Methylated CpG dinucleotides in the 5-α reductase 2 gene may explain finasteride resistance in benign prostatic enlargement patients.

The inhibition of 5-α reductase type 2 (SRD5A2) by finasteride is commonly used for the management of urinary obstruction resulting from benign prostatic enlargement (BPE). Certain BPE patients showing no SRD5A2 protein expression are resistant to finasteride therapy. Our previous work showed that methylated cytosine-phosphate-guanine (CpG) islands in the SRD5A2 gene might account for the absence or reduction of SRD5A2 protein expression. Here, we found that the expression of the SRD5A2 protein was variable and that weak expression of the SRD5A2 protein (scored 0-100) occurred in 10.0% (4/40) of benign adult prostates. We showed that the expression of SRD5A2 was negatively correlated with DNA methyltransferase 1 (DNMT1) expression. In vitro SRD5A2-negative BPH-1 cells were resistant to finasteride treatment, and SRD5A2 was re-expressed in BPH-1 cells when SRD5A2 was demethylated by 5-Aza-2'-deoxycytidine (5-Aza-CdR) or N-phthalyl-L-tryptophan (RG108). Furthermore, we determined the exact methylation ratios of CpG dinucleotides in a CpG island of SRD5A2 through MassArray quantitative methylation analysis. Ten methylated CpG dinucleotides, including four CpG dinucleotides in the promoter and six CpG dinucleotides in the first exon, were found in a CpG island located from -400 bp to +600 bp in SRD5A2, which might lead to the silencing of SRD5A2 and the absence or reduction of SRD5A2 protein expression. Finasteride cannot exert a therapeutic effect on patients lacking SRD5A2, which may partially account for the resistance to finasteride observed in certain BPE patients.

Laparoscopic radical cystectomy with novel orthotopic neobladder with bilateral isoperistaltic afferent limbs: initial experience

ABSTRACT Purpose To introduce a new method of constructing an orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs, and to describe its clinical outcomes. Materials and Methods From January 2012 to December 2013, 16 patients underwent a new method of orthotopic ileal neobladder after laparoscopic radical cystectomy for bladder cancer. To construct the neobladder, an ileal segment 60cm long was isolated approximately 25cm proximally to the ileocecum. The proximal 20cm of the ileal segment was divided into two parts for bilateral isoperistaltic afferent limbs. The proximal 10cm of the ileal segment was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb, and the remaining proximal 10cm ileal segment was reserved for the left isoperistaltic afferent limb. The remaining length of the 40cm ileal segment was detubularized along its antimesenteric border to form a reservoir. The neobladder was sutured to achieve a spherical configuration. Results All procedures were carried out successfully. The mean operative time was 330 min, mean blood loss was 328mL, and mean hospital stay was 12.5 days. The mean neobladder capacity 6 and 12 months after surgery was 300mL and 401mL, respectively. With a mean follow-up of 22.8 months, all patients achieved daytime continence and 15 achieved nighttime continence. The mean peak urinary flow rate was 11.9mL/s and 12.8mL/s at 6 and 12 months postoperatively, respectively. Conclusions This novel procedure is feasible, safe, simple to perform, and provides encouraging functional outcomes. However, comparative studies with long-term follow-up are required to prove its superiority.

Laparoscopic radical cystectomy with novel orthotopic neobladder with bilateral isoperistaltic afferent limbs: initial experience.

