Validity and reliability of the patient's perception of intensity of urgency scale in overactive bladder

Study Type – Prognosis (outcomes research)
Level of Evidence 2c What’s known on the subject? and What does the study add? Improvement in urinary urgency is an important goal for patients with overactive bladder, and should be measured along with change in other key symptoms in overactive bladder clinical trials. Existing scales that measure urinary urgency during completion of a bladder diary have incomplete evidence of validity. Used as part of a 3‐day bladder diary the Patient’s Perception of Intensity of Urgency Scale has good test‐retest reliability and responsiveness. It correlates with other measures of condition severity, and distinguishes well between patient groups. The scale should therefore be useful both in clinical practice and in research.

OBJECTIVE

• ? To assess the measurement characteristics of the Patient Perception of Intensity of Urgency Scale (PPIUS) in patients with overactive bladder (OAB).

PATIENTS AND METHODS

• ? Adult women with at least a 3‐month history of OAB. The design was a 4‐week, double‐blind, randomized, placebo‐controlled trial of transdermal oxybutynin, with a 2‐week placebo run‐in and 8‐week, open‐label extension.
• ? Symptom improvement was assessed using 3‐day bladder diaries incorporating the PPIUS, and disease‐specific health‐related quality of life was assessed using the King’s Health Questionnaire (KHQ). Convergent validity was shown by correlation with the KHQ, and other bladder diary variables. Known groups validity was assessed by comparison of baseline mean urge ratings, and urgency episode frequency for continent and incontinent patients, and by comparison with the same measures from a historical control group of 40 asymptomatic female volunteers.
• ? Between‐ and within‐groups responsiveness was assessed using standardized effect sizes (Cohen’s d and effect size r). Reliability was assessed for the two arms of the trial at different time points and intervals, using intraclass correlation (ICC) and a t‐test for the difference between mean scores.

RESULTS

• ? In total, 96 women were randomized. Urgency episode frequency showed moderate correlation with total KHQ score (r= 0.500, P < 0.001) and with daytime and night‐time voiding frequency.
• ? There were significant differences in continent and incontinent subgroups for mean urge ratings (difference in means, ?0.61/void, P < 0.001), and urgency episodes (difference in means, ?2.67 episodes/day, P < 0.001), as well as between OAB patients and normal controls (mean urge rating: difference in means 1.22 per void, P < 0.001; urgency episodes: difference in means 2.93 episodes/day, P < 0.001).
• ? Between‐groups analysis of effect size found that urgency episode frequency (d= 0.679, r= 0.321) was more responsive than mean urge rating (d= 0.480, r= 0.233). In both subgroups, urgency episode frequency (d= 0.421–0.454, r= 0.206–0.222) had better within‐groups responsiveness than mean urge rating.
• ? Urgency episodes (ICC, 0.65–0.81) were measured more reliably than urgency urinary incontinence episodes (ICC, 0.50–0.65).

CONCLUSIONS

• ? Assessment of urgency episodes using the PPIUS shows good reliability, excellent known groups validity, high responsiveness and convergence with subjective measures of severity.
• ? PPIUS is freely available, and should be useful in both clinical practice and research studies when assessing women with urgency, with or without urgency urinary incontinence.

     

Altered bladder function in elastin-deficient mice at baseline and in response to partial bladder outlet obstruction

Study Type – Aetiology (case control) Level of Evidence 3b What's known on the subject? and What does the study add? As one of the major components of the extracellular matrix, elastic fibres are believed to enhance tissue compliance. However, the role of elastic fibres in normal bladder function and dysfunction remains speculative. Although transgenic mice overexpressing elastin showed increased bladder compliance, the findings in patients with non‐compliant bladders are inconsistent. Using transgenic elastin‐deficient mouse models, this study provides the first direct evidence that sufficient elastin content is critical for healthy bladder function, and elastin is involved in the detrusor response to partial bladder outlet obstruction.

OBJECTIVE

• ? To examine functional and molecular changes of the bladders from elastin‐haploinsufficient mice (Eln^+/?) at baseline as well as in response to partial bladder outlet obstruction (pBOO).

MATERIALS AND METHODS

• ? Female Eln^+/? and wild type (Wt) mice (3–4 months old) were studied.
• ? The bladder elastin content was quantified by measuring desmosine.
• ? Mice were divided into two groups to undergo surgery to create pBOO or to undergo sham surgery. Three days after surgery, bladder function was evaluated by in vivo cystometry, and the contractile response of bladder strips exposed to electrical field stimulation (EFS) and carbachol was examined by ex vivo myography.

RESULTS

• ? The Eln^+/?‐sham mice had a 33.6% decrease in bladder elastin compared with Wt‐sham mice.
• ? Cystometry showed significantly decreased bladder compliance and capacity in Eln^+/?‐sham vs Wt‐sham mice; pBOO increased bladder compliance and capacity to a greater extent in Eln^+/? mice compared with Wt mice.
• ? Bladder strips from Eln^+/?‐sham mice showed a significantly heightened contractile response to both EFS and carbachol compared with Wt‐sham mice.
• ? A significantly increased contractile response to carbachol was detected in Wt‐pBOO vs Wt‐sham but not between Eln^+/?‐pBOO and Eln^+/?‐sham mice.

CONCLUSION

• ? The results that elastin‐deficient mice had decreased bladder compliance and capacity and increased bladder contractility; and that Wt‐pBOO mice showed an enhanced contractile response to carbachol, but Eln^+/?‐pBOO mice did not, suggest that elastin is critical for normal bladder function and is involved in bladder response to pBOO.

