Serum insulin-like growth factor-binding protein-2 (IGFBP-2) is increased and IGFBP-3 is decreased in patients with prostate cancer: correlation with serum prostate-specific antigen.

Insulin-like growth factors (IGFs) are potent mitogens that stimulate the growth of prostate cells. In serum, IGFs circulate bound to IGF-binding proteins (IGFBPs), which modulate their proliferative action. We studied the electrophoretic pattern of IGFBPs in the serum of patients with prostate cancer and in individuals with increased serum levels of prostate-specific antigen (PSA) in the absence of prostate malignancy. Serum IGFBP-2 was dramatically increased in patients with metastatic prostate cancer compared with healthy controls (23.83 +/- 6.93% vs. 2.95 +/- 0.52% of total serum IGFBPs; P < 0.02). A moderate rise in IGFBP-2 was also observed among patients with increased PSA without malignancy. In contrast, a decrease in serum IGFBP-3 was detected in most patients with metastatic prostate cancer (68.2 +/- 9.1% vs. 95.4 +/- 0.9% of total serum IGFBPs; P < 0.02) and was more pronounced in advanced cases. A highly significant correlation between serum IGFBP-2 and PSA levels was found (r = 0.62; P < 0.002), with a significant negative correlation between serum PSA and IGFBP-3 (r = -0.63; P < 0.002). We suggest that IGFBPs may be involved in growth modulation of prostate malignancy and that alterations in their serum levels may serve as a marker for prostate cancer.

Bladder replacement with use of a detubularized right colonic segment: preliminary report of a new technique.

Dissatisfaction with the long-term results of cutaneous urinary diversion and a demand for a more socially acceptable solution have prompted the development of procedures that allow continent urinary diversion. Creation of an internal reservoir from reconstructed bowel segments, which is anastomosed to the patient's urethra and allows continence and urination through the urethra, is a particularly attractive option. We describe a technique that is relatively easy to perform and that incorporates a detubularized right colonic segment. The advantages of this procedure are discussed.

Percutaneous ablation of malignant liver tumor in rabbits using low radio frequency energy.

Radio frequency (RF) current has been used successfully to ablate normal human tissue. To further investigate the clinical application of this modality in tumors we studied the potential of using RF percutaneously to destroy experimental liver tumors. Thirty five outbred albino rabbits underwent liver VX2 tumor direct-implantation during open surgery. After 21 days ultrasonography was performed revealing tumor presence and size. A shielded RF needle was designed so that it could be inserted percutaneously through an introducing needle, and an electrical insulation shield covering the RF needle could be retracted to control the length of the exposed RF needle inside the tissue. Twenty two days after tumor implantation RF was applied via the aforementioned needle using a ZoMed International RF generator. In one group of rabbits the procedure was performed under direct vision during open surgery and on the other group treatment was applied percutaneously, guiding the needle by tumor palpation. Rabbits were killed 3 days later and pathology revealed 4 to 25 mm intratumoral RF induced lesions. A direct relation was found between lesion size, power and duration of RF application (At 7.5 W, r = 0.48, p = 0.032). Based on our preliminary results we may conclude that RF may have clinical application in the near future for percutaneous local tumor control in parenchymal organs.

Raz bladder neck suspension in women younger than sixty-five years compared with elderly women: three years' experience.

OBJECTIVE: To verify the efficacy of Raz bladder neck suspension in producing cure of genuine stress incontinence (GSI) in women younger than sixty-five years compared with elderly women, and to find out whether or not elderly patients are more prone to failure with this technique. METHOD: We reviewed our results with this procedure in 67 women younger than sixty-five years (group I) compared with 21 elderly women (group II). Seventeen patients in group I and 4 patients in group II had bladder neck suspension for grade I-II incontinence, and 50 patients in group I and 17 in group II had additional cystocele repair by the four-corner technique. Rectocele repair and vaginal hysterectomy were also performed when indicated. RESULTS: With a mean follow-up period of 18.2 months for group I and 16.8 months for group II, 57 women (85.1%) in group I were completely cured of stress incontinence, 6 (8.9%) had marked improvement, and 4 (6.0%) had recurrence, while in group II, 19 (90.4%) were completely cured, 1 (4.8%) had marked improvement, and 1 (4.8%) had recurrence. Namely, in group I, 94 percent of the patients were either cured or improved, as compared with 95.2 percent in group II (P = 0.6; Fisher's exact test). Postoperative complications were few, and there was no permanent urinary retention. CONCLUSION: We conclude that, in a relatively short-term follow-up, Raz bladder neck suspension is equally successful in curing stress urinary incontinence in young and elderly females.

