Management of non-penetrating renal trauma (NPRT) associated with urinary tract rupture (AAST Grade IV-V) is not clearly codified regarding the usefulness of upper tract drainage with stent insertion. The aim of this study was to compare the outcomes of an early upper urinary tract drainage (ED) to a conservative management (CM) after a NPRT with a urinary extravasation (UE) at initial CT-scan assessment.
A multicenter retrospective national study was conducted, including all patients treated for renal trauma in 16 centers from 2005 to 2015. Patients who had a UE at the initial CT-scan assessment delayed phase were considered for inclusion. Penetrating traumas, hemodynamically unstable patients and those who were initially treated with nephrectomy were excluded. Patients were divided into 2 groups: ED defined by drainage of upper urinary tract of the injured kidney within the 48 hours following the admission and CM. The persistence of UE at repeat CT-scan, the need for delayed drainage, length of stay, complications rate and specific death related to the trauma were analyzed.
Among a total of 1500 kidney trauma over the studied period 268 patients met the inclusion criteria. The median age was 25 years and 158 (79%) patients were male. Clinicians performed an ED with ureteric stent insertion for 69 patients (26%). A persistent UE was found in 50 patients (36%) of the CM on the repeat CT in mean delay of 6 days. This persistent leak required a delayed ureteric stent insertion in 23 patients (17%). The mean length of stay was longer after ED 21 days vs. 14 days after CM (p=0,03). There was no difference in complications rate and death related to the trauma between the 2 groups.
Table: Results after NPRT with urinary extravasation
|Early urinary drainage:||<0.001|
|External ureteric catheter||0||6(8%)|
|Persistent urinary extravasation at repeat CT:||0.47|
|Delayed urinary drainage:||0.04|
|Length of stay(days):||14||21||0.03|
|Death related to trauma:||1|
|Chronic kidney disease||1(1%)||1(3%)|
Our results suggest that CM should be considered for the management of renal trauma associated with urinary extravasation at the initial CT-assessment. CM was associated with good outcomes as 83% of the patients didn’t required any drainage of their upper tract and the urinary extravasation at repeat CT was still present for 36% of the patients only. Initial clinical monitoring and repeat CT-scan to re-assess the urine leak might be useful and less invasive than a systematic ED.
We have previously shown that penile stromal derived factor-1 (SDF1) injections improve erectile function following cavernous nerve injury (CNI). To better understand the mechanism of this, we tested whether SDF1 treatment of major pelvic ganglion (MPG) neurons augments neurogenesis.
MPGs were isolated from male Sprague-Dawley rats weighing ~350g. MPGs were cultured in matrigel and serum free media whole or dissociated into single neurons for 72 hours with and without human SDF1 treatment (500ng/mL). SDF1 treated MPGs were also treated with and without the SDF1 receptor (CXCR4) antagonist AMD3100 (5uM). CXCR4 expression was evaluated with immunofluorescence. Neurite growth from the MPG was measured using bright field microscopy. Expression of 27 growth factors, cytokines, and neurotrophins were assessed using a protein array (Neuromics Edina, MN, USA).
MPG neurons express CXCR4. Furthermore, SDF1 treatment increases neuron CXCR4 expression over controls (77.1 vs. 44.7 fluorescent intensity, p<0.0001, n=4/group). MPGs treated with SDF1 demonstrated greater neurite growth (1045.7 vs. 739.6 uM, p=0.002, n=5/group). This growth enhancement was not seen when SDF1 treated MPGs were also treated with the CXCR4 antagonist AMD3100 compared to controls (771.7 uM, p=0.7). MPGs treated with SDF1 demonstrated significantly increased protein levels in 9 growth factors including brain-derived neurotrophic factor, insulin-like growth factor 1, basic fibroblast growth factor, epidermal growth factor receptor, fibroblast growth factor 7, growth hormone, bone morphogenetic protein 4, endocrine gland-derived vascular endothelial growth factor, and insulin-like growth factor binding protein 2 on protein array (n=4/group).
MPG neurons express the SDF1 receptor CXCR4, which is increased by SDF1 treatment. MPG neurite outgrowth is enhanced by SDF1 treatment, which is prevented by CXCR4 blockade. SDF1 treatment is associated with increased growth factor and neurotrophin protein expression, which may explain the increased neurite outgrowth. Therefore, the beneficial effects of SDF1 on erectile function may be in part due to its direct neurotrophic effects on MPG neurons.
Diagnostic of urolithiasis composition is the keystone for prophylactic treatment of stone disease. To date, the gold standard for stone composition analysis remains the infrared spectroscopy (IRS) with morphological study, that should be performed in all first-time formers. The objective of our study was to assess the feasibility of Raman Spectroscopy (RS) in biological environments for stone composition analysis and to develop a laser fiber for intraoperative diagnosis.
