The cardiovascular risk factors in men with lower urinary tract symptoms.

OBJECTIVE: It has been hypothesized that endothelial dysfunction and pelvic atherosclerosis may contribute to lower urinary tract symptoms (LUTS). We assessed the relationship between cardiovascular risk factors and LUTS severity in male patients presented to urology clinic. METHODS: It is a cross-sectional study on patients who presented between 2013 and 2015 with LUTS. A total of 1176 male patients were encountered, and 966 were included for analysis after excluding patients with urinary tract malignancy, urethral stricture, bladder stone and history of urinary tract surgery. Cardiovascular risk factors including components of Framingham risk score, body mass index, uroflowmetry, International Prostate Symptoms Score, fasting blood glucose and serum prostate-specific antigen (PSA) were assessed. Correlation between Framingham risk score, cardiovascular risk factors and severity of LUTS was investigated. RESULTS: Multinomial logistic regression analysis showed that severe LUTS significantly associated with Framingham score (P = 0.008) and its components of total cholesterol (OR = 1.318; P = 0.010) and age (OR = 1.032; P = 0.006) compare with mild symptoms. Framingham risk score was found to correlate with storage symptoms (CC = 0.083; P < 0.0001) but not voiding symptoms (CC = - 0.029; P = 0.185). CONCLUSIONS: Severity of LUTS and storage symptom significantly increases Framingham risk score, particularly with the components of total cholesterol level and age.

The Use of the da Vinci SP System for Retzius-sparing Radical Prostatectomy in Cadaveric Model.

OBJECTIVE: To evaluate the use of a new single-port robotic system, da Vinci SP (Intuitive Surgical, Sunnyvale, CA) in performing retzius-sparing radical prostatectomy in a cadaveric model. METHODS: A cadaver was placed in supine position on operating table. A 4-cm skin incision was made above the umbilicus for insertion of the robotic port via a GelPoint Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA). An additional 10-mm assistant port was inserted in the right lower quadrant. The operating table was then placed at a 30° Trendelenburg position and the robotic system was docked. The robotic endoscopic camera was set to pass in at the 6 o'clock to facilitate upward viewing during surgery. The parietal peritoneum was incised at the anterior surface of the rectovesical pouch. Vas deferens and seminal vesicles were dissected. Posterior dissection was performed till the prostatic apex. Lateral dissection was then performed with division of the prostatic pedicles. The dissection was continued distally and anteriorly until reaching the apical region. The lateral contour of the prostate was defined. The vesicoprostatic junction was identified by careful dissection of the perivesical fat and following the contour of the lateral prostatic surface. Bladder neck was identified and incised. Prostate was then retracted downward and the anterior prostatic surface was dissected. Finally, urethra was divided just distal to prostatic apex after urethra catheter withdrew. The vesicourethral anastomosis was completed with 2 barbed sutures. RESULT: The procedure was completed without conversion and the total robotic surgical time was 146 minutes. CONCLUSION: The use of da Vinci SP system (Intuitive Surgical, Sunnyvale, CA) for retzius sparing radical prostatectomy was feasible. The flexible robotic camera provides additional benefit in viewing the operating field, in particular during the posterior dissection, bladder dissection, and anastomosis.

Monopolar vs. bipolar transurethral resection for non-muscle invasive bladder carcinoma: A post-hoc analysis from a randomized controlled trial.

