Laparoscopic pelvic lymph node dissection, laparoscopically assisted seminal vesicle mobilization, and total perineal prostatectomy versus radical retropubic prostatectomy for prostate cancer

OBJECTIVES

The outcomes of patients with prostate cancer who were candidates for radical prostatectomy were compared with patients who underwent either: (1) radical retropubic prostatectomy (RRP); or (2) laparoscopic pelvic lymph node dissection, laparoscopically assisted seminal vesicle mobilization, and total perineal prostatectomy (LN-SV-TPP).

METHODS

The staging, surgical, and early postoperative characteristics of 10 consecutive patients treated by RRP were compared with 12 consecutive patients who underwent LN-SV-TPP.

RESULTS

Patients who underwent LN-SV-TPP versus RRP had respective median blood loss of 450 versus 1250 cc (P = 0.001), median anesthesia time of 330 versus 287.5 minutes (P = 0.05), median surgical time of 237.5 versus 237.5 minutes (P = 0.6), median units transfused of 0 versus 1 (P = 0.05), median time to ambulation of 1 versus 2 days (P = 0.002), median time to oral intake of 1 versus 3.5 days (P < 0.001), median hospital stay of 3 versus 6 days (P < 0.001), and median morphine requirements of 44 versus 119 mg (P < 0.001).

CONCLUSIONS

LN-SV-TPP is less morbid than RRP concerning blood loss, blood transfusions, pain, and postoperative recovery. Compared with LN-SV-TPP, RRP is faster and is particularly indicated for ease of performing a nerve-sparing radical prostatectomy.

Immunohistochemical localization of cathepsin B in neoplastic human prostate

Cathepsin B (CB) has been shown to degrade extracellular matrix (ECM) proteins, and has been reported to be involved in invasion and metastasis of several types of solid organ tumors in human and animals, but CB has not been studied in human prostate cancer (CAP). Our objective was to determine the CB protein immunostaining pattern in CAP and to correlate the immunostaining with the degree of malignancy as reflected in the Gleason grading system. We used two types of CB antibodies (namely, monospecific, polyclonal antibodies to human liver CB prepared in rabbits, and polyclonal antibody produced in sheep) to establish CB localization patterns in neoplastic prostate. Our analysis showed a heterogeneous CB immunostaining pattern in the neoplastic human prostate. CB immunostaining occurred in many, but not all, of the neoplastic columnar/cuboidal cells of acini and isolated cells, i.e., in small ragged glands and clusters (groups) of invasive cells in the prostatic stroma. We have shown that, in general, there was a positive correlation of the intensity of CB immunostaining with the Gleason histologic score (or Gleason grade sum) tumors, i.e., from the lowest scores through score 8, but many of the tumors with scores 9 and 10 showed little CB immunostaining. Our study indicated that the increased CB immunostaining in the Gleason grade sum 5-8 tumors may be associated with increased degradation of ECM, but not in 9 and 10 despite the fact that the latter tumors are more malignant clinically. In well-differentiated tumors, fewer CB immunostaining cells were present than the moderately-differentiated tumors. In other words, most of the stromal invasion of the prostatic ECM occurred in tumors of Gleason grade sums 5-8. We suggest that CB immunostaining might be a useful method to assess stromal invasion of prostatic carcinoma, especially in the higher grade tumors.

Influence of the combination of time of feeding and ration level on the diurnal hormone rhythms in rainbow trout

