Incidental finding of an angiomyxoma of the urinary bladder: A case report of a rare but aggressive tumour.

Angiomyxoma is a rare mesenchymal tumor arising in the pelvic and perineal regions. Diagnosis of urinary bladder angiomyxoma is difficult, as it lacks typical signs and symptoms, and relies on immunochemistry. We present the case of a 53 year old patient presenting with an incidental finding of bladder tumor during an ultrasound. After a complete transurethral resection was performed, the pathology report led to angiomyxoma diagnosis. After 6 weeks a secondary TURB, along with a CT urogram showed no evidence of residual volume. Transurethral resection seems to be a safe and effective treatment of urinary bladder angiomyxoma.

Diagnosis of Low-Grade Urothelial Neoplasm in the Era of the Second Edition of the Paris System for Reporting Urinary Cytology.

BACKGROUND: The Paris System for Reporting Urinary Cytology (TPS) is considered the gold standard when it comes to diagnostic classifications of urine specimens. Its second edition brought some important changes, including the abolition of the diagnostic category of "low-grade urothelial neoplasm (LGUN)", acknowledging the inability of cytology to reliably discern low-grade urothelial lesions. METHODS: In this retrospective study, we assessed the validity of this change, studying the cytological diagnoses of histologically diagnosed low-grade urothelial carcinomas during a three-year period. Moreover, we correlated the sum of the urinary cytology diagnoses of this period with the histological diagnoses, whenever available. RESULTS: Although all the cytological diagnoses of LGUN were concordant with the histological diagnoses, most low-grade urothelial carcinomas were misdiagnosed cytologically. Subsequently, the positive predictive value (PPV) of urinary cytology for the diagnosis of LGUN was 100%, while the sensitivity was only 21.7%. Following the cyto-histopathological correlation of the sum of the urinary cytology cases, the sensitivity of urinary cytology for the diagnosis of high-grade urothelial carcinoma (HGUC) was demonstrated to be 90.1%, the specificity 70.8%, the positive predictive value (PPV) 60.3%, the negative predictive value (NPV) 93.6% and the overall accuracy 77.2%, while for LGUN, the values were 21.7%, 97.2%, 87.5%, 58.6% and 61.9%, respectively. Risk of high-grade malignancy was 0% for the non-diagnostic (ND), 4.8% for the non-high-grade urothelial carcinoma (NHGUC), 33.3% for the atypical urothelial cells (AUCs), 65% for the suspicious for high-grade urothelial carcinoma (SHGUC), 100% for the HGUC and 12.5% for the LGUN diagnostic categories. CONCLUSIONS: This study validates the incorporation of the LGUN in the NHGUC diagnostic category in the second edition of TPS. Moreover, it proves the ability of urinary cytology to safely diagnose HGUC and stresses the pivotal role of its diagnosis.

Treatment of relapsed urothelial bladder cancer with vinflunine: real-world evidence by the Hellenic Genitourinary Cancer Group.

Relapsed urothelial cancer represents an unmet medical need. Vinflunine is a third-generation antimicrotubuline inhibitor and is currently the only approved drug for second-line treatment across the European Union. We conducted a retrospective analysis assessing the efficacy and safety of vinflunine in 71 Greek patients with relapsed urothelial cancer who were treated between 2005 and 2014. An overall 84% of our patients received vinflunine as second-line treatment, 77% had a performance status of Eastern Cooperative Oncology Group scale 0 or 1, and 30% had liver metastasis at the time of vinflunine administration. A median of four cycles of vinflunine were administered (range 1-16). The most common reported adverse events were constipation, fatigue, and anemia. Median progression-free survival was 6.2 months (95% confidence interval: 4.4-8.8) and overall survival was 11.9 months (95% confidence interval: 7.4-21). Two patients (3%) achieved a complete remission, seven a partial remission (10%), and 22 (31%) had stable disease according to an intention-to-treat analysis. Hemoglobin level less than 10 g/dl and Eastern Cooperative Oncology Group performance status greater than 1 were independent adverse prognostic factors. Stratification according to the Bellmunt risk model was also associated with progression-free survival and overall survival in our population. Vinflunine appears to be a safe and effective treatment modality for relapsed urothelial cancer. More effective therapies and more accurate prognostic algorithms should be sought.

