Long-term Outcomes of Cystectomy and Crossfolded Ileal Reservoir Combined with an Afferent Tubular Segment for Heterotopic Continent Urinary Diversion: A Longitudinal Single-centre Study.

BACKGROUND: The crossfolded ileal reservoir combined with an afferent tubular isoperistaltic segment for heterotopic continent urinary diversion has been performed on a regular basis for over 20 years. Yet data on long-term-outcomes remain sparse. OBJECTIVE: To report long-term functional and oncological outcomes, gastrointestinal and metabolic disturbances, urinary tract infections (UTIs), and quality of life. DESIGN, SETTING, AND PARTICIPANTS: Long-term functional and oncological outcomes of a consecutive series of 118 patients undergoing cystectomy and construction of a continent cutaneous crossfolded ileal reservoir from 2000 to 2018 were evaluated. INTERVENTION: Patients underwent cystectomy and construction of a continent cutaneous crossfolded ileal reservoir according to the Studer technique for bladder reconstruction. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Pre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. Self-reported questionnaires regarding quality of life, patient satisfaction, and difficulty in catheterisation were sent to patients preoperatively; after 3, 6, 12, and 24 mo; and at last follow-up, and were then manually entered in the departmental database. RESULTS AND LIMITATIONS: The median follow-up was 7.8 (interquartile range 3-12.7) yr. Patient satisfaction was high in 77.4% and moderate in 16.9%. Serum creatinine and estimated glomerular filtration rate remained stable during follow-up. Of all patients, 81% (96/118) had at least one UTI during follow-up. Recurrent UTIs occurred in 67% (79/118) of patients. Urolithiasis was found in 12% (14/118), with 6% (7/118) having a single and 6% a recurrent event. Of all stone formers, 79% (11/14) had recurrent UTIs. In oncological patients, 12.5% (10/79) developed a local recurrence. Cancer-specific survival and overall survival were 90% and 88%, and 68% and 56% after 1 and 10 yr, respectively. A limitations is the retrospective analysis from prospectively assessed data. CONCLUSIONS: A high satisfaction level, stability of kidney function, and low rates of urolithiasis in patients with a heterotopic continent ileal reservoir can be achieved, provided that close attention is paid to intra- and postoperative details. Regular lifelong follow-up is essential for timely detection and treatment of complications. Oncological outcome is not affected by the urinary diversion. PATIENT SUMMARY: In patients with a continent cutaneous ileal reservoir, good quality of life and a high satisfaction rate are possible provided that patients adhere to regular lifelong follow-up.

Functional Results, Complications Associated with the Serosa-lined Tunnel, and Quality of Life with a Cross-folded Ileal Reservoir Combined with an Afferent Tubular Isoperistaltic Segment for Heterotopic Continent Urinary Diversion: An Observational Long-term Cohort Analysis.

BACKGROUND: In patients who do not qualify for an orthotopic urinary diversion, for example, the urethra cannot be spared or is functionally impaired, a heterotopic continent cutaneous cross-folded ileal reservoir offers a good alternative. OBJECTIVE: To describe the indication, surgical technique, and postoperative management, and to report the reservoir-related outcomes and complications associated with the serosa-lined tunnel. DESIGN, SETTING, AND PARTICIPANTS: Perioperative outcomes of 118 consecutive patients after cystectomy and a heterotopic ileal reservoir adapted from the Studer bladder substitute technique, operated between 2000 and 2018, were evaluated. The catheterisable serosa-lined tunnel was constructed from the appendix (Mitrofanoff, n = 63), an ileal segment (Yang-Monti, n = 48), or a fallopian tube (n = 7). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Pre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. The chi-square test was used to compare proportions. RESULTS AND LIMITATIONS: Median follow-up was 94 (interquartile range 36-152) mo. No peri- or postoperative mortality was observed within 90 d of surgery. Patient satisfaction was high in 77.5% and moderate in 16.9%. Overall, complications associated with the serosa-lined tunnel occurred in 52% (61/118) of patients. Stenosis of the continent outlet developed in 38% (45/118) of patients: 33/45 (75%) were simply dilated/incised at the outpatient clinic, of those 24% (8/33) required additional endoscopic dilatation. Of patients with stenosis of the continent outlet, 27% (12/45) needed open revision surgery. During follow-up, 8% (nine/118) of patients required revision of the serosa-lined tunnel due to incontinence. Twelve months postoperatively, 95% (92/97) patients were continent. A limitation is the retrospective analysis from prospectively assessed data. This could limit the generalisability of these findings, as selection bias cannot be excluded. CONCLUSIONS: The heterotopic continent cutaneous cross-folded ileal reservoir achieves good functional results. Complications associated with the serosa-lined tunnel occur in about half of the patients but generally are easy to manage. As a result, patient satisfaction is high. PATIENT SUMMARY: In patients who do not qualify for an orthotopic bladder substitute, a heterotopic continent cutaneous cross-folded ileal reservoir offers a viable alternative with good postoperative functional results and high patient satisfaction.

