The artificial urinary sphincter after a quarter of a century: a critical systematic review of its use in male non-neurogenic incontinence.

CONTEXT: The artificial urinary sphincter (AUS) has historically been considered the gold standard for the surgical management of non-neurogenic stress urinary incontinence (SUI) in men. As new surgical alternatives attempt to offer alternatives to treat male SUI, a contemporary assessment of the evidence supporting the use of AUS appears mandatory for clinical decision making. OBJECTIVE: To conduct a critical systematic review of long-term outcomes after AUS implantation in male patients with non-neurogenic SUI. EVIDENCE ACQUISITION: A literature search was conducted in PubMed/Medline and Embase databases using the keywords urinary incontinence and urinary sphincter, artificial and male, restricted to articles published in Dutch, English, French, and German between 1989 and 2011. Studies were included if they reported outcomes after AUS implantation in patients with non-neurogenic SUI with a minimum follow-up of 2 yr. Studies with heterogeneous populations were included if information about non-neurogenic patients was displayed separately. EVIDENCE SYNTHESIS: Twelve reports were identified, gathering data about 623 patients. Only three studies were prospective. Continence, evaluated only by patient-reported pad use and various questionnaires, was achieved in 61-100% of cases (no pad or one pad per day). Dry rates (no pad) were only available in seven studies and varied from 4% to 86%. A pooled analysis showed that infection or erosion occurred in 8.5% of cases (3.3-27.8%), mechanical failure in 6.2% of cases (2.0-13.8%), and urethral atrophy in 7.9% (1.9-28.6%). Reoperation rate was 26.0% (14.8-44.8%). Patient satisfaction was evaluated in four studies with four different tools and seems to improve after AUS implantation. CONCLUSIONS: Quality of evidence supporting the use of AUS in non-neurogenic male patients with SUI is low, based on heterogeneous data, low-quality studies, and mostly out-of-date efficacy outcome criteria. AUS outcomes need to be revisited to be compared with new surgical alternatives, all of which should be prospectively evaluated according to current evidence-based medicine standards.

Clinical significance of routine urinary bacterial culture after transurethral surgery: results of a prospective multicenter study.

OBJECTIVES: The objective of this study was to evaluate the prevalence and the clinical outcomes of asymptomatic postoperative bacteriuria after transurethral operations, along with the need for postoperative urinalysis. METHODS: A prospective study of 456 patients who underwent transurethral resection of the prostate (TURP) or transurethral resection of the bladder (TURB) at 2 urological centers in France, between January 2008 and March 2009. All patients had urine cultures preoperatively, on the day of catheter removal, and at 1 month postoperatively. Only patients with symptoms suggesting a urinary tract infection were treated. Univariate logistic regression and multiple logistic regression were used to estimate the odds ratios and P values. RESULTS: TURP was performed in 217 patients, and TURB was performed in 239 patients. A total of 35 patients (7.6%) had positive postoperative urine cultures. Only 9 patients (1.9%) were treated. Patient age and postoperative catheterization duration were identified as risk factors for postoperative bacteriuria (OR = 1; 95% CI = 1.0-1.1; P = .03 and OR = 3.6; 95% CI = 2.3-5.7; P = .0001, respectively), and preoperative bacteriuria was not risk factor for postoperative bacteriuria (OR = 0.9; 95% CI = 0.3-1.4; P = .8). A total of 45 patients had a positive urinalysis at 1 month, and 29 presented an infectious complication during follow-up. A positive postoperative urinalysis was not a risk factor either for a positive urinalysis at 1 month or for an infectious complication during follow-up (OR = 3.2; 95% CI = 0.4-22.4, P = .2 and OR = 1.4; 95% CI = 0.4-4.9, P = .5, respectively). CONCLUSIONS: Based on our study findings, postoperative bacteriuria is not a risk factor for infectious postoperative complications. Therefore, routine postoperative urinalysis should be advocated only in symptomatic patients.

