High levels of nm23 expression are related to cell proliferation in human prostate cancer.

Reduced expression of the nm23 gene has been correlated with high metastatic potential in rodent mammary tumors and human breast cancer. The expression of this gene was studied in human prostate cancer tissue from 43 patients by immunohistochemistry using anti-nm23-H1 antibodies. Intense immunostaining was observed in 71.4% of the patients with clinical stage D disease as compared to 23.1% in clinical stage B and 18.7% in stage C disease (P < 0.05). Similarly intense immunostaining was present in 75% of poorly differentiated cancers versus only 28.6% in men with moderately differentiated cancer. nm23-H1 mRNA expression was measured by Northern blot analysis during phases of the cell cycle in DU 145, PC-3, LNCaP, and TSU-Prl human prostate cancer cell lines. Cells were synchronized in G0-G1 phases by serum deprivation and at the G1-S boundary by aphidicolin. nm23-H1 mRNA levels declined during serum deprivation and increased rapidly following serum addition. Although nm23-H1 was expressed continuously throughout the cell cycle, higher expression was observed in late G1, early S, and G2-M phases. These results indicate that nm23-H1 gene expression is related to the proliferative phase of cell growth.

Androgen up-regulates epidermal growth factor receptor expression and binding affinity in PC3 cell lines expressing the human androgen receptor.

Androgens are required for the optimal growth and development of both the normal prostate and steroid-sensitive prostate cancer. PC3 prostate cancer cell lines stably expressing the human androgen receptor (AR) and possessing an androgen-sensitive phenotype (PC3-hAR) were used to examine the role of the epidermal growth factor receptor (EGFR) in androgen-stimulated prostate cancer cell growth. Epidermal growth factor (EGF) and dihydrotestosterone (DHT) independently induced the growth of PC3-hAR cells. Moreover, EGF and DHT in combination exerted a synergistic effect on PC3-hAR cell growth. DHT-exposed PC3-hAR cells expressed a greater than 2-fold increase in EGFR mRNA and 50% more EGFR protein than controls. Time course radioligand-binding assays confirmed these findings by showing an elevation in EGF binding in the DHT-exposed PC3-hAR cells. In addition, radioligand competition-binding studies revealed a 2-fold increase in EGFR-EGF binding affinity in the PC3-hAR cells after DHT treatment. However, no enhancement of transforming growth factor alpha or EGF expression was detected because DHT did not affect the levels of these cytokines in the PC3-hAR cell lysate or conditioned media. Our observations suggest that DHT increases both EGFR number and receptor-ligand affinity in androgen-sensitive prostate cancer cells and that these effects correlate with increased EGF binding and an enhanced mitogenic response to EGF.

Regional loss of chromosome 6 in two urological malignancies.

Immunogenetic evidence suggests a genetic association between the major histocompatibility complex and the two genitourinary neoplasms, testicular teratocarcinoma and renal cell carcinoma. In order to develop a possible explanation for these findings, we designed a series of experiments to investigate the existence of a tumor suppressor gene in the region of HLA by looking for loss of germ line heterozygosity in these neoplasms at loci within and centromeric to HLA on chromosome 6. Restriction enzyme-digested DNA, from 15 human teratocarcinoma tumors, and corresponding normal somatic DNA, from peripheral blood mononuclear cells, were hybridized to one of three chromosome 6 probes determined to be polymorphic in this region. Probe 4c11 (6p11-cen) revealed loss of germ line DNA in three of 14 tumors. In contrast, probes pC22A (6p21.3) and p308 (6cen), which hybridize to chromosome 6p sequences, telomeric and centromeric to those sequences recognized by 4c11, did not demonstrate loss or sequence alteration in a total of 14 analyzable tumors. A total of 33 renal cell carcinoma specimens was also analyzed with the informative 4c11 probe with loss demonstrated in six of 33 tumors. In contrast, 23 different samples representing 15 other tumor types were examined with 4c11. Loss of chromosome 6p DNA was demonstrated in only two samples. These data support the hypothesis that there is nonrandom loss of DNA centromeric to HLA on chromosome 6 in both testicular teratocarcinoma and renal cell carcinoma.

Re-purposing cryoablation: a combinatorial 'therapy' for the destruction of tissue.

