Intravesical Use Research Articles

The Novel Platinum Analog Dicycloplatin Provides Reliable Growth Inhibition of Urothelial Carcinoma Cells In Vitro.

Platinum-based chemotherapies are a component of standard-of-care regimens for urothelial carcinoma (UC). These nephrotoxic drugs are often dose-limiting, with cisplatin and carboplatin being the most commonly used. Dicycloplatin (DCP) has better solubility and stability, with comparable efficacy and better tolerability. Some suggest the use of DCP as primary treatment for non-muscle-invasive bladder cancer. We exposed UC cell lines to DCP in vitro to assess its efficacy. A high grade (IV) in vitro UC cell line (TCCSUP) was exposed to varying concentrations of cisplatin (0-600 μg/ml), carboplatin (0-600 μg/ml), oxaliplatin (0-4.0 μg/ml), and DCP (0-350 μg/ml). Grade II-IV cells were exposed to varying concentrations of DCP (0-350 μg/ml) to assess time- and concentration-dependent growth inhibition, and simulate intravesical treatment. Growth inhibition was determined following 24, 48, and 72 h of exposure, using a tetrazolium dye to assess mitochondrial dehydrogenase activity. DCP, cisplatin, and carboplatin effectively achieved >90% cell kill at 72 h. Concentrations of 325 μg/ml DCP, 50 μg/ml cisplatin, and 600 μg/ml carboplatin were sufficient for >90% cell-kill, with cisplatin demonstrating the highest efficacy at the lowest concentration/time intervals. Dose- and time-dependent cell kill were demonstrated at varying concentrations of DCP in grade II-IV cell lines, including cells exposed intravesically. In vitro, DCP demonstrates cell-killing efficacy in a time- and concentration-dependent manner in grade II-IV UC cell lines, showing promise for its intravenous, oral, and intravesical use for bladder UC in both primary and adjuvant/neoadjuvant settings.

Intravesical sustained release system of lidocaine and oxybutynin results from in vitro and animal study.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic debilitating condition of unknown etiology. Intravesical lidocaine demonstrated pain relief in patients with IC/BPS. Intravesical oxybutynin has shown therapeutic efficacy in patients with urinary bladder disorders. However, loss of drug with urination requiring multiple administrations and immediate dilution of drug concentration by residual urine in the bladder mitigated intravesical use of both drugs in clinical practice. The aim of this study was to evaluate the efficacy and safety of fixed-dose combination of lidocaine and oxybutynin, forming in the urine a sustained delivery system named TRG-042. In-vitro, we have quantitatively tested the concentration of lidocaine and oxybutynin released from TRG-042 in artificial urine. Following the successful in-vitro study weekly formulation of TRG-042 was instilled intravesically to six pigs. All pigs were followed with cystoscopy to assess the gradual degradation of the delivery system and to evaluate bladder response over 7 days. Daily blood samples were tested for drug quantization. In-vitro studies have demonstrated oxybutynin and lidocaine sustained release over 1-week period coupled with full degradation of the matrix. None of the animals demonstrated any side effects following instillation. Cystoscopy examination observed gradual disintegration of TRG-042 over 1-week with no adverse reaction to the mucosa. Plasma concentrations of oxybutynin and lidocaine were uniformly stable over the 1-week period [1.46 ± 0.176ng/ml and 4.29 ± 2.48ng/ml respectively(mean ± SEM)] with almost undetectable concentration of N-desethyloxybutynin (NDO)[0.032 ± 0.068ng/ml]. The in-vitro and animal data demonstrated that TRG-042 can safely be used for intravesical sustained release of lidocaine and oxybutynin in the treatment of BPS/IC.

Contrast-enhanced ultrasound: a comprehensive review of safety in children.