     

Expression of androgen and oestrogen receptors and its prognostic significance in urothelial neoplasm of the urinary bladder

What's known on the subject? and What does the study add? Steroid hormone receptor signals have been implicated in bladder tumourigenesis and tumour progression. The expression of androgen and/or oestrogen receptors has been assessed in bladder cancer, leading to conflicting data of expression levels and their relationship to histopathological characteristics of the tumours. We simultaneously analyze three receptors in non‐neoplastic bladder tissues as well as in primary and metastatic bladder tumour specimens. Our data demonstrate that the expression status correlates with tumour grades/stages and patients’ outcomes.

OBJECTIVE

• ? To assess the expression of the androgen receptor (AR) and oestrogen receptors (ERs) in bladder tumours because recent studies have shown conflicting results and the prognostic significance of their expression remains unclear.

PATIENTS AND METHODS

• ? We investigated the expression of AR, ERα and ERβ in 188 bladder tumour specimens, as well as matched 141 non‐neoplastic bladder and 14 lymph node metastasis tissues, by immunohistochemistry.
• ? We then evaluated the relationships between their expression and the clinicopathological features available for the present patient cohort.

RESULTS

• ? AR/ERα/ERβ was positive in 80%/50%/89% of benign urothelium, 50%/67%/41% of benign stroma, 42%/27%/49% of primary tumours and 71%/64%/71% of metastatic tumours.
• ? Significantly lower expression of AR/ERα was found in high‐grade tumours (36%/23%) and tumours invading muscularis propria (33%/19%) compared to low‐grade tumours (55%; P= 0.0232/38%; P= 0.0483) and tumours not invading muscularis propria (51%; P= 0.0181/35%; P= 0.0139), respectively.
• ? Significantly higher expression of ERβ was found in high‐grade tumours (58%) and tumours invading muscularis propria (67%) compared to low‐grade tumours (29%; P= 0.0002) and tumours not invading muscularis propria (34%; P < 0.0001), respectively.
• ? Kaplan–Meier and log‐rank tests further showed that positivity of ERβ (but not AR or ERα) was associated with the recurrence of low‐grade tumours (P= 0.0072); the progression of low‐grade tumours (P= 0.0005), high‐grade tumours not invading muscularis propria (P= 0.0020) and tumours invading muscularis propria (P= 0.0010); or disease‐specific mortality in patients with tumours invading muscularis propria (P= 0.0073).

CONCLUSIONS

• ? Compared to benign bladders, a significant decrease in the expression of AR, ERα or ERβ in bladder cancer was seen.
• ? Loss of AR or ERα was strongly associated with higher grade/more invasive tumours, whereas ERβ expression was increased in high‐grade/invasive tumours and predicted a worse prognosis.

     

Temporal diabetes and diuresis-induced alteration of nerves and vasculature of the urinary bladder in the rat

What’s known on the subject? and What does the study add? Diabetes mellitus seriously affects urinary bladder function. Diabetes induces time‐dependent bladder hypertrophy and altered tissue composition. However, the alterations of the density of nerves and vasculatures in bladder under diabetes remains poorly studied. Diabetes induced time‐dependent changes of density of the nerves and vasculatures in the bladder tissues. In addition, diabetes‐related polyuria plays an important role in this alteration.

OBJECTIVE

• ? To characterize the temporal changes of the nerves and vasculature of the bladder in diabetic rats.

MATERIALS AND METHODS

• ? A total of 36 Sprague–Dawley rats were divided into three groups: streptozotocin‐induced diabetics, 5% sucrose‐induced diuretics and age‐matched controls.
• ? The characteristics of the nerves and vasculature in the equatorial cross‐sectional areas of the bladder were examined by immunofluorescence staining of their specific markers, neurofilament 200 (NF200) and CD31, at 1, 9 or 20 weeks after induction.
• ? The distributions of the nerves and blood vessels were observed and the densities were quantified.

RESULTS

• ? Diabetes caused a significant reduction in body weight. Bladder weight increased in diabetic and diuretic rats, but not in controls.
• ? The total cross‐sectional wall area and detrusor muscle area at the equatorial midline were greater in bladders of diabetic and diuretic rats than in controls.
• ? Neurofilament 200‐immunoreactive (NF200‐IR) nerves were mainly distributed in the detrusor muscle. CD31‐immunoreactive blood vessels were mainly distributed in the mucosa/submucosa.
• ? There were no significant differences in the NF200‐IR nerve terminal area among control, diabetic and diuretic groups. However nerve density was decreased at 9 and 20 weeks in the muscle, and at 20 weeks in the mucosa/submucosa in diabetic and diuretic animals.
• ? Blood vessel density decreased in the diabetic and diuretic groups at 20 weeks in the muscle.

CONCLUSIONS

• ? Diabetes induced time‐dependent changes in the density of the nerves and vasculature in the bladder tissues.
• ? Diabetes‐related polyuria plays an important role in these changes.

     

Angiotensin II type 1 (AT-1) receptor inhibition partially prevents the urodynamic and detrusor changes associated with bladder outlet obstruction: a mouse model

Study Type – Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Angiotensin II is the main effector peptide in the bladder local renin‐angiotensin system. This experiment demonstrates the role of this local renin‐angiotensin system with respect to bladder outlet obstruction.

OBJECTIVE

• ? To determine if treatment with an angiotensin II type 1 (AT‐1) receptor antagonist, losartan, can prevent the structural and functional changes that occur in a mouse model of bladder outlet obstruction (BOO).

