Laparoscopic gonadectomy and excision of müllerian remnant in an adult intersex patient

Laparoscopy can assist in the diagnosis and treatment of intersex patients. We report a rare case in which laparoscopic gonadectomy and hysterosalpingectomy were performed in a phenotypically-male intersex patient first diagnosed in adulthood.

Contractile protein expression in bladder smooth muscle is a marker of phenotypic modulation after outlet obstruction in the rabbit model

PURPOSE

We determined changes in contractile protein expression before and after the relief of partial bladder outlet obstruction in the rabbit model and assessed their potential role as predictors of recovery.

MATERIALS AND METHODS

We examined the ratio of the smooth muscle myosin heavy chain isoforms SM2-to-SM1, caldesmon isoform expression and bladder function in obstructed and unobstructed adult rabbit bladders. Cystometry, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis were done to determine changes in bladder function and contractile protein expression.

RESULTS

Overall we observed significant correlation of bladder weight with the SM2-to-SM1 ratio (p <0.05). Regardless of the duration of obstruction (up to 10 weeks) the ratio appeared to stabilize around a value comparable to that in fetal rabbit smooth muscle cells, suggesting a reversal of SM2 and SM1 expression to a level similar to that at the fetal stage. The pattern of h and l-caldesmon isoform expression showed an increase in l-caldesmon expression in obstructed bladders. Except for decreased leak point pressure in the obstructed group we noted no statistically significant urodynamic changes in bladder capacity or compliance.

CONCLUSIONS

There is significant correlation of bladder weight, which is the best known marker of obstruction, with the SM2-to-SM1 ratio. The myosin heavy chain isoform expression ratio appears to be an indicator of phenotypic modulation in bladder smooth muscle before and after the relief of bladder outlet obstruction. Thus, it may be useful as a marker of bladder dysfunction and predictor of functional recovery. Regression to a fetal pattern of protein expression may suggest irreversible damage to smooth muscle cells, possibly limiting recovery.

Alpha-blockade downregulates myosin heavy chain gene expression in human benign prostatic hyperplasia

OBJECTIVES

Smooth muscle (SM), a major component of prostate stroma, plays an important role in the pathogenesis of benign prostatic hyperplasia. In many muscle systems, steroid hormones and alpha(1)-adrenergic neurotransmitters tightly regulate expression of contractile proteins. In this study, SM content and the expression of myosin heavy chain (MHC) in tissues from patients with benign prostatic hyperplasia treated with androgen ablation or alpha-blockade were compared with untreated controls.

METHODS

Prostatic periurethral tissue specimens from patients receiving luteinizing hormone-releasing hormone analogues (n = 12), alpha-blocking agents (n = 12), and no treatment (n = 13) were examined. The samples were analyzed for SM MHC mRNA expression using competitive reverse transcription-polymerase chain reaction. SM content was measured by morphometric analysis of trichrome-stained sections.

RESULTS

Stromal SM constituted 45.4% +/- 8.6%, 48.1% +/- 18.4%, and 45.9% +/- 10.8% of the total tissue in androgen ablated, alpha-blocked, and untreated tissues, respectively. No significant difference was observed among these three groups (P = 0.84, analysis of variance). However, SM MHC mRNA expression was markedly decreased in the alpha-blockade group (0.15 +/- 0.02 attomole/mg tissue) compared with the androgen-ablated (0.58 +/- 0.15 attomole/mg tissue) or control (0.44 +/- 0.10 attomole/mg tissue) groups. The relationship between SM content and expression of SM MHC significantly differed among the groups (P = 0.02, analysis of variance).

CONCLUSIONS

Androgen ablation and alpha-blockade do not appear to alter the histologic characteristics of prostate stroma in men with symptomatic benign prostatic hyperplasia. However, contractile protein gene expression in stromal SM cells is significantly altered after alpha-blockade. These data suggest that, in addition to the simple relaxation of muscle tone, alpha-blocking agents may affect the phenotypic expression of contractile proteins in prostate SM cells.

The mismatch repair gene hMSH2 is mutated in the prostate cancer cell line LNCaP

PURPOSE

Mismatch repair genes are responsible for the coordinated correction of misincorporated nucleotides formed during DNA replication. Inactivating and inherited mutations in the prototypic mismatch repair gene hMSH2 have been described in a cancer predisposition syndrome known as hereditary nonpolyposis colon cancer. Patients with hereditary nonpolyposis colon cancer are at increased risk for colon cancer and extracolonic cancers such as upper tract transitional cell carcinoma but not prostate cancer. We investigated expression of hMSH2 in prostate cancer cell lines using genetic and molecular analysis.

MATERIALS AND METHODS

We used the 3 well described prostate cancer cell lines, DU145, LNCaP and PC3. Western blot analysis with monoclonal antibody to hMSH2 was used to assess expression. Southern blot and polymerase chain reaction of genomic DNA were used to identify genetic alterations in the hMSH2 gene. Single cell cloning, dinucleotide repeats and BAT-26 were used to assess the cell lines for microsatellite instability.

RESULTS

The prostate cancer cell line LNCaP did not express hMSH2 and was found to have a homozygous deletion of hMSH2 exons 9 to 16, resulting in truncation of the protein. While microsatellite analysis did not reveal alterations at the BAT-26 locus, single cell cloning produced several LNCaP subclones with alteration at 1 dinucleotide repeat.

CONCLUSIONS

The well described prostate cancer cell line LNCaP has a mutation in the hMSH2 gene, resulting in loss of expression and possible evidence of microsatellite instability. To our knowledge our finding is the first demonstration of a genetic alteration in hMSH2 in a prostate cancer cell line.

Smooth muscle myosin heavy chains are developmentally regulated in the rabbit bladder

PURPOSE

In smooth muscle (SM), myosin heavy chain (MHC) is expressed predominantly as two isoforms, SM1 and SM2, which are encoded by a single gene and expressed by alternative splicing mechanisms. Although functional differences of these isoforms are unknown, changes in SM1/SM2 ratio have been reported in various pathophysiologic conditions. We analyzed MHC composition of bladder detrusor SM from rabbits of different ages to determine whether SM1 and SM2 isoform expressions are developmentally regulated.

MATERIALS AND METHODS

Rabbit bladders on the -11, -4, 1, 7, 14, 21, and 90th days of life were analyzed for SM MHC isoform expression at protein and mRNA levels. Porous sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), S1 protection assay, and histological analysis were employed.