Ureteral substitution using the isolated interposed vermiform appendix in a patient with a single kidney and transitional cell carcinoma of the ureter.

A patient with a single kidney presented with ureteral obstruction caused by a combination of primary transitional cell carcinoma of the ureter and extrinsic involvement of the ureter by a second primary malignant retroperitoneal lymphadenopathy. Due to the complexity of the case, we chose to perform a partial ureterectomy and used a method of ureteral substitution using the interposed vermiform appendix in combination with a psoas hitch. Application of the psoas hitch may allow the use of the appendix in most cases in which ureteral substitution becomes necessary. Antireflux mechanism is easily achieved with the appendix using the split cuff nipple technique. Finally, the use of the appendix allows complete retroperitonealization of the anastomoses to both ureter and bladder. We anticipate that the appendix will be used more commonly in the future as a ureteral substitute as more urologists become more comfortable with it through its use in various reconstructive procedures.

Results and morbidity of percutaneous nephrolithotripsy.

The medical records of the first 210 patients treated with percutaneous nephrolithotripsy at Duke University Medical Center were reviewed. Eleven patients were treated for bilateral stones for a total of 221 renal units. The procedure failed in 6 patients (2.7%). Stone fragments were retained in 55 patients (24.9%), with unplanned fragments in 41 cases (18.6%). Open surgery was subsequently performed in 4 patients (1.8%). There were no nephrectomies or deaths in our patients. Percutaneous nephrolithotripsy is a highly successful method for removal of upper tract stones and has a complication rate no higher than that of open surgical procedures.

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma.

OBJECTIVES: Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy. METHODS: A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery. RESULTS: Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation. CONCLUSIONS: In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Urethral strictures in boys.

While common in adult males, urethral strictures are comparatively rare in boys. We report our experience with this condition in 19 boys. Ten of the strictures were iatrogenic, seven traumatic, and three inflammatory in origin. Dilation is reportedly unsatisfactory for the management of most urethral strictures in children. In our series, however, 9 patients (47.3%) underwent urethral dilation as the only definitive form of treatment, while urethroplasty was successfully performed in the other 10 cases.

Ureterocutaneous fistulas secondary to urinary calculous disease.

Fistulas of the ureter are uncommon and are usually secondary to trauma or iatrogenic in nature. Spontaneous rupture of the ureter is rare, usually ending in a periureteral abscess. Two cases of spontaneous rupture of the ureter secondary to calculous disease resulting in ureterocutaneous fistulas are described.

Prophylactic antimicrobial treatment in transurethral prostatectomy. How long should it be instituted?

Eighty-one patients with proved preoperative sterile urine and undergoing transurethral resection of the prostate were studied. The patients were divided into 3 groups: group A received sulfamethoxazole-trimethoprim (ST) preoperatively and postoperatively for ten days; group B received ST in 2 divided doses, one pre- and one postoperatively; group C received no prophylaxis. In groups A and B, we found urinary infection in 3.8 per cent of patients compared with 32 per cent in group C. Performing prostatic chip cultures, we found that most urinary infections were unrelated to a prostatic source. When the prostate was infected, 75 per cent had infected urine postoperatively. We believe that prophylactic antimicrobial treatment should be given to all patients undergoing transurethral prostatectomy. However, it seems that immediate perioperative treatment suffices.

Role of linear tomography in evaluation of patients with nephrolithiasis.

One hundred twenty-four consecutive patients with suspected or known nephrolithiasis were referred for evaluation by linear tomography. Renal calculi were detected in 98 patients (79%). Linear tomography revealed more renal calculi than did preliminary KUB films in 46 patients (37%), although in only 10 cases (8%) was the tomogram positive if the KUB was negative. Exact quantification of the numbers and locations of renal stones is important in patients to be managed metabolically, and in those being evaluated in advance of or following percutaneous or extracorporeal lithotripsy.