MATERIALS AND METHODS

• ? Twenty‐four Balb/CAN mice underwent partial urethral obstruction for 6 weeks.
• ? Twelve mice were given oral losartan (10 mg/kg/day), and 12 were not. Six mice served as unobstructed controls, and six unobstructed mice were given oral losartan (10 mg/kg/day) to determine the effect of angiotensin II inhibition on the normal bladder.
• ? Bladder capacity (C), detrusor pressure during voiding (Pdet) and volume at first non‐voiding contraction (NVC1) as a percentage of C were recorded after 6 weeks.
• ? Bladders were stained with haematoxylin and eosin for measurement of detrusor muscular thickness, and graded as 1 = atrophy (<100 µm thick), 2 = normal (100–200 µm thick), 3 = hypertrophy (>200 µm thick) compared with controls.

RESULTS

• ? Compared with controls, BOO mice had greater C (153.5 ± 20.9 vs 57.5 ± 7.4 µl, P < 0.01), higher Pdet (28.8 ± 2.1 vs 12.1 ± 2.1 mm Hg), lower NVC1 (median = 24% vs 54% P= 0.03). BOO mice manifested greater bladder weight (93.2 ± 11.7 mg vs 26.8 ± 2.40 mg, P < 0.01) and greater detrusor muscle thickness (median 3 vs 2, P= 0.02).
• ? Compared with untreated BOO mice, mice treated with losartan had greater mean C (248.8 ± 28.6 vs 153.5 ± 20.9 µL, P= 0.01), no significant change in mean Pdet (24.7 ± 1.6 vs 28.8 ± 2.1 mm Hg, P= 0.2) and a higher mean NVC1 (47% vs 24%, P= 0.02).
• ? Treatment with losartan mediated an insignificant reduction in mean bladder weight (68.1 ± 9.1 mg vs 93.2 ± 11.7 mg, P= 0.10), but a significant reduction in detrusor muscle thickness (median 2 vs 3, P= 0.02). Losartan did not mediate any significant structural or functional changes in the unobstructed mouse bladder.

CONCLUSION

• ? In a mouse model of BOO, treatment with an AT‐1 antagonist partially prevented the urodynamic and structural changes that otherwise occur with BOO.

     

Secondary bladder cancer after upper tract urothelial carcinoma in the US population

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? It is known that a certain percentage of patients treated for upper tract urothelial carcinoma (UTUC) will go on to develop a secondary bladder cancer; however, the risk factors for developing a secondary bladder tumour have not been studied in a population‐based setting. Given the large changes in how UTUC has been diagnosed and managed in recent years, this study aimed to evaluate the natural history of UTUC in the US population over a 30‐year period, with a particular emphasis on the development of secondary bladder cancer.

OBJECTIVE

• ? To assess the natural history of upper tract urothelial carcinoma (UTUC) and the development of lower tract secondary cancer.

PATIENTS AND METHODS

• ? Patients diagnosed with UTUC between 1975 and 2005 were identified within nine Surveillance, Epidemiology and End Results registries.
• ? Baseline characteristics of patients with and without secondary bladder cancer were compared.
• ? A multivariate logistic regression model was fitted to test if the year of diagnosis predicted the likelihood of developing a secondary bladder cancer.

RESULTS

• ? Of the 5212 patients with UTUC, 242 (4.6%) had a secondary bladder cancer (range: 1.7–8.2%).
• ? There was a mean interval of 26.5 (95% CI: 22.2–30.8) months between cancer diagnoses.
• ? Compared with those without secondary tumours, patients with secondary bladder malignancy were more likely to present with larger tumours (4.2 vs 3.1 cm, P < 0.001) and with tumours located in the ureter (P < 0.001).
• ? Year of diagnosis was not a predictor of the likelihood of having a secondary bladder malignancy in a multivariate analysis controlling for demographic and tumour characteristics (odds ratio: 0.99; 95% CI: 0.95–1.03)

CONCLUSIONS

• ? Patients with larger urothelial tumours located in the ureter were those most likely to develop a secondary lower tract tumour.
• ? No longitudinal changes in the rate of secondary bladder cancer were noted among patients with UTUC over the 30‐year study period.

     

Reversing bladder outlet obstruction attenuates systemic and tissue oxidative stress

What's known on the subject? and What does the study add? Oxidative damage in bladder tissue and systemic oxidative biomarkers were both found to be increased in rabbits with partial bladder outlet obstruction. It is shown that the reversal of partial bladder outlet obstruction will attenuate the systemic oxidative stress.

OBJECTIVE

• ? To investigate whether partial bladder outlet obstruction (PBOO) increases systemic oxidative stress and whether relief of PBOO could attenuate this stress.

MATERIALS AND METHODS

• ? Surgically created PBOO in male New Zealand white rabbits was assessed after 4 weeks in one group of rabbits (n = 4), and was relieved in two additional groups of rabbits (n = 4 each) that were assessed at 4 and 8 weeks after relief of PBOO.
• ? Four sham‐operated rabbits served as controls. The assessed oxidative stress biomarkers included urinary and plasma 8‐hydroxy‐2′‐deoxyguanosine (8‐OHdG) and plasma malondialdehyde (MDA), total anti‐oxidant capacity (TAC) and glutathione (GSH).
• ? In addition, the copy number of mitochondrial DNA and the 8‐OHdG content in bladder tissues from these rabbits were also determined at the beginning and at indicated time points in the experiments.

