Significance of S100A8, S100A9 and calprotectin levels in bladder cancer.

OBJECTIVES: Members of the S100 protein family, S100A8, S100A9 and their heterodimer complex known as calprotectin are thought to be involved not only in inflammatory pathways but also in tumorigenesis and cancer progression. Therefore, they have been widely studied in various types of cancer; however, there is limited knowledge about their role in bladder cancer. In this study, our aim was to determine the levels of S100A8 and S100A9 in the sera, and calprotectin levels in the sera and urines of bladder cancer patients and compare it to urinary BTA, a tumor marker that can be used in the diagnosis of bladder cancer. MATERIALS AND METHODS: The study was comprised of two major groups: 52 healthy controls and 82 patients with bladder cancer. The patient group was also divided into subgroups according to tumor stage and grade. Urine BTA levels, serum S100A8 and S100A9 levels, and serum and urine calprotectin levels in healthy controls and patients were determined using commercially available ELISA kits. RESULTS: While serum S100A8 and S100A9 levels did not differ between the controls and patients significantly, serum and urine calprotectin levels and urine BTA levels were significantly elevated in patients compared to controls. Serum calprotectin or urine BTA levels did not differ significantly among the patient subgroups. However, urine calprotectin levels were significantly elevated in muscle-invasive tumors (T2-4) compared to lower stages (Ta and T1). CONCLUSIONS: Urine calprotectin levels can be used in the diagnosis and staging of bladder cancer as a marker for muscle invasion.

Detection of bladder cancer recurrence with real-time three-dimensional ultrasonography-based virtual cystoscopy.

This prospective study evaluated the accuracy of grey-scale two-dimensional (2D) ultrasonography and real-time threedimensional (3D) ultrasonography-based virtual cystoscopy for detecting early recurrence of bladder cancer in previously treated patients (n = 40). Real-time 3D ultrasonography-based virtual cystoscopy images were compared with both 2D ultrasonography and interval conventional cystoscopy pathology results. Ultrasound examinations were performed before routine follow-up with conventional cystoscopy. Overall sensitivity for real-time 3D ultrasonography-based virtual cystoscopy was lower than for 2D ultrasonography, indicating it did not provide additional information. The results of combined (2D and 3D) ultrasonography and conventional cystoscopy differed significantly. Where lesions were detected with combined ultrasonography, the number of previous cystoscopies was lower and the tumour stage was significantly higher at initial diagnosis, compared with cases where no lesions were detected. The results suggest that ultrasonography before cystoscopy can be performed more frequently - or, if no lesions are detected by ultrasonography, the interval between cystoscopies can be prolonged - in patients at high risk of bladder cancer recurrence.

The relationship between antioxidant enzymes and bladder cancer.

Carcinogenesis proceeds through at least three distinct stages - initiation, promotion and progression. Free radicals play an important role in the multistep complex course of carcinogenesis. Urinary bladder has been recognized as a target organ for many carcinogens, including benzidine, beta-napthylamine, 2 napthylamine, 4-aminobiphenyl. Antioxidants have been shown to inhibit both initiation and promotion in carcinogenesis. The aim of presented study was to determine and compare the oxidant and antioxidant status in different clinical stages of bladder cancer and of control groups. Study was conducted in fifty-two (n=52) patients with transitional cell epithelial cancer of bladder and in twenty-four (n=24) healthy adults as plasma and erythrocyte controls. Malondialdehyde levels (4.636+/-1.118, 2.853+/-0.576 / 262.112+/-61.772, 203.788+/-35.340) were significantly higher and erythrocyte glutathione levels (6.272+/-1.708, 7.523+/-1.346) were significantly lower in bladder cancer patients group than in control group. Erythrocyte glutathione reductase and glutathione peroxidase (3.935+/-1.155, 5.481+/-1.626 / 8.729+/-1.614, 12.362+/-1.707) activities were significantly lower in cancer patients. In the other hand, glutathione S-transferase activities (3.100+/-1.177, 1.071+/-0.471) were found significantly increases. We suggest that the values of glutathione S-transferase enzyme activity can be used for a tumor detection approach and even as an indicator of the biological behavior of the bladder carcinoma.