Supramolecular organization of S12363-liposomes prepared with two different remote loading processes.

The S12363 anticancer drug was encapsulated into liposomes in an attempt to increase its therapeutic index. Loading of S12363 was achieved using two different processes based on the formation of either a pH gradient or an ammonium gradient between the acidic inner liposomal compartment and the basic outer phase. High encapsulation yields (>90%) were obtained using both processes for sphingomyelin/cholesterol/cholesterol-PEG vesicles. Spectrofluorimetry measurements have shown that liposomes were characterized by an internal pH around 4 for both loading processes. This internal pH was stable over a period of at least 20 days. Differential scanning calorimetry coupled with time-resolved synchrotron X-ray diffraction was used to study the drug/carrier supramolecular organization. In ammonium sulfate, S12363 was inserted into the bilayer in the vicinity of the polar headgroup. In citrate buffer, S12363 was mainly adsorbed at the water-lipid interface. The drug partitioning into the membrane was inhomogeneous and led to the formation of drug-rich and drug-poor domains. This effect was enhanced in the presence of cholesterol, especially in ammonium sulfate. To conclude, for both processes, the encapsulated drug was found inside the liposome aqueous core but strongly interacting with the membrane.

Biodistribution and anticancer activity of a new Vinca alkaloid encapsulated into long-circulating liposomes.

S12363 is a potent therapeutic agent with a strong in vitro activity against a variety of tumor types but also a high in vivo toxicity. Loading of this drug into long-circulating liposomes is expected to enhance its therapeutic index. Pharmacokinetics of liposomal S12363 showed that circulating S12363 was entrapped into liposomes until 24 hours after intravenous injection in mice. The liposomal formulation significantly increased the plasma concentration, half-life, and AUC and decreased the plasma clearance rates and volume of distribution of S12363. Liposome extravasation was evaluated with two tumor models by both microscopic analysis and liposome radiolabeling. Liposome accumulation was much more important in the case of B16 melanoma, compared to H460 tumor, with both inoculated subcutaneously and with comparable size. H460 tumor was also inoculated into the lung. The tumor localization did not influence liposome accumulation into the tissue. The liposomal formulation injected into mice bearing B16 melanoma allowed a 10-fold accumulation of S12363 into the tumor interstitium, as compared to the solution. Bioluminescence data, supported by the survival curves of the animals, showed that S12363-liposomes were able to significantly restrict B16 melanoma progression and increase mice survival.

Management of bladder cancer in older patients: Position paper of a SIOG Task Force.

Median age at bladder cancer (BC) diagnosis is older than for other major tumours. Age should not determine treatment, and patients should be fully involved in decisions. Patients should be screened with Mini-Cog™ for cognitive impairment and the G8 to ascertain need for comprehensive geriatric assessment. In non-muscle invasive disease, older adult patients should have standard therapy. Age does not contraindicate intravesical therapy. Independent of age and fitness, patients with muscle-invasive BC should have at least cross-sectional imaging. Data suggest extensive undertreatment in older adult patients, leading to poor outcomes. Standard treatment for a fit patient differs between countries. Radical cystectomy and trimodality therapy are first-line options. Radical cystectomy patients should be referred to an experienced centre and prehabilitation is mandatory. Older adult patients should be considered for neoadjuvant and adjuvant therapy, according to guidelines. In urinary diversion, avoiding bowel surgery for reconstruction of the lower urinary tract significantly reduces complications. If a patient is unfit for or refuses standard treatment, RT alone, or TURBT in selected cases should be considered. In metastatic BC, older adult patients should receive standard systemic therapy, depending on fitness for cisplatin and prognosis. Efficacy and tolerability of immunotherapy (IO) appears similar to younger patients. Second line IO is standard in platinum pre-treated patients, with benefit and tolerability in the older adult similar to younger patients. The toxicity profile seems to favour IO in the older adult but more data are needed. Patients progressing on IO may respond to further systemic treatment. In metastatic disease, palliative care should begin early.