Contrast-enhanced ultrasound (CEUS) has been increasingly used in pediatric radiology practice worldwide. For nearly two decades, CEUS applications have been performed with the off-label use of gas-containing second-generation ultrasound contrast agents (UCAs). Since 2016, the United States Food and Drug Administration (FDA) has approved the UCA Lumason for three pediatric indications: the evaluation of focal liver lesions and echocardiography via intravenous administration and the assessment of vesicoureteral reflux via intravesical application (contrast-enhanced voiding urosonography, ceVUS). Prior to the FDA approval of Lumason, numerous studies with the use of second-generation UCAs had been conducted in adults and children. Comprehensive protocols for clinical safety evaluations have demonstrated the highly favorable safety profile of UCA for intravenous, intravesical and other intracavitary uses. The safety data on CEUS continue to accumulate as this imaging modality is increasingly utilized in clinical settings worldwide. As of August 2021, 57 pediatric-only original research studies encompassing a total of 4,518 children with 4,906 intravenous CEUS examinations had been published. As in adults, there were a few adverse events; the majority of these were non-serious, although very rarely serious anaphylactic reactions were reported. In the published pediatric-only intravenous CEUS studies included in our analysis, the overall incidence rate of serious adverse events was 0.22% (10/4,518) of children and 0.20% (10/4,906) of all CEUS examinations. Non-serious adverse events from the intravenous CEUS were observed in 1.20% (54/4,518) of children and 1.10% (54/4,906) of CEUS examinations. During the same time period, 31 studies with the intravesical use of UCA were conducted in 12,362 children. A few non-serious adverse events were encountered (0.31%; 38/12,362), but these were most likely attributable to the bladder catheterization rather than the UCA. Other developing clinical applications of UCA in children, including intracavitary and intralymphatic, are ongoing. To date, no serious adverse events have been reported with these applications. This article reviews the existing pediatric CEUS literature and provides an overview of safety-related information reported from UCA uses in children.

PD27-11 PRELIMINARY PHARMACOKINETIC DATA OF AN IN VITRO AND ANIMAL STUDY OF A NOVEL INTRAVESICAL SUSTAINED DELIVERY SYSTEM OF LIDOCAINE AND OXYBUTYNIN (TRG-042)

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology (PD27)1 Sep 2021PD27-11 PRELIMINARY PHARMACOKINETIC DATA OF AN IN VITRO AND ANIMAL STUDY OF A NOVEL INTRAVESICAL SUSTAINED DELIVERY SYSTEM OF LIDOCAINE AND OXYBUTYNIN (TRG-042) Boris Chertin, David Dothan, Nadav Malchi, Avi Gordon, and Dan Touitou Boris ChertinBoris Chertin More articles by this author , David DothanDavid Dothan More articles by this author , Nadav MalchiNadav Malchi More articles by this author , Avi GordonAvi Gordon More articles by this author , and Dan TouitouDan Touitou More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002020.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Interstitial Cystitis / Bladder pain syndrome (IC/BPS) is a chronic debilitating condition of unknown etiology. Intravesical lidocaine administration has demonstrated pain relief in patients with IC/BPS. Intravesical administration of Oxybutynin has a well-documented therapeutic effect in patients with urinary bladder disorders due to a direct local anesthetic, antimuscarinic and spasmolytic effect within the bladder wall. However, intravesical use of the both drugs in the clinical practice did not stand the test of time due to rapid dilution and loss of drug with urination requiring multiple administrations. The ability to prolong drug retention in the urinary bladder enhances the bladder wall tissue exposure to adequate therapeutic level of drugs. The aim of this study was to evaluate the efficacy and safety of fixed-dose combination of Lidocaine and Oxybutynin novel polymeric composition forming instantly in the urine a sustained delivery system named TRG-042. METHODS: We have In-Vitro tested release of Lidocaine and Oxybutynin from TRG-042 in artificial urine (AUF) and have quantitatively determined Oxybutynin and Lidocaine concertation utilizing high-pressure liquid chromatography(HPLC). Following the successful In-Vitro study weekly formulation of TRG-042 was instilled into urinary bladder of 6 pigs. All pigs were followed with cystoscopy and US in order to assess the gradual degradation of the intravesical delivery system and to evaluate the response of the bladder over the seven days. Daily blood samples were tested for drug quantitation. Three pigs, who received TRG-042 without Oxybutynin and Lidocaine served as a control. RESULTS: In-Vitro studies have demonstrated Oxybutynin and Lidocaine sustained release over the one-week period coupled with the full degradation of the matrix. None of the animals demonstrated any side effects following instillation. Cystoscopy examination observed gradual disintegration of the TRG-042 over one-week period with no adverse reaction of the bladder mucosa. Plasma concentrations of Oxybutynin and Lidocaine were uniformly high and stable over the one-week study period 1.46+/-0.176 ng/ml and 4.29+/-2.48 ng/ml respectively (mean+/-SEM) with almost undetectable concentration of active metabolite N-desethyloxybutynin (NDO) 0.032+/-0.068 ng/ml. CONCLUSIONS: The In-Vitro and animal data suggest that TRG-042 can safely be used for possible intravesical sustain release of Lidocaine and Oxybutynin in the treatment of BPS/IC. Our preliminary results should be further confirmed in clinical studies. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e448-e448 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Boris Chertin More articles by this author David Dothan More articles by this author Nadav Malchi More articles by this author Avi Gordon More articles by this author Dan Touitou More articles by this author Expand All Advertisement Loading ...

