A comparative study of tissue ω-6 and ω-3 polyunsaturated fatty acids (PUFA) in benign and malignant pathologic stage pT2a radical prostatectomy specimens.

OBJECTIVE: To analyze different polyunsaturated fatty acid (PUFA) tissue levels in malignant compared with benign prostatic tissue from the same prostate specimens. MATERIALS AND METHODS: Fresh frozen benign and malignant prostatic tissue was obtained from radical prostatectomy specimens in 49 men with pathologic stage pT2a prostate cancer. Histopathologic examination confirmed that all tissues from each prostate being analyzed were either completely benign or almost totally malignant. The PUFA composition in these tissues was determined by gas-liquid chromatography on a capillary column. The relative amount of each PUFA (% of total fatty acids) was quantified by integrating the area under the peak and dividing the result by the total area of all fatty acids. RESULTS: Tissue levels of dihomo-γ-linolenic acid, (C20:3w6), an ω-6 PUFA and a major precursor of ω-6 PUFA metabolites, were significantly higher in malignant compared with benign tissues (P = 0.002). Tissue levels of the downstream ω-6 metabolites, arachidonic acid (AA) (20:4ω6), and adrenic acid, (22:4ω6), were significantly lower in cancer tissues, (P < 0.0001 and P = 0.013, respectively). Overall, the total levels of ω-6 PUFA were lower in cancer (P = 0.001). CONCLUSION: We found that the ω-6 PUFA AA and adrenic acid are decreased in malignant prostatic tissues compared with benign tissues from the same prostates. These findings provide additional evidence that dietary fat is associated with prostatic carcinogenesis.

Expression of immunomodulating genes in prostate cancer and benign prostatic tissue.

OBJECTIVE: To investigate the expression of immunomodulating genes in prostate cancer and benign prostatic tissue. STUDY DESIGN: We investigated by quantitative real-time polymerase chain reaction the expression of indoleamine 2,3-dioxygenase, arginase 1, arginase 2, inducible form of nitric oxide synthase, cyclooxygenase 2 (COX-2), programmed death ligand 1 and interleukin 10 in 36 matched pairs of samples from prostate cancer and benign prostatic tissue. RESULTS: Among the genes analyzed, arginase 2 and COX-2 showed statistically significant up-regulation and down-regulation, respectively, in malignant compared to benign prostate tissue. In addition, arginase 1 was more often present in cancer than benign samples. No significant modulation was detected for the other genes under investigation. CONCLUSION: Our data suggest that arginine metabolism may be involved in prostate cancer immune response evasion, whereas COX-2 may play a role in pathogenesis. We provide a snapshot of immunosuppressive gene expression at the transcriptional level in the prostate tumor microenvironment.

Birth weight, abdominal obesity and the risk of lower urinary tract symptoms in a population based study of Swedish men.

PURPOSE: Lower urinary tract symptoms and obesity are prominent health problems. Low birth weight increases the adult risk of adiposity and insulin resistance, which may increase sympathetic activity and potentially lower urinary tract symptoms. Results of obesity and lower urinary tract symptoms studies are conflicting, and low birth weight and lower urinary tract symptoms relationships have not been investigated. MATERIALS AND METHODS: This cross-sectional study examines lower urinary tract symptoms, body measures, activity, birth weight and lifestyle data collected by questionnaire from 1997 to 1998. Overall 27,858 men were analyzed and odds ratios calculated after excluding those with cancer, cerebrovascular accident, diabetes and incomplete information. RESULTS: After adjustment for age, activity level, smoking, alcohol, coffee intake and body mass index, a significant positive association was seen between abdominal obesity (waist-to-hip ratio) and moderate to severe lower urinary tract symptoms. The risks of moderate to severe and severe lower urinary tract symptoms were 22% (95% CI 1.09-1.37) and 28% (95% CI 1.01-1.63) higher, respectively, for the top vs the lowest abdominal obesity quartile. The risk of nocturia (twice or more per night) was 1.16 (95% CI 1.02-1.33) in men in the top compared to the bottom waist-to-hip ratio quartile. Men with low birth weight (less than 2,500 gm) had a 61% (95% CI 1.12-2.30) higher risk of severe lower urinary tract symptoms compared to men with normal birth weight (2,500 to 3,999 gm). Men in the top waist-to-hip ratio quartile who had low birth weight had twice the risk of severe lower urinary tract symptoms (95% CI 1.29-3.02) compared to men with normal birth weight and in the lowest waist-to-hip ratio quartile. CONCLUSIONS: Low birth weight and abdominal adiposity are associated with increased risk of moderate to severe lower urinary tract symptoms in adults. Further investigations are needed to determine if decreases in obesity can ameliorate lower urinary tract symptoms.