The study examined the combined effects of time of feeding (post-dawn, midday-pre-dusk) and ration level (1.5%, 2.0%, 2.5%) on the diurnal rhythms of plasma growth hormone (GH), L-thyroxine (T4), triiodo-L-thyronine (T3), cortisol and glucose concentrations in rainbow trout (Oncorhynchus mykiss) maintained under constant ambient water temperature and natural photoperiod.Plasma GH and glucose concentrations exhibited marked diurnal rhythms, with significant postprandial peaks that were phase-shifted with time of feeding. The ration level did not appear to alter these feeding time-entrained rhythms, but the amplitude of the changes (peaks) were more pronounced in trout fed the higher ration levels. Plasma cortisol concentrations showed distinct diurnal rhythms, with peaks during the photophase and the scotophase in all the treatment groups. The time of feeding did not appear to influence these rhythms, and there was no evidence of a postprandial increase in any group.Plasma GH, cortisol and glucose concentrations were significantly higher in groups fed the 2.5% ration compared with animals fed either 1.5 or 2.0% rations.The diurnal rhythms of plasma T4 concentrations were not affected by the time of feeding or ration level; the peak values generally occurred during the photophase in all the treatment groups. Plasma T3 concentrations did not show any significant diurnal patterns, nor were they influenced by ration levels or time of feeding.

Laparoscopic ureteroneocystostomy

The technique of laparoscopic ureteral reimplantation is reported and discussed. This approach represents another surgical procedure that may be performed by the less invasive laparoscopic method.

A comparative study of picomolar affinity 2-[(125)I]iodomelatonin binding sites in the hearts of three salmonid species

The hearts of three cultured salmonid species, collected at either mid-light or mid-dark were studied for their binding to 2-[(125)I]iodomelatonin, a specific melatonin agonist. The binding was saturable, reversible, and highly specific. The equilibrium dissociation constant (Kd) ranged from 30.1 ± 3.0 pmole 1(-1) in Arctic charr (Salvelinus alpinus) to 40.5 ± 2.3 pmole 1(-1) in rainbow trout (Oncorhynchus mykiss) indicating a high binding affinity. The maximum density of binding (Bmax) was at the low femtomolar level of 0.57 to 0.87 fmole mg(-1) protein. Higher Bmax appeared to be demonstrated in the mid-light samples when compared to the mid-dark samples but the difference was not significant (p > 0.05). Competition study with various indoles showed the following order of potency: 2-iodomelatonin > melatonin > 6-chloromelatonin ≫ N-acetylserotonin ⋙ serotonin. Guanosine 5'-O-(3-thiotriphosphate) (GTPγS) strongly inhibited the binding (IC50 = 0.66 μmole 1(-1)) in the rainbow trout heart, suggesting that these binding sites belong to the superfamily of G-protein linked receptors. Our results suggest the presence of melatonin receptors in the fish heart. In addition, there was no marked intraspecies differences in Kd, Bmax and specificity that could be correlated with the phylogeny or life history of the salmonid species.

The effects of cortisol on hepatocyte metabolism in rainbow trout: a study using the steroid analogue RU486

The objective of this study was to examine if RU486, a corticosteroid antagonist, modified hepatocyte metabolism and blocked the metabolic effects of exogenously administered cortisol in rainbow trout (Oncorhynchus mykiss). The fish were given a single intraperitoneal implant of either coconut oil alone or coconut oil containing RU486 (100 mg.kg-1), cortisol (100 mg.kg-1), or a combination of RU486 and cortisol and were sampled 7 days postimplantation. The RU486 implants had no effect on plasma cortisol and glucose concentrations, hepatocyte glycogen content, and total glucose production, but increased in vitro hepatocyte glycogen breakdown. Cortisol implantation had no effect on plasma glucose concentration, hepatocyte glycogen content, glycogen breakdown, or total glucose production, while it significantly increased alanine oxidation and gluconeogenesis in rainbow trout hepatocytes. Hepatocyte responsiveness to epinephrine and glucagon stimulation of total glucose production was not modified by either RU486 or cortisol treatment, whereas the insulin response on total glucose production was decreased with cortisol. RU486 treatment modified hepatocyte glycogen metabolism and blocked the cortisol-induced increases in alanine gluconeogenesis and glycogen mobilization for endogenous use by the hepatocytes. These results indicate that cortisol enhances the metabolic potential of hepatocytes, thereby adapting the fish to cope with stress. This study provides further validation of RU486 as a tool for studying metabolic actions of cortisol in fish.

