Showing papers in "International Journal of Urology in 2011"

Bacillus Calmette-Guerin treatment of non-muscle invasive bladder cancer

Abstract: Bacillus Calmette-Guerin (BCG) has been used in the intravesical treatment of non-muscle invasive bladder cancer (NMIBC) for nearly 35 years; however, its use is still subject to controversy. The objective of this paper is to review the role of BCG in the treatment of patients with NMIBC. Clinical trials, meta-analyses and guidelines related to the administration, safety and efficacy of intravesical BCG were reviewed. Intravesical BCG is more effective than intravesical chemotherapy in decreasing the risk of recurrence and progression to muscle invasive disease; however, it is associated with more local and systemic side-effects. It is the gold standard in patients at high risk of progression. Maintenance BCG is required in order to achieve the best therapeutic results; however, the optimal dose, induction and maintenance schedules, and duration of treatment are unknown and might be different for each patient. Patients failing BCG treatment have a poor prognosis, and cystectomy is then the recommended treatment. Patients at low risk of recurrence and progression should not receive BCG, because of its side effects. Intermediate-risk patients might be treated with either intravesical chemotherapy or BCG; however, for patients at high risk of progression, BCG is recognized as the treatment of choice. Further research is urgently needed to identify markers associated with BCG failure and to develop effective alternatives to cystectomy in patients failing BCG.

Outline of JUA clinical guidelines for benign prostatic hyperplasia.

Abstract: The Japanese Urological Association has developed Clinical Guidelines for Benign Prostatic Hyperplasia (BPH) for men with suspected BPH, which have been abridged and translated into English. This article is a shortened version of the English translation. The Guidelines were formulated on the basis of evidence retrieved from the PubMed database between 1995 and 2009, as well as other relevant sources. The target patients of these Guidelines are men with suspected BPH, and the target users are urologists. A mandatory assessment should include a medical history, a physical examination, the completion of symptom and quality of life questionnaires, urinalysis, prostate ultrasonography, measurement of serum prostate specific antigen and postvoid residual urine, and an uroflowmetry. Optional tests include a bladder diary, the measurement of serum creatinine, and upper urinary tract ultrasonography. Care should be taken to not overlook coexisting diseases such as an infection or malignancy that may obscure the diagnosis. Treatment should consist of conservative therapy or the use of medications such as α(1) -adrenoceptor antagonists, or both. The use of 5α-reductase inhibitors or anticholinergic agents should be considered in patients with an enlarged prostate (>30 mL) or overactive bladder symptoms (overactive bladder symptom score ≥ 6), respectively. Surgical intervention is indicated when non-surgical treatments fail to provide sufficient symptomatic relief and bladder outlet obstruction is highly suspected.

Effects of three types of alpha-1 adrenoceptor blocker on lower urinary tract symptoms and sexual function in males with benign prostatic hyperplasia.

Abstract: Objectives: The aim of the present study was to explore the effects of three different types of alpha-1 adrenoceptor blockers (α1-blocker) on lower urinary tract symptoms (LUTS), erectile dysfunction (ED) and ejaculatory dysfunction (EjD) in patients with benign prostatic hyperplasia. Methods: A total of 136 male LUTS patients aged 50–80 years with International Prostate Symptom Score (IPSS) ≥8 were enrolled. They were divided into three groups. Group S received silodosin at 4 mg twice a day; group T received tamsulosin at 0.2 mg once a day; and group N received naftopidil at 50 mg once a day. Assessment included IPSS, quality of life indexes (QOL), International Index of Erectile Function (IIEF-5), an ejaculation questionnaire, Qmax and post-void residual urine volume (PVR). These parameters were recorded at baseline, and at 1 and 3 months after treatment had ended. Results: Mean IPSS and Qmax significantly improved after treatment in all groups without any significant difference among them. As for the IIEF-5 score, only group N significantly improved at 1 and 3 months. After treatment, 2.6 and 2.4% of patients complained of a de novo reduced volume of ejaculation in both groups T and N, respectively. Ten out of 41 patients (24.4%) complained of a total absence of antegrade ejaculation in group S after treatment. Conclusions: All three types of α1-blockers provided an objective and subjective improvement of LUTS in the present study population. However, erectile function only improved in patients treated with naftopidil and a higher rate of EjD was observed in those receiving silodosin. Because of their variable effects, we should consider the sexual dimension when prescribing α1-blockers for LUTS.

Industry‐based retrospective cohort study of the risk of prostate cancer among rotating‐shift workers

Abstract: Objectives: The risk of prostate cancer among shift workers was examined in the present industry-based retrospective cohort study. Methods: The study was established based on a health-care database from a Japanese manufacturing corporation. Work schedules of 4995 male workers (mean age = 55.5 years) were followed up retrospectively; mean follow-up period = 25.0 years. Of the subjects, 4168 had previously undertaken only daytime work (daytime workers), whereas 827 had undertaken rotating three-shift work for >80% of their career (shift workers). All subjects had undergone prostate-specific antigen (PSA) testing. Prostate cancer incidence data were obtained from the health insurance records of 13 daytime and four shift workers. Multivariate logistic regression was used to estimate the relative risk of prostate cancer for the two groups with adjustments for age, body mass index, alcohol intake, smoking, exercise and marital status. Results: Compared with daytime workers, shift workers showed a non-significant increase in the risk of prostate cancer (odds ratio = 1.79; 95% confidence interval = 0.57, 5.68; P-value = 0.32). Conclusions: Some increase in the risk of prostate cancer for shift workers was observed, although the result was not statistically significant as a result of the small number of cases. To identify the prostate cancer risk among shift workers, longer-term follow up, including the period after retirement, is required.

