angeles who have contributed the first of four mini-reviews in this section. THE DISEASE definitions for micro-invasion, which is an important criterion to determine the risk of Other mini-reviews examine the Cancer of the urinary bladder is a major metastasis. Most significantly, the basic tools epidemiological problem that continues to available to determine tumour behaviour, role of hand-assisted laparoscopy grow each year. Bladder cancers encompass malignant potential and chance for in urology, a contribution to the urothelial carcinomas (UCs, or TCCs), recurrence provided by the current sometimes heated argument about squamous cell carcinomas, adenocarcinomas pathological staging methods can be whether laparoscopy should be and certain other infrequent tumour types. It highly subjective. Thus, while current is the fourth most common malignancy in histopathological criteria can provide ‘pure’ or hand-assisted: in addition, males and the ninth most common important morphological information about two mini-reviews describe the role malignancy in females in the USA. An average tumours in patient populations, they are of photodynamic diagnosis in of 260 000 new cases of urinary bladder unable to specify the risk for progression or cancer are diagnosed worldwide every year, response to treatment for an individual managing superficial bladder with an estimated 63 210 new cases in 2005 patient with UC. Esrig et al. [3] showed the cancer, and the contribution of in the USA alone, with ª13 180 deaths [1]. wide difference in recurrence and survival non-surgical factors to the success rates between patients of the same of hypospadias repair. pathological stage with differences in their THE PROBLEM tumour p53 status. In a cohort of 243 patients with UC treated by radical cystectomy, the The current treatment for UC is based on the recurrence rates for stage pT1, pT2a and pT2b pathological staging of the tumour. The tumours with negative p53 nuclear reactivity staging therefore is crucial for clinical were 7%, 12% and 11%, respectively, in decision-making and exploring the various contrast to 62%, 56% and 80%, respectively, treatment options, and the therapy thus for tumours that had p53 immunoreactivity. chosen can result in significant morbidity and That study indicated the need to incorporate financial burden to the patient. The traditional objective staging methods using molecular TNM classification or the WHO classification markers specific to UC to complement the system for UC [2] relies on pattern recognition morphological approach, and devise a refined and nomenclature for reporting biopsies, the system of staging that focuses on the interpretation of which can be highly biological behaviour of the tumour and its subjective and can have a high frequency predicted clinical outcome, thereby equipping of inter- and intra-observer variability. the clinician with a better insight on the Interpretations of biopsies can be confounded appropriate treatment regimen to be by sampling problems such as the absence of instituted. the muscular layer in the specimen, or the exclusion of the bladder wall in biopsies of THE PLAYERS large tumours growing exophytically that can affect the staging. Even among trained Recent studies in the molecular biology of UC pathologists there are no uniformly accepted have opened new avenues for investigative

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research to identify molecular markers for the marker in UC, some have failed to show this recurrence rate and lower survival rate than disease. While loss of heterozygosity on relationship as independent from other those with maintained p21 expression levels, chromosome 9 has been implicated in UC, prognostic factors. A meta-analysis by irrespective of tumour grade, pathological recent studies have shown that allelic loss on Schmitz-Drager et al. [6] of 138 publications stage and lymph node status. The association chromosome 9 is found exclusively in early reporting on 43 studies comprising 3764 between p21 status and tumour progression well-differentiated tumours, while late patients with UC showed considerable was particularly notable in patients with tumours showed other genetic lesions [4]. The differences in the clinical outcome, which organ-confined (carcinoma in situ, T1, T2a, tumour suppressor genes on chromosome 9 the authors attributed to the p53 T2b) and extravesical disease (T3, T4) with no (characterized by allelic losses in 9p and 9q, immunohistochemistry protocols used, evidence of lymph node metastases. Also, and deletions between 9p12 and 9q34, which patient selection and study design. They maintenance of p21 expression appeared to spans the p16INK4A locus) have been implicated opined that the current need is for new negate the deleterious effects of p53 in UC formation. These tumours have a good prospective multicentre clinical trials alterations on UC progression [9]. prognosis and low invasive and metastatic examining p53 alterations in patients potential. This is in contrast to alterations on with UC. chromosome 17p, the site for the p53 gene, RETINOBLASTOMA (RB) GENE which is associated with a more aggressive While adjuvant chemotherapy, radiation and/ AND PROTEIN phenotype [5]. or immunotherapy are effective for patients with locally advanced UC, such treatment is The RB gene forms a phosphorylated not traditionally used for patients with nucleoprotein (pRb) that interacts with many p53 invasive organ-confined disease, as only a cell-cycle regulatory proteins involved at the proportion of them are at risk of progression. G1/S transition [5]. Deletion of chromosome The gene for p53 is critical for regulating the However, there is an urgent need to re- 13q is the most common cause of RB gene cell cycle and apoptosis, and plays a key role categorize these patients by considering their inactivation. Miyamoto et al. [10] showed that in mediating growth arrest and DNA damage p53 status, so as to better define those who RB gene mutations are involved in low-grade at the G1/S transition [6]. The p53 gene acts as are most likely to progress and those who and noninvasive UC, and in high-grade and a tumour-suppressor gene, and loss of would benefit from systemic adjuvant invasive cancers. The loss of expression of pRb heterozygosity of one allele followed by chemotherapy. With this in mind, an is important in the progression of UC. mutation of the remaining allele is an international randomized p53-targeted However, we have shown that a significant important mechanism for gene inactivation. therapy trial is currently underway to study proportion of tumours expressing the highest This mutation results in a longer half-life for the effects of three cycles of adjuvant levels of pRb have clinical outcomes similar to the protein, which is then localized to the methotrexate, vinblastine, adriamycin and those with no detectable pRb with lower nucleus and can be detected by cisplatin chemotherapy after radical recurrence-free and overall survival [11]. We immunohistochemistry. cystectomy for pathological T1-T2 tumours explained the biological basis for this by with negative lymph nodes and altered p53 showing that hyperphosphorylation is Our studies have shown that nuclear expression. This is the first UC clinical trial associated with loss of p16 expression and/or accumulation of p53 is significantly targeting a molecular lesion, led by us at the cyclin D1 overexpression [12]. associated with a greater risk of recurrence of University of Southern California, along with UC and decreased overall survival (both other collaborators from institutions across P < 0.001) [3]. As noted previously, the USA and Europe; it is based on the data OTHER MOLECULAR MARKERS immunohistochemical analysis of organ- that tumours with altered p53 are at greater confined UC showed lower 5-year recurrence risk of progression and selectively respond to Various other molecular markers are being rates for stage pT1, pT2a and pT2b tumours chemotherapy containing cisplatin. The trial explored for the determination of prognosis in with no detectable p53 nuclear reactivity than thus aims to elucidate the prognostic value of UC. MDM2, involved in an autoregulatory for the same tumours with positive p53 p53 in organ-confined UC [7]. feedback loop with p53, is amplified in UC. immunoreactivity. A multivariate analysis This amplification frequency increases with stratified according to grade, pathological stage (Ta to T4) and grade (low-grade to stage and lymph node status showed p21 high-grade) [13]. that nuclear p53 accumulation was an independent predictor of recurrence-free and The cyclin-dependent kinase inhibitor Overexpression of cyclin D1 has been overall survival (P < 0.001). These results p21WAF1/CIP1 (p21) is a downstream effector of described in a variety of tumour types [14]. support the hypothesis that within organ- p53 and thus a potential tumour-suppressor As noted above, we also showed that confined carcinoma, it is the presence or gene. Shariat et al. [8] showed that positive overexpression of cyclin D1 along with a loss absence of nuclear p53 accumulation p21 expression was independently associated of p16 may cause hyperphosphorylation and (suggestive of a p53 alteration/mutation) and with UC recurrence and progression in functional inactivation of pRb [12]. Cyclin E not the depth of invasion that determines carcinoma in situ with no muscle-invasive overexpression may also be associated with survival. disease, possibly by p53-independent aggressive tumour growth in UC [15]. Cellular modulation of p21. Our studies have shown transition through the G1 to S phase is While many other studies also concluded that that patients with p53-altered, p21-negative regulated by cyclin-dependent kinases (CDKs). p53 can serve as an independent prognostic tumours have a significantly greater The frequency of amplification of the CDK4

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gene increases with the stage and grade of UC may offer important predictive and markers, using >70 genes controlling various [13]. In addition, there are frequent deletions prognostic information, but because the aspects of the cell cycle, apoptosis, and methylations of the INK4A gene in disease is multifactorial, their individual roles angiogenesis, transcription, signal noninvasive UC, but only those that affect become restricted. transduction, cell growth, and invasion, that both p16INK4a and p14ARF, the major CDK will be studied in combination to develop a inhibitors, correlate with the worst prognosis Several studies have tried to show the new molecular paradigm to refine the [16]. There is also evidence to suggest that interplay between individual markers as a pathological staging of UC, to enhance its low expression of p27(Kip1) correlates with combined tool to determine outcome. This is correlation with prognosis, therapeutic decreased disease-free and overall survival in partly based on the grouping of major genes response and final clinical outcome. UC [17]. or proteins according to their functional role in the cell cycle, apoptosis, angiogenesis Alterations in the angiogenesis pathway are and other independent cascades in the THE TECHNOLOGY USED also important in UC. Our studies have shown oncogenesis control machinery, that might that expression of thrombospondin-1, a reveal a cooperative or synergistic effect on The compilation, analysis and application of potent angiogenesis inhibitor, is significantly clinical outcome. results from a comprehensive molecular associated with disease recurrence and overall marker panel as described above, to better survival in UC, and is significantly associated Data from our laboratory show that stage an individual patient with UC, requires with altered p53 levels and microvessel alterations in both p53 and pRb may act co- the use of sophisticated, high-throughput density counts [18]. operatively or synergistically to promote technology that can produce accurate and tumour progression [11]. Examination of 185 reproducible results reflective of the High expression of epidermal growth factor cases of UC showed that patients with altered molecular grade of the tumour (Fig. 1). We receptor on human UC cells corresponds to p53 and pRb had significantly greater rates of briefly discuss below certain applications that decreased responsiveness to standard modes recurrence and lower survival (both P < 0.001) can be used in the expression profiling of UC of therapy [19]. Immunohistochemistry than those with no alterations in either p53 or [26]. studies have correlated loss of TGF-b pRb. Stein et al. [9] showed that the receptors (TbRs) with tumour grade, combination of p53 and p21 status provides a Analysis and validation of tumour pathological stage and lymph node status better indicator of prognosis than any one subclassification by expression microarray (TbR-I and II), and with tumour progression indicator analysed alone. In that study, analysis is being widely used at present. These and decreased survival (TbR-I) [20]. Loss of E- examination of UC specimens from 242 arrays offer overall views of gene expression cadherin expression correlates with an patients who underwent cystectomy showed to present comprehensive pictures of cell aggressive phenotype of primary UC [21]. that patients with p53-altered/p21-negative function. Incorporating high degrees of Increased expressions of proteinases tumours had a higher rate of recurrence and sensitivity, specificity and reproducibility, degrading the extra-cellular matrix, e.g. worse survival than those with p53-altered/ these arrays can sort through the activities of matrix metalloproteinase-9 [22] and p21-positive tumours (P < 0.001). thousands of genes and recognize the major urokinase plasminogen activator [23], also players. Monitoring many genes in parallel correlate with an unfavourable prognosis. Recently, we published results examining the allows the identification of reliable classifiers Increased cytoplasmic expression levels of combined effects of p53, p21 and pRb or ‘signatures’ of UC. Dyrskjot et al. [27] tenascin-C correlate with better survival expression in the progression of UC [25]. identified clinically relevant subclasses of UC rates [24]. While altered expressions of these markers are (Ta, T1 and T2-4, with Ta tumours being independent determinants of prognosis, we further subclassified) by expression showed that they acted co-operatively or microarray analysis of 40 well-characterized THE TRANSLATION synergistically to promote tumour bladder tumours. Using bioinformatics, such progression. The patients were classified into data generated from microarray analysis can From this discussion it is apparent that there four groups: group I (no alteration in any also be used to design genetic algorithms to is a wide array of molecular markers available marker, 47), group II (any one marker altered, classify subsets of expression profiles into for determining the prognosis in a patient 51), group III (any two markers altered, 42) different categories, depending on the clinical with UC. Unfortunately, no single marker can and group IV (all three markers altered, 24). outcome. be solely relied upon to provide a complete The 5-year recurrence rates in these groups prognostic picture. were 23%, 31%, 60% and 93%, respectively Apostolakos et al. [28] and Crawford et al. [29] (log-rank P < 0.001), and the 5-year survival developed a modified quantitative method of THE LOGIC USED rates were 68%, 56%, 28% and 8%, standardized competitive RT-PCR (StaRT-PCR) respectively (log-rank P < 0.001). that allows simultaneous measurements of The absence of a single ‘gold standard’ many genes, using nanogram amounts of predictive molecular marker in the case of UC, These findings point strongly towards the use cDNA. The transcript levels are expressed as and indeed in the case of any cancer, although of multiple markers to better stage tumours, numerical values per million molecules of seemingly disappointing, is not a surprise. It and to better determine the prognosis and b-actin, thus affording intra- and intersample has been acknowledged that UC is a multistep predict the therapeutic response of individual comparisons. We have used this technique to genetic process [6] wherein individual patients to specific treatment. Our group is obtain transcript profiles of >70 genes crucial alterations in single molecular determinants currently working on developing a panel of in various cellular pathways, as noted above.

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FIG. 1. Two approaches used for molecular staging of urothelial carcinomas. The tumour sample obtained from surgery or biopsy can be processed to generate an expression profile of molecular markers. (A) Expression microarray analysis uses labelled cDNA fragments generated from PCR-amplified target DNA to hybridize with an array of specific DNA probes on a microarray chip, yielding expression profiles that can be quantified between samples. (B) Standardized RT-PCR uses competitive templates and cDNA derived from tumour mRNA to quantify gene expression relative to an internal standard like b-actin. Expression profiles thus generated can be used as an input for genetic programme algorithms to obtain classifier rules that can predict staging.

Tumour Tissue A. Expression Microarray Analysis B. StaRT-PCR mRNA

cDNA from mRNA of Reverse transcription 5¢ 3¢ normal bladder tissue 3¢ 5¢

5¢ 3¢ cDNA ¢ ¢ PCR PCR 3 5 Competitive template synthesis

Amplified DNA target cDNA (Native Template) normalized to b-actin Fragmentation and end-labelling Competitive PCR followed by product separation

Gel electrophoresis Capillary electrophoresis Labelled small DNA fragments

Hybridization on gene expression microarray

Stain, scan, quantitate Quantitative analysis

Generation of expression profile and signature

Input into genetic program algorithm

Generation of classifier rules

Our preliminary analysis shows that medium- system, with the corresponding clinical LOOKING INTO THE FUTURE to high-throughput transcript profiling can staging and patient outcome. From these identify important gene subsets that can inputs a set of rules, in the form of computer The clues to unravel the propensity of a be used in molecular class prediction, programs, are produced that will accurately tumour to metastasize are hidden within the identification of high-risk patients who can predict staging or patient outcome endpoints. complexity of tumour cells and objective benefit from adjuvant therapy, and help in Validation sets of similar information are then criteria are needed to classify patients determining the prognosis. used to check the generality of the rules appropriately, such that the staging is developed. Such programs can then be used reproducible with minimum subjectivity and We are also experimenting with the use of to formulate generic criteria for patient representative of the final clinical outcome. A genetic programming to obtain an outcome staging, using multiple molecular staging based on a panel of molecular analysis of patients [30]. This is a machine- determinants to predict the clinical outcome markers can complement the current learning approach based on the concepts of and tailor the therapy accordingly. Our clinicopathological staging to accurately natural selection and population dynamics to analysis shows that using a machine-learning indicate the risk of disease progression and ‘evolve’ diagnostics in-silico. It is an iterative approach to analyse expression profiles for identification of specific molecular targets analytical process wherein baseline patient molecular staging may prove to be more that may be more amenable to specific and tumour information obtained from a accurate than traditional histopathology therapies. Such a staging can then be used for retrospective resource database is fed into the (manuscript in preparation). administering targeted therapy that can be

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individually tailored to meet a patient’s Mostofi FK. The World Health sufficient for cells arrested in G1 to molecular profile and projected response, Organization/International Society of complete the cell cycle. Proc Natl Acad Sci thus decreasing morbidity. Urological Pathology Consensus USA 1994; 91: 8022–6 Classification of urothelial (transitional 15 Makiyama K, Masuda M, Takano Y et al. From a research standpoint, the application of cell) neoplasms of the urinary bladder. Am Cyclin E overexpression in transitional cell a revised molecular staging of UC can be used J Surg Pathol 1998; 22: 1435–48 carcinoma of the bladder. Cancer Lett to design better clinical trials (such as p53- 3 Esrig D, Elmajian D, Groshen S et al. 2000; 151: 193–8 targeted therapy trial in bladder cancer) to Accumulation of nuclear p53 and tumor 16 Orlow I, LaRue H, Osman I et al. identify new molecular targets that are progression in bladder cancer. N Engl J Deletions of the INK4A gene in superficial responsive to chemotherapy. The follow-up of Med 1994; 331: 1259–64 bladder tumors. Association with patients can be in the least obtrusive and 4 Ruppert JM, Tokino K, Sidransky D. recurrence. Am J Pathol 1999; 155: 105– most cost-effective way possible, by analysing Evidence for two bladder cancer 13 the changes in the marker panel and thereby suppressor loci on human chromosome 9. 17 Sgambato A, Migaldi M, Faraglia B identifying the high-risk subpopulation where Cancer Res 1993; 53: 5093–5 et al. Cyclin D1 expression in papillary intervention can be instituted earlier. We will 5 Cote RJ, Chatterjee SJ. Molecular superficial bladder cancer: its association need to incorporate demographic variables determinants of outcome in bladder with other cell cycle-associated proteins, and physiological differences in these studies, cancer. Cancer J Sci Am 1999; 5: 2–15 cell proliferation and clinical outcome. Int and intercalate them with the molecular 6 Schmitz-Drager BJ, Goebell PJ, Ebert T, J Cancer 2002; 97: 671–8 findings into computer programs derived Fradet Y. p53 immunohistochemistry as a 18 Grossfeld GD, Ginsberg DA, Stein JP from genetic programming, to obtain high- prognostic marker in bladder cancer. et al. Thrombospondin-1 expression in throughput techniques that can subclassify Playground for urology scientists? Eur transitional cell carcinoma of the bladder: patient types for the purposes of screening Urol 2000; 38: 691–9 Association with p53 alterations, tumor and diagnosis. 7 Cote RJ, Datar RH. Therapeutic angiogenesis and tumor progression. approaches to bladder cancer: identifying J Natl Cancer Inst 1997; 89: 219–27 The ultimate goals of molecular staging will targets and mechanisms. Crit Rev Oncol 19 Ravery V, Grignon D, Angulo J et al. be to assign patients to more logical tiers of Hematol 2003; 46: S67–83 Evaluation of epidermal growth factor classification, based on their predicted 8 Shariat SF, Kim J, Raptidis G, Ayala GE, receptor, transforming growth factor response to therapy and projected clinical Lerner SP. Association of p53 and p21 alpha, epidermal growth factor and c- outcome. This will provide patients with a expression with clinical outcome in erbB2 in the progression of invasive better quality of life, and clinicians with a patients with carcinoma in situ of the bladder cancer. Urol Res 1997; 25: clearer idea of how to tailor the treatment for urinary bladder. Urology 2003; 61: 1140– 9–17 each patient so as to obtain an optimal 5 20 Tokunaga H, Lee DH, Kim IY, Wheeler therapeutic response. 9 Stein JP, Ginsberg DA, Grossfeld GD TM, Lerner SP. Decreased expression of et al. Effect of p21WAF1/CIP1 expression transforming growth factor b receptor on tumor progression in bladder cancer. type I is associated with poor prognosis ACKNOWLEDGEMENTS J Natl Cancer Inst 1998; 90: 1072–9 in bladder transitional cell carcinoma 10 Miyamoto H, Shuin T, Torigoe S, patients. Clin Cancer Res 1999; 5: The authors thank Dr Peter Lenehan and Bill Iwasaki Y, Kubota Y. Retinoblastoma 2520–5 Worzel of Genetics Squared Inc., for their gene mutations in primary human 21 Byrne RR, Shariat SF, Brown R et al. valuable inputs for the manuscript. bladder cancer. Br J Cancer 1995; 71: E-cadherin immunostaining of bladder 831–5 transitional cell carcinoma, carcinoma in 11 Cote RJ, Dunn MD, Chatterjee SJ et al. situ and lymph node metastases with CONFLICT OF INTEREST Elevated and absent pRb expression long-term followup. J Urol 2001; 165: is associated with bladder cancer 1473–9 None declared. Source of funding: The progression and has cooperative effects 22 Papathoma AS, Petraki C, Grigorakis A molecular studies of bladder cancer with p53. Cancer Res 1998; 58: 1090–4 et al. Prognostic significance of matrix progression are funded by National Institutes 12 Chatterjee SJ, George B, Goebell PJ metalloproteinases 2 and 9 in bladder of Health Grants CA-65726, CA-70903 and et al. Hyperphosphorylation of pRb: a cancer. Anticancer Res 2000; 20: 2009– CA-86871; while the p53-targeted therapy mechanism for RB tumour suppressor 13 trial in bladder cancer is funded by NCI Grant pathway inactivation in bladder cancer. 23 Seddighzadeh M, Steineck G, Larsson P #CA-71921. J Pathol 2004; 203: 762–70 et al. Expression of UPA and UPAR is 13 Simon R, Struckmann K, Schraml P et al. associated with the clinical course of Amplification pattern of 12q13-q15 urinary bladder neoplasms. Int J Cancer REFERENCES genes (MDM2, CDK4, GLI) in urinary 2002; 99: 721–6 bladder cancer. Oncogene 2002; 21: 24 Brunner A, Mayerl C, Tzankov A et al. 1 American Cancer Society. Cancer Facts 2476–83 Prognostic significance of tenascin-C and Figures 2005. Atlanta: American 14 Musgrove EA, Lee CS, Buckley MF, expression in superficial and invasive Cancer Society, 2005 Sutherland RL. Cyclin D1 induction in bladder cancer. J Clin Pathol 2004; 57: 2 Epstein JI, Amin MB, Reuter VR, breast cancer cells shortens G1 and is 927–31

25 Chatterjee SJ, Datar R, Youssefzadeh D Frampton MW, Utell MJ, Willey JC. Programming Theory and Practice II. NY: et al. Combined effects of p53, 21, and Measurement of gene expression by Springer Science+Business Media, Inc., pRb expression in the progression of multiplex competitive polymerase chain 2005: 245–62 bladder transitional cell carcinoma. J Clin reaction. Anal Biochem 1993; 213: 277– Oncol 2004; 22: 1007–13 84 Correspondence: Richard J Cote, Department 26 Pagliarulo V, Datar RH, Cote RJ. Role of 29 Crawford EL, Warner KA, Khuder SA, of Pathology, University of Southern genetic and expression proﬁling in Zahorchak RJ, Willey JC. Multiplex California Keck School of Medicine, Los pharmacogenomics: the changing face of standardized RT-PCR for expression Angeles CA 90033, USA. patient management. Curr Issues Mol Biol analysis of many genes in small samples. e-mail: [email protected] 2002; 4: 101–10 Biochem Biophys Res Commun 2002; 27 Dyrskjot L, Thykjaer T, Kruhoffer M et al. 293: 509–16 Abbreviations: UC, urothelial carcinoma; RB, Identifying distinct classes of bladder 30 MacLean CD, Wollesen EA, Worzel WP. retinoblastoma (gene); CDK, cyclin- carcinoma using microarrays. Nat Genet Listening to data: tuning a genetic dependent kinase; StaRT-PCR, standardized 2003; 33: 90–6 programming system. In O’Reilly U-M, Yu competitive reverse transcriptase polymerase 28 Apostolakos MJ, Schuermann WH, T, Riolo R, Worzel WP eds, Genetic chain reaction.

The role of hand-assisted laparoscopy in urology: a critical appraisal

ABHAY RANE and J. STUART WOLF* Departments of Urology, East Surrey Hospital, Redhill, Surrey UK and *University Of Michigan, Ann Arbor, MI, USA Accepted for publication 22 November 2004

KEYWORDS HAND-ASSISTANCE DEVICES uses the HAL device, as is most common, then one hand is placed into the operative field and laparoscopy, hand assistance, nephrectomy Several devices are commercially the other used to work the laparoscopic manufactured which allow the hand to be instruments. Some choose to always use the introduced into an insufflated abdomen while subordinate hand intra-abdominally, freeing INTRODUCTION maintaining the pneumoperitoneum. The up the dominant hand to manipulate Pneumosleeve® (Dexterity Inc., Atlanta, USA) laparoscopic instruments, while others vary Laparoscopic techniques are now part of the was the first device, introduced in 1997. The the inserted hand depending on the operated standard armoury for extirpative and Intromit® (Applied Medical, Rancho Santa side. An assistant (or robotic arm) operates reconstructive urological procedures. Hand- Margarita, USA) and the HandPort® (Smith the laparoscope. Whatever port configuration assisted laparoscopy (HAL) is a variant of and Nephew, Huntingdon, UK) followed is chosen, general principles dictate that the laparoscopy; a pneumoperitoneum is created, shortly thereafter, but all have been hand should have easy access to the renal a laparoscope inserted and laparoscopic discontinued in favour of the three superior hilum while maintaining full flexion/extension instruments used for the surgery, with the ‘second-generation’ products currently at the wrist, and avoid clashing with the only difference between standard laparoscopy available. laparoscope and/or laparoscopic instruments. and HAL being that the surgeon is able to introduce a hand into the operative field. The GelPort® (Applied Medical), based on coaptative gel, is snapped onto an abdominal DISCUSSION The objective of this review is to examine the ring. The LapDisc® (Hakko Ltd, Tokyo, Japan, advantages and disadvantages of the marketed by Ethicon Endo-Surgery, Bracknell, Since the first reports of HAL nephrectomy by selective use of hand-assistance in UK) is based on an the principle of an iris valve Nakada et al. there have been numerous laparoscopic urology, and the evidence creating an airtight seal for the surgeon’s publications explaining the efficacy and comparing its efficacy with standard hand. Finally, the Omniport® (ASC Limited, efficiency of the technique. Several laparoscopic techniques. Wicklow, Ireland, marketed by TYCO, Gosport, comparative studies have been reported, UK) is inflated with air to fix it into place and where HAL has been compared with open maintain pneumoperitoneum. All of these surgery, standard laparoscopy and HISTORY OF HAL IN UROLOGY devices are effective (Fig. 1), and selection retroperitoneoscopy for RN, radical NU and depends on surgeon preference, the patient’s DN. HAL surgery is being widely used in general habitus and history of previous abdominal surgery and gynaecology for colon resections, surgery. SIMPLE AND RADICAL NEPHRECTOMY splenectomy, distal pancreatectomy, partial hepatectomy and hysterectomy [1–4]. In Nakada et al. [8] compared a group of 18 urology, HAL was first introduced in 1996 TECHNIQUE patients who underwent HAL RN with a when Bannenberg et al. [5] performed the first contemporary cohort who had an open HAL nephrectomy in a pig. They reported that The patient is placed supine or in a partial (not surgical RN. Patients were matched for age, HAL nephrectomy was quick and easy, and complete) flank position, and secured to the body mass index and American Society of compared with conventional laparoscopic table by several cloth tapes; the table is then Anesthesiology score. In the HAL group, the nephrectomy, the surgery was quicker (30–45 rotated laterally allowing the viscera to mean operating-room time was 220.5 min, vs 90–120 min). In 1997, Nakada et al. [6] fall away inferiorly. One common port the length of stay 3.9 days, the time to return performed the first HAL nephrectomy in a configuration for left-sided renal surgery is to normal activity 15.8 days, and the time human for a chronically infected kidney from shown in Fig. 2, and is similar to that used by taken to return to work 26.8 days. The median stone disease. Since 1997 many investigators both the present authors. An assisting port is time taken to return to completely normal have reported their experience with HAL for sometimes placed caudal and well lateral to was 28.0 days. In the open group, the complex laparoscopic urological procedures, the camera port. The figure assumes the corresponding times were 117.8 min, 5.1 days, including radical nephrectomy (RN), surgeon is right-handed; for a left-handed 23.5 days, 52.2 days and 150 days; three nephroureterectomy (NU), donor surgeon, or for procedures on the right-side, patients never recovered normal activity. The nephrectomy (DN), partial nephrectomy (PN) various port-placement schemes are in use authors concluded that HAL nephrectomy and cystectomy. [7]. If the surgeon rather than the assistant offers considerable benefits for patient

RANE and WOLF

recovery, at the expense of longer FIG. 1. Currently available HAL surgery devices (from FIG. 2. A common port-placement scheme for left surgery. top to bottom): GelPort, LapDisc and OmniPort. HAL nephrectomy by a right-handed surgeon.

Comparing 22 HAL and 16 standard laparoscopic RNs, Nelson and Wolf [9] noted significantly faster surgery with the HAL approach, at 4.5 v 3.4 h. There were no significant differences in analgesic use, time to oral intake, duration of hospital stay or time to full recovery. Three other studies [10–12] comparing HAL and standard transperitoneal laparoscopic RN found no significant improvement in operative time with HAL; however, the comparisons were confounded by issues with case order and previous experience.

Rehman et al. [13] reported a series of three patients who had simultaneous HAL bilateral nephrectomy for end-stage renal disease and symptoms resulting from autosomal dominant polycystic kidney disease. The mean operative duration was 5.5 h and mean estimated blood loss 200 mL. Patients Landman et al. [19] found the latter speeded resumed oral intake on the ﬁrst day after the surgery by 72 min. Convalescence surgery, had a mean hospital stay of 4.3 days measures were similar in the two groups, and returned to normal activity after a mean except that the hospital stay was longer after of 2 weeks. Similar results were reported by HAL NU (3.3 vs 4.5 days). Troxel et al. [14] for bilateral nephrectomy before renal transplantation. DN

There is only one reported comparison of the Wolf et al. [20] performed a randomized HAL vs the retroperitoneoscopic route for RN, controlled trial between HAL DN and open DN, wherein data by Batler et al. [15] showed that with 50 patients randomly assigned to the HAL approach did not result in a longer undergo each (live DN). This trial showed that time to oral intake or longer hospital stay; in in the HAL group there was 47% less addition, there was no signiﬁcant difference analgesic use, 35% decrease in inpatient in narcotic usage or time to normal activity in hospital stay, 33% faster return to light both groups. The same group published an activity and 73% less pain at 6 weeks after elegant small study suggesting that HAL RN surgery than in the open group. The HAL DN may be safe when used by urologists with patients had complete recovery sooner and minimal laparoscopic experience [16]. had fewer long-term residual effects. There were no signiﬁcant differences in graft NU function.

Stifelman et al. [17] compared their results of Stifelman et al. [21] compared 60 patients HAL NU in 11 patients with a matched group slower with the laparoscopic approach (320 who had undergone HAL DN with 31 who had of contemporary open NUs. The surgery was vs 199 min) but the hospital stay was 3.9 vs had open surgery. The time to patient slower with the HAL approach (mean 291 min 5.2 days, time taken to resume driving 17.1 vs recovery, blood loss, analgesic use and for vs 232 min for the open procedure), but 37.7 days, and time to achieve normal light hospital stay were all less in the HAL DN the mean blood loss was 144 vs 311 mL, oral activity 18.2 vs 38.1 days, in the HAL NU group, while operative times and narcotic requirement 5.8 vs 16 tablets, and and open groups, respectively. Minor complication rates were similar. Again, there length of stay 4.6 vs 6.1 days for the HAL NU complications occurred in 19% of were no signiﬁcant differences in graft and open groups, respectively. laparoscopic and 27% of open surgical function. procedures. Cancer control was similar in Seifman et al. [18] reported similar results both groups. Ruiz-Deya et al. [22] compared patients who comparing 16 patients who underwent had undergone open surgery, laparoscopic HAL NU with 11 contemporary patients In a comparison of 11 standard and 16 HAL surgery and HAL DN, noting that HAL DN was undergoing open surgery. The surgery was NUs performed at the same institution, faster than a conventional laparoscopic

HAND-ASSISTED LAPAROSCOPY

hydronephrotic nonfunctioning kidneys, are TABLE 1 Published series comparing standard transperitoneal laparoscopic with HALS donor more effectively addressed by conventional nephrectomy laparoscopic techniques. The main disadvantages of hand-assistance include the Operative Warm Hospital reduced working space taken up by the hand, N patients, duration, ischaemia, Complications Conversion stay the potential for loss of pneumoperitoneum Ref route min min (N) (N) (days) because of a leaking hand-assistance device, [22] 11 standard 215 3.9 1/1 0 1.6 and the cosmetic issues associated with an 23 HAL 165 1.6 2/0 1 2.0 upper abdominal incision (for left [23] 11 standard 270 5.0 3/0 0 6.5 nephrectomy). 11 HAL 197 3.6 0/0 0 6.2 [24] 40 standard 255 – – 3 3.2 CONCLUSION 60 HAL 260 – – 1 2.6 [25] 15 standard 276 3.8 1/0 0 2.0 HAL surgery offers clear advantages over 29 HAL 205 2.4 2/0 1 2.3 traditional open surgery, including decreased [26] 29 standard 311 3.7 5/2 4 4.1 blood loss, pain medication requirement, 18 HAL 269 3.4 2/1 1 4.1 hospital stay and convalescence. It appears to [27] 28 standard 306 3.0 0/0 0 2.0 be at least as effective as conventional 17 HAL 249 2.0 1/0 0 2.0 laparoscopic techniques, and offers the Total 134 standard 278* 3.7* 14.2%† 5.2%† 3.1* beneﬁts of proprioception and three- 158 HAL 232* 2.5* 8.1%† 2.5%† 2.8* dimensional spatial orientation. In summary, HAL surgery appears to be a safe, reproducible *weighted mean; †% occurrence of summed totals. and minimally invasive technique to perform extirpative renal surgery.

CONFLICT OF INTEREST approach and offered significantly shorter complications were reported. The average warm-ischaemia times. There were no tumour diameter was 1.9 cm and there were None declared. differences in long-term graft function. no positive surgical margins. REFERENCES Table 1 summarizes six published In another study, Wolf et al. [29] compared 10 comparisons of HAL and standard laparoscopic PNs (eight with hand assistance) 1 Pelosi MA, Pelosi MA III. Hand-assisted laparoscopic DN [22–27]. HAL is faster, to a contemporary cohort of 10 who had open laparoscopy for complex hysterectomy. associated with a shorter warm-ischaemia PN. Most tumours were peripheral, exophytic J Am Assoc Gynecol Laparosc 1999; 6: time, less frequently required conversion to and of a similar size (mean 2.4 cm in both 183–8 open surgery, had fewer complications, and is groups) Data on patient satisfaction and 2 Sjoerdsma W, Meijer DW, Jansen A, followed by a shorter hospital stay. However, recovery were obtained via self-administered den Boer KT, Grimbergen CA. in the studies that assessed narcotic use, questionnaires. The mean operative time was Comparison of efficiencies of three there tended to be somewhat more 24% longer in the laparoscopic group. techniques for colon surgery. J Lap Adv postoperative narcotic use or longer duration However, in the HAL group, there was 62% Surg Tech 2000; 10: 47–53 of convalescence after HAL. reduction in parenteral narcotic use, 43% 3 Mooney MJ, Elliott PL, Galapon DB, reduction in hospital stay, 64% more rapid James LK, Lilac LJ, O’Reilly MJ. Hand- return to normal light activity, and improved assisted laparoscopic sigmoidectomy for PN pain and physical health scores taken at 2 and diverticulitis. Dis Colon Rectum 1998; 41: 6 weeks. 630–5 Several centres have reported that HAL PN is 4 Ballaux KE, Himpens JM, Leman G, Van safe and reproducible. Stifelman et al. [28] den Bossche MR. Hand-assisted performed HAL PN in 11 patients, nine of CONTRAINDICATIONS laparoscopic splenectomy for hydatid whom had suspicious lesions and two cyst. Surg Endosc 1997; 11: 942–3 of whom had duplex systems with HAL does not seem to have a niche for any 5 Bannenberg JJG, Meijer DW, nonfunctioning upper moieties. The harmonic reconstructive procedure. e.g. pyeloplasty or Bannenberg JH, Hodde KC. Hand- scalpel (Ethicon, Cincinnati, Ohio, USA) was cyst decortication, which can be performed assisted laparoscopic nephrectomy in the used to excise tissue; haemostasis was aided safely and effectively with standard pig: initial report. Minim Invasive Ther with gel-foam and the argon beam laparoscopic techniques. In young children, Allied Technol 1996; 5: 483–7 coagulator. The mean operative duration was during deep pelvic surgery and during 6 Nakada SY, Moon TD, Gist M, Mahvi D. 273 min and the estimated blood loss 319 mL. retroperitoneoscopy, the hand in the Use of the Pneumo Sleeve as an adjunct in Patients resumed oral intake at a mean of operative field takes up too much working laparoscopic nephrectomy. Urology 1997; 1.7 days and were discharged home in space, making visualization and exposure 49: 612–3 3.3 days. There was one conversion; no major difficult. Adrenal surgery, and small/ 7 Lopez-Pujals A, Leveillee RJ. Trocar

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arrangement for HALS. J Endourol 2004; 16 Batler RA, Schoor RA, Gonzalez CM, standard laparoscopic nephrectomy. Surg 18: 319–25 Engel JD, Nadler RB. Hand assisted Endoscopy 2002; 16: 422–5 8 Nakada SY, Fadden P, Jarrard DF, Moon radical nephrectomy. the experience of 24 Velidedeoglu E, Williams N, Brayman TD. Hand-assisted laparoscopic radical the inexperienced. J Endourol 2001; 15: KL et al. Comparison of open, nephrectomy: comparison to open 513–5 laparoscopic, and hand-assisted radical nephrectomy. Urology 2001; 58: 17 Stifelman MD, Hyman MJ, Shichman approaches to live-donor nephrectomy. 517–20 S, Sosa RE. Hand-assisted Transplantation 2002; 174: 169–72 9 Nelson CP, Wolf JS Jr. Comparison nephroureterectomy versus open 25 Gershbein AB, Fuchs GJ. Hand-assisted of hand-assisted versus standard nephroureterectomy for the treatment of and conventional laparoscopic live donor laparoscopic radical nephrectomy for transitional cell carcinoma of the upper nephrectomy: a comparison of two suspected renal cell carcinoma. J Urol tract. J Endourol 2001; 15: 391–5 contemporary techniques. J Endourol 2002; 167: 1989–94 18 Seifman BD, Montie JE, Wolf JS. 2002; 16: 509–13 10 Baldwin DD, Dunbar JA, Parekh DJ et al. Prospective comparison between 26 Mateo RB, Sher L, Jabbour N et al. Single-center comparison of purely hand-assisted laparoscopic and open Comparison of outcomes in laparoscopic. hand-assisted laparoscopic, surgical nephroureterectomy for noncomplicated and in higher-risk donors and open radical nephrectomy in patients urothelial cell carcinoma. Urology 2001; after standard versus hand-assisted at high anesthetic risk. J Endourol 2003; 57: 133–7 laparoscopic nephrectomy. Am Surg 17: 161–7 19 Landman J, Lev R, Bhayani S et al. 2003; 69: 771–8 11 Hayakawa K, Aoyagi T, Ohashi M, Hata Comparison of hand assisted and 27 El-Galley R, Hood N, Young CJ, M. Comparison of gas-less laparoscopy- standard laparoscopic radical Deierhoi M, Urban DA. Donor assisted surgery, hand-assisted nephroureterectomy for the management nephrectomy. A comparison of techniques laparoscopic surgery and pure of localized transitional cell carcinoma. and results of open, hand assisted and full laparoscopic surgery for radical J Urol 2002; 167: 2387–91 laparoscopic nephrectomy. J Urol 2004; nephrectomy. Int J Urol 2004; 11: 20 Wolf JS Jr, Merion RM, Leitchman AB 171: 40–3 142–7 et al. Randomized controlled trial of hand- 28 Stifelman MD, Sosa RE, Nakada SY, 12 Okeke AA, Timoney AG, Keeley FX. assisted laparoscopic versus open surgical Shichman SJ. Hand assisted laparoscopic Hand-assisted laparoscopic nephrectomy: live donor nephrectomy. Transplantation partial nephrectomy. J Endourol 2001; 15: complications related to the hand-port 2001; 72: 284–90 161–4 site. BJU Int 2002; 90: 364–7 21 Stifelman MD, Hull D, Sosa E et al. Hand 29 Wolf JS, Seifman BD, Montie JE. 13 Rehman J, Landman J, Andreoni C et al. assisted laparoscopic donor nephrectomy: Nephron sparing surgery for suspected Laparoscopic bilateral hand assisted a comparison with the open approach. malignancy. Open surgery compared to nephrectomy for autosomal dominant J Urol 2001; 166: 444–8 laparoscopy with selective use of hand polycystic kidney disease: initial 22 Ruiz-Deya G, Cheng S, Palmer E, assistance. J Urol 2000; 163: 1659–64 experience. J Urol 2001; 166: 42–7 Thomas R, Slakey D. Open donor, 14 Troxel S, Das S. Hand-assisted laparoscopic donor and hand assisted Correspondence: Abhay Rane, Department of laparoscopic approach to multiple-organ laparoscopic donor nephrectomy: a Urology, East Surrey Hospital, Redhill, Surrey removal. J Endourol 2001; 15: 895–7 comparison of outcomes. J Urol 2001; UK. 15 Batler RA, Campbell SC, Funk JT, 166: 1270–4 e-mail: [email protected] Gonzalez CM, Nadler RB. Hand assisted 23 Lindstrom P, Haggman M, Wadstrom J. versus retroperitoneal laparoscopic Hand-assisted laparoscopic surgery Abbreviations: HAL, hand-assisted nephrectomy. J Endourol 2001; 15: 899– (HALS) for live donor nephrectomy is laparoscopy; NU, nephroureterectomy; RN, 902 more time- and cost-effective than DN, PN, radical, donor, partial nephrectomy.

The role of photodynamic diagnosis in the contemporary management of superﬁcial bladder cancer

SUNJAY JAIN and ROGER C. KOCKELBERGH* Urology Group, Department of Cancer Studies and Molecular Medicine, University of Leicester, and *Department of Urology, Leicester General Hospital, Leicester, UK Accepted for publication 7 December 2004

KEYWORDS plausible explanations. The penetration of 5- extensively. Unless stated otherwise, the ALA into tumour cells may be eased by their studies reported below used standard 5-ALA. bladder cancer, photodynamic diagnosis, relative permeability; there is also some TURBT, 5-ALA evidence that neoplastic cells actively accumulate 5-ALA. Normally PPIX is THE ROLE OF PDD AT INITIAL metabolized to haem by the enzyme TRANSURETHRAL RESECTION OF BLADDER INTRODUCTION ferrochelatase and this enzyme’s activity TUMOUR (TURBT) appears to be reduced in tumour cells, Photodynamic diagnosis (PDD) for bladder perhaps because of limited iron availability. The high recurrence rate of superficial bladder tumours was reported as long as 40 years ago cancer, up to 70% at 5 years, is responsible for [1], but the modern era was heralded with 5-ALA is generally administered intravesically a huge workload for urologists, and much the first clinical report of the use of 5- 2 h before cystoscopy through a urethral inconvenience for patients. The recurrence aminolaevulinic acid (5-ALA) as a catheter. The procedure requires special rate at the first check cystoscopy (3 months) photosensitizing agent [2]. Numerous studies telescopes and a specific light source (D-Light, varies enormously, even when known risk have followed, most promoting the increased Karl Storz, Germany). Using a foot pedal or a factors are allowed for, suggesting that sensitivity that PDD offers in detecting push-button on the camera it is possible to incomplete resection or failure to detect small bladder cancer. However it is still not in switch between white or blue light during additional tumours may be a risk factor [7]. widespread use, perhaps because clinicians cystoscopy and resection. Papillary tumours Many studies show that taking additional are unsure of exactly which patient groups appear intensely red when viewed under blue biopsies using PDD yields a higher rate of are best served by this technique. This review light and red mucosal patches may represent tumour detection at initial TURBT. In three will attempt to clarify, using the evidence carcinoma in situ (CIS) (Fig. 2). recent studies, patients were randomized available, where exactly PDD fits into the when undergoing the first TURBT to either options available to contemporary white-light cystoscopy (WLC) or PDD and urologists. 5-ALA ESTER then the area re-resected 2–6 weeks later (Table 1) [8–10]. All reports showed that those The speed of onset and degree of PPIX patients having resection under PDD had MECHANISM OF 5-ALA-INDUCED accumulation are related to the amount of 5- significantly less residual tumour, suggesting BLADDER TUMOUR FLUORESCENCE ALA that penetrates the urothelium, and in its that this technique improves the technical standard form 5-ALA is highly charged and quality of TURBT. Ultimately it is the reduction 5-ALA is the starting point of the haem passes across the lipid cell membrane in long-term recurrence that is important. biosynthesis pathway (Fig. 1), haem being a relatively poorly. A standard pharmacological This was assessed by Filbeck et al. [10] in a vital element of the cytochromes involved solution to this problem is esterification of the group of 191 patients with superficial bladder in the respiratory chain. The substance molecule, which can then easily cross the cell cancer. These authors showed that the immediately before haem in this pathway is membrane. Non-specific esterases within the recurrence rate at 2 years was 34% in the protoporphyrin IX (PPIX) and it is this cell then release the active compound. After WLC group and only 10% in the PDD group intermediate that is fluorescent, appearing extensive preclinical work the optimum (P = 0.004). That study provides strong red when viewed under blue-violet light. formulation for esterification of 5-ALA was support for the routine use of PDD at first Normally the accumulation of PPIX is found to be hexylester ALA (h-ALA) [4]. A TURBT to reduce subsequent recurrence rates. prevented in the presence of adequate haem clinical study showed that when h-ALA molecules by negative feedback on the was used for PDD there was twice the Another method of reducing the recurrence synthesis of 5-ALA, but exogenous fluorescence, with a decreased dwell time rate of superficial bladder cancer is the administration of 5-ALA overcomes this. and a 20-times lower concentration [5]. administration after TURBT of intravesical Subsequently this has been confirmed in chemotherapy, as confirmed by a recent PDD relies on the selective accumulation of bladder biopsies, which show greater PPIX meta-analysis [11]. None of the above studies PPIX in neoplastic cells, up to 10 times more in accumulation within cells when h-ALA is used used this, despite evidence that it is the tumour than normal tissue [3]. Although [6]. h-ALA is likely to become the standard ‘standard’, and hence it is not possible to say the precise reason for selective PPXI agent for PDD but at present it is not widely if PDD has any additional effect. Definite accumulation is unknown, there are several available and has not been investigated acceptance of PDD will require a further

JAIN and KOCKELBERGH

randomized controlled trial that includes FIG. 1. The haem biosynthesis pathway. An exogenous excess of 5-ALA leads to the accumulation of PPIX. adjuvant chemotherapy. Porphobilinogen 5-ALA DETECTION OF CIS; 1 case of CIS detected but othe rwise unh elpful IMPLICATIONS FOR PROGRESSION

Negative feedback CIS is notoriously difﬁcult to recognize on standard cystoscopy, as it may appear Uroporphyrinogen III macroscopically identical to normal urothelium. The progression rate of untreated HAEM CIS to invasive disease is about 50% and ‘missed’ cases may be responsible for progression in otherwise ‘low-risk’ patients. Coporphyrinogen III Two studies have produced meaningful data Ferrochelatase +Fe2+ on the detection of CIS by PDD.

In the first, a large study of 1012 fluorescence endoscopies, CIS was found on 88 occasions Protoporphyrin IX [12]; 50 of these cases (57%) were not Protoporphyrinogen IX detected on a preliminary standard WLC. A more recent study specifically set out to consider the diagnosis of CIS using PDD. h- ALA was used as the photosensitizer [13]. [8] [9] [10] TABLE 1 Patients were selected to be particularly at risk Patients 102 101 191 Randomized controlled for CIS and indeed the detection rate was Time to re-TURBT, weeks 6 1.5–2 5–6 trials of the use of PDD in high, at 39% (83/211). A standard WLC was Residual disease, % reducing residual tumour carried out together with a single random on WLC 39 53 25 after TURBT; none of the biopsy, and this was followed by PDD on PDD 16 33 5 studies used adjuvant cystoscopy. Of the 83 patients, 62 were chemotherapy after TURBT detected both on WLC and PDD, 18 on PDD P 0.005 0.031 <0.001 alone and three on WLC alone. FU for recurrence No No Yes (42 months)

Because of its high potential for progression, random biopsies have been taken to try to detect CIS. Neither of the above ROLE OF PDD AT CHECK CYSTOSCOPY particularly BCG, is of interest. The largest studies compared PDD with random study examining this found that patients who biopsies. Also, although it would be hoped In the current situation, where PDD is not had undergone recent IVT (within 6 months) that any improved method for detecting standard practice, the use of PDD at check had significantly more false-positive biopsies CIS could potentially contribute to a cystoscopy may have value even in low-risk using PDD (65/164, 40%) than those who reduction in the development of invasive patients. This would be related to the were >6 months after IVT or had never had it disease, it was shown that random biopsies do detection of previously invisible tumours, (205/753, 27%) [18]. Despite the high false- not influence this [14]. Hence a randomized especially CIS. In a group of patients positive rate, additional cases of residual trial would be required to clarify this issue for undergoing a second TURBT using PDD tumour or CIS are still found using PDD in this PDD. 6 weeks after conventional TURBT, 14% patient group, and so it may still be of value. (seven of 50) had tumours in previously unresected areas of the bladder [17]. RE-RESECTION DETECTION OF HIGH-GRADE DYSPLASIA Assuming that all patients have received PDD at the first resection, the question arises as When G3pT1 bladder tumours are diagnosed As well as CIS there have been reports that to which ones require it at subsequent most urologists will be suspicious of the PDD can be used to detect bladder dysplasia cystoscopy. There are some specific groups to possibility that invasive disease is being with much greater sensitivity than WLC consider. missed and will perform early re-resection at [15,16]. The significance of this is uncertain, 6 weeks. This involves a thorough resection of as there is controversy as to the natural AFTER INTRAVESICAL THERAPY all scar tissue. In this situation PDD is unlikely history of dysplasia. However, given that some (IVT, E.G. BCG OR CHEMOTHERAPY) to be of benefit because it detects only have suggested it is associated with superficial disease. There have been no formal progression in superficial disease, it will be PDD can give false-positive results in studies of PDD in re-resection of G3pT1 interesting to see if increased detection conditions such as inflammation, and disease, but a small study that included a allows clarification of this issue. therefore the effect of previous IVT, variety of histological types highlighted

PHOTODYNAMIC DIAGNOSIS FOR MANAGING SUPERFICIAL BLADDER CANCER

FIG. 2. Examples of appearances under PDD and WLC: a, papillary tumour; b, papillary tumour with CYTOLOGY surrounding carcinoma in situ not visible under white light; c, carcinoma in situ. In the follow-up of patients with low-grade a TCC, noninvasive methods are continually being sought. Urine cytology has been used but lacks sensitivity for low-grade lesions. A recent report described ﬂuorescence cytology as a possible method of overcoming this [19]. However, the sensitivity was only increased from 79% to 86% and clearly all patients have to be catheterized, meaning this technique is unlikely to become popular in its present form.

b PROBLEMS WITH PDD

Current formulations of 5-ALA are unstable and require preparation immediately before administration, usually by a pharmacist. This may cause logistical problems in getting patients ready for an early-morning operating list. Newer preparations are being developed that can be made up by nursing staff on the ward, and ultimately it is hoped that a stable formulation can be created. PPIX is degraded when exposed to light (blue or white) and its ﬂuorescence reduced. In initial c demonstrations of PDD this was a problem, but it has not been a practical issue in its routine use.

While training is required in the use of PDD it is a relatively straightforward procedure. One source of error for trainees is the fluorescent appearance of tangentially viewed mucosa because of the nonspecific accumulation of PPIX in normal urothelium. This can be clarified by varying the observation angle.

Up to a third of fluorescent areas on PDD may be histologically benign. These can occur in another problem, frequent false-positive will be detected, but whether this is previous resection sites and be a result of fluorescence of the scar [17]. cost-effective will need to be cystitis, squamous metaplasia or previous IVT. determined. It will be impossible to completely eliminate false-positive results but one approach to THE ROLE OF PDD IN A reducing them has been in vivo quantification HAEMATURIA CLINIC OTHER POTENTIAL USES OF PDD of PPIX fluorescence [20]. This relies on digital calculation of the ratio of fluorescence to Flexible cystoscopy using PDD has recently UPPER TRACT STUDIES background and has been shown to reduce become possible with the development of a false-positive results by 30% without more powerful light source (D-Light C). The The patient with persistently positive urinary compromising sensitivity. potential role in the haematuria clinic is not cytology but a normal cystoscopy and upper clear. Detecting additional tumours is unlikely tract imaging is a clinical dilemma. Flexible PHOTODYNAMIC THERAPY to be of benefit if patients are undergoing ureteroscopy is used to directly visualize the subsequent TURBT using PDD. There would no ureters and renal collecting system, but may Photodynamic therapy uses the selective doubt be a few occasions where solitary miss flat lesions. With the new more powerful uptake of photosensitizers by bladder cancer tumours that might have been missed light source, PDD of the upper tracts might be cells as a method of treatment. Essentially, completely on standard flexible cystoscopy possible and is being investigated. when these cells are exposed to light in the

JAIN and KOCKELBERGH

presence of oxygen, local hyperthermia leads bladder carcinoma. Cancer 1964; 17: postoperative instillation of to cell death. This is an attractive idea for the 1528–32 chemotherapy decreases the risk of therapy of widespread CIS or multifocal 2 Kriegmair M, Baumgartner R, Knuechel recurrence in patients with stage Ta T1 papillary disease. Unfortunately, initial R et al. Fluorescence photodetection of bladder cancer: a meta-analysis of attempts were associated with significant neoplastic urothelial lesions following published results of randomized rates of bladder contracture because of the intravesical instillation of 5- clinical trials. J Urol 2004; 171: 2186– nonspecific accumulation of photosensitizers aminolevulinic acid. Urology 1994; 44: 90 in the detrusor muscle. It was suggested that 836–41 12 Zaak D, Kriegmair M, Stepp H et al. this is much less of a problem with 5-ALA, 3 Datta SN, Loh CS, MacRobert AJ, Endoscopic detection of transitional cell which does not penetrate the urothelium to Whatley SD, Matthews PN. Quantitative carcinoma with 5-aminolevulinic acid: any significant extent. There are relatively few studies of the kinetics of 5- results of 1012 fluorescence endoscopies. clinical reports to date, but they are aminolaevulinic acid-induced Urology 2001; 57: 690–4 encouraging in terms of safety and fluorescence in bladder transitional cell 13 Schmidbauer J, Witjes F, Schmeller N, tolerability [21–23]. carcinoma. Br J Cancer 1998; 78: 1113–8 Donat R, Susani M, Marberger M. 4 Marti A, Lange N, van den Bergh H, Hexvix PCB301/01 Study Group. HYPERICIN Sedmera D, Jichlinski P, Kucera P. Improved detection of urothelial Optimisation of the formation and carcinoma in situ with Hypericin is a naturally occurring substance distribution of protoporphyrin IX in the hexaminolevulinate fluorescence derived from St John’s Wort (Hypericum urothelium: an in vitro approach. J Urol cystoscopy. J Urol 2004; 171: 135–8 perforatum) and has been used clinically as an 1999; 162: 546–52 14 Kiemeney LA, Witjes JA, Heijbroek RP, antidepressant. It was shown to be a potent 5 Lange N, Jichlinski P, Zellweger M et al. Koper NP, Verbeek AL, Debruyne FM. photosensitizer in TCC. Initial clinical reports Photodetection of early human bladder Should random urothelial biopsies be claim a higher specificity than 5-ALA-based cancer based on the fluorescence of 5- taken from patients with primary PDD, although there were false-positive aminolaevulinic acid hexylester-induced superficial bladder cancer? A decision results in patients who had received protoporphyrin IX. a pilot study. Br J analysis. Members of the Dutch South- intravesical BCG [24]. While offering some Cancer 1999; 80: 185–93 East Co-Operative Urology Group. Br J advantages over 5-ALA, such as relative ease 6 Marti A, Jichlinski P, Lange N et al. Urol 1994; 73: 164–71 of preparation, there is not enough data Comparison of aminolevulinic acid and 15 Zaak D, Hungerhuber E, Schneede P available on hypericin at present to be able to hexylester aminolevulinate induced et al. Role of 5-aminolevulinic acid in evaluate its clinical role. protoporphyrin IX distribution in human the detection of urothelial premalignant bladder cancer. J Urol 2003; 170: 428–32 lesions. Cancer 2002; 95: 1234–8 CONCLUSIONS 7 Brausi M, Collette L, Kurth K et al. 16 Landry JL, Gelet A, Bouvier R, Variability in the recurrence rate at first Dubernard JM, Martin X, Colombel M. In the decade since its first clinical use it has follow-up cystoscopy after TUR in stage Detection of bladder dysplasia using been shown that PDD using 5-ALA is a safe Ta T1 transitional cell carcinoma of the 5-aminolaevulinic acid-induced adjunct to cystoscopy and which allows the bladder: a combined analysis of seven porphyrin fluorescence. BJU Int 2003; detection of otherwise invisible tumour. One EORTC studies. Eur Urol 2002; 41: 523– 91: 623–6 randomized study showed that its use can 31 17 Filbeck T, Roessler W, Knuechel R, reduce the recurrence of superficial TCC. It is a 8 Riedl CR, Daniltchenko D, Koenig F, Straub M, Kiel HJ, Wieland WF. 5- relatively easy technique to learn and because Simak R, Loening SA, Pflueger H. aminolevulinic acid-induced fluorescence it allows an accurate assessment of the Fluorescence endoscopy with 5- endoscopy applied at secondary adequacy of resection at TURBT, it is likely to aminolevulinic acid reduces early transurethral resection after be a useful aid for training junior urologists in recurrence rate in superficial bladder conventional resection of primary the future. With the development of h-ALA cancer. J Urol 2001; 165: 1121–3 superficial bladder tumors. Urology 1999; and more user-friendly formulations, it will be 9 Kriegmair M, Zaak D, Rothenberger KH 53: 77–81 used increasingly and should become the et al. Transurethral resection for bladder 18 Grimbergen MC, van Swol CF, Jonges standard method of primary TURBT. However, cancer using 5-aminolevulinic acid TG, Boon TA, van Moorselaar RJ. evidence for its use in other situations is at an induced fluorescence endoscopy versus Reduced specificity of 5-ALA induced earlier stage and indications will be better white light endoscopy. J Urol 2002; 168: fluorescence in photodynamic diagnosis defined over the next 10 years. 475–8 of transitional cell carcinoma after 10 Filbeck T, Pichlmeier U, Knuechel R, previous intravesical therapy. Eur Urol CONFLICT OF INTEREST Wieland WF, Roessler W. Clinically 2003; 44: 51–6 relevant improvement of recurrence-free 19 Tauber S, Schneede P, Liedl B, Liesmann None declared. survival with 5-aminolevulinic acid F, Zaak D, Hofstetter A. Fluorescence induced fluorescence diagnosis in cytology of the urinary bladder. Urology REFERENCES patients with superficial bladder tumors. 2003; 61: 1067–71 J Urol 2002; 168: 67–71 20 Zaak D, Frimberger D, Stepp H et al. 1 Whitmore WF, Bush IM, Esquivel E. 11 Sylvester RJ, Oosterlinck W, van der Quantification of 5-aminolevulinic acid Tetracycline ultraviolet fluorescence in Meijden AP. A single immediate induced fluorescence improves the

PHOTODYNAMIC DIAGNOSIS FOR MANAGING SUPERFICIAL BLADDER CANCER

specificity of bladder cancer detection. single-center study. Urology 2003; 61: Correspondence: Sunjay Jain, Urology Group, J Urol 2001; 166: 1665–8 338–41 Department of Cancer Studies and Molecular 21 Shackley DC, Briggs C, Gilhooley A et al. 23 Waidelich R, Beyer W, Knuchel R et al. Medicine, University of Leicester, Leicester, UK. Photodynamic therapy for superficial Whole bladder photodynamic therapy e-mail: [email protected] bladder cancer under local anaesthetic. with 5-aminolevulinic acid using a white BJU Int 2002; 89: 665–70 light source. Urology 2003; 61: 332–7 Abbreviations: PDD, photodynamic diagnosis; 22 Berger AP, Steiner H, Stenzl A, Akkad T, 24 D’Hallewin MA, Kamuhabwa AR, PPIX, protoporphyrin IX; 5-ALA, h-ALA, 5-, Bartsch G, Holtl L. Photodynamic Roskams T, De Witte PA, Baert L. hexylester-, aminolaevulinic acid; IVT, therapy with intravesical instillation of 5- Hypericin-based fluorescence diagnosis intravesical therapy; CIS, carcinoma in situ; aminolevulinic acid for patients with of bladder carcinoma. BJU Int 2002; 89: TURBT, transurethral resection of bladder recurrent superficial bladder cancer: a 760–3 tumour; WLC, white-light cystoscopy.

NONSURGICAL FACTORS IN THE SUCCESS OF HYPOSPADIAS REPAIR WOODHOUSE and CHRISTIE

Nonsurgical factors in the success of hypospadias repair

CHRISTOPHER R.J. WOODHOUSE and DEBORAH CHRISTIE* The Institute of Urology and Nephrology, and *Department of Child and Adolescent Psychological Services, University College London and Middlesex Hospitals, London, UK Accepted for publication 10 January 2005

KEYWORDS on the nonsurgical aspects of hypospadias experience rivalry with the parent of the same repair are reviewed and compared with the sex and develop an attachment with the hypospadias, psychology, sexuality, outcome practices of surgeons in the UK, as assessed parent of the opposite sex. The guidelines by a questionnaire. from the American Academy of Pediatrics now recommend operations for hypospadias INTRODUCTION THE TIMING OF SURGERY before 30 months old, to minimize the psychological impact on body image and Hypospadias is a common congenital disorder Early practice guidelines from the American gender identity [14]. affecting ª1 in 300 live male births. Academy of Pediatrics recommended that Classically it is a triad consisting of a children with hypospadias should be operated BODY IMAGE malpositioning of the urethral meatus, a on after 4 years of age [5]. It was felt that the ventral curvature of the penis and an parental separation from the child would be BEFORE SURGERY abnormal distribution of foreskin, giving a detrimental to the child’s development, and ‘hooded’ appearance [1]. The resulting surgery should best be delayed until after the Impending surgery for hypospadias induces defect varies, with 80% having a distal phase of separation anxiety, thought to end at anxieties in both parents and children that are malpositioning of the meatus, requiring a ª4 years old. This recommendation has not seen in families with other surgical single-stage repair, and 20% having a more changed for two reasons; first, surgical and conditions of similar severity. Genital severe, proximal malpositioning, which may anaesthetic techniques for infants have awareness is thought to develop at 3–5 years require two or three operations to repair. The improved [6], and second, there was a large old, earlier if there are older male siblings [8]. more severe the initial problem the higher the move within paediatrics as a whole to This is when the child begins to widen his complication rate, and the more operations encourage parents to stay with their child. social circle in nursery and play-groups, and the patient is likely to require. This allowed the admission of young children has the opportunity to compare genitals [9]. with no increase in anxiety as a result of There are many reports describing the surgical separation [7]. More recently, hypospadias has In severe hypospadias the genitalia may be management of hypospadias. The results may been repaired as a day-case procedure, ambiguous [15]. If the parents are anxious be measured easily in terms of complications. avoiding the concerns of separation anxiety. about the ‘maleness’ of the child, there may The appearance and the acceptability to the be an adverse affect on body image [9]. A patient are just starting to be considered [2,3]. Four papers focused on the timing of elective preoperative assessment of children aged The difficulty is that the patients are children surgery in hypospadias and agreed that an 2–6 years with hypospadias found that and it may not be their opinions that are early operation minimizes the potential parents were indeed concerned about the sought, but only those of their parents [2]. psychological damage caused by genital ‘maleness’ of their child, which mirrored Although the many operations described surgery [6,8–10]. Surgery when aged 6–15 findings in the children themselves, who suggest that none is perfect, the results now months avoids five particularly sensitive showed predominantly genital-centred are sufficiently good that nonsurgical factors, phases of psychosocial development, the anxieties, as measured on the Robertson and particularly the psychological aspects, disruption of which is thought to predispose Auditory Projective Test [16]. The assessment should be considered in assessing the to psychological problems in later life by Robertson and Walker also compared the outcomes [4]. However, there is little (Table 1) [11]. This period was derived on the anxieties of the parents of children with cleft published that describes what psychological basis of theory rather than research, a point palate with those who had hypospadias. They problems need addressing (if any), what noted by the authors. Indeed, little research, found that the parents of the hypospadias interventions have proved useful or how least of all prospective or controlled, has been group had anxieties based on the future often they are offered. done to verify these theories [12]. Mondaini potency of the child, whereas the children et al. [13] studied 40 hypospadias patients themselves, and both the parents and children Adult patients who are now available for and compared them to over 10 000 in the cleft palate group, had anxieties based outcome analysis had their surgery in the unaffected controls; the age at which surgery more on the present operation. The authors 1970s; much of the evidence cited in the took place was not associated with abnormal felt that the main difference between the present review comes from surgery that is psychological adjustment later in life. groups was the presence of a hidden ‘guilty even older. Techniques have changed and secret’ which prevented the parents from surgical results have improved. However, Usefully, the timing of the development of discussing the operation within the family. against this must be set the increase in body image also corresponds to the Freudian patient expectations that has come with ‘phallic stage’ of development and the Oedipal Ironically, there are many men who have a greater education. In this review, publications Complex, where the child is supposed to hypospadiac meatus for which they have

NONSURGICAL FACTORS IN THE SUCCESS OF HYPOSPADIAS REPAIR

sexual inhibitions as a result [22]. Genital TABLE 1 The ages of main psychosexual milestones in infancy and early childhood body image in hypospadias patients was negatively correlated with the initial severity Age Psychological event Other high risk periods of the hypospadias [13,19], and positively Infancy Maternal bonding 18–24 months with the terminal position of the meatus [20]. 4–6 years Importantly, one study found the better 18 months Rapprochement the genital body image, the better the Stranger anxiety psychological function [22]. Therefore, in Separation anxiety children who have had an operation for 3–4 years Development of genital body image hypospadias a good cosmetic result is most 2–7 years Cognitive development important for future psycho-sexual 5 years Oedipal/phallic awareness functioning. It is not known whether this is Castration anxiety because having surgery raises an expectation of a perfect outcome, or whether there is an intrinsic desire to have a perfect penis.

TABLE 2 The number of patients in three age groups with a stretched penile length in different centiles; Size may also be a cause of dissatisfaction. adapted from [3] The hypospadiac penis is often said to be short. In part this may be because of the No. of patients circumcised appearance, especially in Age group, years (n) <10th centile Average >90th centile societies where infant circumcision is 9–12 (16) 1 12 3 unusual. However, where a formal 13–15 (10) 2 8 0 measurement has been made, a fifth of 16–18 (7) 4 3 0 hypospadiac penises were below the 10th centile. The finding was most marked in adolescents, with four of seven being below the 10th centile (Table 2) [3]. never had surgery and of which, in many that of the patient [3]. In that study, the cases, they are unaware. In a prospective surgeon based a good cosmetic outcome on Penile size is a source of considerable anxiety analysis of 500 men presenting for prostate those variables that were surgically corrected, in many adolescents. Limited research is surgery, 65 had a hypospadiac meatus (but no such as meatal position. Patients tended to available on the relationship of penile size to chordee); 60% of patients and 55% of their place emphasis on other factors that are sexual satisfaction. Men with micropenis and partners were unaware of the abnormality not currently operable. Mureau et al. [3] with epispadias report intercourse that is [17]. identified eight features of importance in satisfactory to themselves, although the judging the outcome of hypospadias opinions of their partners has not been AFTER SURGERY surgery: investigated [23]. An investigation of women with several sexual partners suggested that Early operations concentrated on functional Surgically correctable: intercourse with an uncircumcised penis gives correction, believing that ‘minor’ cosmetic greater pleasure than a circumcised one [24]. abnormalities, such as a coronal hypospadias, • meatal position could be ignored. Surgeons felt that the • glans shape cosmetic appearance was only of concern to • scars PSYCHOLOGICAL OUTCOME the parents, not the patients [18]. Nowadays it • scrotum is felt that poor cosmetic results are not • general appearance. EARLY OUTCOME accepted by patients [1] and have an effect on genital body image [19]. Recent papers Uncorrectable: An early paper assessing boys at 2–6 years old specifically assessing patient satisfaction found an increase in initial withdrawal found that the meatal position was important • volume of the glans behaviour followed by an increase in to the patient and was reflected in their level • penile size aggressive behaviour [25]. This study used a of satisfaction [3,20]. This finding was • penile thickness. ‘unblinded’ ‘formal observation’ approach replicated by a further study which found that with no controls, but it replicated the clinical the cosmetic appearance, together with Much disagreement among surgeons and feeling at the time that patients who were satisfactory sexual function, were correlated patients centres on the uncorrectable operated on at a later stage experienced more with overall satisfaction, with micturition features. distress [8]. Some studies agree with this being less important [21]. preliminary research, showing more Studies of the long-term effects of behavioural problems than in controls [26], There is little research into what makes a good hypospadias surgery on body image have more inferiority [12], and an increase in cosmetic result, although it was reported that found that patients were more embarrassed shyness and enuresis [27]. However, two the surgeon’s view has little correlation with than controls about their penis, and had more recent studies were unable to show any

WOODHOUSE and CHRISTIE

emotional or behavioural differences between a FIG. 1. patients and controls [22,28], although 18 a, The age of sexual milestones in Sandberg et al. [28] noted that higher rates of 16 men operated in childhood for hospital admissions were associated with an 14 hypospadias (red bars) compared increase in emotional problems. rs 12 with age-matched men operated a 10 for hernia (green bars). Data 8 LATE EFFECTS adapted from [19]; b, The Age, ye 6 4 percentage of men operated in The studies assessing late effects of 2 childhood for hypospadias (red hypospadias surgery divide their findings into 0 bars) compared with age- three groups: psychological, psychosocial and Necking Masturbation Intercourse matched men operated for psychosexual. Although there have been therapeutic circumcision (green b several studies evaluating the psychological bars) who were satisfied with 100 sequelae of hypospadias, most comprise few aspects of sexuality. The data patients and have poor controls, often 80 were collected in Finland, where comparing the surgical patient with a circumcision in infancy is only for community control. Where papers assessed 60 medical indications. Adapted tients behavioural changes after surgery the sample a from [33]. patients were frequently those who had been 40 operated on when aged 3–6 years, and it % of p could be argued that the resulting behaviour 20 was a consequence of operating during a 0 psychologically vulnerable age. Up to 20% of Erection Ejaculation Overall patients with severe hypospadias and genital ambiguity felt that their psychological well- being had been impaired, and 10% had responsible jobs than surgical controls [27]. Some studies have focused on the evidence of mild depression [29]. There are several other studies which development of general and gender-role have not found such a correlation, and behaviour. An early study reported that However, with those less severely affected suggest that the hypospadias patient is compared with matched controls, patients there is some variation in findings. One study, psychosocially unimpaired in the long term with hypospadias were less secure in their using open interviews, found that patients [19,22,31,33]. maleness and had a tendency to take a who had been operated on for hypospadias more feminine sex role, although had showed more neurotic symptoms, e.g. Psychosexual research has also given rise to similar sexual orientation to controls [35]. depression and anxiety, used immature conflicting results. Mureau et al. [19] assessed Other research groups reported more defence mechanisms and had poor sexual inhibition in men operated in behavioural problems and lower social relationships as a result [27]. In the same childhood for hypospadias and age-matched competency than in nonclinical controls, but patient group, a second study, using men operated for hernia; 24% and 2%, 61% found better adjustment than a psychiatric Rorschach’s test, found that patients who had and 71% and 15% and 28%, respectively, clinical control group. Boys with hypospadias been operated on for hypospadias had more were considered ‘inhibited’, ‘not inhibited’ or showed more cross-gender behaviour than neurotic symptoms, less self-esteem and less ‘don’t know’. In other reports, up to 19% of the psychiatric controls [26], although this capacity for relations, which was felt to prove hypospadias patients had more sexual was associated with hospitalization rather the existence of the castration complex [30]. difficulties and inhibitions, and anticipated than severity of the condition. In a larger The converse was found in another study, more ridicule, than surgical controls. They sample the same research team subsequently again using an unblinded interview, which were older at the first sexual intercourse reported fewer men exhibiting masculine found no psychological problems in and they had fewer partners as a result behaviour, although once again the adulthood [31]. [20,34]. number of hospitalizations for surgery were correlated with gender-atypical Research into psychosocial factors is similarly However, importantly in the study of behaviour rather than severity of the divided. Those studies which have found Bracka [20], those men who were satisfied hypospadias [36]. The significance of the psychosocial deficits showed that some with their penile appearance had a near- data in that study is very dependent on patients who have been operated on for normal age of sexual debut (15.6 years), the selection of the subjects. Apparently hypospadias have less capacity to form the delay being mainly in those who the reasoning for the gender-atypical relationships or felt that their relationships were dissatisfied (debut at 19.0 years). behaviour was the hypo-androgenization were affected by the disorder [20,27]. One Even in those who were dissatisfied, associated with hypospadias rather than study found that the marriage rate was 20% sexual debut frequently occurred before the surgery itself. In most patients with lower than in a community population [32]. In the ‘final’ surgery was completed. In hypospadias the pituitary and testicular addition, one study suggested that adults contrast, some studies found that patients axis is normal, and so the presence of who had had a hypospadias repair were had a normal adult sex life (Fig. 1a,b) hypo-androgenization must imply some employed in less competitive and less [19,31,33,34]. selection bias [20].

NONSURGICAL FACTORS IN THE SUCCESS OF HYPOSPADIAS REPAIR

FIG. 2. An artiﬁcial erection showing persistent chordee in a man operated for hypospadias in childhood. experienced the appropriate hypospadias surgery as repeated abuse, and had subsequently become a sexual offender [37]. A cognitive behavioural model was used to break a pattern of offending. The authors argue that a psychodynamic model would have been more appropriate if the boy had engaged with the treatment consistently. Treatment for his offending failed, although earlier treatment (implying during surgery and before offending) may have altered the outcome. The difﬁculty with this view is that the huge majority of men born with hypospadias are not criminals and therapy aimed at preventing such behaviour in all patients would not be practical or useful.

Work has been carried out in clients with eating disorders or body dysmorphic disorder, and shows some success in challenging and changing distorted views on body image using a cognitive-behavioural model [38,39]. FIG. 3. Clinical photograph of the penis of a man • Surgery outside the optimum age bracket. This is an area of potential development for who had undergone several operations in childhood • Severity of the hypospadias. the psychological treatment of hypospadias. for hypospadias. He has the features of a • Number of operations. However, again it would not be practical to ‘hypospadias cripple’, with an eccentric, patulous • Child’s/parent’s unfavourable view of provide all hypospadias patients with and misplaced meatus, extensive scarring and no hypospadias. individual cognitive therapy. It would be normal skin. useful to establish the risk factors for a poor Most have not been rigorously tested and rely psychological outcome and so be able to on psychodynamic theories. Probably the target psychological treatments effectively. most important are the severity of the hypospadias and the number of operations It is also reasonable to question whether needed for correction. These two factors are psychological treatment for all patients would understandably difficult to differentiate, as be beneficial. Bracka [20] suggested that all the one will frequently lead to the other. Poor children should have regular follow-up to surgical results (Figs 2 and 3) are associated identify surgical and psychological problems with a delayed age of sexual debut. at an early stage. Possibly a regular visit to hospital for an inspection of the genitalia TREATMENTS (which the child may think are normal) might generate a psychological problem that Most authors cited have agreed that previously had not existed. Work in our unit psychological support would be beneficial for with adolescents born with exstrophy has this group of patients. This rarely occurs and suggested that patients wish to be considered one study found that two-thirds of patients normal, and that facilities provided by adults had received no guidance, 60% stating that to help in fact serve only to emphasize they had never even heard of the term the abnormalities from which they wish to ‘hypospadias’! [20]. Studies, especially of escape [40]. severely affected patients, emphasize ‘the importance of follow-up in adolescence and adult life with adequate counselling when SURVEY necessary’ [29]. However, to date there are no studies that have assessed what therapies are The psychological factors in hypospadias useful, for how long they should run, or which might be considered sufficiently well patients are suitable; all are questions worth documented that surgeons would be aware of RISK FACTORS investigating. them and adjust their practices accordingly. After all, the operations are, in many cases, Several risk factors for a poor psychological One case study reported a prepubescent boy cosmetic in intent, so that the psychological outcome can be conjectured: who was described as having subjectively outcome ought to be very important [4];

WOODHOUSE and CHRISTIE

sadly, at least in the UK, this appears not to be always accord with the available evidence. most helpful or to whom it should be offered. the case. Where surgeons did have concerns, most This is an area that needs further research. made referrals only when a specific problem In a mailing to 193 urology centres (71% occurred. Although we still lack proof that surgery is response rate) we identified 34 surgeons in less traumatic, in the broadest sense, in 30 hospitals who regularly carried out infants aged < 30 months, the theoretical hypospadias surgery. Ten were paediatric CONCLUSIONS basis for early surgery is sound. Those urologists, 20 were general urologists and surgeons, particularly those with no specialist four were plastic surgeons. The mean age at Which nonsurgical factors are important in practice, should pay attention to the which the hypospadias was repaired was successful hypospadias treatment? There is established psychological aspects and operate strongly related to the speciality and good evidence that a better surgical result within the recommended age limits. experience of the surgeon, at 21, 36 and does produce a happier adult. However, there 40 months (range 12–120) for the three is also evidence that the patients and CONFLICT OF INTEREST groups of surgeons, respectively; and 21, 30 surgeons do not agree on that which and 51 months for those with a case load of constitutes a good result. For the surgeon, None declared. more than seven, two to four, or ‘rarely’ each successful relocation of the meatus and year. Paediatric surgeons and those with a correcting chordee may constitute success. REFERENCES greater case load usually operated within For the patient with hypospadias, the goal is a the optimum age range. Most surgeons normal penis. This is a significant challenge 1 Mouriquand P, Persad R, Sharma I. apparently were aware of the relevant when some of the features of hypospadias are Hypospadias repair. current principles and psychological factors, but those who operated not surgically correctable, with a particular procedures. Br J Urol 1995; 76 (Suppl. 3): late misinterpreted the data which were cited difficulty in the increasing number of 9–22 as a reason to justify their practice. Some societies which do not routinely circumcise. 2 Holland AJA, Smith GHH, Ross FI, Cass surgeons who operated late were under the DT. HOSE: an objective scoring system for illusion that the penis grows significantly Although psychological evidence is limited, evaluating the results of hypospadias between 18 and 36 months. several consistent findings suggest that in the surgery. BJU Int 2001; 88: 255–8 long term some patients show a greater 3 Mureau MAM, Slijper FME, Koos Of the surgeons, 60% had no concerns about tendency towards low mood and low self- Slob A, Verhulst FC, Nijman RJM. psychological problems in the children under esteem. Whilst patients are later in initiating Satisfaction with penile appearance after their care. Many of those who did have such intercourse and feel that their relationships hypospadias surgery. the patient and concerns thought that the immediate peri- have been affected (often expecting more surgeon view. J Urol 1996; 155: 703–6 operative period was the most important, ridicule from their partners) most ultimately 4 Thomas DFM. Hypospadiology: science often more for the parents than the child. The experience a satisfying sexual relationship. and surgery. BJU Int 2004; 93: 470–3 support used was mainly from nurses and However, importantly, most of these studies 5 Kelalis PP. The timing of elective surgery play therapists; only 18% of current support were focused on patients who would have on the genitalia of male children with was from a psychologist (or similar been operated at the standard age (i.e. particular reference to undescended psychosocial professional). When it was 3–6 years) which is different from current testes and hypospadias. Pediatrics 1975; realized that psychological help was needed, accepted practice. 56: 479–89 80% had an idea about how to refer, with 6 Manley C, Epstein E. Early hypospadias 56% referring to a paediatric psychiatrist or Several risk factors for a poorer psychological repair. J Urol 1981; 125: 189–700 psychologist. outcome can be conjectured. These include 7 Robertson J. Young Children in Hospital, the severity of hypospadias, the timing of the 2nd edn. London: Tavistock Publishers Ltd, The opinions expressed did not always seem operation and individual ways of dealing with 1970 to be based on the medical evidence, and were hypospadias, e.g. negative cognitive schema 8 Manley C. Elective general surgery at one sometimes self-contradictory. Some surgeons associated with physical appearance. In our year of age: psychological and surgical felt that having the child in nappies was survey, practising surgeons identified the considerations. Surg Clinics North Am helpful, while others thought it to be a main psychological issues as parental anxiety, 1982; 62: 941–53 disadvantage. Penile size and anaesthetic risk anticipatory anxiety and some anxieties about 9 Schultz J, Klykylo W, Wacksman J. were used to support surgery at all ages. The future sexual function. However, so far there Timing of hypospadias repair in children. contradictions were even more marked when is little rigorous evidence that these really are Pediatrics 1983; 71: 342–51 surgeons were citing the psychological risk factors for postoperative psychological 10 Duskova M, Helclova H. The problem of reasons for their choice. It would appear that distress. timing surgical treatment for hypospadias surgeons use an often spurious psychological from the surgeons and psychologists reason to support their personal prejudice. Given these hypotheses, it should be possible point of view. Acta Chirugica Plastica to consider carefully that which surgeons 1987; 29: 220–8 There appeared to be little support for the could be doing to facilitate improved 11 Freud S. A Case of Hysteria: Three Essays notion that all children had psychological psychosocial outcomes in both the short- and on Sexuality and Other Works. London: problems as a result of hypospadias and its long-term. It is not clear at what point or Hogarth Press, 1955 surgery. Of more concern, the views did not what type of psychological support would be 12 Purschke C, Standke M. Psychological

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characteristics of boys with hypospadias. 22 Mureau MAM, Slijper FME, Slob AK, penile hypospadias on sex behavior in the Paediatric Genzgeb 1993; 31: 175–85 Verhulst FC. Psychosocial functioning of fertile age. Zeitung Urologe Nephrologe 13 Mondaini N, Ponchietti R, Bonafe M children, adolescents and adults following 1989; 82: 121–5 et al. Hypospadias: incidence and effects hypospadias surgery; a comparative 33 Aho MO, Tammela OKT, Somppi EMJ, on psychosexual development as study. J Paediatric Psychol 1997; 22: 371– Tammela TLJ. A long term comparative evaluated with the Minnesota Multiphasic 87 follow up study of voiding, sexuality and Personality Inventory Test in a sample of 23 Woodhouse CRJ. Sexual function in boys satisfaction among men operated for 11,649 young Italian men. Urol Int 2002; born with exstrophy, myelomeningocoele hypospadias and phimosis during 68: 81–5 and micropenis. Urology 1998; 52: 3–11 childhood. Eur J Urol 2000; 37: 95–101 14 American Academy of Pediatrics. 24 O’Hara K, O’Hara J. The effect of male 34 Svensson J, Berg R, Berg G. Operated Timing of elective surgery on the genitalia circumcision on the sexual enjoyment of hypospadiacs; late follow up. Social, of male children with particular reference the female partner. BJU Int 1999; 83 sexual and psychological adaptation. to the risks, benefits and psychological (Suppl. 1): 79–84 J Pediatric Surg 1981; 16: 134–5 effects of surgery and anesthesia. 25 Lepore A, Kessler R. Behaviour of 35 Berg R, Berg G. Penile malformations, Pediatrics 1996; 97: 590–4 children undergoing hypospadias repair. gender identity and sexual orientation. 15 Al-Agha A, Thomsett M, Batch J. The J Urol 1979; 122: 68–70 Acta Psychiatrica Scand 1983; 68: 154– child of uncertain sex: 17 years of 26 Sandberg D, Meyer-Bahlburg H, 66 experience. J Paediatr Child Health 2001; Aranoff G, Sconzo J, Hensle T. Boys with 36 Sandberg DE, Meyer-Bahlburg HFL, 37: 348–51 hypospadias: a survey of behavioural Yager TJ, Hensle TW, Levitt S, Reda E. 16 Robertson M, Walker D. Psychological difficulties. J Paediatric Psychol 1989; 14: Gender development in boys born with factors in hypospadias repair. J Urol 1975; 491–514 hypospadias. Psychoneuroendocrinology 113: 698–700 27 Berg R, Berg G, Svensson J. Penile 1995; 20: 693–709 17 Fichtner J, Filipas D, Mottrie AM, Voges malformation and mental health. Acta 37 Morgan J, Mezey G. Surgery experienced GE, Hohenfellner R. Analysis of meatal Psychiatrica Scand 1982; 66: 398–416 as sexual abuse: a case of pre-pubescent location in 500 men: wide variation 28 Sandberg D, Meyer-Bahlburg H, Yager T sexual offending and hypospadias. questions the need for meatal et al. Psychosocial adaptation of middle Clin Child Psychol Psychiatry 1999; 4: advancement in all pediatric anterior childhood boys with hypospadias after 543–50 hypospadias cases. J Urol 1995; 154: genital surgery. J Paediatric Psychol 2001; 38 Fairburn C. The management of bulimia 833–4 26: 465–75 nervosa and other binge eating problems. 18 Backus L, Defilice C. Hypospadias then 29 Miller MAW, Grant DB. Severe Adv Psychiatric Treat 1997; 3: 2–8 and now. Plastic Reconstructive Surg hypospadias with genital ambiguity: adult 39 Veale D, Gournay K, Dryden W et al. 1960; 25: 146–68 outcome after staged hypospadias repair. Body dysmorphic disorder. A cognitive 19 Mureau MAM, Slijper FME, Nijman Br J Urol 1997; 80: 485–8 behavioural model and pilot randomised RJM, van der Meulen JC, Verhulst FC, 30 Berg G, Berg R. Castration complex, control trial. Behavioral Res Therapy 1995; Koos Slob A. Psychosexual adjustment of evidence from men operated for 34: 717–29 children and adolescents after different hypospadias. Acta Psychiatrica Scand 40 Wilson C, Christie D, Woodhouse CRJ. types of hypospadias repair: a norm 1983; 68: 143–53 The ambitions of adolescents born with related study. J Urol 1995; 154: 1902–7 31 Cracco A, Dettin C, Cordarro S, exstrophy – a structured survey. BJU Int 20 Bracka AA. A long term view of Angriman A, Donadio P, Belloli G. 2004; 94: 607–12 hypospadias. Br J Plastic Surg 1989; 42: Psychological study of adults surgically 251–5 treated in childhood for hypospadias. Correspondence: Christopher R.J. Woodhouse, 21 Tammela OKT, Tammela TLJ. Aspects of Pediatric Med Chirugie 1989; 11: 447– The Institute of Urology and Nephrology, adult satisfaction with the result of 50 University College London, 48, Riding House surgery for hypospadias performed in 32 Schubert J, Kelly LU, Trinckauf HH. The Street, London, W1P 7 PN, UK. childhood. Eur Urol 1997; 32: 218–22 effect of plastic corrective measures in e-mail: [email protected]

In a multi-institutional study Racial differences in serum authors from the USA and Austria attempt to determine if there are prostate-specific antigen (PSA) differences in several indices doubling time, histopathological between African-American and white men undergoing radical variables and long-term PSA prostatectomy. They did not find race to be an independent risk recurrence between African-American factor for PSA recurrence, but and white American men undergoing found that other variables commonly associated with PSA radical prostatectomy for clinically recurrence are also important in localized prostate cancer African-Americans. ASHUTOSH TEWARI, WOLFGANG HORNINGER*, KETAN K. BADANI, Using data extracted from the MAZEN HASAN, STEVEN COON, E. DAVID CRAWFORD†, EDUARD J. GAMITO†, JOHN WEI‡, DAVID TAUB‡, JAMES MONTIE‡, CHRIS PORTER¶, Hospital Episodes database, GEORGE W. DIVINE, GEORG BARTSCH* and MANI MENON authors from England describe Josephine Ford Cancer Center and Vattikuti Urology Institute, Henry Ford Health, System, Detroit, national trends in radical MI, †ANNs in CaP Project, Institute for Clinical Research, Washington, DC and University of nephrectomy between 1995 and Colorado Health Sciences Center, Denver, Colorado, ‡University of Michigan, Ann Arbor, MI, ¶Virginia Mason, Seattle, USA, and *Department of Urology, Medical University Innsbruck, 2002. They found a considerable Austria increase in the annual number of Accepted for publication 3 January 2005 radical nephrectomies, with an expected increase in the number of laparoscopic procedures. They also OBJECTIVE were available for the cohort. The chi-square found a decrease in emergency test of proportions and t-tests were used to To determine if there are significant assess basic associations with race, and log- admissions and length of hospital differences in biochemical characteristics, rank tests and Cox regression models for time stay. biopsy variables, histopathological data, and to PSA recurrence. Forward stepwise variable rates of prostate-specific antigen (PSA) selection was used to assess the effect on the recurrence between African-American (AA) risk of PSA recurrence for race, adjusted by and white American (WA) men undergoing the other variables added one at a time. radical prostatectomy (RP), as AA men are twice as likely to die from prostate cancer RESULTS than their white counterparts. The AA men had higher baseline PSA levels, PATIENTS AND METHODS more high-grade prostatic intraepithelial neoplasia (HGPIN) in the biopsy, and more We established a cohort of 1058 patients (402 HGPIN in the pathology specimen than WA AA, 646 WA) who had RP and were followed men. The AA men also had a shorter mean (SD) for PSA recurrence. Age, race, serum PSA, PSA doubling time before RP, at 4.2 (4.7) vs biopsy Gleason score, clinical stage, 5.2 (5.9) years. However, race was not an pathological stage, and PSA recurrence data independent predictor of PSA recurrence

TEWARI ET AL.

(P = 0.225). Important predictors for PSA addition, is there a role for competing causes FIG. 1. Recurrence-free survival estimates by race recurrence in a multivariable model were of death such as comorbidity and age? Finally, (all ages; red, WA; green, AA). biopsy HGPIN (P < 0.014), unilateral vs do poverty, socio-economic status and bilateral cancer (P < 0.006), pathology education have a role? [4]. 1.0 Gleason score and positive margin status 0.8 (both P < 0.001). Several authors [4–10] have examined an 0.6 important surrogate, PSA recurrence, as a CONCLUSIONS measure of prostate cancer-specific mortality. 0.4 These studies evaluated clinical and 0.2 This study indicates that while there are racial pathological variables before and after differences in baseline serum PSA and surgery, socio-economic factors, and delivery 0.0 0 24 48 72 96 120 144 168 incidence of HGPIN, race is not an of healthcare; the results are conflicting Months independent risk factor for PSA recurrence. [4–10]. Recently there has been interest in the Rather, other variables such as pathology PSA doubling time as a surrogate for the Gleason score, bilateral cancers, HGPIN and ultimate outcome of prostate cancer [11]. and radiation and oncology consultations. The margin positivity are independently Differences in PSA doubling times before and American Joint Commission on Cancer system associated with PSA recurrence. The PSA after treatment among races have been is used to determine the stage of disease by doubling time after recurrence may also be studied in a few series [5], but there is no evaluating tumour size, extent of invasion, important, leading to the increased mortality comprehensive report of this subject in AAs in microscopic involvement of lymph nodes and of AA men with prostate cancer. an equal-access setting. To address this issue, presence of metastases. HFHS Registry we evaluated differences in PSA doubling staff link this data with the Detroit area KEYWORDS times, histopathological variables, and the Surveillance, Epidemiology and End Results incidence of PSA recurrence between AA and Program records, and conduct an annual prostate cancer, African-American, PSA WA men with clinically localized prostate follow-up for vital status and recurrence; the doubling time, pathological stage, radical cancer. Accordingly, the analysis was limited annual follow-up is estimated at 94%. Thus prostatectomy, PSA recurrence to patients undergoing radical retropubic the tumour registry of the HFHS was searched prostatectomy (RP) to ensure the availability for all patients with an ICD-9 code of 185 of histopathological data from the excised (prostate cancer), who were treated by RP and INTRODUCTION surgical specimen. followed during the period 1 January 1990 to 31 December 2000; only men with localized The number of new cases of prostate cancer cancer (i.e. a negative bone scan) were was estimated at 513 000 worldwide and PATIENTS AND METHODS included in the study. 173 000 in the USA, accounting for 15.3% of all cancers in men in developed countries in This retrospective cohort study was aimed at Patients were excluded who were not AA or 2000 [1]. Within the next 15 years, prostate comparing pathological stage and PSA Caucasian, as were those who had incomplete cancer is predicted to be the most common recurrence in AA and WA men with prostate follow-up information. Patients who cancer in men [1]. The incidence of prostate cancer and who were treated with RP at a developed bone metastasis within a year of cancer varies widely among ethnic large healthcare system in the mid-West USA, diagnosis were also excluded, as we felt that populations, and the rate of this disease can the Henry Ford Health System (HFHS), a these men most likely had pre-existing differ by as much as 90 times among various vertically integrated healthcare system metastatic disease. Patients were also populations. Specifically, African-American incorporating the nation’s 10th largest health excluded if they received preoperative (AA) men in the USA have the highest maintenance organization. The population hormonal, radiation, cryotherapy, or received incidence of prostate cancer (137 per served by HFHS is large and racially diverse, immediate adjuvant hormonal or radiation 100 000 per year) [2]. with ª30% of the patients being AA. The therapy for extracapsular disease, including HFHS has a computerized medical seminal vesicle involvement. According to the 2000 USA Census, AAs information system and medical record comprise the second largest racial group in database. Comprehensive data are also The diagnosis of cancer was established by the USA; that AA men have a 2.5 times greater available from computerized health-claims histological examination of prostate biopsy mortality from prostate cancer than white databases. This study was part of an specimens by HFHS pathologists; tumour Americans (WA) has become a significant Institutional Review Board-approved project grade was reported as Gleason score 2–10, health concern in the USA [2]. This strikingly for evaluating the effect of various and the disease was staged using the 1992 higher mortality for AA men raises several demographic, clinical and histopathological TNM classification. questions. Is the difference in mortality a variables on prostate cancer recurrence. result of diagnosis at later, more advanced Relevant baseline variables were recorded, e.g. disease stages? Or is it because prostate HFHS maintains a computerized tumour race, age, clinical stage, serum PSA, biopsy cancer is more biologically aggressive in AA registry database accredited by the American Gleason score (minor and major), side(s) of men? [3]. It may also be possible that AA men College of Surgeons. Registry staff use a positive cores, perineural infiltration (PNI), are receiving different treatments for their thorough case-finding system, including a high-grade prostatic intraepithelial neoplasia prostate cancer than other populations [4]. In review of all pathology and cytology reports, (HGPIN), and prostatic inflammation.