Prognostic significance of cytoreductive nephrectomy in patients with synchronous metastases from renal cell carcinoma treated with first-line sunitinib: a European multiinstitutional study.

INTRODUCTION/BACKGROUND: The aim of this study was to evaluate the prognostic role of CN in patients with mRCC and synchronous metastases treated with the VEGF receptor TKI, sunitinib. PATIENTS AND METHODS: Patients with a diagnosis of metastases before, at the time of, or within 3 months from the diagnosis of renal cell carcinoma (RCC) and first-line treatment with sunitinib were included. Baseline characteristics were correlated with overall survival (OS) according to hazard ratios estimated from univariate Cox proportional hazards models. Significant factors were then included in a multivariate Cox proportional hazards model. RESULTS: One hundred eighty-six patients treated between January 2006 and March 2012 were selected. Thirty-six (19%) had not undergone CN. CN was offered to younger patients with better prognoses. Patients who underwent CN lived significantly longer than patients without CN (median OS, 23.9 [95% confidence interval (CI), 20.8-28.8] vs. 9 [95% CI, 4-16.4] months; P < .001). Multivariate analysis showed that CN had an independent prognostic significance. No specific subgroup benefiting from CN was identified. CONCLUSION: CN was an independent favorable prognostic factor in patients with synchronous metastases from RCC, treated with sunitinib. Information regarding the selection of mRCC patients likely to benefit from CN might be derived by ongoing phase III trials.

Terazosin treatment induces caspase-3 expression in the rat ventral prostate.

BACKGROUND: Quinazoline-based alpha1-adrenergic receptor antagonists may not act solely on smooth muscle contractility. We evaluated the in vivo effect of terazosin on the expression of caspase-3 in the rat ventral prostate. METHODS: Fifteen Wistar rats were treated with terazosin (1.2 mg/kg body weight, given orally every second day) for 120 days. Another 15 control animals received the same amount of distilled water. The expression of caspase-3 was assessed immunohistochemically in formalin-fixed, paraffin-embedded tissue sections. RESULTS: Terazosin treatment did not affect prostate weight and histomorphology. In controls caspase-3 was expressed weakly and sporadically. In contrast, strong and weak expression was evident in 67% and 33% of the terazosin-treated specimens, respectively. CONCLUSIONS: These findings implicate the induction of caspase-3 expression by terazosin as a potential molecular mechanism of its apoptotic action on prostate cells.

Radical nephrectomy with transperitoneal subcostal incision for large and locally advanced tumors of the right kidney.

BACKGROUND: Several surgical approaches have been used for radical nephrectomy for large and locally advanced tumors of the right kidney. AIM: To present our experience with radical nephrectomy using a right subcostal incision with a transperitoneal approach in patients with very large tumors of the right kidney. PATIENTS AND METHODS: Between 2003 and 2010, 34 patients with very large tumors of the right kidney were submitted to surgery. Eighteen patients underwent a transperitoneal approach with a right subcostal incision (intervention group) and 16 patients were operated on with retroperitoneal flank incision (control group). RESULTS: No significant complications during surgery were observed in the intervention group; two patients needed blood transfusions of 300 cc during the first postoperative day. In the control group, injury of the renal vein or inferior vena cava (IVC) was a relatively common complication; five patients needed blood transfusions of 300 cc during the first postoperative day. CONCLUSION: A transperitoneal right subcostal incision for radical nephrectomy in patients with large and locally advanced tumors of the right kidney seems to offer better access to the renal pedicle, and to the great vessels of the area as well as better exposure of the organs of the abdominal cavity. This approach could be more useful in cases in which liver involvement is possible.

Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies.

UNLABELLED: Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C-index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial. OBJECTIVE: • To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN). PATIENTS AND METHODS: • Seventy-four consecutive patients in a single academic tertiary institution underwent open PN. • Incidence of 90-day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case. • The severity of complications was also categorized with the Clavien system. RESULTS: • The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73-1.00). • Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications. • Also, PADUA score ≥ 8 identified a group of patients with almost 20-fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79-28.35; P= 0.015). • Patients with papillary histology had greater risk for complications than those with clear-cell tumours (HR = 4.88; 95% CI, 1.34-17.76; P= 0.016). CONCLUSIONS: • The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre. • The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery. • However, it should be applied to laparoscopic and robot-assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

Symptoms of acute posttraumatic stress disorder in prostate cancer patients following radical prostatectomy.

Psychological morbidity is increasingly reported in cancer survivors. The authors' objective was to determine the presence of acute posttraumatic stress disorder (PTSD) symptoms in prostate cancer (PC) patients following radical prostatectomy. Fifteen patients who underwent radical prostatectomy for localized prostate cancer were assessed for the presence of PTSD-related symptoms by completing the Davidson Trauma Scale (DTS), a month following the procedure. A group of 20 patients who underwent surgery for benign prostate hyperplasia (BPH) served as the control group. PTSD total scores were significantly higher in PC patients when compared with BPH patients, whose PTSD scores did not differ from those reported in the general population (32.6 ± 18.5 vs. 11.3 ± 9.7, p = .001). PTSD did not vary among PC patients when adjusted for educational status. PTSD symptoms are common among patients undergoing radical prostatectomy and independent of their educational level. Research investigating these aspects of posttreatment psychological adjustment is needed for developing well-targeted psychological interventions.

Effect of a hypercholesterolemic diet on serum lipid profile, plasma sex steroid levels, and prostate structure in rats.

OBJECTIVES: The purpose of this study was to examine the impact of a hypercholesterolemic diet (HD) on serum lipid profile, plasma sex steroid levels, and ventral prostate structure in rats. METHODS: Beginning at 120 days of age, male Wistar rats were fed for 5 months with either standard rat chow (15 animals) or standard chow enriched with 4% cholesterol and 1% cholic acid (15 animals). The body and ventral prostate weights (VPWs), plasma sex steroid levels, and lipid profiles were determined, and prostate morphology in fixed tissue sections were studied. RESULTS: The body weight of rats fed with HD did not differ from that of controls. However, both absolute and relative VPWs of HD animals were significantly lower than those of controls. HD resulted in significant elevation in total serum cholesterol and LDL levels, whereas HDL and triglyceride levels were comparable. Plasma total testosterone and estriol levels did not differ between groups, but their free fraction, along with sex hormone-binding globulin levels, were significantly affected. HD also affected the microscopic structure of the ventral prostate. Epithelial cells of the distal area formed papillary projections within the acinar lumen and had more cytoplasm than controls. In most cases, vesicular formations within the cytoplasmic area were also noted. CONCLUSIONS: Hypercholesterolemia causes marked changes in the ventral prostate, serum lipid profile, and plasma sex steroid profile in rats and possibly alters prostate morphology by affecting the sex steroid axis, thus contributing to prostatic disease pathogenesis.

(1)H NMR metabonomic analysis in renal cell carcinoma: a possible diagnostic tool.

(1)H NMR based metabonomic approach was applied in order to monitor the alterations of plasma metabolic profile in Renal Cell Carcinoma (RCC) patients and controls. (1)H NMR spectra of plasma samples from 32 RCC patients and 13 controls (patients exhibiting benign urologic disease) were recorded and analyzed using multivariate statistical techniques. Alterations in the levels of LDL/VLDL, NAC, lactate, and choline were observed between RCC patients and controls discriminating these groups in Principal Component Analysis (PCA) plots. Post OSC PLS-DA presented a satisfactory clustering between T1 with T3 RCC patients. Decrease in plasma lipid concentrations in RCC patients was verified using conventional clinical chemistry analysis. The results suggest that combination of (1)H NMR spectroscopy with PCA has potential in cancer diagnosis; however, a limitation of the method to monitor RCC is that major biomarkers revealed (lipoproteins and choline) in this metabolic profile are not unique to RCC but may be the result of the presence of any malignancy.