Immunohistochemical biomarkers for bladder cancer prognosis

Abstract: Urothelial carcinoma of the bladder (UCB) is an especially complex and heterogeneous disease with a broad spectrum of histologic findings and potentially lethal behavior. Despite advances in surgical techniques, as well as intravesical and systemic therapies, up to 30% of patients with non-muscle-invasive UCB and 50% of patients with muscle-invasive UCB experience disease progression, recurrence, and eventual death. Standard prognostic features, such as pathologic stage and grade, have limited ability to predict the outcomes of this heterogeneous population. Current risk-stratification algorithms using clinical and pathologic parameters are limited in their prognostic ability. Molecular medicine holds the promise that clinical outcomes will be improved by more accurate prognostication and directing therapy towards the mechanisms and targets associated with the growth of an individual patient's tumor. Immunohistochemical analysis of biomarker expression has provided insight into the molecular pathogenesis of UCB and offers the potential for improving clinical decision making. Numerous candidate immunohistochemical biomarkers for patients with UCB have been identified, with those relating to the cell cycle and apoptosis/cell proliferation being the most extensively studied. The present review discusses the most promising immunohistochemical biomarkers. Special attention is paid to recent data from a multi-institutional collaboration that has implemented a regulated, phased biomarker discovery and validation pathway. Because UCB tumorigenesis and progression is a process involving multiple genetic and epigenetic alterations, multiple biomarkers need to be integrated into a prognostic signature to accurately predict outcomes. There is no doubt that biomarkers will eventually guide our clinical decision making regarding follow-up scheduling and treatment choice.

Oncological outcomes of the prostate cancer patients registered in 2004: report from the Cancer Registration Committee of the JUA.

Abstract: Objectives: In 2001, the Cancer Registration Committee of the Japanese Urological Association initiated a data collection of prostate cancer patients into a computer-based database. The aim of the present study is to report the clinical and pathological characteristics and outcomes of prostate cancer patients diagnosed in 2004 in Japan. Methods: Overall, 11 385 patients from 239 institutions were registered into the database. After excluding 1105 patients because of insufficient data, duplication or insufficient follow up, 10 280 patients were eligible for the analysis. Most of them (10 198, 99.2%) were Japanese and 1195 (11.6%) had metastatic disease at the time of diagnosis. The mean and median follow up was 53.2 months and 61.5 months, respectively. Results: The 5-year overall and prostate cancer-specific survival rate was 89.7% and 94.8%, respectively. The 5-year prostate cancer-specific survival rate of M0 and M1 disease was 98.4% and 61.1%, respectively. For 8424 cases of organ-confined or regional disease, Japanese urologists used as the initial treatment hormone ablation therapy alone (3360, 39.9%), radical prostatectomy (3140, 38.1%), radiation therapy (1530, 18.2%) and watchful waiting (394, 4.7%) including active surveillance or palliative observation. Conclusions: This is the first large population report of survival data in Japanese prostate cancer patients. In Japan, the disease population, survival period with metastatic disease and ratio of patients having hormone ablation therapy differ from those in Western countries.

Diffusion-weighted magnetic resonance imaging in the differentiation of angiomyolipoma with minimal fat from clear cell renal cell carcinoma

Abstract: The aim of the present study was to evaluate diffusion-weighted (DW) magnetic resonance imaging (MRI) in differentiating between minimal fat angiomyolipoma (MFAML) and clear cell renal cell carcinoma (CCRCC). Forty-one solid renal tumors without visible macroscopic fat on unenhanced computed tomography images were evaluated by MRI, including DW-MRI, and were diagnosed pathologically as CCRCC (n = 36) or MFAML (n = 5). To evaluate the heterogeneity of diffusion in each tumor, the signals of the tumors on DW-MRI were analyzed subjectively and the apparent diffusion coefficient (ADC) values and histograms assessed objectively. Thirty-three of 36 CCRCC (92%) exhibited a heterogeneous signal on DW-MRI and several peaks in the ADC value histogram, whereas four of five MFAML exhibited a homogeneous signal on DW-MRI and a single prominent peak in the histogram. The standard deviations of the ADC values were significantly smaller for MFAML than for CCRCC (P = 0.0015). In conclusion, DW-MRI can be considered a useful and noninvasive addition to the preoperative differentiation of CCRCC and MFAML.

Risk factors for pelvic lymphoceles post‐radical prostatectomy

Abstract: Background: Lymphoceles (LC) represent a well-described rare complication post-radical prostatectomy (RP). Our aim was to determine risk factors and to develop possible prevention strategies for LC in a community-based study. Methods: Data from 1163 RP-patients from 67 clinics between January 2002 and December 2004 were retrospectively evaluated. Patients underwent pelvic imaging procedures/LC-management during 3 weeks of rehabilitation post-RP. Results: LC were identified in 304 patients (26%). Lymphadenectomy was carried out in 92% of patients (1001/1086 patients), from which 28% had LC (n = 277) versus 14% without lymphadenectomy (12/85, P = 0.007). Complications (lower limb edema, pain, thrombosis, infection and bladder compression) were observed in 9% of patients (28/304; 2.4% of total patients); necessitating therapy. LC therapy was carried out in 59 patients (5.9%) with pelvic lymph node dissection (PLND) and in no patients (0%) without PLND (P = 0.021). Risk factors included were patients' age, body mass index, prostate volume, TNM-classification, number of removed lymph nodes, previous surgery/therapy, heparin prophylaxis, surgical instruments and pelvic lymphadenectomy. Univariate analysis showed lymphadenectomy as the only significant risk factor for the development of LC post-RP (P = 0.007). When applying multivariate analyses using stepwise logistic regression, only lymphadenectomy was associated with a significant risk for lymphoceles (odds ratio = 2.6, 95% CI = 1.3–4.9, P = 0.004). Adjusting for other factors, no other factor came close to being significant (P < 0.05). All symptomatic LC were successfully treated without further sequelae. Conclusions: Subclinical LC post-RP are more common than thought, and rarely necessitate intervention. Pelvic lymphadenectomy represents the only significant factor contributing to LC-development. Because of this, prevention remains difficult.