Starting a pediatric contrast ultrasound service: made simple!

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.

Recurrent Sigmoid Diverticulitis After Intravesical Bacillus Calmette-Guérin (BCG) Immunotherapy for Bladder Cancer

Bacillus Calmette-Guerin (BCG), a live attenuated strain of Mycobacterium bovis, is a popular adjunctive therapy for superficial bladder cancer as it triggers local immune response. Localized cystitis is a common complication, but systemic infections or sepsis is rare. Diverticulitis has never been reported as a complication of intravesical BCG use. We report two episodes of sigmoid diverticulitis in a patient with urinary bladder papillary urothelial carcinoma after each intravesical BCG treatment, which subsided after the BCG treatment was discontinued. This case report raises awareness of acute diverticulitis as a potential side effect of intravesical BCG therapy for superficial bladder cancer. The use of antibiotics in concurrence with intravesical BCG therapy should be used with caution as evidence is not sufficient to evaluate the effect of antibiotics on BCG. Therefore, a change in therapy is warranted if recurrence of diverticulitis occurs and requires antibiotic therapy.

The Impact of a New Interleukin-2-Based Immunotherapy Candidate on Urothelial Cells to Support Use for Intravesical Drug Delivery.

(1) Background: The intravesical instillation of interleukin-2 (IL-2) has been shown to be very well tolerated and promising in patients with bladder malignancies. This study aims to confirm the use of a new IL-2 containing immunotherapy candidate as safe for intravesical application. IL-2, produced in mammalian cells, is glycosylated, because of its unique solubility and stability optimized for intravesical use. (2) Materials and Methods: Urothelial cells and fibroblasts were generated out of porcine bladder and cultured until they reached second passage. Afterwards, they were cultivated in renal epithelial medium (REM) and Dulbecco’s modified Eagles medium (DMEM) with the IL-2 candidate (IMS-Research) and three more types of human interleukin-2 immunotherapy products (IMS-Pure, Natural IL-2, Aldesleukin) in four different concentrations (100, 250, 500, 1000 IU/mL). Cell proliferation was analyzed by water soluble tetrazolium (WST) proliferation assay after 0, 3, and 6 days for single cell culture and co-culture. (3) Results: Proliferation assays showed that all IL-2 products induced very similar cultivation results and none of the IL-2 variants had a negative impact on the proliferation of urothelial cells and fibroblast in either concentration. (4) Conclusion: Human recombinant glycosylated IL-2 as well as human non-glycosylated IL-2 have no negative influence on the tissue cell proliferation of porcine urothelial cells and fibroblasts in vitro and represent a promising and innovative potential intravesical therapy candidate for patients in high need.

Abstract 110: Quantitative high throughput screening as a tool to identify novel therapies in bladder cancer

Abstract Introduction: Bladder cancer (CaB) is the 4th most common cancer among men in the US. It is the most expensive malignancies to treat from diagnosis to death. No new pharmacological agents have been approved for treatment of bladder cancer since the approval of BCG in 1990. Thus, there is an urgent need for development of new treatment therapies. Quantitative high throughput screening (qHTS) of representative cancer lines with oncology drugs may identify new treatments or re-purpose already existing therapies for different disease. We utilized this technique to identify new therapies in two primary bladder lines (T24 and UMUC3) and their metastatic lines (T24T, SLT3 and FL3 of T24 and LUL-2 for UMUC3). Methods: We screened 7 bladder cancer cell lines against 1,912 oncology drugs using a 48 hour cell proliferation assay with an ATP−based readout (CellTiterGlo) to determine activity and potency of compounds in a dose response manner. One of the candidate drugs inhibitory in all cell lines tested is flavopiridol, a pan CDK inhibitor. We further characterized the mechanism of action and in vivo effects of flavopiridol using various cell based assays and mouse xenograft studies. Results: The initial screen identified 95 compounds active in 7 cell lines. The top 50 compounds were further analyzed for molecular size of >200 g/mol and TPSA<90. This identified mitomycin C and 8 novel compounds. Further testing revealed Flavopiridol to be most consistent with qHTS data having IC50 of 100-300nM in all the cell lines tested. Flavopiridol induces G2/M arrest; however, very little apoptosis was seen suggesting cytostatic rather than cytotoxic mechanism of flavopiridol action. Flavopiridol showed dose dependent inhibition of migration, invasion and colony formation in CaB cell lines tested. Xenograft studies in rapidly growing UMUC-3 cells showed slowing of tumor growth but not complete reduction indicating cytostatic mechanism of flavopiridol. However, in slow growing cells, 5637, 5/8 treated mice showed complete tumor reduction. Conclusions: qHTS can identify novel compounds. Flavopiridol seems to be a very effective inhibitor both in vitro and in vivo. Physical properties of Flavopiridol are most suited for intravesical use which may lead to it being an effective inhibitor of CaB in the bladder at higher doses without any/few systemic toxicities. Studies are underway to elucidate the use of flavopiridol as a single intravesical agent. Citation Format: Reema Railkar, Thomas Sanford, L. Spencer Krane, Piyush K. Agarwal. Quantitative high throughput screening as a tool to identify novel therapies in bladder cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 110. doi:10.1158/1538-7445.AM2017-110