RACIAL DIFFERENCES IN PSA DOUBLING TIME AND RECURRENCE

Pathological variables after RP were also TABLE 1 Baseline and histopathological characteristics between AA and WA recorded, e.g. specimen weight, pathological stage, PNI, HGPIN, prostatic inflammation, Variable WA AA P percentage tumour, margin status, seminal N 656 402 vesicle involvement, and lymph node spread. Before RP The baseline (preoperative) PSA doubling time Mean (SD): was calculated by a linear regression model age, years 63.0 (6.5) 62.8 (6.9) 0.499 using at least four PSA values. PSA, ng/mL 8.6 (10.3) 10.5 (12.6) <0.001 PSA doubling time, years 5.2 (5.9) 4.2 (4.7) 0.015 The primary endpoint of the analysis was the Clinical stage, n (%) difference in PSA recurrence and doubling T1a 1 (<1) 0 0.032 time. PSA recurrence was defined as two or T1b 5 (1) 3 (1) more consecutive samples with a PSA level of T1c 383 (70) 285 (78) >0.2 ng/mL. The PSA doubling time after T2a 128 (23) 54 (15) recurrence required at least three PSA values T2b 34 (6) 22 (6) during the follow-up [11]. The secondary T2c 0 1 (<1) endpoints were differences in pathological T3 0 1 (<1) variables, e.g. percentage cancer, HGPIN, PNI, Mean (SD) inflammation, margin status, seminal vesicle Primary Gleason grade 3.0 (0.6) 3.1 (0.6) 0.105 invasion and lymph node spread. Gleason score 6.2 (1.1) 6.3 (1.1) 0.168 Percentage cancer, n (%): A univariate analysis was used to compare the PNI 35 (6) 27 (7) 0.389 pathological variables at baseline and after RP HGPIN 53 (8) 50 (13) 0.025 between the racial groups. Comparisons of Inflammation 12 (2) 6 (2) 0.659 PSA recurrence were based on survival Mean (SD) analysis. The Cox proportional-hazards model Biopsy % cancer 13.8 (14.5) 15.0 (14.5) 0.278 was used for multivariate survival analysis, Positive cores which allowed an estimate of the PSA unilateral 370 (59) 246 (62%) 0.290 recurrence time, controlling for differences in bilateral 256 (41) 148 (38) follow-up time and risk factors that may Pathological variables, n (%) affect survival, including confounding Stage 0.050 variables and effect modifiers. All relative risks T2a 85 (13) 47 (12) were derived from the multivariate Cox T2b 370 (57) 228 (58) models. Adjusted survival curves were T2c 18 (3) 19 (5) generated using the empirical cumulative T3a 114 (17) 49 (12) hazard estimate of the survivor function. T3b 57 (9) 49 (12) Differences in the duration of survival were T3c 8 (1) 3 (1) calculated by measuring differences in the Mean (SD): adjusted survival curves at median survival. Specimen weight, g 47.4 (19.8) 51.1 (23.4) 0.010 All P values were two-sided. Primary Gleason grade 3.2 (0.9) 3.2 (0.6) 0.291 Gleason score 6.6 (1.1) 6.7 (1.2) 0.272 Percentage cancer 19.9 (15.7) 21.3 (16.4) 0.128 RESULTS N (%): PNI 110 (17) 73 (18) 0.549 The baseline characteristics of the cohort of HGPIN 113 (17) 94 (24) 0.013 1058 patients are summarized in Table 1. An Inflammation 18 (3) 11 (3) 0.999 important and surprising finding of the study Margin positive status 181 (28) 119 (30) 0.475 was that at baseline, AA men had a shorter Seminal vesicle invasion 57 (9) 49 (12) 0.065 PSA doubling time than WA men (Table 1). Lymph node spread 21 (3) 12 (3) 0.851 PSA recurrence 196 (30) 117 (29) 0.789 Table 1 also summarizes the study endpoints Mean (SD) between the cohorts; even though PSA PSA doubling time, years* 9.7 (13.5) 5.9 (8.1) 0.071 recurrence was no different between the Follow-up, months 75.8 (30.3) 73.6 (27.8) 0.296 racial groups, after PSA recurrence was diagnosed the PSA level increased at a faster *After recurrence. rate in AA men than WA men. This was not statistically significant because the doubling time was calculable only in a few patients who eventually had PSA recurrence. However,

TEWARI ET AL.

these data showed that there was >3 years TABLE 2 Univariate and multivariate modelling assessing the effect of the recorded variables on PSA difference in PSA doubling time between the recurrence racial groups. None of the other study endpoints, i.e. margin positivity, seminal Univariate Multivariate vesicle infiltration and lymph node spread, Variable HR (95% CI) P HR (95% CI) P were statistically different between the cohorts. Baseline AA 1.18 (0.93–1.48) 0.169 1.21 (0.89–1.64) 0.225 As shown in Table 2, AA origin was not an Age, decades 0.86 (0.72–1.03) 0.093 0.74 (0.58–0.95) 0.017 independent predictor of PSA recurrence in PSA 1.00 (0.99–1.00) 0.613 0.99 (0.98–1.01) 0.377 the univariate model. Other known variables, Log PSA 1.01 (0.90–1.12) 0.924 – e.g. clinical stage, Gleason score, percentage Clinical stage 0.71 (0.53–0.94) 0.018 0.52 (0.36–0.73) <0.001 cancer and pathological stage, were Gleason (biopsy) 1.43 (1.29–1.58) <0.001 1.11 (0.93–1.32) 0.254 significantly associated with PSA recurrence. Biopsy inflammation 1.15 (0.43–3.08) 0.788 0.66 (0.20–2.16) 0.493 Importantly, HGPIN and specimen weights Biopsy PNI 1.17 (0.78–1.77) 0.449 1.47 (0.87–2.48) 0.146 were also important predictors of recurrence. Biopsy HGPIN 1.80 (1.22–2.64) 0.003 1.81 (1.13–2.91) 0.014 HGPIN had a hazard ratio (HR) of 1.8, and Biopsy % cancer 1.02 (1.01–1.03) <0.001 – greater than margin positivity (1.76) and Uni- or bilateral +ve cores 0.84 (0.67–1.07) 0.157 0.63 (0.46–0.87) 0.006 Gleason score (1.46; Table 2). RP Specimen weight 0.99 (0.98–0.99) <0.001 0.99 (0.98–1.00) 0.059 In the Cox proportional-hazard model race Percent cancer 1.01 (1.00–1.02) <0.001 1.00 (0.99–1.02) 0.443 was not an independent predictor of PSA Primary Gleason grade 1.38 (1.29–1.47) <0.001 1.39 (1.21–1.59) <0.001 recurrence (Table 2, HR 1.21), but other Gleason score 1.46 (1.33–1.60) <0.001 1.34 (1.13–1.58) <0.001 variables, e.g. biopsy HGPIN, unilateral cancers N stage 1.39 (0.86–2.25) 0.174 1.35 (0.70–2.59) 0.366 in the biopsy, pathology Gleason score and Seminal vesicles 1.58 (1.18–2.12) 0.002 0.97 (0.60–1.57) 0.910 positive margin status, were independent Margin positive 1.76 (1.40–2.20) <0.001 1.75 (1.27–2.42) <0.001 predictors of PSA recurrence. Interestingly Pathological stage 1.49 (1.19–1.87) <0.001 0.89 (0.60–1.31) 0.548 there was a counterintuitive significant PNI 1.08 (0.81–1.43) 0.611 1.39 (0.90–2.14) 0.138 association between clinical stages T1 and T2 HGPIN 0.80 (0.59–1.09) 0.162 0.84 (0.52–1.36) 0.472 cancers, showing that T2 cancers had a lower Inflammation 0.65 (0.24–1.76) 0.401 0.79 (0.19–3.40) 0.756 HR for recurrence; we do not know the significance of this finding.

DISCUSSION independent risk factor for PSA recurrence. recurrence after RP was 18.9% per month for Rather, other variables, e.g. pathology Gleason AA men and 16.3% per month for WAs Overall mortality from prostate cancer is score, bilateral cancers, HGPIN and margin (P = 0.73). The present results may differ greater in AA than WA men; historically, this positivity, were independently associated with because the follow-up was longer has been attributed to a more advanced PSA recurrence. The present study is unique in (78 months) than that assessed by Banerjee et tumour stage in AA men at diagnosis. More that it includes a significant proportion of AA al., where the median follow-up was recently, increased awareness and the patients (38%) and has many additional 39 months. The brevity of the PSA doubling widespread use of PSA screening has variables that could affect PSA recurrence. time was also noted before RP in the present dramatically increased the detection of earlier Further, we also showed that while PSA series, but the significance of this finding is stage cancers. This has been associated with a recurrence rates are no different between AA unknown. Several studies reported that a clear improvement in mortality and survival and WA men, PSA levels double much faster in rapid PSA doubling time may be associated rates, especially in AA men, where there has the former than the latter. The biological with more aggressive disease [4–7,9,10,12]. been an improvement of 21% in organ- significance of a rapid PSA doubling time is We postulate that even though PSA confined disease. Some have argued that the currently unknown, but given the association recurrence rates are comparable, AA men who treatment outcome has been better in WA of a rapid PSA doubling with earlier develop PSA recurrence may have a more than AA men for localized prostate cancer, but development of metastasis [11,13], it can be accelerated course of disease. This hypothesis others have argued that there is no significant postulated that after PSA recurrence, AA men is currently being tested at our centre in racial difference in treatment outcome may have a more aggressive course of disease. patients for whom long-term survival data [4–7,9,10,12]. This finding is in contrast with results from a are available. detailed study by Banerjee et al. [5], who The present study indicates that there are reported that the mean average relative PSA Whether race is truly predictive of PSA racial differences in baseline serum PSA, PSA velocity for AA and WA men having disease recurrence after RP has been controversial. doubling times, clinical and pathological recurrence was 0.25 and 0.11 ng/mL per Earlier reports stated that race is an stages, and the incidence of HGPIN. However, month, respectively (P = 0.21). The rate of PSA independent predictor of outcome, while race alone did not appear to be an increase in patients who developed disease recently many authors reported that there is

RACIAL DIFFERENCES IN PSA DOUBLING TIME AND RECURRENCE

no racial disparity in progression-free survival recurrence. Early PSA testing and aggressive factor for prostate cancer recurrence among men with clinically localized prostate evaluation of abnormal PSA, and of HGPIN, following radical prostatectomy in an cancer. In an elegant study by Powell et al. could result in the diagnosis of early prostate equal access health care setting. J Urol [3,5,10,14–18] a subgroup of younger AA cancer and ultimately prolong survival. 1996; 155: 1667–73 patients (aged <65 years) were evaluated, and 10 Powell IJ, Banerjee M, Novallo M et al. they had a greater risk of recurrence. Using ACKNOWLEDGEMENTS Prostate cancer biochemical recurrence multivariate modelling, we re-examined this stage for stage is more frequent among issue in the present cohort, but there was no Funding: Institute for Clinical Research at African-American than white men with statistically significant racial difference in the Veterans Affairs Medical Center, locally advanced but not organ-confined younger AA patients. This discrepancy could Washington, DC. disease. Urology 2000; 55: 246–51 be attributed to an inherent difference in the 11 Newcombe H. PSA doubling times. study populations; in contrast to the series of CONFLICT OF INTEREST Lancet Oncol 2000; 1: 14–5 Powell et al., the present had < 1% clinical 12 Carroll P. Rising PSA after a radical stage T3 cancer. None declared. treatment. Eur Urol 2001; 40 (Suppl. 2): 9 13 Partin AW, Hanks GE, Klein EA et al. 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Prostate cancer and African- recurrence; we conclude that race is not 3 Powell IJ. Prostate cancer in the African American men. Oncology (Huntingt) 1997; independently associated with PSA recurrence American: is this a different disease? 11: 599–605 but must acknowledge that AA men have a Semin Urol Oncol 1998; 16: 221–6 16 Powell I. Keynote address: prostate shorter PSA doubling time, which may 4 Optenberg SA, Thompson IM, Friedrichs cancer among African-American men – translate into more aggressive disease. Our P et al. Race, treatment, and long-term from the bench to the community. J Natl centre is currently studying long-term data survival from prostate cancer in an equal- Med Assoc 1998; 90: S705 from these patients. access medical care delivery system. 17 Powell IJ, Banerjee M, Sakr W et al. JAMA 1995; 274: 1599–605 Should African-American men be tested Another strength of the present study 5 Banerjee M, Powell IJ, George J et al. for prostate carcinoma at an earlier age is that it includes several additional Prostate specific antigen progression than white men? Cancer 1999; 85: 472–7 histopathological variables which could affect after radical prostatectomy in African- 18 Powell IJ, Dey J, Dudley A et al. Disease- PSA recurrence. Specifically, we assessed American men versus white men. Cancer free survival difference between African differences in PNI, inflammation and 2002; 94: 2577–83 Americans and whites after radical percentage cancer in the biopsy. None of 6 Freedland SJ, Jalkut M, Dorey F et al. prostatectomy for local prostate cancer: a these variables was more prevalent in AA Race is not an independent predictor of multivariable analysis. Urology 2002; 59: patients, but the incidence of HGPIN was biochemical recurrence after radical 907–12 significantly greater in AA men and associated prostatectomy in an equal access medical with a greater incidence of PSA recurrence. An center. Urology 2000; 56: 87–91 Correspondence: Wolfgang Horninger, important limitation of the study is its 7 Grossfeld GD, Latini DM, Downs T et al. Department of Urology, Medical University retrospective design, but the large sample size Is ethnicity an independent predictor of Innsbruck, Anichstrasse 35, 6020 Innsbruck, and inclusion of several confounding prostate cancer recurrence after radical Austria. variables potentially offset this limitation. prostatectomy? J Urol 2002; 168: 2510–5 e-mail: [email protected] 8 Grossfeld GD, Latini DM, Lubeck DP In conclusion, AA race is not an independent et al. Predicting recurrence after radical Abbreviations: AA, African-American; WA, risk factor for PSA recurrence in patients prostatectomy for patients with high risk white American; RP, radical prostatectomy; undergoing RP, and AA men have no greater prostate cancer. J Urol 2003; 169: 157–63 HFHS, Henry Ford Health System; HGPIN, incidence of HGPIN, higher baseline PSA level, 9 Moul JW, Douglas TH, McCarthy WF high-grade prostatic intraepithelial neoplasia; or rapid PSA doubling before RP or after et al. Black race is an adverse prognostic PNI, perineural invasion; HR, hazard ratio.

Installation of telerobotic surgery and initial experience with telerobotic radical prostatectomy

ANTHONY J. COSTELLO, HODO HAXHIMOLLA, HELEN CROWE and JUSTIN S. PETERS Department of Urology, The Royal Melbourne Hospital, Division of Surgery, University of Melbourne and The Australian Institute for Robotic Surgery, Epworth Hospital, Melbourne, Australia Accepted for publication 10 March 2005

OBJECTIVE The TRP was performed robotically by the rates showed equivalent efficacy and safety surgeon at the remote console unit. to open and pure laparoscopic methods. To assess the ability of untrained laparoscopic Perioperative data and pathological results surgeons to learn and implement laparoscopic were recorded. The two surgeons spent CONCLUSION telerobotic radical prostatectomy (TRP) using 1 week in a skills laboratory using a porcine the daVinci Surgical System (Intuitive model of laparoscopic TRP, and then cadaveric TRP represents a novel computer-based Surgical, CA), and assess the education, safety robotic prostatectomy. The first six cases were surgical approach to prostate cancer, which and efficacy issues when instituting this mentored by an experienced telerobotic offers the benefits of minimally invasive system. surgeon. surgery without the extensive experience associated with the laparoscopic method. It remains to be seen whether the robotic PATIENTS AND METHODS RESULTS approach can deliver better outcomes in continence and potency over time. Between December 2003 and October 2004, The TRP was conducted by two surgeons with 122 consecutive TRPs were performed by two no previous laparoscopic experience. There KEYWORDS surgeons for clinically localized prostate were no conversions to open surgery. cancer. The individual robotic surgeon was Assessing the complications, postoperative telerobotic, radical prostatectomy, Da Vinci assisted at the bedside by another surgeon. continence, operating time and transfusion system, outcome

INTRODUCTION where the operating surgeon (master) directs early to determine whether improved surgical the robotic surgical arms (slave) via a dexterity and visualization will actually Telerobotic surgery allows a closed telerobotic videoscopic link. improve postoperative potency. This is a key laparoscopic abdominal approach, placing a area where technology may improve the computer between the patient and surgeon. The DaVinci system represents an important results [1]. The surgeon’s hand movements are digitized technological breakthrough. It has to improve dexterity. The system has the transformed conventional laparoscopic The need for transfusion is much reduced in added benefit of three-dimensional surgery from a two-dimensional counter- our TRP series compared to our open series. visualization compared to the conventional intuitive procedure to a fully intuitive natural Three patients in the first 100 required a blood laparoscopic approach. Pure laparoscopy is surgical procedure using excellent transfusion. Historically in our open RP series, counter-intuitive compared with telerobotic visualization. Previous laparoscopic surgery 60% of patients usually had an autologous radical prostatectomy (TRP), which is intuitive has some advantages over open approaches transfusion. There are reports worldwide with for the surgeon. for RP. These relate to reduced pain, early much lower open transfusion rates than ours discharge and early return to normal activity. [1]. However, in our hands one of the Robotic surgery is a beguiling surgical Laparoscopic TRP has the potential to improve remarkable advances of laparoscopic innovation and some of the enthusiasm patient outcomes compared with open RP. prostatectomy relates to haemostasis and during installation of robotic systems relates reduced blood loss. to maintenance or increasing surgical market Tangible benefits relate to improve share. The novelty of the technology means visualization via pneumoperitoneum, which To establish a functioning telerobotic surgical that it is at present unproven, with high also provides tamponade reducing the service, ideally it should be multidisciplinary. capital cost. intraoperative bleeding. The absence of an Significant training requirements were abdominal incision means less postoperative necessary before establishing the service for The DaVinci Surgical Robotic System (Intuitive pain, improved cosmesis and early discharge. operating room nurses and technicians, and Surgical, CA, USA) is a master-slave At present there is no evidence to suggest engineering staff responsible for maintaining telemanipulation system (Fig. 1). The master- that there is any improvement in the rates of the equipment. The operating room had to be slave system consists of a remote console return to urinary continence, and it is too reconfigured. Cardiovascular surgeons have

INITIAL EXPERIENCE WITH TELEROBOTIC RADICAL PROSTATECTOMY

FIG. 1. The components of the DaVinci System. activate electrocautery, for repositioning the master handles and for focusing. The surgeon views the surgical ﬁeld through the binocular display in the hood of the console. The robotic arms are deactivated when the surgeon’s eyes are removed from the display. The surgeon’s console and the robotic-arm cart are connected via a data cable. In the USA, Food and Drug Administration approval for this technology mandates that the operating surgeon is in the same room as the patient. However tele-surgery in which the patient and surgeon are remote is possible, and has been reported [4].

MASTER HANDLES

In addition to providing direction to the robotic arms, the master handles are also used to control other aspects of the video display system and robotic arms, such as endoscope selection and motion-scaling ratio. The master handles ﬁlter tremor in the surgeon’s FIG. 2. hands and arms (Fig. 2). The majority of tactile The Da Vinci Master Handle. feedback is provided indirectly by the video monitor, that is visually, and the tensile feedback through the robotic arms.

The robotic-arm cart is placed beside the patient on the operating table. It holds three, or more recently four, robotic arms on a central tower. One arm holds the videoscope and the others are used to attach instrument adapters which are connected to robotic instrumentation through reusable trocars. Stereoscopic vision is supplied by a 30∞ or 0∞ specialized three-dimensional endoscope, which provides the surgeon at the console with binocular vision in the operative ﬁeld.

The robotic surgical instruments have both an elbow joint and wrist, enabling seven degrees of freedom and two degrees of axial rotation, mimicking the natural motions of open surgery. This is in contrast also embraced the technology, mainly for the ELEMENTS OF THE DA VINCI to conventional laparoscopic surgery, where repair of mitral valves and atrial septal SURGICAL SYSTEM the surgeon’s hand movements are counter- defects. intuitive and in two dimensions. There is a The surgical console provides the computer range of different instruments available Surgeons who are skilled open surgeons can interface between surgeon and surgical which can be used up to 10 times, after which transfer their skills very easily to a telerobotic robotic arms. The surgeon controls the robotic the robotic system deactivates them and laparoscopic approach. There appears to be no arms through the use of master handles, prevents further use. requirement for previous general laparoscopic which are located in virtual three- skills [2]. Certainly a single-team approach dimensional space below the visual display. with two surgeons and consistent table-side The surgeon’s hand movements are digitized PATIENTS AND METHODS assistance, and trained operating room and transmitted to the robotic arms, which nursing staff, has made the institution of this perform in identical movements in the In all, 122 men (mean age 61.2 years, range programme much easier [3]. operative ﬁeld. Foot controls are used to 48–72) underwent TRP by two surgeons

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between December 2003 and December 2004. RESULTS TABLE 1 Clinical and pathological staging of the Information on continence after TRP was 122 men collected by questionnaires sent to all No patient required conversion to open patients, with a return stamped, self- surgery. The mean (range) preoperative PSA Positive margin* addressed envelope included. level was 8.4 (1.2–25) ng/mL, the prostatic Stage n (%) (% of T stage) volume 44.7 (20–106) mL and the body mass Clinical index 27.2 (20.2–38.1) kg/m2. The clinical and T1a 1 (1) 0 SURGICAL TECHNIQUE pathological T stage is shown in Table 1. The T1b 1 (1) 0 mean (range) stay after TRP was 2 (1–9) days, T1c 87 (73) 15 (17) The technique of TRP was adapted from that and the indwelling catheter time 8.4 (5– T2a 14 (12) 0 described by surgeons using a purely 33) days (median 7). The margin status is T2b 16 (13) 4 (25) laparoscopic approach [5,6]. A protocol of shown in Table 2; the overall positive margin T3a 1 (1) 1 surgical steps was used in all the present rate (tumour at the inked margin) was 16.3%, Pathological patients, and all were transperitoneal. The including six patients who had positive pT2a 11 (9) technique we adapted was originally seminal vesicle involvement. pT2b 22 (18) described as the Montsouris technique, pT2c 63 (53) modified at the University of California Irvine. Data were available on urinary continence in pT3a 19 (16) The same surgical steps are used in all cases: 93 patients at 3 months (Table 3); four pT3b 5 (4) (i) Establishing pneumoperitoneum via patients were incontinent before TRP and Hassan cannula (used in preference to Veress wore pads, thus they were excluded from the *tumour at inked margin. needle after the first 30 cases); (ii) placing the analysis of continence after TRP. Only one trocars; (iii) docking the robot; (iv) taking patient declined to complete the continence down the urachus and defining the space of questionnaire. At 3 months, 65 patients (73%) Retzius for dividing the superficial dorsal reported they were pad-free or wearing one veins of the penis; (v) incision of the lateral ‘security’ pad; by 6 months 82% of patients TABLE 2 Margin status pelvic fascia; (vi) dividing the puboprostatic were continent. ligaments; (vii) staple ligation of the dorsal Negative Positive venous complex; (viii) dividing the junction of Preliminary data were available for erectile Margins, n (%) 102 (84) 20 (16)* the bladder neck and prostate; (ix) dividing function but were too premature for a Capsule 94 (77) 28 (13) the fascial layer above the seminal vesicles, meaningful assessment of long-term erectile Seminal vesicle† 114 (93) 6 (7) with dissection of the vasa deferentia and dysfunction after TRP. It may take up to control of the blood vessels supplying these 2 years for the return of erectile function *three patients, two margins +ve; †two patients, structures; (x) dividing the anterior layer of after nerve-sparing robotic RP. Four patients no data. Denonvilliers’ fascia, exposing the anterior (3%) received blood transfusions; other wall of the rectum; (xi) dividing the prostatic complications are listed in Table 4. pedicles; (xii) dissecting bilaterally the neurovascular bundles; (xiii) dividing the TABLE 3 The frequency of incontinence during prostate and urethra at the apex; (xiv) DISCUSSION the follow-up, and pad use/24 h removing the prostate in an endoscopic bag. TRP was popularized and championed at the 3 months 6 months This technique has been used in all but one Vattikuti Urology Institute by Menon and n (%) (89 men) (49 men) patient at our centre; in the one case, the Tewari [7] and Tewari et al. [8]. The present Incontinent dissection had to be retrograde, from apex of report shows the replacement of an open Never 14 (16) 8 (16) the prostate to bladder neck, because of operation with TRP. Laparoscopic RP has an Almost never 17 (19) 16 (33) difficulty with rectal dissection. equivalent oncological outcome to reported Sometimes 43 (48) 21 (43) open series [9]. Weider and Soloway [10] Always 15 (18) 4 (8) The modifications to the technique in the reported overall positive margin rates of 28%; N pads/24 h present series relate to the use of a those for laparoscopic RP are reportedly 0 27 (30) 24 (49) suprapubic needle to the lasso in the Foley 19–23% [11,12]. 1 38 (43) 16 (33) catheter after dividing the bladder neck. The 2 2 (3) 4 (8) needle is passed through the eye of the The morbidity (safety) of this new procedure ≥3 14 (16) 4 (8) catheter with a one Nylon suture, which is would appear to be at least equivalent to the then brought out suprapubically to add experience in major centres with open surgery traction to the prostate anteriorly. Two other [11]. The rate of return to continence at surgical ports are placed, one in the left iliac 6 months was 82%, with patients using no or The true benefits of this procedure over open fossa and one below the left costal margin. one pad per day, which would appear to be RP clearly relate to reduced blood loss, These ports are used by the bedside surgeon acceptable. Further follow-up beyond a year absence of abdominal incision, early for instrumentation being suction, irrigation for both continence and erectile function is discharge and early return to normal activity. and surgical retraction. necessary and underway. Nerve sparing was attempted in almost all

INITIAL EXPERIENCE WITH TELEROBOTIC RADICAL PROSTATECTOMY

In urology TRP now seems to have an TABLE 4 Complications enduring position. Further applications in urology will relate to partial nephrectomy, Complication N cystoprostatectomy [15], pyeloplasty and Prolonged D/T leak 6 ureterolysis. Bladder neck stenosis requiring BNI 5 Clot retention requiring readmission 1 CONFLICT OF INTEREST Pneumaturia (settled with extended catheterization) 1 Anastomosis breakdown (settled with conservative management) 1 None declared. Rectal injury (over-sewn) 1 Acute urinary retention: REFERENCES on day of catheter removal 1 5 days after catheter removal (both passed repeat trial of voiding) 1 1 Herrell SD, Smith JA. Laparoscopic and Pelvic haematoma + recto-urethral fistula 1 robotic radical prostatectomy: what are Paralytic ileus (settled with conservative management) 1 the real advantages? BJU Int 2005; 95: 3– 4 2 Ahlering TE, Skarecky D, Lee D, patients (step xii). The vision system allows surgical tremor, which is compensated on the Clayman RV. Successful transfer of excellent visualization of the neurovascular end motion by computer filters. A further open surgical skills to a laparoscopic bundles. advantage to the surgeon is improved environment using a robotic interface: visualization via the three-dimensional Initial experience with laparoscopic Robotic technology has long been present in camera system, which has ¥10 magnification radical prostatectomy. J Urol 2003; 170: industry but only recently has it been an in a more appropriate comfortable ergonomic 1738–41 option for surgeons [13]. A cholecystectomy environment. The three-dimensional 3 Steers WD, LeBeau S, Cardella J, Fulmer was conducted between New York and Paris magnified view is a dramatic improvement B. Establishing a robotics program. Urol by telerobotic means [4]. The Zeus System has over conventional two-dimensional Clin 2004; 31: 773–80 been trialled for several years, as a voice- laparoscopic visualization. 4 Challacombe BJ, Kavoussi LR, Dasgupta activated surgical robot. We think that the P. Trans-oceanic telerobotic surgery. BJU introduction of telerobotic laparoscopic Pelvic open surgery for retropubic RP requires Int 2003; 92: 678–80 surgery is a watershed in surgical the surgeon and assistant to adopt sometimes 5 Guillonneau B, Vallancien G. development, and constitutes a major anatomically difficult positions, stressing the Laparoscopic radical prostatectomy: The technological advance in minimally invasive cervical and lumbar spines. Benefits are Montsouris technique. J Urol 2000; 163: surgery. Laparoscopy has confirmed benefits conferred to the operating surgeon as a result 1643–9 for reduction in length of stay, absence of of the ergonomic set-up of the surgeon 6 Guillonneau B, El-Fettouh H, Baumert incision and early return to normal activity, console. H et al. Laparoscopic radical reduced infection, improved cosmesis and prostatectomy: Oncological evaluation possibly less interference with the immune Retropubic RP is a difficult open surgical after 1,000 cases at Montsouris Institute. response. operation and lends itself to the telerobotic J Urol 2003; 169: 1261–6 laparoscopic approach, with improved 7 Menon M, Tewari A. Vattikuti Institute A major advance provided by ‘intuitive’ dexterity and visualization in an anatomically Prostatectomy Team. Robotic radical robotics vs laparoscopy is that the robotic confined area of subpubic access; it is prostatectomy and the Vattikuti Urology approach allows the surgeon’s natural hand- macrosurgery performed in a microsurgical Institute technique: an interim analysis of eye coordination and a natural enhanced fashion. results and technical points. Urology dexterity. This contrasts with the two- 2003; 61 (Suppl. 1): 15–20 dimensional counter-intuitive reverse-hand These advantages perhaps outweigh the 8 Tewari A, Srivasatava A, Menon M. movement of pure laparoscopy. Many clear problems of the shift to robotics. The A prospective comparison of radical surgeons have found the transition to high capital costs, lack of compatible retropubic and robot-assisted laparoscopy difficult. The new minimally instrumentation, large physical size of the prostatectomy: experience in one invasive surgeon with little or no laparoscopic robot and eventual obsolescence are institution. BJU Int 2003; 92: 205–10 experience can quickly adapt to the obviously concerns to be addressed over time. 9 Thomas K, Slabaugh JR, Marshall F. A laparoscopic approach to RP using robotics. If robotics are expected to be embraced comparison of minimally invasive open widely, exciting additional advances could and laparoscopic radical retropubic The ability to view the surgical field in three ensue. The overlay of MRI and CT images for prostatectomy. J Urol 2004; 172: dimensions using natural hand and arm surgical guidance, and the addition of haptic 2546–8 movements, and the use of filters for hand feedback, are potentially feasible. The 10 Wieder JA, Soloway MS. Incidence, and arm tremor, is significant. The addition of application of telerobotics across all surgical etiology, location, prevention and motion scaling, such that large movements disciplines is likely [14] and application of this treatment of positive surigical margins are reduced to fine movements, is an system is limited only by the surgeon’s after radical prostatectomy for prostate advantage. The robotic system removes imagination. cancer. J Urol 1998; 160: 299–315

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11 Stolzenburg JU, Do M, Rabenalt R et al. MD, Desai P, Meyers MD. Robotic institutional pilot study. Urology 2004; Endoscopic extraperitoneal radical surgery: a current perspective. Ann Surg 63: 51–5 prostatectomy: initial experience after 70 2004; 239: 14–21 procedures. J Urol 2003; 169: 2066–71 14 Darzi A, Mackay S. Recent advances in Correspondence: Anthony J. Costello, Director 12 Rassweiler J, Zeeman O, Schulze M, minimal access surgery. BMJ 2002; 324: of Urology, The Royal Melbourne Hospital, Tebr D, Hatzinger M, Frede T. 31–4 Grattan Street, Parkville, Victoria 3050, Laparoscopic versus open radical 15 Balaji KC, Yohannes P, McBridge CL, Australia. prostatectomy: a comparative study at a Oleynikov D, Hemstreet GP. Feasibility e-mail: [email protected] single institution. J Urol 2003; 169: 1689– of robot-assisted totally intracorporeal 93 laparoscopic ileal conduit urinary Abbreviations: (T)RP, (telerobotic) radical 13 Lanfranco AR, Castellanos AE, Jaydev diversion: Initial results of a single prostatectomy.

Robot-assisted vs pure laparoscopic radical prostatectomy: are there any differences?

JEAN V. JOSEPH*, IVELISSE VICENTE*, RALPH MADEB*, ERDAL ERTURK* and HITENDRA R.H. PATEL*,† *Section of Laparoscopic and Robotic Surgery, Department of Urology, University of Rochester Medical Center, Rochester, New York, USA, and †Institute of Urology, University College London, UK Accepted for publication 7 February 2005

OBJECTIVE collating intraoperative data and early CONCLUSIONS functional outcome. To compare our experience of pure Both LRP and RAP are technically demanding, laparoscopic radical prostatectomy (LRP) with RESULTS but feasible, with the patient clearly robot-assisted radical prostatectomy (RAP). benefiting. There were no major surgical The mean surgical time for LRP and RAP was differences between the techniques, but RAP PATIENTS AND METHODS 235 and 202 min (P > 0.05) and mean (95% is more costly. confidence interval) blood loss 299 (40) and The two techniques were compared 206 (63) mL (P = 0.014), with no transfusions retrospectively in 100 patients with localized in either group. The positive margin rate did KEYWORDS prostate cancer who had LRP or RAP (50 not differ significantly (14% LRP and 12% each). Both groups were similar in age, serum RAP) and there was no biochemical continence, erectile function, laparoscopy, prostate-specific antigen level, Gleason score recurrence in either group. Early functional outcomes, prostatectomy, prostate cancer, and clinical stage. Their charts were reviewed, outcomes were similar. robotics

INTRODUCTION PATIENTS AND METHODS and draping of the surgical field, a 16 F urethral catheter was inserted. Laparoscopic surgery for localized prostate We retrospectively assessed LRP and RAP in cancer is becoming standard in many the last 50 patients undergoing LRP and RAP A balloon dilator was then placed through a institutions. Recently, laparoscopic (total 78 and 200, respectively); the LRP series 2-cm para-umbilical incision, under visual technology (e.g. robots) and technique have was completed before the RAP series. control, which developed the extraperitoneal advanced, resulting in significant progress in Perioperative data with early oncological and space. Five ports (two robotic arms, one the development of minimally invasive basic functional results were recorded by robotic camera port, two assistant ports) were surgery (MIS) for prostate cancer. The chart review. The indications for surgery were required for the RAP and four ports for the combination of lower postoperative identical to those for open retropubic RP. LRP (two working ports, one camera, one morbidity, improved cosmesis, shorter Patients were counselled about all possible assistant). The endopelvic fascia was dissected convalescence and comparable oncological treatments for prostate cancer [5]. from the base to the apex of the prostate. The outcome has driven the demand for pure dorsal vein complex (DVC) was suture-ligated laparoscopic radical prostatectomy (LRP) Some patients had previous surgery (bilateral and the bladder neck dissected from the base compared to the open retropubic approach hernia mesh repair in two, appendicectomy of the prostate. The vas deferens and seminal [1,2]. Consequently, various centres now in two and previous laparotomy in one). vesicles were then dissected to the level of regularly use LRP routinely for prostate Two of these men required conversion to posterior Denonvilliers’ fascia. The vascular cancer. a transperitoneal approach (bilateral pedicles were bipolar cauterized, preserving hernia mesh repair), as the extraperitoneal the neurovascular bundles. The apical urethra At our institution we have found this space could not be opened sufficiently for and DVC were transected. Lymph nodes were procedure to be technically reproducible, surgery. sampled if the Gleason score was >7 and/or performing >70 LRPs. These skills were the PSA level >10 ng/mL, but in the 100 transferred to perform robotic-assisted All patients were positioned similarly; after patients reviewed this was not required prostatectomies (RAP), now used in the USA general anaesthesia was established, an (Table 1). The vesico-urethral anastomosis and Europe, with early results still being orogastric tube was placed. The supine was made using two continuous polyglactin reported [1,3,4]. The initial benefits are similar position was adopted, with Trendelenburg tilt sutures. The specimen was extracted through to LRP, except that it is more easily learned by (15–20∞ for RAP and 30–40∞ for LRP), and the the para-umbilical incision in an entrapment surgeons trained in open techniques. We legs abducted to allow access for the robot bag, and a drain placed at the anastomosis. assessed the operative, pathological and and/or to the perineum. The arms were tucked functional outcomes from our unique beside the body and thoracic ‘X’ straps placed After surgery all patients were mobilized experience of LRP and RAP. across the chest. After aseptic preparation within 4 h of surgery, and generally

JOSEPH ET AL.

discharged home within 23–48 h. The urethral TABLE 1 Patient demographics, data before, during and after RP, and recovery of urinary continence after catheter was routinely removed at 7 days catheter removal after surgery.

Variable LRP RAP P One team of genitourinary pathologists Mean (95% CI): analysed the pathological specimen, noting age, years 61.8 (1.6) 59.6 (1.6) 0.06 pathological stage, Gleason grade and PSA, ng/mL 6.0 (0.83) 7.3 (1.2) 0.06 surgical margin. All perioperative data, Gleason grade 6 (0.14) 6 (0.15) 0.13 including age, preoperative PSA, clinical stage, N with clinical stage Gleason grade, prostate weight, pathological T1c 34 43 – variables (pathological Gleason grade, stage, T2a 14 6 – margin status), blood loss, nerve-sparing and T2b 2 1 – operating room times (total time including Mean (95% CI): anaesthesia time, pre-docking/after total operating time 264 (38) 277 (14) NS undocking times, robot operating times) were surgical time, min 235 (12) 202 (38) NS recorded. blood loss, mL 299 (40) 206 (63) 0.014 prostate weight, g 51 (4.1) 53 (5.3) 0.29 Early functional outcomes were assessed N with pathological stage: during the follow-up, including erectile T2a 13 8 function (interview and the International T2b 27 36 Index of Erectile Function-5, IIEF5, T3a 7 6 questionnaire). Spontaneous erections were T3b 2 – documented at the consultations before PIN 1 – surgery; the quality of the erections was not Preservation of neurovascular bundles, n noted afterward, but IIEF-5 scores were unilateral 10 1 – recorded at 3 months. Continence was bilateral 24 46 – deﬁned as being totally dry and using no pads, Total 34 47 <0.001 either for wetness or security. The time to none 16 3 – total urinary continence was assessed by Urinary continence, n interview and examination (Valsalva Immediate 10 23 <0.001 manoeuvre and coughing with a full bladder). <1 month 12 13 NS Data are expressed as the mean (95% CI) and <2 months 14 4 <0.001 compared using the paired t-test, with <3 months 10 5 <0.001 P < 0.05 taken to indicate statistical Still using liner for security 4 5 NS signiﬁcance. Overall continence rate, % 92 90 NS

PIN, prostatic intraepithelial neoplasia. RESULTS

The demographics were similar in both groups (Table 1); the mean total operating-room time (including anaesthesia) and surgery time were was similar for both groups, at 14% (LRP) and immature. When interviewed, the LRP group similar (Table 1); the estimated blood loss 12% (RAP). There was no biochemical had 22% spontaneous erections, with 36% differed but there were no blood transfusions recurrence of prostate cancer in any of the requiring drug aid (sildenafil or tadalafil), with in either group. Nerve sparing was less in LRP 100 patients at a mean (range) of 5.3 a mean IIEF-5 score of 37 (15); when than RAP, but the mean specimen weights (2–9) months after surgery. interviewed, the RAP group reported were similar. spontaneous erections in 40%, with a further Continence was verified by the absence of 46% requiring drug aid, and an IIEF-5 score of There were four bladder neck contractures urinary leakage on Valsalva manoeuvre or 34 (11). (one after LRP and three after RAP) treated coughing after catheter removal, at intervals by urethral dilatation, and two urinary leaks (immediately, 4, 8, 12 and >12 weeks). At DISCUSSION (one in each group) treated by prolonged 3 months after catheter removal, 46 patients catheterization (10 days). There were no other (92%) in the LRP group and 45 (90%) in the LRP aims to combine the advantages of open minor or major complications up to 30 days RAP group were totally continent; the other retropubic RP with those of minimally after surgery. patients were still using an underwear liner invasive surgery, to allow better for security only (Table 1). intraoperative and functional outcomes. The The pathological staging was comparable in LRP and RAP groups were comparable for the two groups (Table 1), with a mean Gleason The assessment of erectile function after patient and cancer demographics, and grade of 6. The positive surgical margin rate surgery was inconclusive as the data are outcomes during and after surgery (Table 1).

ROBOT-ASSISTED VS PURE LAPAROSCOPIC RADICAL PROSTATECTOMY

Limitations of the present study are the of prostatectomy used an extraperitoneal allows patients to leave hospital within single-centre experience with relatively few approach with its obvious advantages [7], the 1–2 days, and to return to their initial routine patients and use of chart review, all increasing leaks were localized. The contractures are within a few weeks. Although this is difficult observer and comparison bias. Both groups difficult to explain, as there was good to measure from the present retrospective had a higher prevalence of clinical stage T1c mucoso-mucosal apposition at the time series, it is a reasonable assumption; we are tumours, probably a result of patient selection of suturing, because of the excellent planning long-term studies in this area. In over time. An important consideration was visualization afforded by MIS techniques. We contrast, open surgery, even in the best hands, that the LRP series preceded the RAP series, can only suggest that a combination of may have a similar outcome to MIS in terms and thus experience was gained in the overzealous diathermy at the bladder neck of hospital stay but the patients’ return to laparoscopic anatomy required for these with over-tight suturing may have caused the preoperative activity usually takes several operations. To avoid any comparison bias problem, although we have no direct evidence weeks, in our experience. The important caused by this factor (robotic set-up, team for this. message from this is that as the incisions and training, laparoscopic anatomy), we overall trauma of surgery decrease, return to compared the last 50 patients in each group, The pathological/oncological outcome is an preoperative activity should logically take less allowing a comparison after gaining the important measure of the effectiveness of a time [13]. experience, thereby minimizing the bias. modified technique compared with the Ultimately the goal was to show not only the standard. The present two groups had The overall cost affects two areas, i.e. the ease of conversion from LRP to RAP, but also comparable clinical staging, with most being hospital and society. The latter is not easily to compare the clinical outcomes, which biopsy-confirmed localized prostate cancer measurable, but the cost of losing days from should be similar with either technique. (T1c). The mean weights of the prostate work/life affects everyone. In the present specimens were similar, at 51–53 g, but this study we compared two minimally invasive The mean surgical times were no different includes glands of 23–105 g. The positive procedures, which both provide a good between the groups; this is interesting, as the surgical margins were similar in both groups, recovery after surgery. If cost is measured as suturing aspects of this form of surgery are and lower than other reported in initial series the clinical outcome alone, either technique is easier with the robotic arms in unskilled [4,8]. good, but financially RAP is a costly hands [6], but if already skilled in pure procedure. laparoscopy there should be no anticipated Functional outcome is also an important difference. The blood loss was less in the RAP benchmark for a newer procedure; the Laparoscopically experienced surgeons with group, with no blood transfusions in either present results are early, but the outcomes are assistants generally untrained in laparoscopy group. This difference was not expected and encouraging compared with open surgery. By undertook all the present surgery. The may primarily be a result of the magnified, 3 months, both groups had reached ª90% changes in the team added time and effort to three-dimensional imaging of the robot, total continence (Table 1); this high rate (with the operations but this depiction of reality is which allows the surgeon to perform more no use of pads) is promising. The mechanism important if these technologies are to be deliberate and accurate haemostatic for achieving this is probably a combination embraced. The laparoscopic skills allowed a manoeuvres. of preserving the length of the distal urethra smoother transition to RAP. Importantly, after and bladder neck urethra, and the our experience we suggest that surgeons The anatomical bilateral nerve-sparing neurovascular bundles and pubo-prostatic should train appropriately and not simply take dissection appeared to be easier during RAP ligaments [9,10]. Also, accurate bipolar a 1–2 day course before attempting this than LRP, with a 92% preservation rate cautery and controlled dissection below the demanding procedure. Indeed, the level of (Table 1). The comparable LRP group had a endopelvic fascia avoids nerve and muscle laparoscopic skills required to perform RAP 48% bilateral nerve-preservation rate. The damage, which may be important in has been underestimated [6], although there obvious bias is that patient selection may preserving the continence mechanism [11]. has been some attempt to address this [14], have improved, as suggested by the slightly by groups who have laparoscopic experience higher incidence of T3 prostate cancers in the Assessing early erectile function for available to them. If a surgeon wishes to use LRP group. The surgeon may also have been comparison with other series of RP is difficult, RAP, he or she should have appropriate more confident with the margins of surgery as the recovery of the neurovascular supply to laparoscopic experience available, or be a as experience increased and the optics the erectile tissue occurs 12–18 months after trained laparoscopist. The current improved, and thus the RAP group benefited surgery [12]. Interestingly, in the RAP group disadvantage is the enormous cost of the from the LRP experience. nearly half the patients reported spontaneous robot- assisted approach compared with pure erections, but the IIEF scores were not equally laparoscopy. There are usually complications during high; these data require further maturity surgery; the objective of any improvement in before any meaningful comments can be CONFLICT OF INTEREST a surgical procedure is that the morbidity made. is reduced and outcomes improved. There None declared. were some urinary leaks or bladder neck The present study highlights the feasibility of contractures in the present patients. The leaks successful RP by either technique. The REFERENCES may have occurred as a result of loose importance of this to the health-policy suturing, as our technique involves a makers and providers cannot be over- 1 Rassweiler J, Seemann O, Schulze M, continuous suture. However, as our technique emphasized. The use of MIS for the prostate Teber D, Hatzinger M, Frede T.

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Laparoscopic versus open radical radical prostatectomy. J Urol 2003; 170: Burnett AL. Patient-reported urinary prostatectomy: a comparative study at a 1738–41 continence and sexual function after single institution. J Urol 2003; 169: 1689– 7 Joseph JV, Patel HR. Re: Transperitoneal anatomic radical prostatectomy. Urology 93 or extraperitoneal approach for 2000; 55: 58–61 2 Guillonneau B, Vallancien G. laparoscopic radical prostatectomy: a 13 Herrell SD, Smith JA. Laparoscopic and Laparoscopic radical prostatectomy: the false debate over a real challenge. J Urol robotic radical prostatectomy: what are Montsouris experience. J Urol 2000; 163: 2004; 172: 1545 the real advantages? BJU Int 2004; 95: 3– 418 8 Salomon L, Levrel O, de la Taille A et al. 4 3 Wolfram M, Brautigam R, Engl T et al. Radical prostatectomy by the retropubic, 14 Menon M, Tewari A, Peabody J and Robotic-assisted laparoscopic radical perineal and laparoscopic approach: 12 The VIP Team. Vattikuti Institute prostatectomy: the Frankfurt technique. years of experience in one center. Eur Urol prostatectomy: technique. J Urol 2003; World J Urol 2003; 21: 128–32 2002; 42: 104–10 169: 2289–92 4 Menon M, Shrivastava A, Sarle R, 9 Eastham JA, Kattan MW, Rogers E et al. Hemal A, Tewari A. Vattikuti Institute Risk factors for urinary incontinence after Correspondence: Jean V. Joseph, Director, Prostatectomy. a single-team experience radical prostatectomy. J Urol 1996; 156: Section of Laparoscopic and Robotic Surgery, of 100 cases. J Endourol 2003; 17: 1707–13 Department of Urology, University of 785–90 10 Lowe BA. Preservation of the anterior Rochester Medical Center, 601 Elmwood 5 Patel HR, Mirsadraee S, Emberton M. A urethral ligamentous attachments in Avenue, Box 656, Rochester, New York patient’s dilemma: prostate cancer maintaining post-prostatectomy urinary 14642–8656, USA. treatment choices. J Urol 2003; 169: 828– continence: a comparative study. J Urol e-mail: [email protected] 33 1997; 158: 2137–41 6 Ahlering TE, Skarecky D, Lee D, 11 Stief CG. Apical dissection during radical Abbreviations: L(RP), laparoscopic (radical Clayman RV. Successful transfer of retropubic prostatectomy without prostatectomy); RAP, robot-assisted open surgical skills to a laparoscopic ligature. World J Urol 2003; 21: 139– prostatectomy; MSI, minimally invasive environment using a robotic interface: 43 surgery; DVC, dorsal vein complex; IIEF-5, initial experience with laparoscopic 12 Walsh PC, Marschke P, Ricker D, International Index of Erectile Function-5.

Radical prostatectomy versus high-dose rate brachytherapy for prostate cancer: effects on health-related quality of life

YOSHIMASA JO, HIRATSUKA JUNICHI*, FUJII TOMOHIRO, IMAJO YOSHINARI* and FUJISAWA MASATO Departments of Urology and *Radiation Oncology, Kawasaki Medical School, Kurashiki, Japan Accepted for publication 11 February 2005

OBJECTIVE specific QoL using the University of California (P = 0.009) and sexual bother (P = 0.013) even Los Angeles Prostate Cancer Index (UCLA-PCI). than 30 men treated with unilateral nerve- To examine the effects of different treatments sparing RP. on the health-related quality of life (HRQoL) RESULTS of men with localized prostate cancer. CONCLUSIONS Questionnaire responses were obtained from 151 of 182 patients; there was no significant In terms of HRQoL, RP and HDR-BT did not PATIENTS AND METHODS difference in SF-36 scale scores between men differ, but HDR-BT resulted in better urinary treated with RP or HDR-BT. In the UCLA-PCI, and sexual function than RP. When planning Between October 1997 and August 2002, 182 the HDR-BT group had better urinary function treatment, QoL concerns, including mental men diagnosed with prostate cancer (T1c to (P < 0.001) and sexual function scores (P = health issues associated with prostate cancer, T3bN0M0) had radical prostatectomy (RP, 89) 0.043). Men treated with RP had better bowel need to be addressed with the patients, as do or 192iridium high-dose rate brachytherapy bother scores (P = 0.027). In patients with the potential side-effects. (HDR-BT, 93) with external beam radiotherapy, ≥2 years of follow-up, urinary function and were followed for ≥6 months. A postal (P < 0.001) and sexual bother (P = 0.029) were KEYWORDS survey was sent in which HRQoL was assessed better for men treated with HDR-BT than for using the 36-item Short-Form Health Survey men treated with RP. Men treated with HDR- prostate cancer, quality of life, high-dose-rate (SF-36) QoL questionnaire, and disease- BT had significantly better urinary function brachytherapy, prostatectomy

INTRODUCTION Several tools have been developed for The primary objective of the present study evaluating QoL. The concept of health-related was to examine the effects of different The prognosis associated with localized QoL (HRQoL) is multidimensional and includes treatments on the HRQoL of men with prostate cancer is excellent, with a 5-year physical, psychosocial and emotional status, localized prostate cancer. We measured relative survival rate approaching 100% [1]. as well as patient autonomy, and is applicable HRQoL (using the SF-36) and disease- Quality of life (QoL) issues therefore are key to to various medical conditions. A generic specific QoL (using the UCLA-PCI) in deciding among treatment options which can measuring instrument, the 36-item Short- men treated with 192Ir high-dose rate impinge on everyday activities to differing Form Health Survey (SF-36), is used brachytherapy (HDR-BT), and in men extents. Several therapeutic options for extensively throughout the world [8,9]. This treated with RP. localized prostate cancer, including radical survey is considered to be valid and prostatectomy (RP), external beam comprehensive, without being time- radiotherapy (EBRT), and brachytherapy (BT), consuming, and is readily applicable to PATIENTS AND METHODS affect sexual, urinary, and bowel function assessing individual patients. In addition, deleteriously for many men. In general, men numerous international cross-cultural Between October 1997 and August 2002, 182 who undergo RP report more urinary adaptations of the original instrument, men diagnosed with prostate cancer (T1c to dysfunction (greater incontinence and greater as well as validation data for normal T3bN0M0) were treated with RP (89) or HDR- need to use absorptive pads) and more sexual subjects and patients with various chronic BT (93) with 36.8 Gy EBRT, and were followed dysfunction (reduced erectile capacity and conditions, are available [10]. The University for 6–64 months. A postal survey was sent to decreased sexual desire) than men treated of California Los Angeles Prostate Cancer the patients, including HRQoL assessment with EBRT [2–7]. Bowel dysfunction (urgency Index (UCLA-PCI) was the first, and is the using the SF-36, and a urinary and bowel and diarrhoea) and irritative urinary most often used, measure of disease- symptom assessment using the UCLA-PCI. We dysfunction are reported more often by men specific QoL available for evaluating obtained questionnaire responses from 151 of treated with EBRT and BT than by men who treatments for early-stage prostate 182 patients (83%), including 70 treated with undergo RP [4,6]. cancer [11]. RP and 81 treated with HDR-BT. Survey

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participation rates of RP and HDR-BT patients RP (70) HDR-BT (81) TABLE 1 were 78.7% and 87.1%, respectively. The Age, years Patients’ characteristics patients’ characteristics at presentation are mean (SD) 71.7 (6.3) 72.7 (6.4) summarized in Table 1. Clinical classification median (range) 72 (56–77) 74 (51–84) (HDR-BT) and pathological classification (RP) Median (range) follow-up, months 38 (6–64) 36 (6–64) were determined in accordance with the 1997 Prostate cancer stage, n unified TNM system. Neoadjuvant hormone T1c – 15 therapy was administered to 12 of the 70 RP T2a 14 27 patients (17%) and 34 of the 81 HDR-BT T2b 26 20 patients (42%). Unilateral nerve-sparing T3a 23 10 surgery (NSS) was used in 30 of the 70 RP T3b 7 9 patients (43%). Gleason sum, n 2–6 46 48 HDR-BT, using 192Ir followed by EBRT, 7 17 19 consisted of external irradiation (four-port) of 8–10 7 14 the prostate at 2.3 Gy ¥ 16 times (36.8 Gy) Initial PSA, ng/mL and HDR-BT using a microSelectron mean (SD) 13.2 (9.2) 21.1 (32.4) (Nucletron) at 6 Gy ¥ four times (24.0 Gy) median (range) 8.6 (4.3–54) 11.2 (1.1–248) within 30 h. Neoadjuvant hormone therapy, n 12 34 Unilateral NSS, n 30 – We used the Japanese version of the SF-36 (version 1.2); this contains 36 questions to assess eight aspects of HRQoL: physical functioning; role-physical functioning; bodily pain; general health; vitality; social TABLE 2 Comparison of patients in the present study with previously reported series functioning; role-emotional functioning; and mental health. Each question was given a [16] [17] [18] [19] Present study score from 0 to 100, and a mean score was Variable PLND, RT RT RT RT RP HDR-BT obtained for each, with higher scores N 46 159 189 101 70 81 indicative of a better outcome. We also used Follow-up, years 13.6 1 £6 >3 >3 >3 the Japanese version of the UCLA-PCI (version Age, years 80 68 74 71 72 4 1.2), a disease-specific instrument focusing SF-36 scores on health concerns of men treated for physical functioning 66.4 75 80 76 83 79 prostate cancer. The questions assess levels role-physical 47.1 72 71 71 68 69 of bowel, urinary, bladder and sexual bodily pain 72.4 80 82 74 80 76 functioning, and the degree to which such general health 65.2 62 70 61 54 56 symptoms were burdensome: urinary vitality 53.2 67 65 61 68 73 function; urinary bother; bowel function; social functioning 74.1 83 88 84 78 83 bowel bother; sexual function; and sexual role-emotional 66.7 83 85 79 71 73 bother. All scores in each section were given mental health 80.1 78 82 80 72 78 equal weight, being linearly transferred from UCLA-PCI scores a scale of 0–100, with higher scores urinary function 65.0 79 89 88 53 84 representing a better level of functioning and urinary bother 61.0 88 81 82 72 80 less burden. bowel function 72.6 80 – 90 85 81 bowel bother 64.8 78 – 82 91 84 All descriptive data are reported as the mean sexual function 15.4 – 40 24 9 14 (SD) with differences in mean values between sexual bother 42.2 – 51 60 55 67 RP and HDR-BT patients analysed by two- tailed, unpaired t-tests or the Mann–Whitney PLND, pelvic lymph node dissection; RT, radical radiotherapy. test, or by ANOVA as appropriate. Significance was defined at the 5% level.

RESULTS ≥2 years and <2 years of follow-up. When physical functioning (P = 0.007) and role- patients were divided according to age, those physical functioning (P = 0.031) scores than Data from the SF-36 are shown in Fig. 1a,b. aged ≥65 years (HDR-BT, 66; RP 56) showed men treated with HDR-BT (Fig. 1b). There were There was no apparent significant difference no significant difference in any SF-36 scale no patients with bilateral preservation of for any scale score between RP and HDR-BT, score. Men treated with RP including neurovascular bundles in the present and no significant difference in patients with unilateral NSS (30) had significantly higher study.

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HRQoL AFTER DIFFERENT TREATMENTS FOR PROSTATE CANCER

FIG. 1. Comparison of QoL scores; a, SF-36 among patients after RP (red bars) and HDR-BT (green bars); b, SF- men in the HDR-BT group. Men in the HDR-BT 36 among patients after RP and unilateral NSS, and HDR-BT. *P = 0.007, **P = 0.031. PF, physical functioning; group had significantly better scores for RP, role-physical functioning; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role- urinary function and sexual bother than men emotional functioning; MH, mental health; c, UCLA-PCI among RP patients and HDR-BT patients; *P < 0.001, treated with RP including unilateral NSS. **P = 0.043, ***P = 0.027; d, UCLA-PCI among patients with RP and unilateral NSS, and HDR-BT patients; There were no significant treatment-related *P < 0.001, **P = 0.032, ***P = 0.02; UF, urinary function; UB, urinary bother; BF, bowel function; BB, bowel differences for urinary bother, bowel function bother; SF, sexual function; SB, sexual bother. and sexual function between RP with unilateral NSS and HDR-BT (Fig. 1d). a The SF-36 and UCLA-PCI results showed no significant differences among HDR-BT 100 or RP patients between subgroups with neoadjuvant hormone therapy or not. There were no significant differences comparing 80 patients with the same clinical stage, with the same duration of follow-up. 60

40 DISCUSSION

20 The primary objective of the present study was to examine the effects of different 0 treatments on the HRQoL of men with PF RP BP GH VT SF RE MH localized prostate cancer, comparing disease- specific and general HRQoL outcomes b between RP and HDR-BT. The general HRQoL * ** (from the SF-36) showed no significant difference between RP and HDR-BT in overall outcome. Men treated with RP including unilateral NSS had significantly higher 100 physical functioning and role-physical functioning scores than men treated with HDR-BT, but no HRQoL data were obtained 80 before treatment.

60 As for disease-specific QoL (UCLA-PCI), HDR- BT was associated with better urinary and sexual function than RP. Men treated with 40 HDR-BT had significantly better scores for sexual bother than men treated with RP and unilateral NSS. There was no significant 20 difference in sexual function between RP with unilateral NSS and HDR-BT. The present 0 results show that HDR-BT has a better PF RP BP GH VT SF RE MH outcome for sexual life than RP with unilateral NSS.

Figure 1c,d present data from the UCLA-PCI; bother scores (P = 0.029). Among patients Brandeis et al. [12] compared men treated men in the HDR-BT group reported better with <2 years of follow-up, men treated with with BT (low-dose rate BT, both with and with urinary function (P <0.001) and sexual HDR-BT (30) had significantly higher scores no pretreatment EBRT) with men who had RP; function (P = 0.043) than men in the RP for urinary function (P < 0.001) and sexual the RP group reported greater urinary leakage group, whereas men in the RP group had function (P = 0.029) than men treated with than the BT group, but the BT group reported better bowel bother scores (P = 0.027). There RP (24). Men aged ≥65 years treated with more obstructive and irritative urinary were no significant treatment-related HDR-BT had significantly higher scores for symptoms (increasing frequency and urgency, differences for urinary bother, bowel function urinary function (P < 0.001) and sexual nocturia, and weak urine stream). Other and sexual bother. Among patients with function (P = 0.019) than men of similar age authors also concluded that BT has significant ≥2 years of follow-up (HDR-BT, 51; RP, 46) treated with RP. Men in the RP group, effects on the urinary tract. Arterbery et al. men treated with HDR-BT had significantly including unilateral NSS, had significantly [13] evaluated short-term complications of better urinary function (P < 0.001) and sexual high scores for bowel bother (P = 0.032) than low-dose rate BT, reporting nocturia,

JO ET AL.

frequency, dysuria and hesitancy lasting 12– FIG. 1. Continued 24 weeks. Kaye et al. [14] reported that half of c patients treated with low-dose rate BT had * irritative and/or obstructive urinary ** *** symptoms (acute urinary retention, 4%; some degree of incontinence, 13%; urethral stricture, 3%; signiﬁcant perineal pain, 18%). 100 Thus, while patients treated with either RP or BT had urinary tract symptoms, speciﬁc symptoms differed. By contrast, HDR-BT 80 showed an advantage for sexual function compared with RP. Desai et al. [15] reported 60 that after 125I-interstitial implantation of the prostate gland, IPSS and acute urinary side-effects peaked at 1 month and 40 gradually returned to baseline at 24 months. 20 When comparing the present HDR-BT data with the results from other reports of radical 0 EBRT (Table 2; [16–19]) there was no UF UB BF BB SF SB difference in SF-36 scores. The present UCLA- PCI data showed that HDR-BT had better d results for sexual bother, but Japanese * ** *** patients might be less concerned about sexual function before treatment. 100 In the present study, patients treated with HDR-BT received subsequent EBRT (36.8 Gy). In the future, treatment with HDR-BT 80 omitting EBRT in low-risk patients with low PSA levels, low-grade tumour histology and tumours of < T3 could result in much better 60 HRQoL. Better results would be expected for urinary and sexual function, and bowel function might not differ from that 40 after RP.

There are a few limitations of the present 20 study; no information was obtained on pretreatment function, so no firm conclusions can be drawn about treatment-related 0 changes. Future studies will need to be UF UB BF BB SF SB prospective, longitudinal and long-term. Assessing patients at baseline before treatment and following them over time will CONFLICT OF INTEREST Stoddard ML, Flanders SC, Carroll PR. provide important insights into treatment- Changes in health-related quality of life in related differences in QoL. None declared. the first year after treatment for prostate cancer: results from CaPSURE. Urology No significant differences were evident REFERENCES 1999; 53: 180–6 between RP and HDR-BT for general HRQoL. 4 Fowler FJ Jr, Barry MJ, Lu-Yao G, By contrast, patients treated with HDR-BT 1 Greenlee RT, Murray T, Bolden S, Wingo Wasson JH, Bin L. Outcomes of external- showed better urinary and sexual function PA. Cancer statistics, 2000. CA Cancer J beam radiation therapy for prostate than those treated with RP when disease- Clin 2000; 50: 7–33 cancer: a study of Medicare beneficiaries specific QoL was assessed. In planning 2 Litwin MS, Hays RD, Fink A et al. in three Surveillance, Epidemiology, and treatment, QoL concerns, including mental Quality-of-life outcomes in men treated End Results areas. J Clin Oncol 1996; 14: health issues associated with prostate cancer, for localized prostate cancer. JAMA 1995; 2258–65 need to be addressed with patients, as do the 273: 129–35 5 Lim AJ, Brandon AH, Fiedler J et al. potential side-effects. 3 Lubeck DP, Litwin MS, Henning JM, Quality of life: radical prostatectomy

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versus radiation therapy for prostate Leake B, Brook RH. The UCLA Prostate Koning HJ, Kirkels WJ, van der Maas PJ, cancer. J Urol 1995; 154: 1420–5 Cancer Index: development, reliability, and Schroder FH. Health-related quality-of- 6 Shrader-Bogen CL, Kjellberg JL, validity of a health-related quality of life life effects of radical prostatectomy and McPherson CP, Murray CL. Quality of measure. Med Care 1998; 36: 1002–12 primary radiotherapy for screen-detected life and treatment outcomes: prostate 12 Brandeis JM, Litwin MS, Burnison CM, or clinically diagnosed localized prostate carcinoma patients’ perspectives after Reiter RE. Quality of life outcomes after cancer. J Clin Oncol 2001; 19: 1619–28 prostatectomy or radiation therapy. brachytherapy for early stage prostate 18 Smith DS, Carvalhal GF, Schneider K, Cancer 1997; 79: 1977–86 cancer. J Urol 2000; 163: 851–7 Krygiel J, Yan Y, Catalona WJ. Quality- 7 Lilleby W, Fossa SD, Waehre HR, Olsen 13 Arterbery VE, Wallner K, Roy J, Fuks Z. of-life outcomes for men with prostate DR. Long-term morbidity and quality of Short-term morbidity from CT-planned carcinoma detected by screening. Cancer life in patients with localized prostate transperineal I-125 prostate implants. Int 2000; 88: 1454–63 cancer undergoing deﬁnitive radiotherapy J Radiat Oncol Biol Phys 1993; 25: 661–7 19 Livsey JE, Routledge J, Burns M et al. or radical prostatectomy. Int J Radiat 14 Kaye KW, Olson DJ, Payne JT. Detailed Scoring of treatment-related late effects Oncol Biol Phys 1999; 43: 735–43 preliminary analysis of 125iodine in prostate cancer. Radiother Oncol 2002; 8 Stansfeld SA, Roberts R, Foot SP. implantation for localized prostate cancer 65: 109–21 Assessing the validity of the SF-36 using percutaneous approach. J Urol General Health Survey. Qual Life Res 1997; 1995; 153: 1020–5 Correspondence: Yoshimasa Jo, Department 6: 217–24 15 Desai J, Stock RG, Stone NN, Iannuzzi of Urology, Kawasaki Medical School, 9 Ware J. SF-36 Health Survey: Manual and C, DeWyngaert JK. Acute urinary Kurashiki, Japan. Interpretation Guide. Boston: The Health morbidity following I-125 interstitial e-mail: [email protected] Institute, 1993 implantation of the prostate gland. 10 Fujisawa M, Isotani S, Gotoh H, Okada Radiat Oncol Investig 1998; 6: 135–41 Abbreviations: HR(QoL), health-related H, Arakawa S, Kamidono S. Health- 16 Johnstone PA, Gray C, Powell CR. (quality of life); RP, radical prostatectomy; BT, related quality of life with orthotopic Quality of life in T1–3N0 prostate cancer brachytherapy; HDR, high-dose rate; EBRT, neobladder versus ileal conduit according patient treated with radiation therapy external beam radiotherapy; 36-item, short- to the SF-36 survey. Urology 2000; 55: with minimum 10-year follow-up. Int J form health survey; UCLA-PCI, The University 862–5 Radiat Oncol Biol Phys 2000; 46: 833–8 of California Los Angeles Prostate Cancer 11 Litwin MS, Hays RD, Fink A, Ganz PA, 17 Madalinska JB, Essink-Bot ML, de Index; NSS, nerve-sparing surgery.

Does neoadjuvant hormone therapy for early prostate cancer affect cognition? Results from a pilot study

VALERIE A. JENKINS, DAVID J. BLOOMFIELD*, VALERIE M. SHILLING and TRUDI L. EDGINTON Cancer Research UK, Psychosocial Oncology Group, Brighton & Sussex Medical School, University of Sussex, and *Sussex Cancer Centre, Brighton & Sussex University Hospitals, Brighton, UK Accepted for publication 28 January 2005

OBJECTIVE but before radiotherapy, and 9 months later tasks of spatial memory and ability. At T3 (T3). Eighteen men with no prostate cancer there was significant cognitive decline in 11 To examine, in a prospective study, the (controls subjects) completed the cognitive (34%) patients and five (28%) control subjects influence that temporary reversible medical tests at the same times. In addition, (odds ratio 1.37, P = 0.631). castration for localized prostate cancer has on psychological functioning and quality of life cognition, by assessing whether temporary were assessed at the same times, together CONCLUSION 3–5 month treatment with a luteinizing- with serum free and bound testosterone, b- hormone releasing hormone (LHRH) agonist oestradiol and sex hormone-binding globulin This pilot study suggests that short-term before radical radiotherapy had a short- or levels. LHRH therapy for early-stage prostate cancer long-term affect on cognitive function. has modest short-term consequences on RESULTS men’s cognitive functioning; a larger PATIENTS, SUBJECTS AND METHODS prospective study is warranted. There was a significant cognitive decline (on Thirty-two patients with localized prostate at least one cognitive task) at T2 in 15 (47%) cancer had cognitive assessments at baseline patients vs three (17%) of controls (odds ratio KEYWORDS (T1) before the start of drug treatment, at 3 4.412, P = 0.033). Most patients (nine of 15) months (T2) or on completing drug treatment who had a change in performance declined on prostate cancer, LHRH therapy, cognition

INTRODUCTION The neuropsychological literature suggests which makes cognitive comparisons that testosterone is related positively to problematic. Over the last 30 years there have been cognitive functioning [8,9] and therefore the significant advances in the detection, impact of hormone therapy on prostate Conversely, in the American study [11] there prognosis and management of prostate cancer, which reduces the amount of were no differences in performance on cancer [1]. Prostate cancer is highly bioavailable testosterone, may be negative. cognitive tasks between a group of patients responsive to hormone therapy. Huggins and Three recent cognitive studies in Australia, who received 9 months of androgen Hodges [2] first described the effects of America and Finland involving men with suppression (flutamide or bicalutamide for castration on advanced metastatic prostate prostate cancer produced variable results 2 weeks followed by monthly injections of cancer in 1941, yet the indications and timing [10–12]. leuprolide for nine doses) and a healthy of hormone therapy are only recently being control group. In that study the participants clarified. In localized prostate cancer a short The Australian study (6-month data reported performed cognitive assessments at baseline, course of LHRH therapy before radical in 2002 [10,13]) involved 77 men with 9 and 12 months. However, when the radiotherapy reduces the planning target extraprostatic prostate cancer, randomized to patients’ performance was examined using a volume, improves the therapeutic ratio [3] receive leuprorelin, goserelin (both LHRH calculation of reliable change, almost half the and has benefits in some groups of patients analogues), cyproterone acetate (an group had a clinically significant decline for [4]. The guidelines from the National Institute antiandrogen) or close monitoring (no seven of eight tasks. Unfortunately the of Clinical Excellence [5] suggest that treatment). Memory and attention after authors did not report the extent of hormone therapy for early prostate cancer (in randomization to treatments were significant decline that also would have terms of medical castration) and potential assessed at baseline (77 men), 6 (65 men) occurred in some members of the control side-effects associated with this treatment and 12 months (62 men). Patients randomized group. should be discussed fully with patients. Some to the drug treatments had a significant of the side-effects are well recognized by the decline in performance for several tasks that In contrast to the results from both studies, medical profession, e.g. erectile dysfunction, required complex information processing, the Finnish study [12] reported improvements hot flushes and decreased quality of life (QoL) relative to a group of 15 healthy controls. in semantic memory and object recall in a [6,7], but an area that has come under recent However, as the authors noted, the control group of men receiving androgen deprivation scrutiny is whether these drugs have a group had a higher than average intelligence therapy. Cognitive function, QoL and mood detrimental affect on cognition. and education level than the patients, were assessed in 25 newly diagnosed patients

COGNITION AND NEOADJUVANT HORMONE THERAPY FOR EARLY PROSTATE CANCER

errors made is calculated and used to predict Patients Controls TABLE 1 the Full Scale Intelligence Quotient. N3218 The characteristics of the Mean (SD) [range] patient and control groups Verbal ability was assessed using a phonemic age, years 67.5 (4.7) [55–76] 65.4 (5.3) [57–75] verbal fluency task. Participants are given 60 s estimated FSIQ 109.3 (12.3) [82–126] 114.39 (7.8) [95–124] to generate as many exemplars as they can, n (%) beginning with a given letter, e.g. (F, A, S), With a partner 28 (88) 15 (83) FSIQ, Full Scale Intelligence avoiding proper nouns and additional verb Retired 21 (66) 10 (56) Quotient. derivatives. Alternate letter forms are used at different sample times. The total number of words generated for the three letters is treated with combined androgen therapy before radiotherapy, and 9 months later (T3). recorded. (flutamide and an unspecified LHRH In addition, psychological functioning and analogue) at baseline, 6 and 12 months. quality of life were measured at the same Verbal memory was assessed using the Rey Healthy controls (52) were also recruited and times, together with serum free and bound Auditory-Verbal Learning Test [15], which assessed on the same measures, although testosterone, b-oestradiol and sex hormone- consists of five presentations with recall of a they were only tested at baseline. Cognitive binding globulin (SHBG) levels. Cognitive 15-word list, one presentation of a second deficits in sustained attention, verbal and assessments were conducted at the 15-word list and a sixth recall trial, which visual motor performance were apparent in participants’ homes or in a quiet room in the altogether takes 10–15 min. Retention of the the patients at baseline (before treatment) unit at each sample time. All participants in list is also tested after a 30-min delay. compared with controls. The researchers the study gave fully informed written Alternate word lists are used at each sample reported cognitive improvements during consent. time to avoid practice effects. The scores androgen deprivation at 6 and 12 months in reported from this test are the ‘supraspan’ episodic and semantic memory, with no In all, 36 of 41 (88%) patients consented to (number of words recalled from the first cognitive impairment on any other measure the study and 32 were analysed (two protocol presentation of the list), and delayed recall or any decline in any of the QoL measures. The violation, two withdrew with no reason score (total words recalled after a 0.5 h delay). authors concluded that cognitive function is given). All were treated with 3 weeks of maintained in patients with prostate cancer cyproterone acetate (antiandrogen) to Visual memory was assessed using the when treated with combined androgen prevent tumour flare, followed by monthly Complex Figure Task, with two alternate forms therapy. However, with no similar testing injections of goserelin (LHRH analogue) for used at different sample times [16,17]. This protocol in the healthy controls the 3–5 months before a course of radical task requires participants to copy a complex interpretation of the results is limited and radiotherapy to the prostate alone. geometric figure and then reproduce the the impact of any practice effects cannot figure from memory in an immediate recall be adequately assessed or statistically The control group comprised 25 healthy men and after a 30-min delay. The figures are analysed. with no prostate cancer, recruited as control scored according to the correct reproduction subjects; one withdrew and six who had of different aspects of the figure; the highest In the present study we examined the effects outlying scores on intelligence tests (>2 SD possible score is 36. of temporary and reversible medical from the group mean estimated full-scale castration with an LHRH agonist before intelligence) were excluded from the analyses, Visual-spatial memory was assessed using a radical radiotherapy for localized prostate resulting in a control group of 18 men. The computerized mental rotation task [18]. cancer. This gave an opportunity to study the final group was similar in age (P = 0.16) and Participants are asked to judge whether pairs effects of cognition and QoL before, during intelligence (P = 0.118) to the patients of two-dimensional figures are mirror images and on recovery from testosterone (Table 1). or the same images when presented at suppression, and to assess any correlation selected angles of rotation. Reaction times with serum testosterone levels. The cognitive test battery assesses several (milliseconds) and the number of errors (%) broad areas of cognitive function. The tasks are recorded for each trial, to provide a are divided into auditory/verbal memory; measure of speed and accuracy. PATIENTS AND METHODS visual memory; working memory and attention; processing speed and vigilance, Working memory capacity reflects the ability Patients with localized prostate cancer whose and intelligence. All of the tests are fully to maintain substantial quantities of management would routinely (in local standardized and validated, and were taken information whilst sometimes performing practice) include neoadjuvant LHRH therapy from published test batteries with population manipulations of or calculations involving the were identified by the clinician (D.B.) in the norms. data being stored. It is assessed using two clinic and recruited to the study by the Wechsler Memory Scale III tasks, the digit- research psychologists. Participants Intelligence was estimated using the National span task and the spatial-span task [19]. In consented to cognitive, QoL and blood Adult Reading Test [14]. This task requires the first the participant is read an increasingly assessments at three times, i.e. at baseline (T1) participants to read aloud 50 irregular words long string of digits which they must repeat in before starting drug treatment, at 3 months that cannot be determined phonetically, e.g. the same order (condition a) and in reverse (T2) or on completing drug treatment but ‘deny’, ‘quadruped’, ‘capon’. The number of order (condition b). Performance scores are

JENKINS ET AL.

the total correct responses to both conditions. 120 FIG. 1. Finally, in the spatial-span task, the * The mean serum blood levels in experimenter, using a board containing 10 100 patients; the differences from T1 blue blocks arranged randomly, taps out a to T2 are signiﬁcant, *P <0.001. sequence. The participant must tap the 80 pattern back in the same order (condition a) and in reverse order (condition b). 60 * Performance scores are the total correct mmol/L responses to both conditions. 40

Processing speed was assessed with the KDCT 20 * Kendrick Assessment of Cognitive Ageing battery [20]; this task requires the participant 0 to copy 100 digits (0–9) arranged in a 10 ¥ 10 T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 b matrix as quickly as possible, with the time to Free Total SHBG testosterone testosterone oestradiol complete the task (seconds) used as the performance score. measure, was used to assess individual in all three analyses) and at 12 months The General Health Questionnaire (GHQ12) performance across sample times [23]. In testosterone levels remained significantly [21], a self-reported questionnaire designed neuropsychological testing, group lower than at baseline (P = 0.035 and 0.026, to detect nonpsychotic psychiatric disorder in comparisons can sometimes mask significant respectively). b-oestradiol levels returned to community and medical settings, was impairment in a subgroup of the population, baseline and SHBG levels did not change administered at the same sample times to all which can lead to the under- or significantly with treatment (Fig. 1). participants. In addition, patients completed overestimation of cognitive impairment. the Functional Assessment of Cancer Therapy Using the method proposed by Jacobson and For the cognitive test performance, repeated- – Prostate (FACT-P) instrument [22] relating Truax [24], an RCI was calculated for each measures ANOVA showed no difference to QoL. The FACT-P incorporates a cognitive measure using the baseline and between the groups on any task (Table 2). comprehensive measure of overall QoL follow-up data of the control subjects. The Table 3 shows the changes within each group comprising five subscales, physical (seven RCI was calculated as follows. The test-retest using the reliable-change analysis. There was items), social (seven items), emotional (six reliability coefficient (rxx) was computed for a decline (on at least one task) in 15 (47%) items), functional (seven items) well-being each measure. The SE of measurement (SEm) patients and three (17%) of controls (odds and additional concerns specific to men with was calculated as SD1(÷[1 – rxx]), where SD1 is ratio 4.412, P = 0.033, two-sided) at T2, but it prostate cancer (12 items). High scores equate the SD of the baseline score. The SE of the was not significant at T3, when 11 (34%) 2 with a good QoL and lower scores with a difference (SEdiff) was calculated as ÷ [2(SEm) ]. patients and five (28%) controls declined on poorer one. The Trial Outcome Index (TOI) is The SEdiff describes the spread of distribution at least one task (odds ratio 1.37, P = 0.631). the sum of physical and functional well-being of change scores that would be expected if no In contrast seven patients and six controls and additional concerns subscale scores, and change occurred. had a reliable improvement at T2, and at T3, a change of 5 points is considered clinically five and three, respectively. relevant. Both FACT-P and TOI are familiar and To establish a 90% CI for the RCI the SEdiff was validated endpoints frequently used in multiplied by ±1.64 SD [25]. These thresholds Broadly grouping the tasks into verbal, visual prostate cancer treatment trials to detect were corrected for practice effects [23], which spatial and processing speed categories meaningful differences among groups. The for each variable is the mean difference provides an indication of which aspect of total FACT-P scores were compared at the between the follow-up and baseline scores. cognition was most affected (Table 4). At both different times, together with prostate- Thus, for each variable a 90% CI was T2 and T3 many patients had reliably declined specific scores and TOI. A semistructured calculated as SEdiff ¥ (±1.64) + practice effect. on visual spatial tasks compared with the interview was also undertaken at the final For each participant, a difference score was control group. assessment to determine whether patients calculated representing the performance had noticed any changes in their memory and difference on each measure (T2 - T1). If this At T1, seven of 32 (22%) patients scored attention. score fell outside the RCI, a statistically above the threshold on the GHQ12 (>4 significant change in performance was denotes probable psychological morbidity). At Groups were compared for cognitive considered to have occurred. T2 this had decreased to five (16%) and by T3 performance at T1, T2 and T3 using one-way only two (6%) still had raised levels. In and repeated measures ANOVA, and chi- contrast, only one control had scores above squared tests as appropriate. Pearson’s the threshold at one sample (T2). A recent correlations were used to examine the RESULTS health study stated that 20% of the relationship between serum testosterone population will score above the threshold on levels, QoL and cognitive test scores. The There was a significant reduction in free and the GHQ12 [26]. There was no relationship reliable change index (RCI), with a correction total testosterone and b-oestradiol levels for between levels of anxiety above the threshold for observed practice effects on each the patients after LHRH treatment (P < 0.001 and the decline in cognitive task performance.

COGNITION AND NEOADJUVANT HORMONE THERAPY FOR EARLY PROSTATE CANCER

TABLE 2 The test scores for the patient and control group at each time

T1 T2 T3 Mean (SD) score Patient Control Patient Control Patient Control FAS total 45.0 (13.96) 42.2 (8.11) 44.1 (13.66) 44.1 (12.79) 46.7 (14.36) 47.2 (11.93) AVLT supraspan 10.4 (1.9) 10.2 (2.4) 10.5 (2.6) 10.7 (2.4) 11.0 (2.6) 11.5 (2.3) AVLT delayed score 7.16 (3.4) 7.5 (2.8) 7.5 (3.4) 8.0 (3.07) 8.5 (3.5) 8.33 (2.9) Digit span total 17.0 (4.28) 17.6 (3) 17.1 (4.89) 18.5 (4.14) 17.2 (4.62) 18.5 (3.73) Spatial span total 14.7 (2.56) 14.2 (2.77) 15.2 (2.68) 15.1 (2.59) 14.4 (2.64) 15.1 (3.42) Complex ﬁgure: immediate total 22.9 (7.8) 23.0 (6.6) 23.4 (6.14) 24.5 (5.15) 23.5 (7.62) 27.4 (7.22) delayed total 21.3 (7.5) 22.5 (6.6) 22.7 (7.15) 23.9 (5.41) 23.7 (7.58) 26.6 (7.22) Processing speed total 71.5 (11.8) 67.8 (14.26) 72.9 (17.7) 66.4 (13.9) 73.6 (13) 67.4 (13.3) Mental rotation speed, s 39.6 (17.63) 40.1 (24.82) 31.4 (14.23) 29.8 (17.85) 31.4 (14.23) 29.8 (17.85) Mental rotation accuracy, % 89.9 (8.13) 89.1 (10.24) 91.3 (6.64) 91.4 (7.96) 91.3 (6.64) 91.4 (7.97)

FAS, phonemic verbal ﬂuency task; AVLT, Auditory-Verbal Learning Test.

compared with baseline. These scores indicate TABLE 3 The number of participants who either significantly declined, significantly improved, both that intense combined therapy for early-stage improved and declined (mixture) on one or more cognitive task, or showed no changes in performance prostate cancer affects a patient’s QoL, but after RCI analyses it recovers in over half the patients by 12 months. Reliable change Significant decline Significant improvement Mixture No change T1/T2 changes Neither QoL, level of anxiety nor decline in Patients 15 7 6 4 performance on the cognitive tasks correlated Controls 3 6 5 4 with a decline in free and total testosterone T2/T3 changes levels. All men had a significant reduction in Patients 11 5 12 4 serum testosterone after LHRH therapy but Controls 5 3 5 5 not all had a significant decline in QoL.

In the semistructured interviews, at T3 eight (25%) patients considered that their memory had become worse during the treatment, and TABLE 4 Participants who showed a reliable decline on specific areas of cognition five of them had reliably declined on at least one cognitive task. T2 T3 Area Patients Controls Patients Controls Verbal (FAS, AVLT) 9 6 4 3 Visual-spatial 13 4 13 5 DISCUSSION (Mental rotation, complex figure) Working memory 4 3 7 2 Despite the lack of an overall group effect of (Digit span, spatial span) the treatment, the significant change, as Processing speed (KCDT) 3 0 3 0 measured by the RCI method, clearly shows that LHRH therapy affects cognitive FAS, phonemic verbal fluency task; AVLT, Auditory-Verbal Learning Test; KCDT, Kendrick Assessment of functioning for some men. The pattern of Cognitive Ageing. deficit was more noticeable for tasks measuring spatial ability and spatial memory. There is some evidence to suggest a beneficial relationship between higher testosterone The overall score on the FACT-P showed a 35.8, P = 0.034), which also recovered by T3 levels and spatial ability in older men [27], but trend towards a significant decrease in QoL (36.7), as did the TOI, with values at T1–3 of others investigating cognition and treatments from T1 to T2 (mean 127.9 to 123.1, P = 0.051) 85.5, 81,0 and 84.1, P = 0.024 and 0.121). for prostate cancer do not support this followed by a recovery to baseline levels at T3 Seventeen (53%) men had a clinically reliable finding. In the present pilot study there was (127.7). The prostate-specific symptom scale decline in QoL after LHRH therapy at T2 and no clear correlation between a decrease in showed a clear decline at T2 from T1 (38.3 to T3, and 11 (34%) still had a clinical decline bioavailable testosterone and performance

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on cognitive tasks, probably because there Although a consensus is difficult to determine castration on advanced carcinoma of the was insufficient power in this exploratory in such a new area, it is clear that testosterone prostate gland. Arch Surg 1941; 43: 1941 study. has some role in mediating cognitive ability, 3 Zelefsky MJ, Leibel SA, Burman CM and therefore is of potentially great relevance et al. Neoadjuvant hormonal therapy While Cherrier et al. [11] reported a decline in when considering the possible side-effects of improves the therapeutic ratio in patients spatial ability in their group of patients, others hormonal treatment for prostate cancer, with bulky prostatic cancer treated with reported either a decline across a range of particularly if it is prescribed long-term. three-dimensional conformal radiation tasks associated with complex information- therapy. Int J Radiat Oncol Biol Phys 1994; giving [10], or an improvement in semantic We acknowledge that there were too few 29: 755–61 and spatial memory [12]. The lack of participants and the differences detected are 4 Pilepich MV, Winter K, John MJ et al. consensus is probably caused by differences subtle, but pooled with results from newly Phase III radiation therapy oncology in the methods used in these studies and the emerging studies, we suggest that a larger group (RTOG) trial 86–10 of androgen interpretation of the data. prospective study is warranted. deprivation adjuvant to definitive radiotherapy in locally advanced One confounding variable when trying to There is a good evidence-base for much of the carcinoma of the prostate. Int J Radiat identify a common theme in previous reports current use of hormone therapy in prostate Oncol Biol Phys 2001; 50: 1243–52 is that a wide variety of neuropsychological cancer, but there seems to be increasing use 5 NICE. Improving Outcomes in Urological tasks was used, purporting to measure spatial of LHRH therapy in early disease with Cancers: The Manual. London: National and verbal ability. Some studies did not use uncertain indications [28] and anecdotal Institute for Clinical Excellence; 2002 adequate tests to measure visual-spatial impression of the extensive early use of 6 Carmack Taylor CL, Smith MA, de Moor functioning, which traditionally is thought to hormones for asymptomatic PSA failure of C et al. Quality of life intervention for be most susceptible to fluctuations in radical treatments, which is understandable prostate cancer patients: design and testosterone levels. Other studies used many given the significance of the PSA result to baseline characteristics of the active for different tests to assess the same general patients [29]. However, it is therefore very life after cancer trial. Control Clin Trials areas of cognitive function, yet the tasks important that both clinicians and patients 2004; 25: 265–85 involved may not be assessing exactly the are made aware of any potentially harmful 7 Potosky AL, Reeve BB, Clegg LX et al. same construct, e.g. whilst a city-map task side-effects, to be balanced against benefit, Quality of life following localized prostate and a block-design task can both be before determining treatment route. cancer treated initially with androgen considered measures of spatial or visual- deprivation therapy or no therapy. J Natl spatial ability, the measures themselves have Cancer Inst 2002; 94: 430–7 different intrinsic qualities. Block design can ACKNOWLEDGEMENTS 8 Cherrier MM, Asthana S, Plymate S be classified as a relatively pure measure of et al. Testosterone supplementation visuo-spatial organizational ability where the The authors thank all the patients, volunteers improves spatial and verbal memory in subject has to construct a three-dimensional and staff who participated in the study and healthy older men. Neurology 2001; 57: object from a picture. In contrast, a city-map the BUPA Foundation for the funding. We also 80–8 task requires the subject to memorize a route thank Joseph Buckman and Jan Tuson for data 9 Halpern DF, Tan U. Stereotypes and marked in a city map for 2 min and later to collection and Dr Iverson for blood analysis steroids: using a psychobiosocial model to draw the learned route on an unmarked map. and advice. The BUPA Foundation sponsored understand cognitive sex differences. Therefore studies using one task may find a Dr Trudi Edginton; Cancer Research UK funds Brain Cogn 2001; 45: 392–414 relationship between visuo-spatial memory Drs Jenkins and Shilling. This is an original 10 Green HJ, Pakenham KI, Headley BC and testosterone levels, whereas no such piece of research that has not been published et al. Quality of life compared during relationship is found using the other task. This elsewhere, apart from an abstract in the pharmacological treatments and clinical leads to the disparity of findings and proceedings from the ASCO conference New monitoring for non-localized prostate confusion surrounding the role of Orleans June 2004 cancer: a randomized controlled trial. BJU testosterone in mediating cognitive function. Int 2004; 93: 975–9 11 Cherrier MM, Rose AL, Higano C. The In addition to the types of tasks used, age and CONFLICT OF INTEREST effects of combined androgen blockade intelligence are factors known to influence on cognitive function during the first cognitive test performance. As individuals None declared. Source of funding: The BUPA cycle of intermittent androgen age, performance on some tasks has a Foundation. suppression in patients with prostate tendency to decline and therefore the older cancer. J Urol 2003; 170: 1808–11 patient may have reduced performance from 12 Salminen E, Portin R, Korpela J et al. the outset. The same argument applies to REFERENCES Androgen deprivation and cognition in those who have below-average intelligence. prostate cancer. Br J Cancer 2003; 89: In this pilot study, age and intelligence 1 Denmeade SR, Isaacs JT. Development of 971–6 quotient were not perfectly matched between prostate cancer treatment: the good 13 Green HJ, Pakenham KI, Headley BC groups, which is one possible confounding news. Prostate 2004; 58: 211–24 et al. Altered cognitive function in men factor, together with the small sample size, 2 Huggins C, Stevens RE, Hodges CV. treated for prostate cancer with that needs to be addressed in future work. Studies on prostate cancer II. 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analogues and cyproterone acetate: a 22 Esper P, Hampton JN, Smith DC, Pienta free testosterone concentration predicts randomized controlled trial. BJU Int 2002; KJ. Quality-of-life evaluation in patients memory performance and cognitive 90: 427–32 receiving treatment for advanced prostate status in elderly men. J Clin Endocrinol 14 Nelson H. National Adult Reading Test cancer. Oncol Nurs Forum 1999; 26: 107– Metab 2002; 87: 5001–7 (NART) Manual. Windsor: NFER-Nelson, 12 28 Cooperberg MR, Small EJ, D’Amico A, 1991 23 Sawrie SM, Chelune GJ, Naugle RI, Carroll PR. The evolving role of androgen 15 Rey A. L’Examen Clinique En Psychologie. Luders HO. Empirical methods for deprivation therapy in the management Paris: Presses Universitaires de France; assessing meaningful neuropsychological of prostate cancer. Minerva Urol Nefrol 1964 change following epilepsy surgery. 2003; 55: 219–38 16 Rey A. Psychological examination of J Int Neuropsychol Soc 1996; 2: 556– 29 Lofters A, Juffs HG, Pond GR, Tannock traumatic encephalopathy. Arch 64 IF. ‘PSA-itis’. knowledge of serum prostate Psychologie 1941; 28: 286–340 24 Jacobson NS, Truax P. Clinical specific antigen and other causes of 17 Taylor L. Psychological assessment of significance: a statistical approach to anxiety in men with metastatic prostate neurosurgical patients. In Munil Lezak ed. defining meaningful change in cancer. J Urol 2002; 168: 2516–20 Neuropsychological Assessment. Oxford: psychotherapy research. J Consult Clin Oxford University Press, 1995: 476–575 Psychol 1991; 59: 12–9 Correspondence: Valerie Jenkins, Cancer 18 Vandenberg SG, Kuse AR. Mental 25 Kneebone AC, Andrew MJ, Baker RA, Research UK, Psychosocial Oncology Group, rotations, a group test of three- Knight JL. Neuropsychologic changes Brighton & Sussex Medical School, University dimensional spatial visualization. Percept after coronary artery bypass grafting. use of Sussex, Falmer, Brighton BN1 9QG, UK. Mot Skills 1978; 47: 599–604 of reliable change indices. Ann Thorac e-mail: [email protected] 19 Weschler D. The Weschler Memory Scale- Surg 1998; 65: 1320–5 Revised. San Antonia, TX: The 26 Pevalin DJ. Multiple applications of the Abbreviations: QoL, quality of life; SHBG, sex Psychological Corporation, 1998 GHQ-12 in a general population sample: hormone-binding globulin; GHQ12, General 20 Kendrick D, Watts G. The Kendrick an investigation of long-term retest Health Questionnaire; FACT-P, Functional Assessment Scales of Cognitive Ageing. effects. Soc Psychiatry Psychiatr Assessment of Cancer Therapy – Prostate; TOI, Windsor, UK: NFER Nelson, 1999 Epidemiol 2000; 35: 508–12 Trial Outcome Index; RCI, reliable change 21 Goldberg D, Williams P. A User’s Guide 27 Moffat SD, Zonderman AB, Metter EJ, index. to the General Health Questionnaire. Blackman MR, Harman SM, Resnick Windsor: NFER-Nelson, 1988 SM. Longitudinal assessment of serum

Surgical treatment of stage pT3b renal cell carcinoma in solitary kidneys: a case series

SHOMIK SENGUPTA, HORST ZINCKE, BRADLEY C. LEIBOVICH and MICHAEL L. BLUTE Urology Department, Mayo Clinic, Rochester, MN, USA Accepted for publication 3 February 2005

OBJECTIVE RESULTS CONCLUSIONS

To describe the surgical management of NSS was successful in seven patients (four in NSS combined with venous tumour patients with renal cell carcinoma (RCC) in a situ and three extracorporeally). Five patients thrombectomy for treating T3b RCC involving solitary kidney (managed preferentially by had radical nephrectomy (RN), four after a solitary kidney is feasible, albeit nephron-sparing surgery, NSS, to avoid failed NSS. The mean (SEM) operative duration complicated. There was oncological success in dialysis) and extending into the renal vein or was longer for NSS, at 5.8 (0.7) h, than RN, at a third of the patients. The treatment of these inferior vena cava (T3b). 3.3 (0.6) h. There was one death during patients needs to be individualized, as surgery before nephrectomy, and eight other alternatives to NSS (RN or observation) have complications in six patients. At a median obvious disadvantages. PATIENTS AND METHODS (range) follow-up of 24 (0–204) months, eight patients had died, four from RCC (all We identified 13 patients treated surgically having had NSS) at a median interval of between 1977 and 2002 for stage T3b RCC in 9.5 (7–16) months. Of the five patients alive KEYWORDS a solitary kidney; their charts were reviewed at a median follow-up of 25 months, four had to ascertain details of management, no identifiable disease, whilst one had carcinoma, renal cell, nephrectomy, vena pathology and outcomes. systemic recurrence. cava, inferior, surgery

INTRODUCTION Clinic Nephrectomy Registry (Table 1). Charts be converted to RN, because of intraoperative were reviewed to ascertain patient bleeding and extensive hilar tumour, RCC has a particular propensity to involve the demographics, surgical details, early and late respectively, and one patient died during renal vein or inferior vena cava, when it is complications, renal function, tumour surgery before nephrectomy. In five cases then classified as TNM stage T3b. The surgical pathology and oncological outcomes. The removal of the kidney, extracorporeal cooling management of stage T3b RCC, while follow-up was not standardized, with some and bench surgery was undertaken in demanding, is well established, and usually patients seen at the clinic and others followed preparation for auto-transplantation [4,9]. entails radical nephrectomy (RN) with by their local physicians. The duration of This was successful in three patients, but appropriate manoeuvres to resect the venous follow-up was to the latest information auto-transplantation was precluded in the tumour thrombus [1–3]. The management of available on file or until the date of death. The other two by insufficient size of the renal stage T3b RCC in a solitary kidney is difficult, cause of death was identified from death remnant and tumour invasion of the venous as this mandates nephron-sparing surgery certificates. Data are expressed as the mean wall, respectively. Thus five patients had the (NSS) [4–6], to leave the patient with (SEM) or median (range), as appropriate, and entire kidney extirpated, either planned or for sufficient functioning renal tissue to avoid groups were compared using the t-test, a failed NSS. dialysis. NSS in conjunction with venous with statistical significance deemed at tumour thrombectomy poses a surgical P < 0.05. The tumour thrombus involved the renal vein challenge, and there are few reports of such in 11 patients and with the infra-hepatic cases [7,8]. Thus our aim is to report the Two women and 11 men (median age 61 years, inferior vena cava in two. In most cases, after surgical management at the Mayo Clinic of range 35–74) were treated, with seven appropriate clamping for in situ procedures, a stage T3b RCCs arising in patients with tumours involving the right kidney and six the venotomy was made and tumour thrombus solitary kidneys. left. The kidney was operated through a flank removed with the concomitant parenchymal incision in two patients, and through an segment [1]. In one patient the tumour anterior transperitoneal approach in the other containing renal vein was sacrificed, as PATIENTS AND METHODS 11, using a subcostal incision in eight and a preoperative imaging had shown a large chevron incision in three. NSS was planned in collateral vein draining the rest of the With Institutional Review Board approval, 12 cases and successfully completed in seven. kidney (Fig. 1). Where required, venous patients who had been treated between 1977 In seven cases, partial nephrectomy was reconstruction was undertaken, and attention and 2002 for stage T3b RCC arising in a attempted in situ, with cooling of the kidney paid to closing the collecting system after solitary kidney were identified from the Mayo and tumour removal [4,6]. Two of these had to NSS. Those patients who underwent auto-

RCC WITH VENOUS EXTENSION IN SOLITARY KIDNEYS

TABLE 1 Details of 13 patients treated surgically for T3b RCC in a solitary kidney

Age/ Year of Contralateral Follow-up, sex surgery Side kidney status Surgery Pathology Complications years Outcome 40/M 1979 Left RCC (2 years) – G3T3b Pulmonary embolus, operative death 0 Dead, UC 72/M 1980 Left Urolithiasis RN: planned G2T3b Pulmonary embolus, haemoperitoneum 7 Dead, UC 58/F 1982 Right RCC (7 years) RN: hilar tumour G1T3b Nil 6 Dead, UC 51/M 1983 Right Agenesis Bench NSS + AT G3T3b Urine leak, wound dehiscence 17 Alive: NED perinephric fat involved 74/M 1983 Left RCC (14 years) Bench NSS failed AT G1T3b Nil 2.3 Dead, UC remnant too small 68/M 1989 Left PUJO Bench NSS + AT G3T3b Nil 0.9 Dead: RCC 61/M 1991 Right RCC (5 years) Bench NSS + AT G3T3b, N1 Respiratory difficulty 0.7 Dead: RCC 73/M 1991 Left Agenesis In situ NSS G4T3b Graft vessel thrombosis 0.6 Dead: RCC 35/M 1992 Right Agenesis Bench NSS failed G2T3b Nil 11 Alive: NED AT, renal vein inv 68/M 2001 Left RCC (17 years) In situ NSS G3T3b Respiratory difficulty 2 Alive, systemic +ve margin recurrence 64/M 2001 Right PUJO In situ NSS G2T3b, M1 Nil 1.3 Dead: RCC 62/F 2002 Right Agenesis RN: bleeding G2T3b Nil 2.1 Alive: NED 43/M 2003 Right PUJO In situ NSS, renal vein G2T3b Urine leak 0.7 Alive: NED sacrificed

NED, no evidence of disease; UC, unrelated causes; AT, auto-transplant; PUJ, PUJ obstruction.

transplantation had a JJ stent placed, which There were nine early complications in seven term no complications were identified and was subsequently removed after recovery. patients (Table 1); one patient died during none of the seven patients who had surgery secondary to pulmonary embolus. undergone NSS required dialysis. Five secondary procedures were required in RESULTS three patients, to repair a calyceal fistula, to All tumours were of the clear-cell subtype, de-bride and close a wound disruption, to with a mean size of 8.34 (0.81) cm. All Five patients had had a previous nephrectomy place a caval filter for pulmonary emboli, to tumours were classified as T3b and were for contralateral RCC, a median of 7 (2–17) explore and wash out a haemoperitoneum, grade 1, 2, 3 and 4 in two, five, five and one years previously. The contralateral kidney was and to undertake arterial thrombectomy from patient, respectively. Perinephric fat invasion, congenitally absent in four patients and had an auto-transplant. One perinephric abscess positive resection margins, involved regional been removed or rendered atrophic secondary was treated successfully by percutaneous lymph nodes and distant metastasis were to benign disease in the other four, each in the drainage; there was no associated urine leak found in one patient each, all in the NSS distant past. Nine patients presented with or haematoma. Two patients had respiratory group. The patients were followed for a haematuria, two with pain, one with a complications, one of whom required median (mean, range) of 24 (55.2, 0–204) pathological fracture related to metastasis endotracheal intubation and admission to months, during which four died from RCC, at and one with constitutional symptoms. the ICU. a median interval of 9.5 (10.5, 7–16) months. Four other patients died from unrelated The mean operative time was 4.78 (0.61) h but Initially after surgery the serum creatinine causes, including the one death during this was significantly longer in patients who level increased from the baseline, at surgery. Five patients were alive at the last had NSS, at 5.84 (0.74) h, than in those who 135.7 (13.3) mmol/L in all patients, more so in follow-up, at a median of 25 (73.4, 8–204) did not, at 3.30 (0.62) h, reflecting the those patients rendered anephric, to months, one with systemic recurrence, and additional time required for reconstruction or 1312 (149.8) mmol/L, than in those who were four free of disease, and in this group the auto-transplantation. The median recorded not, at 442 (115.3) mmol/L. Two patients had serum creatinine was 266 (106) mmol/L. All blood loss was 1200 (650–5400) mL, and all acute tubular necrosis after NSS, requiring four deaths from cancer and the systemic patients required some blood transfusion. transient haemodialysis, while all five patients recurrence were in patients who had had NSS. Four patients were managed in the intensive who were anephric started long-term care unit (ICU) after surgery, while another haemodialysis. Before discharge the DISCUSSION required admission to the ICU 3 days after serum creatinine level improved, to surgery for respiratory difficulties. The median 1021 (124.1) mmol/L in anephric patients and This study of the surgical treatment of stage hospital stay was 13 (8–27) days. 286 (82.5) mmol/L in the others. In the long- T3b RCC in a solitary kidney shows the

SENGUPTA ET AL.

feasibility of NSS in conjunction with venous despite the adverse pathology represented, FIG. 1. High-quality imaging is vital to the surgical tumour thrombectomy, thus preserving renal four patients were alive with no evidence of management of stage T3b RCC involving the solitary function and avoiding dialysis. Bench surgery disease at a median of 81.5 months (mean kidney. CT showing (a) a large renal tumour with auto-transplantation was used in five of 93.8, range 8–204). These results are involving a solitary right kidney and extending the earlier patients, as in situ cooling and comparable to those reported by Angermeier through the main renal vein into the inferior vena reno-protection seemed unreliable at that et al. [8], where four of nine patients died cava (arrowhead). (b) Coronal reconstruction shows time [9,10]. Currently, improved preoperative from RCC at a mean of 35.5 months after a second, tumour-free renal vein (arrowhead), imaging and extensive experience with NSS surgery, with the remaining five alive with no which allowed sacrifice of the main renal vein mean that many more patients should be evidence of disease at a mean follow-up of (arrow) in the course of partial nephrectomy. amenable to partial nephrectomy in situ [5,6]. 33.2 months. However, given that many of T3b RCCs are not a ideally suited to NSS, there was a significant The patient and physician faced with venous failure rate in the present series, with a third tumour thrombus in the context of a solitary of patients requiring RN. In a previous report kidney or bilateral disease has a difficult of nine RCCs with venous involvement treated decision to make. We hope that our results by NSS [8], no information was provided on will help with that decision, where it is whether some patients had undergone RN as important to consider the advantages and a result of failed NSS. disadvantages of the alternative treatment strategies. NSS allows these patients to avoid Those patients who had RN had quicker dialysis, but is associated with prolonged and surgery and fewer complications, but a similar complex surgery. In well-selected RCCs, NSS length of hospital stay, than those who had can provide an equivalent oncological NSS. The difficulty of combined NSS and outcome to RN [14], but in the present series venous tumour thrombectomy is shown by all deaths from cancer were after NSS. Thus, in the fact that, compared with published data the face of adverse pathological features such [6,11–13], the present patients fared worse in as nodal or distant metastases, positive terms of blood loss (250–350 mL), operative surgical margins or perinephric fat invasion, b times (2–3 h), hospitalization (median 5 days) NSS may be oncologically inadequate and and complication rates (15–30%). NSS in a should probably be avoided. solitary kidney is associated with higher complication rates than NSS that is not However, RN renders these patients anephric imperative [11]. Also, series of venous tumour and exposes them to the significant morbidity thrombectomy [1,2], which include patients [15,16] and mortality [17,18] of chronic with more extensive vena caval thrombus dialysis. Given the few patients in the present than the present, reported similar operative series, it remains unclear whether RN times and blood loss to the present NSS prolongs survival in patients with T3b RCC in group, perhaps indicating similar operative a solitary kidney, compared to NSS. Although complexity. However, complications are fewer the site of relapse was not identified in this and, perhaps partly as a consequence of that, study, for the subset of patients who relapse hospital stays are shorter for routine venous at distant sites as a result of micrometastatic tumour thrombectomy [1,2] than those disease, outcomes after RN and NSS are likely carried out with NSS in the present series. to be similar. Thus, the limited life-expectancy treatment needs to be individualized to the of such patients would be compromised after patient, and may be dictated largely by The oncological outcome of this series was RN by having to undergo dialysis. patients’ preferences. that four of the patients died from disease recurrence and one had systemic recurrence, The third management option in such CONFLICT OF INTEREST all within 18 months; all were patients who patients is observation, which would lead had undergone NSS. However, there were also inexorably to the subsequent development of None declared. adverse findings, e.g. nodal and distant local complications and morbidity, which can metastasis, invasion of the perinephric fat and be troublesome and difficult to palliate REFERENCES involvement of the resection margin, in these effectively [19,20]. Leaving the tumour patients, but not in those who had RN. untreated may also accelerate the 1 Blute ML, Leibovich BC, Lohse CM, Empirically, none of these adverse features development of systemic disease and death. Cheville JC, Zincke H. The Mayo Clinic except the one positive margin would have Unfortunately, given the retrospective nature experience with surgical management, been more effectively treated by RN. Four of this study, we cannot comment on how complications and outcome for patients patients died from unrelated causes but there often this management strategy was chosen, with renal cell carcinoma and venous was prolonged disease-free survival (median and what the outcome was. No single tumour thrombus. BJU Int 2004; 94: 33– 72 months, mean 76.8, range 8–204) in seven, protocol can be recommended for all patients 41 including both NSS and RN. Encouragingly, with T3b RCC in a solitary kidney. Ultimately, 2 Sweeney P, Wood CG, Pisters LL et al.

