Detection and isolation of Toxoplasma gondii from fresh semen of naturally infected dogs in Southern Brazil.

The aim of this study was to isolate Toxoplasma gondii and determine the viability of the parasite in fresh semen samples of clinically healthy adult dogs naturally infected. Eleven seropositive dogs with T. gondii IgG antibodies from southern Brazil were selected to confirm the presence and viability of T. gondii in fresh semen samples using in vitro isolation in Vero cell culture, polymerase chain reaction (PCR) and sequencing analysis. The presence of viable T. gondii was confirmed by in vitro isolation and PCR in five semen samples. The ITS1 region of the isolated protozoa (TG S4) was amplified and sequenced. The nucleotide sequence obtained was 99% compatible with the T. gondii DNA sequences stored in the GenBank. It has been shown that T. gondii tachyzoites may be isolated in vitro from fresh semen samples of clinically healthy dogs seropositive for T. gondii.

Differentiation of prostate cancer from normal tissue in radical prostatectomy specimens by desorption electrospray ionization and touch spray ionization mass spectrometry.

Radical prostatectomy is a common treatment option for prostate cancer before it has spread beyond the prostate. Examination for surgical margins is performed post-operatively with positive margins reported to occur in 6.5-32% of cases. Rapid identification of cancerous tissue during surgery could improve surgical resection. Desorption electrospray ionization (DESI) is an ambient ionization method which produces mass spectra dominated by lipid signals directly from prostate tissue. With the use of multivariate statistics, these mass spectra can be used to differentiate cancerous and normal tissue. The method was applied to 100 samples from 12 human patients to create a training set of MS data. The quality of the discrimination achieved was evaluated using principal component analysis - linear discriminant analysis (PCA-LDA) and confirmed by histopathology. Cross validation (PCA-LDA) showed >95% accuracy. An even faster and more convenient method, touch spray (TS) mass spectrometry, not previously tested to differentiate diseased tissue, was also evaluated by building a similar MS data base characteristic of tumor and normal tissue. An independent set of 70 non-targeted biopsies from six patients was then used to record lipid profile data resulting in 110 data points for an evaluation dataset for TS-MS. This method gave prediction success rates measured against histopathology of 93%. These results suggest that DESI and TS could be useful in differentiating tumor and normal prostate tissue at surgical margins and that these methods should be evaluated intra-operatively.

Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND: Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes. MATERIALS AND METHODS: Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy. RESULTS: A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients. CONCLUSION: The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

The presence of benign prostatic glandular tissue at surgical margins does not predict PSA recurrence.

BACKGROUND: Serum prostate specific antigen (PSA) increases after radical prostatectomy are thought to indicate recurrent disease, although some suggest they result from benign prostatic epithelial tissue left at surgical margins. AIMS: To investigate whether presence, location, and extent of benign prostatic tissue at radical prostatectomy surgical margins influence patient outcome. METHODS: One hundred and ninety nine patients with prostate cancer and negative surgical margins were studied. The prostectomy specimens were totally embedded using the whole mount technique. The apex and bladder neck, dissected as a cone from the specimen, were serially sectioned. The total length of benign prostatic tissue at the margins, measured for each location using an ocular micrometer, was obtained by summing the length of all positive sites. The presence, anatomical location, and extent of benign prostatic tissue at the margin were correlated with clinicopathological characteristics and postoperative PSA increases. RESULTS: Fifty five cases had benign prostatic glandular tissue at the surgical margin. The mean length was 2.19 mm (0.1-14.7). The most frequent location of benign prostatic tissue was the apex (40 patients). Presence, anatomical location, and length of benign prostatic tissue at the margin were not significantly associated with age, preoperative PSA, prostate weight, pathological stage, tumour volume, largest tumour dimension, Gleason score, extraprostatic extension, seminal vesical invasion, tumour multifocality, perineural invasion, or PSA recurrence. CONCLUSIONS: Benign prostatic tissue was frequently found in margins of apex and bladder base, but uncommon in the anterior or posterior prostate. The presence of benign prostatic tissue at surgical margins had no prognostic relevance.

The influence of extent of surgical margin positivity on prostate specific antigen recurrence.

