AIDS retrovirus induced cytopathology: giant cell formation and involvement of CD4 antigen.

The formation of multinucleated giant cells with progression to cell death is a characteristic manifestation of the cytopathology induced by the AIDS retrovirus in infected T lymphoid cells. The mechanism of giant cell formation was studied in the CD4 (T4/Leu 3) positive T cell lines JM (Jurkat) and VB and in variants of these lines that are negative for cell surface CD4 antigen. By means of a two-color fluorescent labeling technique, multinucleated giant cells in infected cultures were shown to form through cell fusion. Antibody to CD4 specifically inhibited fusion, and uninfected CD4 negative cells, in contrast to uninfected CD4 positive cells, did not undergo fusion with infected cells, suggesting a direct role for the CD4 antigen in the process of syncytium formation. These results suggest that, in vivo, cell fusion involving the CD4 molecule may represent a mechanism whereby uninfected cells can be incorporated into AIDS virus infected syncytia. Because the giant cells die soon after they are formed, this process may contribute to the depletion of helper/inducer T cells characteristically observed in AIDS.

A comparison of dual energy X-ray absorptiometry of the hip and accuDEXA of the finger for the diagnosis of osteoporosis in men on androgen deprivation therapy for advanced prostate cancer.

Dual energy X-ray absorptiometry (DEXA) of the hip or spine has been shown to be an effective screening tool for osteoporosis in men undergoing androgen deprivation therapy (ADT) for advanced carcinoma of the prostate. A less expensive alternative to DEXA is the use of peripheral scanners, such as accuDEXA, which measures bone mineral density (BMD) the finger. In this paper, we reviewed 59 patients on ADT who underwent both accuDEXA scan of the non-dominant hand and DEXA scan of the hip. The mean T-scores calculated by the two techniques were similar; however, the individual T-scores correlated poorly with each other. We conclude that men who require ADT for prostate cancer should undergo standard DEXA of the hip for osteoporosis screening.

Long term effects of administration of a gonadotropin-releasing hormone superagonist analog in men with prostatic carcinoma.

Administration of the superagonist analog of GnRH, D-Leu6-GnRH proethylamide, profoundly reduced plasma LH, FSH, testosterone, and dihydrotestosterone levels when given for 6-11 weeks to adult men with prostatic carcinoma. Since patients with prostatic carcinoma can be expected to receive this analog for as long as 3-4 yr, we questioned whether the same degree of reduction could be maintained during chronic administration. In 22 men who had received D-Leu6-GnRH proethylamide for at least 1 yr, LH and testosterone remained at the initial low levels. Plasma dihydrotestosterone concentrations, on the other hand, gradually fell further with long term administration. FSH levels reached a nadir of 5.7 +/- 0.94 (+/- SEM) mIU/ml at 10-11 weeks. Unexpectedly, the plasma levels of this gonadotropin then gradually increased, and between 25 and 97 weeks were approximately 10-15 mIU/ml. This pattern occurred identically in patients receiving either 1 or 10 mg D-Leu6-GnRH proethylamide daily. These data indicate persistent suppression of LH and androgen levels during prolonged therapy and suggest that D-Leu6-GnRH-induced "medical castration" can be maintained with chronic administration.

Immunoperoxidase localization of prostate-specific antigen.

In instances of metastatic tumor from an unknown primary site, it is important to isolate those cases which are attributable to prostatic carcinoma. Immunoperoxidase localization of human prostate-specific antigen (PSA) would be useful in this regard if it were reliably detectable in prostatic carcinoma. We have studied 15 specimens from 14 patients with carcinoma of the prostate by immunoperoxidase techniques. The presence of PSA correlates with the Gleason grade. All cases of Gleason grade 9 or less demonstrated strong staining for PSA. Of the seven specimens with a Gleason grade 10, only four (57%) demonstrated significant staining, while two were entirely devoid of PSA. PSA is thus useful when it is present, but the absence of PSA in a poorly differentiated tumor of undetermined origin does not unequivocally rule out the possibility of a prostatic carcinoma.

Neodymium:yttrium-aluminum-garnet laser prostatectomy.

