Long-term Urological Outcomes in Pelvic Genitourinary Rhabdomyosarcoma: A 48-Year Single-center Experience.

PURPOSE: Multimodal therapy has improved survival in genitourinary rhabdomyosarcoma, a rare pediatric cancer. However, little is reported regarding postoperative complications and long-term urinary and sexual function and quality of life. MATERIALS AND METHODS: We reviewed records from 1970-2018 to identify patients with genitourinary rhabdomyosarcoma of the bladder, prostate, pelvis, vagina, and uterus. We assessed modes of therapy, and if surgical, the type of resection, reconstruction, and reoperation. Primary outcomes included urinary continence, urinary tract infection occurrence, and stone formation. We also surveyed patients older than 18 years for urinary and sexual function. RESULTS: Fifty-one patients were identified for the post-treatment outcomes cohort. All received chemotherapy, 46 (90.2%) underwent surgery, and 34 (67%) received radiation. Twenty-nine patients (56.9%) received trimodal therapy, 17 (33.3%) received chemotherapy/surgery, and 5 (9.8%) received chemotherapy/radiation. Twenty-six had up-front radical surgery (with staged continence mechanism creation); these patients had higher rates of continence, similar rates of urinary tract infection, and higher rates of stone formation compared to those who were organ-spared. A third (4/12) of organ-spared patients underwent additional corrective surgery. Thirty patients with genitourinary rhabdomyosarcoma were surveyed and 14 responded to questionnaires. Overall, urinary complaints were mild, but both male and female respondents reported significant sexual dysfunction. CONCLUSIONS: Organ-sparing treatment was more likely to predispose patients to high rates of additional reconstructive surgery due to compromised urological function. In survey results, both men and women reported poor sexual function, but the majority of patients remained satisfied with their urinary function.

Quantifying and Statistically Modeling Residual Pneumoperitoneum after Robotic-Assisted Laparoscopic Prostatectomy: A Prospective, Single-Center, Observational Study.

BACKGROUND: Laparoscopic surgery (LS) requires CO2 insufflation to establish the operative field. Patients with worsening pain post-operatively often undergo computed tomography (CT). CT is highly sensitive in detecting free air-the hallmark sign of a bowel injury. Yet, the clinical significance of free air is often confounded by residual CO2 and is not usually due to a visceral injury. The aim of this study was to attempt to quantify the residual pneumoperitoneum (RPP) after a robotic-assisted laparoscopic prostatectomy (RALP). METHODS: We prospectively enrolled patients who underwent RALP between August 2018 and January 2020. CT scans were performed on postoperative days (POD) 3, 5, and 7. To investigate potential factors influencing the quantity of RPP, correlation plots were made against common variables. RESULTS: In total, 31 patients with a mean age of 66 years (median 67, IQR 62-70.5) and mean BMI 26.59 (median 25.99, IQR: 24.06-29.24) underwent RALP during the study period. All patients had a relatively unremarkable post-operative course (30/31 with Clavien-Dindo class 0; 1/31 with class 2). After 3, 5, and 7 days, 3.2%, 6.4%, and 32.3% were completely without RPP, respectively. The mean RPP at 3 days was 37.6 mL (median 9.58 mL, max 247 mL, IQR 3.92-31.82 mL), whereas the mean RPP at 5 days was 19.85 mL (median 1.36 mL, max 220.77 mL, IQR 0.19-5.61 mL), and 7 days was 10.08 mL (median 0.09 mL, max 112.42 mL, IQR 0-1.5 mL). There was a significant correlation between RPP and obesity (p = 0.04665), in which higher BMIs resulted in lower initial insufflation volumes and lower RPP. CONCLUSIONS: This is the first study to systematically assess RPP after a standardized laparoscopic procedure using CT. Larger patients tend to have smaller residuals. Our data may help surgeons interpreting post-operative CTs in similar patient populations.

The Role of New Technologies in the Diagnosis and Surveillance of Non-Muscle Invasive Bladder Carcinoma: A Prospective, Double-Blinded, Monocentric Study of the XPERT© Bladder Cancer Monitor and Narrow Band Imaging© Cystoscopy.