BACKGROUND: Positive surgical margins are an adverse prognostic factor in patients undergoing prostatectomy for prostate cancer. The extent of margin positivity varies and its influence on clinical outcome is uncertain. AIMS: To evaluate the linear extent of margin positivity and the number and location of positive sites as prognostic indicators in a series of prostatectomy specimens evaluated with the whole mount technique. METHODS: Eighty six consecutive margin positive prostatectomy specimens were evaluated, and all pathology data were collected prospectively. The linear extent of margin positivity was measured with an ocular micrometer and the total extent of all positive sites was summed. The total number of sites with positive margins and anatomical sites of the positive margins were analysed. RESULTS: The linear extent of margin positivity ranged from 0.01 to 68 mm (mean, 6.8; median, 3.0) and was associated with prostate specific antigen (PSA) recurrence in univariate logistic regression (p = 0.031). In addition, the extent of margin positivity weakly correlated with preoperative PSA (p = 0.017) and tumour volume (p = 0.013), but not with age, prostate weight, Gleason score, pathological stage, or perineural invasion. The total number of positive sites was significantly higher in patients with PSA recurrence (p = 0.037). The location of the positive margin site was not associated with PSA recurrence. The extent of margin positivity correlated with PSA recurrence in univariate analysis, although it had only marginal predictive value when adjusted for Gleason score (p = 0.076). CONCLUSIONS: The extent of margin positivity correlates with PSA recurrence in univariate analysis, although it has no predictive value independent of Gleason score.

Molecular genetic evidence for different clonal origin of components of human renal angiomyolipomas.

Renal angiomyolipoma is a benign neoplasm composed of variable proportions of blood vessels, smooth muscle, and adipose tissue. Smooth muscle, adipose tissue, blood vessels, and adjacent normal kidney tissue were separately microdissected from sections prepared from formalin-fixed, paraffin-processed tissues from angiomyolipomas from 18 women. X chromosome inactivation analysis using the methylation pattern at exon 1 of the human androgen receptor gene on chromosome Xq11-12 was used to study the clonal origin of each component. Nonrandom inactivation of X chromosomes was found in six of the 15 informative tumors. The smooth muscle and adipose tissue showed differing patterns of nonrandom inactivation of X chromosomes in five angiomyolipomas and the same pattern of nonrandom inactivation of X chromosomes in one. Samples from the blood vessels showed random inactivation of X chromosomes in all informative cases. Our data showed that the adipose tissue and smooth muscle cells of renal angiomyolipoma are both monoclonal but may arise independently. The coexistence of tumor subclones with morphologic heterogeneity can lead to the formation of a clinically detectable tumor.

The pathophysiology of hyperchloremic metabolic acidosis after urinary diversion through intestinal segments.

The pathophysiology of hyperchloremic metabolic acidosis after urinary diversion through intestinal segments has not been defined. This study employs a canine model in which an ileal segment is interposed between one kidney and the urinary bladder. Comparison of urinary solute excretion rates between the normal and interposed renal units allows quantitation of solute reabsorption and secretion by the ileal segment. Ileal segments reabsorb urinary chloride, potassium, and ammonium. Ammonium is reabsorbed in part as its conjugate free base, ammonia, with the liberated hydrogen ion reabsorbed with chloride or excreted as titratable acid. Inability to excrete acid as ammonium results in depletion of body buffers and a diminished capacity to compensate an additional acid challenge. Bicarbonate is secreted by the ileal segments but not in amounts that are physiologically significant. Impaired renal function predisposes to the development of this syndrome but is not a primary pathophysiologic mechanism.

Cavoatrial tumor thrombectomy using cardiopulmonary bypass without circulatory arrest.

Of 29 patients with inferior vena caval tumor thrombus, 14 with supradiaphragmatic extension were deemed suitable for operation. Patients (age, 7.5 to 70 years) had renal cell carcinoma (n = 8), Wilms' tumor (n = 2), transitional cell carcinoma (n = 1), and adrenal carcinoma (n = 3). Seven patients had stage III disease, and 7 patients had stage IV disease. Two patients (group A) had unresectable disease at exploratory celiotomy, 4 patients (group B) underwent tumor thrombectomy without cardiopulmonary bypass, and cardiopulmonary bypass was employed in 8 patients (group C). Three of 8 group C patients had Budd-Chiari syndrome at diagnosis. Cardiopulmonary bypass with moderate hypothermia, and inferior vena caval interruption (clip or filter), was employed in all patients. There were no perioperative deaths. Transient neurological impairment was observed postoperatively in 2 patients. Coagulopathy developed in 1 patient who had hepatic encephalopathy and Budd-Chiari syndrome preoperatively and in another patient in whom protamine could not be administered. No patient had acute renal failure requiring hemodialysis. Median survival is 41 and 17 months in groups B and C, respectively. Some authors have advocated profound hypothermia and circulatory arrest in these patients. We find that satisfactory visualization and excision can be performed with cardiopulmonary bypass and moderate hypothermia, avoiding potential renal, hepatic, neurological, and septic complications associated with circulatory arrest.

