In the cystoscopic follow-up of non-muscle-invasive transitional cell carcinoma, NMP-22 works for high grades, but unreliable in low grades and upper urinary tract tumors.

INTRODUCTION AND OBJECTIVES: Two percent of the bladder non-muscle-invasive (NMI) transitional cell carcinomas (TCC) are associated with upper urinary tract (UUT) TCC. We evaluated the role of nuclear matrix protein-22 (NMP-22) (BladderChek) test in the diagnosis of lower urinary tract and UUT-TCC. METHODS: From March 2009 to June 2011, 122 patients with bladder NMI-TCC underwent 205 control cystoscopy. A total of 95 (78 men and 17 women, mean age 60.7 years, range, 27-88) patients who were followed regularly with NMP-22 test and with follow-up cystoscopies (145 episodes; min. 1-max. 5) were included in this study. For routine monitoring of the UUT, IVU or CT urography was used once a year for high grades (HG), and once in every other year for low grades (LG). The sensitivity and specificity of NMP-22 were evaluated by ROC curves, and sensitivity, specificity, and positive and negative predictive values were calculated. Chi-square test was used for the differences between the subgroups. RESULTS: Cystoscopy and NMP-22 results of the patients included in the study revealed the sensitivity (44.4%) of the test was very low and the specificity (98.4%) was quite high (p < 0.001). Among the 10 cystoscopies where NMP-22 was negative, but cystoscopy was positive for tumor, 8 had LG and 2 had HG TCC. NMP-22 was never positive in low-grade tumors, in other words, all of the NMP-22-positive 8 tumors were high grade. On the other hand, in 20% (2/10) of the cases, NMP-22 can be negative although the tumor was high grade. Two (2.1%) HG UUT-TCC were detected in 95 patients. These 2 patients were within the 125 cystoscopies (75 patients) where both NMP-22 and cystoscopy were negative for tumor. CONCLUSIONS: Nuclear matrix protein-22 cannot detect LG TCC. However, it detects overwhelming majority of HG TCC. For this reason, positive NMP-22 test largely indicates HG TCC. NMP-22 is also not reliable in UUT-TCC, even in HG tumors.

Is stent placement necessary after uncomplicated ureteroscopy for removal of impacted ureteral stones?

BACKGROUND AND PURPOSE: Ureteral stent placement after ureteroscopic lithotripsy has some advantages and disadvantages. In this randomized study, the necessity of ureteral stent placement after uncomplicated ureteroscopy for impacted ureteral stones was assessed. MATERIALS AND METHODS: Between 2005 and 2007, 60 evaluable patients were equally randomized to groups with and without stents. Patients underwent ureteroscopic pneumatic lithotripsy for ureteral stones. The operation was completed with or without stent placement according to the randomization order. Excretory urography was performed 3 months after the procedure. All stents were cystoscopically removed at the third postoperative week. Sociodemographic and clinical variables (age, sex, stone location, stone size, operative time, hospital stay, narcotic and nonnarcotic analgesic use), and postoperative complications (fever, pain delaying discharge, emergency department visit, urinary retention, stent-related irritative symptoms) were evaluated. RESULTS: Mean stone size was not significantly different in both groups. Mean operative time was significantly longer in the stent group: 30.5 +/- 9.6 vs 43.7 +/- 11.6 minutes. On the operation day and until postoperative day (POD) 5, narcotic (P = 0.004) and nonnarcotic analgesic (P = not significant) use was more frequent in the no-stent group. At POD 5 and later, although narcotic and nonnarcotic analgesic use were frequently necessary in the stent group, both were almost unnecessary in the no-stent patients. Stent-related irritative symptoms were overwhelmingly higher (10% vs 93%) in the stent group. Discharge was delayed (23% vs 10%) and unplanned emergency department visits (20% vs 10%) were exercised almost two times more commonly in the no-stent group. Stone-free rates were identical (n = 29/30; 97%) in both groups. CONCLUSION: Routine placement of a ureteral stent is not mandatory in patients without complications after ureteroscopic lithotripsy for impacted ureteral stones. Stent placement can be argued and agreed with the patients preoperatively in the light of the data presented above.

Duration of androgen suppression in the treatment of prostate cancer.