Predictors of symptomatic lymphocele after radical prostatectomy and bilateral pelvic lymph node dissection.

Abstract: Objectives: Lymphocele is the most common complication of pelvic lymphadenectomy (PLND). We sought to determine predictors of symptomatic lymphocele after radical prostatectomy (RP) and PLND, and in particular, to determine if the number of drains placed represents an independent predictor. Methods: Between January 1999 and June 2007, 4173 consecutive patients underwent bilateral PLND at the time of either open or laparoscopic RP. Lymphoceles were identified in patients undergoing imaging as a result of symptoms suspicious for lymphocele, such as fever, abdominal pain or lower extremity swelling. Routine postoperative imaging was not carried out. Cox proportional hazards analysis was carried out using forced variable entry to obtain maximum likelihood estimates of the hazard ratios and 95% confidence intervals using the number of drains placed, number of nodes removed, RP approach and use of prophylactic low-molecular-weight heparin (LMWH) as predictors of symptomatic lymphocele. Results: There were 164 patients (4%) with a symptomatic lymphocele on follow up, with a median time to presentation of 19 days. The primary presenting complaints were fever in 47%, abdominal pain in 40%, lower extremity swelling in 37%, genital swelling in 25%, groin pain in 22%, abdominal swelling in 9%, and back and flank pain in 6% and 5%, respectively. Median lymphocele diameter was 5 cm. Significant predictors of symptomatic lymphocele on multivariate analysis included number of nodes removed and use of LMWH, but not number of drains placed. Conclusions: Use of prophylactic LMWH and a higher node count are predictive of a higher incidence of symptomatic lymphocele after RP and PLND.

Impact of diabetes mellitus on recurrence and progression in patients with non-muscle invasive bladder carcinoma: a retrospective cohort study.

Abstract: Objective: The aim of the present study was to investigate the relationship between diabetes mellitus (DM) and tumor features in patients with non-muscle invasive bladder cancer (NMIBC). Methods: Data from 251 patients who underwent transurethral resection (TUR) for NMIBC from January 2000 to June 2010 were analyzed retrospectively. Patients were divided into two groups: Group I, 159 patients (63%) who did not have DM at the time of surgery; and (ii) Group II, 92 patients (37%) who had DM at the time of surgery. Recurrence- and progression-free survival was assessed in both groups. Preoperative HbA1c levels, as parameter of glycemic control, were determined in Group II patients, with patients divided into two subgroups: (i) HbA1c 7.0%; and (ii) HbA1c <7.0%. The clinical features of the bladder tumor were compared in these two subgroups. Results: Compared with Group I, Group II patients were older and had a higher rate of hypertension, recurrence, and progression (P < 0.05). Univariate survival analysis showed that gender, DM, smoking, and serum creatinine were associated with recurrence-free survival (P < 0.05), whereas DM, stage, grade, intravesical instillation, and serum creatinine were associated with progression-free survival. In multivariate survival analysis, DM was found to be an independent factor for recurrence- (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.4–3.2; P = 0.001) and progression-free survival (HR 9.35; 95% CI 3.1–28.6; P = 0.001). Furthermore, patients with HbA1c 7.0% exhibited a significantly higher rate of multiplicity (P = 0.001), tumor grade (P = 0.03), and intravesical treatment (P = 0.04). Conclusions: In conclusion, DM seems to be an independent predictor of recurrence- and progression-free survival in NMIBC patients. Further prospective studies are needed to establish the prognostic significance of postoperative glycemic control in this patient population.

Renal mass sampling : An enlightened perspective

Abstract: Renal mass sampling (RMS) can be carried out by core biopsy or fine needle aspiration with each presenting potential advantages and limitations. The literature about RMS is confounded by a lack of standardized techniques, ambiguous terminology, imprecise definitions of accuracy, substantial rates of non-informative biopsies, and recurrent diagnostic challenges with respect to eosinophilic neoplasms. Despite these concerns, RMS has an expanding role in the evaluation and treatment of renal masses, in order to stratify biological aggressiveness and guide management that can range from surgery to active surveillance. Non-informative biopsies can be managed with surgical excision or repeat biopsy, with the latter showing encouraging results in recent studies. We propose a new classification in which all biopsies are categorized as non-informative versus informative, with the latter being subclassified as confirmed accurate, presumed accurate or confirmed inaccurate. This terminology will facilitate the comparison of results from various studies and stimulate progress. Incorporation of novel biomarkers and molecular fingerprinting into RMS protocols will likely allow for more rational management of patients with renal masses in the near future.