Retrospective analysis of outcome in patients with nodal metastases from transitional cell carcinoma of lower urinary tract.

OBJECTIVE: To determine the outcome in patients with nodal metastases from transitional cell carcinoma (TCC) using currently available surgical and chemotherapeutic techniques. METHODS: A retrospective analysis of all patients with TCC of the lower urinary tract who underwent radical cystectomy or lymph node dissection at our institution since 1980 was performed. Thirty-one patients were identified who had documented pelvic lymph node metastases prior to or at the time of radical cystectomy. These patients' records were reviewed in-depth with regard to treatment approach, presenting features, and outcome. RESULTS: Outcome was poor despite the treatment approach taken, including whether or not chemotherapy was administered prior to or after cystectomy. Median survivals of patients receiving no chemotherapy, adjuvant chemotherapy, and neoadjuvant chemotherapy were 14.5, 9.5, and 15.0 months, respectively. Only 4 of 28 patients survived more than three years, and only one of these received chemotherapy. CONCLUSIONS: Survival of patients with lymph node metastases from transitional cell carcinoma remains poor despite aggressive surgical therapy and the use of adjuvant or neoadjuvant platinum-based chemotherapy.

Urinary solute transport by gastric mucosa: a comparison with ileum using a rat model.

OBJECTIVES: This study was conducted to quantitate and compare urinary solute transport by stomach and ileum using an in vivo rat model. METHODS: An artificial urine solution was perfused through isolated gastric and ileal segments in the anesthetized rat. Concentrations of solutes and a volume marker were periodically determined in the perfusate and net solute flux was calculated. RESULTS: The stomach secretes less sodium and very little bicarbonate in comparison with ileum. Hydrogen ion and chloride are absorbed by ileum but secreted in large quantities by the stomach. Ammonium, potassium, and urea are absorbed by both segments but to a much lesser degree in the stomach. Overall, there was a net osmolar absorption by ileum, and a net secretion by the stomach. Both segments secrete water to a similar degree. CONCLUSIONS: These findings both suggest the mechanism of the hypochloremic metabolic alkalosis seen after urinary reconstruction with the stomach and provide insight into potential therapeutic approaches. Solute fluxes in both the stomach and the ileum are consistent with the known physiology of these segments.

Femoral neuropathy complicating urologic abdominopelvic procedures.

We report on 3 cases of femoral neuropathy following radical surgery for urologic malignancy. The defect was bilateral in 2 patients. Compression from self-retaining retractors was the presumed mechanism of injury in all patients. Spontaneous improvement was observed in each case although the symptoms did not resolve completely. The pathophysiology contributing to this operative complication as well as measures for prevention and treatment are discussed.

Renal cell carcinoma in patients with end-stage renal disease: a comparison of clinical significance in patients receiving hemodialysis and those with renal transplants.

OBJECTIVES: This review was undertaken to determine the clinical significance of renal cell carcinoma in the populations undergoing renal transplantation and those undergoing chronic dialysis. METHODS: We reviewed all medical records of patients with renal cell carcinoma treated at our institutions over the last 10 years. From this review we identified 20 patients with end-stage renal disease and renal cell carcinoma. Patients' charts were reviewed to determine presenting features, tumor histologic type, and clinical outcome. RESULTS: Seven patients had functioning renal transplants and 13 patients were on chronic maintenance hemodialysis. Ninety-two percent of the dialysis group had no metastatic disease and there were no deaths from renal cancer. In contrast, 53% of the transplant group did have metastatic disease and 2 patients died of renal cancer. Despite similar pathologic appearances of the tumors in these 2 groups, patients with renal cell carcinoma and renal transplant presented with higher-stage disease and had less favorable clinical courses. CONCLUSIONS: Considering the morbidity of hemodialysis as well as the other comorbidities of this patient population, the clinical significance of renal cell carcinoma in patients undergoing chronic dialysis must be questioned. In contrast, renal cancer in the transplant population behaves aggressively and warrants careful attention both before and after renal transplantation.

Continent urinary reconstruction versus ileal conduit: a contemporary single-institution comparison of perioperative morbidity and mortality.