Follow-up is essential for the early detection of recurrent non-muscle invasive bladder cancers (NMIBC). This study investigates the clinical relevance of new diagnostic tools such as an mRNA-based urine test (XPERT© Bladder Cancer Monitor, XBCM) and Narrow Band Imaging© (NBI) and compares them with the established follow-up diagnostics (white-light cystoscopy (WLC) and urine cytology). This was a prospective, double-blind, single-center study that involved patients undergoing NMIBC screening at a tertiary care center. Enrollment occurred between January 2018 and March 2020. In addition to standard care (WLC, cytology, and ultrasound), patients underwent XBCM urine testing and NBI cystoscopy. In total, 301 WLCs were performed; through this, 49 patients demonstrated NMIBC recurrence. NBI cystoscopy was congruent with WLC in all patients. Cytology showed a sensitivity (SE) and specificity (SP) of 27% and 97% (PPV: 65%; NPV 87%), respectively, whereas XBCM showed SE and SP of 58% and 89%, respectively (PPV: 51%; NPV: 92%; AUC: 0.79 (0.716-0.871)). Subgroup analysis showed improved SE and similar SP (PPV, NPV) for high grade (HG) recurrence, with a SE of 74% and SP of 89% (39%, 97%). NBI cystoscopy does not necessarily provide additional benefit over standard WLC. However, the XBCM may provide better SE and a diagnostic advantage in instances of HG disease recurrence.

Secondary adenocarcinoma of the urinary bladder attributed to metastatic gastroesophageal cancer.

Metastases of advanced gastrointestinal malignancy to the bladder is a rare phenomenon. Few such cases have been reported. Here, we describe the case of a man with recurrent local gastroesophageal adenocarcinoma who presented with acute kidney injury and bilateral ureteral obstruction ultimately found to have de novo metastatic esophageal disease in the urinary bladder.

Suicide Risk Among Patients with Genitourinary Malignancies: Where Do We Stand?

Urologists should optimize personalized care for individuals with a mental health illness following diagnosis of a genitourinary malignancy, be mindful of psychiatric wellbeing, and involve mental health specialists at the earliest opportunity to improve primary and secondary treatment outcomes.

A Prospective Analysis of the Effects of Nerve-Sparing Radical Prostatectomy on Urinary Continence Based on Expanded Prostate Cancer Index Composite and International Index of Erectile Function Scoring Systems.

PURPOSE: This study aims to objectively characterize the effect of successful nerve sparing (NS) during radical prostatectomy (RP) on postoperative urinary continence (UC) using International Index of Erectile Function (IIEF)-scores and a previously described Expanded Prostate Cancer Index Composite (EPIC) score cutoff value (COV) for UC. Several notable studies on this topic present conflicting outcomes. This is largely due to a lack of clear definitions and consensus regarding preserved erectile function (EF) and UC. METHODS: This study is comprised of all patients who underwent RP at the Kantonsspital Baden, Switzerland, between 2004 and 2013. Patients completed self-assessment questionnaires for UC (EPIC) and EF (IIEF) pre- and postoperatively (3, 6, 9, 12, 18, and 24 months; yearly thereafter). We used a previously described EPIC subscore COV, with "satisfactory continence" signified by a score >85. Statistical analysis was performed using Kaplan-Meier and Cox regression analyses for "surgeon-" and "IIEF-defined" NS definitions. RESULTS: Of 236 men with a median age of 63 years (interquartile range [IQR], 59-66 years) and median follow-up time of 48 months (IQR, 30-78 months), 176 underwent unilateral (n=33) or bilateral (n=143) NS RP. Fifty-four underwent non-NS (NNS) RP. Kaplan-Meier analyses identified the following risk factors for UC: age, prostate volume, cancer risk group, and NS status. In surgeon-defined NS RP cases, multivariate analysis for regaining continence demonstrated no significant difference (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.48-1.25; P=0.3). With successful IIEF-defined NS RPs, regression analysis demonstrated no significant difference (HR, 0.89; 95% CI, 0.59-1.35; P=0.58). CONCLUSIONS: In our population, analysis and comparison of surgeon- and IIEF-defined NS and NNS cohorts revealed that NS RP did not improve postoperative UC. The conservation of UC alone should not motivate surgeons or patients to pursue NS RP.