PURPOSE: To introduce a new method of constructing an orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs, and to describe its clinical outcomes. MATERIALS AND METHODS: From January 2012 to December 2013, 16 patients underwent a new method of orthotopic ileal neobladder after laparoscopic radical cystectomy for bladder cancer. To construct the neobladder, an ileal segment 60cm long was isolated approximately 25cm proximally to the ileocecum. The proximal 20cm of the ileal segment was divided into two parts for bilateral isoperistaltic afferent limbs. The proximal 10cm of the ileal segment was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb, and the remaining proximal 10cm ileal segment was reserved for the left isoperistaltic afferent limb. The remaining length of the 40cm ileal segment was detubularized along its antimesenteric border to form a reservoir. The neobladder was sutured to achieve a spherical configuration. RESULTS: All procedures were carried out successfully. The mean operative time was 330 min, mean blood loss was 328mL, and mean hospital stay was 12.5 days. The mean neobladder capacity 6 and 12 months after surgery was 300mL and 401mL, respectively. With a mean follow-up of 22.8 months, all patients achieved daytime continence and 15 achieved nighttime continence. The mean peak urinary flow rate was 11.9mL/s and 12.8mL/s at 6 and 12 months postoperatively, respectively. CONCLUSIONS: This novel procedure is feasible, safe, simple to perform, and provides encouraging functional outcomes. However, comparative studies with long-term follow-up are required to prove its superiority.

The intriguing role of fibroblasts and c-Jun in the chemopreventive and therapeutic effect of finasteride on xenograft models of prostate cancer.

In a large clinical trial, finasteride reduced the rate of low-grade prostate cancer (PCa) while increasing the incidence of high-grade cancer. Whether finasteride promotes the development of high-grade tumors remains controversial. We demonstrated the role of fibroblasts and c-Jun in chemopreventive and therapeutic effect of finasteride on xenograft models of PCa. LNCaP (PC3) cells or recombinants of cancer cells and fibroblasts were implanted in male athymic nude mice treated with finasteride. Tumor growth, cell proliferation, apoptosis, p-Akt, and p-ERK1/2 were evaluated. In LNCaP (PC3) mono-grafted models, finasteride did not change the tumor growth. In recombinant-grafted models, fibroblasts and c-Jun promoted tumor growth; finasteride induced proliferation of LNCaP cells and repressed PC3 cell apoptosis. When c-Jun was knocked out, fibroblasts and/or finasteride did not promote the tumor growth. Finasteride inhibited p-Akt and p-ERK1/2 in mono-culture cancer cells while stimulating the same signaling molecules in the presence of fibroblasts. Reduced p-Akt and p-ERK1/2 were noted in the presence of c-Jun-/- fibroblasts. Fibroblasts and c-Jun promote PCa growth; finasteride further stimulates tumor growth with promoted proliferation, repressed apoptosis, and up-regulated pro-proliferative molecular pathway in the presence of fibroblasts and c-Jun. Stromal-epithelial interactions play critical roles in finasteride's therapeutic effects on PCa. Our findings have preliminary implications in using finasteride as a chemopreventive or therapeutic agent for PCa patients.

["Sandwich" urethra reconstruction improves the early continence following laparoscopic radical prostatectomy].

OBJECTIVE: To explore the safety and efficacy of "sandwich" urethra reconstruction in laparoscopic radical prostatectomy (LRP) for the early recovery of continence. METHODS: LRP was performed using a urethra surrounding tissue reconstruction in 37 consecutive patients, and without reconstruction procedure in 34 consecutive patients at the same period from March 2012 to January 2013. The baseline data, preoperative data: The patient age, body mass index (BMI, kg/m2), International prostate symptoms score (IPSS), prostate volume, preoperative PSA, Gleason score were assessed retrospectively; Operative data: The neurovascular bundle preservation, operation time, blood loss were assessed; and the primary outcome measure was urinary continence assessed at the end of 1, 2, 4, 12 and 24 weeks after the catheter was removed. Other data recorded were duration of indwelling catheter, positive margin rate and complications. RESULTS: There were no significant differences between the two groups with respect to baseline,preoperative and operative data except of the operative time (P=0.003). Between the two groups, the continence of the reconstruction group was higher than that of the control group at the end of 4 and 12 weeks (P=0.007, P=0.020, respectively). CONCLUSION: Urethra surrounding tissue reconstruction in LRP is safe and feasible, and it could improve early recovery of continence.

Differential expression of 5-alpha reductase isozymes in the prostate and its clinical implications.