Inverted papilloma of the ureter: study of a rare case with emphasis on clinicopathologic implications.

A 62-year old male patient presented complaining of intermittent macroscopic hematuria. The ultrasonographic investigation revealed a hydronephrosis of remarkable degree with indiscrete renal parenchyma. The abdominal computed tomography scan identified a ureteral lesion with proximal dilatation, hydronephrosis and a functionless ipsilateral renal unit. The retrograde urography showed a 4-cm lesion with multiple filling defects and a smooth contour. The endoscopic examination showed an exophytic lesion, highly suspicious for malignancy. Urine cytology revealed atypia. Right nephroureterectomy was performed and the pathology revealed a ureteral inverted papilloma (UIP). Polymerase chain reaction examination for the presence of human papilloma virus, using GP5+/6+ consensus primers, was negative. The presence UIP should be considered in patients with urotheleal lesions in the ureter when the diagnostic workup for malignancy is inconclusive. The clinical course of the disease seems to be favorable.

Prediction of muscle-invasive bladder cancer using urinary proteomics.

PURPOSE: Minimally invasive methods of predicting the risk of muscle-invasive urothelial bladder carcinoma may expedite appropriate therapy and reduce morbidity and cost. EXPERIMENTAL DESIGN: Here, capillary electrophoresis coupled mass spectrometry was used to identify urinary polypeptide bladder cancer biomarkers in 127 patients. These markers were used to construct a panel discriminating muscle-invasive from noninvasive disease, which was refined in 297 additional samples from healthy volunteers, patients with malignant and nonmalignant genitourinary conditions. Sequencing of panel polypeptides was then done. Finally, the ability of the panel to predict muscle-invasive disease was evaluated prospectively in 130 bladder carcinoma patients. Four sequenced polypeptides formed a panel predictive of muscle-invasive disease. RESULTS: Prospective evaluation of this panel revealed a sensitivity of 81% [95% confidence interval (CI), 69-90] and specificity of 57% (95% CI, 45-69) for muscle-invasive disease. Multivariate analysis revealed the panel (P < 0.0001) and tumor grade (P = 0.0001), but not urine cytology, predict muscle invasion. A model including grade and panel polypeptide levels improved sensitivity [92% (95% CI, 82-97)] and specificity [68% (95% CI, 55-79)] for muscle-invasive disease. A model score of >0.88 provided a negative predictive value of 77% and positive predictive value of 90% for muscle invasion. CONCLUSIONS: Use of urinary peptides seems promising in estimating the probability a patient harbors muscle-invasive urothelial bladder cancer. These peptides may also shed novel insights into the biology of bladder tumor progression not obtainable by other methods. Clinical trials seem warranted to evaluate the effect of this approach on practice.

TRUS versus transabdominal ultrasound as a predictor of enucleated adenoma weight in patients with BPH: a tool for standard preoperative work-up?

BACKGROUND: Despite being formally included in the assessment of patients presenting with lower urinary tract symptoms (LUTS), transrectal ultrasonography (TRUS) is not routinely offered to these patients. This tactic however might not be optimum since data exist on the superiority of TRUS over transabdominal ultrasound in accurately predicting prostate volumes. We aimed to evaluate TRUS as a standard tool in the evaluation of patients with benign prostate hyperplasia (BPH) with a special focus on the potential impact it might have on the decision of open versus transurethral surgery. PATIENTS AND METHODS: Seventy-one patients presenting with LUTS due to BPH and eventually managed with open surgery based on their preference and prostate volume were included in the protocol. TRUS was performed in all patients preoperatively and calculations of the transition zone were made. These were compared with respective transabdominal calculations of the prostate volume as well as the enucleated specimen weight (W). RESULTS: TRUS slightly underestimated W by 4.4% (95% CI 10.5, 1.7) while transabdominal ultrasound overestimated it by 55.7% (95% CI 31.8, 79.6). Regression analysis indicated TRUS as a better predictor of W (R (2) = 0.817, P < 0.0005) followed by transabdominal ultrasound (R (2) = 0.669, P < 0.0005). Strictly based on European Association of Urology (EAU) criteria, transabdominal measurements miscategorized 25 cases by falsely assigning them to the open surgery (>80 cc) group while TRUS did so for four cases. CONCLUSION: TRUS is more accurate than transabdominal ultrasound in predicting adenoma volume in patients with BPH and its standard use might lead to fewer open approaches, with consequent less morbidity and hospitalization.

