False-positive results of the NMP22 test due to hematuria.

PURPOSE: The problem with available markers for bladder cancer is their low specificity and low positive predictive value due to false-positive results. False-positive results of the NMP22 nuclear matrix protein test (Matritech, Cambridge, Massachusetts) are usually observed in some clinical categories that are usually associated with hematuria and pyuria. This problem is especially serious in bladder cancer since 85% of patients present with hematuria. We investigated the effect of the degree of hematuria and pyuria on NMP22 results in an experimental model and human subjects. MATERIALS AND METHODS: This study was performed in 202 urine samples from 30 healthy individuals (group 1), 20 with symptomatic urinary tract infection (group 2) and 32 with known bladder carcinoma (group 3). In the first group to achieve 0, 10, 100, 1,000 and 5,000 red blood cells per high power field the blood obtained from each patient was added to test tubes at 0.02, 0.2, 2 and 10 microl, respectively. RESULTS: In the first group median urinary NMP22 in healthy individuals was 4 units per ml. (range 1.6 to 9.5). When blood was added to the urine sample, the NMP22 increase paralleled the increase in the amount of red blood cells in the sediment. When greater than 2 microl./ml. blood or 1,039.5 red blood cells per high power field (range 278 to 1,438) were added to the urine of a healthy individual, the NMP22 level reached and surpassed the level in patients with bladder carcinoma. The leukocyte count in the urine sediment also had a significant impact on urinary NMP22 in group 2. The degree of hematuria and pyuria did not significantly effect NMP22 in group 3. The sensitivity, specificity, positive and negative predictive values of NMP22 were 78.1%, 66%, 59.5% and 82.5%, respectively. Test sensitivity increased as grade and stage progressed. CONCLUSIONS: In an experimental model pyuria and hematuria significantly affected urinary NMP22. The effect of white blood cells was more pronounced than that of red blood cells. The source of NMP22 in isolated hematuria remains to be elucidated. On the other hand, in group 3 the tumor was the main source of NMP22, and urinary erythrocytes and/or leukocytes had a negligible effect.

Evaluation of nuclear matrix protein 22 (NMP22) as a tumor marker in the detection of bladder cancer.

We prospectively evaluated the performance of urinary NMP22 test in the detection of transitional carcinoma (TCC) of the bladder. Urine samples were obtained from 39 patients with known bladder cancer, 37 patients with primary hematuria. 18 with benign urological conditions and 20 healthy subjects. Overall sensitivity and specificity of NMP22 with reference value of 10 U/ml was 72 and 73%, respectively. Sensitivity for pT1 and pT2 tumors was 83%, whereas that for pTa tumors was 55%. When the test was determined before and after transurethral resection (TUR) of bladder tumor, it was shown that the TUR effected the NMP22 level. Urinary NMP22 was highly sensitive for high-risk bladder cancer. However, the sensitivity of the test is somewhat lower in low grade and stage tumors. Additionally, the effect of previous resection limits its value in the follow up of patients with superficial tumors. The larger series with longer follow up may lead us to determine the time to neglect the effect of TUR on NMP22 and the test kit should be upgraded by the manufacturer to exclude the false positive results due to inflammatory conditions.

Enuresis: point prevalence and associated factors among Turkish children.

The aim of this study was to establish the prevalence and associated factors of enuresis nocturna and to better understand nocturnal bladder control in Turkish children. A randomized epidemiological study was performed among primary school children, aged four to 12 years, living in Aydin, Turkey. After data collection via a self-administered questionnaire completed by the parents, data of 2,300 children were accepted for the analysis. The overall prevalence of reported marked nocturnal enuresis (at least weekly) was 11.6 percent and of day wetting 0.8 percent. Enuresis was more frequent in boys than in girls. Age, family history of enuresis, large family size, urinary tract infections and low parental socioeconomic class were all statistically associated with reported enuresis nocturna. Familial history among the enuretics and non-enuretics was 40.7 percent and 9.5 percent, respectively. Of the enuretics, 11 percent were treated professionally, 65 percent were treated traditionally by the family and 25 percent sought no help to manage the enuresis. A reference age of 2.9 +/- 1.6 years was calculated for nocturnal bladder control of the children studied. These results suggest that prevalence of enuresis nocturna and development of bladder control in Turkish children are not so different from that seen in other European and Middle East countries, and that the most significant factors associated with enuresis are socioeconomic and familial ones. Turkish families do not have a high level of concern about enuresis, even in the older children. This study demonstrated that enuresis is a sizable problem in Turkey and that a great ignorance about enuresis by both parents and physicians exits.

