Multiple drug resistance mutations in human immunodeficiency virus in semen but not blood of a man on antiretroviral therapy.

The concept that the male reproductive tract harbors isolated reservoirs of human immunodeficiency virus (HIV) infection has now been widely accepted. The significance of semen viral burden to sexual transmission of HIV is obvious; however, its contribution to disease progression is unknown. We report a case study that demonstrates the emergence of resistance-conferring mutations to antiviral therapy in infected seminal leukocytes from a man with asymptomatic prostatitis associated with leukospermia. This finding demonstrates the potential importance of male reproductive tract organs to the development of therapy resistance in HIV-infected men.

Prostate specific antigen is detectable in formalin-fixed semen.

OBJECTIVE: To conduct a pilot study to test whether or not prostate specific antigen (PSA) and/or PSA-positive cells can be detected and characterized in semen specimens archived in aldehyde fixative. MATERIALS AND METHODS: Specimens from 12 men were examined, six before elective vasectomy and six undergoing infertility evaluation. Fixed semen elements were assessed immunocytologically using monoclonal antibodies against PSA and leucocyte common antigen, CD 45, as a control. RESULTS: PSA was detectable in the semen from the fertile men as amorphous protein and contained within round vesicles (prostasomes). Semen from men undergoing infertility evaluation contained a greater variation in detectable forms and amount of PSA than the specimens from the fertile men, including PSA associated with some nonspermatozoal cells (NSCs). CONCLUSION: PSA is detectable by immunocytological analysis of semen specimens archived in aldehyde-based fixative. Three forms of PSA were detected; within round vesicles characteristic of prostasomes, associated with some NSCs, and as amorphous protein. The detected variations suggest that analysis of PSA-positive semen elements may provide important insights into prostate physiology.

Human immunodeficiency virus in semen arises from a genetically distinct virus reservoir.

The reservoir of human immunodeficiency virus (HIV) in semen is unknown. Several lines of evidence suggest that semen HIV may not arise from the same reservoir of infection as peripheral blood. If true, the viral burden in the two compartments could be qualitatively and quantitatively different, a scenario of potentially profound significance for the design of effective strategies of treatment, disease monitoring, and infection containment. We report here that the ratio of infected to uninfected leukocytes in ejaculated semen specimens is highly discordant with paired blood samples, demonstrating that they derive from distinct populations of infected cells. In addition, infectious HIV was isolated from semen cells, but not from blood cells, of an individual on triple antiretroviral therapy; the absence of major resistance-conferring mutations in the semen virus indicates that it was replicating in isolation from the antiviral agents. The compartmentalization of blood and semen infection was further supported by genetic analysis of several infectious HIV clones isolated from semen cells and peripheral blood cells of another donor not on antiretroviral therapy. Protease gene sequence analyses revealed significant divergence of the two viral populations. These findings confirm the distinct compartmentalization of HIV in the semen of this study cohort, and support the concept that semen HIV arises from an isolated reservoir of infection that may function independently in the pathobiology of HIV disease.

Semen leukocytes: friends or foes?

OBJECTIVE: To test the hypothesis that male reproductive tract leukocytes function in the elimination of abnormal spermatozoa from ejaculated semen. DESIGN: Semen specimens with > or = 2 x 10(6) nonspermatozoal cells/mL were examined for leukocytes and for mature sperm with ideal morphology. SETTING: Andrology laboratory of a Center of Assisted Reproductive Technology. RESULTS: Semen specimens with elevated concentrations of leukocytes contained a significantly higher frequency of sperm with ideal morphology than semen specimens with elevated numbers of immature germ cells and low numbers of leukocytes. CONCLUSIONS: The direct correlation between leukocyte density and sperm with ideal morphology supports the concept that sperm surveillance is a normal function of male reproductive tract leukocytes. Understanding such germ cell-leukocyte interactions may provide valuable new insights into immunologic control mechanisms in male reproductive tract tissues.

Management of recurrent priapism with epinephrine self-injection and gonadotropin-releasing hormone analogue.

A case of recurrent priapism in a young black man without sickle cell anemia is reported. Due to almost daily episodes of prolonged painful erections, the patient was instructed in intracorporeal injection using an epinephrine self-injection kit, which provided complete detumescence on 31 occasions. The patient refused surgical intervention and was treated with monthly intra-muscular gonadotropin-releasing hormone analogue. Priapism episodes completely abated by the second and final monthly gonadotropin-releasing hormone analogue injection without recurrence during 4 months of followup. Normal erectile function was maintained during and after gonadotropin-releasing hormone analogue therapy. Epinephrine self-injection and gonadotropin-releasing priapism.

Use of dynamic two-dimensional transesophageal echocardiography for renal cell carcinoma with cavoatrial tumor thrombus.

