Hypothesis That Urethral Bulb (Corpus Spongiosum) Plays an Active Role in Male Urinary Continence.

The proximal urethral bulb in men is enlarged, surrounds the bulbous urethra, and extends dorsally towards the perineum. During intercourse engorgement takes place due to increased blood flow through the corpus spongiosum. Antegrade ejaculation is facilitated by contraction of the bulbospongiosus muscles during climax. Micturition during sexual stimulation is functionally inhibited. Supporting the bulb may indirectly facilitate continence in a certain subset of patients with postprostatectomy incontinence. During physical activity with increased abdominal pressure, reflex contraction of the pelvic floor muscles as well as the bulbospongiosus muscles occurs to support sphincter function and limit urinary incontinence. Operations to the prostate may weaken urinary sphincter function. It is hypothesized that the distal urinary sphincter may be supported indirectly by placing a hammock underneath the urethral bulb. During moments of physical stress the "cushion" of blood within the supported corpus spongiosum helps to increase the zone of coaptation within the sphincteric (membranous) urethra. This may lead to urinary continence in patients treated by a transobturator repositioning sling in patients with postprostatectomy incontinence. This paper describes the possible role of the urethral bulb in male urinary continence, including its function after retroluminal sling placement (AdVance, AdVance XP® Male Sling System, Minnetonka, USA).

High risk of under-grading and -staging in prostate cancer patients eligible for active surveillance.

BACKGROUND: Active surveillance (AS) is increasingly offered to patients with low risk prostate cancer. The present study was conducted to evaluate the risk of tumor under-grading and -staging for AS eligibility. Moreover, we analyzed possible biomarkers for predicting more unfavorable final tumor histology. METHODS: 197 patients who underwent radical prostatectomy (RPE) but would have met the EAU (European Association of Urology) criteria for AS (PSA<10 ng/ml, biopsy GS ≤ 6, ≤ 2 cancer-positive biopsy cores with ≤ 50% of tumor in any core and clinical stage ≤ T2a) were included in the study. These AS inclusion parameters were correlated to the final histology of the RPE specimens. The impact of preoperative PSA level (low PSA ≤ 4 ng/ml vs. intermediate PSA of >4-10 ng/ml), PSA density (<15 vs. ≥ 15 ng/ml) and the number of positive biopsy cores (1 vs. 2 positive cores) on predicting upgrading and final adverse histology of the RPE specimens was analyzed in uni- and multivariate analyses. Moreover, clinical courses of undergraded patients were assessed. RESULTS: In our patient cohort 41.1% were found under-graded in the biopsy (final histology 40.1% GS7, 1% GS8). Preoperative PSA levels, PSA density or the number of positive cores were not predictive for worse final pathological findings including GS >6, extraprostatic extension and positive resection margin (R1) or correlated significantly with up-grading and/or extraprostatic extension in a multivariate model. Only R1 resections were predictable by combining intermediate PSA levels with two positive biopsy cores (p = 0.004). Sub-analyses showed that the number of biopsy cores (10 vs. 15 biopsy cores) had no influence on above mentioned results on predicting biopsy undergrading. Clinical courses of patients showed that 19.9% of patients had a biochemical relapse after RPE, among all of them were undergraded in the initial biopsy. CONCLUSION: In summary, this study shows that a multitude of patients fulfilling the criteria for AS are under-diagnosed. The use of preoperative PSA levels, PSA density and the number of positive cores were not predictable for undergrading in the present patient collective.

Surgical reconstruction of the urinary sphincter after traumatic longitudinal disruption.

The question is whether the urethral sphincter may be reconstructed after longitudinal injury similar to anal sphincter injuries. Analogue to obstetric, anal sphincter repair, an approximation repair of the sphincter may be feasible. An overlap repair is possible in anal sphincter repair, but because of the little tissue available in the urethral sphincter this is not an option. We describe three cases of urethral sphincter injury of different aetiologies. All resulted in a total longitudinal disruption of the muscular components of the urethral sphincter complex. After making the diagnosis of urethral sphincter injury, a primary approximation repair was done. Follow-up of at least two and up to three years is promising with one male patient being completely continent and the two female patients needing one safety pad per day. Longitudinal disruption of the muscular elements of the sphincteric urethra may be primarily reconstructed with good success using an approximation technique with simple interrupted sutures.