PURPOSE: Traditionally, transurethral resection of bladder tumors (TURB) is performed using monopolar technique. Bipolar resection has been postulated to reduce complications. In this study we compare safety and efficacy between monopolar TURB (mTURB) and bipolar TURB (bTURB) for patients with primary non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: Data were obtained from an international multicenter randomized clinical trial that compared the use of white light cystoscopy with narrow band imaging-assisted TURB using the Olympus system between 2010 and 2014. Main outcomes of interest were operative time, perioperative, and postoperative complications, and 12-month recurrence-free survival. RESULTS: In total, 716 patients were treated for primary NMIBC with mTURB (310 patients) or bTURB (406 patients). The use of white light cystoscopy or narrow band imaging was equally distributed between the 2 resection techniques. Multilevel logistic and linear regression corrected for possible confounders showed no significant difference between mTURB and bTURB for postoperative complications (OR = 1.76, P = 0.180), postoperative bleeding (OR = 1.27, P = 0.722), and the combination of intra + postoperative bleeding (OR = 1.992, P = 0.108). Additionally, no significant difference was found between mTURB and bTURB concerning operative time (1.05min. longer for bTURB, P = 0.536), intraoperative bleeding requiring intervention (OR:1.38, P=0.809), incidence of obturator reflex (OR = 0.93, P = 0.854), and bladder perforation (OR = 3.05, P = 0.195). In total, 185 patients (25.8%) developed a recurrence (mTURB = 88, bTURB = 97). Recurrence-free survival at 12 months in the mTURB and bTURB group was 70% and 74% (P = 0.410), respectively. CONCLUSION: Based on these results, bTURB is as safe and effective as mTURB in treatment of primary NMIBC. bTURB seems to have no evident advantages over mTURB with respect to operation time, perioperative and postoperative complication rates, and recurrence rates at 12 months.

Prostatic artery embolization in treating benign prostatic hyperplasia: a systematic review.

INTRODUCTION: We systemically reviewed the current evidence on prostatic artery embolization (PAE) in treating men with benign prostatic hyperplasia. METHODS: A systemic literature search was conducted in PubMed, EMBASE and Web of Science on 1 May 2016 without time constraints. Outcomes of interest included the changes in the International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, peak urinary flow (Qmax), post-void residual urine (PVR), International Index of Erectile Function (IIEF) score, prostate volume (PV) and prostate-specific antigen (PSA) level. RESULTS: A total of 987 records were identified through database searching. After removing duplicates, screening and reviewing full-length texts, a total of five records remained, with two randomized controlled trials and three non-randomized cohort studies. Transurethral resection of prostate resulted in better IPSS than PAE. Open prostatectomy had better IPSS, QOL score, Qmax and PVR, but worse IIEF score than PAE at 1 year. Unilateral PAE had higher rate of poor clinical outcome than bilateral PAE, but the difference became statistically insignificant after adjusting for age; IPSS, QOL score, Qmax, PVR, IIEF score, PV and PSA did not differ between the two groups. PAE with 100 µm PVA particles resulted in greater reduction in PSA level, but worse IIEF score than PAE with 200 µm PVA particles; IPSS, QOL score, Qmax, PVR, PV and poor clinical outcome did not differ between the two groups. CONCLUSION: Evidence on different aspects of PAE was limited. Further studies are warranted to investigate the role of PAE as compared to other forms of medical and surgical treatment.

Cell-free urinary microRNA-99a and microRNA-125b are diagnostic markers for the non-invasive screening of bladder cancer.

BACKGROUND: Evidence implicated the diagnostic significance of microRNAs in whole urine/urine sediments in urothelial carcinoma of the bladder (UCB). However, the contaminated blood cells in patients with haematouria significantly altered the expression profiles of urinary microRNA, influencing the test accuracy. METHODS: MicroRNA profiles of the urine supernatants of UCB patients and controls without any malignancy and profiles of malignant and corresponding normal mucosa tissues from the patients were determined by microRNA microarray and compared to identify differentially expressed microRNAs. The differential expression was verified in the tissues of an independent patient cohort by RT-qPCR. The diagnostic significance of selected microRNAs as biomarkers in the urine supernatant was investigated in the expanded cohorts. RESULTS: MicroRNA-99a and microRNA-125b were down-regulated in the urine supernatants of UCB patients. The degree of down-regulation was associated with the tumor grade. A diagnostic model was developed using a combined index of the levels of microRNA-99a and microRNA-125b in the urine supernatant with a sensitivity of 86.7%, a specificity of 81.1% and a positive predicted value (PPV) of 91.8%. Discriminating between high- and low-grade UCB, the model using the level of microRNA-125b alone exhibited a sensitivity of 81.4%, a specificity of 87.0% and a PPV of 93.4%. CONCLUSIONS: The results revealed a unique microRNA expression signature in the urine supernatants of UCB patients for the development of molecular diagnostic tests. An effective cell-free urinary microRNA-based model was developed using a combined index of the levels of microRNA-99a and microRNA-125b to detect UCB with good discriminating power, high sensitivity and high specificity.

