Immunohistochemical pattern of T lymphocytes population within bilharzial-associated bladder neoplasm microenvironment.

The present work aimed to investigate the cellular and immunochemical pattern of T cells population in biopsy material from chronic schistosomiasis haematobium Egyptian patients complicated with bladder cancer. Digital real-time quantitative photocytometry was applied to auto-analyze 29 stained tissue sections from cases and 17 controls using STAT4, GATA3, FOXP3, and CD8 markers specific for Th1, Th2, T regulatory, and T cytotoxic cells, respectively. Area percentage showed significant high level of GATA, followed by FOXP3 and low level of both STAT and CD8 was reported. Tissue samples from five healthy bladder tissues showed significant lower optical density (OD) values. Tissue samples from 12 non-bilharzial bladder cancers showed variable OD values, reflecting wide disparity in the control group.Our results hypothesized an exclusive pattern of T population in long standing complicated schistosomiasis haematobium. Our cases were poorly controlled by unbalanced Th1/Th2 in which Th2 was dominated. FOXP3 increased significantly, however, failed to downregulate Th2, instead, the relation between Th1 and T cytotoxic was forcibly limited by the high level of FOXP3, resulting in loss of their power in defending the host against both parasite and carcinogenic changes. These results provide more clarification for the immune evasion process played by the parasite and tumor cells under the supervision of T regulatory cells. Additionally a critical role of FOXP3 is suggested in manipulating STAT4 and CD8 in favor of malignant transformation in this life-threatening parasite.

Genomic instability in complicated and uncomplicated Egyptian schistosomiasis haematobium patients.

BACKGROUND: Exploration of genetic changes during active Schistosoma infection is important for anticipation and prevention of chronic sequelae. This study aimed to explore the genomic instability in chromosomal and cellular kinetics in Egyptians suffering from uncomplicated active schistosomiasis haematobium infection in addition to chronic schistosomiasis haematobium cases complicated by bilharzial-associated bladder cancer (BAC). RESULTS: This study was conducted on 46 schistosomiasis haemotobium cases, 22 were active (Viable S. haematobium eggs in urine samples as detected by microscopy) and 24 were chronic complicated with bladder cancer. Three cytogenetic techniques were applied; the first was quantitative nuclear-morphocytometry by means of which the Feulgen-stained nuclei were analyzed for parameters including shape, size, integrated optical-density and nuclear area. The second was Fluorescent In-Situ Hybridization (FISH) for specific p53gene-locus of chromosome 17 and the third technique was karyotyping. Concerning chronic complicated cases, the mean ± SD of DNA-content in urinary bladder tissue sections was 3.18 ± 0.65. Five samples (20.83%) of bladder tissue sections of chronic complicated cases showed diploid nuclei, 6 urinary bladder tissue samples (25%) were tetraploid, while 13 bladder samples (54.16%) were aneuploid. Epithelial cells of urine samples demonstrated aneuploidy (mean ± SD = 3.74 ± 0.36).Nuclear contents showed high proliferative DNA index in all urinary epithelial cells. In the acute uncomplicated group, nuclear-DNA of urinary epithelial cells was found diploid with mean nuclear-DNA content of 2.2 ± 0.16SD. Half of these diploid smears had a high proliferation index. The difference between nuclear DNA-contents in acute and chronic cases was significant (P = 0.0001). FISH technique for specific p53gene-locus and karyotyping were done on urinary bladder tissue specimens and peripheral blood monocytes of 8 chronic cases respectively. Three samples (37.5%) with invasive BAC had a deletion of the p53 gene. Karyotyping showed three cases out of the 8 chronic schistosomiasis haematobium patients with chromosomal fragmentations. CONCLUSIONS: DNA morphometry was valuable in detection of gross genetic changes in urothelial tissues. It is an important prognostic factor in established schistosomiasis haematobium induced bladder malignancy. It has the great advantage of being applicable on urine cells making it suitable for the prediction of a tendency towards genetic instability in active schistosomiasis haematobium patients.