RCC WITH VENOUS EXTENSION IN SOLITARY KIDNEYS

Surgical management of renal cell with extracorporeal surgery and 16 Rozenbaum EA, Chaimovitz C, carcinoma associated with complex autotransplantation for renal cell and Bearman JE. Quality of life of patients on inferior vena caval thrombi. Urol Oncol transitional cell cancer of the kidney. chronic dialysis. Isr J Med Sci 1984; 20: 2003; 21: 327–33 J Urol 1988; 140: 25–7 104–8 3 Jibiki M, Iwai T, Inoue Y et al. Surgical 10 Novick AC, Stewart BH, Straffon RA. 17 Okechukwu CN, Lopes AA, Stack AG, strategy for treating renal cell carcinoma Extracorporeal renal surgery and Feng S, Wolfe RA, Port FK. Impact of with thrombus extending into the inferior autotransplantation: indications, years of dialysis therapy on mortality risk vena cava. J Vasc Surg 2004; 39: 829–35 techniques and results. J Urol 1980; 123: and the characteristics of longer term 4 Zincke H, Engen DE, Henning KM, 806–11 dialysis survivors. Am J Kidney Dis 2002; McDonald MW. Treatment of renal cell 11 Stephenson AJ, Hakimi AA, Snyder ME, 39: 533–8 carcinoma by in situ partial nephrectomy Russo P. Complications of radical and 18 Chertow GM, Johansen KL, Lew N, and extracorporeal operation with partial nephrectomy in a large Lazarus JM, Lowrie EG. Vintage, autotransplantation. Mayo Clin Proc contemporary cohort. J Urol 2004; 171: nutritional status, and survival in 1985; 60: 651–62 130–4 hemodialysis patients. Kidney Int 2000; 5 Novick AC. Nephron-sparing surgery for 12 Campbell SC, Novick AC, Streem SB, 57: 1176–81 renal cell carcinoma. Annu Rev Med 2002; Klein E, Licht M. Complications of 19 Munro NP, Woodhams S, Nawrocki JD, 53: 393–407 nephron sparing surgery for renal tumors. Fletcher MS, Thomas PJ. The role of 6 Ghavamian R, Cheville JC, Lohse CM, J Urol 1994; 151: 1177–80 transarterial embolization in the Weaver AL, Zincke H, Blute ML. Renal 13 Gill IS, Matin SF, Desai MM et al. treatment of renal cell carcinoma. BJU Int cell carcinoma in the solitary kidney. an Comparative analysis of laparoscopic 2003; 92: 240–4 analysis of complications and outcome versus open partial nephrectomy for renal 20 Yonover PM, Sharma SK, Flanigan RC. after nephron sparing surgery. J Urol tumors in 200 patients. J Urol 2003; 170: Role of nephrectomy in metastatic kidney 2002; 168: 454–9 64–8 cancer. Cancer Treat Res 2003; 116: 119– 7 Pruthi RS, Angell SK, Brooks JD, Gill H. 14 Leibovich BC, Blute ML, Cheville JC, 35 Partial nephrectomy and caval Lohse CM, Weaver AL, Zincke H. thrombectomy for renal cell carcinoma in Nephron sparing surgery for Correspondence: Horst Zincke, Department of a solitary kidney with an accessory renal appropriately selected renal cell Urology, Mayo Clinic, 200 First St SW, Gonda 7 vein. BJU Int 1999; 83: 142–3 carcinoma between 4 and 7 cm results in South, Rochester, MN 55905, USA. 8 Angermeier KW, Novick AC, Streem SB, outcome similar to radical nephrectomy. e-mail: [email protected] Montie JE. Nephron-sparing surgery for J Urol 2004; 171: 1066–70 renal cell carcinoma with venous 15 Thomas N. Measurement of quality of life Abbreviations: ICU, intensive care unit; involvement. J Urol 1990; 144: 1352–5 for elderly people on dialysis. Br J Nurs NSS, nephron-sparing surgery; RN, radical 9 Zincke H, Sen SE. Experience 1992; 1: 284–5 nephrectomy.

A description of radical nephrectomy practice and outcomes in England: 1995–2002

MARTIN NUTTALL*, PAUL CATHCART*, JAN VAN DER MEULEN*†, DAVID GILLATT‡, GREGOR MCINTOSH¶ and MARK EMBERTON*§ *Clinical Effectiveness Unit, The Royal College of Surgeons of England, †Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, ‡Southmead Hospital, Bristol, ¶Salisbury Healthcare NHS Trust, Salisbury, and §Institute of Urology and Nephrology, University College, London, UK Accepted for publication 3 February 2005

OBJECTIVES RESULTS ª40%, from 17 in 1995 to 24 in 2001. The annual number of laparoscopic RNs nationally To describe national trends in the practice of Patient age and the proportion who were increased from seven in 1995 to 84 in 2002. radical nephrectomy (RN) in England between men did not change over the study period. The 1995 and 2002. proportion of patients admitted as an emergency decreased from 14.0% to 7.5% CONCLUSIONS METHODS over this period (P < 0.001). The mean waiting duration increased by almost 6 days The annual number of RNs in England Data were extracted from the Hospital (P < 0.001) and length of stay by ª1 day, from increased by almost a fifth and this was Episode Statistics database of the Department 11.7 days in 1995 to 10.8 days in 2001 accompanied by an increase in annual of Health in England between 1995/1996 and (P < 0.001). In-hospital mortality decreased hospital volume of about two-fifths. There 2001/2002. Patients were included in the from 2% to 1.5% (P = 0.134). In-hospital was a large proportional increase in the study if an International Classification of mortality and length of stay were higher in number of laparoscopic RNs. Emergency Diseases diagnosis code (ICD-10) for older patients and in those admitted as an admission rates and length of stay decreased malignant neoplasm of the kidney, renal emergency. Women had a longer stay than but this was not accompanied by a significant pelvis or ureter, and an operative procedure men (11.5 vs 11.1 days), but in-hospital change in in-hospital mortality rate. code (OPCS-4) describing total or partial mortality was higher in men (2.3% vs 1.6%). excision of the kidney by either a laparoscopic The national number of RNs per year or open approach, were present in any of the increased by ª20%, from 2254 in 1995 to KEYWORDS diagnosis or operative procedure fields. 2671 in 2001. Over the same period the mean Overall, 17 308 patients were included. annual hospital volume of RN increased by radical nephrectomy, outcomes, England

INTRODUCTION care are expensive and labour-intensive. An The objective of the present study was to alternative approach is to conduct studies describe changes in surgical activity, and Renal malignancies account for ª2% of newly using national administrative databases. This patient characteristics and outcomes for RNs diagnosed malignancies per year in the UK [1]. approach has been used increasingly in the in England between 1995 and 2002, using the Over the last 20 years the annual number of USA, in particular using the Medicare HES database. renal malignancies diagnosed has increased database [6–10]. The Hospital Episode worldwide by ª70%, with most recent values Statistics (HES) database of the Department indicating that ª5700 people are affected of Health in England could be considered as METHODS each year in the UK [2]. Each year an the English equivalent of the Medicare estimated 95 000 deaths worldwide are from database; it records medical, demographic Data were extracted from the HES database renal malignancy, with >3000 such deaths and administrative data relating to all for 1995/1996 to 2001/2002 for all patients annually within the UK [2]. In the USA, 31 800 patients admitted to National Health Service recorded as having undergone a RN. Patients new cases of carcinoma of the kidney and of (NHS) hospitals in England [11]. Over 12 were included in the study if first, there was the renal pelvis were diagnosed in 2002, with million records are collected each year, which an International Classification of Diseases 11 600 deaths attributed to these diseases include private patient admissions to NHS code (ICD-10) for malignant neoplasm of the [3]. Urological surgical intervention in the hospitals but do not include patients treated kidney, renal pelvis or ureter in any of the form of radical nephrectomy (RN) or within independent-sector hospitals. HES seven diagnostic fields, and second, there was nephroureterectomy is considered the data are being increasingly used to illustrate an Office of Population Censuses and Surveys primary curative treatment [4,5]. variations in health status and delivery of operative procedure code (OPCS-4) indicating care. They are also used in medical research, RN and excision of perirenal tissue (M021), Large-scale national audits to investigate assessing performance and in policy nephroureterectomy not elsewhere classified surgical activity and the quality of surgical development [12,13]. (M022), bilateral nephrectomy (M023),

RADICAL NEPHRECTOMY IN ENGLAND: 1995–2002

TABLE 1 Patient characteristics and outcomes, and the annual number and mean annual hospital volumes of RN, in England between 1995 and 2002

Year Variable 1995–96 1996–97 1997–98 1998–99 1999–2000 2000–01 2001–02 P trend Mean (SD) age, years 63.3 (12.3) 64.1 (11.8) 64.1 (11.9) 63.9 (11.9) 64.3 (12.2) 64.0 (12.2) 63.9 (12.1) 0.201 Male, n (%) 1421 (63.4) 1446 (62.5) 1454 (62.2) 1572 (63.5) 1621 (62.5) 1660 (62.9) 1713 (64.2) 0.470 Emergency adm, n (%) 314 (14.0) 260 (11.2) 277 (11.8) 283 (11.4) 247 (9.5) 244 (9.3) 199 (7.5) <0.001 Mean (SD): waiting time, days 21.2 (26.7) 21.7 (25.4) 23.1 (28.9) 23.0 (26.5) 23.6 (24.3) 24.9 (25.6) 27.0 (29.5) <0.001 length of stay, days 11.7 (8.2) 11.6 (11.1) 11.5 (9.6) 11.3 (9.2) 11.1 (8.3) 10.8 (8.2) 10.8 (9.7) <0.001 In-hospital death, n (%) 46 (2.0) 46 (2.0) 53 (2.3) 63 (2.5) 63 (2.4) 44 (1.7) 40 (1.5) 0.134

Annual National procedural volume, n 2254 2319 2354 2476 2595 2639 2671 Mean (SD) hospital 17 (10) 17 (9) 18 (10) 19 (11) 22 (14) 24 (15) 24 (15) volume, n N hospitals using RN 198 197 196 189 176 174 162 N LRN* 7 4 4 5 13 23 84 N hospitals using LRN 7 4 4 5 6 13 24 volume of PN* 49 69 67 85 83 115 108 N hospitals using PN 35 47 41 44 42 54 52

*Included within the overall national annual procedural volume of RN. LRN, laparoscopic radical nephrectomy; PN, partial nephrectomy; RN, radical nephrectomy.

nephrectomy not elsewhere classified (M025), 1995 and 2002 in England are described in who waited >4 weeks for their operation and other specified total excision of kidney Table 1. About half of the patients were aged those who waited <4 weeks. Patients who (M028), unspecified total excision of kidney ≥65 years and about two-thirds were men. were admitted as an emergency had a stay (M039), other specified partial excision of The proportion of patients admitted as an ª8 days longer than those admitted kidney (M038) or unspecified partial excision emergency decreased from 14.0% to 7.5% electively. of kidney (M049) in any of the four operative over this period (P < 0.001). There was no procedure fields [14,15]. Overall, 17 308 significant change in either patient age or the In-hospital mortality rates increased with age patients were included. proportion of male patients over the study (Table 2), e.g. in those aged £55 years it was period. The mean waiting duration increased 0.6% but 4.7% in those aged >80 years. In- Within the HES database, waiting duration is by almost 6 days over the study period hospital mortality was also slightly higher in defined as the time in days from the date on (P < 0.001). The mean length of stay men than women. There appeared to be no which it was decided to admit the patient for decreased by ª1 day, from 11.7 days in 1995 statistically significant association between surgery to the date of admission to hospital to 10.8 days in 2001 (P < 0.001). There was no waiting duration and in-hospital mortality. when the surgery took place. Annual hospital significant change in in-hospital mortality Furthermore, in-hospital mortality was volumes were determined by counting the rate, although this increased from 2.0% in almost 2.5 times higher in those admitted as number of patients treated within each NHS 1995 to 2.5% in 1998, but decreased to 1.5% an emergency than those admitted electively. Trust. by 2001. Patients who died had a longer stay in hospital before death than those who were For statistical analysis, logistic and linear There was a statistically significant increase in discharged (15.8 and 11.1 days, respectively). regression were used to define associations waiting duration with age (Table 2), e.g. between in-hospital mortality and length of patients aged <55 years waited a mean of The national number of RNs annually stay, respectively on the one hand, and patient 20.8 days for admission for surgery, compared increased by ª20%, from 2254 in 1995 to characteristics on the other. All P values are to 26.1 days for those aged >80 years. The 2671 in 2001 (Table 1). Over the same period two-sided and P < 0.05 was deemed to mean length of stay also increased with age, the mean annual hospital volume of RN indicate statistical significance. e.g. it was 9.4 days for those aged £50 years increased by ª40%, from 17 in 1995 to 24 in and 14.9 days for those aged ≥80 years. Men 2001. However, in this period the total waited a mean of almost 2 days longer than number of hospitals recorded as using RN RESULTS women, and had a shorter stay than women, decreased from 198 to 162. The annual although this was not clinically significant number of laparoscopic RNs (LRNs) nationally The characteristics and short-term outcomes (Table 2). There appeared to be no significant increased from seven in 1995 to 84 in 2001, of the 17 308 patients who had RN between difference in length of stay between those and the number of hospitals recorded as

NUTTALL ET AL.

using LRN increased from seven in 1995 to 24 TABLE 2 Waiting time, length of stay and in-hospital mortality by patient characteristics for radical in 2001. The annual number of partial nephrectomy in England nephrectomies (PNs) also increased from 49 to 108, and these were in 35 hospitals in 1995 Characteristic Mean (SD), days and 52 in 2001 (Table 1). (N patients) waiting time length of stay In-hospital mortality, N (%) DISCUSSION All patients (17308) 23.6 (26.8) 11.2 (9.2) 355 (2.1) Age, years 20.8 (27.5) In summary, the annual number of RNs in <55 (3806) 9.4 (6.3) 23 (0.6) 21.2 (20.7) England increased by almost a fifth over the 55–59 (1904) 10.4 (11.4) 13 (0.7) 23.9 (27.9) study period, and this was accompanied by an 60–64 (2378) 10.5 (7.2) 49 (2.1) 24.1 (24.4) increase in annual hospital volume of about 65–69 (2962) 11.1 (9.6) 54 (1.8) 25.9 (29.1) two-fifths. There was also a large proportional 70–79 (4889) 12.4 (9.7) 154 (3.2) 26.1 (26.1) increase in the number of LRNs and PNs. ≥80 (1320) 14.9 (11.1) 62 (4.7) Length of stay was longer in older patients, Missing (49) in women and in those admitted as an P for trend <0.001 <0.001 <0.001 emergency. In-hospital mortality was higher Gender for older patients, men, and in those admitted Male (10887) 24.2 (27.5) 11.1 (9.1) 249 (2.3) as an emergency. Female (6387) 22.7 (25.6) 11.5 (9.3) 104 (1.6) Missing (34) There are several limitations associated with P 0.001 0.001 0.003 the use of administrative data sources such as Waiting time HES. First, although the 20% increase in the 0–4 weeks (10656) 13.5 (7.5) 10.2 (7.3) 187 (1.8) annual number of RNs over the study period >4 weeks (3825) 52.0 (38.4) 10.3 (7.2) 58 (1.5) may partly be explained by the 2% annual Missing (2827) increase in the incidence of renal P – 0.233 0.180 malignancies also reported over this period, it Method of admission may also be explained by lower or varying Elective (15468) 23.6 (26.8) 10.4 (8.3) 274 (1.8) thresholds for surgical intervention, or by Emergency (1824) – 18.0 (12.7) 81 (4.4) improvements in the accuracy and coding of Missing (16) clinical data. It is not possible to determine P – <0.001 <0.001 the relative contributions of these effects from the present data. the number of hospital trusts in England 8.4 days, compared to 11.3 days for open RN. Second, in-hospital mortality rates decreased submitting data to the HES database A national UK audit of LRN for several from 2.0% to 1.5% over the period; this could decreased over this period, partly through indications between 2001 and 2002 reported reflect improvements in the quality of surgical hospital mergers, and this may also explain a median stay after surgery of 4 days in 263 care, but also could be related to the the observed increase in hospital volume [18]. patients [22], of which 113 (43%) were for simultaneous decrease in the length of cancer. Although the study periods do not hospital stay over the period. This explanation The demographic characteristics of the overlap exactly, in the final year of the present cannot be excluded, as shorter hospital stays patients included within this study are similar study we identified 84 RNs that were coded as increase the chances of observing higher to those included within several previous having been laparoscopic. Importantly, the mortality rates in the period after discharge studies of RN [3,19]. The present mean present study included patients only from [16]. hospital stay was 11.2 days, which compares England, whereas the nationwide audit with a French study of 656 patients included patients from elsewhere in the UK. The finding that the proportional increase in undergoing RN between 1986 and 1997, that Without formal case-note validation it is not the annual hospital volume of RN was about reported a stay of 11 days [19], but contrasts possible to determine how many of the twice that of the national number of RNs was with a nationwide USA study of the Medicare patients included in these two studies overlap. surprising. Several explanations could database (only including patients aged In comparison to the USA, in the UK the account for this. First, this could suggest a >65 years), which reported a stay of 7.5 days proportion of RNs that were laparoscopic is degree of centralization of cancer services for [20]. The reasons for this difference are likely smaller, but this is increasing rapidly [23]. RN in England. However, national guidance to be multifactorial, but will include physician, recommending that local hospitals should not hospital, cultural, social and financial factors. The present in-hospital mortality rate of 2.1% perform RN in cases where the procedure was is lower than a national USA study of 58 990 likely to be complex (e.g. for tumours invading The surgical approach clearly also influences Medicare patients undergoing RN between major blood vessels, or for patients with von the length of stay after RN. In a single-centre 1994 and 1999, where it was 3% [7]. However, Hippel-Lindau disease) was issued only in USA study, the length of stay for open RN was for only those patients aged >65 years in the 2002, and therefore should not affect the 3.6 days, vs 1.7 days for LRN [21]. In the present study the in-hospital mortality rate results of the present study [17]. Second, present study, the mean stay for LRN was was 2.9%, very similar to the national USA

RADICAL NEPHRECTOMY IN ENGLAND: 1995–2002

study. In a large single-centre French study of JB, Montie JE, Wei JT. Impact of surgical routine statistics. BMJ 2002; 324: 1069– 656 patients, the mortality rate was only volume on mortality and length of stay 70 0.6%, considerably lower than either the after nephrectomy. Urology 2004; 63: 17 National Institute of Clinical present or the USA study [19]. Another single- 862–7 Excellence. NICE Guidance on Cancer centre study between 1995 and 2002 of 1049 4 Robson CJ, Churchill BM, Anderson W. Services. Improving Outcomes in patients in the USA undergoing RN reported a The results of radical nephrectomy for Urological Cancers. London: National perioperative mortality rate of 0.2% [24]. This renal cell carcinoma. J Urol 1969; 101: Institute of Clinical Excellence, 2002 illustrates the low mortality rates that can be 297–301 Available from: http://www.nice.org.uk attained in some centres, but it is not clear 5 Novick AC, Campbell SC. Renal tissues. 18 Department of Health. The HES Book. how generally applicable these single-centre In Walsh PC, Retik AB, Vaughan ED et al. London: Department of Health 2000 results are to a national level, given the eds, Campbell’s Urology. Eighth edn. Available from http://www.doh.gov.uk/ possible role of confounding factors such as Chapter 75. Philadelphia: Elsevier hes/ differences in disease severity and degree of Saunders, 2002 19 Mejean A, Vogt B, Quazza JE, Chretien comorbidity. 6 Birkmeyer JD, Stukel TA, Siewers AE, Y, Dufour B. Mortality and morbidity Goodney PP, Wennberg DE, Lucas FL. after nephrectomy for renal cell This study used the HES database because it is Surgeon volume and operative mortality carcinoma using a transperitoneal the only source of national information on all in the United States. New Engl J Med anterior subcostal incision. Eur Urol 1999; NHS admissions in England. These data will 2003; 349: 2117–27 36: 298–302 provide useful indicators for comparative 7 Birkmeyer JD, Siewers AE, Finlayson 20 Goodney PP, Stukel TA, Lucas FL, local audit and clinical governance. In the EVA et al. Hospital volume and surgical Finlayson EVA, Birkmeyer JD. Hospital future, studies using the BAUS Complex mortality in the United States. New Eng J volume, length of stay, and readmission Operations database should allow similar Med 2002; 346: 1128–37 rates in high-risk surgery. Ann Surg 2003; assessments that address some of the 8 Potosky AL, Warren JL, Riedel ER, 238: 161–9 limitations associated with the HES database, Klabunde CN, Earle CC, Begg CB. 21 Shuford MD, McDougall EM, Chang SS, including accuracy of clinical coding and Measuring complications of cancer LaFleur BJ, Smith JA, Cookson MS. paucity of information on disease severity and treatment using the SEER Medicare data. Complications of contemporary radical stage. These studies may also permit some Med Care 2002; 40: 62–8 nephrectomy: comparison of open vs. element of validation of the HES data, and 9 Yao SL, Lu-Yao G. Population-based laparoscopic approach. Urol Oncol: Semin report on the effect of recent national targets study of relationships between hospital Original Invest 2004; 22: 121–6 which aim to improve access to cancer volume of prostatectomies, patient 22 Keoghane SR, Keeley FX, Timoney AG, services, on waiting times and clinical outcomes, and length of hospital stay. Tolley DA, Joyce A, Downey. The British outcomes [25]. J Natl Cancer Inst 1999; 91: 1950–6 Association of Urological Surgeons 10 Iezzoni LI. Assessing quality using Section of Endourology audit of ACKNOWLEDGEMENTS administrative data. Ann Intern Med 1997; laparoscopic nephrectomy. BJU Int 2004; 127: 666–74 94: 577–81 We thank the Department of Health in 11 Kang JY, Hoare J, Majeed A, Williamson 23 Allan JD, Tolley DA, Kaouk JH, Novick England for supplying the data extract used in RCN, Maxwell JD. Decline in admission AC, Gill IS. Laparoscopic radical this study. Funding: Martin Nuttall is funded rates for acute appendicitis in England. nephrectomy. Eur Urol 2001; 40: 17–23 by the Bob Young Research Fellowship and BJS 2003; 90: 1586–92 24 Stephenson AJ, Hakimi AA, Snyder ME, the Research Fellowship Scheme of The Royal 12 Anonymous. The New NHS. Modern and Russo P. Complications of radical College of Surgeons of England. Jan van der dependable. A National Framework for and partial nephrectomy in a large Meulen received a NHS Public Health Career Assessing Performance. Leeds, UK: NHS contemporary audit. J Urol 2004; 171: Scientist Award. Executive, 1998 130–4 13 Bloor A, Maynard K, Freemantle N. 25 Department of Health. The NHS Cancer CONFLICT OF INTEREST Variation in activity rates of consultant Plan. 2003 Available from: http:// surgeons and the influence of reward www.dh.gov.uk/PolicyAndGuidance/ None declared. Source of funding: Royal structures in the English NHS. J Health HealthAndSocialCareTopics/Cancer/fs/en College of Surgeons of England Research Serv Res Policy 2004; 9: 76–84 Fellowship and Bob Young Research 14 World Health Organisation (WHO). Correspondence: Martin Nuttall, Clinical Fellowship. International Classification of Diseases. Effectiveness Unit, The Royal College of 10th Rev. Geneva: WHO, 1994 Surgeons of England, Lincoln’s Inn Fields, REFERENCES 15 Offices of Population Censuses and London, UK. Surveys (OPCS). Classification of Surgical e-mail: [email protected], 1 Office of National Statistics. Cancer Operations and Procedures. Fourth [email protected] registrations. Available from: Revision. London: OPCS, 1987 www.statistics.gov.uk 16 Goldacre MJ, Griffith M, Gill L, Abbreviations: R(L)(P)N, radical 2 Cancer Research UK. Available from: Mackintosh A. In-hospital deaths as a (laparoscopic) (partial) nephrectomy; NHS, www.cancerresearchuk.org fraction of all deaths within 30 days of National Health Service; HES, Hospital 3 Taub DA, Miller DC, Cowan JA, Dimick hospital admission for surgery: analysis of Episode Statistics.

The relationship between angiogenesis and cyclooxygenase-2 expression in prostate cancer

RONO MUKHERJEE*†, JOANNE EDWARDS*, MARK A. UNDERWOOD† and JOHN M.S. BARTLETT* *Endocrine Cancer Group, Division of Cancer Studies and Molecular Pathology, and †Department of Urology, Glasgow Royal Inﬁrmary, Glasgow, UK Accepted for publication 8 February 2005

OBJECTIVE prostatic hyperplasia (BPH, 26) and these data COX-2 expression, but the effect of increased correlated with levels of COX-2 expression in COX-2 expression on MVD was not marked. To test the hypothesis that angiogenesis in the same dataset. The mean microvessel prostate cancer is associated with tumour density (MVD) was analysed as a marker of CONCLUSION invasion and metastasis, and that this is angiogenesis, using the endothelial antigen mediated through increased cyclooxygenase- CD34 stained by immunohistochemistry. These data suggest that COX-2 drives tumour 2 (COX-2) expression. spread in prostate cancer by means other RESULTS than the promotion of angiogenesis. PATIENTS AND METHODS There was no difference in MVD in progressive KEYWORDS Angiogenesis was assessed in 105 patients tumour stages compared with BPH. There was with either prostate cancer (79) or benign a negative correlation between MVD and prostate cancer, angiogenesis, COX-2

INTRODUCTION not always been shown to predict local correlation between COX-2 staining intensity, recurrence, nor relate to Gleason score or Gleason score and poor prognosis in prostate Angiogenesis, the formation of new blood stage [6]. In addition, some studies were cancer was reported in some studies [16–18], vessels, is vital in the growth, progression and unable to confirm that MVD can act as an but not others [13]. We recently showed metastasis of many cancers [1]. Solid tumours independent prognostic variable for prostate higher levels of COX-2 expression in locally induce the formation of new capillaries to cancer when subjected to multivariate advanced prostate cancer [19]. Studies in avoid oxygen starvation and obtain the analysis [1,7]. hormone-resistant prostate cancer cell lines required nutrients to grow beyond 2–3 mm in show a link between COX-2, PGE2 production diameter [1]. The regulation of angiogenesis Cyclooxygenase-2 (COX-2) is the inducible and the hypoxic up-regulation of VEGF, which depends on a complex interplay between pro- form of COX which is involved in the may be reversed by adding a selective COX-2 angiogenic factors, e.g. vascular endothelial formation of prostaglandins (PGs) such as inhibitor [20]. Similarly, studies of prostate growth factors (VEGFs) and inhibitory factors, PGE2 from arachidonic acid, which in turn cancer in mice show that treatment with known as the ‘angiogenic switch’ [1,2]. regulates VEGF production, thereby selective COX-2 inhibitors prevents the up- Immunohistochemical (IHC) studies for promoting angiogenesis [8]. Aberrant or regulation of VEGF, decreasing tumour MVD endothelial antigens such as von Willebrand’s increased expression of COX-2 has been and tumour growth [21]. factor (Factor VIII), CD31 and CD34 implicated in the pathogenesis of several are frequently used to quantify human cancers, including colorectal [9] and We tested the hypothesis that angiogenesis in neovascularization in tumours. Such studies breast [10,11]. A recent report revealed a prostate cancer is associated with tumour have suggested that estimating the mean correlation between COX-2 expression and invasion and metastasis, and mediated microvessel density (MVD) predicts local tumour MVD as measured by CD31 in breast through increased COX-2 expression. The spread and recurrence in several cancers cancer [11]. This provides the rationale for the confirmation of angiogenesis and COX-2 as [1,3,4]. In addition, studies suggest that use of selective COX-2 inhibitors in treating consistent prognostic markers in prostate angiogenesis contributes to the metastatic selected cancers, to reduce neovascularization cancer would support further clinical potential of prostate cancer [1,5]. The and therefore cell growth, which are currently assessment of angiogenesis and COX-2 administration of angiogenesis inhibitors under investigation [1]. inhibitors, which have already shown promise suppresses the primary and metastatic in various trials [1,22]. growth of prostate tumours in vivo [1]. Increased expression of COX-2 has already Several retrospective studies showed that been shown in the prostate cancer cell lines mean MVD correlates with increasing Gleason LNCaP (androgen-sensitive) and PC-3 PATIENT AND METHODS score and disease progression (from (androgen-insensitive) [10,12]. Studies using extraprostatic extension to metastasis) in IHC, including ours, have confirmed high A database of 105 tumour biopsies was prostate cancer [4,5]. However, the clinical levels of COX-2 expression in human prostatic established with archival tissue specimens value of measuring angiogenesis remains cancer tissue and high-grade prostatic (formalin-fixed, paraffin-embedded). Detailed controversial; estimates of mean MVD have intraepithelial neoplasia [13–17]. A data on stage, presence of metastasis,

ANGIOGENESIS AND COX-2 EXPRESSION IN PROSTATE CANCER

FIG. 1. Analysis of MVD using IHC for CD34. ¥200. FIG. 2. 45 Scattergraph representing the 40 mean MVD scores plotted against 35 COX-2 expression. 30 25 20 n MVD a 15 Me 10 5 0 0 50 100 150 200 250 300 COX-2 histoscore

Gleason grade and survival data, if available, was taken as the mean MVD. Every tenth slide age, Gleason sum and mean survival for all were documented by reviewing case notes. To was double-scored by an independent patients in the database are shown in Table 1. develop this patient cohort, we obtained observer. There was no significant difference in multiple research ethical committee approval angiogenesis, as measured by MVD, between and the support of the Scottish Urological COX-2 expression was previously determined tumour groups (all groups combined) Oncology Group, and recruited patients using a monoclonal antibody (mouse IgG1, compared with BPH, nor with T3/4 compared throughout Scotland. Tissue specimens were Cat. No. 160112, Cayman Chemical Co., USA) with T1/2 (Table 1) when assessed using a then divided into two groups by stage (T1/2 at 1 : 80 concentration. This was quantified by t-test. Nor were there significant differences and T3/4), with BPH specimens as a control. the same two observers, while unaware of between patients with or without metastasis Two further subgroups with nonmetastatic sample origin, using a weighted histoscore at diagnosis, either in total or when further and metastatic disease at presentation were method, calculated from the sum of subdivided by individual tumour stage also identified. COX-2 expression data (1 ¥ percentage weak staining) + (Table 2). In patients with a high MVD (above were also available for each tumour in this (2 ¥ percentage moderate staining) + the mean) there was no significantly different cohort [19]. (3 ¥ percentage strong staining), providing a survival time from those with a low MVD semiquantitative classification of staining (below the mean; P = 0.15). Tumour angiogenesis was assessed by IHC intensity. The interclass correlation using a monoclonal antibody to the coefficients between each observer for each There was a negative correlation between endothelial cell-surface marker CD34 (mouse protein were >0.7, which is classed as COX-2 expression and angiogenesis, as IgG1, QBEnd/10, Novocastra, UK). Tissue excellent. measured by MVD (P = 0.02; r = - 0.23; sections (5 mm) were dewaxed in xylene and y = -0.027 x + 18.58; Fig. 2), but the Gleason rehydrated through graded alcohols. Antigens MVD scores are shown as the mean (SD), and score did not correlate with MVD (P = 0.75; were retrieved by incubating sections in 0.1% results were analysed statistically using r = -0.037) or COX-2 expression (P = 0.40, trypsin in 0.1% calcium chloride (w/v, pH 4) Student’s t-test to compare differences in r = 0.104). for 25 min at 37 ∞C. Sections were then scores between BPH and individual tumour incubated with primary antibody at 1 : 50 stages. Spearman rank correlation coefficient dilution for 30 min at room temperature. was used to determine any correlation DISCUSSION Negative control sections were incubated between COX-2 expression, angiogenesis with an isotype-matched control antibody. (as determined by the mean MVD), and We previously reported an association Bound antibody was visualized using a Gleason score. Kaplan-Meier survival plots between high COX-2 expression and biotinylated secondary antibody, streptavidin- were used to correlate MVD scores with increased tumour stage (T3/4), and increased horseradish peroxidase complex (DAKO, UK) survival. COX-2 expression in prostate cancer and 3,3¢-diaminobenzidine as chromogen compared with BPH [19]. This confirmed (Vector Laboratories, Burlinghame, CA). previous studies in which COX-2 expression Tissue sections were counterstained with RESULTS was associated with aggressive disease in haematoxylin and dehydrated through graded prostate cancer [16–18], and led to the alcohols and xylene. Subjective analysis of the In all, 105 patients were retrospectively hypothesis that COX-2 drives increased tissue sections was used to identify the four recruited into the study; 79 had prostate neovascularization. In support of this, a recent most vascular regions or ‘hot spots’ (areas of cancer (46 with stage T1/2 and 31 with stage study of breast cancer reported a positive maximum endothelial cell staining of T3/4, and two stage unknown) and 26 had relationship between COX-2 expression (as microvessels) at low magnification (¥200) BPH (Table 1). Tumour groups were also measured by a weighted histoscore) and (Fig. 1). The vessels in each hot spot were then subdivided into metastatic (11 T1/2, seven angiogenesis as measured by the mean MVD counted at higher magnification (¥400) in T3/4, two unknown) and nonmetastatic using the CD31 antigen [11]. Interestingly, in four fields of vision; the mean of these counts (35 T1/2, 24 T3/4) at presentation. The median the present study there was a significant

MUKHERJEE ET AL.

TABLE 1 Patient age, follow-up information, mean MVD scores

Pathology Variable BPH pT1/pT2 pT3/pT4 Non-metastatic Metastatic All tumours Median (IQR) age, years 75 (71–75) 64 (60–63) 73 (63–76) 64 (61–74) 74 (68–80) – Mean (SD): Gleason score N/A 6 (2) 7 (2) 6 (2) 7 (1) – follow-up, months 59 (10) 66 (27) 58 (24) 68 (27) 40 (33) – time to death, months 38 (7) 44 (15) 42 (26) 44 (23) 24 (6) – % death 4 30 42 28 55 – MVD Total scored 26 46 31 59 20 79 Mean (SD) MVD 15.6 (6) 12.9 (6) 13.4 (9) 13.0 (7) 14.2 (9) 13.4 (8)

IQR, interquartile range; N/A, not available; % death, % of patients dying from prostate cancer during the follow-up.

negative correlation between angiogenesis, as TABLE 2 The MVD scores within individual tumour stages measured by CD34 expression, and COX-2 expression. This would contradict the Stage Total scored Mean (SD) MVD P hypothesis that COX-2 acts as a pro- T1/2 with no metastasis 35 12.9 (6) angiogenic stimulant, at least in prostate T1/2 mets at presentation 11 14.9 (8) 0.39 cancer, and could suggest that COX-2 inhibits T3/4 with no metastasis 24 13.4 (9) new blood vessel formation. However, the T3/4 mets at presentation 7 14.1 (14) 0.96 decrease in MVD associated with an increase in COX-2 expression was lower than the observed variation in MVD at individual COX- 2 expression levels (Fig. 2). For example, an measuring COX-2 expression is therefore well between mean MVD and advancing disease in increase in COX-2 expression from 100 to 300 established and was used previously in prostate cancer [4,5,24,25]. There are similar histoscore units would result in a theoretical comparison with mean MVD scores in breast inconsistencies with the use of MVD as a reduction in MVD from 15.88 to 10.48 tissue [11,16–19]. prognostic indicator in colorectal cancer, microvessels/field (a decrease of 5.4 units). where MVD was lower in metastatic than However, the actual mean (SD) MVD between Whilst the present results therefore may primary tumours [26], and to a lesser extent in COX-2 histoscores of, e.g. 140–160, is reflect the methodological problems breast cancer [27]. These differences may be 17.76 (9.9) microvessels/field. At this point associated with measuring MVD it may also related to the use of different antibodies, as the variation in MVD scores is almost twice imply that COX-2 drives tumour progression the present MVD scores were lower than the maximum change predicted (as 90% independently of neovascularization. For those previously published using Factor VIII of samples have a COX-2 histoscore of example, COX-2 has well documented roles in and CD31 as an endothelial antigen [5,6,25]. 100–300). This suggests that the variation in promoting the inflammatory response, This was also reported in breast cancer when estimates of MVD would preclude its use as a inhibiting apoptosis via the Akt/bcl-2 CD31 was compared to Factor VIII [6]. prognostic or predictive factor. Furthermore, pathway, and is involved in the control of However, disparities between MVD scores the large variation in MVD scores for cellular proliferation via the interleukin-6 were also reported between studies using the individual COX-2 scores would undermine the pathway [23]. Studies in breast cancer show same antibody [4,6]. Furthermore, a recent biological significance of the observed that cellular proliferation, as measured by the report associating MVD with the outcome negative correlation between MVD and COX-2 mitotic activity index, have no association after radical prostatectomy cited scores of a expression. Perhaps a sub-analysis comparing with angiogenesis as measured by MVD [3]. similar magnitude to the present when using the mean MVD in focal areas of high or low CD34 as an antigen [28]. Similar scores were COX-2 expression alone may have produced The importance of angiogenesis in tumour also reported when the present protocol for less variation, but in practice this would not metastasis has been well established for over measuring MVD using CD34 was incorporated be technically feasible because of the diffuse 30 years [1]. In theory, inhibiting angiogenesis into a pilot study of breast cancer specimens and heterogeneous nature of COX-2 staining might provide a further therapeutic option by within our laboratory (unpublished data). within individual tissue sections. There are targeting cancer growth and spread. However, There are other well documented also inherent difficulties in accurately in the present study angiogenesis, as controversies in determining angiogenesis, comparing protein expression within specific measured by mean MVD in prostate cancer, e.g. the presence of tumour heterogeneity areas between different tissue sections, in the did not increase with increasing tumour stage [1,7]. Other aspects of the methods, e.g. the absence of a dual-staining technique. or metastases, in line with other studies [6,7]. actual region selected for vessel counting, The weighted histoscore technique for However, others reported a relationship may be as important [1,6]. If measuring

ANGIOGENESIS AND COX-2 EXPRESSION IN PROSTATE CANCER

angiogenesis alone is to be exploited for 3 de Jong JS, van Diest PJ, Baak JP. Hot 15 Gupta S, Srivastava M, Ahmad N, clinical use, current methods involving spot microvessel density and the mitotic Bostwick DG, Mukhtar H. Over- MVD analysis need to be simplified and activity index are strong additional expression of cyclooxygenase-2 in human standardized [1]. Further prospective studies prognostic indicators in invasive breast prostate adenocarcinoma. Prostate 2000; are needed to explore its potential as a cancer. Histopathology 2000; 36: 306–12 42: 73–8 prognostic marker in prostate cancer. 4 Bostwick DG, Wheeler TM, Blute M 16 Madaan S, Abel PD, Chaudhary KS et al. However, despite the possible inverse et al. Optimized microvessel density Cytoplasmic induction and over- correlation between the mean MVD and COX- analysis improves prediction of cancer expression of cyclooxygenase-2 in human 2 expression in the present study, it does not stage from prostate needle biopsies. prostate cancer: implications for preclude the targeting of angiogenesis as a Urology 1996; 48: 47–57 prevention and treatment. BJU Int 2000; treatment method. Angiogenesis is regulated 5 Brawer MK, Deering RE, Brown M, 86: 736–41 by a complex series of molecular pathways Preston SD, Bigler SA. Predictors of 17 Yoshimura R, Sano H, Masuda C et al. which, whilst they include the modulation of pathologic stage in prostatic carcinoma. Expression of cyclooxygenase-2 in VEGF via PGE2 produced by COX-2, are The role of neovascularity. Cancer 1994; prostate carcinoma. Cancer 2000; 89: subject to many other modulatory factors. We 73: 678–87 589–96 therefore conclude that it is unrealistic to 6 Gettman MT, Bergstralh EJ, Blute M, 18 Lee LM, Pan CC, Cheng CJ, Chi CW, Liu correlate COX-2 with a distant endpoint such Zincke H, Bostwick DG. Prediction of TY. Expression of cyclooxygenase-2 in as angiogenesis. A more appropriate patient outcome in pathologic stage T2 prostate adenocarcinoma and benign relationship may be found if VEGF expression adenocarcinoma of the prostate: Lack of prostatic hyperplasia. Anticancer Res was determined directly. significance for microvessel density 2001; 21: 1291–4 analysis. Urology 1998; 51: 79–85 19 Edwards J, Mukherjee R, Munro AF, In summary, tumour angiogenesis, as 7 van Moorselaar RJ, Voest EE. Wells AC, Almushatat A, Bartlett JMS. measured by the MVD using an antibody to Angiogenesis in prostate cancer. its role in HER2 and COX-2 expression in human CD34, does not increase with tumour stage, disease progression and possible prostate cancer. Eur J Cancer 2004; 40: and appears to have a weak negative therapeutic approaches. Mol Cell 50–5 relationship with the expression of the pro- Endocrinol 2002; 197: 239–50 20 Liu XH, Kirschenbaum A, Yao S et al. angiogenic factor COX-2. The present study 8 Kirschenbaum A, Liu XH, Yao S, Levine Upregulation of vascular endothelial raises the possibility that COX-2 may AC. The role of cyclooxygenase-2 in growth factor by cobalt chloride- influence tumour progression in prostate prostate cancer. Urology 2001; 58 (2A): simulated hypoxia is mediated by cancer through mechanisms other than the 127–31 persistent induction of cyclooxygenase-2 promotion of angiogenesis. The use of 9 Sano H, Kawahito Y, Wilder RL et al. in a metastatic human prostate cancer selective COX-2 and angiogenesis inhibitors Expression of cyclooxygenase-1 and -2 in cell line. Clin Exp Metastasis 1999; 17: may still have a role in the targeted treatment human colorectal cancer. Cancer Res 687–94 of prostate cancer in the future, and indeed 1995; 55: 3785–9 21 Liu XH, Kirschenbaum A, Yao S, Lee R, this study suggests that these agents could be 10 Hwang D, Scollard D, Byrne J, Levine E. Holland JF, Levine AC. Inhibition used in combination. Expression of cyclooxygenase-1 and of cyclooxygenase-2 suppresses cyclooxygenase-2 in human breast angiogenesis and the growth of prostate cancer. J Natl Cancer Inst 1998; 90: 455– cancer in vivo. J Urol 2000; 164: 820–5 ACKNOWLEDGEMENTS 60 22 Fujita J, Mestre JR, Zeldis JB, 11 Davies G, Salter J, Hills M, Martin LA, Subbaramaiah K, Dannenberg AJ. The authors thank Dr W J Angerson for his Sacks N, Dowsett M. Correlation Thalidomide and its analogues inhibit statistical advice. The work was supported by between cyclooxygenase-2 expression lipopolysaccharide-mediated induction of grants from Prostate Research Campaign UK and angiogenesis in human breast cancer. cyclooxygenase-2. Clin Cancer Res 2001; and Glasgow Royal Infirmary Research Clin Cancer Res 2003; 9: 2651–6 7: 3349–55 Endowment Fund. 12 Tjandrawinata RR, Dahiya R, Hughes 23 Hussain T, Gupta S, Mukhtar H. Fulford M. Induction of cyclo- Cyclooxygenase-2 and prostate CONFLICT OF INTEREST oxygenase-2 mRNA by prostaglandin E-2 carcinogenesis. Cancer Lett 2003; 191: in human prostatic carcinoma cells. Br J 125–35 None declared. Cancer 1997; 75: 1111–8 24 Hall MC, Troncoso P, Pollack A et al. 13 Kirschenbaum A, Klausner AP, Lee R Significance of tumor angiogenesis in REFERENCES et al. Expression of cyclooxygenase-1 and clinically localized prostate carcinoma cyclooxygenase-2 in the human prostate. treated with external beam radiotherapy. 1 Campbell SC. Advances in angiogenesis Urology 2000; 56: 671–6 Urology 1994; 44: 869–75 research: relevance to urological 14 Uotila P, Valve E, Martikainen P, 25 Huss WJ, Hanrahan CF, Barrios RJ, oncology. J Urol 1997; 158: 1663–74 Nevalainen M, Nurmi M, Harkonen P. Simons JW, Greenberg NM. 2 Hanahan D, Folkman J. Patterns and Increased expression of cyclooxygenase-2 Angiogenesis and prostate cancer: emerging mechanisms of the angiogenic and nitric: oxide synthase-2 in human Identification of a molecular progression switch during tumorigenesis. Cell 1996; prostate cancer. Urol Res 2002; 29: switch. Cancer Res 2001; 61: 2736–43 86: 353–64 25–8 26 Mooteri S, Rubin D, Leurgans S, Jakate

S, Drab E, Saclarides T. Tumor 28 Bono AV, Celato N, Cova V, Salvadore Department of Surgery, Level II Queen angiogenesis in primary and metastatic M, Chinetti S, Novario R. Microvessel Elizabeth Building, Glasgow Royal Inﬁrmary, colorectal cancers. Dis Colon Rectum density in prostate carcinoma. Prostate Glasgow, G31 2ER, UK. 1996; 39: 1073–80 Cancer Prostatic Dis 2002; 5: 123–7 e-mail: [email protected] 27 Axelsson K, Ljung BM, Moore DH et al. Tumor angiogenesis as a prognostic Correspondence: John M.S. Bartlett, Abbreviations: VEGF, vascular endothelial assay for invasive ductal breast Endocrine Cancer Group, Section of Surgical growth factor; IHC, immunohistochemistry; carcinoma. J Natl Cancer Inst 1995; 87: and Translational Research, Division of Cancer MVD, microvessel density; COX-2, 997–1008 Sciences and Molecular Pathology, University cyclooxygenase-2; PG, prostaglandin.

Testicular-sparing microsurgery for suspected testicular masses

GIOVANNI MARIA COLPI, LUCA CARMIGNANI*, FRANCO NERVA, PIEDIFERRO GUIDO, FRANCO GADDA* and FABRIZIO CASTIGLIONI Andrology Unit, San Paolo Hospital, and *Department of Medicine and Surgery, Urology Unit, IRCCS Ospedale Maggiore, University of Milan, Milan, Italy Accepted for publication 11 February 2005

OBJECTIVE testicle was isolated after sectioning the albuginea. In the follow-up for infertility gubernaculum testis. In a separate operative reasons, no scarring was observable on the To describe a microsurgical technique for field, an equatorial incision of the albuginea tunica albuginea in the men who had removing suspected testicular masses with was made in a plane orthogonal to the major conservative therapy. One year later the sparing of the testicular parenchyma, and to axis of the testicle, sparing the subtunical patient with seminoma was free of disease. describe case studies. vasa. The parenchymal lobuli were dislodged and the seminiferous tubules dissociated, the CONCLUSIONS PATIENTS AND METHODS nodule identified and completely removed, together with ª1 mm of surrounding healthy The increasingly frequent detection of benign Six men were referred with testicular lesions tissue. This technique can also be used for testicular lesions, particularly in infertile men, (3–6 mm) detected on ultrasonography (US); microsurgical testicular sperm extraction calls for a surgical approach that must be as in one, the lesion was palpable. US showed (MicroTESE), to retrieve sperm in infertile men. conservative as possible for the testicular hypoechoic lesions and in two cases were parenchyma. We think that microsurgery mixed hypoechoic and anechoic. In these RESULTS should be the first-line technique in small men, the testicular lesion was identified by US suspected testicular lesions in infertile men. before surgery, giving three-dimensional In two infertile men MicroTESE was also coordinates to facilitate intraoperative performed. Histology revealed one case each KEYWORDS recognition. A traditional inguinal incision of seminoma, Leydig-cell tumour, Leydig cell was used and the funiculus clamped hyperplasia, atrophy, normality in the infertility, testicular neoplasm, conservative subinguinally without opening the canal. The incidental forms, and complicated cysts of the surgery, Leydig cell tumour

INTRODUCTION intraparenchymal branches of the testicular subinguinally without opening the canal. The artery, as well as a greater precision in testicle is isolated, the gubernaculum testis The increasing use of testicular removing testicular parenchyma for clinical sectioned, and the tunica vaginalis opened. ultrasonography (US) to evaluate infertile evaluation [4]. The microsurgical technique The lesion site is checked during surgery with men or to monitor scrotal pathology has can also be used advantageously for a 15 MHz ultrasound probe. Using a ¥15–20 led to the detection of more tumours. MicroTESE in men with unobstructive operating microscope, in a separate operative Furthermore, the greater attention paid by infertility [5]. field, an equatorial incision of the tunica men to their genitals, in the form of self- albuginea is made in a plane orthogonal to examination or visits to their GP, makes early The objective of the present study was to the major axis of the testicle, from one identification of small palpable testicular describe a microsurgical technique for quarter to about three-quarters of its lesions possible. As a significant percentage of removing suspected testicular masses, with circumference, depending on the depth of the these lesions are benign, especially in infertile sparing of the testicular parenchyma, and to lesion, sparing the subtunical vasa. men [1,2], the surgical approach should be as report our case studies. Haemostasis of the vessels that cannot be conservative as possible of the testicular spared is ensured by using microsurgical parenchyma. bipolar forceps, while 1–2 min compression PATIENTS AND METHODS with gauze soaked in saline solution Schlegel [3] developed a microsurgical and gentamicin is sufficient to stem approach specifically for detecting The microsurgical technique was that microbleeding of the parenchyma (ordinarily seminiferous tubules containing residues of described by Goldstein [5], with a few haemostasis is carried out when the spermatogenesis in men with unobstructive variations. The testicular lesion is identified by spermatic cord is unclamped). The azoospermia (microsurgical testicular sperm US before surgery, giving three-dimensional parenchymal lobuli are dislodged and the extraction, MicroTESE); this approach, which coordinates to facilitate intraoperative seminiferous tubules dissociated; the nodule is now used by others [4], allows optimal recognition. A traditional inguinal incision is is identified and completely removed, sparing of the albuginea vasa and of the made and the funiculus clamped together with ª1 mm of surrounding healthy

COLPI ET AL.

TABLE 1 The patients’ characteristics

Age, Testicular lesion Frozen-section years size, mm Ultrasonogram diagnosis Final diagnosis Infertility 42 4 hypoechoic negative atrophy yes 38 4 hypoechoic negative Leydig hyperplasia yes 34 5 hypoechoic Leydig tumour Leydig tumour yes + monorchid 39 3 hypoechoic germ cell tumour seminoma yes 40 6 hypo/anechoic albuginea cyst albuginea cyst no + monorchid 38 4 hypo/anechoic normal tissue normal tissue yes

tissue. The tissue is then sent for of the albuginea in the man with a palpable lesions discussed are relatively small, and extemporaneous histological examination. If lesion. Orchifuniculectomy with inguinal infiltration of the funiculus in this type of the man also has unobstructive azoospermia, canal opening was used in the man with lesion does not appear very likely. The surgery is always by a circumferential incision seminoma, identified as a germ cell tumour advantages of microTESE have already been for three-quarters of the tunica albuginea, in the extemporaneous histological described [4]. and completed by taking ª30 microsamples examination; CT and chest X-ray was of seminiferous tubules from the two sides of negative, and he had precautionary The pathologist is important in determining the open parenchyma, as described by radiotherapy, as advised by the oncologists. In the choice of treatment. Diagnosis from Schlegel [3]. In the presence of histological the follow-up for infertility reasons, no inspection of frozen sections has achieved a evidence of malignancy, the inguinal canal is scarring was observable on the tunica high degree of certainty, so the surgeon opened while the funiculus is clamped, and albuginea in the men who had conservative should rarely be faced with a difficult decision the inguinal portion of the spermatic cord therapy. [8,9]. However, the decision might be difficult recovered. In the case of histologically benign in the case of stromal tumours, i.e. in Sertoli nodules, the tunica albuginea is sutured with cell tumours, because they are difficult to 5/0–6/0 slow-absorption monofilament using DISCUSSION diagnose, and in Leydig cell tumours because an atraumatic needle. The tunica vaginalis is it is difficult to differentiating between closed with continuous nonabsorbable suture An increase in the incidence of testicular benign and malignant forms. with an intracavitary cortisone instillation lesions was reported recently [6,7]; these before completion. lesions are found fairly often in infertile men The increase in incidental US findings of [6], hence the need to spare as much testicular lesions, particularly in infertile men, Between April 2001 and February 2004, six testicular parenchyma as possible, and many calls for an approach that must be more men were referred to us with testicular lesions of these lesions are benign. From the present conservative of the testicular parenchyma; detected by US; in five the lesion was an data, microsurgery appears to be the least this can be obtained by microsurgery. This incidental finding during a scrotal scan for invasive treatment, allowing most or all of the technique is effective and minimally invasive, infertility, and in one the lesion was palpable subtunical vessels to be spared, and all the and is useful if a concurrent TESE is required. with a hypotrophic contralateral testicle. In all branches of the testicular artery, thus greatly We think it should be the first-line approach men the preliminary tumour markers were reducing possible areas of ischaemia. in the case of small suspected testicular negative. Table 1 shows the ages of the men Microsurgery also allows the lesion to be lesions in infertile men. and the US dimensions of the lesions; the better identified, enabling as little perilesional mean age of the men was 39.8 years. tissue as possible to be removed in the case of CONFLICT OF INTEREST benign pathologies. Furthermore, in cases in which a TESE must be used, it can be done None declared. RESULTS microscopically, selecting the most appropriate tissue; the amount of tissue REFERENCES Six men had microsurgery using the method extracted is thus limited, increasing the described; microTESE was also used in two percentage of men with positive recovery of 1 Horstman WG, Haluszka MM, Burkhard with unobstructive azoospermia, and in one spermatozoa, as already described [3,4]. The TK. Management of testicular masses of these a varicocele was also corrected. choice of subinguinal clamping of the incidentally discovered by ultrasound. The frozen-section examination yielded a spermatic cord is a compromise between the J Urol 1994; 151: 1263–5 diagnosis of germ cell tumour in one case and traditional inguinal approach and the scrotal 2 Carmignani L, Gadda F, Gazzano G et al. benign findings in the remaining five (Table 1). approach. Vascular clamping takes place High incidence of benign testicular Definitive histology revealed one each of before any manipulation of the testicle and in neoplasm diagnosed by ultrasound. J Urol classic seminoma, Leydig cell tumour, Leydig case of malignancy clamping is maintained, 2003; 170: 1783–6 cell hyperplasia, atrophy, normality in the the inguinal canal is opened, and the 3 Schlegel PN. Testicular sperm extraction: incidental forms, and some complicated cysts remaining part of the funiculus removed. The microdissection improves sperm yield

TESTICULAR-SPARING MICROSURGERY FOR TESTICULAR MASSES

with minimal tissue excision. Hum Reprod analysis. Fertil Steril 2001; 76 (Suppl. 1): frozen section examination of testicular 1999; 14: 131–5 S50 tumors of uncertain origin. Eur Urol 2002; 4 Silber SJ. Microsurgical TESE and the 7 Jacobsen R, Bostofte E, Engholm G 41: 290–3 distribution of spermatogenesis in non- et al. Risk of testicular cancer in men obstructive azoospermia. Hum Reprod with abnormal semen characteristic: Correspondence: Luca Carmignani, 2000; 15: 2278–84 cohort study. BMJ 2000; 321: 789– Department of Medicine and Surgery, Urology 5 Hopps CV, Goldstein M. Ultrasound 92 Unit, University of Milan, IRCCS Ospedale guided needle localization and 8 Leroy X, Rigot JM, Aubert S, Ballereau Maggiore, Via Luigi Sacco 7, 20146, Milan, microsurgical exploration for incidental C, Gosselin B. Value of frozen section Italy. nonpalpable testicular tumors. J Urol examination for the management of e-mail: address: [email protected] 2002; 168: 1084–7 nonpalpable incidental testicular tumors. 6 Norbert C, Goldstein M. Increased Eur Urol 2003; 44: 458–60 Abbreviations: MicroTESE, microsurgical incidence of testicular cancer in men 9 Elert A, Olbert P, Hegele A, Barth P, testicular sperm extraction; US, with infertility and abnormal semen Hofmann R, Heidenreich A. Accuracy of ultrasonography.

Authors from Mannheim describe Extracorporeal application of their experience with high- intensity ultrasound for locally high-intensity focused ultrasound conﬁned prostatic carcinoma. This for prostatic tissue ablation was essentially an in vivo efﬁcacy and safety study, as well as a AXEL HÄCKER, KAI UWE KÖHRMANN‡, WALTER BACK*, OLIVER KRAUT†, clinical feasibility study. They ERNST MARLINGHAUS†, PETER ALKEN and MAURICE STEPHAN MICHEL found a positive answer to all Departments of Urology and *Pathology, University Hospital Mannheim, Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Germany, †Storz Medical AG, questions asked. It will be Kreuzlingen, Switzerland and ‡Department of Urology, Theresienkrankenhaus Mannheim, interesting to see if further Germany evaluation leads to a potential Accepted for publication 3 February 2005 clinical use for this technology.

A study from the Cleveland Clinic is OBJECTIVE showed sharply demarcated coagulative necrosis. Side-effects, including skin and presented, of the 2-year follow-up To investigate the efficacy and safety of rectal burns, occurred only after transvesical results in 34 patients who had an extracorporeal prostatic tissue ablation using application in the in vivo study. There were no outpatient mid-urethral sling using high-intensity focused ultrasound (HIFU) in side-effects in patients after perineal porcine small intestine submucosa. vivo in animals, and in a clinical feasibility application. study in men, as this is an investigational The technique is described, with minimally invasive treatment alternative for CONCLUSION cure of incontinence in 27 of the locally confined prostatic carcinoma, but may 34 women. There was no prolonged have significant side-effects. Extracorporeal HIFU is technically feasible and induces sharply demarcated tissue damage in retention or erosion. PATIENTS, MATERIALS AND METHODS the prostate. From the early results of this phase 1 study, the perineal approach seems to Ultrasound (1.04 MHz excitation frequency) be safe. was generated by an extracorporeal cylindrical piezo-ceramic element and KEYWORDS focused by a paraboloidal reflector to a focal size of 32 ¥ 4 mm. The focal distance and high-intensity focused ultrasound, tissue aperture diameter were both 100 mm. HIFU ablation, prostate was applied extracorporeally at different intensities and pulse duration (up to 6 s) to 11 dog prostates in vivo (median intensity INTRODUCTION 1192 W/cm2) and eight patients (median intensity 3278 W/cm2, range 2384–3576) Over the last few years there has been a rapid under general anaesthesia. The lesions were development of minimally invasive therapies assessed macroscopically and histologically for treating infravesical obstruction caused by after HIFU and any side-effects evaluated. BPH or locally confined prostatic carcinoma. New energy sources using different RESULTS temperatures to destroy prostatic tissue have been promulgated as alternatives to TURP, the Thermoablation was feasible in vivo and in all reference standard of treatment, or to radical patients. Macroscopic analysis and histology prostatovesiculectomy. For treating BPH these

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FIG. 1. Schematic diagram of the generator for FIG. 2. Applicator with a water coupling cushion for applying clinical HIFU. applying HIFU.

Focal point 32 ¥ 4 mm Focal 1 MHz distance ultrasound field 100 mm

Piezoelectric Paraboloid cylinder reflector

B-mode Aperture diameter 100 mm alternatives include transurethral microwave thermotherapy, transurethral needle ablation, transurethral vaporization and interstitial laser coagulation. Prostatic carcinomas can be treated using cryoablation and microwave application. present study was to investigate the efficacy monitored using of a diagnostic 3.5 MHz and safety of extracorporeal prostatic ultrasound transducer (B-mode imaging) High-intensity focused ultrasound (HIFU) has ablation using HIFU in vivo in dogs and in a positioned in the centre of the cylindrical been used to treat both BPH and prostatic clinical feasibility study in men. piezo-ceramic element. The transducer was carcinoma [1,2], with the probe used to apply moved and positioned with a mechanical the energy inserted transrectally. Contrary to positioning device which can be manually the invasive approach of cryoablation, the PATIENTS, MATERIALS AND METHODS moved in all directions. A dedicated computer energy source used for HIFU need not be program is used to identify the focal position inserted into the prostatic tissue to be treated. Ultrasound waves were generated by a in the diagnostic ultrasonogram. Ultrasound waves are applied outside the cylindrical piezo-ceramic element and organ and focused on a target area within the focused by a paraboloidal reflector (Fig. 1). In each prostate, different discrete areas in tissue. The power density of the converging The excitation frequency was 1.04 MHz, and the centre of the prostate parenchyma were ultrasound waves is highest when the waves aperture diameter and focus distance both selected by the integrated diagnostic reach the focus. This allows high energy 100 mm. The average size of the rotational ultrasound transducer. The treatment areas densities to be reached even in deeper tissue ellipsoid was 32 ¥ 4 mm (focal size). The were ≥5 mm apart and were subjected to one layers. Absorption of the acoustic energy by geometric dimensions of the applicator and ultrasound pulse with an interval of 30 s the tissue and its conversion into thermal focus were identical for in vivo and clinical between each application. energy induces thermonecrosis [3]. application. The in vivo model comprised 11 male beagle Although the reported follow-up periods are During the animal tests, ultrasound waves dogs under intubation anaesthesia and fixed short, the oncological results obtained to date were coupled to the bodies of the dogs inside in a basin filled with degassed water (animal after treating locally confined prostatic a water basin filled with degassed water test permission: ref. no. 37–9185.81/80/93, carcinoma using transrectal HIFU are (37 ∞C). The main feature of the generator Land Government Office, Karlsruhe). The promising [2,4–10]. According to Thüroff used for clinical application is that it allows abdominal skin was shaved and degreased in et al. [11], side-effects encountered after ultrasound waves to be directly coupled to the the coupling area. Focused HIFU was applied transrectal treatment include rectal mucosal body surface using a cushion filled with to the prostate transvesically through the burns in 0.7–15% [11], recto-urethral fistula cooled (16 ∞C) degassed water. The amount of filled urinary bladder. Because of the anatomy in 0.5–5% [11,12], urethral strictures in up to water inside the cushion can be controlled of the animal, it was not possible to find a 10% [12] and impotence in ª70% of patients electronically to allow the penetration depth coupling window for perineal application. [11,13]. These significant side-effects are to be adjusted to each patient and the specific Focused HIFU was applied at an intensity of partly caused because the ultrasound waves distance between the skin surface and 1192 W/cm2 and with a pulse duration of are applied transrectally. prostate (Fig. 2). 1–6 s; the median (range) focal depth was 46 (38–59) mm. Identical treatments were We have developed a HIFU application system For both the dog and human application, the repeated at least five times each. During designed for the extracorporeal ablation of tissue areas to be treated and the focal autopsy, within 1 h of completing HIFU, the prostatic tissue, and the objective of the position inside the tissue were located and prostatic lesions and possible thermonecrosis

HIFU FOR THE PROSTATE

FIG. 3. Perineal coupling of the ultrasound applicator for prostatic treatment. TABLE 1 Patient and treatment variables for the clinical application of HIFU (pulse duration 4 s)

Number Patient Penetration of Intensity, no. depth, mm pulses W/cm2 1 70 17 3576 2 65 3 2682 3 80 12 3576 4 80 5 2980 5 62 9 2384 6 69 28 3576 7 53 50 3576 8 60 7 2980

perineally coupled to the patient’s body using ultrasound gel, and the water cushion filled with water according to the required penetration depth (Fig. 3). The integrated ultrasound transducer was used to locate an optimum sonic window for coupling the FIG. 4. Macroscopic findings of sharply demarcated coagulation necroses after applying HIFU to prostatic water cushion and to make sure that no bone tissue in vivo. structures (pubic bone) or air (rectum) could interfere with the propagation of the ultrasound waves by absorption or reflection.

All patients were treated under intubation anaesthesia. For each prostate, focused HIFU was applied at different intensities (median 3278 W/cm2, range 2384–3576) and total number of pulses (median 10.5, range 3–50). In all, 131 pulses were applied to eight prostates, with a pulse duration in all cases of 4 s (Table 1). The skin in the perineal region was examined after completing the treatment to identify thermal skin lesions. The patients were then positioned for open prostatic adenoma enucleation or TURP, which followed the standard procedure. In the case of adenoma enucleation, the prostatic tissue was examined macroscopically immediately after surgical removal, then fixed in a 10% formalin solution for histological tissue preparation (haematoxylin and eosin, 4 mm) to allow the induced lesions to be examined. in the skin and ultrasound path distal from enucleation (five) or TURP (three) were After discharge, the patients were followed up the focus were evaluated. The prostates were recruited for HIFU. After the patients had been by the office urologist. cut into 3 mm tissue slices for macroscopic informed about the treatment and risks tissue preparation, and the maximum lesions involved, and given their consent (ref. no. per area measured using a sliding calliper. The 166/98, Ethics Commission of the Baden– RESULTS tissue was then fixed in a 10% formalin Württemberg Medical Association), they were solution for histological assessment prepared for surgery in accordance with the In the dog model, it was possible to induce (haematoxylin and eosin staining; 4 mm clinic’s internal standards. To allow HIFU thermal lesions in all 11 prostates; 5–31 sections). treatment patients were placed in the areas were treated in each prostate. The lithotomy position, had their perineum macroscopic lesions showed a sharply For the clinical study, eight patients originally shaved and the skin degreased. Before HIFU circumscribed long, oval white/yellow lesion scheduled for open prostatic adenoma application the source shown in Fig. 2 was with a haemorrhagic seam (Fig. 4). With

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FIG. 5. Microscopic ﬁndings of a coagulation necrosis after applying HIFU to prostatic tissue in vivo (¥ 25). TABLE 2 The maximum prostatic lesion size after HIFU (intensity 4769 W/cm2)

Pulse Maximum lesion Animal duration, s size, mm 12 6 ¥ 3 22 11 ¥ 2 3 3 20 ¥ 4 45 7 ¥ 6 55 7 ¥ 2 65 7 ¥ 4 75 8 ¥ 5 8 5 19 ¥ 3 9 5 20 ¥ 4 10 5 22 ¥ 10 11 6 8 ¥ 5

identical treatment parameters (pulse duration and penetration depth) the lesion size was reproducible but there was a difference in size in different animals. The mean diameters of the macroscopic lesions are shown in Table 2; the median diameter sections after adenoma enucleation in five During HIFU it was not possible to observe was 8 ¥ 4 mm, the largest 22 ¥ 10 mm and showed sharply circumscribed lesions with and monitor the time-dependent the smallest 6 ¥ 3 mm. There was no tissue destruction. Because of the surgical development of the lesion. This was caused by correlation between lesion size and pulse procedure it was not possible to measure the back-scattering of the HIFU waves in the duration. lesion size exactly. The lesions corresponded tissue, which over-modulated the diagnostic to the anatomical areas that had been ultrasonography and created a totally white Histological analysis (Fig. 5) showed that exposed to HIFU under ultrasonographic image in the B-mode scan. After the power the central coagulation necrosis was guidance. The histological analysis of the pulse, a hyper-echogenic area at the expected characterized by complete and homogeneous tissue sections showed that most lesions were focal region was sometimes apparent in denaturation of all tissue structures, with mechanical, with haemorrhage and minor the undisturbed B-mode scan. Therefore, immediate interruption of the blood tissue necrosis. Histology showed sharply online monitoring and reliable visualization circulation caused by vascular coagulation. demarcated lesions. of the thermonecrosis by diagnostic Incomplete tissue destruction was identified ultrasonography was not possible. in the boundary zone, along with ruptured As assessed immediately after HIFU and blood vessels. during the clinical follow-up, there was no thermal or mechanical injury of the urethra, DISCUSSION After HIFU application to the prostate at an bladder and rectal mucosa, or fistula. None of intensity of 1192 W/cm2 and a pulse duration the patients had thermal skin lesions; in the HIFU has been used for ª50 years to treat of 6 s (21 areas), one animal had muscular five treated by open prostatectomy there were patients with various indications; organs haemorrhage of 40 ¥ 35 mm in the no lesions in the tissue traversed by the treated to date include the brain (Parkinson’s penetrated healthy tissue, caused by ruptured ultrasound waves in the abdominal wall disease [14]), eyes (glaucoma [15,16]), liver blood vessels. Histology showed no incision or in the bladder. No other HIFU- [17], uterus [18] and urinary bladder [19]. thermonecrosis in this area. One animal had specific side-effects and complications after Apart from extracorporeal application to some minor diffuse bleeding in the pre- surgery were identified. these organs, HIFU has also been applied prostatic fat tissue. Ulceration of the rectal transrectally to treat prostatic tissue. Initial mucosa was identified in all cases, with a Because of the multidirectional flexibility of results of an in vivo study published in the median (range) diameter of 9 ¥ 4.5 (35 ¥ 20 the water cushion, it was possible to couple 1990s documented the feasibility of the to 3 ¥ 2) mm. A whitish serosal necrosis the transducer and to place the focal point in contact-less induction of thermonecrosis appeared in four animals, and first-degree the prostate in different anatomical positions [20]. In 1993, Foster et al. [21] reported on the skin burns in two. in the eight patients. Using the central first 15 patients who had received transrectal 3.5 MHz diagnostic inline ultrasonography, prostatic treatment by HIFU. Since then, Perineal extracorporeal HIFU application was good visualization of all areas of the prostate various groups have treated BPH by HIFU, and possible in all eight patients; all had surgery was possible and the target tissue could be these studies provided histological evidence immediately after HIFU. Macroscopic precisely positioned in the focal point of the of coagulation necrosis within the prostate, examination of the prepared prostatic tissue system. followed by a reduction of obstructive urinary

HIFU FOR THE PROSTATE

disorders on subsequent clinical examination transrectal treatment, in the present study we treat larger areas with more pulses; further [1,22]. However, because HIFU was not assessed the suitability of a generator for clinical studies are necessary. effective in the long-term, treatment of BPH extracorporeal HIFU treatment of prostatic by HIFU was eventually discarded [23]. tissue. In conclusion, extracorporeal HIFU therapy of prostatic tissue, using a cylindrical piezo- In parallel with its use for prostatic adenoma Using the integrated diagnostic ultrasound ceramic element and a paraboloidal reflector tissue, HIFU was also used to treat prostatic transducer, good visualization of all areas of to focus the ultrasound waves, induces carcinoma. Initial results showed the the prostate was possible and the target sharply demarcated tissue necrosis. The possibility of local tumour control with tissue could be positioned precisely in the application is flexible and technically feasible. negative control biopsies in half the patients focal point of the system. However, online With monitoring by diagnostic inline [24]. After assessing PSA values and biopsy visualization of the thermonecrosis was not ultrasonography, HIFU tissue ablation was results at different follow-up intervals, possible. Several groups [26,27] providing safe and reliable in a pilot study of eight various groups provided evidence of comparable findings described the limitations patients. This method is an alternative to promising remission rates [2,4–10]. As noted of diagnostic ultrasonography in terms of transrectal HIFU, and larger-scale follow-up previously, there were various significant visualizing detectable tissue changes during studies are required to confirm that the side-effects after transrectal treatment or after HIFU. Possible solutions for improving perineal is better than the transrectal [11–13], with stress incontinence identified online monitoring of complete tissue ablation approach. in 3.9–24% of patients [2,13], partly caused might be provided by direct computer-aided by applying HIFU transrectally. evaluation of ultrasound signals, Doppler ultrasonography or MRI [28]. These new CONFLICT OF INTEREST In a histopathological study of nine technologies are currently in the development prostatectomy tissue sections (radical stage. None declared. Source of funding: E. prostatovesiculectomy 7–12 days after Marlinghaus and O. Kraut: Storz Medical AG, transrectal HIFU treatment of a prostatic Macroscopic analysis of the present prostates Kreuzlingen, Switzerland; Faculty of Clinical carcinoma), Beerlage et al. [25] showed that showed sharply demarcated lesions similar to Medicine Mannheim, University of Heidelberg. thermonecrosis was induced in the treated those identified after transrectal application prostatic tissue, but that it was incomplete on [1], and histology showed that mechanical the dorsal side in two samples. These authors lesions, in the form of ruptured tissue and REFERENCES concluded that incomplete thermonecrosis haemorrhages, prevailed over thermal lesions. is caused by several factors specific to Susani et al. [29] described similar histological 1 Madersbacher S, Kratzik C, Susani M, transrectal HIFU. The first was the safe findings immediately after transrectal HIFU; Marberger M. Minimally invasive therapy distance (3–6 mm) between the rectal wall epithelial cells had dark-staining pycnotic of benign prostatic hyperplasia with and dorsal prostatic capsule required for nuclei, with the surrounding cytoplasm being focused ultrasound. Urologe A 1995; 34: transrectal application, to avoid thermal narrow and irregularly vacuolated. The 98–104 rectal lesions, such that tissue directly at the epithelium was detached from the basal 2 Gelet A, Chapelon JY, Bouvier R, prostatic capsule is not exposed. Second, the membrane and single cells were dissociated. Rouviere O, Lyonnet D, Dubernard JM. ellipsoidal focal configuration causes the Electron microscopy of the fresh lesions (2–3 Transrectal high intensity focused maximum energy concentration to be reached h after HIFU) showed severe changes at the ultrasound for the treatment of localized in the centre of the ellipse, whereas the subcellular level. After 7 days, the target area prostate cancer: factors influencing the energy dose in the treated tissue at the ends appeared to be a classic haemorrhagic outcome. Eur Urol 2001; 40: 124–9 of the ellipse may be insufficient to induce necrosis; within 10 weeks, the coagulative 3 ter Haar GR. High intensity focused thermonecrosis. Third, the ultrasound waves necrosis was resorbed by tissue rich in ultrasound for the treatment of were coupled to the prostate using a balloon macrophages and capillary sprouts, and a scar tumors. Echocardiography 2001; 18: filled with cooled water and placed in the was formed. The border between HIFU treated 317–22 rectum. Because of this cooling effect and untreated tissue was extremely sharp, 4 Thuroff S, Chaussy C, Vallancien G et al. the temperature required to induce comprising 5–7 cell layers. High-intensity focused ultrasound and thermonecrosis on the dorsal side of the localized prostate cancer: efficacy results organ may fall below the threshold In the present in vivo dog study, the lesions from the European multicentric study. temperature of ª60 ∞C. were of variable size and the dimensions not J Endourol 2003; 17: 673–7 reproducible. The side-effects on the rectal 5 Chaussy C, Thuroff S. High-intensity The transrectal applicators used have a mucosa were basically caused by the focused ultrasound in prostate cancer: penetration depth of up to 45 mm, and anatomical proximity of the prostate and results after 3 years. Mol Urol 2000; 4: consequently, complete tissue treatment may rectum in dogs (3–5 mm apart [30]). It was 179–82 be anatomically impossible for larger not the aim of this study to ablate large tissue 6 Chaussy C, Thuroff S. Results and side prostates (>40 mL). Thus Chaussy et al. [7] volumes and thus only small tissue areas were effects of high-intensity focused suggested TURP before HIFU to ensure treated. Because the technique is new, we did ultrasound in localized prostate cancer. effective treatment even of peripheral areas, not know the exact pulse duration and J Endourol 2001; 15: 437–40 after reducing the tissue mass. Thus in view of number to be delivered in human prostates. 7 Chaussy C, Thuroff S. The status of high- these technical drawbacks and side-effects of Only experience will enable us to progress and intensity focused ultrasound in the

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treatment of localized prostate cancer glaucoma with high intensity focused 24 Gelet A, Chapelon JY. Effects of high- and the impact of a combined resection. ultrasound. Int Ophthalmol 1989; 13: intensity focused ultrasound on the Curr Urol Rep 2003; 4: 248–52 167–70 human prostate. J Urol (Paris) 1993; 99: 8 Kiel HJ, Wieland WF, Rossler W. Local 17 ter Haar G, Sinnett D, Rivens I. High 350 control of prostate cancer by transrectal intensity focused ultrasound – a surgical 25 Beerlage HP, van Leenders GJ, HIFU-therapy. Arch Ital Urol Androl 2000; technique for the treatment of discrete Oosterhof GO et al. High-intensity 72: 313–9 liver tumours. Phys Med Biol 1989; 34: focused ultrasound (HIFU) followed after 9 Uchida T. High intensity focused 1743–50 one to two weeks by radical retropubic ultrasound for localized prostate 18 Chan AH, Fujimoto VY, Moore DE, prostatectomy. results of a prospective cancer. Nippon Rinsho 2000; 58 (Suppl): Martin RW, Vaezy S. An image-guided study. Prostate 1999; 39: 41–6 303–5 high intensity focused ultrasound device 26 ter Haar G. High intensity ultrasound. 10 Uchida T, Muramoto M, Kyunou H, for uterine ﬁbroids treatment. Med Phys Semin Laparosc Surg 2001; 8: 77–89 Iwamura M, Egawa S, Koshiba K. 2002; 29: 2611–20 27 Vaezy S, Shi X, Martin RW et al. Real- Clinical outcome of high-intensity 19 Watkin NA, Morris SB, Rivens IH, time visualization of high-intensity focused ultrasound for treating benign Woodhouse CR, ter Haar GR. A focused ultrasound treatment using prostatic hyperplasia: preliminary report. feasibility study for the non-invasive ultrasound imaging. Ultrasound Med Biol Urology 1998; 52: 66–71 treatment of superﬁcial bladder tumours 2001; 27: 33–42 11 Thuroff S, Chaussy C. Therapy of local with focused ultrasound. Br J Urol 1996; 28 Kennedy JE, Ter Haar GR, Cranston D. prostatic carcinoma with high intensity 78: 715–21 High intensity focused ultrasound. focussed ultrasound (HIFU). Outcome and 20 Foster RS, Bihrle R, Sanghvi N et al. surgery of the future? Br J Radiol 2003; side-effects. Urologe A 2001; 40: 191–4 Production of prostatic lesions in canines 76: 590–9 12 Uchida T, Sanghvi NT, Gardner TA et al. using transrectally administered high- 29 Susani M, Madersbacher S, Kratzik C, Transrectal high-intensity focused intensity focused ultrasound. Eur Urol Vingers L, Marberger M. Morphology of ultrasound for treatment of patients with 1993; 23: 330–6 tissue destruction induced by focused stage T1b-2n0m0 localized prostate 21 Foster RS, Bihrle R, Sanghvi NT, Fry FJ, ultrasound. Eur Urol 1993; 23 (Suppl. 1): cancer: a preliminary report. Urology Donohue JP. High-intensity focused 34–8 2002; 59: 394–8 ultrasound in the treatment of prostatic 30 Hill CR, ter Haar GR. Review article: high 13 Thuroff S, Chaussy C. High-intensity disease. Eur Urol 1993; 23 (Suppl. 1): 29– intensity focused ultrasound – potential focused ultrasound. complications and 33 for cancer treatment. Br J Radiol 1995; adverse events. Mol Urol 2000; 4: 22 Nakamura K, Baba S, Fukazawa R 68: 1296–303 183–7 et al. Treatment of benign prostatic 14 Fry W, Fry F. Fundamental neurological hyperplasia with high intensity focused Correspondence: Axel Häcker, Department of research and human neurosurgery using ultrasound: an initial clinical trial in Urology, University Hospital Mannheim, intense ultrasound. IRE Transactions Med Japan with magnetic resonance imaging Faculty of Clinical Medicine Mannheim, Electronics 1960; 7: 166–81 of the treated area. Int J Urol 1995; 2: Ruprecht-Karls-University of Heidelberg, 15 Sterk CC, Borsje RA, van Delft JL. 176–80 Theodor-Kutzer-Ufer 1–3, 68135 Mannheim, The effect of high-intensity focused 23 Madersbacher S, Schatzl G, Djavan B, Germany. ultrasound on intraocular pressure in Stulnig T, Marberger M. Long-term e-mail: [email protected] therapy-resistant glaucoma 3–4 months outcome of transrectal high- intensity heidelberg.de and 1 year after treatment. Int focused ultrasound therapy for benign Ophthalmol 1992; 16: 401–4 prostatic hyperplasia. Eur Urol 2000; 37: Abbreviations: HIFU, high-intensity focused 16 Valtot F, Kopel J, Haut J. Treatment of 687–94 ultrasound.