Renal cell carcinoma with inferior vena caval tumor thrombus extending to the level of the right atrium occurs in about 1% of all cases. Dynamic two-dimensional transesophageal echocardiography is a minimally invasive safe technique that can demonstrate preoperatively the cephalad extent of the cavoatrial tumor thrombus with an accuracy that appears equal to or better than that of any other method currently available. When used intraoperatively, it provides invaluable data to aid in the anesthetic and surgical management of the patient, obviating the need for and potential risk of placing a Swan-Ganz pulmonary artery catheter before complete removal of the tumor thrombus.

Resection of cavoatrial renal cell carcinoma employing total circulatory arrest.

Intracaval extension of renal cell carcinoma to the right atrium is a life-threatening presentation that may result in fatal tricuspid valve obstruction or pulmonary embolization. From 1981 to 1989 we treated 10 patients with such extension of tumor, the last 7 of whom underwent resection in which hypothermic circulatory arrest was used. No postoperative deaths, myocardial infarctions, or strokes occurred. Four patients were alive with no evidence of disease at 4, 10, 16, and 39 months after resection, and 1 patient was alive with pulmonary and spine metastases at 34 months after resection. Two patients died of metastatic disease at 7 and 12 months. In the absence of diffuse metastatic disease, lymph-node involvement, or invasion of contiguous organs, radical resection of cavoatrial hypernephroma may result in excellent palliation and possibly a cure.

Management of recurrent pelvic tumors.

The management of regional tumor recurrence in the pelvis traditionally has been a difficult problem for surgeons and oncologists. The only meaningful therapy for these patients is a potentially curative re-resection. The records and operative reports of 29 patients with regional pelvic tumor recurrence treated between 1981 and 1986 were reviewed. The operative procedures performed included three bowel resections, six abdominoperineal resections, eight pelvic exenterations, eight resections of tumor recurrence, and four conservative procedures. There was one operative death in this group. Significant morbidity was noted in the group but was clustered in a small number of patients operated on early in the series. The median follow-up in this series was 13 months (range, two to 51 months). Nineteen (65%) of the patients are surviving at a median follow-up of ten months (range, two to 51 months). The median survival (following resection) in the ten patients (35%) who died was 18 months. In 15 (52%) of the patients, a complete resection was performed. In this group, the survival is 80% with a median follow-up of 11 months. Seven (37%) are surviving with no evidence of disease. Palliation of symptoms occurred in 23 (79%) of the 29 patients. Radical resection of tumor recurrence in the pelvis can be performed with acceptable mortality and complication rates. This therapy should be considered for further clinical trials combining surgical and adjuvant therapy in patients with regional pelvic tumor recurrence.

Management of the urinary tract involved by recurrent cancer.

We present our experience from 1982 to the present in treating 33 patients with recurrent cancers (colorectal, 22; gynecologic, six; breast, two; melanoma, two; and lung, one) secondarily involving the genitourinary tract. All patients had severe symptoms that required palliation. Endoscopically placed stents relieved ureteral obstruction in 18 (75%) of 24 patients with widespread metastatic disease. Two patients required percutaneous nephrostomy tubes, and five required open operations. Good to excellent palliation was achieved in 23 of 24 patients. Mean survival in the group with diffuse metastases was 13 months (range, six to 29 months). Nine patients with localized recurrences underwent surgical procedures. For localized pelvic recurrences, total exenteration (with or without intraoperative radiotherapy) provided excellent palliation with low morbidity. At the time of this report, five of six such patients had no evidence of disease, and one had a small asymptomatic pelvic recurrence, with a mean follow-up of 13 months (range, five to 19 months).

Palisading granulomas of the prostate associated with prior prostatic surgery.

We report a case of a unique granulomatous lesion of the prostate and recurrent bladder neck obstruction. The lesion was histologically identical to a rheumatoid nodule and it has only been seen in patients who have undergone prior prostatic surgery. There appears to be no clinical correlation with connective tissue disease, and the lesion differs clinically and morphologically from other types of granulomatous prostatitis.

Management of urinary and bowel complications after ileal conduit diversion.

Serious urinary and bowel complications after ileal conduit diversion are associated with significant morbidity and mortality rates. We reviewed 9 patients treated at our institution during the last 5 years for sequelae after ileal conduit diversion for bladder cancer. Of these patients 8 are well and 1 died postoperatively of a myocardial infarction. In all, 33 operations were required to treat complications after initial diversion. A variety of surgical procedures, including anastomotic revision, ileal ureter, stomal revision, transverse colon conduit and nephrectomy, was used to treat urinary complications. A treatment outline emphasizing an initial conservative approach, the importance of nutritional support and the appropriate options for reconstruction is presented.

Mixed mucinous and papillary adenocarcinoma involving male urethra, probably originating in periurethral glands.

The case of a patient with primary adenocarcinoma involving the urethra is described. Morphologic evidence supporting an origin in the periurethral glands is presented. The urologist and pathologist must maintain a high index of suspicion in evaluating patients with urethral structure or urethrocutaneous fistulae because superficial transurethral biopsy may fail to obtain adequate depth to demonstrate malignancy.