Transplantation of mature adipocyte‐derived dedifferentiated fat (DFAT) cells improves urethral sphincter contractility in a rat model

Abstract: Objectives: To examine the effects of mature adipocyte-derived dedifferentiated fat (DFAT) cell transplantation on urethral tissue regeneration and sphincter function. Methods: Sixteen female Sprague–Dawley rats underwent vaginal distension (VD) for 3 h. Subsequently, green fluorescence protein (GFP)-labeled DFAT cells (1 × 106 in 20 µL saline, DFAT group, n = 8) or saline (20 µL, control group, n = 8) were injected into paraurethral connective tissue. Two weeks following VD, leak point pressure (LPP) was measured and an immunohistochemical analysis of the urethra was performed to evaluate urethral sphincter regeneration. Results: The VD model was characterized by atrophy of the urethral sphincter and showed a decrease in LPP. DFAT cell transplantation resulted in a significant improvement of LPP (DFAT group: 37.3 ± 6.4 vs control group: 21.7 ± 5.7 mmHg, P < 0.01). Immunohistochemistry revealed that the striated muscle thickness and smooth muscle α−actin-positive area were significantly (P < 0.05) larger in the DFAT group than in the control group. DFAT cell transplantation enhanced macrophage accumulation followed by an increased number of cells in the proliferative state. Transplanted DFAT cells were observed in the damaged smooth muscle layer and showed positive staining for smooth muscle α−actin, suggesting conversion into the smooth muscle cell phenotype. Conclusions: DFAT cell transplantation promotes sphincter muscle regeneration and improves LPP in the rat VD model.

Long-term outcome of ovotesticular disorder of sex development: a single center experience.

Abstract: Objectives: To describe the clinical features of children with ovotesticular disorder of sex development (DSD) and to review cases of ovotesticular DSD in Japan. Methods: Medical records of eight children diagnosed with ovotesticular DSD at our institute during the past 17 years were retrospectively evaluated. A review of 165 reported cases of ovotesticular DSD from Japanese institutions was carried out. Results: Mean follow up was 8.2 years for six children, with two children lost to follow up. Mean age at first presentation was 2.4 months. All children were Japanese. The most common initial manifestation was ambiguous genitalia. The female : male ratio as the sex of rearing was 1:1. Gender reassignment, from male to female, was carried out in one child at 4-months-old. Genital surgery was always carried out in early childhood as per family desire. Appropriate gonadal tissue was preserved except for one child. No gonadal tumors were detected during follow up. Spontaneous pubertal development occurred in one boy. In reviewing Japanese data, the frequency of testes was higher than in other ethnicities and this was related to the higher incidence of 46,XY. Conclusions: According to our experience, most families in Japan desire early genital surgery in the case of ovotesticular DSD. Chromosomal and gonadal distributions in patients with ovotesticular DSD differ between Japanese and other ethnic groups. Treatment for these patients needs to be provided after considering the cultural and social backgrounds of DSD in Japan.

Efficacy of selective α1A adrenoceptor antagonist silodosin in the medical expulsive therapy for ureteral stones.

Abstract: Recently, we reported that α1A adrenoceptor (AR) is the main participant in phenylephrine-induced human ureteral contraction. We therefore decided to carry out a prospective randomized study to evaluate the effects of silodosin, a selective α1A AR antagonist, as a medical expulsive therapy for ureteral stones. A total of 187 male patients, who were referred to our department for the management of symptomatic unilateral ureteral calculi of less than 10 mm, were randomly divided into two groups: group A (92 patients), who were instructed to drink 2 L of water daily, and group B (95 patients), who received the same instruction and were also given silodosin (8 mg/daily) for a maximum of 8 weeks. Expulsion rate, mean expulsion time and need for analgesics were examined. Overall, the mean expulsion time was 15.19 ± 7.14 days for group A and 10.27 ± 8.35 days for group B (P = 0.0058). In cases involving distal ureteral stones, the mean expulsion time was 13.40 ± 5.90 and 9.29 ± 5.91 days, respectively (P = 0.012). For stones of 1–5 mm in diameter, the mean expulsion time was 14.28 ± 6.35 and 9.56 ± 8.45 days, respectively (P = 0.017). For stones of 6–9 mm in diameter, the stone expulsion rate was 30.4% and 52.2% (P = 0.036), and the mean expulsion time was 21.00 ± 9.9 and 11.33 ± 8.31 days, respectively (P = 0.038). Herein, we report the first on silodosin in the management of ureteral lithiasis. Our findings suggest that silodosin might have potential as a medical expulsive therapy for ureteral stones.

Factors predicting continence recovery 1 month after radical prostatectomy: Results of a multicenter survey

Abstract: Objectives: To assess the factors associated with continence recovery 1 month after radical prostatectomy (RP) and to identify the correlation between these factors. Methods: In total, 2408 men treated with RP for prostate cancer (PCa) were enrolled in the present multicenter prospective study. Clinical (age, body mass index) and urological (catheterization or transurethral resection of the prostate) records, quality of life (QOL) scores determined using various instruments (including the International Index of Erectile Function [IIEF] and University of California Los Angeles, Prostate Cancer Index [UCLA-PCI]), PCa characteristics (clinical stage [cT], prostate-specific antigen, biopsy Gleason score), surgical features (surgical approach, nerve and bladder neck sparing, catheterization), and pathologic outcomes (pT, pN+, Gleason score, positive surgical margins) were recorded. Continence status prior to surgery and at 1 month after RP was assessed and classified as followed: (i) full continence; (ii) 0–1 pads/day; or (iii) >1 pad/day. Only patients determined to have full continence prior to surgery were included in the analysis. Data were evaluated using Spearman's correlation analysis and multivariate logistic regression. Results: Data from 1972 patients with full continence preoperatively and complete postoperative data were analyzed. At 1 month after RP, 644 patients (32.7%) were fully continent, 810 (41.1%) were using 0–1 pads/day, and 518 (26.3%) were using >1 pad/day. Univariate analysis indicated that clinical and urological data, QOL, PCa characteristics, surgical features, and pathologic outcomes were determinants for continence recovery. Multivariate analysis indicated that preoperative sexual activity (UCLA-PCI Sexual Function P = 0.005; IIEF P = 0.040), bladder neck sparing (P = 0.003), catheterization time (P = 0.007), and catheter diameter (P = 0.046) were associated with 1 month continence recovery. Conclusions: Age and nerve sparing are not significant predictors of continence recovery 1 month after RP. Preoperative erectile function can predict post-prostatectomy incontinence. Bladder neck preservation has a significant effect on early continence recovery after RP.