Association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symptoms in older American men: ﬁndings from the third National Health And Nutrition Examination Survey

SABINE ROHRMANN*, CARLOS J. CRESPO†, JASON R. WEBER*, ELLEN SMIT†, EDWARD GIOVANNUCCI‡¶ and ELIZABETH A. PLATZ*§ *Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, †Department of Social and Preventive Medicine, University at Buffalo, State University of New York, Buffalo, NY, ‡Channing Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, ¶Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA, and §The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA Accepted for publication 2 February 2005

OBJECTIVES prostate surgery unrelated to cancer were not statistically signiﬁcantly inversely associated included as cases. Controls were men with no with LUTS (P trend, 0.06), whereas men who To examine the association of cigarette symptoms or surgery. We adjusted for age and reported no leisure-time physical activity had smoking, alcohol consumption and physical race in logistic regression models and used a greater odds of LUTS (2.06; 1.26–3.39). activity with lower urinary tract symptoms sampling weights to account for selection (LUTS) in older men. probability. CONCLUSIONS

SUBJECTS AND METHODS RESULTS Moderate alcohol consumption and physical activity may be protective against LUTS. The study included 2797 men participating in Current cigarette smokers had no higher odds Current cigarette smoking was not the Third National Health and Nutrition of LUTS than ‘never’ smokers, but former consistently associated with the condition. Examination Survey (NHANES III), who were heavy smokers (≥ 50 pack-years) had a higher The possible association in former smokers aged ≥60 years. During an interview, LUTS, odds of LUTS than never smokers (odds ratio warrants further investigation. smoking history, alcohol consumption and 2.01; 95% conﬁdence interval 1.04–3.89). physical activity were assessed. Cases Men who drank alcohol daily had a lower KEYWORDS comprised men with at least three of the chance of LUTS than non-drinkers (0.59; symptoms of nocturia, hesitancy, weak stream 0.37–0.95; P trend, 0.07). All levels of NHANES III, LUTS, smoking, physical activity, and incomplete emptying. Men who had had moderate and vigorous activity were alcohol consumption

INTRODUCTION cigarette smoking and alcohol consumption SUBJECTS AND METHODS with LUTS are more controversial. Most LUTS are a common bothersome condition in studies found either no [3–8] or a positive NHANES III is a nationally representative older men. Although BPH is thought to be one [9–11] association between cigarette smoking cross-sectional study of the non- cause of these symptoms not all men with and LUTS. Fewer studies have evaluated the institutionalized civilian USA population symptoms have an enlarged prostate [1]; association of alcohol intake with LUTS; two conducted between 1988 and 1994 [12]. A changes in the tone of prostate and bladder studies reported an inverse association [4,11] multistage probability sampling design was smooth muscle may also contribute to these whereas in others there were positive used with oversampling of non-Hispanic symptoms. Despite the high prevalence of associations [3,7,9]. blacks, Mexican-Americans and older LUTS not much is known about their causes. participants. Subjects participated in an Age is the only well-established risk factor, The Third National Health and Nutrition interview conducted at home and had an but it has been hypothesized that common Examination Survey (NHANES III) is a large extensive physical examination. In the present lifestyle factors such as smoking, American cross-sectional study conducted analysis we included 3117 men who were consumption of alcohol, or physical inactivity between 1988 and 1994. Using the data aged ≥60 years at participation. Of these, might contribute to the symptoms. collected in NHANES III, we evaluated the we excluded those men with a mobility association of cigarette smoking, alcohol impairment (103) or who were not self- While physical activity generally has been consumption and physical activity with LUTS respondents (133); we further excluded 84 found to be inversely associated with the in a multi-ethnic group of older men men who reported during the interview of prevalence of LUTS [2,3] the associations of representative of the USA. having had a diagnosis of prostate cancer at

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some point before the interview. The beverages, those who drank up to once per consumption and physical activity. In the remaining 2797 men were included in the week, more than once per week but less than logistic regression models, we adjusted for analysis. once per day, and those who drank alcohol age (5-year categories) and race (non- once a day or more. During the physical Hispanic black, non-Hispanic white, Mexican- During the interview, all men who were aged examination at the Mobile Examination American, other). We further included in the ≥60 years were asked to report the following Center a 24-h dietary recall was administered, models the waist circumference (continuous symptoms, which are part of the AUA which assessed the amount of alcohol variable) as a possible confounder, and Symptom Index [13]: (a) How many times per consumed during the previous day. From mutually adjusted cigarette smoking, alcohol night do you usually get up to urinate (pass these data, the daily intake of alcohol (in consumption and physical activity. Trends for water)? (‘nocturia’); (b) when you urinate grams) was calculated. We grouped men as alcohol consumption and physical activity (pass water), do you usually feel like you have having an intake of 0, 1–15, 16–37 or ≥38 g/ were tested by assigning to each man the not completely emptied your bladder? day. Furthermore the type and frequency of median value for the exposure category into (‘incomplete emptying’); (c) do you usually leisure-time physical activity in the past which he fell and modelling this term as a have trouble starting to urinate (pass water)? month were ascertained during the interview. continuous variable, the coefficient for which (‘hesitancy’); and (d) has the force of your Physical activities were coded and classified was evaluated by the Wald test. urinary stream of water decreased over the by rate of energy expenditure (i.e. by intensity) years? (‘weak stream’). In the present analysis, according to a standardized coding scheme RESULTS men were considered as having LUTS if they developed by Ainsworth et al. [14]. Men were reported at least three of the four symptoms. grouped by their weekly frequency of Of the 2797 men in the analysis, 28.8% had Nocturia was included as a symptom when moderate and vigorous activity, defined as no LUTS and had never had prostate surgery men had to get up at least twice per night. walking, jogging or running, biking, (controls), 46.7% reported one or two Men were also asked if they had ever had swimming, aerobics, dancing, calisthenics, symptoms and 10.3% reported three or four surgery for their prostate not related to gardening, lifting weights, and other physical symptoms (cases). Men with LUTS were older cancer. Those men who reported such surgery activities, if the metabolic equivalent of the than men in the control group and had fewer were excluded from the cases because activity compared to at rest (METs) was >2.4 years of education (Table 1). These men also removing the hyperplastic tissue may have for men aged 60–64, >1.9 for men aged drank less alcohol, but smoking patterns and reduced or eliminated symptoms. The controls 65–79, or >1.25 for men aged > 79 years. We weekly frequency of physical activity did not were men who reported none of the four further evaluated the frequency of vigorous differ. symptoms and had never had prostate activity only, which was defined as walking surgery unrelated to cancer. Men with only (for men aged > 79), jogging or running (all Men who currently smoked up to 35 one or two symptoms were excluded from the men), biking (for men aged > 64), swimming cigarettes/day had no greater odds of LUTS, analysis to increase the specificity of the LUTS (all men), aerobics (all men), dancing (for men but there was insignificantly greater odds of definition. In a cohort of similarly aged men aged > 64), calisthenics (for men aged > 64), LUTS in men who smoked ≥35 cigarettes/per unselected for urological problems and in gardening (for men aged > 64), lifting day (Table 2). However, this association was which the AUA Symptom Index was weights (for men aged > 79), and other strongly attenuated after adjusting for waist administered [11], the Pearson correlation physical activity if METs were >5.9 for men circumference, the frequency of alcohol coefficient between the AUA symptom score aged 60–64, >4.7 for men aged 65–79, or consumption, and the frequency of moderate and the index using only the four symptoms >2.9 for men aged > 79 [15]. The waist and vigorous activity. Of these factors, waist of the abbreviated score was 0.7 (P < 0.001). circumference of the participants was circumference caused the strongest The agreement between using as the measured during the physical examination. attenuation of the OR for heavy smoking. threshold a score of 3 or 4 on the abbreviated Men were considered to have a history of Former smokers had a slightly but not index and using a score of 15+ on the full hypertension if they currently used statistically significant greater odds of LUTS index as the indicator of high moderate/ medication to treat hypertension or if they than never smokers. Men who had ever severe LUTS was 69%. were told by their doctor on two occasions smoked ≥50 pack-years had a higher odds of that they had hypertension/high blood LUTS than never smokers. This association was Smoking history was assessed during the pressure. limited to former smokers; there was no interview and men were classified according association among current smokers who had to their smoking habit into current (1–34, or The results were analysed statistically using smoked ≥50 pack-years. Further adjustment ≥35 cigarettes/day), former, or never smokers. SAS v8.1 (SAS Institute, Cary, NC) and for waist circumference, but not for We also calculated pack-years of smoking SUDAAN [16] software. We used sample hypertension, attenuated the association of from smoking history, a pack-year being weights that took into account several pack-years with LUTS in both ever and former defined as 20 cigarettes/day for 1 year. The features of the NHANES III survey, i.e. the smokers. consumption frequency of alcoholic specific probabilities of selection for the beverages (beer, wine, liquor) during the past individual domains that were over-sampled as There was an inverse association between the month was assessed using a food-frequency well as non-response and differences frequency of alcohol consumption and LUTS questionnaire during the interview. This between the sample and the total USA in this group of older men (Table 2). Compared method captures long-term habits of alcohol population [12]. Logistic regression was used to non-drinkers, men who drank alcohol daily consumption. We categorized men into those to calculate the odds ratio (OR) and 95% CI had a significantly lower odds of LUTS. This who consumed none of these three alcoholic of LUTS for cigarette smoking, alcohol association was not substantially altered after

SMOKING, ALCOHOL, PHYSICAL ACTIVITY AND LUTS IN OLDER MEN

for total frequency of moderate and TABLE 1 Age-adjusted baseline characteristics of men aged ≥60 years in the NHANES III, 1988–94 vigorous physical activity as well as waist circumference, smoking and alcohol drinking Factor Controls Cases P did not change the association for walking. Unweighted sample size 715 320 % of total sample 28.8 10.3 Mean (SEM) DISCUSSION Age, years 67.6 (0.3) 71.0 (0.6) <0.001* Current waist size, cm 100.4 (0.66) 101.2 (0.65) 0.46* In this group of older men in the USA, alcohol Years of education 11.3 (0.2) 10.4 (0.4) 0.03* consumption and physical activity (moderate Smoking habits, % and vigorous) were both inversely associated Never 28.7 23.6 0.21† with LUTS. Men who walked regularly were Former 48.3 57.5 less likely to have LUTS than men who did not. Current (1–34/day) 19.0 12.9 There was no association between current Current (≥35/day) 4.1 6.0 cigarette smoking and LUTS, but we could not Mean (SEM) exclude that former heavy smokers were more Alcohol consumption likely to have LUTS. Frequency‡, n/month 15.6 (1.89) 9.5 (1.25) 0.02* median 0.85 0 Several studies have examined the association Intake, g/day 11.1 (1.19) 7.0 (1.60) 0.02* between cigarette smoking and LUTS, with median 0 0 inconsistent results. Most studies found no Race/ethnicity, % statistically significant association between Non-Hispanic white 85.9 86.2 0.17† cigarette smoking and LUTS [3–8], whereas Non-Hispanic black 6.9 7.5 three studies reported a statistically Mexican-American 1.9 3.7 significantly positive association [9–11]. In an Others 5.5 2.6 analysis of the Health Professionals Follow-up Physical activity¶, mean (SEM) times/week Study [11], heavy smokers had a significantly Moderate + vigorous 6.90 (0.35) 5.97 (0.63) 0.24* higher risk of LUTS than never smokers, median 5.23 4.11 whereas moderate smokers did not. Similarly, Vigorous 3.58 (0.26) 3.18 (0.35) 0.46* in NHANES III, there was no association for median 0.42 0.75 current cigarette smoking, but a suggestion of a higher occurrence of LUTS in heavier All percentages and means are calculated using sampling weights; adjusted for age; *t-test; †chi-square current, lifetime and former smokers. test; ‡assessed by food frequency questionnaire during the household interview; ¶assessed by 24-h recall during the physical examination (see text). There may be several explanations for LUTS possibly being more common in long-term heavy smokers. Nicotine increases FIG. 1. Age- and race-adjusted OR of LUTS by Men who reported no leisure-time physical sympathetic nervous system activity [17] and walking (miles/week) in men aged ≥60 years in the activity had a significantly higher odds of LUTS might contribute to LUTS via an increase in NHANES III, 1988–94. (OR = 2.09, 95% CI 0.14–1.2, P trend 0.08) the tone of the prostate and bladder smooth than men who reported some physical activity, muscle. Furthermore, smoking is thought to 10.00 and adjusting for smoking, alcohol intake and be associated with higher concentrations of waist circumference did not change this testosterone [18]. A higher testosterone association. All levels of moderate or vigorous concentration might be associated with 1.00 physical activity were also associated with a higher intraprostatic dihydrotestosterone significantly lower odds of LUTS than men levels, which is thought to be important in the

OR, 95% CI who reported no moderate or physical activity development of BPH and LUTS [19]. (Table 2). These results did not change after 0.10 0 (ref.) 0.01–0.99 1.00–2.99 3.00+ further adjusting for history of hypertension There was a slightly greater chance of LUTS in Walking, miles/week or for the presence of the metabolic syndrome former smokers and these men also had a (data not shown). However, vigorous physical higher odds of LUTS when they smoked ≥50 adjusting for waist circumference, physical activity alone was not consistently inversely pack-years over their lifetime. Platz et al. [11] activity and cigarette smoking, or for associated with LUTS. The most frequently also reported a higher risk of LUTS in former hypertension. Using a second approach to reported activity was walking. Fewer men with smokers. The reasons for a greater risk of LUTS assess alcohol consumption by 24-h dietary LUTS than men without reported walking in former smokers are not clear. The greater recall, men with an alcohol intake of ≥38 g/ (33.2% vs 50.8%, P = 0.003). Men who waist circumference in former than in current day had a lower OR of LUTS (OR = 0.41, 95% reported walking had a lower odds of LUTS smokers in this group of men might CI 0.14–1.2, P trend 0.08) than men with no than men who did not, although the OR did contribute to LUTS via increased insulin alcohol intake. not decrease monotonically (Fig. 1). Adjusting resistance [20]. Also, men who develop

ROHRMANN ET AL.

symptoms might be more likely to stop TABLE 2 The OR of LUTS by current smoking status, pack-years of smoking, alcohol consumption and smoking than men without symptoms. In physical exercise addition, we cannot exclude chance as an explanation for this finding. Factor OR (95% CI)*† OR (95% CI) Cigarette smoking status‡ Men who frequently consumed alcohol were Never 1.00 1.00 less likely to have LUTS than men who did not. Former 1.46 (0.88–2.40) 1.37 (0.79–2.36) There was also a lower odds of LUTS with Current, cigarettes/day increasing daily alcohol intake when using a 1–34 0.84 (0.46–1.54) 0.78 (0.39–1.56) second dietary assessment tool that captured ≥35 1.83 (0.74–4.53) 0.75 (0.31–1.82) intake the day before the interview. These Pack-years of cigarette smoking results support the findings of two other All men studies reporting negative associations Never 1.00 1.00 between alcohol consumption and LUTS <21 1.27 (0.78–2.04) 1.22 (0.69–2.14) [4,11], whereas the association was positive in 21–49.9 1.10 (0.66–1.83) 1.22 (0.68–2.19) two others [3,7]. Platz et al. [11] reported ≥50 1.72 (0.99–2.99) 1.43 (0.80–2.59) lower odds in moderate drinkers, but this Current smokers only protective effect was attenuated in men who Never 1.00 1.00 consumed >50 g alcohol/day (ª 3.5 or more <21 0.52 (0.14–1.91) 0.64 (0.13–3.06) drinks per day). This pattern was also apparent 21–49.9 1.08 (0.50–2.32) 0.78 (0.25–2.44) in another USA cohort study [9], in which ≥50 1.19 (0.55–2.56) 1.08 (0.44–2.65) African-American men with an intake of Former smokers only >72 g/day (five or more drinks per day) had a Never 1.00 1.00 significantly higher odds of LUTS than non- <21 1.34 (0.82–2.20) 1.21 (0.65–2.25) drinkers, whereas there was no association in 21–49.9 1.07 (0.59–1.94) 1.22 (0.64–2.31) moderate consumers. Light to moderate ≥50 2.16 (1.12–4.17) 1.91 (0.97–3.78) alcohol consumption is associated with Alcohol consumption, frequency§ improved insulin sensitivity [21] and Never 1.00 1.00 decreased testosterone concentration [22]. As <1/week 0.60 (0.33–1.09) 0.53 (0.24–1.18) an alternative explanation, we cannot exclude >1/week but <1/day 0.74 (0.37–1.45) 0.99 (0.47–2.08) that the observed inverse association between ≥1/day 0.59 (0.36–0.97) 0.59 (0.34–1.03) the frequency of alcohol consumption and P trend 0.08 0.25 LUTS is caused by avoidance of fluids, Frequency of physical activity, times/week¶ especially of alcoholic beverages that have a Moderate and vigorous diuretic effect, by men with LUTS, as there 0 1.00 1.00 was an insignificantly lower odds of LUTS in 0.1–3.0 0.48 (0.24–0.99) 0.32 (0.14–0.74) men who drank caffeinated beverages at least 3.1–6.0 0.41 (0.18–0.91) 0.23 (0.09–0.57) four times a week (data not shown). >6.0 0.49 (0.29–0.84) 0.35 (0.18–0.67) P trend 0.05 0.07 In NHANES III, men who were physically active Vigorous in their leisure time were less likely to have 0 1.00 1.00 LUTS. All levels of moderate and vigorous 0.1–2.0 0.52 (0.25–1.10) 0.36 (0.15–0.87) activity were inversely associated with LUTS, 2.1–4.0 0.85 (0.40–1.82) 0.78 (0.32–1.88) but the association for vigorous activity did >4.0 0.80 (0.46–1.40) 0.77 (0.37–1.60) not decrease consistently. Two previous P trend 0.88 0.80 studies reported inverse associations between the frequency of physical activity and LUTS *All results were calculated using sampling weights; †adjusted for age and race; ‡second column: [2,3]. smoking status: adjusted for age, race, frequency of moderate and vigorous physical activity, frequency of alcohol consumption and current waist circumference (continuous); §second column: alcohol Physical activity is associated with improved consumption: adjusted for age, race, frequency of moderate and vigorous physical activity, smoking insulin sensitivity [23]. We previously reported status and current walst circumference (continuous); ¶second column: physical activity: adjusted for age, statistically significant positive associations race, frequency of alcohol consumption, smoking status and current waist circumference (continuous). of glycosylated haemoglobin, a long-term marker of glucose and insulin metabolism, and the metabolic syndrome with LUTS in this group of men [24]. Alternatively, reductions in elicit adaptations in the adrenergic system, in a reduction of the resting system activity the odds of LUTS by physical activity might be because the sympathetic nervous system is [25]. In contrast to Platz et al. [2] there was no caused by changes of sympathetic nervous activated through each bout of exercise, and consistently inverse association between system activity. Aerobic exercise training may repeated activation of this system could result vigorous physical activity and LUTS in the

SMOKING, ALCOHOL, PHYSICAL ACTIVITY AND LUTS IN OLDER MEN

present study. Only men who reported the results reflect associations and are not 8 Lee E, Park MS, Shin C et al. A high-risk vigorous activity up to twice a week had a necessarily causal. group for prostatism: a population-based statistically significantly lower odds of LUTS, epidemiological study in Korea. Br J Urol but the association was weaker in men who In conclusion, physical activity, even moderate 1997; 79: 736–41 were more vigorously active. However, in this activity like walking, may be beneficial for 9 Joseph MA, Harlow SD, Wei JT et al. Risk general population, few men reported LUTS. Additionally, moderate alcohol factors for lower urinary tract symptoms participating in vigorous physical activity consumption might be associated with a in a population-based sample of African- more than twice a week. reduction in the occurrence of LUTS, whereas American men. Am J Epidemiol 2003; 157: heavy cigarette smoking in the past may 906–14 In addition to an inverse association between increase the occurrence of LUTS in older men. 10 Koskimaki J, Hakama M, Huhtala H, total moderate and vigorous activity, men Intervention studies are needed to determine Tammela TL. Association of smoking with who walked, the most often reported physical whether the frequency of LUTS can be lower urinary tract symptoms. J Urol activity in this group of older men, were modulated by changes in these lifestyle 1998; 159: 1580–2 less likely to have LUTS. This association factors. 11 Platz EA, Rimm EB, Kawachi I et al. was reported previously in the Health Alcohol consumption, cigarette smoking, Professionals Follow-up Study [2]. A small ACKNOWLEDGEMENTS and risk of benign prostatic hyperplasia. case-control study in Japan [26] reported that Am J Epidemiol 1999; 149: 106–15 walking 10 000 steps or more per day for Dr Rohrmann is supported by the Fund for 12 National Center for Health Statistics. 12 weeks was inversely associated with Research and Progress in Urology, Johns Plan and operation of the Third National sympathetic nervous activity and blood Hopkins Medical Institutions. Dr Crespo is Health and Nutrition Examination Survey, pressure in hypertensive men compared supported by DAMD grant no. 170210252 and 1988–94. Series 1: programs and with sedentary men. Therefore, men who NIH grant no. 1P20CA096256. collection procedures. Vital Health Stat walk regularly might be less likely to have 1994; 1: 1–407 LUTS because of the lower tone of the CONFLICT OF INTEREST 13 Barry MJ, Fowler FJ Jr, O’Leary MP prostate and bladder smooth muscle, and et al. The American Urological Association lower blood pressure, previously been shown None declared. Source of funding: S. symptom index for benign prostatic to be positively associated with LUTS Rohrmann: post doc funding through hyperplasia. The Measurement Committee [9,20,24]. discretionary funds in the Department of of the American Urological Association. Urology – no project funding was needed. J Urol 1992; 148: 1549–57 Several aspects of the study design merit 14 Ainsworth BE, Haskell WL, Leon AS further discussion. First, NHANES III is a cross- REFERENCES et al. Compendium of physical activities: sectional study representative of the USA classification of energy costs of human population of older men, thus aiding in the 1 Thorpe A, Neal D. Benign prostatic physical activities. Med Sci Sports Exerc broad general applicability of these results. hyperplasia. Lancet 2003; 361: 1359–67 1993; 25: 71–80 Also, the elderly were over-sampled, allowing 2 Platz EA, Kawachi I, Rimm EB et al. 15 U.S. Department of Health and Human for more stable estimates in the analysis of Physical activity and benign prostatic Services. Physical activity and Health. A older men. Second, the questions on LUTS in hyperplasia. Arch Intern Med 1998; 158: report of the Surgeon General. Atlanta, NHANES III covered four of the seven 2349–56 GA. U.S. Department of Health and questions of the AUA Symptom Index, which 3 Prezioso D, Catuogno C, Galassi P, Human Services, Centers for Disease also includes frequency, intermittency and D’Andrea G, Castello G, Pirritano D. Control and Prevention. National Center urgency, which together discriminated Life-style in patients with LUTS suggestive for Chronic Disease Prevention and between men with and with no BPH in a of BPH. Eur Urol 2001; 40: 9–12 Health Promotion, 1996 clinical setting [13]. To increase the specificity 4 Klein BE, Klein R, Lee KE, Bruskewitz 16 Shah BV, Barnwell BG, Bieler GS. of the present analysis, we included only men RC. Correlates of urinary symptom scores SUDAAN user’s manual. Software for with three or four symptoms in the case in men. Am J Public Health 1999; 89: analysis of correlated data. Research group; we exclude men with only one or two 1745–8 Triangle Park, NC. Research Triangle symptoms in the control or case group 5 Roberts RO, Jacobsen SJ, Rhodes T et al. Institute, 1995 because individually these symptoms are not Cigarette smoking and prostatism: a 17 Narkiewicz K, van de Borne PJH, specific for LUTS. Third, we cannot completely biphasic association? Urology 1994; 43: Hausberg M et al. Cigarette smoking exclude that some men in the control group 797–801 increases sympathetic outflow in humans. did not report LUTS because they were taking 6 Roberts RO, Tsukamoto T, Kumamoto Y Circulation 1998; 98: 528–34 medications to treat their symptoms. et al. Association between cigarette 18 Allen NE, Appleby PN, Davey GK, Key However, this is unlikely because NHANES III smoking and prostatism in a Japanese TJ. Lifestyle and nutritional determinants was conducted between 1988 and 1994, and community. Prostate 1997; 30: 154–9 of bioavailable androgens and related medication for treating BPH symptoms was 7 Haidinger G, Temml C, Schatzl G et al. hormones in British men. Cancer Causes not approved until 1992 (finasteride) [27] and Risk factors for lower urinary tract Control 2002; 13: 353–63 1993 (terazosin) [28]. Finally, smoking, alcohol symptoms in elderly men. For the Prostate 19 Carson C, IIIRittmaster R. The role of consumption and physical activity were Study Group of the Austrian Society of dihydrotestosterone in benign prostatic assessed concurrently with LUTS. Therefore, Urology. Eur Urol 2000; 37: 413–20 hyperplasia. Urology 2003; 61: 2–7

20 Hammarsten J, Hogstedt B, Holthuis N, insulin sensitivity: a review. Int J Sports 27 Food and Drug Administration. Mellstrom D. Components of the Med 2000; 21: 1–12 Electronic Orange Book: Approved Drug metabolic syndrome-risk factors for the 24 Rohrmann S, Smit E, Giovannucci E, Products with Therapeutic Equivalence development of benign prostatic Platz EA. Association between markers of Evaluations. http://www.accessdata. hyperplasia. Prostate Cancer Prostatic Dis the metabolic syndrome and lower fda.gov/scripts/cder/ob/docs/ 1998; 1: 157–62 urinary tract symptoms in the Third tempaidet.cfm?Appl_No=020180&TABLE 21 Sierksma A, Patel H, Ouchi N et al. Effect National Health and Nutrition 1=Rx of moderate alcohol consumption on Examination Survey (NHANES III). 28 Anonymous. Terazosin now indicated for adiponectin, tumor necrosis factor-a, and International J Obes Relat Metab Disord benign prostatic hyperplasia. Am J Hosp insulin sensitivity. Diabetes Care 2004; 2005; in press Pharm 1994; 51: 25 27: 184–9 25 Brown MD, Dengel DR, Hogikyan RV, 22 Sierksma A, Sarkola T, Eriksson CJ, van Supiano MA. Sympathetic activity and Correspondence: Elizabeth A. Platz, Johns der Gaag MS, Grobbee DE, Hendriks HF. the heterogenous blood pressure Hopkins Bloomberg School of Public Health, Effect of moderate alcohol consumption response to exercise training in Department of Epidemiology, 615 N. Wolfe St., on plasma dehydroepiandrosterone hypertensives. J Appl Physiol 2002; 92: Rm. E 6138, Baltimore, MD 21205, USA. sulfate, testosterone, and estradiol levels 1434–42 e-mail: [email protected] in middle-aged men and postmenopausal 26 Iwane M, Arita M, Tomimoto S et al. women: a diet-controlled intervention Walking 10,000 steps/day or more reduces Abbreviations: NHANES III, Third National study. Alcohol Clin Exp Res 2004; 28: blood pressure and sympathetic nerve Health and Nutrition Examination Survey; 780–5 activity in mild essential hypertension. MET, metabolic equivalent of the activity 23 Borghouts LB, Keizer HA. Exercise and Hypertens Res 2000; 23: 573–80 compared to at rest; OR, odds ratio.

Relevance and variability of the severity of incontinence, and increased daytime and night-time voiding frequency, associated with quality of life in men with lower urinary tract symptoms

JOHANNES HALTBAKK, BERIT R. HANESTAD and STEINAR HUNSKAAR Department of Public Health and Primary Health Care, University of Bergen, Norway Accepted for publication 31 January 2005

OBJECTIVES BPH were collected by questionnaire shortly CONCLUSION after referral from their general practitioner in To estimate the distribution of the severity of 1997–2000. The International Continence The perception of increased night and urinary incontinence (UI) and daytime and Society – Benign Prostatic Hyperplasia Index, daytime frequency, as measured by symptom night-time voiding in patients with lower Sandvik’s Incontinence Severity Index, and the severity and bother, varied greatly. The urinary tract symptoms (LUTS) suggestive of World Health Organization Quality of Life severity of UI and its effect on men waiting benign prostatic hyperplasia (BPH); to Survey – Abbreviated Version (WHOQoL-bref) for a urological assessment of LUTS estimate the proportion of ‘subjectively were used to assess symptoms and QoL. suggestive of BPH also varied widely. In relevant’ symptoms within each severity general, the symptoms and their impact were category; to identify differences in quality of RESULTS slight to moderate. The WHOQoL-bref could life (QoL) by degree of subjectively relevant be used to differentiate among groups of daytime and night-time symptoms; and to There was a large heterogeneity of self- subjectively relevant symptoms, and in so identify differences in QoL in men with reported symptom severity and related bother doing supported information generated by subjectively relevant UI or no UI. in the three symptoms of UI, increased the bother question. daytime voiding frequency and night-time PATIENTS AND METHODS voiding in these referred patients. The KEYWORDS WHOQoL-bref showed signiﬁcant group Data from a group of 480 men awaiting differences of subjectively relevant LUTS, BPH, quality of life, storage, urinary urological assessment for LUTS suggestive of symptoms. incontinence, subjective relevance, bother

INTRODUCTION two studies investigated the association on an overall assessment of his GP’s between the ‘bothersomeness’ of LUTS and description of the patient in the referral letter, Urinary incontinence (UI) and increased well-being/health status, concepts closely the urologist made the tentative diagnosis of daytime and night-time voiding frequency are related to QoL; the correlations were high in BPH for 612 referred patients, who were often regarded as the most bothersome LUTS these studies [9,10]. subsequently enrolled in the study. The [1–5]. Bother reflects men’s overall distress eligible patients were sent information about with having LUTS [6]. Subjectively relevant The purpose of the present study was to the waiting list situation, a request to symptoms must be distinguished from estimate the distribution of the severity of UI, participate in the study and a questionnaire. healthy functioning. For UI and increased and daytime and night-time voiding in Patients agreed to participate by returning the daytime and night-time voiding frequency, patients with LUTS suggestive of BPH, and to questionnaire and a signed consent form in a this differentiation may be achieved by estimate the proportion of subjectively pre-stamped envelope; one reminder was estimating the bother associated with leakage relevant symptoms within each severity sent. Ethics approval was obtained from the and the number of voids during day or night. category. Further, we identified differences in regional ethics review board. QoL by the degree of subjectively relevant Generally, it seems that LUTS suggestive of daytime and night-time symptoms, and The ICS has defined UI as the complaint of any BPH do not greatly impair quality of life (QoL) differences in QoL in men with subjectively involuntary leakage of urine [1]. Increased [7,8]; there are few reports on the association relevant UI and men with no UI. daytime frequency is defined as the complaint between the subjective relevance of storage by the patient that he/she voids too often by symptoms and QoL, e.g. to date, the QoL PATIENTS AND METHODS day [1]; night-time frequency is defined as questionnaire developed by the WHO (brief voids that occur from the time the individual version, WHOQoL) has not been used to Men waiting for a urological evaluation at goes to bed with the intention to sleep, to the investigate differences in QoL in patients Trondheim University Hospital, Norway, in time the individual wakes with the intention bothered by LUTS suggestive of BPH. However, 1997–2000 were eligible for the study. Based of rising [1,11,12].

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TABLE 1 QoL in the three bother groups by UI, daytime and night-time voiding frequency, and mean differences in each pair of groups

Domain UI Daytime Night-time and groups* N Mean (SD) n – n D† N Mean (SD) n – n D† N Mean (SD) n – n D† Overall QoL 1 275 3.8 (0.9) 2 – 1 0.3 112 4.0 (0.7) 1 – 2 0.3 78 4.1 (0.7) 1 – 2 0.4 2 53 3.4 (0.9) 2 – 3 ns 202 3.6 (0.9) 2 – 3 0.3 221 3.7 (0.8) 2 – 3 0.3 3 23 2.9 (1.0) 3 – 1 0.8 118 3.4 (0.9) 1 – 3 0.6 132 3.4 (0.9) 1 – 3 0.7 Overall health perception 1 274 3.4 (0.9) 2 – 1 ns 111 3.7 (0.9) 1 – 2 0.4 75 3.7 (1.0) 1 – 2 0.3 2 55 3.6 (1.0) 2 – 3 ns 207 3.3 (0.9) 2 – 3 ns 224 3.4 (0.9) 2 – 3 ns 3 22 2.9 (1.0) 3 – 1 ns 115 3.2 (1.0) 1 – 3 0.5 132 3.2 (0.9) 1 – 3 0.5 Physical 1 272 14.9 (2.8) 2 – 1 1.3 112 15.6 (2.9) 1 – 2 1.2 76 15.8 (2.9) 1 – 2 1.3 2 52 13.6 (2.8) 2 – 3 2.0 199 14.4 (2.7) 2 – 3 0.8 220 14.6 (2.6) 2 – 3 1.0 3 20 11.6 (3.5) 3 – 1 3.3 114 13.6 (3.0) 1 – 3 2.1 126 13.6 (3.0) 1 – 3 2.3 Psychological 1 272 15.3 (2.3) 2 – 1 0.9 114 15.6 (2.2) 1 – 2 ns 77 16.1 (2.2) 1 – 2 1.2 2 53 14.4 (2.5) 2 – 3 ns 198 14.9 (2.3) 2 – 3 ns 219 14.9 (2.2) 2 – 3 ns 3 20 14.0 (2.5) 3 – 1 1.3 114 14.7 (2.6) 1 – 3 0.8 127 14.9 (2.4) 1 – 3 1.2 Social relations 1 269 14.6 (2.4) 2 – 1 ns 111 14.4 (2.3) 1 – 2 ns 76 14.9 (2.8) 1 – 2 ns 2 53 14.1 (3.1) 2 – 3 ns 198 14.4 (2.7) 2 – 3 ns 218 14.4 (2.3) 2 – 3 ns 3 19 12.8 (2.8) 3 – 1 1.8 127 14.3 (2.6) 1 – 3 ns 126 14.2 (2.7) 1 – 3 ns Environment 1 272 15.4 (2.2) 2 – 1 ns 114 15.8 (2.4) 1 – 2 0.6 78 16.0 (2.5) 1 – 2 0.7 2 53 14.8 (2.0) 2 – 3 ns 199 15.2 (2.2) 2 – 3 ns 219 15.3 (1.9) 2 – 3 ns 3 20 13.8 (2.0) 3 – 1 1.7 113 14.8 (2.2) 1 – 3 1.0 126 14.9 (2.3) 1 – 3 1.0

*For UI: 1, no leakage; 2, subjectively relevant UI (some); 3, subjectively relevant UI (much/major); for voiding: 1, no problem; 2, a bit of a problem; 3, quite/a serious problem. †Mean difference, signiﬁcant at P < 0.05 (ANOVA with Bonferroni correction) or ns, not signiﬁcant.

Symptoms were defined as ‘subjectively This index was validated against a 48-h pad- daytime and night-time frequency and their relevant’ when the patient regarded the weighing test in women, according to which corresponding bother issue were assessed in symptom as at least ‘quite a problem’ for slight, moderate, severe and very severe this study, i.e. the time interval between daytime and night-time voiding. This group incontinence represent mean (95% CI) voiding (item 1) and night-time frequency was divided into two categories, i.e. ‘some leakages (g/24 h) of 6 (2–9), 23 (15–30), (item 2). bother’ and ‘much/major bother’. When the 52 (38–65) and 122 (84–159), respectively patient associated the UI with at least ‘some [13]. Hanley et al. [14] reported good test– Validation studies showed differentiation bother’, it was defined as subjectively retest reliability and ability to detect change between community and clinical samples, but relevant. This group was divided into two after treatment using the index. Cronbach’s a a poor relation between questions assessing further categories, i.e. ‘a bit of a problem’ and was not reported in the validation studies; the strength of stream and uroflowmetry [15]. ‘quite a problem/a serious problem’. Men present study had a Cronbach’s a of 0.83. The Excellent test-retest reliability was reported reporting no UI, or reporting the impact of impact of UI was measured by a five-category and Cronbach’s a is 0.69–0.85 for the their UI as ‘no problem/a small nuisance’, were scale, i.e. no problem, a small nuisance, some symptom and bother subscales [15]. Lifestyle defined as having no subjectively relevant bother, much bother and a major problem. items are ‘fairly’ related to the Short-Form symptom. Missing responses were not replaced. Health Survey (SF-36) and have a Cronbach’s a of 0.59 [16]. In the present study the The following indices were chosen as The ICS-BPH is a 34-item questionnaire Cronbach’s a was 0.41 for this subscale. outcome variables: Sandvik’s Incontinence examining symptoms relating to lifestyle and Missing responses were not replaced. The Severity Index, the ICS–BPH and a five- sexual function, including five questions validity and reliability of the Norwegian category impact scale. The Sandvik index was about urination habits, catheterization version of ICS–BPH have not been published. used to characterize the degree of UI [13] incidents, flow rate, and two open-ended (Table 1). Men who stated the presence of UI questions. Twenty-six (score range 0–4) of the The 26-item WHOQoL-bref is based on a or who gave answers about frequency, 34 items are immediately followed by a definition of QoL as the individuals’ perception amount and type of leakage were considered corresponding bother issue (score range 0–3) of their position in life in the context of the to have incontinence. [15,16]. Two items addressing increased cultural and value systems in which they live

SEVERITY OF INCONTINENCE, VOIDING FREQUENCY AND QoL IN MEN WITH LUTS

FIG. 1. The size of the groups of subjective relevance examined separately, i.e. overall perception of night. For other symptoms, the proportion of in each: a, severity group of UI (no relevance, open QoL and overall perception of health. men with subjectively relevant night-time bar; some bother, green; much or major bother, red; voiding symptoms increased markedly with 156; 20 respondents with UI were excluded because Where >20% of data were missing from an increasing severity. When the men with no there was no information of their level of bother); b, individual assessment, that assessment was subjectively relevant symptoms were number of daytime voids (465; no relevance, open excluded from the analysis. Where the excluded, ª20% of men reporting one night- bar; a bit of a problem, green; serious/quite a response to an item was missing, the mean time void reported that this was a serious problem, red); and c, number of night-time voids value of the other items in the same domain problem or ‘quite a problem’. This proportion (467; no relevance, open bar; a bit of a problem, was substituted. Each domain had a range of increased to ª80% for patients reporting four green; serious/quite a problem, red). 4–20, with the higher scores indicating better or more voids per night (Fig. 1c). QoL. The scores for the two single items were a 1–5, with the higher scores indicating a better Between the categories of subjectively 100 QoL or better health [17]. The psychometric relevant UI and no UI there were signiﬁcantly properties of the Norwegian version of different mean scores of QoL among all three 80 WHOQoL-bref were tested recently [18]. groups in the physical dimension (Table 1). For 60 the other domains there were differences in

N Frequency analyses and simple distributions mean QoL between several of the domains, 40 were obtained to estimate the symptom but not in overall health. severity distribution and the distribution of 20 subjectively relevant symptoms within each For daytime voiding frequency, the men with 0 severity category. ANOVA was used to assess subjectively relevant symptoms differed in Slight Moderate Severe differences of mean QoL scores in the groups mean QoL from those who regarded their N 56 86 14 of subjectively relevant symptoms. number of daytime voids as no problem, or ‘a Severity groups bit of a problem’. In the social relationships domain, there was no difference in overall b RESULTS QoL, whereas for the physical domain there 100 were differences among all three categories 80 Of the 612 questionnaires, 480 (78%) were of the condition (Table 1). There was a similar returned and analysed. The mean (SD, median, tendency in the groups of subjectively 60 range) age of the patients was 67.0 (10.6, 69, relevant night-time frequency (Table 1). N 40 39–91) years. Involuntary leakage was reported by 176 patients (37%); most with 20 UI had moderate or slight leakage. The DISCUSSION proportion of men with subjectively relevant 0 1–6 7–8 9–10 11–12 13+ UI increased markedly with increasing This study shows the distribution of self- N 178 159 83 26 19 severity. When the men with no subjectively reported symptom severity and related bother Number of daytime voidings relevant symptoms were excluded, 20% of in UI, increased daytime voiding frequency, those with slight and moderate symptoms and night-time voiding in a sample of c reported that this was ‘much bother’ or a patients with LUTS suggestive of BPH. All 100 major problem. Slightly less than three- patients had been referred by their GP to a 80 quarters of this group of men with severe UI urologist for evaluation. Despite the GPs experienced ‘much bother’ or a major problem having ﬁrst evaluated and then referred 60 (Fig. 1a). the patients, the self-reported symptom

N severity and degree of bother varied 40 In all, 465 men reported their number of widely. 20 daytime voids; most voided eight or fewer times a day. The proportion with a subjectively Peters et al. [19] stated that symptom 0 relevant symptom increased markedly with occurrence alone does not necessarily reﬂect 0 1 2 3 4+ increasing severity. When excluding men with the degree of bother caused by LUTS, so it is N 31 138 148 93 57 no subjectively relevant symptoms, <20% of also important to consider the bother caused Number of night time voiding men with subjectively relevant symptoms and by the symptoms. Berges et al. [20] suggested reporting one to six daytime voids reported that the bother level may discriminate and in relation to their goals, expectations, that this was a serious problem or ‘quite a between individuals with moderate symptoms standards and concerns [17]. It includes four problem’. This proportion increased to ª90% who may be followed by ‘watchful waiting’ domains: physical health, psychological for patients reporting 13 or more voids a day and those in need of active therapy. Perry health, social relationships and environment. (Fig. 1b). et al. [21] referred to the group with The sum scores of the four domains denote an signiﬁcant incontinence as potential patients, individual’s perception of QoL in each In all, 469 men reported their number of and Boyle et al. [22] found that bother particular domain. Two additional items are night-time voids; most voided once or twice a associated with UI was a more important

HALTBAKK ET AL.

determinant of visiting the doctor than the In conclusion, what is regarded as increased Millian I, Lorenzo-Romero JG, Segura- level of UI symptoms. In the present study, night- and daytime frequency among Martin M, Fernandez-Olano C, Virseda- most patients referred by their GP for a patients referred for urological evaluation of Roddriguez JA. Quality of life in patients urological evaluation did not have severe UI, LUTS suggestive of BPH seems to vary greatly, on the waiting list for benign prostatic or increased daytime or night-time voiding as measured by self-reported QoL, symptom hyperplasia surgery. Qual Life Res 2001; frequency. Furthermore, they were not severity and bother. Further, the severity of UI 10: 543–53 particularly bothered by their symptoms, even and its impact among patients referred for 9 Eckhardt MD, Venrooij van GEPM, though the three symptoms measured are a urological evaluation varies widely, with Melick van HHE, Boon TA. Prevalence regarded as the most bothersome. More only a few patients considering it a major and bothersomeness of lower urinary studies are needed to investigate which men problem. The WHOQoL-bref could be used to tract symptoms in benign prostatic with subjectively relevant symptoms are differentiate between groups of subjectively hyperplasia and their impact on well- potential patients in need of active treatment. relevant storage symptoms, and in doing so being. J Urol 2001; 166: 563–8 supported the information generated by the 10 Boyle P, Robertson C, Mazzetta C et al. When assessing night-time voids, only 3% of bother question. The relationship between lower urinary patients reported them as a serious problem, tract symptoms and health status. The and 28% as ‘quite a problem’. The small CONFLICT OF INTEREST UREPIK Study. BJU Int 2003; 92: 575–80 proportion of men bothered by night-time 11 Kerrebroeck van P, Abrams P, Chaikin D voids might reflect that we not only registered None declared. Source of funding: University et al. The standardization of terminology the number of times the patient woke to void, of Bergen. in nocturia: Report from the but also the number of voids before sleep and standardization subcommittee in the after waking. Nevertheless, we hesitate to REFERENCES international continence society. BJU Int conclude that to get up twice or more per 2002; 90 (Suppl. 3): 11–5 night is extremely bothersome to patients 1 Abrams P, Cardozo L, Fall M et al. The 12 Kerrebroeck van P. Standardization of (as other studies have) and thus must be standardisation of terminology of lower terminology in nocturia: Commentary on considered symptomatic [23,24]. The ICS urinary tract symptoms: Reports from the the ICS report. BJU Int 2002; 90 (Suppl. 3): committee concluded that the number of standardisation sub-committee of the 16–7 voids per night is not important for definition International Continence Society. 13 Sandvik H, Seim A, Vanvik A, Hunskaar purposes, as long as the patient is awake Neurourol Urodyn 2002; 21: 167–78 S. A severity index for epidemiological before voiding and they return to sleep 2 Haltbakk J, Hanestad BR, Hunskaar S. surveys of female urinary incontinence: afterwards [12]. The ICS committee defines The diversity of urinary symptoms in Comparison with 48-hour pad-weighing nocturia as waking at night to void. It tentatively diagnosed BPH patients tests. Neurourol Urodyn 2000; 19: 137–45 is problematic that this definition does referred to a urologic clinic in Norway. 14 Hanley J, Capewell A, Hagen S. Validity not indicate when nocturia becomes Scand J Urol Nephrol 2004; 38: 454–61 study of the severity index, a simple bothersome [24]. 3 Djavan B. Lower urinary tract symptoms/ measure of urinary incontinence in benign prostatic hyperplasia. Fast control women. BMJ 2001; 322: 1096–7 For the three symptoms a few men found of the patient’s quality of life. Urology 15 Donovan JL, Abrams P, Peters KJ et al. each a serious or major problem. The mean 2003; 62 (Suppl. 3A): 6–14 The ICS-‘BPH’ study. The psychometric QoL decreased with increasing bother but the 4 McGrother CW, Donaldson MMK, validity and reliability of the ICS male differences between the groups were very Matthews RJ et al. Storage symptoms of questionnaire. Br J Urol 1996; 77: 554–62 small, so the clinical relevance of the the bladder: Prevalence, incidence and 16 Donovan JL, Kay HE, Peters TJ et al. relationship between bother and QoL should need for services in the UK. BJU Int 2004; Using the ICSQoL to measure the impact not be overestimated. Eckhardt et al. [9] and 93: 763–9 of lower urinary tract symptoms on Boyle et al. [10] found a strong association 5 Roehrborn CG, McConnell JD, Saltzman quality of life: Evidence from the ICS- between bothersomeness, health status and B et al. Storage (irritative) and voiding ¢BPH¢ study. Br J Urol 1997; 80: 712–21 well-being. Their reports do not discuss their (obstructive) symptoms as predictors of 17 WHOQOL Group. The World Health concepts of ‘well-being’ and ‘bother’ as being benign prostatic hyperplasia progression Organization quality of life assessment very close [25], and their strong association and related outcomes. Eur Urol 2002; 42: (WHOQOL): Position paper from the World might therefore be a result of content overlap 1–6 Health Organization. Soc Sci Med 1995; in the definitions of each. Mozes et al. [7] 6 Glover L, Gannon K, McLoughlin J, 41: 1403–9 concluded that the relative weight of the Emberton M. Men’s experiences of 18 Hanestad BR, Wahl A, Rustøen T, Lerdal impact of a symptom in LUTS on QoL domains having lower urinary tract symptoms: A, Knudsen Ø. Validation of the is changed by the presence of other Factors relating to bother. BJU Int 2004; WHOQOL-Bref in a Norwegian population. competing factors, e.g. comorbidity or 94: 563–7 Abstract. The 2001 international society sociodemographic attributes. Such factors 7 Mozes B, Maor Y, Shmueli A. The for quality of life research (ISOQOL) were not controlled for in the present competing effects of disease states on annual meeting. Qual Life Res 2001; 10: study and therefore limit the conclusions quality of life of the elderly: The case of 206 that can be drawn from the QoL scores in urinary symptoms in men. Qual Life Res 19 Peters TJ, Donovan JL, Kay HE et al. The patients with LUTS referred for urological 1999; 8: 93–9 International Continence Society ‘Benign evaluation. 8 Salinas-Sanchez AS, Hernandez- Prostatic Hyperplasia’ study. The

SEVERITY OF INCONTINENCE, VOIDING FREQUENCY AND QoL IN MEN WITH LUTS

bothersomeness of urinary symptoms. 22 Boyle P, Robertson C, Mazzetta C 25 Haltbakk J, Hanestad BR, Hunskaar S. J Urol 1997; 157: 885–9 et al. The prevalence of male urinary Use and misuse of the quality of life 20 Berges RR, Pientka L, Hofner K, incontinence in four centres. The UREPIK concept in evaluations of surgical Senge T, Jonas U. Male lower urinary Study. BJU Int 2003; 92: 943–7 treatments of LUTS. BJU Int 2003; 91: tract symptoms and related health care 23 Abraham L, Hareendran A, Mills IW 380–8 seeking in Germany. Eur Urol 2001; 39: et al. Development and validation of a 682–7 quality-of-life measure for men with Correspondence: Johannes Haltbakk, 21 Perry S, Shaw C, Assassa P et al. An nocturia. Urology 2004; 63: 481–6 Department of Public Health and Primary epidemiological study to establish the 24 Coyne KS, Zhou Z, Bhattacharyya SK, Health Care, University of Bergen, Kalfarveien prevalence of urinary symptoms and felt Thompson CL, Dhawan R, Versi E. The 31, N- 5018, Bergen, Norway. need in the community: The Leicestershire prevalence of nocturia and its effect on e-mail: [email protected] MRC incontinence study. Leicestershire health-related quality of life and sleep in MRC incontinence study team. J Public a community sample in the USA. BJU Int Abbreviations: UI, urinary incontinence; QoL, Health Med 2000; 22: 427–34 2003; 92: 948–54 quality of life.

The prevalence and correlates of urinary tract symptoms in Norwegian men: The HUNT Study

ARNFINN SEIM, CATHRINE HOYO*, TRULS ØSTBYE* and LARS VATTEN Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway, and *Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA Accepted for publication 31 January 2005

OBJECTIVES estimated the prevalence of LUTS and used history of stroke, muscle complaints and logistic regression analysis to study lifestyle osteoarthritis. To estimate the prevalence of lower urinary and anthropometric factors, and comorbidity tract symptoms (LUTS) by severity (using the related to LUTS. CONCLUSION International Prostate Symptom Score, IPSS) in a population-based study of men aged RESULTS The ﬁndings from this population-based ≥20 years, and to assess the association study suggest that the prevalence of LUTS between putative risk factors and the The overall prevalence of moderate to severe among men aged ≥20 years may be lower presence of moderate to severe LUTS. LUTS was 15.8% (13.2% moderate and 2.6% than previously estimated. Although LUTS severe). The prevalence of LUTS increased may be viewed as an inevitable consequence SUBJECTS AND METHODS strongly with age, from ª5% among men of ageing, it appears to be exacerbated by aged <40 years to >30% when aged lifestyle factors and comorbid conditions. Between 1995 and 1997, LUTS data were ≥70 years. Factors positively associated with collected from 21 694 male residents aged an increased risk of moderate and severe LUTS ≥20 years in Nord Trøndelag County in were anthropometric (body mass index and KEYWORDS Norway, using the IPSS; from the IPSS (score waist hip ratio) and lifestyle factors (alcohol 0–35) LUTS was deﬁned as a score of ≥8, consumption and smoking), as well as LUTS, prevalence, men, Norway, comorbidity, indicating moderate to severe symptoms. We comorbid conditions, including diabetes, lifestyle

INTRODUCTION study showed less variation in prevalence metabolic syndrome, neurological disorders, (16–25%) in the Netherlands, France, UK and and rheumatic diseases [14,19,22]. LUTS can cause personal suffering and Korea [11], but other community studies reduced quality of life for many men [1–5]; in reported different prevalence estimates The purpose of the present study was to the USA, ª380 000 TURPs are carried out among populations [12,13]. estimate the prevalence of LUTS by severity annually to alleviate LUTS, and the procedure (using the IPSS) in a population-based study is also common in other western societies. Despite the evidence that LUTS represent a of men aged ≥20 years, and to assess the However, the reported prevalence of LUTS burden, especially among elderly men, little is association between putative risk factors and varies considerably among studies. This known about their causes [14]. Apart from the the presence of moderate to severe LUTS. can partly be explained by the lack of positive association with age, high levels of consensus on a common definition of LUTS; circulating androgens appear to increase the SUBJECTS AND METHODS e.g. some authors [6,7] restrict the diagnosis risk of LUTS, possibly via its association with of LUTS to patients with severe symptoms, benign prostate enlargement [9,14–16]. LUTS Data were derived from the second Nord- whereas others have used a broader also appear to be negatively associated with Trøndelag Health Study (HUNT-2), a definition. socio-economic status and positively population-based study of residents in Nord- associated with obesity [14,17]. Other lifestyle Trøndelag County in Norway who were aged Recently, the definition of LUTS was factors, e.g. cigarette smoking, alcohol ≥20 years between 1995 and 1997. The HUNT standardized and the IPSS has now been consumption and consumption of coffee or study was conducted as a collaboration widely adopted [8,9]. Nonetheless, studies tea, may also be positively associated with between the National Health Screening that have used the IPSS have also shown LUTS [14,17,18], whereas physical activity may Service, the National Institute of Public substantial variation in the prevalence of be inversely related to the symptoms [19,20]. Health, and the Norwegian University of LUTS. In one study comparing the community However, the results of studies are conflicting Science and Technology, and has been prevalence of LUTS among four countries, the [14,17–21]. LUTS also tend to occur in described in detail elsewhere [23,24]. Briefly, proportion of men who reported moderate to conjunction with other age-related participants were asked to complete a severe symptoms was 14%, 18%, 38% and conditions. Thus, studies have shown that baseline questionnaire, which was mailed 56% in France, Scotland, Olmsted County LUTS may be present together with together with the invitation to attend a (USA) and Japan, respectively [10]. A recent cardiovascular disease, diabetes and physical examination. The examination

PREVALENCE OF LUTS IN NORWEGIAN MEN

a slightly higher prevalence of LUTS among % within each IPSS category TABLE 1 those with a higher WHR, but with no clear Age group (n) None Mild Moderate Severe The proportion of LUTS as trend across categories (quintiles) of WHR. IPSS 0 1–7 8–19 20–35 measured by the IPSS in different age groups N 6406 11 855 2865 568 Several lifestyle factors were also associated 20–29 (2414) 45.4 50.5 3.9 0.2 with the risk of LUTS. Men who reported 30–39 (3515) 43.6 50.4 5.4 0.5 having 6–10 drinks (of beer, wine or liquor) 40–49 (5067) 36.7 53.0 8.9 1.4 per week were more likely (OR 1.41, 95% CI 50–59 (4192) 24.0 58.5 14.6 2.9 1.19–1.66) to report LUTS than men who 60–69 (3260) 15.7 58.0 21.6 4.7 abstained from alcohol (Table 2). Comparing 70–79 (2570) 12.7 57.8 23.6 5.8 current and former smokers to never- 80–89 (640) 10.0 52.0 30.8 7.2 smokers, cigarette smoking was associated ≥90 (36) 11.1 41.7 33.3 13.9 with a higher prevalence of LUTS. Among Total (21694) 29.5 54.6 13.2 2.6 former smokers the results indicated a dose- response relationship between the number of cigarettes and prevalence of LUTS. Men who had smoked >20 cigarettes/day were ª50% included measurements of height, weight and hip circumference, cigarette smoking, more likely to have LUTS than men who had blood pressure. At the examination, all consumption of alcohol, coffee or tea, and never smoked. Among current smokers the participants received a gender-speciﬁc information on comorbidity, including pattern was somewhat different; smoking questionnaire to be completed at home and diabetes, muscular complaints, osteoarthritis, >16 cigarettes/day was positively associated returned by mail. This questionnaire included and history of stroke or coronary heart with LUTS. Although not signiﬁcantly, the seven IPSS questions that aim at detecting disease. smoking <16 cigarettes/day seemed to be the presence and severity of LUTS [25]. associated with a lower prevalence of LUTS. The overall prevalence of LUTS was calculated Consumption of coffee or tea also showed In all, 66 140 men and women were invited to by clinical severity in 10-year age groups, and weak positive associations with LUTS. the HUNT-2 Study, and 71.2% of those who related to factors previously associated with were invited attended the examination. LUTS. We used logistic regression analysis to Men with comorbid conditions were also Among the 30 860 men who attended and estimate the association between the more likely to report LUTS (Table 2); men with received the second questionnaire, 21 856 independent variables and the presence of diabetes were more likely to have LUTS than (70.8%) completed and returned the IPSS LUTS, by comparing men who reported men without. There was a similar association questions. From those who responded, we moderate to severe LUTS with men who between muscle complaints and LUTS, and excluded 162 because they had previously reported mild or no LUTS. The associations are between osteoarthritis and LUTS. Men with a been diagnosed with prostate cancer. Thus, presented as odds ratios (OR, corrected for history of stroke also had higher prevalence information from 21 694 men aged ≥20 years age) with 95% CIs. of LUTS. was used in the current analysis.

All participants signed a consent form that RESULTS included information about the study DISCUSSION objectives. The study was approved by the Among the 21 694 men, 15.8% reported regional committee for ethics in medical moderate to severe LUTS (13.2% moderate In this population-based study of nearly research, by the Norwegian Data Inspectorate, and 2.6% severe; Table 1); the prevalence of 22 000 Norwegian men aged ≥ 20 years, and by the Institutional Review Board of Duke LUTS increased rapidly with age, such that where the IPSS was used to assess the University Medical Center. ª95% of men aged <40 years reported no presence of LUTS, the total prevalence of LUTS, whereas of men aged 60–69 years, moderate to severe LUTS was ª16%, but it The IPSS was calculated for all men who 26.3% had LUTS. The prevalence increased increased rapidly with age. Before the age of responded to the seven symptom questions gradually from hardly any LUTS in the 40 years LUTS was very rare, but one in ﬁve (items). Each item has response categories of younger groups to more than a third with men aged ≥40 years reported moderate to 0 (not at all) to 5 (almost always); the IPSS is LUTS among men aged ≥70 years. severe LUTS. Among men aged ≥70 years the sum of the seven items, with a total score about a third had LUTS. of 0–35. In the analysis, we categorized LUTS Table 2 shows the association between according to total score as no symptoms anthropometric variables and the prevalence Compared with the present results the (IPSS 0), mild (1–7), moderate (8–19) or of LUTS. There was a weak but positive prevalence of LUTS was substantially higher severe symptoms (20–35), according to association between body mass index (BMI) among African-Americans [14] and among recommendations made by the developers of and the prevalence of LUTS. Men with a BMI American men in the NHANES study [26], and the IPSS [8]. of 35–39 kg/m2 were ª40% more likely to among Australian [12] and European men have LUTS than men with a BMI of <25, and [27]. However, in a population-based study From the general health survey we also used there was a positive trend across categories of from the Netherlands, France, UK and Korea information on age, height, weight, waist and BMI. For the waist/hip ratio (WHR), there was the prevalence of LUTS was similar to that in

SEIM ET AL.

the present study [11]. These differences No. of men with IPSS TABLE 2 suggest that the prevalence of LUTS may have Variable 0–7 ≥8 OR (95% CI)* ORs (95% CI) for moderate geographical or racial variations, but the or severe LUTS (IPSS ≥ 8) results also suggest that men in different Age 20–29 2 316 98 1.0 (Reference) associated with age and cultures may have different thresholds for 30–39 3 306 209 1.49 (1.16–1.90) anthropometric measures, discomfort before reporting the presence of 40–49 4 547 520 2.69 (2.16–3.36) lifestyle factors and disease urinary symptoms. 50–59 3 459 733 4.99 (4.01–6.19) status 60–69 2 404 856 8.38 (6.75–10.4) Previously, some investigators reported a 70–79 1 813 757 9.83 (7.89–12.2) negative association between cigarette 80–89 397 243 14.4 (11.1–18.6) ≥90 19 17 21.1 (10.6–41.8) smoking and LUTS [19,20,28,29], but others BMI, kg/m2 found a positive association [7,14,17,30]. In <25 6 526 1033 1.0 (Reference) the present study there was a positive 25–29 9 156 1816 1.13 (1.04–1.23) association between cigarette smoking and 30–34 2 206 483 1.20 (1.06–1.35) LUTS among former smokers. A possible 35–39 286 65 1.39 (1.04–1.85) negative association between light or ≥40 45 11 1.79 (0.90–3.56) WHR (quintiles) moderate smoking and LUTS among current <0.851 3 940 425 1.0 (Reference) smokers has been shown by others [31]. 0.851–0.881 3 683 591 1.20 (1.05–1.38) Previous studies also reported discrepant 0.882–0.906 3 663 700 1.22 (1.07–1.39) findings for the consumption of coffee or 0.907–0.942 3 642 731 1.11 (0.97–1.26) tea and related LUTS [18,32]. Because ≥0.943 3 273 959 1.32 (1.15–1.50) coffee and tea are ubiquitous exposures, Height, cm (quintiles) the potential for public health intervention <173 4 116 1048 1.0 (Reference) 173–176 3 973 825 1.10 (0.99–1.23) can be sizeable if the association is causal. 177–179 3 070 570 1.15 (1.02–1.29) However, there was no clear association 180–183 3 641 562 1.11 (0.99–1.26) with tea or coffee consumption in the ≥184 3 419 403 1.04 (0.90–1.18) present men. Lifestyle Alcohol, units/week Men with comorbid conditions were also 0 3 007 707 1.0 (Reference) 1–5 10 616 1738 1.12 (1.01–1.25) more likely to report LUTS. Possibly, these 6–10 1 515 258 1.41 (1.19–1.66) conditions may have a general impact on ≥11 323 46 1.23 (0.88–1.72) lower urinary tract function, or the medical Smoking, n cigarettes/day treatment of the conditions may influence Never 7 147 999 1.0 (Reference) lower urinary tract function or urine Former excretion. Thus, men with diabetes were more 1–5 592 158 1.08 (0.89–1.32) 6–10 1 920 462 1.10 (0.97–1.25) likely to report LUTS than men without 11–15 909 213 1.25 (1.06–1.49) diabetes, suggesting that the pathogenesis 16–20 839 214 1.34 (1.13–1.59) may either be vascular or neurological. ≥20 470 141 1.52 (1.24–1.87) Patients whose diabetes is not optimally Current treated will tend to have glucosuria, and 1–5 558 103 0.99 (0.79–1.24) thereby be more likely to report urinary 6–10 1 728 273 0.94 (0.81–1.09) symptoms. Similarly, men who have muscle 11–15 1 442 176 0.89 (0.75–1.06) 16–20 731 142 1.38 (1.14–1.68) complaints may experience pain that could ≥20 195 48 1.72 (1.23–2.39) possibly influence smooth muscle function in Coffee/tea consumption, cups/day the urinary system through neurological 0–5 9 976 1864 1.0 (Reference) mechanisms. However, pain-relieving ≥6 8 071 1499 1.09 (1.01–1.17) medication per se has been suggested to Disease status increase the risk of LUTS [22]. A positive Diabetes No 17 753 3228 1.0 (Reference) association between osteoarthritis and LUTS Yes 474 185 1.25 (1.04–1.49) was also reported by others [22]. Stroke No 17 966 3265 1.0 (Reference) In conclusion, ª20% of men aged ≥40 years Yes 251 145 1.61 (1.30–2.00) reported moderate to severe LUTS; in men Muscle complaints aged ≥70 years about a third reported these No 16 031 2640 1.0 (Reference) Yes 947 325 1.68 (1.46–1.93) symptoms. Although LUTS may be viewed as Osteoarthritis an inevitable consequence of ageing, our No 16 307 2592 1.0 (Reference) results also suggest that LUTS are associated Yes 1 054 513 1.69 (1.50–1.91) with lifestyle factors, and may be exacerbated by comorbid conditions. *Age-adjusted.

PREVALENCE OF LUTS IN NORWEGIAN MEN

ACKNOWLEDGEMENTS Madsen-Iversen, Boyarsky and hyperplasia. Arch Intern Med 1998; 158: Maine Medical Assessment Program 2349–56 The authors thank Jaspreet Chowdhary, symptom indexes. Measurement 21 Kupeli B, Soygur T, Aydos K, Ozdiler E, MPH, for technical help with the manuscript. Committee of the American Urological Kupeli S. The role of cigarette smoking in The Norwegian Medical Research Council Association. J Urol 1992; 148: 1558– prostatic enlargement. Br J Urol 1997; 80: and Merck Co supported the study 63 201–4 financially. 9 Guess HA. Benign prostatic hyperplasia 22 Koskimäki J, Hakama M, Huhtala H, and prostate cancer. Epidemiol Rev 2001; Tammela TL. Association of non- CONFLICT OF INTEREST 23: 152–8 urological diseases with lower urinary 10 Sagnier PP, Girman CJ, Garraway M tract symptoms. Scand J Urol Nephrol None declared. et al. International comparison of the 2001; 35: 377–81 community prevalence of symptoms of 23 Holmen J, Midthjell K, Krüger Ø et al. REFERENCES prostatism in four countries. Eur Urol The Nord-Trondelag Health Study 1996; 29: 15–20 1995–97 (HUNT 2). Objectives, contents, 1 Blanker MH, Groeneveld FP, Prins A, 11 Boyle P, Robertson C, Mazzetta C et al. methods, and participation. Norsk Bernsen RM, Bohnen AM, Bosch JL. The prevalence of lower urinary tract Epidemiologi 2003; 13: 19–32 Strong effects of definition and symptoms in men and women in four 24 The Nord-Trøndelag health study nonresponse bias on prevalence rates of centres. The UrEpik study. BJU Int 2003; (HUNT). Available at http:// clinical benign prostatic hyperplasia: the 92: 409–14 www.medisin.ntnu.no/hunt/ Krimpen study of male urogenital tract 12 Sladden MJ, Hughes AM, Hirst GH, index.php?side=english problems and general health status. BJU Ward JE. A community study of lower 25 IPSS. Available at: http://www.usrf.org/ Int 2000; 85: 665–71 urinary tract symptoms in older men in questionnaires/AUA_SymptomScore. 2 Eckhardt MD, van Venrooij GE, van Sydney, Australia. Aust N Z J Surg 2000; html. Accessed May 10, 2004 Melick HH, Boon TA. Prevalence and 70: 322–8 26 Platz EA, Smit E, Curhan GC, Nyberg bothersomeness of lower urinary tract 13 Rosen R, Altwein J, Boyle P et al. Lower LM, Giovannucci E. Prevalence of and symptoms in benign prostatic hyperplasia urinary tract symptoms and male sexual racial/ethnic variation in lower urinary and their impact on well being. J Urol dysfunction: the multinational survey of tract symptoms and non-cancer prostate 2001; 166: 563–8 the aging male (MSAM-7). Eur Urol 2003; surgery in US men. Urology 2002; 59: 3 Gacci M, Bartoletti R, Figlioli S et al. 44: 637–49 877–83 Urinary symptoms, quality of life and 14 Joseph MA, Harlow SD, Wei JT et al. Risk 27 Apolone G, Cattaneo A, Columbo P, La sexual function in patients with benign factors for lower urinary tract symptoms Vecchia C, Cavazzuti L, Bamfi F. prostatic hypertrophy before and after in a population-based sample of African- Knowledge and opinion on prostate and prostatectomy: a prospective study. BJU American men. Am J Epidemiol 2003; 157: prevalence of self-reported BPH and Int 2003; 91: 196–200 906–14 prostate-related events. A cross sectional 4 Bortolotti A, Bernardini B, Colli E et al. 15 Chute CG, Panser LA, Girman CJ et al. survey in Italy. Eur J Cancer Prev 2002; 11: Prevalence and risk factors for urinary The prevalence of prostatism: a 473–9 incontinence in Italy. Eur Urol 2000; 37: population-based survey of urinary 28 Sidney S, Quesenberry C Jr, Sadler MC, 30–5 symptoms. J Urol 1993; 150: 85–9 Lydick EG, Guess HA, Cattolica EV. Risk 5 Treagust J, Morkane T, Speakman M. 16 Verhamme KM, Dieleman JP, Bleumink factors for surgically treated benign Estimating a population’s needs for the GS et al. Incidence and prevalence of prostatic hyperplasia in a prepaid treatment of lower urinary tract lower urinary tract symptoms suggestive health care plan. Urology 1991; 38 symptoms in men: what is the extent of of benign prostatic hyperplasia in primary (Suppl.): 13–9 unmet need? J Public Health Med 2001; care-the Triumph project. Eur Urol 2002; 29 Morrison AS. Risk factors for surgery for 23: 141–7 42: 323–8 prostatic hypertrophy. Am J Epidemiol 6 Gann PH, Hennekens CH, Stampfer MJ. 17 Haidinger G, Temml C, Schatzl G et al. 1992; 135: 974–80 A prospective evaluation of plasma Risk factors for lower urinary tract 30 Haidinger G, Madersbacher S, prostate-specific antigen for detection of symptoms in elderly men. Eur Urol 2000; Waldhoer T, Lunglmayr G, Vutuc C. The prostatic cancer. JAMA 1995; 273: 289– 37: 413–20 prevalence of lower urinary tract 94 18 Gass R. Benign prostatic hyperplasia. The symptoms in Austrian males and 7 Platz EA, Rimm EB, Kawachi I opposite effects of alcohol and coffee associations with sociodemographic et al. Alcohol consumption, cigarette intake. BJU Int 2002; 90: 649–54 variables. Eur J Epidemiol 1999; 15: 717– smoking, and risk of benign prostatic 19 Meigs JB, Mohr B, Barry MJ, Collins 22 hyperplasia. Am J Epidemiol 1999; MM, McKinlay JB. Risk factors for 31 Roberts RO, Jacobsen SJ, Rhodes T et al. 149: 106–15 clinical benign prostatic hyperplasia in a Cigarette smoking and prostatism: a 8 Barry MJ, Fowler FJ Jr, O’Leary MP, community-based population of healthy biphasic association? Urology 1994; 43: Bruskewitz RC, Holtgrewe HL, Mebust aging men. J Clin Epidemiol 2001; 54: 797–801 WK. Correlation of the American 935–44 32 Prezioso D, Catuogno C, Galassi P, Urological Association symptom index 20 Platz EA, Kawachi I, Rimm EB et al. D’Andrea G, Castello G, Pirritano D. with self-administered versions of the Physical activity and benign prostatic Life-style in patients with LUTS

suggestive of BPH. Eur Urol 2001; 40 Norwegian University of Science and Abbreviations: BMI, body mass index; WHR, (Suppl. 1): 9–12 Technology, MTFS, NO-7489 Trondheim, waist/hip ratio; OR, odds ratio. Norway. Correspondence: Arnﬁnn Seim, Department e-mail: Arnﬁ[email protected] of Public Health and General Practice,

A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self- catheterization in men with chronic urinary retention

IBRAHIM FATHI GHALAYINI, MOHAMMED A. AL-GHAZO and ROBERT S. PICKARD* Faculty of Medicine, Jordan University of Science & Technology, King Abdullah University Hospital, Irbid, Jordan and *University of Newcastle, Newcastle upon Tyne, UK Accepted for publication 9 February 2005

OBJECTIVE indicated, and the second was taught CISC. in symptoms or urodynamic variables. Men in both groups were reviewed at 3 and Detrusor overactivity was found in 17 (41%) To determine whether a preliminary period of 6 months after surgery or the start of CISC, by patients, of whom six had upper tract clean intermittent self-catheterization (CISC) the IPSS, urine culture and assay of plasma dilatation which resolved after before transurethral resection of the prostate creatinine, and upper tract imaging and treatment. (TURP) improves bladder contractility and repeat PFS at 6 months. The primary outcome surgical outcome in men with chronic urinary variables were IPSS, maximum urinary flow CONCLUSION retention (CUR), and whether pressure-flow rate, voiding and end-filling pressures, and studies (PFS) before TURP predict the mean PVR; secondary variables included The present results emphasize the usefulness outcome. treatment failure, complications and other of CISC in ensuring the recovery of bladder urodynamic measures. function in men with CUR. Measuring the voiding pressure before TURP can predict the PATIENTS AND METHODS RESULTS surgical outcome. Both CISC and immediate TURP are effective for relieving LUTS and The study was a two-centre, pragmatic and Of the 41 patients, 17 (mean age 67 years, result in a better quality of life. A preliminary randomized trial. Included were 41 men range 52–84) were randomized to immediate period of CISC before TURP for men with CUR scheduled for TURP with lower urinary tract TURP and 24 (mean age 69 years, range and low voiding pressure may be valuable. symptoms (LUTS), an International Prostate 55–85) to CISC. There was a significant The presence of upper tract dilatation is Symptom Score (IPSS) of >7, benign prostatic improvement in IPSS and quality of life at associated with high end-void and end-fill enlargement and a persistent postvoid 6 months in both groups (P < 0.001). bladder pressures, and such men have a good residual urine volume (PVR) of >300 mL. They In the CISC group there was a significant outcome from surgery. had conventional PFS using unphysiological improvement in voiding and end-filling filling. The patients then gave consent and pressures, indicating recovery of bladder KEYWORDS were randomized into two treatment groups; function (P < 0.001 for each). Of the 41 men, the first had TURP after stabilizing renal nine (22%) with voiding pressures of prostate, urinary retention, prostatic function by indwelling catheterization if £45 cmH2O had no significant improvement hyperplasia.

INTRODUCTION stabilized, followed by surgery to relieve the detrusor hypocontractility. Contractility has likely BOO, but with no prior urodynamic been shown to improve after starting CISC [4], Chronic urinary retention (CUR) is defined as assessment. Previous studies that used whilst other management options, such as the consistent presence of a significant pressure-flow studies (PFS) to obtain a muscarinic agonists and prokinetic agents, residue after voiding. The magnitude of the urodynamic diagnosis lend some support for have not been successful. postvoid residual volume (PVR) taken to this empirical line of management, but also define CUR in previous studies has been reveal some possible disadvantages [1,2]. In the present study we investigated first arbitrarily set at 300 mL [1]. Common Clean intermittent self-catheterization (CISC) whether re-establishing the normal filling and clinical manifestations include nocturnal is now a well-established method of ensuring emptying cycle by a period of CISC can incontinence, a palpable but painless bladder, complete bladder emptying for those with improve both bladder contractility and results dilatation of the upper urinary tracts and incomplete voiding, particularly patients with of bladder outlet surgery for men with CUR, impaired renal function, whilst causative neurological bladder dysfunction [3]. and second, whether a symptomatic and factors include detrusor hypocontractility, urodynamic assessment after a period of CISC chronic BOO and neurological bladder The relief of BOO, which will have the effect of will aid selection for bladder outlet surgery dysfunction. At present most men with CUR decreasing opening pressure, may not be in such cases. We also tried to identify if are treated by catheter drainage and fluid sufficient to allow bladder emptying for all preoperative PFS can predict a poor replacement until the creatinine level is men with CUR, particularly those with outcome of TURP and hence identify a

GHALAYINI ET AL.

subgroup of men who will not beneﬁt from FIG. 1. The patient ﬂow diagram for both arms of the trial. surgery. CUR

PATIENTS AND METHODS Standard Evaluation & PFS The study was a two-centre pragmatic randomized controlled trial, stratiﬁed by centre. All analysis was by intent-to-treat, following CONSORT guidelines [5,6]. The study Randomization was approved by the local ethics committees at each participating centre and all patients provided written informed consent before Stabilization study entry.

The study included men with LUTS and an IPSS of >7 [7], together with CUR, defined as a PVR of >300 mL measured by CISC Immediate TURP ultrasonography on two occasions [1], with patients and physicians agreeing that the findings justified intervention. Patients were Review & evaluation at 3 months Review & evaluation at 3 months excluded from study if there was clinical evidence of prostate cancer, previous prostatic surgery, uncontrolled renal Review, evaluation & PFS at 6 Review, evaluation & PFS at 6 impairment, a life-expectancy of <6 months, months months proven neurological bladder dysfunction, or inability to practise CISC. The urine of all patients was sterile at the time of the study. Discharge Those men who elected to participate in the No obstruction Obstruction trial had conventional unphysiological filling cystometry and PFS with no drainage of residual urine, according to ICS approved methods [8]. Measurements taken from the resultant recordings included cystometric capacity, end-filling pressure, voiding CISC TURP pressure (Pdet.Qmax) and maximum flow rate

(Qmax). Prophylactic oral antibiotics were administered before and for 3 days after the F/U investigation.

The patients gave consent and were with no urodynamic evidence of obstruction randomization because of prostate cancer randomized into two treatment groups were offered the choice of TURP, continued (one), PVR < 300 mL (eight) and inability to (Fig. 1); the first was managed conventionally CISC or an indwelling catheter. use CISC (two). Three men with uncontrolled by TURP, ª4 weeks after stabilization of the severe renal impairment or significantly creatinine level by indwelling catheterization, The symptomatic outcome was measured by dilated upper tracts on ultrasonography, and the second was also managed by an the change in the IPSS and associated quality- characteristic of high-pressure CUR, were initial period of indwelling urethral of-life score; the urodynamic outcome was excluded and treated as an emergency, catheterization but were then taught CISC, determined by the change in the end-filling because it was difficult to stabilize their renal using a 12 or 14 F catheter every 6 h. pressure, Pdet.Qmax, Qmax and PVR. Differences function during the trial. After randomization between means of the outcome variables three patients in the CISC group withdrew Both groups were reviewed at 3 and 6 months were analysed using a paired Student’s from the study, being sufficiently happy with after TURP or the start of CISC. At the 3- and t-test. their management, and seven (five TURP, two 6-month review the IPSS, urine culture and CISC) failed to attend for follow-up visits serum creatinine assay were repeated, with (Fig. 2). This left 41 men who completed the additional renal ultrasonography and PFS at RESULTS study, of whom 17 (42%; mean age 67 years, 6 months. Men in the CISC group with range 52–84) were randomized to TURP and urodynamic evidence of BOO were advised to In all, 65 patients were considered for 24 (58%; 69 years, range 55–85) were have TURP at the end of the study, and men inclusion, but 11 were excluded before randomized to CISC.

TURP OR CATHETERIZATION FOR CHRONIC URINARY RETENTION

FIG. 2. The chronic retention trial profile. The baseline primary outcome variables were similar in both groups (Table 1); the end- Considered for study filling pressure was significantly higher in n = 65 men randomized to TURP (P = 0.004). In all, eight (20%) men (four in each group) had an elevated creatinine level which was associated Not eligible for trial n = 11 with hydroureteronephrosis in all but one. Eligible for trial n = 54 These men had significantly higher end-filling pressure (P < 0.001) and voiding pressure (P = 0.016) than those with no upper tract dilatation. The mean (range) resting end-void Number randomized Not randomized n = 3 subtracted bladder pressure (baseline filling- n = 51 [For reason see text] phase pressure), i.e. the intrinsic pressure within the bladder at the end of micturition when the bladder is supposedly empty, was significantly higher in these patients, at

CISC TURP 25.75 (12–42) cmH2O (P < 0.001). They all n = 29 n =22 had a 4–6-week period of indwelling catheterization to stabilize renal function before starting the allocated management. There was phasic detrusor overactivity (DO) Withdrawn Lost in F/U Completed Completed Lost in F/U during ﬁlling in 17 (42%) patients, of whom n = 3 n = 2 n = 24 n = 17 n = 5 six had upper tract dilatation. Nine (22%) patients (seven CISC, two TURP) found to have 6 months a voiding pressure of £40 cmH2O (two CISC) had an acontractile bladders.

TURP There was a significant improvement in the n = 24 IPSS and quality-of-life score at 3 months in both groups (P < 0.001). Four patients from the CISC and two from the TURP group Patients completed developed complications during the follow- n = 41 up, i.e. symptomatic infection (two), bleeding (two) or both (two). Renal function remained TABLE 1 Baseline comparability of the two treatment groups, and the changes in primary variables from stable for all men of both groups. baseline to the 6-month follow-up At 6 months, both treatment groups had a Variable CISC TURP P (t-test) significant improvement in IPSS and quality- N patients 24 17 of-life score at 6 months (Table 1, P < 0.001). Mean (SD): In the CISC group, there was a significant Age, years 69 (7.3) 67 (8.0) 0.46 increase in end-filling, end-void pressures IPSS 23.2 (6.1) 25.8 (4.2) 0.13 and Pdet.Qmax (P < 0.001, 0.001 and 0.015, IPSS quality of life 4.2 (1.1) 4.4 (0.9) 0.42 respectively); conversely, in the TURP group,

Qmax, mL/s 5.5 (4.2) 5.2 (3.4) 0.78 there was a signiﬁcant decrease in all three PVR, mL 963 (503) 954 (531) 0.96 variables (P = 0.01, 0.004 and <0.001,

Pressures, cmH2O respectively). The PVR decreased signiﬁcantly voiding 85 (57.1) 102 (44.7) 0.305 from baseline to the 6-month follow-up End-ﬁlling 11 (7.5) 22 (15.4) 0.004 (P < 0.001 for both groups). End void 10.3 (8.1) 13.9 (11.4) 0.25 Change, baseline to 6-month follow-up There was a good outcome overall, with Mean (95% CI) complete bladder emptying, in 32 (78%) IPSS -12.25 (-15.53, -8.97) -20.29 (-24.85, -15.74) patients, the remainder having persistent IPSS quality of life -2.54 (-3.11, -1.97) -3.00 (-3.75, -2.25) symptoms and poor bladder emptying, PVR, mL -600.5 (-826.6, -374.3) -854.4 (-1078.1, -630.7) although most were happy continuing CISC.

Pressures, cmH2O Nine (22%) patients (seven CISC and two voiding 8.96 (1.94–15.97) -47.7 (-67.12, -28.17) TURP) with a voiding pressure of £45 cmH2O end-ﬁlling 3.54 (1.84–5.24) -7.12 (-12.32, -1.92) had no signiﬁcant improvement, whilst two in end void 2.33 (1.12–3.54) -7.41 (-12.17, -2.65) the CISC group with voiding pressures of 45 and 40 cmH2O, respectively, had a minimal

GHALAYINI ET AL.

improvement and required continued CISC to A few patients refused to enter the trial detrusor failure from the beginning are empty their bladder. In summary, 19 (79%) because of a fear of CISC; while many reports not expected to have a good outcome, patients from the CISC and 15 (88%) from the acknowledge that CISC improved the patients’ especially when the voiding pressure was

TURP group had a satisfactory symptomatic quality of life, very few go on to identify and £40–45 cmH2O. The PVR decreased and urodynamic outcome after surgery. For discuss daily-life activities that are affected significantly in all patients with a good patients with a successful outcome, 29% by having to use CISC [15]. The main reason symptomatic outcome, but five in each group from the CISC and delayed TURP group, and for the failure of CISC is that patients do not still had a PVR of >250 mL and needed CISC 33% from the immediate TURP group, comply, and with a better understanding of for 6–8 weeks after surgery. Seven (29%) required CISC after TURP for 6–8 weeks. All the problems carers would be able to give patients from the CISC and two (12%) from the patients with DO and upper tract practical help and support [15]. The present the TURP group required CISC in the longer dilatation had a good surgical outcome, with study shows that CISC and TURP are effective term after TURP failed to improve bladder persistent dilatation in only one. Eight (33%) for relieving LUTS, and improving quality of emptying. patients from the CISC and two (12%) from life. There was a significant increase in end- the TURP group developed complications filling and voiding pressure on conventional There was DO in 17 patients (41%) during during the follow-up, i.e. symptomatic urodynamic assessment after a 6-month filling cystometry, six of whom also had upper infection (six), bleeding (two) or both period of CISC. A previous report also tract dilatation, and all had a good outcome (two). emphasized the usefulness of this technique after surgery. Styles et al. [2,18] confirmed the in ensuring recovery of bladder function after finding that involuntary detrusor contraction the acute detrusor failure sometimes during ambulatory, long-term bladder- DISCUSSION subsequent to other than urological surgery pressure monitoring was associated with [4]. The voiding and end-filling pressures upper tract dilatation, and correlated with Previous randomized controlled trials have decreased significantly after relieving the an impaired GFR. Conventional cystometry tended to exclude men with CUR from obstruction in the TURP group, but the end- using unphysiological filling tends to analysis because it was expected that they filling pressure was higher in the TURP than in mask DO and it was suggested that CUR would be generally less healthy at the onset the CISC group; the reason for this finding is should be investigated by natural-filling than those with uncomplicated LUTS, and uncertain. cystometry [19]. The fill rate of 100 mL/ would be more likely to have a poor outcome min used in the present study may have and complications [9,10]. Despite this There was a good surgical outcome, with hampered our ability to detect DO in these exclusion, men with CUR are a clinically adequate bladder emptying in 78% of patients. important group, comprising up to a patients with CUR. In contrast, Abrams et al. quarter of men undergoing TURP in the UK [1] reported a good surgical outcome in 59% Complications such as renal failure, acute [11,12]. of patients, the remainder having persistent retention and UTIs are uncommon in men symptoms and poor bladder emptying. Similar with a large, chronic PVR [20]. Eight (33%) The present study confirmed the findings of results were reported by George et al. [16], patients from the CISC and two from the others, that most patients with high-pressure with 53% having a satisfactory result from TURP group developed complications during CUR have a good outcome after bladder bladder neck surgery. In both these studies a the follow-up, i.e. infection, bleeding or both. outlet surgery. The renal function was usually poor outcome was associated with low end- CISC reduces infection hazards and greatly improved or remained stable and bladder filling and voiding pressures on conventional improves the lives of many patients with emptying was satisfactory in most cases urodynamic assessment before surgery. voiding disorders [21]. With a better [13,14]. Patients with high-pressure CUR Others [2,14] reported a good overall understanding of the problems, carers often present with late-onset enuresis, a improvement in upper urinary tract function would be able to give practical help and tense, palpable bladder, hypertension, and and urodynamic variables, but commented support [15]. progressive impairment associated with that the PVR remained high in a significant bilateral hydronephrosis and hydroureter, proportion of patients (22% and 32%, In conclusion, urodynamics before surgery commonly leading to uraemia and death, respectively) and tended to increase with a can be used to predict the outcome. CISC may whilst voiding urological symptoms are longer follow-up. The latter study also found, be useful in ensuring recovery of bladder typically absent in uncomplicated cases. The in contrast to previous reports, that function after CUR and before a delayed diagnosis was confirmed by finding an preoperative urodynamic values could not be TURP. DO in association with good voiding abnormally high end-void and bladder used to predict the operative outcome. There and end-filling pressures is a positive pressure during cystometry before draining is also evidence that men with CUR treated by prognostic sign. Upper tract dilatation was residual urine [13]. outlet surgery may still progress to renal significantly associated with high-pressure failure requiring dialysis [17]. In the present bladder filling, with a better response to TURP. Similar to other series, the present study series, CISC for 6–8 weeks after surgery The poor response of patients with low- confirmed that patients with CUR are decreased the PVR significantly (P < 0.001) pressure filling was a result of the high commonly elderly and present, not necessarily in men who had poor emptying after incidence of inadequate detrusor contraction, to a urologist, with late-onset enuresis or TURP. leading to a persistent PVR. Using CISC for a symptoms of cardiac decompensation [13]. period before TURP may be worthwhile for After appropriate management most can be A poor outcome was associated with low end- patients with a low-voiding pressure but expected to make a satisfactory recovery. filling and voiding pressures; those with >40–45 cmH2O.

TURP OR CATHETERIZATION FOR CHRONIC URINARY RETENTION

CONFLICT OF INTEREST 8 Schafer W, Abrams P, Liao L et al. 16 George NJR, Fenely RCL, Roberts JBM. International Continence Society. Good Identification of the poor risk patient with None declared. urodynamic practices. uroflowmetry, ‘prostatism’ and detrusor failure. Br J Urol filling cystometry, and pressure-flow 1986; 58: 290–5 REFERENCES studies. Neurourol Urodyn 2002; 21: 261– 17 Sacks SH, Aparico SAJR, Bevan A, 74 Oliver DO, Will EJ, Davison AM. Late 1 Abrams PH, Dunn M, George N. 9 Doll HA, Black NA, McPherson K et al. renal failure due to prostatic outflow Urodynamic findings in chronic retention Differences in outcome of transurethral obstruction: a preventable disease. BMJ of urine and their relevance to results of resection of the prostate for benign 1989; 298: 156–8 surgery. BMJ 1978; 2: 1258–60 prostatic hypertrophy between three 18 Styles RA, Neal DE, Griffiths CJ, 2 Styles RA, Ramsden PD, Neal DE. The diagnostic categories. Br J Urol 1993; 72: Ramsden PD. Long-term monitoring of outcome of prostatectomy on chronic 322–30 bladder pressure in chronic retention of retention of urine. J Urol 1991; 146: 10 Neal DE. The national prostatectomy urine: the relationship between detrusor 1029–33 audit. Br J Urol 1997; 79: 69–75 activity and upper tract dilatation. J Urol 3 Webb RJ, Lawson AL, Neal DE. Clean 11 Embertan M, Neal DE, Black N et al. The 1988; 140: 330–4 intermittent catheterisation in 172 adults. National Prostatectomy Audit. The clinical 19 Machin DG, Gardner BP, Woolfenden Br J Urol 1991; 68: 20–3 management of patients during hospital KA, Desmond AD, Parsons KF. A 4 Anderson JB, Grant JBF. Postoperative admission. Br J Urol 1995; 75: 301–16 physiological approach to the retention of urine: a prospective 12 Gujral S, Abrams P, Donovan JL et al. A investigation of chronic urinary retention. urodynamic study. BMJ 1991; 302: 894–6 prospective randomized trial comparing Br J Urol 1985; 57: 141–4 5 Begg C, Cho M, Eastwood S et al. transurethral resection of the prostate 20 Bates TS, Sugiono M, James ED, Stott Improving the quality of reporting of and laser therapy in men with chronic MA, Pocock RD. Is the conservative randomized controlled trials. The urinary retention: the ClasP Study. J Urol management of chronic retention in men CONSORT Statement. JAMA 1996; 276: 2000; 164: 59–64 ever justified? BJU Int 2003; 92: 581–3 637–9 13 George NJ, O’Reilly PH, Barnard RJ, 21 Winder A. Intermittent self- 6 Altman DG. Better reporting of Blacklock NJ. High pressure chronic catheterization. Nurs Times 2002; 98: randomized controlled trials: the retention. BMJ 1983; 286: 1780–3 50 CONSORT statement. BMJ 1996; 313: 14 Jones DA, Gilpin SA, Holden D, Dixon 570–1 JS, O’Reilly PH, George NJR. Correspondence: Ibrahim F. Ghalayini, PO Box 7 International Consensus Committee Relationship between bladder 940165, Amman – 11194, Jordan. 1993. Recommendations of the morphology and long term outcome of e-mail: [email protected] International Consensus Committee 1993. treatment in patients with high pressure In Cockett ATK, Khoury S, Aso Y et al. eds, chronic retention of urine. Br J Urol 1991; Abbreviations: CUR, chronic urinary retention; Proceedings of the 2nd International 67: 280–5 PVR, postvoid residual volume; PFS, pressure- Consultation on Benign Prostatic 15 Woodward S, Rew M. Patients’ quality flow studies; CISC, clean intermittent self-

Hyperplasia (BPH). Jersey, Channel of life and clean intermittent self- catheterization; Pdet.Qmax, voiding pressure at

Islands: Scientiﬁc Communication catheterization. Br J Nurs 2003; 12: 1066– Qmax; Qmax, maximum urinary ﬂow rate; DO, International, 1993: 556–64 74 detrusor overactivity.

Preoperative administration of chlormadinone acetate reduces blood loss associated with transurethral resection of the prostate: a prospective randomized study

OSAMU UKIMURA, AKIHIRO KAWAUCHI, MOTOHIRO KANAZAWA*, HIROAKI MIYASHITA*, KIMIHIKO YONEDA†, MUNEKADO KOJIMA¶, TSUNEYUKI NAKANOUCHI*, and TSUNEHARU MIKI, for the Benign Prostatic Hyperplasia Study Group of Kyoto Prefectural University of Medicine Departments of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan, *Omihachiman City Hospital, Shiga, Japan, †Nantan General Hospital, Kyoto, Japan, and ¶Nagoya Urology Hospital, Nagoya, Japan Accepted for publication 8 February 2005

OBJECTIVES RESULTS resected prostate tissue was significantly less after CMA treatment (P < 0.001). To assess the effects of giving chlormadinone In all, 33 patients in the CMA+ (median acetate (CMA) before surgery on blood loss duration of treatment 34.5 days) and 38 in associated with transurethral resection of the the CMA- group were evaluable. The mean CONCLUSIONS prostate (TURP), in a prospective randomized blood loss during TURP was less in the CMA+ controlled study. (237.3 mL) than in the CMA- group CMA given for 1 month before TURP could (263.1 mL), but the difference was not reduce blood loss to some extent during and PATIENTS AND METHODS significant. There was significantly less blood after TURP, and this may be related to a loss per gram of resected prostate tissue in decrease in microvessel density. Candidates for TURP among patients with the CMA+ (9.6 mL/g) than in the CMA- group benign prostatic hyperplasia were randomized (13.3 mL/g) (P < 0.05). Haematuria on the day to either treatment with CMA (CMA+) or not of and the day after TURP was also KEYWORDS (CMA-). In principle, CMA was started at least significantly less severe in the CMA+ than in 28 days before TURP and continued until just the CMA- group (P < 0.001 and P < 0.05, prostate, chlormadinone acetate, TURP, blood before surgery. respectively). The mean microvessel density of loss, microvessel density

INTRODUCTION been widely used in treating BPH and PATIENTS AND METHODS prostatic cancer in Japan. CMA at 50 mg/day Despite the development of various minimally for treating BPH is sufficient to inhibit Of patients with BPH attending the authors’ invasive therapies for BPH, TURP is androgen uptake in the prostate, and institutions between April 2002 and August therapeutically beneficial and still remains the competitively antagonises androgen 2003, 92 candidates for TURP were standard treatment for BPH. However, TURP is receptors and androgen binding. Inhibition of randomized to receive either CMA occasionally associated with considerable androgen-receptor binding was reported to 50 mg/day (CMA+) or no CMA (CMA-). bleeding during and after surgery, sometimes be ª23 and 10 times greater for CMA than The procedures were permitted by the leading to serious adverse events. Therefore, it for hydroxyflutamide and bicalutamide, Committee for Clinical Research on Human is important for both the surgeon and patient respectively [5]. CMA can induce apoptosis in Subjects at the relevant institutions. For all that the blood loss associated with TURP is prostate tissue and is effective for prostatic patients enrolled, serum PSA (Tandem-R, controlled. Recent reports show that taking atrophy [6–9], and apoptosis-inducing and Hybritech, San Diego, CA) was measured the 5a-reductase inhibitor finasteride before prostate-reducing activity were reported to before TURP; when the PSA level was surgery is effective in controlling the blood be more potent for CMA than for finasteride abnormally high (>4 ng/mL) a prostate loss associated with TURP [1–3]. The exact [9,10]. needle biopsy was taken to exclude prostate mechanism by which intraoperative blood cancer. loss is reduced by finasteride is unknown, but The present prospective randomized study seems to involve a decrease in prostate blood was designed to compare men treated with Patients were excluded by the following flow and microvessel density (MVD) within CMA before TURP with those not taking CMA criteria: men who previously received the prostate. for blood loss during and after surgery, to antiandrogens other than CMA, drugs with assess the effect of CMA in reducing the loss, anti-androgenic activity, or gonadal Since 1981, chlormadinone acetate (CMA), a and for the MVD of the resected prostate hormones; patients whose serum creatinine steroidal antiandrogen shown to reduce the tissue; the correlation between MVD and level was >180 mmol/L; patients whose liver prostate blood flow in a rat model [4], has blood loss was also evaluated. function test values were at least twice the

CHLORMADINONE ACETATE FOR REDUCING BLOOD LOSS ASSOCIATED WITH TURP

rabbit antihuman factor VIII polyclonal Mean (SD) CMA+ CMA- TABLE 1 antibody (Dako A0082, DakoCytomation A/S, Age, years 71.5 (5.9) 73.5 (4.8) Patient characteristics and Glostrup, Denmark). The primary antibody was Prostate volume, mL 44.3 (16.6) 42.5 (15.8) outcomes of surgery detected using a biotinylated goat antirabbit TZ volume, mL 24.3 (10.0) 24.8 (12.4) IgG. Antigen binding was visualized by Resected weight, g 22.1 (11.2) 22.9 (11.4) diaminobenzidine incubation of the sections, Duration of TURP, min 60.4 (20.6) 60.8 (21.3) after lightly counterstaining with Blood loss, mL 237.3 (138.6) 263.1 (141.1) haematoxylin. Blood loss /resected weight, mL/g 9.6 (6.2) 13.3 (8.0)* The mean MVD was calculated as the number /duration of TURP, mL/min 3.9 (2.0) 4.4 (1.7) of microvessels in a ¥200 field (¥20 objective and ¥10 ocular, 0.754 mm2), and expressed *P < 0.05. per mm2. Large vessels with thick muscular walls and large vessels of lumina more than eight blood cells in diameter were excluded from the counts. Three visual fields per standard value; and patients with serious blood) before surgery. The VS was calculated patient were selected to calculate the mean cardiovascular disorders. as the percentage of blood volume in the MVD, the groups compared, and the collected irrigation fluid ¥ volume of the correlation between mean MVD and blood To determine the period of CMA treatment a collected irrigation fluid. For the VS method, loss during surgery assessed. preliminary study was conducted in 10 a 7-grade scale was used, with known patients with BPH; CMA 50 mg/day was concentrations of blood volume (grade A, The results are expressed as the mean (SD) administered for 4 or 8 weeks before TURP, ≥0.1%, to G, £20%) to check colour tone and unless otherwise indicated. The two-sample and changes in prostate blood flow thus assess blood volume in the irrigation t-test, Mann–Whitney U-test and regression determined using power Doppler fluid. analysis were used to compare data as ultrasonography (SSD-2000, Aloka, Tokyo, appropriate for the scale and properties of the Japan) every 2 weeks to calculate the resistive In addition to examining the correlation data, with P < 0.05 considered to indicate index [11,12]. Blood flow signals within the between blood loss as calculated by these statistical significance. prostate decreased after the first 2-week methods, the correlation between blood loss period of CMA before TURP, and the mean calculated by the haemoglobin (Hb) method resistive index of prostate vessels decreased [3] and the VS method, and between blood RESULTS from 0.81 (10 men) to the nadir level of loss calculated by the RBC method and the Hb 0.60–0.70 at 4 weeks. From these findings and method, were also evaluated. The Hb method During a 16-month period, 44 patients in the those reporting that finasteride administered uses the following equation: concentration CMA+ and 48 in the CMA- group were for 2 weeks before TURP reduced the blood of Hb (g/mL of the collected irrigation enrolled; any men who had protocol loss associated with surgery [1], the fluid) ¥ volume of the collected irrigation deviations were excluded, and consequently administration period required to reduce the fluid, divided by the concentration of Hb the final totals were 33 and 38, respectively. prostate blood flow was set to ≥4 weeks before surgery. The median (range) duration of CMA before TURP. administration was 34.5 (28–141) days. There The blood loss per gram of resected prostate was no statistically significant difference The present study required that the urologists tissue was calculated for each patient, and the between the groups in patient age, weight of had at least 10 years of experience with TURP. mean blood loss per gram of resected prostate the prostate before surgery, and weight of the Variables measured were: age, weight of tissue then calculated by dividing the total TZ (Table 1). The resected weight for all 71 resected prostate tissue, duration of surgery, individual blood loss by the number of patients was 22.5 (11.3) g and the mean volume of the prostate and transition zone evaluable patients. Similarly, the mean blood duration of surgery 60.6 (20.8) min. The (TZ) before treatment, haematology findings, loss per duration of surgery was calculated. median (range) surgeons’ experience with urine analysis findings, macroscopic urine After urine was pooled and thoroughly stirred, TURP was 18 (10–24) years. analysis/urinary sediments, volume of the haematuria after TURP was visually assessed irrigation fluid and volume of blood loss on a 7-grade scale using the VS (A–G) and the For 20 patients in whom both the RBC and the during TURP, and the severity of haematuria results compared between the groups. VS method were used to determine blood afterward. loss during surgery, there was a positive Of 71 evaluable patients, 48 had the MVD correlation between them (r = 0.70, After the irrigation fluid was thoroughly measured in the resected prostate tissue, to P < 0.001). Blood loss was also assessed by stirred, blood loss during TURP was calculated assess the effects of CMA on microvessels in the Hb method in the irrigant and by either the red blood cell (RBC) method or the prostate. The MVD was calculated as preoperative blood in 17 men; these estimates the visual scale (VS) method, or both. The RBC described by Nakanouchi et al. [13]. The were also closely correlated with those method was calculated as the volume of the excised prostate was fixed in formalin, obtained by the VS and RBC methods (VS collected irrigation fluid ¥ RBCs (/mL of embedded in paraffin wax and cut into method, r = 0.85, P < 0.001; RBC method, irrigation fluid) divided by the RBCs (/mL of sections, and the sections incubated in the r = 0.96, P < 0.001).

UKIMURA ET AL.