Flavoperidol as a novel therapeutic agent for bladder cancer.

357 Background: Bladder cancer (CaB) is the 4th most common cancer among men in the US but receives substantially less research resources than many other cancer types. There has been little change to the management of bladder cancer over the past 25 years. Quantitative high throughput screening (qHTS) of representative cancer lines with oncology drugs may identify new treatments or re-purpose already existing therapies for different disease. We utilized this technique to identify new therapies in three primary bladder lines (RT4, T24, and UMUC3) and their metastatic lines (T24T, SLT3 and FL3 for T24 and LUL-2 for UMUC3). Methods: We screened 8 bladder cancer cell lines (including RT4, T24, and UMUC3) against 1,912 oncology drugs using a 48 hour cell proliferation assay with an ATP−based readout to determine activity and potency of compounds in a dose response manner. One of the candidate drugs inhibitory in all cell lines tested is flavopiridol, a pan CDK inhibitor. We further characterized the mechanism of action and in vivo effects of flavopiridol using various cell based assays and mouse xenograft studies. Results: The initial screen identified 95 compounds active in 8 cell lines. The top 50 compounds were further analyzed for molecular size of >200 g/mol and TPSA<90. This identified mitomycin C and 8 novel compounds. Further testing revealed Flavopiridol to be most consistent with qHTS data having IC50 of 100-300nM in all the cell lines tested. Flavopiridol induces G2/M arrest; however, very little apoptosis was seen suggesting a cytostatic rather than a cytotoxic mechanism of flavopiridol action. Flavopiridol showed dose dependent inhibition of migration, invasion and colony formation in all cell lines tested. Xenograft studies in rapidly growing UMUC-3 cells showed slowing of tumor growth but not complete reduction indicating cytostatic mechanism of flavopiridol. Conclusions: A high throughput drug screen can identify novel compounds in bladder cancer. Flavopiridol seems to be a very effective inhibitor both in vitro and in vivo. Physical properties of Flavopiridol are most suited for intravesical use, which may lead to it being an effective inhibitor of CaB in the bladder at higher doses without any/few systemic toxicities.

Dynamic contrast-enhanced ultrasound of the bowel wall with quantitative assessment of Crohn's disease activity in childhood.

BackgroundContrast-enhanced ultrasound (CEUS) has become an established non-invasive, patient-friendly imaging technique which improves the characterization of lesions. In addition, dynamic contrast-enhanced ultrasound (DCE-US) provides valuable information concerning perfusion of examined organs. This review addresses current applications of CEUS in children, focused on DCE-US of the bowel wall in patients with Crohn disease, which enables realtime assessment of the bowel wall vascularity with semi-quantitative and quantitative assessment of disease activity and response to medical treatment.ConclusionsCrohn’s disease is a chronic inflammatory relapsing disease. Frequent imaging re-evaluation is necessary. Therefore, imaging should be as little invasive as possible, children friendly with high diagnostic accuracy. US with wide varieties of techniques, including CEUS/DCE-US, can provide an important contribution for diagnosing and monitoring a disease activity. Even if the use of US contrast agent is off-label in children, it is welcome and widely accepted for intravesical use, and a little less for intravenous use, manly in evaluation of parenchymal lesions. To our knowledge this is the first time that the use of DCE-US in the evaluation of activity of small bowel Crohn disease with quantitative assessment of kinetic parameters is being described in children. Even if the results of the value and accuracy of different quantitative kinetic parameters in published studies in adult population often contradict one another there is a great potential of DCE-US to become a part of the entire sonographic evaluation not only in adults, but also in children. Further control studies should be performed.