RESULTS

• ? There were significant increases in both the 8‐OHdG levels of urine, plasma and bladder tissue and the plasma MDA after induction of PBOO.
• ? There were also significant decreases in the TAC, in GSH levels and in mitochondrial DNA copy number in bladder tissues after PBOO.
• ? Most importantly, all of the values returned toward the control levels after the PBOO was reversed at 8 weeks.

CONCLUSION

• ? PBOO increases systemic and oxidative stress and its reversal results in a progressive reduction of both systemic and tissue oxidative stress.

     

A methylation assay for the detection of non-muscle-invasive bladder cancer (NMIBC) recurrences in voided urine

What's known on the subject? and What does the study add? Multiple studies report on the detection of methylation in voided urine samples as a possible approach for the follow‐up of non‐muscle invasive bladder cancer patients. Previous studies analyze methylation gene panels in a mixture of primary and recurrent tumours. As primary tumours are larger than recurrent tumours and thus easier to detect in urine, validation of methylation markers in urine samples from patients with primary tumours will result in a test sensitivity that does not reflect the true sensitivity of the assay. This study is the first to select a subset of genes specifically methylated in non‐muscle invasive bladder cancer recurrences and validates the gene panel in two independent sets of urine samples from recurrent patients, thus simulating the disease course according to the clinical presentation.

OBJECTIVE

• ? To develop a methylation‐specific multiplex ligation‐dependent probe amplification (MS‐MLPA) assay for the detection of non‐muscle invasive bladder cancer (NMIBC) recurrences in voided urine.

PATIENTS AND METHODS

• ? Genes frequently methylated in NMIBC tumours (n= 37) were selected to develop a BC‐specific MS‐MLPA assay.
• ? Genes methylated in blood from patientswith BC (n= 29) and genes methylated in urine from patients with no history of BC (n= 46) were excluded.
• ? A four‐gene panel with the highest predictive value was selected from the initial assay. This four‐gene panel was tested and validated on urine from patients with a histologically confirmed recurrence (n= 68 test set; n= 49 validation set) and urine samples from patients without BC (n= 91, test set) and urine from recurrence‐free BC (rec‐free BC) patients (n= 60, validation set).
• ? A model was developed to predict the probability of having a recurrence based on methylation of the four‐gene panel and a threshold probability with the highest sensitivity and specificity was determined.
• ? The outcome of the model was validated on BC urine samples (n= 65) and on urine samples from rec‐free BC patients (n= 29).

RESULTS

• ? The BC MS‐MLPA assay consisted of 23 methylation probes. The selected four‐gene panel included: APC_a, TERT_a, TERT_b, and EDNRB. This panel reached an area under the receiver operating characteristic curve (AUC) of 0.82 (test set) and AUC 0.69 (validation set). Sensitivity and specificity for the detection of a concomitant tumour were 63.3% and 58.3% respectively (test set) and 72.3% and 55.2%, respectively (validation set).

CONCLUSIONS

• ? We have developed a methylation detection assay specifically for the detection of recurrences in patients with NMIBC in voided urine.
• ? The findings are promising and improvement of this test could eventually contribute to a more individualized patient friendly surveillance.

     

Use of fluorescein isothiocyanate-human serum albumin for the intravesical photodiagnosis of non-muscle-invasive bladder cancer: an in vitro study using multicellular spheroids composed of normal human urothelial and urothelial cell carcinoma cell lines

OBJECTIVE

• ? To evaluate human serum albumin (HSA), fluorescently labelled with fluorescein isothiocyanate (FITC), as a potential intravesical photodiagnostic method for the early detection of non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? By using multicellular spheroids prepared from normal human urothelial (NHU) cells and from different urothelial cell carcinoma (UCC) cell lines (T24, J82), we simulated three‐dimensionally the normal urothelium and non‐muscle‐invasive UCCs present in the bladder of patients.
• ? The distribution of FITC‐HSA in these spheroids was investigated.

RESULTS

• ? Our data showed that fluorescently labelled albumin is quite evenly dispersed throughout the spheroids. However, in the case of the 10 mg/mL incubations, the fluorescence intensity seems to increase slightly towards the spheroid core.
• ? Using 1 mg/mL, the penetration of FITC‐HSA in T24 differed significantly from the penetration in NHU spheroids, but this was not the case for J82 spheroids.
• ? When the concentration of FITC‐HSA was increased 10‐fold, all UCC spheroids exhibited a significantly different accumulation of FITC‐HSA.

CONCLUSIONS

• ? As spheroids represent a suitable in vitro model for predicting the in vivo behaviour of compounds, our data suggest that FITC‐HSA could be used for the early detection of non‐muscle‐invasive bladder cancer.
• ? Human serum albumin conjugates of new or already available intravesical drugs could be generated to create alternative bladder cancer therapies with increased selectivity.

     

Bladder preservation multimodality therapy as an alternative to radical cystectomy for treatment of muscle invasive bladder cancer

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? The subject of bladder preservation multimodality protocols in muscle invasive bladder TCC is not new. In our study, even in a highly selected group of patients, multimodality protocol with M‐VAC and radiation therapy achieved suboptimal results at 1 year. This emphasized the role of radical cystectomy as the gold standard treatment for invasive bladder TCC.

OBJECTIVE

• ? To evaluate the efficacy of a bladder preservation multimodality protocol for patients with operable carcinoma invading bladder muscle.

