Red Area, eURO Auditorium 2
Neurogenic detrusor overactivity (NDO) combined with detrusor sphincter dyssynergia (DSD) due to spinal cord injury (SCI) may lead to high intravesical pressure causing structural damage to the lower and upper urinary tract with a relevant risk for life-threatening end-stage renal failure. Currently, no causal therapy is available to treat this dangerous condition. We therefore investigate if antibodies against the nerve fiber growth inhibitory central nervous system protein Nogo-A applied to the injured spinal cord in rats could prevent the development of neurogenic lower urinary tract dysfunction, in particular DSD.
Lower urinary tract function of 86 female Lewis rats with no injury (n=17), complete (n=28) or incomplete (n=41) SCI at thoracic level 8 was assessed using our novel urodynamic model (Schneider MP et al., BJUI 2015) allowing repetitive longitudinal measurements of both bladder and external urethral sphincter function in the same animal under fully awake conditions.
Four weeks after large but incomplete thoracic SCI, DSD had developed in all untreated or control antibody infused animals. In contrast, 2 weeks of intrathecal anti-Nogo-A antibody treatment lead to a significantly reduced maximum detrusor pressure during voiding and a reduction of electromyographic high frequency activity in the external urethral sphincter. Importantly, no effect of anti-Nogo-A therapy on lower urinary tract function was observed in animals with a complete SCI. Four weeks after incomplete SCI, animals treated with control antibodies showed a significant decrease in CRF-innervation in lamina X compared to non-injured animals. In contrast, the density of CRF fibers and terminals in this region in the injured anti-Nogo-A antibody treated rats was not different from that of intact rats but was significantly higher than that of the control antibody SCI animals.
Our findings indicate that anti-Nogo-A antibody treatment has beneficial effects on the lower urinary tract in rats re-establishing a physiological status and preventing DSD after incomplete SCI, presumably by influencing the neuronal wiring of descending micturition circuits. Thus, anti-Nogo-A immunotherapy, which currently enters clinical trials, could become a unique causal treatment option for lower urinary tract dysfunction in patients with SCI.
More than half of Barrington’s neurons express corticotropin-releasing hormone (CRH) and recent studies using CRH-ires-CRE knock-in mice has enabled optogenetic manipulation of their activity (Cell 2016, Nature Neuro. 2018). Those studies indicate that the Barr-CRH neurons caused bladder contraction and an increase in the probability of co-ordinated micturition but they do not regulate external urethral sphincter (EUS) activity. We hypothesised that the Barr-CRH neurons are not high-fidelity controllers of bladder pressure but they do influence timing of voids. To address our hypothesis, we recorded the activity of optogenetically identified Barr-CRH neurons.
Stereotaxic injections of Cre-inducible vector (AAV-EF1a-DIO-hChR2-mCherry) in CRH-ires-CRE mice allowed to express Channelrhodopsin2 and opto-activation. Subsequently under urethane anaesthesia an optic fibre was placed above Barrington’s for optogenetic stimulation. Recordings from the Barr-CRH neurons used a 32 channel silicon probe (NeuroNexus) and an open-ephys system. Spike waveforms were clustered in Kilosort and verified in Phy followed by analysis in MATLAB. Bladder pressure and EUS-electromyography (EMG) were recorded.
The bladder contractions were induced by optogenetic activation (473 nm, 20ms, 20Hz for 5sec) of Barr-CRH during filling phase and the amplitude of these bladder contractions significantly increased during the phase of micturition cycle, in turn, eventually caused voiding (P<0.001, Figure 1A). The Barr-CRH neurons were optoidentified by reliable short latency spike entrainment (Figure 1B). In total 128 neurons were recorded in isolation in 4 mice and 27 units were identified as Barr-CRH neuron. They showed a characteristic pattern of activity during the micturition cycle with bursting (20.5 ± 4.1 Hz of bursting) just before micturition (Figure 1C). The optogenetic stimulation evoked Barr-CRH activity which was independent of micturition phase (ranging from 22.4 ± 7.7 to 24.0 ± 6.5 Hz across 5 different micturition phases, Figure 1A).
This is first study to investigate Barr-CRH firing activity from optogenetically identified neurons. The bladder pressure change induced by optoactivation of CRH neurons is dependent upon the phase of the micturition cycle indicating that the response to stimulation reflects the state of the downstream parasympathetic circuit.
Green Area, Room 2
To develop a preoperative nomogram for predicting stone-free rate (SFR) in case of performing flexible ureteroscopy (FURS) or percutaneous nephrolithotomy (PCNL) for patients with solitary medium sized (ranging from 1 to 2 cm) renal stones in adults.
We retrospectively analyzed the data of 100 FURS and 100 PCNL procedures for removal of a solitary medium sized renal stone (1-2 cm) in adults performed starting from January 2015 till September 2018. All the patients were evaluated by ultrasound (1 month) and CT (6 months) after FURS and PCNL procedures to detect the stone free rate. The stone-free status was defined as absence of any gravel more than 2 mm on the follow-up radiology. Preoperative predictors, that were statistically significant (P< 0.05) in the univariate logistic analysis, were included in the multivariate logistic regression analysis, which was performed to screen independent predictors for stone free status. Independent predictors (P < 0.05) in the multivariate logistic regression analysis as well as clinical significant predictors were included in the nomogram construction. The nomogram was validated internally; the internal validation was performed by a calibration method and the area under the receiver operating characteristic (ROC) curve (AUC), the AUC indicate good concordance.
