Paul Zupkas

Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome

OBJECTIVES To examine populations with diagnosed clinical interstitial cystitis (IC) and urethral syndrome and normal controls using the potassium sensitivity test (PST), to determine the incidence of PST-provoked pain and/or urgency, and to document the type and location of IC and urethral syndrome pain, association of pain with sexual intercourse, and family history of female urgency/frequency problems. METHODS The PST and a questionnaire were administered to 466 patients with clinical IC, 116 patients with urethral syndrome, and 42 controls. RESULTS The PST was positive in 78% of patients with clinical IC, in 55% of patients with urethral syndrome, and in 0% of the controls. Of the patients with clinical IC, 9% responded to the PST with pain only and 8% with urgency only. Patients with clinical IC reported the pain as dysuria (58%), urethral/vaginal (76%), above the pubic bone (53%), lower abdomen (47%), lower back (35%), vaginal (51%), and inguinal (28%). The results were similar for patients with urethral syndrome. Of the sexually active men and women, 71% with clinical IC and 59% with urethral syndrome reported pain associated with intercourse. Urgency/frequency problems in female relatives were reported by 35% of patients with IC and 33% of those with urethral syndrome. CONCLUSIONS The significant potassium sensitivity in both patients with clinical IC and those with urethral syndrome and the absence of potassium sensitivity in normal controls indicates that a positive PST suggests the presence of an abnormal bladder epithelium. The lower rate of positive PSTs in patients with urethral syndrome reflects the less severe, more intermittent, nature of the symptoms in urethral syndrome (early IC). Pelvic pain of bladder origin may occur anywhere in the pelvis. Finally, IC appears to have a genetic component.

Quantifying symptoms in men with interstitial cystitis/prostatitis, and its correlation with potassium-sensitivity testing

To determine whether men previously diagnosed with prostatitis also have pathology originating in the bladder.

Alkalinized Lidocaine and Heparin Provide Immediate Relief of Pain and Urgency in Patients with Interstitial Cystitis

INTRODUCTION It has been reported in an open-label study that the combination of alkalinized lidocaine and heparin can immediately relieve the symptoms of urinary urgency, frequency, and pain associated with interstitial cystitis (IC). This combination has also been reported to relieve pain associated with sex in patients with IC. AIM The aim of this study was to corroborate these findings in a multicenter setting. METHODS The study design was a multicenter prospective, double-blind, crossover, placebo-controlled trial. Each participant met all of the clinical National Institute of Diabetes and Digestive and Kidney Diseases criteria (excluding cystoscopy) for IC. Each patient received drug and control, in random order, within 48 hours of enrolling in the study. MAIN OUTCOME MEASURES The primary outcome measure was percent change in pain score (11-point analog pain scale) 12 hours after receiving the drug or control. Secondary measures were the global assessment response (GAR) of symptoms and 12-hour average urgency reduction determined from 11-point urgency scales. RESULTS Eighteen (18) patients completed the trial. The average reduction of pain over 12 hours was 21% for control and 42% for active drug (P = 0.0363). GAR was 13% for control and 50% for drug (P = 0.0137). Average urgency reduction was 13% for control and 35% for drug (P = 0.0328). CONCLUSIONS The combination of alkalinized lidocaine and heparin provides up to 12 hours of relief from urgency and pain associated with IC. This combination provides significant immediate relief of symptoms for patients with IC.

Intraoperative mapping of renal lymphatic drainage: technique and application in a porcine model.