RESULTS

The predominant MHC isoform in fetal and neonatal bladders was SM1. In the third postnatal week, the SM1/SM2 ratio decreased from 2.3 to 1.0. A stable SM1/SM2 ratio of 0.6 was observed in the adult animal. Although expression of SM1 mRNA was 2.6-fold greater than that of SM2 in the fetus, the relative amount of SM2 mRNA increased rapidly after birth and remained the predominant isoform throughout adult life. Developmental changes in relative amounts of SM1 and SM2 protein in bladder tissues were virtually identical to those of SM1 and SM2 mRNA. SM cell growth and disappearance of primitive mesenchyme from the bladder occurred concomitantly with the MHC isoform shift.

CONCLUSIONS

The parallel temporal course of MHC mRNA and protein isoform levels suggests detrusor SM MHC expression may be developmentally regulated at the mRNA level.

Myosin heavy chain gene expression in normal and hyperplastic human prostate tissue

BACKGROUND

Benign prostatic hyperplasia (BPH) is common among aging men. Over 80% of males 50-60 years and older have various degrees of bladder outlet obstruction secondary to BPH. Despite the tremendous medical impact of BPH, its molecular pathophysiology remains unclear. Current BPH research focuses on steroid hormonal effects, stromal-epithelial cell interaction, and oncogenes and growth factors. But little is known about the potential prostatic smooth muscle (SM) alterations that may occur during stromal hyperplasia.

METHODS

To study SM phenotypic modulation in hyperplastic prostatic growth, we isolated and characterized the 3' end of human SM myosin heavy chain (SMMHC) cDNA as a molecular probe. Expression of SMMHC and nonmuscle myosin heavy chain (NMMHC) in human prostates was analyzed using Western blot, Northern blot, and in situ hybridization to determine if BPH tissue expresses significantly less SMMHC and more NMMHC than a normal prostate. In addition, a competitive, reverse transcription (RT) polymerase chain reaction (PCR) method was adapted to quantify SMMHC and NMMHC mRNA expression at the sensitivity level of 10(-21) mole per mg of wet tissue.

RESULTS

Western blot, Northern blot, and in situ hybridization results reveal that both SMMHC and NMMHC are expressed in the human prostate, while SMMHC is the predominant form found in normal prostate stroma. Results from competitive RT-PCR analysis indicate that NMMHC mRNA expression is approximately 10(-20) mole/mg of tissue. The SMMHC mRNA expressed is approximately 10(-18) mole/mg. No significant difference was found when NMMHC mRNA expression was compared between normal and BPH periurethral tissues. However, SMMHC expression was reduced almost fivefold in BPH compared to normal prostate, despite an increase in prostatic stromal mass.

CONCLUSIONS

Our results suggest the pathogenesis of BPH is associated with a unique type of SM proliferation. Such proliferation is characterized by downregulation of SMMHC mRNA expression but without upregulation of NMMHC mRNA expression, the pattern seen in proliferating SM cells in culture and in other pathologic forms of SM hyperplasia (e.g., atherosclerosis). These findings support a model of BPH typified by active smooth muscle proliferation early in the disease process, and supports clinical observations that suggest ongoing prostate growth of the prostate is minimal in older men. Therapeutic strategies to prevent disease progression should therefore focus on early phases of prostatic growth.

Expression of the human mismatch repair gene hMSH2: a potential marker for urothelial malignancy

BACKGROUND

The human mismatch repair (MMR) gene hMSH2 (human mutS homolog-2) is a DNA repair gene that has been reported to be mutated in 40% of hereditary nonpolyposis colon cancer (HNPCC) kindreds and a small percentage of sporadic tumors. HNPCC is a cancer predisposition syndrome with an increased risk of carcinoma of the colon, endometrium, stomach, small intestine, ovary, ureter, and renal pelvis. Immunohistochemical analysis demonstrated increased hMSH2 expression in sporadic colon carcinoma and in the replicative compartment of normal epithelium. A recent immunohistochemical analysis of hMSH2 in bladder tumors correlated reduced hMSH2 expression with recurrence and higher tumor grade. In the current study, we examined hMSH2 expression in urothelial malignancy using immunohistochemical analysis and developed a molecular assay for the detection of hMSH2 expression in bladder washes.

METHODS

Immunohistochemical analysis of 17 tumors from the genitourinary tract and reverse transcription coupled with polymerase chain reaction (RT-PCR) of 40 bladder washes were used to investigate hMSH2 expression in noninvasive and invasive urothelial malignancies.

RESULTS

Increased expression of hMSH2 was detected in all tumors examined using immunohistochemical analysis independent of grade or stage. Reverse transcription-PCR of hMSH2 mRNA from bladder washes detected 17 of 21 patients with primary or recurrent urothelial neoplasms or tumors involving the urothelial system. Four patients with urothelial malignancies without detectable hMSH2 expression from their bladder washes had high grade lesions. Ten of 13 patients without pathologic or cystoscopic evidence of bladder tumors were negative for hMSH2 expression in bladder washes. Two patients with bladder tumors and bladder washes that were positive for hMSH2 subsequently were found to be negative for hMSH2 after treatment of their tumors and at last follow-up had remained recurrence free for at least 1 year.

CONCLUSIONS

The results of the current study suggest that hMSH2 expression is increased in low and high grade urothelial neoplasms, similar to the expression pattern in sporadic colon carcinoma. However, a fraction of high grade lesions may not express hMSH2 as detected by RT-PCR from bladder washes. The ability to detect hMSH2 expression in bladder washes may allow the use of hMSH2 expression as a marker for urothelial malignancy. In addition, the ability to define hMSH2 deficient tumors using bladder washes may have prognostic significance in the treatment of patients with urothelial carcinoma.

Expression of the human mismatch repair gene hMSH2: a potential marker for urothelial malignancy

BACKGROUND

The human mismatch repair (MMR) gene hMSH2 (human mutS homolog-2) is a DNA repair gene that has been reported to be mutated in 40% of hereditary nonpolyposis colon cancer (HNPCC) kindreds and a small percentage of sporadic tumors. HNPCC is a cancer predisposition syndrome with an increased risk of carcinoma of the colon, endometrium, stomach, small intestine, ovary, ureter, and renal pelvis. Immunohistochemical analysis demonstrated increased hMSH2 expression in sporadic colon carcinoma and in the replicative compartment of normal epithelium. A recent immunohistochemical analysis of hMSH2 in bladder tumors correlated reduced hMSH2 expression with recurrence and higher tumor grade. In the current study, we examined hMSH2 expression in urothelial malignancy using immunohistochemical analysis and developed a molecular assay for the detection of hMSH2 expression in bladder washes.