Consequences of ions and pH on the supramolecular organization of sphingomyelin and sphingomyelin/cholesterol bilayers.

For drug delivery purpose the anticancer drug S12363 was loaded into ESM/Chol-liposomes using either a pH or an ammonium gradient. Association between the drug and the liposome depends markedly on the liposome membrane structure. Thus, ESM and ESM/Chol bilayer organization had been characterized by coupled DSC and XRDT as a function of both cholesterol concentration and aqueous medium composition. ESM bilayers exhibited a ripple lamellar gel phase P(beta') below the melting temperature and adopted a L(beta)-like gel phase upon Chol insertion. Supramolecular organization of ESM and ESM/Chol bilayers was not modified by citrate buffer or ammonium sulfate solution whatever the pH (3< or = pH < or =7). Nevertheless, in ESM bilayer, ammonium sulfate salt induced a peculiar organization of head groups, leading to irregular d-spacing and weakly correlated bilayers. Moreover, in the presence of salts, a weakening of van der Waals attraction forces was seen and led to a swelling of the water layer.

[Oral bioavailability and drug/carrier particulate systems]. / Biodisponibilité et vecteurs particulaires pour la voie orale.

The oral route remains the preferred route of administration to ensure patient satisfaction and compliance. However, new chemical entities may exhibit low bioavailability after oral administration because of poor stability within the gastrointestinal tract, poor solubility in gastrointestinal fluids, low mucosal permeability, and/or extensive first-pass metabolism. Consequently, these new drug substances cannot be further developed using conventional oral formulations. This issue is addressed by an innovative approach based on the entrapment of drug molecules in drug/carrier assembling systems. The carrier materials are lipids, naturally occurring polymers or synthetic polymers, which are considered as nontoxic and biocompatible materials. Drug entrapment is intended to protect drug substances against degradation by gastrointestinal fluids. Fine drug/carrier particle size ensures increased drug dissolution rates. Carriers and particle supramolecular organization can be designed to enhance drug absorption through the intestinal epithelium and lymphatic transport. Promising preclinical results have been obtained with model drugs like paclitaxel, insulin, calcitonin, or cyclosporin. Attention has focused on mucoadhesive carriers like chitosan that favor an intimate and extended contact between drugs and intestinal cells, thus enhancing absorption. Addition of ligands such as lectins improves intestinal drug absorption through specific binding of the carrier to intestinal cell carbohydrates. In conclusion, drug/carrier particulate systems are an attractive and exciting drug delivery strategy for highly potent drug substances unsuitable for oral use. Further evidence will determine whether this approach has marked therapeutic benefits over conventional drug formulations and is compatible with large-scale industrial production and stringent registration requirements. Producing highly effective particulate systems requiring low-complexity manufacturing processes is therefore an ongoing challenge.

Impact of antinucleants on transdermal delivery of testosterone from a spray.

The goal was to explore whether the incorporation of antinucleant polymers into a testosterone spray formulation could stabilize a putative supersaturated state and improve the delivery of the drug across the skin. Several antinucleants were screened using differential scanning calorimetry (DSC) and two candidates showed particular promise: a cyclodextrin derivative (RAMEB) and a vinylpyrrolidone/vinyl acetate copolymer (Kollidon VA64). These agents also improved significantly the long-term stability of saturated solutions of the drug. Further, using the method of mixed cosolvents, it was possible to create, in the presence of 5% w/v antinucleant polymer, supersaturated ethanol/propylene glycol/water (4:1:1 v/v) solutions of the drug with degrees of saturation between 1.4 and 2.6; however, these metastable systems existed only transiently under carefully controlled conditions and had reverted back to equilibrium solubilities of the drug within 6 h. When the same solutions were administered to hairless rat skin in vitro from mechanical sprays, no improvement in testosterone delivery, relative to a nonstabilized control, was observed. It appears, therefore, that the in situ crystallization process of the drug is more complex and incompletely understood (and cannot be predicted from DSC experiments). The complicated evaporation/volatilization process, which takes place when a spray is pulverized, requires better characterization before the use of supersaturation for testosterone delivery can be optimized.

Identification of penetration enhancers for testosterone transdermal delivery from spray formulations.

