Comparative analysis of blood plasma epidermal growth factor concentrations, hormonal profiles and semen parameters of fertile and infertile males.

The relationship between male reproductive function and the blood plasma level of epidermal growth factor (EGF) is of interest in the light of the role that circulating EGF appears to play in regulating mouse spermatogenesis. We measured the concentrations of EGF in the blood plasma of 39 fertile men (sperm count > 20 x 10(6)/ml) and compared them with those of 31 infertile men (sperm < 20 x 10(6)/ml). Blood plasma levels of follicle stimulating hormone (FSH), luiteinising hormone (LH), prolactin and testosterone were also determined. The infertile patients had mean blood plasma EGF concentrations of 0.75 +/- 0.10 ug/L. The value was significantly lower than that of the fertile group (1.28 +/- 0.14 ug/L; P < 0.005). There were statistically significant differences between the fertile and infertile groups in sperm count, sperm viability, mean forward progression, testosterone, LH and FSH (P values between 0.0001 and 0.023). There was no significant difference in the prolactin concentrations between the two groups. Although overall average blood plasma EGF concentrations are significantly lower in the infertile males, regression analysis failed to reveal any direct relationships among the various parameters studied.

Laparoscopic lymphadenectomy based on magnetic resonance imaging: is a unilateral dissection adequate for staging prostate cancer?

Laparoscopic pelvic lymphadenectomy is a satisfactory alternative to open lymphadenectomy for staging prostate cancer. Specific information obtained by endorectal coil magnetic resonance imaging may be used to predict the most likely side for lymph node metastases. These criteria may be used to define side selection for performing a unilateral laparoscopic lymphadenectomy without the risk of missing contralateral nodes that may be positive. A unilateral dissection when feasible reduces operative time and morbidity.

Solitary late recurrence of renal cell carcinoma presenting as duodenal ulcer.

The natural history of renal cell carcinoma is often unpredictable and even bizarre. We report a case of solitary late recurrence of renal cell carcinoma presenting as a duodenal ulcer and review the relevant literature.

The management of transitional cell carcinoma in solitary renal units.

Ten patients with urothelial malignancies involving a solitary functioning renal unit were treated at our center for an average of 24 months or until death. These patients were all managed by parenchyma-sparing methods, including percutaneous as well as ureteroscopic tumor resection. Of our patients 9 have received adjunctive chemotherapy in the form of bacillus Calmette-Guerin instillations. At the time of this report 5 of our patients were alive without evidence of disease, 4 were alive with evidence of either residual or recurrent neoplasia and 1 was dead of disease 5 years after original presentation. Patients with higher grade tumors or carcinoma in situ did less well than patients with low grade disease. We present an analysis of our experience with this complex patient population and discuss the implications of these data within the context of a growing literature on the topic of upper tract urothelial malignancy.

Effect of lithotripsy on immature rabbit bone and kidney development.

Although extracorporeal shock waves have been used to treat kidney stones for several years, little is known to their effect on developing tissue. In order to determine if lithotripsy has any negative effects on development, immature rabbits were used to study the relationship of extracorporeal shock waves to renal and skeletal growth. Rabbits in both the control and treatment groups had metallic clips placed surgically to demarcate the kidneys. Following unilateral kidney and femoral head treatment of the respective study groups with the Dornier Lithotripter Model HM-3, the rabbits were allowed to grow to maturity (six months). Plain radiographs were taken at three months. There was no significant difference between control and study groups when length of the kidneys or femurs, the diameter of the femoral heads, or the rabbits weights were compared. At six months of age, the rabbits were weighed, then sacrificed. The kidneys and femurs were removed. Comparisons between the control and study groups were then made for weight of the rabbit, weight and volume of the individual kidneys, femoral length, and femoral head diameter. Following these measurements sectioning and histologic examinations were done. In all parameters grossly and histologically, there was no statistically significant difference. It is concluded from this study that treatment with extracorporeal shock waves does not adversely affect overt rabbit renal or bone growth, making treatment of pediatric patients with ESWL appear safe in regard to these parameters. Future studies will be directed at confirming these findings in children.

