Comparative study of the treatment of renal stones with flexible ureterorenoscopy in normal weight, obese, and morbidly obese patients.

OBJECTIVE: To compare the efficacy and the safety of flexible ureterorenoscopy (f-URS) in the treatment of kidney stones according to the body mass index (BMI), which seems to be less influenced by weight compared with shock wave lithotripsy and percutaneous nephrolithotomy. METHODS: We conducted a retrospective monocentric study in patients with a known BMI who underwent an f-URS for kidney stones between 2006 and 2008. Success rates in the obese patients (OP) group (BMI ≥30 kg/m(2)) were compared with success rates in the normal weight patients (NWP) control group (BMI <25 kg/m(2)). Patients with a BMI ≥40 kg/m(2) were defined as morbidly obese patients (MOP), a subgroup of the OP group. The success was defined as a stone-free status (no or ≤2 mm residual stone) at the time of control, 3 months after the procedure assessed by kidneys-ureters-bladder radiography coupled with ultrasound (only in NWP with radiopaque stones), or computed tomography-scan. RESULTS: A total of 327 procedures were performed, including 97 f-URS in 87 OP (including 14 procedures in 13 MOP) and 230 procedures for 188 NWP. The overall success rate was 67.4% and 68% in the NWP and OP, respectively; P = .91 (71.4% in the MOP subgroup). Success rates decreased with an increasing stone size without any differences between the groups. Regardless of location and stone size (<10, 10-20, >20 mm), there was no statistical difference in the success rate. Postoperative morbidity was similar in both groups and occurred in 2.44% of cases. CONCLUSION: f-URS for kidney stones resulted in similar outcomes in NWP and OP, and even MOP, regardless of stone size and location and with equivalent morbidity.

Can we improve the biopsy quality of upper urinary tract urothelial tumors? Single-center preliminary results of a new biopsy forceps.

OBJECTIVE: Our aim was to evaluate the biopsy quality of upper urinary tract urothelial transitional cell carcinoma with a new biopsy forceps (BIGopsy®, Cook Medical) compared to a classic biopsy forceps (Piranha®, Boston Scientific). PATIENTS AND METHODS: From December 2009 to December 2011, 20 patients with upper urinary tract urothelial transitional cell carcinoma underwent conservative treatment endoscopically. All lesions were evaluated and biopsied with 3 Fr cup forceps using both types of forceps (BIGopsy and Piranha). A single pathologist blindly analyzed the specimens in order to determine the optimal biopsy for each patient. Specimen histopathology results were graded; however, they were staged if the lamina propria was not invaded (T1) or if the tumor was detected at the lamina propria (T1+). RESULTS: Of the 20 upper urinary tract lesions, 12 (60%) were in the renal pelvis, 3 (15%) in the upper calyx, 1 (5%) in the middle calyx, 1 (5%) in the lower calyx, 1 (5%) in the upper third of the ureter and 2 (10%) in the middle third of the ureter. We did not detect T1 in all biopsies. One patient had no valid biopsies by both forceps. A diagnosis of urothelial carcinoma was made in 17 BIGopsy biopsies compared to 7 Piranha biopsies. CONCLUSION: Despite the limited number of cases, our study demonstrated the advantage of the new forceps (BIGopsy) in obtaining a valid biopsy of upper urinary tract urothelial tumors. Therefore, we recommend it in evaluating this pathology for optimal treatment.

Diagnostic, staging, and grading of urothelial carcinomas from urine: performance of BCA-1, a mini-array comparative genomic hybridisation-based test.

BACKGROUND: Cytogenetic abnormalities occur at an early stage of bladder urothelial carcinomas (BUC), and their frequency increases as the cancer becomes more advanced. OBJECTIVE: To assess the diagnostic performance of a test based on cytogenetic abnormalities to diagnose, stage, and grade BUC from the urine. DESIGN, SETTING, AND PARTICIPANTS: We used a 341 bacterial artificial chromosome (BAC) comparative genomic hybridisation (CGH)-array chip (BCA-1) designed to include loci affected in BUC. The chip was first used on 32 frozen BUC biopsies to design staging (BN0) and grading (BN1 and BN2) prediction models based on Bayesian networks analysis. The models were then validated on external data obtained from 98 tumour samples using a 2464 BAC CGH-array chip. The performance of the test was finally assessed on 44 urine pellets collected, including 22 patients who had BUC and 22 controls. MEASUREMENTS: We measured sensitivity and specificity to diagnose BUC stage and grade from urine pellets. RESULTS AND LIMITATIONS: In the urine, BCA-1 test sensitivity was 95%, specificity was 86%, and accuracy was 91%. The BN0 staging model identified T1-4 tumours in the urine with a sensitivity of 90%, a specificity of 83%, and an accuracy of 87%. The BN1 and BN2 grading models detected high-grade disease with a sensitivity, specificity, and accuracy of 86%, 88%, and 87%, respectively, using BN1 and 100%, 63%, and 82%, respectively, using BN2. BN models performed with similar sensitivity but reduced specificity using the external data. BCA-1 failed to produce results for eight additional samples (failure rate: 9%). The test needed high quantities and quality of DNA, and external validation in larger, prospective, and better-designed studies is necessary to confirm feasibility and performance. CONCLUSIONS: The BCA-1 mini-CGH-array chip detected BUC in urine with a high diagnostic performance. It could also accurately discriminate low-grade from high-grade tumours and, to a lesser extent, lamina propria-invasive tumours from pTa tumours.