Comparison of the self-reported training level between Mexican and Western Europe residents in urology: results of an international survey.

OBJECTIVE: To find out how Mexican residents in urology perceive their own level of training in comparison with how residents in Europe perceive theirs. METHODS: A questionnaire of self-assessment was distributed to 104 European and 24 Mexican urologists-in-training. We assessed the perception of residents about their level of training and factors associated with self-perceived performance. RESULTS: Mean age of 128 residents was 32.69 +/- 3.33 years. Mexican residents spent significantly more time in urological departments than European residents. The weekly amount of hours spent at work was higher in Europe; while the number of residents per hospital was higher in Mexico. Mexican residents reported more reliable support from a supervising senior. European residents perceived they had a superior level regarding transplantation in female urology and urinary lithiasis, whereas Mexican residents felt more confident regarding urological infections and paediatric urology. Factors associated with better self-perceived performance were the number of months in urology, the number of non-urologic rotations and a supervising senior. CONCLUSION: Mexican residents in urology perceive that their own level of training is similar to that of European residents. The number of months of training in urology, the number of non-urologic rotations and a supporting senior are associated with a better self-perceived performance.

Chromosomal and proteome analysis of a new T24-based cell line model for aggressive bladder cancer.

Cell line models aid in understanding cancer aggressiveness. The aim of this study was the establishment of a metastatic variant (T24M) of the T24 bladder cancer cell line and its initial characterization at chromosomal and proteomic levels. T24M were spontaneously developed in mice from T24 cells, following cycles of subcutaneous injections and culture in vitro. Transwell migration assays and injections in mice revealed increased migration and tumorigenic properties of T24M compared to the T24 cells. Cytogenetic analysis demonstrated that T24M retained several karyotypic characteristics of the parental cells and also acquired novel chromosomal aberrations related to aggressive bladder cancer. Proteomic analysis of the T24 and T24M cells by 2-DE and MS led to the generation of their 2-DE proteomic map and revealed differences in multiple proteins. These include proteases of the lysosomal and proteasome degradation pathways, mitochondrial and cytoskeletal proteins. The 2-DE findings were confirmed by immunoblotting of cell lysates and immunohistochemistry of bladder cancer tissue sections for cathepsin D and activity assays for proteasome. Collectively, our results suggest that the T24M cells reflect many known chromosomal and proteomic aberrations encountered in aggressive bladder cancers but also provide access to novel findings with potentially clinical applications.

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.

Characterization of the human urine proteome by preparative electrophoresis in combination with 2-DE.

The protein components of urine are useful indicators of renal function and human health in general. Urine samples are easily attainable making them ideal substrates for biomarker research. Analysis of the urine proteome however, has been hindered by the great variability of the urine specimens, and the presence of various proteins in low abundance or modified forms. To alleviate some of these problems urine samples from five different individuals were pooled, concentrated and the proteome characterized by a combination of preparative electrophoresis and 2-DE, followed by PMF. A total of 778 protein spots corresponding to 141 different gene products were identified. In comparison, 171 spots corresponding to 44 unique proteins were identified in the unfractionated starting material. Among the proteins identified from the preparative electrophoresis were many of low abundance such as proteins involved in signal transduction. Furthermore, the median molecular mass of the identified proteins from the preparative electrophoresis was significantly lower in comparison to the proteins identified from the unfractionated starting material (39 886 Da versus 71 317 Da, respectively). Concluding, application of this methodology provides a coherent analysis of the urine proteome and contributes to the generation of the urine protein map in health and disease.