2-[125I]iodomelatonin binding in the brains of four salmonids

[125I]-Labelled iodomelatonin binding to brain membrane preparations was examined in adults of 4 species of salmonid fishes; 3 species were of cultured stock (Arctic charr, Atlantic salmon, rainbow trout) and 1 was taken from the wild (coho salmon). The specific binding of 2-[125I]iodomelatonin to the brain membrane preparations collected from all 4 species was specific, stable, saturable, reversible and of high affinity. Competitive inhibition studies showed that only melatonin, 2-iodomelatonin, 6-chloromelatonin and N-acetylserotonin showed significant inhibition of radioligand binding. In the 4 species studied, the equilibrium dissociation constant (Kd) ranged from 9.3 +/- 0.2 pmol/l in coho salmon to 13.2 +/- 0.7 pmol/l in rainbow trout, and those in rainbow trout were significantly higher (p < 0.05) than in the others. The maximum number of binding sites (Bmax) of the Atlantic salmon preparations (14.3 +/- 0.7 fmol/mg protein) was significantly higher than those of the other 3 species (means ranging from 9.9 to 11.6 fmol/mg protein). Hill coefficients of all 4 species were close to unity indicating one class of binding site. The interspecies differences in Kd and Bmax could not be correlated with phylogeny or life history of the various species. For the three cultured species, samples were collected at both mid-dark and mid-light to examine for diurnal variations; none were found.

The North American experience with the UroLume endoprosthesis as a treatment for benign prostatic hyperplasia: long-term results. The North American UroLume Study Group

OBJECTIVES

To determine the efficacy and safety of the UroLume endoprosthesis as a treatment for obstructive benign prostatic hyperplasia in healthy men.

METHODS

One hundred twenty-six men were enrolled prospectively in a multicenter North American Clinical Trial. Ninety-five men (mean age 68 +/- 7 years) had moderate or severe prostatism, whereas 31 participants (mean age 76 +/- 8 years) were in urinary retention. Voiding function for all patients was assessed prior to stent placement and in follow-up at 1, 3, 6, 12, and 24 months with the Madsen-Iversen symptom questionnaire, peak urinary flow rate, postvoid residual urine volume, and cystoscopic examination.

RESULTS

For the nonretention cohort at 24-month follow-up, the results were as follows: (1) total symptom score decreased from 14.3 +/- 0.5 preinsertion to 5.4 +/- 0.5 (p < 0.001); (2) peak urinary flow rate increased from 9.1 +/- 0.5 mL/s preinsertion to 13.1 +/- 0.7 mL/s (p < 0.001); and (3) postvoid residual urine volume decreased from 85 +/- 9 mL to 47 +/- 8 mL (p = 0.02). For the retention group, the total symptom score, peak urinary flow rate, and postvoid residual urine volume at 24 months were 4.1 +/- 0.5, 11.4 +/- 1.0 mL/s and 46 +/- 7 mL, respectively. By 12-month follow-up, most endoprostheses were completely covered with urothelium. Although significant long-term complications were minimal, 17 endoprostheses have been explanted for an overall removal rate of 13%. All devices were removed transurethrally without subsequent sequelae to the external urinary sphincter or urethra.

CONCLUSIONS

The long-term results from this North American Clinical Trial suggest that the UroLume endoprosthesis can be an effective and safe treatment for properly selected healthy men with obstructive benign prostatic hyperplasia. Randomized clinical trials comparing this minimally invasive procedure with transurethral resection of the prostate are now underway to document further its efficacy and safety.

Does the time of feeding affect the diurnal rhythms of plasma hormone and glucose concentration and hepatic glycogen content of rainbow trout?