BACKGROUND: The combination of radiotherapy plus long-term medical suppression of androgens (> or = 2 years) improves overall survival in patients with locally advanced prostate cancer. We compared the use of radiotherapy plus short-term androgen suppression with the use of radiotherapy plus long-term androgen suppression in the treatment of locally advanced prostate cancer. METHODS: We randomly assigned patients with locally advanced prostate cancer who had received external-beam radiotherapy plus 6 months of androgen suppression to two groups, one to receive no further treatment (short-term suppression) and the other to receive 2.5 years of further treatment with a luteinizing hormone-releasing hormone agonist (long-term suppression). An outcome of noninferiority of short-term androgen suppression as compared with long-term suppression required a hazard ratio of more than 1.35 for overall survival, with a one-sided alpha level of 0.05. An interim analysis showed futility, and the results are presented with an adjusted one-sided alpha level of 0.0429. RESULTS: A total of 1113 men were registered, of whom 970 were randomly assigned, 483 to short-term suppression and 487 to long-term suppression. After a median follow-up of 6.4 years, 132 patients in the short-term group and 98 in the long-term group had died; the number of deaths due to prostate cancer was 47 in the short-term group and 29 in the long-term group. The 5-year overall mortality for short-term and long-term suppression was 19.0% and 15.2%, respectively; the observed hazard ratio was 1.42 (upper 95.71% confidence limit, 1.79; P=0.65 for noninferiority). Adverse events in both groups included fatigue, diminished sexual function, and hot flushes. CONCLUSIONS: The combination of radiotherapy plus 6 months of androgen suppression provides inferior survival as compared with radiotherapy plus 3 years of androgen suppression in the treatment of locally advanced prostate cancer. (ClinicalTrials.gov number, NCT00003026.)

Prostate-specific antigen progression predicts overall survival in patients with metastatic prostate cancer: data from Southwest Oncology Group Trials 9346 (Intergroup Study 0162) and 9916.

PURPOSE: Prostate-specific antigen progression (PSA-P) is an indicator of progression in hormone-sensitive (HS) and castration-resistant (CR) prostate cancer (PC). We evaluated different definitions of PSA-P as predictors of overall survival (OS). PATIENTS AND METHODS: A total of 1,078 patients with HSPC who were on hormones (Southwest Oncology Group [SWOG] trial 9346 [S9346]) and 597 patients with CRPC who were treated with chemotherapy (SWOG trial 9916 [S9916]) were eligible for this analysis. PSA-P definitions tested included the following: PSA Working Group, Prostate Cancer Working Group (PCWG 2008), and other definitions. A time-varying approach analyzed associations between PSA-P at any time and OS. A landmark analysis examined the relationship between PSA-P status at 7 months for S9346, or 3 months for S9916, and subsequent OS. RESULTS: In the time-varying analysis, both working groups definitions were strongly associated with OS (P < .001) in both study settings. In patients enrolled onto S9346, both definitions predicted a 2.4-fold increased risk of death (ROD) and a greater than four-fold increased ROD if PSA-P occurred in the first 7 months. In S9916, they predicted a 40% increase in ROD and a two-fold increase in ROD if PSA-P occurred at 3 months. In landmark analyses of patients on S9346 by using the PCWG 2008 definition of PSA-P, median subsequent OS was 10 months versus 44 months in patients who did or did not have PSA-P by 7 months, respectively; in S9916, data were 11 months versus 18 months for patients who did or did not have PSA-P by 3 months, respectively. CONCLUSION: PSA-P, defined as an increase of > or = 25% greater than the nadir and an absolute increase of at least 2 or 5 ng/mL, predicts OS in HSPC and CRPC and may be a suitable end point for phase II studies in these settings.

An international field study of the EORTC QLQ-PR25: a questionnaire for assessing the health-related quality of life of patients with prostate cancer.

AIM: To evaluate the psychometrics of the EORTC QLQ-PR25, a questionnaire assessing the health-related quality of life of prostate cancer patients. METHODS: The QLQ-PR25 and the QLQ-C30 were administered to 642 prostate cancer patients from 13 countries treated with curative or palliative intent. The QLQ-PR25 assesses urinary, bowel and sexual symptoms and functioning, and the side-effects of hormonal treatment. RESULTS: Five hundred and nine patients were available for the final analysis. Multitrait scaling analyses confirmed the hypothesised scale structure of the QLQ-PR25. Internal consistency reliability was good (coefficient alpha=0.70-0.86) for the urinary symptoms and sexual function scales, but lower for the bowel function and side-effects of hormonal treatment scales (alpha<0.70). The module discriminated clearly between clinically distinct patient subgroups, and was responsive to changes in health status over time. CONCLUSION: In general, the QLQ-PR25 demonstrates acceptable psychometric properties and clinical validity. Some caution should be used in interpreting the bowel function and side-effects of hormonal therapy scales; results can be reported at the individual item and scale level.