Abstract 3758: Quantitative high-throughput screening as a tool to identify novel therapies in bladder cancer: lessons from flavopiridol

Abstract Introduction and Objectives: Bladder cancer (CaB) is the 4th most common cancer among men and 12th most common among women in United States. It is one of the most expensive malignancies to treat from diagnosis to death. No new pharmacological agents have been approved for the treatment of bladder cancer in the last two decades. Therefore, there is an urgent need for development of new treatment therapies. Quantitative high throughput screening (qHTS) of representative cancer cell lines with oncology drugs may identify new treatments and pathways. We utilized this technique to identify new targets and therapies in two primary bladder lines (T24 and UMUC3) and their metastatic derivatives (T24T, SLT3 and FL3 of T24 and LUL-2 for UMUC3). Methods: We screened 7 bladder cancer cell lines (T24T, SLT3, FL3, LUL-2, RT4, T24, and UMUC3) against 1,912 oncology drugs using a 48 hour cell proliferation assay with an ATP−based readout (CellTiterGlo) to determine activity and potency of compounds in a dose response manner. One of the candidate drugs inhibitory in all cell lines tested is flavopiridol, a pan-CDK inhibitor. We further characterized the mechanism of action of flavopiridol using various cell based assays such as cell proliferation, cell cycle analysis, apoptosis assays, and modified colony forming assays. Finally, mouse xenograft studies were carried out to elucidate the in vivo effects of flavopiridol. Results: The initial screen identified 95 compounds active in 7 cell lines. The top 50 compounds were further analyzed for molecular size of >200 g/mol and TPSA<90. These parameters are consistent with lipophilicity and may help identify compounds that can be used as intravesical agents. The selection parameters identified mitomycin C and 8 novel compounds. Cell proliferation assays of these 8 novel compounds in cell lines not part of the initial screen revealed that flavopiridol most consistently achieved IC50s of 100-150 nM, consistent with the qHTS data. Flavopiridol induces G2/M arrest; however, it induces little apoptosis as per the Annexin V FITC-PI assay. Growth in Low Attachment (GILA) assay showed inhibition of colony formation in the presence of flavopiridol. Xenograft studies using the UMUC-3 cell line implanted subcutaneously demonstrated cytostatic inhibition of tumor growth in the presence of systemically delivered flavopiridol. However, intravesical administration has not yet been evaluated. Conclusions: qHTS can identify novel compounds. Flavopiridol is an effective inhibitor both in vitro and in vivo. Although it merely caused cytostatic inhibition in a xenograft model when delivered systemically, its physical properties are most suited for intravesical use which may lead to it being more effective as higher doses can be administered into the bladder with minimal/no systemic toxicities. Studies are now underway to evaluate the use of flavopiridol as an intravesical agent. Citation Format: Reema Railkar, Achuth Nair, Keidren Lewi, Spencer Krane, Rajarshi Guha, Marc Ferrer, Craig Thomas, Piyush K. Agarwal. Quantitative high-throughput screening as a tool to identify novel therapies in bladder cancer: lessons from flavopiridol. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3758.

Contrast-enhanced voiding urosonography: in vitro evaluation of a second-generation ultrasound contrast agent for in vivo optimization.

Pediatric contrast-enhanced ultrasound (CEUS) is primarily performed outside the United States where a track record for safety in intravenous and intravesical applications has been established. Contrast-enhanced voiding urosonography (ceVUS) has also been shown to have a much higher rate of vesicoureteral reflux detection compared to voiding cystourethrography. US contrast agents available in the United States differ from those abroad. Optison® (GE Healthcare, Princeton, NJ) is such an US contrast agent. While Optison® has similar characteristics to other second-generation agents, it has never been used for ceVUS. In vitro optimization of dose and imaging parameters as well as assessment of contrast visualization when delivered in conditions similar to ceVUS are necessary starting points prior to in vivo applications. To optimize the intravesical use of Optison® in vitro for ceVUS before its use in pediatric studies. The experimental design simulated intravesical use. Using 9- and 12-MHz linear transducers, we scanned 20-mL syringes varying mechanical index, US contrast agent concentration (0.25%, 0.5%, 1.0%), solvent (saline, urine, radiographic contrast agent) and time out of refrigeration. We evaluated mechanical index settings and contrast duration, optimized the contrast dose, measured the effect of urine and radiographic contrast agent, and the impact of length of time of contrast outside of the refrigerator on US contrast appearance. We scanned 50-ml saline bags to assess the appearance and duration of US contrast with different delivery systems (injection vs. infusion). Consistent contrast visualization was achieved at a mechanical index of 0.06-0.17 and 0.11-0.48 for the L9 and L12 MHz transducers (P < 0.01), respectively. Thus, it was necessary to increase the mechanical index for better contrast visualization of the microbubbles with a higher transducer frequency. The lowest mechanical index for earliest visible microbubble destruction was 0.21 for the 9MHz and 0.39 for the 12MHz (P < 0.01) transducers. The 0.5% US contrast agent volume to bladder filling was the most optimal. At this concentration, the mean time to visualize homogenous contrast was 2min and destruction of approximately half of the microbubbles in the field of view occurred in 7.8min using the 9-MHz transducer. During contrast infusion, the contrast dose needed to be reduced to 0.12% for maintenance of optimal visualization of microbubbles. There was no deleterious effect on the visualization of contrast in the presence of urine or radiographic contrast agent. Infusion of the US contrast agent speeded visualization of homogeneous enhancement compared with injection. Time outside refrigeration did not affect contrast performance. Transducer mechanical index settings need to be optimized. A very low dose of the US contrast agent Optison® will suffice for intravesical application, i.e. 0.12% to 0.50% of the bladder filling volume. The presence of urine or radiographic contrast agent did not compromise contrast visualization. The best mode of administration is the infusion method due to fast homogenous distribution at the lowest dose of 0.12%. Leaving the US contrast agent outside the refrigerator for an hour does not affect the microbubbles.