Since 1986, benign prostatic hyperplasia has been treated with lasers, but clinical use was not practical until the right-angled fiber was developed in the early 1990s. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is one of four types available for treating the prostate. Laser energy levels can be adjusted to provide coagulation (at lower energy densities) or vaporization (at higher energy densities). In a randomized study of these two techniques, symptom scores were similar at 1-year follow-up, but the peak urinary flow rate was higher and the reoperation rate was lower in the patients who received vaporization treatment. In randomized investigations that have compared laser prostatectomy and transurethral resection of the prostate (TURP), symptom scores and urinary flow rates improved in both groups, but results were somewhat better after TURP. Cumulative data for 3-year follow-up after laser prostatectomy have shown that the improved symptom scores and urinary flow are durable. The major disadvantages with use of Nd:YAG prostatectomy are delayed time to voiding, posttreatment dysuria (which occurs in 15 to 30% of patients), and total cost. Overall, Nd:YAG prostatectomy has both pros and cons. In comparison with TURP, the laser procedure is shorter, has fewer complications, can be done on an outpatient basis, and provides quicker recovery and equivalent results.

Prostate-specific antigen response to withdrawal of megestrol acetate in a patient with hormone-refractory prostate cancer.

Clinically significant responses after withdrawal of flutamide in patients with hormone-refractory prostate cancer (HRPC) are well documented. Failure to recognize this syndrome of response results in potential morbidity due to salvage therapy, confusion in interpretation of disease state, and introduction of a possible source of error in clinical trials. In this case report, we describe a patient with HRPC whose prostate-specific antigen levels decreased substantially in response to withdrawal of megestrol acetate. Such a response should be considered when megestrol acetate is used in the treatment of HRPC.

Differences in judgments of learning difficulty.

Academically successful and less successful fifth graders were asked to make judgments about the ease of understanding and remembering various sentences and were given the opportunity to attempt to remember some of them before being asked to judge new sets of sentences. The results of the first experiment indicate that, at the beginning of the experiment, the successful students were much more likely than their less successful peers to realize that sentences expressing arbitrary relationships were more difficult to remember. These differences became even greater after students were given the opportunity to attempt to remember some of the sentences they had judged initially. The memory performance of the successful students also improved as they became more familiar with the experimental task, but the performance of the less successful students did not. The results of the second experiment showed that less successful students who had received appropriate training were able to use information about the arbitrariness of relationships as the basis for their judgments of learning difficulty. The training also facilitated their ability to remember. Implications of these findings are discussed.

Nephrogenic metaplasia of the ureter.

We present what, to our knowledge, is the first reported case of nephrogenic metaplasia of the ureter. Nephrogenic metaplasia involves the transitional epithelium of the urinary tract and results in the formation of epithelial tubules, which are histologically similar to renal tubules. Special stains demonstrated both intracellular and intraluminal mucin. Ultrastructurally, the lesion consisted of epithelial cells with sparse microvilli and a thick basal lamina. The criteria for diagnosis and differentiation from carcinoma are discussed.

Lasers in urology. II. Laser therapy.

To date four laser wavelengths are commercially available which have urologic applications. The experience with all of these lasers is reviewed. The major urologic lesions treatable by the laser are: condylomata acuminata, superficial penile carcinoma, and bladder carcinoma. The carbon dioxide (CO2) laser is most applicable for external genital lesions while the Nd:YAG laser is better suited for the endoscopic treatment of bladder tumors. Due to its preferential absorption by hemoglobin, the argon laser is useful in treating vascular lesions. The tunable dye laser with hematoporphyrin-derivative therapy has exciting potential, but is too new to evaluate its therapeutic efficacy.

Lasers in urology. I. Laser physics and safety.

Interest in the use of the laser in urology is increasing. A thorough understanding of the physical principles governing the laser will aid greatly in the choice of the proper laser for each indication. The tenets of laser safety are stressed, along with the current federal guidelines.

DES lead-in to use of luteinizing hormone releasing hormone analogs in treatment of metastatic carcinoma of prostate.

Luteinizing hormone releasing hormone (LHRH) analogs have been shown to be an effective alternative endocrine treatment of metastatic prostatic carcinoma. After a transient stimulation of testosterone (T) and dihydrotestosterone (DHT) during the first week of therapy, continued administration of LHRH analogs has reliably suppressed serum androgens to castrate levels. About 10 per cent of previously untreated patients begun on LHRH therapy will experience transient worsening of disease symptoms corresponding to the initial rise in androgen levels. In an attempt to eliminate the early rise of T and DHT, 9 patients with metastatic prostatic carcinoma were pretreated with diethylstilbestrol (DES), 3 mg/day, for one week prior to the initiation of LHRH therapy. Following this, both DES and LHRH were given concomitantly for a week, after which DES was discontinued. LHRH was then continued as long as patients experienced clinical benefit. T and DHT levels were performed pre-study and on days 4, 8-11, 13, 15, and 29 of study. Results indicate that pretreatment with DES did not completely prevent the rise in T and DHT seen during the first week of LHRH therapy, although T and DHT levels rose to only slightly above baseline during the first four days. T and DHT levels then markedly decreased, and castrate levels were achieved by day 29 of treatment.

