Differential expression of nuclear retinoid receptors in normal and malignant prostates.

PURPOSE: To determine (1) whether nuclear retinoic acid receptors (RARs) and retinoid X receptors (RXRs) are differentially expressed in normal and in cancerous human prostate tissues and (2) whether oral fenretinide therapy impacts the expression of these receptors in prostate cancer. PATIENTS AND METHODS: In situ hybridization with antisense riboprobes was used to probe for RAR and RXR transcripts in prostate tissues in a two-phased study: (1) expression of retinoid receptors in eight normal prostates was compared with their expression in 10 randomly picked radical prostatectomy specimens (group A); (2) expression of retinoid receptors was determined in 22 radical prostatectomy specimens from participants in a clinical study (group B). Twelve patients received oral fenretinide 200 mg/d, and 10 received placebo pills for 28 days before surgery. RESULTS: RARalpha, RARgamma, RXRalpha, and RXRgamma mRNAs were detected in most normal and cancerous prostates. In group A, RARbeta mRNA was expressed in only four of 10 malignant prostates but was present in seven of eight benign prostates (P =.05). RXRbeta mRNA was expressed in four of eight benign prostates and in zero of 10 malignant prostates (P =.023). In group B prostates, RARbeta and RXRbeta mRNAs were markedly reduced in all cancers and in the adjacent, nonmalignant tissue. There were no differences between receptor expression in the fenretinide-treated group and the placebo group. CONCLUSION: RARbeta and RXRbeta mRNAs are selectively lost in both prostate cancer and adjacent morphologically normal prostatic tissue, supporting the concept of a field of carcinogenesis. One month of oral fenretinide (200 mg/d) did not influence the expression of retinoid receptors in prostate cancer.

Preoperative plasma levels of transforming growth factor beta(1) (TGF-beta(1)) strongly predict progression in patients undergoing radical prostatectomy.

PURPOSE: Elevated local and circulating levels of transforming growth factor beta(1) (TGF-beta(1)) have been associated with prostate cancer invasion and metastasis. We tested the hypothesis that preoperative plasma TGF-beta(1) levels would independently predict cancer stage and prognosis in patients who undergo radical prostatectomy. PATIENTS AND METHODS: The study group consisted of 120 consecutive patients who underwent radical prostatectomy for clinically localized prostate cancer (median follow-up, 53.8 months). Preoperative plasma levels of TGF-beta(1) were measured and correlated with pathologic parameters and clinical outcomes. TGF-beta(1) levels also were measured in 44 healthy men without cancer, in 19 men with prostate cancer metastatic to regional lymph nodes, and in 10 men with prostate cancer metastatic to bone. RESULTS: Plasma TGF-beta(1) levels in patients with lymph node metastases (14.2 +/- 2.6 ng/mL) and bone metastases (15.5 +/- 2.4 ng/mL) were higher than those in radical prostatectomy patients (5.2 +/- 1.3 ng/mL) and healthy subjects (4.5 +/- 1.2 ng/mL) (P <.001). In a preoperative analysis, preoperative plasma TGF-beta(1) level and biopsy Gleason sum both were predictors of organ-confined disease (P =.006 and P =.006, respectively) and PSA progression (P <.001 and P =.021, respectively). In a postoperative multivariate analysis, preoperative plasma TGF-beta(1) level, pathologic Gleason sum, and surgical margin status were predictors of PSA progression (P =.020,P =.020, and P =.022, respectively). In patients who progressed, preoperative plasma TGF-beta(1) levels were higher in those with presumed distant compared with local-only failure (P =.019). CONCLUSION: Plasma TGF-beta(1) levels are markedly elevated in men with prostate cancer metastatic to regional lymph nodes and bone. In men without clinical or pathologic evidence of metastases, the preoperative plasma TGF-beta(1) level is a strong predictor of biochemical progression after surgery, presumably because of an association with occult metastatic disease present at the time of radical prostatectomy.

Fenretinide therapy in prostate cancer: effects on tissue and serum retinoid concentration.