The diurnal rhythms of plasma glucose, cortisol, growth hormone (GH) and thyroid hormone (T4, T3) concentrations and hepatic glycogen content were measured in rainbow trout that had been entrained to a specific time of daily feeding (post-dawn, midday, pre-dusk); the purpose of the study was to investigate the significance of feeding time on hormones and metabolite patterns. Plasma GH, cortisol and T4 concentrations all showed evidence of a diurnal rhythm in some treatment groups. There was a significant interaction between the time of feeding and plasma GH and cortisol concentration rhythms; for GH, this appeared to be related to the phase-shifting of the post-prandial increases in plasma GH concentrations, and for cortisol, the rhythms were only evident in fish fed in the post-dawn period [diurnal rhythms were not evident in treatment groups fed in at midday or pre-dusk]. Peak plasma T4 concentrations were evident during the photophase in all three treatment groups; however, the time of feeding had a negligible effect on the timing of those peaks. There were no apparent diurnal rhythms of plasma T3 and glucose concentrations, hepatic glycogen content or hepatosomatic index in any of the three treatment groups.

Value of transrectal ultrasound in identifying local disease after radical prostatectomy

Transrectal ultrasound was performed on 15 men with clinical suspicion of local disease after radical retropubic prostatectomy. Clinical suspicion was defined as an elevation in serial serum prostate-specific antigen (PSA, above 0.4 ng/mL, Tandem-R + Assay) and/or palpable mass in the rectal vault. Post-radical prostatectomy ultrasound was normal if there was smooth tapering of the bladder neck to the urethra with no foci of variable echogenicity, and suspicious if any hyper- or hypo-echoic foci were present or if a mass was detected. Thirteen of 15 ultrasounds (87%) were described as suspicious while 2 of 15 (13%) were described as normal. Only 6 of 13 patients (46%) with suspicious findings on ultrasound had biopsy-proved carcinoma. Both patients with normal findings on post-radical prostatectomy ultrasound had biopsy-proved cancer. Transrectal ultrasound of the prostatic fossa when used independently is of no value in the diagnosis of local disease after radical prostatectomy. Transrectal ultrasound may help to direct systematic biopsies of the prostatic fossa in those patients in whom local disease is suspected on the basis of elevated serum PSA and/or a mass found on rectal examination.

The risk of exposure to potentially contaminated body fluids in urological surgery

To determine the risk of exposure to body fluids potentially contaminated with infectious organisms we instituted a prospective study of all urological procedures performed at our institution. Urological procedures were divided into 3 categories: open, cystoscopic and endoscopic surgical (transurethral resection of the prostate or bladder tumor, ureteroscopy and percutaneous procedures). We have complete data analysis on 594 consecutive patients who underwent an operation at our institution: 77 (13%) underwent an open procedure, 75 (13%) underwent an endoscopic surgical procedure and the remaining 442 (74%) underwent cystoscopic procedures. All procedures were performed by supervised house staff using universal precautions. The operating surgeon was exposed to potentially contaminated body fluids in 173 of 594 cases overall (29%). There was exposure in 17% of all open procedures, 41% of all endoscopic surgical procedures and 29% of all cystoscopic procedures. Urologists must consider themselves at high risk for exposure to potentially contaminated body fluids and take appropriate precautions.

Intracerebral polyposis. Case report

A 25-year-old man presented with nontraumatic cerebrospinal fluid rhinorrhea and meningitis. On investigation, he was found to have a multiloculated intracerebral cystic lesion of the right frontal lobe with a bony lesion inside the cyst, just above the right cribriform plate. Surgery revealed multiple grape-like cystic pedunculated lesions with narrow stalks attached to a bony outgrowth which was adherent to the right cribriform plate. Macroscopically and microscopically, the excised lesions were similar to nasal polyps.