Blood group antigens and bladder carcinoma: a perspective.

A review of the current literature relative to the measurement of blood group antigens on bladder epithelium is presented. The determination of the presence or absence of such antigens on bladder tumors has enabled us to separate patients into two predictive groups at a time when their routine histologic patterns are identical. Group I consists of those patients with detectable blood group antigens by specific red cell adherence testing (SRCA). Regardless of the grade of their lesion, these patients have a low incidence (0-19%) of the ultimate development of invasive disease. Group II consists of those patients without demonstrable blood group antigens on their bladder carcinomas. These patients have a 60 to 93 per cent change of invasive disease developing within five years. Treatment thus can be predicated not only on the grade and stage, but also on a prediction of future behavior. Studies mapping cystectomy specimens, as well as those studying random mucosal biopsies, have shown that when the primary tumor lacks demonstrable blood group antigens, other areas of the bladder are also SRCA negative. These findings may help explain the frequent recurrences and ultimate development of invasive lesions in some of these patients. The role of the measurments of blood group antigens in urine cytology is reviewed, as well as those situations in which red cell adherence may be less definitive, i.e., those patients with carcinoma in situ, after radiotherapy, or thiotepa, and in those patients with blood group O. Future areas of usefulness of blood group antigens are discussed including other organs, i.e., kidney, renal pelvis, testes, and prostate.

Penile intraepithelial neoplasia in patients examined for exposure to human papilloma virus.

Female genital malignancies have recently been associated with infection with various types of human papilloma virus. We present 9 cases of penile intraepithelial neoplasia found in men examined for exposure to human papilloma virus. Six of these men had acetowhite lesions and underwent biopsies to confirm the potential presence of condylomata acuminata. The remaining 3 patients had lesions that were visible but whose nature was in doubt. In addition to condylomata acuminata, penile intraepithelial neoplasia may be a consequence of human papilloma virus infection in the male.

Immunoperoxidase localization of prostatic antigens. Comparison of primary and metastatic sites.

Immunoperoxidase staining for prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) help to identify patients with prostatic carcinoma presenting as metastatic disease from an occult primary source. To clarify further the reliability of these prostatic tissue antigens, we have examined the primary tumor and metastatic sites in 16 autopsy cases. Eleven of these had diffusely positive findings for PSA and PAP in the primary and all metastatic sites, and 1 case lacked both antigens in all locations. Four cases demonstrated variability between these antigens and among various sites. Prostatic primary lesions contained PAP and PSA in 13 (81%) and 12 (75%) cases, respectively. The most reliable metastatic sites were lymph nodes, seminal vesicles, lung, bone, and kidney; while liver, adrenal, and colorectal sites were less reliable. No relationship existed between serum PAP levels and tissue detectability of PAP. The use of both PAP and PSA increases the likelihood of properly identifying the prostate as the organ of origin of metastatic disease. In spite of the use of both markers, however, three primary lesions would have been misdiagnosed, and 1 case lacked both antigens in all metastatic sites as well. In poorly differentiated lesions, the lack of both antigens does not unequivocally eliminate the possibility of prostatic carcinoma.

Complications in patient with triple penile prosthesis.

A case report of a man with three poorly functional prosthetic implants in his penis is presented. Complications resulting from the insertion of penile implants are reviewed and suggestions are made on evaluating a patient who had previous prosthetic surgery.

Clinical effects of gonadotropin-releasing hormone analogue in metastatic carcinoma of prostate.

Leuprolide is a new, potent analogue of gonadotropin-releasing hormone which, after an initial transient stimulation, causes a profound suppression of serum gonadotropins and testosterone. One hundred eighteen patients with advanced carcinoma of the prostate have undergone treatment with leuprolide in a multi-institutional trial. Minimal evidence of objective response was seen in patients who had failed prior endocrine therapy with orchiectomy or estrogens. In patients without previous hormonal treatment, leuprolide induced an objective disease response (72%) comparable to alternative primary endocrine therapy. Considering the lack of significant side effects seen with long-term GnRH agonists, compounds such as leuprolide may prove to be the preferred initial endocrine therapy for selected patients with metastatic carcinoma of the prostate.

Superficial bladder cancer.