BACKGROUND AND PURPOSE The use of lymphadenectomy in renal-cell carcinoma (RCC) is controversial. Proponents argue that lymphadenectomy improves survival, whereas opponents challenge the procedure on the basis of its morbidity and the variable lymphatic drainage of the kidney. Intraoperative gamma probes have been used to guide resection of radiolabeled sentinel nodes in cancers of the breast, penis, and head and neck and in melanoma. Our goal in applying this technique to RCC is to improve detection and to limit sampling of lymph nodes during lymphadenectomy. This preliminary study in a porcine model evaluated the feasibility and transit time of radiolabeled tracer injected into the kidney. MATERIALS AND METHODS Data were collected on four 40-kg Yorkshire pigs. The right kidney was exposed through a flank incision. Using both blue dye and technetium-99m, mapping and resection of the sentinel lymph nodes was performed with the assistance of an intraoperative gamma probe (Neoprobe). Remote cervical lymph nodes were utilized as controls. Vascular counts along the carotid vessels were obtained to confirm that the radioisotope was not being dispersed systemically. RESULTS Within 10 minutes of renal injection of the tracer, excised sentinel lymph nodes demonstrated significant radioactive counts compared with controls. Vascular counts confirmed that radioisotope tracer did not enter the venous circulation. CONCLUSIONS Sentinel lymph node sampling using a gamma probe and blue dye appears to be feasible in the porcine kidney. Further studies using this technique in humans will evaluate the impact of selective lymphadenectomy on survival in RCC.

Small intestinal submucosa as a tunica albuginea graft material.

PURPOSE We evaluated the morphological, immunological and functional response to small intestinal submucosa grafting of the tunica albuginea to determine its potential as a grafting material for penile surgery. MATERIALS AND METHODS Male New Zealand White rabbits underwent a sham procedure (6) or tunical excision and grafting with small intestinal submucosa (6). The erectile response to the intracavernous vasoactive agents sodium nitroprusside plus a papaverine, phentolamine and prostaglandin E1 combination (Sigma Chemical Co., St. Louis, Missouri) was evaluated 45-day postoperatively. The area under the graft was evaluated for stromal collagen and smooth muscle content by Massons trichrome stain. Protein expression of smooth muscle specific alpha-actin and the inflammatory markers inducible nitric oxide synthase (NOS) and transforming growth factor-beta1 (TGF-beta1) was evaluated by immunohistochemical methods. Total RNA was extracted from the corpora cavernosum underlying the small intestinal submucosa graft and reverse transcriptase-polymerase chain reaction (RT-PCR) was done using an Access system (Promega, Madison, Wisconsin) with gene specific primers for inducible NOS, TGF-beta1 and vascular endothelial growth factor (VEGF). RESULTS Grafting of the tunica albuginea with small intestinal submucosa had no significant effect on the magnitude or duration of the erectile response to intracavernous vasoactive agents. Histological examination demonstrated no inflammatory changes in the tunica albuginea or corporeal tissue underlying the area of the small intestinal submucosa graft and there was no appreciable alteration in smooth muscle or collagen content. The 2 groups showed intense positive immunostaining to alpha-actin. Weak expression of TGF-beta1 predominantly associated with smooth muscle fibers was identified in the 2 groups of rabbits by immunostaining and RT-PCR. No significant inducible NOS was detected by immunostaining or RT-PCR in either group. Strong VEGF expression was observed in grafted rabbits. The most noticeable (3-fold) increase in expression was detected in splice variant 165. CONCLUSIONS Small intestinal submucosa grafting of the tunica albuginea preserves the duration and magnitude of the erectile response to vasoactive agents. This type of tunical grafting does not stimulate a significant inflammatory response, or cause corporeal fibrosis or loss of cavernous smooth muscle content. Stimulating VEGF may facilitate wound healing and the maintenance of normal erectile function.

A Multi-Site Study Confirms Abnormal Glycosylation in the Tamm-Horsfall Protein of Patients With Interstitial Cystitis