Multivariate analyses identified stone site (p = 0.0146), maximum density using Hounsfield unit (p =0.0212), skin to stone distance (p = 0.0375), associated UTI (p=0.0002), comorbidities (p=0.0029) and age (p=0.0403) as independent predictive factors for the stone-free status after SWL. Based on these preoperative parameters, we developed a nomogram to predict SFR after FURS and PCNL. Total nomogram score (maximum 11) was derived from summing individual scores of each predictive variable; a high total score was predictive of successful outcome, whereas a low total score was predictive of unsuccessful outcome. The area under the receiver operating characteristics for nomogram predictions was 0.72 for PCNL, 0.86 for FURS and 0.76 for both procedures.
We developed a feasible and user-friendly nomogram to predict SFR after FURS and PCNL of a solitary renal stone; further external validation studies are required to test its generalizability on datasets other than the development one.
Reusable flexible ureteroscopes (USc) are reprocessed for subsequent use. So far, little is known about the effectiveness of USc reprocessing, especially with regard to cumulative USc use. We hypothesize that the effectiveness of reprocessing declines with cumulative USc use as USc wear and tear can result in surface irregularities that might form a breeding ground for microorganisms. This study evaluates the frequency of preoperative and persistent microbial contamination of flexible ureteroscopes after reprocessing, and the relation of contamination with cumulative USc use.
From December 2015 until December 2017, data on scope use and microbiological cultures were collected prospectively for 20 new USc’s (Karl Storz FlexXc and X2, Olympus URF V2 and P6). High-level disinfection with peracetic acid was used for USc reprocessing. To assess pre- and post-operative contamination, two microbiological samples of the USc were taken before and after the procedure (1. stirring the distal USc shaft tip in 10 mL saline, 2. flushing the working channel with 10 mL of saline). All four samples were sent for culture on bacteria and yeasts. The possibility of cross-contamination was evaluated by comparing the postoperative culture with the subsequent preoperative culture of the same USc. A positive culture was defined by ≥30 CFU/mL of skin flora or ≥10 CFU/mL of uropathogens. A generalized estimating equation model (GEE) was used to analyse if cumulative USc use was associated with an increased probability of positive preoperative cultures.
Microbial samples were collected in 389 procedures. Preoperative ureteroscope cultures were positive in 47/389 (12.1%) procedures, of which uropathogens were found in 9/389 (2.3%) and skin flora in 38/389 (9.8%) procedures. In one case, the preoperative culture contained the same bacteria type as the prior postoperative culture. Cumulative USc use was not associated with a higher probability of positive preoperative cultures (figure 1).
Figure 1. Association between cumulative USc use and the probability of a positive preoperative culture (GEE).
Microbial contamination of reprocessed ureteroscopes was found in one eighth of all procedures. Notably, uropathogenic microorganisms were found in a small proportion of all procedures. Cumulative ureteroscope use was not associated with a higher probability of microbial contamination.
Green Area, Room 4
The uropathogenic E.coli (UPEC) is responsible for causing between 60 to 80% of all UTI cases. The AnTIC study was a randomised, open-label, superiority trial which compared the antibiotic prophylaxis versus short term antibiotic treatment for recurrent UTI prevention in CISC patients. Our aim was to genetically define AnTIC UPEC isolates and correlate bacterial motility, a UTI virulence factor, and antibiotic use asking: 1) Does antibiotic treatment select specific genetic subgroupings? 2) What is the nature of multi-drug resistance (MDR) development? and 3) Does the genetics of motile strains aid our understanding of the observed clade structure and antibiotic use?
The AnTIC bio-bank of bacterial isolates generated during the RCT phase was the source of 96 random UPEC isolates that were genotyped. A phylogenetic tree was generated. Motility was assessed using motility agar assays and correlated to clade data. Finally, we exploited next-generation sequencing technology to sequence the whole genome of specific samples from our cohort, based on motility and antibiotic resistance profiles.
AnTIC E.coli showed a bias toward clades B2 and D (Fig1),while B2 isolation is expected from rUTI, the incidence of clade D members was not. 44% of all isolates were non-motile, and if motile 63% exhibited an unexpected low motility phenotype (< or =1cm;p< 0.001) (Fig2) compared to commensal E.coli (average motile swarm: 3.3 cm). Analysis for MDR amongst UPEC isolates has led to ongoing whole genome sequencing of 50 more AnTIC isolates and all clade D strains.
Our work provides a unique insight of UPEC isolated during a CISC based clinical trial. The greater frequency of clade D and reduced motility may reflect the source of the isolates. Whole genome sequence analysis will further improve our understanding of host-microbe interactions during CISC use.
The introduction of NGS allows a comprehensive analysis of the genomic profile of rectal microbiota and, most importantly, the identification of resistance genes to the standard antibacterial empiric prophylaxis. The aim of our pilot study was to evaluate NGS of rectal swabs in patients before transrectal biopsy of the prostate, seeking to prevent urinary tract infection (UTI).