Prostate surgery.

Benign prostatic hyperplasia is probably the most common neoplasm in man, and carcinoma of the prostate now leads the list of newly diagnosed malignancies in males. Even though there is no known direct etiologic relationship between these disorders, they are by no means mutually exclusive; if a man lives long enough, he is likely to be afflicted by one or both. Although most men will not require surgery, the increasing size of the geriatric population and the frequency of these disorders result in a problem of impressive magnitude from both a medical and a socioeconomic standpoint. Newer diagnostic and therapeutic modalities continue to evolve in this rapidly changing field. In many areas, further investigation is required to determine the true value of certain techniques, such as transrectal ultrasonography for screening or magnetic resonance imaging for staging of prostate cancer. Controversy now exists regarding the relative safety of transurethral and open surgical techniques for benign disease, and further comparisons will need to be made with the newer, less invasive interventional and pharmacologic techniques that are being developed. Will the advances in radical surgery result in improved survival of patients with localized prostate cancer? These and other questions will need to be addressed by the primary care physicians, geriatricians, and urologists who care for these patients.

Radiographic imaging and urologic decision making in the management of renal and ureteral calculi.

Without question, significant changes, and for the most part significant advances, have been made in the management of patients with urolithiasis during the past decade. The newer therapeutic measures have generally made it easier for patients to be treated, but the decision-making process for the urologist has become more complex. In the past, the issue whether to follow a patient with a stone or to intervene with surgery or transurethral cystoscopic basketing was decided based on well-established guidelines that had developed over many years. Today, the indications for intervention appear to be less stringent, and in the minimally symptomatic or asymptomatic patient who would not have been operated on previously, there appears to be an expanding desire for prophylactic management. For whatever reasons, once it has been established that a stone is present and the decision has been made to intervene, subsequent decisions regarding the technical approach may also not be as simple as in the past. Ten years ago, for example, a stone in the abdominal ureter was removed by a ureterolithotomy, and the principal decision involved placement of the incision. Today, the same calculus may be approached by ESWL with or without a stent, by antegrade percutaneous techniques, or by retrograde ureteroscopic techniques using rigid or flexible endoscopes with baskets, ultrasonic lithotrites, or lasers. Although the specific indication for specific techniques continue to evolve, it has become evident that information obtained by the radiographic evaluation of the urinary tract is critical in the decision-making process. The intravenous urogram, including the initial plain film, remains the primary diagnostic modality and, in the absence of extenuating clinical features, is often the sole test required to make a decision regarding the best therapeutic modality. A variety of clinical features from the history or physical examination, or concerns raised by the intravenous urogram, may necessitate alternative or additional techniques to better define the anatomy, the renal function, or other pathology. The urologist therefore needs to be familiar with the information that can be obtained from the uroradiologist's vast armamentarium in order to make the most appropriate recommendations to the patient for diagnosis and management.

Extracorporeal shock wave lithotripsy treatment of calculi in horseshoe kidneys.

From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.

The development of steinstrassen after ESWL: frequency, natural history, and radiologic management.

Stone fragments that develop after extracorporeal shock-wave lithotripsy (ESWL) may lodge within the ureter. This column of fragments is referred to as a "steinstrasse" (plural, steinstrassen). We evaluated the first 1000 patients treated with ESWL at our institution to determine the frequency of steinstrasse formation, the clinical course of patients with steinstrassen, and the types of intervention, if any, required. Steinstrassen were seen in 20% of 1000 patients treated with ESWL. In 65% of the patients studied, the steinstrassen passed spontaneously. Of the remaining patients, all but 3% required treatment for ureteral obstruction. Seventy-five percent were treated urologically (ureteroscopy, ureteral catheterization), but 25% required radiologically directed intervention, either percutaneous nephrostomy or fluoroscopically monitored retrograde ureteral catheter/stent placement. Twenty-seven percent of our patients with persistent steinstrassen had silent obstruction. In view of the insidious manner in which kidney function may be jeopardized by steinstrassen, they should be managed with great circumspection. Radiologists dealing with steinstrassen should be skillful in both antegrade and retrograde methods of urinary tract intervention.