The development of human benign or malignant prostatic diseases is closely associated with androgens, primarily testosterone (T) and dihydrotestosterone (DHT). T is converted to DHT by 5-alpha reductase (5-AR) isozymes. Differential expression of 5-AR isozymes is observed in both human benign and malignant prostatic tissues. 5-AR inhibitors (5-ARI) are commonly used for the treatment of benign prostatic hyperplasia (BPH) and were once promoted as chemopreventive agents for prostate cancer (PCa). This review discusses the role of the differential expression of 5-AR in the normal development of the human prostate and in the pathogenesis and progression of BPH and PCa.

Retroperitoneal laparoendoscopic single-site surgery for the treatment of retrocaval ureter.

PURPOSE: To present our surgical techniques for retroperitoneal laparoendoscopic single-site (LESS) pyelopyelostomy for retrocaval ureter and our initial experience with this method in 4 patients. METHODS: From June 2010 to May 2011, 4 patients with retrocaval ureter underwent retroperitoneal LESS pyelopyelostomy with a homemade single-port device and standard straight laparoscopic instruments. The single-port device was made with a surgical glove and Foley catheter and allowed the introduction of three trocars. A 3-cm incision was made at the middle axillary line, midway between the iliac crest and the twelfth rib. The retrocaval segment of the ureter was mobilized and transposed anteriorly to the inferior vena cava. The pyelopyelostomy anastomosis was completed with intracorporeal freehand suturing. A double-pigtail ureteral stent assembly was implanted in 3 of the 4 patients. RESULTS: All retroperitoneal LESS pyelopyelostomies were successful without conversion to standard laparoscopy or open surgery. The mean operating time was 105 min (range, 90-135 min). The mean blood loss was 18 mL (range, 5-50 mL). None of the patients required blood transfusion. The double-pigtail ureteral stent was removed 4-6 weeks postoperatively. The mean postoperative hospital stay was 7.3 days (range, 6-9 days). No intraoperative or postoperative complications occurred. At a mean follow-up of 10 months, excellent improvement in the ureteral obstruction was observed. CONCLUSIONS: We report our initial experience using LESS for the treatment of retrocaval ureter. Our results in 4 patients suggest that this minimally invasive approach is a feasible treatment of retrocaval ureter. Long-term follow-up of more cases is needed to confirm its benefits.

[A novel technique of ureterointestinal anastomosis for urinary diversion].

OBJECTIVE: To introduce a novel technique of ureterointestinal anastomosis for urinary diversion and report the preliminary clinical data. METHODS: Between June 2007 and June 2011, a total of 50 patients underwent radical cystectomy and ileal neobladder for invasive bladder carcinoma or carcinoma in situ. A novel, separate and direct end-to-end technique for ureteral reimplantation to the entrance of a segment of ileum was applied. in all patients. Details are as follow. The entrance of afferent loop was divided equally in to two lumens. Then each ureter was directly, end-to-end anastomosed to the above lumens respectively after lengthwise incisions for 1.5 cm. The mean follow-up period was 22 months (range, 3 - 48 months). RESULTS: Ureterointestinal anastomosis was performed successfully in 100 units. The operative durations were (18.4 ± 4.2) minutes. Ureteral stricture developed in 4 of 100 (4%) units and refluxing in 6 of 100 (6%) units. One patient with stricture was successful repaired by balloon dilation. CONCLUSION: With low stricture and reflux rates, this novel procedure of ureterointestinal anastomosis is simple to handle and worthy of further promotion.

[Pilot study of laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder].

