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

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

Neodymium:yttrium-aluminum-garnet laser prostatectomy.

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

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

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

Risk of nodal metastases at laparoscopic pelvic lymphadenectomy using PSA, Gleason score, and clinical stage in men with localized prostate cancer.

Laparoscopic pelvic lymph node dissection (LPLND) is a low-morbidity procedure used to stage prostate cancer accurately prior to definitive local therapy. To better select patients for LPLND, we reviewed the clinical features of 120 patients with clinically localized prostate cancer who underwent LPLND to define significant risk factors for nodal metastases. The age ranged from 43 to 79 years (mean 68). Serum prostate specific antigen (PSA) concentration ranged from 1.3 to 329 ng/mL, Gleason score ranged from 2 to 9, and clinical stage ranged from T1b to T3c. Nodal metastases were discovered in 15 patients (13%). Among men with a Gleason score > or = 7, 21% had nodal metastases (P = 0.004). A serum PSA > 20 ng/mL and clinical stage T1b, T2b, or greater also were statistically significant predictors of lymph node metastases (20% and 19%, respectively). In multivariate analysis, Gleason score significantly predicted nodal metastases when controlling for all other clinical measures. Therefore, LPLND is indicated for any patient with a Gleason score > or = 7, PSA > 20 ng/mL, and advanced clinical T stage, independently or in combination.

Application of immunomagnetic beads in combination with RT-PCR for the detection of circulating prostate cancer cells.

Recently published protocols using Reverse Transcriptase Polymerase Chain reaction (RT-PCR) for prostate specific antigen (PSA) provide a sensitive means for detecting circulating prostate cancer cells. Attempts to use these assays for staging of prostate cancer have produced conflicting results. As a first step towards rectifying these discrepancies, a modified immunobead-RT-PCR assay capable of detecting as few as 10 prostate cancer cells in 8cc of blood was developed. This 10 fold increase in sensitivity was achieved in part by introducing two target cell enrichment steps. As a model system to assess sensitivity of the modified assay, template RNA was extracted from PSA positive human carcinoma cells suspended in human blood and isolated with immunomagnetic beads following incubation with an epithelium specific antibody. After 45 cycles of PCR, product from as few as 10 target cells could be readily detected when displayed on a 2% agarose gel stained with SYBR Green fluorescent dye. The identity of amplified DNA fragments was confirmed by Southern blot hybridization. When applied to blood samples from patients with proven metastatic disease, the immuno-bead RT-PCR assay was successful in detecting circulating PSA positive epithelial cells, suggesting this assay may be useful for assessment of disease progression or recurrence.

Effect of treatment of hyperthyroidism on renal function in cats.

OBJECTIVE: To determine whether increases in BUN and serum creatinine (SCr) concentrations, which have been reported to develop after surgical bilateral thyroidectomy in hyperthyroid cats, also develop after treatment of hyperthyroidism with radioactive iodine and methimazole. DESIGN: Prospective, clinical trial. ANIMALS: 58 hyperthyroid cats. PROCEDURE: Urine specific gravity, SCr, BUN, and serum thyroxine (T4) concentrations were determined before and 30 and 90 days after treatment of hyperthyroidism with radioactive iodine, methimazole, or surgical bilateral thyroidectomy. RESULTS: Mean SCr and BUN concentrations determined 30 and 90 days after treatment were significantly higher than those measured before treatment. Mean SCr, BUN, and T4 concentrations were not different among groups before treatment or 30 and 90 days after treatment. CLINICAL IMPLICATIONS: Reduction of serum T4 concentrations after treatment of hyperthyroidism may result in azotemia in older cats with chronic renal disease. Treating azotemic hyperthyroid cats with methimazole until it can be determined whether correction of the hyperthyroid state will exacerbate the azotemia may be prudent.

Direct retroperitoneoscopic adrenalectomy in the porcine model.

An experimental protocol was developed to determine the safety and feasibility of retroperitoneoscopic adrenalectomy in the porcine model. We describe the technique and our experience with this exciting new endoscopic surgical modality.

Laparoscopic unroofing of symptomatic renal cysts: three distinct surgical approaches.

Although they are rarely associated with complaints, benign renal cysts may be the cause of pain, hypertension, or other problems. Simple aspiration is rarely definitive treatment. We have had good results with three laparoscopic approaches to cyst unroofing: transperitoneal, with reflection of the colon medially or dissection through the mesocolon and direct retroperitoneoscopy. We recommend initial percutaneous aspiration with cytology study both to rule out malignancy and to identify those cysts clearly in need of unroofing.

Laparoscopic unroofing of a renal cyst via a mesocolonic window: a different approach.

We report a case of an elective laparoscopic transperitoneal removal of a large renal cyst by dividing the colonic mesentery without mobilizing the colon to gain access to the kidney. This appears to be a safe and potentially less costly approach compared to the standard flank approach of these simple renal cysts.

Laparoscopic versus subinguinal varicocelectomy: a comparative study.

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

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

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

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

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

Degradation of CD4 following phorbol-induced internalization in human T lymphocytes. Evidence for distinct endocytic routing of CD4 and CD3.

Exposure of T lymphocytes to phorbol esters induces endocytosis of CD4 and the CD3/T-cell receptor complex. We compared the pathway of CD4 internalization to that of CD3 following activation of human T lymphocytes with phorbol 12,13-dibutyrate (PDBu). Both CD3 and CD4 were rapidly internalized in response to PDBu, but only CD3, and not CD4, was recycled to the cell surface after removal of PDBu. In support of a degradative fate for internalized CD4, radioimmuno-precipitation studies revealed that the total amount of cellular CD4 was reduced by greater than 90% after exposure to PDBu for 4 h, whereas total CD3 remained constant. PDBu induced CD4 capping and localization consistent with sequestration in intracellular vesicles, presumably lysosomes, prior to becoming degraded. Lysosomotropic agents, such as NH4Cl, chloroquine, and monensin inhibited CD4 degradation, consistent with a lysosomal fate for CD4. Internalization and degradation of CD4 was blocked by staurosporine, an inhibitor of protein kinase C suggestive of a role for protein kinase C in the endocytic fate of CD4. The results of this study demonstrate that CD3 and CD4 follow distinct endocytic pathways which may be relevant to their having distinct roles in T cell activation and function.

Superficial bladder cancer.

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