Holmium laser enucleation versus photoselective vaporization for prostatic adenoma greater than 60 ml: preliminary results of a prospective, randomized clinical trial.

PURPOSE: To our knowledge we report the first single center, prospective, randomized study comparing holmium laser enucleation and high performance GreenLight™ prostate photoselective vaporization as surgical treatment of prostatic adenomas greater than 60 ml. MATERIALS AND METHODS: A total of 80 patients with a large prostatic adenoma were randomly assigned to surgical treatment with holmium laser enucleation or photoselective vaporization. International Prostate Symptom Score, International Index of Erectile Function-15, maximum flow rate, post-void residual urine, serum prostate specific antigen and transrectal ultrasound volume were recorded. RESULTS: Patient baseline characteristics were similar for holmium laser enucleation and photoselective vaporization. Operative time and catheter removal time were almost equal in the 2 groups (p = 0.7 and 0.2, respectively). Eight vaporization cases were converted to transurethral prostate resection or holmium laser enucleation intraoperatively due to bleeding. A significantly higher maximum flow rate and lower post-void residual urine were noted in holmium laser cases during the entire followup (at 1 year each p = 0.02). However, no significant difference in International Prostate Symptom Score, quality of life or International Index of Erectile Function-15 was detected. Prostate volume and serum PSA decreased 78% and 88% in the holmium laser group, and 52% and 60% in the vaporization group, respectively. CONCLUSIONS: Holmium laser enucleation and photoselective vaporization are effective for lower urinary tract symptoms due to a large prostatic adenoma. Early subjective functional results (maximum flow rate and post-void residual urine) of holmium laser enucleation appear to be superior to those of photoselective vaporization. In our hands cases intended to be treated with photoselective vaporization were at 22% risk of conversion to another modality. This could reflect our determination to vaporize to the capsule in all vaporization cases.

Antimicrobial therapy for asymptomatic patients with elevated prostate-specific antigen: can the change in prostate-specific antigen reliably guide prostate biopsy decisions?

OBJECTIVES: To assess the effects of a 4-week levofloxacin course on PSA in asymptomatic men with elevated prostate-specific antigen (PSA) and on prostate biopsy decision. METHODS: Fifty asymptomatic men with elevated PSA (4.0-10.0 ng/dl) were given levofloxacin 500 mg/day for 4 weeks followed by repeat PSA. Prostate biopsy was recommended at the end of the study. We compared pre- and post-treatment PSA as well as PSA changes between prostate cancer cases and non-cancer patients. RESULTS: Mean (±SD) PSA decreased from 6.91 ± 2.13 to 6.05 ± 3.0 ng/dl after antimicrobial treatment (p = 0.025). Twenty-five (56.8%) patients had a post-treatment decrease in PSA, including 20 (45.5%) patients to <4.0 ng/dl and/or >25% of the initial PSA value. The difference in PSA change between prostate cancer and non-cancer patients was not statistically significant (p = 0.104). CONCLUSIONS: Levofloxacin resulted in an overall decrease in PSA for asymptomatic men with PSA in the 4-10 ng/dl range. PSA changes, however, were not significantly different between patients with prostate cancer and non-cancer patients. Prostate cancer was detected in 20% of patients with a clinically relevant PSA decline.

A novel antireflux technique for orthotopic ileal bladder substitutes-flat-segment technique: preliminary results.