Histopathologic and Urodynamic Effects of the Anticholinergic Drugs Oxybutynin, Tolterodine, and Trospium on the Bladder.

This study aimed to evaluate the effects of intravesical instillation of the anticholinergic drugs oxybutynin, tolterodine, and trospium on bladder capacity and histopathological changes in the bladder mucosa. The study included 20 male New Zealand white rabbits that were randomly allocated to four groups of five. In the oxybutynin, tolterodine, and trospium groups, the drugs used were 1 mg/kg of crushed tablet mixed with 5 mL of saline, instilled intravesically once per day for 4 weeks. The control group was administered only 5 mL of saline once per day for 4 weeks. Urodynamic measurement of the bladder was made before and after treatment. At the end of the treatment the animals were killed and the bladders were evaluated histopathologically. There were no significant differences between pre- and post-treatment bladder capacity in any of the groups (P > 0.05). Histopathological evaluation showed that the mucosal epithelium was intact and there was minor inflammation in the control group and oxybutynin group (P > 0.05), whereas there was destruction of the mucosal epithelium and findings of diffuse inflammation in the tolterodine (P = 0.014) and trospium (P = 0.014) groups. Intravesical oxybutynin treatment was observed to be safe; however, a single daily dose of oxybutynin may not be sufficient to increase bladder capacity. Intravesical use of trospium and tolterodine at high doses caused epithelial destruction and diffuse inflammation in the bladder mucosa. The irritation associated with epithelial destruction and inflammation prevented an increase in bladder capacity.

Interstitial cystitis/bladder pain syndrome (IC/BPS)

Interstitial cystitis/bladder pain syndrome (BPS) is still an etiologically poorly understood chronic pain syndrome. BPS is a clinical diagnosis. The current treatment modalities are aimed at symptom relief because no cure is possible. Analgesics may be used at any point in treatment but preferably for short-term relief for flares or bladder pain. AUA has issued clinical practice guidelines with a stepwise approach. The first-line therapy begins with self-care and behavior modification. Physical therapy and oral medications such as amitriptyline, PPS, or antihistamines belong to the second-line therapy. Third-line therapy requires cystoscopy and hydrodistension, treatment of Hunner lesions, or intravesical use of e.g. DMSO. Neuromodulation is considered a fourth-line therapy in patients who have failed third-line treatments. Fifth-line therapies consist of intravesical injection of BoNT or oral cyclosporin A. Cystectomy is the sixth-line therapy and the treatment of last resort.

PS-237 Contrast-enhanced Voiding Urosonography With A Second-generation Ultrasound Contrast Agent For Diagnosis Of Vesicoureteric Reflux In 1350 Children: The Experience Of A Single Centre