PURPOSE: To examine the feasibility of using fenretinide (4-HPR) for the prevention and treatment of prostate cancer. MATERIALS AND METHODS: We measured the impact of 4-HPR therapy on retinoid concentrations in vivo, in a mouse model of prostate cancer and clinically, in patients with prostate cancer who were given oral 4-HPR (200 mg/d) or placebo for 4 weeks before undergoing a radical prostatectomy. RESULTS: Prostate tumors in mice treated with 4-HPR contained high levels of 4-HPR and of all-trans-retinoic acid (RA) and reduced levels of retinol (ROH). Patients given 4-HPR were found to have significantly higher concentrations of 4-HPR in the cancerous prostate as compared with the serum levels (463 nmol/L v 326 nmol/L; P =.049), but they were only 1/10 the levels found in mice and were far below the concentrations reported in human breast tissue. Serum and tissue ROH levels were reduced to less than half the concentrations found in untreated controls. RA concentrations in human serum and in cancerous prostates were not significantly affected by 4-HPR treatment, in contrast with the findings in mice. CONCLUSION: The standard oral dose of 4-HPR proposed for breast cancer (200 mg/d) achieved only modest drug levels in the prostate and is unlikely to be effective for prostate cancer prevention or treatment. Higher doses need to be explored.

Effect of 13-cis-retinoic acid on serum prostate-specific antigen levels in patients with recurrent prostate cancer after radical prostatectomy.

The objective of this study was to determine whether there is any beneficial effect of oral 13-cis-retinoic acid (isotretinoin) on prostate cancer, using serum prostate-specific antigen (PSA) levels as a surrogate end point in patients with a rising serum PSA after radical prostatectomy. In the first phase, the effect of the drug on the serum PSA level was tested in 14 control patients with normal prostates. Our goal was to exclude any effect of isotretinoin on PSA secretion and metabolism and thus to validate any observed effect on PSA as indicative of anticancer activity. In the second phase, patients with rising PSA levels after radical prostatectomy and no evidence of metastatic disease were treated with oral isotretinoin at a daily dose of 1.0 mg/kg. Serum PSA levels were checked monthly for the first 4 months after initiation of treatment and every 3 months thereafter. No significant changes in serum PSA levels after 3 months of isotretinoin treatment were recorded in the control group (P = 1.000). Three of 11 postprostatectomy patients (27%) had a PSA reduction of 28%, 15%, and 6.6% after initiation of treatment that lasted for a period of 2-3 months. In two of these three patients, the PSA levels subsequently rose exponentially. Another patient displayed a stabilization of the serum PSA curve for 3 months after an initial sharp rise. No grade 3 or 4 toxicity was recorded in this group of patients. Isotretinoin had a modest, transient effect on the serum PSA level in 4 of 11 (36%) patients with a rising serum PSA after radical prostatectomy. We conclude that this drug is unlikely to be of major therapeutic benefit in prostate cancer patients when used as a single agent. However, its modest effect argues for the exploration of other, more potent retinoids for prostate cancer therapy.

Prostate-specific antigen response and systemic T cell activation after in situ gene therapy in prostate cancer patients failing radiotherapy.

In an extended phase I/II study we evaluated 36 prostate cancer patients with local recurrence after radiotherapy who received single or repeated cycles of replication-deficient adenoviral vector (ADV)-mediated herpes simplex virus-thymidine kinase (HSV-tk) plus ganciclovir (GCV) in situ gene therapy with respect to serum PSA levels, alterations in immune cells, and numbers of apoptotic cells in needle biopsies. An initial cycle of HSV-tk plus GCV gene therapy caused a significant prolongation of the mean serum PSA-doubling time (PSADT) from 15.9 to 42.5 months (p = 0.0271) and in 28 of the injected patients (77.8%) there was a mean PSA reduction (PSAR) of 28%. It took a mean of 8.5 months for the PSA to return to the initial PSA (TR-PSA) value. A repeated cycle of gene therapy failed to significantly extend PSADT but did result in significant increases in PSAR (29.4%) and TR-PSA (10.5 months). Moderately increased serum adenovirus antibody titers were generally observed 2 weeks after initial vector injection. Also at this time there was a statistically significant increase in the mean percent of CD8(+) T cells positive for the HLA-DR marker of activation in peripheral blood (p = 0.0088). Studies using prostate biopsies obtained at the same time point demonstrated that vector DNA was detectable by PCR in most samples yet all patients remained positive for prostate cancer in at least one biopsy core. Further analysis demonstrated a correlation between the level of CD8(+) cells and the number of apoptotic cells in biopsies containing cancer cells (p = 0.042). We conclude that repeated cycles of in situ HSV-tk plus GCV gene therapy can be administered to prostate cancer patients who failed radiotherapy and have a localized recurrence. Biological responses to this experimental therapy including increases in PSADT, PSAR, and TR-PSA, and activated CD8(+) T cells present in the peripheral blood, were demonstrated. Interestingly, the density of CD8(+) cells in posttreatment biopsies correlated with the number of apoptotic cells.