MATERIALS AND METHODS

• ? In this prospective study, we included 33 patients with transitional cell carcinoma (TCC) (T2 and T3, Nx, M0) who were amenable to complete transurethral resection.
• ? These patients refused radical cystectomy as their first treatment option. After maximum transurethral resection of bladder tumour (TURBT), all patients received three cycles of adjuvant chemotherapy in the form of methotrexate, vinblastin, adriamycin and cisplatin (MVAC) followed by radical radiotherapy.
• ? Four weeks later, all cases had radiological and cystoscopical re‐evaluation.
• ? Complete responders were considered to be those patients who had no evidence of residual tumour. All patients were subjected to a regular follow‐up by cystoscopy and tumour site biopsy conducted every 3 months. Abdomino‐pelvic computed tomography and chest X‐ray were conducted every 6 months.
• ? The study endpoint was the response to treatment after completion of the first year of follow‐up after therapy.

RESULTS

• ? Out of 33 eligible patients, a total of 28 patients completed the study treatment protocol. Their mean ± SD age was 56.7 ± 6 years. Trimodal therapy was well tolerated in most of cases, with no severe acute toxicities. After 12 months of follow‐up, a complete response was achieved in 39.3% and a partial response in 7.1%, with an overall response rate of 46.4%.
• ? By the end of the first year, disease‐free survival was reported in 39.3%, whereas 25% were still alive with their disease, giving an overall survival of 64.3% for all patients who maintained their intact, well functioning bladders.
• ? Tumour stage and completeness of transurethral resection of bladder tumour were the most important predictors of response and survival. T2 lesions had complete and partial response rates of 69.2% and 23%, respectively, whereas T3 lesions had rates of 40% and 13.3%, respectively (P= 0.001).
• ? The response rate in patients who had complete TURBT was 82.6% vs 20% in those with cystoscopic biopsy only (P= 0.001). In addition, disease‐free survival was 72.7% in T2 patients and 27.3% in T3 patients (P= 0.001).

CONCLUSION

• ? In the present study, bladder preservation protocol with MVAC and radical radiotherapy achieved suboptimal response rates at 1 year in patients with localized TCC invading bladder muscle. Patients with solitary T2 lesions that are amenable to complete TURBT achieved the best response rates. Longer follow‐up is needed to verify these results. Patients with localized disease should be encouraged for radical cystectomy, which achieved better results.

     

IL-23 gene therapy for mouse bladder tumour cell lines

OBJECTIVES

• ? To evaluate the antitumour effects of IL‐23 gene transfer into mouse bladder carcinoma (MBT2) cells.
• ? To investigate the mechanisms underlying the subsequent constitutive secrection of IL‐23 by the MBT2 cells

MATERIALS AND METHODS

• ? An expression vector containing IL‐23 gene was introduced into MBT2 cells by liposome‐mediated gene transfer, and secretion of IL‐23 was confirmed by ELISA.
• ? The in vivo antitumour effect of IL‐23‐secreting MBT2 cells (MBT2/IL‐23) was examined by injecting the cells into syngeneic C3H mice.
• ? A tumour vaccination study using mitomycin C (MMC)‐treated IL‐23‐secreting MBT2 cells was carried out, and the usefulness of in vivo CD25 depletion for an additional vaccine effect was also investigated.
• ? The mechanisms underlying the antitumour effects were investigated by antibody depletion of CD8 or CD4 T cells, or natural killer cells, and cells infiltrating the tumour sites in vivo were assessed using immunohistochemistry.

RESULTS

• ? Stable transformants transduced with MBT2/IL‐23 secreted IL‐23 into the culture supernatant.
• ? Genetically engineered IL‐23‐secreting MBT2 cells were rejected in syngeneic mice.
• ? MBT2/IL‐23‐vaccinated mice inhibited the tumour growth of parental MBT2 cells injected at a distant site and this vaccine effect was enhanced by combination with in vivo CD25 depletion by an antibody.
• ? The main effector cells for the direct antitumour effect of MBT2/IL‐23 were CD8 T cells, which was shown by in vivo depletion and immunohistochemical study.

CONCLUSIONS

• ? IL‐23‐secreting MBT2 cells were rejected in syngeneic mice by the activation of CD8 T cells.
• ? MMC‐treated MBT2/IL‐23 can have a tumour vaccine effect for parental MBT2 cells, and this effect was enhanced by combination with in vivo CD25 depletion.

     

Complications after bladder augmentation or substitution in children: a prospective study of 86 patients

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? A lot of information has been gathered on the subject of complications following urinary bladder augmentation and/or substitution in the recent years. The present study, based on the analysis of 86 patients, gives a critical analysis of these complications (stone formation, bowel obstruction, hematuria‐dysuria syndrome, small bowel bacterial overgrowth, persistent vesico‐ureteral reflux, obstruction at the site of ureteral reimplantation, reservoir perforation, premalignant histological changes, decreased bladder capacity/compliance requiring reaugmentation, etc.). The study adds one more new complication (small bowel colonization following colocystoplasty performed with the cecum and ascending colon) and reports complications in a fairly big (by European standards) cohort of patients with a long follow‐up.

OBJECTIVE

• ? To evaluate complications after urinary bladder augmentation or substitution in a prospective study in children.

PATIENTS AND METHODS

• ? Data of 86 patients who underwent urinary bladder augmentation (80 patients) or substitution (6 patients) between 1988 and 2008 at the authors’ institute were analysed.
• ? Ileocystoplasty occurred in 32, colocystoplasty in 30 and gastrocystoplasty in 18. Urinary bladder substitution using the large bowel was performed in six patients.
• ? All patients empty their bladder by intermittent clean catheterization (ICC), 30 patients via their native urethra and 56 patients through continent abdominal stoma. Mean follow‐up was 8.6 years.
• ? Rate of complications and frequency of surgical interventions were statistically analysed (two samples t‐test for proportions) according to the type of gastrointestinal part used.