Flexible ureterorenoscopy with holmium laser in horseshoe kidneys.

OBJECTIVES: To assess the outcome of flexible ureterorenoscopy (F-URS) with the holmium laser in treating stones in the horseshoe kidney (HSK). METHODS: We retrospectively reviewed the records of 17 patients with a HSK stone (17 renal units) who had undergone F-URS with the holmium laser from December 2004 to May 2009. The presenting symptoms were renal colic, urinary tract infection, or hematuria. F-URS was used in as an alternative after the failure of shock wave lithotripsy in 8 patients (47%) and percutaneous nephrolithotomy failure in 4 patients (23.5%). Follow-up examination was performed after 4-6 weeks with plain radiography and either renal ultrasonography or noncontrast computed tomography. Success was defined as stone-free status or residual fragments <3 mm. The use of auxiliary procedures was considered to indicate treatment failure. RESULTS: A total of 17 patients were included in the present study (3 females and 14 males). Their age was 16-52 years (mean age ± SD 34.7 ± 6.3). The HSK stone location was 7 mixed caliceal, 3 mixed pelvic and caliceal, and 7 pelvic. The average stone burden was 16 mm (range 7-35). The overall number of procedures was 25 (mean 1.5 procedures/patient). Of the 17 patients, 15 (88.2%) were rendered stone free. CONCLUSIONS: The results of our study have shown that F-URS with the holmium laser is an efficient minimal invasive procedure for treating HSK stones.

Protocadherin-PC promotes androgen-independent prostate cancer cell growth.

BACKGROUND: Protocadherin-PC (PCDH-PC) expression is upregulated in apoptosis-resistant sublines of the LNCaP human prostate cancer (CaP) cell line. Here, we assess the role of PCDH-PC in CaP cells and its mRNA expression in human prostate tissues. METHODS: LNCaP cells transfected with PCDH-PC were tested for their ability to grow in vitro and in vivo in androgen-deprived conditions. PCDH-PC mRNA expression was evaluated by semi-quantitative RT-PCR and by in situ hybridization. RESULTS: PCDH-PC expression induced Wnt signaling in CaP cells and permitted androgen-independent growth of hormone-sensitive CaP cells. Expression of PCDH-PC-homologous transcripts was low and restricted to some epithelial cells in normal tissue and to CaP cells in tumors. However, hormone-resistant CaP cells expressed significantly higher levels of PCDH-PC-related mRNA. CONCLUSIONS: Our findings suggest a novel mechanism for the progression of CaP involving expression of PCDH-PC. This novel protocadherin induces Wnt signaling, promotes malignant behavior and hormone-resistance of CaP cells.

Profiles of the 2 INK4a gene products, p16 and p14ARF, in human reference urothelium and bladder carcinomas, according to pRb and p53 protein status.

The INK4a/ARF locus encodes 2 cell cycle regulatory proteins: p16 and p14(ARF). P16 inhibits the activities of cdks, which maintain the retinoblastoma protein (pRb) in its active hypophosphorylated state. P14(ARF) blocks MDM2-induced p53 degradation and transactivational silencing. In this study, we investigated the expression of p16 and p14(ARF) in reference human urothelium and in 51 urothelial carcinomas (UCs) of all stages and grades, by reverse transcription-polymerase chain reaction (RT-PCR). Patterns of p14(ARF) and p16 expression were compared with each other and then with patterns of p53 and pRb protein expression, respectively, as determined by immunohistochemistry. P14(ARF) and p16 mRNAs were present at low levels or were undetectable in reference urothelia and in most superficial tumors, whereas they were present at high levels in a subset of tumors of advanced stage and high grade. The expression profiles of these 2 mRNAs were correlated in all but 4 cases, indicating that the 2 INK4a products may have nonredundant functions. Forty-six of the 51 tumors (90%) presented changes to or a lack of activation of the p14(ARF)-p53 pathway and were p53 positive (n = 10), p14(ARF) negative (n = 23), or both p53 positive and p14(ARF) negative (n = 13), suggesting that these 2 components of the pathway may be altered or nonactivated. Markedly high levels of p16 mRNA (n = 5) were associated with the absence of pRb expression, with the exception of 1 case in which the p16 gene contained a deletion mutation. A lack of p16 mRNA or low levels of this mRNA were associated with pRb detection in all but 1 case. In invasive UCs, the p16-pRb pathway, the p14(ARF)-p53 pathway, or in many cases both pathways were altered or not activated, demonstrating the involvement of these pathways in invasive bladder tumorigenesis.