It is now recognized that the tumor microenvironment creates a protective neo-tissue that isolates the tumor from the various defense strategies of the body. Evidence demonstrates that, with successive therapeutic attempts, cancer cells acquire resistance to individual treatment modalities. For example, exposure to cytotoxic drugs results in the survival of approximately 20-30% of the cancer cells as only dividing cells succumb to each toxic exposure. With follow-up treatments, each additional dose results in tumor-associated fibroblasts secreting surface-protective proteins, which enhance cancer cell resistance. Similar outcomes are reported following radiotherapy. These defensive strategies are indicative of evolved capabilities of cancer to assure successful tumor growth through well-established anti-tumor-protective adaptations. As such, successful cancer management requires the activation of multiple cellular 'kill switches' to prevent initiation of diverse protective adaptations. Thermal therapies are unique treatment modalities typically applied as monotherapies (without repetition) thereby denying cancer cells the opportunity to express defensive mutations. Further, the destructive mechanisms of action involved with cryoablation (CA) include both physical and molecular insults resulting in the disruption of multiple defensive strategies that are not cell cycle dependent and adds a damaging structural (physical) element. This review discusses the application and clinical outcomes of CA with an emphasis on the mechanisms of cell death induced by structural, metabolic, vascular and immune processes. The induction of diverse cell death cascades, resulting in the activation of apoptosis and necrosis, allows CA to be characterized as a combinatorial treatment modality. Our understanding of these mechanisms now supports adjunctive therapies that can augment cell death pathways.

Treatment of subclinical intraurethral human papilloma virus infection with interferon alfa-2b.

OBJECTIVES: Anogenital human papilloma virus (HPV) infection represents a growing concern among physicians in the United States. An intraurethral reservoir of the virus has been suggested as a possible source for reinfection between sexual partners, and may contribute to the increase in the number of affected individuals. Treatment reports of intraurethral HPV infection with adequate follow-up have been lacking. Our goals in this study were to identify the patients with cytologic evidence of HPV intraurethral infection, and to attempt treatment with intraurethral instillations of interferon alfa-2b. METHODS: Eighty-nine men with anogenital lesions or known exposure to HPV underwent cytologic examination using a urethral swab after all visible disease was adequately treated. Sixteen patients with positive cytology results were treated with weekly instillations of 25 million U of interferon alfa-2b solution for 6 weeks. Urethral cytology was monitored at 2 and 6 weeks post-treatment, as well as every 3 months thereafter up to a year. Those who had a recurrence during the study were retreated with a 6-week course using 50 million U per instillation. Patients were monitored for possible side effects. RESULTS: Seventeen (19%) of 89 patients who entered the study had urethral cytology positive for HPV infection with no evidence of visible disease. Seven (41%) of these 17 patients did not show external (meatal or skin) manifestations of the disease. Fourteen of 16 (88%) men who underwent the therapy were followed for an average of 11.8 months. Nine of those 14 (64%) remained disease free throughout the follow-up. Of the 5 who had a recurrence, 3 were successfully retreated, with a mean of 7.2 months of disease-free follow-up after the second course. No adverse effects of the treatment were noted by blood testing, semen analysis, and patient report. CONCLUSIONS: The urethra is a significant HPV reservoir and should be investigated in patients exposed to the virus. Interferon is a potentially safe and effective treatment option for intraurethral HPV.

Combined laparoscopic and transurethral neodymium: yttrium-aluminum-garnet laser treatment of invasive bladder cancer.

OBJECTIVES: The feasibility and efficacy of combined cystoscopic and laparoscopic neodymium: yttrium-aluminum-garnet (Nd:YAG) laser coagulation of invasive bladder cancer were investigated. METHODS: Five patients with extensive Stage T2-T3a bladder cancer who were not candidates for radical cystectomy were treated by Nd:YAG laser irradiation. All patients also underwent transperitoneal laparoscopic mobilization of the intestine away from the bladder with continuous monitoring of the laser treatment. In 2 cases, laser therapy of the serosal surface of the bladder at the site of tumor was also administered. RESULTS: The procedure was completed without complications in all 5 patients. A mean of 58,607 joules (J) of energy was delivered transurethrally with an additional 8000 to 10,000 J utilized via laparoscopy in 2 cases. Local disease recurrence was noted within 1 to 4 months in 4 of the 5 patients. Distant metastases were detected within 1 to 9 months postoperatively in 3 of 5 patients. No perioperative bowel or bladder perforation occurred. CONCLUSIONS: The use of laparoscopy allows for the safe delivery of large amounts of laser energy to the bladder. However, in this small group of patients with extensive bladder tumors, effective palliation of local disease could not be reliably achieved. Further study is necessary to determine whether treatment modifications or selection of patients with less extensive tumors will lead to better results with combined laparoscopic and cystoscopic laser therapy.