Between June 2017 and September 2018, 68 patients were prospectively entered into this study before scheduled prostate biopsy. The rectal swabs were processed by MicroGenDX, performing diagnostics via NGS. The profiling of the population of bacterial species, including antibiotic resistance genes, provides for a susceptibility determination that clinicians can adjust using local antibiograms and/or clinical references. The standard protocol for prevention of infection included levofloxacin 0.5g orally and 1g ceftriaxone intramuscularly, with adjustment for targeted prophylaxis in each case.
In all 68 patients, multiple bacterial species were reported, with a median of 10 (range: 2-16). The predominant flora most frequently found was Bacteroides spp. (dorei, fragilis, caccae, massiliensis, uniformis, and vulgatus) in 26 men; Escherichia coli in 18; and Prevotella (copri, timonensis, and corporis) in 11. In 47/68 (69%) men, multiple drug resistance genes were detected. In 32/68 (47%) men, resistance to fluoroquinolones was reported; in 5/68 (7%) men, resistance to β-lactams (without concomitant resistance to fluoroquinolones) was noted; and in 21/68 (31%) patients there was resistance to both groups. These data allowed us to modify our empiric prophylaxis in those 37 patients targeting the most dominant aggressive pathogen(s). In 27 men, fungal species were detected - 15 of these patients harbored multiple fungal species. The presence of a fungal species was used as an indication to supplement prophylaxis with an anti-fungal agent. This NGS-guided prophylaxis strategy was associated with avoidance of serious infectious complications, including urosepsis, in all patients within 30 days after biopsy. Two patients developed epididymitis, and there was only one case of cystitis.
NGS allowed the implementation of truly individualized and targeted prophylaxis for patients undergoing transrectal biopsy. Further studies will be required to compare the efficacy of NGS to standard methods of culture and sensitivity of rectal swabs.
Green Area, Room 5
The prognosis of the patients with hormone refractory and/or metastatic prostate cancer is poor. To overcome this disease, the investigation of novel therapeutic target molecule has been desired. Among various therapeutic target molecules, orphan GPCRs have high potential to treat diseases. Therefore, this study is aimed to identify novel therapeutic target molecules for progressive prostate cancer using integrative genome-wide gene expression analyses.
Microarray data sets of these cell lines, such as LNCaP, DU145 and PC3, were obtained from Gene expression omnibus in NCBI (PC3: n = 9, DU145: n = 6, LNCaP: n = 33) to identify the genes, which expression is remarkably higher in DU145 and PC3 than LNCaP among orphan GPCR genes. Knockout (KO) of target genes in PC3 and DU145 cells were generated by CRISPR/Cas9, and the cell proliferation ability was analyzed by BrdU incorporation. To analyze the significance of the gene in vivo, subcutaneous xenograft mice models were analyzed by in vivo imaging and histological examinations. To explore the gene expressions profiles, RNA-seq, was performed. Also, to ascertain the effects of target gene on the establishment of bone metastasis of prostate cancer, Control and KO PC3-Luc cells were inoculated into the tibia, which were analyses by in vivo imaging, radiological and histological examinations. Kaplan meier plot (KMP) analysis was done using RNA-seq data from The Cancer Genome Atlas project.
Integrative genome-wide analyses successfully identified G Protein-Coupled Receptor Class C Group 5 Member A (GPRC5A) as the target gene. GPRC5A KO PC3 cells exhibited significantly decreased cell proliferation in vitro. In addition, subcutaneous xenograft model displayed that the size and weight of removed tumors were remarkably decreased in GPRC5A KO PC3 cells when compared to Control cells. RNA-seq revealed that the expression of cell cycle related genes were significantly impaired in GPRC5A KO cells. Consistent with this result, the expression of both G2 and M phase genes were significantly elevated and G1 phase genes were significantly decreased by GPRC5A KO. In addition, flow cytometry analyses revealed that GPRC5A KO cells were arrested in the G2/M phase. Furthermore, the expression level of GPRC5A in prostate cancer with bone metastasis is significantly higher in that without bone metastasis. Also, the mice inoculated with Control PC3 cells demonstrated bone destructive metastatic lesions in the proximal tibia, however, GPRC5A KO PC3 cells failed to establish bone metastasis. Finally, KMP analysis showed that patients with high expression of GPRC5A had significantly shorter overall survival.
GPRC5A is essential for cell proliferation and establishment of bone metastasis of prostate cancer, suggesting GPRC5A can be a therapeutic target and prognostic marker molecule for progressive prostate cancer.
The long-term propagation of basal prostate stem cells ex vivo has been very difficult in the past. Our development of methods to enrich and expand these rare cells allows more detailed research regarding their function in prostatic disease. We wondered whether the new methods are useful for enrichment of stem cells from inducible transgenic mice and their subsequent genetic ex vivo manipulation.
Tamoxifen inducible-Cre transgenic mice were crossed with Rosa26-eYFP transgenic Reporter mice. Prostate basal stem cell lines out of these mice (Cre/Rosa-eYFP) were generated by our previously described methods to enrich and amplify basal prostate stem cells ex vivo (microdissection of the prostate, enzymatic digestion, MACS EpCAM enrichment, stem cell culture using experimentally defined combinations of culture flask surface and serum-free growth factor conditioned media).