As there was a significant correlation between TABLE 2 Comparison of episodes of haematuria after TURP, graded as described in the text the RBC and the VS method, blood loss measured by the latter was converted values Day of TURP 1 day after TURP of the RBC method to compare blood loss Grade (% blood) CMA+ CMA- CMA+ CMA- during surgery between the groups. Blood loss during surgery was less in the CMA+ than A (≥0.1) 1 0 3 1 in the CMA- group, although the difference B (0.25) 1 1 9 10 was not statistically significant (Table 1). C (0.5) 11 3 5 7 However, blood loss by weight of prostate D (1) 2 19 0 1 tissue was significantly less in the CMA+ than E (5) 0 1 0 2 in the CMA- group (P <0.05; Table 1). F (10) 0 0 0 1 G (≥20) 0 0 0 1 Haematuria after surgery on the day of TURP P <0.001 <0.05 and the day afterward was statistically significantly less severe in the CMA+ than in the CMA- group (P < 0.001 and <0.05, 70 FIG. 1 respectively). There was no blood loss of grade Correlations between the mean E (5%) or greater in the CMA+ group (Table 2). 60 MVD and blood loss; the dotted green line shows the 95% CI. Twenty-two patients in the CMA+ and 26 in 50 the CMA- group were evaluable for MVD in 2 40 the prostate sections. Blood loss was significantly greater in patients with a high 30

MVD (r = 0.35; y = 0.03x + 23.57; P < 0.05; MVD, mm 20 Fig. 1); the MVD was signiﬁcantly lower in CMA+ than the CMA- group, at 25.5 (7.5) and 10 36.8 (9.4) vessels/mm2 (P < 0.001; Fig. 2). 0 200 400 600 800 None of patients in the CMA+ group had a 0 blood loss that required medical treatment, Blood loss, mL nor were there any adverse events associated with CMA. However, in the CMA- group two FIG. 2. Differences in MVD in immunohistochemically stained prostate sections. (a) and (b), CMA+ group; (c) patients had blood loss requiring medical and (d) CMA- group. Blood vessels were stained red and vessels other than large ones with thick muscular treatment (blood transfusion in one and a walls and vessels of lumina more than eight blood cells in diameter were counted. Rabbit antihuman factor haemostatic agent after TURP in another). VIII stain, ¥ 200.

a b DISCUSSION

None of the many current methods for treating BPH is better than TURP in terms of long-term outcome. Thus TURP has maintained its position as the standard treatment for BPH since its introduction half a century ago. Although TURP is highly beneficial for treating BPH, considerable bleeding is an inherent risk. As the visual field of TURP is prone to occlusion as a result of bleeding, a clear field should be ensured by an c d appropriate method to stop the bleeding associated with TURP. However, enlarged prostate glands should be resected before achieving haemostasis at the beginning of surgery, and thus considerable bleeding is likely during the first half of TURP [14]. In addition, TURP is generally associated with a high incidence of blood transfusion; Uchida et al. [15] reported an incidence of 13.4%. Blood transfusion may correlate with the

CHLORMADINONE ACETATE FOR REDUCING BLOOD LOSS ASSOCIATED WITH TURP

development of infection, immune reaction reduced blood loss per gram of resected suburethral prostatic MVD [22,23]. However, and graft-vs-host disease. Because of this, prostate tissue in the CMA+ group (P < 0.05), the present results confirm that there was a some medical institutions use autologous although the 10% lower blood loss in the tendency for a positive correlation between blood transfusion for patients with extremely CMA+ group during TURP was not MVD and blood loss during surgery, and that large prostates, although blood transfusion- significantly different from that in the CMA- MVD within the prostate was statistically related risks are also inherent in autologous group (Table 1). However, the surgeon who significantly less after 4 weeks of CMA. transfusion. Additional blood transfusion is operated on the most patients was associated Furthermore, the preliminary study with occasionally required if there is insufficient with a 33% decrease (263.4 mL in the CMA+ power Doppler ultrasonography already transfusion of pooled blood. Despite vs 394.2 mL in the CMA- group). Accordingly, verified that the nadir value is reached within conducting such autologous pooled blood the present study may provide information on 4 weeks of CMA treatment. In addition, transfusions, risks cannot be completely the clinically beneficial effects of CMA, Shibata et al. [4] reported, using a rat model, avoided. Numerous reports describe blood although the secondary influences of several that blood flow decreased to ª60% of the loss after TURP, including one indicating that surgeons should be considered. The mean control value after 5 days of CMA and the incidence of a loss requiring coagulation weight of the resected prostate was 22.5 g finasteride 20 mg/kg/day. As there was no was 2.4% [15]. and the mean duration of surgery 60.6 min, significant difference between the CMA+ and values in good agreement with the results CMA- groups, apart from the findings noted As noted, the management of blood loss (23.3 g and 68.3 min, respectively) from a above, decreases in prostate blood flow and during and after TURP is a challenge and study which enrolled up to 1931 surgical MVD within the prostate possibly explain the reducing blood loss is essential. The patients in Japan [15]. Furthermore, mechanism by which CMA reduces blood loss. usefulness of finasteride before TURP was Masumori et al. [19] reported that, although investigated in a randomized, placebo- the mean predicted volume of the prostate for Suburethral prostatic MVD was reported to controlled trial [1], where finasteride given for men in their 70s is smaller in Japanese decrease after short-term administration of 2 weeks before TURP reduced the amount of (21.0 mL) than in American men (39.0 mL), the finasteride [22,23]. In the present study, the Hb in irrigation fluid and the amount of Hb proportion of individuals who have both a MVD of the enlarged prostate decreased after per gram of resected tissue; the blood prostate volume of >20 mL and a maximum 1 month of CMA, possibly partly because CMA concentration of Hb immediately after urinary flow rate of <10 mL/s is higher in has stronger anti-androgenic activity than surgery tended to be higher in the group Japanese (41.8%) than in American men finasteride. Finasteride must be taken for treated with finasteride. Hagerty et al. [2] (17.2%). Thus the present surgical results also ≥6 months to significantly reduce prostate reported that blood loss requiring medical appear to be typical in Japan, and indicate size [10,24] but CMA, being a stronger treatment was less after giving finasteride for that TURP is clinically effective for treating antiandrogen, requires only 12 weeks to do so a mean of 2.7 months before surgery in BPH. [25,26]. In a double-blind controlled study patients with BPH, particularly those with comparing finasteride with CMA, the latter large prostates. Sandfeldt et al. [3] assessed Haematuria on the day of surgery and next was better at reducing prostate size [10]. Thus blood loss by the Hb method and showed that day after TURP was significantly less severe in it could be assumed that the difference in 3 months of finasteride before surgery the CMA+ than in the CMA- group, in anti-androgenic activity between CMA and reduced loss during surgery in patients agreement with results obtained by Donohue finasteride results in different reductions in requiring larger resections. Finasteride and et al. [1]. There was no blood loss requiring MVD. As there was a positive correlation cyproterone acetate are reportedly effective medical treatment in any patient in the CMA+ between MVD within the prostate and blood for treating haematuria secondary to BPH group, supporting the results of Hagerty et al. loss during surgery, MVD could be a predictor [16–18]. Based on these results, we [2], confirming that CMA before TURP is for blood loss during surgery. administered CMA before TURP to assess its effective in reducing the associated blood activity in reducing blood loss during and loss. Thus 1 month of CMA 50 mg/day before TURP after surgery, the loss being evaluated by two could be used to reduce blood loss during and irrigation-fluid methods capable of rigorously Possibly decreases in prostate blood flow and after TURP; CMA also decreased the MVD reflecting true blood loss, the RBC and the VS MVD within the prostate may be involved in within the BPH tissue, suggesting that the method. The precision of blood loss estimated the mechanism by which blood loss is reduced effect of CMA in reducing the blood loss by the VS method was comparable (in the by finasteride. Support for this mechanism is associated with TURP may be related to the same patients) with the RBC or Hb method, that short-term dosing with finasteride is MVD. indicating that the VS method is effective, unlikely to reduce the prostate, but various simple and adequate for estimating blood reports show that finasteride was effective in loss, although giving slightly lower values treating haematuria secondary to BPH ACKNOWLEDGEMENTS than those estimated by the Hb or RBC [17,18]; the haematuria recurred when method. To ensure comparability we finasteride was discontinued [17]; the The authors thank the following members of converted values from the VS method to suburethral prostatic MVD was high in the Benign Prostatic Hyperplasia Study Group, those of the RBC method. patients with BPH and haematuria [20]; Kyoto Prefectural University of Medicine, who 7 days of finasteride at 40 mg/kg per day are not listed in the title page, for their All seven surgeons who conducted TURP had significantly decreased prostate blood flow cooperation: H. Ohe, N. Iwamoto, M. sufficient experience with the procedure. CMA [21]; and finasteride taken for >6 weeks Maekawa, Y. Mizutani, K. Okihara, K. Kamoi, given for 1 month before surgery significantly before surgery significantly reduced the T. Nakamura, Y. Naitoh, S. Ushijima, M. Inaba,

T. Iwata, N. Kanemitsu, A. Fujihara, H. Seki, 9 Shibata Y, Fukabori Y, Ito K, Suzuki K, J et al. Japanese men have smaller Y. Kimura, K. Yano, and Y. Yamada. Yamanaka H. Comparison of histological prostate volumes but comparable urinary compositions and apoptosis in canine flow rates relative to American men. CONFLICT OF INTEREST spontaneous benign prostatic hyperplasia results of community based studies in 2 treated with androgen suppressive agents countries. J Urol 1996; 155: 1324–7 None declared. chlormadinone acetate and finasteride. 20 Foley SJ, Bailey DM. Microvessel density J Urol 2001; 165: 289–93 in prostatic hyperplasia. BJU Int 2000; 85: REFERENCES 10 Aso Y, Homma Y, Kumamoto Y et al. 70–3 Phase III study of 5a-reductase inhibitor, 21 Lekås E, Bergh A, Damber J-E. Effects of 1 Donohue JF, Sharma H, Abraham R, MK-906 in patients with benign prostatic finasteride and bicalutamide on prostatic Natalwala S, Thomas DR, Foster MC. hyperplasia – A comparative double blind blood flow in the rat. BJU Int 2000; 85: Transurethral prostate resection and study with chlormadinone acetate long 962–5 bleeding: a randomized, placebo acting tablets. Jpn J Urol Surg 1995; 8: 22 Hochberg DA, Basillote JB, Armenakas controlled trial of the role of finasteride 237–56 NA et al. Decreased suburethral prostatic for decreasing operative blood loss. J Urol 11 Okihara K, Watanabe H, Kojima M. microvessel density in finasteride treated 2002; 168: 2024–6 Kinetic study of tumor blood flow in prostates: a possible mechanism for 2 Hagerty JA, Ginsberg PC, Harmon JD, prostatic cancer using power doppler reduced bleeding in benign prostatic Harkaway RC. Pretreatment with imaging. Ultrasound Med Biol 1999; 25: hyperplasia. J Urol 2002; 167: 1731–3 finasteride decreases perioperative 89–94 23 Pareek G, Shevchuk M, Armenakas NA bleeding associated with transurethral 12 Kojima M, Ochiai A, Naya Y, Okihara K, et al. The effect of finasteride on the resection of the prostate. Urology 2000; Ukimura O, Miki T. Doppler resistive expression of vascular endothelial growth 55: 684–9 index in benign prostatic hyperplasia. factor and microvessel density: a possible 3 Sandfeldt L, Bailey DM, Hahn RG. Blood correlation with ultrasonic appearance of mechanism for decreased prostatic loss during transurethral resection of the the prostate and infravesical obstruction. bleeding in treated patients. J Urol 2003; prostate after 3 months of treatment with Eur Urol 2000; 37: 436–42 169: 20–3 finasteride. Urology 2001; 58: 972–6 13 Nakanouchi T, Okihara K, Kojima M 24 Gormley GJ, Stoner E, Bruskewitz RC 4 Shibata Y, Ono Y, Kashiwagi B et al. et al. Possible use of transrectal power et al. The effect of finasteride in men with Hormonal and morphologic evaluation of Doppler imaging as an indicator of benign prostatic hyperplasia. N Engl J Med the effects of antiandrogens on the blood microvascular density of prostate cancer. 1992; 327: 1185–91 supply of the rat prostate. Urology 2003; Urology 2001; 58: 573–7 25 Yoshida H, Haraguchi C, Ogawa Y et al. 62: 942–6 14 Kato H, Saito M, Kaneto H, Irisawa C. A Clinical effects of chlormadinone acetate 5 Gotanda K, Shinbo A, Nakano Y, Sasaki study on hemorrhage during and after (PROSTAL) on patients with prostatic T, Honma S, Miyasaka K. The effects of operation of TURP. Hinyokika Kiyo 1986; hypertrophy – with preference to chlormadinone acetate on the prostate of 32: 827–33 estimation of size and weight of prostate rats treated with adrenal androgens. Med 15 Uchida T, Ohori M, Soh S et al. Factors by means of transrectal ultrasonography. Cons New-Remed 1999; 36: 277–83 influencing morbidity in patients Hinyokika Kiyo 1983; 29: 1419–26 6 Murakoshi M, Ikeda R, Fukui N, undergoing transurethral resection of the 26 Suzuki K, Ichinose Y, Hashimoto K et al. Nakayama T. Relationship between prostate. Urology 1999; 53: 98–105 Clinical studies on morphological changes prostatic atrophy and apoptosis in the 16 Perimenis P, Gyftopoulos K, Markou S, of prostates of patients with benign canine spontaneous benign prostatic Barbalias G. Effects of finasteride and prostatic hypertrophy after antiandrogen hyperplasia (BPH) following cyproterone acetate on hematuria therapy – by means of transrectal chlormadinone acetate (CMA). Tokai J Exp associated with benign prostatic ultrasonotomography. Hinyokika Kiyo Clin Medical 2001; 26: 71–5 hyperplasia: a prospective, randomized, 1990; 36: 557–60 7 Murakoshi M, Ikeda R, Fukui N. The controlled study. 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Porcine small intestinal submucosa as a percutaneous mid-urethral sling: 2-year results

J. STEPHEN JONES, RAYMOND R. RACKLEY, RYAN BERGLUND, JOSEPH B. ABDELMALAK, GERARD DeORCO and SANDIP P. VASAVADA Section of Voiding Dysfunction and Female Urology, Cleveland Clinic Urological Institute, Cleveland, OH, USA Accepted for publication 26 January 2004

OBJECTIVE of the SIS sling was placed through the eyelet inﬂammation at 10, 21 and 45 days after of the ligature carrier. Extraction was used to surgery; all resolved, but one had a recurrence To report the 2-year follow-up results on position the sling at the mid-urethra, of SUI. No prolonged retention, erosion or patients treated with a novel minimally providing a backboard of support that was other complications were noted. invasive outpatient procedure for placing a remodelled with ingrowth of the patient’s mid-urethral sling, using porcine small autologous tissue. CONCLUSIONS intestinal submucosa (SIS). RESULTS Early results with the percutaneous mid- PATIENTS AND METHODS urethral placement of SIS are promising and SUI was reportedly cured in 27 of the 34 potentially comparable with those after using Thirty-four women with urodynamic evidence women (79%) at the 2-year follow-up; three synthetic minimally invasive slings. of stress urinary incontinence (SUI, 19) or of (9%) of those with no complete resolution SUI with a positive cough test (15) were were pleased with their results, because the treated. A curved ligature carrier was used to improvement allowed them to wear an KEYWORDS create a tract between bilateral suprapubic average one or fewer pads per day. One stab incisions and a 2-cm mid-urethral patient developed de novo urge incontinence. sling, incontinence, nonsynthetic, small vaginal incision. A suture secured to each end Three patients (9%) developed suprapubic intestine submucosa, percutaneous

INTRODUCTION report the 2-year follow-up from the initial dissection was carried laterally only widely series of patients. enough to palpate the undersurface of the The surgical correction of stress urinary pubic arch. The catheter guide was used for incontinence (SUI) by placing a sling beneath traction of the bladder neck and urethra away the bladder neck and proximal urethra can PATIENTS AND METHODS from the side of interest. A curved Stamey give excellent results [1], but traditionally ligature carrier pierced the skin just medial to requires major surgery, hospitalization and Thirty-four patients were selected based on the pubic tubercle, and was advanced through several weeks of convalescence. Although urodynamic evidence of SUI (19) or a clear rectus fascia and the retropubic space, direct comparative data are lacking, similar history of SUI combined with a positive cough along the dorsal surface of the pubis. The results are reported using all the various test (15); those assessed by urodynamics subordinate index ﬁnger was placed into the operative approaches and sling materials [2]. before surgery had a mean (range) leak-point suburethral incision lateral to the proximal or

pressure of 74 (47–99) cmH2O. mid-urethra, guiding the needle through the Placing a mid-urethral sling is effective using urethro-pelvic complex into the vagina; this minimally invasive techniques [3–5], by After inducing regional or general was repeated on the opposite side (Fig. 1). placing polypropylene mesh either anaesthesia, the patient was placed in the percutaneously (PVT) or transvaginally (TVT, dorsal lithotomy position and prepared using With both ligature carriers in position, the Gynecare, Somerville, NJ). The main a formal vaginal and lower abdominal catheter was removed and cystoscopy used to disadvantage of these procedures is the risk of povidone-iodine solution and intravenous confirm that the bladder had not been infection or erosion of the permanent cefazolin. The bladder was drained with a 16 F entered; the urethra was then inspected while synthetic material left in the surgical site [6,7]. urethral catheter, through which a catheter manipulating the ligature carriers to confirm Such experience with previous artificial sling guide was then placed. A 2 ¥ 30 cm Stratisis® their proper placement. The needle was materials has made many surgeons hesitant (Cook Urological, Spencer, IN) sling was replaced if it had entered the urinary tract. to use these procedures [8]. prepared by securing a 2–0 absorbable suture The sutures securing each end of the sling through each end. Placement and handling were inserted through the ligature carrier To avoid these risks, we placed a commercially was easiest if only the distal third of each end eyelet and the carrier extracted. The sutures available nonsynthetic small intestinal was moistened with saline after placing the were gently pulled to advance the sling submucosa (SIS) sling using a percutaneous suture. A 2-cm sagittal vaginal incision was through the retropubic space, abdominal wall route in selected patients with type II SUI and created at the mid-urethra. The periurethral and skin. A 3–0 absorbable stay suture

JONES ET AL.

between the sling edge and the submucosal FIG. 1. Both Stamey needles are placed percutaneously through the retropubic space into the vaginal extents of the vaginal incision prevented incision. rolling of the material.

The sling was positioned with no tension, as described for PVT and TVT, and no ‘cough test’ or other assessment of tension was used. The vaginal incision was closed with absorbable suture. The sling was then cut below the skin level and an adhesive strip placed. No vaginal pack was used. Patients returned to the ofﬁce 1–3 days later to remove the catheter and have a voiding trial, depending on whether the operation was midweek or on Friday (respectively). Catheter use was based on the surgeon’s preference because of concerns that the material might slip more easily than polypropylene. We currently think that catheterization is unnecessary, based on subsequent experience, and no longer place a catheter after surgery.

With institutional review board approval, the patients’ charts were reviewed to assess the outcome at various intervals and results analysed, based on notes taken at the 2-year these four had a component of urge UI shown temporary retention. None of the patients visit or the first visit after the 2-year period. on urodynamics before surgery. Another who with persistent urge UI had retention after All but two patients remained under the care had surgery with no urodynamics beforehand surgery. of the institution, and information was had a clear history of urge UI, which was a available for visits either to the surgeon (in secondary complaint to SUI requiring four Four patients, including the woman described 28), the primary-care physician (in two), or pads/day. Only one woman had de novo urge above with mixed UI, failed to have a the referring gynaecologist (in two). Because UI, but was pleased with her outcome, with significant prolonged improvement in SUI. the two patients whose follow-up was at complete resolution of SUI. One patient with One elderly patient was completely dry until outside institutions were both known to have mixed urge UI and SUI at presentation failed she fell 3 weeks after surgery, fracturing failed, their data were included as such on the to improve and eventually had an open several ribs; her incontinence thereafter was assumption that they remained incontinent at pubovaginal sling, followed by placing a judged as only ‘improved’. Another elderly 2 years. Failure was defined as either the neuromodulation device. She continues to patient who was ‘improved’ had surgery early patient stating she had persistent SUI, or have only a partial response to therapy a year in the series; she had required 18 days of pad use. after her most recent intervention, and she is catheterization after the voiding trial. the only patient of the four with urge UI who Urethral dilatation while placing downward has problems regularly enough to require the traction on a Van Buren sound was used in an RESULTS use of pads. attempt to mobilize the sling; this manoeuvre was thought to have displaced or ruptured The SUI was reportedly cured in 27 of the 34 There was no prolonged urinary retention, the sling. (79%) women at the 2-year follow-up; three although six patients (18%) required (9%) of those with no complete resolution of additional catheter drainage after the initial Additional procedures during the surgery SUI were pleased with the results of their voiding trial (mean 8.6 days, maximum 18). were anterior and posterior repair in five, procedure because of the improvement, and These were early in the series, and presumably major pelvic floor reconstruction (i.e. vaginal all three either wore one pad (two) or no pads were caused by over-tightening of the sling. vault suspension) in four and diagnostic (one) daily. These women they felt the This is a subjective observation, but we noted laparoscopy in two patients. operation had yielded a substantial that retention occurred early in the series, improvement from baseline, which they felt when there was greater concern that the Three patients (9%) developed suprapubic was good enough that they desired no further material would migrate more easily than inflammation 10, 21 and 45 days after intervention. Each had previously used at polypropylene. After ª20 patients we decided surgery; two were minimally inflamed and least three pads daily. The total cured or to place the slings with the same spacing used they had complete resolution with oral improved rate was therefore 88%. for TVT, so a 1–2 mm space was left between fluoroquinolones, although one developed the sling and urethra thereafter. This did not recurrent SUI a few weeks later and Four women (12%) had persistent urge UI, but appear to correlate with a change in success subsequently had an open autologous-fascia only one required the use of pads. Two of rate, but seemed to address concerns of pubovaginal sling placed. A biopsy of her SIS

PORCINE SIS AS A PERCUTANEOUS MID-URETHRAL SLING

FIG. 2. Haematoxylin and eosin staining shows neo- success rate [12]; in that series, another 11% These pilot data are relatively immature and autologous remodelling of SIS with tissue that were judged to be improved. must be validated with a longer-term follow- appears histologically similar to autologous fascia. up, which would ideally involve pad testing Many fibroblasts are visible among a thick collagen The disadvantage in using SIS could and validated questionnaires. Comparison deposition. potentially be related to its advantage, in that with established treatment options is needed. the material is not permanent. However, SIS However, at 2 years, porcine SIS placed is remodelled into a neo-autologous sling percutaneously as described appears to have that appears histologically similar to an success rates and complication rates autologous fascia sling, as shown in Fig. 2. SIS comparable with TVT and other sling options. placed using an open approach appears to be as effective as both autologous slings and TVT In conclusion, a percutaneous nonsynthetic at 4 years after surgery, as reported recently sling of porcine SIS offers a minimally [13], where 93% of patients remained dry invasive option for treating female SUI. after a mean of 48 months. Advantages include easy placement and safety, especially as it avoids placing a Three patients in the present series developed permanent prosthetic material near the subcutaneous inflammation; two were mild urinary tract and vagina. The 2-year results and resolved with antibiotic coverage. The are promising and rival those of synthetic sling taken at the time of her re-operation other had negative cultures, suggesting that slings such as PVT and TVT. was assessed (Fig. 2). The other patient had the reaction could be inflammatory and not incision and drainage, revealing sterile infectious. The material used in the present CONFLICT OF INTEREST inflammatory change in the subcutaneous series is a four-layer, lyophilized version, in tissues, which subsequently resolved during a contrast to the eight-layer, air-dried version J. Stephen Jones is a research consultant for period of empirical oral antibiotic coverage; more commonly in use. The inflammatory Cook Urological. she remains dry 30 months after surgery. process is poorly understood, but we consider, based on communication with the REFERENCES manufacturer, that this thinner tissue may be DISCUSSION more readily remodelled and less likely to be 1 Leach GE, Dmochowski R, Appell RA associated with inflammation (Jason Hodde, et al. Female Stress Incontinence Clinical PVT and TVT procedures have minimized personal communication, 2004). Ho et al. [14] Guidelines Panel summary report on morbidity and recovery, but rely on synthetic recently reported that the inflammation management of female stress urinary materials. These procedures offer promising associated with the eight-ply version appears incontinence. The American Urological results, but carry the risk of infection, urinary to be usually self-limiting and unrelated to Association. J Urol 1997; 158: 875 retention or erosion, and must be surgically success rates. This risk must be weighed 2 Yonneau L, Chartier-Kastler E, Bohin D, incised or removed if these complications against the apparently lower risk of Conort P, Richard F. Materials used in occur [3]. Nonsynthetic slings such as SIS permanent urinary retention (which to our treatment of stress urinary incontinence offer an alternative to those concerns. knowledge has never been reported with SIS, with suburethral sling. Prog Urol 2000; although it is likely that it will be at some 10: 1238–44 Porcine SIS is a membrane from the animal’s time) than with synthetic slings. In addition, 3 Rackley RR, Abdelmalak JB, Tchetgen small intestine, with no theoretical risks of as the material is completely replaced with MB, Madjar S, Jones JS, Noble M. human viral transmission from cadaveric host tissue within months, the risk of vaginal Tension-free vaginal tape and fascia, pericardium or dermis. The cellular or urethral erosion requiring surgical removal percutaneous vaginal tape sling components are mechanically removed, appears to be effectively negated. procedures. Tech Urol 2001; 7: 90–100 leaving a biological scaffold for tissue 4 Ulmsten U, Henriksson P, Johnson P remodelling. Functional growth factors, The present study has the limitations of a et al. An ambulatory surgical procedure primarily fibroblast growth factor-2 [9], are retrospective chart review; it is well- under local anesthesia for treatment of thought to be vital to the regenerative recognized that patients may report a good female urinary incontinence. Int process. Within weeks, the body absorbs the outcome, stemming from a desire to please Urogynecol J Pelvic Floor Dysfunct 1996; material and replaces it with a remodelled their surgeons. Thus we chose to use the most 7: 81–6 sling of neo-autologous tissue [10] (Fig. 2). objective variable available from the chart 5 Olsson I, Kroon U. A three-year review, i.e. pad use, in addition to notes of postoperative evaluation of tension-free Although there seems to be a perception each patient’s response to questions about vaginal tape. Gynecol Obstet Invest 1999; among pelvic surgeons that slings do not fail, success. In addition, the presence or absence 48: 267–9 peer-reviewed reports show that success of urge UI was noted and reported even if not 6 Fynes M, Murray C, Carey M et al. rates are 80–85% [1]. Ward and Hilton requiring pads. It is possible that some women Prognostic factors for continence [11] recently reported that TVT and had SUI that was not severe enough to wear outcome following tension free vaginal colposuspension are both associated with pads and inaccurately denied it to their tape – an observational study. Int success rates well below such perceptions. surgeons on questioning during follow-up Urogynecol J Pelvic Floor Dysfunct 2000; The inventor of the TVT reported an 85% visits. 11 (Suppl. 1): S33

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7 Tamussino K, Hanzal E, Riss P. The Ireland Tension-free Vaginal Tape Trial pubovaginal slings. durability and results. Austrian TVT Registry. Int Urogynecol J Group. Prospective multicentre Urology 2003; 62: 805–9 Pelvic Floor Dysfunct 2000; 11 (Suppl. 1): randomised trial of tension-free vaginal 14 Ho KL, Witte MN, Bird ET. 8-ply small S9 tape and colposuspension as primary intestinal submucosa tension-free sling. 8 Iglesia CB, Fenner DE, Brubaker L. The treatment for stress incontinence. BMJ spectrum of postoperative inﬂammation. use of mesh in gynecologic surgery. Int 2002; 325: 67 J Urol 2004; 171: 268–71 Urogynecol J Pelvic Floor Dysfunct 1997; 12 Nilsson CG, Kuuva N, Falconer C, 8: 105–15 Rezapour M, Ulmsten U. Long-term Correspondence: J. Stephen Jones, Cleveland 9 Hodde JP, Hiles MC. Bioactive FGF-2 in results of the tension-free vaginal tape Clinic Foundation, Urological Institute, A-100, sterilized extracellular matrix. Wounds (TVT) procedure for surgical treatment of 9500 Euclid Ave., Cleveland, OH 44195, USA. 2001; 13: 195–201 female stress urinary incontinence. Int e-mail: [email protected] 10 Cheng EY, Kropp BP. Urologic tissue Urogynecol J Pelvic Floor Dysfunct 2001; engineering with small-intestine 12 (Suppl. 2): S5–8 Abbreviations: (S)UI, (stress) urinary submucosa: potential clinical applications. 13 Rutner AB, Levine SR, Schmaelzle JF. incontinence; (P)(T)VT, (percutaneous) World J Urol 2000; 18: 26–30 Processed porcine small intestine (transvaginal) vaginal tape; SIS, small 11 Ward K, Hilton P; United Kingdom and submucosa as a graft material for intestinal submucosa.

Hyperbaric oxygen therapy for radiation-induced haemorrhagic cystitis

AMOS NEHEMAN, OFER NATIV*, BOAZ MOSKOVITZ*, YEHUDA MELAMED† and AVI STEIN Departments of Urology, Carmel Hospital and *Bnei-Zion Hospital, and the †Hyperbaric Medical Center, Rambam/Elisha Hospitals, Haifa, Israel Accepted for publication 22 February 2005

OBJECTIVE RESULTS after failure of standard regimens. This method was well tolerated even in patients To assess the efﬁcacy of hyperbaric The haematuria resolved completely in all debilitated by advanced cancer and blood loss. oxygen (HBO) for treating haemorrhagic seven patients shortly after treatment; one Long-term remission is possible in most cystitis. had an improvement but died from patients, and re-treatment effectively complications relating to cancer shortly after manages recurrent bleeding. completing treatment, and two had PATIENTS AND METHODS recurrence of gross haematuria. They were re- KEYWORDS treated with HBO until the haematuria From February 1997 to April 2004, resolved. hyperbaric oxygen therapy, radiation therapy, seven patients with radiation-induced hemorrhagic cystitis haemorrhagic cystitis were treated with HBO; CONCLUSIONS they received a mean (range) of 30 (18–57) HBO treatments and the follow-up was 24 Radiation-induced haemorrhagic cystitis can (3–53) months. be treated successfully with HBO primarily or

INTRODUCTION cystectomy may be ultimately necessary in and primitive neuro-ectodermal tumour the most severe cases. (PNET) in the women. Radiation was given for Haemorrhagic cystitis can occur from 2 local disease and the mean dosage delivered months to ≥10 years after pelvic irradiation. The potential clinical benefits of HBO have was 64 Gy. Levenback et al. [1] reported on 1784 patients been reported for several decades. Among who received radiotherapy for stage Ib confirmed hyperoxygenation physiological Patients with haemoglobin levels of <80 g/L, cervical cancer over 29 years; haemorrhagic mechanisms operating in HBO are the cardiac debilitated patients with haemoglobin cystitis developed in 6.5%. Other studies induction of capillary angiogenesis and levels of <90 g/L and patients with a fast reported an incidence of moderate to severe increased fibroblast concentration. These have decline in haemoglobin levels received a blood haematuria of 3–5% after radiotherapy for also been established as micro-anatomical transfusion. Stabilization was defined as three prostate cancer. The primary treatment for effects of HBO in irradiated tissues. HBO also consecutive haemoglobin levels of >100 g/L haemorrhagic cystitis is bladder irrigation; induces healing of tissue damage, and in 24 h. we initially start bladder irrigation with decreases oedema, necrosis and leukocyte continuous saline, and the next step is infiltration [2]. Recently HBO has emerged as The interval from original radiation treatment cystoscopy and fulguration to stop bleeding a potential primary option for managing this to HBO therapy was 3–180 months; before bladder mucosa. If this treatment fails we challenging condition; we review our therapy six patients had cystoscopy and initiate alum silver nitrate bladder irrigation. If experience treating refractory haemorrhagic biopsies to exclude malignancy. All random all these methods fail we refer the patients for cystitis with HBO. biopsies showed histological changes hyperbaric oxygen (HBO) therapy. consistent with post-radiation cystitis. One patient had had a nephroureterectomy for Oral and intravenous agents, e.g. PATIENTS AND METHODS upper tract TCC before the diagnosis of aminocaproic acid, oestrogens and sodium prostate cancer and radiotherapy. Cystoscopy, pentosan polysulphate, have been tried with Four men and three women (mean age ureteroscopy, urine cytology and random limited success. Intravesical treatments with 63 years, range 21–80) received HBO therapy biopsy were used to exclude an underlying alum silver nitrate, prostaglandins or formalin for radiation-induced haemorrhagic cystitis. disease. are sometimes used if bleeding persists. Ionizing radiation was administered for Finally, selective embolization of the prostate cancer in the men, and metastatic HBO was administered at 0.2 MPa for 90 min hypogastric arteries, urinary diversion and breast cancer in one, cervical cancer in one daily in a walk-in multiplace hyperbaric

NEHEMAN ET AL.

chamber; patients were monitored during the at the rate of 2.3 volume percentage of environment [15]. Follow-up for up to treatment. Five treatments were given weekly hyperoxaemia per 0.1 MPa AA. This amount of 4 years after HBO therapy showed that (on weekdays), with a mean (range) of 30 hyperoxygenation cannot be achieved by any transcutaneous oxygen measurements (18–57) treatments administered. other means available in medical practice. remain near normal levels, implying that the These high doses of oxygen promote angiogenesis is essentially permanent [16]. physiological mechanisms that have clinical RESULTS affects in different pathological conditions, Case series of radiation-induced e.g. impaired oxygen delivery or impaired haemorrhagic cystitis treated with HBO have Of the seven patients, all had complete oxygen metabolism. HBO is considered an been reported [17–29]; despite differences in resolution or a marked improvement of adjunctive treatment to medical and surgical the number of HBO treatments administered haematuria after HBO therapy. Two patients care, as in acute traumatic ischaemic injury. and characteristics of hyperbaric exposure had recurrence of haematuria and received 30 HBO treatment has been shown to reduce among the various reports, most authors (in one) and 37 (in the other) additional oedema and enhance aerobic metabolism concluded that HBO therapy is effective for treatments until the haematuria resolved. All [5–7]. HBO may also facilitate the transport of intractable radiation-induced haemorrhagic patients but one had cystoscopy before HBO some antibiotic agents across the bacterial cystitis. If the earlier case series reported are to exclude causes of bleeding other than cell wall, thus improving their overall combined, 82% of patients treated with HBO haemorrhagic cystitis. These patients also had effectiveness [8]. In addition, hyperoxaemia had an improvement or resolution of cystoscopy after HBO therapy, to visually improves collagen formation, fibroblast haematuria. The response to HBO depended assess the response to treatment, which growth and angiogenesis, which also enhance on the severity of the presenting haematuria. revealed objective improvements in bladder wound healing. mucosal appearance. One patient (the 21- Although various authors reported a positive year-old woman with PNET) had resolution of At the joint consensus meeting of the response to HBO for treating radiation- haematuria after 20 HBO treatments, but she European Society for Therapeutic Radiation induced haemorrhagic cystitis the duration of died from her underlying disease 3 months and Oncology and the European Committee follow-up varied. Del Pizzo et al. [25] reported after stopping the HBO treatment. for Hyperbaric Medicine (Lisbon, 2001) it was on 11 patients treated with 28–64 HBO established that according to evidence-based treatments and followed for a mean of medicine criteria, the effect of HBO treatment 5.1 years. At a mean follow-up of 2.5 years DISCUSSION on angiogenesis and osteogenesis in eight of 11 patients were asymptomatic, while irradiated tissue is graded as level 1 [9]. at 5.1 years five of the remaining eight had Radiation-induced tissue injury is the result recurrent haematuria requiring of progressive endarteritis, leading to The therapeutic effects of HBO for the treating hospitalization, blood transfusion and hypovascular, hypocellular and hypoxic tissue long-term radiation effects were initially ultimately supravesical urinary diversion. Of (the ‘three-H’ tissue). The ability to replace described by Marx and Ames [10] these five patients two eventually required normal collagen and cellular loss is for post-irradiated head and neck cancer. Marx embolization and cystectomy. Of the 11 compromised, resulting in tissue breakdown, [3] redefined the sequence of the pathogenesis patients, three had a complete and durable and once irradiated tissue breaks down it is of radionecrosis as 1 (radiation), 2 (hypoxic- resolution of symptoms at a mean of 5 years. unlikely that it will heal [3]. Gross haematuria hypocellular-hypovascular tissue), 3 (tissue This study highlights the progressive nature caused by the breakdown of bladder mucosa breakdown) and 4 (chronic non-healing of radiation injury. The possibility that repeat and damaged pathological blood vessels in wound). Beneficial effects of HBO on HBO treatments might provide additional the bladder wall may ensue weeks or decades radiation-damaged tissue are related benefit has not been explored in detail. after irradiation therapy. Cystoscopy findings to the hyperoxia-induced primary Investigators at Duke University analysed all reveal patchy diffused bleeding ulcers in the neovascularization and secondary growth of published series and found that 40 HBO bladder. healthy granulation tissue [11,12]. Additional treatments was the optimum for acute benefits include vasoconstriction, which may resolution of symptoms and a long-term Technically, the delivery of HBO therapy help in reducing oedema, and improvements in durable result [30]. occurs when the patient rests the whole body wound healing and immune function [12–14]. and breathes 100% oxygen in a treatment The potential side-effects of HBO therapy are chamber which is above atmospheric HBO therapy enhances healing in a variety of usually well tolerated. Some diabetic patients pressure, e.g. >0.1 MPa (absolute atmospheric radiation-injured tissues [12]. In an animal may have an exaggerated hypoglycaemic pressure, AA). Pressurization at 1.4–3 times model, breathing 100% oxygen at normal response to hyperoxia, the mechanism of AA while the patient inhales oxygen meets the atmospheric pressure produced no effect on which is yet to be defined. To minimize these Undersea and Hyperbaric Medicine Society angiogenesis in irradiated tissues. However, side-effects, the patients’ glucose level should definition of HBO treatment [4]. HBO at 2.4 AA produced an 8–9-fold increase be monitored. Patients with emphysema, a in vascular density in irradiated tissues over history of spontaneous pneumothorax and The hyperbaric chamber provides conditions normobaric oxygen and air-breathing any other obstructive pulmonary disease in which a very high dose of oxygen may be controls. This stimulus for angiogenesis should be closely monitored. CNS or administered to the tissue. In these conditions appears to be mediated at least partly through pulmonary oxygen toxicity is unlikely in HBO the haemoglobin is fully saturated and the tissue macrophages responding to the steep treatment, which does not expose the patient oxygen dissolved in the blood plasma oxygen gradient achieved in the hyperbaric to those oxygen side-effects.

HYPERBARIC OXYGEN THERAPY FOR RADIATION-INDUCED HAEMORRHAGIC CYSTITIS

In conclusion, haemorrhagic cystitis is a for Therapeutic Radiology and Oncology oxygen – an effective tool to treat debilitating complication of radiation therapy and the European Committee for radiation morbidity in prostate cancer. for pelvic malignancy. Standard therapeutic Hyperbaric Medicine; Proceeding Book Radiother Oncol 2001; 61: 151–6 methods have limited success and may have October 2001 Lisbon-Portugal 22 Mathews R, Rajan N, Josefson L, signiﬁcant side-effects. HBO therapy is safe 10 Marx RE, Ames JR. The use of hyperbaric Camporesi E, Makhuli Z. Hyperbaric and noninvasive for treating the underlying oxygen in bony reconstruction of the oxygen therapy for radiation induced histological changes that occur with radiation irradiated and tissue-deﬁcient patient. hemorrhagic cystitis. J Urol 1999; 161: injury, resulting in long-term complete J Oral Maxillofacial Surg 1982; 40: 435–7 resolution in a large proportion of patients in 412–20 23 Weiss JP, Stember DS, Chaikin DC, whom standard treatment regimens fail. Early 11 Marx RE, Ehler WJ, Tayapongsak P, Blaivas JG. Hyperbaric oxygen treatment institution of HBO results in rapid resolution Pierce LW. Relationship of oxygen dose of hemorrhagic radiation cystitis: 14 year of haematuria. HBO therapy should be added to angiogenesis induction in irradiated experience. J Urol 1998; 159: 305, as a preferred option for treating persistent tissue. Am J Surg 1990; 160: 519–24 A1177 haemorrhagic cystitis. 12 Weiss JP, Mattei DM, Neville EC, Hanno 24 Miyazato T, Yusa T, Onaga T, Sugaya K, PM. Primary treatment of radiation- Koyama Y, Hatano T. Hyperbaric oxygen CONFLICT OF INTEREST induced hemorrhagic cystitis with HBO. for radiation-induced hemorrhagic 10 year experience. J Urol 1994; 151: cystitis. Nippon Hinyokika Gakkai Zasshi None declared. 1514–7 1998; 89: 552–6 13 Risberg J, Tyssebotn I. Hyperbaric 25 Del Pizzo JJ, Chew BH, Jacobs SC, Sklar

REFERENCES exposure to a 5 ATA He-N2–O2 atmosphere GN. Treatment of radiation induced affects the cardiac function and organ hemorrhagic cystitis with hyperbaric 1 Levenback C, Eifel PJ, Burke TW, Morris blood ﬂow distribution in awake trained oxygen: long-term followup. J Urol 1998; M, Gershenson DM. Hemorrhagic cystitis rats. Undersea Biomed Res 1986; 13: 77– 160: 731–3 following radiotherapy for stage Ib cancer 90 26 Miura M, Sasagawa I, Kubota Y, Iijima I, of the cervix. Gynecol Oncol 1994; 55: 14 Knighton DR, Halliday B, Hunt TK. Sawamura T, Nakada T. Effective 206–10 Oxygen as an antibiotic. The effect of hyperbaric oxygen with prostaglandin E1 2 Buras J. Basic mechanisms of hyperbaric inspired oxygen on infection. Arch Surg for radiation cystitis and colitis after oxygen in the treatment of ischemia- 1984; 119: 199–204 pelvic radiotherapy. Int Urol Nephrol reperfusion injury. Int Anesthesiol Clin 15 Knighton DR, Hunt TK, Scheuenstuhl H, 1996; 28: 643–7 2000; 38: 91–109 Halliday BJ, Werb Z, Banda MJ. Oxygen 27 Bevers RF, Bakker DJ, Kurth KH. 3 Marx RE. Osteoradionecrosis. a new tension regulates the expression of Hyperbaric oxygen treatment for concept of its pathophysiology. J Oral angiogenesis factor by macrophages. haemorrhagic radiation cystitis. Lancet Maxillofac Surg 1983; 41: 283–8 Science 1983; 221: 1283–5 1995; 346: 803–5 4 Thom TR. Hyperbaric oxygen therapy: a 16 Marx RE, Johnson RP. Problem wounds 28 Weiss JP, Mattei DM, Neville EC, Hanno committee report. Bethesda, Maryland: in oral and maxillofacial surgery: the role PM. Primary treatment of radiation- Undersea and Hyperbaric Medicine of hyperbaric oxygen. In Davis JC, Hunt TK induced hemorrhagic cystitis with Society, 1992 eds, Problem Wounds: the Role of Oxygen. hyperbaric oxygen: 10-year experience. 5 Nylander G, Nordstrom H, Lewis D, New York: Elsevier Science Publishing Co, J Urol 1994; 151: 1514–7 Larsson J. Metabolic effects of hyperbaric 1988 29 Akiyama A, Ohkubo Y, Takashima R, oxygen in postischemic muscle. Plastic 17 Nakada T, Yamaguchi T, Sasagawa I, Furugen N, Tochimoto M, Tsuchiya A. Reconstr Surg 1987; 79: 91–7 Kubota Y, Suzuki H, Izumiya K. Hyperbaric oxygen therapy in the 6 Nylander F, Nordstrom H, Franzen L, Successful hyperbaric oxygenation for successful treatment of two cases of Henriksson KG, Larsson J. Effects of radiation cystitis due to excessive radiation-induced hemorrhagic cystitis. hyperbaric treatment in post-ischemic irradiation to uterus cancer. Eur Urol Nippon Hinyokika Gakkai Zasshi 1994; 85: muscle. Scand J Plastic Reconstr Surg 1992; 22: 294–7 1269–72 Hand Surg 1988; 22: 31–9 18 Rijkmans BG, Bakker DJ, Dabhoiwala 30 Matsuo H, Shinomiya N, Suzuki S. 7 Monies-Chass I, Hashmonai M, Hoere NF, Kurth KH. Successful treatment of Hyperbaric stress during saturation diving D, Kaufman T, Steiner E, Schramek A. radiation cystitis with hyperbaric oxygen. induces lymphocyte subset changes and Hyperbaric oxygen treatment as an Eur Urol 1989; 16: 354–6 heat shock protein expression. Undersea adjuvant to reconstructive vascular 19 Schoenrock GJ, Cianci P. Treatment of Hyperb Med 2000; 27: 37–41 surgery in trauma. Injury 1977; 8: 274–7 radiation cystitis with hyperbaric oxygen. 8 Shupak A, Halpern P, Ziser A, Melamed Urology 1986; 27: 271–2 Correspondence: Amos Neheman, Michal 7 Y. Hyperbaric oxygen therapy for gas 20 Lee HC, Liu CS, Chiao C, Lin SN. st., Carmel Hospital, Department of Irology, gangrene casualties in the Lebanon Israeli Hyperbaric oxygen therapy in Haifa, Israel 34362. War, 1982. J Med Sci 1984; 20: 323–6 hemorrhagic radiation cystitis. a report of e-mail: [email protected] 9 Lartigau E, Mathieu D. Hyperbaric 20 cases. Undersea Hyperb Med 1994; 21: Oxygen Therapy in the Treatment of 321–7 Abbreviations: HBO, hyperbaric oxygen; AA, Radio-Induced Lesions in Normal Tissues, 21 Mayer R, Klemen H, Quehenberger F, absolute atmospheric (pressure); PNET, Consensus Conference. European Society Sankin O, Mayer E, Hackl A. Hyperbaric primitive neuro-ectodermal tumour.

In this section, authors from Magnetic resonance imaging as a Mansoura describe their experience with MRI as the sole sole method for the morphological method for the morphological and and functional evaluation of live functional evaluation of live kidney donors. They recommend this kidney donors technique in both instances. TAREK A. EL-DIASTY, MOHAMED E. ABO EL-GHAR, AHMED A. SHOKEIR, HOSSAM M. GAD, EHAB W. WAFA, MOHAMED E. EL-AZAB, A series of studies from Detroit AHMED B. SHEHAB EL-DIN and MOHAMED A. GHONEIM show that oxalate and Urology & Nephrology Center, Mansoura University, Mansoura, Egypt hyperoxaluria induced free-radical Accepted for publication 31 January 2005 generation, which resulted in injury to renal tubular cells. In this paper they show for the first time that OBJECTIVE estimated by MRI or MAG3. For the right and left kidneys the mean isotope clearance was hyperoxaluria-induced injury To evaluate gadolinium-enhanced dynamic not significantly different from that of mean promotes individual calcium magnetic resonance imaging (MRI) as the sole MRI clearance. MR urography allowed oxalate crystal attachment in the method for the anatomical and functional visualization of the urinary tract and the renal tubules. They also showed assessment of potential live-kidney donors. detection of any abnormality. that this was prevented by vitamin SUBJECTS AND METHODS CONCLUSION E treatment. The study included 50 consecutive kidney Gd-enhanced dynamic MRI can provide donors; in addition to routine donor accurate information about the anatomy of evaluation, the kidney was imaged with Gd- the urinary tract and vasculature of the enhanced dynamic MRI, which was also used kidney, and can be used to accurately estimate for selectively determining the glomerular the selective GFR of each kidney. Therefore, filtration rate (GFR) of each kidney. All donors we recommend MRI as a single imaging had a m99Tc-mercaptoacetyltriglycine (MAG3) diagnostic method for assessing potential live renal scan as the reference standard to kidney donors. measure GFR. The anatomical results of MRI were compared with the findings at donor KEYWORDS nephrectomy, and the GFR estimated from MRI compared with that from MAG3 kidney, transplantation, living donors, MRI, scintigraphy. GFR

RESULTS INTRODUCTION MR angiography had 100% sensitivity, 94% speciﬁcity and 96% overall accuracy for Renal transplantation is an effective detecting the number of renal arteries, and treatment for patients with end-stage renal 100% sensitivity, 98% speciﬁcity and 98% failure. Although cadaveric transplants overall accuracy for the number of renal veins. continue to outnumber live-donor There was a close correlation (r = 0.54, transplants by three to one, the number of P < 0.01) between the GFR of each kidney live-donor renal transplants has increased

EL-DIASTY ET AL.

steadily over the past decade. Transplants and 20 women, mean age 35 years, range The imaging parameters for coronal T2 were from living-related donors have better short- 22–55) were prospectively included in the 5 mm thickness, no interslice gap, repetition and long-term survival rates than do study. Apart from the routine evaluation of time 8000–1000 ms, time to echo 75–95 ms, transplants from cadavers. the donors, including abdominal US (to field of view 40 ¥ 40 cm and matrix exclude renal stones or other abnormalities), 256 ¥ 196; the respective values for coronal Selectively assessing the anatomy and the kidneys were imaged with Gd-enhanced FSPGR were 4 mm, no interslice gap, function of each kidney is a fundamental part MRI that was also used for selectively 30–40 ms, 2–3 ms, flip angle 70∞, 42 ¥ 42 cm of evaluating potential donors. It is important measuring the GFR of each kidney. All donors and 256 ¥ 160, for MRA were 2.6 mm, no gap, for the urologist to have detailed anatomical had a 99 mTc-MAG3 renal scan as the reference 0.9, 40 ¥ 32 cm, 256 ¥ 128 and slab thickness information about the vasculature and standard for measuring GFR; the two 30–50 mm. Reformatted maximum intensity morphology of the kidney and ureter, and to estimates of GFR were then compared. The projection (MIP) was used in different planes, ensure that the donor has two well- anatomical results of MRI were compared e.g. coronal, sagittal oblique, axial and axial functioning kidneys, and that renal function is with the findings at donor nephrectomy. oblique, in the arterial and venous phases, to evenly divided. If there is unusual asymmetry All donors were evaluated clinically and detect the number of vessels and to define of function in the donor then measuring had essentially normal biochemical any vascular abnormalities. Coronal and individual renal function should prevent the clearance. sagittal MIP for MRU was also used to identify donor being deprived of the better kidney [1]. the pelvicalyceal system and ureteric For decades, the morphology and function of All MRI was conducted on a 1.5 T scanner anatomy, and to define any abnormalities. the donor’s kidneys were traditionally (Signa Horizon LX Echo speed, General Electric Coronal T2 images were reviewed for any assessed by several separate procedures, most Medical Systems, Milwaukee, WI, USA) with parenchymal or contour abnormalities, and to commonly by ultrasonography (US), catheter the use of phased-array torso surface coil. calculate parenchymal volume. The volume of angiography, excretory urography and Before the start of MRI, 10 mg of frusemide the each renal unit was then calculated by radioisotope renal scans. In a recent study, was administered intravenously. The drawing a manual region of interest (ROI) contrast-enhanced spiral CT was procedure started by obtaining a coronal around each kidney at each T2 scan. The recommended a single method for the localizer (scout image) to identify the calculated surface area of pixels in each anatomical and functional assessment of abdominal aorta and the origins of the renal scan was transformed into millimetres potential live-kidney donors [1]. However, CT arteries, followed by a coronal T2-weighted automatically by the software. The total subjects the patient to the risk of a high sequence for the whole of both kidneys, and volume of the kidneys was calculated by radiation dose. Moreover, the use of six coronal fast-spoiled gradient (FSPGR) adding the surface areas for each kidney and radiocontrast materials may increase the risk slices of the centre of the kidney. then the total surface area was multiplied by of renal and systemic toxicity. However, MRI Gadodiamide (Omniscan 0.5 mmol/mL Gd- the slice thickness. offers donors the advantages of avoiding DTPA-BMA; Nycomed, Ireland) was injected both radiation exposure and injection of via a wide-bore veno-catheter in the For dynamic scans, we first started by visually potentially nephrotoxic iodinated contrast antecubital vein at 3–4 mL/s. The contrast interpreting the images, comparing the materials. medium in the abdominal aorta, at suprarenal series before and after contrast medium, level, was automatically detected using to determine the corticomedullary A combined MR examination including Gd- SmartPrep software (General Electric Medical differentiation, degree of parenchymal enhanced MR angiography (MRA), MR Systems). MRA used a breath-hold, three- enhancement and the excretory power of nephrography and MR urography (MRU) dimensional (3D)-FSPGR acquisition in the each renal unit. Renographic dynamic MRI offers several potential advantages over coronal plane. The total amount of contrast was generated by drawing ROIs over the conventional studies for anatomical medium was 20–30 mL, according to body kidney, excluding the renal pelvis. Using the evaluation [1,2]. In the present study, we weight, with a mean dose of 0.3 mmol/kg. The functional software tool (GE Medical System) describe a new ‘all-in-one’ MRI technique that acquisition time was 12 s for each of the that merges all series, a curve resembling that provides both anatomical and functional arterial and venous phases, with a 10-s gap from isotope renography was obtained. The information for each kidney. The diagnostic between. MR dynamic renographic curve plots the accuracy of the new technique for identifying enhancement units vs time (Fig. 1), and from the number of renal arteries and veins, and After finishing the arterial and venous phases the curve the time to the peak, the relative the morphology of the collecting system, was of MRA, the pre-contrast six-slice coronal maximum units of enhancement (total assessed by comparing the results with the FSPGR at the centre of the kidney was enhancement units for each kidney minus the findings at donor nephrectomy; the repeated 10 times every 30 s and then at total on the unenhanced scan) and the correlation between the GFR measured using 15 min from injection of contrast medium. response to diuretic were obtained. Curves the new MRI technique was also compared Gd-enhanced excretory MRU was then were then obtained for the cortex and with that determined from a conventional generated from a coronal contrast material- medulla for each kidney by applying a manual radioisotope renogram. enhanced 3D-FSPGR with imaging ROI over each at the same scan level, and parameters identical to those of MRA. No from these curves the time at which the SUBJECTS AND METHODS donors had contraindications for MRI; all medullary response exceeded the cortex was studies were completed with no major also calculated (Fig. 2). Other circular ROIs Between January and December 2003, 50 complications. Only four subjects had were obtained from the aorta to determine consecutive potential kidney donors (30 men claustrophobia, overcome by assurance. the peak relative enhancement of the aorta

MRI FOR EVALUATING LIVE KIDNEY DONORS

FIG. 1. Cortical (1) and medullary (2) curves of MR FIG. 3. MRA in the identiﬁcation of arterial supply. TABLE 1 The agreement between the number of renography show the point of crossover. (A) Double left renal arteries with closed ostia on renal arteries and veins at nephrectomy and on reformatted coronal oblique MIP image. (B) Triple 189 MRA 180 left renal arteries and double right renal arteries on coronal MIP MRA. 160 1 Actual N at nephrectomy 140 2 MRA Single Multiple 120 A Arteries tive) a 100 Single 30 1 80 Multiple – 19 rt 60 Veins

NR Units (rel Single 45 1 40 Multiple – 4 20 0 -9 0 s 40 80 120 160 200 240 280 320 360 400 440 480507 kidneys, which included 30 single, 16 double and two triple renal arteries (Fig. 3a,b). One B FIG. 2. The whole kidney MR renographic curves case was diagnosed as a single artery but was (1, 2) indicate the normal rate of excretion. double, and one was diagnosed as double but was quadruple. Six cases with early branches 168 were diagnosed accurately. MRA had 100% 160 2 sensitivity, 94% speciﬁcity and 96% overall 1 140 accuracy in identifying the arterial supply 120 (Table 1). tive) a 100 For renal veins depicted at the second pass of 80 3D-FSPGR, MRA accurately diagnosed three 60 cases with a retro-aortic left renal vein, two NR Units (rel 40 with circumaortic left renal veins and one 20 with a double inferior vena cava. For 0 identifying the number of veins, 45 cases with -9 0 s a single vein and four with double veins were 40 80 120160200240280320360400440480507 diagnosed accurately. Only one case with double veins was diagnosed as a single vein. The sensitivity, speciﬁcity and overall accuracy (peak enhancement units at aorta minus peak for identifying renal veins at MRA was 100%, units of the aorta on the unenhanced scan). 98% and 98%, respectively (Table 1).

To obtain an approximate GFR for each kidney, The MR nephrogram in the axial and coronal the total volume of each renal unit was planes provided estimates of renal size and multiplied by its peak relative enhancement, The sensitivity, specificity and overall accuracy contour (Fig. 4a,b) that correlated with then divided by the peak relative of MRI for detecting the number of arteries information from other complementary enhancement of the aorta (to minimize the were calculated. The proportion of surgically imaging. In one donor, a small (<1 cm) effect of differences in dose of contrast media confirmed single renal arteries or veins was solitary renal cyst was seen on the MR and body weight of each subject, and defined as sensitivity and the proportion of nephrogram. differences in the rate of injection). The surgically confirmed multiple renal arteries mean (range) post-processing time was or veins was defined as specificity. The MRU correctly depicted the renal collecting 60 (45–70) min. correlation between MR clearance and system and ureters; 48 donors had single, isotope clearance was assessed using simple unduplicated systems and ureters (Fig. 5). The results for vascular anatomy were linear regression analysis, and mean MR and One donor had a unilateral malrotated reviewed and compared with operative data, isotope clearance compared using Student’s pelvicalyceal system and another had a considered the reference standard for t-test. unilateral duplicated collecting system. These vascular anatomy, including the number of data agreed completely with the findings at renal arteries and veins. Functional data were donor nephrectomy. correlated with the results of renographic RESULTS clearance and 24-h total creatinine clearance. For the functional assessment, the isotope MRU results were also correlated with MRA in the 50 donors enabled the correct clearance for each kidney was 54–77 mL/min, operative findings. identification of the arterial supply to 48 while the MR values were 217–277 units;

EL-DIASTY ET AL.

correlating the MR value with isotope FIG. 4. Dynamic study and MR nephrogram. (A) TABLE 2 The mean isotope and MR clearance clearance in each renal unit, the mean isotope Dynamic scan image showing the corticomedullary values clearance was 25 (20–33)% of the MR differentiation. (B) Coronal image in the renographic value, and thus the corrected nephrographic phase for calculating renal size. Mean (SD) GFR, mL/min GFR for each unit was calculated from the MR Kidney Isotope MR P study by dividing the MR value by 4. A Right 61 (8.7) 56.2 (8.2) 0.33 A comparison between the isotope GFR of Left 56.6 (9.0) 54.9 (11.6) 0.42 each kidney with the corresponding MRI GFR Total 117.8 (16) 111 (18.7) 0.81 showed a close correlation (r = 0.54, P < 0.01) and there was also a strong correlation between total 24-h creatinine clearance, total FIG. 5. Excretory MRU; coronal MIP image shows a isotope GFR (r = 0.44, P < 0.01) and total MR single unduplicated pelvicalyceal system and ureter clearance (r = 0.45, P < 0.01), confirming the bilaterally. validity of the isotope and MR techniques for assessing GFR. The mean isotope clearance was not significantly different from that of mean MR clearance for the right and left kidneys (Table 2). There was no significant B difference between mean (SD) 24-h creatinine clearance and mean total MR clearance, at 118 (16) and 111 (19) mL/min, respectively.

The peak of enhancement was cortical and within the first 3 min, with a mean (SD, range) of 114.5 (40.28, 68–179) s, followed by a smoothly decreasing slope. The corticomedullary exchange also occurred in the first 3 min, at 101.61 (35.58, 60–182) s, and then both curves decreased, the medullary at a slightly higher level than the cortical. The contrast media excretion began to appear in the cortex after 3 min, and the radiation dose and increasing the risk of renal calyces and ureter were completely defined at and systemic toxicity [4]. the 15 min scan; this was represented in the whole-kidney MR renographic curve. As MRI continues to develop, renal MRA will probably expand to include extensive functional information about creatinine DISCUSSION clearance, flow and response to pharmacological agents, as well as reported by Rajab et al. [11], who stated that Gd-based MRI contrast agents that are small spectroscopy, diffusion, perfusion and MR interpretations correctly identified the molecules, similar to inulin, are distributed in other techniques [5]. The advantages of vascular anatomy of the donor kidneys in 173 the vascular space and then rapidly into the comprehensive MRI include its noninvasive of 189 (91.5%). However, they concluded that extracellular space. These agents can serve as nature, no use of iodinated contrast materials, noninvasive MR evaluation of donor extracellular fluid markers and are freely absence of exposure to ionizing radiation, renovascular anatomy is an acceptable filtered in the glomeruli. As they are neither decreased morbidity and reduced cost substitute for traditional angiography, secreted nor absorbed, they are an excellent compared with that of conventional because the misinterpretation of the MR indicator of renal function [3]. Nuclear angiography combined with excretory angiography did not adversely affect the medicine renography provides functional urography [6]. recipients’ outcome. Hussain et al. [12] stated information but with relatively poor spatial that MRI provides valuable information resolution. US has better spatial resolution Several studies have used contrast-enhanced comparable with that from other imaging than nuclear methods but provides no MRA for evaluating potential living donors, methods, e.g. US, IVU and digital subtraction functional information, although new US with excellent results [7–10]. The present angiography. CT angiography is currently not contrast agents could be promising for the results showed a very high sensitivity, used in living kidney donors at their hospital. study of renal dynamics. CT offers excellent specificity and overall accuracy, similar to the spatial resolution with the potential to assess results in previous studies for detecting Other investigators [9,13] compared CT and renal dynamics, but many exposures and accessory renal arteries, early branching and MRA, reporting substantial agreement. iodinated contrast agents are needed, vascular pathology, as compared with the Interobserver disagreement in the subjecting the patients to the risk of high reference standard. Less accurate results were interpretation of CT and MR angiograms is

MRI FOR EVALUATING LIVE KIDNEY DONORS

related to 1–2-mm diameter vessels [7]. CT continued at a slightly higher level than the renal size and contour, and can identify angiography and MRA provide all the cortical plateau. The brightness of signals at parenchymal defects. Finally, MRU allows the information required by the surgeon. Both the calyces was apparent after ª3 min, visualization of the pelvicalyceal system, methods may miss small accessory renal depending on the excretory power of the ureter and bladder, with the detection of any arteries. MRA does not use potentially toxic kidney, and at delayed 15-min scans the abnormality. Therefore, we recommend Gd- contrast material or radiation and is the ureter could be visualized adequately. enhanced dynamic MRI as a single imaging preferred investigation, with CT reserved for method for assessing potential live-kidney patients unable to tolerate MRI [9]. Beside general contraindications there are donors. some limitations of MRI. It does not show MRU is obtained from the same Gd-enhanced most renal calculi and therefore we CONFLICT OF INTEREST 3D-FSPGR acquisition used for the MRA, after recommend that US be used beforehand. US is a delay of ª15 min from injecting frusemide also used as a screening method to detect None declared. before the contrast material, leading to rapid other urinary or extra-urinary abnormalities uniform Gd distribution inside a relatively that might preclude safe renal donation. REFERENCES distended collecting system. The present Moreover, motion artefacts may degrade the results of MRU for depicting the collecting image quality of MRI and can be reduced with 1 El-Diasty TA, Shokeir AA, Abo El-Ghar system and ureters were comparable with the the use of fast and ultrafast sequences. Also, ME, Gad HM, Refaie AF, Shehab El-Din operative data. Like CT with delayed images, the relatively long post-processing time can AB. Contrast enhanced spiral Gd-enhanced MRI has a high sensitivity and be overcome by improving the software. computerized tomography in live kidney specificity for depicting the pelvicalyceal donors. A single session for anatomical anatomy and pathology. The accumulation of On the basis of a decision- and cost- and functional assessment. J Urol 2004; bright contrast material in the renal pelvis and effectiveness analysis, Liem et al. [17] 171: 31–4 calyces is sufficient to provide a high concluded that digital subtraction 2 Courlay WA, Yucel EK, Hakaim AG et al. resolution of renal anatomy and good image angiography is the most cost-effective Magnetic resonance angiography in the quality. The overall ureteric position and strategy if it has a specificity of >99% for evaluation of living related renal donors. morphology are evaluated well by Gd- detecting renal disease; otherwise, MRA with Transplantation 1995; 60: 1363–6 enhanced MRI, with no ureteric blurring from CT angiography is the most cost-effective 3 Wolf GL, Hoop B, Cannillo JA, the peristaltic waves [14,15]. strategy. The cost-effectiveness is not only Rogowska JA, Halpern EF. Measurement direct but also includes the advantage of lack of renal transit of gadopentate Coronal images of the kidney (six slices, 5 mm of exposure to ionizing radiation from dimmeglumine with echo-planar MR thick) are acquired before and after injection conventional angiography, CT and imaging. J Magn Reson Imaging 1994; 4: with contrast material, to obtain a MR renography, and avoiding the potential 365–72 renographic study similar to the radionuclide adverse reaction to iodinated contrast 4 Katzberg RW, Buonocore MH, Ivanovic renogram. The present MR renograms were material, that may include anaphylaxis and M, Pellot-Barakat C, Ryan JM, Whang similar to those obtained by Katzberg et al. [4], nephrotoxicity. K. Functional dynamic and anatomic MR as there was an initial peak, representing the urography: feasibility and preliminary vascular component of contrast medium in In the present study we tried to use a simple findings. Acad Radiol 2001; 8: 1083–99 the glomerular tufts in the cortex [3,16], technique for easy quantification of 5 Zhang H, Prince MR, Renal MR followed by the tubular response that reflects parenchymal enhancement by multiplying the angiography. Magn Reson Imaging Clin N the passage of contrast agent through the total volume of each renal unit by its peak Am 2004; 12: 487–503 glomeruli into the tubular system, manifested enhancement, and then divided by the aortic 6 Low RN, Martinez AG, Steinberg SM by accumulation of contrast agent in the enhancement. Using this technique there was et al. Potential renal transplant donors. medulla with increasing concentration. The a good correlation between GFR values Evaluation with gadolinium-enhanced third phase of the dynamic renogram is the obtained by MR and those by isotope MR angiography and MR urography. ductal phase, manifested by the higher renography. By multiplying the MR Radiology 1998; 207: 165–72 plateau of the signal intensity curve over time renographic value by 0.25 we estimated a 7 Halpern EJ, Mitchell DG, Wechsler RJ, for the medulla vs the cortex. The fourth corrected MR GFR equivalent to isotope GFR. Outwater EK, Mortiz MJ, Wilson GA. phase is the calyceal phase, in which contrast Preoperative evaluation of living renal medium is excreted into the pelvicalyceal In conclusion, Gd-enhanced dynamic MRI has donors. Comparison of CT angiography system. However, the present results were several advantages for assessing potential and MR angiography. Radiology 2000; markedly different from those reported by live-kidney donors. In the vascular phase, 216: 434–9 Semelka et al. [16], who found that the MRA can clearly visualize the number of renal 8 Fink C, Hallscheidt PJ, Hosch WP et al. medullary signal intensity was lower than arteries and veins, and detect any congenital Preoperative evaluation of living donors. cortical intensity for all kidneys over or acquired vascular anomaly. Moreover, in value of contrast-enhanced 3D magnetic time in normal kidneys and those with the parenchymal phase, MRI is as accurate as resonance angiography and comparison hydronephrosis. In the present study, the time radioisotope renography in determining the of three rendering algorithms. Eur Radiol at which the medullary curves of normal relative GFR of each kidney, allowing selection 2003; 13: 794–801 kidneys crossed those of the cortex of the kidney for nephrectomy. In addition, 9 Rankin SC, Jan W, Koffman CG. was < 3 min and the medullary curves the MR nephrogram provides estimates of Noninvasive imaging of living related

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kidney donors. Evaluation with CT 13 El-Diasty TA, Ateia M, Kamal T, enhanced MR imaging. Radiology 1990; angiography and gadolinium-enhanced El-Azab M, Gad H, Ghoneim M. 175: 797–803 MR angiography. Am J Roentgenol 2001; Comprehensive MR evaluation of 17 Liem YS, Kock MC, Ijzermans JN, 177: 344–55 potential kidney transplant donors. Eur Weimar W, Visser K, Hunink MG. 10 Moritz M, Halpern E, Mitchell D et al. Radiol 2000; 10 (Suppl): E1–26 Living renal donors optimizing the Comparison of CT and MR angiography 14 El-Diasty T, Mansour O, Farouk A. imaging strategy-decision-and cost- for evaluation of living renal donors. Diuretic contrast-enhanced magnetic effectiveness analysis. Radiology 2003; Transplant Proc 2001; 33: 831–2 resonance urography versus intravenous 226: 53–62 11 Rajab A, Khabiri H, Pelletier RP et al. urography for depiction of nondilated Magnetic resonance angiography for urinary tract. Abdom Imaging 2003; 28: Correspondence: Ahmed A. Shokeir, Urology & preoperative evaluation of potential 135–45 Nephrology Center, Mansoura University, kidney donors. J Surg Res 2004; 120: 15 Li W, Chavez D, Edelman RR, Prasad PV. Mansoura, Egypt. 195–200 Magnetic resonance urography by e-mail: [email protected] 12 Hussain SM, Kock MC, Ijzermans JN, breath-hold contrast enhanced three- Pattynama PM, Hunink MG, Krestin GP. dimensional FISP. J Magn Reson Imaging Abbreviations: US, ultrasonography; MRA(U), MR imaging. A ‘onestop shop’ modality 1997; 7: 309–16 MR angiography (urography); (3D)-FSPGR, for preoperative evaluation of potential 16 Semelka RC, Hricak H, Tomei A, Floth A, (three-dimensional)-fast-spoiled gradient living kidney donors. Radiographics 2003; Stoller M. Obstructive nephropathy: (scan); MIP, maximum intensity projection; 23: 505–20 Evaluation with dynamic Gd-DTPA- ROI, region of interest.

Vitamin E therapy prevents hyperoxaluria-induced calcium oxalate crystal deposition in the kidney by improving renal tissue antioxidant status

SIVAGNANAM THAMILSELVAN and MANI MENON Department of Urology, Vattikuti Urology Institute and Henry Ford Health Sciences Center, Detroit, Michigan, USA Accepted for publication 14 March 2005

OBJECTIVE radicals and enzymatic activity were then CONCLUSION assessed. To determine whether vitamin E prevents This is the ﬁrst study to demonstrate in-vivo hyperoxaluria-induced stone formation, using RESULTS evidence that hyperoxaluria-induced a new animal model of calcium oxalate peroxidative injury induces individual calcium stone disease, as our previous in- vitro and EG treatment in group 1 lead to increased lipid oxalate crystal attachment in the renal in-vivo studies showed that oxalate and peroxidation, protein thiol, excretion of tubules. In addition, excess vitamin E hyperoxaluria induce free-radical generation, urinary enzymes, oxalate and decreases in completely prevented calcium oxalate which results in peroxidative injury to renal urinary calcium, antioxidant enzymes and deposition, by preventing peroxidative injury tubular cells. altered glutathione redox balance. Although and restoring renal tissue antioxidants and renal function was not altered, there was glutathione redox balance. Therefore, vitamin increased water intake, urine volume and E therapy might provide protection against lowered urinary pH in these rats. These the deposition of calcium oxalate stones in MATERIALS AND METHODS changes were more intense, with extensive the kidney of humans. calcium-oxalate crystal deposition, in rats in Ethylene glycol (EG) was administered at group 3, and prevented in rats in group 2, KEYWORDS 150 mg/day by gavage for 3 weeks to rats fed except for urinary oxalate levels, which on diets with adequate (group 1), excess remained high. Histopathological examination lipid peroxidation, urolithiasis, hyperoxaluria, (group 2) or deﬁcient (group 3) vitamin E. showed that there was no deposition of vitamin E, antioxidants, ethylene glycol, Several indicators of peroxidation, free calcium oxalate crystals in rats in group 2. Sprague-Dawley rats

INTRODUCTION several causes, including increased gut endowed with several antioxidant systems, absorption, reduced tubular reabsorption, and including enzymatic (superoxide dismutase, Hyperoxaluria is one of the major risk factors resorptive hypercalciurea characterized by SOD, catalase and glutathione peroxidase, for calcium oxalate kidney stone formation in increased bone demineralization [7]. Levels of GPx) and non-enzymatic, e.g. reduced humans [1]. Oxalate is normally excreted by urinary oxalate are increased in 15–50% of glutathione (GSH), vitamins E, A and C, to limit the kidneys, and 60–80% of renal calculi are patients with idiopathic calcium oxalate the extent of lipid peroxidation. Up to a composed of calcium oxalate [1–3]. Oxalate urolithiasis [1,8]. The diagnosis and initial certain limit, the cells are able to control the present in many foods is poorly absorbed management of urolithiasis has developed damage with GPx, catalase, SOD or other from the intestine, with only 5–15% of considerably in recent years. Various antioxidative mechanisms. However, once a dietary oxalate appearing in the urine; the therapies, including alkali citrate, thiazide, threshold of damage or rate of damage remaining 85% of the oxalate is produced dietary modiﬁcations, reduction in animal is exceeded the cellular defences are endogenously [4]. A recent report showed an protein, and foods rich in glycolate and overwhelmed and a very small additional endogenous contribution closer to 50%, and glyoxylate, have been tried in an attempt to insult results in severe cellular injury. Thus, the the remainder being of dietary origin [5]. prevent stone recurrence [7,9]. Despite recent oxidant-antioxidant balance is a critical advances in endourological, ureteroscopic determinant of cell sensitivity to free-radical The prevalence of urinary tract stone disease and ESWL, stone recurrence can be reduced by injury. Several laboratories reported that is estimated to be 2–20 per 10 000 [3]. The only half. oxalate causes renal tubular injury by increase recurrence rate with no treatment for calcium generation of free radicals [14,15]. In the oxalate renal stones is ª10% at 1 year, 33% at It is clear from our previous in vitro and in vivo present study therefore we sought to 5 years and 50% at 10 years [6]. Most patients studies that oxalate-induced peroxidative determine whether vitamin E offers with calcium oxalate renal calculi excrete injury is involved in the nucleation, promise as a therapeutic agent for large amounts of calcium and/or oxalate in aggregation and development of calcium preventing kidney stone formation in an their urine. Hypercalciuria can result from oxalate stone disease [10–13]. The cell is animal model of hyperoxaluria, and describe

THAMILSELVAN and MENON

a new model of calcium oxalate stone rat and differed among rats, thus we haematoxylin and eosin for microscopic disease. monitored water intake for 30 days for examination. individual rats. Markers of oxidative stress were MATERIALS AND METHODS To estimate the amount of oxalate excretion malondialdehyde (MDA) content, after exposure to ethylene glycol (EG), rats representing lipid peroxidation, determined by Male Sprague-Dawley rats (40–45 g) were were selected for a preliminary experiment as the thiobarbituric acid reactive method [16]. used; they were kept in a temperature- described below. The rats were divided into Protein carbonyls were measured according controlled room with 12-h light and 12-h four groups with six in each and fed vitamin to the method of Levine et al. [17]. dark cycles, housed individually in stainless- E-adequate diet: (A) control, (B) 100 mg EG, Antioxidants comprised vitamin E, determined steel cages and given free access to diet and (C) 150 mg EG, and (D) 200 mg EG. EG was by the method of Arnaud et al. [18] using deionized water. The experimental protocol given once to each rat by gavage. Urine HPLC. SOD was measured as described by was reviewed and approved by the was collected for the first and second 24-h Misra and Fridovich [19] and catalase using institutional animal care and use committee. periods after giving EG and assayed for the method of Sinha [20]. The variables in the oxalate. glutathione redox system, were GSH content, The rats received one of three diets: the first analysed with a modification of the enzymatic group had a diet adequate in vitamin E Based on the preliminary data obtained, a recycling assay using 5-thio-2-nitrobenzoate (Purified diet, Harlan Teklad, Madison, WI; 100 separate set of animals from a similar group to form a spectrophotometrically detectable U vitamin E/kg) containing 50.0 g/kg corn oil were given 0, 100, 150 or 200 mg EG each day product at 412 nm (e = 1.36 ¥ 104 mole-1 with mineral mix #170915 and 0.2 g/kg a- by gavage for 7, 14 or 21 days. The gain in cm-1) by the method of Tietze [21]. tocopherol acetate (specific activity 500 U/g), body weight was monitored every week. The GPx activity was measured by the with the following nutrients: vitamin-free rats were killed 24 h after the last dose at 7, spectrophotometric method of Paglia and casein, 200 mg/g; DL-methionine, 3.0 mg/g; 14 and 21 days. The kidney was removed and Valentine [22], and glutathione reductase dextrose monohydrate, 674.5 mg/g; cellulose fixed in formaldehyde for histopathological activity in total cell homogenates with a fibre, 50 mg/g; calcium carbonate, 3.5 mg/g; evaluation. spectrophotometric assay [23]. Glucose-6- choline dihydrogen citrate, 3.5 mg/g; dry phosphate dehydrogenase (G6PD) activity vitamin A palmitate, 0.04 mg/g (specific For the main study, rats were divided into six was determined according to the method of activity 500 000 U/g); dry vitamin D3, experimental groups (eight per group). The Deutsch [24]. 0.0044 mg/g (specific activity 500 000 U/g); rats were selected based on food intake vitamin B12, 0.05 mg/g; biotin, 0.0004 mg/g; (18.5 ± 3 g/day), water intake (24 ± 2 mL/day) Markers of glomerular and tubular damage calcium pantothenate, 0.066 mg/g; folic acid, and body weight (initial body weight 40 ± 5 g; were blood urea nitrogen (BUN), measured 0.002 mg/g; inositol, 0.11 mg/g; menadione, body weight on the first day of EG according to the method of Crocker [25]. 0.05 mg/g; niacin, 0.1 mg/g; pyridoxine HCl, administration 340 ± 10 g). Groups I and II Serum creatinine was measured by the 0.022 mg/g; riboflavin, 0.022 mg/g; and received a diet adequate in vitamin E, III and method reported previously [26] using a thiamine HCl, 0.022 mg/g. The a-tocopherol IV excess vitamin E, and V and VI deficient spectrophotometer; 24-h urine samples were acetate content of the diet adequate in in vitamin E, for 6 weeks, after which processed for the determination of the semisynthetic vitamin E (normal control) was hyperoxaluria was induced in groups II, IV and following enzymes as described in our earlier calculated based on the composition of VI by EG (by gavage) at 150 mg/rat per day for studies [27]. Lactate dehydrogenase was standard rodent diet Teklad #8640 (109.54 IU/ 3 weeks. Groups I, III, and V were considered analysed spectrophometrically using pyruvate kg) and Teklad #8604 (90.18 IU/kg). In the as controls (no EG). Food and water intake as a substrate [28]. A tubular brush border second group, rats were fed a diet with excess was recorded every day, and body weights marker enzyme, alanine aminopeptidase, was vitamin E (Purified diet, Harlan Teklad, monitored weekly. Twenty-four hour urine determined by the method of Jung and Scholz 2000 U/kg) containing corn oil 50.0 g/kg with samples were collected at 0, 7, 14 and 21 days [29]. Alkaline phosphatase and g-glutamyl mineral mix #170915 and 4.0 g/kg of a- in 50 mL centrifuge tubes kept on ice and transpeptidase (GGT) were assayed using a tocopherol acetate, with the above nutrients. attached to urine-collecting funnels. Water commercial kit (Trinity Biotech, MO). The third group were fed a diet deficient in intake, urine volume, crystalluria and pH were vitamin E, containing 10% tocopherol- recorded. For the enzyme determinations, Urinary oxalate and calcium were determined stripped corn oil (Purified diet, Teklad Test urine samples were dialysed for 3 h at 4 ∞C by an ion-exchange chromatography method Diets), with the above nutrients. All diets were against distilled water. The rats were killed with some modifications [27], with a Dionex stored refrigerated in tight polythene bags. 24 h after the last oral dose of EG; the animals gradient ion-chromatography system Food was changed every day to minimize were anaesthetized with pentobarbital equipped with a 0.4 ¥ 25 cm AS11 anion vitamin E oxidation. The levels of vitamin E in (50 mg/kg body weight), and the kidneys exchange analytical column with a AG11 the diet did not influence the growth rate of quickly excised and used for the following guard column for oxalate or CS12A cation the rats for the treatment period. analyses. A portion of the kidney was exchange analytical column with a CG12A homogenized and assayed for enzyme guard column for calcium. Sample (25 mL) MODEL VALIDATION activities. For the histopathological analysis, was injected using an auto-sampling injector kidney tissue was fixed in 10% neutral and eluted with 40 mmol/L NaOH/deionized A preliminary study showed that the total buffered formalin, embedded in paraffin wax, water at 1.0 mL/min with a linear gradient intake of water per day was constant for each sectioned at 5–6 mm, and stained with from 10% to 75% NaOH, 90% to 25%

VITAMIN E AND HYPEROXALURIA-INDUCED CALCIUM OXALATE CRYSTAL DEPOSITION

urolithiasis (0.75% EG through drinking scoring system shown in Table 1. From these TABLE 1 Scoring system for estimating crystal water) for our experiments with rats on results we estimated that EG at 150 mg/day abundance in the kidney section of rats (six per purified diets with adequate, excess and through gavage induces a controlled amount treatment) fed a vitamin E-adequate diet deficient vitamin E, we had difficulty of oxalate synthesis to produce hyperoxaluria followed by EG interpreting the experiments. This widely used and may prove a useful in-vivo model to model for human stone disease resulted in study stone disease. In addition, this model Days of EG massive crystal deposition is some rats and no may offer an appropriate option for EG, mg/day 71421 or fewer crystal deposits in others. Normal evaluating therapeutic approaches and 100 -- - Sprague-Dawley rats drink 10–35 mL of advantages over the uncontrolled oxalate 150 - + +++ water/day. When we monitored individual synthesis in 0.75% EG given to rats in drinking 200 + +++ ++++ rats the water intake of one rat was 10.5 water. Although there were calcium oxalate (3.0) mL/day; the water intake was constant crystals in the papillary region, a comparison -, no crystals; +, few crystals (one or two per for this rat and did not differ significantly between Randall’s plaque and the present field); ++, moderate number of crystals (10–20 from day by day. The intake of another rat observations is hampered by several per field); +++, frequent crystals (≥ 20 per field); was 35.2 (4.3) mL/day, and for a third difficulties. First, there is the obvious ++++, abundant crystals (>100 per field). 25.4 (2.9) mL/day. Therefore, each rat has a difference in species (human vs rat). Second, unique, constant drinking water requirement. the approach (deductive vs inductive); and Rats drinking 10 mL/day of 0.75% EG had no last, there is a difference between the crystal deposition in the kidney by 30 days but electrolytes involved (calcium oxalate vs deionized water for oxalate or 40% of those drinking 25 mL/day of 0.75% EG various calcium phosphates and carbonates) 30 mmol/L methane sulphonic acid and 60% developed calcium oxalate depositions by [32,33]. Khan [34] noted many similarities deionized water (isocratic) for calcium, after 15 days, and those drinking 35 mL/day of between the effects in experimental helium degassing. The column elution was 0.75% EG did so by 7 days. Moreover, EG nephrolithiasis (including the EG protocol) monitored using a conductivity cell and peak consumption causes polyuria or polydipsia, induced in rats, and human kidney stone area measured with Peaknet chromatography and therefore increased consumption of EG, formation. It was also reported that the rat automation software v6.20. Background from 35 to 45–50 mL/day on day 5, resulted in model of calcium oxalate nephrolithiasis can conductivity was minimized by using an ASRS increased oxalate synthesis and massive be used to investigate the mechanisms anion self-regenerating micromembrane blockages of renal tubules with calcium involved in human kidney stone formation suppressor for oxalate or CSRS cation self- oxalate crystals in all the groups. Therefore, [34]. regenerating micromembrane suppressor for we developed a new calcium oxalate stone calcium and with recycled eluent. Sample model to induce controlled endogenous As peroxidation was considered an important oxalate or calcium concentration was then oxalate synthesis. mechanism involved in many pathological calculated based on an oxalate or calcium conditions, we sought to determine whether standard curve. To estimate the amount of oxalate excretion vitamin E supplementation prevents after giving EG, male Sprague-Dawley rats peroxidation in rats treated with EG. Kidney All experiments were repeated eight separate were divided into four groups with different tissue lipid peroxidation was estimated as times in duplicate, with the results given as amounts of EG (0, 100, 150, 200 mg) given MDA level (Table 2), and protein carbonyls the mean (SD). Data were analysed by three- once to each rat by gavage. Oxalate was were assessed as an indicator of protein way ANOVA with Tukey’s multiple comparison, significantly increased in urine on the first day peroxidation products (Table 2). Rats in group with P < 0.05 considered to indicate (0–24 h) after EG in the four groups (A-D, II had significant greater MDA levels and significant differences. Multivariate 0–200 mg EG), at 3.52 (0.42), 32.09 (5.23), protein carbonyls than in group I. regression analysis were used to assess the 83.45 (9.85) and 125.46 (12.6) mmol/24 h. The Hyperoxaluria-induced generation of MDA relationship between excretion of oxalate and following day’s collection (24–48 h after EG) and protein carbonyls was significantly tissue antioxidants, urinary enzymes and lipid showed that oxalate was completely excreted prevented in group IV. There was no peroxidation, and between peroxidation, within 24 h for groups B and C, whereas the significant change in MDA or protein carbonyl tissue antioxidants and urinary enzymes. oxalate was still higher in group D, with content in rats in groups I, III and V. However, respective values of 3.31 (0.26), 2.8 (0.32), rats in group VI had a dramatic increase in 4.50 (0.52) and 6.36 (0.45) mmol/24 h. This MDA and protein carbonyl contents. RESULTS shows that increased excretion of oxalate was Supplementation with vitamin E therefore has directly proportional to the amount of EG a protective role against hyperoxaluria- Most animal models of calcium oxalate stone administered. induced oxidative injury. disease have required the generation of fairly severe hyperoxaluria. Various approaches The next set of animals, treated with 0, 100, To provide evidence that supplementation have been used for this, including exposure 150 or 200 mg EG each day by gavage for 7, with vitamin E protects against to EG, oxalate infusion or feeding, and 14 or 21 days, showed that the EG-treated hyperoxaluria-induced renal peroxidative pyridoxine depletion [30]. However, the utility rats gained substantially less body weight damage, the kidney tissue vitamin E levels of these treatments is compromised by one or than the control group (data not shown). In were also measured; as shown in Table 2, more limitations [31]. When we used the the histopathological evaluation, each kidney hyperoxaluria was induced in rats in group II previously available conventional model of was scored for crystal deposition using the and resulted in a significant decrease in the

THAMILSELVAN and MENON

TABLE 2 Lipid peroxidation and protein carbonyls, vitamin E level, antioxidant and blood and urinary variables in the kidney of rats in groups I to VI after 21 days

Group Mean (SD) variable I II III IV V VI MDA, nmol/mg protein 1.23 (0.22) 3.26 (0.18)*a 1.11 (0.16)*b 1.36 (0.24)*b 1.63 (0.21)*bc 5.77 (0.48)*abcde Protein carbonyls, 3.34 (0.42) 5.94 (0.39)*a 2.88 (0.27)*b 3.32 (0.35)*b 3.72 (0.41)*bc 7.78 (0.37)*abcde nmol/mg protein a-tocopherol, mg/g 37.2 (3.2) 22.4 (2.5)*a 70.6 (4.6)*ab 60.5 (4.2)*ab 2.5 (0.3*)abcd 1.5 (0.2)*abcde Antioxidant enzymes and glutathione-redox system components SOD, U/mg protein 30.2 (2.8) 16.8 (1.1)*a 34.0 (1.9)*b 26.2 (2.2)*bc 27.9 (3.4)*b 11.2 (1.3)*abcde a b b b abcde Catalase, mmol H2O2 35.1 (2.4) 20.7 (1.8)* 33.6 (2.7)* 28.5 (2.5)* 31.9 (1.7)* 11.0 (1.3)* consumed/min/mg protein GPx, U/mg protein 160.0 (14.3) 82.6 (6.5)*a 166.2 (7.3)*b 131.5 (10.8)*bc 155.2 (10.5)*b 48.7 (3.4)*abcde Glutathione reductase, nmol NADPH 120.5 (5.8) 55.2 (4.2)*a 125.2 (7.3)*b 113.4 (6.8)*b 112.0 (6.5)*b 32.6 (3.7)*abcde oxidized/min/mg protein G6PD, U/mg protein 17.7 (1.3) 9.6 (0.8)*a 18.5 (1.7)*b 14.6 (1.1)*bc 16.4 (1.4)*b 5.8 (0.8)*abcde GSH, nmol/mg protein 19.4 (1.5) 11.6 (0.9)*a 22.6 (1.1)*b 17.2 (1.2)*bc 17.8 (1.5)*b 6.2 (0.7)*abcde Blood values BUN, mg/L 220 (22) 252 (18) 230 (21) 242 (21) 250 (21) 496 (34)*abcde Creatinine, mg/L 6.7 (0.5) 7.1 (0.5) 6.3 (0.6) 7.0 (0.8) 7.0 (0.3) 8.9 (0.4)*abcde Urinary variables Water intake, ml/24 h 22.6 (2.2) 44.2 (3.6)*a 23.0 (2.4)*b 31.2 (2.0)*abc 22.9 (2.8)*bd 55.2 (3.2)*abcde Urine volume, ml/24 h 10.2 (1.3) 32.6 (3.2)*a 12.2 (1.2)*b 18.6 (1.1)*abc 13.1 (1.7)*b 42.2 (3.64)*abcde pH 6.04 (0.04) 5.71 (0.05)*a 6.10 (0.04)*b 5.81 (0.05)*a 6.05 (0.06)*b 5.70 (0.05)*ace Calcium, mg/24 h 1.72 (0.32) 0.64 (0.08)*a 1.96 (0.22)*b 0.78 (0.10)*ac 1.83 (0.17)*bd 0.51 (0.09)*ace

*P < 0.05, eight rats. Comparisons: a, significant vs I; b, significant vs II; c, significant vs III; d, significant vs IV; e, significant vs V.

levels of tissue vitamin E concentration; this restored these enzyme activities and GSH (LDH) had significantly greater activity in the may indicate the consumption of vitamin E levels towards the control levels. As expected, urine of all EG-treated rats at 7, 14 and by hyperoxaluria-induced free radical hyperoxaluria induced in rats in group VI 21 days than in the control groups (Fig. 1a). generation. The concentration of vitamin E in produced a significant lower antioxidant Urine from rats in group IV had a significantly the kidney was significantly higher in the rats enzyme and GSH concentration than in group lower LDH activity than in group II. There were in group III and IV; exposure to EG was also II. There were no significant changes in the no significant differences among the control associated with the consumption of vitamin E, antioxidant or glutathione redox levels in rats rats in any group, but the urinary excretion of as indicated by the decrease in the tissue on the three control diets. These data strongly LDH was significantly higher in group VI than vitamin E concentration, indicating that indicate that dietary vitamin E strengthened in group II at 7 and 14 days. Brush border vitamin E positively combats hyperoxaluria- the tissue antioxidative defence system. marker enzymes, GGT (Fig. 1b), alkaline induced free radical generation. However, the Vitamin E was accordingly found to reduce phosphatase (Fig. 1c), and alanine amino tissue levels of vitamin E remained higher in the hyperoxaluria-induced accumulation of peptidase (Fig. 1d), had significant changes in group IV than in group V. Vitamin E deficiency reactive oxygen species and to significantly their excretion pattern in groups II, IV and VI in rats in groups I and V was validated by improve the tissue antioxidant status. (EG). The activity of brush border marker measuring the tissue vitamin E content. After enzymes was significantly greater in urine at vitamin E deprivation, there was a marked The indices of renal function are also 7, 14 and 21 days in rats in group II. These (93%) decrease in the levels of vitamin E in summarized in Table 2. In groups II and IV, EG enzyme excretions were further increased in the kidneys. The tissue vitamin E content was caused no significant increase in BUN or group VI for up to 14 days and drastically significantly less in rats in group VI. serum creatinine levels, whereas in group VI decreased at 21 days. Rats in group IV had a rats had significantly lower renal function, as significant restoration of these enzyme To examine the effect of vitamin E on indicated by the increased BUN and serum activities towards control levels. There were hyperoxaluria-induced changes in kidney creatinine levels. As changes in renal tubular no significant changes in these urinary antioxidant and glutathione redox status, the enzymes in 24-h urine are a sensitive index of enzyme activities in the control rats in any of enzymatic and non-enzymatic antioxidant renal tubular damage we studied the effect of the vitamin E regimens. levels were also assessed (Table 2). Rats in vitamin E on EG-induced changes in the group II at 21 days had significant less SOD, excretion of renal tubular enzymes. Rats in Rats in groups II, IV and VI (EG-treated) had catalase, GPx, glutathione reductase and group II had a significant change in the significantly greater urinary oxalate levels G6PD activities, and GSH levels than in group activity of renal enzymes at all sample times. (Fig. 2) and lower calcium excretion (Table 2) I. In group IV the excess vitamin E significantly The cytosolic enzyme lactose dehydrogenase than controls at all sample times. Rats in

VITAMIN E AND HYPEROXALURIA-INDUCED CALCIUM OXALATE CRYSTAL DEPOSITION

FIG. 1. Urinary excretion of (a) LDH; (b) GGT; (c) alkaline phosphatase; and (d) alanine aminopeptidase in the 10 days (six rats); group I, 1.10 (0.09); group II, rats in groups I–VI (respectively, green closed circles; light green open circles; red closed triangles; light red 1.79 (0.15); group IV, 1.26 (0.10); group VI, open triangles; red closed squares; red open squares) expressed as the mean (SEM). *P < 0.05. 2.6 (0.37) nmol/mg protein. After 14 days of EG in group II, individual crystals were b a nucleated on the renal tubular membrane 700 surface, concurrent with increased lipid 8 peroxidation, with an MDA content of

600 se, U/24 h

da 2.29 (0.26) nmol/mg protein, six rats), as 500 6 400 shown in Fig. 4(B). These results strongly

nspepti imply that the hyperoxaluria-induced mU/24 h 4

300 a peroxidation of renal tubular membrane is a 200 LDH, 2 prerequisite for nucleation of calcium oxalate myl tr

100 a t

u crystals, and is one of the major mechanisms 0 -gl

0 involved in the attachment and development 0 71421g 0 7 14 21 Days Days of calcium oxalate kidney stones. As the renal c d tubules continued to be exposed to oxalate, nucleated crystals started to grow toward 250 the centre of the tubules and resulted in 60 complete occlusion of renal tubules, as shown se, mU/24 h moles/24 h

m in Fig. 4C; this leads to further mechanical da

se, 40 200 damage to the tubular epithelium. a t a Kidney sections of a rat from group V had a

20 mino pepti a 150 normal epithelium under polarized light nine line phosph 0 microscopy; the kidney was also of normal a

a 0 0 7 14 21 0 7 14 21 Al size, at 1.12 (0.08) g (Fig. 5A). The results were Alk Days Days similar in groups I and III (data not shown). Calcium oxalate crystals were present in the renal parenchyma of rats in group II after FIG. 2. Urinary excretion of oxalate in the rats in excretion of oxalate was plotted against MDA, 21 days but precipitation of calcium oxalate groups I–VI (symbols as Fig. 1), expressed as the the correlation was much stronger (y = crystals (+++) showed focal involvement of mean (SEM). *P < 0.05. -33.31 + 31.88x; r = 0.99; P < 0.001). There the renal parenchyma, with some areas were signiﬁcant positive correlations between remaining free of crystal deposition. 100 excretion of urinary oxalate and GGT (y = Disruption of crystal-containing tubules was 80 -49.06 + 17.65x; r = 0.94; P < 0.001), and also evident. Numerous crystals were present signiﬁcant negative correlations between in the cortex, medulla and in the papilla. The 60 urinary oxalate and catalase (y = 159.19 - kidney was enlarged and it was heavier than 40 4.32x; r = - 0.97; P < 0.001, plot not shown), in group I (Fig. 5B). The kidney sections of rats te, mmoles/24 h a

l urinary oxalate and a-tocopherol in group IV after 21 days showed no calcium a 20 (y = 156.81 - 4.02x; r = - 0.96; P < 0.001). oxalate crystal deposition in any part of the Ox 0 The kidney tissue MDA was positively nephron segment. Five of the eight rats had a 0 7 14 21 correlated with the urinary excretion of GGT normal kidney size and weight; three rats had Days (y = - 0.47 + 0.55x; r = 0.94; P < 0.001), and mild enlargement of the kidney and the there was a significant negative correlation kidney was heavier (Fig. 5C). The pathological between MDA and GSH (y = 6.22 - 0.26x; r = evaluation of kidney sections of rats in group group VI had significantly greater urinary -0.99; P < 0.001), and MDA and a-tocopherol VI showed diffuse and markedly extensive oxalate levels at 7 and 14 days, but (y = 5.8 - 0.12x; r = -0.92; P < 0.001). (++++) calcium oxalate deposits in the significantly lower levels at 21 days. There tubules of the cortex, medulla and collecting were statistically significant increases in In group II, after 7 days of EG-increased tubules (Fig. 5D). The crystal rosettes often water intake and urine output, and a lower hyperoxaluria there was calcium oxalate completely occluded the tubular lumens. urine pH, in the rats in group II at 21 days crystalluria and enzymuria with increased Intraluminal cellular debris and lymphocytic (Table 2). These changes were drastically MDA contents, 1.44 (0.12) in the absence of infiltration were sometimes found in greater in group VI. Rats in group IV had water crystal deposition. Crystal deposition was association with crystal deposits. The intake, urine output, and pH levels partly but completely absent even after 10 days of EG in decrease in urinary enzyme activities and significantly restored compared with rats in rats in group II or IV (Fig. 4A). Occasional reduced renal function, with the increase group II. crystal deposits were found in rats in group VI in urine volume in rats in group VI after at 10 days (data not shown). Furthermore, 21 days may be caused by extensive calcium Scatterplots of the multivariate regression increased enzymuria was associated with oxalate crystal deposition and significant analysis are shown in Fig. 3; when the urinary increased MDA content of the renal tissues at blockage of renal tubules, which might

interfere with the ﬁltration processes. The FIG. 3. Scatterplots showing the correlation between: A, oxalate and MDA; B, oxalate and GGT; C, oxalate and kidney was signiﬁcantly larger than in the a-tocopherol; D, MDA and GGT; E, MDA and GSH; F, MDA and a-tocopherol. controls. 80 80 AB 70 70 Control DISCUSSION 60 60 EG 50 50 The present study provides direct evidence moles/24 h 40 moles/24 h 40 m that vitamin E supplementation completely m te, 30 te, 30 a a l prevented calcium oxalate crystal deposition l a 20 a 20

in the kidney, by preventing free radical- Ox Ox induced renal injury and by restoring 10 10 antioxidant levels. Hyperoxaluria reduced 0 0 12342345678 vitamin E levels and increased MDA content MDA, nmol/mg protein GGT, U/24 h and protein carbonyl in rats in group II, indicating increased demand for vitamin E 80 4 C during hyperoxaluria. This is direct evidence 70 D of increased use of vitamin E when free- 60 3 radical generation is induced by 50 hyperoxaluria, and therefore outlines the moles/24 h 40 protective role of vitamin E in mitigating m

te, 30

a 2 hyperoxaluria-induced free-radical l a 20

generation. Earlier studies showed that Ox increased lipid peroxidation reduces 10 MDA, nmol/mg protein tocopherol levels in microsomal membranes 0 1 10 20 30 40 50 2345678 [35]. a-tocopherol, mg/g GGT, U/24 h

We previously reported that oxalate-induced 4 4 E F lipid peroxidation in renal tubular epithelial cells in culture was associated with a greater production of superoxide and hydroxyl free 3 3 radicals. The production of these free radicals is greater when the cells are exposed to 2 2 oxalate and calcium oxalate monohydrate crystals. This reveals that oxalate itself is MDA, nmol/mg protein MDA, nmol/mg protein injurious to cells and that calcium oxalate 1 1 crystals potentiate the toxicity [11]. The 10 11 12 13 14 15 16 17 18 19 20 21 10 20 30 40 50 GSH, nmol/mg protein significant increase in lipid peroxidation and a-tocopherol, mg/g protein carbonyl content in rats in group VI with hyperoxaluria is in agreement with the FIG. 4. Polarized light photomicrographs of a rat kidney showing the binding of calcium oxalate crystals to previous reports that vitamin E and selenium the inner wall of a renal tubule of a rat from group II. Haematoxylin-eosin, ¥1000. A, cross section of a kidney deficiency enhance free radical generation in tubule after 10 days of EG, showing no calcium oxalate crystal deposition in the tubular membrane surface; rats [36]. Therefore, dramatically increased B, An individual calcium oxalate monohydrate crystal found nucleated in the inner tubular membrane lipid peroxidation and protein carbonyls in the surface at 14 days of EG; C, As the hyperoxaluria continued, the nucleated crystals were overgrown by rats in group VI indicates that vitamin E aggregation with other crystals, and crystal growth was directed towards the centre of the tubules at 21 days deficiency potentiates the oxalate-induced after EG. free-radical production in the kidney. Grases et al. [37] showed that free radical-damaged cells produce a favourable environment for crystal development, and that phytic acid prevents calcium oxalate crystallization by its antioxidant properties. Recent studies show increased urinary excretion of MDA in human calcium-oxalate kidney stone formers [38]. In addition, another recent study provided more evidence indicating that oxidative stress plays decreased GSH, and decreased GPx in human that excess dietary vitamin E significantly a role in human calcium oxalate kidney stone kidney stone formers [39], which is similar to decreased oxalate-induced kidney lipid formation [39]. The authors also reported the levels observed in our present studies with peroxidation, and strongly support the increased MDA, decreased vitamin E, the rat model. The present results clearly show suggestion of our previous report that

FIG. 5. Polarized light photomicrographs of a kidney of rats from groups II, IV and VI (EG 150 mg/day) for as calcium in calcium oxalate crystals is 21 days. Haematoxylin-eosin, ¥400. A, a rat from group I, showing normal epithelium and normal size of the derived from the glomerular filtrate [44], and kidney (kidney weight, 1.12 ± 0.08 g, eight rats); B, a rat from group II at 21 days, showing calcium oxalate oxalate is readily filterable at the glomerulus crystals deposited in the renal parenchyma. Disruption of crystal-containing tubules was evident. The kidney and secreted by the proximal tubules [45,46]. was enlarged and was significantly heavier, at 1.52 (0.07) g; C, a rat from group IV at 21 days. There was no In humans, various changes in urine calcium oxalate crystal deposition in any part of the nephron segments. Five of eight rats had normal kidney chemistry, including hyperoxaluria, size and weight; three had mild enlargement of the kidney and weight increased to 1.30 (0.05) g. Kidney hypercalciuria and hypocitraturia, can lead to tubules remained free from calcium oxalate crystals. D, a rat from group VI at 21 days. The kidney section had the development of abundant crystals within diffuse and markedly extensive (++++) calcium oxalate deposits in the tubules of the cortex, medulla, and in the renal tubules. Using calculations based on the collecting tubules. The kidney was significantly heavier, at 1.91 (0.09) g. the concentration of ions in the renal tubules, Finlayson and Reid [47] reported that crystals are not usually retained and could not reach a size large enough to occlude the tubular lumen within the urinary transit time. In normal kidneys, it takes 3 min for urine to pass from the glomerulus to the renal pelvis; it would take several hours for crystals to become large enough to obstruct a collecting duct [47], suggesting that unless calcium oxalate crystals bind to the tubular membrane surface, stone development would not be possible. In agreement with Finlayson and Reid, we showed that hyperoxaluria-induced antioxidants may have a protective effect In the current study the treatment of rats in renal tubular peroxidative damage associated against free-radical injury associated with group II resulted in hyperoxaluria, calcium with antioxidant imbalance resulted in crystal oxalate treatment [10]. There is lipid oxalate crystalluria and enzymuria. The attachment, subsequent aggregation and peroxidation and antioxidant depletion in excretion of tubular marker enzymes was growth of calcium oxalate kidney stones. several pathophysiological conditions, further increased, indicating renal tubular including cigarette smoking, ischaemic stroke damage, and appeared to correlate with the Oxalate-generated free radicals disrupt the and congestive heart failure [40]. retention and deposition of crystals in the structural integrity of the membranes in renal kidneys. However, renal function was epithelial cells [10,14]. Wiessner et al. showed The decreased antioxidant enzymes (SOD, unaltered. The excretion of oxalate by rats in [48] that coating crystals with urinary catalase, and GPx) activities in the group IV was increased and similar to that of macromolecules enhanced the attachment of hyperoxaluric groups were attributed to in group II, indicating that neither oxalate the crystals to injured renal cells at a pH of peroxidative damage to the tissue caused synthesis nor calcium oxalate crystalluria was <6.0. Surface exposure and redistribution of by increased oxalate excretion, while prevented by excess vitamin E. However, the phosphatidylserine was reported to mediate supplementation with vitamin E contributed extra vitamin E significantly reduced the stone crystal attachment to the renal tubular to maintaining the antioxidant enzymes at an levels of these enzymes in the urine of cell epithelium [49–51]. Studies show that optimum level by protecting renal tubules hyperoxaluria-induced rats, indicating that crystal formation results in cell damage and from peroxidative injury. In the absence of a hyperoxaluria and formation of calcium cell detachment from the basement sufficient concentration of vitamin E in the oxalate crystals were eliminated without membrane, and the released degradation diet, the kidney antioxidants are adversely causing renal damage. Thus, vitamin E has a products can promote heterogeneous affected by hyperoxaluria. These results protective effect against hyperoxaluria- nucleation of calcium salts such as calcium confirm that vitamin E acts as an excellent induced lipid peroxidative injury to the renal oxalate and calcium phosphate. The exposed antioxidant for the kidney, which is greatly tubules. Earlier studies reported that region of the tubular basement membrane susceptible to oxalate-induced free radical increased excretion of urinary enzymes could serve as a site for crystal nucleation and damage. by rats occurs as a result of chronic aggregation [52]. Smith [53] showed that hyperoxaluria induced by various dilute acid-induced damage to the rat urinary The results indicate that EG-induced hyperoxaluric challenges, including EG, tract mucus lining promoted calcium oxalate hyperoxaluria significantly decreased renal hydroxyl-L-proline or ammonium oxalate [42]. crystal adherence and treatment with GSH level. However, the greatest depletion of An increase in urinary enzymes was also glycosaminoglycan decreased this adherence. renal GSH, in group VI, suggests tissue reported in patients with renal stones [43]. In addition, lipid asymmetry also increased antioxidant imbalance. The decrease in the affinity of lipid for calcium oxalate glutathione reductase and G6PD after We are the first to demonstrate direct monohydrate crystal attachment [54]. Lipid hyperoxaluria appears to indicate impaired evidence in vivo that hyperoxaluria-induced peroxidation reportedly correlates with reduction of oxidized glutathione (GSSG) to peroxidation of renal tubular membrane binds changes in membrane phospholipid GSH by depletion of reducing equivalents of individual calcium oxalate crystals and asymmetry [55]. The present NADPH, which is a cosubstrate and is required initiates kidney stone formation. The crystals histopathological studies also showed a for glutathione reductase activity [41]. are first formed in the renal proximal tubules, relationship between hyperoxaluria-induced

crystal deposition and peroxidative damage of the dose–response effects of vitamin E are 11 Thamilselvan S, Byer KJ, Hackett RL, to the renal tubular epithelium. Even warranted in the prevention of calcium Khan SR. Free radical scavengers, though there was EG-induced hyperoxaluria oxalate stone deposition. catalase and superoxide dismutase and calcium oxalate crystalluria in provide protection from oxalate- rats in group IV for up to 22 days, associated injury to LLC-PK1 and MDCK histopathological findings showed ACKNOWLEDGEMENTS cells. J Urol 2000; 164: 224–9 complete prevention of calcium oxalate 12 Thamilselvan S, Selvam R. Effect of crystal deposition. We thank Dr Raymond L. Hackett, Emeritus vitamin E and mannitol on renal calcium Professor of Pathology, Department of oxalate retention in experimental Vitamin E is the most effective chain-breaking Pathology and Laboratory Medicine, nephrolithiasis. Indian J Biochem Biophys lipophilic antioxidant found within biological University of Florida, Florida for valuable 1997; 34: 319–23 membranes and that can prevent biological input and critical reading of the manuscript. 13 Thamilselvan S, Khan SR. Oxalate and damage [56]. Tocopherols lack sufficient This work was supported by a grant from the calcium oxalate crystals are injurious to water solubility to be excreted directly in urine National Institutes of Health RO1-DK 56249 renal epithelial cells: results of in vivo and and the major route of elimination of its (to S. T). in vitro studies. J Nephrol 1998; 11 (Suppl. water soluble metabolite, 2,7,8-trimethyl-2- 1): 66–9 (b-carboxyethyl)-6-hydroxychroman (CEHC), CONFLICT OF INTEREST 14 Bhandari A, Koul S, Sekhon A et al. is through urine [57]. CEHC increased when Effects of oxalate on HK-2 cells, a line of the plasma level of RRR-a-tocopherol was None declared. proximal tubular epithelial cells from exceeded [58] by an excess a-tocopherol normal human kidney. J Urol 2002; 168: supply. Recently, it was reported that a-CEHC REFERENCES 253–9 has antioxidant properties similar to those of 15 Scheid C, Koul H, Hill WA et al. Oxalate trolox, a synthetic water-soluble vitamin E 1 Robertson WG, Peacock M. toxicity in LLC-PK1 cells. role of free homologue [59]. Studies show that a-CEHC Pathogenesis of urolithiasis. In Schneider radicals. Kidney Int 1996; 49: 413–9 had a protective effect against chromate- and HJ ed. HS-V &. Urolithiasis, Etiology, 16 Buege JA, Aust SD. Microsomal lipid thallium-induced nephrotoxicity in the rat Diagnosis. Chapter 3. New York, Springer peroxidation. Meth Enzymol 1978; 52: model, caused by its antioxidant effect [60]. 1985: 185–301 302–10 Therefore, vitamin E with its lipophilic and 2 Hodgkinson A. Oxalic acid in Biology 17 Levine RL, Williams JA, Stadtman hydrophilic properties, could act as an and Medicine. New York: Academic Press ER, Shacter E. Carbonyl assays for effective antioxidant in vivo against 1984 determination of oxidatively modified hyperoxaluria-induced peroxidative damage 3 Robertson WG. Urinary Tract Calculi. In proteins. Meth Enzymol 1994; 233: 346– in the kidney. In addition to the antioxidant Nordin BEC, AG Na HAM, Hong Kong: 57 properties of vitamin E, the absence of Churchill Livingston, 1993: 249 18 Arnaud J, Fortis I, Blachier S, Kia D, calcium oxalate crystal deposition in group IV 4 Laker MF. The clinical chemistry of Favier A. Simultaneous determination of might be due to interference of calcium oxalate metabolism. Adv Clin Chem 1983; retinol, alpha-tocopherol and beta- oxalate crystals with the carboxyl group of 23: 259–97 carotene in serum by isocratic high- water-soluble CEHC. The possible existence of 5 Holmes RP, Goodman HO, Assimos DG. performance liquid chromatography. an interaction between calcium oxalate Contribution of dietary oxalate to urinary J Chromatogr 1991; 572: 103–16 crystals and CEHC remains, at present, a oxalate excretion. Kidney Int 2001; 59: 19 Misra HP, Fridovich I. The role of matter of speculation and worth further 270–6 superoxide anion in the autoxidation of investigation. 6 Uribarri J, Oh MS, Carroll HJ. The first epinephrine and a simple assay for kidney stone. Ann Intern Med 1989; 111: superoxide dismutase. J Biol Chem 1972; In conclusion, these findings present 1006–9 247: 3170–5 novel and direct evidence in vivo that 7 Menon M, Koul H. Clinical review 32: 20 Sinha AK. Colorimetric assay of hyperoxaluria-induced peroxidative damage Calcium oxalate nephrolithiasis. J Clin catalase. Anal Biochem 1972; 47: 389– to the renal tubular membrane surface Endocrinol Metab 1992; 74: 703–7 94 provides a favourable environment for 8 Smith LH. Idiopathic calcium oxalate 21 Tietze F. Enzymic method for individual calcium oxalate crystal attachment urolithiasis. Endocrinol Metab Clin North quantitative determination of nanogram and subsequent development of kidney Am 1990; 19: 937–47 amounts of total and oxidized stones. Vitamin E treatment completely 9 Tiselius HG. Possibilities for preventing glutathione: applications to mammalian prevented calcium oxalate crystal deposition recurrent calcium stone formation. blood and other tissues. Anal Biochem in the kidney, by preventing hyperoxaluria- Principles for the metabolic evaluation of 1969; 27: 502–22 induced lipid peroxidation and tissue patients with calcium stone disease. BJU 22 Paglia DE, Valentine WN. Studies antioxidant imbalance. 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Methods of Enzymatic Analysis. 3rd edn. investigation. Mol Pharmacol 1993; 44: phosphatidylserine increases calcium New York: Academic Press, 1983: 258– 222–7 oxalate crystal attachment to IMCD 65 37 Grases F, Garcia-Ferragut L, Costa- cells. Am J Physiol 1997; 272: F55– 24 Deutsch J. Glucose-6-phosphate Bauza A. Development of calcium oxalate 62 dehydrogenase. In Bergmeyer HV ed. crystals on urothelium: effect of free 50 Cao LC, Jonassen J, Honeyman TW, Methods in Enzymatic Analysis. 3rd edn. radicals. Nephron 1998; 78: 296–301 Scheid C. Oxalate-induced redistribution Vol. 3. New York: Academic Press, 1983: 38 Huang HS, Ma MC, Chen CF, Chen J. of phosphatidylserine in renal epithelial 190–7 Lipid peroxidation and its correlations cells: implications for kidney stone 25 Crocker CL. Rapid determination of urea with urinary levels of oxalate, citric acid, disease. Am J Nephrol 2001; 21: 69– nitrogen in serum or plasma without and osteopontin in patients with renal 77 deproteinization. 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Calcium oxalate implications for fetal alcohol syndrome. 55 Shvedova AA, Tyurina JY, Kawai K urolithiasis in the rat. is it a model for Adv Exp Med Biol 1994; 366: 291–305 et al. Selective peroxidation and human stone disease? A review of recent 42 Khan SR, Shevock PN, Hackett RL. externalization of phosphatidylserine in literature. Scan Electron Microsc 1985; Urinary enzymes and calcium oxalate normal human epidermal keratinocytes PT2: 759–74 urolithiasis. J Urol 1989; 142: 846–9 during oxidative stress induced by 31 Kumar S, Sigmon D, Miller T et al. A new 43 Baggio B, Gambaro G, Ossi E, Favaro S, cumene hydroperoxide. J Invest Dermatol model of nephrolithiasis involving tubular Borsatti A. Increased urinary excretion of 2002; 118: 1008–18 dysfunction/injury. J Urol 1991; 146: renal enzymes in idiopathic calcium 56 Meydani M. Vitamin E. Lancet 1995; 384–9 oxalate nephrolithiasis. J Urol 1983; 129: 345: 170–5 32 de Bruijn WC, Boeve ER, van Run PR 1161–2 57 Swanson JE, Ben RN, Burton GW, et al. Etiology of calcium oxalate 44 Jordan WR, Finlayson B, Luxenberg M. Parker RS. Urinary excretion of 2,7,8- nephrolithiasis in rats. I. Can this be a Kinetics of early time calcium oxalate trimethyl-2-(beta-carboxyethyl)-6- model for human stone formation? nephrolithiasis. Invest Urol 1978; 15: hydroxylchroman is a major route of Scanning Microsc 1995; 9: 103–14 465–8 elimination of gamma-tocopherol in 33 de Bruijn WC, Boeve ER, van Run PR 45 Larsson L, Tiselius HG. Hyperoxaluria. humans. J Lipid Res 1999; 40: 665– et al. Etiology of calcium oxalate Miner Electrolyte Metab 1987; 13: 242– 71 nephrolithiasis in rats. II. The role of the 50 58 Schultz M, Leist M, Petzika M, papilla in stone formation. Scanning 46 Weinman EJ, Frankfurt SJ, Ince A, Gassmann B, Bridglius-Flohe R. Novel Microsc 1995; 9: 115–25 Sansom S. Renal tubular transport of urinary metabolite of alpha-tocopherol, 34 Khan SR. Animal models of kidney stone organic acids. Studies with oxalate and 2,5,7,8–tetramethyl-2 (2¢–carboxyethyl)- formation: an analysis. World J Urol 1997; para-aminohippurate in the rat. J Clin 6–hydroxychroman, as an indicator of an 15: 236–43 Invest 1978; 61: 801–6 adequate vitamin E supply? Am J Clin Nutr 35 Palozza P, Krinsky NI. The inhibition of 47 Finlayson B, Reid F. The expectation of 1995; 62: 1527S–34S radical-initiated peroxidation of free and fixed particles in urinary stone 59 Betancor-Fernandez A, Sies H, Stahl microsomal lipids by both alpha- disease. Invest Urol 1978; 15: 442–8 W, Poridori MC. In vitro antioxidant tocopherol and beta-carotene. Free Radic 48 Wiessner JH, Hung LY, Mandel NS. activity of 2,5,7,8–tetramethyl-2–(2¢– Biol Med 1991; 11: 407–14 Crystal attachment to injured renal carboxyethyl-6–hydroxylchroman 36 Kadiiska MB, Hanna PM, Jordan SJ, collecting duct cells. influence of urine (alpha–CEHC), a vitamin E metabolite. Free Mason RP. Electron spin resonance proteins and pH. Kidney Int 2003; 63: Rad Res 2002 36: 915–21 evidence for free radical generation in 1313–20 60 Appenroth D, Karge E, Kiebling G, copper-treated vitamin E- and selenium- 49 Bigelow MW, Wiessner JH, Kleinman Wechter WJ, Winnefeld K, Fleck C. LLU- deficient rats: in vivo spin-trapping JG, Mandel NS. Surface exposure of alpha, an endogenous metabolite of

gamma-tocopherol, is more effective Health System, One Ford Place, Detroit, MI- oxidized glutathione; GSH, reduced against metal nephrotoxicity in rats than 48202, USA. glutathione; G6PD, glucose-6-phosphate gamma-tocopherol. Toxicol Lett 2001; e-mail: [email protected] dehydrogenase; BUN, blood urea nitrogen; 122: 255–65 GGT, g-glutamyl transpeptidase; LDH, Abbreviations: SOD, superoxide dismutase; lactose dehydrogenase; CEHC, 2,7,8- Correspondence: Sivagnanam Thamilselvan, GTP, glutathione peroxidase; EG, ethylene trimethyl-2-(b-carboxyethyl)-6- Department of Urology, Ste 2D/34, Henry Ford glycol; MDA, malondialdehyde; GSSG, hydroxychroman.