The Adipose Stromal Vascular Fraction as a Complex Cellular Source for Tissue Engineering Applications.

A major challenge in tissue engineering is the generation of sufficient volumes of viable tissue for organ transplant. The development of a stable, mature vasculature is required to sustain the metabolic and functional activities of engineered tissues. Adipose stromal vascular fraction (SVF) cells are an easily accessible, heterogeneous cell system comprised of endothelial cells, macrophages, pericytes, and various stem cell populations. Collectively, SVF has been shown to spontaneously form vessel-like networks in vitro and robust, patent, and functional vasculatures in vivo. Capitalizing on this ability, we and others have demonstrated adipose SVF's utility in generating and augmenting engineered liver, cardiac, and vascular tissues, to name a few. This review highlights the scientific origins of SVF, the use of SVF as a clinically relevant vascular source, various SVF constituents and their roles, and practical considerations associated with isolating SVF for various tissue engineering applications.

Urinary Incontinence-85: An Expanded Prostate Cancer Composite (EPIC) Score Cutoff Value for Urinary Incontinence Determined Using Long-term Functional Data by Repeated Prospective EPIC-Score Self-assessment After Radical Prostatectomy.

PURPOSE: To determine an objective cutoff value (COV) for urinary incontinence (UI) using the Expanded Prostate Cancer Composite (EPIC) score after radical prostatectomy (RP). METHODS: From 2004-2013, all RP patients at our institution completed the EPIC urinary domain (EPIC-UD) questionnaire preoperatively and 6 weeks; 3, 6, 9, 12, and 18 months postoperatively; and yearly thereafter. The EPIC-UD is composed of several questions, 4 of which address UI qualitatively (EPIC-UI). Furthermore, patients were asked to complete a global quality of life (QoL) questionnaire regarding continence. The EPIC COV was calculated using receiver operating characteristic (ROC) analysis. Correlations between the EPIC-UI and quantitative QoL were evaluated using the Kendall-Tau test. RESULTS: We analyzed 239 patients with a median age of 63 years (interquartile range [IQR], 59-66 years), a median follow-up of 48 months (IQR, 30-78 months) and a median preoperative EPIC-UI score of 100 (IQR, 91.75-100). The ROC analysis for the distinction between EPIC-UI and the use of ≤1 pad/day yielded an EPIC-UI COV of >85, which we termed the UI-85, with an area under the curve of 0.857 (P<0.0001). A stronger correlation was seen between QoL scores and the UI-85 (1 year postoperatively: correlation coefficient [CC], 0.592; P<0.0001) than between QoL and not using a pad (CC, 0.512; P<0.0001). CONCLUSIONS: The calculated COV of the EPIC-UI for continence was 85. UI is a multidimensional condition that cannot be adequately characterized by a single piece of information, such as pad usage only. Hence, the UI-85 represents a nuanced and straightforward tool for monitoring and comparing continence between different time points and cohorts in a multidimensional and objective manner.

The impact of the 2005 International Society of Urological Pathology Gleason grading consensus on active surveillance for prostate cancer.

INTRODUCTION: Current treatment plans for localized prostate carcinoma (PC) are based on core needle biopsies (CNB) classified using the Gleason score (GS). Recently, many institutions have started using the latest version of International Society of Urological Pathology (ISUP) guideline revision from 2014 for PC grading. Interestingly, this adoption is occurring without first understanding whether the 2005 ISUP revisions had a positive clinical impact. CNB-based GS may underestimate tumor aggressiveness and, therefore, critically impact patient eligibility for active surveillance (AS). The 2005 ISUP recommendations bore a significant impact on the grading of Gleason 6 and 7 PCs - a range that is meaningful for AS. The objective of this study was to compare the concordance between GS in CNB and radical prostatectomy (RP) before and after the 2005 ISUP guideline revisions, with an emphasis on its clinical impact on AS. MATERIAL AND METHODS: This was a single-center, prospective observational study. CNB were performed in a standardized manner. GS of CNB and RP specimens were compared across three time periods: 1999-2005 (pre-revision), 2006-2007 (transitional period), and 2008-2015 (post-revision). AS is usually employed in patients with GS 6 or GS 7 PC. Thus, we therefore focused on the analysis of patients with CNBs of GS ≤7. RESULTS: Between 1999 and 2015, 380 men with GS ≤7 PC underwent RP at our institution (median age: 62y; median PSA: 5.8 ng/ml). Of these, 231 CNB specimens were classified as GS ≤6, while 149 were GS 7.46% (pre-revision), 43% (transitional), and 54% (post-revision) of CNB with original scores ≤6 were later upgraded in corresponding RP specimens (p <0.001). CONCLUSIONS: The 2005 ISUP GS revisions did not lower the rates of GS upgrades in RP specimens when compared to corresponding initial CNBs. Thus, these revisions did not improve AS selection. Future advances in molecular diagnostics may provide additional valuable information that facilitates patient enrollment in AS programs.

