Molecular detection of prostate cells in ejaculate and urethral washings in men with suspected prostate cancer.

PURPOSE: To determine whether prostatic cells were normally present in ejaculate and if the sensitivity and specificity of the detection of malignant prostate cells in ejaculate and urethral washings from men with suspected prostate cancer could be improved using the more sensitive molecular technique of reverse transcriptase-polymerase chain reaction (RT-PCR). MATERIALS AND METHODS: RT-PCR for prostate-specific antigen (PSA), prostate-specific membrane antigen (PSM) and Apoliprotein D (3 putative prostate-specific and/or cancer-specific markers) was performed on RNA extracts of ejaculate (80) and urethral washings (52) from 77 men with suspected prostate cancer and 12 young controls (<30 years of age) and urines from 5 men who had radical prostatectomies and 10 women. RESULTS: PSA, PSM and Apolipoprotein D expression was detected in ejaculates and urethral washings from both patient and control groups. No differences were observed in the results obtained for 58 men with suspected or 19 men with confirmed prostate cancer or the 18 vasectomized men within the patient group. Urines from the 5 men who had radical prostatectomies and 10 women were all negative for PSA, but PSM was detected in 2 female urines and in 3 radical prostatectomy samples. As few as 10 LNCaP prostate tumor cells could be detected by PSA RT-PCR when added to female urine. CONCLUSION: We have established a sensitive method of detecting prostatic cells in ejaculate and urethral washings and shown that PSA RT-PCR is a reliable indicator of prostate cells in these samples. However, RT-PCR for PSA, PSM and Apoliprotein D were not useful for discriminating malignant from non-malignant prostate cells.

Experimental pyeloureterectomy and calyceal neck transection with autotransplantation and bladder advancement.

OBJECTIVE: To determine whether Dexon mesh, closely applied to the kidney, provides purchase for sutures to permit bladder/parenchymal apposition on autotransplantation and that, if this line of apposition were some distance from but surrounding renal papillae, urothelium would proliferate to cover exposed parenchyma to form a widely patent lumen; this should facilitate removal of the whole of an upper tract collecting system, retaining renal parenchyma alone. MATERIALS AND METHODS: To test this possibility and explore the practicability of the concept, nine dogs underwent bilateral nephrectomy followed by unilateral autotransplantation: the other kidney was discarded. Because the canine renal pelvis is intrarenal, the ureter was stretched maximally before passing fine scissors into the renal hilum to transect the collecting system as close to the kidney as possible in six of the nine dogs. In the remaining three dogs, partial nephrectomy was performed with division of the calyceal necks under vision. Thinned bladder wall was sutured to Dexon mesh some distance from the collecting tubules; omentum was applied to the suture line. RESULTS: Three dogs were killed prematurely at < 2 weeks because of perioperative complications. Four were killed at 2, 4, 5 and 8 weeks and two at 12 months. Dexon mesh proved to be an effective anchoring fabric, providing close apposition of bladder wall and parenchyma. There was no adhesion of the kidney to peritoneal contents. Urothelial proliferation to cover exposed parenchyma occurred early and by 12 months, a thin stroma was interposed between parenchyma and epithelium. The kidney was preserved in all but one removed electively, this dog having both cystitis and pyelonephritis at 12 months. CONCLUSIONS: This study showed that autotransplantation of a kidney after removal of its collecting system and advancement of thinned bladder wall to renal parenchyma is practicable, with regenerated urothelium bridging the deficiency by covering exposed parenchyma, to create a widely patent lumen.

Intussuscepted partial-thickness ileal valve in continent urinary diversion.