PURPOSE We confirm the single site observation of decreased sialylation and abnormal glycosylation of Tamm-Horsfall protein in patients with interstitial cystitis compared to control subjects. MATERIALS AND METHODS Urine samples from 41 controls and 48 patients with interstitial cystitis from a total of 5 North American sites were obtained in blinded fashion as to participant status. Tamm-Horsfall protein was isolated from urine samples by salt precipitation. Protein content was determined by size exclusion chromatography and normalized to creatinine. Sialic acid was quantified by 1,2-diamino-4,5-methylene dioxybenzene (Sigma®) high performance liquid chromatography with fluorescence detection. Neutral and amino sugars were determined by high pH anion exchange chromatography with pulsed amperometric detection. N-glycans were labeled with 2-aminobenzamide and profiled using high pH anion exchange chromatography with fluorescence detection. Samples were also analyzed by matrix assisted laser desorption/ionization-time of flight mass spectrometry. Permethylated N-glycans were analyzed in the mass-to-charge ratio range of 3,000 to 6,000. RESULTS There was no difference in the protein-to-creatinine ratio of Tamm-Horsfall protein from patients with interstitial cystitis vs controls (49.12 vs 46.4 mg/gm, p = 0.26). Sialic acid content (67 vs 77 nmol/mg Tamm-Horsfall protein, p = 0.025) and total monosaccharide content (590.9 vs 680.6 nmol/mg Tamm-Horsfall protein, p = 0.003) were significantly decreased in patients with interstitial cystitis vs controls. Results were supported by 2-aminobenzamide N-glycan profiling and mass spectrometry, which showed a 45% decrease in a major tetra-sialylated peak (mass-to-charge ratio 4,590) in Tamm-Horsfall protein from patients with interstitial cystitis compared to controls. CONCLUSIONS These multisite data validate that abnormal glycosylation of Tamm-Horsfall protein occurs in patients with interstitial cystitis and may have a role in interstitial cystitis causation.

Intravesical Ethanol as Quantitative Measure of Bladder Hyperpermeability

BACKGROUND AND PURPOSE Bladder surface hyperpermeability may be a factor in the etiology of interstitial cystitis (IC). We evaluated the intravesical instillation of ethanol as a quantitative measure of bladder hyperpermeability in an experimental model in male New Zealand White rabbits. MATERIALS AND METHODS In two study groups (N = 4 each), the glycosaminoglycan (GAG) layer on the bladder surface was disrupted via a 10-minute exposure to 10% protamine sulfate (PS). The study groups then underwent bladder instillation of 10% (group 1) and 20% (group 2) ethanol. The control groups underwent bladder instillation of either 10% (N = 2) or 20% ethanol (N = 2) without exposure to PS. Ten minutes after ethanol instillation, venous blood was sampled, and the ethanol concentration was determined by mass spectrometry. Study group animals were sacrificed after blood sampling. Control animals were sacrificed at 2 weeks and 4 weeks for histologic examination of the bladder. RESULTS The blood alcohol concentration was 0 in the control animals exposed to 10% or 20% ethanol, 14.5+/-2.2 ng/dL in the 10% ethanol study group, and 25.6+/-3.6 ng/dL in the 20% ethanol study group. Histologic examination of bladder tissue revealed no ethanol-induced abnormalities in the control animals. CONCLUSION Intravesical instillation of 10% and 20% ethanol is a safe and reliable quantitative measure of bladder hyperpermeability in an animal model. Clinical trials are ongoing to evaluate the utility of the intravesical ethanol test for diagnosing IC and monitoring the response to therapy.

SOLUBILITY OF AMMONIUM ACID URATE NEPHROLITHS FROM BOTTLENOSE DOLPHINS (TURSIOPS TRUNCATUS)

Nephrolithiasis has been identified in managed populations of bottlenose dolphins (Tursiops truncatus); most of these nephroliths are composed of 100% ammonium acid urate (AAU). Several therapies are being investigated to treat and prevent nephrolithiasis in dolphins including the alkalization of urine for dissolution of nephroliths. This study evaluates the solubility of AAU nephroliths in a phosphate buffer, pH range 6.0-8.0, and in a carbonate-bicarbonate buffer, pH range 9.0-10.8. AAU nephroliths were obtained from six dolphins and solubility studies were conducted using reverse-phase high performance liquid chromatography with ultraviolet detection at 290 nm. AAU nephroliths were much more soluble in a carbonate-bicarbonate buffer, pH range 9.0-10.8 compared to phosphate buffer pH range 6.0-8.0. In the pH range 6.0-8.0, the solubility was 45% lower in potassium phosphate buffer compared to sodium phosphate buffer. When citrate was used along with phosphate in the same pH range, the solubility was improved by 13%. At pH 7 and pH 8, 150 mM ionic strength buffer was optimum for dissolution. In summary, adjustment of urinary pH alone does not appear to be a useful way to treat AAU stones in bottlenose dolphins. Better understanding of the pathophysiology of AAU nephrolithiasis in dolphins is needed to optimize kidney stone prevention and treatment.