Wnt5a Regulates the Assembly of Human Adipose Derived Stromal Vascular Fraction-Derived Microvasculatures.

Human adipose-derived stromal vascular fraction (hSVF) cells are an easily accessible, heterogeneous cell system that can spontaneously self-assemble into functional microvasculatures in vivo. However, the mechanisms underlying vascular self-assembly and maturation are poorly understood, therefore we utilized an in vitro model to identify potential in vivo regulatory mechanisms. We utilized passage one (P1) hSVF because of the rapid UEA1+ endothelium (EC) loss at even P2 culture. We exposed hSVF cells to a battery of angiogenesis inhibitors and found that the pan-Wnt inhibitor IWP2 produced the most significant hSVF-EC networking decrease (~25%). To determine which Wnt isoform(s) and receptor(s) may be involved, hSVF was screened by PCR for isoforms associated with angiogenesis, with only WNT5A and its receptor, FZD4, being expressed for all time points observed. Immunocytochemistry confirmed Wnt5a protein expression by hSVF. To see if Wnt5a alone could restore IWP2-induced EC network inhibition, recombinant human Wnt5a (0-150 ng/ml) was added to IWP2-treated cultures. The addition of rhWnt5a significantly increased EC network area and significantly decreased the ratio of total EC network length to EC network area compared to untreated controls. To determine if Wnt5a mediates in vivo microvascular self-assembly, 3D hSVF constructs containing an IgG isotype control, anti-Wnt5a neutralizing antibody or rhWnt5a were implanted subcutaneously for 2w in immune compromised mice. Compared to IgG controls, anti-Wnt5a treatment significantly reduced vessel length density by ~41%, while rhWnt5a significantly increased vessel length density by ~62%. However, anti-Wnt5a or rhWnt5a did not significantly affect the density of segments and nodes, both of which measure vascular complexity. Taken together, this data demonstrates that endogenous Wnt5a produced by hSVF plays a regulatory role in microvascular self-assembly in vivo. These findings also suggest that manipulating Wnt signaling could enhance control of hSVF vascularization in tissue engineering applications.

Restoration of Physiologically Responsive Low-Density Lipoprotein Receptor-Mediated Endocytosis in Genetically Deficient Induced Pluripotent Stem Cells.

Acquiring sufficient amounts of high-quality cells remains an impediment to cell-based therapies. Induced pluripotent stem cells (iPSC) may be an unparalleled source, but autologous iPSC likely retain deficiencies requiring correction. We present a strategy for restoring physiological function in genetically deficient iPSC utilizing the low-density lipoprotein receptor (LDLR) deficiency Familial Hypercholesterolemia (FH) as our model. FH fibroblasts were reprogrammed into iPSC using synthetic modified mRNA. FH-iPSC exhibited pluripotency and differentiated toward a hepatic lineage. To restore LDLR endocytosis, FH-iPSC were transfected with a 31 kb plasmid (pEHZ-LDLR-LDLR) containing a wild-type LDLR (FH-iPSC-LDLR) controlled by 10 kb of upstream genomic DNA as well as Epstein-Barr sequences (EBNA1 and oriP) for episomal retention and replication. After six months of selective culture, pEHZ-LDLR-LDLR was recovered from FH-iPSC-LDLR and transfected into Ldlr-deficient CHO-a7 cells, which then exhibited feedback-controlled LDLR-mediated endocytosis. To quantify endocytosis, FH-iPSC ± LDLR were differentiated into mesenchymal cells (MC), pretreated with excess free sterols, Lovastatin, or ethanol (control), and exposed to DiI-LDL. FH-MC-LDLR demonstrated a physiological response, with virtually no DiI-LDL internalization with excess sterols and an ~2-fold increase in DiI-LDL internalization by Lovastatin compared to FH-MC. These findings demonstrate the feasibility of functionalizing genetically deficient iPSC using episomal plasmids to deliver physiologically responsive transgenes.

