Pekka Hellström

Factors Explaining Recurrence in Patients Undergoing Chemoimmunotherapy Regimens for Frequently Recurring Superficial Bladder Carcinoma

OBJECTIVES To study the factors determining new recurrences in patients with frequently recurring superficial bladder tumors. METHODS Of all 205 eligible patients, each received 5 weekly intravesical instillations of mitomycin C (MMC), with the first instillation given perioperatively. This was followed, according to randomization, by BCG instillations alone or by alternating instillations of interferon-alpha and BCG monthly for up to 1 year. Impact of 12 variables on time to first recurrence was retrospectively studied with the Cox multiple hazards regression and Kaplan-Meier analysis. RESULTS Type of regimen was the most significant factor determining new recurrences, with preceding recurrence rate being the most important prognostic factor. Timing of the first MMC was the third significant predictor in the main multivariate analysis, with more than a two-fold relative risk for a new recurrence if the first MMC instillation was given later than on day 0. CONCLUSION Preceding recurrence rate, most accurately reflects, in patients with frequently recurring tumors, the inherent risk for new recurrences. This risk can be considerably reduced by use of an effective chemoimmunotherapy regimen, and in addition, by inclusion of an early perioperative chemotherapy instillation in such a regimen.

Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study.

Objective To study the lifetime occurrence of prostatitis in Finnish men and their exposure to the disease.

Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland.

Objective To determine the occurrence of mental distress related to prostatitis in Finnish men.

Treatment of renal cysts with single-session percutaneous drainage and ethanol sclerotherapy: long-term outcome

OBJECTIVES To evaluate the safety, efficacy, and long-term outcome of single-session ethanol sclerotherapy for non-neoplastic renal cysts. METHODS In a prospective study, 32 patients with a simple renal cyst were treated with ultrasound-guided percutaneous aspiration, and no more than 100 mL sterile 99% ethanol was injected into the cyst. The procedure was performed under local anesthesia, and the patients were hospitalized overnight. The serum concentrations of alcohol immediately after the sclerotherapy and 1 hour later and the corresponding urine concentrations were measured. The mean follow-up period was 55 months (range 12 to 156). Control checkups were scheduled at 1, 3, 6, 9, and 12 months after the sclerotherapy. During the control visits, the patients underwent ultrasound measurement of the size of the cyst. The history concerning renal pain especially was evaluated by the urologist. The patients were asked if they did or did not have pain. The severity of pain was not evaluated. RESULTS Sclerotherapy with ethanol was performed successfully in all 32 patients with a simple renal cyst. The cyst disappeared completely in 7 patients (22%). The mean size of all cysts decreased from 7.8 cm (range 3 to 16) to 1.7 cm (range 0 to 9; P <0.0001). Before the sclerotherapy, 24 patients had symptoms due to the cyst, and 18 of these (75%) were asymptomatic after the ethanol sclerotherapy. In 2 patients the pain decreased, 2 patients were without change, and in 2 patients the pain increased. There was no correlation between the size of the cyst and the intensity of pain. No major complications occurred. The serum concentration of alcohol varied from 0 to 0.30 g/L and that in urine from 0.04 to 0.27 g/L. CONCLUSIONS Percutaneous aspiration and sclerotherapy with ethanol for simple renal cysts is simple, fast, safe, effective, and inexpensive. The results are comparable to those reported earlier. The treatment is without major complications. We propose sclerotherapy with 99% ethanol as the primary treatment of simple renal cyst. The treatment can be done in an outpatient clinic.

Bacillus Calmette-Guérin Is Superior to a Combination of Epirubicin and Interferon-α2b in the Intravesical Treatment of Patients with Stage T1 Urinary Bladder Cancer. A Prospective, Randomized, Nordic Study ☆

BACKGROUND Bacillus Calmette-Guérin (BCG) instillation is regarded as the most effective bladder-sparing treatment for patients with high-grade T1 tumours and carcinoma in situ (CIS). The major problem with this therapy is the side-effects, making maintenance therapy difficult, even impossible, in a proportion of patients. Thus, alternative schedules and drugs have been proposed. OBJECTIVE To compare BCG to the combination of epirubicin and interferon-alpha2b as adjuvant therapy of T1 tumours. DESIGN, SETTING, AND PARTICIPANTS This is a Nordic multicenter, prospective, randomised trial in patients with primary T1 G2-G3 bladder cancer. Initial transurethral resection (TUR) was followed by a second-look resection. Patients were randomised to receive either regimen, given as induction for 6 wk followed by maintenance therapy for 2 yr. MEASUREMENTS The drugs were compared with respect to time to recurrence and progression. Also, side-effects were documented. RESULTS AND LIMITATIONS A total of 250 patients were randomised. At the primary end point, 62% were disease free in the combination arm as opposed to 73% in the BCG arm (p=0.065). At 24 mo, there was a significant difference in favour of the BCG-treated patients (p=0.012) regarding recurrence, although there was no difference regarding progression. The subgroup analysis showed that the superiority of BCG was mainly in those with concomitant CIS. In a multivariate analysis of association with recurrence/progression status, significant variables for outcome were type of drug, tumour size, multiplicity, status at second-look resection, and grade. A corresponding analysis was performed separately in the two treatment arms. Tumour size was the only significant variable for BCG-treated patients, while multiplicity, status at second-look resection, and grade were significant for patients treated with the combination. CONCLUSIONS For prophylaxis of recurrence, BCG was more effective than the combination. There were no differences regarding progression and adverse events between the two treatments.

Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery

Objective. There is an impression that ureteric injuries have become more common during the past decade, and therefore this study aimed to determine the incidence, aetiology, features, treatment and outcomes of ureteric injuries over an extended period. Material and methods. Records of patients treated for ureteric injury in 1986–2006, divided into three 7-year periods, were reviewed retrospectively. The numbers of open and laparoscopic gynaecological, surgical and endourological operations were ascertained. Results. All 72 ureteric injuries recorded were iatrogenic, being diagnosed in 60 females and 11 males (mean age 52 years). Only five injuries occurred during the first 7-year period (1986–1992), but the incidence was markedly higher during the following two 7-year periods, 28 (1993–1999) and 39 (2000–2006), respectively. The injuries were mostly secondary to gynaecological procedures (64%) or general surgery (25%). Only 11% occurred in association with a urological procedure. The cause was mostly laparoscopic (56%) or open surgery (33%), and the injury was in most cases located in the lower ureter (89%). The diagnosis was usually delayed (in 79%), with a median time to diagnosis of 6 days. The injuries were managed by ureteroneocystostomy (49%), a ureteral stent (19%) or end-to-end anastomosis (12%). The complication rate was 36%. Conclusions. Iatrogenic ureteric injuries have increased markedly during the past two decades. Gynaecological laparoscopic procedures account for more than half of the injuries, and the most common location is the lower ureter. Most injuries are treated by ureteroneocystostomy, but endourological treatment yields acceptable results. To improve the management of ureteric injury there must be a high index of suspicion, especially during laparoscopic operations.

Effect of diagnostic hydrodistension and four intravesical hyaluronic acid instillations on bladder ICAM-1 intensity and association of ICAM-1 intensity with clinical response in patients with interstitial cystitis

OBJECTIVES To study the clinical effect of diagnostic overdistension plus hyaluronic acid (HA) instillations in interstitial cystitis and the association of the clinical response with the intensity of intercellular adhesion molecule (ICAM)-1 expression. HA is an important component in the urothelium. It inhibits adherence of immune complexes to polymorphonuclear cells, leukocyte migration, and aggregation. HA binds to lymphocytes and endothelial cells expressing ICAM-1. METHODS Eleven patients with interstitial cystitis who fulfilled the diagnostic criteria of the National Institutes of Health were selected for the trial. The bladder was distended for 1 minute with a pressure of 80 cm H2O and biopsies were taken from the petechial areas. The patients were treated with four weekly intravesical HA instillations (40 mg/50 mL NaCl solution). Biopsies were repeated 2 weeks after the instillations. The ICAM-1 intensity was blindly determined in the lymphocytes and endothelial cells of the vessels from the histologic biopsies. A semiquantitative scoring index was used to measure the inflammatory effect of ICAM-1 receptors. RESULTS In the long-term responders (2 women and 1 man) and short-term responders (5 women), the pretreatment ICAM-1 index was 3.7 (range 3 to 4); it was 1.8 (range 1.5 to 2) in the nonresponders. Two weeks after the final instillation, the index was 3.5 (range 3 to 4) in the long-term responders and 3.4 (range 3 to 4) in the short-term responders; in the nonresponders, it had increased to 2.8 (range 2.5 to 3.5). CONCLUSIONS Increased ICAM-1 intensity was found in patients with interstitial cystitis; it was higher in those who responded to overdistension plus HA instillations. By blocking the ICAM-1 receptors, HA presumably alleviates the inflammatory processes, but repeated instillations are needed to maintain the response.

A double-blind, randomized, placebo-controlled pilot study to investigate the effects of finasteride combined with a biodegradable self-reinforced poly L-lactic acid spiral stent in patients with urinary retention caused by bladder outlet obstruction from benign prostatic hyperplasia.

Objective To assess whether patients in acute urinary retention from benign prostatic enlargement can be treated with a combined therapy comprising finasteride and a bioabsorbable self‐reinforced poly l‐lactic acid (SR‐PLLA) urethral stent.

Efficacy and safety of clean intermittent catheterization in adults.

A prospective study was carried out on the efficacy and safety of clean intermittent catheterization (CIC). The series included 41 adults (15 females, 26 males), the mean follow-up time being 40 months. Most patients were suffering from neurogenic bladder disorders. All of them used a self-lubricating hydrophilic catheter. Thirty-one patients (76%) continued to undergo CIC, but 9 discontinued. Thirty patients (73%) experienced bacteriuria during the procedure. Three males had epididymitis. Contrary to many earlier reports, urinary tract infections seem to increase after CIC, raising the question of whether prophylactic antibiotic therapy should be used more often in these cases. There were no urethral complications suggesting that the self-lubricating hydrophilic catheters may be less traumatic than those used previously.

Mechanisms of pain in chronic pelvic pain syndrome: influence of prostatic inflammation

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), is of considerable interest in clinical urology. During the past decade, several new approaches have been made to discover its aetiology and pathophysiological mechanisms and to develop treatment modalities. The aetiology of CPPS has remained unresolved. Bacterial, chemical, urodynamic and immunological aetiologies have been suggested, but none of these has been conclusively proven. The histopathological changes in CP and CPPS are relatively well known, but the pathophysiological changes that lead to chronic inflammation and prolonged symptoms are still poorly understood. This review proposes an additional approach to the pathophysiology of CPPS. The concept of prostate tissue pressure is introduced as an objectively measurable parameter in evaluating the inflammatory process in CPPS. Chronic pain due to neurogenic inflammation and altered mast cell function is also discussed.