Phase I/II trial evaluating combined radiotherapy and in situ gene therapy with or without hormonal therapy in the treatment of prostate cancer--a preliminary report.

PURPOSE: To report the preliminary results of a Phase I/II study combining radiotherapy and in situ gene therapy (adenovirus/herpes simplex virus thymidine kinase gene/valacyclovir) with or without hormonal therapy in the treatment of prostate cancer. METHODS AND MATERIALS: Arm A: low-risk patients (T1-T2a, Gleason score <7, pretreatment PSA <10) were treated with combined radio-gene therapy. A mean dose of 76 Gy was delivered to the prostate with intensity-modulated radiotherapy. Arm B: high-risk patients (T2b-T3, Gleason score >or=7, pretreatment PSA >or=10) were treated with combined radio-gene therapy and hormonal therapy. Hormonal therapy was comprised of a 4-month leuprolide injection and 2-week use of flutamide. Arm C: Stage D1 (positive pelvic lymph node) patients received the same regimen as Arm B, with the additional 45 Gy to the pelvic lymphatics. Treatment-related toxicity was assessed using Cancer Therapy Evaluation Program common toxicity score and Radiation Therapy Oncology Group (RTOG) toxicity score. RESULTS: Thirty patients (13 in Arm A, 14 in Arm B, and 3 in Arm C) completed the trial. Median follow-up was 5.5 months. Eleven patients (37%) developed flu-like symptoms (Cancer Therapy Evaluation Program Grade 1) of fatigue and chills/rigors after gene therapy injection but recovered within 24 h. Four patients (13%) and 2 patients (7%) developed Grade 1 and 2 fever, respectively. There was no patient with weight loss. One patient in Arm B developed Grade 3 elevation in liver enzyme, whereas 11 and 2 patients developed Grade 1 and 2 abnormal liver function tests. There was no Grade 2 or above hematologic toxicity. Three patients had transient rise in creatinine. There was no RTOG Grade 3 or above lower gastrointestinal toxicity. Toxicity levels were as follows: 4 patients (13%), Grade 2; 6 patients (20%), Grade 1; and 20 patients (67%), no toxicity. There was 1 patient with RTOG Grade 3 genitourinary toxicity, 12 patients (40%) with Grade 2, 8 patients (27%) with Grade 1, and 9 patients (30%) with no toxicity. No patient dropped out from the trial or had to withhold treatment because of severe toxicity. CONCLUSIONS: This is the first trial of its kind in the field of prostate cancer that aims to expand the therapeutic index of radiotherapy by combining in situ gene therapy. Initial experience has demonstrated the safety of this approach. There is no added toxicity to each therapy used alone. Long-term follow-up and larger cohort studies are warranted to evaluate long-term toxicity and efficacy.

Cytopathic effect of in situ gene therapy in prostate cancer.

This is a morphologic study of in situ gene therapy effects in patients with prostate cancer using the Herpes Simplex VirusThymidine Kinase gene (HSV-tk) followed by ganciclovir. Prostatectomy specimens from the first 4 patients showed the following morphologic changes: (1) various degrees of necrosis were seen in cancer foci; (2) cytopathic changes were seen across the whole spectrum of Gleason grades; (3) the normal prostate was rarely affected by necrosis, but contained an intense mononuclear infiltrate; (4) loss of nuclear detail was a common finding. Volumetric studies showed that only portions of the tumor show morphologic effects as well as an inverse relationship between percentage of affected tumor and prostate and tumor size. An inflammatory response was observed, with predominance of CD20-positive cells in normal prostate tissue, CD8 (cytotoxic T cells) in the tumor, and macrophages in all areas of the treated prostates. We believe that these changes represent the cytopathic effect of our in situ gene therapy on prostate cancer, and that they trigger a local immune response.