Objective. Although a large debate exists regarding the need for reflux prevention in ileal orthotopic neobladders, it is our policy to continue performing nonrefluxing ureteroileal anastomoses for our patients. An ideal uretero-ileal anastomosis must be simple, nonrefluxing, as well as non-obstructive. Here, we present a new antireflux mechanism for orthotopic ileal neobladders. Methods. 12 radical cystectomy patients for muscle invasive bladder cancer were candidates for orthotopic urinary diversion and underwent a non-refluxing uretero-ileal anastomosis using the flat-segment technique with a follow up of 6 to 18 months. Results. Preliminary results after the short-term followup showed that the success rate in reflux prevention was 92% and no cases of obstruction. The upper tracts were preserved or improved in all 12 patients. Operative time for neobladder creation ranged between 120-240 minutes, with a mean of 165 minutes (±36 minutes). No diversion-related complications. Conclusions. Based on our early data, we believe that the flat-segment uretero-ileal anastomosis technique for reflux prevention in orthotopic ileal bladder substitutes is simple, easy to learn and carries no additional morbidity to a standard refluxing uretero-ileal anastomosis, but has the advantage of effective reflux prevention. A longer follow-up period study with more patient numbers is ongoing.

Percutaneous nephrolithotomy in horseshoe kidneys: is rigid nephroscopy sufficient tool for complete clearance? A case series study.

BACKGROUND: this study represents a case series to evaluate how successful is the rigid percutaneous nephroscopy as a tool for clearance of all stones in various locations in horseshoe kidneys. METHODS: Between 2005 and 2009, we carried out PCNL (percutaneous nephrolithotomy) for calculi in horseshoe kidneys in 21 renal units (17 patients) in our department. The indications were large stone burden in 18 units and failed SWL(shock wave lithotripsy) in 3 renal units. All procedures were done under general anesthesia; using fluoroscopic guidance for localization and standard alkan dilatation followed by rigid nephroscopy and stone extraction with or without stone disintegration. We analyzed our results regarding the site and number of the required access, the intra and postoperative complications, the presence of any residual stones, as well as their location. RESULTS: The procedure was completed, using a single access tract in 20 renal units, with the site of puncture being the upper calyx in nine units and the posterior middle calyx in eleven units. Only in one renal unit, two access tracts (an upper and a lower calyceal) were required for completion and a supracostal puncture was required in another case. There was no significant intraoperative bleeding and no blood transfusion was required in any patient. A pelvic perforation occurred in one case, requiring longer PCN (percutaneous nephrostomy) drainage. One patient with infection stones suffered urosepsis postoperatively which was successfully managed. Three cases had residual stones, all located in the renal isthmus, all residuals were un approachable with the rigid instrument; resulting in a overall stone-free rate of 85.7% at discharge. CONCLUSION: Percutaneous nephrolithotomy is generally safe and successful in the management of stones in horseshoe kidneys. However, location of the stones in these patients is crucial to decide the proper tool for optimal stone clearance result.

Safety and efficacy of tubeless percutaneous renal surgery.

PURPOSE: We challenge the requirement for routine placement of a nephrostomy tube after percutaneous renal surgery, assessing the outcome, safety, and efficacy of tubeless procedures. PATIENTS AND METHODS: A total of 128 patients underwent tubeless percutaneous renal surgery from May 2001 to May 2004: stone extraction in 120 patients and endopyelotomy +/- stone extraction in 8. The stone sizes ranged from 2 to 7 cm with a mean of 4.1 cm. An external ureteral catheter was used in 120 patients and was removed after 24 hours if a retrograde study revealed no extravasation. An antegrade Double-J stent was used in 8 patients and removed 4 to 6 weeks postoperatively. Among the 128 patients treated by the tubeless technique, we met situations that mandated insertion of a nephrostomy tube in 18. RESULTS: The stone free-rate was 90.4%. The mean hospital stay was 1.7 days. The incidence of significant intraoperative bleeding was 1.5% and that of significant postoperative hematuria was 4.6%. Postoperative sonography revealed a small perirenal collection (<50 mL) in 10 patients (7.8%) and significant perirenal collections (100-250 mL) in 3 (2.3%). The postoperative retrograde study revealed minor extravasation in 14 patients (12%) and significant extravasation in 3 (2.3%) CONCLUSION: Tubeless percutaneous renal surgery with an externalized ureteral catheter is a safe procedure that is suitable for any patient who can be rendered stone free with a single procedure regardless of the initial stone burden.