A pilot study of ice-slurry application for inducing laparoscopic renal hypothermia.

OBJECTIVE: To assess, in a pilot study, the feasibility of delivering a microparticulate ice slurry (MPS) to provide regional hypothermia, as renal cooling during laparoscopic procedures is cumbersome and inefficient. MATERIALS AND METHODS: An ex vivo preparation was used to simulate the boundary conditions of a kidney. Four pig kidneys were placed onto a thin membrane overlying a constant temperature bath (37 degrees C) with parenchymal thermocouples. Renal surfaces were coated with MPS and temperatures recorded. In an in vivo pig model we assessed laparoscopic delivery and cooling ability of the MPS under physiological conditions. Kidneys in two pigs were laparoscopically exposed; thermocouple probes were placed throughout the kidney and the hilum was clamped. MPS was delivered through a modified 5-mm laparoscopic suction/irrigation cannula. Cortical and core body temperatures were measured. RESULTS: In the ex vivo study, the mean (sd) initial temperature was 37.1 (0.4) degrees C; the mean time to reach 15 degrees C was 10.3 (2.6) min and the mean nadir temperature was 13.0 (1.5) degrees C. In vivo, the MPS was delivered with no technical difficulty; the mean renal unit starting temperature and core body temperature were 37.2 degrees C and 37.0 degrees C, respectively. The mean (range) time to reach 15 degrees C was 16.5 (5.5-28.6) min. The mean nadir core body temperature was 34.0 degrees C. CONCLUSION: This initial study showed efficient and rapid induction of renal hypothermia using MPS delivered through 5-mm laparoscopic ports, with no technical difficulty. These exploratory pilot findings support further, larger scale, histopathological and renal functional investigations of topical ice slurries as a means of providing renal hypothermia in laparoscopic procedures.

Karolinska prostatectomy: a robot-assisted laparoscopic radical prostatectomy technique.

OBJECTIVE: The last decade has witnessed an increasing trend towards minimally invasive management of prostate cancer, including laparoscopic and, more recently, robot-assisted laparoscopic prostatectomy. Several different laparoscopic approaches have been continuously developed during the last 5 years and it is still unclear which technique yields the best outcome. We present our current technique of robot-assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS: The technique described has evolved during the course of >400 robotic prostatectomies performed by the robotic team since the robot-assisted laparoscopic radical prostatectomy program was introduced at Karolinska University Hospital in January 2002. SURGICAL PROCEDURE: Our procedure comprises several modifications of previously reported ones, and we utilize fewer robotic instruments to reduce costs. An extended posterior dissection is performed to aid in the bladder neck-sparing dissection. In nerve-sparing procedures the vesicles are divided to avoid damage to the erectile nerves. In order to preserve the apical anatomy the dorsal venous complex is incised sharply and is first over-sewn after the apical dissection is completed. CONCLUSIONS: Our technique enables a more fluent dissection than previously described robotic techniques. Minimizing changes of instruments and the camera not only cuts costs but also reduces inefficient operating maneuvers, such as switching between 30 degrees and 0 degrees lenses during the procedure. We present a technique which in our hands has achieved excellent functional and oncological results.

Impact of surgical margin status on long-term cancer control after radical prostatectomy.