The efficacy of extracorporeal shock wave lithotripsy for isolated lower pole calculi compared with isolated middle and upper caliceal calculi.

PURPOSE: We assess the efficacy of extracorporeal shock wave lithotripsy monotherapy for isolated lower pole nephrolithiasis, and compare it to that for isolated middle and upper caliceal calculi. MATERIALS AND METHODS: We treated 714 renal units in 687 patients with isolated caliceal stones using a Lithostar lithotriptor (Siemens Medical Systems, Erlangen, Germany). The stones were localized in the lower, mid and upper calices in 455, 104 and 128 patients, respectively. Stone load was recorded in cm.2. Patients were stratified into 3 groups based on stone burden. The energy and shock waves, use of anesthesia, number of treatment sessions, auxiliary measures and complications were noted. Patients were evaluated with intravenous urogram or plain film of kidneys, ureters and bladder, and ultrasonography when stone-free, or clinically significant residual fragment status, including nonobstructive and noninfectious insignificant fragments 4 mm. or less, was noted at the fluoroscopic control 2 to 4 weeks after the last session. Final clinically significant residual fragment decision was made 10 to 12 weeks after the last session. Extracorporeal shock wave lithotripsy was considered a failure if no fragmentation was noted after session 3 and continued if fragmentation was noted. Results regarding caliceal localization were compared. RESULTS: Complete data were available on 591 renal units. Auxiliary procedures were used in 81 (14%) units before treatment. Anesthesia was given to 101 (17%) patients. The mean number of shock waves and energy used were 2,022 and 17.4 kV., respectively. The difference in shock wave, energy and treatment rate among 3 caliceal locations reached statistical significance only for energy delivered to the lower and upper calices. The effectiveness quotient of extracorporeal shock wave lithotripsy was 36%, 46% and 41% for lower, middle and upper pole stone disease, respectively (p = 0.4). There was a highly significant correlation between stone-free and re-treatment rates, and stone burden. The overall stone-free rate was 66%, and 63%, 73% and 71% for lower, middle and upper caliceal stones, respectively (p = 0.1). For the group with stones greater than 2 cm.2 overall stone-free rate decreased to 49%, and 53%, 60% and 23% in lower, middle and upper caliceal locations, respectively. Overall, extracorporeal shock wave lithotripsy monotherapy failed in 46 (7.7%) renal units. Steinstrasse developed in 39 (6.5%) patients who were then treated with repeat lithotripsy. CONCLUSIONS: Extracorporeal shock wave lithotripsy appears to be successful for management of isolated caliceal stone disease. Treatment efficacy was not significantly different among stones localized in lower, middle and upper poles. We recommend it as the primary treatment of choice for stones less than 2.0 cm.2 in all caliceal locations. Treatment should be individualized for management of caliceal stones greater than 2.0 cm.2 until large prospective randomized trials comparing shock wave lithotripsy and percutaneous nephrolithotomy are available.

Metastatic adenocarcinoma of the prostate to the uvea as the initial presenting symptom in a 49-year-old man.

We report a case of a 49-year-old man who presented with symptoms related to his right eye. Subsequent workup revealed carcinoma of the prostate metastatic to the uvea. On ophthalmologic evaluation, choroidal metastasis was noted. His prostate was firm on digital rectal examination, and the serum prostate-specific antigen level was 124 ng/mL. Prostate biopsy was consistent with adenocarcinoma, Gleason score 9. The patient was treated with total androgen blockade and radiation to the eye. Although his ocular lesions disappeared, the patient died of hormone-refractory disease 32 months after the diagnosis. The first case of prostate cancer metastatic to the uvea was reported more than 1 century ago; however, only a few cases have been reported subsequently. To our knowledge, we present the first published report in the urological literature of a patient in whom ocular complaints were the presenting symptoms that led to the diagnosis of prostate cancer. The urologist should be cognizant of the distinct possibility of ocular metastasis if a patient with prostate cancer presents with complaints related to the eye.