METHODS

Immunohistochemical analysis of 17 tumors from the genitourinary tract and reverse transcription coupled with polymerase chain reaction (RT-PCR) of 40 bladder washes were used to investigate hMSH2 expression in noninvasive and invasive urothelial malignancies.

RESULTS

Increased expression of hMSH2 was detected in all tumors examined using immunohistochemical analysis independent of grade or stage. Reverse transcription-PCR of hMSH2 mRNA from bladder washes detected 17 of 21 patients with primary or recurrent urothelial neoplasms or tumors involving the urothelial system. Four patients with urothelial malignancies without detectable hMSH2 expression from their bladder washes had high grade lesions. Ten of 13 patients without pathologic or cystoscopic evidence of bladder tumors were negative for hMSH2 expression in bladder washes. Two patients with bladder tumors and bladder washes that were positive for hMSH2 subsequently were found to be negative for hMSH2 after treatment of their tumors and at last follow-up had remained recurrence free for at least 1 year.

CONCLUSIONS

The results of the current study suggest that hMSH2 expression is increased in low and high grade urothelial neoplasms, similar to the expression pattern in sporadic colon carcinoma. However, a fraction of high grade lesions may not express hMSH2 as detected by RT-PCR from bladder washes. The ability to detect hMSH2 expression in bladder washes may allow the use of hMSH2 expression as a marker for urothelial malignancy. In addition, the ability to define hMSH2 deficient tumors using bladder washes may have prognostic significance in the treatment of patients with urothelial carcinoma.

Elastin gene expression in benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is mainly a stromal process, showing an increased ratio of stromal to epithelial elements, a collagen type III downregulation, and a collagen types I and IV upregulation. Little is known about elastin gene expression in BPH tissues due to difficulties related to extensive alternative splicing of the elastin gene. Therefore, we analyzed and quantified elastin gene expression in BPH.

METHODS

A competitive reverse transcriptase-polymerase chain reaction (competitive RT-PCR) quantitative technique was used, and a quantitative elastin mRNA analysis with normal (n = 10) and BPH (n = 12) tissues was performed with two newly designed elastin primers. Small tissue samples (4-8 mg) were homogenized and sonicated, and cDNA was synthesized from mRNA using a RT reaction. Various target (wild-type) elastin cDNAs with unknown concentrations were competitively coamplified with known serial dilutions of the control mutant template, differing from the target cDNA by a short deletion. Gel fractions and computerized densitometry, were performed and cDNA concentration was calculated by linear regression.

RESULTS

The primers identified in our study (BOB-1 and BOB-2) accurately amplified a consistent length of the elastin cDNA, avoiding areas of alternative splicing. The average elastin mRNA concentration in BPH tissues was 53 attomole/mg +/- 11.6 vs. 140.6 attomole/mg +/- 19.6 in normal prostatic tissue (P = 0.019). The variation within every sample was less than 10%.

CONCLUSIONS

Our observations suggest a significant downregulation (70%) of the elastin mRNA gene in the transition zone of BPH patients.

Physiologic sequelae of partial infravesical obstruction in the mouse: role of inducible nitric oxide synthase

PURPOSE

To develop a mouse model for partial infravesical obstruction, and determine the resultant changes in bladder function, with particular emphasis on the role of inducible nitric oxide synthase (iNOS) in the bladder response.

MATERIALS AND METHODS

Wild type mice were subjected to no intervention, sham operation, and varying durations of partial outlet obstruction (1, 3, and 5 weeks). They then underwent cystometric evaluation, bladder strip stimulation studies using carbachol, and relaxation studies using l-arginine, sodium nitroprusside, and 8-bromoguanosine 3'-5' cyclic guanosine monophosphate. Bladder tissue was subjected to RT-PCR and Western analysis for iNOS. Bladders were also studied histologically using morphometric analysis.

RESULTS

Bladders from mice obstructed for 5 weeks were heavier (weight increased by 110%), larger (capacity increased by 73%), and had a higher frequency of abnormal appearing cystometric curves than normal bladders. Tissue bath studies demonstrated decreased contractility in response to cholinergic stimulation at 5 weeks of obstruction (decreased by 55% at maximal stimulation). RT-PCR demonstrated iNOS in approximately 70% of bladders obstructed for 1 and 3 weeks, while the iNOS protein was apparent in 50% of the bladders from the same groups.

CONCLUSIONS

This new animal model of infravesical obstruction is reliable and reproducible. Moreover, the physiologic changes noted are comparable to other models, but an added advantage is the relevance of this model with regard to studying new transgenic or knockout mice. Enhanced expression of iNOS seen early after obstruction may serve to improve oxygenation during obstruction-induced ischemia.

Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia. PLESS Study Group

OBJECTIVES

Prostate-specific antigen (PSA) is produced exclusively in the prostate gland and is currently the most useful clinical marker for the detection of prostate cancer. In this report, we examine whether serum PSA is also a predictor of important benign prostatic hyperplasia (BPH)-related outcomes, acute urinary retention (AUR), and the need for BPH-related surgery.

METHODS

Three thousand forty men were treated with either placebo or finasteride in a double-blind, randomized study of 4-year duration. Serum PSA was measured at baseline, and baseline prostate volume was measured in a 10% subset of 312 men. Probabilities and cumulative incidences of AUR and BPH-related surgery, as well as reduction in risk of events with finasteride, were calculated for the entire patient population, stratified by treatment assignment, baseline serum PSA, and prostate volume.

RESULTS

The risk of either needing BPH-related surgery or developing AUR ranged from 8.9% to 22.0% during the 4 years in placebo-treated patients stratified by increasing prostate volume and from 7.8% to 19.9% when stratified by increasing serum PSA. In comparison with symptom scores, flow rates, and residual urine volume, receiver operating characteristic curve analyses showed that serum PSA and prostate volume were the most powerful predictors of spontaneous AUR in placebo-treated patients (area under the curve 0.70 and 0.81, respectively). Finasteride treatment reduced the relative risk of needing surgery or developing AUR by 50% to 74% and by 43% to 60% when stratified by increasing prostate volume and serum PSA, respectively.

CONCLUSIONS

Serum PSA and prostate volume are powerful predictors of the risk of AUR and the need for BPH-related surgery in men with BPH. Knowledge of baseline serum PSA and/or prostate volume are useful tools to aid physicians and decision makers in predicting the risk of BPH-related outcomes and choosing therapy for BPH.

Decreased elastin gene expression in noncompliant human bladder tissue: a competitive reverse transcriptase-polymerase chain reaction analysis

PURPOSE

In low capacity noncompliant fibrotic bladders, as seen in patients with myelomeningocele, elevated storage pressures ultimately can lead to renal damage. Earlier studies have described an increased deposition of extracellular matrix protein, especially type III collagen, in the detrusor muscle. We analyzed elastin gene expression and quantified elastin gene alteration in the obstructed bladder, correlating urodynamically measured compliance with elastin messenger ribonucleic acid (mRNA) concentration.