Quantitative study of mast cells in experimentally induced benign prostatic hyperplasia.

INTRODUCTION: Mast cells are involved in a number of biological responses to exocrine and endocrine stimuli, by releasing growth factors and certain cytokines. The aim of this study was to evaluate their number and distribution in experimentally induced benign prostatic hyperplasia in rats. MATERIALS AND METHODS: Adult Wistar rats (100 days old) were given citral transdermally for 1 month. Morphological characteristics and mast cell concentration were studied in proximal and distal zones after staining with hematoxylin-eosin and Giemsa, respectively. RESULTS: Citral induced mild benign prostatic hyperplasia. Mast cell numbers were increased significantly in both the proximal (2.97 +/- 0.52 vs. 1.4 +/- 0.17, p = 0.004) and distal zone (2.8 +/- 0.68 vs. 1.16 +/- 0.11, p = 0.011). CONCLUSION: Transdermal citral application resulted in a significant increase of mast cell numbers in the stroma of the rat ventral prostate. Furthermore, these mast cells were larger, contained a significant number of intracytoplasmic granules and degranulated. This finding suggests a role for mast cells in the pathogenesis of benign prostatic hyperplasia.

Beta-adrenergic receptor blockade and prostate peptide growth factor expression in the rat.

BACKGROUND AND AIM: In the rat prostate, beta-adrenoreceptor (beta-AR) stimulation does not alter basal prostatic tone but may inhibit alpha1-AR-mediated, field stimulation-induced or receptor-independent contractile responses. The present study was designed to assess the alteration of basic fibroblast growth factor (bFGF) and transforming growth factor-beta (TGFbeta) expression in the rat ventral prostate in response to beta-AR blockade with propranolol. RESULTS: At sacrifice, body weight as well as ventral prostate weight and prostate morphology were not significantly affected by propranolol treatment. Stromal elements and the majority of prostatic epithelial cells in control animals demonstrated positive staining for the anti-bFGF antibody, while positive staining for TGFbeta was seen only in epithelial cells. Propranolol treatment resulted in considerable decrease of bFGF staining intensity in both stromal and epithelial cells, while the immunostaining pattern for TGFbeta was almost abolished. RESULTS AND CONCLUSIONS: The results from this study provide evidence to suggest that prolonged propranolol treatment affects peptide growth expression in the rat ventral prostate as in other tissues, and confirms the notion that autonomic nervous system controls, at least partly, prostate gland functional characteristics. Moreover, it may also affect prostate homeostasis by intervening in stromal-epithelial interaction through alterations in the expression of peptide growth factors without affecting prostate volume.

Patient awareness of smoking as a risk factor for bladder cancer.

INTRODUCTION: Data on general population's and bladder cancer patients' perception of smoking as a risk factor for bladder cancer are limited. To determine urological patients' awareness of smoking as a risk factor for bladder cancer. METHODS: This prospective observational study included 202 consecutive urological inpatients, using a structured questionnaire. We evaluated urological patients' awareness of smoking as a risk factor for bladder cancer and other smoking-related pathologies. Smoker-bladder cancer patients were asked whether they believed that smoking was related to their present bladder problem, whether their treating urologist had ever advised them on the same, and whether they intended to quit. RESULTS: Only 118 of 202 patients (58.4%) stated that they were aware of smoking as a risk factor for bladder cancer, as apposed to 94.6% for chronic obstructive pulmonary disease, 91.6% for heart and vascular problems, and 92.1%, for lung cancer. Perception was unrelated to age, gender, smoking habits, or history of heart or chronic lung disease. Of current smokers/TCC patients, 56.4% believed that smoking is related to their problem and 61.5% intended to quit. The majority (84.6%) had been already warned by their attending physicians. CONCLUSIONS: Urological patients' awareness of smoking as a risk factor for bladder cancer is lower than that for other smoking-related entities. The role of the urologist should not be restricted only to diagnosis and treatment, but should also include counseling patients on the need for radical changes of their life style.