OBJECTIVE: To determine whether previously described technical modifications that significantly decreased the positive surgical margin (PSM) rate have translated into improved long-term cancer control, as SM status is generally recognized as an independent risk factor for biochemical recurrence (BR) after radical retropubic prostatectomy (RRP), and is the only factor that can be modified by surgical technique. PATIENTS AND METHODS: Between March 1994 and December 2004, 996 consecutive patients had RRP as the sole treatment for clinically localized prostate cancer. The surgery was done by one surgeon (C.B.B.) and the data were prospectively reviewed. RESULTS: The overall PSM rate was 8.8%; the PSM rate by pathological stage was 1.7%, 24.2% and 27.1% for men with pT2, pT3a and pT3b disease, respectively (P < 0.001). In all, 968 of 996 (97.2%) patients were available for the follow-up (mean 6.4 years); 69 of 883 (7.8%) with negative SMs (NSMs) developed BR, vs 29 of 85 (34%) with PSMs (P < 0.001). The actuarial 5- and 10-year biochemical disease-free survival was 92.1% and 89.6%, and 70.6% and 59.9%, for patients with NSM and PSM, respectively (P < 0.001). On multivariate analysis, PSM, pathological stage and Gleason grade were the strongest predictors of BR (P < 0.001). The preoperative prostate-specific antigen level, and clinical stage T1c and T2a disease were not associated with recurrence. The hazard ratio (95% confidence interval) for BR in patients with PSMs was 3.27 (2.1-5.1). CONCLUSIONS: RRP including the previously described surgical modifications not only decreased the PSM rate but also resulted in excellent long-term cancer control. The importance of meticulous surgical technique in RRP cannot be overemphasised.

A new animal model of hyperoxaluria and nephrolithiasis in rats with small bowel resection.

An association between small bowel resection and stone disease has been noted, which is primarily due to increased gut oxalate absorption and resulting excretion by the kidney. In order to better understand the factors affecting both oxalate absorption and renal excretion, and the resulting renal lesions, we have developed a rodent model of small bowel resection and hyperoxaluria. Using this model, we have studied the renal histology in animals with hyperoxaluria over time spans from 2 weeks to 7 months. The initial lesion appears to be crystal formation along the brush border of the proximal tubule, with eventual crystal deposition in collecting ducts and papillary interstitium, and eventual tubule obstruction, interstitial inflammation and fibrosis. Crystal formation appears to dissociate from urinary supersaturation. We hypothesize that oxalate transporters in the proximal tubule may increase local saturations, leading to crystal formation at this site initially. Further studies are required to better characterize the causes and consequences of hyperoxaluria in this animal model.

Necrotic pancreatic graft causing acute urinary retention.

Urologic complications are frequently encountered after pancreas transplantation with a graft duodenocystostomy. Urinary infections, hematuria, and irritative voiding symptoms are some of the most frequent complications with a bladder-drained pancreas allograft. While voiding dysfunction is common in these patients due to underlying neuropathy, to our knowledge, we report the first case of obstructive uropathy in a female due to retained necrotic graft material.

Nephrolithiasis and nephrocalcinosis in rats with small bowel resection.

Intestinal resection (IR) may lead to hyperoxaluria and nephrolithiasis. A rat model of IR was developed, in which kidney stones form. We describe the urine chemistries and histopathologic features. Rats underwent resection of 40-45 cm of distal ileum (n=16) or sham resection (SR) (n=8), and were then fed a 1% Na oxalate, 0.02% Ca diet. After 1 week on the diet, 24 h urine samples were obtained for stone chemistries. At 4-7 months after surgery, kidneys were examined grossly and by light microscopy. The extent and location of crystallization was assessed by polarized light. Histochemistry and infrared spectroscopy were used to determine crystal composition. IR rats had higher urine oxalate excretion (P<0.01) and concentration (P<0.001) than SR rats, and lower urine citrate excretion; only IR rats formed kidney stones (12/15 surviving rats). Tissue calcification was found only in kidneys from IR rats, located in the cortex (83% of kidneys), medulla (73%) and papillary tip (47%). Crystals, composed of CaOx, apatite, and calcium carbonate, filled collecting duct lumens, and were associated with tubular obstruction, and interstitial inflammation. Crystals in the papillary interstitium incited inflammation with tubular destruction and development of progressive papillary erosion. This new rat model of nephrolithiasis and nephrocalcinosis resembles the pattern of urinary abnormalities and tissue calcification that may be seen in humans with small bowel resection. The model allows further studies of the mechanisms of renal crystal formation, and possible therapeutic interventions.

Comparison of external catheters with subcutaneous vascular access ports for chronic vascular access in a porcine model.