OBJECTIVE: This study was undertaken to ascertain the feasibility of fashioning a nipple valve from partial-thickness ileum and to assess the competence and durability of that valve. The approach employed was designed to circumvent the necessity for considerable lengths of bowel to be committed to valve formation and to avoid the tendency for desusception, present with other forms of nipple valves. METHODS: A technique in which a subterminal segment of partial-thickness ileum was 'skinned' circumferentially of serosa and muscularis propria and then intussuscepted to form a continent nipple-valve mechanism was studied for up to 4 months in 10 dogs. The intussuscepted partial-thickness ileal valve was in continuity with a terminal ileal segment sutured flush with skin and, internally, with another segment laid open and anastomosed to the bladder. RESULTS: All valves were competent, withstanding intravesical pressures up to 90 cm H2O. Six dogs were catheterized, without difficulty, twice daily up to 104 days. The valve mucosal surfaces were smooth due to a loss of plicae circulares, and, between 'back-to-back' submucosal layers, a fine stroma developed. CONCLUSIONS: This simple technique, which is frugal in its use of bowel, provided a robust and effective ileal continence mechanism. Furthermore, because of denervation and interposing fibrous tissue, this nipple valve is considered most unlikely to desuscept subsequently. The intussuscepted partial-thickness ileal valve approach is recommended now for clinical evaluation.

Abnormal prostatic cells in ejaculates from men with prostatic cancer--a preliminary report.

OBJECTIVE: To relate findings from a novel approach, ejaculate cytology, to the established reference, histopathology from transrectal ultrasonography (TRUS)-guided prostatic biopsies, in patients at risk of having prostatic cancer on the basis of an abnormal digital rectal examination (DRE) and/or an elevated serum prostate specific antigen (PSA). PATIENTS SUBJECTS AND METHODS: Thirty-seven men suspected of having prostatic carcinoma provided ejaculate specimens which were collected in Hanks solution. The specimens were centrifuged to form a pellet from which smears were made for cytological examination. Immunohistochemical staining for PSA and prostatic acid phosphatase (PAP) were performed on embedded blocks of these cells. TRUS-guided sextant biopsies were performed for histological specimens using standard clinical procedures. A control group of 32 men < 30 years of age, with no family history of prostatic cancer, also produced specimens of ejaculate which were processed similarly. RESULTS: Frankly malignant and atypical prostatic cells were identified in ejaculate specimens from 14 of the 37 patients. Of 12 patients with TRUS biopsies positive for malignancy, nine (75%) had abnormal cells in their ejaculates. Furthermore, five of 25 patients with negative biopsies for adenocarcinoma also had abnormal ejaculate cytology; two of these five patients had high-grade prostatic intra-epithelial neoplasia (PIN). In the control group, no PSA- or PAP-positive prostatic epithelial cells were identified. Normal prostatic cells were not seen in any of the ejaculate specimens examined. CONCLUSIONS: These results indicate that ejaculate cytology, which is a non-invasive and easily repeated investigation, may prove to be a useful approach in the early detection of cancer of the prostate. However, its value in this role, together with the clinical significance of cytological findings, needs to be established, especially in relation to PSA and TRUS biopsy.

Immunohistological expression of p53 in primary pT1 transitional cell bladder cancer in relation to tumour progression.

OBJECTIVE: To determine whether p53 expression is a marker of tumour progression in superficially invasive (pT1) transitional cell carcinoma of the bladder. PATIENTS AND METHODS: The immunohistochemical status of the p53 protein in 28 pT1 primary bladder cancers was determined on frozen tissue and archival paraffin block sections using three primary antibodies (CM-1, PAB1801 and D07). The findings were compared with the patients' progress. All the patients, except for those who died during the course of the study, were followed up by check cystoscopy for a minimum of 2 years. RESULTS: Immediately adjacent frozen sections stained identically in 10 of 16 cases for CM-1 and PAB1801. For paraffin sections, identical staining patterns were seen for PAB1801 and D07 in 21 of 26 sections. However, inter- and intra-tumour staining for p53 was very variable, even with the same antibody. The heterogeneity of p53 positive cell distribution in the tumours indicates potential for significant sampling errors if random sections are chosen as representative of p53 status. CONCLUSION: The p53 status of the primary tumours did not relate to patient outcome. The results obtained do not support the use of immunohistological p53 expression as a discriminating prognostic indicator in pT1 transitional cell carcinoma of the bladder.

Mucin expression by transitional cell carcinomas of the bladder.