Terazosin treatment suppresses basic fibroblast growth factor expression in the rat ventral prostate.

PURPOSE: Alpha1-adrenergic receptor antagonists may not act solely on smooth muscle contractility. We evaluated the in vivo effect of the alpha1 blocker, terazosin, on the expression of basic fibroblast growth factor (bFGF) in the rat ventral prostate. METHODS: Wistar rats were treated with terazosin (1.2 mg/kg body weight, po, every second day) for 120 days. The expression of bFGF was assessed immuno-histochemically in tissue sections and by Western blotting in whole tissue preparations. RESULTS: Terazosin treatment did not affect prostate weight or histomorphology. In the control group, epithelial and stromal cells demonstrated positive staining for the anti-bFGF antibody. In contrast, the same staining in terazosin-treated specimens was either absent or extremely weak. An analogous difference was observed among the corresponding immunoblots. CONCLUSIONS: These findings implicate the reduction of bFGF expression by terazosin as a potential additional molecular mechanism of its action that may include alterations in peptide growth factor mediated prostate homeostasis.

Safety of anticholinergics in patients with benign prostatic hyperplasia.

BACKGROUND: Storage lower urinary tract symptoms (LUTS) or overactive bladder (OAB) often coexist with voiding symptoms in patients with benign prostatic obstruction (BPO). Anticholinergic medications to treat storage LUTS are often withheld in such patients for fear of significantly increasing post-void residual urine volumes or provoking acute urinary retention (AUR). OBJECTIVE: To assess the clinical validity of concerns regarding urinary safety of anticholinergics in patients with benign prostatic hyperplasia. METHODS: Review of indexed literature and congress abstracts. RESULTS/CONCLUSIONS: Existing urinary and non-urinary safety data on BPO patients administered anticholinergics, either alone or in combination with alpha-blockers, do not seem to support the above-mentioned concerns. Nevertheless, precise criteria for patient and drug selection to ascertain safe and effective administration are not yet established and need to be investigated in future trials.

Phosphodiesterase-5 inhibitors in the treatment of lower urinary tract symptoms and benign prostatic hyperplasia.

BACKGROUND: Lower urinary tract symptoms (LUTS) are prevalent in ageing men and commonly coexist with erectile dysfunction. Preclinical data on the involvement of the nitric oxide/cyclic guanosine monophosphate/phosphodiesterase pathway in the regulation of lower urinary tract smooth muscle activity have been available for several years. Phosphodiesterase 5 (PDE5) is expressed in the prostate and bladder and PDE5 inhibitors have been shown to relax precontracted muscle strips from these organs. OBJECTIVE: To assess the clinical benefit of PDE5 inhibitors in LUTS treatment. METHODS: Clinical trials published as full papers in peer-reviewed journals were reviewed. RESULTS/CONCLUSION: Data from early clinical trials show a consistent improvement in International Prostate Symptom Score with PDE5 inhibitor therapy in men presenting with erectile dysfunction or LUTS. The lack of significant changes in objective outcomes in these trials, despite symptomatic improvement, reflects gaps in our understanding of LUTS pathophysiology/PDE5 inhibitors' mechanism of action. More trials are needed to further establish the clinical benefit of PDE5 inhibitors in LUTS treatment and to set criteria for patient and drug selection.

Differences in presentation characteristics of renal cell carcinoma in the last 25 years: a single center experience.