Radiation therapy in non-surgically-treated nonmetastatic prostate cancer: geographic and demographic variation.

OBJECTIVES: To examine the geographic variation in the use of radiation to treat nonmetastatic prostate cancer and to identify factors that explain the variation in the United States. METHODS: This study was based on data from the nine geographic regions of the Surveillance, Epidemiology, and End Results Program for 1983 through 1996. Patients with localized or regional prostate cancer who did not undergo surgical treatment were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radiation. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radiation explained by each factor of interest. RESULTS: Compared with San Francisco, the adjusted odds ratios for 6 of the 8 geographic areas had highly significant P values, suggesting the use of radiation therapy varies from region to region. However, geographic location only explained less than 3% of the total variation in the use of radiation. The geographic location explained a much higher proportion of variation in the youngest (younger than 55 years) and the oldest (80 years old or older) groups. Overall, age was the most important factor that influenced the use of radiation. CONCLUSIONS: The finding that geographic location explains a significant proportion of the variation in the use of radiation in the youngest and oldest age groups demonstrates the outcome of longstanding controversies in the nonsurgical treatment of prostate cancer. Documenting the impact of the interaction of age and geographic location on the treatment approaches provides for better understanding of the impact of patients and physicians making clinical decisions in the management of nonmetastatic prostate cancer.

Complications of the Mainz pouch II (sigma rectum pouch).

OBJECTIVE: The complications of the sigma rectum pouch were analyzed. METHODS: A total of 60 patients who underwent a construction of the Mainz pouch II was analyzed retrospectively. Data on early complications was available for all patients, while long-term follow-up data was available for 50 patients. RESULTS: Perioperative mortality was nil. Early complications were encountered in 2 (3.3%) patients. Oral alkalizing supplementation therapy was required in 30 (60%) of the patients; 3 (6%) patients needed hospitalization for severe acidosis and hypokalemia. Hydronephrosis developed in 5 (5%) of 98 renoureteral units anastomosed. Acute pyelonephritis was observed in 3 (8%) patients. All of the patients were continent except for 1 female patient who had had previous radiotherapy to the pelvis. The mean voiding frequency during the day and night was 5.1+/-1.1 and 1.9+/-0.7, respectively. The psychological state and general health of 2 patients became progressively worse until they died of probable malnutrition and metabolic abnormalities. Mechanical bowel obstruction developed in 1 patient 2 years after surgery. CONCLUSION: The complication rate of the Mainz pouch II appears to be acceptable with a median follow-up of 31 months. Patient selection and cooperation are of paramount importance for a successful outcome.

Periprostatic local anesthesia before ultrasound guided prostate biopsy.

PURPOSE: We assessed the morbidity and benefit of periprostatic local anesthesia administered before ultrasound guided prostate biopsy. MATERIALS AND METHODS: After placing the transrectal ultrasound probe and visualizing the prostate 50 consecutive patients received local anesthesia before prostate biopsies. RESULTS: There was no morbidity associated with the infiltration of local anesthesia into the periprostatic neurovascular plexus. Only 1 patient had discomfort during prostate biopsies, and 10 patients who previously underwent biopsies without anesthesia commented favorably on the dramatic difference. CONCLUSIONS: Many patients have pain during transrectal ultrasound guided biopsies of the prostate and few clinicians provide a periprostatic nerve block before this procedure. A periprostatic nerve block administered before the biopsies dramatically decreases discomfort. We urge all urologists to attempt this procedure, and we are confident that they will adopt it as part of their practice.