OBJECTIVE: To examine the presence of a membrane-associated and secreted mucin (MUC1) and a secreted gel-forming mucin (MUC2) in normal and malignant urothelium. MATERIALS AND METHODS: Sections were obtained from archival paraffin blocks from 11 patients with nonmalignant urological conditions and 89 patients with transitional cell carcinomas (TCC). Mucin expression was examined by immunohistochemistry using monoclonal antibodies BC2 and 4F1, reactive with epitopes on the protein core of MUC1 and MUC2 respectively. RESULTS: In normal urothelium MUC1 was limited predominantly to the apical membranes of the umbrella cell layer. MUC1 was present in all cases of TCC, and the pattern of expression divided into three categories: luminal membrane staining only, luminal plus cytoplasmic staining of intermediate +/- basal layers, or staining of only isolated cells or cell groups. These staining patterns were significantly associated with both tumour grade and stage (P < 0.001), with cytoplasmic staining more prevalent in higher grade and stage tumours. MUC2 was not detected in normal urothelium, and was present in 40% of cases of TCC, characterized by intense granular cytoplasmic staining. No association between MUC2 expression and either tumour grade or stage was demonstrated. CONCLUSION: MUC1 mucin was expressed by both normal and malignant urothelium, with increased expression characteristic of higher grade and stage tumours. MUC2 expression was found in 40% of tumours but not in normal urothelium. The role of these mucins in the biology of the bladder requires further investigation.

An immunohistological demonstration of c-erbB-2 oncoprotein expression in primary urothelial bladder cancer.

Sections of formalin-fixed, paraffin-blocked tissue from 116 primary transitional cell carcinomas were stained immunohistochemically using a polyclonal antibody against the c-erbB-2 oncoprotein. Positive staining of cell membranes, known to correlate with gene amplification, was seen in 22 (19%) of the 116, with variable staining from tumour to tumour and within tumours themselves. Consistent with its mooted value as a prognosticator in bladder cancer, the c-erbB-2 oncoprotein was detected in 13 (of 40) grade III and 9 of the 26 muscle-invasive tumours examined compared to 1 (of 25) grade I and 6 (of 66) mucosa only (pTa) lesions. These results support further examination of c-erbB-2 expression in bladder cancer.

Evaluation of a bladder advancement extension graft technique.

A bladder advancement extension technique was developed to provide a reliable method for creating an extra length of bladder in continuity, so that Boari flap and psoas hitch procedures, with or without the extension grafts, would reach sufficiently high routinely to permit these procedures to become the preferred practical options for accommodating significant proximal ureteric deficiencies or for replacing the whole of the ureter. In addition, an omentally supported bladder graft was established separately for use in a "retrieval" procedure should extension graft stenosis develop subsequently. Of 10 dogs studied for 6 months, 2 required "retrieval" pedicled island patch grafts for stenoses at extension graft/upper ureteric junctions. Healthy urothelium with muscle in the walls was seen in grafts resting on their supporting omental beds. At the time of sacrificing, none of the operated upper tracts was obstructed.

Application of the invaginated sleeve technique to form a continent ileal urostomy.

The invaginated sleeve technique has been adapted to produce a continent urostomy, able to be catheterised, from a length of canine ileum measuring less than 10 cm. Of the 4 dogs catheterised twice daily up to 13 weeks, narrowing was present in the extra-ileal segment in 2, but all intra-ileal double-barrelled lumina remained healthy with preservation of bowel mucosa.

Development of the invaginated sleeve technique for continent cystostomies in dogs.

Two studies were undertaken in dogs to evaluate oblique tunnels through bladder walls lined by urothelium for use in continent cystostomies. In the first study, the tracts were lined completely by urothelium by 10 weeks, but tract calibre reduced considerably after stent removal and periluminal fibrosis was a prominent feature. In the second study a tubularised partial-thickness pedicle graft was invaginated through an oblique tunnel in the bladder wall, with the graft extending extravesically and then being wrapped in omentum. This technique provided complete urothelial covering by 2 weeks with much less periluminal fibrosis. In the 3 dogs catheterised daily up to 120 days, this technique afforded continence with generous tracts for catheterisation.