OBJECTIVE: To summarize the preliminary experiences of 13 cases of laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder and evaluate the oncological and functional outcomes of this procedure. METHODS: From August 2005 through July 2009, 13 patients underwent radical cystectomy and standard lymphadenectomy followed by construction of orthotopic T pouch ileal neobladder via mini-laparotomy for muscular invasive bladder cancer. The data were analyzed according to procedure time, blood loss volume, transfusion volume, number of dissected lymph nodes, peri-operative complications, morphology and function of upper urinary tract and status of urinary continence. RESULTS: The mean operating duration was 6 (5 - 8) hours, estimated volume of blood loss 480 (100 - 800) ml, transfusion volume 133 (0 - 400) ml and the number of dissected lymph nodes 16 (8 - 22). There was no peri-operative mortality. The peri-operative complications were found in 15.4% (2/13) and included urine leak at neobladder-urethra junction managed by drainage (n = 1) and urine leak at ureter-neobladder junction repaired (n = 1). The complete daytime continence rate was 84.6% (11/13), complete nocturnal continence rate 46.1% (6/13) and < 1 pad in 30.8% (4/13). No reflux into afferent limb of neobladder was observed by cystography. Temporary dilation of upper urinary tract was observed in 23.1% (3/13) at Day 45 post-operation and later it disappeared spontaneously. Serum creatinine remained in a normal range in all patients. Within a follow-up of 24 (16 - 63) months, 7.7% (1/13) died of myocardial infarction at Month 55 post-operation. And 92.3% (12/13) survived without a local relapse or a distal metastasis. CONCLUSION: Within an intermediate follow-up period, the oncological and functional outcomes are encouraging after laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder via mini-laparotomy. The anti-reflux mechanism is effective to preserve the morphology and function of upper urinary tract.

A single institution experience using the LigaSure vessel sealing system in laparoscopic nephrectomy.

BACKGROUND: Vascular control and tissue dissection are crucial steps in successful laparoscopic surgery. Recently, a new commercially available vessel sealing technology, the LigaSure vessel sealing system (Valleylab, Boulder, USA), has been introduced. The aim of the present study was to evaluate the benefits of the LigaSure in laparoscopic nephrectomy. METHODS: From January 2005 to March 2010, 170 laparoscopic nephrectomies were performed with the LigaSure vessel sealing system, including simple and radical nephrectomy and nephroureterectomy. In a retrospective study, the laparoscopic operating time, estimated intraoperative blood loss, duration of postoperative drainage, total amount of postoperative drainage, as well as postoperative hospital stay, were recorded and studied. RESULTS: All 170 laparoscopic nephrectomies using LigaSure were accomplished successfully without conversion to open surgery. There was no severe vascular complication or other serious complications. The mean laparoscopic operating time was 124.2 minutes (range, 14 - 230 minutes); mean blood loss was 148.6 ml (range, 20 - 540 ml); mean time for postoperative drainage was 3.1 days (range, 1 - 7 days); mean amount of postoperative drainage was 206.5 ml (range, 27 - 435 ml) and mean postoperative hospital stay was 6.9 days (range, 3 - 18 days). CONCLUSIONS: Laparoscopic nephrectomy using LigaSure appears technically feasible and easy, and produces satisfactory results. The LigaSure provides a safe and fast way to seal vessels and tissue bundles during nephrectomy.

[Orthotopic T pouch ileal neobladder: evaluations of urodynamics and upper urinary tract functions].

OBJECTIVE: To evaluate the urodynamics and functions of upper urinary tract in a substitute of orthotopic T pouch ileal bladder. METHODS: From June 2004 through September 2009, 90 patients underwent the construction of an orthotopic T pouch ileal neobladder after radical cystectomy for muscle-invasive bladder cancer. The radiographic or ultrasound evaluation of upper urinary tract, determination of renal functions and urodynamic evaluation of T pouch ileal neobladder were performed by data analysis. RESULTS: Renal function as determined by serum creatinine remained in a normal range in all patients. Temporary dilation of renal pelvic and ureter was observed in 18 patients (20.0%) at Day 45 post-operation and then disappeared spontaneously in the late follow-up. A slight dilation of collecting system was found in other 4 patients (4.4%), but there was no negative impact on renal function. Reflux into afferent limb of neobladder was observed in 4 patients (4.4%) by cystography. Excellent daytime and nighttime continence was reported in 100% and 82.2% of evaluated patients respectively. The urodynamic assessment showed a mean capacity of (316 ± 96) ml with a mean intra-bladder pressure of (16 ± 10) cm H2O. These evaluated patients voided with a mean maximum intra-bladder pressure of (87 ± 25) cm H2O, a mean maximum flow rate of (17 ± 10) ml/s and a mean residual urine of (33 ± 29) ml. CONCLUSION: With an intermediate follow-up, the functional results of T pouch ileal neobladder are encouraging with an excellent capacity and compliance, successful daytime and nighttime continence and anti-reflux mechanism.