Purpose To evaluate the diagnostic performance and safety of intravesical administration of a-second-generation ultrasound contrast-agent (UCA) for the diagnosis of vesicoureteric reflux (VUR) in children. Methods and materials 1350 children (587 boys/763 girls, mean-age 2.6y, range 15d-17y) with 2720 pelvi-ureter-units, underwent contrast-enhanced voiding urosonography (ceVUS) to rule out VUR and urethral pathology. A second-generation UCA (SonoVue ® , Bracco, Milan) was administered intravesically through 5–8F feeding-tube at a dose of 0.5 ml/bladder filling. Possible adverse-events were monitored during the examination and followed-up for 7 days after the ceVUS by phone-calls. Urine analysis and culture were performed 3–5 d before ceVUS in all children and 24–48 h in any patient reported with adverse-events. Results VUR was detected in 450/1350(33%) patients (162 boys/288 girls). This was in 653 pelvi-ureter-units (reflux-grade distribution: grade I = 1, grade II = 276, grade III = 266, grade IV = 100, grade V = 10). The urethra was normal in all children. Mean duration of examination was 14 ± 7 min, including urethral imaging. Minor adverse-events were reported in 45(3.3%) children. These included dysuria (n = 39), abdominal pain (n = 2), increased frequency of micturition (n = 1), vomiting (n = 1), perineal irritation (n = 1), and urinary-tract-infection after ceVUS (n = 1). The onset of adverse-events were subacute in 92% and delayed in 8% and were self-limited non-requiring hospitalisation. Conclusions There were no serious adverse-events with intravesical use of SonoVue ® . Only a few minor adverse-events were reported during ceVUS most likely due to catheterization process. Thus ceVUS with intravesical administration of a second generation UCA (SonoVue ® ) for VUR and urethral pathology detection is a safe and reliable diagnostic procedure in children.

Voiding urosonography with second-generation ultrasound contrast versus micturating cystourethrography in the diagnosis of vesicoureteric reflux

Vesicoureteric reflux has been associated with paediatric urinary tract infection. Fluoroscopic micturating cystourethrography (MCU) has been the gold standard of diagnostic test for decades; however, it has been criticized owing to its lower detection rate and radiation dose to children. Therefore, new radiation-free reflux imaging modalities have been developed, in which ultrasound-based contrast-enhanced voiding urosonography (ceVUS) is a good example. However, ultrasonography has been considered as an operator-dependent examination. Therefore, our study aimed to examine the inter-observer agreement of this sonographic technique, which has not been evaluated before. Moreover, the second-generation ultrasound contrast SonoVue has been recently marketed, and the data on its efficacy on intravesical use in ceVUS is relatively scarce. Thus, we also aimed to investigate the diagnostic performance and safety profile of SonoVue-enhanced VUS in the diagnosis of vesicoureteric reflux. Our prospective comparative study compared the diagnostic performance of ceVUS with MCU in young children presenting with first episode of urinary tract infection. We performed sequential ceVUS and MCU examinations in 31 patients (62 pelvi-ureter units). Perfect inter-observer agreement (Cohen’s kappa statistics = 1.0, p < 0.001) was achieved in ceVUS, suggesting its good reliability in reflux detection and grading. Using MCU as reference, ceVUS had 100 % sensitivity and 84 % specificity and carried higher reflux detection rate than MCU (p < 0.001). There was no complication encountered. Conclusion: Voiding urosonography is a reliable, sensitive, safe and radiation-free modality in the investigation of vesicoureteric reflux in children. It should be incorporated in the diagnostic algorithm in paediatric urinary tract infection.

Experience of using fluorescence cystoscopy in the diagnosis of superficial bladder cancer

Experience of using fluorescence cystoscopy in the diagnosis of superficial bladder cancer. The study involved 103 patients of both sexes (mean age 58,7 ± 6,3 years) who underwent photodynamic diagnosis (PDD) of bladder cancer. For this purpose 5 mg of photoditazine were injected into the bladder dissolved in 20 ml of saline. The exposure time of the drug in the bladder was from 60 to 90 minutes. Then sequentially performed cystoscopy in white and blue light. For fluorescence diagnosis the light flux with a wavelength of 402 nm was used, which corresponded to the maximum peak of photoditazine absorption. The use of PDD revealed bladder cancer in all 103 patients, while in 69 (67 %) patients were identified in a total of 125 plots mucosa, fluorescent in blue light and unaltered in white light. Histological examination of these sites of mucosa in 52 (41.6 %) cases the tumor (transitional cell carcinoma) was morphologically confirmed, in 14 (11.2 %) cases of dysplasia was detected, in 15 (12 %) - squamous metaplasia of the urothelium, in 31 (24.8 %) - inflammatory changes in the urothelium, in 13 (10.4 %) - leukoplakia of the bladder. Thus, the diagnostic sensitivity of the standard cystoscopy in white light was 62.3 %, and PDD with intravesical use of the drug photodithazine - 96.7 %.