PURPOSE: The aim of this study was to examine trends in clinicopathological characteristics of renal cell carcinoma (RCC) cases at presentation in a single institution over a 25-years period. PATIENTS AND METHODS: The medical files of 505 patients with histologically confirmed primary RCC from 1981 to 2006 were retrospectively reviewed. Host and tumor characteristics at presentation were compared following stratification by hospitalization period (1981-1990, 1991-2000, and 2001-2006). RESULTS: Age at presentation did not change significantly over time. The incidentally diagnosed cases increased significantly by time (10.2, 40.5, 62.7%), in proportion to small (<4 cm) tumors (8.6, 17.3, 30.6%), while tumor diameter decreased significantly (8.5 +/- 3.8, 7.4 +/- 3.5, 5.8 +/- 2.9). The rate of organ-confined tumors increased significantly (42.1, 63.6, 68.9%), followed by a less pronounced decrease of metastatic cases (12.3, 8.9, 6.8%). CONCLUSIONS: The evolution of tumor characteristics at presentation in a single institution is apparent within the last 25 years. Major changes were noticed within organ-confined and small tumors and call for familiarization of urologists with nephron-sparing techniques and novel ablation technologies.

Androgens and bladder outlet obstruction: a correlation with pressure-flow variables in a preliminary study.

OBJECTIVES: To determine the relationship between androgens, lower urinary tract symptoms (LUTS) and urodynamic variables of bladder outlet obstruction (BOO) in patients with LUTS/benign prostatic hyperplasia (BPH), as androgens are important in the pathogenesis of LUTS. PATIENTS AND METHODS: Twenty-five men with symptomatic BPH were enrolled in the study and had a complete urodynamic investigation, establishing BOO. Age, prostate-specific antigen level, prostate volume and postvoid residual volume were recorded and the International Prostate Symptom Score (IPSS) was estimated. Detrusor pressure at maximum flow (P(det)Q(max)), at urethral closure (P(det)Cl, the pressure at the end of urinary flow) and maximum detrusor pressure (P(detmax)) was recorded, while detrusor overactivity (DO) was noted when present. Blood samples were collected to measure total testosterone (T), and free T (FT) was calculated. Patients were grouped according to FT levels as low (<72 pg/mL) and normal (FT > or =72 pg/mL). RESULTS: Ten patients had a low FT level, with a mean (sd) of 54.3 (16.5) pg/mL, and 15 a normal level of FT, of 90.5 (11) pg/mL. FT was negatively correlated with P(det)Cl, and P(det)Q(max); the mean P(det)Cl and P(det)Q(max) differed significantly between patients with low and normal FT levels. Fourteen patients had DO and they had significantly lower levels of FT than those with no DO. All patients with a FT level of <60 pg/mL had DO, and the presence of instability differed significantly from the rest of the group. CONCLUSIONS: Low T levels in clinical BOO correlated negatively with P(det)Cl and P(det)Q(max), while promoting DO. Androgen seems to have an ameliorating role in lower urinary tract function.

Contemporary diagnosis of bladder cancer.

BACKGROUND: Early diagnosis of bladder cancer is mandatory, as a delay in treatment has been shown to affect prognosis. The current diagnostic standard of cystoscopy and cytology is costly, invasive and inconvenient, whereas advances in molecular biology have resulted in the evolvement of several markers. OBJECTIVE: To review diagnostic considerations in the use of old and new technical modalities and tests for the detection of bladder cancer. METHODS: A PubMed search of the literature concerning bladder cancer diagnosis was performed. Reviews are included on certain topics to avoid extensive reference to separate studies. CONCLUSION: Recent technical advances have an impact on the management of patients with suspected bladder cancer. Cytology is still an important adjunct in the diagnostic work-up, whereas urine-bound tests may have a role in screening and surveillance. However, cystoscopy is the standard of care for the detection of bladder cancer. Fluorescence cystoscopy is an adjunctive tool, especially for the prompt identification of carcinoma in situ.