MATERIALS AND METHODS

Using a reverse transcriptase-polymerase chain reaction quantitative technique elastin mRNA can be reliably measured in 5 to 8 mg. samples of bladder tissue. We compared tissue samples from patients with urodynamically demonstrated noncompliant bladders (less than 10 cc/cm. water) to a control group with normal bladder compliance (greater than 20 cc/cm. water). Tissue samples were homogenized and sonicated, and complementary deoxyribonucleic acid (cDNA) was synthetized from mRNA using reverse transcriptase. Wild type and mutant elastin cDNA were synthetized, and target elastin cDNA with unknown concentration was competitively co-amplified with known serial dilutions of the mutant template (competitive polymerase chain reaction). Computerized densitometry allowing cDNA concentration measurement was performed and competitive reverse transcriptase-polymerase chain reaction was repeated at least twice for every sample.

RESULTS

Elastin mRNA concentration ranged from 27.6 to 63.2 attomole per mg. in noncompliant bladders compared to 62 to 190 attomole per mg. in controls. The variation within the same sample was less than 10%. There was a statistically significant difference between mean plus or minus standard deviation elastin cDNA concentration in noncompliant bladders (37.48 attomole per mg. +/- 12.06) and controls (119.63+/-41.01 attomole per mg.).

CONCLUSIONS

A significant decrease in elastin mRNA matches the decreased deposition of elastic fibers noted in previous immunohistochemical studies. Our data suggest that this decrease is mainly due to a transcriptional down regulation of the elastin gene in noncompliant bladders.

The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group

BACKGROUND

Finasteride is known to improve urinary symptoms in men with benign prostatic hyperplasia, but the extent to which the benefit is sustained and whether finasteride reduces the incidence of related events, including the need for surgery and the development of acute urinary retention, is not known.

METHODS

In this double-blind, randomized, placebo-controlled trial, we studied 3040 men with moderate-to-severe urinary symptoms and enlarged prostate glands who were treated daily with 5 mg of finasteride or placebo for four years. Symptom scores (on a scale of 1 to 34), urinary flow rates, and the occurrence of outcome events were assessed every four months in 3016 men. Prostate volume was measured in a subgroup of the men. Complete data on outcomes were available for 2760 men.

RESULTS

During the four-year study period, 152 of the 1503 men in the placebo group (10 percent) and 69 of the 1513 men in the finasteride group (5 percent) underwent surgery for benign prostatic hyperplasia (reduction in risk with finasteride, 55 percent; 95 percent confidence interval, 41 to 65 percent). Acute urinary retention developed in 99 men (7 percent) in the placebo group and 42 men (3 percent) in the finasteride group (reduction in risk with finasteride, 57 percent; 95 percent confidence interval, 40 to 69 percent). Among the men who completed the study, the mean decreases in the symptom score were 3.3 in the finasteride group and 1.3 in the placebo group (P<0.001). Treatment with finasteride also significantly improved urinary flow rates and reduced prostate volume (P<0.001).

CONCLUSIONS

Among men with symptoms of urinary obstruction and prostatic enlargement, treatment with finasteride for four years reduces symptoms and prostate volume, increases the urinary flow rate, and reduces the risk of surgery and acute urinary retention.

Comparison of three assays for total serum prostate-specific antigen and percentage of free prostate-specific antigen in predicting prostate histology

OBJECTIVES

To determine the statistical performance of three different assays for prostate specific antigen (PSA) and the percentage of free PSA with respect to the differentiation of histologic benign prostatic hyperplasia (BPH) and prostate cancer in men who underwent surgical removal of prostate tissue.

METHODS

Serum of 86 men scheduled for prostate surgery (transurethral resection of the prostate [TURP], simple open prostatectomy, radical prostatectomy, cystoprostatectomy) was frozen and subjected to measurement in batches using three different assays for total PSA (Hybritech Tandem-E, Abbott IMx, Tosoh AIA-600) and free PSA by the Hybritech method after a single freeze-thaw cycle. The histologic diagnosis of the removed tissue (35 BPH and 51 cancer) was used as a "gold standard" for classification of disease status. Sensitivity, specificity, positive and negative predictive values, and diagnostic efficiency were calculated for the three total PSA assays and the free/total PSA ratios for the entire cohort and subsets. Receiver-operating characteristic (ROC) curve analysis was used to compare the performance of the assays and ratios.

RESULTS

Mean and median total PSA values differed slightly between the three assays for all patients, and for those with BPH and cancer, but this difference was not significant. Because of a considerable overlap, the differences between the mean PSA values for men with BPH and prostate cancer were not significant. At a cutpoint of 4.0 ng/mL, sensitivity with respect to the differentiation between BPH and prostate cancer was 68.6% for all three total PSA assays; the respective AUCs (0.613-0.625) were not significantly different. While the performance of the free/total PSA ratios was superior, the differences were only significant when subsets of patients were considered with a total PSA between 4 and 10 ng/mL or 4 and 15 ng/mL (AUCs 0.789-0.816). Likewise, sensitivity, specificity, and diagnostic efficiency was better in these subsets of patients.

CONCLUSIONS

In this study in which a "gold standard" based on histologic analysis of the entire (or large part of) the prostate gland was used to classify disease status, the three assays for total serum PSA (Hybritech Tandem-E, Abbott IMx, and Tosoh AIA-600) performed very similarly with identical sensitivities (at a cutpoint of 4.0 ng/mL) and comparable AUCs with respect to the differentiation of men with histologic BPH and prostate cancer. The ratios of free/total PSA calculated as free PSA by the Hybritech manual immunoradiometric assay (IRMA) method over all three total PSA assays, performed marginally better in the entire patient population. However, in the subsets of patients with a PSA of 4-10 ng/mL and 4-15 ng/mL, all three ratios performed significantly better than the three total PSA assays. The proper choice of a cutpoint for the ratio (15%, 17%, 19%, or 21%) depends on the desirability of maximizing either sensitivity or specificity while optimizing diagnostic efficiency.