Quantitative measurement of the androgen receptor in prepuces of boys with and without hypospadias.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Despite diverse anatomical and histological trials in humans and animal models, the aetiology of hypospadias remains unknown and currently there is no clear molecular explanation about the emergence of this disease; however, genetic, endocrine and environmental mechanisms have been suggested. The aim of the present study was to quantify and compare the androgen receptor (AR; mRNA and protein) levels in 40 prepuces of boys with and without hypospadias using quantitative real-time polymerase chain reaction, Western Blot and standardised, automated immunohistochemistry. AR mRNA (P = 0.013) and AR protein (P = 0.014) was significantly elevated in the prepuces of boys with hypospadias compared with boys without hypospadias. Altogether our data indicate that elevated AR mRNA and protein levels can be considered as a biochemical response of an AR signalling defect as an identified cause in boys with hypospadias. Additionally, nuclear staining intensity for AR-protein in specimens of boys with hypospadias was higher than in boys with phimosis. OBJECTIVE: To address the role of the androgen receptor (AR) on mRNA and protein levels in prepuces of boys with and without hypospadias. PATIENTS AND METHODS: Data from 40 foreskin specimens of consecutive circumcised boys (20 with vs 20 without hypospadias) were enrolled in this prospective study. After surgery, samples were fixed in formaldehyde and frozen in liquid nitrogen. Total RNA was isolated from frozen tissue and transcribed to complementary DNA. The amount of AR mRNA was measured by quantitative real-time polymerase chain reaction and Western Blot and standardised, automated immunohistochemistry were used to assess AR protein levels. RESULTS: The mean age at time of surgery was 61.8 and 30.9 months in boys without and with hypospadias, respectively. There was penile, coronal and sine hypospadias in seven (35%), nine (45%), and four (20%) boys, respectively. AR mRNA was significantly elevated in the prepuces of boys with hypospadias compared with boys without hypospadias, at a mean (sd) of 28.33 (5.39) vs 15.31 (1.85) (P = 0.013). Furthermore, the amount of AR protein was higher in boys with, compared with boys without hypospadias, at a mean (sd) of 133.25 (6.17) vs 100 (4.45) (P = 0.014). CONCLUSIONS: Different AR mRNA expression and protein levels seem to be an indication of an AR signalling defect as a cause in boys with hypospadias. Decreased AR DNA binding and functional capability may result in a compensatory up-regulation of both AR mRNA and protein. Further studies are necessary to perform structural analysis of the AR and to corroborate these preliminary findings.

Autologous fibroblast transplantation at the vesico-ureteral junction as potential reconstructive cell replacement in an animal model.

PURPOSE: To evaluate the cellular survival of donor fibroblasts after transplantation at the vesico-ureteral junction (VUJ) and to analyse their potential for reconstructive cell replacement in an animal model as autologous fibroblasts have been used as soft tissue augmentation material for scared and damaged tissue. METHODS: Muscles biopsies were procured from the lower limb muscles of 4 pigs; cytoplasm of fibroblasts was labelled with nano-sized iron oxide particles. Six weeks after taking of the muscle biopsies, fibroblast transplantation was performed, 3 × 10(6) cells suspended in transplantation medium (in 1-ml syringes) were injected at the VUJ using the modified STING technique. Animals were killed 8 weeks later; seeded fibroblasts were identified using prussian blue staining protocol; histological evaluation and morphological analysis were performed by light microscopy (Mayer's haematoxylin-eosin staining); and bladders were scanned by MRI for visualization and localization of the iron-labelled donor cells. RESULTS: Donor fibroblast cell colonization and cellular viability at the VUJ was demonstrated by MRI and histochemically indicating cellular uptake of iron particles at the VUJ. It was also evident that transplanted fibroblasts integrate into the extracellular matrix of the distal ureter augmenting ureteral host tissue. CONCLUSIONS: Labelled implanted autologous fibroblasts were visualized by staining procedure as well as MRI scan demonstrating persistence at the VUJ, suggesting that in vitro expanded fibroblasts survived in vivo after transplantation.