Available evidence about efficacy of different restoring agents of glycosaminoglycans for intravesical use in interstitial cystitis

ObjectivesTo compare the different endovesical therapeutic regimes in terms of clinical effectiveness based on glycosaminoglycan replenishment agents (RA-GAG) available on the market in Spain. Material and methodsA bibliographic analysis was made of the studies published in Medline from 1996 to 2012 on RA-GAG of application in the bladder, placing emphasis on the clinical results. A post hoc comparison was made of the efficacy of this treatment in the studies conducted in patients with interstitial cystitis in different conditions by calculating the effect sizes to analyze improvement on the pain visual analogue scale (VAS) and clinical response rate. The number of patients needed to treat (NNT) for the different agents were calculated based on the odds ratio and associated economic implications. ResultsThe globally available evidence is scarce. There are 38 articles about RA-GAGs in different indications, 71 of them in interstitial cystitis and only 8 may assist in establishing a comparison between the results presented. The treatments used were placebo, 0.8% high molecular weight hyaluronic acid (Cystistat®), 2% chondroitin sulfate sodium (Uracyst®) and a combination of 1.6% low molecular weight hyaluronic acid plus 2% chondroitin sulfate (Ialuril®), between 6 and 12 instillations. Another low molecular weight hyaluronic acid preparation (Uromac®) lacks any scientific evidence. All the therapeutic elements studied show a mean score decrease on the pain VAS and increase in the rate of post-treatment response. The NNT for the treatments that are statistically more beneficial over placebo ranges from 1.6 to 4.1. The post hoc comparison of the response rates has established that Cystistat® 12 instillations (OR 18.8; 95% CI 6.4–57.2; p=.001) or 10 instillations (OR 19.2; 95% CI 5.3–75.3; p=.001) are the treatment regimes that obtain maximum effectiveness. In both cases, the NNT was 1.6. ConclusionsThis study has multiple limitations inherent to the nature of the design. However, although the available literature is scarce, it shows that there are differences regarding the clinical effectiveness of the different agents and regimes used for endovesical treatment of interstitial cystitis. These differences also entail economic type implications.

Application of a second-generation US contrast agent in infants and children—a European questionnaire-based survey

No US contrast agent (US-CA) is currently licensed for use in children. To survey the off-label use in children of a second-generation US-CA. Questionnaires were e-mailed to European paediatric radiologists, who were asked about their experience with the second-generation US-CA Sonovue® (Bracco, Milan, Italy). Number of examinations per indication and adverse effects were recorded. Examinations were categorised by intravenous or intracavitary use of US-CA. Out of 146 respondents, 88 stated that they did not perform contrast-enhanced US in children, but 36 of these (44%) would appreciate paediatric approval. Forty-five centres reported 5,079 examinations in children (age mean: 2.9years; range: birth-18years, M/F: 1/ 2.8). The majority (4,131 [81%] in 29 centres) were intravesical applications. The minority (948 [19%] in 30 centres) were intravenous applications. No adverse effects had been recorded from intravesical use. Six minor adverse effects (skin reaction, unusual taste, hyperventilation) had been recorded after five intravenous studies (0.52%). Responses suggest a favourable safety profile of this second-generation US-CA in children. It also demonstrates a demand for such US-CA from paediatric radiologists.

A Phase I Trial of Intravesical Nanoparticle Albumin-Bound Paclitaxel in the Treatment of Bacillus Calmette-Guérin Refractory Nonmuscle Invasive Bladder Cancer

Up to 50% of patients treated with intravesical agents for high grade nonmuscle invasive bladder cancer will have disease recurrence. Response rates to current second line intravesical therapies are low and for these high risk patients novel agents are necessary. Our previously completed phase I trial showed docetaxel was a safe agent for intravesical use. Nanoparticle albumin-bound paclitaxel (Abraxane®, ABI-007) has been shown to have increased solubility and lower toxicity compared to docetaxel in systemic therapy. Thus, we assessed the dose limiting toxicity and maximum deliverable dose of intravesical nanoparticle albumin-bound paclitaxel. Inclusion criteria for this institutional review board approved phase I trial were recurrent high grade Ta, T1 and Tis transitional cell carcinoma of the bladder for which at least 1 prior standard intravesical regimen failed. Six weekly instillations of nanoparticle albumin-bound paclitaxel were administered with a modified Fibonacci dose escalation model used until the maximum deliverable dose was achieved. The primary end point was dose limiting toxicity and the secondary end point was response rate. A total of 18 patients were enrolled in the study. One patient demonstrated measurable systemic absorption after 1 infusion. Grade 1 local toxicities were experienced by 10 (56%) patients with dysuria being the most common, and no grade 2, 3 or 4 drug related local toxicities were encountered. Of the 18 patients 5 (28%) had no evidence of disease at posttreatment evaluation. Intravesical nanoparticle albumin-bound paclitaxel exhibited minimal toxicity and systemic absorption in the first human intravesical phase I trial to our knowledge. A larger phase II study has begun to formally evaluate the activity of this regimen.