RESULTS

• ? In all, 30 patients had no complications. In 56 patients, there were a total of 105 complications (39 bladder stones, 16 stoma complications, 11 bowel obstructions, 5 reservoir perforations, 7 VUR recurrences, 1 ureteral obstruction, 4 vesico‐urethral fistulae, 4 orchido‐epididymitis, 4 haematuria‐dysuria syndrome, 3 decreased bladder capacity/compliance, 3 pre‐malignant histological changes, 1 small bowel bacterial overgrowth and 7 miscellaneous).
• ? In 25 patients, more than one complication occurred and required 91 subsequent surgical interventions. Patients with colocystoplasty had significantly more complications (P < 0.05), especially more stone formation rate (P < 0.001) and required more post‐ operative interventions (P < 0.05) than patients with gastrocystoplasty and ileocystoplasty.

CONCLUSIONS

• ? Urinary bladder augmentation or substitution is associated with a large number of complications, particularly after colocystoplasty.
• ? Careful patient selection, adequate preoperative information and life‐long follow‐up are essential for reduction, early detection and management of surgical and metabolic complications in patients with bladder augmentation or substitution.

     

Evans blue as a selective dye marker for white-light diagnosis of non-muscle-invasive bladder cancer: an in vitro study

What's known on the subject? and What does the study add? We found that Evans blue preferentially accumulate in spheroids prepared from urothelial cell carcinoma (UCC) cells as compared to spheroids composed of normal human urothelial (NHU) cells. The present findings could be important for future developments in clinical diagnostics for early bladder cancer detection staging and grading involving white light cystocopy.

OBJECTIVE

• ? To develop a diagnostic method relying on the preferential accumulation of a dye in non‐muscle‐invasive bladder cancer (NMIBC) that is visible in conjunction with white‐light cystoscopy (WLC).

MATERIALS AND METHODS

• ? We investigated in detail the permeation of Evans blue in urothelial cell carcinoma (UCC) spheroids prepared from T24, J82 and RT‐112 human cell lines and spheroids composed of normal human urothelial (NHU) cells.
• ? To gain more insight into the differential accumulation, all spheroids were investigated ultrastructurally using transmission electron microscopy (TEM).

RESULTS

• ? We found that, after exposure to Evans blue for 2 h, UCC spheroids accumulated dramatically more dye than spheroids composed of NHU cells.
• ? Using TEM it was found that the malignant spheroids contain similar ultrastructural characteristics, i.e. a wide intercellular space and a decreased number of desmosome‐like cell attachments, to those from clinical samples of non‐papillary carcinoma in situ of the bladder.

CONCLUSION

• ? We believe the present findings could be important for future developments in clinical diagnostics for early bladder cancer detection, staging and grading involving WLC.

     

Risk group stratification to predict recurrence after transurethral resection in Japanese patients with stage Ta and T1 bladder tumours: validation study on the European Association of Urology guidelines

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? EAU guidelines on non‐muscle‐invasive bladder tumours have been widely used for the prediction of recurrence after TUR. However, there are substantial differences in bladder cancer incidence and mortality rates between European countries and Japan. This study provides useful factors for predicting recurrence and validation of EAU guidelines on the risk group stratification to predict recurrence in Japanese patients with stage Ta and T1 bladder tumours.

OBJECTIVE

• ? To validate the European Association of Urology (EAU) guidelines on risk group stratification to predict recurrence in Japanese patients with stage Ta and T1 bladder tumours.

PATIENTS AND METHODS

• ? A cohort of 592 Japanese patients who were treated with transurethral resection (TUR) and histopathologically diagnosed with Ta and T1 urothelial carcinoma of the bladder were enrolled in this retrospective study.
• ? The primary endpoint of the present study was recurrence‐free survival, and the median follow‐up duration was 37 months in recurrence‐free survivors.

RESULTS

• ? Multivariate Cox proportional hazards regression analysis showed that the Eastern Cooperative Oncology Group performance status (ECOG PS), prior recurrence rate, number of tumours and T category were independent predictors of time to recurrence (P < 0.05). According to the EAU guidelines for predicting recurrence, the vast majority of Japanese patients were classified into intermediate risk.
• ? The intermediate‐risk patients were further divided into intermediate‐low‐risk and intermediate‐high‐risk subgroups based on the European Organization for Research and Treatment of Cancer risk table, and a significant difference in the recurrence‐free survival rates was found between these subgroups (P < 0.001).
• ? It was also found that patients with high risk combined with intermediate‐high risk had significantly poorer recurrence‐free survival rates than those with low risk combined with intermediate‐low risk (P < 0.001).

CONCLUSIONS

• ? This is the first report on the ECOG PS as a potentially useful predictor for bladder tumour recurrence.
• ? The risk group stratification of the EAU guidelines for recurrence might not be applicable to Japanese patients with Ta and T1 bladder tumours, but the subgroup classification of intermediate risk could be appropriate.