Smooth-muscle myosin heavy-chain isoform expression in bladder-outlet obstruction

Bladder-outlet obstruction leads to detrusor smooth-muscle hypertrophy/hyperplasia. Despite this overall increase in muscle mass, smooth-muscle contractility decreases and bladder emptying is impaired. The goal of this study was to determine whether smooth-muscle myosin heavy-chain (MHC) alterations occur in conjunction with partial obstruction of the rabbit bladder. Total MHC and MHC-isoform protein concentrations were determined by quantitative gel electrophoresis in rabbit bladders partially obstructed for 1-4 weeks. MHC gene expression was assessed by Northern and nuclease protection assays. Two MHC isoforms (SM1/SM2) were identified in the normal rabbit bladder. After 2 weeks of obstruction the ratio of SM1/SM2 changed from 0.4:0.6 to 0.5:0.5 (P < 0.01). As compared with sham-operated values, the level of MHC mRNA decreased significantly as of 1 day after obstruction. Quantitation of MHC-isoform mRNA levels revealed a nearly 3-fold increase in the SM1/SM2 ratio. In this animal model of bladder-outlet obstruction, early changes in MHC isoforms as well as an overall decrease of MHC mRNA expression were demonstrated, suggesting that obstruction induces significant alterations in myofilament gene expression.

Is screening for prostate cancer necessary in men with symptoms of benign prostatic hyperplasia?

In this report, we review the critical issues concerning the early detection of prostate cancer in patients presenting with symptoms of benign prostatic hyperplasia (BPH). Only with the recent introduction of serum prostate-specific antigen (PSA) testing and transrectal ultrasonography (TRUS)-guided biopsy has the question arisen to what extent the treating physician has a responsibility to rule out prostate cancer before recommending treatment-or watchful waiting-for men with clinical BPH. Uneasiness and uncertainty also result from the development of alternative therapies that do not provide tissue for pathological analysis, or alter serum PSA levels in a poorly predictable fashion. Current early detection strategies, in this clinical situation, pose unique problems, largely because of the great degree of overlap in serum PSA among men with localized prostate cancer and BPH. The underlying goal is to distinguish patients with BPH alone from those with clinically significant, but organ-confined and potentially curable prostate cancer. Treatment for prostate cancer may take precedence over BPH management strategies, while at the same time address the symptoms associated with coexistent clinical BPH. The issues discussed in this report should aid the clinician in the evaluation of patients with clinical BPH. Further studies are clearly needed that may ultimately enhance our ability to discriminate patients with clinically significant organ-confined prostate tumors from those with BPH alone.

Smooth-muscle physiology

In the last several years, significant advances have been made in the understanding of bladder smooth muscle physiology. This article provides a summary for the clinician of current knowledge about the detrusor smooth muscle cell structure, function, and the relationship of structure to function in terms of bladder storage and physical properties such as compliance. The integration of this basic science knowledge into clinical practice is illustrated in discussion of two common disorders: detrusor instability, and outflow obstruction.

Increased expression of early growth response-1 messenger ribonucleic acid in prostatic adenocarcinoma

PURPOSE

We isolated genes whose expression differs between normal and malignant prostate.

MATERIALS AND METHODS

Differential display polymerase chain reactions revealed a messenger ribonucleic acid (mRNA) with higher expression in prostatic adenocarcinoma versus age matched normal tissue. Deoxyribonucleic acid sequencing identified this mRNA as the product of the early growth response-1 gene.

RESULTS

Early growth response-1 mRNA levels were elevated in 12 of 12 intraprostatic adenocarcinomas but not in breast or ovarian cancers, or in rapidly dividing rat ventral prostate cells. Early growth response-1 mRNA was detected in epithelial and stromal cells at tumor margins but not in lymph node metastases.

CONCLUSIONS

Early growth response-1, a nuclear transcription factor, is implicated in the growth and invasion of intraprostatic cancers.

The effect of zanoterone, a steroidal androgen receptor antagonist, in men with benign prostatic hyperplasia. The Zanoterone Study Group

PURPOSE

Zanoterone (100 to 800 mg.) versus placebo was studied in 463 patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

Study end points were maximum urinary flow rate, American Urological Association symptom index, prostate volume, prostate specific antigen and sex steroid concentrations after 6 months of treatment.

RESULTS

Mean increases in maximum urinary flow rate were 2 to 3-fold over placebo, although only the 200 mg. group had significant results (1.7 ml. per second, p = 0.026). There were no statistically significant differences between the zanoterone and placebo groups in symptom index or prostate volume. Estradiol and testosterone concentrations, and the incidence of breast pain and gynecomastia increased significantly with zanoterone compared with placebo. Prostate specific antigen levels decreased significantly.

CONCLUSION

Zanoterone did not demonstrate a favorable risk-to-benefit profile for the treatment of benign prostatic hyperplasia.

The outcome of suprapubic prostatectomy: a contemporary series in the developing world

OBJECTIVES

To assess the appropriateness of the technique of suprapubic prostatectomy using a removable bladder neck partition suture for use in a developing world hospital and to provide contemporary open prostatectomy outcome data currently lacking in the world's literature.

METHODS

From 1984 to 1994, 240 consecutive patients presenting to a developing world hospital with acute urinary retention underwent suprapubic prostatectomy using a removable bladder neck partition suture. The average length of time from bladder decompression until operation was 2.5 months. The outcome of these cases was retrospectively analyzed.

RESULTS

The overall early complication rate was 19.6%. There were no deaths. The transfusion rate was 4.6%. Clot retention occurred in 6.7%, and 2.9% required return to the operating room for evaluation. For the second half of the series, the early complication rate decreased to 8.3%, the clot retention rate to 0.8%, and the transfusion rate to 1.7%. Other early and late complications were minimal. The length of delay from decompression until operation did not affect outcome.

CONCLUSIONS

The technique of suprapubic prostatectomy using a removable bladder neck partition suture is appropriate for use in developing world hospitals because of its low morbidity and mortality rates. The outcome in this contemporary series of open prostatectomy cases compares favorably with the outcome from reported contemporary transurethral resection of the prostate (TURP) series. These data demonstrate that suprapubic prostatectomy is an acceptable option when the patient's anatomy or the state of local medical facilities precludes TURP.

Benign prostatic hyperplasia. Hormonal treatment

Androgen withdrawal therapy appears to produce a 20% to 30% decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy. Longer periods of treatment do not result in further prostatic regression, but further growth of the gland is not apparent in men treated with finasteride for 4 years. Although biopsy studies indicate that epithelial regression occurs to a much more significant degree than stromal regression, this may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uroflow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on hormonal therapy, as opposed to surgery, where relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of androgen withdrawal therapy. Most importantly, partial involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does following surgery. Incomplete blockade of androgen action, as well as compliance issues, may also limit efficacy. Long-term studies validate a modest but significant clinical response rate of finasteride therapy with preservation of sexual function in most men. Of the available hormonal therapeutic agents, only finasteride appears to have an acceptable risk-benefit ratio. Other 5 alpha-reductase inhibitors in the "pipeline," such as episteride, may have similar benefits. In the long term, this class of drugs may have a much larger role in patients who present with the early signs of BPH, to prevent any further progression of the disease. Presently, no form of antiandrogen therapy is as effective as transurethral resection of the prostate in relieving symptomatology. Because of patient preferences, however, medical therapy will play an increasingly important role in the management of patients with BPH.

