Periurethral injection therapy for urinary incontinence in women.

BACKGROUND: Periurethral or transurethral injection of bulking agents is a surgical procedure most often used for the treatment of stress urinary incontinence a common, troublesome symptom amongst adult women. OBJECTIVES: To assess the effects of periurethral/transurethral injection therapy in the treatment of urinary incontinence in women. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (28 February 2007), MEDLINE (January 1996 to March 2007, PREMEDLINE (7 February 2007) and the reference lists of relevant articles. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of treatment for urinary incontinence, in which at least one management arm involved periurethral/transurethral injection therapy. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently using a standard form and clarification concerning possible unreported data sought directly from the investigators. MAIN RESULTS: We identified twelve trials including 1318 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis. Injection of autologous fat was compared to placebo in a study of 68 women which was terminated early because of safety concerns. No differences in subjective or objective outcome were found in the two groups. No studies were found comparing injection therapy with conservative treatment. Two studies that compared injection with surgical management found significantly better objective outcome in the surgical group. Eight studies compared different agents - all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol and carbon spheres gave improvements equivalent to collagen. Porcine dermal implant gave improvements comparable to silicone at six months. A comparison of periurethral and transurethral methods of delivery of the bulking agent found similar outcome but a higher rate of early complications in the periurethral group. AUTHORS' CONCLUSIONS: Despite five additional trials, this updated review is still an unsatisfactory basis for practice. The trials were small and generally of moderate quality. The only evidence of benefit comes for within-group short-term changes following injection. The finding that placebo saline injection was followed by a similar symptomatic improvement questions the mechanism of any effects. There were no trials in comparison with pelvic floor muscle training -the obvious non-surgical comparator. Greater symptomatic improvement was observed after surgery, although these advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents; one small trial suggests that periurethral injection may carry more risks than transurethral injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side-effects. Pending further evidence, injection therapy may represent a useful option for short-term symptomatic relief amongst selected women with co-morbidity that precludes anaesthesia - two or three injections are likely to be required to achieve a satisfactory result.

erbB receptor expression patterns in human bladder cancer.

OBJECTIVES: To investigate expression patterns of erbB receptors in a panel of 58 human bladder tumors. Aberrant functional and structural interactions of erbB type I receptor tyrosine kinase cell surface receptors are important in the development and maintenance of the malignant phenotype. Few studies have focused on the remaining family members or patterns of receptor coexpression in urothelial cancer. METHODS: Frozen tumor samples from 58 patients with newly diagnosed bladder cancer were collected; 18 had Stage Ta, 20 Stage T1, and 20 had Stage T2 or worse. The grade was G1 in 5, G2 in 24, and G3 in 29 patients. Seven normal urothelial samples were obtained from patients with benign urologic conditions. The tumor material was probed using conventional immunoblotting and enhanced chemiluminescence. The blots were captured with digital imaging, and protein expression was quantified with gel analysis software. RESULTS: Most tumors exhibited detectable expression of at least one erbB receptor. Examples of coexpression of epidermal growth factor receptor (EGFr) and erbB-2 were also found. Detectable erbB-3 or erbB-4 protein expression was lacking in this series. Compared with other tumors, the T1 samples exhibited the greatest mean levels of erbB-2 protein expression (P = 0.0028). Of the 58 tumors, 10 (17.2%) coexpressed EGFr and erbB-2; this was associated with T1 disease (P = 0.03). CONCLUSIONS: Varied levels of expression of both EGFr and erbB-2 appear to exist in human bladder cancer. These preliminary data do not support erbB-3/4 as major protagonists in this tumor system. The observations presented suggest a role for EGFr and erbB-2 in the development and progression of bladder cancer that should be explored further.

Free/total serum prostate-specific antigen ratio: how helpful is it in detecting prostate cancer?

OBJECTIVE: To determine whether the use of free/total (f/t) serum prostate specific antigen (PSA) ratio would help reduce the number of prostate biopsies performed without compromising the detection of prostate cancer. in the setting of a transrectal ultrasonography (TRUS) clinic. PATIENTS AND METHODS: The study included 93 consecutive patients referred to the clinic for TRUS and biopsy. Serum samples were assessed for total PSA and free PSA, and the f/t PSA ratio calculated: 70 biopsies were taken. Patients over the age of 70 years with TRUS findings consistent with benign prostatic hyperplasia and with PSA levels < 10 ng/mL were not biopsied. RESULTS: Tumour was detected in 23 patients; receiver operating characteristic curves showed no advantage for the f/t PSA ratio when compared with total PSA in detecting prostate cancer. If a f/t PSA ratio of < 0.15 had been used to determine the necessity for biopsy in the group with a total PSA of 4-10 ng/mL, then two-thirds of all tumours would have been undetected. CONCLUSION: The f/t PSA ratio had no advantage over total PSA in improving specificity at a given sensitivity for detecting prostate cancer. Therefore, it cannot be recommended as a means of decreasing unnecessary biopsies in patients with a raised PSA level and/or an abnormal digital rectal examination. This applied particularly to the group of patients with a total PSA of 4-10 ng/mL.