     

Evidence of bladder oversensitivity in the absence of an infection in premenopausal women with a history of recurrent urinary tract infections

Study Type – Prevalence (case control) Level of Evidence 4 What's known on the subject? and What does the study add? Urinary tract infections (UTIs) have been implicated in the aetiology of interstitial cystitis/painful bladder syndrome (IC/PBS). Prior studies have described symptoms and laboratory tests suggestive of UTI at the onset of IC/PBS as well as a significant history of childhood recurrent UTIs. However, the mechanism by which recurrent UTIs contribute to the development of IC/PBS is not clear. Our study shows that women with recurrent UTI suffer from bladder oversensitivity. Our findings have useful clinical implications. Women with bladder oversensitivity complain of urinary frequency which is often misdiagnosed as an infection and treated with unnecessary antibiotics. Additionally, there are no effective therapies for bladder oversensitivity. Therefore, women with recurrent UTI should undergo prompt evaluation and treatment of episodes of infection to prevent the development of bladder oversensitivity. Our findings also provide a possible mechanism for the development of IC/PBS. Whether women with recurrent UTI are at increased risk for developing IC/PBS in the future will need to be confirmed in future studies.

OBJECTIVE

• ? To compare the mean voided volume and bladder sensation during filling cystometry in women with a history of recurrent urinary tract infection (UTI) and controls.

PATIENTS AND METHODS

• ? This was a case–control study including adult women seen in the urogynaecology clinic.
• ? The cases were 49 women with at least three documented positive urine cultures >105 colonies/mL in the previous 12 months and no active infection at the time of data collection.
• ? Controls were 53 women with stress urinary incontinence and no history of recurrent UTI or coexistent urge urinary incontinence.
• ? We compared bladder diary variables and filling cystometry data in the absence of an active infection.

RESULTS

• ? There was no significant difference in the median age, parity and body mass index of women with a history of recurrent UTI and controls.
• ? The median number of voids per day and median number of voids per litre of fluid intake was significantly greater in women with recurrent UTI than controls (12 vs 7 voids/day and 6 vs 4 voids/L, P= 0.005 and P= 0.004 respectively).
• ? The median average voided volume was significantly lower in women with recurrent UTI than controls (155 vs 195 mL, P= 0.008).
• ? On filling cystometry, median volumes of strong desire to void and maximum cystometric capacity were significantly lower in women with recurrent UTI than controls (all P < 0.05).

CONCLUSION

• ? In the absence of an infection, premenopausal women with a history of recurrent UTI have significantly greater urinary frequency, lower average voided volume and a lower threshold of bladder sensitivity than controls.

     

Detection of circulating tumour cells in peripheral blood of patients with advanced non‐metastatic bladder cancer

What’s known on the subject? and What does the study add? Circulating tumour cells (CTC) have prognostic relevance for patients with different metastatic carcinomas. Detection of CTC using the CellSearch system has also been reported in bladder cancer, but mainly in patients with metastatic disease. This is the largest report demonstrating that detection of CTC in non‐metastatic bladder cancer patients is feasible using the CellSearch system. Presence of CTC may be predictive for early systemic disease.

OBJECTIVE

• ? To prospectively detect and evaluate the biological significance of circulating tumour cells (CTC) in patients with bladder cancer, especially in those patients with non‐metastatic, advanced bladder cancer (NMABC).

PATIENTS AND METHODS

• ? Between July 2007 and January 2009, blood samples of 50 consecutive patients with localized bladder cancer and five patients with metastatic disease scheduled for cystectomy were prospectively investigated for CTC. Peripheral blood (7.5 ml) was drawn before cystectomy.
• ? Detection of CTC was performed using the USA Food and Drug Administration‐approved CellSearch^TM system. Data were compared with the clinical and histopathological findings.

RESULTS

• ? CTC were detected in 15 of 50 patients (30%) with non‐metastatic disease and five of five patients with metastatic disease. The overall mean number of CTC was 33.7 (range: 1–372; median: 2). In non‐metastatic patients, the mean number of CTC was 3.1 (range: 1–11; median: 1). Except for a univariate association between CTC with vessel infiltration (P= 0.047), all other common clinical and histopathological parameters did not reveal a significant correlation with CTC detection.
• ? A median 1‐year follow up was available for 53 patients (96.4%). Ten out of 19 preoperatively CTC‐positive patients died as a result of cancer progression.
• ? CTC‐positive patients showed significantly worse overall (P= 0.001), progression‐free (P < 0.001) and cancer specific survival (P < 0.001) compared to preoperatively CTC‐negative patients.

CONCLUSION

• ? This is the largest study demonstrating that detection of CTC in NMABC patients is feasible using the CellSearch^TM system. Our findings suggest that the presence of CTC may be predictive for early systemic disease.

     

Inhibition of bladder overactivity by stimulation of feline pudendal nerve using transdermal amplitude-modulated signal (TAMS)

What's known on the subject? and What does the study add? It is known that direct stimulation of pudenal nerve using a cuff electrode can inhibit normal bladder activity. This study further indicates that overactive bladder activity can be inhibited using non‐invasive skin surface electrodes and a transdermal amplitude‐modulated signal (TAMS).

OBJECTIVE

• ? To develop a non‐invasive neuromodulation method targeting the pudendal nerve.

MATERIALS AND METHODS

• ? Bladder overactivity induced by acetic acid (AA) irritation was partially suppressed by electrical stimulation of the pudendal nerve in α‐chloralose anaesthetized cats using a transdermal amplitude‐modulated signal (TAMS).