Current and future roles of laparoscopic surgery in urology.

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.

Candida epididymitis: newly recognized opportunistic epididymal infection.

Epididymitis is common, yet it is rarely associated with fungal pathogens. We report a case of Candida albicans epididymitis in a diabetic which was ultimately treated by orchiectomy. Opportunistic infections of the genitourinary tract in immunosuppressed patients are becoming more prevalent; examples include fungal infections in patients with acquired immune deficiency syndrome or after organ transplant. The fact that opportunistic organisms can invade the epididymis and produce infection suggests that in cases of persistent epididymitis, which have failed to respond to conventional therapy, more aggressive diagnostic procedures should be considered. Needle aspiration with cultures for fungus and viral organisms should be performed. This is especially true in patients with preexisting chronic illness or an immune compromised state.

Laparoscopic bilateral nephrectomy for renin-mediated hypertension.

Hypertension arising from retained native kidneys complicates the management of recipients of renal transplants. Reluctance to administer angiotensin-converting enzyme inhibitor (ACEI) drugs to patients taking cyclosporine has reopened the question of performing native nephrectomies for poorly controlled, renin-dependent hypertension. We report the first published cases of simultaneous bilateral laparoscopic nephrectomies in 2 patients: 1 in preparation for living-related donor transplantation and the other ten months following cadaver transplantation in a patient whose end-stage renal disease was from malignant nephrosclerosis. Both had very severe hypertension resistant to multiple drugs and both became normotensive with little or no antihypertensive medication following nephrectomies. A bilateral nephrectomy is currently feasible using a laparoscopic approach.

An observational urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin.

OBJECTIVES: To assess the urodynamic changes in men with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction treated with doxazosin and to correlate these changes with voiding symptoms. METHODS: Fifty patients with LUTS were treated with doxazosin at a dose of 4 mg/day for 3 months. All men were initially evaluated by International Prostate Symptom Score (I-PSS) questionnaires, measurements of urinary flow rate, and complex urodynamic study. Those patients completing the 3-month study underwent repeat testing. RESULTS: Forty-four (88%) men underwent initial and follow-up urodynamic evaluation. The mean I-PSS improved from 20.6 to 10.5 (P < 0.001), mean peak urinary flow rate increased for 11.7 to 13.2 cc/s (P = 0.20), mean detrusor pressure at peak flow decreased from 9 3.6 to 83.0 cm H20 (P = 0.15), and mean cystometric bladder capacity increased from 266 to 304 cc (P = 0.07). Using the Abrams-Griffiths nomogram and number, more than 58% of patients remained obstructed after treatment with doxazosin for 3 months. Men with and without objective evidence of bladder outlet obstruction at the outset of the study had similar improvement in voiding symptoms. Most patients elected to continue treatment with doxazosin at the completion of the study (41/44, 93%). CONCLUSIONS: The majority of patients had objective evidence of persistent bladder outlet obstruction after treatment with doxazosin for 3 months despite significant benefit. The results of complex urodynamic evaluation did not predict treatment response in men with LUTS suggestive of bladder outlet obstruction. Urodynamic study does not appear to be helpful in the evaluation of patients with uncomplicated LUTS prior to treatment with doxazosin.

Doxazosin in men with lower urinary tract symptoms: urodynamic evaluation at 15 months.

OBJECTIVES: To assess the results of doxazosin treatment in men with lower urinary tract symptoms (LUTS) treated for 15 months and to correlate symptomatic changes with alterations in urodynamic measures. METHODS: After an initial 3-month treatment period with doxazosin 4 mg/day, 50 men with LUTS were given the choice of continued treatment with this agent or other therapeutic options. All patients were evaluated by International Prostate Symptom Score (IPSS) questionnaires and urodynamic evaluation initially and after 3 months of treatment. Patients were followed for an additional 12 months and those who continued doxazosin treatment underwent repeat urodynamic testing. RESULTS: Among the original 50 patients, 24 men (48%) continued doxazosin treatment for 15 months, 18 men (36%) discontinued therapy, and 8 men (16%) were either dead or lost to follow-up or had been diagnosed and treated for prostate cancer. Comparison of values at 3 and 15 months of follow-up (9.4 versus 13.4, P = 0.03) showed significant worsening of voiding symptoms, as assessed by the IPSS, in the 24 men still receiving doxazosin. This deterioration of subjective results with doxazosin occurred despite continued improvements in peak urinary flow rate (Qmax), detrusor pressure at peak flow (PdetQmax), and objective measures of obstruction (Abrams-Griffiths number) from 3 to 15 months of follow-up. CONCLUSIONS: Relief of voiding symptoms in men with LUTS treated with doxazosin over prolonged intervals of 15 months does not correlate well with changes in urodynamic measures.