Nephron-sparing surgery in a duplex system associated with a vaginal ectopic ureter.

Continuous dribbling of urine is the major symptom in girls with an ectopic vaginal ureter. However, the diagnosis is somewhat difficult in girls with such an entity before toilet-training has been achieved. The current concept in the management of these entities is to remove the renal moieties with the vaginal ectopic ureter drain. We report on a case of an obstructed vaginal ectopic ureter associated with a duplicated collecting system which was managed successfully by renal-sparing surgery.

Intestinal testis tumor metastasis as a cause of intussusception: a case report.

We report on an extraordinary testicular tumour causing intussusception with its intestinal metastases.

Urothelium-preserving augmentation cystoplasty covered with a peritoneal flap.

OBJECTIVES: To present the results of bladder autoaugmentation covered with a peritoneal flap in patients with bladder dysfunction. PATIENTS AND METHODS: Thirteen patients (seven male and six female, mean age 11.9 years, range 4-25) who underwent autoaugmentation covered with a peritoneal flap were evaluated. Seven had different forms of myelodysplasia, four had spinal cord injury and two had Hinman syndrome as the cause of bladder dysfunction. Indications for augmentation included upper tract deterioration, urinary incontinence and recurrent urinary tract infection, despite anticholin-ergic therapy. RESULTS: The mean bladder capacity increased by 18.6% after surgery and the mean compliance at capacity increased from 3.4 to 5.8 cmH2O/mL. All patients were incontinent before surgery and continence was achieved in only six afterward. Four patients showed no clinical or urodynamic improvement and required re-augmentation using intestinal segments. Only three patients needed no anticholinergic therapy after surgery. All four patients in whom the procedure failed had capacities of < 30% of that expected for their age. There were no metabolic problems. CONCLUSION: Autoaugmentation combined with a peritoneal flap is an easy procedure but the clinical results are poor in some patients, especially those with a small initial bladder capacity. The need for secondary augmentation with enteric segments was common. The use of a peritoneal flap does not appear to increase the capacity and compliance more than is obtained with the classical technique; it may prevent adhesion to the abdominal wall and make a secondary procedure easier. As the increase in capacity and compliance is limited with this technique, a urothelium-preserving augmentation should be reserved for those bladders with a relatively good initial capacity.

Ureterocystoplasty: an alternative reconstructive procedure to enterocystoplasty in suitable cases.

PURPOSE: The objective of the report is to present the results of ureterocystoplasty in 6 children with megaureters and low-capacity, high-pressure bladders. METHODS: Of the 6 patients, 2 had valve bladders, 1 had Hinmann's syndrome, 1 had neuropathic bladder, and the remaining 2 with ureterocutaneostomy were mainly diverted because of refluxing megaureters. Nephrectomy was performed in both of the boys with posterior urethral valve because of vesicoureteral reflux dysplasia (VURD) syndrome, and the ipsilateral ureter was used for the augmentation. In 2 patients with ureterocutaneostomy and in 1 with Hinmann's syndrome, a transureteroureterostomy was carried out, and the distal part of the ureter was used to perform augmentation. The patient with neuropathic bladder had a nonfunctioning crossed ectopic left kidney with an associated ipsilateral, refluxing megaureter, and the ureter was used for augmentation after the nephrectomy. RESULTS: All of the patients are continent, and 4 patients who are neurologically normal void spontaneously without requiring clean intermittent catheterization (CIC). The average increase in bladder capacity is 263% (range, 190% to 340%). CONCLUSIONS: Ureterocystoplasty is the bladder augmentation of choice for patients with a nonfunctioning kidney with an associated ipsilateral, refluxing megaureter and for patients with kidneys both in good function and megaureters suitable for a transureteroureterostomy.

Comparison of granisetron, ondansetron and tropisetron for control of vomiting and nausea induced by cisplatin.

