Successful replantation of self-amputated penis using microvascular repair resulting in restoration of voiding and erectile function.

Intentional self-amputation of the penis is rarely encountered and usually occurs in the context of an underlying psychiatric illness. We report the case of a 42-year-old male who intentionally amputated his penis, both testicles, and a large portion of the scrotum en bloc using garden shears. Microscopic and macroscopic replantation of the penis was undertaken, resulting in restoration of normal urinary function and moderate erectile function.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Randomized, double-blind, placebo-controlled trial of polyphenon E in prostate cancer patients before prostatectomy: evaluation of potential chemopreventive activities.

Compelling preclinical and pilot clinical data support the role of green tea polyphenols in prostate cancer prevention. We conducted a randomized, double-blind, placebo-controlled trial of polyphenon E (enriched green tea polyphenol extract) in men with prostate cancer scheduled to undergo radical prostatectomy. The study aimed to determine the bioavailability of green tea polyphenols in prostate tissue and to measure its effects on systemic and tissue biomarkers of prostate cancer carcinogenesis. Participants received either polyphenon E (containing 800 mg epigallocatechin gallate) or placebo daily for 3 to 6 weeks before surgery. Following the intervention, green tea polyphenol levels in the prostatectomy tissue were low to undetectable. Polyphenon E intervention resulted in favorable but not statistically significant changes in serum prostate-specific antigen, serum insulin-like growth factor axis, and oxidative DNA damage in blood leukocytes. Tissue biomarkers of cell proliferation, apoptosis, and angiogenesis in the prostatectomy tissue did not differ between the treatment arms. The proportion of subjects who had a decrease in Gleason score between biopsy and surgical specimens was greater in those on polyphenon E but was not statistically significant. The study's findings of low bioavailability and/or bioaccumulation of green tea polyphenols in prostate tissue and statistically insignificant changes in systemic and tissue biomarkers from 3 to 6 weeks of administration suggests that prostate cancer preventive activity of green tea polyphenols, if occurring, may be through indirect means and/or that the activity may need to be evaluated with longer intervention durations, repeated dosing, or in patients at earlier stages of the disease.

The laminin binding integrin alpha6beta1 in prostate cancer perineural invasion.

Metastasizing prostate tumor cells invade along nerves innervating the encapsulated human prostate gland in a process known as perineural invasion. The extracellular matrix laminin class of proteins line the neural route and tumor cells escaping from the gland express the laminin binding integrin alpha6beta1 as a prominent cell surface receptor. Integrin alpha6beta1 promotes aggressive disease and supports prostate tumor cell metastasis to bone. Laminins and their integrin receptors are necessary for the development and maintenance of the peripheral nervous system, indicating the potential role for integrin receptors in directing prostate tumor cell invasion on nerves during perineural invasion.

PSA markers in prostate cancer detection.

The PSA revolution that has occurred over the previous 2 decades has positively impacted the detection and treatment of men with prostate cancer. Although methods to improve specificity have shown promise (eg, PSAD, age-specific PSA, and PSA velocity), meaningful interpretation has yet to be uniformly accepted within clinical practice. The identification of other molecular forms of PSA within serum has led to a new era in PSA markers. Initial application employing %fPSA has provided improved discrimination between benign and malignant prostatic disease; however, questions remain regarding the ultimate threshold value. The discovery of various free forms of PSA--such as proPSA, BPSA, and iPSA--also have introduced the potential for improved specificity in detection. Although early results are encouraging, further evaluation is anticipated. The development of improved methods to detect and measure cPSA has demonstrated provocative results, and exhibits the potential to replace PSA as a standard diagnostic test in cancer screening.

Modern Tumor Marker Discovery in Urology: Surface Enhanced Laser Desorption and Ionization (SELDI).

During the last two decades, biomarker research has benefited from the introduction of new proteomic analytical techniques. In this article, we review the application of surface enhanced laser desorption/ionization time-of-flight (SELDI-TOF) mass spectroscopy in urologic cancer research. After reviewing the literature from MEDLINE on proteomics and urologic oncology, we found that SELDI-TOF is an emerging proteomic technology in biomarker discovery that allows for rapid and sensitive analysis of complex protein mixtures. SELDI-TOF is a novel proteomic technology that has the potential to contribute further to the understanding and clinical exploitation of new, clinically relevant biomarkers.