OBJECTIVES: To compare postoperative morbidity and mortality in a concurrent and contemporary series of patients who underwent radical cystectomy with ileal conduit versus orthotopic neobladder. METHODS: The data of 198 patients were reviewed, 117 with orthotopic reconstruction and 81 with ileal conduit during a 5-year time frame. Thirty-day morbidity, mortality, reoperative rates, and parameters associated with the surgical procedures were obtained from chart review. RESULTS: No perioperative or postoperative deaths occurred in either group. The median operative time for the ileal conduit was 201 minutes (range 140 to 373), and for the orthotopic neobladder, it was 270 minutes (range 230 to 425). The median blood loss was 389 and 474 mL, respectively. The median length of hospitalization was 8 days for the ileal conduit group and 7 days for the orthotopic neobladder group. Diversion-related complications recognized within 30 days that ultimately required a return to the operating room occurred in 3.4% of those with a neobladder and 1.2% of those with an ileal conduit. CONCLUSIONS: The orthotopic neobladder is a longer and technically more complex procedure than the ileal conduit procedure. However, no demonstrable difference in morbidity or perioperative complications were found between the two procedures in our review.

Prospective development of a cost-efficient program for radical retropubic prostatectomy.

OBJECTIVES: We designed and implemented a broad-based program to decrease costs while maintaining quality of care in patients undergoing radical retropubic prostatectomy. METHODS: This program initially involved identification of factors that contribute to patient costs after radical prostatectomy and elimination or control of items that were deemed unnecessary. Patient care was standardized with a collaborative care pathway coordinated by a clinical nurse specialist and that served as a goal for each case. RESULTS: Length of total hospital stay was reduced from a mean of 5.7 days to 3.6 days after full implementation of the program (p < 0.0001). A reduction in operating room time, material utilization, antibiotic use, routine laboratory studies, and refinements in postoperative pain management contributed significantly to cost savings. Overall, the average adjusted total hospital charges were reduced from $13,783 to $7741 (p < 0.0001) by the implementation of this program, with no discernible adverse effect on morbidity rates. CONCLUSIONS: Careful analysis of the critical components of medical care and implementation of a standardized pathway with emphasis on a collaborative approach can substantially increase the cost efficiency of medical care.

Are we selecting the right patients for treatment of localized prostate cancer? Results of an actuarial analysis.

OBJECTIVES: To determine our accuracy in selecting patients with at least a 10-year life expectancy for aggressive treatment of localized prostate cancer. METHODS: The medical records of 261 consecutive patients who underwent radical retropubic prostatectomy were submitted to the actuarial division of American General Life and Accident Insurance Company (AGLA) for estimation of life expectancy, excluding the diagnosis of prostate cancer. Survival curves were generated from predicted individual survivals. In patients with less than a 10-year life expectancy, AGLA provided us with the basis for assigning suboptimal survival rates. RESULTS: The mean life expectancy for the group was 15.2 years. Two hundred ten men (80%) were projected to have a life expectancy of more than 10 years, including 27 of 55 (49%) and 4 of 8 (50%) men who were older than or equal to 70 and 75 years of age, respectively. Coronary artery disease and diabetes mellitus were the most common coexisting medical conditions that adversely affected risk as single disease entities. CONCLUSIONS: Although clinicians do not estimate life expectancy with the scientific exactitude of an actuary, the ability to assess the patient in person and assimilate pertinent medical information in a less rigid format yields similar results. Selection of men for definitive treatment of localized prostate cancer should be based on the inherent aggressiveness of the disease and the health of the individual and should not be limited by specific age cutoffs. Populations of men undergoing radical prostatectomy are younger and healthier than those in reported series of watchful waiting for prostate cancer.

Bropirimine immunotherapy of upper urinary tract carcinoma in situ.

OBJECTIVES: Bropirimine has been shown to be effective in treating approximately 50% of patients with carcinoma in situ (CIS) of the bladder in recent clinical trials. Patients with upper tract CIS were treated with bropirimine to determine whether this oral drug might be effective in that setting. METHODS: Twenty-four patients with negative radiographic findings and positive cytologic evidence for upper tract CIS in one or both ureters received bropirimine (3.0 g/day orally) for 3 consecutive days each week for up to 1 year. Ureteral collection of urine or barbotage for cytologic analysis was performed quarterly thereafter. RESULTS: Ten (48%) of 21 evaluable patients had a negative ureteral cytologic analysis after 12 weeks (5 patients) or 24 weeks (5 patients). Of these 10 patients, 8 continue to have negative cytology for a period of 3 to 30 months (median, more than 9 months). In 2 patients, negative cytology reverted to positive at 6 and 9 months, respectively, during therapy. Twelve (50%) of the 24 patients reported no toxicity. Three patients stopped treatment at 2, 3, and 3 weeks due to pruritic rash, nausea and vomiting, and severe bone pain, respectively. Therapy was stopped in 1 additional patient between 4 and 5 months because of transient liver enzyme elevations, yet this patient has had a continuous negative cytologic analysis for more than 9 months. CONCLUSIONS: Orally administered bropirimine may be effective therapy for CIS of the ureter or renal pelvis, with acceptable toxicity in most patients. Further efforts to better define this activity as well as the possible need for maintenance or intermittent long-term therapy are warranted.