Current management practice for bladder cancer in Hong Kong: a hospital-based cross-sectional survey.

OBJECTIVES: To examine current practice in the management of bladder cancer in Hong Kong government and private hospitals. DESIGN: Cross-sectional survey. SETTING: All government hospitals and the major private institutions in Hong Kong, which provide urological services. PARTICIPANTS: Urologists responding to an anonymous, self-administered, web-based questionnaire regarding practices in smoking cessation, treatment of non-muscle invasive bladder cancer and muscle invasive bladder cancer, and research into bladder cancer. RESULTS: Of the 29 urologists from 11 government hospitals and eight private institutions who were invited, 18 from 11 (100%) government hospitals and seven from six (75%) private institutions responded, which amounted to an 86% response rate. In all, 88% of the respondents seldom or never referred their bladder cancer patients to smoking cessation programmes. Hong Kong urologists showed good compliance in the management of non-muscle invasive bladder cancer according to international guidelines. There was great variation with regard to regimens for maintenance of intravesical immunotherapy. There was underuse of perioperative systemic chemotherapy, despite wide acceptance of this practice; fewer than 10% of the patients received neo-adjuvant and adjuvant systemic chemotherapy for the treatment of muscle invasive bladder cancer. Of the surveyed urologists, 80% expressed an inadequacy of resources for bladder cancer research and 96% agreed that a local inter-hospital bladder cancer database was needed. CONCLUSIONS: This study demonstrated great diversity in the use of intravesical immunotherapy, perioperative systemic chemotherapy, and surgical treatment of bladder cancer among urology service providers. There is a need for clear recommendations in these areas.

The prevalence of lower urinary tract symptoms in a Chinese population, and the correlation with uroflowmetry and disease perception.

OBJECTIVES: To evaluate the prevalence of lower urinary tract symptoms (LUTS) in a population of Chinese men, and its correlation with uroflowmetry and disease perception. MATERIALS AND METHODS: Male volunteers above 40-year old were recruited in the community. Assessment with International Prostatic Symptom Score (IPSS), uroflowmetry, and a quiz on prostatic disease knowledge with 12 true-false-type questions were performed. Correlation of IPSS with uroflowmetry results and prostatic disease knowledge was analyzed. RESULTS: A total of 319 men were recruited for the study, with a mean age of 62 ± 8 years. About 69.3 % of them had moderate-to-severe symptoms on IPSS. A statistically significant correlation was found between IPSS and Q max (r = -0.260, p < 0.001), IPSS and quality of life (r = -0.172, p = 0.002), and IPSS and post-void residuals (r = 0.223, p < 0.001). About 53.0 % of subjects had less than 4 correct answers for the 12 true-false questions. Negative correlation was noted between the number of correct answers and IPSS (r = -0.185, p = 0001). In other words, for the better knowledge on prostatic diseases, the lower IPSS was found. CONCLUSIONS: In a cohort of community-dwelling Chinese men, a significant portion of the population had moderate-to-severe LUTS. While uroflowmetry parameters were found to correlate with IPSS, the degree of knowledge on prostatic diseases also shared a statistically significant correlation with IPSS. This has an implication on the role of urological health education in the future.

Clinical outcomes of augmentation cystoplasty in patients suffering from ketamine-related bladder contractures.