Asymptomatic retained surgical gauze towel diagnosed 32 years after nephrectomy.

Retained surgical gauze is a rare but known problem in patients who have medical history of surgery. Suspicion and evaluation of this rare condition is sometimes very difficult for the clinician because retained surgical sponges can be totally asymptomatic or can hide themselves perfectly in the plain abdominal films. For this reason clinican should excersize high rate of suspicion, should not solely depend upon plain films and should consider more sophisticated examinations like ultrasonography (US) or computerized tomography for the appropriate management of these retained sponges. We present here a very unusual and late presentation of surgically retained gauze which gave a false appearance of a kidney with decreased functional activitity in the excretory urography (EU) 32 years after nephrectomy.

Combined "periprostatic and periapical" local anesthesia is not superior to "periprostatic" anesthesia alone in reducing pain during Tru-Cut prostate biopsy.

OBJECTIVES: To evaluate, in a prospective study, the benefit of adding local periapical prostatic anesthesia to routine periprostatic infiltration to the prostate-seminal vesicle junction in a randomized fashion. Transrectal ultrasound-guided biopsy is the reference standard in the diagnosis of prostate cancer. Although well tolerated by most patients, it can be associated with discomfort. METHODS: A total of 120 consecutive evaluable patients with an elevated total prostate-specific antigen (tPSA) level, increased tPSA velocity, and/or abnormal digital rectal examination findings were enrolled. The patients were randomized into two groups. Group 1 received periprostatic infiltration of 6 mL 1% lidocaine. Group 2 received periprostatic and apical infiltration: 4 mL 1% lidocaine at the prostate-seminal vesicle junction and 2-mL infiltration at the prostatic apex 15 minutes before transrectal ultrasound-guided biopsy. Pain was assessed using a 10-point modified visual analog scale. RESULTS: The mean patient age was 63.7 +/- 1.2 years and 64.2 +/- 1.1 years, the mean tPSA level was 12.1 +/- 1.5 ng/mL and 13.6 +/- 2.7 ng/mL, the mean biopsy duration was 6.2 +/- 2.5 minutes and 6.1 +/- 2.2 minutes, and the mean visual analog scale pain score was 1.26 +/- 0.1 and 1.23 +/- 0.1 for groups 1 and 2, respectively. No statistically significant difference was observed with respect to age, tPSA level, mean biopsy duration, or pain score between the two groups. CONCLUSIONS: Periprostatic lidocaine infiltration provides local anesthesia that results in improved visual analog scale pain scores. Additional apical infiltration did not improve patient discomfort further. However, comparative evidence has indicated that increasing the time elapsed between the anesthetic infiltration and the biopsy procedure may further improve pain control.

Absolute prostate-specific antigen value after androgen deprivation is a strong independent predictor of survival in new metastatic prostate cancer: data from Southwest Oncology Group Trial 9346 (INT-0162).

PURPOSE: To establish whether absolute prostate-specific antigen (PSA) value after androgen deprivation (AD) is prognostic in metastatic (D2) prostate cancer (PCa). PATIENTS AND METHODS: D2 PCa patients with baseline PSA of at least 5 ng/mL received 7 months induction AD. Patients achieving PSA of 4.0 ng/mL or less on months 6 and 7 are randomly assigned to continuous versus intermittent AD on month 8. Eligibility for this analysis required a prestudy PSA with at least two subsequent PSAs and that patients be registered at least 1 year before analysis date. Survival was defined as time to death after 7 months of AD. Associations were evaluated by proportional hazards regression models. RESULTS: One thousand one hundred thirty four of 1,345 eligible patients achieved a PSA of 4 ng/mL or less. At end of induction, 965 patients maintained PSA of 4 or less and 604 had a PSA of 0.2 ng/mL or less. After controlling for prognostic factors, patients with a PSA of 4 or less to more than 0.2 ng/mL had less than one third the risk of death (ROD) as those with a PSA of more than 4 ng/mL (P < .001). Patients with PSA of 0.2 ng/mL or less had less than one fifth the ROD as patients with a PSA of more than 4 ng/mL (P < .001) and had significantly better survival than those with PSA of more than 0.2 to 4 ng/mL or less (P < .001). Median survival was 13 months for patients with a PSA of more than 4 ng/mL, 44 months for patients with PSA of more than 0.2 to 4 ng/mL or less, and 75 months for patients with PSA of 0.2 ng/mL or less. CONCLUSION: A PSA of 4 ng/mL or less after 7 months of AD is a strong predictor of survival. This data should be used to tailor future trial design for D2 prostate cancer.