A set of stones (>1000) were analyzed by the gold standard technique. The purest (>85% of same composition) were selected to be analyzed on a specific RS setup. We used a laser with a 785nm wavelength. A first analysis was performed in the air to obtain the spectral characteristics of each stone. Then an analysis in urinary environment was performed. Different urinary dilutions were tested to obtain the minimum concentration of proteins for interpretable spectra. A RS analysis with a specific small caliber fiber was then performed and the evaluation of the best settings for a potential peroperative use was done.
Seven different classes of stones were analyzed: weddellite, whewellite, struvite, brushite, carbapatite, cystine and uric acid. A specific spectral signature was obtained in the air for each class of stones. A RS was performed in urine at different dilution, we were able to obtain the same spectral signature than in the air but with less intensity. In urine diluted, the intensity of the signal was stronger than in urine concentrated. Brushite stones has the worst signal in RS compared to the other one, presence of blood clots or proteins reduced the intensity and increased background noise. Our specific setup with laser fiber was able to give all the specific spectral signature for each stone in the air or in the urine.
The distance between the laser and the stone impacted the intensity: the signal was maximum when the fiber was in contact of the stone. All the signals were obtained in less than 20 seconds.
Raman spectroscopy analysis of stone composition in urine is feasible and reproducible with a 785nm laser. We identified the best settings for a good analysis (urine diluted, fiber in contact...) and we were able to perform the analysis in less than 20 seconds. These results show the potential applicability of RS for a clinical endoscopic use in order to diagnose peroperatively the stone composition and adapt laser settings for the destruction of the stone.
The role of post nephro-ureterectomy treatment for UTUC is unclear. POUT (CRUK/11/027; NCT01993979) is a UK led trial that addresses whether adjuvant chemotherapy improves disease free survival (DFS) for patients with histologically confirmed pT2-T4 N0-3 M0 UTUC.
Patients (maximum n=345), WHO performance status 0-1, ≤90 days post NU were randomised (1:1) to 4 cycles of gemcitabine-cisplatin (gemcitabine-carboplatin if GFR 30-49ml/min) or surveillance with chemotherapy given on recurrence if required. Patients had 6 monthly cross sectional imaging and cystoscopy for the first 2 years, then annually to 5 years. Toxicity was assessed by CTCAE v4. The primary endpoint was DFS. The trial was powered to detect a hazard ratio (HR) of 0.65 (i.e. improvement in 3 year DFS from 40% to 55%; 2-sided alpha=5%, 80% power) with Peto-Haybittle (p<0.001) early stopping rules for efficacy and inefficacy. Secondary endpoints included metastasis-free survival, overall survival, toxicity (CTCAE v4) and patient reported quality of life (assessed by EORTC QLQ-C30 and EQ5D).
Between 31st May 2015 and 5th September 2017, 248 patients were randomized (123 surveillance; 125 chemotherapy) at 57 UK centres. In October 2017, the independent trial oversight committees recommended POUT close to recruitment as data collected thus far (data snapshot 5th September 2017) met the early stopping rule for efficacy. At the time of interim analysis, median follow-up was 17.6 months (IQR 7.5-33.6). Patients had median age 69 years (range 36-88), 30% pT2, 65% pT3; 91% pN0. Grade ≥3 toxicities were reported in 60% chemotherapy patients and 24% surveillance patients. During the treatment period the most common grade ≥3 [≥4] toxicities in chemotherapy patients were neutropenia 29% [5%] (vs. 0% surveillance) and thrombocytopenia 7% [6%] (vs. 0%). 47/123 (surveillance) and 29/125 (chemotherapy) DFS events were reported; unadjusted HR = 0.47 (95% CI: 0.29, 0.74) in favour of chemotherapy (log-rank p= 0.0009). Two year DFS was 51% for surveillance (95% CI: 39, 61) and 70% for chemotherapy (95% CI: 58, 79). Metastasis-free survival also favoured chemotherapy: HR = 0.49 (95% CI: 0.30, 0.79, p=0.003).
Adjuvant chemotherapy is tolerable and improved metastasis-free survival in UTUC. Recruitment to the POUT trial was terminated early because of efficacy favouring the chemotherapy arm; follow up for overall survival continues. POUT is the largest randomised trial in UTUC and its results support the use of adjuvant chemotherapy as a new standard of care.
Guidelines advise mpMRI in patients with prior negative prostate biopsies and a persisting suspicion of prostate cancer (PCa), enabling target biopsy of MRI lesions. Three techniques of MRI targeted biopsy (MRI-TB) are available and no consensus exists on which should be preferred. The FUTURE trial is a multicenter RCT comparing detection rates of (significant) PCa for three techniques of MRI-TB (cognitive TRUS, MR-TRUS fusion, in-bore MRI).