Urinary hyaluronic acid and hyaluronidase: markers for bladder cancer detection and evaluation of grade.

PURPOSE: Specific patterns of progression and frequent recurrence of bladder tumors determine the choice of treatment, frequency of surveillance, quality of life, and ultimately, patient prognosis. The prognosis would be improved if an accurate noninvasive test was available for diagnosis. Identification of markers that function in bladder cancer progression would be helpful in designing such diagnostic tests. The glycosaminoglycan, hyaluronic acid (HA), promotes tumor metastasis. Hyaluronidase (HAase), an endoglycosidase, degrades HA into small fragments that promote angiogenesis. We have previously shown that both HA and HAase are associated with bladder cancer and may function in bladder tumor angiogenesis. In this study we examined whether urinary HA and HAase levels serve as bladder cancer markers. MATERIALS AND METHODS: Among the 513 urine specimens analyzed, 261 were from transitional cell carcinoma (TCC) patients, 9 from patients with non-TCC tumors, and 243 from controls (normals, patients with other genitourinary (GU) conditions or a history of bladder cancer (HxBCa)). The urinary HA and HAase levels were measured by two ELISA-like assays that utilize a biotinylated HA binding protein for detection. These levels were normalized to total urinary protein and were expressed as ng./mg. (HA test) and mU/mg. (HAase test), respectively. RESULTS: The urinary HA levels were elevated (2.5 to 6.5 fold) in bladder cancer patients (1173.7+/-173.4; n = 261) as compared with normals (246.1+/-38.5; n = 41); GU patients (306.6+/-32.2; n = 133), and patients with a HxBCa (351.1+/-49.1; n = 69) (p <0.001). The urinary HAase levels were elevated (3 to 7 fold) in G2/G3 bladder cancer patients (26.2+/-3.2) as compared with normals (4.5+/-0.9) and patients with either GU conditions (5.8+/-1.3), HxBCa (8.2+/-2.6) or G1 tumors (9.7+/-2.5) (p <0.001). The HA test showed 83.1% sensitivity, 90.1% specificity and 86.5% accuracy in detecting bladder cancer, regardless of the tumor grade. The HAase test showed 81.5% sensitivity, 83.8% specificity and 82.9% accuracy to detect G2/G3 patients. Combining the inferences of the HA and HAase tests (HA-HAase test) resulted in detection of bladder cancer, regardless of tumor grade and stage, with higher sensitivity (91.2%) and accuracy (88.3%), and comparable specificity (84.4%). CONCLUSION: Our results show that the HA-HAase urine test is a noninvasive, highly sensitive and specific method for detecting bladder cancer and evaluating its grade.

Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis.

OBJECTIVES: To correlate the extent and location of positive surgical margins after radical prostatectomy with disease progression. METHODS: Data on 495 patients who underwent radical prostatectomy by one surgeon were analyzed. All radical prostatectomy specimens were sectioned entirely using 2 to 3-mm step sections by one pathologist. One hundred fifty-one patients (30.5%) had one or more positive surgical margins and were subjected to further detailed analysis. Recurrence was defined as a serum prostate-specific antigen (PSA) level of 0.2 ng/mL and rising on at least two postoperative measurements. RESULTS: The mean follow-up was 25.3 months (range 3 to 73). The overall recurrence rate was 13.3%. Neoadjuvant hormonal treatment was given to 37 (25%) of those with a positive margin. Patients with positive surgical margins had a significantly higher incidence of recurrence compared with those with negative margins (27.8% versus 6.9%, P = 0.001). The recurrence rate for various locations was 29% apex/urethra, 30% posterior, 33% anterior, 36% lateral, 48% posterolateral, and 57% bladder neck. Time to recurrence was shorter in patients older than 70 years (P<0.055); with a preoperative PSA greater than 10 ng/mL (P<0.0001); with a biopsy Gleason score greater than 7 (P = 0.02); with a prostatectomy Gleason score greater than 7 (P<0.001); with seminal vesicle invasion (P = 0.0001); having more than 1 location of a positive margin (P = 0.002); or having a positive margin at the bladder neck (P = 0.0003) or the posterolateral surface of the prostate (P = 0.02) compared with other locations. Multivariate proportional hazards analyses indicated that age older than 70 (P = 0.005), a prostatectomy Gleason score of 7 (P = 0.015) or 8 to 10 (P = 0.003), and positive margin(s) at the bladder neck (P = 0.003) were independently associated with a shorter time to recurrence among patients with a positive margin. CONCLUSIONS: In our study, among patients with positive surgical margins, those with multiple positive margins, or a margin involving the bladder neck or the posterolateral surface of the specimen carried a higher risk of progression. A positive margin at the bladder neck appears to be the most significant adverse prognostic indicator. This information may help in decisions regarding additional therapy.