RESULTS

• ? During cystometrography (CMG), intravesical infusion of 0.25% AA significantly decreased the mean (se ) bladder capacity to 28.8 (5.9)% of the capacity measured during saline infusion.
• ? The TAMS stimulation inhibited AA‐induced bladder overactivity at 5, 7 and 10 Hz, and significantly increased the mean (se ) bladder capacity to 61.8 (9.9)%, 51.3 (14.5)%, 53.6 (14.9)%, respectively, of the control capacity during saline infusion, whereas stimulation at 20–40 Hz had no effect.
• ? Under isovolumetric conditions at a bladder volume ranging between 130 to 160% of the bladder capacity measured during AA infusion, TAMS stimulation at all frequencies (5–40 Hz) significantly suppressed the irritation‐induced rhythmic bladder contractions, reduced the area under the bladder pressure curve, and decreased the frequency of bladder contractions. However, the amplitude of rhythmic bladder contractions was only significantly decreased at stimulation frequencies of 5–20 Hz.
• ? At bladder volumes above the AA control capacity, TAMS stimulation with frequencies of 20–30 Hz had an excitatory effect, resulting in large amplitude (>25 cmH₂O) bladder contractions.

CONCLUSIONS

• ? TAMS stimulation targeting the cat pudendal nerve can inhibit C‐fibre afferent‐mediated bladder overactivity.
• ? Thus, clinical research seems warranted to explore the usefulness of this technology for patients with overactive bladder symptoms.

     

Enhanced S100 calcium‐binding protein P expression sensitizes human bladder cancer cells to cisplatin

What’s known on the subject? and What does the study add? So far, several molecules have been reported to be involved in cisplatin resistance. This study revealed that a decreased expression of S100P is implicated in cisplatin resistance. In addition, S100P overexpression rendered bladder cancer cells sensitive to cisplatin.

OBJECTIVE

• ? To investigate the role of S100 calcium‐binding protein P (S100P) in the gain of cis‐diamminedichloroplatinum (II) (cisplatin) resistance in bladder cancer, having previously found, with cDNA microarrays using two pairs of parental (T24, KK47) and their cisplatin‐resistant bladder cancer cell lines (T24/DDP10, KK47/DDP20), that S100P mRNA expression was significantly reduced in cisplatin‐resistant cells.

MATERIALS AND METHODS

• ? S100P mRNA and protein expression levels were investigated by northern and western blot analyses, respectively.
• ? Intracellular S100P localization was examined by immunocytochemistry and immunohistochemistry.
• ? S100P over‐expression, obtained by transfection with S100P expression plasmid, was used to investigate whether or not S100P affected cellular resistance to cisplatin.

RESULTS

• ? S100P mRNA showed increased expression by cisplatin stimulation in parental cell lines.
• ? On the other hand, S100P mRNA and protein expression levels were markedly reduced in cisplatin‐resistant cells.
• ? The over‐expression of S100P in resistant cells resulted in an increased sensitivity to cisplatin.

CONCLUSIONS

• ? In bladder cancer cells, S100P was expressed and localized mainly in the nucleus.
• ? S100P expression was also involved in cisplatin sensitivity.
• ? S100P might thus represent a molecular marker predicting cisplatin sensitivity and a molecular therapeutic target for cisplatin‐based chemotherapy.

     

Prognostic value of apoptotic markers in squamous cell carcinoma of the urinary bladder

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Apoptotic pathways are important in carcinogenesis. Many studies, involving small numbers of patients, have found an association between one or two apoptotic markers and some of the pathological features of squamous cell carcinoma (SCC). This study included a large number of patients who had undergone radical cystectomy (RC) for SCC with long‐term follow‐up, allowing us to study biomarker alterations and their prognostic role. This is the first study on the prognostic role of a panel of apoptotic‐related markers in SCC of the urinary bladder, introducing the novel concept of a prognostic marker score based on the number of altered markers. We found that apoptotic markers can improve prediction of oncological outcomes after RC for SCC and might potentially help in patient selection for adjunct therapies.

OBJECTIVE

• ? To evaluate the association of cleaved caspase‐3 (CC‐3), Bax, COX‐2, and p53 expression with pathological features and clinical outcomes in patients with squamous cell carcinoma (SCC) of the urinary bladder.

METHODS

• ? Immunohistochemistry for CC‐3, Bax, COX‐2, and p53 was performed on tissue microarray sections of radical cystectomy specimens with pure SCC from 1997 to 2003. The relationship between the expression of these markers and pathological features was assessed.
• ? A prognostic marker score (PS) was defined as favourable if ≤2 biomarkers were altered and unfavourable if >2 biomarkers were altered and the association of the PS with oncological outcomes was examined.

RESULTS

• ? The study included 151 patients, of whom 98 were men and 53 were women, with a mean age of 52 years. SCC was associated with schistosomiasis (bilharziasis) in 122 (81%) patients.
• ? Pathological stage was T2 in 50%, T3 in 38%, T1 in 6% and T4 in 6% of patients. Tumours were low grade in 53%, lymph node metastasis was found in 30.5% and lymphovascular invasion was found in 16% of patients.
• ? Median follow‐up was 63.2 months.
• ? Advanced stage was associated with COX‐2, p53 and CC‐3 alterations and high grade was associated with COX‐2 alterations (P < 0.05). The total number of altered markers and unfavourable PS were associated with both disease recurrence and bladder cancer‐specific mortality in Kaplan–Meier analyses (P < 0.05). Unfavourable PS was an independent predictor of disease recurrence (hazard ratio [HR] 2.694, 95% confidence interval [CI] 1.386–5.235, P= 0. 003) and bladder cancer‐specific mortality (HR 2.868, 95% CI 1.209–6.802, P= 0. 017) in multivariable Cox regression analysis.

CONCLUSION

• ? Markers of apoptosis pathways may play an important role in the prognosis of SCC of the bladder. An increased number of altered markers and an unfavourable PS may identify patients who might benefit from multimodal therapies.