The generated basal prostate stem cell line from double transgenic mice was treated with various tamoxifen regimens to induce gene deletion at a self-defined time point. Treatment with dihydrotamoxifen in vitro (500nM and 2μM) lead to successful deletion of the loxP flanked STOP sequence, thus expression of the EYFP (Enhanced Yellow Fluorescent Protein) was enabled in these cells. Flow cytometry results subsequently detected positive EYFP fluorescence (45% with 500nM, 51% with 2μM) while viability of basal prostate stem cells could be preserved as measured by propidium iodide co-staining.
This proof of principle of genetic alterability in ex vivo enriched and amplified primary prostate basal stem cells reveals the usefulness of our developed techniques in future basic research projects to investigate essential pathways in aetiology of prostate cancer and prostatic diseases.
Green Area, Room 12
To develop an individualized immune-related gene signature that predicts oncologic outcomes and immune status of ccRCC.
Our study retrospectively analyzed expression profile of ccRCC including 1 microarray data set and 1 RNA-Seq data set. The immune related gene pair (IGP) index was constructed and validated based on pairwise comparison in 634ccRCC patients. Association with overall survival (OS), progression-free interval (PFI) and disease specific survival (DSS) was evaluated by Kaplan-Meier analysis, univariate and multivariate cox regression survival analysis. Prognostic values of different risk models were compared using Harrel’s C-index.
The IGP index of 17 gene pairs was an adverse independent risk factor in multivariate analyses for OS (HR, 1.718; P=0.001), PFI (HR, 1.550; P=0.006) and DSS (HR, 2.201; P=0.001) in ccRCC patients. It showed comparable prognostic accuracy with ccA/ccB signature (C-index for OS, 0.657 vs 0.640; P=0.686) and better intra tumor homogeneity. Immunosuppressive immune cell, markers and pathways referring to immune suppression were all enriched in high immune risk tumors. The integrated immune-clinical prognostic score outperformed ccA/ccB signature and UISS risk model in terms of C-index for estimation of OS (P<0.001), PFI (P<0.001) and DSS (P<0.001).
The proposed IGP index is a robust and promising biomarker for estimating oncologic outcomes in ccRCC. High immune risk tumors are highly immunosuppressive.
Renal cell carcinoma (RCC) is the most common type of urinary malignancy. Clear cell RCC (ccRCC) is the predominant RCC subtype, accounting for 70–80% of RCC. microRNAs (miRs) are small non-coding RNAs that regulate protein expression. miRs have been proved to regulate cancer progression and represent potential diagnostic and prognostic biomarkers. Our aim was to find a profile of miRs in urine capable of distinguishing between ccRCC patients and controls.
Two clinical groups were recruited: 54 RCC patients from whom three urine samples were obtained (t0= before surgery, t1=3 months after surgery, t2=one year after surgery) and 58 healthy volunteers (controls) with an ultrasound scan to rule out urological tumours from whom one urine sample was obtained. The expression level of 179 miRs was studied in urine of 16 selected ccRCC patients (at t0 and t1) and 16 controls, age and gender matched, using the Serum/plasma Focus microRNA PCR Panel V4 (Exiqon). An endogenous reference miR was selected as that with the highest stability using RefFinder software. Normalization of miR expression was conducted with the ∆∆Ct method, and subsequently results were also normalized with the level of creatinine. Statistical analysis was performed using R (v3.2.3).
The most stable miR was miR-20a-5p and therefore we used it as endogenous reference. We adjusted an Elastic Net logistic regression model for the diagnosis of ccRCC using the miR expression levels in urine of patients at t0 and controls. This model included 3 miRs: miR-200a-3p, miR-34a-5p and miR-365a-3p. Moreover, with the Wilcoxon test we identified 5 dysregulated miRs comparing the miR expression level of patients at t0 and controls: miR-200a-3p, let-7d-5p, miR-205-5p, miR-34a-5p and miR-365a-3p. Furthermore, we identified 5 dysregulated miRs comparing patients at t0 and t1: let-7d-5p, miR-152-3p, miR-30c-5p, miR-362-3p and miR-30e-3p. These last 5 miRs could be involved in the prognosis of ccRCC.
We have obtained a urine profile of 3 miRs with potential diagnostic value for ccRCC. We also identified 5 dysregulated miRs in patients comparing before and after surgery, and other 5 dysregulated miRs comparing patients and controls discovering an easy and non-risk procedure to achieve a closer personalized follow-up in high-risk patients. Our findings could shed light on the molecular mechanism of ccRCC. Validation of our statistical models in a larger cohort of patients is required. ISCIII-FEDER (PI14/00079, PI14/00512, FI14/00269, CPII15/00002, PI17/00495), GVA (PrometeoII/2015/017, ACIF/2017/138), Sociedad Española de Trombosis y Hemostasia.
Red Area, eURO Auditorium 2
The periaqueductal gray (PAG) has been an area of great interest in the study of brain activity related to bladder function. The PAG is implicated to be involved in both storage and voiding of urine, and is assumed to serve as a relay station projecting afferent information from the bladder to cortical and subcortical brain areas. The use of ultra-high-field functional MRI (fMRI) will allow for the investigation of PAG activity at sub-millimeter resolution in human participants. This study aims to investigate PAG activity related to bladder sensations using 7 Tesla resting-state (RS) fMRI at during a bladder filling protocol. We hypothesize that dynamic RS connectivity between PAG clusters will show significant changes during filling of the bladder with saline.