Long-term biostability and bioactivity of "fibrin linked" VEGF121in vitro and in vivo.

Despite major advances in understanding angiogenesis over the last few years, the ability to induce angiogenesis in ischemic wounds or larger tissue-engineering constructs remains elusive. Serious risks and limited control over dose, duration, and localization of growth factor delivery make materials-based approaches viable alternatives. In an effort to minimize passive diffusion and control the release profile of delivered growth factors, matrix properties have been engineered with regard to pore size, growth factor affinity or stable growth factor binding. Recently, fibrin or biomimetic hydrogels have been engineered towards the covalent immobilization of vascular endothelial growth factor (VEGF). Most of the studies pertaining to VEGF delivery by fibrin gel constructs have focused on characterizing release profiles, receptor activation, and the angiogenic response in vitro and in vivo. Herein we demonstrate that gels containing covalently-linked VEGF (α2PI1-8-VEGF121), compared to diffusible VEGF, elicit stronger and longer-lasting angiogenic responses in subcutaneous implants of mice. This superior angiogenic response was due to both the sustained release and significant retention of bioactivity (80%) of the delivered engineered VEGF over a 12-day period. To the best of our knowledge, this is the first report to characterize long-term matrix liberated α2PI1-8-VEGF121 bioactivity, important for future efforts in angiogenesis research.

Dissecting the role of human embryonic stem cell-derived mesenchymal cells in human umbilical vein endothelial cell network stabilization in three-dimensional environments.

The microvasculature is principally composed of two cell types: endothelium and mural support cells. Multiple sources are available for human endothelial cells (ECs) but sources for human microvascular mural cells (MCs) are limited. We derived multipotent mesenchymal progenitor cells from human embryonic stem cells (hES-MC) that can function as an MC and stabilize human EC networks in three-dimensional (3D) collagen-fibronectin culture by paracrine mechanisms. Here, we have investigated the basis for hES-MC-mediated stabilization and identified the pleiotropic growth factor hepatocyte growth factor/scatter factor (HGF/SF) as a putative hES-MC-derived regulator of EC network stabilization in 3D in vitro culture. Pharmacological inhibition of the HGF receptor (Met) (1 µm SU11274) inhibits EC network formation in the presence of hES-MC. hES-MC produce and release HGF while human umbilical vein endothelial cells (HUVEC) do not. When HUVEC are cultured alone the networks collapse, but in the presence of recombinant human HGF or conditioned media from human HGF-transduced cells significantly more networks persist. In addition, HUVEC transduced to constitutively express human HGF also form stable networks by autocrine mechanisms. By enzyme-linked immunosorbent assay, the coculture media were enriched in both angiopoietin-1 (Ang1) and angiopoietin-2 (Ang2), but at significantly different levels (Ang1=159±15 pg/mL vs. Ang2=30,867±2685 pg/mL) contributed by hES-MC and HUVEC, respectively. Although the coculture cells formed stabile network architectures, their morphology suggests the assembly of an immature plexus. When HUVEC and hES-MC were implanted subcutaneously in immune compromised Rag1 mice, hES-MC increased their contact with HUVEC along the axis of the vessel. This data suggests that HUVEC and hES-MC form an immature plexus mediated in part by HGF and angiopoietins that is capable of maturation under the correct environmental conditions (e.g., in vivo). Therefore, hES-MC can function as microvascular MCs and may be a useful cell source for testing EC-MC interactions.