OBJECTIVE: To evaluate the outcomes of augmentation cystoplasty in patients with bladder contractures secondary to chronic ketamine abuse. METHOD: Patients who had received augmentation cystoplasty to treat ketamine-related bladder contractures in two hospitals in our region were reviewed retrospectively. Their history of ketamine consumption, presenting symptoms, history of treatment, surgical information and post-operative conditions were retrieved from clinical records and then summarized. RESULTS: Between 2006 and 2011, four patients (three women and one man), aged 21-30 years (mean 27 years), underwent augmentation cystoplasty for ketamine-related bladder contractures. The duration of ketamine consumption ranged from 3 to 15 years, and all four patients resumed ketamine consumption after surgery. The mean maximal baseline and post-operative bladder capacity was 37.5 cc (range 25-50 cc) and up to 400-500 cc, respectively. Three patients experienced a further deterioration in renal function that was secondary to new-onset ureteral strictures in two cases and to sepsis in the other. At the time of the last follow-up, three patients could void spontaneously and one required regular intermittent catheterization. CONCLUSION: Ketamine cystitis is an emerging medical condition that requires a multi-disciplinary approach to manage the patients. Simple surgical management of the physical component of the contracted bladder may produce only suboptimal results, and could even cause further problems in some patients. The importance of compliance with post-operative care and abstinence from drug use should be stressed to the patients before surgery. In view of the high complication rate, the option of a simple ileal conduit should also be discussed prior to surgical intervention.

In vivo targeted contrast enhanced micro-ultrasound to measure intratumor perfusion and vascular endothelial growth factor receptor 2 expression in a mouse orthotopic bladder cancer model.

PURPOSE: We evaluated the feasibility of using targeted contrast enhanced micro-ultrasound imaging to assess intratumor perfusion and vascular endothelial growth factor receptor 2 expressions in a mouse orthotopic bladder cancer model. MATERIALS AND METHODS: We created an orthotopic mouse model by implanting MBT-2 murine bladder cancer cell lines in the bladder of syngeneic C3H/He mice (Jackson Laboratory, Bar Harbor, Maine). Successful tumor implantation was confirmed by transabdominal micro-ultrasound imaging on post-implantation day 11. Contrast enhanced micro-ultrasound imaging was done on days 14 and 21. Vascular endothelial growth factor receptor 2 targeted contrast agent was prepared by adding biotinylated anti-vascular endothelial growth factor receptor 2 monoclonal antibodies to streptavidin coated microbubbles. The targeted contrast agents were injected via the retro-orbital route. We quantified intratumor perfusion, vascular endothelial growth factor receptor 2 endothelial expression and blood volume in real time. RESULTS: In the initial study intratumor perfusion data and vascular endothelial growth factor receptor 2 expression could only be measured in 10 of 14 mice (71%) due to motion artifact. We modified our technique by applying an elastic band over the lower abdomen to minimize body wall movement. After the modification complete images were acquired in all mice at 2 consecutive imaging sessions. Measurements were made of intratumor perfusion and in vivo vascular endothelial growth factor receptor 2 expression. No adverse effects occurred due to anesthesia or the ultrasound contrast agent. CONCLUSIONS: Targeted contrast enhanced micro-ultrasound imaging enables investigators to detect and monitor vascular changes in orthotopic bladder tumors. It may be useful for direct, noninvasive, in vivo evaluation of novel anti-angiogenesis therapeutic agents. With the modified technique target enhanced contrast ultrasound can be applied in an orthotopic bladder cancer model.

Pneumovesicum approach to en-bloc laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial cancer: midterm oncological results.