Authors from London carried out a Treatment of pelvic fracture-related survey of current practice for treating urethral trauma urethral trauma: a survey of current associated with pelvic fracture in practice in the UK the UK. The interesting findings are described, and it is suggested that DANIELA E. ANDRICH, TAMSIN J. GREENWELL and ANTHONY R. MUNDY even within specialised units such Institute of Urology, London, UK cases are uncommon, and that Accepted for publication 6 February 2005 surgical management often differs significantly from what might be OBJECTIVE were identified and targeted; half used published by so-called experts in urethral mobilization and spatulated the field. To quantify experience of pelvic fracture- anastomosis alone. Only three surgeons related urethral trauma (PFUT), a condition performed more than five procedures a year. not often encountered and managed by urologists. CONCLUSION

METHODS Whatever a specialist reconstructive unit might do, practice in the wider urological The consultant urologists of the UK and community is different. Even within Ireland were contacted informally to establish specialized units, PFUT is rare and the surgical their experience with PFUT and its management is often signiﬁcantly different management, both immediate and delayed. In from published ‘expert’ opinion. addition, particular individuals thought to have a speciﬁc interest in PFUT were targeted KEYWORDS for more data. pelvic fracture, urethral trauma, distraction RESULTS defect, urethroplasty

The overall response rate was 49% (235 responders), representing 78% of urological INTRODUCTION departments, including all the targeted individuals. Of the responders, 129 (55%) had The annual incidence of pelvic fracture- never seen PFUT in 1–25 years of consultant related urethral trauma (PFUT) is not practice. Only four urologists (2% of accurately documented. According to responders) saw three or more cases a year. Hospital Episode Statistics (HES) data Another four (2%) saw one or two cases per collected centrally by the Department of year and the remaining 98 (41%) saw PFUT Health in England, and published on their less frequently. Acutely, 69% of urologists website (www.doh.gsi.gov.uk/hes), there were, who treated PFUT did so by placing a urethral over the last 3 years, an annual mean of 6349 catheter. Subsequent strictures were treated pelvic fractures in men (127 pelvic fractures endoscopically for as long as this was per million) and annually 159 associated possible. The other 31% inserted a suprapubic urethral injuries (2.5%) registered in England. catheter and referred the patient for This is a lower incidence of PFUT than reconstructive surgery if needed. Those who generally quoted, at 5–10% [1,2]. These used urethroplasty for strictures after PFUT ﬁgures do not specify the severity and type

ANDRICH ET AL.

r FIG. 1. of associated urethral injuries, i.e. whether a 50 there was partial or complete disruption of 45 The annual experience of the 27 the urethra. PFUT is therefore uncommon, and surgeons using posterior sties/ye 40 a urethroplasties in the UK and general urologists will not often see such 35 injuries and manage them; in the present Ireland who do so at least once 30 rethropl

study we sought to quantify this experience. u per year. Twenty surgeons 25 operated on established PFU 20 distraction defects; only three do METHODS 15 more than ﬁve procedures per 10 year. 5

In all, 478 consultant urologists of the UK and mber of posterior u

Ireland were contacted informally by letter to N 0 establish their experience in PFUT and its 1591317Surgeon management, both immediate and delayed. The overall response rate was 49% (235 replies), although the responding urologists TABLE 1 Surgical approach of surgeons using posterior urethroplasty in the UK and Ireland; 27 urologists represented 78% of departments of urology reported a life-time experience of 755 patients. Steps 1–4 are as described in the text in the UK and Ireland. In addition, particular individuals regarded as having surgical N Total cases Step, % experience of strictures after PFUT were Surgeons Procedures by group 1234 targeted for more detail. 11 1–5 34 62 34 4 0 4 6–10 32 57 43 0 0 4 11–20 59 53 30 11 6* RESULTS 4 21–30 102 63 29 5 3 1 404095500 Of the 235 responders, 129 had never seen 1 6060583390 PFUT in 1–25 years of consultant practice. 1 868610562410 Only four urologists (2%), all of whom were 1 342 342 9 51 11 29 particularly targeted for their experience, saw more than three cases per year, four (2%) saw *One surgeon reported an experience of six cases and had used all four steps in all six patients. one or two, 54 (23%) saw one every 1–5 years and 44 (18%) saw a case less frequently.

In the acute situation, 69% of consultant particularly by surgeons who manage TABLE 2 Surgical approach of expert surgeons urologists manage PFUT by passing a urethral strictures less often after PFUT. Very few using posterior urethroplasties in the USA, all catheter, by whatever means (blindly, under surgeons more extensively mobilize the doing ≥15 procedures annually and with an endoscopic control or by open surgery) and urethra with inferior pubectomy and re- overall experience of 100–300 procedures each. continue to manage established strictures routing of the urethra. The surgical approach They were all approached directly by the senior endoscopically, usually with self- also varies amongst experts in posterior author. The steps are described in the text catheterization between times thereafter. urethroplasty in the USA (Table 2). Only when this proves impossible or Step, % unreasonable would the patient be referred to Surgeon 1234 a specialist unit for further management. Only DISCUSSION 31% of consultant urologists treat PFUT by A 0 87 13 <1 placing a suprapubic catheter and then The present study confirmed that PFUT is B701515<1 advising urethroplasty ª3 months later if uncommon; in England the reported C702181 necessary. incidence, as calculated from HES data, is D 8 43 12 38 2.5%. This amounts to about three stricture E 0 73 20 7 There are 27 surgeons in the UK and Ireland cases after PFUT per million of the population who have experience of urethroplasty for per year, of which one patient per year finally established strictures after PFUT. Only three of has an anastomotic urethroplasty. These Internationale d’Urology in 2002 [3]. This these surgeons do more than five posterior figures suggest that PFUT is less common report, having extensively surveyed the world urethroplasties per year (Fig. 1). The surgical than generally reported. In the immediate publications and canvassed expert opinion, approach in repairing strictures after PFUT management of PFUT, 31% of responding recommended that a patient with suspected among those using a posterior urethroplasty urologists in the UK and Ireland place urethral injury, or with blood at the meatus, in the UK and Ireland varied considerably suprapubic catheters and advise should have an ascending urethrogram. If (Table 1). Urethral mobilization and urethroplasty 3 months later if indicated. This there is extravasation of contrast medium the spatulated anastomosis alone or with is in line with the Consensus Report on patient should have a suprapubic catheter corporal separation were used most often, Urological Trauma produced by the Societé placed, either percutaneously with

TREATMENT OF PELVIC FRACTURE-RELATED URETHRAL TRAUMA

ultrasonographic control or by open urethral mobilization with anastomosis of the All this begs the question of how many cystotomy. Absence of blood at the meatus is spatulated healthy ends. Step two develops surgeons should be doing this type of surgery. not an indication that urethral injury is trivial, the intercrural space to accommodate the In the UK, at least 24 of the 27 surgeons using so if no blood is present at the external mobilized urethra and thereby reduce the posterior urethroplasty are doing so fewer meatus but the patient cannot void, then length of the defect. In step three the length than five times a year; is this sufficient to gentle urethral catheterization by an of the defect is further reduced by resecting maintain their skills? Certainly it is lower than experienced urologist may be attempted, the inferior aspect of the pubic symphysis. the rates recommended by other disciplines but failure should be followed by a If this still does not give a tension-free for maintaining surgical competence. To urethrogram and suprapubic catheter anastomosis then the final technical step is to maintain proficiency, a urethral surgeon insertion. re-route the urethra around one corpora managing strictures after PFUT should cavernosum. The need for successive steps probably serve a population of ≥20 million, Interestingly, in the acute situation, 69% of from a simple to a complex repair is which would generate 20–30 procedures a urologists would try to pass a urethral determined by intraoperative findings. year, i.e. the UK would need two or three catheter by whatever means possible and Imaging before surgery, e.g. with an specialist centres to service the national manage any subsequent stricture ascending urethrogram and micturating demand. Countries with a population of <5 endoscopically. We did not ascertain the cystogram, cannot predict the extent of million might have to pool resources or ‘buy usage and findings of ascending urethral mobilization necessary to achieve a in’ appropriate expertise. urethrography, and can only therefore tension-free anastomosis [10]. speculate that in this group partial tears of In conclusion, whatever a specialist the urethra were usual, as only a few Of the 27 surgeons who manage PFUT in the reconstructive unit might do, practice in the urologists reported aggressive endoscopic UK and Ireland, only three have a caseload of wider urological community is different. Even manoeuvres or open ‘realignment’ to pass a more than five per year and seven manage within specialized units PFUT is a rare injury urethral catheter. There are no accurate fewer than one case per year. The remaining and the surgical management is often published data on the incidence of partial and 24 surgeons operate on strictures after PFUT significantly different from published expert complete urethral disruptions associated with only occasionally. The technical repertoire also opinion. Interestingly, two of the replies pelvic fractures. These observations may varies among the 27 UK surgeons and among received commented that they were well explain why the incidence of PFUT from the the five American expert surgeons who were aware of what the published expert opinion HES data is three per million per year, whereas asked about their experience. Only some use was, but they did not believe it, because that of urethroplasty for an established all surgical manoeuvres to mobilize the bulbar experts clearly have a vested interest in their distraction defect is only one per million per urethra completely. Why there is such surgical views! year. variability is uncertain; possibly, once a surgeon is familiar with all the surgical CONFLICT OF INTEREST The difference in managing PFUT might be of techniques of urethral mobilization, the no importance if it did not affect the patient’s tendency might be to use them more than is None declared. outcome adversely. Unfortunately, repeated actually necessary to achieve a tension-free instrumentation seems to affect the outcome spatulated anastomosis. However, someone REFERENCES adversely if a urethroplasty is subsequently not trained in more complex mobilization necessary [4]. Whatever, a lifetime of manoeuvres may have a different perception 1 Palmer JK, Benson GS, Corriere JN Jr. instrumentation, albeit infrequent, does not of the tension needed to bring the urethral Diagnosis and initial management of compare well with a long-term stricture-free ends together. Indeed, tension is a subjective urological injuries associated with 200 survival after urethroplasty of >90% [5]. assessment at the time of surgery. Another consecutive pelvic fractures. J Urol 1983; reason might also be relevant; it is very 130: 712–4 There are several mechanisms of urethral difficult to differentiate a partial urethral 2 Devine PC, Devine CJ Jr. Posterior injury in PFUT (e.g. crush, laceration, avulsion injury from a complete urethral disruption by urethral injuries associated with pelvic or distraction) and complete disruption of the a urethrogram alone, but the potential fractures. Urology 1982; 20: 467 membranous urethra is less common than implication on loss of urethral length is 3 Chapple C, Barbagli G, Jordan G et al. partial injury [6]. In complex cases there may important. In a complete urethral disruption Consensus statement on urethral trauma. be additional injury of the bladder neck, pelvic there is no loss of urethral length and the BJU Int 2004; 93: 1195–202 floor or ano-rectum. Complete disruptions fibrotic gap between the healthy ends is 4 Andrich DE, O’Malley KJ, Greenwell TJ, never heal without scar formation separating typically 1–2 cm (provided the pelvic fracture Mundy AR. Does urethrotomy jeopardize the distracted ends, and only partial urethral was reduced). Severe partial urethral the outcome of urethroplasty? BJU Int tears have the potential to heal injuries have less distraction and heal by 2003; 91 (Suppl. 2): 89 spontaneously [7]. fibrosis involving a variable length of 5 Andrich DE, Dunglison N, Greenwell TJ, bulbomembranous urethra. Therefore, Mundy AR. The long-term results of The surgical repair of an established stricture perhaps different surgeons see a different urethroplasty. J Urol 2003; 170: 90–2 is described as a transperineal progression proportion of complete and severe partial 6 Andrich DE, Day AC. A correlation of through four main technical stages, stopping urethral injury, reflecting their need to pelvic fracture classification and lower at the stage which first gives a tension-free mobilize the bulbar urethra to a greater or urinary tract trauma. J Urol 2004; 171 anastomosis [8,9]. Step one involves simple lesser degree. (Suppl. 4): A67, 17

ANDRICH ET AL.

7 Weaver RG, Schulte JW. Experimental 9 Mundy AR. Reconstruction of posterior Correspondence: Anthony R. Mundy, and clinical studies of urethral urethral distraction defects. Atlas Urol Institute of Urology, 48 Riding House Street, regeneration. Surg Gyn & Obst 1962; 115: Clin N Am 1997; 5: 139–74 London W1W 4RE, UK. 729–36 10 Andrich DE, O’Malley KJ, Summerton e-mail: [email protected] 8 Webster GD, Ramon J. Repair of pelvic DJ, Greenwell TJ, Mundy AR. The type of fracture posterior urethral defects using urethroplasty for a pelvic fracture Abbreviations: PFUT, pelvic fracture-related an elaborated perineal approach: urethral distraction defect cannot be urethral trauma; HES, Hospital Episode Experience with 74 cases. J Urol 1991; predicted pre-operatively. J Urol 2003; Statistics. 145: 744–8 170: 464–7

The three papers in this section Upper and lower urinary tract cover a wide range of subjects. Authors from Indianapolis present outcome after surgical repair a three-decade experience in upper of cloacal malformations: and lower urinary tract outcomes after the surgical repair of cloacal a three-decade experience malformations. An objective assessment of their results of RICHARD C. RINK, C.D. ANTHONY HERNDON*, MARK P. CAIN, MARTIN KAEFER, ANDREW M. DUSSINGER, SHELLY J. KING and ANTHONY J. CASALE hypospadias surgery is described by Departments of Paediatric Urology, Riley Hospital for Children, Indianapolis, IN, and *University authors from Manchester. Finally, of Alabama, Birmingham, AL, USA the question is asked by authors Accepted for publication 4 January 2005 from Athens; is bladder muscle decompensation in boys with a history of PUV caused by secondary OBJECTIVE and spinal cord untethering in four; a nephrectomy was required in three and bladder neck obstruction? To report the urological outcome of the partial nephrectomy in one. Upper tract surgical correction of persistent cloaca, which dilation was still present in six patients. Age- is technically demanding and may require adjusted creatinine levels were abnormal in many procedures in an effort to preserve four (18%) patients and borderline in another renal function and provide urinary six (26%). In the nine patients with a solitary continence. kidney (six solitary, three after nephrectomy), the age-adjusted creatinine level was PATIENTS AND METHODS abnormal in two and borderline in four. A vesicostomy was initially performed in 11 A retrospective chart review from 1971 to patients. The method of bladder emptying is 2003 identified 23 patients with cloacal known in 22; 10 void, 11 require clean malformations (two posterior, 21 classical) intermittent catheterization (five abdominal that were reconstructed. The confluence of stoma, six urethral) and one was diverted the urethra, vagina and rectum was noted to with a conduit. Of the 18 patients aged be high in 16, low in five and unknown in two; >47 months 15 were continent (14 complete one patient was a conjoined twin. >4 h, one partial 2–4 h), and three are wet (one conduit). Reconstruction of the lower RESULTS urinary tract included four bladder augmentations (one ureteric, one ileal, two The mean (range) follow-up was 9.3 colon), five bladder neck procedures (two (0.4–31.6) years. Urinary anomalies included artificial sphincter, one each bladder neck 14 patients with renal anomalies (six solitary repair, sling, bladder neck division) and six kidneys, four renal dysplasia, two pelvi- catheterizable channels (one now with a ureteric junction, one each duplex and colon conduit). The ureters were re-implanted crossed fused) and two duplicated bladders. in 12 patients. Vesico-ureteric reflux was present in 13 patients (57%), hydronephrosis at birth in 13, CONCLUSION a bony vertebral abnormality in 14 and the VACTERL association in four. Total urogenital Although the surgical correction of this rare mobilization (TUM) was used in six patients malformation is complex, the upper urinary

RINK ET AL.

and lower urinary tract outcome can be that were reconstructed. A classical cloaca TABLE 1 The associated anomalies in the 23 favourable, albeit after several reconstructive was defined by a common perineal opening cloacal patients procedures. TUM has emerged as the primary that drained the bladder, vagina and rectum. A method for vaginal reconstruction, but the posterior cloaca was defined by a very Anomaly N (#) long-term lower tract outcome after this anteriorly placed rectum that entered Renal 14 (17) procedure is awaited. proximal to the urogenital sinus and shared a Solitary kidney(after nephrectomy) 6 (9) common mucosal lining, as previously Renal dysplasia 3 KEYWORDS described by Pena and Kessler [19]. The level Multicystic dysplastic kidney 1 of confluence was defined by both PUJ 2 cloaca, children, surgery, outcome cystoscopic and anatomical assessment at the Duplex 1 time of reconstruction. A high confluence was Crossed fused 1 defined by the vaginal takeoff being above the Duplicated bladder 2 INTRODUCTION external sphincter mechanism if visualized, VUR 13 and/or near the bladder neck. A low Hydronephrosis 13 Cloacal anomaly or persistent cloaca is an confluence was defined as distal to any Bony vertebral anomaly 14 extremely rare disorder with a varied external sphincter mechanism and/or well VACTERL 4 presentation and that demands surgical separated from the bladder neck. The Conjoined twin 2 expertise in managing both anorectal and common channel length was not used as a urogenital malformations. The external factor to classify patients, because some had a genital appearance represents a wide masculinized phallic structure that gave them spectrum. There may be a perineal opening a long common channel but also a low that exits onto a ‘doll-like’ perineum, or nearly vaginal confluence. In the present patients, posterior sagittal while prone and supine in normal external genitalia, to a well the confluence was high in 16, low in five and eight. Total urogenital mobilization (TUM) was masculinized phallic structure. The overall unknown in two. used in six patients and spinal cord incidence is estimated to be ª1 in 50 000 untethering in four. deliveries [1]. In terms of managing the cloaca, all patients initially were allowed to void. Intermittent A nephrectomy was required in three patients The surgical approach to these patients catheterization of the cloaca was instituted in and an upper pole nephrectomy in one, all for should be directed at correcting life- the setting of infections, urinary retention, a poorly functioning renal unit. Upper tract threatening conditions, e.g. metabolic acidosis worsening VUR, abdominal distension dilatation remains in seven patients; in six it and cardiac anomalies, before addressing the or metabolic acidosis. A vesicostomy was decreased in grade. One patient developed reconstruction of the common cloaca. created in patients in whom intermittent mild hydronephrosis and has had spinal cord Associated congenital anomalies such as catheterization failed. Other congenital untethering. The mean (range) serum myelomeningocele and renal malformations defects were present, as listed in Table 1. creatinine level was 62 (26–283) mmol/L; the are common [2,3]. Over the last three decades age-adjusted creatinine level was abnormal in the surgical approach to manage these Urinary continence was assessed in patients four (18%) patients and borderline in another patients has developed [1–11]. Major aged >47 months, and defined as complete if six (26%). In the nine patients with a solitary advances in reconstruction have been the voiding interval was >4 h, partial if 2–4 h kidney (six solitary, three after nephrectomy), pioneered independently by both Hendren and wet if <2 h. the age-adjusted creatinine level was and Pena [4,8,10,11]. Furthermore, the abnormal in two and borderline in four. genitourinary anatomy can be very complex, Renal function was based on age-adjusted involving but not limited to duplication of the serum creatinine levels, although longitudinal A vesicostomy was initially created in 11 vagina, bladder and the presence of accessory values were not available for analysis. Age- patients in whom clean intermittent urethral channels [12]. Recently, refinements adjusted normal creatinine values (mmol/L) catheterization of the cloaca failed, and in in the surgical approach and mobilization of were: 0–5 years, 17.7–53.2; 5–10 years, two in whom an initial ‘cutback’ of the phallic the urogenital sinus have greatly facilitated 26.6–62.1; 11–13 years, 35.5–71; 14–17 years, cloaca failed. The method of bladder emptying reconstruction [13–16]. However, there are 35.5–79.8; >16 years, 62.1–133 [20]. is known in 22 patients; 10 void, 11 require few reports of the long-term urinary outcome Borderline values were considered as within clean intermittent catheterization (five after reconstruction [17,18]. Thus the aim of 8.9 mmol/L of the highest accepted normal abdominal stoma, six urethral) and one was the present study was to evaluate the long- value. diverted with a conduit. Bladder neck term upper and lower urinary outcome in competence before reconstruction was patients who had a persistent cloaca repaired. assessed in 12 patients and was defined as RESULTS coapting in six and open in six. Three patients in both groups void and three intermittently PATIENTS AND METHODS The mean (range) follow-up from when catheterize. initially seen to the time of review was A retrospective chart review from 1971 to 9.3 (0.4–31.6) years. The surgical approach In the 18 patients aged >47 months, 16 are 2003 identified 23 patients with cloacal was posterior sagittal while prone in 13 continent diurnally (86%, 14 complete, two malformations (two posterior, 21 classical) patients, while supine in two and combined partial). Voiding with continence was present

URINARY TRACT OUTCOME AFTER SURGERY FOR CLOACAL MALFORMATION

in only a third of the patients. The status of stated, but the ability of this factor in dealing with a high confluence. In the the bony spine did not alter this rate, with predicting future continence is not uniformly situation where supine positioning is also four of 12 with an abnormality and two of six agreed [8,18]. Although not significant in the required, we have been able to reposition the without achieving continence with voiding. present series, the data of Pena [1] suggest patient with no difficulty. Similar to other Reconstruction of the lower urinary tract that sacral bony status may affect urinary centres that have used the TUM [15], the included: four bladder augmentations (one continence. Although over half of the present continence status is not yet available, but ureteric, one ileal, two colon), five bladder patients had a spinal abnormality, spinal cord certainly is a concern. The use of TUM has neck procedures (two artificial sphincter, one untethering was used in only four (17%). facilitated reconstruction of the persistent each bladder neck repair, sling and bladder Because this retrospective review spans three cloaca. neck division) and six catheterizable channels decades, MRI may not have been used in all (one now with a colon conduit). The ureters patients. Klugo et al. [3] reported a spinal cord Upper tract deterioration has been a concern were reimplanted in 12 patients. The bladder defect in a third of their patients. Finally, in patients with persistent cloaca. The neck appearance was available in 10 of these Hendren [7] reported spinal cord tethering in complexity and unique nature of these 18 patients and was not a predictor of 27% of his patients who were evaluated with patients, including the presence of spinal cord ultimate continence, but four of five with an MRI, with an overall continence rate of 96%. tethering, persistent hydronephrosis, the need open bladder neck required reconstruction of for bladder augmentation and the presence of the bladder and/or bladder neck, compared The reported initial and long-term approach reflux, make it extremely difficult to reach an with one of five with a coapting bladder neck. to managing bladder emptying varies overall conclusion about renal function in The level of vaginal confluence (in 17 patients) significantly; factors contributing to this these patients. Although hydronephrosis was did not affect the ultimate continence rates include the need for temporary diversion, initially present in 57% of the present nor the need for bladder reconstruction. In six bladder augmentation, status of the spinal patients, it remained a persistent finding in patients with a low confluence, three are dry cord and the desire for continence. Temporary 26%; in all but one the severity decreased. and two required urinary reconstruction. In urinary diversion was required in nearly half Hydronephrosis was of new onset in one the 10 with a high confluence six are dry and the present patients because of the failure of patient who had spinal cord untethering. four required urinary reconstruction. a conservative treatment plan that included VUR was present initially in 57% and intermittent catheterization of the cloaca. A reimplantation required in 53%. Similar VUR vesicostomy was shown to adequately findings were reported by other institutions, DISCUSSION decompress the cloaca, mainly the vagina, in 53–54% of patients [7,17]. It is imperative and allows delayed definitive reconstruction to understand the bladder dynamics after As others have reported [2], associated [21]. As we previously reported, antenatal initial reconstruction of the cloaca, to prevent congenital anomalies were common in the urinary ascites may be a predictor of those renal deterioration. present patients and indicates the complexity patients in whom a vesicostomy may be in both their surgical reconstruction and required [22]. After formal reconstruction, There are few reports of long-term renal evaluating their urological outcome. most of the present patients empty via function in patients with cloacal Although complex, an accurate diagnosis is intermittent catheterization (52%) In the malformation. Although age-adjusted serum not always made before referral, which could series of Hendren [11], 39 of 60 secondary creatinine levels were used as a reflection of potentially place the newborn at significant cases had undergone diversion before renal function in the present patients, we risk of urosepsis or death [12]. reconstruction. Ultimately, 64% of the feel that this is not an entirely accurate patients eventually voided spontaneously. The assessment of renal function. Nadir creatinine Urinary continence was achieved in 83% of Great Ormond Street series [18] cited a and longitudinal values could not be obtained the present patients, a rate comparable with spontaneous voiding rate of only 22% in their in the present patients. Also, inherent those in other reports, of 60–92% [7,8,18]. continent patients, an obvious reflection of differences in patient size could affect age- Although most of the present patients are dry, the need for bladder reconstruction. Finally, adjusted values of serum creatinine. urinary reconstruction was required in a third; Pena [8] reported a spontaneous voiding rate Nonetheless, it is important to include these furthermore, only a third void spontaneously of 60% in his patients who were dry. data because they provide a gross assessment and are continent. Although bladder neck of renal function. The age-adjusted value was competence was not a predictor of ultimate TUM was used in six of the present patients abnormal in 18% of the patients and there continence status, it could be used to and was considered to enhance the was a borderline increase in another 26%. In discriminate those patients who went on reconstruction, similar to the original findings patients with a solitary kidney, there was an to require urinary reconstruction. In the described by Pena [13]. As we previously abnormal or borderline value in two-thirds. series from Great Ormond Street [18] the described, TUM also allows for the sinus tissue The Great Ormond Street group reported a reconstruction rate was 60%, with an overall to be used for a dorsal, ventral or lateral flap higher incidence of renal disease, with chronic continence rate of 80%. Bladder neck during urethral or vaginal reconstruction [16]. renal failure developing in half of their competence was felt to be a predictor of In addition, eight of the present patients patients and progression to end-stage renal future continence in that series. In the present required both prone and supine positioning. disease in 17%. All of the patients with a series the level of confluence was not a We consider that the prone position enhances solitary kidney in their group had at least mild predictor of continence or the need for the surgeon’s ability to sight down the renal insufficiency [17]. This discrepancy is urinary reconstruction. Common channel introitus when dissecting the plane between partly reflected by the renal function being length was not used for reasons previously the bladder and the vagina, particularly when based on age-adjusted serum creatinine levels

RINK ET AL.

in the present patients, rather than the more 3 Klugo RC, Fisher JH, Retik AB. without division of the rectum. J Urol accurate GFR. Management of urogenital anomalies in 1997; 158: 1293–7 cloacal dysgenesis. J Urol 1974; 112: 832– 15 Hamza AF, Soliman HA, Abdel Hay SA, In conclusion, although the surgical 5 Kabesh AA, Elbehery MM. Total correction of the persistent cloaca is complex, 4 Pena A, Devries PA. Posterior sagittal urogenital mobilization in the repair of the upper and lower urinary tract outcome anorectoplasty. Important technical cloacal anomalies and congenital adrenal can be favourable, albeit with several considerations and new applications. hyperplasia. J Ped Surg 2001; 36: 1656–8 reconstructive procedures. Spinal cord J Ped Surg 1982; 17: 796–811 16 Rink RC, Cain MP. Further uses of tethering and underlying neuropathic 5 Hendren HA. Further experience in mobilized sinus in total urogenital sinus changes to the bladder affect the need for reconstructive surgery for cloacal mobilization. American Academy of subsequent lower tract surgery. Up to half of anomalies. J Ped Surg 1982; 17: 695–717 Pediatrics; Boston 2002 Abstract #2 the patients may ultimately need intermittent 6 Hendren HA. Urological aspects of 17 Warne SA, Wilcox DT, Ledermann SE, catheterization for bladder management. cloacal malformations. J Urol 1988; 140: Ransley PG. Renal outcome in patients Urinary continence is achievable in most 1207–13 with cloaca. J Urol 2002; 167: 2548–51 patients, but some will require bladder/ 7 Hendren HA. Cloacal malformations: 18 Warne SA, Wilcox DT, Ransley PG. bladder neck reconstruction to do so. TUM Experience with 105 cases: J Ped Surg Long-term urological outcome of patients has emerged as the primary method to 1992; 27: 890–901 presenting with persistent cloaca. J Urol mobilize the vagina, but the long-term effects 8 Pena A. Anorectal malformations. Semin 2002; 168: 1859–62 on the lower tract are awaited. Renal Pediatr Surg 1995; 4: 35–47 19 Pena A, Kessler O. Posterior cloaca: a deterioration may occur in this population 9 Hendren HA. Urogenital sinus and unique defect. J Urol 1998; 33: 407–12 and therefore lifelong surveillance is cloacal malformations. J Ped Surg 1996; 5: 20 Gearhart J, Rink RC, Mouriquand PDE mandatory. In particular, patients with a 72–9 eds. Appendix. In Pediatric Urology 2001: solitary kidney appear to be at high risk of 10 Hendren HA. Management of cloacal 1038 renal insufﬁciency. malformations. J Ped Surg 1997; 6: 217–7 21 Alexander F, Kay R. Cloacal anomalies. 11 Hendren HA. Cloaca, the most severe Role of vesicostomy. J Ped Surg 1994; 29: CONFLICT OF INTEREST degree of imperforate anus. Ann Surg 74–6 1998; 228: 331–6 22 Adams MC, Ludlow J, Brock JW, Rink None declared. 12 Allen TA, Hussman DA. Cloacal RC. Prenatal urinary ascites and anomalies and other urorectal septal persistent cloaca: risk factors for poor REFERENCES defects in female patients: a spectrum of drainage of urine or meconium. J Urol anatomical abnormalities. J Urol 1991; 1998; 160: 2179–81 1 Pena A. The surgical management of 145: 1034–9 persistent cloaca: Results in 54 patients 13 Pena A. Total urogenital sinus Correspondence: Richard C. Rink, Riley treated with a posterior sagittal approach. mobilization-an easier way to repair Hospital for Children, 702 Barnhill Drive, J Ped Surg 1989; 24: 590–8 cloacas. J Ped Surg 1997; 32: 263–7 # 4230, Indianapolis, IN 46202, USA. 2 Kay R, Tank ES. Principles of 14 Rink RC, Pope JC, Kropp BP, Smith e-mail: [email protected] management of the persistent cloaca in ER Jr, Keating MA, Adams MC. the female newborn. J Urol 1977; 117: Reconstruction of the high urogenital Abbreviations: TUM, total urogenital 102–4 sinus: early perineal prone approach mobilization.

An objective assessment of the results of hypospadias surgery

MOSCHOS VERVERIDIS, ALAN P. DICKSON and DAVID C.S. GOUGH Paediatric Urology, Royal Manchester Children’s Hospital, Pendlebury, Manchester, UK Presented at the XIV Annual Meeting of the European Society of Paediatric Urology, Madrid, 19–22 March 2003 Accepted for publication 14 March 2005

OBJECTIVE asked to grade cosmesis as poor, and overall appearance 0.62 (0.24–1.0) unsatisfactory, satisfactory or very good (P = 0.01) points higher for the Snodgrass To compare the cosmetic result of tubularized (points 1–4) for each of the following aspects repair. The Snodgrass technique was more incised-plate urethroplasty (Snodgrass of penile appearance: meatus, glans, shaft and effective in producing a vertically orientated method) with that of two established overall appearance. Photographs were taken meatus (87.5%) than the Mathieu and techniques, the meatal-based flap and onlay in a standard way, with a standard distance, Duckett onlay repairs (37.5%; P = 0.009). island flap repair. lighting and two views, one of the dorsal surface and one ventral, for each patient. CONCLUSION SUBJECTS AND METHODS Signed written consent for the study was obtained from each family. The Snodgrass technique, as assessed by this Photographs of the penis after hypospadias panel, had a better cosmetic outcome than repair in 32 boys were assessed by a panel of RESULTS the Mathieu and Duckett onlay island flap five independent health professionals, repairs. The assessment of cosmesis in including four surgeons with variable The mean assessment score for any aspect of hypospadias surgery is potentially more paediatric urological experience and a urology cosmesis was significantly higher for the objective when several health professionals, nurse. Twenty patients had a distal and 12 a Snodgrass technique (P < 0.05). The mean not involved in the surgery, compared the proximal meatus. The Snodgrass technique score (95% confidence interval) for the various methods of repair. was applied by one paediatric urologist meatus was 0.76 (0.4–1.1) points higher for for either distal (10) or proximal (six) the patients with a Snodgrass repair than KEYWORDS hypospadias. A Mathieu repair was used for those with a Mathieu or onlay island flap distal hypospadias (10) and an onlay preputial repair (P = 0.002). Correspondingly, the values hypospadias, tubularized incised-plate island flap for proximal hypospadias (six) by a for the glans were 0.67 (0.38–0.97) urethroplasty, meatal-based flap, onlay island second paediatric urologist. The panel was (P = 0.003), shaft 0.42 (0.16–0.69) (P = 0.01) flap

INTRODUCTION the technique was later recommended for Our aim was to evaluate whether tubularized- proximal [5] and re-operative [6] hypospadias incised plate urethroplasty has better The traditional goals of hypospadias repair. cosmetic results than two other established surgery have been focused on the techniques. functional aspects of the repair, which are a Most reviews which measure the cosmetic straight penis with a glanular meatus to outcome of hypospadias surgery have been permit voiding while standing, and to allow based on assessing the views of surgeons SUBJECTS AND METHODS effective coitus in adulthood [1]. In recent involved in the managing the patients. The years several techniques have been proposed patients’ view on the results of older A panel of five health professionals assessed aiming to improve cosmesis, which is the techniques was analysed recently; there was a the photographs of the penis after principal aim of hypospadias surgery in distal significant disparity of opinion between hypospadias repair in 32 boys. The operations hypospadias. Snodgrass initially proposed patients and surgeons about the cosmetic were performed by two paediatric urologists tubularized-incised urethral plate result [7]. In general, there is a lack of who applied different techniques for urethroplasty as a surgical method of objective assessment of the cosmetic comparable groups of patients. The Snodgrass repairing distal hypospadias [2]. This results of hypospadias repair by independent technique was used by one surgeon for either method has become popular, as it claims health professionals who have not been distal (10) or proximal (six) hypospadias. A to produce a vertically orientated, normal- involved in the patients’ care. No direct Mathieu repair was used by the second looking meatus which is cosmetically comparison has been attempted between the surgeon for distal hypospadias (10), and an superior to other techniques [3]. The Snodgrass repair and other established onlay preputial island flap for proximal complication rate was acceptable [4], and techniques. hypospadias (six). Photographs of each

VERVERIDIS ET AL.

patient were taken in a standard way, with a TABLE 1 The mean assessment scores for the S and M/D groups standard distance, lighting and two views, one of the dorsal surface and one of the Meatus Glans Shaft Overall ventral. Signed written consent for the study Assessor S M/D S M/D S M/D S M/D was obtained from each family. The visual presentation was in one sitting lasting ª1 h, 1 3.56 2.94 3.43 2.88 3.38 2.88 3.44 2.88 in which slide images were projected onto a 2 3.00 2.44 3.13 2.69 2.81 2.67 3.06 2.88 standard lecture-theatre screen. The slides 3 3.38 2.38 3.25 2.56 2.94 2.38 3.06 2.38 were presented for assessment in two 4 2.81 2.25 2.94 2.31 2.88 2.60 2.88 2.31 consecutive groups of distal and proximal 5 3.63 2.56 3.63 2.56 3.53 2.87 3.64 2.57 hypospadias repair. The sequence in each group was according to alphabetical order of the patients’ names.

The panel (three men and two women) Feature Mean difference (95% CI) [SD]PTABLE 2 included three paediatric surgeons with Meatus 0.76 (0.45–1.10) [0.25] 0.002 Comparison between the S variable experience, an adult urologist and a Glans 0.67 (0.38–0.97) [0.24] 0.003 and M/D onlay techniques urology nurse. They had not been involved in Shaft 0.42 (0.16–0.69) [0.21] 0.01 the clinical management and were not aware Overall 0.62 (0.24–1.00) [0.30] 0.01 of the identity and type of repair of the individual patients. The aspects of penile appearance that were assessed were the meatus, glans, shaft and overall appearance. no chordee; the median age at surgery was Mathieu repair (3 days) than after Snodgrass Cosmesis was graded as poor, unsatisfactory, 23 (15–27) months. A dripping stent was left repair (6 days, range 4–7; P < 0.05). There was satisfactory or very good (points 1–4). The in the urethra for 2–3 days. A preputial onlay no difference between the groups in proximal panel was also asked to guess which type of island flap technique, as described by Duckett hypospadias repair (median catheterization repair was used in each case. Finally, one of [9], was used for mid or proximal penile 7 days, range 5–10). The median (range) the authors assessed the incidence of a hypospadias; the median age at surgery was duration of follow-up (and time of vertical slit-like meatus in each group. 33 (19–50) months. A dripping urethral stent photography) was 21 (1–120) months and remained for 7 days with additional proximal not significantly different between the The number of patients included in each diversion via a balloon suprapubic catheter. groups. group was limited because the Snodgrass The technique for constructing the external technique has only recently been applied in urethral meatus and glansplasty was identical The mean assessment score of the panel for our hospital. Consequently this number was in the patients with the meatal-based and each cosmetic variable is shown in Table 1; defined by the availability of hypospadias island-flap repairs. score for any aspect of cosmesis was cases with the most recent type of repair. significantly higher for the Snodgrass Twenty-seven patients who had had incised- The results are expressed as the mean, technique (Table 2). Examples of photographs plate urethroplasty (Snodgrass technique) median, range or 95% CI, with study groups are shown in Figs 1–6. (The number of points [2,3] from 1998 to 2001 were invited for compared using a paired sample t-test corresponds to the average ranking by the review in the clinic. Sixteen of them (group S) (means of scoring points in various aspects of panel). presented at the follow-up to have the cosmesis), Fisher’s exact test (incidence of slit- photographs taken (median age at operation like meatus) and Mann–Whitney U-test The incidence of vertically orientated meatus, 24 months, range 16–45) after distal (duration of urethral stent and follow-up), as assessed by one of the authors, was hypospadias with no chordee, and 33 with P < 0.05 considered to indicate significantly higher (P = 0.009) in group S (23–42) months in those with a mid or significance. (88%) than in group M/D (38%). The proximal shaft meatus. A silicone balloon configuration of the meatus in the remaining catheter or feeding tube was left for 5–7 days patients was stenotic, circular or irregular. to stent the repair. RESULTS Inflammation and oedema from a recent repair contributed to the irregularity of the The patients who had a Mathieu or Duckett There was no difference in the age at primary meatus in two cases in the M/D group. The onlay flap repair (group M/D) were selected operation among the groups. Data on the transversely lying, mouth-like meatus which prospectively and consecutively as they preoperative configuration of the urethral is commonly reported after a Mathieu repair presented for their follow up in the urology plate were not available in most of cases. Four was not found in any patient. outpatient clinic over 6 months (January to patients (two in each group) of the proximal June 2002). The recruitment of patients in this variety had severe chordee and two (both The results of the panel’s guess about which group stopped when there were as many as in with a Duckett onlay repair) had a Nesbitt technique was used for each patient are group S. A meatal-based flap technique, as procedure. All patients were circumcised. The shown in Table 3. The higher percentage of described by Mathieu [8], was used for median duration of urethral catheterization successful guesses by assessors 1, 2 and 3 subcoronal and distal penile hypospadias with for distal hypospadias surgery was less after a implies that the general appearance of penis

OBJECTIVE ASSESSMENT OF THE RESULTS OF HYPOSPADIAS SURGERY

FIG. 1. Snodgrass repair for distal hypospadias (one FIG. 3. Snodgrass for distal hypospadias (less than FIG. 5. Snodgrass for proximal hypospadias of the best results, 3.6 points) satisfactory, 2.8 points) (unsatisfactory, 2 points)

FIG. 2. Mathieu repair (one of the best results, 3.3 FIG. 4. Mathieu repair (unsatisfactory, 2 points) FIG. 6. Duckett onlay (less than satisfactory, 2.5 points) points)

and, in particular, the conﬁguration of the in the few patients in whom the Snodgrass DISCUSSION meatus, is distinctly different in most cases, to repair produced an abnormal or stenotic permit recognition of the technique. Most of meatus. The failure of assessor 4 (a nurse) to Previous studies have stressed the advantage the wrong guesses applied to the cases with have a successful guess and the total inability of the Snodgrass repair in producing a M/D onlay repairs which produced a vertical of assessor 5 to guess are ascribable to their vertically orientated, slit-like normal-looking meatus, giving the impression of a Snodgrass vague knowledge of the type of techniques meatus [2,5,10]. Nevertheless, most reviews of technique. Some of the failures also occurred under consideration. the outcome of hypospadias surgery were by

VERVERIDIS ET AL.

inherent quality of the procedures. This clearly TABLE 3 The panel’s guess (%) as to the method of repair is not feasible. Most surgeons are fully committed to certain types of repair and they Assessors Successful Wrong Unable to judge are not prepared to do anything other than 1682210 what in their hands they have found to be 2591328 safe and effective. 3711910 4191959 In the present pilot study assessing whether a 500100 surgeon or other health professional in a panel can tell the difference in the cosmetic outcome between the techniques under consideration, incised-plate urethroplasty the surgeons who did the repairs. We the surgeon. The opinion of patients and had a better cosmetic result than the two conﬁrmed the superiority of meatal parents, although far from objective, is of older techniques, but we cannot draw general appearance of incised-plate urethroplasty, paramount importance when assessing conclusions. A method of assessing cosmetic using an objective method of assessment. In outcome. The present patients were too outcome in hypospadias surgery is proposed. addition to the meatus, the cosmesis was young to comment on appearance. On direct rated higher in the Snodgrass repair for the questioning at the follow-up all parents were other aspects of cosmesis (glans and shaft). satisﬁed with the appearance. ACKNOWLEDGEMENTS

The Mathieu and Duckett onlay techniques The issue of stricture after the Snodgrass The authors express their thanks to Mr Aivar can produce a vertical meatus in about a third technique may be a problem in the long term, Bracka for his invaluable help for the of patients. A deep cleft in the urethral plate is considering that most patients with this construction of the study, to the departments most likely to lead to a vertical meatus, complication after various types of of Medical Illustration of Royal Manchester irrespective of the technique. Although the hypospadias surgery have been reported to Children’s Hospital and Wythenshaw Hospital, meatus was circular or irregular in most cases ultimately require open urethroplasty [15]. to Mr Andy Vail for assistance with statistical in the Mathieu group, no case of horizontally The concern that incising the urethral plate analysis and to the State Scholarship orientated configuration was identified. This could cause scarring and stricture led to the Foundation of Greece (IKY) for funding the implies that it is technically possible to avoid application of a dorsal inlay graft to the research. this complication, which is regarded as the defect [16]. Others have recommended a main disadvantage of this technique. In 1989, more careful selection of patients and Rich et al. [11] modified the meatal-based flap modifications of the Snodgrass procedure to CONFLICT OF INTEREST and onlay island flap procedures by hinging reduce the complication rate in distal the urethral plate, with no increased hypospadias [17]. We showed previously that None declared. morbidity and a significant improvement in the Mathieu repair is safe and reliable for meatal cosmetic results. Modifications of the correcting distal hypospadias with no Mathieu repair, by incising the urethral plate, chordee. It has the advantage of a REFERENCES have recently been claimed again to improve complication rate of <5% and can be the cosmetic result [12,13]. A longer follow- achieved with limited hospital stay and 2 days 1 Baskin LS, Duckett JW. Hypospadias. In up is necessary to show that these of postoperative urinary drainage [18]. The Stringer MD, Oldham KT, Mouriquand modifications do not increase the incidence of Snodgrass repair required longer urethral PDE, Howard ER eds, Pediatric Surgery and stricture. stenting afterward in the present study. Urology: Long Term Outcomes. Chapt 45. Nevertheless, in a recent report, the absence Philadelphia: WB Saunders Co, 1998: The nonspecialist members of the panel, a of a urethral catheter after incising the 559–67 nurse and a surgeon with no experience with urethral plate in distal hypospadias did not 2 Snodgrass W. Tubularized incised plate the techniques under consideration, were seem to increase the morbidity [19]. urethroplasty for distal hypospadias. least likely to guess the type of repair from the |J Urol 1994; 151: 464–5 appearance alone. A study which evaluated We think that an objective evaluation of 3 Snodgrass W, Koyle M, Manzoni G, the view of the patients on various aspects of appearance is important before concluding Hurwitz R, Caldamone A, Erlich R. penile appearance after hypospadias repair that a new technique is better than previous Tubularized incised plate hypospadias by older techniques showed that the ones. An ideal study would be a multicentric repair. Results of a multicenter configuration of the meatus was a motive for randomized prospective trial involving several experience. J Urol 1996; 156: 839–41 improvement in only a very few (1.7%) [14]. surgeons. The greatest obstacle in such a 4 Snodgrass W. Does tubularized incised Other aspects of cosmesis, like circumcision, study is the need for participating surgeons to urethral plate hypospadias repair create scars and penile size, were much more be prepared to use both surgical techniques neourethral strictures? J Urol 1999; 162: common causes of concern (11.2%, 10.3% in randomized fashion, otherwise any 1151–61 and 13.8%, respectively). This implies that the differences in the results might merely reflect 5 Snodgrass W, Koyle M, Manzoni G, appearance of the meatus may not be as differences in the standard of surgical Hurwitz R, Caldamone A, Erlich R. significant for the patient or the parent as for technique, rather than differences in the Tubularized incised plate hypospadias

OBJECTIVE ASSESSMENT OF THE RESULTS OF HYPOSPADIAS SURGERY

repair for proximal hypospadias. J Urol incision/hinge of the plate. BJU Int 2002; Correspondence: David C.S. Gough, 1998; 159: 2129–31 89 (Suppl. 2): 75 Department of Paediatric Urology, Royal 6 Retic AB, Borer JG. Primary and 14 Mureau MA, Slijper FM, Nijman RJ, Manchester Children’s Hospital, Hospital reoperative hypospadias repair with the Van der Meulen JC, Verhulst FC, Road, Pendlebury, Manchester M27 4HA, UK. Snodgrass technique. World J Urol 1998; Slob AK. Psychosexual adjustment of e-mail: [email protected] 16: 186–91 children and adolescents after different 7 Mureau MA, Slijper FM, Slob AK, types of hypospadias surgery: a norm Verhulst FC, Nijman RJ. Satisfaction related study. J Urol 1995; 154: 1902– NOTE FROM THE EDITOR with penile appearance after hypospadias 7 surgery. the patient and the surgeon’s 15 Duel BP, Barthold JS, Gonzales R. Unfortunately and sadly, between acceptance view. J Urol 1996; 155: 703–6 Management of urethral strictures after of this paper and its publication, David Gough 8 Mathieu P. Traitement en un temps hypospadias repair. J Urol 1998; 160: has died, aged only 57, after a very short de l’hypospadias balanique et 170–1 illness. He was a most enthusiastic person juxtabalanique. J Chir 1932; 39: 481 16 Kolon TF, Gonzales ET. Dorsal inlay graft who brought this characteristic to his chosen 9 Duckett JW. The island flap technique for for hypospadias repair. J Urol 1998; 159: speciality of paediatric urology. He developed hypospadias repair. Urol Clin North Am A149, 41 a special expertise in congenital abnormalities 1981; 8: 513–59 17 Jayanthi VR. The modified Snodgrass of the lower urinary tract, particularly bladder 10 Holland AJA, Smith GHH, Cass DT. hypospadias repair-reducing the risk of exstrophy. He was an enthusiastic proponent Clinical review of the Snodgrass fistulae and meatal stenosis. BJU Int 2002; and founder member of the British hypospadias repair. Aust NZJ Surg 2000; 89 (Suppl. 2): 76 Association of Paediatric Urologists, 70: 597–600 18 Gough DCS, Dickson A, Tsang T. established in 1992. He was also a Board 11 Rich MA, Keating MA, Snyder HM, Mathieu hypospadias repair: Member of the European Society of Paediatric Duckett JW. Hinging the urethral plate in postoperative care. In Thuroff JW, Surgeons. A graduate of Liverpool University, hypospadias meatoplasty. J Urol 1989; Hohenfellner M eds, Reconstructive he subsequently took up his appointment at 142: 1551–3 Surgery of the Lower Urinary Tract in the Royal Manchester Children’s Hospital. He 12 Ali T, Porkolab Z. Modified Snodgrass Children. Oxford: Isis Medical Media Ltd, was a very fine surgeon who made important and Mathieu technique for treatment of 1995: 55–8 contributions to research and the literature, hypospadias. BJU Int 2002; 89 (Suppl. 2): 19 Leclair MD, Camby C, Hetet JF, Garcia and was a first-rate teacher. He will be greatly 75 S, Heloury Y. Is urethral stent necessary missed. 13 Soliman SM. A naturally appearing after tubularized incised-plate glanular meatus after a Mathieu urethroplasty? BJU Int 2003; 91 (Suppl. JOHN M. FITZPATRICK procedure combined with Snodgrass 1): 64 Editor-in-Chief

Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

PHILIPPOS A. ANDROULAKAKIS, DIMITRIOS K. KARAMANOLAKIS, GEORGIOS TSAHOURIDIS, ANTONIOS A. STEFANIDIS and ILIAS PALAEODIMOS Department of Paediatric Urology, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece Accepted for publication 2 February 2005

OBJECTIVE measurement of urine before and after significant reduction of their postvoid voiding, a urodynamic examination with residual urine. To investigate whether myogenic bladder simultaneous multichannel recording of decompensation in patients treated for pressure, volume and flow relationships congenital posterior urethral valves (PUV, the during the filling and voiding phases, coupled CONCLUSION most serious cause of infravesical obstruction with video-cystoscopy at least twice. The in male neonates and infants) may be mean (range) follow-up was 9.3 (6–17) years. Despite early valve ablation, a large secondary to bladder neck obstruction, as proportion of boys treated for PUV have despite prompt ablation of PUV these patients RESULTS gradual detrusor decompensation, which may can have dysfunctional voiding during later be caused by secondary bladder neck childhood or adolescence, the so-called ‘valve Urodynamic investigation showed myogenic obstruction leading to obstructive voiding bladder syndrome’. failure with inadequate bladder emptying in and finally detrusor failure. Surgical or 10 patients; five with myogenic failure also pharmacological intervention to improve PATIENTS AND METHODS had unstable bladder contractions. On video- bladder neck obstruction may possibly avert cystoscopy the posterior bladder neck lip this course, but further studies are needed to The study comprised 18 boys (mean age appeared elevated in all patients but in those validate this hypothesis. 14 years, range 6.2–18.5) who had had with myogenic failure it was strongly successful transurethral ablation of PUV suggestive of hypertrophy, with evidence of between 1982 and 1996, and had completed a obstruction. At the last follow-up one patient KEYWORDS follow-up which included serial assessment with myogenic failure who had had bladder of serum creatinine, completion of a standard neck incision and four others who were being posterior urethral valves, valve bladder, voiding diary, ultrasonography with treated with a-adrenergic antagonists had a urodynamics, puberty

INTRODUCTION examine this hypothesis, we retrospectively cooperative; this is why no urodynamic reviewed a cohort of adolescent and pubertal studies were used before the age of 5 years. PUV have a broad spectrum of clinical boys who previously had had PUV ablated; presentation; currently, most present in utero these boys had had many urodynamic and The diagnosis of PUV was based on UTI in 10 with a variable effect on the upper and lower video-endoscopic evaluations. patients, a palpable abdominal mass in three, urinary tract [1–4]. Their effect is generally electrolyte imbalance with dehydration in but not specifically related to the severity of three and prenatal ultrasonography (US) in valvular obstruction. The effect on bladder PATIENTS AND METHODS two. At diagnosis, seven patients had function may be evident long after valve unilateral (five) or bilateral (two) VUR (nine ablation, leading to a variety of abnormal This study included 18 patients treated for ureteric units); there was moderate urodynamic findings, with a tendency to PUV in our department between 1982 and hydronephrosis in 10 patients on the basis of myogenic decompensation as these boys 1992 (mean age 14 years, range 6.2–18.5; renal-bladder US. Treatment consisted of reach adolescence and adulthood [5,6]. De Table 1) and who fulfilled the following endoscopic valve ablation in all patients. The Gennaro et al. [6] suggested that myogenic criteria: early diagnosis (<3 months old), serum creatinine at the initial presentation decompensation develops secondary to treatment started and continued in our was compromised in 10 patients (>88 mmol/L) chronic increased detrusor pressure when hospital, and at least a 6-year follow-up and it was normal in the remaining eight. younger. This progressive deterioration leads (mean 9.3, range 6–17) with at least two to poor bladder emptying with large postvoid urodynamic and video-cystoscopic studies All patients were evaluated throughout their residual volumes (PVRs). In some cases during their routine follow-up evaluations. follow-up according to the following protocol this deterioration may be secondary to Urodynamic studies were part of our follow- used in our department: (a) At 2 months after obstruction at the level of the bladder neck. To up protocol, provided the child was treatment; voiding cysto-urethrography and

BLADDER-NECK OBSTRUCTION IN PUV

addition of a 99mTc-DMSA scan in the presence Bcap associated with a P during TABLE 1 The demographic characteristics of the max detmax of a hypo-functioning kidney on the dynamic voiding of < 20 cmH O, inability to generate a patients 2 scan. (d) At 5 years after treatment, i.e. at the sustained detrusor contraction and a PVR of age of ≥5 years, with a urodynamic study, >15% of Bcap [11]. Age at last max coupled with video-cystoscopy, followed by at Age at valve urodynamic and least one further urodynamic and video- At the last follow-up four boys were in ablation, videocystoscopic cystoscopic study within the follow-up after chronic renal failure, two had already received No. months follow-up, years an interval of 1 year. No patient was treated a kidney transplant and the other 12 had 1 2 12.7 with anticholinergics before or after their normal renal function (plasma creatinine 2 1.2 11.3 urodynamic investigation. <88 mmol/L). VUR had resolved in six of nine 3 3 8.0 ureters, one ureter had been successfully 4 3 15.6 Urodynamics was conducted using an Etude reimplanted and two were still refluxing. 53 10 (Dantec, Denmark) multichannel apparatus, 63 18 and consisted of free voiding uroflowmetry 7 3 12.2 with measurement of the PVR and 8 0.5 6.1 cystomanometry with a second measurement RESULTS 9 4 16.3 of the PVR. The bladder was filled at a 10 1 12.9 constant perfusion rate of 5 mL/min with Four patients had two, four had three and the 11 2 8.9 0.9% saline at room temperature. The use of remaining 10 more than three urodynamic 12 2 9.1 microtip transducers on 7 F catheters allowed and video-cystoscopic studies. There was 13 0.3 9.6 continuous recording of abdominal and some urodynamic abnormality in all the 14 3 18.4 bladder pressures. patients; an unstable bladder in four (three 15 3 16.3 after the follow-up), a low BC in five and 16 1.3 13.7 The following variables were assessed: a free myogenic failure in nine; one patient 17 1 12.9 voiding uroflow which was analysed with instability and hypercontractility 18 1.4 11.6 according to the nomogram of Mattson and developed myogenic failure with detrusor Spanberg [7]; PVR obtained by immediate decompensation during the follow-up, and US after voiding; uninhibited detrusor thus 10 had myogenic failure with inadequate contractions; maximum bladder capacity bladder emptying. FIG. 1. Videocystoscopic view of the bladder neck in (Bcapmax); bladder compliance (BC); maximum a boy with myogenic failure. The bladder neck is very detrusor storage pressure (Pdetmax); and During videocystoscopy the posterior lip of thick and fixed in a semi-closed position. maximum flow rate, during the voiding phase, the bladder neck appeared elevated in the using the standards sponsored by the patients with no myogenic failure, but in the European Association of Urology Guidelines 10 (9 + 1) boys with myogenic failure there on Paediatric Urology [8]. was videocystoscopic evidence strongly suggestive of secondary bladder neck

The Bcap expected for age (BcapE) was obstruction, i.e. the bladder neck was overall calculated using Koff’s formula, ((age in very thick and ﬁxed in a semi-closed position

years ¥ 30) + 30)) mL; Bcapmax was measured (Fig. 1). One of these boys was treated with

and compared to BcapE in children aged transurethral bladder neck incision (BNI) and £12 years, and in those aged >12 years to four were given a1-adrenergic antagonist 450 mL [9]. PVR was considered pathological medication (tamsulosin). When re-evaluated,

if >15% of Bcapmax during the ﬁlling phase of their bladder neck appeared more open, and the cystomanometric procedure. The BC was they felt their ﬂow had improved, although

calculated by dividing the volume by Pdet at there were no formal measurements of ﬂow several intervals throughout ﬁlling. We rate. In the patient after BNI, the PVR was

graded BC as proposed by Misseri et al. [10], <15% of Bcapmax and in the other four on i.e. impaired when the volume/pressure tamsulosin it decreased but not to <15% of

relationship was <30 mL/cmH2O and not Bcapmax.

when it was >30 mL/cmH2O at Bcapmax. if necessary repeat valve ablation (four Detrusor instability was defined as an Two patients with a low-compliance bladder patients). (b) Regular assessment of serum uninhibited contraction of any magnitude who had a nonfunctioning kidney caused by creatinine, blood pressure, urine culture and causing incontinence or significant urgency, unilateral renal dysplasia had a nephrectomy urine analysis. (c) At 1 year after treatment, or any uninhibited contraction of >10 cmH2O and ureteric-bladder augmentation, after with renal/bladder US, IVU or dynamic 99mTc- during the filling phase, even with no which they used clean intermittent DTPA scan and repeat voiding cysto- leakage [10]. catheterization; in these two patients, US urethrography in the presence of initial VUR. showed that the hydronephrosis initially These investigations were repeated thereafter Myogenic failure (overdistended bladder) was present had resolved. There was no as dictated by each patient’s course, with the diagnosed when there was an increased correlation between the type of urodynamic

ANDROULAKAKIS ET AL.

disorder with renal function, the presence or myogenic failure in three (6%), all findings, seem to support this latter view. absence of VUR or hypertension. anticholinergically induced. In the present Although the finding of a prominent posterior study there was myogenic failure in nine of 18 lip of the bladder neck was common in all the patients but five of them also had evidence of patients, boys with myogenic failure had DISCUSSION bladder instability, thus leaving only four with anatomical evidence of genuine bladder pure myogenic failure. Others [5,25,30] neck obstruction (Fig. 1). Despite video- Even after prompt valve ablation, a significant suggested that the pattern of urodynamic urodynamics not being included in the proportion of boys with a history of PUV disorder may change with age, with a present study, the endoscopic evidence of not present during late childhood and tendency to bladder hypocontractility and just a prominent but also totally hypertrophic, adolescence with voiding dysfunction and detrusor decompensation as patients with a semi-closed and fixed bladder neck permits renal failure [12,13]. The reported incidence of history of PUV reach puberty, hence the the hypothesis that voiding under such voiding dysfunction in patients treated for incidence of myogenic failure may be greater circumstances may be obstructive at the PUV is 13–38% [12,14–22]. In a previous as patients approach adulthood. level of bladder neck, and cause detrusor study, compiling the results of seven previous decompensation by a prolonged and series of PUV, an average rate of 21% was However, a more crucial question is the increased bladder outlet resistance. That BNI reported [23]. Persistent bladder dysfunction possible cause leading to bladder (one patient) or tamsulosin (four) had a has been implicated as a cause of decompensation. In older studies the theory positive effect on bladder emptying, deterioration of the upper urinary tract and most widely accepted was that detrusor substantially lowering the PVR and changing kidney function, and this has lead to the instability remaining after valve treatment the bladder neck appearance, supports of urodynamic investigation of boys with a has an obstructive effect on voiding, from the this view, and is in accordance with the history of PUV as part of their regular follow- attempt to maintain continence by tightening observations of Misseri et al. [10], who also up [1]. In 1979, Bauer et al. [1] reported the pelvic floor and external sphincter during treated three boys with secondary bladder retrospectively on the specific urodynamic the unstable contractions [29]. Another neck obstruction with tamsulosin. findings in nine boys with voiding possible explanation for progressive bladder Furthermore, hydronephrosis decreased in disturbances after valve treatment, and soon overdistension and decompensation could be three of the five patients, but the lack of after the concept of the ‘valve bladder the constant presence of significant pseudo- urodynamic data in these patients after syndrome’ emerged to define the spectrum residual urine caused by defective urine treatment is a limitation of the study. of urodynamic disorders found in these concentration and the production of large patients [2,3]. urine volumes, gradually leading to bladder However, few patients have been treated and overdistension [3,28]. to validate our hypothesis we intend to report It was suggested that the different patterns of further results of a1-adrenergic antagonist in urodynamic disorders found in patients However, DeGennaro et al. [26] found no clear more boys treated for PUV with secondary treated for PUV are variations of the same relation between bladder function and bladder neck obstruction and myogenic basic bladder dysfunction. Myogenic failure impairment of renal function, and the present failure, with detailed urodynamic data before is one of the three major urodynamic results also show no correlation between the and after treatment. If a1-adrenergic abnormalities in these patients [24–26], but type of urodynamic disorder and kidney antagonists are effective in improving the definition of myogenic failure and its function. In their retrospective study, Misseri uncoordinated voiding in patients with a reported incidence vary greatly among studies et al. [10] expressed the view that myogenic history of PUV, their use after valve ablation [27–29]. Misseri et al. [10] defined myogenic failure is unlikely to develop when patients could possibly avert myogenic failure and failure as either an acontractile detrusor or with abnormal urodynamic findings are bladder decompensation. one that cannot generate a sustained treated with anticholinergics when young, contraction sufficient to empty the bladder but three of their patients developed CONFLICT OF INTEREST adequately. They considered a PVR > 30% of myogenic failure while on anticholinergics.

Bcapmax to be significant and indicative of The authors concluded that it was iatrogenic, None declared. myogenic failure, but others think the secondary to anticholinergic therapy threshold should be > 20% [11]. In the present administered in boys treated for PUV who had REFERENCES study we considered 15% of Bcapmax as the symptoms of day-time wetting resulting from critical limit for defining significant PVR. unstable bladder contractions, rather than a 1 Bauer SB, Dieppa RA, Labib KB et al. The However, apart from a critical threshold of preordained consequence of valve disease; bladder in boys with posterior urethral PVR for defining myogenic failure, we also this should not be overlooked. However, they valves: a urodynamic assessment. J Urol think that urodynamic evidence of poor also acknowledged that in some boys detrusor 1979; 121: 769–73 detrusor contractility, reflected in a Pdetmax of decompensation with time could be a 2 Glassberg KI, Hendren WH, Tanagho EA

<20 cmH2O during voiding, is an important consequence of some persistent obstructive et al. Persistent ureteral dilatation criterion for its diagnosis [10]. process secondary to bladder neck dyskinesia, following valve resection. Dialogues where a very thickened and ﬁxed bladder neck Pediatr Urol 1982; 5: 2–8 The incidence of myogenic failure and bladder hinders the ﬂow of urine. 3 Glassberg KI, Schneider M, Haller JO decompensation varies among studies. et al. Observations on persistently dilated Misseri et al. [10], in their retrospective The present videocystoscopic results, when ureter after posterior urethral valve uncontrolled study of 51 patients, noted correlated with the respective urodynamic ablation. Urology 1982; 20: 20–8

BLADDER-NECK OBSTRUCTION IN PUV

4 Hendren WH. Posterior urethral valves in 14 Atwell JD. Posterior urethral valves in the 25 De Gennaro M, Capitanucci ML, Silveri boys. A broad clinical spectrum. J Urol British Isles: a multicenter B.A.P.S. review. M et al. Detrusor hypocontractility 1971; 106: 298 J Pediatr Surg 1983; 18: 70–4 evolution in boys with posterior urethral 5 Holmdahl G, Sillen U, Bachlard M et al. 15 Cass AS, Stephens FD. Posterior urethral valves detected by pressure flow analysis. The changing urodynamic pattern in valve valves. Diagnosis and management. J Urol J Urol 2001; 165: 2248–52 bladder during infancy. J Urol 1995; 153: 1974; 112: 519–25 26 De Gennaro M, Capitanucci ML, 463–7 16 Churchill BM, Krueger RP, Fleisher MH Mosiello G, Gatti C, Lais A. Urodynamic 6 De Gennaro M, Capitanucci ML, et al. Complications of posterior urethral development to bladder hypocontractility Mosiello G et al. The changing surgery and their prevention. Urol Clin in boys with PUV does not depend on urodynamic pattern from infancy to North Am 1983; 10: 519–30 renal functional impairment. BJU Int adolescence in boys with posterior 17 Egami K, Smith ED. A study of the 2003; 91 (Suppl 1): E41 urethral valves. BJU Int 2000; 85: 1104–8 sequelae of posterior urethral valves. 27 Jaureguizar E, Lopez Pereira P, Martinez 7 Mattson S, Spanberg A. Urinary flow in J Urol 1982; 127: 84–7 Urrutia MJ et al. Does neonatal healthy schoolchildren. Neurourol 18 Johnston JH, Kulatilake AE. The pyeloureterostomy worsen bladder Urodynam 1994; 13: 281–96 sequelae of posterior urethral valves. Br J function in children with posterior 8 Riedmiller H, Androulakakis P, Beurton Urol 1971; 43: 743–8 urethral valves? J Urol 2000; 164: 1031–3 D, Kocvara R, Köhl U. EAU Guidelines on 19 Kurth K-H, Alleman EJR, Schroder FH. 28 Koff SA, Mutabagani KH, Jayanthi Pediatric Urology. Chapter 11. EAU Major and minor complications of VR. The valve bladder syndrome. Guidelines, EAU Healthcare Office, 2001: posterior urethral valves. J Urol 1981; pathophysiology and treatment with 47–8 126: 517–9 nocturnal bladder emptying. J Urol 2002; 9 Koff S. A: Estimating bladder capacity in 20 Scott JES. Management of congenital 167: 291–7 children. Urology 1983; 21: 248 posterior urethral valves. Br J Urol 1985; 29 Glassberg KI. The valve bladder 10 Misseri R, Combs AJ, Horowitz M et al. 57: 71–7 syndrome: 20 years latter. J Urol 2001; Myogenic failure in posterior urethral 21 Williams DI, Whitaker RH, Barratt TM 166: 1406–14 valve disease: real or imagined? J Urol et al. Urethral valves. Br J Urol 1973; 45: 30 Holmdahl G, Sillen U, Hanson E et al. 2002; 168: 1844–8 200–10 Bladder dysfunction in boys with 11 Peters CA, Bolkier M, Bauer SB et al. The 22 Whitaker RH, Keeton JE, Williams DI. posterior urethral valves before and after urodynamic consequences of posterior Posterior urethral valves: a study of puberty. J Urol 1996; 155: 694–8 urethral valves. J Urol 1990; 144: 122–6 urinary control after operation. J Urol 12 Parkhouse HF, Barratt TM, Dillon MJ 1972; 108: 167–71 Correspondence: Dimitrios K. Karamanolakis, et al. Long-term outcome of boys with 23 Peters CA, Bauer SB. Evaluation and Odos Abydou 142, 15772 Ano Ilisia – posterior urethral valves. Br J Urol 1988; management of urinary incontinence Zografou, Athens, Greece. 62: 59–62 after surgery for posterior urethral valves. e-mail: [email protected] 13 Smith GHH, Duckett JW. Urethral Urol Clin North Am 1990; 17: 379–87 lesions in infants and children. In 24 De Gennaro M, Capitanucci ML, Abbreviations: PVR, postvoid residual volume; Gillenwater JY, Grayhack JT, Howards SS, Capozza N et al. Detrusor US, ultrasonography; Bcap, bladder capacity;

Duckett JW eds. Adult and Pediatric hypocontractility in children with BC, bladder compliance; Pdetmax, maximum Urology, Chapt. 51. 3rd edn. St Louis, posterior urethral valves arises before detrusor storage pressure; BNI, bladder neck Missouri: Mosby 1996: 2411–31 puberty. BJU Int 1998; 81: 81–5 incision.

EDITORS Helmut Klocker Jack Schalken Bill Watson ASSOCIATE EDITORS Georg Bartsch David Neal

EDITORIAL BOARD Karl-Eric Andersson Kazem Azadzoi Olivier Cussenot Christopher Foster Robert Getzenberg Martin Gleave Hans Lilja Marston Linehan Norman Maitland Bruce Malkowicz Joel Nelson John Stein Ulf-Håkan Stenman Christian Stief George N. Thalmann Dan Theodorescu Tapio Visakorpi

BJUINTERNATIONAL EDITOR-IN-CHIEF JOHN M. FITZPATRICK Original Article EXPRESSION OF KI-67 IN SQUAMOUS CELL CARCINOMA OF THE PENIS BERDJIS et al.

Expression of Ki-67 in squamous cell carcinoma of the penis

NAVID BERDJIS, AXEL MEYE, JOHANNES NIPPGEN, DAG DITTERT*, OLIVER HAKENBERG, GUSTAVO B. BARETTON* and MANFRED P. WIRTH Department of Urology and *Institute of Pathology, University Hospital Carl Gustav Carus, Dresden, Germany Accepted for publication 3 February 2005

OBJECTIVE During a mean follow-up of 35.6 months, tendency for a high Ki-67 LI to be associated four patients had disease progression. Tumour with advanced local tumour stage, nodal To investigate the Ki-67 labelling index (LI) as tissue was stained immunohistochemically metastasis and clinical disease progression, a prognostic factor for the outcome of penile using the streptavidin-biotin method. The but these correlations were not statistically carcinoma, as in squamous cell carcinoma mean Ki-67 LI was defined as the percentage significant (P = 0.07, 0.07 and 0.06, (SCC) of the larynx the expression of this of total tumour cells that were Ki-67-positive. respectively). marker correlates with histological features The results were compared with pathological indicative of prognosis. tumour stage, grade, nodal status and clinical CONCLUSIONS disease progression. PATIENTS AND METHODS The Ki-67 LI is correlated with tumour grade RESULTS in penile cancer, and may indicate a greater We retrospectively analysed the records of 44 risk of nodal metastasis. patients in whom primary SCC of the penis The mean (range) Ki-67 LI was 40.5 was treated with amputation and bilateral (6.4–93.0)%; a high mean Ki-67 LI was KEYWORDS lymphadenectomy (pT1, in 24, pT2 in 20, pN+ significantly inversely correlated with tumour in 10; G1 in 12, G2 in 28 and G3 in four). differentiation (P < 0.005) and there was a penile carcinoma, Ki-67, lymph nodes

INTRODUCTION PATIENTS AND METHODS Hodgkin-lymphoma (type Burkitt-lymphoma) prepared as described above was used as the The prognosis for patients with squamous cell We retrospectively analysed the records of 44 positive control. Slides treated the same way carcinoma (SCC) of the penis is strongly patients (mean age 61.4 years, range 35–89) but omitting the specific antibody served as influenced by presence and extent of regional in whom primary SCC of the penis was treated negative controls. Four representative regions lymph-node metastases [1,2]; 30–60% of in our department by partial or total to the tumour were selected (by D.D.) and patients with penile carcinoma present amputation and bilateral lymphadenectomy, ≥1000 cells scored on each slide at high with enlarged lymph nodes at physical between 1992 and 2003. The 2003 TNM magnification (¥400) under light microscopy examination, which can be caused by system was used for staging. None of the (by B.N. and D.D.). The mean Ki-67 labelling metastatic involvement or inflammatory patients had received previous treatment or index (LI) was defined as the percentage of reaction. The incidence of occult lymph-node had distant metastases. total tumour cell nuclei that were Ki-67- metastases in clinically node-negative cases is positive. The results were compared with pT 10–15% [3]. The depth of invasion, tumour Briefly, 5 mm sections of cancer tissue fixed in stage, nodal status, grade and clinical disease grade, vascular and lymphatic involvement neutral buffered formalin were stained progression at follow-up. are the most important risk factors related to immunohistochemically for Ki-67 using the the occurrence of nodal metastases in penile streptavidin-biotin method (MIB-1; Dako, carcinoma [4–8]. Inguinal lymphadenectomy Hamburg). To facilitate antigen retrieval, the RESULTS is associated with a high morbidity rate of sections were incubated in a microwave oven 30–68% [1,9,10]. Therefore, additional in boiling 10 mmol/L citrate buffer for 10 min. The pathological stage was pT1 in 24 patients prognostic markers that can predict the After incubation with normal horse serum and pT2 in 20; 10 had lymph-node presence of lymph-node involvement are (Vector Labs, Burlinghame, CA), the slides metastases. During a mean follow-up of useful. In the present study we investigated were incubated with Ki-67 antibody (1 : 100 35.6 months, six patients had disease the relationship of Ki-67 labelling in primary dilution) for 1 h at 37 ∞C. Diaminobenzidine progression and two were lost to follow-up. penile carcinoma with relevant was used as final chromogen and The distribution of histological grade is shown clinicopathological variables and survival of haematoxylin as the nuclear counterstain. An in Table 1. There was positive Ki-67 the patients. archived case of a highly proliferating non- immunostaining in all cases, with a mean

EXPRESSION OF KI-67 IN SQUAMOUS CELL CARCINOMA OF THE PENIS

statistically significant (P = 0.07). There was CONFLICT OF INTEREST TABLE 1 The relationship between mean Ki-67 LI also a tendency for high Ki-67 expression and clinicopathological variables with advanced local tumour stage and disease None declared. progression, but these correlations were not Variable N tumours Ki-67 LI, % statistically significant either (P = 0.07 and REFERENCES Grade 0.06). G1 12 20 1 Ornellas AA, Seixas ALC, Marota A, G2 28 46 Wisnescky A, Campos F, de Moraes JR. G3 4 66 DISCUSSION Surgical treatment of invasive squamous T stage cell carcinoma of the penis: Retrospective T1 24 36.2 Ki-67 is a non-histone nuclear matrix protein analysis of 350 cases. J Urol 1994; 151: T2 20 45.3 expressed in all cell-cycle phases except G0. 1244–9 Lymph nodes An assessment of Ki-67 protein expression by 2 Ravi T. Correlation between the extent of N0 34 38.6 immunohistochemistry is a reliable means of nodal involvement and survival following N1 10 51.4 evaluating tumour cell proliferation [11]. To groin dissection for carcinoma of the No progression 38 39.1 our knowledge, there are no previous reports penis. Br J Urol 1993; 72: 817–9 Disease progression 6 48.7 on the correlation between the Ki-67 LI and 3 Horenblas S. Lymphadenectomy for clinicopathological variables for SCC of the squamous cell carcinoma of the penis. penis. Studies show that for SCC of the head Part 1: Diagnosis of lymph node and neck there is a correlation between the metastasis. BJU Int 2001; 88: 467–72 FIG. 1. (A) Diffuse nuclear immunohistochemical proliferation rate determined by Ki-67 and 4 Horenblas S, van Tinteren H. Squamous staining for Ki-67 in most tumour cells of a high- tumour de-differentiation, nodal involvement cell carcinoma of the penis, IV. Prognostic grade SCC of the penis (original ¥100). (B) Weakly or disease progression [12–14]. In the present factors of survival: Analysis of tumor, positive immunostaining for Ki-67 in a well- study there was a significant association only nodes and metastasis classification differentiated penile carcinoma (original ¥ 100). between the Ki-67 LI and tumour grade, but system. J Urol 1994; 151: 1239–43 there was a tendency towards a higher LI with 5 Lopes A, Hidalgo GS, Kowallski LP, A tumour stage, nodal metastasis and clinical Torloni H, Rossi BM, Fonseca FP. disease progression at follow-up. The lack of Prognostic factors in carcinoma of the correlation for these factors might be because penis: Multivariate analysis of 145 there were too few patients. patients treated with amputation and lymphadenectomy. J Urol 1996; 156: In a recent report, Martins et al. [15] examined 1637–42 the proliferative activity in penile carcinoma 6 Solsona E, Iborra I, Ribio J, Ricos JV, using immunostaining for proliferating cell Calabuig C. Prospective validation of the nuclear antigen (PCNA); the PCNA LI had a association of local tumor stage and significant correlation in univariate analysis grade as a predictive factor for occult with the presence of nodal metastasis. In lymph node micrometastasis in patients B contrast to the present findings for Ki-67 LI, with penile carcinoma and clinically there was no correlation between the PCNA LI negative inguinal lymph nodes. J Urol and tumour grade. 2001; 165: 1506–9 7 Morgenstern NJ, Slaton JW, Levy DA, Emerson et al. [8] found that the depth of Ayala AG, Santos MW, Pettaway CA. stromal tumour invasion, measured by a Vascular invasion and tumor stage are computerized micrometer, and vascular independent prognosticators of lymph invasion were predictive for cancer node metastasis in squamous penile progression in patients with penile SCC. In cancer. J Urol 1999; 161: 158, A608 two other studies the immunohistochemical 8 Emerson RE, Ulbright TN, Eble JN, overexpression of tumour-suppressor gene Geary WA, Eckert GJ, Cheng L. product p53 in penile carcinoma was Predicting cancer progression in patients correlated with disease progression [15,16]. with penile squamous cell carcinoma. the (range) LI of 40.5 (6.4–93)%. The proliferation importance of depth of invasion and rate was categorized as low (<40.5%) or high Further investigations of molecular markers vascular invasion. Mod Pathol 2001; 14: (≥40.5%), from the mean Ki-67 LI. A high LI to predict tumour behaviour in penile 963–8 was significantly associated with poorly carcinoma, and cohorts with more cases, are 9 Fraley EE, Zhang G, Manivel C, differentiated tumours (P < 0.005, Fig. 1). The needed for this relatively rare tumour. Besides Niehans GA. The role of ilioinguinal mean LI was higher in patients with regional known prognostic factors like pT stage and lymphadenectomy and significance of lymphatic spread (51.4%) than in those with grade, they might be helpful in selecting histological differentiation in treatment localized disease confined to the penis patients who would benefit from inguinal of carcinoma of the penis. J Urol 1989; (37.6%), but this difference was not lymphadenectomy. 142: 1478–82

BERDJIS ET AL.

10 Bevan-Thomas R, Slaton JW, Pettaway 13 Welkoborsky HJ, Hinni M, Dienes HP, 16 Lopes A, Bezerra ALR, Lopes Pinto CA, CA. Contemporary morbidity from Mann WJ. Predicting recurrence and Serrano SV, Abdon de Mello C, Villa LL. lymphadenectomy for penile squamous survival in patients with laryngeal cancer p53 as a new prognostic factor for lymph cell carcinoma: The M.D. Anderson Cancer by means of DNA cytometry, tumor front node metastasis in penile carcinoma. Center experience. J Urol 2002; 167: grading, and proliferation markers. Ann analysis of 82 patients treated with 1638–42 Otol Rhinol Laryngol 1995; 104: 503–10 amputation and bilateral 11 Scholzen T, Gerdes J. The Ki-67 protein. 14 Pignataro L, Capaccio P, Pruneri G et al. lymphadenectomy. J Urol 2002; 168: 81– from the known and the unknown. J Cell The predictive value of p53, MDM-2, 6 Pathol 2000; 182: 311–22 cyclin D1 and Ki67 in the progression 12 Liu M, Lawson G, Delos M et al. from low-grade dysplasia towards Correspondence: Navid Berdjis, Department Predictive value of the fraction of cancer carcinoma of the larynx. J Laryngol Otol of Urology, Royal Melbourne Hospital, Grattan cells immunolabeled for proliferating cell 1998; 112: 455–9 Street, Parkville, Victoria 3050, Australia. nuclear antigen or Ki67 in biopsies of 15 Martins ACP, Faria SM, Cologna AJ, e-mail: [email protected] head and neck carcinomas to identify Suaid HJ, Tucci S. Immunoexpression of lymph node metastasis: Comparison with p53 protein and proliferating cell nuclear Abbreviations: SCC, squamous cell carcinoma; clinical and radiologic examinations. Head antigen in penile carcinoma. J Urol 2002; LI, labelling index; PCNA, proliferating cell Neck 2003; 25: 280–8 167: 89–93 nuclear antigen.

Accuracy of the routine detection of mutation in mismatch repair genes in patients with susceptibility to hereditary upper urinary tract transitional cell carcinoma

MORGAN ROUPRÊT1,5,6, FLORENCE COULET2, ABDEL-RAHMÈNE AZZOUZI3,5,6, GAËLLE FROMONT4,5 and OLIVIER CUSSENOT1,5,6 Departments of 1Urology of Tenon Hospital, and 2Cytogenetics and 3Urology of Pitiè-Salpètrière Hospital AP-HP, the 4Institut Mutualiste Montsouris, the 5CeRePP Group, UFR Biomèdicale, University Paris V and 6EA 3104, University Paris VII, Paris France Accepted for publication 26 January 2005

OBJECTIVE hereditary tumour; in three a mutation in CONCLUSION hMSH2 was detected. For the other patients, To establish the clinical beneﬁts of systematic clinical data were collated, and DNA gene For the rare patients with UUT-TCC testing for hMSH6 and hMLH1 mutations in sequences analysed to detect mutations in who are suspected of carrying mismatch the very rare patients with upper urinary tract hMLH1 and in hMSH6 genes. repair gene mutations if no hMSH2 mutation transitional cell carcinomas (UUT-TCCs), a is found by genetic testing, complementary clinical predisposition for hereditary tumour RESULTS DNA sequencing for hMLH1 and hMSH6 and no mutation detected in hMSH2 gene. mutation does not seem to contribute Five patients were assessed (mean age at the and should not be recommended in daily diagnosis of UUT-TCC 65.2 years, SD 8, range practice. PATIENTS AND METHODS 54–71; two aged <60 years). Three patients had a personal history of hereditary In all, 164 UUT-TCC specimen blocks were nonpolyposis colorectal related-cancer (three KEYWORDS screened for microsatellite instability (MSI); colorectal). There were only mutations in 27 (16%) had high MSI levels. Eight patients hMSH2 gene detected, with none in hMSH6 microsatellite instability, germline mutation, (30%) had clinical criteria suspicious of and hMLH1. ureter, HNPCC, TCC

INTRODUCTION overlooking a hereditary cancer, we showed consensus [13], any pair of samples of normal that patients with a high MSI level and a DNA and tumour DNA that had instability at Upper urinary tract (UUT) TCCs are rare history of HNPCC-associated cancer or aged two or more of these five loci was scored as tumours which account for <5% of all <60 years should be tested for hMSH2 having high-frequency MSI, whereas a sample urothelial carcinomas [1]. UUT-TCCs belong to mutation [12]. The aim of the present study pair with no instability at these five loci was the spectrum of hereditary nonpolyposis was to establish the clinical benefits of scored as having MSI. Any sample pair having colorectal carcinomas (HNPCC) [2,3], an systematic testing for hMSH6 and hMLH1 instability at one of the five loci was tested autosomal dominant syndrome predisposing mutations in the very rare patients with UUT- again at that locus to exclude artefact. If MSI to colorectal carcinoma but sometimes also to TCC, a clinical predisposition for hereditary was confirmed additional loci were tested to extracolonic tumours such as UUT-TCCs (5% tumour and no mutation detected in hMSH2 determine whether the phenotype of the of cases) [4]. HNPCC is caused by germ-line gene. sample was low-frequency (1–4 loci) or high- mutations affecting one or several mismatch frequency MSI (five or more loci). For repair genes, i.e. hMSH2 (60% of the time), additional loci, we used markers that we had hMHL1 (30%) and hMSH6 (5–8%) [4–6]. More PATIENTS AND METHODS already tested in UUT-TCC [10,14]: MFD15 recently, genes such as hMLH3, hPMS1, (1q23), APC (5q22), BAT40 (1p13.1), d18s58 hPMS2, TGFbRII and EX01 have also been The files of 164 patients treated for sporadic (18q22), D18S69 (18q21), d10s197 (10p12), implicated [7,8]. Together, deleterious UUT-TCC over 12 years were reviewed; all MYC1L (1p34), UT5320 (8q24), ACTBP2 (6q13), mutations of these other genes, account for tumour blocks retrieved were screened for CFS1R (5q33-q35), D20S82 (20p12), d11s488 <5% of cases. Tumour microsatellite MSI. Paired DNA from tumours and normal (11q24) and D9S242 (9q33). PCR amplification instability (MSI) indicates probable mutations tissues were amplified by PCR using five was carried out with ª10 ng of DNA in or epigenetic alterations in these mismatch microsatellite markers from the Bethesda a 20-mL final volume of reaction mixture repair genes [4,9]. High MSI levels are panel [13]: BAT25 (4q12), BAT26 (2p16), (0.25 mmol/L dNTP in 1 mol/L Tris, 0.9 mol/L detected in nearly 15% of patients with UUT- D2S123 (2p16), d5s346 (5q21–22) and boric acid, 0.01 mol/L EDTA, 20 pmol of each TCC [10,11]. We already established that high D17S250 (17q) (for primer sequences, sense/ primer (MWG Biotech, Ebersberg, Germany), MSI status is useful to indicate a hMSH2 antisense, see http://www.gdb.org). In 0.75 mL of DMSO, and 1 U Taq Polymerase mutation in these patients [12]. To avoid accordance with National Cancer Institute (Qbiogen, Illkirch, France). Cycling parameters

ROUPRÊT ET AL.