Adverse pathological findings in needle biopsy gleason score 6 prostate cancers with low and intermediate preoperative PSA levels following radical prostatectomy.

AIM: We retrospectively analyzed the risk associated with undergrading Gleason score 6 (GS6) prostate cancer (PCa) at biopsy, in patients with preoperative PSA levels of 2-3,99 and 4-10 ng/ml. PATIENTS AND METHODS: A total of 674 patients with needle biopsy-diagnosed GS6 PCa, who underwent radical prostatectomy (RP) between 1995 and 2011, were evaluated. Patients were stratified by preoperative PSA levels into low PSA (2-3,99 ng/ml) and an intermediate PSA of 4-10 ng/ml. Subsequently, the percentage of patients with extracapsular disease (pathological stage ≥pT3a) and/or positive surgical margins was determined among those whose RP GS was still 6 and compared to undergraded cases. RESULTS: Out of 674 patients with needle biopsy-diagnosed GS6 PCa, 36.2% had no difference between biopsy and RP GS while 11.4% had been overgraded and 52.4% of patients were undergraded at biopsy. Stratified according to preoperative PSA levels, there was a significantly higher incidence of undergrading in the intermediate PSA group. Among those with ≥pT3a tumors, 74.1 % were undergraded in needle biopsy, out of which 67.7% had intermediate PSA levels and 32.3% low PSA levels. Among patients with R1 resections 75.1 % were underdiagnosed, out of which 75.9% had intermediate PSA levels. Stratifying these data according to preoperative PSA levels, ≥pT3a tumors and R1 resection were found significantly more often in the intermediate-PSA group. CONCLUSION: The incidence of adverse pathological findings, including extraprostatic extension and positive surgical margins, is significantly higher in patients with undergraded biopsy GS6. Low preoperative PSA levels improved the correlation between primary and final GS and led to the reduction of unfavorable pathological findings.

Diagnosis and management of pediatric urethral injuries.

OBJECTIVE: The incidence of urethral injuries in children is rare due to the fact that the urethra is short, mobile and protected by the pubic bone. The management of urethral trauma in childhood remains controversial because of the limited expertise of most urologists. MATERIAL AND METHODS: We performed a literature review by searching the Medline database for articles published between 1975 and 2010 based on clinical relevance. Electronic searches were limited to the keywords 'pediatric', 'urethral injury', 'trauma' and 'reconstruction'. RESULTS: Retrograde urethrography is considered the gold standard for diagnosis of urethral injuries. The initial management should ensure drainage of the bladder either by suprapubic cystostomy or urethral realignment if possible: in complete anterior urethral disruption as well as in children with life-threatening pelvic and intra-abdominal injuries after posterior urethral injuries, a deferred repair after 3 months is necessary. Immediate primary suturing of disrupted and dislocated urethral ends should be avoided because of high complication rates. Primary repair, however, of the defect is possible in girls avoiding a 2-stage approach. CONCLUSION: The aim of therapy is minimizing remote damages such as urethrocutaneous fistulae, periurethral diverticulae, strictures, incontinence and impotence with different therapeutic management depending on classification of the injury and the presence of life-threatening injuries.

In young adults with a low body mass index ultrasonography is sufficient as a diagnostic tool for ureteric stones.