INTRODUCTION: We reported the pneumovesicum (PV) approach to lower ureter and bladder cuff excision and closure. We believe that this approach bears the closest resemblance to the laparoscopic skill set of intravesical dissection and suturing. Herein, we report the midterm oncological results of the approach's use in a series of patients with upper tract urothelial cancer. MATERIALS AND METHODS: From July 2004 to May 2010, 10 patients with upper tract urothelial cancer who underwent PV-assisted laparoscopic nephroureterectomy (LNU) were reviewed. Laparoscopic ports were inserted into the bladder via a suprapubic route, and carbon dioxide PV was induced. Laparoscopic dissection of the lower ureter and excision of the bladder cuff were then performed. The bladder defect was securely closed using laparoscopic suturing, and standard LNU followed. RESULTS: Nine men and one woman with a mean age of 71.6 years (47-82) underwent the procedure. Six of the patients had renal pelvic tumor, two had upper ureter tumor, one had midureter tumor, and one had synchronous renal pelvis and upper ureter tumor. In terms of final pathology, there were three, two, and five patients with T1, T2, and T3 diseases, respectively. All of the patients had grade 2 (G2) disease, except for two with grade 3 (G3) disease. Over a median follow-up of 46 months (22-67 months), four patients developed superficial bladder tumor recurrence. The bladder and systemic recurrence rates were 40% and 10%, respectively. There was no port site recurrence. CONCLUSION: Based on our midterm follow-up information, it can be concluded that the PV approach to en-bloc bladder cuff excision and LNU for upper tract urothelial cancer provides intermediate oncological results comparable to those of other approaches to en-bloc excision of the bladder cuff.

Using urine microscopy and cytology for early detection of bladder cancer in male patients with lower urinary tract symptoms.

OBJECTIVES: Irritative urinary symptoms and micro-hematuria are the common findings in bladder cancer patients. In this study, we investigated the use of urine microscopy and cytological examination for early detection of bladder cancer in patients with lower urinary tract symptoms (LUTS). METHODS: Male patients presented with LUTS to urology clinic were enrolled. Voiding symptoms were evaluated with international prostate symptoms score, and urine samples were collected for microscopy and cytological examination. Cystoscopy was performed in patients with microscopic hematuria, suspicious/malignant cells in urine or at the time of transurethral resection of prostate. Subjects, who had no indication and did not receive cystoscopy, were followed up in clinic for progress of symptoms, including gross hematuria and occurrence of bladder cancer. RESULTS: Nine hundred and eighty-eight patients were enrolled during the period of 2005-2007. Fifty-two (5.26%) urine samples were documented as atypical, and 936 (94.7%) were negative. There was no suspicious or malignant cytology result in this series. Micro-hematuria was noticed in six patients (0.61%). The mean follow-up time was 29.1 ± 12.5 months. One (0.10%) patient had bladder cancer 44 months after the first visit in the cohort, who had micro-hematuria, atypical urine cytology, but normal cystoscopy before diagnosis. CONCLUSION: The prevalence rate of bladder cancer in male patients with LUTS is low. This study adds to information that microscopy and cytological examination are not useful to detect bladder cancer. Due to the economic concerns and burden of unnecessary investigations, the routine use of these tests is in doubt.

Primary bladder amyloidosis--case report of a patient with delayed upper urinary tract obstruction 3 years after the diagnosis.

Primary bladder amyloidosis is a rare disease. There are approximately 100 reported cases. The lesions can be confused with bladder neoplasm and are characterised histologically by the classical apple green birefringence under polarised light. In this article, we report a 51-year-old lady with known history of primary bladder amyloidosis presenting with gross hydronephrosis 3 years after the first diagnosis. Laparoscopic ileal replacement of bilateral ureters was performed. There was no recurrent ureteric obstruction 2 years after surgery. This case demonstrates the progressive nature of primary amyloidosis of bladder. The diagnosis of primary bladder amyloidosis warrants long-term surveillance of upper urinary tract.

Transabdominal micro-ultrasound imaging of bladder cancer in a mouse model: a validation study.