After obtaining ethical committee approval, and gathering informed consent, we evaluated data from 3 healthy female participants (ages 24, 27, and 53). Two sets of RS fMRI datasets were acquired for each subject: the first during filling of the bladder and the second when the participants indicated they experienced urge. After preprocessing the data, we anatomically defined the PAG for each participant and selected all voxels within this region-of-interest (ROI) during the scan with a full bladder. We computed a voxel-by-voxel correlation matrix and subsequently parcellated this matrix using the Louvain module detection algorithm (Fig. 1.A). The resulting clusters were used as input for a dynamic connectivity analysis, which measures changes of functional interaction between ROIs over time.
A linear regression analysis was used to determine whether the connectivity between the PAG clusters changed as a function of bladder filling (Fig. 1.B). For each participant, we found a significant change in dynamics between PAG sub-clusters as a function of bladder filling. Our findings are illustrated in Fig. 1.C.
Our results indicate that PAG activity in a full bladder state can be subdivided in clusters, and these clusters show significant changes in dynamic connectivity during bladder filling. We have shown that ultra-high-field 7T fMRI dynamic connectivity analysis indicates differences in connectivity between areas inside the PAG. This opens new avenues to investigate treatment or disease-specific bladder filling related dynamic signal processing in this small brain structure.
Mechanical obstruction was associated with the driven force loss in voiding process. The aim of the study was to evaluate the relationship prostatic apex shape (PAS) with voiding symptom and urine flow.
A total of 806 healthy men who underwent transrectal ultrasonography (TRUS) at our hospital during routine health examinations were included. For our analyses, patients were categorized into four different groups according to the shape of the prostatic apex shown on the midsagittal TRUS scan. For implementation of finding to correlate voiding symptom measured by the International Prostate Symptom Score (IPSS) and PAS, patients with no history of BPH/LUTS treatment and performing by uroflowmetry were collected.
Of 806 patients, group 1 had 105 patients (13.0%), group 2 had 322 (40.0%), group 3 had 23 (2.9%) and group 4 had 356 (44.2%). Group 4 was composed of patients with the prostatic apex not overlapping with membranous urethra either anteriorly or posteriorly on TRUS and had a significantly lower percentage of patients with a moderate and severe of BPH/LUTS compared with the other groups. Multivariate regression analysis revealed significant relationship between PAS and total IPSS score, IPSS questions 3 or 5. For 329 patients performed uroflowmetry, group 3 overlapping with membranous urethra posteriorly had the lowest maximum flow rate. PAS is significantly associated with IPSS and urinary flow rate.
These results provided the first evidence for PAS being an independent risk factor for voiding symptom and low max flow rate severity.
Green Area, Room 4
The diagnosis and treatment of patients with chronic bacterial prostatitis (CBP) remains to be challenging. Patients are often treated empirically based on symptoms and positive results for detected bacteria in expressed prostatic secretions, while studies with urine and/or semen cultures are generally lacking using typical culture methodology. Furthermore, the most studies suggested that only a minority of patients with CBP had a positive culture results. The aim of our study was to evaluate deoxyribonucleic acid next generation sequencing (DNA NGS) as a potential new test in the diagnosis and subsequent management of patients with symptoms of CBP.
A retrospective review of the semen DNA NGS results of 17 patients with symptoms of chronis CBP (NIH category II) was performed. All fresh semen specimens were collected from patients and processed through the whole bacterial and fungal semen microbiota spectrum by MicroGen DX, a US based CLIA certified laboratory. Two methods of molecular microbial diagnostic testing were performed: Level 1 Panel is a quantitative real-time PCR test for bacterial and fungal genes with specific assay for presence of antimicrobial drug resistance genes. The Level 2 Panel is a comprehensive NGS of all genomic DNA present in the patient specimen which aims to catalog all microbial and fungal pathogens present based on a database of 25,000 known species. The catalog of the microbial species, including drug resistance targets, provides detailed data that clinicians can utilize to supplement their local antibiograms and/or clinical pathways.
All 17 patients had positive DNA NGS results. The average number of microorganisms present in each specimen was of 4.4 species, range (1-10). Resistance genes to different antibiotics detected were found in 4/17 specimens. 9/17 semen samples had primarily gram-positive bacteria mostly from Enterococcus family, 6/17 had mixed and 2/17 primarily gram-negative pathogens. In two cases a high bacterial load (>107microorganisms} was revealed, in 4- a moderate load (106-107), and in 11/17 - a low load (≤105), respectively. Two patients had fungal species in association with bacterial pathogens.
The diagnosis and treatment of CBP represents a difficult task for practicing urologists. This new technology of DNA NGS may provide a new diagnostic tool to analyze complete genomes of microorganisms in a timely manner and implement targeted and individual treatment of CBP. A significant number of patients had gram-positive organisms representing mostly Enterococcus family, which may stimulate us to revisit our approach to the treatment paradigms for CBP in the prospective studies further.