The role of reactive oxygen species and apoptosis in the pathogenesis of varicocele in a rat model and efficiency of vitamin E treatment.

We investigated role of reactive oxygen species (ROS) and apoptosis in the pathogenesis of infertility in experimental model of varicocele. The protective effect of vitamin E was also examined. Three groups of rats were constructed as the first group had sham operation, experimental varicoceles were established by partial ligation of the left renal vein in later two groups. Third group had received vitamin E. Production of ROS was determined by chemiluminescence assay (CL). The in situ end labelling technique was utilized to investigate apoptosis. Tissue vitamin E levels were measured by high performance liquid chromatography. The differences between luminol enhanced CL levels of groups were not statistically significant. However, the difference between CL levels of lucigenin probe in left testicles of sham and varicocele groups were statistically significant ( p = 0.0007). Similarly, the results of the third group receiving vitamin E significantly differed from the varicocele group ( p = 0.0025). The difference of apoptotic index was also statistically significant between sham and varicocele groups ( p = 0.0038). Although the values of apoptotic index detected in the vitamin E group were lower compared with the varicocele group, the difference was not significant. This study proposes that ROS production and apoptosis in the testicles were induced with experimental varicocele. Vitamin E had a protective role. An increased rate of apoptosis with experimental varicocele suggests a molecular alteration, which may involve ROS overproduction as the triggering mechanism. Consequently, this study indicates an association between varicocele and infertility at molecular level through stimulation of ROS and apoptosis.

Lack of effect of intrarectal lidocaine for pain control during transrectal prostate biopsy: a randomized prospective study.

INTRODUCTION AND OBJECTIVES: Transrectal ultrasound guided biopsy is an essential part in the diagnosis of prostate cancer. Although this procedure is well tolerated by most patients, sometimes it can result in some uneasiness. In this randomised double-blind placebo controlled study, we evaluated the effectiveness of intrarectal lidocaine during TRUS guided biopsy. MATERIALS AND METHODS: 100 consecutive eligible patients who had elevated total prostate specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included into this study. Patients were randomised into two groups. Group I received 20 cc of 2% intrarectal lidocaine 20 minutes before transrectal ultrasound guided biopsy and Group II received same amount of serum physiologic. Pain was assessed using a 10 point modified visual analog scale. RESULTS: Mean patient age was 65.5+/-2.5 and 64.5+/-11.5 years, mean tPSA was 12.3+/-3.6 and 11.3+/-1.7 ng/ml, mean biopsy duration was 6.8+/-2.5 and 6.6+/-2.2 minutes, mean pain score during transrectal ultrasound guided biopsy was 4.8+/-2.2 and 4.4+/-2.1 in Groups I and II, respectively. No statistically significant difference was observed with respect to age, tPSA, mean biopsy duration and pain score between these groups. There was only one patient who could not tolerate the procedure at all, and he was paradoxically in the lidocaine group. CONCLUSION: The use of intrarectal lidocaine is not superior to placebo during transrectal prostate biopsy for pain control.

Accuracy of transrectal ultrasound guided prostate biopsy: histopathological correlation to matched prostatectomy specimens.

BACKGROUND: The Gleason grading system is currently the world's most commonly used histological system for prostate cancer. It provides significant information about the prognosis. Therefore, Gleason score is accepted as an important factor in therapeutic decision-making for prostate cancer. This retrospective study assessed the correlation of transrectal ultrasound (TRUS) guided biopsy and radical prostatectomy specimens in terms of Gleason scores. METHODS: We reviewed the records of 103 patients who underwent radical prostatectomy due to clinically localized prostate cancer. The Gleason scores of the TRUS biopsies were compared with the respective Gleason scores of surgical specimen. RESULTS: In 28.7% of cases, the TRUS biopsy score was the same as that of the radical prostatectomy specimen. The most significant discordance was the upgrading of well-differentiated tumors after surgery in 71.7% of cases. However, in 81.8% of cases with high Gleason score on TRUS, biopsy was correlated with poorly differentiated tumor after surgery. CONCLUSIONS: Well-differentiated tumors on TRUS biopsy did not correlate with the grades of final pathology in the majority of cases; however, a high Gleason score on TRUS biopsy usually indicated a poorly differentiated tumor on prostatectomy specimen. Therefore, the treatment algorithms for particularly well-differentiated tumors should not be deduced from biopsy histology alone.