Correction of congenital or acquired penile curvature through a simple corporoplication technique.

Sexual dysfunction resulting from penile deformity is amenable to surgical correction. Thirty-five cases of penile deformity either 29 congenital or six secondary to Peyronie's disease were treated by simple plication of the tunica albuginea with non-absorbable sutures through a small skin incision made on the convex side of the curved penis. Postoperative complications such as impaired erection or loss of sensitivity of the glans were not reported. After an average follow-up of 36 months (range 12-60 months) all patients have straight erections and retain normal erectile function.

Intracavernous injections: still the gold standard for treatment of erectile dysfunction in elderly men.

The objective of this work was to determine the effectiveness of intracavernous injections (ICI) of vasoactive drugs in elderly men with erectile dysfunction and to compare the results obtained with the injection of two different drug combinations. It was a case control study. The sample consisted of 300 men, 63-85 y of age (mean 67.1) with erectile dysfunction of organic origin. Among the patients 180 underwent first trial with injection of prostaglandin E1 (PE). Further on these 180 patients and another 120 (in total 300 patients) were treated with a triple combination of papaverine hydrochlorate, phentolamine messylate and prostaglandin E1 (PPR). The number of responders to the injection of either PE alone or the drug combination was recorded. The quality of the erections was evaluated in the outpatient clinic by the medical staff and through patient's report after home trial. The average volume of either PE or PPR necessary to obtain a functional erection was measured. We observed a statistically significant association between the results obtained after the injection of PPR as compared to PE (chi2 with 2 d.f.: 34.666; P= < 0.001). A functional erection was obtained in 224/300 (74.7%) after the injection of PPR as compared to 87/180 men (48.3%) treated with PE. The average volume of PPR necessary to obtain a functional erection was 0.35+/-0.14 ml whereas that of PE was 1.3+/-0.3 ml. intracavernous injection of vasoactive drugs is still one of the most successful therapies for patients suffering from organic impotence. It is less effective in the older age group as compared to younger. However, if this form of therapy is chosen for aged men the triple combination therapy (PPR) yields a higher response rate than that obtained with prostaglandin alone.

Does the narrow operating field in perineal radical prostatectomy lead to more positive surgical margins?

AIMS: To assess the risk of leaving cancer-positive surgical margins in the perineal approach for radical prostatectomy as compared to the retropubic approach. METHODS: Seventy-six patients with clinically organ-confined prostate cancer (stage T1-2 NoMo) underwent radical prostatectomy. The 57 patients who underwent retropubic prostatectomy were compared to 19 patients in whom the perineal approach was undertaken. The two groups were compared for pre-operative PSA levels, clinical stage, biopsy Gleasson score, and any correlation between pre- and post-operative stage and grade of the disease and rate of cancer-positive surgical margins. RESULTS: Although there were no significant differences in the rate of organ-confined diseases and specimen Gleasson score in the two groups, the rate of positive surgical margins in the perineal approach was significantly lower (15.7 vs 29.8%) and the rate of extracapsular disease with negative margins was significantly higher (15.7 vs 7%). CONCLUSIONS: The narrow surgical field in the perineal approach for radical prostatectomy does not pose a higher risk for positive surgical margins and it might be the procedure of choice in stage T1C prostate cancer with a Gleasson score of below 7.

Oncoprotein coexpression in human aberrant crypt foci and minute polypoid lesions of the large bowel.

BACKGROUND: Genetic aberrations observed in the large bowel during the neoplastic progression have a cumulative effect and are responsible for the propagation of the multistep malignant process. In the present study we evaluated the immunoreactivity of c-fos, ras, bcl-2 and p53 in aberrant crypt foci (ACF) and minute polyps of the large bowel obtained from patients with colorectal cancer. METHODS: ACF and minute polyps were collected from macroscopically normal colonic mucosa. Protein immunoreactivity was detected on parafin sections utilizing the biotin-streptavidin method on 25 hyperplastic, 10 dysplastic ACF, 5 hyperplastic and 10 dysplastic adenomas. RESULTS: 41% of the lesions displayed positive ras immunoreactivity. bcl-2 immunoreactivity was positive in six minute polyps of which five were neoplastic. fos immunoreactivity was detected in five ACF and seven minute polyps, mainly in dysplastic lesions. Two neoplastic polyps were positive for p53 immunoreactivity. Coexpression of two or more oncoproteins was found with increasing frequency in dysplastic versus hyperplastic lesions and in polypoid lesions versus ACF. CONCLUSION: Abnormal expression and coexpression in oncoproteins can be identified in the earliest stages of colorectal tumorigenesis and may contribute to the progression of selected lesions during ACF-adenoma-carcinoma sequence.