OBJECTIVE: • To identify additional factors that might improve the diagnosis of ureteric stones using ultrasonography (US) as the primary diagnostic method. PATIENTS AND METHODS: • We performed a retrospective study of 228 patients who underwent rigid ureterorenoscopy (URS) for obstructive ureteric stones. • Patient age, sex, body mass index (BMI) and stone location and size were recorded. • All patients underwent US for stone detection before surgery. • If no cause of the flank pain was found by US, computer tomography (CT) was performed to confirm the absence of ureteric stones. RESULTS: • In 57 (25%), 15 (6.6%) and 156 (68.4%) patients a stone was localized on the proximal, mid- and distal ureter, respectively. • In 96 (42.1%), 122 (53.5%) and 10 (4.4%) patients the stone measured 0-5, 6-10 and >10 mm, respectively. • The mean (range) BMI of the patients was 24.7 (17.3-37.2) kg/m(2). • The overall stone detection rate using US was 86.4% overall, and 96.4% in adults ≤ 35 years. In 72/197 patients (36.5%) the stones found using US measured ≤ 5 mm and in 24/31 patients (77.4%) the stones found using CT measured ≤ 5 mm. • Age (P= 0.008), stone size (P < 0.001) and BMI (P= 0.013) were factors that independently affected ureteric stone diagnosis using US. CONCLUSION: • Although CT has served as the 'gold standard' for stone detection, its high costs and radiation dose, together with the high detection rate of US in the hands of experienced radiologists, lead us to conclude that US should be the first choice for primary diagnostic purposes, especially in young slim adults as no patient ≤ 35 years with a BMI ≤ 24 kg/m(2) needed unenhanced CT for ureteric stone diagnosis.

The anti-interleukin-6 antibody siltuximab down-regulates genes implicated in tumorigenesis in prostate cancer patients from a phase I study.

BACKGROUND: Interleukin-6 (IL-6) is associated with prostate cancer morbidity. In several experimental models, IL-6 has been reported to have anti-apoptotic and pro-angiogenic effects. Siltuximab (CNTO 328) is a monoclonal anti-IL-6 antibody which has been successfully applied in several models representing prostate cancer. This study was designed to assess preliminary safety of siltuximab in patients with early prostate cancer. PATIENTS AND METHODS: Twenty patients scheduled to undergo radical prostatectomy received either no drug or siltuximab (6 mg/kg, five patients per group with administration once, two times, and three times prior to surgery). Blood samples were collected for pharmacokinetic and pharmacodynamic analyses. Expression of elements of IL-6 signaling pathways was analyzed in tumor tissue by immunohistochemistry. Gene analysis in tumor specimens was performed with the DASL array. RESULTS: No adverse events related to siltuximab were observed. Patients treated with siltuximab presented with higher levels of proliferation and apoptosis markers. Following a single dose, serum concentrations of siltuximab declined in a biexponential manner. This study revealed a decrease in phosphorylation of Stat3 and p44/p42 mitogen-activated protein kinases. In addition, gene expression analyses indicate down-regulation of genes immediately downstream of the IL-6 signaling pathway and key enzymes of the androgen signaling pathway. CONCLUSIONS: Preliminary safety of siltuximab is favorable. Future studies in which siltuximab could be combined with androgen-deprivation therapy and experimental therapies in advanced prostate cancer are justified.

Unilateral renal agenesis with absent ductus deferens, epididymis and seminal vesicle: incidental finding in a 22-year-old patient with maldevelopment of the mesonephric duct.

Unilateral renal agenesis with an absence of the seminal vesicle, epididymis and ductus deferens is rare and is the result of a developmental disorder of the mesonephric or Wolffian duct. We report the case of a 22-year-old man who presented with testicular pain on the left side of 3 weeks' duration. During the clinical investigation of the scrotum a nonpalpable ductus deferens on the left side was found incidentally. As a result of the urological ultrasound the diagnosis of renal, epididymal, seminal vesicle and ductus deferens agenesis on the left was confirmed. As a vascular variety the CT demonstrated 2 renal veins and 2 renal arteries on the right originating from the superior mesenteric artery together with the right hepatic artery. The testicular artery was placed on both sides. Further diagnostic investigations including a spermiogram, hormone analysis and kidney function tests were normal. Congenital urogenital malformations can be found in various combinations even in adults. Unilateral absence of the vas deferens during clinical examination should alert the clinician to an underlying renal, seminal vesicle and epididymal anomaly; further urological investigation is mandatory. A genetic investigation of the CFTR gene is not necessary in the absence of both ductus deferentes with renal agenesis.