Surgical procedures for benign prostatic hyperplasia: a nationwide survey in Japan

Abstract: We investigated the trend in surgical procedures for benign prostatic hyperplasia (BPH) during the past 10 years in Japan. A questionnaire inquiring about the number of operations and surgical procedures for BPH in 1999, 2004 and 2009 was sent to 1824 institutes belonging to the Japanese Urological Association and/or the Japanese Clinical Urologists Association. Responses were obtained from 767 institutes (42.1%). The number of operations showed a gradual increase during the 10 years (n = 17,221 in 1999, 18,772 in 2004, 20,413 in 2009). Transurethral resection of the prostate, including transurethral resection in saline, was consistently the most common procedure (72.5% to 79.2%). Holmium laser enucleation of the prostate and transurethral enucleation with a bipolar system have dramatically increased, becoming the second most common in 2009 (n = 3416), although enucleation by open prostatectomy was still a viable option in 2009 (n = 555). Photoselective vaporization of the prostate was the third most common method in 2009 (n = 572). Coagulation and thermotherapy have become uncommon (n = 2039 in 1999, 217 in 2009), whereas incision and stenting were unchanged during the period. Thus, surgical procedures for BPH have been increasing in Japan during the past decade. Transurethral resection remains the standard, whereas enucleation and vaporization have been increasing.

Photodynamic diagnosis of positive margin during radical prostatectomy: Preliminary experience with 5-aminolevulinic acid

Abstract: Objectives: To investigate the feasibility of intraoperative photodynamic diagnosis (PDD) by 5-aminolevulinic acid (ALA) for the identification of positive surgical margins (PSM) during retropubic radical prostatectomy (RRP) in patients with prostate cancer (PCa). Methods: Intraoperative PDD was carried out in 16 patients with pathologically confirmed PCa by biopsy of the apex, or carrying >25% of probability of extraprostatic extension as defined by Japan PC Table. Before operation, 1.0 g of ALA was given orally. During open RRP, the resection margins inside the body were examined by PDD system with a fluorescence laparoscope. After their removal, 12 harvested prostates were divided and also investigated by PDD. Red fluorescent-positive lesions were biopsied and compared with the pathological result. Results: All 16 patients were fluorescence-negative inside the body, and negative margins were pathologically confirmed during PDD. Among the 43 specimens of 12 cases obtained by biopsy under PDD, 11 specimens (25.6%) were pathologically diagnosed as malignant tissue (adenocarcinoma, 10 specimens; high grade prostatic intraepithelial neoplasia, 1 specimen) and 19 specimens (44.2%) were evaluated as positive fluorescence by PDD with a sensitivity of 81.8%, a specificity of 68.8% and a predictive accuracy of 72.1%. No side-effects were observed and the procedures were well tolerated. Conclusions: PDD mediated by ALA during RRP might be a feasible and safe modality for detection of surgical margins. Further prospective randomized studies with larger populations are required.

Risk factors for overactive bladder in the elderly population: A community-based study with face-to-face interview

Abstract: Objectives: The aim of this study was to measure the prevalence of and risk factors for overactive bladder (OAB) in the elderly. Methods: A cross-sectional study of elderly subjects was conducted by analyzing data from a community-based Comprehensive Geriatric Assessment on people aged 70 years or older. Trained interviewers performed face-to-face interviews for the assessment of urological symptoms. OAB definition was based on urgency and eight or more episodes of urination per day. The subjects completed a self-administered questionnaire including lifestyle evaluation, Geriatric Depression Scale, Mini-Mental Status Examination and medical history. Brachial-ankle pulse wave velocity was recorded to assess atherosclerotic disease. The analysis included 833 subjects, after the exclusion of 115 subjects who provided insufficient information. Results: Based on the definition of OAB, 153 subjects (18.4%) were identified as having OAB. Univariate analysis showed a significant association between OAB and depressive symptoms. Multivariate analysis showed that the risk of having OAB was significantly higher in subjects with depressive symptoms, current drinkers, and overweight subjects with odds ratios of 2.37 (1.60–3.52, 95% confidence interval), 1.65 (1.04–2.62), and 1.51 (1.02–2.24), respectively. Conclusions: This is the first report to show an association between OAB and depressive symptoms and alcohol intake in an epidemiological study of elderly people. The reasons for these correlations remain unclear, but should be the foci of future OAB studies.

Naftopidil vs silodosin in medical expulsive therapy for ureteral stones: a randomized controlled study in Japanese male patients.