Age as a prognostic factor for disease recurrence after radical prostatectomy.

OBJECTIVES: To assess whether age has an impact on biochemical recurrence after radical prostatectomy for localized adenocarcinoma of the prostate. METHODS: Four hundred eighty-nine consecutive patients who underwent radical retropubic prostatectomy and did not have metastases to the lymph nodes were retrospectively analyzed. Disease recurrence was defined as a serum prostate-specific antigen greater than 0.2 ng/mL and rising on at least two postoperative measurements. Biochemical progression was compared in patients 70 years old or younger and older than age 70. The Kaplan-Meier estimator and Cox's proportional hazards model were employed to investigate the impact of age on time to recurrence. Neoadjuvant androgen deprivation was treated as a stratification variable in the Cox models. RESULTS: The mean follow-up was 25.4 +/- 20.8 months. The Gleason score and extent of cancer in the pathologic analyses of the prostatectomy specimen was not significantly different between the two groups. Biochemical recurrence was detected in 12% of patients 70 years old or younger and in 25% of those older than 70 (P = 0.01). In multivariate analyses, after adjusting for all prognostic factors, younger age (70 years or younger) was independently associated with a longer time to recurrence (P <0.02). CONCLUSIONS: Our results suggest that age per se may be an independent prognostic factor for disease recurrence after radical prostatectomy. This implies that patients 70 years old or younger are more likely to benefit from surgery. This information may be useful when counseling patients with clinically localized carcinoma of the prostate.

Is there a role for digital rectal examination in the followup of patients after radical prostatectomy?

PURPOSE: We determine the role of digital rectal examination in the followup of patients after radical prostatectomy. MATERIALS AND METHODS: We retrospectively analyzed data on 501 consecutive patients who underwent radical retropubic prostatectomy between 1992 and 1998, and were followed at the University of Miami. Patients were evaluated at 3 to 6-month intervals after surgery with serum prostate specific antigen (PSA) and digital rectal examination. Biochemical recurrence was defined as PSA greater than 0.2 ng./ml. and increasing on at least 2 consecutive measurements. Local recurrence, detected by an abnormal digital rectal examination, was defined as an induration or nodularity in the prostatic fossa. RESULTS: Mean followup plus or minus standard deviation was 25.4+/-20.8 months. Disease recurred in 72 patients (14.4%) and was biochemical in all. An abnormal digital rectal examination was noted in 4 patients, none of whom had an undetectable PSA at the time of a palpable abnormality. CONCLUSIONS: Our results suggest that an abnormal digital rectal examination after radical prostatectomy is always associated with a detectable PSA, which implies that performing a digital rectal examination in the absence of a detectable PSA may not be necessary.

Comparison of digital rectal examination and biopsy results with the radical prostatectomy specimen.