Polyurethane stent for treatment of urethral strictures.

The use of stents in the treatment of urethral strictures is offered as an alternative to repeated internal urethrotomies, urethral dilations, and urethroplasties. We report our experience in 42 patients with bulbar and membranous strictures (33 and 9 patients, respectively). In 10 patients, the stent was removed after 3 to 5 months, and the treatment was curative in 4 patients in this group. In 16 patients, the stent was removed after 12 months, and in 6 it was removed after 24 months. Thirty-two patients voided satisfactorily after stent insertion. The stent did not prevent recurrent strictures after its removal in most of the patients, but if changed regularly, once a year, it may avert repeated urethrotomies, dilations, and urethroplasties, which makes it a valid alternative in elderly patients.

Early postureteroscopy vesicoureteral reflux--a temporary and infrequent complication: prospective study.

BACKGROUND: Early complications after ureteroscopy include discomfort, renal colic, urinary infection, and hematuria. Vesicoureteral reflux has been reported as a late complication. The presence of early vesicoureteral reflux after ureteroscopy has not been investigated. METHODS: Forty patients were randomly selected for a study in which early vesicoureteral reflux after ureteroscopy was searched for through retrograde cystography. RESULTS: In four patients (10%), vesicoureteral reflux was found. Follow-up cystograms 2 weeks after ureteroscopy were normal in all four. CONCLUSION: These results suggest that early vesicoureteral reflux after ureteroscopy is rare and that if it appears, it is of low grade and temporary.

The prognostic value of DNA ploidy in small renal cell carcinoma.

The objective was to study the prognostic value of Deoxyribonucleic Acid (DNA) ploidy status in small renal cell carcinomas (RCC). The nuclear DNA content of renal cell carcinoma tissues from patients who underwent radical or partial nephrectomy has been analyzed by flow cytometry. The results of the DNA ploidy have been correlated to the size of tumors and disease progression. Of the 50 patients with RCC studied, 8 (16%) progressed. Tumors with non-diploid DNA patterns were found in 24 (48%) of the 50 patients and in 4 of the 8 patients who progressed. Overall the median tumor size in our series was 50 mm. A tumor diameter of 50 mm or less was measured in 26 patients (group I) and above 50 mm in 24 (group II). Non-diploid DNA patterns were found in 11 (42.3%) and 13 (54.2%) patients in groups I and II, respectively. This difference between the groups was not significant. Only one patient in group I (3.8%) developed metastatic disease and died 72 months after the operation. In group II, 7 patients (29.2%) presented tumor progression and 5 died of metastatic disease. The survival probability in group I was 95% at 5 and 8 years (95% CI 70% to 99%) and for group II 94% at 5 years (95% CI 67%-99%) and 67% at 8 years (95% CI 39%-83%). DNA ploidy is an inaccurate predictor of tumor behavior in patients with RCC, even in small tumors. Tumor size is a more significant predictor of outcome.

A case of myospherulosis occurring in the perirenal adipose tissue.

The authors report a case of spontaneous myospherulosis that developed in the right perirenal adipose tissue, presented like an abscess, in an 82-year old man of the A, Rh+ blood group. The patient had a history of chronic lymphocytic leukaemia. Fine needle aspiration and histological examination of the renal cyst allowed the observation of 4- to 7-micron spherules (or endobodies) enclosed in saccular structures (or parent bodies) and accompanied by a foreign body-type response. The walls of the parent bodies were negative for PAS, Gomori's methenamine silver and Giemsa's stain. Immunohistochemical study was positive with anti A antibody specific of A1/A2 blood group and with anti glycophorin A antibody. The authors reviewed the literature concerning this rare lesion: it usually occurs in subcutaneous fat or in the paranasal sinuses, nose and middle ear but, up to now, no previous case has ever been reported in the urinary tract. The only case of visceral myospherulosis previously reported occurred in a cystic teratoma of the ovary. The reported case is also peculiar by the unusual thickness of the parent bodies. The authors also discuss the mechanism of the disease and suggest that, in the present observation, myospherulosis could have been induced by the rupture of a preexisting cyst in the perirenal adipose tissue.