Cost-effective strategies for the follow-up of patients with germ cell tumors.

Cost-effective strategies for the follow-up of patients with germ cell tumors must be based on the known natural history of the disease, the accuracy and cost of diagnostic modalities, and the efficacy and effectiveness of therapy when recurrences are detected. The natural history of stage I and stage II germ cell tumors are reviewed, including the unique circumstances of late recurrences. The accuracy and cost of imaging modalities are also reviewed and general recommendations to cost-effective follow-up are proposed.

Local recurrence of squamous cell carcinoma of the penis.

Given the excellent local control rates achieved with partial penectomy, it is important to consider laser treatment or radiation therapy of squamous cell carcinoma of the penis cautiously. Emotional issues surrounding preservation of a functional penis should not be allowed to compromise adequate therapy. On the other hand, some penile cancers undoubtedly can be managed adequately by techniques other than partial penectomy. The fundamental question is, then, how great a compromise laser treatment or radiation therapy introduces. In patients who present with bulky, long-neglected penile cancers, the point is moot: Partial or even total penectomy is indicated. However, other treatments are feasible in many patients, and an attempt at functional organ preservation should not be restricted simply to the rare small tumor. Lesions up to 2 cm in size can be controlled adequately without amputation. Because tumor grade correlates highly with depth of invasion, the presence of nodal metastasis, and survival, most poorly differentiated squamous cell tumors of the penis probably should be treated by amputation. As mentioned above, it may be several months after laser treatment or radiation therapy before local treatment failure is recognized. Although this is a concern, it probably does not ultimately result in therapeutic compromise in most patients. With most urologic cancers, local recurrence equates with the inability to cure the patient and, ultimately, death. With locally recurrent carcinoma of the penis, however, the situation can be salvaged by converting to partial penectomy. Thus, the patient compromises his chances for cure only if tumor dissemination occurs during the few months between the end of treatment and recognition of failure.

Metabolic consequences of urinary diversion through intestinal segments.

The use of intestinal segments in the reconstruction of the urinary tract for a variety of malignant and nonmalignant conditions is generally accepted. Metabolic derangements may result any time urine is in contact with the intestinal mucosa. Numerous studies concerning the pathophysiology of this syndrome have demonstrated that it is in large part secondary to reabsorption of urinary acid as ammonium and, to a lesser degree, to bicarbonate secretion into the urine. The syndrome of metabolic acidosis resulting from urinary diversion has been most common after ureterosigmoidostomy, often in the setting of renal insufficiency secondary to pyelonephritis and obstruction. It became a lesser clinical problem with the popularization and frequent use of conduit urinary diversions. At present, with a greater emphasis on the construction of large-capacity continent urinary diversions, there is an increased likelihood of metabolic derangements, especially in the setting of renal insufficiency. Furthermore, although the reported incidence of clinically problematic metabolic derangements is low with the newer modes of continent urinary diversion, it is impossible to assess the significance of a mild or asymptomatic acidosis, which may occur even in the setting of normal serum electrolytes. Only with close long-term follow-up can the significance of this change be determined.

Penile carcinoma: the case for primary lymphadenectomy.

In the preceding sections, the authors have presented an approach to the management of patients with squamous-cell carcinoma of the penis selected to maximize the therapeutic benefits in high-risk patients while minimizing morbidity in low-risk patients. A clinical staging system is presented in order to approach this problem in a logical fashion. Patients with stage I penile carcinomas are all managed by eradication of the primary lesion followed by expectant management of the inguinal lymph nodes. Persistent inguinal adenopathy after treatment of the primary lesion has been a very rare occurrence in this group of patients in our experience. Patients with stage II penile carcinoma are managed by eradication of the primary lesion, 6-8 weeks of antibiotic therapy, and inguinal lymphadenectomy. The available literature suggests a high incidence of inguinal lymphatic metastases in this group of patients and supports the need for early lymphadenectomy. Finally, patients with clinical stage III disease, i.e., persistent adenopathy after eradication of the primary lesion and 6-8 weeks of antibiotic therapy, all undergo inguinal lymphadenectomy. This group is at extremely high risk and does poorly without aggressive surgical management.