TABLE 1 The characteristics of patients predisposed to hereditary UUT-TCC

History of cancer Stage N/sex/age, years personal familyUUT-TCC site Grade pT TNM hMSH2* hMSH6 hMLH1 1/F/58 Colon, breast No Renal pelvis 2 1 T1N0M0 811del4* – – 2/M/71 Colon No Ureter 3 2 T2N0M0 – – – 3/M/57 Colon No Renal pelvis 2 2 T2N0M0 R711X* – – 4/M/59 No No Renal pelvis 3 2 T2N0M0 – – – 5/M/73 Colon No Renal pelvis 3 3 T3N1M0 – – – 6/M/69 Colon Mother (breast) Ureter 2 1 T1N0M0 – – – 7/M/54 No No Ureter 2 1 T1N0M0 – – – 8/F/54 Endometrium No Ureter 2 a TaN0M0 R389X* – –

*results from previous study [12].

were described previously [10]; 1 mL of PCR human genome sequence (GenBank previously explored for hMSH2 gene [12] product was added to 1 mL blue Dextran and NM_000179). Sequencing reactions were provides no support for the hypothesis that 3 mL formamide. After a 2-min denaturation conducted with the ABI Prism Big Dye DNA sequencing of hMLH1 and hMSH6 might step at 94∞C, the mixture was immediately Terminator Cycle sequencing kit and analysed be useful to detect hereditary disease among immersed in an ice bath. The amplified on an ABI310 sequence analyser (both Applied these rare cases of UUT-TCCs. Undoubtedly fragments were separated by denaturing gel Biosystems). some hereditary cancers, whether of the colon electrophoresis in Tris-borate-edetic acid or UUT-TCC, are misclassified as sporadic and buffer/4% polyacrylamide (acryl-to-bisacryl their incidence is underestimated [3,4,12]. In 29 : 1), 6 mol/L urea (gel) using an PRISM 377 RESULTS addition, the incidence of de novo mutations Genetic Analyser (Applied Biosystems, Palo is not negligible, especially in hMSH2 [17,18]. Alto, California); GeneScan 3.1 Fragment Of the 27 patients with high MSI levels, eight Moreover, in half of patients, UUT-TCC shows Analysis software (Applied Biosystems) was (30%) met the clinical criteria for hereditary the presence of HNPCC and, conversely, the used to analyse the data. UUT-TCC. Their gender, age, personal and relative risk of UUT-TCC in HNPCC patients is family history, and tumour characteristics are 14 [3]. The daily practice of diagnosis in Twenty-seven patients (16%) had high MSI given in Table 1. Of these eight patients five hereditary cancers must be improved; in such levels; the following data were collated: age, were included in the present study (mean age cases, when gene mutations are detected, personal or family history of a HNPCC- at the diagnosis of UUT-TCC 65.2 years, SD 8, the patient and his family benefit from associated tumour, history of other cancers, range 54–71; two aged <60 years). Three multidisciplinary management [5,19]. The tumour stage (TNM 1997) and grade. None of patients had a personal history of cancer presence of other HNPCC-associated cancers these 27 patients met the Amsterdam clinical related to the HNPCC spectrum; UUT-TCC was is sought and patients closely monitored. criteria for HNPCC [15]. These 27 patients had never the first cancer in their personal history. Genetic counselling is provided to the their DNA sequenced to detect hMSH2 No patient had a family history of HNPCC- patient’s family. So that a hereditary cancer is mutation, which were found in three (11%). associated cancer. Of the five patients, two not overlooked, we already suggested Consequently, clinical criteria were defined to developed UUT-TCC in the renal pelvis and changing screening strategies in UUT-TCCs suspect a predisposition for hereditary UUT- three in the ureter. No patient had metastases based on the above tests [12]. Screening for TCC, i.e. a personal or familial history of when the UUT-TCC was diagnosed. Of the five MSI is now warranted as routine in all HNPCC-associated cancer and/or aged tumours, two were superficial (pT1) and three patients with UUT-TCC, as for colorectal <60 years [12]. Only those patients who met were invasive (pT2, pT3). All patients had a cancers, irrespective of age at diagnosis. these criteria and had no hMSH2 mutation radical nephroureterectomy; two had a A panel of five microsatellite markers is were included in the present study. recurrence (one bladder cancer, one cancer of usually used to determine MSI; when the the contralateral upper urinary tract). As discrimination is poor, a further 10 markers or For genetic testing, blood samples were reported in Table 1, only mutation in hMSH2 more are used [13]. In our choice of markers, obtained from all participating subjects and was detected, with no mutation on MLH1 and we applied the criteria of the 1998 consensus kept frozen at -30 ∞C until DNA extraction. MSH6 after DNA sequencing in these patients. [13] and used markers that were relevant in DNA was isolated from peripheral blood our earlier studies on UUT-TCC [10,14]. In lymphocytes using a purification kit (QIAamp future, the more precise 2004 criteria need to blood kit, Qiagen, Courtaboeuf, France). All DISCUSSION be implemented [20]. MSI screening identifies coding exons of the hMSH6 and hMLH1 were a further 5% of hereditary cancers than when sequenced by PCR amplification with intronic This study of patients suspected of having applying the stringent clinical criteria for flanking primers, as described elsewhere [16]. hereditary UUT-TCC caused by germline diagnosing HNPCC (Amsterdam criteria) Briefly, primers were designed using the mutation of mismatch repair genes and [4,12]. Immunohistochemistry can be a useful

GENETIC TESTING IN UPPER URINARY TRACT CARCINOMA

additional test to indicate which mismatch cancer: risks and screening options. J Urol nonpolyposis colorectal cancer (HNPCC, repair gene might be involved [12]; some 1998; 160: 466–70 Lynch syndrome) proposed by the authors even consider that the results are 4 Lynch HT, de la Chapelle A. Hereditary International Collaborative group on sufficiently well correlated with MSI colorectal cancer. N Engl J Med 2003; HNPCC. Gastroenterology 1999; 116: phenotype to act as a surrogate for MSI 348: 919–32 1453–6 determination, especially as it is quicker 5 Hendriks YM, Wagner A, Morreau H 16 Charbonnier F, Raux G, Wang Q et al. [21,22]. However, tumour MSI phenotype et al. Cancer risk in hereditary Detection of exon deletions and determined by PCR is more specific for nonpolyposis colorectal cancer due to duplications of the mismatch repair genes changes in DNA repair genes and is still the MSH6 mutations. impact on counseling in hereditary nonpolyposis colorectal standard method [12,20,23]. and surveillance. Gastroenterology 2004; cancer families using multiplex 127: 17–25 polymerase chain reaction of short DNA sequencing, as the last step for a positive 6 Thibodeau SN, French AJ, Roche PC fluorescent fragments. Cancer Res 2000; diagnosis, is long, complex and expensive, and et al. Altered expression of hMSH2 and 60: 2760–3 needs to be restricted to few patients [12,16]. hMLH1 in tumors with microsatellite 17 Suter CM, Martin DI, Ward RL. Germline DNA sequencing requires specialized instability and genetic alterations in epimutation of MLH1 in individuals with equipment and is time-consuming. Given that mismatch repair genes. Cancer Res 1996; multiple cancers. Nat Genet 2004; 36: a significant relationship was shown between 56: 4836–40 497–501 the presence of hMSH2 mutation, a history of 7 Jiricny J, Nystrom-Lahti M. Mismatch 18 Desai DC, Lockman JC, Chadwick RB HNPCC-associated cancer and UUT-TCC repair defects in cancer. Curr Opin Genet et al. Recurrent germline mutation in occurrence when aged <60 years [12], in the Dev 2000; 10: 157–61 MSH2 arises frequently de novo. J Med present study we selected patients for further 8 Muller A, Fishel R. Mismatch repair and Genet 2000; 37: 646–52 investigation. Mutations in hMLH1 and the hereditary non-polyposis colorectal 19 Lynch HT. Family information service and hMSH6 are involved in hereditary tumours in cancer syndrome (HNPCC). Cancer Invest hereditary cancer. Cancer 2001; 91: 625– only 30% and <8% of cases, respectively 2002; 20: 102–9 8 [4,5,8]. Furthermore, detecting mutations in 9 de la Chapelle A. Microsatellite 20 Umar A, Boland CR, Terdiman JP these two genes is not currently always instability. N Engl J Med 2003; 349: 209– et al. Revised Bethesda Guidelines for available [24]. As sporadic UUT-TCCs are very 10 hereditary nonpolyposis colorectal cancer rare tumours, only five of the present 164 10 Amira N, Rivet J, Soliman H et al. (Lynch syndrome) and microsatellite patients were included in this study, and the Microsatellite instability in urothelial instability. J Natl Cancer Inst 2004; 96: final result was of little practical value. The carcinoma of the upper urinary tract. 261–8 reported risk for all HNPCC-related tumours is J Urol 2003; 170: 1151–4 21 Parc Y, Gueroult S, Mourra N significantly lower in MSH6 or in MLH1 than 11 Blaszyk H, Wang L, Dietmaier W et al. et al. Prognostic significance of in MSH2 mutation carriers [5,8]. Upper tract urothelial carcinoma: a microsatellite instability determined by Consequently, there is no doubt that clinicopathologic study including immunohistochemical staining of MSH2 searching systematically for hMLH1 and microsatellite instability analysis. Mod and MLH1 in sporadic T3N0M0 colon hMSH6 mutations by genetic testing is not Pathol 2002; 15: 790–7 cancer. Gut 2004; 53: 371–5 cost-effective and is unwarranted in daily 12 Roupret M, Catto J, Coulet F 22 Lindor NM, Burgart LJ, Leontovich O practice for managing UUT-TCC. et al. Microsatellite instability as et al. Immunohistochemistry versus indicator of MSH2 gene mutation in microsatellite instability testing in CONFLICT OF INTEREST patients with upper urinary tract phenotyping colorectal tumors. J Clin transitional cell carcinoma. J Med Genet Oncol 2002; 20: 1043–8 None declared. 2004; 41: E91 23 Ruszkiewicz A, Bennett G, Moore J et al. 13 Boland CR, Thibodeau SN, Hamilton Correlation of mismatch repair genes REFERENCES SR et al. A National Cancer Institute immunohistochemistry and microsatellite Workshop on Microsatellite Instability instability status in HNPCC-associated 1 Hall MC, Womack S, Sagalowsky AI, for cancer detection and familial tumours. Pathology 2002; 34: 541–7 Carmody T, Erickstad MD, Roehrborn predisposition: development of 24 Parc Y, Boisson C, Thomas G, CG. Prognostic factors, recurrence, and international criteria for the Olschwang S. Cancer risk in 348 French survival in transitional cell carcinoma of determination of microsatellite instability MSH2 or MLH1 gene carriers. J Med Genet the upper urinary tract: a 30-year in colorectal cancer. Cancer Res 1998; 58: 2003; 40: 208–13 experience in 252 patients. Urology 1998; 5248–57 52: 594–601 14 Catto JW, Azzouzi AR, Amira N et al. Correspondence: Morgan Rouprêt, 23 quai dí 2 Watson P, Lynch HT. The tumor Distinct patterns of microsatellite Anjou, 75 004 Paris, France. spectrum in HNPCC. Anticancer Res 1994; instability are seen in tumours of the e-mail: [email protected] 14: 1635–9 urinary tract. Oncogene 2003; 22: 8699– 3 Sijmons RH, Kiemeney LA, Witjes JA, 706 Abbreviations: UUT, upper urinary tract; Vasen HF. Urinary tract cancer and 15 Vasen HF, Watson P, Mecklin JP, Lynch HNPCC, hereditary nonpolyposis colorectal hereditary nonpolyposis colorectal HT. New clinical criteria for hereditary carcinoma; MSI, microsatellite instability.

Mesenchymal cells inﬁltrating a bladder acellular matrix gradually lose smooth muscle characteristics in intraperitoneally regenerated urothelial lining tissue in rats

KIMIHIKO MORIYA, HIDEHIRO KAKIZAKI, SATOSHI WATANABE*, HIROSHI SANO and KATSUYA NONOMURA Departments of Urology and *Anatomy, Hokkaido University Graduate School of Medicine, Sapporo, Japan Accepted for publication 11 January 2005

OBJECTIVE grafted onto the mesentery of the previously identified at 14 and 28 days, and fibrocytes partially cystectomized rat. were the main population at 56 days. To characterize serial long-term histological changes in mesenchymal cells infiltrating a RESULTS CONCLUSIONS collagen-based matrix, as in a hollow organ with differentiated urothelial lining created The grafted urothelial cells on the BAM, which Although epithelial-mesenchymal intraperitoneally by grafting cultured formed a monolayer before grafting, stratified interactions have been assumed to be one of urothelial cells, mesenchymal cells with into three to four layers as early as 4 days the most critical factors in smooth-muscle smooth-muscle immunohistochemical after grafting. Although the regenerated development, mesenchymal cells infiltrating characteristics infiltrated into the scaffold, urothelium became thinner with time, there the scaffold in this intraperitoneal despite no mesenchymal cells being seeded was urothelial stratification and a peculiar regeneration model gradually lost smooth into the scaffold before grafting. angular appearance on the apical surface of muscle characteristics with time. These results the regenerated urothelium even after 56 suggest that interactions between cultured MATERIALS AND METHODS days. The mesenchymal cells infiltrating the urothelial cells and infiltrating mesenchymal BAM showed positive immunohistochemical cells alone could not maintain the smooth To regenerate a urothelial lining tissue staining to a-smooth muscle actin or desmin muscle character of infiltrating mesenchymal intraperitoneally, rat urothelial cells were at 7 days. Subsequently, the number of actin- cells. cultured and seeded with the feeder-layer or desmin-positive cells gradually decreased technique onto bladder acellular matrix with time. On transmission electron KEYWORDS (BAM). After 7 days of cultivation to attach microscopy, the infiltrating mesenchymal urothelial cells on the BAM, the matrix was cells were characterized as myofibroblasts at urothelial cells, regenerated tissue, folded with the urothelial cells inside and 7 days. Smooth muscle-like cells were mesenchymal cells, smooth muscle

INTRODUCTION site where the scaffold was grafted. It was also shown that smooth muscle Urodynamic studies have shown that this development is facilitated by placing the Various techniques have been developed for composite bladder can function as a low- epithelium onto the surface of the matrix. bladder reconstruction using native tissues pressure reservoir and empty efficiently in Thus, epithelial-mesenchymal interactions are other than the urinary tract. Among them, neurologically intact animals. These necessary for the development of bladder current approaches favour the use of regenerated tissues have a luminal surface smooth muscle. Recent data showed that by gastrointestinal segments to augment the covered with differentiated urothelium, which implanting embryonic urothelium seeded on bladder. However, the use of gastrointestinal avoids the disadvantages of gastrointestinal bladder acellular matrix (BAM) into the segments can lead to various complications grafts [2–6]. immunodeficient mouse, fibroblastic cells including chronic infection, electrolyte differentiated into smooth muscle cells [9]. derangement, mucus secretion and stone Nonetheless, the mechanism of bladder These results suggest that the epithelium is formation [1]. regeneration remains unclear. In the important for smooth muscle regeneration regeneration of smooth muscle and bladder from migrating mesenchymal cells into the Recent advances in tissue-engineering wall, it was speculated that mesenchymal scaffold. techniques have enabled the regeneration of cells, which were derived from de- functional bladder wall from a scaffold with differentiation of mature bladder smooth We previously reported that cultured or without bladder cells. These techniques muscle and migrated into an acellular matrix, autologous urothelial cells on a collagen- have allowed the reconstitution of normal would re-differentiate into bladder smooth based matrix were successfully implanted into bladder wall consisting of mucosa, muscularis muscle via diffusible growth factors that the peritoneal cavity of the rat to create a mucosa, detrusor muscle and serosa at the might be produced from the urothelium [7,8]. hollow-like tissue with differentiated

MESENCHYMAL CELLS IN BLADDER ACELLULAR MATRIX

FIG. 1. Experimental design for implanting urothelial cells on the BAM. The BAM was opened (A) and ﬁxed (B) on the six-well-plate with ﬁbrin. Cultured urothelial cells were seeded onto BAM with the feeder-layer technique (C). After 7 days of cultivation for attaching the cells, they were grafted onto the mesentery of the terminal ileum.

AB C Cultured urothelial cells

Cut Grafting onto seed mesentery

BAM fibrin

urothelium [10]. In that created tissue, DNase (Takara, Osaka, Japan). After digestion, The harvested BAMs were fixed in 10% mesenchymal cells infiltrating the matrix they were digested twice in 4% sodium buffered formalin and processed for paraffin- showed smooth muscle characteristics [10]. deoxycholic acid (Sigma, St Louis, MO, USA) wax embedding. Immunohistochemistry was The aims of the present study were to containing 0.1% sodium azide (Sigma). Each used with antibodies for a-smooth muscle characterize the serial histological changes in process was used for 10–14 h with serial actin (Sigma) and desmin (DAKO, Carpinteria, mesenchymal cells infiltrating a scaffold agitation at a room temperature. After this CA, USA) using commercially available kits grafted with urothelial cells. chemical digestion, the BAM was opened by (Nichirei, Tokyo, Japan). Paraffin-embedded cutting from the edge to the dome (Fig. 1A,B) sections of the rat bladder were used as and placed in six-well plates with the inner controls. MATERIALS AND METHODS surface facing upwards. The opened BAM was fixed on the plate with fibrin made from 10 mL For transmission electron microscopy Female Wistar rats (7–8 weeks old) were used; of 40 mg/mL fibrinogen solution and the (TEM), specimens were fixed in 2% the primary culture of urothelial cells was as same aliquot of 3 U/mL thrombin solution paraformaldehyde and 2.5% glutaraldehyde previously reported with slight modifications (Fujisawa Pharmaceutical, Osaka, Japan). They in 0.1 mol/L phosphate buffer at 4∞C, and

[10]. Briefly, the apical two-thirds of the rat were incubated overnight under the same post-fixed with 1% OsO4 solution for 2 h. They bladder was harvested and the epithelial layer conditions as the cell culture. were then stained with 2% aqueous uranyl peeled. Isolated urothelial cells obtained from acetate for 2 h at 4∞C, dehydrated in a graded the epithelial layer by trypsinization were After making a feeder layer on the BAM fixed ethanol series, cleared in propylene oxide and cultured with the feeder-layer technique in a in the six-well plate, urothelial cells cultured embedded in Epon 812. Ultra-thin sections humidified, 37∞C, 95% air/5% carbon dioxide from each sample of bladder tissues were were cut and examined with a transmission environment. The primary cultures became seeded onto each BAM in a culture medium electron microscope (H7100, Hitachi, Katsuta, confluent in 10–12 days, when there was a containing 0.15 TIU/mL aprotinin (Sigma) Japan). mean (range) of 2.9 (1.5–5.1) ¥ 106 cultured (Fig. 1C). After 7 days of culture the BAM was urothelial cells per sample of bladder tissue. removed from the well and folded with the urothelial layer inside. The edges were RESULTS BAM was prepared as previously reported, running-sutured with 9–0 Nylon to form a with slight modifications [4]; briefly, the closed pouch. Then the BAM was grafted into There was urothelial lining on all matrices at bladder tissues after de-epithelialization for the previously partially cystectomized rat as it 14 days or earlier after grafting but it was also urothelial culture were treated with 10 mmol/ was wrapped with the mesentery of the identified in four of five matrices at 28 days, L PBS and 0.1% sodium azide, then in 1 mol/L terminal ileum. The grafted BAMs were and in three of four at 56 days. There was no sodium chloride containing 60 units/mL harvested after 4, 7, 14, 28 and 56 days. stone formation on the suture materials.

MORIYA ET AL.

FIG. 2. Representative micrographs of regenerated urothelium. Implanted urothelial cells, formed a monolayer on the BAM before grafting, and were stratiﬁed in three to four layers as early as 4 days. Subsequently, regenerated urothelium became ﬂatter and thinner with time. A, before grafting; B, 4 days; C, 7 days; D, 14 days; E, 28 days; F, 56 days. Bar 50 mm.

ABC

DEF

Urothelial cells, which formed as a monolayer FIG. 3. on the BAM before grafting (Fig. 2A), were Regenerated urothelium at 56 stratified into three or four layers as early as 4 days on TEM. The peculiar angular days after grafting (Fig. 2B–D). While grafted appearance was apparent on the urothelial cells became flatter and the apical surface of regenerated regenerated urothelium became thinner with urothelium (arrowhead). Bar time (Fig. 2E,F), TEM showed the presence of a 1 mm. peculiar angular appearance, which is specific to the urothelium, on the apical surface of the regenerated urothelium even at 56 days (Fig. 3).

There were infiltrating mesenchymal cells in the outer half of the matrices at 4 days (Fig. 4A) and throughout the matrices at 7 (Fig. 4B) and 14 days. The matrices on which urothelial cells were identified at 28 and 56 days had two layers histologically. The inner layer, just below the urothelial lining, had days, and smooth muscle-like cells were and in animals with a diseased bladder [11]. In numerous mesenchymal cells, and the outer apparent from 14 days, with fibrocytes our previous study in which a collagen-based layer had few mesenchymal cells (Fig. 4C). In present from 28 days, forming the matrix was used as a scaffold for urothelial each matrix on which urothelial cells did not main population in the BAM at 56 days cell implantation, the 4-week survival rate of survive at 28 and 56 days only a few (Fig. 6). autologous urothelial cells was low [10]. mesenchymal cells infiltrated into the matrix. Therefore in the present study, we used BAM as a scaffold for the implantation of Mesenchymal cells infiltrating the BAM had DISCUSSION intraperitoneal urothelial cells, expecting positive immunohistochemical staining to better survival of the urothelial cells. actin and/or desmin at 7 days (Fig. 5A/A¢). We characterized histologically the fate of Subsequently, the number of actin- or mesenchymal cells infiltrating the BAM that However, urothelial cells failed to survive in desmin-positive cells gradually decreased was used for the intraperitoneal regeneration one of five and one of four matrices at 28 and with time (Fig. 5B/B¢, C/C¢), and were of urothelial lining tissues. BAM is one of the 56 days, respectively. As collagenase is identified mainly underneath the regenerated best matrices for bladder regeneration when synthesized via keratinocyte growth factor urothelium at 56 days (Fig. 5D/D¢). grafted to a partially cystectomized bladder. [12], which is secreted via epithelial- The excellent histological and functional mesenchymal interactions [13], it seems that Infiltrating mesenchymal cells were properties of the regenerated bladder were the degradation of BAM through the characterized mainly as myofibroblasts at 7 reported in normally voiding animals [4–7] remodelling process of the extracellular

MESENCHYMAL CELLS IN BLADDER ACELLULAR MATRIX

FIG. 4. Representative micrographs of implanted matrices. Inﬁltrating mesenchymal cells were apparent in the outer half of the matrices at 4 days (A) and throughout the matrices at 7 days (B). The matrices on which urothelial cells were identiﬁed at 56 days (C) had two layers histologically; the inner layer (i) had numerous and the outer layer (o) had fewer mesenchymal cells. Bar 20 mm.

A B C i i

FIG. 5. Representative micrographs of inﬁltrating mesenchymal cells on immunohistochemistry for a-smooth muscle actin (A–D) and desmin (A¢–D¢); the cells showed positive staining to actin and/or desmin at 7 days. The number of actin- or desmin-positive cells gradually decreased, but were identiﬁed underneath urothelium at 56 days. A/A¢, 7 days; B/B¢, 14 days, C/C¢, 28 days; D/D¢, 56 days. Bar 100 mm.

A B C D

A¢ B¢ C¢ D¢

matrix by collagenase at least partly affected desmin at 7 days after grafting. These actin- character of infiltrating mesenchymal cells, the urothelial survival in the present model. and/or desmin-positive cells gradually from myofibroblasts (7 days) and smooth decreased with time and finally localized muscle-like cells (14 and 28 days), to Mesenchymal cells infiltrating the BAM mainly underneath the regenerated fibrocytes thereafter. Thus, in the present showed positive staining for actin and/or urothelium. TEM showed serial changes in the study, infiltrating mesenchymal cells

MORIYA ET AL.

gradually lost smooth muscle characteristics FIG. 6. Infiltrating mesenchymal cells on TEM, characterized mainly as myofibroblasts (*), which had rough with time. One possible explanation for these endoplasmic reticulum and microfilaments, at 7 days (A). Smooth muscle-like cells (arrowhead), which had results might be that regenerated urothelium microfilaments and less rough endoplasmic reticulum, were apparent at 14 (B) and 28 days (C). Fibrocytes which became flatter and thinner with time (arrow), which had a small cytoplasm and a flat nucleus, appeared from 28 days (C) and were the main was insufficient to maintain epithelial- population by 56 days (D). Bar 1 mm. mesenchymal interactions. A B In previous studies using a bladder augmentation model, mesenchymal cells * infiltrating BAM became smooth muscle cells * via a diffusible growth factor that might be produced from the urothelium, and formed * muscle bundles [4–7]. Although mesenchymal * cells infiltrating in a bladder augmentation model are thought to originate from the host bladder [7], even the heterotypic epithelial- mesenchymal interactions can induce mesenchymal cells in smooth muscle [14]. CD Recruitment and transdifferentiation of fibroblasts into smooth muscle were reported in BAM after implanting embryonic rat urothelium under the renal capsule or skin of the immunodeficient mouse [9]. These results indicate that the existence of mesenchymal cells originating from the native bladder is not critical for smooth muscle regeneration.

There are some differences between previous studies [4–7,9] and the present study in the When the bladder is augmented with BAM, In conclusion, epithelial-mesenchymal source of the grafted urothelium (embryonic mesenchymal cells migrating into BAM are interactions have been assumed to be one of or adult rat urothelium), grafting methods thought to be derived from bladder smooth the most critical factors in smooth muscle (grafting into immunodeficient animals muscle cells [5,7]. However, Badylak et al. [15] development. In the present intraperitoneal or autologous implantation) or grafting showed that ª70% of cells migrating into regeneration model, mesenchymal cells sites (bladder augmentation or ectopic subcutaneously implanted acellular matrix infiltrating the scaffold gradually lost smooth implantation onto the mesentery). These were derived from bone marrow. A rigorous muscle characteristics with time. The present differences in the materials and methods demand for tissue repair may recruit results suggest that interactions between might affect the fate of infiltrating circulating or resident stem cells and trigger cultured adult urothelial cells and infiltrating mesenchymal cells. In the present study, we them to undergo differentiation into various mesenchymal cells alone could not maintain attempted to create a cystic tissue with a cells [16]. These bone marrow-derived cells the smooth muscle characteristics of luminal surface covered with regenerated are capable of maintaining, generating and infiltrating mesenchymal cells. autologous urothelium in an ectopic site replacing terminal differentiated cells, (mesentery) with no continuity with the including smooth muscle cells [17,18]. In this ACKNOWLEDGEMENTS native bladder, which we considered would be regard, cells in the regenerated bladder in an the ideal method of bladder regeneration and augmentation model could be derived not Authors especially thank Teruko Ueda and would have the potential for neobladder only from native bladder tissue but also from Midori Muranaka for technical support. creation. The present study showed that the bone marrow. Fibrocytes, which were existence of cultured epithelium seeded onto apparent after 56 days in the present study, CONFLICT OF INTEREST BAM with no continuity with the native were reported to have features of bladder is not the sole definitive factor for haematopoietic cells and are considered to be None declared. infiltrating mesenchymal cells to maintain derived from bone marrow [19]. Accordingly, their smooth muscle characteristics. Soon mesenchymal cells infiltrating BAM in the REFERENCES after grafting, epithelial-mesenchymal present model might have been derived from interactions seem to be important for the bone marrow and from surrounding tissues 1 Khoury JM, Timmons SL, Corbel L, infiltrating mesenchymal cells to maintain (mesentery). Further studies are needed to Webster GD. Complications of smooth muscle characteristics. However, clarify the possible role of various factors, enterocystoplasty. Urology 1992; 40: 9– epithelial-mesenchymal interactions alone including bone marrow-derived and 14 could not maintain these characteristics in circulating stem cells, in bladder 2 Oberpenning F, Meng J, Yoo JJ, Atala A. infiltrating mesenchymal cells. regeneration. De novo reconstruction of a functional

MESENCHYMAL CELLS IN BLADDER ACELLULAR MATRIX

urinary bladder by tissue engineering. 9 Master VJ, Wei G, Liu W, Baskin LS. 15 Badylak SF, Park K, Peppas N, McCabe Nature Biotec 1999; 17: 149–55 Urothelium facilitates the recruitment G, Yoder M. Marrow-derived cells 3 Kropp BP, Rippy MK, Badylak SF and transdifferentiation of fibroblasts populate scaffolds composed of et al. Regenerative urinary bladder into smooth muscle in acellular matrix. zenogeneic extracellular matrix. Exp augmentation using small intestinal J Urol 2003; 170: 1628–32 Hematol 2001; 29: 1310–8 submucosa. urodynamic and 10 Moriya K, Kakizaki H, Murakumo M 16 Kollet O, Shivetiel S, Chen Y et al. HGF, histopathologic assessment in long–term et al. Creation of luminal tissue covered SDF-1 and MMP-9 are involved in stress- canine bladder augmentation. J Urol with urothelium by implantation of induced human CD34+ stem cells 1996; 155: 2098–104 cultured urothelial cells into peritoneal recruitment to the liver. J Clin Invest 2003; 4 Sutherlands RS, Baskin LS, Haywood cavity. J Urol 2003; 170: 2480–5 112: 160–9 SW, Cunha GR. Regeneration of bladder 11 Cayan S, Chermansky C, Schlote N et al. 17 Korbling M, Estrov Z. Adult stem cells urothelium, smooth muscle, blood vessels The bladder acellular matrix graft in a rat for tissue repair - A new therapeutic and nerves into an acellular tissue matrix. chemical cystitis model. Functional and concept? N Engl J Med 2003; 349: J Urol 1996; 156: 571–7 histologic evaluation. J Urol 2002; 168: 570–82 5 Wefer J, Sievert K, Schlote N et al. Time 798–804 18 Sata M, Saiura A, Kunisato A et al. dependent smooth muscle regeneration 12 Putnins EE, Firth JD, Uitto VJ. Hematopoietic stem cells differentiate and maturation in a bladder acellular Stimulation of collagenase (matrix into vascular cells that participate in the matrix graft: Histological studies and in metalloproteinase-1) synthesis in pathogenesis of atherosclerosis. Nat Med vivo functional evaluation. J Urol 2001; histiotypic epithelial cell culture by 2002; 8: 403–9 165: 1755–9 heparin is enhanced by keratinocyte 19 Yang L, Scott PG, Giuffre J et al. 6 Kanematsu A, Yamamoto S, Noguchi T, growth factor. Matrix Biol 1996; 15: Peripheral blood fibrocytes from burn Ozeki M, Tabata Y, Ogawa O. Bladder 21–9 patients. Identification and quantification regeneration by bladder acellular matrix 13 Maas-Szabowski N, Stark HJ, of fibrocytes in adherent cells cultured combined with sustained release of Fusenig NE. Keratinocyte growth from peripheral blood mononuclear cells. exogenous growth factor. J Urol 2003; regulation in defined organotypic cultures Lab Invest 2002; 82: 1183–92 170: 1633–8 through IL-1-induced keratinocyte 7 Wu H, Baskin LS, Liu W, Hayward S, growth factor expression in resting Correspondence: K. Moriya, Department of Cunha GR. Understanding bladder fibroblasts. J Invest Dermatol 2000; 114: Urology Hokkaido University Graduate School regeneration: Smooth muscle ontogeny. 1075–84 of Medicine North-15 West-7 Kita-Ku J Urol 1999; 162: 1101–5 14 DiSandro MJ, Li Y, Baskin LS, Cunha G. Sapporo, 060–0824 Japan. 8 Liu W, Li Y, Hayward S, Baskin L. Mesenchymal–epithelial interactions in e-mail: [email protected] Diffusible growth factors induce bladder bladder smooth muscle development: smooth muscle differentiation. In Vitro epithelial specificity. J Urol 1998; 160: Abbreviations: BAM, bladder acellular matrix; Cell Dev Biol Anim 2000; 36: 476–84 1040–6 TEM, transmission electron microscopy.

Apoptosis: a key effector mechanism of lymphocyte action in human nonseminomatous testicular carcinoma?

HANS U. SCHMELZ*‡, MATTHIAS PORT†, EKKEHARD W. HAUCK‡, MICHAEL J. SCHWERER¶, WOLFGANG WEIDNER‡, CHRISTOPH SPARWASSER* and MICHAEL ABEND† *Federal Armed Forces Hospital, Departments of Urology and ¶Pathology, Ulm, †Institute of Radiobiology, Federal Armed Forces, Munich, and ‡Department of Urology, Justus Liebig University of Giessen, Giessen, Germany Accepted for publication 9 February 2005

OBJECTIVE apoptotic index (AI) was assessed in various tumour cells showed these features of categories (DNA condensation and apoptosis. The overall AI in NSGCT was To correlate the number of tumour- fragmentation) using in-situ end-labelling to 7.9%. infiltrating T lymphocytes (TILs) with the identify typical apoptotic DNA strand breaks, extent of apoptosis in testicular germ cell and nuclear staining to identify typical CONCLUSIONS tumours, as TILs are considered to be a apoptotic morphology. favourable prognostic factor of human TILs do not seem to induce apoptosis in testicular tumours, especially of seminomas, RESULTS testicular tumours. Embryonal cell carcinomas but the mechanism by which TIL contribute to might be susceptible to lymphocyte attack, an improved outcome is unclear. In seminomatous GCT there was no resulting in apoptosis of the tumour cell. correlation between the number of TILs and The mechanisms of interaction between MATERIALS AND METHODS any AI. In NSGCT there was only a relationship lymphocytes and testis tumour cells need between lymphoid infiltration and those AIs further investigation. Tissue samples from 47 patients with showing morphological criteria of apoptosis nonseminomatous germ cell tumour (NSGCT) in a small subgroup of NSGCT, i.e. KEYWORDS and 15 with seminomatous GCT were metastasized embryonal cell carcinomas. Only investigated immunohistochemically for 1.2% (AI, chromatin condensation) and 0.8% apoptosis, testicular cancer, tumour lymphocyte infiltration and apoptosis. The (AI, fragmentation and condensation) of all infiltrating lymphocytes

INTRODUCTION of the breast, or lymphomas [15–17]. In fragmentation and chromatin condensation previous studies of the apoptotic index (AI) of [19,20], and thus TIL infiltration was Human testicular tumours, especially tumour cells and lymphocytes in testicular correlated separately with cells showing one seminomatous tumours, are typically cancer, AIs of both cell types were or both of these features. infiltrated by numerous lymphoid cells significantly higher in the tumour region than [1,2]. According to concepts of tumour in tumour-associated tissue. It was suggested immunology, tumour-infiltrating that there is a lymphocyte-tumour cell MATERIALS AND METHODS lymphocytes (TILs) are believed to attack and interaction restricted to the tumour eliminate tumour cells, thus being significant region, thus supporting the hypothesis Tissue samples obtained from 47 patients determinants of outcome for a variety of of apoptosis being a major biological effect with nonseminomatous and 15 with malignancies [3–5]. TILs also seem to be a of lymphoid tumour infiltration [8]. Others seminomatous GCTs were examined under the favourable prognostic factor of seminomas, questioned the capability of TILs to induce guidance of an experienced pathologist. The although the functional role of TILs in apoptosis in testicular tumour cells, as they cases were selected from files of diagnosed seminomas was questioned [1,2,6,7]. Only showed a low activity of perforin and surgical specimens at the authors’ institution, recently was significant lymphoid infiltration FasL [18]. and selected for evaluation by the pathologist reported in nonseminomatous germ cell according to the quality of the histological tumours (NSGCTs) [8,9]. To date the degree of lymphoid infiltration sections. All investigations had the approval has not been correlated with the degree of of the local Human Investigations The mechanism of action of TILs is not clear; apoptosis in human testicular cancer. Thus Committee. triggering apoptosis in tumour cells may be the objective of the present study was to one possible way [10]. There is considerable determine whether the number of TILs In all, 26 NSGCT were pure embryonal cell evidence that apoptosis is a relevant factor of correlates with the extent of apoptosis in carcinoma (ECC) and 21 were different tumorigenesis and tumour progression in testicular GCTs. As in previous investigations tumour entities; there were no metastases in several tumours, including human testicular there was a discrepancy in the number of cells 24 patients (12 each pure ECC and 12 mixed GCTs [11–14]. This was shown for several with the two main apoptotic features in GCT) and 23 had metastatic disease (14 pure tumours, e.g. colorectal carcinoma, carcinoma human testicular tumours, DNA ECCs and nine mixed).

LYMPHOCYTE INFILTRATION AND APOPTOSIS IN HUMAN TESTICULAR CARCINOMA

All NSGCT patients with no signs of K (Boehringer Mannheim, Germany) diluted in Leica, Wetzlar, Germany) equipped with a metastasis on CT of the abdomen (clinical distilled water for 8 min at 37 ∞C, washed in filter block for DAPI excitation (excitation stage, CS, I) had a retroperitoneal lymph node distilled water (four times), incubated with 270–380 nm; emission 410–580 nm). When dissection, confirming pathological stage I in TdT mix according to the manufacturer’s changing the filter block with the filter wheel, 24; six had pathological stage IIA after protocol for 60 min at 37 ∞C in a humidified the same cells were examined for FITC signals investigating histological sections of the chamber, washed three times in distilled (excitation 450–490 nm; emission ≥ 520 nm, lymph node dissection. Initially 17 patients water and incubated with antidig-fluorescein long-pass filter) enabling differentiation of had retroperitoneal metastases on CT of isothiocyanate (FITC) for 30 min at room morphologically normal or apoptotic cells the abdomen (CS IIA in seven, CS IIB in four, temperature in a humidified chamber. The which either FITC signals (DNA fragmentation) CS IIC in one) or of the lung (CS III in five). DNA specific dye 4¢,6-diamidino-2- or not. T-lymphocytes were also visualized All received at least three cycles of phenylindole (DAPI, final concentration with the epifluorescence microscope using a polychemotherapy with cisplatin, etoposide 1.0 mg/mL; Serva, Heidelberg, Germany) was filter for rhodamine signals (excitation 546– and bleomycin or cisplatin, etoposide and added to examine nuclear apoptotic 552 nm; emission 570 nm). This gave three ifosfamide. morphology and incubated for 5 min. Slides different AIs, i.e. of morphologically normal

were washed three times with distilled water, cells showing DNA fragmentation (AIDNAfrag), of Ten patients with pure seminoma showed no dried at room temperature and mounted in morphologically apoptotic cells with no metastasis at the time of primary diagnosis glycerol/paraphenylenediamine (anti-fading DNA fragmentation (Aichrom-cond) and of and five did (CS IIA in two, CS IIB in two, CS IIC agent; final concentration 1 mmol/L, Aldrich, morphologically apoptotic cells with DNA in one). All patients with CS I seminoma Steinheim, Germany). HL-60 cells (as the fragmentation (AIfrag+cond). The sum of these received radiotherapy to the para-aortic/ positive control) were treated similarly, only AIs was considered to represent all apoptotic paracaval field as initial adjuvant treatment. omitting the first treatment step with cells that could be detected in the tissue

Patients with metastatic disease were treated proteinase K. For negative controls, TdT was section, and therefore termed AIall. with three cycles of polychemotherapy with omitted from the reaction mixtures. The cisplatin, etoposide and bleomycin. method was optimized (e.g. duration of The main aim was to assess whether TILs proteinase K exposure) in several preliminary induce apoptosis in tumour cells; clinically it Microdissection was not used for NSGCT experiments (not shown). Cells with a FITC is relevant to correlate the number of TILs because there were too few evaluable cases of signal in the nucleus were considered to with the degree of apoptosis separately for each subtype to detect significant differences contain fragmented DNA. metastatic and non-metastatic NSGCTs, to between the histological components (ECC in have some impression of whether there is 17, yolk sac in six, chorion carcinoma in five, Morphologically, cells were differentiated into any clinical significance of TILs in NSGCT seminoma in five, mature teratoma in three, non-apoptotic cells, characterized by a warranting further investigation. This was not and immature teratoma in six). There were homogeneous distribution of DNA in the done for the seminomas as all patients in CS I even fewer evaluable cases because in some normal-sized nucleus and therefore received radiation therapy. All AIs were of the tumours the percentage of the specific considered to represent normal cells, and correlated with the size of the tumour, to region was too small to investigate enough apoptotic cells (condensed DNA) using DAPI exclude the possibility that a large tumour microscopic fields to get a representative cell as a DNA-specific fluorescent dye. volume is associated with greater apoptosis, count for the specific tumour entity. However, thus falsifying other correlation data. to have some impression of possible T-cells were visualized in the same tissue differences among histological subtypes, pure sections as used to determine the AI, using a For statistical analysis, 15 microscopic fields ECCs were investigated separately. double-immunofluorescence technique with were scored per testis tumour tissue sample, a CD45RO mouse antibody (clone OPD4 Fa, with a mean (SD) of 1517 (365) cells examined. All patients were followed regularly at Dako, Hamburg, Germany) using a Significance levels for the difference between intervals according to the European Germ Cell rhodamine-conjugated goat anti-mouse groups were calculated using Student’s t-test, Cancer Consensus Group [21]. All patients are secondary antibody (Fa.Dako, Hamburg or if the equal-variance test failed, with the still alive and relapse-free after a median Germany), using the standard protocol Mann-Whitney rank sum test. The AI and follow-up of 91.9 months. published recently [9]. Tissue sections of degree of TIL was expressed as the percentage activated lymph nodes were used as positive of apoptotic cells from all investigated cells of To evaluate apoptosis, the in-situ end- controls. the tumour, if not indicated differently; values labelling (ISEL) method and DNA shown are the mean (SD). Non-apoptotic TILs counterstaining was used. Paraffin-embedded The amount of apoptosis was quantified as were correlated with the AI of tumour cells tissues were fixed in 4% buffered formalin the AI, i.e. the percentage of apoptotic cells in using Spearman rank order correlation. and processed by standard methods; 5 mm all investigated cells of the tumour. A recent consecutive sections were mounted on coated report showed a significant difference in the RESULTS slides (Superfrost/Plus, Menzel Gläser, AI in testicular tumours depending on the

Munich, Germany). The ApopTaq Plus Kit detection method used [20]. Therefore, the AIs The AIDNAfrag, AIchromcond and Aifrag+cond differed (Oncor, Appligene, Heidelberg, Germany) was were obtained with ISEL and by counting significantly in testicular tumours, used for ISEL as reported previously [19]. In typical apoptotic morphology. The slides were independent of the histological subtype, as brief, after deparaffinisation, tissue sections scored for the two methods using an reported recently [20]. Briefly, in all NSGCT were incubated with 20 mg/mL of proteinase epifluorescence microscope (¥400; Orthoplan, investigated the AIDNAfrag, at 7.37 (10.4)%, was

SCHMELZ ET AL.

significantly higher than AI , at chromcond TABLE 1 Correlation of tumour size or lymphoid infiltration and AI; there was no significant correlation 1.20 (1.74)%, and Ai , at 0.78 (1.0)% frag+cond with size or infiltration in any GCT subgroup (P < 0.001). The distribution was similar for seminomatous tumours, with respective AI AI Ai AI values of 2.30 (1.7)%, 0.49 (0.4)% and all apop DNA frag chromcond frag & cond Subgroup Prs Prs Prs Prs 0.39 (0.3)% (P < 0.001). AIall was 7.99 (6.8)% in NSGCTs and 3.18 (2.0)% in seminomas. Seminoma metastatic 0.352 0.600 0.233 0.700 0.683 0.300 0.683 -0.300 Only lymphocytes which showed no feature non-metastatic 0.631 0.158 0.404 0.286 0.535 0.213 0.838 -0.067 of apoptosis were used for Spearman rank ECC correlation with apoptotic tumour cells, as metastatic 0.444 0.219 0.659 0.124 0.856 0.049 0.727 0.099 they were considered to be unable to induce non-metastatic 0.572 0.171 0.869 0.05 0.635 0.149 0.154 0.675 apoptosis in tumour cells. In NSGCT, Mixed 81.7 (21.03)%, and in seminomas, metastatic 0.434 -0.276 0.520 -0.234 0.263 -0.485 0.520 -0.226 89.8 (6.65)%, of all TILs showed no features of non-metastatic 0.445 -0.254 0.377 -0.275 0.456 0.232 0.498 -0.212 apoptosis; the proportion of TILs was Lymphoid infiltration significantly higher in seminomas, at Seminoma 25.3 (12.41)%, than in NSGCT, at 5.0 (5.83)% metastatic 0.450 -0.500 0.233 -0.700 0.783 -0.200 0.450 -0.500 (P < 0.001). There was no difference in non-metastatic 0.759 0.103 0.838 0.067 0.512 -0.229 0.468 0.241 proportion of TILs in metastatic and non- metastatic ECC, at 6.38 (8.81)% and 5.01 (4.77)% (P = 0.875) or in mixed GCTs, at 4.76 (2.68)% and 3.57 (4.21)% (P = 0.465). DISCUSSION the clinical perspective these results are surprising, as a correlation would be expected The mean diameter of the tumour was similar Lymphocytic infiltration is common in between the AI and lymphoid infiltration in in all subgroups, i.e. metastatic and non- testicular carcinoma, both for seminomatous non-metastatic rather than metastatic metastatic, respectively, pure ECC, mixed GCT [7] and NSGCT [8,9]. The degree of tumours. However, the AIs showing this and seminoma, at 2.37 (1.9), 3.06 (2.0), lymphocytic infiltration in testicular cancer, at correlation (AIchromcond, Aifrag+cond) make only a 3.4 (2.2), 3.00 (1.5) and 3.49 (1.7) cm. There least in seminomas, seems to correlate with a very small contribution to the overall AI. was no significant difference between favourable outcome [7]. However, we could Indeed the overall AI did not differ between metastatic and non-metastatic tumours not confirm these findings for NSGCTs in the metastatic and non-metastatic tumours (data within one entity nor among these tumour present study; there was no difference in TILs not shown), in agreement with previous types. There was also no correlation between between metastatic and non-metastatic results [8]. Therefore the clinical significance tumour size and AI (Table 1) or in tumours. of this correlation seems questionable. seminomatous tumours between the degree of lymphocyte infiltration and AI (Table 1). The mechanism by which TILs interact with Nevertheless, these data suggest the selective tumour cells is not fully understood [10,18]; activation of a distinct apoptotic programme In NSGCT the situation differed; for all NSGCT a possible mechanism might be the induction in ECC. DNA fragmentation and the typical independent of their metastatic status or of apoptosis. If apoptosis is a key biological apoptotic morphology in testicular cancers histological subtype, there was a significant effector mechanism of cytotoxic action of might be a consequence of two independent positive correlation between the degree of TILs [10] a correlation would be expected genetic programmes [8]. Evidence for this was lymphoid infiltration and AIchromcond and between TILs and apoptosis in testicular based particularly on the finding that most of

Aifrag+cond (Fig. 1A). There was no correlation for GCTs. the apoptotic bodies representing the ﬁnal both either Aiall.apop (rs = 0.075, P = 0.613) or stage of the apoptotic process had no DNA

AIDNAfrag (rs = 0.055, P = 0.710). The equivalence of methods for detecting fragmentation; at least in this stage the apoptosis in human testicular tumours is occurrence of both apoptotic features should Further differentiation of all NSGCT into pure questionable; only ª30% of all apoptotic cells be expected [8,19]. In other systems the ECC and mixed GCTs showed a highly could be detected using typical apoptotic morphological features of apoptosis also significant correlation in pure ECC (Fig. 1B), morphology, compared to ª80% using an occur in the absence of DNA fragmentation whereas in mixed germ cells this correlation ISEL method [20]. Thus we correlated the and vice versa [22,23]. could not be confirmed (Fig. 1C). Considering degree of lymphocyte infiltration separately metastatic status, there was the same with cells showing one or both of these That only in a distinct subgroup of NSGCT was significant correlation for metastatic ECC only features. there a significant correlation between TILs (Fig. 1D). All other subgroups showed no and the AI implicates tumour-specific correlation between lymphoid infiltration and For NSGCT there was no correlation between changes that make tumour cells susceptible any AI. Thus the significant correlation of TILs and the AI in the tumour tissue, except in to lymphocytic attack, resulting in apoptosis lymphoid infiltration and AIchromcond and the subgroup of metastasized ECCs, in which of the tumour cell. Indeed, seminomas have a

Aifrag+cond in all NSGCTs is a consequence of there was a correlation between TILs and different gene expression pattern than do this correlation in metastatic pure ECC. AIchromcond and Aifrag+cond, but not with AIall. From NSGCT [24]; it cannot be excluded that a

LYMPHOCYTE INFILTRATION AND APOPTOSIS IN HUMAN TESTICULAR CARCINOMA

FIG. 1. Spearman rank correlation between TILs and AI in: A, NSGCT (metastatic and not); B, pure ECC were not correlated. Taken together, these (metastatic and not); C, mixed GCTs (metastatic and not); and D, metastasized pure ECC. In A, B and D there results further suggest that subgroups of was a signiﬁcant correlation for AIchromcond and Aifrag+cond but not in C for either. In each plot, a shows Aichromcond NSGCT may have distinct genetic programmes and b AI fr+cond. that can be executed according to apoptotic stimuli. However, the clinical A signiﬁcance in testicular tumours seems a 30 r = 0.320, P = 0.028 b questionable. s rs = 0.299, P = 0.041 25 Although there were too few seminomas 20 treated by surveillance to allow an assessment 15

TIL, % of metastatic and non-metastatic seminomas 10 in the present study, it was clear that the 5 number of TILs did not correlate with the AI in this entity. There might be several reasons for this lack of correlation in most of the NSGCT 01 2 3 4 012345678 subgroups and in seminomas. One could be AI AIchrom cond fr+cond the underestimation of the AI as a result of B rapid phagocytosis. Irrespective of the initiating insult, apoptosis is quick [26], thus a r = 0.495, P = 0.010 b 30 s rs = 0.537, P = 0.004 in any statistical analysis, very few apoptotic 25 cells would be apparent at any given instant, 20 reﬂecting a considerable contribution to cell turnover [27], thus failing to detect any

TIL, % 15 correlation between lymphocyte infiltration 10 and the degree of apoptosis. 5 Another reason might be a disturbed 012345678 01234 interaction between both cell types; Bols et al. AI AIchrom cond fr+cond [18] found CD4+ T cells, CD8+ T cells and B cells present within the infiltrate in similar C proportions, while others found B cells were a b r = -0.160, P = 0.484, ns more sparse [6]. Seminoma cells do not 10 r = 0.173, P = 0.445, ns s s express MHC class I molecules [28] and 8 therefore they are not thought to be 6 susceptible to conventional T cell attack. TIl, % 4 Moreover CD8+ T cells within the infiltrate show low levels of activity, as measured by 2 their expression of perforin [18]. This contradicts the findings of Yakirevich et al. 0123 456 0.0 0.5 1.0 0.5 2.0 [29], who found activated granzyme B+ AIchrom cond AIfr+cond lymphocytes to correlate strongly with the tumour cell AI in testicular seminoma. They D suggested that apoptotic tumour cell death in a 30 b this neoplasm is triggered by this cytotoxic rs = 0.859, P < 0.001 rs = 0.845, P < 0.001 25 granule effector. 20 15 The Fas/FasL system is a further possible TIL, % 10 mechanism of interaction [30,31]. FasL in lymphocytic cell lines is induced by re- 5 stimulation of previously activated T cells, thus executing the organism’s antitumour 0.0 0.5 1.0 0.5 2.0 01234 response by inducing apoptosis in Fas- AI AIchrom cond fr+cond releasing tumour cells [32]. Recently Fas and FasL expression in tumour cells was shown in human seminoma and NSGCT, but there was similar correlation would be found in other The AIs may depend on the size of the tumour, no correlation with the AI. It was suggested pure NSGCTs, and therefore further as with increasing size oxygen and nutritional that the Fas/FasL system is unlikely to be investigations on a larger cohort of pure supply may decrease [25]. Therefore the AIs responsible for immune escape of the tumour NSGCT are necessary. were compared with tumour size, but they in testicular cancer [9,33,34].

SCHMELZ ET AL.

This supports the findings of other groups, transforming growth factor beta as phenotype of tumor infiltrating that apoptosis does not seem to be the key prognostic factors in breast carcinoma. lymphocytes in medullary carcinoma of effector mechanism for lymphocyte-tumour Int J Cancer 1997; 74: 492–501 the breast. Mod Pathol 1999; 12: 1050–6 cell interaction. If it is confirmed that the 6 Bell DA, Flotte TJ, Bhan AK. 18 Bols B, Jensen A, Braendstrup O. number of TILs correlates with a more Immunohistochemical characterization of Immunopathology of in situ seminoma. favourable outcome in patients with seminoma and its inflammatory cell Int J Exp Pathol 2000; 81: 211–7 seminoma, other mechanisms than apoptosis infiltrate. Hum Pathol 1987; 18: 511–20 19 Abend M, Schmelz HU, Kraft K, Rhein should be responsible. 7 Parker C, Milosevic M, Panzarella T et al. AP, van Beuningen D, Sparwasser C. The prognostic significance of the tumor Intercomparison of apoptosis Thus the present results contradict the infiltrating lymphocyte count in stage I morphology with DNA cleavage on single hypothesis that apoptosis is a biological key testicular seminoma managed by cells in vitro and on testis tumors. J Pathol effector of lymphoid infiltration in testicular surveillance. Eur J Cancer 2002; 38: 2014– 1998; 185: 419–26 tumours in most of NSGCT or seminomas. In 9 20 Schmelz HU, Abend M, Port M et al. NSGCT there might be a subgroup that is 8 Schmelz HU, Abend M, Kraft K, Van Comparative analysis of different susceptible to lymphocyte attack, resulting in Beuningen D, Pust R, Sparwasser C. apoptosis detection methods in human apoptosis of the tumour cell, but the clinical Apoptosis in human embryonal cell testicular cancer. Urol Res 2004; 32: 332–7 significance of this finding is questionable. carcinoma: preliminary results. Urol Res 21 Schmoll HJ, Souchon R, Krege S et al. The mechanisms of interaction between 1999; 27: 368–75 European consensus on diagnosis and lymphocytes and testis tumour cells need 9 Schmelz HU, Abend M, Kraft K et al. treatment of germ cell cancer: a report further evaluation. Fas/Fas ligand system and apoptosis of the European Germ Cell Cancer induction in testicular carcinoma. Cancer Consensus Group (EGCCCG). Ann Oncol 2002; 95: 73–81 2004; 15: 1377–99 ACKNOWLEDGEMENTS 10 Podack E. Execution and suicide: cytotoxic 22 Schulze-Osthoff K, Walczak H, Droge lymphocytes enforce Draconian laws W, Krammer PH. Cell nucleus and DNA The authors thank the German Department of through separate molecular mechanisms. fragmentation are not required for Defense who supported this study generously Curr Opin Immunol 1995; 7: 11–6 apoptosis. J Cell Biol 1994; 127: 15–20 (51 K 3 S 14 99 00). 11 Abend M, Port M, Schmelz HU, Kraft K, 23 Cohen GM, Sun XM, Snowden RT, Sparwasser C. Significance of apoptosis Dinsdale D, Skilleter DN. Key in metastasizing testis tumors. Urol Res morphological features of apoptosis may CONFLICT OF INTEREST 2004; 32: 28–35 occur in the absence of internucleosomal 12 Fernandez Y, Gu B, Martinez A, DNA fragmentation. Biochem J 1992; None declared. Source of funding: German Torregrosa A, Sierra A. Inhibition of 286: 331–40 Ministry of Defense. apoptosis in human breast cancer cells: 24 Port M, Schmelz HU, Sparwasser C, role in tumor progression to the Albers P, Pottek T, Abend M. Gene metastatic state. Int J Cancer 2002; 101: expression profiling in seminoma and REFERENCES 317–26 nonseminoma. J Clin Oncol 2005; 23: 58– 13 Richter EN, Oevermann K, Buentig N, 69 1 Mostofi FK, Sesterhenn I. Plenary Storkel S, Dallmann I, Atzpodien J. 25 Grossmann J. Molecular mechanisms of lecture: lymphocytic infiltration in Primary apoptosis as a prognostic index ‘detachment-induced apoptosis-Anoikis’. relationship to urologic tumors. Natl for the classification of metastatic renal Apoptosis 2002; 7: 247–60 Cancer Inst Monogr 1987; 49: 133–41 cell carcinoma. J Urol 2002; 168: 460–4 26 Coles HSR, Brune JF, Raff MC. Large- 2 Torres A, Casanova JF, Nistal M, 14 Scaife CL, Kuang J, Wills JC et al. scale normal cell death in the developing Regadera J. Quantification of Nuclear factor kappaB inhibitors induce rat kidney and its reduction by epidermal immunocompetent cells in testicular adhesion-dependent colon cancer growth factor. Development 1993; 118: germ cell tumors. Histopathology 1997; apoptosis: implications for metastasis. 777–84 30: 23–30 Cancer Res 2002; 62: 6870–8 27 Saraste A. Morphologic criteria and 3 Ansell SM, Stenson M, Habermann TM, 15 Naito Y, Saito K, Shiiba K et al. CD8+ T detection of apoptosis. Herz 1999; 24: Jelinek DF, Witzig TE. CD 4+ T-cell cells infiltrated within cancer cell nests as 189–95 immune response to large B-cell non- a prognostic factor in human colorectal 28 Nouri AM, Hussain RF, Oliver RT, Handy Hodgkin’s lymphoma predicts patient cancer. Cancer Res 1998; 58: 3491–4 AM, Bartkova I, Bodmer JG. outcome. J Clin Oncol 2001; 19: 720–6 16 Oudejans JJ, Jiwa NM, Kummer JA et al. Immunological paradox in testicular 4 Schumancher K, Haensch W, Roefzaad Analysis of major histocompatibility tumours. the presence of a large number C, Schlag PM. Prognostic significance of complex class I expression on Reed- of activated T-cells despite the complete activated CD8(+) T cell infiltrations within Sternberg cells in relation to the cytotoxic absence of MHC antigens. Eur J Cancer esophageal carcinomas. Cancer Res 2001; T-cell response in Epstein-Barr virus 1993; 29A: 1895–9 61: 3932–6 positive and negative Hodgkin’s disease. 29 Yakirevich E, Lefel O, Sova Y et al. 5 Ropponen KM, Eskelinen MJ, Lipponen Blood 1996; 87: 3844–51 Activated status of tumour-infiltrating PK, Alhava E, Kosma VM. Prognostic 17 Yakirevich E, Ben Izhak O, Rennert G, lymphocytes and apoptosis in testicular value of tumor infiltrating and Kovacs ZG, Resnick MB. Cytotoxic seminoma. J Pathol 2002; 196: 67–75

30 Nagata S, Goldstein P. The Fas death 33 Braendstrup O, Bols B, Jensen L. Fas and Hospital, Oberer Eselsberg 40, 89081 Ulm, factor. Science 1995; 267: 1449–56 Fas-ligand expression in seminomatous Germany. 31 Suda T, Okazaki T, Naito Y et al. testes. APMIS 1999; 107: 431–6 e-mail: [email protected] Expression of the Fas ligand in cells of T 34 Sugihara A, Saiki S, Tsuji M cell lineage. J Immunol 1995; 154: 3806– et al. Expression of Fas and Fas Abbreviations: TIL, tumour-inﬁltrating 13 ligand in the testes and testicular germ lymphocytes; (nonseminomatous), germ cell 32 Alderson MR, Armitage RJ, cell tumors: an immunhistochemical tumour; AI, apoptotic index; ECC, embryonal Maraskowsky E et al. Fas transduces study. Anticancer Res 1997; 17: 3861–5 cell carcinoma; CS, clinical stage; ISEL, in-situ activation signals in normal human T- end-labelling; FITC, ﬂuorescein lymphocytes. J Exp Med 1993; 178: 2231– Correspondence: Hans U. Schmelz, isothiocyanate; DAPI, 4¢,6-diamidino-2- 5 Department of Urology, Federal Armed Forces phenylindole.

In vivo and in vitro response of corpus cavernosum to phosphodiesterase-5 inhibition in the hypercholesterolaemic rabbit

FARZEEN FIROOZI, PENELOPE A. LONGHURST and MARK D. WHITE Division of Urology, Albany Medical College, and Department of Basic and Pharmaceutical Sciences, Albany College of Pharmacy, Albany, New York, USA Accepted for publication 28 January 2005

OBJECTIVE nitroprusside (SNP) and PDE-5 inhibitors were except 1 Hz. Corpora from both HC and evaluated for 2 h in conscious rabbits. Penile control rabbits had greater responses to EFS To investigate the effects of length was measured and the area under the after exposure to vardenafil and sildenafil; N¢- hypercholesterolaemia (HC) on rabbit corpus curve calculated. Relaxant responses of nitro-L-arginine methyl ester diminished the cavernosa in vivo and in vitro, and evaluate corpus cavernosal strips to electrical-field response to EFS. the efficacy of vardenafil and sildenafil stimulation (EFS) were measured before and in normal and HC rabbits, as the after exposure to PDE-5 inhibitors and the CONCLUSIONS phosphodiesterase-5 (PDE-5) inhibitors nitric oxide synthase inhibitor N¢-nitro-L- vardenafil and sildenafil are widely used for arginine methyl ester. There was a significantly lower in vivo and in treating erectile dysfunction (ED) and most vitro erectile response in HC rabbits than in organic causes of ED are associated with controls; erectile function measured in vascular risk factors like HC. RESULTS conscious rabbits can be used to assess quantitatively the efficacy of different agents, HC rabbits had a lower erectile response to e.g. sildenafil and vardenafil, in pathological MATERIALS AND METHODS SNP than controls; in both control and HC animals. In addition, both agents improve in rabbits there was a greater erectile response vitro responses of erectile tissue from HC Male New Zealand White rabbits were after simultaneous exposure to SNP and rabbits to EFS. randomly divided into two groups; 11 HC vardenafil, or SNP and sildenafil. However, the rabbits were fed a 2% cholesterol diet, and 12 responses of the HC rabbits were still KEYWORDS age-matched control rabbits received a significantly less than those of the controls. regular diet. After 12–14 weeks, erectile Corpora from control rabbits responded to erectile dysfunction, hypercholesterolaemia, responses to intravenous sodium EFS with greater relaxations at all frequencies, nitric oxide, rabbit

INTRODUCTION smooth muscle contraction with concomitant independent) relaxation of corporal smooth detumescence [2]. muscle, were not responsible for the HC- Penile erection depends on smooth muscle induced impairment of erectile function [8]. relaxation effected by endothelial and neural There are several causal factors involved factors [1]. The main neurotransmitter in male erectile dysfunction (ED), i.e. With greater knowledge of the physiology of responsible for the erectile response is nitric psychogenic, organic, pharmacological and penile erection, the management of ED oxide (NO), produced by innervated vasculogenic. Most cases of ED are associated changed dramatically about a decade ago endothelium in the corpora cavernosa [2]. In with vascular risk factors, e.g. hypertension, with the advent of the selective PDE-5 addition, other neurotransmitters, e.g. hypercholesterolaemia (HC), diabetes and inhibitor, sildenafil [9]. The efficacy of noradrenaline, have been shown to be smoking [4]. These factors have been shown sildenafil was confirmed in vivo and in vitro, in involved in erectile function [3]. By to cause atherosclerotic changes in penile both animal and human studies [9,10]. Newer stimulating the formation of the intracellular arteries, which in turn result in poor arterial agents, which include vardenafil and tadalafil second messenger cGMP, a cascade of events inflow [5]. In addition, these factors impair have also been approved [11–15]. Recent is initiated, which results in smooth muscle endothelium-mediated relaxation of blood studies comparing the efficacy of sildenafil dilatation and ultimately the erectile response vessels [6,7]. Recent studies showed that HC and vardenafil show that the latter was [2]. Conversely, the erectile response is inhibits endothelium-dependent relaxation of significantly more effective than sildenafil in eventually terminated when cGMP-specific rabbit corpus cavernosum smooth muscle [8], facilitating erection in anaesthetized rabbits phosphodiesterases (PDEs) catalyse the and that changes in the formation of [10]. In addition, using normal animals, a hydrolysis of cGMP to 5¢-GMP, thus halting arachidonate and cyclooxygenase products, conscious-rabbit penile-erection model was the cascade of reactions and leading to or in cGMP-dependent (endothelium- designed for the same purposes of evaluating

RESPONSES OF CORPUS CAVERNOSUM FROM HC RABBITS TO PDE-5 INHIBITION

FIG. 1. The length of uncovered penile mucosa rabbits by measuring intracavernosal Grass Instruments, Quincy, MA). The changes measured after intravenous (A) SNP (0.2 mg/kg), (B) pressures. A clear disadvantage with this in muscle tension were recorded on a sildenafil (5 mg/kg) and SNP, and (C) vardenafil approach is the possible effect of anaesthesia polygraph (7E, Grass Instruments). All strips (0.5 mg/kg) and SNP in conscious control (green on erectile function in the animal, and were stretched to a resting tension of 1 g and closed circle) and HC rabbits (red closed square). consequently the studies may tend to be less washed for 30 min with Krebs solution to *P <0.05 vs control. physiological. The conscious-rabbit penile establish equilibrium. After this period the erection model bypasses this possible flaw by length of the strips was measured. The strips a not requiring any anaesthetic [17]. This new were pre-contracted with 1 mmol/L 6 model has not been used for rabbits in a noradrenaline. After the contraction reached 5 pathological state. Thus we investigated the a plateau the strips were subjected to 4 effects of HC on erectile function in rabbits, electrical-field stimulation (EFS) using ring using both in vitro and in vivo methods, and platinum electrodes. The strips were 3 the effect of sildenafil and vardenafil on stimulated with increasing frequencies (1, 2, 2 erectile function in HC rabbits, with objective 4, 8, 16 and 32 Hz) for 15 s at 80 V for 0.01 ms

Penile length, mm 1 of evaluating whether PDE-5 inhibitors could with a 3-min interval between stimulations. ** 0 * improve in vitro and/or in vivo erectile The strips were then washed in Krebs and re- function in this pathological state. equilibrated for 30 min. The strips were then 0 10 20 30 60 120 incubated with one of the following: Krebs Time after SNP, min solution (time control), N¢-nitro-L-arginine b MATERIALS AND METHODS methyl ester (L-NAME, 100 mmol/L), sildenaﬁl, 25 or vardenaﬁl (10 mmol/L) for 30 min, pre- Adult male New Zealand White rabbits contracted again with noradrenaline, and 20 (Millbrook Breeding Laboratories, Amherst, subjected again to EFS as described. MA) were randomly divided into two groups 15 fed normal control diets or diets containing All data are expressed as the mean (SEM); the 10 2% cholesterol (Purina LabDiet, St. Louis, area under the curve (AUC) for the erectile ** * Missouri). For the in vivo study, after response was calculated as penile length

Penile length, mm 5 ** * * 12–14 weeks on the diets, rabbits were (mm) ¥ time of measurement (min). Relaxant 0 randomly chosen and placed in a restraining responses to EFS are expressed relative to the device. Three rabbits from each group pre-contraction response to noradrenaline. 0 10 20 30 60 120 received intravenously (via the lateral ear Groups were compared using Student’s t-test Time after Sildenafil + SNP, min vein) one of: sodium nitroprusside (SNP, or ANOVA, followed by Bonferroni analysis, as c 0.2 mg/kg) followed immediately by saline, appropriate, with P < 0.05 taken to indicate 25 SNP followed immediately by sildenafil significant differences. (5 mg/kg), or SNP followed immediately by 20 vardenafil (0.5 mg/kg) [17]. The volumes RESULTS 15 introduced intravenously were 0.1 mL/kg for SNP and 2.5 mL/kg for the PDE-5 inhibitors. HC rabbits weighed significantly less than 10 The length of uncovered penile mucosa was controls after 12–14 weeks on the 2% ** ** measured with callipers at 0, 2.5, 5, 7.5, 10, 15, cholesterol diet, at a respective mean (SEM) of Penile length, mm 5 * * * 20, 30, 60 and 120 min, as described by 3.04 (0.12) and 4.21 (0.05) g, and had * 0 Bischoff and Schneider [17]. significantly higher blood cholesterol, at 6284 (677) and 193 (10) mg/L, and 0 10 20 30 60 120 For the in vitro study, rabbits were triglyceride levels, at 2034 (304) and 779 Time after Vardenafil + SNP, min anaesthetized with intravenous ketamine (110) mg/L, respectively. Two rabbits in the HC (25 mg/kg) and blood drawn from the inferior group died during the study (one at 9 and the vena cava to measure plasma cholesterol, other at 10 weeks) secondary to severe potential efficacy of these agents, with no using the Cholesterol-SL and Triglyceride-SL aortic occlusion resulting from marked need for complicated surgery and the assay kits (Diagnostic Chemicals Ltd, atherosclerotic disease, and were excluded associated disadvantages of the open method Charlottetown, Prince Edward Island, Canada). from the study. [16–18]. The investigators were able to The entire penis was then removed, the corpus quantify erectile response to various agents cavernosa dissected into two or three strips of In the in vivo study, SNP-stimulated erections reproducibly and consistently. 2 ¥ 10 mm, and the strips then suspended in were <6 mm long and lasted <10 min. The organ chambers filled with 10 mL Krebs erectile response of the HC group to SNP was Although HC has been shown to cause solution (containing indomethacin 10 mmol/L) significantly less than that of the control reduced erectile function in rabbits in in vitro and equilibrated with 95% O2/5% CO2 at 37∞C. group (Fig. 1A). Intravenous vardenafil studies it has yet to be confirmed in a (0.5 mg/kg) with SNP caused a significant conscious in vivo model. Most models used Each strip was attached by a 3-0 silk ligature increase in erectile response in both groups previously assessed erectile function in to a force-displacement transducer (FT0.03, (Fig. 1). The maximum was at 2.5 and 5 min,

FIROOZI ET AL.

FIG. 2. Relaxation of corpus cavernosum smooth 100 FIG. 3. muscle from 12 control (green circles) and 11 HC Relaxation of corpus cavernosum * rabbits (red squares) to EFS before treatment with * smooth muscle from 12 control 80 * * drugs. *P <0.05 vs control. * rabbits to EFS before (green closed line response

a circles) and after treatment with 60 * * ren sildenaﬁl (1 mmol/L, red closed ad squares), vardenaﬁl (1 mmol/L, 100 * * * * 40 * light green open circles), or L- 80 line response * * * m a * NAME (100 mol/L, light red open tion, % nor ren 60 a 20 * squares). *P < 0.05 vs before drug x

ad * a treatment.

40 Rel * 0 20 1 2 4 8 16 32 tion, % nor

a Frequency, Hz x 0 a 124816 32 Rel Frequency, Hz and thereafter penile length gradually 100 FIG. 4. decreased over the 2-h period. The erectile * Relaxation of corpus cavernosum response of the HC group to SNP and * smooth muscle from 11 HC rabbits 80 * vardenafil was significantly less than that of * * to EFS before (green closed circles) the control group (Fig. 1B). The AUC was and after treatment with line response * significantly greater in control rabbits a 60 sildenafil (red closed squares), ren * receiving SNP and vardenafil than in those ad * vardenafil (light green open receiving SNP alone, and significantly greater 40 circles), or L-NAME (light red open than that of HC rabbits receiving SNP and * squares). *P < 0.05 vs before drug vardenafil (Table 1). treatment. tion, % nor 20 a x a Intravenous sildenafil (5 mg/kg) with SNP Rel caused a significantly greater amplitude of 0 12481632 response and AUC than in rabbits given SNP alone (Fig. 1A,C and Table 1). Controls had a Frequency, Hz significantly greater amplitude and AUC than HC rabbits (Figs 1C and Table 1). The onset of action and time course of erection were TABLE 1 The effects of intravenous SNP, sildenafil and vardenafil on the duration of the erectile response, similar to those with vardenafil (Fig. 1B,C). The calculated as the AUC of erectile response maximum amplitude, similar to that with vardenafil, was at 2.5 and 5 min, with Mean (SEM) AUC Control HC erections waning over the 2-h period. SNP 22.08 (3.25) 2.19 (2.19)* + sildenafil 567.9 (49.4)† 176.3 (21.9)* In the in vitro study, there was no difference in + vardenafil 616.3 (10.3)† 181.3 (16.35)* contractile response to noradrenaline between corporal strips from the HC and *P < 0.05 vs control; †P < 0.05 vs SNP alone. control groups (data not shown). Relaxation of corpus cavernosum smooth muscle in response to EFS was significantly less in strips from the HC group than controls at all the presence of the PDE-5 inhibitors. L-NAME the PDE-5 inhibitors. L-NAME decreased the frequencies except 1 Hz (Fig. 2). There was no caused a significant decrease in the relaxant relaxant response at 16 Hz only (Fig. 4). significant effect of time on the relaxant response of corpora from controls at 16 and response of strips to EFS in either group; 32 Hz (Fig. 3). DISCUSSION repeating the frequency-response curve with no PDE-5 inhibitors caused similar responses The effects of PDE-5 inhibition were The aim of the present study was two-fold: to the first curve (data not shown). Corporal qualitatively similar in corpora from HC first, to determine if there was a difference in strips from control rabbits had significantly rabbits, but the changes were significantly in vivo and in vitro erectile responses of greater relaxant responses to EFS after smaller. Incubation with sildenafil and control and HC rabbits to PDE-5 inhibition, incubation with both sildenafil and vardenafil vardenafil increased the relaxant response and second, to determine whether these at all frequencies (Fig. 3). There were no significantly at most frequencies (Fig. 4); agents could stimulate erections measured in significant differences between responses in there was no significant difference between conscious HC rabbits. HC rabbits had

RESPONSES OF CORPUS CAVERNOSUM FROM HC RABBITS TO PDE-5 INHIBITION

significantly lower in vitro and in vivo erectile Schneider [17], to bypass the complicated Grant in Aid. Support was also provided by the responses than the controls, and treatment surgery required to monitor intracavernosal Division of Urology, Albany Medical College. with the PDE-5 inhibitors improved both in pressure, and the potential inhibitory effects Sildenafil hydrochloride (UK-92,480–11) was vitro and in vivo erectile responses in controls of anaesthesia on erectile function. Although a gift from Pfizer, Sandwich, England. and, to a significantly lesser extent, HC the efficacy of sildenafil and vardenafil had Vardenafil hydrochloride was a gift from rabbits. been tested using this method in normal Bayer, AG, Leverkusen, Germany. L-NAME, rabbits, the efficacy had not been confirmed noradrenaline hydrochloride and SNP were Relaxation of the corpus cavernosum smooth in a pathological animal model. In the absence obtained from Sigma Chemical Co., St. Louis, muscle requires an intact penile endothelium of sexual stimulation the method requires a Missouri. [8,19–21]. Recent studies showed that HC source of NO, provided by SNP. There was a impairs endothelium-dependent relaxation significant potentiation of the erectile in the corpus cavernosum smooth muscle response in control rabbits when given either CONFLICT OF INTEREST [8]. The mechanism is postulated to be sildenafil or vardenafil with SNP, and a greater multifactorial. The main attributed factor is overall duration of erectile response M.D. White was the recipient of a North- the impaired ability of the endothelium to (measured as the AUC) with the combined eastern Section AUA Grant for research produce NO, a key component in the pathway treatments. Sildenafil (5 mg/kg) and support. of erectile response [2,8]. Other studies vardenafil (0.5 mg/kg) were equally effective showed that atherosclerotic, ischaemia- in terms of the timing of the greatest induced corporal veno-occlusive dysfunction amplitude of the erectile response and AUC in REFERENCES may result in alterations in corpus control rabbits. cavernosum smooth muscle relaxation or 1 Andersson KE. Erectile physiological and changes in structural properties of erectile In HC rabbits there was also a significantly pathophysiological pathways involved in tissue [20,21]. As the erectile response relies greater amplitude of erectile response and erectile dysfunction. J Urol 2003; 170: on intact endothelium and its production of AUC after treatment with sildenafil or S6–13 NO, we attempted to show the efficacy of vardenafil with SNP. As in the control group, 2 Kim N, Azadzoi KM, Goldstein I et al. different PDE-5 inhibitors, both in vitro and in there were no significant differences between A nitric oxide-like factor mediates vivo, in HC rabbits and the influence of L- the chosen doses of sildenafil and vardenafil nonadrenergic-noncholinergic NAME, a NOS inhibitor that decreases NO when comparing the time of greatest erectile neurogenic relaxation of penile corpus formation. amplitude or AUC in HC rabbits. However, we cavernosum smooth muscle. J Clin Invest confirmed the utility of the conscious-rabbit 1991; 88: 112–8 As expected, the in vitro studies showed penile erection model for evaluating the 3 Diederichs W, Stief CG, Lue TF et al. a lower relaxant response of corpus efficacy of different agents in animals in this Norepinephrine involvement in penile cavernosum smooth muscle strips in the HC pathological state. detumescence. J Urol 1990; 143: 1264–6 group than in controls. There was no 4 Johannes CB, Araujo AB, Feldman HA significant difference in the contractile Thus we successfully used the conscious- et al. Incidence of erectile dysfunction in response of corpus cavernosum smooth rabbit penile erection model to test the men 40–69 years old: longitudinal results muscle from control or HC rabbits to efficacy of different agents for improving from the Massachusetts Male Aging noradrenaline, as reported previously [8]. erectile function, in both normal and HC Study. J Urol 2000; 163: 460–3 Confirming these studies, there were no rabbits. The ability to use this test with 5 Virag R, Bouilly P, Frydman D. Is significant differences in the relaxant consistent reproducibility on HC rabbits, impotence an arterial disorder? A study of responses of corpus cavernosa of control showing significant differences from control arterial risk factors in 440 impotent men. rabbits after treatment with sildenafil and rabbits, allows experiments with other Lancet 1985; 1: 181–4 vardenafil [8]. Despite an impaired ability to controlled disease states that may impair 6 Saenz de Tejada I, Goldstein I, Azadzoi relax in response to EFS under control erectile function. We showed that in vivo, K et al. Impaired neurogenic and conditions, which was consistent with the erectile function is probably affected by endothelium-mediated relaxation of findings of Azadzoi et al. [8] in their study atherosclerotic disease (as reduced blood flow penile smooth muscle from diabetic men showing impaired endothelium lacking the and hampered innervation), and in vitro, with impotence. N Engl J Med 1989; 320: appropriate NO production as the causative secondary to decreased NO from an impaired 1025–30 factor, we showed a significant increase in endothelium. With this knowledge the 7 Nehra A, Azadzoi KM, Moreland RB relaxant responses of corpus cavernosum present findings in the HC rabbit can be et al. Cavernosal expandability is an smooth muscle from HC rabbits after applied to the current management of ED in erectile tissue mechanical property treatment with sildenafil or vardenafil. Similar humans with atherosclerotic disease which predicts trabecular histology in to the present findings in the control animals, secondary to HC. an animal model of vasculogenic erectile there were no significant differences between dysfunction. J Urol 1998; 159: 2229–36 the effects of vardenafil and sildenafil on 8 Azadzoi KM, Saenz de Tejada I. responses to EFS. ACKNOWLEDGEMENTS Hypercholesterolemia impairs endothelium-dependent relaxation of For the in vivo studies we used the conscious- Dr White was the recipient of a North-eastern rabbit corpus cavernosum smooth rabbit model described by Bischoff and Section of the AUA Post-residency Research muscle. J Urol 1991; 146: 238–40

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9 Goldstein I, Lue TF, Padma-Nathan H erectile dysfunction. BJU Int 2003; 91: 20 Azadzoi KM, Siroky MB, Goldstein I. et al. Oral sildenafil in the treatment of 466–8 Study of etiologic relationship of arterial erectile dysfunction. The Sildenafil Study 15 Brock GB, McMahon CG, Chen KK et al. atherosclerosis to corporal veno- Group. N Engl J Med 1998; 338: 1397– Efficacy and safety of tadalafil for the occlusive dysfunction in the rabbit. J Urol 404 treatment of erectile dysfunction: results 1996; 155: 1795–800 10 Choi S, O’Connell L, Min K et al. Efficacy of integrated analyses. J Urol 2002; 168: 21 Azadzoi KM, Goldstein I, Siroky MB of vardenafil and sildenafil in facilitating 1332–6 et al. Mechanisms of ischemia-induced penile erection in an animal model. 16 Bischoff E. Rabbits as models for cavernosal smooth muscle relaxation J Androl 2002; 23: 332–7 impotence research. Int J Impot Res 2001; impairment in a rabbit model of 11 Saenz de Tejada I, Angulo J, Cuevas P 13: 146–8 vasculogenic erectile dysfunction. J Urol et al. The phosphodiesterase inhibitory 17 Bischoff E, Schneider K. A conscious- 1998; 160: 2216–22 selectivity and the in vitro and in vivo rabbit model to study vardenafil potency of the new PDE5 inhibitor hydrochloride and other agents that Correspondence: Farzeen Firoozi, Division of vardenafil. Int J Impot Res 2001; 13: influence penile erection. Int J Impot Res Urology, Albany Medical College, South 282–90 2001; 13: 230–5 Clinical Campus, 23 Hackett Boulevard, 12 Montorsi F, Hellstrom WJ, Valiquette L 18 Bischoff E, Niewoehner U, Haning H Albany, NY 12208–3499, USA. et al. Vardenafil provides reliable efficacy et al. The oral efficacy of vardenafil e-mail: [email protected] over time in men with erectile hydrochloride for inducing penile erection dysfunction. Urology 2004; 64: 1187–95 in a conscious rabbit model. J Urol 2001; Abbreviations: SNP, sodium nitroprusside; 13 Hellstrom WJ, Gittelman M, Karlin G 165: 1316–8 AUC, area under the curve; NO(S), nitric oxide et al. Vardenafil for treatment of men with 19 Azadzoi KM, Kim N, Brown ML et al. (synthase); PDE, phosphodiesterase; ED, erectile dysfunction: efficacy and safety Endothelium-derived nitric oxide and erectile dysfunction; HC, in a randomized, double-blind, placebo- cyclooxygenase products modulate hypercholesterolaemia(ic); EFS, electrical- controlled trial. J Androl 2002; 23: 763–71 corpus cavernosum smooth muscle tone. field stimulation; L-NAME, N¢-nitro-L- 14 Holmes S. Tadalafil: a new treatment for J Urol 1992; 147: 220–5 arginine methyl ester.

Effect of bladder ischaemia/reperfusion on superoxide dismutase activity and contraction

ERIM ERDEM*, ROBERT LEGGETT, BRIAN DICKS†, BARRY A. KOGAN† and ROBERT M. LEVIN Albany College of Pharmacy and Stratton VA Medical Center, †Urology, Albany Medical College, Albany, New York, USA, and *Urology Department, Mersin University School of Medicine, Mersin, Turkey Accepted for publication 27 January 2005

OBJECTIVES contractile studies. The contractile responses the muscle, and was significantly reduced to field stimulation, carbachol (10 mmol/L), by both ischaemia and all times of To correlate the effect of bilateral in-vivo ATP and KCl were determined. The balance of reperfusion. bladder ischaemia/reperfusion on superoxide the bladder body was separated into muscle dismutase activity (SOD) and then to correlate and mucosa sections and analysed for SOD CONCLUSIONS this with contractile responses to various activity. forms of stimulation. These studies show clearly that both RESULTS ischaemia and reperfusion result in MATERIALS AND METHODS significantly lower activity of SOD, and in There were few effects on contraction either contractile dysfunctions, and that reperfusion Twenty mature male New Zealand White directly after ischaemia or after 1 day of results in greater decreases in both SOD rabbits were divided into five equal groups: reperfusion. However, all contractile activity and contractile responses than group 1 (controls); group 2, 2 h of in-vivo responses were significantly reduced at 7 and ischaemia alone. bilateral bladder ischaemia; and groups 3–5, 14 days after ischaemia. SOD activity of the 2 h of in-vivo ischaemia followed by 1, 7 or detrusor muscle was reduced significantly KEYWORDS 14 days of reperfusion (recovery). At the end immediately after ischaemia and at 7 and of the treatment period, bladder strips were 14 days of reperfusion. SOD activity of the bladder, superoxide dismutase, ischaemia, incubated and placed in isolated baths for mucosa was significantly greater than that of reperfusion

INTRODUCTION addition to partial BOO, acute overdistension SOD would be important to the recovery of (retention) has also been shown to result in the bladder. We have direct evidence The function of the lower urinary tract is ischaemia [11]. Also, rabbits fed a high (unpublished observations) that partial BOO collecting and storing urine at low pressures cholesterol diet developed severe ischaemia results in the generation of free radical and expelling it by maintaining adequate and contractile dysfunction of the lower damage to detrusor smooth muscle proteins, intravesical pressures [1,2]. Normal bladder urinary tract [7,12]. which supports the importance of SOD within function depends on the integrity of its the bladder. autonomic innervation, cellular structure and A recent study indicated that reperfusion may metabolism [1,2]. Currently it is thought that cause a more severe injury than ischaemia The specific aim of the present study was to various bladder disorders, including alone [13]. Further evidence for an ischaemic determine the effects of bilateral ischaemia obstructive bladder dysfunction, cause of obstructive and ischaemic bladder (in a model of pure I/R) on SOD activity and to hyperactivity, hypercholesterolaemia and disorders comes from studies showing correlate it with the effects on contractile diabetes, may in part be caused by ischaemia/ that phytotherapeutic products rich in responses to various forms of stimulation. reperfusion (I/R) injury [3–7]. For partial BOO, antioxidants have significant protective Greenland et al. [5,6] showed clearly that in effects on rabbits subjected to both partial normal pigs, bladder contraction during BOO and in vivo ischaemia [14–16]. MATERIALS AND METHODS micturition results in cyclical decreased blood flow and simultaneous decreased tissue- Superoxide dismutase (SOD) is the cell’s chief Twenty mature male White New Zealand oxygen tension, both of which recovered after defence against activated-oxygen free rabbits were divided into five equal groups: voiding. In pigs with partial BOO the radicals; it comprises a family of enzymes, of group 1 (controls); group 2, 2 h of in vivo ischaemia and tissue hypoxia were which three unique members have been bilateral ischaemia; and groups 3–5, 2 h of significantly and substantially greater. described [17,18]. They all act by converting ischaemia followed by 1, 7 or 14 days of Reperfusion after the cyclical periods of superoxide to peroxide which is then further reperfusion (recovery), respectively. At the end ischaemia/hypoxia would also be significantly broken down by catalase to oxygen and water. of the experimental period each rabbit was greater in these pigs. Decreased blood flow Because I/R is a major causal factor in the anaesthetized and the bladder rapidly excised; (ischaemia) has also been shown in rat, rabbit pathological response of the rabbit to partial two bladder strips were prepared from the and dog models of partial BOO [8–10]. In BOO and other disorders [3–12], activation of bladder body for contractility studies. The

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balance of the bladder body was separated by 10 FIG. 1. blunt dissection into muscle and mucosa Contractile responses of the sections, frozen in liquid nitrogen, and stored control bladder. Each bar is the ss

a 8 at -70 ∞C for biochemical analysis of SOD. mean (SEM) of four individual e m

u bladders. To create ischaemia, each rabbit was 6 anaesthetized with isoﬂuorane (1–3%) and

the bladder base exposed. The vesical ctile response, g 4 arteries were isolated and clamped with a

microvascular clamps for 2 h, after which the Contr

tension/100 mg tiss 2 bladder was either immediately excised (group 2) or the clamps removed and the wound closed with 2–0 silk in layers for 1, 7 or 0 14 days (groups 3–5). 2 Hz 8 Hz 32 Hz ATP Carb KCl

Each strip was mounted in a separate 15-mL xanthine oxidase reactions with with P < 0.05 taken to indicate statistical bath containing Tyrode’s solution (in mmol/L; ferricytochrome C. SOD activity is calculated signiﬁcance.

124.9 NaCl, 2.6 KCl, 23.8 NaHCO3, 0.5 MgCl2, from the degree of inhibition of this reaction

0.4 NaH2PO4, 1.8 CaCL2 and 5.5 dextrose) at and recorded as the change in optical density 37 ∞C. Tissues were equilibrated with a (mOD) at 550 nm (using a spectrophotometer) RESULTS mixture of 95% O2 and 5% CO2 at 2 g tension per milligram of protein. for 120 min to allow for full recovery of ATP Figure 1 shows the maximum responses to after ischaemia. In a previous study we Specifically, bladder tissue was homogenized the various forms of stimulation used, and correlated the rate of recovery of contractile in a 50-mmol/L phosphate buffer (pH 7.8) at Fig. 2a the effect of bilateral ischaemia on the function with the rate of recovery of the 200 mg/mL. The homogenate was centrifuged contractile responses to FS. Data are intracellular ATP concentration after 60 min at 18 000 g for 10 min. The pellet was presented as the percentage of the control of in-vitro anoxia. Maximal contractile and eliminated and the supernatant used for the response. The response to FS at 2 Hz was ATP was recovered after 60 min, thus we were following assay: 2 mL of solution A (0.76 mg decreased by ischaemia alone; there was no confident in using 120 min to allow for full xanthine in 10 mL of 1 mmol/L NaOH, added significant difference in the responses after recovery [13]. to 50 mg cytochrome C +3.7 mg EDTA in 1 day of reperfusion but after 7 days all were 100 mL 50 mmol/L phosphate buffer) at 25 ∞C significantly less, and further reduced at One end of each strip was connected to a was incubated with 50 mL of the tissue sample 14 days. Fig. 2b shows the effect of bilateral force-displacement transducer and or SOD standards in a 3-mL cuvette; 200 mL ischaemia on the contractile responses to ATP, contractile responses recorded using a Model of solution B (5.63 mL xanthine oxidase in carbachol and KCl. The response to ATP was D Polygraph (Grass Instruments, Quincy, MA). 1 mL 0.1 mmol/L EDTA) was used to start the decreased by ischaemia alone and after all The signal was then digitized using the reaction. After mixing, the absorbance change periods of reperfusion; there were no Polyview A/D (Grass Instruments) computer indicating cytochrome C reduction was significant differences in the responses after analytical system. measured in a spectrophotometer at 550 nm ischaemia alone or after 1 day of reperfusion for 2 min. The change in absorbance with time for carbachol or KCl. The responses at 7 days Field stimulation (FS) was applied using over the first 2 min for all preparations was after ischaemia for carbachol and KCl were platinum electrodes set on each side of the linear, and used in the plots shown. significantly lower and further reduced at muscle strip, using a stimulator (S-88, Grass 14 days. In general, the responses to FS were Instruments) delivering square-wave pulses Responses were compared quantitatively as significantly more sensitive to reperfusion of 80 V and 1 ms duration at 2, 8 and 32 Hz. the concentration of enzyme (protein) that than to either carbachol or KCl.

FS was maintained for 20 s, the tension inhibited the reaction by 25% (IC25); although recorded and calculated as grams tension/ the IC50 is used more widely, several of the Figure 3 shows the SOD activity curve for

100 mg tissue. preparations did not reach 50% inhibition. For purified SOD; the IC25 was 0.5 ng/mL. The SOD comparison the reaction curve of pure SOD is activity curves for detrusor smooth muscle Following FS, maximal responses were also given. and mucosa are shown in Fig. 4a,b with a determined sequentially for 1 mmol/L ATP, comparison of the IC25 in Fig. 5. In both 20 mmol/L carbachol and 120 mmol/L KCl. Purified SOD (Sigma Chemical Co., St Louis, muscle and mucosa the control bladders had Between the pharmacological stimulations, MO) was prepared at 25 ng/mL and diluted 1 : the highest SOD activity (the greater the rate each strip was washed three times with fresh 1 to 0.39 ng/mL for a standard curve, with of mOD decrease the greater the activity). Tyrode’s solution at 15 min intervals. specificity confirmed by heating both The activity of the control mucosa was preparations for 10 min at 90 ∞C, which significantly greater than that of the control SOD (total) activity was determined by the eliminated all activity. muscle. Ischaemia alone resulted in method of Flohe and Otting [19], using a significant decreases in SOD activity in both cytochrome C reduction test. In this model, Data were assessed using ANOVA followed by a muscle and mucosa. In the muscle, the oxygen free radicals are generated by Bonferroni test for individual differences, activity increased to control levels at 1 day of

EFFECT OF BLADDER ISCHAEMIA/REPERFUSION ON SOD ACTIVITY AND CONTRACTION

FIG. 2. Effect of bilateral I/R with time on the contractile responses to a, FS and b, ATP, carbachol and KCl. Each FIG. 3. The activity of purified SOD; each point is the bar is the mean (SEM) response in four individual bladders. *P < 0.05, significantly different from the response mean (SEM) of four individual preparations, with of control bladders, . activity quantified as the IC25.

a 0.30 160 0.25 0.20 140 0.15 0.10 120 Activity, mOD 0.05 100 0.00 0 5 10 15 20 25 * SOD concentration, ng/mL 80 * 60

ctile response, % of control * a * compression of the blood vessels (probably * 40 the veins) and results in decreased blood flow Contr * and tissue hypoxia. As mentioned above, this * has been shown best in studies on the 20 obstructed pig. Partial BOO resulted in significant cyclical ischaemia-hypoxia. When 0 the bladder empties, the contraction results in Reperfusion days 01714 01714 01714 significant ischaemia and tissue hypoxia, 2 832followed by a rapid increase in blood flow Field stimulation, Hz (reperfusion) during bladder filling [3,5,6].

b In both animal models and man, bladder 140 overdistension (retention) results in significant decreases in blood flow. 120 Decompression (catheterization and rapid emptying) of the bladder results in a rapid and significantly increased blood flow for a period 100 [22,23]; it is this rapid increase in blood flow * that results in the generation of reactive * oxygen and nitrogen species that can then 80 * * * cause oxidative damage to lipids, proteins and DNA. Similarly, in the present model of 60 * * bilateral ischaemia the clamped arteries induce a period of ischaemia which is then ctile response, % of control a followed by a period of reperfusion when the 40 clamped arteries are released [13]. Contr

20 * Previous studies have indicated that after bilateral ischaemia, injury caused by reperfusion is worse than ischaemic injury 0 Reperfusion days 01714 01714 01714 alone, by the increase in free oxygen radicals [13]. These studies support the importance of ATP Carbachol KCl SOD in the response of the bladder to I/R insults. reperfusion but remained low in the mucosa. DISCUSSION Hypercholesterolaemia, induced by feeding The SOD activity of the muscle decreased to rabbits a high-cholesterol diet, results in very low levels at 7 days of reperfusion and Ischaemia and reperfusion have been significant atherosclerosis, which mediates recovered somewhat by 14 days, although implicated as important causes in lower urinary tract ischaemia and hypoxia; still significantly low. The SOD of the mucosa deteriorating bladder function [3–13,20–25]. the result is compromised contractile remained low at 7 days and was reduced Whenever the bladder contracts, the function [7,12]. Partial BOO and in vivo further at 14 days. increased intra-wall pressure results in ischaemia result in significant increases in

ERDEM ET AL.