Substratification of stage T1C prostate cancer based on the probability of biochemical recurrence.

OBJECTIVES: To evaluate the influence of preoperative prostate-specific antigen (PSA), biopsy Gleason sum, and prostate biopsy quantitative histologic findings on the probability of biochemical failure in an attempt to identify criteria to substratify Stage T1c prostate cancer more accurately. METHODS: We reviewed the records of 1149 patients who underwent prostatectomy for T1c disease between 1988 and 2000. Biochemical recurrence (PSA 0.2 ng/mL or greater) defined the endpoint in this study. Recursive partitioning analysis was used to establish cutpoints for preoperative PSA level, biopsy Gleason sum, number of positive biopsy cores, and maximal percentage of any single biopsy core involved with cancer. These cutoff values were then evaluated using Kaplan-Meier estimations to determine the probability of remaining biochemically recurrence free. RESULTS: Using a PSA cutpoint of 10 ng/mL or a biopsy Gleason sum of 7, two groups of patients were identified (T1cI and T1cII). The rate of freedom from PSA recurrence at 3, 5, and 10 years after surgery for T1cI was 98%, 96%, and 96%, respectively, and for T1cII was 86%, 83%, and 73%, respectively (P <0.001). For T1cII patients, the greatest percentage of cancer in a single biopsy core was found to be a predictor of biochemical failure on multivariate analysis and, using a cutoff value of 50%, further stratified the PSA recurrence-free rates for the men in group T1cII (90% and 85% versus 75% and 56% at 5 and 10 years after surgery, respectively, P = 0.03). CONCLUSIONS: The results of this study demonstrate that within Stage T1c there are two populations of patients with significantly different recurrence probabilities: T1cI (Gleason sum less than 7 and PSA 10 ng/mL or less) and T1cII (Gleason sum 7 or greater or PSA greater than 10 ng/mL). Furthermore, using a cutpoint of 50% of cancer in a single core of biopsy tissue, additional risk stratification is afforded to men with higher risk "T1cII" cancer.

A critical analysis of the interpretation of biochemical failure in surgically treated patients using the American Society for Therapeutic Radiation and Oncology criteria.

PURPOSE: The use of prostate specific antigen (PSA) to indicate biochemical failure has become an accepted procedure to measure the effectiveness of therapy. Because long-term randomized studies comparing radiation modalities to radical prostatectomy are not available, use of biochemical recurrence as a surrogate measure of efficacy is increasing. Unfortunately, the definition of failure is not uniform among therapies. We evaluate how the American Society for Therapeutic Radiation and Oncology (ASTRO) criteria affect the interpretation of failure when applied to radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed data from 2,691 men who underwent anatomical radical prostatectomy for localized disease between 1985 and 2000. All patients had regular followup visits ranging from 6 months to 15 years (mean 6). No patients were treated with radiation or hormonal therapy preoperatively or postoperatively until clinical recurrence. Biochemical failure was defined as any measurable PSA 0.2 ng./ml. or greater. We evaluated how elements of the ASTRO criteria affected the failure rate when applied to this series. We looked at 1) backdating the failure date to the midpoint between nadir and first PSA greater than 0.2 ng./ml., 2) early censoring if only 1 or 2 increasing values were available and 3) defining failure after 3 consecutive PSA increases and backdating failure time (midpoint of nadir and first PSA increase). RESULTS: Using actuarial analysis of the data defining failure as the first PSA 0.2 ng./ml. or greater, biochemical freedom from failure at 5, 10 and 15 years was 85%, 77% and 68%, respectively. In contrast, when backdating was used in this series, almost all failures occurred early with rare late failures (freedom from failure 82%, 80% and 80% at 5, 10 and 15 years, respectively). The difference in failure became even more pronounced when ASTRO criteria were applied requiring 3 consecutive increases, and backdating failure to the midpoint between nadir and first PSA (freedom from failure 90%, 90% and 90% at 5, 10 and 15 years, respectively). CONCLUSIONS: The application of ASTRO criteria to a mature series of surgically treated patients with localized prostate cancer produced an apparent improvement in the probability of being biochemically free of disease at 15 years from 68% to 90%. Until prospective trials comparing these different therapies become available, caution should be exercised when interpreting outcomes between series due to the inherent differences in definition of biochemical failure.