PURPOSE: Digital rectal examination is integral to staging prostate cancer. Ultrasound guided biopsy establishes the diagnosis, and it may provide useful information regarding disease grade and extent. Treatment decisions are largely based on information gained from digital rectal examination and biopsy but this information is only useful if it correlates with the radical prostatectomy specimen and prognosis. We correlated digital rectal examination and transrectal ultrasound guided biopsy results with a detailed analysis of the radical prostatectomy specimen. MATERIALS AND METHODS: The accuracy of an abnormal digital rectal examination for predicting the location and extent of cancer was assessed in 89 patients thought to have clinical stage T2 disease. We evaluated 155 patients with clinical stages T1c and T2 disease to correlate the location of positive biopsies with the tumor site in the prostate. Radical prostatectomy specimens were completely sectioned at 2 mm. intervals, and tumor extent and location were recorded. RESULTS: In 85 patients a unilateral lesion was suspicious on digital rectal examination, that is stage cT2. The final pathological review revealed cancer on the suspicious side in 82 cases (96%) with tumor confined to the same lobe in only 23 (27%), bilateral disease in 59 (69%) and tumor confined to the contralateral lobe in 3 (4%). In 4 patients with a palpable bilateral abnormality a bilateral lesion was confirmed on final pathological evaluation. Digital rectal examination demonstrated a 36 and 31% incidence of extracapsular tumor extension and positive surgical margins, respectively, on the clinically benign side. In 100 patients only unilateral biopsy was positive. The final pathological evaluation revealed cancer in the biopsy positive side in 95 cases (95%) with tumor confined to the ipsilateral lobe in only 26 (26%), bilateral disease in 69 (69%) and tumor confined to the contralateral lobe in 5 (5%). In 46 of the 55 patients (84%) with bilateral positive biopsies tumor involved both sides but the pathologist did not identify cancer in both lobes in 9 (16%). While 100 patients had a unilateral negative biopsy, analysis of the prostatectomy specimen revealed carcinoma in the benign lobe in 74 (74%). Moreover, extracapsular tumor extension and a positive surgical margin were observed on the biopsy negative side in 31% of the patients. The degree to which digital rectal examination and biopsy results confirmed the final pathological evaluation was assessed using the kappa statistic, which revealed only slight agreement with each factor. The correlation of digital rectal examination and biopsy results with the location of extracapsular extension and positive margins was evaluated by the Spearman coefficient of correlation, which indicated poor agreement. When patients with unilateral versus bilateral positive biopsy were compared with respect to prognostic parameters, the difference was statistically significant for initial serum prostate specific antigen, the percentage of surface involved by tumor, biopsy and final Gleason scores, and the incidence of extracapsular extension of tumor. CONCLUSIONS: Digital rectal examination and the interpretation of prostate biopsy are not accurate clinical tools for defining the location and extent of prostatic carcinoma. Bilateral positive biopsy may be useful as an adjunct to the current clinical staging system.

Intravesical therapy for transitional cell carcinoma of the bladder: the community practice.

OBJECTIVES: To assess how the community urologist employs intravesical therapy in patients with transitional cell carcinoma (TCC) of the bladder because most data on intravesical therapy reflect the experience of major referral centers. METHODS: The medical records of 234 consecutive patients with TCC were reviewed. Sixty-nine patients received intravesical treatment before referral. The initial pathologic findings, the indication for treatment (eg, grade and stage, initial versus recurrent tumor), the schedule of intravesical therapy, and the drug selected for each course of treatment were assessed. RESULTS: A total of 1 39 courses of intravesical treatment were given to 69 patients; thus, the avarage number of courses was 2.02 per patient. The drug used was bacillus Calmette-Guerin (BCG) in 81 (58%), mitomycin C in 34 (24%), thiotepa in 16 (12%), Adriamycin in 4 (3%), and unknown in 4 (3%). Intravesical treatment was given after transurethral resection of the initial tumor in 33 patients; the initial pathologic finding was high grade (ie, grade 3 or carcinoma in situ) and/or Stage T1 in 22, TaG1-G2 in 9, and unknown in 2. One course of treatment was administered to 34 patients (49%) and two or more courses to 35 patients (51%). Eleven patients with TaG 1 -2 tumors were treated repetitively despite failure, with an average of 3.5 courses per patient; the drug used was BCG in 44%. Nineteen percent of patients received maintenance therapy. Intravesical therapy had to be discontinued in 10 patients because of side effects; 8 patients (12%) developed small contracted bladders and severe irritative symptoms, 3 required cystectomy despite the lack of bladder cancer. CONCLUSIONS: Intravesical therapy in community practice conforms with the generally accepted indications for high-grade and T1 disease. However, the use of BCG for low-grade TCC appears to be quite common. Repeated courses may result in significant side effects. We emphasize that excessive treatment should be avoided for low-grade, Ta lesions and BCG reserved for patients with TaG3, carcinoma in situ, or T1 TCC.