Controlled trial of high spermatic vein ligation for varicocele in infertile men.

OBJECTIVE: To determine whether high ligation is an effective treatment for infertile men with clinical varicocele. DESIGN: A randomized, controlled trial of high spermatic vein ligation was carried out. The patients were treated and observed for 3 years. SETTING: Infertility treatment clinic and andrology laboratory in a hospital. PATIENTS: Infertile men with abnormal semen analysis because of varicocele only. INTERVENTION: High ligation 1 year postrecruitment (group A) and at the beginning of the study (group B). RESULTS: Among the 20 couples in group A, 2 pregnancies (10%) were achieved within the 1st year of observation period. During the year after high ligation, there were 8 pregnancies (44.4%), and during the 2nd year after high ligation, there were 4 more pregnancies (22.2%). In group B, 15 pregnancies (60%) occurred within the 1st year after operation. Three pregnancies (12%) and 1 pregnancy (4%) occurred during the 2nd and 3rd year, respectively. After operation in all patients of both groups, there was significant improvement in semen parameters, regardless of pregnancy occurrence. The difference in pregnancy rate (PR) between the operated group B and nonoperated group A during the 1st year of study was found to be highly significant. CONCLUSIONS: It is concluded that in a population of infertile men presenting varicocele as the only demonstrable factor of infertility, the varicocele is clearly associated with infertility and reduced testicular function, and its correction by ligation improves sperm parameters and fertility rate. Furthermore, the highest PR in both groups occurred during the 1st year postoperation.

Acute scrotum caused by Henoch-Schönlein purpura, with immediate response to short-term steroid therapy.

The authors report a case of acute scrotum caused by Henoch-Schönlein purpura. It involved bilateral swelling of the epididymis and testes, which was documented by scrotal ultrasonography and which responded immediately to systemic steroid treatment.

Variations of intestinal motor activity in bladder replacements and in the intestine.

Urinary reservoirs are made from intestinal segments. The motor activity of the intestinal tract is regulated by hormonal and neurological controls. This study compares the motor activity of intestine in situ with those of a neobladder, following oral intake. The changes in motor activity before and after ingestion of standardized 570 Kcal meal were measured simultaneously in the duodenum and in the neobladder of 4 patients who underwent a Camey tubularized ileocystoplasty. Similar motor movements were produced in the graft and in the duodenum. Modifications due to oral intake were then measured in 14 patients with various types of urinary reservoirs (ilea, ileo-colic or colic; and tubularized or detubularized) by measuring the pressure inside the graft. After oral intake the compliance of the detubularized colic and ileocolic reservoirs was greater than that of ileal reservoirs, even after detubularization, since the motor activity and the basal pressure increased greatly in the tubularized or detubularized ileal bladders and much less in the detubularized colic and ileocolic bladders. It is well known that digestion is maximal in the second half of the night, therefore this link between intestinal and neobladder motor activity might explain one of several mechanisms involved in nocturnal increase in reservoir pressure and urine incontinence.

[Primary retroperitoneal extra-gonadal germ cell tumor].

Malignant retroperitoneal tumors are relatively rare. The most likely diagnosis by a surgeon encountering a retroperitoneal mass is metastatic disease, but primary retroperitoneal malignant disease or benign tumor should also be considered. The most common primary retroperitoneal tumors are lymphoma and sarcoma. Primary extragonadal germ cell tumors constitute 1-2% of all germ cell tumors, most of which are found in the mediastinum and retroperitoneum. We report the successful treatment of a 20-year-old man whose primary retroperitoneal extragonadal germ cell tumor was treated by chemotherapy and surgery.

[Radical prostatectomy--experience with 50 patients].

Between 1986-1991 we treated 50 men with adenocarcinoma of the prostate by radical prostatectomy. Ages ranged from 44-74 and clinical stages were A-C. Follow-up lasted 1-63 months (mean 15.1) and was designed to rule out recurrence and/or spread of the disease and to evaluate quality of life. The rate of complications was low, the postoperative course short and uneventful, and there was preservation of urinary continence in 96% and of potency in 10.2%. As compared with radiotherapy, surgery gave superior results and is recommended.