Molecular aspects of bladder outlet obstruction

In an animal model of obstruction, increasing load induces significant smooth muscle hypertrophy which is associated with a down-regulation of myosin heavy chain expression. This undoubtedly contributes to the decreased smooth muscle contractility seen in this model. Moreover, obstruction-induced hypertrophy leads to the development of a dedifferentiated smooth muscle phenotype, as evidenced by a revision of the cell to fetal (of non-muscle) gene expression patterns. Similar alterations are seen in atherosclerotic vessels and other pathologic smooth muscle systems. In these systems, dedifferentiation is also associated with significant alterations in extracellular matrix expression. It seems likely that obstruction in the bladder induces dedifferentiation of the smooth muscle cell which alters contractility as well as extracellular matrix expression, leading to altered bladder performance and decreased compliance.

Cell type specific expression of steroid 5 alpha-reductase 2

Isozymes of steroid 5 alpha-reductase (5 alpha-reductase) have crucial roles in androgen physiology by synthesizing the potent hormone dihydrotestosterone. The expression pattern of the 5 alpha-reductase type 2 isozyme was determined in genital and extragenital tissues by developing an immunohistochemical assay using formalin-fixed tissue and affinity purified polyclonal antibodies that specifically recognize this isozyme. Expression was detected in basal epithelial and stromal cells of the normal prostate but not in luminal epithelial cells. Stromal cells of the seminal vesicle also expressed the type 2 isozyme. In contrast, staining was detected in epithelial cells of the epididymis but not in the surrounding stroma. Myofibroblasts in foreskin samples of normal and hypospadiac individuals expressed antigen and were distributed in bands throughout the prepuce, suggesting a clonal origin. In most cells the type 2 isozyme exhibited a perinuclear subcellular distribution. However, in liver hepatocytes the protein was distributed throughout the intracellular membrane compartment.

Expression and regulation of steroid 5 alpha-reductase 2 in prostate disease

The androgen dihydrotestosterone is synthesized by the enzyme steroid 5 alpha-reductase, and it is required for growth and development of the prostate. We used immunohistochemistry to examine the expression of the type 2 isozyme of 5 alpha-reductase in benign prostatic hyperplasia and prostate cancer. The type 2 isozyme is highly expressed within stromal cells in both disease states. No type 2 isozyme is detectable in a lymph node metastasis. Immunoblotting studies show that androgen ablation therapies substantially decrease isozyme expression in the epididymis but have a lesser effect on expression in the prostate. Finasteride therapy (2 weeks to 3 years) did not abolish expression of the prostatic type 2 isozyme nor did this drug treatment induce expression of the type 1 isozyme.

Analysis of factors contributing to success or failure of 1-stage urethroplasty for urethral stricture disease

We reviewed charts with adequate documentation and followup (mean 24.6 months) between 1970 and 1987 of 110 patients who had undergone 1-stage urethroplasty for urethral stricture disease at our institutions. Two age peaks were observed, 1 in the younger population (21 to 30 years old) with traumatic strictures (50% of all strictures) and 1 in elderly men (61 to 70 years old) with mainly post-inflammatory strictures (28.2% of all strictures). The majority of all strictures (63.6%) were in the bulbous urethra. Only strictures induced by trauma were located in the membranous urethra (total 28.2%). A patch graft repair was used in 49.1% of all cases, an end-to-end technique in 29.1% and a transpubic repair in 21.8%. Overall, a 57% rate of excellent results was observed with 24% failures. The results were best for patch graft repairs (65% excellent), followed by end-to-end repairs (56% excellent) and transpubic repairs (42% excellent). The choice of the surgical approach in urethral stricture surgery is dictated by the location of the stricture. The location in turn is dependent on the etiology of the stricture. Consequently, the cause of the stricture affects the location and character of the stricture and, therefore, has an immediate impact on the choice of the surgical approach and, thus, the outcome of the patient. The failure rate doubled overall when the patients had a previous manipulation for the stricture disease or if the urine was infected preoperatively despite antibiotic coverage. While our patient population may not be representative for other institutions, some general conclusions regarding proper management and treatment selection can be drawn from our experience.

Benign prostatic hyperplasia: diagnosis and treatment. Agency for Health Care Policy and Research

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline of Benign Prostatic Hyperplasia: Diagnosis and Treatment. The Benign Prostatic Hyperplasia Guideline Panel, a private-sector panel of health care providers, developed the guideline after comprehensively analyzing the research literature. As a result, this guideline comprises the most current scientific knowledge of the development, diagnosis, and treatment of benign prostatic hyperplasia (BPH). The guideline makes specific recommendations to identify both the most effective methods for diagnosing BPH and the most appropriate treatments for BPH based on patient preference and clinical need. BPH affects quality of life and is very rarely a life-threatening disease. Motivation to seek active treatment will, for most patients, depend on how much their symptoms bother them. Many patients choose a regimen of "watchful waiting." The guideline details the relative benefits and harms associated with all diagnostic and treatment approaches. Treatment options discussed include watchful waiting, alpha blocker and finasteride medications, balloon dilation, and the surgical options of transurethral incision, transurethral resection, and open prostatectomy.

Tissue distribution and ontogeny of steroid 5 alpha-reductase isozyme expression

The synthesis of dihydrotestosterone is catalyzed by steroid 5 alpha-reductase isozymes, designated types 1 and 2. Mutation of type 2 results in male pseudohermaphroditism, in which the external genitalia are phenotypically female at birth. Two striking and unexplained features of this disorder are that external genitalia of affected males undergo virilization during puberty and that these individuals have less temporal hair regression. The tissue-specific and developmental expression patterns of the 5 alpha-reductase isozymes were investigated by immunoblotting. The type 1 isozyme is not detectable in the fetus, is transiently expressed in newborn skin and scalp, and permanently expressed in skin from the time of puberty. There was no qualitative difference in 5 alpha-reductase type 1 expression between adult balding vs. nonbalding scalp. The type 2 isozyme is transiently expressed in skin and scalp of newborns. Type 2 is the predominant isozyme detectable in fetal genital skin, male accessory sex glands, and in the prostate, including benign prostatic hyperplasia and prostate adenocarcinoma tissues. Both isozymes are expressed in the liver, but only after birth. These results are consistent with 5 alpha-reductase type 1 being responsible for virilization in type 2-deficient subjects during puberty, and suggest that the type 2 isozyme may be an initiating factor in development of male pattern baldness.

Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group

BACKGROUND

Benign prostatic hyperplasia is a progressive, androgen-dependent disease resulting in enlargement of the prostate gland and urinary obstruction. Preventing the conversion of testosterone to its tissue-active form, dihydrotestosterone, by inhibiting the enzyme 5 alpha-reductase could decrease the action of androgens in their target tissues; in the prostate the result might be a decrease in prostatic hyperplasia and therefore in symptoms of urinary obstruction.

METHODS

In a double-blind study, we evaluated the effect of two doses of finasteride (1 mg and 5 mg) and placebo, each given once daily for 12 months, in 895 men with prostatic hyperplasia. Urinary symptoms, urinary flow, prostatic volume, and serum concentrations of dihydrotestosterone and prostate-specific antigen were determined periodically during the treatment period.

RESULTS

As compared with the men in the placebo group, the men treated with 5 mg of finasteride per day had a significant decrease in total urinary-symptom scores (P less than 0.001), an increase of 1.6 ml per second (22 percent, P less than 0.001) in the maximal urinary-flow rate, and a 19 percent decrease in prostatic volume (P less than 0.001). The men treated with 1 mg of finasteride per day did not have a significant decrease in total urinary-symptom scores, but had an increase of 1.4 ml per second (23 percent) in the maximal urinary-flow rate, and an 18 percent decrease in prostatic volume. The men given placebo had no changes in total urinary-symptom scores, an increase of 0.2 ml per second (8 percent) in the maximal urinary-flow rate, and a 3 percent decrease in prostatic volume. The frequency of adverse effects in the three groups was similar, except for a higher incidence of decreased libido, impotence, and ejaculatory disorders in the finasteride-treated groups.

CONCLUSIONS

The treatment of benign prostatic hyperplasia with 5 mg of finasteride per day results in a significant decrease in symptoms of obstruction, an increase in urinary flow, and a decrease in prostatic volume, but at a slightly increased risk of sexual dysfunction.

Finasteride, an inhibitor of 5 alpha-reductase, suppresses prostatic dihydrotestosterone in men with benign prostatic hyperplasia

The oral administration of finasteride, a 4-aza-steroid inhibitor of 5 alpha-reductase, decreases serum dihydrotestosterone levels, but has little effect on serum testosterone. The current study was designed to assess the effect of finasteride on dihydrotestosterone levels in the prostates of men with benign prostatic hyperplasia. In a double blind, placebo-controlled study, 69 men with symptomatic prostatic hyperplasia were treated with placebo or 1, 5, 10, 50, or 100 mg/day finasteride for 7 days before transurethral resection of the prostate. In the placebo group the mean concentration of prostatic dihydrotestosterone was 10.3 +/- 0.6 nmol/kg (+/- SE), and the mean concentration of testosterone was 0.7 +/- 0.1 nmol/kg. After 7 days of treatment with all doses of finasteride, prostatic dihydrotestosterone declined to 15% or less of control levels, and the testosterone concentration increased in a reciprocal fashion. Compared to the placebo group, there was no significant difference in the mean prostatic dihydrotestosterone level achieved in any of the finasteride-treated groups. However, prostatic dihydrotestosterone levels were lower in the groups receiving higher doses of the drug. In two additional patients, finasteride treatment for 2 days also caused a decrease in prostatic dihydrotestosterone levels. No significant adverse experiences occurred during the study. We conclude that finasteride causes profound decrease in prostatic dihydrotestosterone.

What will replace TURP?

Benign prostatic hyperplasia (BPH) is almost ubiquitous. About 25% to 40% of men in their lifetime will undergo treatment for BPH. Surgical therapy produces in excess of 400,000 prostatectomies a year at a cost of more than 4 billion dollars. Given the magnitude of the clinical problem and its overall impact on health care in the United States, the interest in alternatives to transurethral resection of the prostate (TURP) is intense. From the panoply of contenders, the panel nominates those most likely to succeed.

Temperature mapping in the canine prostate during transurethrally-applied local microwave hyperthermia

Although the therapeutic effects of heat on tumors have been known for more than a century, only recently has hyperthermia been applied in the treatment of various solid tumors in a scientific fashion. In preliminary clinical trials, heat applied by transurethrally or transrectally placed microwave antennas has been used in the treatment of benign prostatic hyperplasia (BPH) with some success. However, basic information about prostatic temperature distribution and the cellular effects of hyperthermia is lacking. In an attempt to establish the safety of local hyperthermia of the prostate and the precise temperature distribution within the gland, we performed temperature mapping studies in canine prostates. Eight mongrel dogs were anesthetized, and a 16 Fr catheter with three helical coil microwave antennas was placed in the bladder through a perineal urethrostomy. Laparotomy was performed and the bladder opened. The antennas were placed under direct control in the prostatic urethra. Linear array and single point thermometers (Clini-Therm TS1200 thermometry system) were placed (1) within the catheter alongside the antennas, (2) alongside the Foley catheter in the urethra, and (3) longitudinally and radially in the prostate for mapping of tissue temperature. Heating was performed with a 915-MHz ISM frequency Z-80 microprocessor controlled microwave power generator (Prostek 3000, Clini-Therm Corporation, Dallas, TX) using 2-9 watts per channel (6-27 watts total) for 30 min to 1 hr. Baseline body temperatures varied between the individual dogs from 37 degrees to 38 degrees C, but temperature distribution within the prostate was even prior to heating. With relatively low power (6 watts total), temperatures of greater than or equal to 45 degrees C were reached within the catheter. Therapeutic temperatures of approximately 43 degrees C were achieved in the periurethral prostate. Intraurethral temperatures were in general 1-2 degrees C lower than within the catheter. The radial temperature dropoff in the prostate was sharp and about 1 degrees C per 3-mm distance from the catheter. This would limit the area of effectiveness to a periurethral zone of 1 cm in diameter in this model. No unsafe temperature peaks were noted either intraurethrally or between the prostate and the rectum during steady-state conditions. Histologic studies demonstrated an intact rectal wall and varying degrees of prostatic inflammation and/or necrosis despite uniform treatment regimens administered. These studies demonstrate the short-term safety of microwave hyperthermia in the canine prostate. Further studies will be necessary to determine the clinical efficacy and toxicity in men with BPH.