Severe nausea and vomiting are common and one of the most feared side effects of cisplatin-based chemotherapy. A total of 106 patients were randomized to receive a single dose of 8 mg ondansetron or 3 mg granisetron or 5 mg tropisetron intravenously as prevention of cisplatin-induced acute nausea and vomiting. Antiemetic therapy was done within 30 minutes before initiating chemotherapy. A questionnaire evaluating nausea, vomiting and retches was administered to patients and the responses were categorized as complete, partial or failure. The response determination was repeated in the first 24 hours, and within 24-72 hours following cisplatin administration. The complete response rates for ondansetron, granisetron and tropisetron in the first 24 hours were 51.4%, 65.7% and 61.1% respectively. All three agents were highly effective against cisplatin-induced acute and late vomiting and the results were statistically significant. This study demonstrated no significant difference in effectiveness of these three antiemetics. 5-HT3 (5-hydroxytryptamine 3) receptor antagonists have similar efficacy in the prevention of nausea and vomiting due to cisplatin. Thus, we recommend that drug choice be based on cost-benefit and patient tolerance.

Proposal for changes in cystoscopic follow-up of patients with low-grade pTa bladder tumor.

OBJECTIVES: The cystoscopic follow-up of superficial bladder cancer accounts for a considerable workload for urologists and is also an invasive procedure with high costs. There is a potential benefit both to the urologist and the patient if unnecessary cystoscopies can be avoided. METHODS: The recurrence and progression rates of 120 patients with pTa G1 or G2 and small (<4 cm) transitional cell carcinoma were evaluated retrospectively. RESULTS: The recurrence rate was 6.5% (8/120) at 3 months. The recurrence rates at 6 and 9 months were 6.7 (8/119) and 3.6% (4/112), respectively. However, when the third month (first check) was clear, the recurrence rates at 6- and 9-month cystoscopy were 4.3 (5/116) and 2.7% (3/111), respectively. The recurrence rate at 12 months was 8% (8/99). For G1 tumors, the recurrence rates at 3, 6, 9 and 12 months were 6 (5/84), 5 (5/83), 2.5 (2/80) and 7% (5/71), respectively. The same results for G2 tumors were 8 (3/36), 8 (3/36), 6 (2/32) and 10.5% (3/28), respectively. The progression rate for the first year was lower than 1%. The difference between G1 and G2 tumors according to recurrence rate within the first year was not statistically significant (p>0. 05). CONCLUSIONS: This study supports the proposal that for patients with small and welldifferentiated pTa tumors at diagnosis, if the first control cystoscopy is clear, it is appropriate to perform the second check cystoscopy 1 year from initial resection and subsequent controls yearly. One should note that the study group included the most suitable patients for cystoscopic follow-up according to size and multiplicity of the tumor. This change in policy is further supported by the fact that progression occured in less than 1% in this group of patients.

Comparison of BTA stat and NMP22 tests in the detection of bladder cancer.

OBJECTIVE: This study aimed to compare the BTA (bladder tumour antigen) stat and urinary nuclear matrix protein (NMP22) tests in the detection of bladder cancer. MATERIAL AND METHODS: The office-based qualitative BTA stat and the laboratory-based quantitative NMP22 tests were studied in the same urine samples obtained from 49 patients with a high suspicion of bladder cancer and 20 healthy subjects. RESULTS: A tumour was identified in 36 patients after the cystoscopy. BTA stat demonstrated a sensitivity of 89%, which was superior to the sensitivity of 66.6% with the NMP22 test in detecting the bladder cancer (p < 0.02). The sensitivities for grade I tumours with BTA stat and NMP22 were 55.5% and 33.3%, respectively. The sensitivity of BTA stat was 100% for tumour categories except for the pTa and grade I tumours. No positive result was observed with both tests among the healthy subjects. The specificities for BTA stat and NMP22 were 78.7% and 69.6%, respectively. CONCLUSIONS: The BTA stat test was significantly more sensitive than the NMP22 test in the detection of bladder cancer. Although the sensitivity of BTA stat was not sufficient to replace cystoscopy, its ease and low cost may play a role in reducing the number of control cystoscopies, especially in patients with low risk of progression.

Urological manifestations of the Wolfram syndrome: observations in 14 patients.