The goal of this study was to identify a suitable penetration enhancer-containing formulation for the transdermal delivery of testosterone from a spray. The first step involved in vitro measurement of drug flux from a 1:1 ethanol/water saturated solution across hairless rat skin, which had been pre-treated with a series of penetration enhancers. Isopropyl myristate (IPM) was found to be the most efficient excipient, increasing testosterone transport by more than a factor of 5. The enhancing ability of IPM was also apparent when the drug was formulated in 3:1 ethanol/propylene glycol, a more compatible vehicle for use in a spray. IPM was then incorporated into this formulation directly (as opposed to being used to pre-treat the skin) over a range of concentrations from 10-25% v/v, and testosterone transport was evaluated when delivered from either a solution, or from a mechanical spray, or from an aerosol (which also contained 50% v/v propellant). At the highest level of enhancer, the flux was improved 2.5-fold from both the spray and the aerosol, relative to a control. However, these formulations were far from optimally conceived, in that the amount of drug which eventually contacted the skin represented only approximately 10% of the pulverized quantity from the spray, and approximately 40% of that from the aerosol. Repeated application, especially from the aerosol, improved matters somewhat, but further work is clearly required before the concept can be developed for practical application.

Enhancement of transdermal testosterone delivery by supersaturation.

The objective was to evaluate supersaturation in the development of a spray formulation for transdermal testosterone delivery. The method of cosolvents was used to prepare supersaturated testosterone vehicles, the stability of which was evaluated. Drug delivery from selected formulations, and from a simpler spray, was then assessed across hairless rat skin in vitro. Supersaturated drug solutions were formed either by rapidly adding water to a drug-saturated 4:1:1 ethanol/propylene glycol (PG)/water mixture, or by maintaining the proportion of water constant, while varying the relative amounts of ethanol and PG. In the former case, only small degrees of saturation (DS) could be maintained, and drug flux was increased only modestly. The latter approach produced more stable formulations with DS = 2 to 4. A 1:1 ethanol/PG spray containing saturated testosterone delivered drug as efficiently as a supersaturated vehicle with DS = 2.5. Preparation of supersaturated testosterone formulations is possible, therefore, but significant amounts of water lead to rapid drug crystallization. As percentage PG increases, better stability results, but the practicality of using such vehicles in sprays and aerosols may be questioned. Nevertheless, a simple 1:1 ethanol/PG spray apparently induces supersaturation in situ, and further work to optimize the approach is warranted.

Formulation and evaluation of a testosterone transdermal spray.

The long-term goal is to develop a spray formulation for transdermal testosterone delivery, and to optimize the drug's skin permeability. Testosterone transport from a series of ethanol/propylene glycol (PG)/water formulations was assessed in vitro across hairless rat skin, and the optimal composition determined. The formulation was then modified for delivery from a mechanical spray, and from an aerosol containing a high percentage of propellant. Drug transport was greatest from a saturated solution in 1:1:1 ethanol/PG/water (1.7 +/- 0.2 microg/cm(2) . h); five spray formulations were then tested, but only 1:1 ethanol/PG achieved a comparable flux. Increasing the % ethanol in the mixture increased evaporation rate but did not alter testosterone delivery. Formulation as an aerosol produced primarily unstable vehicles (phase separation, crystallization). Only 3:1 ethanol/PG remained stable, but no significant improvement in drug transport was observed (testosterone precipitated rapidly at the skin surface). The 1:1:1 ethanol/PG/water saturated solution suggested that some penetration enhancement was possible. Eliminating water to improve sprayability identified 1:1 ethanol/PG as a vehicle, which might allow transient supersaturation (and improved delivery). However, this effect was not improved by using a pressurized aerosol due to instability. Finally, testosterone fluxes were 5 to 10-fold lower than those required for useful transdermal therapy.

Testosterone hormone replacement therapy: state-of-the-art and emerging technologies.

In the human male, testosterone is the major circulating androgen. The clinical effects of androgen are numerous, and testosterone deficiency is associated with a number of clinical abnormalities. At present, a variety of preparations containing testosterone is available for the treatment of androgen deficiency. Ideally, those treatments have to produce and maintain physiologic serum concentrations of the hormone. This article reviews the current existing testosterone dosage forms on the market with their advantages and drawbacks and examines new and emerging technology developments concerning this therapy. In particular, the latest innovations in transdermal delivery are explored.