Abstract: The aim of the present study was to compare the efficacy of the selective α1D-adrenoceptor antagonist naftopidil and the selective α1A-adrenoceptor antagonist silodosin (as an example) in the management of ureteral stones in Japanese male patients. A total of 74 patients with symptomatic ≤10 mm ureteral stones were enrolled in a prospective study and randomized into two groups: Group 1 received 50 mg naftopidil daily, whereas Group 2 received 8 mg silodosin daily. Patients were followed-up for up to 6 weeks. The primary endpoint was stone expulsion rate and secondary endpoints were stone expulsion time, the rate of interventions, such as transurethral ureterolithotripsy, extracorporeal shock wave lithotripsy, or ureteral stenting, and side effects. There were no significant differences between the two groups with respect to age, stone size, and location. The stone expulsion rate was 61% and 84% in the naftopidil and silodosin groups, respectively (P = 0.038). No significant differences were noted in stone expulsion time or the rate of interventions between the two groups. The findings suggest that α1A-adrenoceptor blockade was clinically superior for stone expulsion our study population.

Transrectal high-intensity focused ultrasound for treatment of localized prostate cancer.

Abstract: Objectives: To assess the long-term outcomes of transrectal high-intensity focused ultrasound (HIFU) for patients with localized prostate cancer. Methods: From May 2003 to present, 137 consecutive patients with T1-2 prostate cancer were treated using the Sonablate 500 and then followed for more than 12 months after their last HIFU treatment. A prostate biopsy was routinely carried out at 6 months and serum prostate-specific antigen (PSA) was measured every 3 months after HIFU. Oncological outcomes as well as treatment-related complications were assessed. Disease-free survival (DFS) was judged using the Phoenix definition (PSA nadir + 2 ng/mL), negative histological findings and no local or distant metastasis. Results: The median follow up after HIFU was 36 months (range 12–84 months). No patients received adjuvant therapy during this period. The PSA nadir occurred at 2 months after HIFU and the median level was 0.07 ng/mL (0.01–2.01 ng/mL). Of the 133 patients who underwent prostate biopsy or transurethral resection of the prostate at 6 months or later after HIFU, six were positive for cancer cells (4.5%). There were no major postoperative complications, but urge incontinence (16 cases) and dysuria (33 cases) occurred after removal of the urethral catheter. The 5-year DFS rate was 78% based on these criteria, and 91%, 81% and 62% in the low-, intermediate- and high-risk group, respectively. Conclusions: HIFU represents an effective, repeatable and minimally invasive treatment. It is particularly effective for low- and intermediate-risk patients, and it should be considered as an option for localized prostate cancer.

Overexpression of Eg5 predicts unfavorable prognosis in non‐muscle invasive bladder urothelial carcinoma

Abstract: Objective: To investigate the relationship between Eg5 expression and prognosis of patients with non-muscle invasive bladder urothelial carcinoma. Methods: Eg5 expression was examined by immunohistochemistry in non-muscle invasive urothelial carcinoma specimens (grade: G1, 32 cases; G2, 92 cases; and G3, 39 cases. Stage: pTa, 49 cases and pT1, 114 cases). The correlation between clinicopathological characteristics and Eg5 expression was evaluated. The prognostic significance of Eg5 immunoreactivity was analyzed through survival analysis in 163 non-muscle invasive cases that were treated with transurethral resection and adjuvant intravesical instillations. Results: The expression of Eg5 was significantly associated with tumor grade (P = 0.006), with a trend towards significant association with stage (P = 0.057). The 163 patients with non-muscle invasive tumors were regularly followed with the mean of 32.52 (from 6 to 72) months. Univariate analysis showed Eg5 overexpression exhibited a significant unfavorable influence on intravesical recurrence (P = 0.012) while having only a marginal correlation with disease progression (P = 0.070). Subsequent Cox hazard multivariate analysis showed that both grade (P = 0.045) and Eg5 expression (P = 0.029) were independent predictors for early intravesical recurrence. Conclusions: Overexpression of Eg5 correlates with poor differentiation of bladder cancer, and it represents an independent prognostic factor in predicting early intravesical recurrence in non-muscle invasive bladder carcinoma patients.

Early recovery of urinary continence after radical prostatectomy: Correlation with vesico‐urethral anastomosis location in the pelvic cavity measured by postoperative cystography

Abstract: Objectives: To determine the association of vesico-urethral anastomosis location (VUAL) with early recovery of urinary continence (UC) after radical prostatectomy (RP). Methods: A retrospective analysis of 678 patients who underwent RP was carried out. Patients were divided into three groups based on the VUAL as determined by postoperative cystography: group I – VUAL above the upper margin of the symphysis pubis (SP), group II – between the upper margin and the middle of the SP, and group III – below the middle of the SP. Early recovery of UC was defined as using no pads or an occasional security pad within 3 months. Recovery rates were compared between the groups and factors predicting an early recovery of UC were investigated. Results: Among all patients, 62.2% achieved an early recovery of UC. Patients in group I were younger, with a longer membranous urethra, greater percent of nerve sparing and shorter time to continence than those in groups II or III. Early recovery rates were 89.5%, 69.8% and 40.7% in group I, II and III, respectively (P < 0.001). VUAL remained an independent predictor of early recovery of UC (OR 3.2 for group I vs II and 10.8 for group I vs III [P < 0.001]) when adjusted for age, operative time, membranous urethral length and operation by surgeon with high surgical volume. Conclusion: VUAL represents an independent predictor of recovery of UC after RP. A higher VUAL is associated with a higher rate of early recovery of UC.

Increased urethral resistance by periurethral injection of low serum cultured adipose-derived mesenchymal stromal cells in rats.