Recurrent UTI’s (rUTI) in young women can be common and not only impact quality of life (QoL) but also service provision within urology departments. The extent to which these patients require investigation or treatment is variable. Our department changed practice to manage these women in a nurse led service with medical input as required. The aims of this study were to reduce invasive investigations, antibiotic use and attendance at consultant clinics whilst encouraging self-management.
102 patients were referred to the service between March 2016 and 2018. Patients were appointed to see a Nurse Continence Specialist, reviewed and data collected on number of culture proven infections. Patients were assessed for specific triggers, post void residual, bowel habit, lifestyle factors and weight. All patients had US kidneys arranged and if visible haematuria (VH) was noted, referred for flexible cystoscopy. All were given conservative advice leaflets (BAUS cystitis, NICE IBS, bladder training, toilet positions, pelvic floor exercise, intercourse positions and lubrication advice).
72 women aged 15 to 29 years attended. Despite being referred as rUTI, 31 women had no culture proven samples and 16 had only 1 infection. 25 patients had at least 2 proven cultures with the maximum being 6. Triggers were identified in 33 women; 28 (85%) sexual intercourse, 2 alcohol consumption, 2 infrequent voiding and 1 high post void residual. All women had US KUB requested; 60 were performed, of which 49 (82%) were normal. 11 identified an abnormality; none were considered causative for rUTI. 16 women reported VH of which 13 had flexible cystoscopy – 10 (77%) were normal and 3 identified abnormalities - tight meatus, schistosomiasis and cystitis cystica. In the 25 patients with 2 plus proven infections, results were analysed separately after 12 months of input. In those with 2 infections (14 patients) 86% had 0 or 1. Patients with 3 infections (6 patients), 66% had 0 or 1. Those with 4 infections (3 patients), 66% had no further and the 2 patients with 5 or 6 infections both patients had 0. Only 3/25 required prophylactic, 0 required post coital and 1 obtained self-start antibiotics 13/25 (52%) women only required 1 appointment with the service and at 12 months 21/25 no longer require any contact (discharge or DNA).
By changing practice we have significantly reduced the number of rUTI’s in this group using conservative measures. We have proven that invasive investigations are unnecessary and have reduced the number of cystoscopy and dilatations from 222 patients in 2013 to 69 in 2017. The number of new and review slots required in consultant clinics and use of antibiotics has been cut. The continence team continues to develop this autonomous practice and allows patients to receive a holistic, self-directed approach to their healthcare.
Green Area, Room 5
African American (AA) men have a higher incidence of and mortality from prostate cancer (PCa) than European American (EA) men. The potential biological determinants of these racial disparities are still unknown. Cancer genome evaluations with available clinical outcome data have been limited to EA populations. Here we characterize PCa genomes from a large cohort of AA men and identify the associations between genomic alterations and clinical outcomes.
Cancer genomes from 205 AA men treated with radical prostatectomy (RP) were profiled using next-generation sequencing for somatic mutations and percent genome alteration (PGA; defined as percentage of tumor genome with copy number variation). Logistic regression and Cox proportional hazard analyses assessed the association of genomic alterations with pathologic and oncologic outcomes in multivariate models (adjusted for age, PSA, and pathologic grade and/or stage, when applicable). PGA was dichotomized by quartiles in analytical models (≤75th percentile vs >75th percentile).
The median PGA was 3.7% (IQR 0.9-9.4) and increased with pathologic grade (p<0.001) and stage (p=0.02). Median follow-up was 5 years. AA men with the highest quartile of PGA had significantly worse biochemical recurrence (BCR)-free survival (10 year: 33.5% vs 50.2%; p=0.006) and metastasis-free survival (10 year: 47.9%vs 89.0%; p<0.001) than men with lower quartiles of PGA. PGA was associated with increased risks of higher grade (OR 2.0, 95% CI 1.1-3.7, p=0.03), higher stage (OR 2.0, 95% CI 1.1-3.8, p=0.03), BCR (univariate: HR 1.9, 95% CI 1.2-3.2, p=0.01), and metastasis (HR 9.6, 95% CI 2.9-31.3, p<0.001). The most common somatic mutations were SPOP (12.5%, 123/184), FOXA1 (9.2%, 17/184), and TP53 (4.4%, 8/184). Only TP53 was associated with increased risks of adverse outcomes, including higher stage (OR 5.3, 95% CI 1.5-19.4, p=0.01), BCR (non-significant univariate: HR 2.4, 95% CI 1.0-5.9, p=0.06), and metastasis (HR 9.5, 95% CI 2.2-40.6, p=0.002).
In AA men, PCa genome profiles reveal unique genomic alterations. Notably, PGA in AA men predicts adverse pathologic and oncologic outcomes after RP and can potentially be considered a prognostic biomarker in this racial group. This research highlights the increasing importance of racial ancestry in cancer genomics studies and in the development of precision medicine strategies.
Guidelines by AUA and EAU state that there is no evidence for an increased PCa risk for testosterone therapy (TTh) in hypogonadal men.
In a registry study initiated in 2004 in a urology practice, 428 hypogonadal men (T≤350 ng/dL) received testosterone undecanoate (TU) 1000 mg every 3 months following an initial 6-month interval for up to 13 years (T-group). 395 hypogonadal men (age range 51-74) opted against TTh (CTRL). Suspicion of or active PCa was excluded by transrectal ultrasound, digital rectal examination and PSA before treatment/observation initiation. Examinations were repeated between one and four times per year. Biopsies were performed when indicated according to EAU Guidelines.