Use of computerized interactive morphometry in the diagnosis of mammary adenoma and adenocarcinoma in dogs.

We attempted to define quantitative objective criteria for diagnosis of mammary adenoma and adenocarcinoma in dogs. To that end, correlation between diagnosis made by conventional histologic examination and morphometric descriptors, obtained by computerized histologic analysis, was assessed in biopsy specimens of mammary tissue from 63 dogs. We used 2 interactive computer procedures: one assessed mean nuclear perimeter, mean nuclear area, and circularity factor; and the other evaluated nuclear stratification and cell crowding. A data base was generated with 11 specimens from normal mammary tissue, 17 specimens from mammary adenoma, 18 specimens from low-grade mammary adenocarcinoma, and 15 specimens from mammary adenocarcinoma. The mean values of nuclear perimeter, nuclear area, nuclei per millimeter of basement membrane, and minimal distances from cells to basement membrane gradually increased from normal to high-grade malignancy. Distributions of nuclear areas and of minimal distances from cells to basement membrane were shifted in specimens from malignant tumors. Multivariate analysis confirmed the homogeneity of the diagnostic groups.

Mycotic enteritis in a chameleon and a brief review of phycomycoses of animals.

Rectal prolapse in an adult chameleon was surgically replaced. The animal was given tetracycline and dextrose orally, but became comatose 7 days postoperatively and was euthanatized. Necropsy revealed intussusception of the terminal portion of the colon. Phycomycotic hyphae accompanied by necrosis and a mixed leukocytic infiltrate were found in the area of intussusception.

Systemic fungal infections in cats.

Pneumonia and ileitis due to Aspergillus spp was diagnosed at necropsy in an adult female cat. In a 2nd cat, Aspergillus spp caused acute focal necrotizing pneumonia. A 3rd cat had severe necrotizing colitis caused by a phycomycete. Two of the cats had clinical signs and pathologic lesion compatible with feline panleukopenia, which probably increase their susceptiblity to fungal infection. The ability of Aspergillus spp and phycomycetes to invade tissue was probably enhance by prolonged treatment of the cats with antibiotics.

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients.

STUDY OBJECTIVE: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN: Randomized, prospective, open-label study. SETTING: Large referral hospital. PATIENTS: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Does detubularization improve continence in bladder replacement?

Camey in the seventies promoted bladder replacement. In 1987, the French Association of Urology gave us the opportunity to review 729 Tubularized Ileocystoplasty (Camey operation) [1]. The day time continence was excellent or acceptable (mild stress incontinence) on 91% of the patients, the night time continence was excellent (no pads, no leakage) or acceptable (one pad or less than 3 wakes at night) for 44% of the patients (56% had to use a device). Since 1985, the detubularization attempted to improve the continence rate. Today, the review of the literature shows that day time continence has not changed and the night time continence improved less than 20% arising from 44% to 60%. Bladder replacement after prostatocystectomy has been proved to be superior to continent urinary diversion in patients whose urethral and external sphincter can be preserved. Day time continence is excellent in tubularized and detubularized bowel reservoirs. Night time continence, in 30 to 50% of patients, remains an unresolved problem also in detubularized low pressure reservoirs, even if they are of great capacity. The literature is therefore too optimistic when describing night time continence in 85% of the patients. These results are stated in spite of the absence of sensitivity in the neobladder, the loss of reflexic increase in sphincteric activity during bladder filling, and the low sphincteric tonus during sleeping. These optimistic results are due to lack of unanimous criteria for evaluating continence after bladder replacement and not taking into consideration as continence failure the abundant although not frequent nighttime incontinence. In order to improve continence, muscle reeducation and artificial sphincter implantation are the most adequate solutions.(ABSTRACT TRUNCATED AT 250 WORDS)