We sought to compare the outcomes of two chronic vascular access techniques, the externalized catheter and the subcutaneous vascular access port, in pigs. Female farm pigs (n = 30) underwent placement of a chronic vascular access device in the jugular vein for a research protocol: 18 of the animals underwent placement of a tunneled Hickman catheter (THC), and the remaining 12 animals underwent placement of a subcutaneous vascular access port (VAP) without external components. After placement of the devices, animals underwent serial blood sampling. All animals were given identical antibiotic prophylaxis. VAP access required the use of a restraint sling for Huber needle insertion, whereas THC access required no additional equipment. Animals were euthanatized 1 month after placement of the device. In the VAP group, the port was retrieved, cleaned, and steam-autoclaved for reuse. In the THC group, 13 (72%) animals developed infectious complications, and blood and wound cultures were often polymicrobial. One animal was euthanatized secondary to overwhelming sepsis. In addition, three (17%) animals developed thromboembolic complications. In contrast, no thromboembolic complications were noted in the VAP group, and only one animal developed a transient fever which resolved spontaneously; no septic complications or abscesses developed. Blood draws with no anesthesia were successful in both groups. We conclude that subcutaneous vascular access ports are a safe and efficient method for obtaining reliable chronic vascular access for a 1-month period in pigs. The subcutaneous devices were associated with low morbidity. In contrast, externalized catheters can be associated with considerable morbidity.

Early release of the neurovascular bundles and optical loupe magnification lead to improved and earlier return of potency following radical retropubic prostatectomy.

PURPOSE: Since 1999 we have made 2 modifications in the nerve sparing approach to radical retropubic prostatectomy (RRP), namely early release of the neurovascular bundles (NVBs) before division of the posterior membranous urethra and the use of 2.5x optical loupe magnification during NVB preservation. We retrospectively reviewed our results. MATERIALS AND METHODS: Between January 1998 and August 2003, 507 men underwent RRP for prostate cancer. All surgeries were performed by a single surgeon (CBB). Bilateral nerve sparing procedures were performed in 313 men. Modifications were introduced sequentially to the surgical technique and potency rates were compared to those of patients operated on before these modifications. Patients were divided into groups based on the technique of nerve sparing as group 1 (standard release of the NVB), group 2 (early release of the NVB) and group 3 (early release with loupe magnification). All patients were followed for a minimum of 5 months. Postoperative potency rates were compared among the 3 groups. RESULTS: Mean followup was 15.9 months. Mean patient age was 56.2 years. The overall potency rate among groups 1, 2 and 3 was 40.5%, 54.8% and 66.1%, respectively. Mean time to potency was 10.7, 8.5 and 2.0 months, respectively. Significant differences were found in the overall potency rate among all groups (p <0.05). Mean time to potency was significantly improved between groups 1 and 3 (p <0.05) and between groups 2 and 3 (p <0.05). CONCLUSIONS: Minor modifications in nerve sparing technique lead to improved postoperative potency rates and decreased time to potency in men undergoing RRP.

Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures.

PURPOSE: To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS: Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS: At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS: Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.

Eliminating knot tying during warm ischemia time for laparoscopic partial nephrectomy.

PURPOSE: Rapid intracorporeal suturing represents a challenge when performing laparoscopic partial nephrectomy (LPN). During warm ischemia time (WIT) knot tying is a major time-consuming step. We present our technique of eliminating knot tying during LPN and the outcomes of our initial series. MATERIALS AND METHODS: Between October 2002 and October 2003, 32 patients underwent LPN for clinical T1a renal tumors. Our technique includes initial placement of a 5Fr ureteral catheter for collecting system irrigation. The renal hilum is clamped, the tumor is sharply excised and freehand suturing of the collecting system and renal parenchyma is performed using 2-zero and zero polyglactin sutures prepared with an absorbable clip (LapraTy, Ethicon Endosurgery Inc., Piscataway, New Jersey) at the terminal end. Once the suture is passed an additional clip is used to cinch it down, obviating the need for knot tying. This technique is used for closure of the collecting system as well as for placement of parenchymal compressive sutures over bolsters. Subsequent testing for watertightness with methylene blue solution is performed. RESULTS: Pathological mean tumor size was 2.1 cm (range 0.3 to 4.2). Mean operative time was 224.2 minutes (range 105 to 396). In 21 cases (65.6%) the collecting system was entered, necessitating further suturing. Mean WIT was 33.1 minutes (range 13 to 55) and mean estimated blood loss was 222.7 cc (range 5 to 600). No postoperative bleeding or urine leaks were encountered in this series. CONCLUSIONS: The use of LapraTy clips as an alternative to knot tying in LPN is safe and efficient. It simplifies the procedure and allows completion of the necessary suturing tasks during an acceptable WIT.

Renal tolerance to prolonged warm ischemia time in a laparoscopic versus open surgery porcine model.