In the T-group, 12 men (2.8%) were diagnosed with PCa. In CTRL, 44 (11.1%) were diagnosed with PCa. The mean baseline age of PCa patients was 64.9 years in the T-group and 64.1 in CTRL. In the T-group, the average time span between the day of first injection and positive biopsy was 14.2 months (range: 5-18). No patient was diagnosed with PCa beyond 18 months of TTh. In CTRL, PCa was diagnosed at any time during the observation time. In the T-group, radical prostatectomy (RP) was performed in all men. All but 3 patients had a Gleason score (GS) ≤6, and all but 1 had a primary GS of 3. Tumor grade was G2 in all 12 (100%), tumor stage T2a in 7 (58%), T2b in 3 (25%), and T2c in 2 (17%) patients. All but 2 patients are back on TTh after an average time of 25 months. In CTRL, RP was performed in all but 8 patients who primarily received radiation therapy (RT; 6) or hormonal therapy (HT; 2). GS was ≤6 in 2 patients, 7 men had a GS of 7, 21 a GS of 8, and 14 a GS of 9. 4 men had a primary Gleason score of 3, 31 had 4, and 9 had 5. Tumor grade was G2 in 8 (18%) and G3 in 36 (82%) patients, tumor stage T2a in 2 (5%), T2c in 1 (2%), T3b in 15 (34%) and T3c in 26 (59%) patients. In CTRL, biochemical recurrence occurred in 14 (32%) patients. These patients received androgen deprivation therapy (ADT). 12 (27%) patients died of whom 7 were on ADT. In the T-group, no biochemical recurrences or deaths occurred during the observation time.
Less PCa occurred and severity was lower in testosterone-treated hypogonadal patients compared to untreated hypogonadal controls.
Green Area, Room 12
Renal parenchymal damage [RPD] is a key determinant of kidney transplant receivers’ prognosis. However, biopsy of non-tumour tissue is not contemplated in patients treated with radical nephrectomy [RN] for a renal mass and no data on its potential application in urologic patients are available. Our hypothesis stated that RPD is associated with functional outcomes in patients treated with RN.
A prospective study involving 172 patients treated with RN for a renal mass was performed. The variable of interest was RPD, assessed using an established classification system (Remuzzi score) based on glomerulosclerosis, interstitial fibrosis, tubular atrophy, and vascular damage. Two separate samples from each kidney were evaluated by an expert genito-urinary pathologist. RPD was defined as the average score of the two samples and categorized as absent (0), moderate (0.5 - 1.5) or severe (>1.5). The outcome of the study was the estimated glomerular filtration rate [eGFR] measured by CKD-EPI and BIS1 equations. Before RN and during the first 12 months after RN, 396 individual eGFR observations were recorded. Multivariable linear regression analysis [MVA] was used to investigate the impact RPD on the pattern of renal function detriment after accounting for all the potential confounders. RPD-specific patterns of renal function detriments were investigated using Loess regression function.
RPD resulted absent, moderate or severe in 26, 42 and 32% of the study population. At MVA, severe RPD was associated with lower eGFR relative to absent RPD (estimate -7; p=0.01). Conversely, moderate RPD was associated with virtually the same eGFR relative to absent RPD (estimate 4; p=0.1). Age, hypertension, tumour clinical size and time from surgery were also associated with lower eGFR (all p<0.05). Diabetes was associated with higher eGFR (p<0.05). Accordingly, the pattern of renal function detriments after RN resulted similar in patients with absent or moderate RPD whereas in patients with severe RPD renal function detriment after RN was more pronounced (Fig 1).
RPD resulted an independent predictor of renal function in patients treated with RN for a renal mass and deserves special consideration as a prognostic parameter. These observations support renal biopsy of non-tumour tissue for the analysis of RPD at final pathology after RN and imply a paradigm shift in the current pathology protocols.
Reliable biomarkers for renal cell carcinoma (RCC) have yet to be found. Circulating-tumor DNA (ctDNA) is an emerging resource to detect and monitor molecular characteristics of various tumors. This study aims to clarify the clinical utility of ctDNA for RCC.
Fifty-three patients histologically diagnosed as clear cell RCC were enrolled. Targeted sequencing was performed using plasma cell-free DNA (cfDNA) and tumor DNA. We applied droplet digital PCR to validate detected mutations. cfDNA fragment size was also evaluated using a microfluidics-based platform and sequencing. Proportion of cfDNA fragments was defined as the ratio of small (50-166 bp) to large (167-250 bp) cfDNA fragments. Mutant allele frequency in ctDNA was analyzed with respect to clinical course. Prognostic potential was evaluated using log-rank test.