Abstract: Objectives: To evaluate the effects of a periurethral injection of low serum cultured adipose tissue-derived mesenchymal stromal cells (LASC) and to develop a new autologous cell therapy for stress urinary incontinence. Methods: F344 rats were divided into three groups as based on the periurethral injection of LASC, GAX collagen or vehicle (control). At 2 and 4 weeks after injection, leak point pressure (LPP) was measured before and after transection of the pelvic nerves. For cell tracking, LASC of green fluorescent protein transgenic rats were injected into nude rats. Results: At 2 weeks, both the LASC and collagen groups showed significantly higher LPP than the control group. At 4 weeks, the increase in LPP in the LASC group remained , whereas LPP in the collagen group decreased to baseline levels. In the absence of the urethral closure reflex after transection of the pelvic nerves, LPP in the LASC group was significantly higher than that in the other two groups. Histologically, the size of the urethral lumen was smaller in the LASC group than the collagen group. At 4 weeks, most of the LASC were positive for myogenic antigens including a-smooth muscle actin, desmin and calponin I. Conclusions: Periurethral injection of autologous LASC capable of myogenic differentiation made a greater contribution to the increase in urethral resistance than did the conventional collagen bulk injection. Thus, its use for treatment of stress urinary incontinence can be postulated.

Importance of urinary flow studies after hypospadias repair: a systematic review.

Abstract: A systematic review was performed of publications relating to the results of urinary flow studies after hypospadias repair dating back to 1978, when what appears to be the first publication on this topic was found. The literature search was performed using the key words "hypospadias" combined with "urinary flow", "urine flow", "uroflow", "uroflowmetry", and "long-term". We also reviewed the abstracts and full-length articles cited in the reference list of selected articles. Criteria for inclusion in the present systematic review included descriptions of patient selection, surgical technique, the severity of disease (proximal vs distal), and the method used to determine uroflow, as well as a definition of urethral obstruction. In all, 339 article titles were found. Of these, 25 abstracts appeared relevant and the full text of these articles were reviewed, with 22 of the papers included in this review. Sixteen reports had appeared in the literature since 2001, compared with six between 1978 and 2000, suggesting an increasing interest in this topic. On the basis of the results of the present systematic review, we recommend that asymptomatic children operated on for hypospadias in infancy should have one flow study after toilet training, with that study repeated if the results are abnormal. It appears that early abnormal flows improve spontaneously, so that children operated on after toilet training who are asymptomatic should undergo their first uroflow measurement 1 year after surgery. Children with obstructed flow parameters or borderline flows should be followed until adulthood, until long-term follow up studies clarify the significance of abnormal flow parameters. Given the present findings, we anticipate that in the next two decades urologists will need to treat a number of men with strictures resulting from hypospadias repairs performed in childhood.

Laparoscopic promontofixation for pelvic organ prolapse: a 10-year single center experience in a series of 501 patients.

Abstract: Objectives: To assess the long-term outcomes of laparoscopic promontofixation (LP) for the treatment of pelvic organ prolapse (POP). Methods: A total of 501 consecutive patients with POP were included in this prospective study. The patients' mean age was 63.23 (36–90) years, their mean body mass index was 25.14 (15–36) and their mean number of deliveries was 3.3 (0–14). A POP grade ≥3 was diagnosed in 70.4% of the patients and 38.9% of them had a history of abdominal surgery. The patients underwent a Bonney test and urodynamic study. In cases of stress urinary incontinence (SUI), the patients underwent the simultaneous insertion of a tension-free vaginal tape. A prolapse quality of life questionnaire was sent to all patients. Results: The mean operative time was 97.4 min (50–210) and there were 1.7% cases of intra-operative complications. The mean hospitalization time was 3.7 days (1–13 days). During the mean follow-up of 20.7 months (3–120), 91 (17.8%) complications were recorded, including constipation (5.5%), SUI (3.5%), vaginal erosion (2.4%), and urge incontinence (2%). Recurrences were recorded in 11.5% of the patients within an average time of 37.2 months. Risk factors for recurrence were the use of the polypropylene mesh compared with the polyester mesh (P < 0.0001), an intra-operative hysterectomy (P = 0.02), and bleeding (P = 0.049). There was a statistical significant (P < 0.001) improvement in most of the symptoms in the prolapse quality of life questionnaire. Conclusions: LP is safe with effective long-term results, with low recurrence and morbidity rates, and a good quality of life.

Propiverine hydrochloride in Japanese patients with overactive bladder: a randomized, double-blind, placebo-controlled trial

Abstract: Objectives: The aim of this study was to investigate the efficacy and safety of propiverine for overactive bladder (OAB) in Japanese patients. Methods: In this multicentre, randomized, double-blind study, patients ≥20 years old with symptoms of OAB for ≥12 weeks were allocated to either propiverine (20 mg once daily) or placebo for 12 weeks. Efficacy and quality of life were assessed using a 7-day bladder diary, the OAB symptom score, and King's Health Questionnaire. Safety was mainly assessed by adverse events and the QTc interval. Results: A total of 567 patients were allocated. Change in number of micturitions/24 h was significantly greater in the propiverine group than in the placebo group (–1.86 vs−1.36, P = 0.001). Compared to placebo, propiverine produced significant improvements in urgency, urgency incontinence, urine volume/micturition, and the OAB symptom score. Significant improvements in urgency, urgency incontinence, and micturition frequency were observed at the first 4 weeks of treatment. All nine domains of King's Health Questionnaire were improved more with propiverine than with placebo. Adverse effects with propiverine were mostly mild, and no patient developed QTc interval prolongation exceeding 500 ms. Conclusion: Propiverine is effective for Japanese OAB patients by improving their symptoms and quality of life with a predictable side-effect profile.