Application of the Hem-o-lok ligation system in laparoscopic nephrectomy.

BACKGROUND: The Hem-o-lok polymer clip has become the preferred method to control large vessels during operation. We explored the advantages of application of the Hem-o-lok ligation system in laparoscopic nephrectomy. METHODS: From January 2004 to May 2009, 116 laparoscopic nephrectomies were performed using Hem-o-lok clips to control renal artery and vein, including 22 simple nephrectomies, 63 radical nephrectomies, and 31 nephroureterectomies. Operative time, estimated intraoperative blood loss, recovery time of intestinal function, postoperative hospital day, as well as complication rate were recorded and studied retrospectively. The number and cost of Hem-o-lok clips were analyzed. RESULTS: All 116 laparoscopic nephrectomies using Hem-o-lok clips for renal pedicle control were accomplished successfully without conversion to open surgery. No intra/postoperative vascular complications or other clip-related complications occurred. Laparoscopic operating time was 14-275 min (average 146.5 min). Estimated blood loss was 25-600 ml (average 159.2 ml). Mean recovery time of intestinal function was 30.4 h (range 16-72 h). Postoperative hospital stay was 4-22 days, with an average of 7.3 days. The mean number of Hem-o-lok clip used per operation was 5.3 (range 4-8). CONCLUSIONS: Use of the Hem-o-lok ligation system to control renal pedicle is safe and reliable for laparoscopic simple/radical nephrectomy.

Stroma-epithelium crosstalk in prostate cancer.

The critical role played by stroma-epithelium crosstalk in carcinogenesis and progression of prostate cancer has been increasingly recognized. These interactions are mediated by a variety of paracrine factors secreted by cancer cells and/or stromal cells. In human prostate cancer, reactive stroma is characterized by an increase in myofibroblasts and a corresponding amplification of extracellular matrix production and angiogenesis. Permanent genetic mutations have been reported in stromal cells as well as in tumour cells. Transforming growth factor-beta, vascular endothelial growth factor, platelet-derived growth factor and fibroblast growth factor signalling pathways are involved in the process of angiogenesis, whereas hepatocyte growth factor, insulin-like growth factor-1, epidermal growth factor, CXC12 and Interleukin-6 play active roles in the progression, androgen-independent conversion and distal metastasis of prostate cancer. Some soluble factors have reciprocal interactions with androgens and the androgen receptor (AR), and can even activate AR in the absence of the androgen ligand. In this article, we review the complex interactions between cancer cells and the surrounding microenvironment, and discuss the potential therapeutic targets in the stromal compartment of prostate cancer.

[Analysis of clinical efficacy and safety of combining pneumatic and ultrasonic power in percutaneous nephrolithotomy (PCNL) for renal stones].

OBJECTIVE: To investigate the clinical efficacy and safety of combining pneumatic and ultrasonic power during PCNL. METHODS: From Sep 2003 to Aug 2005, we treated 486 patients (509 kidneys) by combining pneumatic and ultrasonic power during percutaneous nephrolithotomy. Clinical data were analyzed retrospectively. RESULTS: The percutaneous renal access was successfully established in 478 patients under ultrasound guidance and immediate phase I lithotripsy was performed, and delayed phase II lithotripsy was performed for 6 patients. Average time required for entire procedure is 73 mins, and average time for stone management is 41 mins. No severe complications occurred. No Residual stone fragment in 438 kidneys, stone free rate was 86.1%. Residual stone fragment was found in 71 kidneys by postoperative KUB and received second PCNL or adjuvant ESWL. CONCLUSION: The combined application of pneumatic and ultrasonic power in PCNL appears to be efficacious and safe for disintegrating and removing renal calculi.

[Percutaneous nephrolithotripsy with pneumatic and ultrasonic power under B-type ultrasound guidance for treatment of renal calculi in non-dilated collecting system].