+2 cytosolic free Ca that then activate speciﬁc a FIG. 4. calcium-activated hydrolytic enzymes, SOD activity of a, smooth muscle, 0.4 including calpain and phospholipases A2 and b, mucosa, in the control [24,25]. Both these enzymes result in (green open circles), ischaemic (no signiﬁcant cellular and subcellular membrane reperfusion, light green closed 0.3 damage, that participates in the disruptive circles) and I/R groups (squares; 1 effects of partial BOO and ischaemia on day, red closed; 7 day, red open; 14 bladder function. day, light red closed); each point is 0.2

ctivity, mOD the mean (SEM) of four individual a Another line of evidence that free radical preparations. damage is important in obstructive and SOD 0.1 ischaemic injury comes from studies showing that natural products high in antioxidants protect the bladder against both functional 0.0 and biochemical damage induced by partial 0246810 BOO and ischaemia [14–16]. These products Protein, mg/mL and agents include Tadenan (Pygeum africanum), Kohki tea and grape products b [14–16]. Perhaps the strongest evidence is 0.4 that the antioxidant vitamin E was one of the most potent protective agents against 0.3 obstructive damage [26]. In addition to this indirect evidence, there is now direct evidence (unpublished observations) that partial BOO 0.2 results in oxidative damage directly to smooth muscle protein. ctivity, mOD a 0.1

An important question about which there is SOD little information is the effect of I/R on natural antioxidant mechanisms. The present 0.0 study assessed the effect of bilateral I/R on 024681012 SOD activity, SOD being the cell’s chief Protein, mg/mL defence against activated oxygen free radicals. SOD1 contains copper and zinc, and 7 FIG. 5. x is located in the cytoplasm, SOD2 contains Comparative SOD activity of manganese and is located in mitochondria, 6 muscle (green) and mucosa while SOD3 exists extra-cellularly [17,18]. (red) quantified as the IC25; 5 They all act by converting superoxide to *significantly different from - + peroxide (2O2 + 2H gives H2O2 + O2) which is x muscle; ¥ significantly different then further broken down by catalase to 4 x [mg protein/mL] from control.

25 x oxygen and water. The intermediate peroxide 3 x is itself a dangerous molecule and could cause x * x damage to the cell if its production exceeds 2 * ctivity, IC the catalytic ability of catalase. The a 1

importance of SOD in attenuating I/R injury SOD * was shown clearly using transgenic animal 0 models [27,28], and that in acute ischaemic ControlI 0 1 7 14 events, the level of intracellular SOD Reperfusion after ischaemia, days decreases, facilitating further injury [29].

The present study clearly shows that the SOD 14 days, whereas in the mucosa the activity These studies show that I/R result in activity of the bladder mucosa is significantly was reduced at 7 days and further reduced at significant decreases in SOD activity in both greater than that of the detrusor smooth 14 days of reperfusion. The progressive the bladder mucosa and muscle, and the time muscle. Direct ischaemia resulted in a decreases in contractile responses during this course observed is consistent with the reduction of SOD activity within the mucosa period correlate very well with the lower SOD hypothesis that reperfusion is more damaging but not in the smooth muscle; however, activity; there was a significant decrease at to the bladder than ischaemia alone. They also reperfusion resulted in a progressive decrease 7 days and a slightly smaller decrease at show the importance of antioxidants and in SOD activity. In the muscle this reached a 14 days. This corresponds with the previous products high in antioxidants, as they protect maximum at 7 days but was still reduced at study by Bratslavsky et al. [13]. the bladder from free radical (reperfusion)

EFFECT OF BLADDER ISCHAEMIA/REPERFUSION ON SOD ACTIVITY AND CONTRACTION

damage in relation to ageing and obstructive 6 Greenland JE, Brading AF. The effect of 17 Zelko IN, Mariani TJ, Folz RJ. bladder disease. This idea is supported by the bladder outflow obstruction on detrusor Superoxide dismutase multigene family. multicentre study currently undertaken by the blood flow changes during the voiding a comparison of the CuZn-SOD (SOD1), National Institutes of Health, comparing the cycle in conscious pigs. J Urol 2001; 165: Mn-SOD (SOD2), and EC-SOD (SOD3) effectiveness of natural products (Pygeum 245–8 gene structures, evolution, and africanum and saw palmetto) in the 7 Azadzoi KM, Shinde VM, Tarcan T, expression. Free Radic Biol Med 2002; treatment of obstructive bladder disease. Kozlowski R, Siroky MB. Increased 33: 337–49 Further studies will be needed to characterize leukotriene and prostaglandin release, 18 Faraci FM, Didion SP. Vascular more completely the importance of cellular and overactivity in the chronically protection: superoxide dismutase defence mechanisms against free radical ischemic bladder. J Urol 2003; 169: 1885– isoforms in the vessel wall. damage in the pathogenesis of specific 91 Arterioscler Thromb Vasc Biol 2004; bladder diseases. 8 Azadzoi KM, Pontari M, Vlachiotis J, 24: 1367–73 Siroky MB. Canine bladder blood flow 19 Flohe L, Otting F. Superoxide dismutase ACKNOWLEDGEMENTS and oxygenation: changes induced by assays. Method Enzymol 1984; 105: filling, contraction and outlet obstruction. 93–9 This material is based on work supported J Urol 1996; 155: 1459–65 20 Lieb J, Chichester P, Kogan B et al. in part by the Office of Research and 9 Saito M, Yokoi K, Ohmura M, Kondo A. Rabbit urinary bladder blood flow Development, Department of Veterans Affairs, Effects of partial outflow obstruction on changes during the initial stage of partial and NIH grant RO-1-DK 067114 bladder contractility and blood flow to the outlet obstruction. J Urol 2000; 164: detrusor: comparison between mild and 1390–7 CONFLICT OF INTEREST severe obstruction. Urol Int 1997; 59: 21 Schröder A, Chichester P, Kogan BA, 226–30 Longhurst PA, Lieb J, Levin RM. Effect None declared. Source of funding: NIH and 10 Tong-Long Lin A, Chen KK, Yang CH, of chronic bladder outlet obstruction on VA. Chang LS. Recovery of microvascular the blood flow of the rabbit urinary blood perfusion and energy metabolism bladder. J Urol 2001; 165: 640–6 REFERENCES of the obstructed rabbit urinary bladder 22 Kershen RT, Azadzoi KM, Siroky MB. after relieving outlet obstruction. Eur Urol Blood flow, pressure and compliance in 1 Steers WD. Physiology of the urinary 1998; 34: 448–53 the male human bladder. J Urol 2002; bladder. In Walsh PC, Retik AB, Stamey TA, 11 Nielsen KK. Blood flow rate and total 168: 121–5 Vaughan ED eds. Campbell’s Urology. blood flow related to length density and 23 Lieb J, Kogan B, Das AK, Leggett RE, Philadelphia: WB Saunders, 1992: total length of blood vessels in mini-pig Schroeder A, Levin RM. The effect of 142–76 urinary bladder after chronic outflow urine volume and nitric oxide on basal 2 Zderic SA, Levin RM et al. Voiding obstruction and after recovery from bladder blood flow: response to function and dysfunction. A – obstruction. Neurourol Urodyn 1995; 14: catheterization and drainage. Neurourol relevant anatomy, physiology, and 177–86 Urodynam 2001; 20: 115–24 pharmacology, and molecular biology. 12 Azadzoi KM, Heim VK, Tarcan T, Siroky 24 Zhao Y, Levin SS, Wein AJ, Levin In Gillenwater JY, Grayhack JT, Howard MB. Alteration of urothelial-mediated RM. Correlation of ischemia/ SS, Duckett JD eds, Adult and tone in the ischemic bladder: role of reperfusion and partial outlet Pediatric Urology, 3rd edn. Chicago: eicosanoids. Neurourol Urodyn 2004; 23: obstruction induced spectrin proteolysis Mosby Year Book Medical Publishers, 258–64 by calpain with contractile dysfunction 1996: 1159–219 13 Bratslavsky G, Kogan BA, Matsumato S, in the rabbit bladder. Urology 1997; 49: 3 Brading AF, Pessina F, Esposity L, Aslan AR, Levin RM. Reperfusion injury 293–300 Symes S. Effects of metabolic stress and of the rat bladder is worse than ischemia. 25 Hass MA, Levin RM. The role of lipids ischaemia on the bladder and the J Urol 2003; 170: 2086–90 and lipid metabolites in urinary bladder relationship with bladder overactivity. 14 Levin RM, Das AK. A scientific basis for dysfunction induced by partial outlet Scand J Urol Nephrol 2004; 38 (Suppl. the therapeutic effects of Pygium obstruction. In Atala A, Slade D eds, 215): 84–92 africanum and Serenoa repens. Urol Res Bladder Disease: Research Concepts and 4 Levin RM, Chichester P, Levin SS, 2000; 28: 201–9 Applications Advances in Experimental Buttyan R. Role of angiogenesis in the 15 Levin RM, Kawashima Y, Leggett RE, Medicine and Biology. New York: Kluwer bladder’s response to partial outlet Whitbeck C, Horan P, Mizutani K. Effect Academic/Plenum Publishers, 2003: 217– obstruction: a review. Scand J Urol of oral Kohki tea on bladder dysfunction 38 Nephrol 2004; 38 (Suppl. 215): induced by severe partial outlet 26 Parekh MH, Lobel R, O’Connor LJ, 37–47 obstruction. J Urol 2002; 167: Leggett RE, Levin RM. Protective effect 5 Greenland JE, Hvistendahl JJ, 2260–6 of vitamin e on the response of the rabbit Andersen H et al. The effect of 16 Agartan CA, Whitbeck C, Leggett RE, bladder to partial outlet obstruction. bladder outlet obstruction on tissue Chichester P, Levin RM. Protection of J Urol 2001; 166: 341–6 oxygen tension and blood flow in the urinary bladder function by grape 27 Asimakis GK, Lick S, Patterson C. pig bladder. BJU Int 2000; 85: 1109– suspension. Phytotherapy Res 2004; 18: Postischemic recovery of contractile 14 1013–8 function is impaired in SOD2 (+/-) but not

SOD1 (+/-) mouse hearts. Circulation cardiac grafts. Circulation 2004; 110: Correspondence: Robert Levin, Albany College 2002; 105: 981–6 200–6 of Pharmacy, 106 New Scotland Ave, Albany, 28 Tanaka M, Mokhtari GK, Terry RD 29 Islekel S, Islekel H, Guner G, Ozdamar NY 12208, USA. et al. Overexpression of human copper/ N. Alterations in superoxide dismutase, e-mail: [email protected] zinc superoxide dismutase (SOD1) glutathione peroxidase and catalase suppresses ischemia-reperfusion injury activities in experimental cerebral Abbreviations: SOD, superoxide dismutase; I/ and subsequent development of graft ischemia-reperfusion. Res Exp Med (Berl) R, ischaemia/reperfusion; FS, ﬁeld coronary artery disease in murine 1999; 199: 167–76 stimulation; mOD, change in optical density.

Original Article ANTIOXIDANTS AND TESTICULAR TORSION KEHINDE et al.

Allopurinol provides long-term protection for experimentally induced testicular torsion in a rabbit model

ELIJAH O. KEHINDE, JEHORAM T. ANIM*, OLUSEGUN A. MOJIMINIYI†, FARIDA AL-AWADI†, AIDA SHIHAB-ELDEEN†, ALEXANDER E. OMU‡, TUNDE FATINIKUN‡, ASHA PRASAD* and MATHEW ABRAHAM Departments of Surgery (Division of Urology), *Pathology, †Biochemistry and ‡Obstetrics and Gynaecology, Faculty of Medicine, Kuwait University, Kuwait Accepted for publication 28 January 2005

OBJECTIVE following antioxidants before reperfusion: lower (but not significantly) left testicular acetyl salicylic acid, ascorbic acid, allopurinol, MDA levels than untreated rabbits, while To assess the effect of five antioxidants on quercetin or superoxide dismutase. Both rabbits given acetyl salicylic acid had even exocrine function of rabbit testes retained in testes were excised at 24 h or 3 months. The higher levels. Allopurinol-treated rabbits had situ for 24 h and 3 months after experimental degree of lipid peroxidation, a measure of free a Johnsen score of >7.6 and those given other torsion. radical damage, was assessed in testicular antioxidants had scores of <7.6 at 3 months. tissue homogenates by measuring the tissue MATERIALS AND METHODS levels of malondialdehyde (MDA). The Johnsen CONCLUSION score was used to assess the morphological The left testes of peripubertal rabbits were damage at 24 h and 3 months for each group. The twisted viable testis treated by clamped for 60 min, after which the clamps orchidopexy contains high free radical levels were removed and the testes allowed to RESULTS at 3 months. Of the antioxidants studied, only reperfuse. The right testes served as internal allopurinol had a beneficial long-term effect, controls. There were eight rabbits in each of At 3 months twisted viable testes allowed to by significantly reducing testicular MDA levels the following experimental groups: (a) sham; reperfuse had higher MDA levels than at 3 months. (b) 60-min ischaemia followed by reperfusion; controls; the left testes of rabbits treated with (c) 60-min ischaemia followed by left allopurinol had significantly lower MDA levels KEYWORDS orchidectomy. In five further groups, rabbits than untreated rabbits and rabbits given other were exposed to 60-min ischaemia followed antioxidants. Rabbits given quercetin, testicular torsion, antioxidants, treatment, by reperfusion, but received one of the ascorbic acid or superoxide dismutase had long-term results.

INTRODUCTION twisted testis and the contralateral testis at for according to Kuwait University Animal 6 weeks [5]. In humans, torsion of testes is Resources Centre guidelines, reared in divided The current view is that the sequelae of common in the peripubertal age group (12– cages at 18–25 °C, a humidity of 50%, and testicular torsion can be explained on the 25 years) [9–12]. The sequelae of the disorder allowed food and water ad libitum. basis of ischaemia/reperfusion (I/R) injury may take years to develop, e.g. reduced [1–6]. Previously the sequelae were attributed fertility is not apparent until the patient In all experiments the right testis served to an autoimmune reaction or a sympathetic attempts paternity, perhaps 5–10 years after as an internal control and the left as the mechanism, among other factors [7,8]. In the initial torsion of the testis [9]. Hence there experimental side. The rabbits were agreement with the I/R injury hypothesis and is a need to assess the long-term protective anaesthetized using intravenous the role of free radicals in the disease process, effects of antioxidants on testicular exocrine pentobarbitone sodium (Sagatal; Rhone numerous experimental animal studies have and endocrine function. In the present Merieux, Dublin, Ireland, 26 mg/kg body confirmed the efficacy of antioxidants like study, we assessed the effect of five weight). The left testis was delivered to the superoxide dismutase (SOD), catalase, antioxidants on testes retained in situ for operating field via a longitudinal scrotal skin allopurinol and aspirin in reducing the short- 3 months after experimental torsion in a incision. Wounds were closed using 4/0 term damaging effect of torsion of the testis rabbit model. chromic catgut sutures. Ischaemia of the left [1–6]. However, nearly all previous studies testis was produced by clamping the reporting beneficial effects of antioxidants spermatic cord structures using surgical were based on short-term observations. Thus MATERIALS AND METHODS spring clips (AtraumaxTM, Applied Vascular beneficial effects were documented in <24 h Devices, California, USA). The small blood [3,4,6], in <168 h [1] and in <4 weeks [2]. Only Conventionally reared New Zealand white supply to the testis via the remnant of the one study to date reported long-term male peripubertal rabbits (aged 3–6 months, gubernaculum was cut during the period of protective effects of antioxidants on both the weight 3–4.5 kg) were used; they were cared ischaemia by applying mosquito artery

KEHINDE ET AL.

forceps to the gubernaculum. The left testis TABLE 1 Johnsen testicular biopsy score system* [22] was subjected to 60 min of ischaemia. In control, sham-operated rabbits (no ischaemia) Score Description of Scoring System the left testis was exposed for 60 min but 10 Complete spermatogenesis with many spermatozoa (determined by head form). cord structures were not clamped. Germinal epithelium organized in regular thickness leaving an open lumen. Reperfusion was established by removing the 9 Many spermatozoa present but germinal epithelium disorganized with marked clips at the end of the period of ischaemia. The sloughing or obliteration of lumen. following groups of rabbits were studied; (A) 8 Only a few spermatozoa present (< 5–10) sham-operated; (B) 60-min ischaemia 7 No spermatozoa but many spermatids present. followed by reperfusion; (C) 60-min ischaemia 6 No spermatozoa and only a few spermatids present (< 5–10) followed by left orchidectomy (no 5 No spermatozoa and no spermatids but several or many spermatocytes present. reperfusion); (D) 60-min ischaemia followed 4 Only a few spermatocytes (< 5) but no spermatids or spermatozoa present. by reperfusion, but given the following 3 Spermatogonia are the only germ cells present. antioxidants before reperfusion (eight rabbits 2 No germ cells, but Sertoli cells are present. each): (D1) acetyl salicylic acid (ASA) 50 mg/ 1 No cells in tabular section. kg body weight intravenously 10 min before reperfusion; (D2) ascorbic acid, 2 mmol/kg *All currently used testicular biopsy scoring systems are modifications of the Johnsen score [23]. body weight intraperitoneally 30 min before reperfusion; (D3) allopurinol 200 mg/kg body weight intraperitoneally 30 min before reperfusion; (D4) quercetin 30 mg/kg body compound formed when MDA couples with among the various treatment groups. Table 2 weight intraperitoneally 50 min before thiobarbituric acid. The protein content of the shows the left testicular MDA levels of rabbits reperfusion; (D5) SOD 3 mg/kg body weight homogenate was determined according to the whose left testes were subjected to 60 min of intravenously 50 min before reperfusion. procedure of Lowry et al. [21] and values ischaemia followed by 24 h reperfusion, but expressed as nmol MDA/mg protein. given various antioxidants before reperfusion. ASA was obtained from Laboratories Table 2 also shows values for rabbits given no Synthelabo Groupe Le Pleisis Robinson, A portion of the harvested testis was fixed in antioxidants. The mean MDA level in the left France; ascorbic acid, allopurinol, quercetin Bouin's solution, processed routinely into testes was lower in rabbits given ASA, ascorbic and SOD were obtained from Sigma Chemical, paraffin wax and stained with haematoxylin acid, quercetin and allopurinol before St Louis, Missouri, USA. and eosin. To minimize intra-observer reperfusion than in rabbits not given variation in using the scoring system, only antioxidants, but the difference was not The dosage and timing of each antioxidant one histopathologist (J.T.A.) assessed all the significant, although much lower in rabbits were based on our preliminary data on the testicular specimens while unaware of origin. given allopurinol (P = 0.093) and ascorbic acid metabolism of the drugs, and on published The mean testicular biopsy score (Johnsen (P = 0.084). Conversely, rabbits given SOD had data, which determined the peak serum score, [22]) was used to compare the histology a higher MDA level than control rabbits. There concentrations of the drugs at the time of testes exposed to 24 h of reperfusion with was no significant difference in the right reperfusion was initiated [3,13–18]. In each those exposed to 3 months of reperfusion. testicular MDA levels among the various group, both testes were harvested in four The Johnsen score (Table 1) is based on the groups. rabbits after 24 h of reperfusion, and after premise that with testicular damage there is 3 months in the remaining four rabbits. At the successive disappearance of the most mature Table 2 also ompares the testicular MDA levels end of the experiments the rabbits were killed cell type, with progressive degeneration of in the right and left testes at 3 months (long- by an overdose of pentobarbitone sodium. germinal epithelium, with the disappearance term reperfusion). Twisted but viable testes After harvesting the testes, each was divided of spermatozoa and spermatids, then allowed to reperfuse (detorsion/orchidopexy) into three equal parts for measuring the level spermatocytes and finally Sertoli cells, in that had higher MDA levels after 3 months than of testicular malondialdehyde (MDA), order [22,23]. controls. Allopurinol-treated rabbits had the histological examination and storage for lowest right and left (both P < 0.001) possible later use. MDA was used as a Testicular MDA was expressed as the mean testicular MDA levels compared to controls. measure of free radical damage, to assess the (SD) and the experimental groups compared Allopurinol-treated rabbits also had lower degree of lipid peroxidation in each testis. by ANOVA, followed by Student's t-test, with right and left testicular MDA levels than Details of the MDA assay and quality control P < 0.05 considered to indicate statistically rabbits given other antioxidants. Quercetin-, are as described previously [19]. significant differences. ascorbic acid- and SOD-treated rabbits had lower left testicular MDA levels than control Testicular tissue was homogenized with rabbits, but these differences were not 1.5% KCl to make a 10% homogenate, using a RESULTS statistically significant; ASA-treated rabbits glass PTFE homogeniser. The degree of lipid had even higher left testicular MDA levels. peroxidation in tissue homogenate was The rabbits had a mean (SD, range) age of assessed by the method of Ohkawa et al. 4.3 (0.7, 3–6) months and weighed 3.45 Figure 1 shows the morphological damage [20], which measures MDA levels as the (0.31, 3–4.5) kg; there were no significant scoring in the testes and Table 2 the mean concentration of a pink chromogen differences in the mean weights and ages testicular biopsy scores (Johnsen score). There

ANTIOXIDANTS AND TESTICULAR TORSION

TABLE 2 Testicular MDA levels and biopsy scores (Johnsen score) of testes in rabbits given various antioxidants. All values are the mean (SD) of four experiments. The testes were harvested after 24 h (short term) and after 3 months (long term).

Treatment group* Results ABCD1D2D3D4D5 Testicular MDA levels, nmol/mg protein Short-term (24 h) right testis 2.5 (1.1) 2.9 (0.9) 2.4 (2.1) 4.1 (2.2) 2.3 (1.2) 2.5 (3.9) 1.0 (0.6) 2.4 (1.1) left testis 1.6 (0.2) 10.0 (3.1) 8.2 (4.4) 7.7 (7.4) 5.3 (3.3) 4.7 (4.3) 6.7 (5.5) 10.5 (6.7) Long-term (3 months) right testis 2.0 (0.9) 5.7 (2.8) 4.0 (0.6) 7.7 (9.0) 2.0 (1.8) 2.1 (1.6)‡ 1.3 (1.3) 4.4 (1.9) left testis 3.0 (2.2) 11.0 (1.1) 4.0 (4.5) 31.6 (7.0)‡ 8.5 (6.9) 4.6 (1.8)‡ 10.2 (11.9) 10.9 (7.0) Johnsen score Short term (24 h) right testis 9.5 (0.9) 9.7 (0.6) 9.7 (0.3) 10 (0) 9.7 (0.6) 9.3 (1.2) 9.3 (1.2) 9.7 (0.6) left testis 9.5 (0.5) 9.3 (0.6) 9.5 (0) 9 (0) 9 (1) 8 (2.6) 9.2 (1.0) 9.2 (1.0) Long term (3 months) right testis 10 (0) 10 (0) 9.8 (0.3) 9.3 (0.6) 9.6 (0.3) 10 (0) 9.5 (0.5) 9.8 (0.3) left testis 9.1 (1) 7.7 (2.5) 9.7 (0.6) 6.5 (2.3) 3.3 (1.5) 7.6 (4.2) 5.3 (2.5) 7.3 (3.1)

*All groups, 60 min left testis ischaemia except group A (none); †Left testis subjected to 60 min ischaemia and excised after 60 min, i.e. not allowed to reperfuse; ‡P < 0.001 vs untreated rabbits (group B).

was little histological damage in the left antioxidants [3,4,6]. Most experiments have damage, as the level of testicular MDA in testes of all rabbits when the reperfusion assessed the short-term effects of rabbits given SOD did not differ much from period was limited to 24 h. However, at antioxidants; to our knowledge, only one [5] controls. The assessment of long-term 3 months rabbits given SOD, ASA and has assessed the effect of antioxidants on (3 month) effects of antioxidant treatment allopurinol had Johnsen scores of >6, while experimentally produced torsion of the testis shows that allopurinol-treated rabbits had those given ascorbic acid and quercetin had over 6 weeks. significantly lower right and left testicular scores of <6, indicating poor protection of MDA levels than controls or rabbits given exocrine function at 3 months by quercetin In the present study, 3 months was chosen to the other antioxidants. Morphologically, and AA. assess the long-term effects of antioxidants allopurinol-treated rabbits at 3 months had because, under laboratory conditions, these Johnsen scores of >7.5, while scores were rabbits have a life-expectancy of 36–48 <7.5 for rabbits given the other antioxidants. DISCUSSION months [28]. They attain puberty at Possible explanations include that in different ≈3 months and become sexually active at tissue systems, different antioxidants are The ideal treatment for torsion of testis ≈6 months [28]. Observations in our Animal effective in preventing free radical damage; remains elusive; 20–40% of patients treated Resources Centre over a 15-year period also e.g. aspirin (ASA) provides better protection by bilateral orchidopexy after unilateral confirm these earlier observations about the for myocardial infarction [29], while ascorbic torsion eventually develop some atrophy of life-cycle of laboratory reared New Zealand acid is more effective in preventing ischaemic the twisted testis, with reduced fertility White rabbits [13]. Thus, extrapolating to damage to the intestine [18]. SOD and [12,24–27]. Factors determining these humans, 3 months in the life of the laboratory quercetin have been shown to prevent free sequelae include the duration and the degree rabbit corresponds to 6–8 years, the radical damage in the transplanted kidney of torsion [26,27]. While the duration of approximate time humans are estimated to [15,17], and others have confirmed that torsion can be shortened by health education, marry after torsion of testis, and attempt to allopurinol also prevents cardiac I/R injury or by asking young men with testicular pain have a family, when the sequelae of torsion during coronary artery bypass graft surgery to report promptly to a hospital, the degree of (atrophy and reduced fertility) become [30], colonic I/R injury [31] and I/R injury of torsion cannot be influenced. Torsion of the apparent [9,12,24,25]. the testis [3]. SOD, together with catalase, has testis causes ischaemia of the testis, and also been shown to prevent I/R injury when treatment by untwisting and orchidopexy The present data confirm the beneficial effect administered to animals whose testes were results in reperfusion. As with any I/R injury, of ASA, ascorbic acid, quercetin and subjected to 60 min of ischaemia, but not for free radicals released during reperfusion allopurinol in reducing free radical damage animals given >60 min of ischaemia [5]. These contribute to the damage. Numerous within 24 h of initiating reperfusion in findings are similar to the present results. experimental animal studies confirm that experimental animals. Allopurinol was Antioxidants do not appear to be of benefit torsion of the testis is associated with free associated with the lowest testicular MDA after prolonged ischaemia, as the organs are radical production, and that the effects of free levels, but SOD was not very effective at likely to become atrophic with time as radicals can be mitigated by using protecting the twisted testis from free radical reperfusion fails [5,32]. Riaz et al. [31] also

KEHINDE ET AL.

reported that in experimental colonic I/R FIG. 1. Photomicrograph of a testicular biopsy to show different stages of spermatogenesis according to the injury, 30 min of ischaemia is followed by Johnsen scoring system. (A) Johnsen score 10, showing normal spermatogenesis, with numerous adequate reperfusion and a response to spermatozoa lining the central lumen. (B) Johnsen score 9, showing sloughing into the lumen, adequate allopurinol and SOD, whereas ischaemia of number of spermatozoa present. (C) Johnsen score 8, showing only few spermatozoa. (D) Johnsen score 7, >30 min is associated with poor reperfusion showing only spermatids on the luminal side of the tubules. (E). Johnsen score 6, showing only few and a poor response to antioxidants. These spermatids. (F). Johnsen score 5, showing only spermatocytes with no spermatids. (G).Johnsen score 4, ﬁndings conﬁrm the importance of showing only few spermatocyes and spermatogonia. (H). Johnsen score 2, showing only Sertoli cells lining determining the point of reperfusion failure in the tubules. Haematoxylin and eosin × 400. experimental I/R injury [32].

We examined the long-term benefits of five antioxidants that can be given intravenously, and are thus of potential value in an emergency, and which have previously been shown to offer protection in short-term experimentally induced torsion of the testis [2–6,32]. The field of I/R injury of the testis is ever-expanding, with new antioxidants being discovered regularly, e.g. caffeic acid phenethyl ester [33], pentoxifylline [34], and vasoactive intestinal peptide [35]. The beneficial effects of inhibiting nitric oxide synthase in I/R of the testis is also emerging as an important therapeutic strategy in minimizing the sequelae of torsion of the testis [36]. An assessment of the long-term benefits of these newer antioxidants is warranted.

The dose of allopurinol (200 mg/kg) used in the present experiments is large and might limit its use in humans; this dose was also found to prevent I/R injury of the rat testis [3] and rat intestine [31], but a lower dose (50 mg/kg) was reportedly effective in protecting the rat liver against I/R injury [37]. From experience of using allopurinol in the treatment of urological diseases like hyperuricaemia, doses of 100–300 mg (three times daily) gave a serum concentration of 37–50 μmol/L [38]. We also measured the serum concentrations of allopurinol and oxypurinol in the rabbits given 200 mg/kg of the drug intraperitoneally, and found peak mean (SD) levels for allopurinol of 41 (13.4) μmol/L and of 70 (16.4) μmol/L for oxypurinol. These data indicate that giving humans up to 300 mg of allopurinol should produce serum levels that provide antioxidant effects with no toxicity. Currently, allopurinol 300 mg (three times daily) can be safely prescribed for patients with hyperuricaemia [38]. Hopefully, clinical trials will reveal a dose of allopurinol that has antioxidant effects in morphometric and cellular characteristics to degeneration of germinal epithelium: humans with little or no toxicity. produce a quantitative description of a spermatozoa and spermatids, then testicular biopsy specimen [23], and is one of spermatocytes and ﬁnally Sertoli cells [22,33]. We used the Johnson scoring system to assess the most cited scoring systems [23]. The For experimentally induced damage to the the damage in the present testes; this is an Johnsen score [22] is based on the premise testis, this premise has been found to be objective grading system that uses that in testicular damage there is progressive largely correct [22,39], and these earlier

ANTIOXIDANTS AND TESTICULAR TORSION

observations are supported by the K.I. Mathew, all of the Faculty of Medicine, torsion in Bristol: a 25-year review. Br J experimental data in Table 2. Kuwait University. We thank Mrs Valsa Rajan Surg 1988; 75: 988–92 for secretarial assistance. Dr A Memon, 12 Al-Hunayan AA, Hanafy AM, Kehinde Randomized placebo-controlled clinical trials Department of Community Medicine provided EO et al. Testicular torsion: a perspective should be undertaken using prophylactic advice regarding statistical analysis for which from the Middle East. Med Princ Pract antioxidants like allopurinol, because, as our we are grateful. 2004; 13: 255–9 experimental studies show, a testis subjected 13 Kehinde EO, Eldeen AS, Ayesha A, Anim to 60-min ischaemia will reperfuse and CONFLICT OF INTEREST JT, Memon A, Al-Sulaiman SM. Effect remain viable at 3 months, but remains very of castration on acetyl salicylic acid high in free radical levels. We suggest that None declared. Source of funding: Research metabolism in rabbits. Urology 2003; 61: part of the deleterious effects of torsion Grant MS 02/99 from Kuwait University. 651–5 might be caused by the high free radical levels 14 Akhter S, Sridhar S, Katlowitz NM et al. in the twisted testis. This provides a rational REFERENCES Immune response to testicular ischaemia explanation for earlier observations that and reperfusion. J Urol 1990; 143: 296 patients with testicular torsion treated by 1 Bergh A, Damber JE, Marklund SL. 15 Land W, Schneeberger H, Schleibner S orchidectomy had less reduction of fertility Morphologic changes induced by short- et al. The beneficial effect of human than those treated by orchidopexy, the term ischemia in rat testis are affected by recombinant superoxide dismutase on current standard treatment. Thus, the removal treatment with superoxide dismutase and acute and chronic rejection events in of a twisted testis effectively prevents catalase. J Androl 1988; 9: 15–20 recipients of cadaveric transplants. significant damage to the contralateral testis 2 Greenstein A, Smith-Harrison LI, Transplantation 1994; 57: 211–7 [24,39,40]. However, orchidectomy is not Wakely PE, Kololgi S, Salzberg AD, 16 Negita M, Ishii T, Kunikata S, always possible, for obvious emotional Koontz WW Jr. The effect of polyethylene Matusuura T, Akiyama T, Kurita T. reasons, so there is a need for agents that glycol-superoxide dismutase Prevention of post transplant acute reduce the damage that occurs to both testes administration on histological damage tubular necrosis in kidney graft by after orchidopexy. This will prevent the following spermatic cord torsion. J Urol perioperative superoxide dismutase present unfortunate situation in which the 1992; 148: 639–44 infusion. Transplant Proc 1994; 26: 2123– salvaged twisted testis are eventually a 3 Akgur FM, Klinic K, Aktug T, Olguner 4 liability to the patient's contralateral testis M. The effect of allopurinol pretreatment 17 Shoskes DA. Effect of bioflavonoids and ultimate fertility. before detorting testicular torsion. J Urol quercetin and curcumin on ischaemic 1994; 151: 1715–7 renal injury: new class of renoprotective The present data indicate that the twisted 4 Blank ML, O'Neill PJ, Steigman CK et al. agents. Transplantation 1998; 66: 147– viable testis treated by orchidopexy contains Reperfusion injury following testicular 52 high free radical levels in the long term. torsion and detorsion in prepubertal rats. 18 Nakamura M, Ozaki M, Fuchinoue S, Administration of allopurinol before Urol Res 1993; 21: 389–93 Teraoka S, Ota K. Ascorbic acid prevents reperfusion of the twisted testis is associated 5 Prillaman HM, Turner TT. Rescue of ischemic-reperfusion injury in the rat with prolonged reduction of free radical level testicular function after acute small intestine. Transplant Int 1997; 10: and maintenance of a good Johnsen score. experimental torsion. J Urol 1997; 157: 89–95 However, quercetin, ascorbic acid, ASA and 340–5 19 Kehinde EO, Mojiminiyi OA, Mahmoud SOD have no significant long-term effect on 6 Bozlu M, Eskandari G, Cayan S, AH, Al-Awadi KA, Al-Hunayan A, Omu testicular free radical levels, although in the Canpolat B, Akbay E, Atik U. The effect AE. The significance of measuring the short term all these antioxidants except SOD of poly (adenosine diphosphate-ribose) time course of serum malondialdehyde were associated with lower testicular MDA polymerase inhibitors on biochemical concentration in patients with torsion of levels. We propose that the outcome of changes in testicular ischemia- testis. J Urol 2003; 169: 2177–80 treating testicular torsion can be improved by reperfusion injury. J Urol 2003; 169: 20 Ohkawa H, Ohishi N, Yagi K. Assay for using prophylactic and effective antioxidants 1870–3 lipid peroxides in animal tissues by like allopurinol. Clinical trials involving 7 Nagler HM, White RD. The effect of thiobarbituric acid reaction. Anal Biochem allopurinol or other effective antioxidants in testicular torsion on the contralateral 1979; 95: 351–8 patients with torsion of the testis are testes. J Urol 1982; 128: 1343–8 21 Lowry OH, Rosenbrough N, Farr AL, warranted. 8 Williamson RC, Thomas WE. Randall RJ. Protein measurement with Sympathetic orchidopathia. Ann R Coll the Folin phenol reagent. J Biol Chem Surg Engl 1984; 66: 264–6 1951; 193: 265–75 ACKNOWLEDGEMENTS 9 Tryfonas G, Violaki A, Tsikopoulos G 22 Johnsen SG. Testicular biopsy score et al. Late postoperative results in males count – a method for registration of This work was supported by Research Grant treated for testicular torsion during spermatogenesis in human testes: normal MS 02/99 from Kuwait University Research childhood. J Pediatr Surg 1994; 29: 553–6 values and results of 335 hypogonadal Administration. We thank the following for 10 Cummings JM, Boullier JA, Sekhon D, males. Hormones 1970; 1: 2–25 their contributions to various analytical Bose K. Adult testicular torsion. J Urol 23 Coburn M, Wheeler TM. Testicular aspects of this project. Mrs Ramani Varghese, 2002; 167: 2109–10 biopsy in male infertility evaluation. In Dr A. Ayesha, Mrs Mona N Al-Roustom and Mr 11 Anderson JB, Williamson RC. Testicular Lipshulz, LI, Howards, SS, eds. Infertility in

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the Male, 2nd edn, Chap 11. St Louis, USA: Kumar P. Free radical generation and role Muhtaroglu S, Tekin Y. The role of nitric Mosby Year Book 1995: 223–53 of allopurinol as a cardioprotective agent oxide in testicular ischemia-reperfusion 24 Krarup T. The testes after torsion. Br J during coronary artery bypass grafting injury. J Pedatric Surg 2000; 35: 101–3 Urol 1978; 50: 43–6 surgery. Can J Cardiol 1996; 12: 138–44 37 Rhoden E, Pereira-Lima L, Lucas M et al. 25 Anderson JB, Williamson RC. The fate of 31 Riaz AA, Wan MX, Schaefer T et al. The effects of allopurinol in hepatic the human testes following unilateral Allopurinol and superoxide dismutase ischaemia and reperfusion: experimental torsion of the spermatic cord. Br J Urol protect against leucocyte–endothelum study in rats. Eur Surg Res 2000; 32: 215– 1986; 58: 698–704 interactions in a novel model of colonic 22 26 Daehlin L, Ulstein M, Thorsen T, ischaemia-reperfusion. Br J Surg 2002; 38 Murrell GA, Rapeport WG. Clinical Hoisaeter PA. Follow-up after torsion of 89: 1572–80 pharmacokinetics of allopurinol. Clin the spermatic cord. Scand J Urol Nephrol 32 Kehinde EO, Anim JT, Mojiminiyi OA, Pharmacokinet 1986; 11: 343–53 Suppl 1996; 179: 139–42 Al-Awadi F, Omu AE, Varghese R. The 39 Bartsch G, Frank S, Marberger H, 27 Sessions AE, Robinowitz R, Hulbert WC, signiﬁcance of determining the point of Mikuz G. Testicular torsion: late results Goldstein MM, Mevorach RA. Testicular reperfusion failure in experimental with special regard to fertility and torsion: direction, degree, duration and torsion of testis. Int J Urol 2005; 12: 81–9 endocrine function. J Urol 1980; 124: disinformation. J Urol 2003; 169: 33 Uz E, Sogut S, Sahin S et al. The 375–8 663–5 protective role of caffeic acid phenethyl 40 Cosentino MJ, Rabinowitz R, Valvo JR, 28 Adams CE. The laboratory rabbit. In Poole, ester (CAPE) on testicular tissue after Cockett AT. The effect of prepubertal TB, ed. The Universities Federation for testicular torsion and detorsion. World J spermatic cord torsion on subsequent Animal Welfare (UFAW) handbook on the Urol 2002; 20: 264–70 fertility in rats. J Androl 1984; 5: 93–8 Care and Management of Laboratory 34 Savas C, Dindar H, Bilgehan A, Ataoglu Animal, 6th edn. England: Longman O, Yucesan S. Pentoxifylline attenuates Correspondence: Elijah O. Kehinde, Scientiﬁc and Technical, 1987: 416–35 reperfusion injury in testicular torsion. Department of Surgery (Division of Urology), 29 Buttner T, Hellwig K, Muller T, Kuhn W. Scand J Urol Nephrol 2002; 36: 65–70 Faculty of Medicine, Kuwait University, P.O. Intravenously administered acetylsalicylic 35 Can C, Tore F, Tuncel N et al. Protective Box 24923, 13110 Safat, Kuwait. acid in combination with low-dose effect of vasoactive intestinal peptide on e-mail: [email protected] heparin in acute ischaemic stroke: a testicular torsion-detorsion injury: safety analysis. Clin Neuropharmacol association with heparin-containing mast Abbreviations: SOD, superoxide dismutase; 1998; 21: 48–51 cells. Urology 2004; 63: 195–200 MDA, malondialdehyde; ASA, acetyl salicylic 30 Movahed A, Nair KG, Ashavaid TF, 36 Ozokutan BH, Kucukaydin M, acid; I/R, ischaemia/reperfusion.

Pharm review Article WYLLIE

The era of ESSTIs is slowly approaching?

Oh no, you say, not another acronym to add to function relative to other physiological, the lexicon of BPH, LUTS, OAB, UUI, ED, PDEs, pathophysiological or disease processes. IIEFs, IVELTs, PE, etc! What’s this one about? Is The most relevant definition of clinical it more pharmaceutical industry hype? Will it selectivity as far as the patient is concerned matter to me, or my patients or my budget? is the ability to produce benefit with no With my usual degree of certainty, I predict obtrusive side-effects. that the arrival of dapoxetine within the next year will usher in the decade of the ejaculo- Examination of early reports shows that selective serotonin transport inhibitor (ESSTI). dapoxetine was removed from development The issue for patient, physician, healthcare as an antidepressant by Lilly and re- provider and scientist is whether dapoxetine positioned for ejaculatory dysfunction, with (or any similar drug) merits this label. As development initially being taken over by a veteran of the ‘uroselective a-blocker’ Detlef Albrecht’s group within Alza/J&J and wars I am anxious to avoid some of the subsequently by Usman Azam’s late-stage confusion created by pharmaceutical industry development group. Certainly at doses three advertising. To help the reader decide on to four times higher than those being used in the appropriateness of this (or any other) premature ejaculation (PE), there was no descriptor some of the more relevant data and antidepressant activity in short- and long- assumptions are provided below. term studies. In part this may have been due to the relatively short half-life (<6 h) of At the risk of alienating the reader I will start dapoxetine. Ironically, this apparent with the basic science. As seen from research pharmacokinetic ‘deficiency’ was considered reports, including a plethora of AUA 2005 by the subsequent developers to be nearly abstracts, dapoxetine is a potent (nanomolar) ideal for ‘on demand’ use by patients with PE, inhibitor of the serotonin re-uptake system in i.e. patients wanted a drug with a relatively human brain slices. The serotonin re-uptake rapid onset that is quickly cleared thereby system is also described (somewhat less reducing the propensity for systemic side- precisely) as the serotonin transport system; effects. so we can accurately describe dapoxetine as a serotonin transport inhibitor (STI). Turning now to efficacy; there is no agreed Furthermore, as dapoxetine inhibits the regulatory route for approval of a drug for PE. monoamine transporter systems at much However, the clinical development group higher (micromolar) concentrations, the drug within J&J have shown convincing efficacy can be considered as ‘selective’, i.e. warranting using a variety of clinically relevant endpoints, a description of an SSTI. including ejaculation latency, patient control and patient/partner satisfaction. This has been Ultimately (cf the a-blocker story) the clinical shown in both short-term studies and long- profile of a drug should be more important term open-label extensions. The effect is than any scientific nuances particularly apparent within the first few doses and is relating to test-tube findings. On this premise maintained, i.e. there is no evidence of then we must turn to the credentials of tachyphylaxis or tolerance. The drug appears dapoxetine as a selective agent in the clinic; in well tolerated with a discontinuation rate particular the relative activity on ejaculatory remarkably low (at <3% in all clinical studies).

WYLLIE

In general the side-effect profile is consistent pharmacokinetics essentially excluded them Almost certainly this will not represent the with the primary mechanism of action. from approval for treating PE, although there end of the story of drug development in PE. Overall, dapoxetine is effective at doses and is some degree of ‘off-label’ use. There is a considerable amount of research situations (on demand) in which it is not into the serotonin receptor subtype involved effective as an antidepressant, and is well We assume that at some stage Karl Thor in producing the increased ejaculation tolerated. QED ‘ejaculo-selective’? within Lilly rationalised that a relatively short- observed with dapoxetine; the elevated acting agent would result in a drug that synaptic serotonin must act on or via a Dapoxetine is, therefore, an sSTI and is would minimise side-effects. Furthermore, an receptor. The major issue is that there is a ‘ejaculo-selective’. It is well known to students on-demand use would be consistent with considerable degree of species variation with of the art of algebra that two lower cases ‘normal’ sexual activity which is (as much as) animal ‘models’, often producing confusing equal one upper case. Dapoxetine can be 49 times per annum. The rest is soon to be and contradictory data. In essence research reasonably considered as the first example of history. into PE is where ED research was before an ESSTI. As the drug is also potent (P), it our understanding of peripheral nitric oxide could be referred to as a PESSTI, particularly The arrival of dapoxetine on the marketplace systems and the action of PDE inhibitors in on 25 January, a date of great significance to is unlikely to be the end of the story. As the 1990s. followers of Rabbie Burns. Let us hope that in the case of PDE inhibitors in the ED the discussions with the FDA do not result in market, several ‘copy-cat’ drugs will follow. We appear to be on the cusp of another ‘the best laid plans of mice and men, going This market, by way of benchmarking for revolution in sexual medicine. Hopefully, with agley’. potential investors, is likely to be similar to or without the ESSTI acronym, dapoxetine will that for PDE inhibitors. The epidemiologists come to the market within the next year. None of the above should in any way detract tell us that the incidence, prevalence and from the significance of the arrival of bother of PE is equivalent to that of ED. Next month I will do my traditional update on dapoxetine as the first drug ‘fit for purpose’ Therapy will be considered to be ‘lifestyle’ tales of derring doo from the AUA 2005. for the treatment of PE. The development of and will therefore be subject to the dapoxetine exemplifies the culmination of a same constraints on reimbursement, and MICHAEL G. WYLLIE rational programme based originally on the pricing is likely to be the same. The major Urodoc Ltd, Maryland, Ridgeway Road, Herne, chance observation of the ejaculation- difference from the ED market is that Kent, CT6 7LN, UK retarding activity of the original selective dapoxetine is unlikely to have the 5-year e-mail: [email protected] serotonin re-uptake inhibitors such as market exclusivity that was afforded to fluoxetine and sertraline. A combination of sildenafil, as several similar agents are already relatively poor benefit-risk ratios and in development.

Laparoscopic O’Conor’s repair for vesico-vaginal and vesico-uterine ﬁstulae

PERCY JAL CHIBBER, HEMENDRA NAVINCHANDRA SHAH and PRITESH JAIN Urology, Grant Medical College & JJ Hospitals, Mumbai, Maharashtra, India Accepted for publication 8 January 2005

INDICATION and laparoscopic repair of VVF may offer the patient less morbidity and quicker recovery Vesico-vaginal fistula (VVF) has been a social than with the traditional transabdominal and surgical problem for centuries. In the approach. We present our retrospective developed world >90% of cases are caused by results of laparoscopic transabdominal inadvertent injury to the bladder during transvesical repair, as described by O’Conor surgery [1]. Obstetric VVF related to prolonged et al. [10–12] for managing supratrigonal VVF labour remains a major medical problem in in the last 4 years. many underdeveloped countries with a low standard of obstetric care [2]. In 1852, Sims reported a successful repair of VVF in female METHOD slaves [3]; since then, many surgical techniques have been developed to correct We analysed retrospectively eight consecutive this abnormality, including transabdominal, patients with VVF and vesico-uterine fistula transvaginal and endoscopic approaches who had a laparoscopic transabdominal [4–9]. The selected route of repair depends transvesical repair at our institute between mostly on the training and experience of the January 2000 and April 2004. Of these, surgeon. The best approach is probably the six patients had VVF after abdominal one with which the surgeon feels most hysterectomy and the other two a vesico- experienced and comfortable. The main uterine fistula after Caesarean section. disadvantages of the abdominal approach include the requirement for laparotomy, The patients with VVF presented with urinary splitting of the bladder, and its associated incontinence at 3–16 days after their surgery; morbidity with longer recovery. For women all had a pelvic examination, IVU and who have a VVF during or after recovery from cystoscopy before repair to confirm the VVF a gynaecological procedure, the prospect of and exclude associated ureteric injury. Two of undergoing further surgery and recovery can the six patients had a recurrent VVF, having also be stressful, especially if laparotomy is had a previous transvaginal repair 10 and required. 12 weeks after abdominal hysterectomy. On cystoscopy all patients had a supratrigonal Ever since its inception, laparoscopy has fistula, with a mean (range) diameter of become increasingly popular in urology, 12 (8–20) mm, and had a laparoscopic repair reducing the invasiveness of treatment and 6–8 weeks after their initial surgery. shortening the period of convalescence. Most ablative and reconstructive surgery in urology The two patients with vesico-uterine fistula can be accomplished with the laparoscope, presented with cyclical menouria and

CHIBBER ET AL.

amenorrhoea of 4 and 6 months’ duration; FIG. 1. Hysterosalphingography showing a utero- FIG. 4. The posterior wall of the bladder being they had normal urinary continence. Both vesical fistula. further dissected from the vagina to permit tension- patients had had a Caesarean section at free bladder suturing. 8 and 9 months previously. On genital examination no fistula was palpable vaginally; the diagnosis was made by bladder hysterosalphingography (Fig. 1). Cystoscopy showed a supratrigonal fistula of 8 and 10 mm diameter. Plane of dissection For the repair, the patients were given an intubated general anaesthesia and placed in the lithotomy position. Initially they had cystoscopy with bilateral ureteric Contrast in Gauze in catheterization using 5 F ureteric catheters to bladder vagina help identify and protect the ureters during surgical dissection. In patients with a VVF a catheter was placed vaginally through the FIG. 5. Mesocolic fat being interposed between the vaginal and bladder suture lines. fistula when possible. A nasogastric tube and FIG. 2. Fistulous opening seen after the bladder is urethral Foley catheter were also placed. bivalved in the midline. Gentle traction was applied on the urethral Foley catheter to mechanically block the bladder neck and prevent leakage of air Bivalved Bladder through the bladder neck. A sponge stick was bladder retracted inserted in the vagina for manipulating the vaginal vault. A primary 10-mm port was inserted with Hassan’s technique in the Mesocolic fat midline infra-umbilically. The laparoscope was vagina introduced and two 5-mm secondary ports fistula were created in both iliac fossae under Sutured laparoscopic vision, with care taken to avoid vagina inferior epigastric vessels by transilluminating the abdominal wall. Adhesions were lysed in the pelvis, and the uterus and bladder were FIG. 6. The posterior wall of bladder being sutured. identified. Another 5-mm port was then The ureteric catheter is seen in the opened bladder created suprapubically in the midline to aid in FIG. 3. The fistula being circumcised to excise the lumen. retracting the bladder during suturing. The fistulous track. bladder was distended with 300 mL of normal saline. Bivalved bladder

Gentle traction on the Foley catheter in the Circumscribed fistula fistula and urethrally helped to retain saline in the bladder. The peritoneum between the Bivalved bladder bladder and vagina was incised with cautery. Using laparoscopic scissors and gentle counter-traction, a plane was developed between the bladder and vagina. The sponge stick inserted in the vagina greatly aided in Guaze in vagina the dissection. Than a vertical cystotomy was created with laparoscopic scissors, starting at the dome and continuing down to the fistula site posteriorly, as described by O’Conor et al. bladder from underlying vagina (Fig. 4). The covered the vaginal suture line (Fig. 5). These [10–12] (Fig. 2). Flaps of bladder wall were edges of the fistula opening in vagina were provide an additional layer of separation with dissected free from the vagina, until the trimmed back to healthy tissue and sutured improved lymphatic drainage. The bladder fistula was separated completely from the with interrupted 3-0 polyglactin sutures in a was then sutured in a single layer with 3-0 vagina (Fig. 3). The catheter placed through single layer. Once the vagina was sutured polyglactin intracorporeal sutures (Figs 6 and the fistula communication was then removed omentum [13], peri-colic or mesenteric fat 7). The laparoscope was then withdrawn, the and adequate bladder margins exposed on all [14] was mobilized and anchored to the cannula removed and the 10-mm port sides of the fistula by further dissecting the vagina with two more sutures, so that it incision closed with 2-0 polyglactin sutures.

LAPAROSCOPIC REPAIR FOR VESICO-VAGINAL AND VESICO-UTERINE FISTULAE

FIG. 7. Bladder suturing completed with return home with a catheter and hence were the indications to incorporate various intracorporeal interrupted sutures. kept in the ward for 15 days. There were no reconstructive procedures. The technique of complications after surgery. The urethral laparoscopic repair of cervicovesical fistula catheter was removed after 2 weeks in seven after Caesarean section was described in patients and was maintained for 3 weeks in detail by Hemal et al. [17], who used an Bladder closure one. In all patients the fistula was cured after extravesical technique, with excision of the removing the urethral catheter, and were fistulous tract using the Nd:YAG laser. Of the asymptomatic during a follow-up of two patients described the procedure required 3–40 months. conversion to open surgery in one because of a technical problem. In the other patient COMPARISON WITH OTHER METHODS in whom the procedure was successful laparoscopically there was an inadvertent The appearance of iatrogenic urogenital bladder tear during dissection that was fistula is one of the most devastating repaired intracorporeally. We used the complications of surgery. The emotional transvesical technique of repair in the present distress to the patient and surgeon is high patients with Youssef’s syndrome, and had The ureteric catheter and Ryle’s tube were because there is little hope offered by the advantages of optimum access to the removed at the end of procedure. A 16 F conservative therapy and most cases need a fistula site and tension-free closure of the urethral Foley catheter was left in place. We second operation to correct the problem. bladder, as in the classical O’Conor repair. The do not place a suprapubic catheter after In our department we favour the conversion in the first patient and difficulty in surgery for bladder drainage. The vagina was transabdominal transvesical approach for intracorporeal suturing was attributed to packed with a betadine ointment-soaked surgical repair of supratrigonal VVF, as early inexperience. However both patients roller gauze at the end of procedure. The described previously [11,12]. This approach were treated successfully and were disease- operative steps during the laparoscopic repair can be used for all fistulae, including free during the follow-up. Although vesico- of the vesico-uterine fistula were similar. complicated VVFs, with advantages of high uterine fistulae are less common than other success rates, optimal surgical access to the urogenital fistulae, worldwide the prevalence Patients were encouraged to take food after fistula and ureters, and the ability to add an of disease is increasing with the frequent use 6 h, and the vaginal pack was removed after interposition graft with this procedure. As of Caesarean section [18]. Surgery is the ª12 h. Patients were given anticholinergic stressed by the original authors, the key is to mainstay and definitive treatment of vesico- agents to prevent bladder spasms and bisect and widely mobilize the bladder from uterine fistulae; from our experience diclofenac sodium to manage pain. All the the vagina to produce a closure with separate laparoscopy should be offered to patients patients were fit for discharge 3 days after tension-free layers. It was their extensive who require surgical treatment for Youssef’s surgery. At 14 days after surgery the patients studies, with success rates of >85%, that syndrome. Laparoscopy has advantages over were assessed by cystography to confirm popularized the suprapubic technique. Among open surgery in producing less pain, shorter complete bladder integrity, during which the successful cases of repaired VVF were hospitalization, better cosmesis and quicker methylene blue was injected into the bladder patients with complex and difficult repairs, recovery. and any leakage into the vagina detected by e.g. radiation-associated cases. Nesrallah et al. inserting a gauze. If there was doubt about [15] investigated the clinical efficacy of the Nezhat et al. [4] first reported the the healing of the bladder, the urethral O’Conor transperitoneal supravesical laparoscopic repair of a VVF, and later catheter was maintained for one more week. technique for repairing supratrigonal VVF in assessed the laparoscopic closure of 29 patients. They found the technique to be intentional and unintentional bladder The laparoscopic procedure was successfully successful in all patients, with no significant lacerations in a series of 20 cystotomies [19]. completed in seven of the eight patients, with bladder dysfunction or decrease in bladder In that study the only complication was one conversion to open surgery in the first, where capacity after repair. They suggested that the VVF that required reoperation, successfully after dissecting the vesico-uterine fistula O’Conor technique be considered the repaired laparoscopically with a single-layer from the uterus there was technical difficulty standard surgical method for repairing closure. The authors concluded that in while suturing the cystostomy incision. The supratrigonal VVF. Blaivas et al. [16] in a study experienced hands, the endoscopic mean (range) operative duration was of 24 patients with VVF found that, once management of complex VVF might be an 220 (190–280) min. There were no other acute local inflammation had subsided, there alternative to the traditional abdominal complications during surgery and no patient is no benefit to be derived from delaying the approach. Von Theobald et al. [6] used an required a blood transfusion. All but two surgery. Delay can have a devastating impact omental J-flap interposition during the patients resumed oral intake after 6 h; the on quality of life and ability to function, laparoscopic repair of VVF. Recurrent VVF remaining two tolerated oral intake 12 and which cannot be underestimated. Considering was similarly successfully repaired 20 h after surgery, the delay being caused by all these factors we favour early intervention laparoscopically by Miklos et al. [7]. Their paralytic ileus. The mean requirement for for the surgical repair of VVF. patient had previous two failed Latzko partial analgesics was 225 (75–375) mg of colpocleisis, and closing the vagina and diclofenac sodium. All patients were We introduced the laparoscopic technique in bladder with an interposed omental flap using ambulatory 1 day after surgery and fit for our department in 1999; after using it for a laparoscopic approach ultimately repaired discharge at 3 days, but five were reluctant to ablative procedures, we gradually extended the persistent fistula. Similar success with the

CHIBBER ET AL.

laparoscopic approach was described by 25 years of experience. J Urol 1980; 123: 12 O’Conor VJ Jr. Review of experience others [8,9]. The results in the present six 370–4 with vesicovaginal fistula repair. J Urol patients with VVF confirmed the feasibility of 2 Evans DH, Madjar S, Politano VA, 1980; 123: 367–9 the laparoscopic approach to VVF, with a Bejony DE, Lyme CM, Gousse AE. 13 O’Conor VJ Jr. Transperitoneal good outcome. Interposition flaps in transabdominal transvesical repair of vesicovaginal vesicovaginal fistula repair: are they really fistula with omental interposition. necessary. Urology 2001; 57: 670–4 AUA Update Series 1991; 10: Lesson ADVANTAGES AND DISADVANTAGES 3 Sims JM. On the treatment of vesico- 13 vaginal fistula. Am J Med Sci 1852; 23: 14 Lytton B. Vesicovaginal fistula: The advantages of laparoscopy are well 59–82 postsurgical. In Resnick MI, Kursh ED eds, known and already discussed; there are few 4 Nezhat CH, Nezhat F, Nezhat C, Current Therapy in Genitourinary Surgery. case reports [4–9] showing the feasibility of Rottenberg H. Laparoscopic repair of a Second Edn. St. Louis: BC Decker, 1992: the laparoscopic repair of VVF and vesico- vesicovaginal fistula: a case report. Obstet 261–5 uterine fistulae. It seems to offer patients a Gynecol 1994; 83: 899–901 15 Nesrallah LJ, Srougi M, Gittes RF. The shorter hospital stay, quicker convalescence, 5 Phillips J. Laparoscopic repair of O’Conor technique: the gold standard for better cosmesis and equal efficacy. posthysterectomy vesicovaginal fistula: supratrigonal vesicovaginal fistula repair. Technically, laparoscopy provides better two case reports. Gynaecol Endos 1996; J Urol 1999; 161: 566–8 visualization through magnification, but is 5: 123–4 16 Blaivas JG, Heritz DM, Romanzi LJ. Early more difficult to learn, as is intracorporeal 6 von Theobald P, Hamel P, Febbraro W. versus late repair of vesicovaginal suturing. Another difficult technical challenge Laparoscopic repair of vesicovaginal fistulae: vaginal and abdominal is treating sufficient patients to stay fistula using an omental J flap. Br J Urol approaches. J Urol 1995; 153: 1110–2 proficient. Larger studies with a comparison 1998; 105: 1216–8 17 Hemal AK, Kumar R, Nabi G. Post- of outcome of the laparoscopic approach with 7 Miklos JR, Sobolewski C, Lucebte V. cesarean cervicovesical fistula: technique that of other open approaches are warranted Laparoscopic management of recurrent of laparoscopic repair. J Urol 2001; 165: to define the exact role of laparoscopy in vesicovaginal fistula. Int Urogynecol J 1167–8 managing VVF. At present, based on our 1999; 10: 116–7 18 Porcaro AB, Zicari M, Zecchini M et al. experience, it appears to be a viable 8 Nabi G, Hemal AK. Laparoscopic repair Vesicouterine fistulae following cesarean alternative for managing VVF and Youssef’s of vesicovaginal fistula and right section: report on a case, review and syndrome for surgeons experienced with nephrectomy for nonfunctioning kidney update of the literature. Int Urol Nephrol laparoscopic suturing techniques. in a single session. J Endourol 2001; 15: 2002; 34: 335–44 801–3 19 Nezhat CH, Seidman DS, Nezhat F. 9 Ou C-S, Huang U-C, Tsuang M, Laparoscopic management of intentional CONFLICT OF INTEREST Rowbotham R. Laparoscopic repair of and unintentional cystotomy. J Urol 1996; vesicovaginal fistula. J Laparoendoscopic 156: 1400–2 None declared. Adv Surgical Tech 2004; 14: 17–21 10 O’Conor V, Sokol J. Vesicovaginal fistula Correspondence: Percy J. Chibber, Urology, from the standpoint of the urologist. Grant Medical College & JJ Hospitals, Mumbai, REFERENCES J Urol 1951; 66: 579 Maharashtra, India. 11 O’Conor VJ Jr, Sokol JK, Bulkley GJ. e-mail: [email protected] 1 Goodwin W, Scardino P. Vesicovaginal Suprapubic closure of vesicovaginal and ureterovaginal fistulae: a summary of fistula. J Urol 1973; 109: 51–4 Abbreviations: VVF, vesico-vaginal fistula

Tied and tested: a cheap and simple method for transurethral resection

AMRITH RAJ RAO, JOHN D. BEATTY, FREDERICK C.L. BANKS and CHARLES HUDD Department of Urology, Wexham Park Hospital, Slough, UK Accepted for publication 7 February 2005

INDICATIONS FIG. 1. Close-up views of the ring-hitch Transurethral endoscopic procedures are knot. common in urology; the minimum set-up for transurethral resection (TUR) requires a light source and its cable, irrigation fluid and its delivery tube, a camera and its cable, and if resection is required, a diathermy cable. These cables are not fixed and their mobility can lead to various problems. It is not uncommon for one of these cables to be displaced from the instrument or the surgeon’s hand and fall to the floor, resulting in contamination or FIG. 2. The elastic band hanging from the theatre FIG. 3. A minimum of slack with freedom of even damage. We describe a technique where light. movement for the operating urologist. a simple braided flat elastic band is used to keep these cables together to prevent these mishaps, and allow increased freedom of movement for the operating urologist.

METHOD

A braided ﬂat elastic band found on the side of oxygen masks or bought from a sewing store is tied to form a band of ª20 cm long. A ring-hitch knot (tête d’alouette) [1] is made around all three leads (Fig. 1) and looped over a knob protruding from the theatre light (Fig. 2) or a drip-stand hook. The length of the FIG. 4. Light-source cable burn of the surgical drape. leads is adjusted so that they can be attached to the resectoscope with the minimum of slack (Fig. 3). This prevents the potential contamination and knotting of the cables that may occur because they are mobile. It is also useful when the resectoscope needs to be changed, as all the cables are suspended in one place. At the end of the procedure the cable tie is removed and sent for sterilization.

ADVANTAGES urology instruments and therefore re-used. (iii) The light-source cable is prevented from (i) The elastic band is cheap, can be bought coming into contact with the drapes, thus easily or taken from oxygen masks; 100 m of avoiding ﬁre and patient injury (Fig. 4). Fire urologist. (v) The added control allows for less six-cord (5 mm wide) black braided elastic caused by igniting surgical drapes with the participation of the scrub nurse and therefore costs £3.88 [2]; this is much cheaper than the light-source cable resulting in serious injuries the operation can be done with no assistant. prototype of the Skyhook® introduced in was reported previously [4]. (iv) The elastic (vi) The operating ﬁeld is cable-free, thus 1996, and costing £275 [3]. (ii) The elastic band allows for freedom of movement of the preventing clutter at the site of surgical band can be autoclaved along with other instruments and the hand of the operating activity.

RAO ET AL.

DISADVANTAGES and something that other urologists can 2 www.sewing.co.uk/elastic.htm. Accessed adopt at virtually no expense. It makes 05/08/2004 (i) Snapping of the elastic band; although this endoscopic resection procedures easier, neater 3 Feneley RCL. The Skyhook. Br J Urol 1994; has not been our experience. (ii) Loss and, most importantly, safer for the patient. 73: 209 of elasticity of the band on repeated 4 MacDonald AG. A brief historical review sterilization; we have noticed that the elastic CONFLICT OF INTEREST of non-anaesthetic causes of ﬁres and band can be sterilized and used up to 10 times explosions in the operating room. Br J on average before discarding it. (iii) The None declared. Anaesth 1994; 73: 847–6 irrigation ﬂuid needs to be at a higher level than the apex of the cables. REFERENCES Correspondence: Amrith Raj Rao, Urology, Wexham Park Hospital, Slough SL2 4HL, In conclusion, this technique of holding the 1 www.tribbler.com/tatman/ring- UK. cables together with an elastic band is simple hitch.html. Accessed 05/08/2004 e-mail: [email protected]

BASIC AND ADVANCED TECHNIQUES IN team approach to prostate cancer. However as ‘an expensive tennis racket does not PROSTATE BRACHYTHERAPY the book is unfortunately let down much guarantee victory at Wimbledon’ and ‘it is no repetition between chapters. good buying a Rolls Royce if their nearest Edited by AP Dicker, GS Merrick, FM agent is in Ruritania’. The references are Waterman, RK Valicenti and LG Gomella Urologists, oncologists, medical physicists, selective and illustrate the text aptly, as do the and pathologists involved with brachytherapy illustrations, particularly the line drawings, Martin Dunitz, 2005; pp 451, £125; ISBN 1 will find this book very useful. In addition, which are outstanding. 84184 298 2 interested trainees and general practitioners may also gain a detailed insight into the Our criticisms are few. However, one Brachytherapy is now increasingly used as a basics of this growing field of uro-oncology. surprising omission is a failure to advocate curative treatment option for prostate cancer. This book deserves a place in the reference current evidenced-based recommendations It was therefore only a matter of time before library of every urological department and which strongly support the use of a single such a definitive textbook was produced. The could be described as the ‘Campbell’s of instillation of cytotoxic drug to minimise editors of this book are to be congratulated brachytherapy’. recurrent tumour formation after TUR of with the ultimate ‘Who’s Who’ of superficial bladder tumours. The line drawing brachytherapy with this book. Their list of PROFESSOR STEPHEN LANGLEY of a patient smoking a pipe with a bladder authors stretches to 91, with 50 chapters irrigation in place is an anachronism, in eight sections. This book describes especially given current official stance on the brachytherapy from a historical perspective, TRANSURETHRAL RESECTION use of tobacco in public places. Throughout patient selection, the rationale behind its the book, there is repeated use of the word choice and even a chapter from a patient By John Blandy, Richard Notley and ‘regime’ instead of ‘regimen’, which may detailing his journey from the beginning to John M. Reynard reflect more an inevitable acceptance of this the end of his treatment. There is much detail term as a result of its widespread misuse, about the technique itself, including Taylor & Francis, November 2005, Hardback, rather than anything else. variations, often subtle, between institutions ISBN 184184408X; £65.00, 236 pp around the world. The dosimetry, morbidity However, with these few reservations, there is and biochemical outcome are also described. This latest monograph is a worthy successor no doubt that this is an excellent book which Much of the text is frank and provides a to previous editions of what, justifiably, has thoroughly deserves a place on the shelf of balanced view of outcome and current become the reference handbook on TUR. every trainee and in every Urology Unit’s controversies surrounding brachytherapy for The treatise is comprehensive, its scope library. Although the three reviewers are at prostate cancer from different units. including history, equipment selection and quite different stages in terms of experience, maintenance, indications for operation, all found the book to be very informative, with Each chapter is well written with subheadings, technical points and pitfalls with TURP and the two trainees advocating that reading the and with a useful summary at the end. They TUR of bladder tumour (TURBT), postoperative book should start before commencing TUR, as are concise and contain an abundance of care and complications, then finally leading to soon as that person is au fait with cystoscopy. excellent diagrams, photographs and imaging alternatives to TURP and medico-legal We anticipate that the fifth edition of that has been reproduced to the highest aspects. Transurethral Resection will have global quality. Although each chapter provides appeal and utility. We recommend it adequate detail, there is also a bibliography The text is easy to read and is very matter-of- wholeheartedly. for those left hungry for more information. fact, in keeping with previous editions. Indeed, There is a detailed index that allows the reader with one’s eyes closed, it is possible to recall DC DANGERFIELD to target areas on interest, and the book also the most senior author speaking through E McLARTY highlights the multidisciplinary oncology some of the anecdotes which are cited, such RA GARDINER

WRITE TO THE EDITOR AT BJU INTERNATIONAL, 47 ECCLES STREET, DUBLIN 7, IRELAND

TECHNICAL CHARACTERIZATION OF AN CONVENTIONAL AND ALTERNATIVE TABLE 2 Dimensions of the HIFU lesions(x-, y-, z- ULTRASOUND SOURCE FOR NONINVASIVE METHODS FOR PROVIDING ANALGESIA IN axis) depending on intensity in the focal zone. THERMOABLATION BY HIGH-INTENSITY RENAL COLIC These intensities are held for 2 s (t ) at 1 MHz FOCUSED ULTRASOUND pulse Sir, Dimensions of necrosis, mm Sir, We read with interest this article [1] on I colliquative Dr Leonid Gavrilov, a member of the Andreyev SAL conventional and alternative medications for W/cm2 coagulation necrosis Acoustic Institute at the Russian Academy renal colic. The paper is very useful in of Sciences, drew our attention to the 2148 0.16, 0.16,1.08 0.11, 0.11, 0.82 situations where conventional medications calculation of the used intensities published 4296 0.89, 0.89, 3.84 0.58, 0.58, 2.74 cannot provide analgesic relief or in patient in your journal in 2002 [1]. Those computed 6443 1.56, 1.56, 7,44 1.28, 1.28, 4.29 with allergies to these drugs. However, we by us were incorrect; we apologise for the 8591 2.26, 2.26, 8.82 1.91, 1.91, 7.9 draw attention to an untapped line of mistake and provide the following Correct management that may prove useful in corrections. 298 0.16, 0.16, 1.08 0.11, 0.11, 0.82 ureteric colic. Even though histamine has 596 0.89, 0.89, 3.84 0.58, 0.58, 2.74 been conﬁrmed as an active mediator The following table on page 250 had incorrect 894 1.56, 1.56, 7,44 1.28, 1.28, 4.29 of ureteric contraction, the use of values; the correct values are shown under 1192 2.26, 2.26, 8.82 1.91, 1.91, 7.9 antihistamines in a clinical setting of ureteric the incorrect: colic has not been documented. In-vitro experiments have shown histamine to be one The formulae used were: of the most potent stimulators of ureteric peristalsis [2,3]. Histological and

Pac = X Pel immunohistochemical studies show a TABLE 1 Acoustic power (P ), spatial averaged uniform and abundant distribution of ac 2 ISAL = 0.867 Pac/D6dB [2] histamine receptors along the entire ureter, intensity without tissue penetration (ISAL(0)) and at 5 cm (I (5)) and 10 cm (I (10)) of tissue in particular H1 receptors [4,5]. Electron SAL SAL -mx penetration calculated for a given electric ISAL(x) = ISAL(0) e [3] microscopic studies of human ureter exposed to urine have shown degranulation of mast power (Pel) of the generator X = 0.55 for the system used; D6dB = 0.4 cm; cells with release of histamine, producing

2 massumed = 0.5 dB/cm forceful peristaltic contractions simulating ISAL, W/ cm renal colic [6]. In-vitro studies again showed Pel, W Pac, W (0) (5) (10) Incorrect We apologise for this error. the inhibitory effects of H1 antagonists in 100 55 2148 1208 679 abolishing the contractions induced by 200 110 4296 2472 1359 STORZ Medical, Switzerland histamines [2,6]. A randomized trial involving 300 165 6443 3623 2037 an H1 receptor antagonist vs placebo will be 400 220 8591 4831 2717 1 Köhrmann KU, Michel MS, Steidler A, interesting and may provide yet another Correct Marlinghaus E, Kraut O, Alken P. alternative medication for renal colic. 100 55 298 167.5 94.2 Technical characterization of an 200 110 596 335 188.3 ultrasound source for noninvasive AMRITH RAJ RAO and ROGER O. PLAIL, 300 165 894 502.5 282.5 thermoablation by high-intensity focused Department of Urology, Conquest Hospital, 400 220 1192 670 376.6 ultrasound. BJU Int 2002; 90: 248–52 Hastings, East Sussex, UK 2 Malcolm AL, ter Haar GR. Ablation of tissue volumes using high intensity 1 Davenport K, Timoney AG, Keeley FX. focused ultrasound. Ultrasound Med Biol Conventional and alternative methods for 1996; 22: 659–69 providing analgesia in renal colic. BJU Int 3 Chen L, ter Haar G, Hill CR, Eccles SA, 2005; 95: 297–300

Consequently, the ISAL values in Table 2 were Box G. Treatment of implanted liver 2 Lennon GM, Bourke J, Ryan PC, also incorrect, and are shown here with the tumors with focused ultrasound. Fitzpatrick JM. Pharmacological options correct values: Ultrasound Med Biol 1998; 24: 1475–88 for the treatment of acute ureteric colic.

LETTERS

An in vitro experimental study. Br J Urol Most studies to date have used similar and better urinary symptoms after treatment. 1993; 71: 401–7 inclusion criteria: Patients are generally <80 Mild (Grade 1) stress incontinence occurs in 3 Ugaily-Thulesius L, Thulesius O, years old and with biopsy-confirmed early ª5% of cases but tends to resolve after a few Angelo-Khattar M, Sivanandasingham prostate cancer in at least six cores (with at weeks. Other less common side-effects P, Sabha M. Mast cells and histamine least four cores being positive for cancer include recto-urethral fistulae. Sexual responses of the ureter, ultrastructural [3,7]); early cancer is typified with a clinical function was intact in 73% of patients [2]. features of cell-to-cell associations and staging of T1–T2N0M0 [1,7–10]; the PSA level functional implications. Urol Res 1988; is <10 ng/mL [2,8] (although <15 ng/mL has In summary, despite some good results from 16: 287–93 also been used [2,3,11]); the Gleason score HIFU, which are comparable to non-surgical 4 Jerde TJ, Saban R, Bjorling DE, is £7 [2]; and the maximum prostate size treatments [12,13] most of the evidence still Steinberg H, Nakada SY. Distribution of 30–40 mL [2]. Patients were either unsuited supports radical prostatectomy as the best neuropeptides, histamine content, and for radical prostatectomy or were unwilling curative treatment for prostate cancer, inflammatory cells in the ureter. Urology to undergo a potentially more dangerous particularly in younger patients. However, 2000; 56: 173–8 procedure [1,5,7–10]. All patients signed there is a role for HIFU in those patients not 5 Bertaccini G, Zappia L, Bezzi E, consent forms and had a preoperative eligible for radical prostatectomy [2]. There is Potenzoni D. Histamine receptors in the assessment with TRUS, a DRE, bone scan with also an advantage in that the treatment is human ureter. Pharmacol Res Commun or without MRI. repeatable and has lower morbidity [3,14]. 1983; 15: 157–66 It can also be used in combination with 6 Ugaily-Thulesius L, Thulesius O. The The follow-up included regular PSA assays radiotherapy or chemotherapy [14]. In effects of urine on mast cells and smooth (from 1 day after surgery, and then at addition, TURP at the time of the procedure muscle of the human ureter. Urol Res 3-monthly intervals), a DRE and TRUS. can reduce urinary retention, which is one of 1988; 16: 441–7 Randomized sextant biopsies were taken at the main side-effects of the treatment. It may regular intervals, e.g. at 6 and 36 months. also be possible to use HIFU in patients with HIGH-INTENSITY FOCUSED ULTRASOUND Bone scans and CT/MRI were used to check for recurrent prostate cancer who have (HIFU) FOR TREATING PROSTATE CANCER metastatic disease in patients with a rising previously undergone radical prostatectomy. PSA level, while complications and symptoms Sir, in patients were assessed by patient-based SURIL PATEL, SHASHI KOMMU and HIFU is proposed as a treatment of great questionnaires (IPSS and quality-of-life RAJ PERSAD, Department of Urology, potential for prostate cancer and is currently measures) although complaints were also Bristol Royal infirmary, Bristol, UK undergoing trials in the UK. Most of the recorded. The median follow-up times ranged current knowledge and experience comes from a mean of 17.6 months [10] up to 3 years. 1 Chartier-Kastler E, Yonneau L, Conort from other European countries where the P, Haertig A, Bitker MO, Richard F. High treatment has been trialled and used for Patients were treated in one to three sessions. intensity focused ultrasound (HIFU) in longer. HIFU uses focused sound waves Blana et al [2]. reported a negative biopsy rate urology. Prog Urol 2000; 10: 1108–17 emitted by a transrectal transducer to cause a of 93% at 22 months of follow-up. They also 2 Blana A, Walter B, Rogenhofer S, rise in the temperature of the target tissue quoted a median PSA level of 0.15 ng/mL and Wieland W. High-intensity focused (prostate), leading to coagulative necrosis, stated that 87% of patients had a constant ultrasound for the treatment of localized cell death and eventually cavitation. The PSA level of <1 ng/mL. This contrasted with prostate cancer: 5-year experience. treatment is delivered with the patient under 77% of patients with negative biopsies at 27 Urology 2004; 63: 297–300 spinal or general anaesthesia. TRUS is used to months in another study [8]. The latter group 3 Chaussy C, Thuroff S. Results and side mark the apex of the prostate gland, and the also found a significant difference between effects of high intensity focused location of the target tissue is very important patients with a preoperative Gleason score of ultrasound in localized prostate cancer. [1]. Usually three overlapping areas (two 2–6 (85%) or with a score of 7–10 (61%). J Endourol 2001; 15: 437–40 lateral and one central) are defined and Gelet et al [9]. reported a much lower overall 4 Chaussy C, Thuroff S. High-intensity treatment is from the apex to the bladder success rate of 66% at a mean follow-up of focused ultrasound in prostate cancer: neck (to treat the whole prostate and seminal 19 months, but confirmed a significant results at 3 years. Mol Urol 2000; 4: 179–82 vesicles near the peripheral prostate) [2]. The difference in outcome with different Gleason 5 Chaussy CG, Thuroff S. High-intensive treatment is computer-led once the settings scores. There was no statistically significant focused ultrasound in localized prostate are fixed, and the treatment head moves change in urinary symptom scores after the cancer. J Endourol 2000; 14: 293–9 three-dimensionally, resulting in multiple procedure. 6 Thuroff S, Chaussy C. Therapy of local lesions, each of which measures 1.3–2.4 cm in prostatic carcinoma with high intensity diameter. There is a cooling device with a gas- Most studies reported a better side-effect focussed ultrasound (HIFU). Outcome free coupling liquid in a balloon which profile than conventional operative Side-Effects Urologe A 2001; 40: 191–4 surrounds the treatment head, thus interventions [6]. The rates of symptomatic 7 Rebillard X, Davin JL, Soulie M and protecting the rectal mucosal surface from UTI were <5%, while chronic pain occurred in Comite de Cancerologie de l’Associ damage. Patients have urethral catheters 1–2%, and infravesical obstruction in 10– Francaise d’Urologie. Treatment by HIFU inserted as part of the procedure, while some 15%. For this reason some studies assessed an of prostate cancer: survey of literature studies also had suprapubic catheters inserted elective TURP at the time of the procedure, and treatment indications. Prog Urol as routine [2–6]. with decreased urinary catheterization time 2003; 13: 1428–56

LETTERS

8 Thuroff S, Chaussy C, Vallancien G et al. anterior wall of the vagina. The three-swab 2 Fichtner J, Voges G, Steinbach F, High-intensity focused ultrasound and test is positive for a VVF, i.e. the swab stains Hohenfellner R. Ureterovesicovaginal localized prostate cancer: efficacy results blue with leakage of urine from the bladder. fistulas. Surg Gynec Obstet 1993; 176: from the European multicentric study. The ureteric urine leak (of unstained urine) 571–4 J Endourol 2003; 17: 673–7 into the swabs is masked by the coloured 9 Chaussy C, Thuroff S. The status of high- leakage from the bladder, from the vesical MANAGING PATIENTS WITH AN intensity focused ultrasound in the component of the fistula. IVU may show the OVERACTIVE BLADDER AND GLAUCOMA: treatment of localized prostate cancer ureteric obstruction, but not uncommonly A QUESTIONNAIRE SURVEY OF JAPANESE and the impact of a combined resection. may show a normal ureter. This happens if the UROLOGISTS ON THE USE OF Curr Urol Rep 2003; 4: 248–52 ureter empties completely into the fistula, and ANTICHOLINERGICS 10 Gelet A, Chapelon JY, Bouvier R et al. thus appears undilated and normal. Thus IVU Transrectal high-intensity focused can be absolutely normal in a patient with a In their paper discussing the potential adverse ultrasound. minimally invasive therapy of ureterovesico-vaginal fistula. The cystoscopy effects of anticholinergics prescribed for an localized prostate cancer. J Endourol findings show a bladder opening in the overactive bladder in patients with glaucoma, 2000; 14: 519–28 supratrigonal region of the bladder, which is Kato et al. [1] rightly present a balanced 11 Paparel P, Chapelon JY, Curiel L, in the line of the ureter and communicating argument of avoiding undue caution in Rabilloud M, Chesnais S, Gelet A. with the vagina. It is only if a ureteric catheter prescribing effective treatment, against Potentiation of focal ultrasound is passed retrogradely that the delay is underestimating the risk of iatrogenic treatment of prostate adenocarcinomas detected. Both the ureter and the bladder angle-closure. Recent advances in the by concomitant chemotherapy with open into a single opening in the vagina understanding of variations in the clinical estramustine phosphate and paclitaxel. through a complex tract. characteristics of angle-closure glaucoma, Prog Urol 2004; 14: 40–6 especially in Asian nations, render some of 12 Gelet A, Chapelon JY, Bouvier R, The treatment of such a fistula involves their comments and recommendations Rouviere O, Lyonnet D, Dubernerd JM. surgical management, as for a complex VVF, incorrect. Transrectal high intensity focused i.e. repair by the abdominal approach, with ultrasound for the treatment of localized bivalving the bladder up to the fistula. In Most cases (75%) of angle-closure in Asians prostate cancer: factors influencing the addition, the involved ureter is dissected to are asymptomatic [2]. Consequently, relying outcome. Eur Urol 2001; 40: 124–9 the juxtavesical region. The dissection in this on symptoms such as pain or a red eye as the 13 Poissonier L, Gelet A, Chapelon J et al. region is sometimes difficult, so if an sole method of identifying a rise in intraocular Results of transrectal focused ultrasound adequate length of the ureter is secured for pressure is inadequate. Furthermore, pupil- for the treatment of localised prostate reimplantation, the ureter can be transected block is not the only mechanism responsible cancer (120 patients with PSA < or +10 at its distal most point, after the lower end is for angle-closure. While 38% of Asian people ng/ml). Prog Urol 2003; 13: 60–72 ligated. After the vaginal opening is closed suffer from angle-closure solely caused by 14 Vallancien G, Prapotcich D, Cathelineau and the posterior wall of the bladder is closed, pupil-block, it is estimated that over half of all X, Baumert H, Rozet F. Transrectal the ureter is reimplanted with an adequate Asian people (54%) have mixed-mechanism focused ultrasound combined with submucosal tunnel. A psoas hitch is a useful disease (pupil-block combined with anterior, transurethral resection of the prostate for adjunct, and interposition of omentum non-pupil-block or ‘plateau iris’ syndrome) the treatment of localized prostate between the posterior wall of the vagina and [3]. An iridotomy will therefore not prevent cancer: feasibility study. J Urol 2004; 171: the bladder is helpful. angle-closure occurring in all cases. Kato et al. 2265–7 also emphasize the association of greater age In the event that a uretero-vesicovaginal with both glaucoma and bladder instability. fistula is operated without a complete The proportion of east-Asian people at risk of VESICO-VAGINAL FISTULA diagnosis (which in a difficult case would only angle-closure rises from 1.5% to 2% in the be by conducting a retrograde ureteric dye 40–49-year age-group to >10% in people Sir, study in a patient with a normal IVU, and no aged ≥70 [4]. Chinese ethnicity seems to be It was with pleasure I read the Surgery evidence of an obstructed/injured ureter), the associated with a considerably greater risk Illustrated article describing the diagnosis and fistula would recur [2]. This recurrence of than in other Asian groups [2]. surgical management of vesico-vaginal fistula would be attributed to improper repair fistulae (VVF) [1]. Although most of the ‘tricks’ of the vesical fistula, but in reality would be It would seem more appropriate to in diagnosis and surgical steps have been due to the hidden ureteric component of this recommend caution in the use of described, I would like to highlight the complex fistula. To avoid this frustrating anticholinergics in cases of glaucoma, rather difficult diagnosis of a ureterovesico-vaginal situation, meticulous care is necessary during than saying there is a contraindication. fistulae [2] masquerading as a simple VVF. the diagnosis of all VVF. However, in Asia, where angle-closure These patients have the injury at the level of glaucoma is a leading cause of blindness, the intramural portion of the ureter, where an NAGESH KAMAT, Consultant Urologist, these agents should only be started in injury at one level will injure both the ureter Kamats Kidney Hospital, Baroda, India patients with established glaucoma after the and the bladder. The patient presents with a involvement of their ophthalmologist. All urinary leak after a pelvic surgical procedure. 1 Chapple C, Turner Warwick RT. Vesico- ethnic Chinese patients aged ≥40 years The vaginal findings show an opening in the vaginal fistula. BJU Int 2005; 95: 193–214 should have an ophthalmic assessment before

LETTERS

using anticholinergic agents. Consideration 1 Kato K, Yoshida K, Suzuki K, Murase T, populations. Chinese Med J 2002; 115: should be given to a similar examination for Gotoh M. Managing patients with an 1706–15 all other Asian people. overactive bladder and glaucoma: a 4 Foster PJ, Oen FT, Machin DS et al. The questionnaire survey of Japanese prevalence of glaucoma in Chinese DAVID GOH*, JIN CHAN*, urologists on the use of anticholinergics. residents of Singapore. A cross-sectional SURESH VASUDEVAN*, BJU Int 2005; 95: 98–101 population survey in Tanjong Pagar JENNIFER L.Y. YIP†‡, and 2 Foster PJ. The epidemiology of primary district. Arch Ophthalmol 2000; 118: PAUL J FOSTER*‡ angle closure and associated 1105–11 *Glaucoma Service, Moorﬁelds Eye Hospital, glaucomatous optic neuropathy. Semin †International Centre for Eye Health, London Ophthalmol 2002; 17: 50–8 School of Hygiene and Tropical Medicine, and 3 Wang N, Wu H, Fan Z. Primary angle ‡Division of Epidemiology, Institute of closure glaucoma in Chinese and Western Ophthalmology, University College London, UK

Surgical Atlas Transureteroureterostomy

JOHN M. BARRY The Oregon Health & Science University, Portland, Oregon, USA

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INDICATIONS • DeBakey ‘Atraugrip’ vascular tissue forceps. • Lahey/Sweet gallbladder duct forceps, The indication for transureteroureterostomy 19 cm. is to bypass a distal ureter without • Potts-style scissors with short blades and compromising the recipient ureter with semi-sharp tips. disease from the donor renal unit. It is • Thin vascular needle holders. useful in patients who have had previous • 5/0 double-armed monofilament pelvic surgery that would make a absorbable sutures. ureteroneocystostomy with a psoas hitch, • Soft suction drain. with or without a bladder flap procedure, • Y-connector system for intraoperative difficult or inadvisable. The procedure is bladder irrigation and drainage. not recommended under the following • Double-pigtail stent with thread left on circumstances: chronic pyelonephritis, renal bladder/distal end. calculus disease, previous ureteric trauma • Cysto-urethroscopy set-up with two open- with scar, idiopathic retroperitoneal fibrosis, ended ureteric catheters to accept guidewires fibrosis following previous aortoiliac vascular (optional). surgery, high-dose radiation therapy, • Foley catheter that will comfortably fit the urosepsis, uroepithelial tumours, pelvic urethra after calibration with bougie à boule. visceral tumours with ureteric involvement, or • Sequential calf-compression devices. inadequate ureteric length for a tension-free anastomosis. The procedure is useful when SPECIFIC PATIENT PREPARATION the better of the two ureters is reimplanted into the bladder. When a normal ureter • Treat urinary tract infection if present. remains after nephrectomy, a • Bowel preparation if the patient has bowel transureteroureterostomy will provide dysfunction, infrequent bowel movements, or drainage for the remaining kidney when its prior abdominal surgery. ureter is diseased. The procedure is of • Antibiotic administration within 30 min of value when the smaller of two ureters is procedure. anastomosed to the larger one, which is then • Calf sequential compression devices to used to bridge the abdominal wall and form a prevent deep venous thrombosis. stoma. SPECIFIC PATIENT POSITIONING SPECIFIC EQUIPMENT/MATERIALS • Lithotomy position for cystoscopy and • Basic Bookwalter table-fixed retractor. bilateral ureteric catheterizations (optional). • Basic laparotomy set. • After cystoscopy and bilateral ureteric • Headlight. catheterization, extended supine position • Magnification if the patient is small. with a break in the table just above the iliac • Morse-Andrews suction tube. crest.

BARRY

Figure 1

Cystoscopy is performed and open-ended ureteric catheters placed. The ureteric catheters are brought out alongside the Foley catheter and each connected to its own drainage system; they will be removed later. The patient is placed supine, slightly hyperextended, sequential calf-compression devices applied (not shown), and the Foley catheter attached to a Y-connector, connected to an irrigation/drainage system so that the anaesthetist can drain and ﬁll the bladder during surgery. The patient is prepared and draped for a vertical midline incision that will be extended as much as necessary to comfortably perform the procedure.

SURGERY ILLUSTRATED

Figure 2

Enough adhesions are taken down to allow the Bookwalter retractor to be placed; the Bookwalter ring is positioned 4–5 cm above skin level. When the abdominal wall retractors are placed, this creates intra-abdominal space to pack the intestines out of the way. The posterior peritoneum is incised as would be done for a retroperitoneal lymphadenectomy. This will expose both ureters. If they are not easily seen, suspicious structures can be plucked and observed for peristalsis, or the previously placed ureteric stents palpated.

BARRY

Figure 3

The donor ureter is traced into the pelvis, and as much peri-ureteric tissue as possible is left with the ureter to provide blood supply. The catheter in the donor ureter is withdrawn from below. The donor ureter is ligated distally and divided proximal to the ligature. The ureter is spatulated on its medial surface to create a 2-cm opening and tagged with a stay suture that will be used for gentle traction. The donor ureter is dissected proximally. The gonadal vessels are divided between ligatures so they will swing medially with the donor ureter. (If the patient has had previous vasectomies, he will probably develop testicular atrophy on the side of the donor ureter.)

The donor ureter is swung over the great vessels towards the recipient ureter. The donor ureter is passed cephalad or caudad to the inferior mesenteric artery depending on which will bring the donor ureter closer to the recipient ureter with no tension. If necessary, a plane lateral to the recipient ureter is opened, and the ureter is teased medially towards the donor ureter until they meet with no tension.

SURGERY ILLUSTRATED

Figure 4

A, 5/0 monoﬁlament stay sutures are placed side-by-side in the recipient ureter at the proposed longitudinal ureterotomy.

The recipient ureter is incised with a #15 blade and the incision is extended with Potts- style scissors to match the opening in the donor ureter; 5/0 absorbable monoﬁlament sutures are placed at either end of the recipient ureterotomy and into the heel and toe of the donor ureter.

B, The posterior wall of the donor ureter is sewn to the medial wall of the recipient ureter from inside the lumen. The recipient ureteric catheter is withdrawn by an unscrubbed assistant until the open end appears in the half-completed anastomosis. A guidewire is a b passed into the end of the recipient ureteric catheter and withdrawal of the ureteric catheter is completed.

A double-pigtail stent is passed over the wire into the bladder. A suture is left on the distal curl in case the curl later retracts up the ureter. The wire is removed and the position of the distal curl confirmed when the anaesthetist fills the bladder through the Y- connector hook-up by clamping the outflow catheter and opening the inflow tube.

A guidewire is passed through a side hole in the double-pigtail stent to straighten the proximal curl, and the proximal stent is passed up the donor ureter into the renal pelvis. The guide wire is removed.

C, The ureteric anastomosis is completed with the running 5/0 monoﬁlament absorbable suture. c d

BARRY

Figure 5

A soft suction drain is placed in the retroperitoneum and brought out lateral to the colon through a stab wound lateral to the abdominal incision. The posterior peritoneal incision is closed with running 3/0 absorbable suture. The intestines are allowed to return to their natural positions. The midline incision is closed with interrupted far-far-near-near 0 monoﬁlament absorbable sutures. If epidural catheter analgesia will not be used, the wound is injected with a long-acting local anaesthetic such as ropivacaine. Scarpa’s fascia is closed with running 3/0 absorbable suture. The skin is closed with a running 4–0 absorbable subcuticular suture. Adhesive strips are applied across the suture line. Dry dressings are placed over the wound and the drainage tube. The Y-connector is removed and the Foley catheter is connected to a urine drainage bag.

SURGERY ILLUSTRATED

CARE AFTER SURGERY of a transureteroureterostomy. Some Although transureteroureterostomy may surgeons will prefer to avoid ureteric seldom be indicated, it is a good procedure to Patient-controlled intravenous analgesia is catheterization for ureteric identification and have available. used. The Foley catheter is removed in a day or rely on simple observation and diuresis to two when the patient can void or resume identify the ureters. Text from this paper originally appeared in intermittent catheterization. If epidural ‘Atlas of Surgical Techniques in Urology’, ed. analgesia is used, urethral catheter removal is Dissecting clamps like the Lahey/Sweet E.D. Whitehead; pp. 370–371. Copyright: delayed for ≥6 h after the epidural has been gallbladder duct forceps have longitudinal Lippincott Williams & Wilkins, 1998. discontinued. rather than cross serrations and do not get Reproduced with permission. caught on tissues during dissection. The wound dressing is removed 2 days after Correspondence: John M. Barry, The Oregon surgery. The adhesive strips will come off Skin closure with an absorbable subcuticular Health & Science University, Portland, Oregon, several days later with a bath or shower. The suture is more comfortable for the patient USA. sequential calf compression devices are than skin staples, clips or nonabsorbable e-mail: [email protected] removed when the patient is ambulating. The sutures any of which must be removed later. suction drain is removed when the drainage is <50 mL/24 h. In ª6 weeks, the patient has One of our more disappointing cases was baseline renal ultrasonography and the donor ureteric obstruction that occurred as a REFERENCES double-pigtail ureteric stent removed via child grew and the ureter became trapped flexible cystoscopy in the clinic 10 min after under the inferior mesenteric artery. 1 Barry JM. Transureteroureterostomy. In instilling a urethral anaesthetic. Whitehead ED ed. Atlas of Surgical Techniques in Urology. Philadelphia: WB CLOSING COMMENTS Saunders, 1997: 369–72 SURGEON TO SURGEON 2 Sharpe BW. Trans-uretero-ureteral Material has been used freely, and with anastomosis. Ann Surg 1906; 44: 687– The Y-connector system can be used to fill permission, from a previous publication [1]. 707 the bladder to consider the option of The procedure was described in dogs and 3 Higgins CC. Transuretero-ureteral ureteroneocystostomy with or without a cadavers nearly 100 years ago [2], and anastomosis: Report of a clinical case. psoas hitch or bladder flap procedure, instead reported in a patient 70 years ago [3]. J Urol 1935; 34: 349–55

In [1], the following error was published on The text was incorrect and should have Hospital, Liverpool, UK, and *Department of page 909. read: Urology, Royal Cornwall Hospital, Truro, UK

Author Listing Author Listing REFERENCE JOE PHILIP and RAMASWAMY MANIKANDAN, JOE PHILIP, RAMASWAMY MANIKANDAN and Department of Urology, Royal Liverpool PALANISWAMY VISWANATHAN*, Department 1 Philip J, Manikandan R. Prostate cancers University Hospital, Liverpool, UK of Urology, Royal Liverpool University in the transition zone: Part 2; clinical aspects. BJU Int 2005; 95: 909

Authors may use the abbreviations in this list, without definition when within the main text, but defined when in the Summary. Other abbreviations must be defined on first mention, both in the Summary and in the main text. Abbreviations of units should be those defined by SI.

AIDS acquired immune deficiency syndrome IVU intravenous urography ANOVA analysis of variance LHRH luteinizing hormone-releasing hormone AUA American Urological Association LUTS lower urinary tract symptoms BAUS British Association of Urological Surgeons MAG mercapto-acetylglycine BCG bacille Calmette-Guérin MAG3 mercapto-acetyltriglycine BPH benign prostatic hyperplasia MHC major histocompatibility complex BSA bovine serum albumin MRI magnetic resonance imaging BOO bladder outlet obstruction NHS National Health Service CI confidence interval NSAIDs nonsteroidal anti-inflammatory drugs CNS central nervous system PAGE polyacrylamide gel electrophoresis CT computed tomography PBS phosphate buffered saline DMSA dimercapto-succinic acid PCR polymerase chain reaction DRE digital rectal examination PSA prostate-specific antigen DTPA diethylene-triamine-penta-acetic acid PTFE polytetrafluoroethylene EDTA ethylenediamine tetra-acetic acid PUJ pelvi-ureteric junction ELISA enzyme-linked immunosorbent assay PUV posterior urethral valves ESWL extracorporeal shock wave lithotripsy RCC renal cell carcinoma FSH follicle-stimulating hormone SD standard deviation GFR glomerular filtration rate SDS sodium dodecyl sulphate GnRH gonadotrophin-releasing hormone TCC transitional cell carcinoma GP general practitioner TGF transforming growth factor hCG human chorionic gonadotrophin TNF tumour necrosis factor HIV human immunodeficiency virus TNM Tumour-Node-Metastasis HPLC high-pressure liquid chromatography TRUS transrectal ultrasonography ICS International Continence Society TURP transurethral resection of the prostate IGF insulin-like growth factor UTI Urinary tract infection

IgXz immunoglobulin (class X, subclass z) VUR vesico-ureteric reﬂux IPSS International Prostate Symptom Score WHO World Health Organization

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