In vitro anti-invasive effects of N-(4-hydroxyphenyl)-retinamide on human prostatic adenocarcinoma.

Components of malignant invasion, namely cellular adhesion, motility, and proteolytic capability provide potential sites of pharmacological intervention for malignancy. In this study, a series of experiments were performed to examine the effects of N-(4-hydroxyphenyl) retinamide (4-HPR, Fenretinide) on cellular adhesion, motility and proteolytic activity of established prostate cancer cell lines, TSU-PR 1 and PC-3. Radioadhesion study showed that the treatment of TSU-PR 1 and PC-3 cells with 10(-6) M of 4-HPR resulted in a 32% and 37% reduction (p < 0.05), respectively, in the cellular adhesion to the matrigel extract. Radiomigration assay also demonstrated that 4-HPR concentration of 10(-6) M reduced the cellular motility by 29% in TSU-PR1 and 28% in PC-3 cells (p < 0.05). Spectrolyse PL indirect chromogenic assay revealed an increase in total activatable uPA activity (TSU-PR 1: 25%, PC-3: 32%, P < 0.05), while Spectrolyse UK direct assay demonstrated a mild, but a statistically significant reduction (PC-3: 5%, TSU-PR1: 9%, P < 0.05) in active uPA activity. Northern analysis and ELISA assays showed that 4-HPR at 10(-6) M enhances the expression of type 1 plasminogen activator inhibitor (PAI-1). Type IV collagenase western blot analysis and densitometry did not demonstrate suppression of the enzyme secretion, but in fact suggested increased translation of the enzyme when treated with 10(-6) M concentration of fenretinide. The results of this study demonstrate that 4-HPR inhibits in vitro cellular adhesion and motility of human prostate adenocarcinoma cell lines, TSU-PR1 and PC-3. Additionally, uPA and PAI-1 assay results suggest that 4-HPR may impair active uPA's proteolytic activity while upregulating the expression of total activatable uPA and PAI-1. The results of this study therefore support 4-HPR's role as a potential anti-invasive agent.

High-frequency electrosurgery using the microcomputer-controlled Erbe ICC 350 unit.

To quantitate electrosurgical and tissue variables during transurethral prostatic resection and electrovaporization, these procedures were performed in five patients using standard endoscopic equipment and the Erbe ICC 350 electrosurgical generator. Current, voltage, power, and resistance were monitored continuously. Energy transfer was quantitated during each electrode pass. Prostatic resection or electrovaporization was successful in each patient. Current, voltage, resistance, and power were similar during resection and electrovaporization, whereas energy transfer was greater during electrovaporization. Generator and tissue characteristics can now be precisely monitored and instantaneously altered during transurethral prostatic electrosurgery to minimize energy transfer to the patient while producing the desired tissue effects.

Molecular mechanisms of testicular carcinogenesis.

Molecular investigations into the neoplastic transformation of a normal spermatogenic precursor cell into a germ-cell malignancy have implicated a wide array of DNA and RNA alterations. Previous epidemiologic and familial patterns of cancer presentation had suggested that testicular cancer developed from one or more genetic alterations. In particular, mutations in cellular oncogenes such as c-kit and tumor-suppressor genes such as the retinoblastoma gene product have been identified as putative etiologic agents in the development and progression of testicular germ-cell tumors. Additionally, alterations in the transcription of RNA that are regulated through a process of genomic imprinting have been identified in human testis cancers. This report provides a framework for integrating this growing literature on the molecular biology of testicular germ-cell tumors into a potential etiologic hypothesis.

Frequent loss of heterozygosity at 11p loci in testicular cancer.