The majority of patients with bladder cancer have superficial disease. Occupational exposure to metabolites of aniline dyes and other aromatic amines has been associated with the development of bladder cancer. Latency periods can reach 50 years. Cigarette smoking has also been strongly linked to bladder cancer as an etiologic factor. The diagnosis of superficial bladder cancer can be elusive because its symptoms mimic those of other common urologic conditions such as urinary tract infection and prostatism. A high index of suspicion is required and a search for bladder cancer should be initiated in any adult (especially those over 50 years of age) who exhibits asymptomatic gross or microscopic hematuria, or irritative voiding symptoms. Cystoscopy is required for the screening and diagnosis of superficial bladder cancer, and resection of the lesion can be performed cystoscopically as well. Laser ablation of superficial lesions provides a treatment alternative that is less invasive and better tolerated by the patient, but it does not yield a tissue specimen for analysis. Urinary cytology has been invaluable in the screening, diagnosis, and follow-up of superficial bladder cancer patients, and now flow cytometry and image analysis techniques can complement it and may eventually supplant it. The key to the management of superficial bladder cancer is to identify those patients that may be at risk for recurrence and, more importantly, those who may progress to invasive or metastatic disease. Fortunately, most superficial bladder cancer remains superficial, and the overall prognosis is good, with 5-year survival rates for superficial disease of approximately 75%. As the natural history of superficial bladder cancer has become more evident through extensive research, risk factors such as tumor size, multiplicity, grade, depth of invasion, and condition of the surrounding mucosa have emerged. T1 lesions, those that invade the lamina propria, have a more ominous course than T0 and TA lesions. The mainstay of treatment for superficial disease is transurethral resection of the lesion or lesions. Intravesical therapy has been shown to have a definite effect in eradicating existing disease as well as reducing recurrences, but it has not been shown to prevent invasive disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Laparoscopic versus subinguinal varicocelectomy: a comparative study.

OBJECTIVE: To determine the relative advantages of the laparoscopic approach to varicocelectomy, postoperative morbidity and pain in patients undergoing subinguinal varicocelectomies were compared with that of patients undergoing laparoscopic varicocele repairs. DESIGN: Retrospective study of concurrent groups of patients undergoing laparoscopic or open subinguinal varicocele repairs. SETTING: Tertiary teaching hospital. PATIENTS: Forty-seven patients with primary or secondary infertility. INTERVENTIONS: Patients were offered a choice between a laparoscopic or open subinguinal varicocele repair. MAIN OUTCOME MEASURES: The total number of pain pills used, the number of days of analgesics, and the number of days off from work after surgery were recorded. RESULTS: Fourteen patients underwent laparoscopic varicocelectomies, and 33 patients underwent subinguinal varicocelectomies. Analgesic use by the laparoscopic patients was no different from that of the subinguinal patients. The length of time off from work was significantly longer for the laparoscopic patients (6.4 days) as compared with the time off from work for the patients who underwent subinguinal varicocele repairs (2.6 days). CONCLUSION: The subinguinal varicocele repair performed with local anesthesia is a safe, low morbid technique offering a quicker recovery period than laparoscopic approaches. Although laparoscopic repairs may offer a shorter recovery period when compared with standard inguinal varicocelectomies, this is not the case when compared with subinguinal approaches.

Laser physics and tissue interaction.

An understanding of basic laser physics and tissue interaction is required to select and utilize the appropriate laser for a given indication. Biophysical principles demonstrate how in-vivo use differs from bench-top physics. Dosimetry studies help to point out the effects of lasers.

Extracorporeal shock wave lithotripsy in patient with cardiac pacemaker in an abdominal location: case report and review of the literature.

A 75-year-old man with complete heart block and a ventricular demand pacemaker with the generator in a left upper-quadrant subcutaneous pouch underwent extracorporeal shock wave lithotripsy (SWL) for a 2-cm proximal right ureteral calculus, receiving 2000 shocks at 24 kV. There was no damage or malfunction of the pacemaker, and the Dornier HM3 lithotripter had no difficulty sensing all paced ventricular complexes. The patient had excellent fragmentation of his calculus. Extracorporeal shock wave lithotripsy may be performed safely on patients with pacemakers directly in the path of the shock waves at maximal kilovoltage when appropriate peri-SWL guidelines are followed. Specifically, the treatment should be approved by a cardiologist knowledgeable about the patient and the pacemaker, and a cardiologist should be nearby with the equipment necessary to deal with any problems. Dual-chamber pacemakers should be reprogrammed to the single-chamber mode, and single-chamber rate-responsive devices should have the activity mode programmed off. Patients with the latter type of pacemaker implanted in the abdomen should not have SWL if the device will be close to F2.