Nuclear accumulation of protein p53 and histological changes in the rat model of unilateral cryptorchidism / Acumulaçäo nuclear da proteína p53 e mudanças histológicas no modelo de rato com criptorquidismo unilateral

Introduçäo: A criptorquidia é considerada um fator de risco substancial para o desenvolvimento subseqüente do câncer de testículo. Sendo que existe elevada expressäo da p53 nos tumores testiculares, este estudo foi realizado para investigar a expressäo anormal da proteína p53 e as mudanças histológicas num modelo de rato com criptorquidia unilateral. Material e métodos: Ratos pré-puberes foram mecanicamente tornados criptorquídicos unilaterais no 15§ dia após o nascimento. Subseqüentemente, os testículos dos ratos dos grupos experimental e falsamente operados foram removidos após 2, 4 e 6 meses para análises imunohistoquímicas e histológicas. Os testículos contralaterais do grupo experimental serviram de controle. Resultados: Näo foram observadas anormalidades histológicas nos testículos dos grupos falsamente operados e controle. Entretanto, os testículos criptorquídicos apresentaram-se menores e acompanhados de uma mudança de cor acentuada. Foi observada uma diminuiçäo significativa do volume testicular no grupo com criptorquidia (p<0,05). Atrofia dos túbulos seminíferos, espessamento da membrana basal, perda de células germinativas e interrupçäo da espermatogênese foram progressivamente mais evidentes com o tempo, sendo maiores no sexto mês. A coloraçäo imunohistoquímica dos cortes em parafina demonstram reaçäo nuclear positiva à p53 em 14 (93,3 por cento) dos 15 testículos criptorquídicos. Por outro lado, os grupos falsamente operados e controle näo apresentaram qualquer acumulaçäo nuclear p53. Conclusäo: Este estudo confirma que os testículos criptorquídicos intra-abdominais säo significantemente danificados devido à sua localizaçäo anormal. A análise imunohistoquímica positiva para proteína p53 nos testículos criptorquídicos é sugestiva de alteraçäo molecular e pode indicar uma relaçäo entre criptorquidia e carcinogênese testicular.

Colocación de doble J, en un caso de extravasación urinaria ureteral espontánea / Use of double J stent in a case of spontaneous ureteral extravasation of urine

OBJETIVOS: A pesar de que hay publicado multitud de casos de ruptura espontánea del sistema colector, fundamentalmente calices o pelvis renal, la ruptura espontánea del uréter es muy infrecuente. MÉTODOS: Presentamos el caso de un paciente con síntomas de abdomen agudo, por rotura espontánea del uréter proximal. RESULTADOS Y CONCLUSIONES: Se trata al paciente de forma conservadora, con la colocación de un doble J, que se retiró al mes, sin incidencias. Un año después el paciente, continua asintomático. Revisamos la patogenia, el diagnóstico y las complicaciones de este raro caso (AU)

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Recidiva quística precoz de un carcinoma primario de testículo en la fosa obturatriz / Early cystic relapse of embryonal carcinoma of testis in obturator fossa

OBJETIVOS: Comunicamos el caso de un carcinoma embrionario Estadio II B localizado en el testículo derecho que tras un tratamiento con quimioterapia y disección linfática retroperitoneal presentó una recidiva quística precoz en la fosa obturatriz. MÉTODOS: Este caso es analizado retrospectivamente y revisada la literatura en relación a las recidivas precoces de tumores testiculares en localizaciones atípicas. Se discute la rareza de la localización en la fosa obturatriz en cuanto a recidivas precoces de tumores testiculares. RESULTADOS: Solamente en la literatura hemos encontrado un caso de tumor testicular con recidiva a nivel de la fosa obturatriz .CONCLUSIONES: Este caso es un ejemplo de la posibilidad de recurrencia en una zona impredecible y en un corto intervalo de tiempo después de las terapeúticas adecuadas y por ello hay que enfatizar la importancia de un seguimiento muy estricto de estos pacientes (AU)