[Anesthetic considerations in laparoscopy for removal of a kidney from a live donor]. / Consideraciones anestésicas en la nefrectomía laparoscópica de donante vivo para trasplante renal.

Kidney transplantation is the main therapeutic alternative for patients with end-stage renal failure. However, the main constraint at present is the lack of available organs. Removal of a kidney from a live donor is a better option than conventional transplantation of a cadaver-donated organ. Among the advantages are a shorter waiting time for the organ recipient and greater assurance of graft quality and survival. The postoperative conditions made possible by laparoscopic surgery have encouraged the donation of tissues by live donors. Anesthetic treatment for patients undergoing laparoscopic surgery must be based on an understanding of the pathophysiologic changes that occur in this type of procedure so that complications can be prevented. This review provides an update of progress in laparoscopic surgery and the repercussions of anesthetic management, particularly with respect to anesthesia for kidney donors.

[A preliminar mathematical model for patients with a previous negative prostate biopsy]. / Desarrollo de un Modelo Matemático preliminar para la detección de cancer de próstata en los pacientes con biopsias prostáticas de repetición.

INTRODUCTION AND OBJECTIVES: It is usual to identify patients with a negative prostate biopsy who are still at risk of prostate cancer. We try to analyse if the classical variables used in the prostate cancer screening are useful for those patients with a previous negative prostate biopsy, and if there is a possibility for making a nomogram witch would help us in the decision to repeat the biopsy. MATERIAL AND METHODS: We studied 179 patients with at least 1 initial negative biopsy. At each biopsy session we recorded: Patient age, serum prostate specific antigen (PSA), free PSA/total PSA, PSA slope, digital rectal examination, prostate volume, PSA density, cancer suspicion in previous transrectal ultrasounds findings, number of negative cores previously obtained, history of precarcinomatous lesions and time between biopsies. Through Logistic regression analysis we determined the association of each variable a positive biopsy. A nomogram was constructed using all variables and discrimination was calculated as the concordance index. RESULTS: Overall 46% of patients had cancer at the repeated biopsy session. In the univariate analysis: Age, digital rectal examination, prostate volume, PSA density, cancer suspicion in ultrasounds findings, and precarcinomatous lesions were associated with repeat positive biopsy for cancer (all p <0.05). In the multivariate study, age, digital rectal examination, prostate volume and history of precarcinomatous lesions were associated with repeat positive biopsy. A nomogram was constructed that had a concordance index of 0.80.

Prostate-specific antigen complexed to alpha(1)-antichymotrypsin in the early detection of prostate cancer.

OBJECTIVES: To study the usefulness of the complexed-to-total (C:T) prostate-specific antigen (PSA) ratio in the early detection of prostate cancer in patients with a total PSA value <4.0 ng/ml. PATIENTS AND METHODS: Total PSA and PSA complexed to alpha(1)-antichymotrypsin were measured in plasma from 193 men with benign prostatic hyperplasia (BPH) and 34 with prostate cancer. The diagnosis was confirmed in 28 BPH and 16 prostate cancer patients by biopsy and in 165 BPH and 18 prostate cancer patients by histological study following transurethral prostatectomy or open prostatectomy. RESULTS: The area under the receiver operating characteristic (ROC) curve was significantly greater for the C:T PSA ratio (0.908) than for total PSA (0.692) (p<0.001). Using a cut-off point of 0.83 for the C:T PSA ratio and regardless of the digital rectal examination (DRE) finding, 20 of the 34 prostate cancer patients would have been given a correct diagnosis (59% sensitivity) and in only 8 of the 193 BPH patients would a biopsy have been necessary (96% specificity). With a cut-off of 0.79, the sensitivity increased to 85% with a specificity of 92%. When the analysis was restricted to the 44 patients with abnormal DRE, the area under the ROC curve for the C:T PSA ratio was 0.919, and a cut-off point of 0. 78 gave a sensitivity of 87% and a specificity of 93%. Using a cut-off of 0.63, all prostate cancers were detected (100% sensitivity) and 54% of the negative biopsies would have been eliminated. For the 183 patients diagnosed following surgery, a cut-off of 0.82 gave a sensitivity of 72% and a specificity of 94%. CONCLUSION: Our results show that the C:T PSA ratio significantly improves the clinical utility of the PSA assay for detecting prostate cancer in patients with total PSA < 4 ng/ml, increasing the sensitivity without significantly increasing the number of biopsies.

Longitudinal evaluation of the complexed-to-total prostate specific antigen ratio in men with prostate disease. Effect of treatment.