Growth, differentiation and senescence of normal human urothelium in an organ-like culture.

OBJECTIVE: To examine the kinetics of growth, differentiation and senescence of normal human urothelium in an organoid-like culture model. MATERIALS AND METHODS: Micro-dissected normal human urothelium explants were grown on porous membranes pretreated with various matrix components. Between 5 and 30 days of culture, cell proliferation was assessed by BrdU incorporation. Differentiation was evaluated on the basis of cytokeratin (Ck) and uroplakin (UP) expression. Epidermal growth factor family mRNA expression was monitored during explant outgrowth. Senescence was assessed by measuring endogenous beta-galactosidase activity and p16(INK4a) mRNA expression. RESULTS: Collagen IV was the most efficient matrix component for urothelial cell expansion. BrdU incorporation by urothelial cells was 5% between 15 and 30 days, corresponding to steady-state urothelium in vivo. Heparin-binding EGF (HB-EGF), Amphiregulin (AR) and Transforming Growth Factor alpha (TGF alpha) expression correlated with increased cell proliferation. UPII expression was stable throughout culture. P16(INK4a) mRNA expression and beta-galactosidase activity increased on day 25, giving signs of senescence. CONCLUSIONS: This model retains many characteristics of the urothelium in vivo. It can be used for pharmacological studies between 15 to 25 days and to study mechanisms such as wound healing, proliferation and senescence.

Prognostic value of EGF receptor and tumor cell proliferation in bladder cancer: therapeutic implications.

Changes in growth factor receptor expression may confer a growth advantage on tumour cells. Epidermal growth factor-receptor (EGF-R) has been associated with the genesis of bladder tumours. We sought a link between EGF-R expression and MIB-1 cell proliferation and examined their prognostic value in the progression of bladder cancer. Fresh frozen samples from 113 transitional cell carcinomas (TCC) of the bladder and 10 healthy bladders were studied by immunohistochemistry, using monoclonal antibodies for EGF-R expression and MIB-1 for cell proliferation. Qualitative and quantitative immunostaining were analyzed in relation to time to progression and compared with clinical and pathologic parameters for prognostic significance in univariate and multivariate analysis (stepwise logistic regression). EGF-R stained more intensively in invasive tumours. Median nuclear over-expression of MIB-1 was 28%. Progression free survival rate estimates (log rank test) were significantly lower in patients EGF-R positive and with MIB-1 score above 28% (P < 0.0001, P < 0.0001, respectively). Multivariate analysis indicated that MIB-1 immunostaining was the most significant independent variable and EGF-R expression had no additional prognostic value over clinical stage and grade and cell proliferation. The MIB-1 proliferation index is a stronger predictor of bladder tumour progression than is EGF-R over-expression. This marker yield significant prognostic information in addition to stage and grade and may be of value for the clinical management of superficial and invasive bladder carcinomas. The pattern of EGF-R immunostaining and its association with tumour progression makes it a candidate for antigrowth factor therapy.

The emergence of protocadherin-PC expression during the acquisition of apoptosis-resistance by prostate cancer cells.

In order to identify gene products associated with the development of acquired therapeutic resistance by prostate cancer cells, we created two novel apoptosis-resistant prostate cancer cell lines, LNCaP-TR (phorbol-ester [TPA]-Resistant) and LNCaP-SSR (Serum Starvation-Resistant) by repeated transient exposure of cultured human LNCaP cells to apoptotic stimuli followed by expansion of surviving cell populations. These cell lines were found to be cross-resistant to the alternative selective agent and also hormone-resistant when xenografted into castrated male immunodeficient mice. RNA from the LNCaP-TR line was comparatively screened using a subtractive hybridization-PCR procedure. This allowed us to identify a 249 bp cDNA fragment that hybridized to a 4.8 kb mRNA preferentially expressed by the apoptosis-resistant cells. Using RACE procedures, we cloned and sequenced the complete 4.8 kb cDNA. It is an unusual member of the protocadherin gene family containing two large overlapping open reading frames encoding homologous polypeptides, one having a signal sequence and the other lacking a signal sequence and we refer to it as protocadherin-PC. LNCaP cells directly transformed with protocadherin-PC cDNA were comparatively resistant to phorbol-ester induced apoptosis. Antibody recognition studies demonstrating the cytoplasmic nature of the protcadherin-PC translation product and its propensity to bind beta-catenin suggest that it might influence the apoptotic sensitivity of prostate cancer cells through a unique mechanism.