PURPOSE: Since the initial description of the Wolfram syndrome, various anomalies have been associated with this rare entity. Urinary tract dilatation and bladder dysfunction, usually in the form of a large, atonic bladder, are coexisting features of this syndrome that are commonly believed to be secondary to high urine output in diabetes insipidus. The presentation and nature of the urological manifestations of this syndrome remain controversial due to the lack of large series in the literature. We evaluated the urological manifestations of this rare syndrome. To our knowledge we report the largest series of patients (14) with the Wolfram syndrome who underwent a complete urological evaluation. MATERIALS AND METHODS: Eight boys and 6 girls with a mean age of 13.4 years underwent upper tract imaging and a video urodynamic investigation. A multidisciplinary consultation was obtained to investigate all components of the syndrome. RESULTS: Upper tract dilatation was present in 11 patients. Urodynamics revealed a normal bladder in only 1 patient, who also had severe hydronephrosis. Seven patients had a low capacity, high pressure bladder, while 6 had an atonic bladder. The type of bladder dysfunction did not correlate with time since the onset of diabetes mellitus or diabetes insipidus, or the severity of hydronephrosis. Three patients with sphincteric dyssynergia also had a hyperreflexic bladder. CONCLUSIONS: Contrary to some earlier reports, our findings suggest that bladder dysfunction does not always present as a large atonic bladder in the Wolfram syndrome. A low capacity, high pressure bladder with sphincteric dyssynergia is also common. The presence and duration of other syndrome manifestations do not correlate with the type of bladder dysfunction, suggesting that bladder dysfunction may also be a primary rather than secondary component of the syndrome.

Nonoliguric renal failure after transurethral resection of prostate.

PURPOSE: To define the relation of nonoliguric renal failure to transurethral resection of the prostate (TURP), its clinical importance, and predictive factors. PATIENTS AND METHODS: The files of 439 patients who had undergone TURP at Hacettepe University School of Medicine, Department of Urology, between January 1991 and 1994 were analyzed. The patients were divided into three groups according to postoperative serum creatinine concentration and the presence of clinical signs and symptoms of TUR syndrome (Group I: patients with preoperative and postoperative creatinine in the normal range; Group II: patients suffering nonoliguric renal failure; and Group III: patients with TUR syndrome). The data of the groups were compared in terms of factors influencing nonoliguric renal failure. RESULTS: The mean postoperative concentrations of sodium, blood urea nitrogen, creatinine, and albumin in Groups II and III were statistically different from those in Group I (P < 0.001). There was a moderate relation between hyponatremia and the occurrence of nonoliguric renal failure (r(s) = -0.56). Capsule perforation increased the risk of nonoliguric renal failure 10.6 fold. All of the patients were managed by a conservative approach, and none of the patients died or progressed to end-stage renal disease. They were all discharged with a mean hospitalization period of 7 days and normal renal function tests. CONCLUSION: Nonoliguric renal failure was thought to be an early step in the pathophysiology of TUR syndrome with acute renal failure. It is an asymptomatic clinical picture that is undiagnosed unless laboratory examinations are performed. A conservative therapeutic approach is enough.

Occupational risk of hepatitis B and C infections in urologists.

The purpose of this study is to evaluate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and the related risk factors among urologic surgery patients and urologists. This cross-sectional, prospective study included 300 consecutive urologic surgery patients and 24 urologists working in our department. The patients and urologists with positive serology for any of the hepatitis viruses were questioned for risk factors including previous transfusions, surgery, endoscopy, intravenous drug abuse and homosexuality. Positive serology for HBV and/or HCV was found in 47.4% of the patients, and the rate of the patients with antigenemia, the major risk group for the urology team, was 9.9%. Of the 24 urologists working in our department, 3 were antibody to HCV (anti-HCV) positive and 2 were hepatitis B surface antigen (HBsAg) positive. The presence of a risk factor among patients with HBsAg was found in 78.9% and in 100% of those with anti-HCV. The prevalence of hepatitis in urologic surgery patients and urologists is poorly described. This study indicates a high prevalence of HBV and HCV seropositivity in urology patients. In urology wards, the risk of hepatitis transmission is estimated to be appreciably high because of the renal transplantation procedure and frequent use of blood and blood-contaminated solutions for transurethral resections or catheter irrigations. Vaccination with HBV vaccine and application of universal precautions during daily practice seem to be the only and most effective means of protection against blood-borne infections.