A total of 38 mutations across 16 (30%) patients were identified from cfDNA, including mutations in TP53 (n = 6), VHL (n = 5), BAP1 (n = 5) and TSC1 (n = 4), and the median mutant allele frequency of ctDNA was 10%. We designed specific droplet digital PCR probes for 11 mutations and detected the same mutations in both cfDNA and tumor DNA. In 5 RCC patients whose plasma cfDNA and tumor DNA were sequenced, at least two mutations were detected in cancer tissue from all 5 patients, and the corresponding mutations in ctDNA were detected for two of these patients, as shown in figure below. Overall, detection of ctDNA was significantly associated with a higher proportion of short cfDNA fragments (P = 0.033), indicating RCC patients with ctDNA had shorter fragment sizes of cfDNA. Interestingly, the changes of mutant allele frequency in ctDNA concurrently correlated with clinical course in 6 RCC patients. Positive ctDNA and fragmentation of cfDNA were significantly associated with poor cancer-specific survival (P < 0.001, P = 0.011, respectively).
Our results show that mutational landscape and fragmentation of plasma cfDNA have promising prognostic potential in RCC patients. The change of mutant allele frequency of ctDNA may be an auspicious monitoring marker for RCC. Given that plasma cfDNA is easily collected from peripheral blood, these newly discovered markers can be convenient and precise tools for understanding RCC.
Green Area, Room 1
In order to improve results of sacral neuromodulation (SNM), assuming that each hemibladder has its own innervation circuit, some authors have studied the interest of dual neuromodulation. Studies on animals but also some studies in humans argue in favor of bilateral SNM to improve the rate of response to therapy but there is no studies about bilateral SNM tests. The main objective of our study was to compare the efficacy of uni and bilateral SNM tests at 1 month post-implantation. The secondary objectives were to compare the improvement in symptom severity via the MHU (Measure of Urinary Disability) scale, the improvement of quality of life via self-questionnaires : Incontinence Quality of Life (I-QOL) King's Health Questionnaire (KHQ) and Medical Outcome Short Study Form 36 (MOS SF-36 ©).
We present a comparative, pilot, randomized, multicenter trial included 55 participants from 23/10/2012 to 20/09/2017. Patients were all consulting for urge incontinence and a first line of medical therapy with anticholinergic has failed. At inclusion, patients were randomized between uni versus bilateral NMS tests. Success was considered when an improvement of at least 50% of one of the number of events per day (urge with or without incontinence) from baseline was observed.The hypothesis was that testing the two sacral nerve roots would allow to choose the side where the stimulation gives the best result. Statistical analyzes were performed in intent to treat. Success rates were compared by chi-2 or Fisher tests. Changes in severity of symptoms or quality of life were compared by Mann-Withney tests.
The success rate observed in the Unilateral SNM test group was significantly (p = 0.0152) higher than in the Bilateral SNM Test group. 9 patients left the study prematurely (7 in the bilateral SNM group). When only the 46 patients who had completed the test phase are taken into account, we found no statistically significant difference (p = 0.0891) but only a trend in favor of the Unilateral SNM test (21/25 (84%) success vs 13/21 (62%) for the bilateral SNM test). No statistically significant difference was found between the 2 groups for the secondary endpoints, except for the "physical state limitations" (MOS SF-36 © questionnaire) with a greater improvement in the unilateral SNM group (p=0.0442). The complication rate observed in the unilateral SNM test group (16%, n=4) was significantly (p=0.0239) lower than that seen in the bilateral group (47%, n=9).
This is the first prospective randomized study comparing the unilateral and bilateral SNM test in the treatment of refractory idiopathic overactive bladder. This pilot study do not confirm the potential benefit of the bilateral test and cannot therefore be recommended in clinical practice.
The objective of SOUNDS is to evaluate clinical effectiveness, Quality of Life (QoL) and safety of InterStim™ Sacral Neuromodulation (SNM) for urinary voiding dysfunctions during 5 years of follow-up in real-life as required by the French Authority for Health. Here we report on effectiveness, QoL, patient-reported outcomes (PROs) and safety.
Patients suffering from intractable urinary voiding dysfunctions were enrolled including overactive bladder (OAB) and non-obstructive urinary retention (NOUR). Decision to implant a permanent system was at the discretion of each investigational site, reflecting standard of care in the French healthcare setting. For effectiveness, QoL and PROs we present data for two follow-up visits: follow-up 1 with a mean (sd) duration of 3.2 (2.7) months and follow-up 2 with a mean duration of 10.1 (3.8) months. Safety data is based on a mean (sd) duration of 24.3 (7.3) months for implanted patients. Data is presented based on a complete case analysis which is similar to intention-to-treat without missing data imputation.
Overall 320 patients were enrolled at 25 sites and 247 were permanently implanted. Patients were predominantly female (84%) with a mean (sd) age of 60.5 (15.1) years. Conversion rate from test to final system was 77% among de-novo patients. Enrolled patients
suffered from OAB (91%) or NOUR (9%) and tested/implanted patients were scheduled for a de-novo (78%) or a replacement procedure (22%) of an existing InterStim™ system. 14% of all patients had double incontinence (DI). Effectiveness, QoL, PROs
and safety data are shown in Table 1. A significant reduction in both leaks and voids/day was seen for de-novo and replacement OAB patients at both follow-ups. QoL and NRS score improved significantly between baseline and follow-ups and safety data
is within the range of previous publications except for the higher rate of Serious Adverse Device Effects which is due to hospitalization procedures in France.
SOUNDS confirms the clinical effectiveness, safety and positive effect of InterStim
™ SNM on QoL and PROs for the treatment of OAB patients in a real-world setting in France. Results for NOUR and DI have to be viewed cautiously due to the lower number of treated patients.