OBJECTIVES: To validate the use of transabdominal micro-ultrasound imaging (MUI) in an orthotopic murine bladder cancer model. The current in vivo imaging systems for murine bladder cancer include magnetic resonance imaging, bioluminescent and fluorescent imaging, and intravesical ultrasound. METHODS: We implanted murine bladder tumor-2 tumor cells into C3H/He female mice. Mice underwent MUI before, and every 3 days after instillation of tumor cells. Three mice were killed at every MUI session. Bladder tumors were measured and tumor volumes were calculated during MUI and gross stereomicroscopy. Bladders were harvested and examined under gross stereomicroscopy to confirm the presence, location, and size of bladder tumors, and were prepared for histology review. RESULTS: Overall, 15 of 33 (45%) mice were confirmed to have tumors, using MUI, gross stereomicroscopy, and histology. Measurements of tumor size by MUI and gross microscopy had a high correlation coefficient (r = 0.97). MUI identified all tumors that were present on final histology. The smallest confirmed tumor on MUI was detected at 0.52 mm(3), and mean tumor volume was 0.95 mm(3). No tumors that were not detected first using MUI were found on final histology. CONCLUSIONS: Transabdominal MUI is a valuable tool to use for translational studies involving orthotopic mouse bladder cancer models. MUI provides real-time, high resolution in vivo images of bladder tumors. Tumor presence can be confirmed with a high degree of accuracy pertaining to tumor volume before initiation of treatment. In addition, tumor growth or regression can be followed up in vivo longitudinally.

Optimizing orthotopic bladder tumor implantation in a syngeneic mouse model.

PURPOSE: We established a reliable technique for orthotopically implanting bladder tumor cells in a syngeneic mouse model. MATERIALS AND METHODS: MBT-2 murine bladder cancer cells were transurethrally implanted in the bladder of syngeneic C3H/He mice (Jackson Laboratory, Bar Harbor, Maine). Different chemical pretreatments were used before tumor implantation, including phosphate buffered saline (control), HCl, trypsin and poly-L-lysine. MBT-2 cells (1 x 10(6) or 2 x 10(6)) were instilled into the intravesical space after chemical pretreatment. Tumor take and bladder tumor volume were determined by micro ultrasound. Bladders were harvested at the end of the study to measure bladder weight and for histopathological examination. RESULTS: Bladder pretreatment with HCl in 5 preparations was discontinued due to significant adverse reactions, resulting in death in 1 mouse, and severe bladder inflammation and hematuria 3 days after pretreatment in 2. Pretreatment with phosphate buffered saline, trypsin and poly-L-lysine in 6 animals each was tolerated well without significant adverse reactions or mortality. The tumor take rate in the control, trypsin and poly-L-lysine pretreatment groups was 33%, 83% and 83%, respectively. The take rate was higher in mice instilled with 2 x 10(6) cells than in those with 1 x 10(6) cells (93% vs 73%, p <0.05). CONCLUSIONS: We report a reliable, feasible method of orthotopically implanting bladder tumor cells into a syngeneic mouse model. Poly-L-lysine and trypsin are useful adjunctive pretreatment agents to improve bladder tumor uptake. This model may be suitable to evaluate treatment paradigms for bladder cancer.

Novel approach of laparoscopic transperitoneal en bloc resection of urachal tumor and umbilectomy with a comparison of various techniques.

Urachal carcinoma is a rare cancer that accounts for less than 1% of all bladder cancers. Surgical resection remains the mainstay of treatment. With partial cystectomy, long-term survival is possible following complete resection of the tumor. In this paper, we describe a novel approach of laparoscopic en bloc partial cystectomy and umbilectomy. We emphasize the importance of complete resection of the tumor and umbilicus and prevention of tumor spillage during the procedure. The literature is also reviewed for the comparison of various laparoscopic techniques.

Cystinuria: a rare diagnosis that should not be missed.

Cystinuria is a rare autosomal recessive defect causing recurrent urinary tract stone formation. Morbidity from stone formation and repeated urological interventions can be reduced by early diagnosis and adequate medical treatment. In this review, we illustrate these points by discussing three patients with cystinuria and give a brief review of its management.