PURPOSE: To our knowledge the effects of renal warm ischemia (WI) during laparoscopic vs open surgery have not been investigated. Decreased renal blood flow during pneumoperitoneum may precondition the kidney to tolerate longer WI time. Traditionally 30 minutes has defined the limit of renal WI time in open surgery. However, recent reports show renal function recovery at WI times of 45 to 120 minutes. We assessed renal function recovery after prolonged WI during laparoscopic vs open surgery in a solitary kidney porcine model. MATERIALS AND METHODS: A total of 32 female farm pigs underwent right laparoscopic nephrectomy to create a single kidney model. At 12 days later the animals were randomized into open and laparoscopic groups, each with 4 subgroups, namely 30, 60 and 90 minutes of WI, and a 90-minute control. Serum creatinine and the glomerular filtration rate were assessed preoperatively and on postoperative days 1, 3, 8 and 15. RESULTS: There was no statistical difference in renal function between the laparoscopic and open groups. Although the early decrease in renal function (72 hours) was highest in the 60 and 90-minute WI groups, by postoperative day 15 this difference was not statistically significant. Postoperative day 15 glomerular filtration rate and serum creatinine values were not significantly different from baseline in any of the WI groups. CONCLUSIONS: We found no difference in renal function recovery when comparing laparoscopic and open WI. Although WI up to 90 minutes resulted in initial renal dysfunction, by 2 weeks postoperatively function normalized. Our results indicate that in a single kidney porcine model the renal unit can fully recover from WI times of up to 90 minutes.

Malignant B-cell lymphoma in renal cyst wall.

Renal cysts are frequently found in adults older than 50 years of age. Bosniak type III and IV cysts are commonly associated with malignancy, but most Bosniak I and II lesions are benign, and the optimal management has not been clearly defined. Although computed tomography and ultrasound examinations have improved diagnostic accuracy, some masses will remain indeterminate and require more invasive evaluation. We report a patient with a Bosniak type II renal cyst associated with malignant B-cell lymphoma in the cyst wall diagnosed after laparoscopic renal exploration.

Acute recovery of pneumoperitoneum using argon gas.

BACKGROUND AND PURPOSE: The argon-beam coagulator (ABC) is widely used in laparoscopic surgery as a method of electrocoagulation. Argon gas possesses properties that make it suitable as an alternative for establishing pneumoperitoneum. We present a case in which an ABC was used to deliver argon gas urgently in order to salvage an acutely compromised pneumoperitoneum. METHODS: During a right partial nephrectomy, after the renal artery was clamped, a failure in the central CO(2) compressor compromised the pneumoperitoneum. Argon gas was delivered from an ABC at a flow rate of 4 L/min and a distance of 1 to 5 cm and directed toward the paranephric fat. RESULTS: Pneumoperitoneum was rapidly reestablished. Stable intra-abdominal pressure was maintained in the range of 14 to 20 mm Hg for 16 minutes until the original CO(2) supply was reestablished. The total warm ischemia time was 32 minutes. No hemodynamic changes were noted while using argon gas, and the procedure was completed successfully with an uneventful postoperative course. CONCLUSIONS: Argon gas delivery from an ABC can be used for emergency salvage of pneumoperitoneum in selected cases of acute CO(2) gas delivery failure and under strict intra-abdominal pressure monitoring.

Minor modifications in apical dissection of radical retropubic prostatectomy in patients with clinical stage T2 prostate cancer reduce positive surgical margin incidence.

OBJECTIVES: To describe modifications in the apical dissection of radical retropubic prostatectomy (RRP) in men with palpable disease that reduce the incidence of positive apical surgical margins. Positive surgical margins occur in up to 45% of patients undergoing RRP, even in contemporary series. The apex is the most common site of positive margins, and patients with palpable (clinical Stage T2) disease are more likely to have positive surgical margins than patients with nonpalpable (clinical Stage T1c) disease. METHODS: Ninety-five men, 48 to 77 years old (mean age 59.6) with clinical Stage T2 tumors underwent RRP between October 1998 and May 2001. Surgical modifications included identification of the prostatic urethral junction by dissection of the levator ani muscle from the prostate and partial transection of the puboprostatic ligaments; variable division of the membranous urethra 1 to 3 mm distal to the prostatic urethral junction; division of prostatic ischial ligaments before dividing the catheter and posterior membranous urethra; and division of the neurovascular bundle at the urogenital diaphragm before liberating the prostate from the rectum. RESULTS: Positive surgical margins occurred in only 8 (8.4%) of 95 patients, even though tumor extended beyond the prostatic capsule in 55% of cases. Only 2 (2.1%) of the 95 patients had isolated positive apical surgical margins. Urinary continence was not adversely affected by these modifications. CONCLUSIONS: Easily applied modifications in the apical dissection of RRP significantly reduce the incidence of positive apical margins in patients with clinical Stage T2 prostate cancer.