Ethical board approval was granted for this study and all patients provided written IC. 642 men were recruited between 2014 and 2017 with prior negative prostate biopsies and a suspicion on prostate cancer (based on PSA≥4 and/or abnormal DRE), and underwent mpMRI. Imaging was centrally evaluated by an expert radiologist using PIRADS v2. If mpMRI demonstrated PIRADS≥3 lesions patients were randomized 1:1:1 for MRI-TB. Overall PCa and significant PCa (Gleason≥7) detection rates were compared using Pearson Chi square test.
231 patients (36.0%) had a PIRADS≥3 lesion on mpMRI, and 223 underwent MRI-TB. There were no significant differences in baseline characteristics, nor were PIRADS scores significantly different between the three groups (p=0.87). Using cognitive TRUS biopsy PCa was detected in 44.0%, and significant PCa in 33.3%. Using MR-TRUS fusion biopsy PCa was detected in 49.3%, and significant PCa in 33.3%. Using in-bore MRI biopsy PCa was detected in 56.2%, and significant PCa in 34.2%. The detection rates of the three MRI-TB techniques were neither significantly different for overall PCa detection (p=0.33) nor for significant PCa (p=0.99).
|Cognitive TRUS (n=75)||MR-TRUS fusion (n=75)||In-bore MRI (n=73)|
|Volume on TRUS (mean)||48,5||46,0||48,7||p=0.46|
|Clinical stage (DRE)
· PIRADS 3
· PIRADS 4
· PIRADS 5
|Lesion size in mm’s (mean)||13,2||14,3||13,9||p=0.66|
|Detection rate of PCa on TB
· PIRADS 3
· PIRADS 4
· PIRADS 5
|Detection rate of significant PCa (Gleason ≥7) on TB
· PIRADS 3
· PIRADS 4
· PIRADS 5
Based on the results of this multicenter RCT there does not seem to be a significant advantage of one specific MRI-TB technique for the detection of (clinically significant) PCa following prior negative prostate biopsies.
Many patients with castration-resistant prostate cancer (CRPC) do not respond to the anti-androgen enzalutamide or develop secondary resistance over time of treatment. In a previous study we found that prostate cancer (PCa) cells exhibit diminished response to enzalutamide when co-cultured with cancer-associated fibroblasts (CAFs) as 3-dimensional (3D) spheroids. In the present study we investigated the molecular changes in 3D cultures of PCa cells in the absence or presence of CAFs to identify potential underlying mechanisms of enzalutamide resistance.
Spheroids were established in 96 well hanging drop plates by seeding PCa epithelial cells (LNCaP, DuCaP) alone or together with CAFs at a ratio of 1:1. Illumina microarrays were used to screen for differentially regulated genes (DRGs) between 2D monolayer culture, 3D monoculture and co-culture spheroids after 8 days of culture. Real-time polymerase chain reaction and Western blotting were used to validate expression levels of selected targets.
3D spheroids of both PCa cell lines without CAFs presented a typical gene signature compared to 2D culture. Specifically, we found an upregulation of “cell adhesion” and “extracellular matrix (ECM)-receptor interaction” and a downregulation of “cell cycle” and “DNA replication” pathways, indicating strong cell-to-cell and cell-to-ECM interaction but low proliferative activity in 3D spheroids. Notably, the 3 most up-regulated genes (GDF-15, growth differentiation factor, SAT1, spermidine/spermine N1-acetyltransferase 1, PLAUR, plasminogen activator, urokinase receptor) were previously associated with PCa. Comparing PCa 3D spheroids with and without CAFs we found genes such as NFkB1 and signal transducer and activator of transcription 3 (STAT3), which have already been associated with enzalutamide resistance, being significantly upregulated in both cell lines. Even more important, cholesterol synthesis and steroid synthesis pathways, which are generally accepted to play a substantial role in CRPC, were significantly upregulated upon co-culture of PCa cells with CAFs. In particular, 3-hydroxy-3-methylglutaryl-Coenzyme A synthase 2 (HMGCS2), aldo-keto reductase family 1 member C3 (AKR1C3) and UDP-glucuronyltransferase 1A1 (UGT1A1) were induced by at least 4-fold. Upregulation of these genes was confirmed by real-time PCR and Western blotting.
In the present study we identified 3 pivotal molecules within cholesterol and steroid biosynthesis that were significantly upregulated in PCa cells upon co-culture with CAFs and which could be targeted to intervene with enzalutamide resistance.