Use of transrectal ultrasound in follow-up of postradical prostatectomy

The appearance of the prostatic fossa on transrectal ultrasound following radical retropubic prostatectomy (RRP) is described. Transrectal ultrasonography was performed on 25 patients with normal bone scans and pelvic computed tomography from three to ninety months after RRP using a biplane high frequency probe. The area of the vesicourethral anastomosis (VUA) was identified, its contour characterized, surrounding tissues described, and changes induced by pelvic muscle contraction recorded. In 16 of these patients who had abnormal postoperative serum prostate-specific antigen levels, digital and ultrasound-guided transrectal needle biopsies for local recurrence were done and compared. The VUA was identifiable in all patients as either a smoothly tapered narrowing usually correlating with the presence of continence or distorted or blunted profile which often correlated with absence of urinary continence. The VUA was surrounded almost invariably by hypoechoic soft tissue which was pathologically nonspecific on biopsy. An extrinsic impression on the anterior bladder wall was noted in 80 percent. There was no clear distinguishing ultrasound feature for biopsy-proved local recurrence. The apparent length of the apposed walls of the urethra suggests a urethral high pressure zone (UHPZ). This lengthened significantly with voluntary contraction of the pelvic floor muscles.

Transrectal US in evaluation of patients after radical prostatectomy. Part I. Normal postoperative anatomy

The appearance of the prostatic fossa on transrectal ultrasound (TRUS) scans obtained after radical retropubic prostatectomy (RRP) was studied in 25 patients believed to have no tumor on the basis of their level of serum prostate-specific antigen (PSA) (< or = 0.4 ng/mL). The profile of the vesicourethral anastomosis (VUA) in the midsagittal plane was tapered in 13 patients (52%) and nontapered in 12 patients (48%). The nontapered profile was associated with incontinence in nine of 11 patients (82%) followed up for less than 12 months but in only four of 14 patients (28%) followed up beyond 1 year. In 20 patients (80%), a hypoechoic soft-tissue lesion (average volume, 1.7 cm3) was seen anterior to the VUA and indented the anterior bladder wall. The length of the urethral high-pressure zone increased with muscular contraction of the pelvic floor. Knowledge of the baseline anatomic structures depicted on TRUS scans obtained after RRP may be useful in selection of tissue for TRUS-guided needle biopsy in patients with elevated levels of PSA. The many post-surgical changes reduced the specificity of the TRUS findings.

Transrectal US in evaluation of patients after radical prostatectomy. Part II. Transrectal US and biopsy findings in the presence of residual and early recurrent prostatic cancer

The anatomic appearance of the prostatic fossa on transrectal ultrasound (TRUS) scans obtained after radical retropubic prostatectomy (RRP) for carcinoma was studied in 16 patients in whom local recurrence was suspected on the basis of rising serum prostate-specific antigen (PSA) levels above 0.4 ng/mL, negative pelvic computed tomographic scans, and negative bone scans. Findings in samples obtained with ultrasound (US)-guided biopsy were compared with those in samples obtained with digitally guided biopsy (DGB); each patient was his own control. When the postoperative anatomic appearance on TRUS scans was compared with that in patients without suspected recurrence of cancer, no significant difference was seen. Needle biopsy was positive for carcinoma in eight patients (50%): US-guided biopsy, in seven patients; DGB, in five patients; and both US-guided biopsy and DGB, in four patients. US-guided biopsy has limited usefulness over DGB in patients with rising PSA levels after RRP, but use of both DGB and US-guided biopsy may maximize sensitivity. The main value of TRUS may be in accurate positioning of the biopsy needle about the vesicourethral anastomosis.