Long-term results of endoureterotomy and open surgical revision for the management of ureteroenteric strictures after urinary diversion.

PURPOSE: Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy. MATERIALS AND METHODS: Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. RESULTS: At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy. CONCLUSIONS: Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.

Detection of alpha-methylacyl-coenzyme A racemase in postradiation prostatic adenocarcinoma.

OBJECTIVES: To assess the utility of alpha-methylacyl-coenzyme A racemase (AMACR), also known as P504S, immunohistochemistry in the detection of postradiation prostatic adenocarcinoma in surgical specimens. Pathologic diagnosis of postradiation prostate cancer is difficult because of the radiation-induced cytologic changes in benign and malignant epithelial cells. AMACR/P504S is a recently identified molecular marker for prostatic adenocarcinoma. It has been demonstrated that AMACR is overexpressed in the vast majority of prostatic adenocarcinoma cases by cDNA microarray, RNA analysis, Western blotting, and immunohistochemistry. METHODS: A total of 80 prostate glands, including 40 irradiated prostate specimens (28 with adenocarcinoma and 12 benign prostates) and 40 nonirradiated prostate specimens (20 with adenocarcinoma and 20 benign prostates), were examined. The specimens were obtained after salvage radical prostatectomy (n = 25), transurethral resection (n = 4), or needle biopsy (n = 11). All samples were immunohistochemically analyzed for AMACR. RESULTS: All 48 carcinoma cases (28 of 28 irradiated and 20 of 20 nonirradiated specimens) showed strongly positive AMACR/P504S immunostaining. AMACR immunostaining was negative for all irradiated (n = 12) and nonirradiated (n = 20) benign prostates, as well as the irradiated benign glands adjacent to carcinoma. 34betaE12 confirmed the presence of basal cells in all benign prostates (32 of 32) and the absence of basal cells in carcinoma (0 of 48). CONCLUSIONS: Our results demonstrate that AMACR is a highly specific and sensitive indicator of postradiation prostate cancer. AMACR immunostaining facilitates the challenging differentiation between prostatic adenocarcinoma and radiation-induced atypia in benign prostatic epithelium and may be of exceptional value in limited needle biopsies.

Nonsurgical management of benign prostatic hyperplasia in men with bladder calculi.

OBJECTIVES: To assess the outcome of men with bladder calculi who did not undergo transurethral resection of the prostate after endoscopic stone removal. Bladder calculi associated with benign prostatic hyperplasia (BPH) have historically been an absolute indication for transurethral resection of the prostate. METHODS: A retrospective analysis of the results of 23 men who underwent endoscopic removal of bladder calculi with subsequent medical management of BPH symptoms was performed. Inclusion criteria included men with bladder stones secondary to BPH, serum creatinine 1.6 mg/dL or less, no evidence of hydronephrosis, and no history of acute urinary retention or neurogenic bladder. The International Prostate Symptom Score and postvoid residual urine volume before and after treatment and the incidence of bladder stone recurrence and associated complications were recorded. All patients were treated with either an alpha-receptor blocker or alpha-receptor blocker and finasteride after bladder stone removal. RESULTS: The follow-up after endoscopic removal of the bladder calculi averaged 30.0 months (range 6 to 96). The International Prostate Symptom Score before and after treatment was 18.3 and 9.4 (P <0.01), respectively. The postvoid residual urine volume before and after treatment was 354 and 179 mL (P <0.01), respectively. Urinary tract infection, acute urinary retention, recurrent calculi, chronic renal insufficiency, or renal failure developed in 21.7% (n = 5), 17.4% (n = 4), 17.4% (n = 4), 4.3% (n = 1), and 0% (n = 0) of the 23 men, respectively. Overall, 18 (78%) did not have any complications. CONCLUSIONS: Many men with bladder stones can be successfully and safely treated with transurethral stone removal and medical management of BPH.