Neoadjuvant Hormonal Therapy Prior to Radical Prostatectomy.

The US T(2b) study of 3 months of neoadjuvant hormonal therapy (NHT) showed a reduction in the likelihood of positive margins from 48% (control group) to 18% in the treated patients. Follow-up at 42 months shows that the cumulative relapse rate (prostate specific antigen) for 129 patients having NHT was not statistically different from that of the 126 control patients. Because the T(2b) study has been criticized for lacking central pathology review, we present a review of a series involving only one surgeon (MS) and one pathologist (FC) of NHT plus prostatectomy (109 patients) v prostatectomy alone (145 patients) with 24 months' follow-up. Positive margins were decreased from 38% in the untreated to 28% in the treated group, the only statistically significant difference in the results. Biochemical recurrence (PSA >0.2 ng/mL) was higher in the treated group, reflecting selection of more aggressive tumors for NHT, but the difference was not statistically significantly. The incidence of extracapsular extension, seminal vesicle invasion, and lymph node metastasis was similar in the two groups. The largest nonrandomized experience with NHT shows a decrease in the incidence of positive surgical margins when used in high-risk patients with clinically localized carcinoma of the prostate. However, it does not have an impact on disease-free survival at a mean 24-month follow-up.

Urologic screening for men with Behçet's syndrome.

OBJECTIVES: To establish the urologic status of men with Behcet's syndrome, because studies assessing the urologic aspect of Behçet's syndrome are rare. METHODS: During a 2.5-year period, we evaluated 104 male patients with Behçet's syndrome, 16 to 50 years old (mean 31+/-7), using a urologic questionnaire and modified Boyarsky symptom score; 44 healthy men, 20 to 46 years old (mean 29+/-7), were used as control subjects. RESULTS: The frequency of epididymitis in patients with Behçet's syndrome was 19.2% in this study. The mean irritative symptom score was 1.22+/-1.37 (significantly higher than the control group). The frequency of lower urinary tract symptoms (eg, dysuria, urgency, nocturia, terminal dribbling, and intermittency) was significantly higher in patients with Behcet's syndrome. CONCLUSIONS: In this study, the frequency of epididymitis in men with Behcet's syndrome was much higher than previously reported. Because some lower urinary tract symptoms were significantly more frequent in these patients, we conclude that screening of such patients with urologic questionnaire and symptom scoring is essential to identify those who need further urologic evaluation.

Multilocular cystic nephroma: an unusual localization.

We present a case of multilocular cystic nephroma with an unusual localization treated by a nephron-sparing procedure. A 21-year-old white woman presented with a history of hematuria and right lumbar pain. Imaging techniques revealed a multilocular cystic mass originating from the renal parenchyma but mainly involving the renal pelvis. The lesion was localized almost entirely within the renal pelvis at surgery and was treated by excision. Pathologic analysis was consistent with multilocular cystic nephroma. The patient remains free of recurrence with 10 years of follow-up. We conclude that multilocular cystic nephroma may present as a cystic lesion localized within the renal pelvis, and we advocate simple excision of these lesions.