Pseudoureteroceles following extracorporeal shock wave lithotripsy.

Routine follow-up urography demonstrated pseudoureteroceles caused by impacted calculus fragments in the distal portion of the ureter in five patients who had undergone extracorporeal shock wave lithotripsy of renal calculi 4-6 weeks before. Although all five patients showed some degree of obstruction at the time of follow-up urography, four were asymptomatic. Either small isolated fragments (two patients) or a column (steinstrasse) of fragments (three patients) was responsible for the abnormality. Two patients required further intervention to relieve the obstruction.

Drug-induced male sexual dysfunction.

Many commonly used drugs can interfere with male sexual function, either by decreasing libido, interfering with erectile function, or causing absent seminal emission or retrograde ejaculation. Although drug-related effects on sexual function may be difficult to distinguish from the effects of organic disease, anxiety, or depression, it is important for the physician to be aware of the drugs most commonly associated with sexual dysfunction. This article considers these drugs and the potential mechanism by which they exert their adverse effects.

Imipramine-induced erection, masturbation, and ejaculation in male horses.

Imipramine hydrochloride was administered to five male horses (400-500 kg b.wt.): one experienced young stallion, two mature normal breeding stallions, one 5-year-old stallion with erection and ejaculatory dysfunction, and one long-term castrated male horse. Oral imipramine treatment (100 to 600 mg, twice daily) led to frequent erection and masturbation while at rest in the stall in a nonsexual context. Intravenous imipramine treatment over a range of doses (50 to 1000 mg) similarly induced erection and masturbation in all animals. Erection typically occurred within 10 minutes after injection, and the erection and masturbation continued intermittently for 1 to 2 hours. These erections proceeded as during sexual excitement to a normal firmness and eventual engorgement of the glans penis. Two stallions ejaculated while masturbating. Mild ataxia and drowsiness appeared at the higher doses, but the animals remained responsive to auditory, visual, and tactile stimuli. Erection and masturbation were often interrupted by activities about the barn or the approach of the handler, suggesting cortical inhibitory control of the erection. When tested in a sexual context immediately following IV treatment (500 mg), the two mature breeding stallions bred normally. The 5-year-old stallion, which had not ejaculated over several months of breeding attempts, spontaneously ejaculated following IV imipramine treatment. Subsequently, this stallion has ejaculated during copulation while on low dose oral (100 mg. twice daily) imipramine treatment. Plasma total androgens increased during treatment in these stallions. The long-term castrate showed erection and masturbation following IV imipramine treatment, suggesting that the effect of imipramine is not testosterone dependent.

Upper urinary tract calculi: extrusion into perinephric and periureteric tissues during percutaneous management.

While the goal of percutaneous management of renal and ureteral calculi is stone extraction or disintegration, perforation of the renal pelvis or ureter may allow stones or stone fragments to become extruded during endourologic manipulations. The authors have encountered six such patients: two with renal and four with ureteral calculi. Three stones were extruded into the perinephric or periureteric tissues during nephroscopy, two during attempted dislodgement with a balloon catheter, and one during antegrade passage of a ureteral catheter. All patients were managed conservatively by means of nephrostomy drainage and, in the four cases of ureteral laceration, ureteral stenting. Follow-up study, ranging from 12 to 24 months, has documented a benign clinical and radiological course. No ureteral strictures have ensued. In the absence of infected urine, urothelial laceration with calculus extrusion appears to be a benign occurrence and may be managed conservatively.