Deletions of segments of chromosome 11 have been found to be involved in several human tumors. Specific deletion of chromosomal band 11p13 has been associated with Wilms' tumors and gonadoblastomas. We performed a deletion analysis of 11p using 6 polymorphic probes and DNA from 30 testicular malignancies with corresponding normal DNA in 19 patients. A cDNA probe (WT 33) was used to evaluate the Wilms' tumor suppressor gene (WT1) for loss by gene dosage analysis. Results using the polymorphic probes revealed loss of heterozygosity on 11p in 59% of informative samples, while use of the WT1 probe revealed loss of hemizygosity in 27% of the samples. Northern blot analysis of WT1 was performed on mRNA from 3 normal and 1 malignant testis, as well as from 4 testicular cancer cell lines (TERA 1, TERA 2, HTE and HTH). Northern blot analysis of the normal testes revealed the presence of the expected 3.2 and 2.7 kb transcripts. The TERA 1, TERA 2 and HTH cell lines were found to express only the 3.2 kb transcript and at levels only 3.3%, 29% and 2.8% of normal testes. The HTE cell line did not express either of the normal transcripts. Our results reveal considerable allelic loss at 11p13 and 11p15, suggesting that these loci may harbor one or more tumor suppressor genes important in the development of testicular cancer.

Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma.

Minimally invasive laparoscopic surgical techniques are being increasingly applied to the treatment of urological diseases. We report a case of a laparoscopically performed modified bilateral retroperitoneal lymph node dissection for clinical stage 1 testicular cancer. The laparoscopic surgical approach to the retroperitoneal nodes is a technically feasible procedure that can remove lymph node tissue from all primary landing sites for testicular cancer metastases with potentially decreased morbidity.

Laparoscopic approach to retroperitoneal lymph node dissection.

Laparoscopic retroperitoneal lymph node dissection is a new surgical procedure used to enhance staging in men with clinical stage I nonseminomatous germ cell tumors of the testis. The procedure has been performed in a limited number of patients at several centers with extensive laparoscopic experience. Laparoscopic retroperitoneal lymphadenectomy is a technically demanding procedure which can be successfully completed in the majority of patients. However, the risk of complications is greater than in patients who undergo standard open retroperitoneal lymph node dissection. The primary advantage of a laparoscopic approach is shortened hospitalization and rapid return to normal activity. The role of laparoscopy in the management of patients with testis malignancy has not been defined. The use of this staging procedure may help minimize the need for surveillance studies following surgery and may be best utilized in men with a lower likelihood of nodal metastases. Ultimately, prospective study in large groups of patients will be necessary to determine the role of laparoscopic retroperitoneal lymph node dissection in patients with testis cancer.

Acute urinary retention secondary to Herpes simplex meningitis.

We report a case of acute urinary retention in a 24-year-old man with Herpes simplex meningitis without genital lesions. Since the differential diagnosis in young patients who present with acute urinary retention also includes multiple sclerosis, lumbosacral disk herniation, rheumatological disorders and drug intoxication, a thorough history and careful neurological examination are of paramount importance in distinguishing these syndromes. As part of a directed neurological evaluation prompt performance of lumbar puncture is indicated; a lymphocytic pleocytosis is suggestive of herpetic meningitis. Culture of Herpes simplex virus from the cerebrospinal fluid should be attempted. We recommend conservative management only, typically with intermittent catheterization, since bladder function usually normalizes within 10 to 14 days.

The role of laparoscopic lymphadenectomy in staging and treatment of urological tumours.

Laparoscopic lymphadenectomy for managing a variety of urological malignancies is likely to continue to increase in popularity. It is essential that the role of these procedures be critically evaluated to ensure that they offer significant benefit without added morbidity as compared with standard techniques. The challenge for the future is to better define selection criteria for laparoscopic surgery, particularly in men with clinically localized prostate cancer, so that both staging methods and therapy can be tailored to the individual patient.

The application of laparoscopy to retroperitoneal surgery in urology.

The application of minimally invasive laparoscopic surgical techniques has provided the urologist with access to retroperitoneal structures previously available only through an abdominal incision. The enhanced visualization provided by video-imaging as well as the ease of access to the retroperitoneum through an incision in the posterior peritoneal envelope has facilitated the manipulation of many retroperitoneal organs. In particular these techniques have been applied to the clinical management of several urologic malignancies, such as adenocarcinoma of the prostate, transitional cell carcinoma of the bladder, and squamous cell carcinoma of the penis. A transperitoneal laparoscopic pelvic lymphadenectomy appears to provide adequate surgical staging of regional pelvic lymph nodes in these malignancies, while providing the patients with reduced morbidity. Additionally, transperitoneal access may be accomplished for an internal spermatic vein ligation, as well as approaches to the kidney, ureter and retroperitoneal lymph nodes. The surgical options are limited only by the availability of the instrumentation and the creativity of the surgeon. However, the indications for these procedures remain unclear and must await further information regarding actual benefits in the form of reduced patient morbidity and cost. The challenge for the future is to more completely define the indications and selection criteria for laparoscopic surgery.