The longitudinal changes in the complexed-to-total prostate specific antigen (PSA) ratio were evaluated in 90 men with benign prostatic hyperplasia (BPH) and 50 men with prostate cancer. The influence of treatment on this ratio was studied in 45 BPH patients and 50 patients with prostate cancer. Using a cut-off of 0.80 for the complexed-to-total PSA ratio, the large majority of prostate cancer patients had a ratio above the cut-off before treatment in serial determinations, whereas most BPH patients had a ratio consistently below that value. However, the few prostate cancer patients who had a ratio < or = 0.80 showed this low ratio in serial determinations, as did BPH patients who had a ratio > or = 0.80. During treatment, the ratio significantly decreased in 43 of the 50 patients with prostate cancer in parallel with the decrease in total PSA, and 34 of the 41 patients that had a pretreatment ratio > 0.80 showed a ratio < or = 0.80 during hormonal therapy. Our results show that neither the physiological changes in total and complexed PSA nor the treatment of BPH patients change the diagnostic efficacy of the complexed-to-total PSA ratio, whereas in prostate cancer patients under hormonal therapy, the ratio decreased in parallel with the decrease in total PSA. This suggests that, apart from improving the diagnostic efficacy of total PSA, the complexed-to-total PSA ratio could also be used to monitor BPH patients for newly developed tumours or to monitor therapy in patients with prostate cancer.

Free and complexed prostate specific antigen in the differentiation of benign prostatic hyperplasia and prostate cancer: studies in serum and plasma samples.

PURPOSE: We prospectively evaluated serum and plasma concentrations of total and free prostate specific antigen (PSA), and PSA complexed to alpha1-antichymotrypsin in 170 patients who underwent biopsy, including 59 with prostate cancer and 111 with benign prostatic hyperplasia. We compared the usefulness of the ratios of free-to-total and complexed-to-total PSA for distinguishing between prostate cancer and benign prostatic hyperplasia, and studied the influence of blood clotting on the ratios. MATERIALS AND METHODS: Blood samples were processed to generate serum and citrated plasma. To calculate complexed-to-total and free-to-total PSA we assayed plasma and serum samples for total and complexed PSA using homemade immunoassays, and total and free PSA using the Immulite assay. The 2 total PSA assays were compared using the Tandem-E PSA assay. Receiver operating characteristics curves were constructed for the total population, and for 2 to 20, 4 to 20, 2 to 10 and 4 to 10 ng./ml. total PSA. RESULTS: In all groups complexed-to-total PSA had higher specificity than free-to-total and total PSA, especially at 90 to 100% sensitivity. Generally citrated plasma samples provided higher specificity than serum samples for all sensitivity values. The best performance for complexed-to-total and free-to-total PSA was obtained in the subset of patients in whom total PSA was 2 to 10 ng./ml. CONCLUSIONS: Our results indicate that the complexed-to-total PSA ratio performed better for classifying disease status than the free-to-total PSA ratio in the whole patient population and in the diagnostic gray zone of 2 to 10 ng./ml. In addition, plasma samples should be used to calculate the complexed-to-total and free-to-total PSA ratio.

Reference ranges for the concentrations of total and complexed plasma prostate-specific antigen and their ratio in patients with benign prostate hyperplasia.

OBJECTIVE: To establish the normal distribution and reference ranges of complexed and total prostate-specific antigen (PSA) and the complexed-to-total PSA ratio according to the age of the patients, so that PSA can be used to distinguish between prostate cancer and benign prostate hyperplasia (BPH). MATERIAL AND METHODS: Using specific ELISAs, total PSA and PSA complexed to alpha 1-antichymotrypsin (complexed PSA) were determined in 237 BPH patients, 160 with histologically confirmed BPH and 77 in whom prostate cancer was excluded by digital rectal examination, transrectal ultrasound and total PSA measurement. RESULTS: Both total and complexed PSA correlated with patient age (r = 0.424 and r = 0.379, p < 0.0001, respectively). However, no correlation was found between the complexed-to-total PSA ratio and age (r = 0.026, p > 0.2). The mean complexed-to-total PSA ratio for the 237 BPH patients was 0.69 +/- 0.11, and only 23 had a ratio > 0.8. CONCLUSIONS: These results show that the cut-off point of 0.8 established for the complexed-to-total PSA ratio is the same for men of all ages, and that the use of this ratio may avoid many negative prostate biopsies, confirming that PSA: alpha 1ACT is a potential marker for differential diagnosis of prostate carcinoma and BPH.

Value of deoxyribonucleic acid ploidy and nuclear morphometry for prediction of disease progression in renal cell carcinoma.