[Delayed spontaneous rupture of the bladder following augmentation enterocystoplasty].

Delayed spontaneous rupture of the urinary bladder following augmentation enterocystoplasty is a serious life-threatening complication of uncertain etiology. Multiple factors are believed to contribute to the mechanism of bladder perforation. Ruptured augmented bladders share a common urodynamic pattern of high leak point pressure of the urethra, with sensory and mechanical tolerance of high filling pressure. This combination seems to be the main predisposing factor for spontaneous perforation. Other risk factors, including catheter trauma during intermittent self-catheterization, urinary retention due to mucus retention or noncompliance with the catheterization protocol, chronic infection, and decreased sensation of bladder filling, may play roles in the mechanism of rupture. Clinically, patients present with sepsis, abdominal pain and distension, ileus, fever, oliguria and peritoneal irritation. The diagnosis is made on low pressure cystography, although failure of cystography to demonstrate extravasation is not unusual. Aggressive surgical treatment consists of immediate exploration, primary repair of the perforation, drainage of the perivesical space, suprapubic cystostomy and broad-spectrum antibiotics. Longterm management includes a strict intermittent catheterization schedule, anticholinergic therapy and urodynamic evaluation. Failure to achieve a low pressure storage reservoir by conservative means entails an increased risk of recurrent perforation. In such cases further surgical intervention should be considered. We present a 21-year-old paraplegic man 5 months after augmentation enterocystoplasty who required operation because of spontaneous rupture of the augmented bladder. Spontaneous delayed rupture of the bladder should be considered in the differential diagnosis of acute abdomen in patients after augmentation enterocystoplasty. Early surgical treatment and subsequent monitoring of the low pressure reservoir are recommended.

[Artificial sphincter for urinary incontinence].

During the past 4 years 21 patients underwent implantation of the model AS-800 artificial urinary sphincter, 4 of whom underwent simultaneous implantation of an inflatable penile prosthesis. The mean age was 48 years (range 33-73). Incontinence was neurogenic in 12 (57%) and a complication of urologic surgery (mainly prostatectomy) in 9 (43%). In 8, in whom intermittent self-catheterization was planned, the sphincter cuff was implanted around the bladder neck, and in the other 13, around the bulbar urethra. The immediate postoperative course was uneventful in 18 (85%), but 2 (10%) had urinary tract infection and 1 had urinary retention. During a mean follow-up of 20 months (range 1-36), 19 (90%) were found to be continent (in 2 of them the cuff had had to be changed to a smaller size due to tissue atrophy), and 1 had suffered from urgency incontinence which disappeared with anticholinergic medication. In 2 with incontinence due to neurogenic bladder, the sphincter had became infected and had had to be removed; 1 of these 2 had undergone simultaneous augmentation cystoplasty. This experience resulted in a change in our policy: we now implant the sphincter and perform augmentation cystoplasty in 2 separate stages. We find implantation of the artificial urinary sphincter very effective treatment for urinary incontinence.

[Reconstruction of lower urinary tract in patients with neurogenic bladder ].

Between 1988-1993 we performed lower urinary tract reconstruction in 30 patients with neurogenic bladder. The indications for surgery included urinary incontinence and/or upper urinary tract deterioration. 18 patients with a follow-up of longer than 18 months are reported. Continence was achieved in 15 of 16 patients and stabilization or improvement of the upper tracts in 17 of 18 patients. There was no mortality, and morbidity was the same as in similar series. Despite its complexity, lower urinary tract reconstruction in patients with neurogenic bladder brings major improvement in quality of life and in preservation of renal function. We recommend such operations in properly selected patients.

[Endometriosis of the bladder].

We report a case of endometriosis of the bladder in a 32-year-old healthy woman suffering from longstanding suprapubic pain, and urinary urgency and frequency. The disease, which is uncommon, usually has a high morbidity rate and is difficult to diagnose. A high level of suspicion is necessary for diagnosis, since neither the clinical presentation, nor imaging procedures are pathognomonic for endometriosis.