Early detection of local disease progression from stage A1 prostate carcinoma by transrectal ultrasonography

Fifty-two patients with Stage A1 prostate cancer diagnosed by transurethral resection performed between 1975 and 1989 were re-examined by transrectal ultrasonography and ultrasonographically guided biopsies. Follow-up after the initial diagnosis ranged from 1 to 15 years (mean, 5.8 years). For eight patients, results of digital rectal examination were abnormal. For 44 patients, results were normal or indicated a low probability of cancer. Serum prostate-specific antigen (PSA) levels (4.6 to 14.6 ng/ml) were elevated in ten patients. Ultrasonography showed from one to three hypoechoic areas in 29 patients. Locally progressive disease, defined as moderately to poorly differentiated cancer, was detected in five (10%) patients, three of whom underwent radical prostatectomy. Histopathologic examination of the specimens revealed localized disease (no capsular invasion). The remaining two patients had radiation therapy. In three patients, results of digital rectal examination and the serum PSA level were normal, but focal, well-differentiated cancer, identical to that initially diagnosed, was detected after a follow-up of 5 to 10 years. Because the clinical significance of this finding is unknown, these three patients were not considered to have progressive disease and did not have additional treatment. Our data suggest that transrectal ultrasonography is valuable in early detection of local disease progression and should be used in the follow-up program for patients with Stage A1 prostate cancer.

Role of thyroid hormones in tilapia larvae (Oreochromis mossambicus): I. Effects of the hormones and an antithyroid drug on yolk absorption, growth and development

Treatment of one-day old yolksac larvae of tilapia (Oreochromis mossambicus) by immersion in 0.05 ppm T4 or 0.01 ppm T3 significantly accelerated the differentiation and growth of all the fins, particularly pectoral and tail fins. Both the treatments also significantly accelerated yolk absorption and transition to free-swimming activity in the larvae. The treatments also significantly accelerated the growth of the larvae, with T3 at 0.01 ppm having a greater effect than T4 at 0.05 ppm. The yolk conversion efficiency was found not to be significantly affected by the hormone treatments but the treated larvae exhibited an increased heart beat, suggesting metabolic stimulation by the hormones.On the other hand, yolk absorption and free-swimming activity were significantly delayed in tilapia larvae immersed in 25 ppm solution of an antithyroid drug, phenylthiocarbamide (PTC). PTC also retarded the growth of the larvae. T4 (0.05 and 0.10 ppm) or T3 (0.01 and 0.02 ppm) therapy removed the PTC-inhibition,albeit not completely, suggesting that thyroid hormones are involved in the larval growth and development of tilapia.

Role of thyroid hormones in tilapia larvae (Oreochromis mossambicus): II. Changes in the hormones and 5'-monodeiodinase activity during development

Thyroid hormone profiles and 5'-monodeiodinase activity were determined in tilapia at different stages of early development. The results showed that both T4 and T3 were present in significant amounts in fertilized eggs. There was a steady decrease in both T4 and T3 levels during embryonic development. The levels continued to decline after hatching until around 7 days later when most of the yolk had been absorbed. The T4 level started to rise then, suggesting that the larval thyroid had begun to produce T4 at this time, which coincided with the period of faster growth of the larvae. The T3 level remained fairly constant until around 20 days after which it rose significantly. In vitro determination of 5'-monodeiodinase activity (5'-D activity) in the whole-body homogenates of larvae showed that the enzymatic conversion of T4 to T3 was not detectable in eggs and 3-day-old larvae but detected in 5-day-old and older larvae. There was a gradual increase in the Vmax as development proceeded indicating increasing 5'-D activity during larval development. The Km values did not differ significantly in the different stages of development. These results are discussed in relation to the growth and development of the larvae.

The colonic neobladder

The neobladder is an excellent form of urinary diversion after cystoprostatectomy. Socially and psychologically, the neobladder offers the best form of urinary reconstruction in the male patient. In addition, because of the antireflux ureteral implantation, it is hoped that renal function will be preserved in the long run. Different bowel segments and configurations can be used to construct a neobladder. The colonic (detubularized sigmoid) neobladder described here is an excellent option. It is simple to construct, uncomplicated, and not time consuming. The bowel is expendable, and there are no metabolic or anatomic sequelae of using this bowel segment. In addition, the functional results are excellent, and patient satisfaction is high.