Update on bladder neck preservation during radical retropubic prostatectomy: impact on pathologic outcome, anastomotic strictures, and continence.

OBJECTIVES: To preserve the bladder neck during radical prostatectomy in an attempt to maintain continence and decrease the incidence of anastomotic stricture without compromising the removal of cancer. METHODS: A retrospective analysis of 365 consecutive radical prostatectomies performed from December 1991 through January 1997 was carried out. The records were reviewed in regard to the pathology of the prostate. In addition, the incidence of anastomotic strictures was determined. Urinary function and continence was evaluated in 195 patients by a quality of life questionnaire. RESULTS: (1) Pathology: positive margins were found in 119 patients (32%). The bladder neck margin was positive in 27 (7%), but the bladder neck was the only positive margin in only 2 patients (0.5%). The mean Gleason score for patients with negative margins was 6.4, for those with positive margins 7.2, and for all those with bladder neck margin positive 7.7. The mean Gleason score for the 2 patients with a solitary positive margin at the bladder neck was 9.0. Of patients with a Gleason score less than 7, 81% had a negative margin, 19% had a positive margin, and 1% had tumor at the bladder neck. Of patients with a Gleason score 7 or more, 58% had a negative margin, 42% had a positive margin, and 11% had a positive bladder neck. Patients with a prostate-specific antigen value of less than 10 ng/mL were more likely to have a favorable pathology. (2) Anastomotic stricture: an anastomotic stricture occurred in 5 patients (1%). Three had a previous transurethral resection of the prostate (TURP) and therefore bladder neck preservation was not possible. (3) Urinary function: 88% of all responders did not wear pads 6 months or more after surgery. Seventy percent of patients did not wear pads less than 6 months after surgery. Ninety percent of patients believed that urinary function did not limit social, physical, or occupational activities. CONCLUSIONS: We believe that bladder neck preservation during radical prostatectomy does not compromise surgical margins. The incidence of anastomotic strictures is less than 1% in patients who have not had a previous TURP. The quality of life questionnaire indicates a high level of continence that may be related in part to preservation of the bladder neck.

Tumor-associated hyaluronic acid: a new sensitive and specific urine marker for bladder cancer.

Hyaluronic acid (HA), a glycosaminoglycan, is known to promote tumor cell adhesion and migration, and its small fragments stimulate angiogenesis. We compared levels of HA in the urine of normal individuals and patients with bladder cancer or other genitourinary conditions, using a sensitive ELISA-like assay. Among the 144 specimens analyzed, the urinary HA levels of bladder cancer patients with G1 (255 +/- 41.7 ng/mg), G2 (291.8 +/- 68.3 ng/mg) and G3 (428.4 +/- 67 ng/mg) tumors are 4-9-fold elevated as compared to those of normal individuals (44.7 +/- 6.2 ng/mg) and patients with other genitourinary conditions (69.5 +/- 6.8 ng/mg; P < 0.001). Urinary HA measurement by the ELISA-like assay shows a sensitivity of 91.9% and specificity of 92.8% to detect bladder cancer. Thus, urinary HA measurement is a simple, noninvasive yet highly sensitive and specific method for bladder cancer detection. The increase in urinary HA concentration is a direct correlate of the elevated tumor-associated HA levels, because the HA levels are also elevated (3-5-fold) in bladder tumor tissues (P < 0.001). The profiles of urinary HA species of normal individuals and bladder cancer patients are different. Although only the intermediate-size HA species are found in the urine of normal and low-grade bladder tumor patients, the urine of high-grade bladder cancer patients contains both the high molecular mass and the small angiogenic HA fragments. These urinary HA fragments stimulate a mitogenic response (2.4-fold) in primary human microvessel endothelial cells, suggesting that the small HA fragments may regulate tumor angiogenesis by modulating endothelial cell functions.