Profilin 1 overexpression in renal cell carcinoma

Abstract: Objectives: To gain information about overexpressed antigens in renal cell carcinoma (RCC) by using a chemical proteomics approach. Methods: RCC cell line 769P was cultured and proteome analysis was subsequently carried out in the culture supernatants. By using sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and tandem mass spectrometry (LC-MS/MS), proteins in the culture supernatants were searched. A MEDLINE search to define the functions of the identified proteins was carried out. Results: Four differentially regulated proteins (profilin 1, amyloid beta A4 protein [APP], proprotein convertase subtilisin/kexin type 1 inhibitor [ProSAAS], galectin-3-binding protein [LGALS3BP]) were selected. These were not overexpressed in normal kidney tissue or reported in RCC. Their levels were measured through western blotting of normal kidney and RCC tissues. No differences were observed in the expression levels of APP, ProSAAS or LGALS3BP between RCC and normal kidney tissues. Profilin 1 was overexpressed in RCC tissue. On the basis of this observation, an immunohistochemical analysis of profilin 1 in normal kidney and RCC tissues was carried out. In normal tissues, tubules that were sources of RCC stained positive for profilin 1. In RCC tissue, in contrast, the stromal cells in the tumors stained positive. Conclusions: Profilin 1 can be a key element in the pathological processes of RCC, such as tumorigenesis and/or tumor growth. Thus, it has the potential to serve as a diagnostic or progression biomarker and therapeutic target in RCC.

Incidental prostate cancer revisited: early outcomes after holmium laser enucleation of the prostate.

Abstract: Incidental prostate cancer (PCa) after treatment of benign prostate hyperplasia (BPH) is becoming less common. This is a result of the changing patterns of BPH treatment. The purpose of the present research was to re-examine the clinical outcomes and importance of cT1a and cT1b PCa in a contemporary cohort after holmium laser enucleation of the prostate (HoLEP). All patients with newly diagnosed PCa after HoLEP were retrospectively identified. Pre- and postoperative prostate-specific antigen (PSA), biopsy history, pathological features and disease progression were examined. Patients were matched to a control group with benign pathology for outcome comparisons. The database consisted of 240 consecutive patients, aged 52–90 years with prostate sizes from 25 to 375 cm3. A total of 28 patients were identified with incidental PCa (14 cT1a and 14 cT1b). Median follow up was 11 months and 13 months for cT1a and cT1b, respectively. Hospitalization time, catheterization time, complications and functional outcomes were similar. Three patients with cT1b required additional treatment as a result of PSA progression. All other cancers are being closely followed. The functional benefits of HoLEP are well established. The incidental PCa detection rate of 11.7% shows the potential benefit of pathological analysis. Just 10.7% of these patients received additional treatment, but this might be significant as these patients would otherwise go untreated. The impact on disease-specific survival and progression requires a longer follow up.

Impact of insulin resistance, insulin and adiponectin on kidney stones in the Japanese population.

Abstract: Objectives: It has been reported that kidney stones are linked to metabolic syndrome (MetS), which is characterized by insulin resistance. The aim of the present study was to examine the association of insulin resistance, insulin and adiponectin with kidney stones in a Japanese population. Methods: From February 2007 to March 2008, 1036 (529 men and 507 women) apparently healthy Japanese subjects, aged 35–79 years, were analyzed. Weight, height, waist circumference and blood pressure were measured. Overnight fasting blood was collected to measure insulin and adiponectin levels. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated to assess insulin resistance. Logistic regression analysis was used to estimate the odds ratio (OR) and 95% confidence intervals for a self-reported history of kidney stones across tertiles of HOMA-IR, insulin and adiponectin. Results: Of the participants, 84 men (15.6%) and 35 women (6.9%) had a history of kidney stones. Age, body mass index, waist circumference, systolic and diastolic blood pressures, HOMA-IR and insulin were significantly higher in women with than in women without kidney stones. There was no difference in adiponectin level between subjects with and without a history of kidney stones in either sex. Furthermore, a significant positive trend was observed in the age-adjusted OR for a history of kidney stones across insulin tertiles (P-value for trend = 0.04) in women. Conclusions: For Japanese women, HOMA-IR and insulin are associated with a history of kidney stones. The findings suggest that MetS components could increase the risk of kidney stones through subclinical hyperinsulinemia and insulin resistance.

Tamsulosin versus transurethral resection of the prostate: Effect on nocturia as a result of benign prostatic hyperplasia

Abstract: Our objective was to compare the effect of tamsulosin versus transurethral resection of the prostate (TURP) for the management of nocturia in previously untreated men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and no other predisposing factors for nocturia. The study group included 66 patients (mean age 68.9 years, range 52-81) randomized to receive either tamsulosin 0.4 mg per os daily (n = 33) or TURP (n = 33). Nocturia was assessed at baseline, after 3 months and after 1 year, by the number of nocturnal awakenings and hours of undisturbed sleep (HUS) obtained from a 72-h Frequency Volume Chart (FVC). Furthermore, the International Prostate Symptom Score (IPSS), the International Consultation on Incontinence Questionnaire Nocturia (ICIQ-N) and the International Consultation on Incontinence Questionnaire Nocturia Quality of Life (ICIQ-NQoL) were recorded. At baseline, there were no statistically significant differences between the two groups. ICIQNQoL and ICIQ-N scores correlated with the number of awakenings and HUS, respectively. Both tamsulosin and TURP improved all examined parameters during the follow up. TURP was associated with a statistically significant improvement in the number of nocturnal awakenings and in the IPSS, ICIQ-N and ICIQ-NQol scores in comparison with tamsulosin. HUS increased in both groups, but without any statistically significant difference. In conclusion, TURP is superior in comparison with tamsulosin for the management of BPH-related nocturia.