OBJECTIVE: To evaluate the efficacy and safety of management of renal stone in non-dilated collecting system by percutaneous nephrolithotripsy (PCNL) under ultrasound guidance. METHOD: From September 2003 to April 2005, 132 cases of renal stone in non-dilated collecting system were performed by percutaneous nephrolithotripsy. A stent was first inserted into the pelvis through cystoscope, and saline was instilled to dilate collecting system. Antegrade percutaneous access was obtained by B-type ultrasound guidance. A combination pneumatic and ultrasonic lithotrite were used to disintegrate and remove stone under direct vision. Clinical data including operation time, complications and stone free rate were analyzed retrospectively. RESULTS: The percutaneous renal access was successfully established under B-type ultrasound guidance in all patients, immediate phase I lithotripsy was performed in 129 cases and delayed phase II lithotripsy in 3 cases. Operation time ranged from 70 to 130 minutes, average time was (89 +/- 11) minutes, 3 cases were supported by blood transfusion, severe complications did not occur during nephrolithotripsy. Stones were cleared in 114 out of 132 cases (86.4%) during immediate phase I lithotripsy, residual stone fragment was found in 18 cases who received second PCNL or adjuvant extracorporeal shock wave lithotripsy. CONCLUSION: The management of renal stone in non-dilated collecting system using PCNL appears to be efficacious and safe under B-type ultrasound guidance.

[Short-term neoadjuvant hormone therapy enhanced expression of clusterin in prostate cancer].

OBJECTIVE: To define changes in clusterin expression following short-term neoadjuvant hormone therapy (NHT) and its biological significance in prostate cancer tissues. METHODS: Twenty-six archival radical prostatectomy (RP) specimens without receiving NHT, 19 needle biopsies and corresponding 19 RP specimens following 3-month NHT, were subjected to immunohistochemical clusterin staining. RESULTS: Staining for clusterin was mainly found in cytoplasm and part of extracellular matrix. Clusterin expression was significantly greater in RP specimens with preoperative NHT (t = 2.91, P < 0.01); Needle biopsies obtained before NHT consistently demonstrated lower staining intensity (1.42 +/- 0.51) than corresponding RP specimens (2.16 +/- 0.60) following 3-month NHT (t = 7.10, P < 0.01). CONCLUSIONS: Upregulation of clusterin in part accounts for malignant progression of prostate cancer through its anti-apoptotic action following androgen withdrawal. These findings support that adjuvant therapy targeting clusterin may enhance androgen ablation therapy in advanced prostate cancer.

[Identification of proteins interacting with androgen receptor- associated coregulator 267-alpha (ARA267-alpha) with the yeast two-hybrid system].

OBJECTIVE: To search for proteins interacting with ARA267-alpha with the yeast two-hybrid system in order to further investigate the function of ARA267-alpha. METHODS: We screened a pretransformed human brain cDNA library with the pGBKT7-PHD-SET recombinant plasmid as a bait which express four PHD(plant homeodomain) and one SET[Su(var)3-9, Enhancer-of-zeste, Trithorax] conserved domains in ARA267-alpha. The plasmids in positive yeast clones were selectively identified by restriction analysis and DNA sequencing. The interactions were retested by yeast two-hybrid assay. RESULTS: There were about six hundreds positive yeast clones on SD/-Ade/-His/-Leu/-Trp/2.5 mmol/L 3-AT/ X-alpha-Gal high-stringency selection plates. The pACT2-cDNA plasmids in sixty-five yeast clones were isolated and thirty-five cDNA inserts were sequenced. Sixteen different genes, including DR6(death receptor-6), PIAS3 (protein inhibitor of activated STAT3)and RanBPM(Ran-binding protein in the microtubule-organizing center), were identified after BLAST in GenBank. The yeast two-hybrid retest showed that all but RanBPM were true interactors of ARA267-alpha-PHD-SET. CONCLUSION: The ARA267-alpha-PHD-SET can interact with several distinct proteins. This suggests that ARA267-alpha is a protein having multiple functions. RanBPM might be a transcriptional factor.