PURPOSE: A retrospective study was performed on 108 patients with localized renal cell carcinoma (pT1 to 3a N0M0) to determine whether ploidy and nuclear morphometry are independent predictive factors in addition to stage and grade. MATERIALS AND METHODS: Deoxyribonucleic acid (DNA) content was analyzed by flow cytometry and nuclear morphometry characterized by 5 nuclear descriptors. A Cox proportional hazards regression model was used to identify significant prognostic factors for disease progression. RESULTS: A model combining tumor stage and grade, DNA ploidy and nuclear minor axis was chosen as optimal with risk of disease progression increased with increasing tumor stage and grade, DNA aneuploidy and increasing nuclear minor axis. CONCLUSIONS: This improved ability to predict disease progression in localized renal cell carcinoma may have important clinical use.

Prostate-specific antigen and its complexes with alpha 1-antichymotrypsin in the plasma of patients with prostatic disease.

OBJECTIVE: To improve the specificity and sensitivity of the prostate-specific-antigen (PSA) assay for the distinction between prostate cancer and benign prostate hyperplasia (BPH). METHODS: Two sensitive immunoassays, one that measures free PSA and PSA complexed to alpha 1-antichymotrypsin (alpha 1-ACT) with the same efficiency (PSAag assay) and another that specifically measures the complex between PSA and alpha 1-ACT, have been designed to measure the PSA forms in the plasma of 84 patients with prostate disease and in the seminal plasma from 60 healthy individuals. RESULTS: The proportion of plasma PSA in complex with alpha 1-ACT was significantly higher in the 34 patients with prostate cancer (89 +/- 12%, mean +/- SD; median, 91%) than in the 50 patients with BPH (71 +/- 12%; 73%) and did not correlate with the total amount of PSA. Normal seminal plasma (n = 60) had 2.1 +/- 0.6 mg/ml PSA, 175 +/- 62 microns/ml alpha 1-ACT and 9.6 +/- 3.4 micrograms/ml PSA: alpha 1-ACT complex. CONCLUSION: These results confirm that PSA: alpha 1-ACT may be a good marker for a differential diagnosis of carcinoma of the prostate and BPH.

A quantitative ELISA for the measurement of complexes of prostate-specific antigen with protein C inhibitor when using a purified standard.

The serine protease inhibitor protein C inhibitor is present in semen at a relatively high concentration and forms in vivo complexes with two plasminogen activators also present in semen, urokinase-type and tissue-type plasminogen activators. Therefore, the fact that prostate-specific antigen (PSA), a major prostate enzyme, complexes and inactivates protein C inhibitor (PCI) in semen could have implications in human reproduction. The present study was undertaken to develop an enzyme-linked immunosorbent assay (ELISA) for complexes of PSA with PCI (PSA:PCI) with purified PSA:PCI complexes as a standard. Seminal plasma was utilized as the starting material for purification of complexes by affinity chromatography on heparin-Sepharose and gel filtration. The final preparation contained equimolar concentrations of PSA and PCI and was used for calibration of an ELISA for PSA:PCI complexes involving polyclonal anti-PSA and horseradish peroxidase-labeled anti-PCI antibodies. The ELISA had a detection limit of about 0.2 ng/ml of complex and was specific for PSA:PCI complexes because no color was developed at PSA or PCI concentrations up to 100 microgram/ml. Normal plasma or plasma from patients with prostate carcinoma who had high PSA levels had no detectable PSA:PCI complexes. Seminal plasma from voluntary donors collected in the absence of inhibitors and incubated at room temperature for at least 3 hours had PSA:PCI complex levels ranging from 30 to 46 micrograms/ml, accounting for up to 34% of the total PCI in seminal plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

[Extracorporeal shockwave lithotripsy: an alternative treatment for lithiasis of caliceal diverticula]. / Litotricia extracorpórea por ondas de choque: una alternativa al tratamiento de las litiasis de divertículos caliciales.

Among all the patients treated in our Lithotrity Unit, 13 of them had lithiasis inside the calyceal diverticulum. They were all treated by extracorporeal shockwaves. In none of the cases complete expulsion of lithiasic mass was achieved. In 3 (23%) cases it was reduced to half. In 2 (15.3%), 75% of the initial mass remained; and in 8 (61.5%) stones were fragmented but none of their debris was eliminated. Out of all the patients who were symptomatic before starting treatment, only 36.6% become asymptomatic. Extracorporeal lithotrity is, therefore, an approach with limited results in the calyceal intradiverticular lithiasis.