The pathophysiology of benign prostatic hyperplasia

Although benign prostatic hyperplasia (BPH) is one of the most common disease processes affecting the aging male, surprisingly little is known about its pathophysiology. Cause-and-effect relationships have not been established, despite intense research efforts in the last four or five decades aimed at elucidating the underlying etiology of prostatic growth in older men. Previously held notions that the clinical symptoms of BPH (prostatism) are due simply to a mass-related increase in urethral resistance are too simplistic. It is now clear that a significant portion of the symptoms are due to obstruction-induced detrusor dysfunction. Moreover, obstruction may induce a variety of neural alterations in the bladder and prostate that contribute to symptomatology. Undoubtedly, the constellation of cellular pathologies that give rise to the symptoms of BPH will be far more complex than we currently realize. Only by unraveling these complexities, however, will we be able successfully to design alternative strategies to treat, and possibly prevent BPH.

A prospective study of urologist-performed sonographic evaluation of the urinary tract in patients with prostatism

In this study 171 consecutive patients hospitalized for prostatectomy were prospectively evaluated by urologist-performed transabdominal ultrasound. The urologist-sonographers were blinded to the results of an excretory urogram (IVP) performed and interpreted by radiologists. All significant upper tract pathology (4 renal cell carcinomas and 1 transitional cell carcinoma of the renal pelvis) identified by an IVP also was detected by ultrasonography. Of 5 clinically silent stones seen on an IVP 4 were identified by sonography. There were 13 patients (7.6%) with severe contrast medium allergies or renal failure who were readily evaluated with ultrasonography. Urologist-performed sonography can safely replace an IVP for routine evaluation of the urinary tract before prostatectomy. Moreover, sonography provided significant additional data on prostate size and post-void residual. However, the cost-effectiveness of upper tract imaging in patients before prostatectomy may be questioned.

Physiologic basis of endocrine therapy for prostatic cancer

Advances in our understanding of hypothalamic-pituitary gonadal regulation have led to the development of pharmaceutical agents that produce a medically castrate state with minimal morbidity. The selection of the method for androgen ablation in a given patient with stage D adenocarcinoma of the prostate should be based on patient preference and on cost, because the therapeutic outcomes of medical castration and orchiectomy are equivalent. The addition of androgen receptor antagonists to a given patient's regimen should be made with the knowledge that the impact on the mortality rate is modest and the cost significant. Further manipulation of androgen production or action in patients with hormonally resistant cancer is unlikely to improve either the disease progression or the mortality rate. Research efforts should be focused on the development of effective chemotherapy for such disease.

Androgen ablation and blockade in the treatment of benign prostatic hyperplasia

Antiandrogen therapy appears to produce a 30 to 40 per cent decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy (Table 5). Longer treatment may result in further prostatic regression, although this remains to be seen. Biopsy studies suggest that epithelial regression occurs to a much more significant degree than does stromal regression, but this finding may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uro-flow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on antiandrogen therapy, in contrast to surgery, in which relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of antiandrogen therapy. Most importantly, prostatic involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does after surgery. Incomplete antiandrogen action of the compounds, as well as compliance issues, may likewise limit efficacy. Although there are no data to suggest that the 5 alpha-reductase inhibitor finasteride will be more effective than other antiandrogen compounds in the treatment of BPH, preliminary studies suggest that it has less toxicity. If long-term studies validate a modest but significant clinical response rate and preservation of sexual function, then finasteride therapy may well be acceptable to a subgroup of men presenting with the symptoms of BPH.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical management of benign prostatic hyperplasia with androgen suppression

Many types of nonsurgical therapy, including balloon dilation, hyperthermia, adrenergic blockade, and hormonal therapy, have been used for the treatment of benign prostatic hyperplasia (BPH). Antiandrogen therapy has been the most extensively studied form of hormonal treatment for BPH, although estrogens, antiestrogens, and antiprolactin agents have also been used (Scott and Coffey: Vitam Horm 33:439-465, 1975). The theoretical basis of antiandrogen therapy will be reviewed along with a summary of relevant clinical trials. Recent advances in the development of agents that more selectively inhibit the androgen-dependent growth of the prostate will be presented.

Urine dipstick vs. microscopic urinalysis in the evaluation of abdominal trauma

This study was designed to assess the accuracy of the urine dipstick and its ability to predict injury to the urinary tract when compared to routine urinalysis: 1,485 patients had dipstick and microscopic urinalysis performed as part of their evaluation for blunt and penetrating trauma. Dipstick analysis was recorded as either positive or negative. Microhematuria was defined as greater than 0-1 RBC/HPF on microscopic analysis. Blunt trauma accounted for 1,347 (91%) of the patients and penetrating injuries accounted for 138 cases (9%): 1,209 (81.4%) of the specimens were dipstick negative, and 276 (18.6%) were dipstick positive. False negative results, consisting of a negative dipstick reading and greater than 1 RBC/HPF on microscopic analysis occurred in 100 (6.9%) of the cases. False positive dipstick readings occurred in 64 (4.3%) of the patients. There were no cases of a missed injury in the group of 100 false negatives. Cost savings by conversion to the use of dipsticks would have saved our institution about $63,000 per year. It is concluded that the urinary dipstick is a safe, accurate, and reliable screening test for the presence or absence of hematuria in patients sustaining either blunt or penetrating abdominal trauma.

Treatment of refractory infertility by transcervical intrauterine insemination of washed spermatozoa

One hundred thirteen couples with either male factor, cervical factor, endometriosis, or idiopathic infertility of at least 3 years' duration were treated by intrauterine insemination (IUI) of washed motile sperm. Of the 68 women who became pregnant or completed at least three cycles of insemination, the overall pregnancy rate was 38.2%, with a mean of 1.7 treatment cycles per pregnancy. The average pregnancy rate per treatment cycle was 11.4%. Women who did not become pregnant underwent an average of 4.7 treatment cycles. Importantly, only two pregnancies occurred independent of treatment in 113 couples. In the male factor group, the pregnancy rate was 42.9% (n = 21). In women with a cervical factor, 34.5% became pregnant (n = 29); in idiopathic infertile couples or women suffering from endometriosis, there was a pregnancy rate of 38.9% (n = 18). The presence of sperm antibodies in either the male or female partner significantly lowered the pregnancy rate (6.7%) when compared with couples without sperm antibodies (50.0%). The authors conclude from these observations that IUI with washed sperm is a successful mode of therapy, especially in the case of males with asthenozoospermia.

Partial purification and characterization of dynein adenosine triphosphatase from bovine sperm

Outer dynein arm polypeptides that possess Mg+2-adenosine triphosphatase (ATPase) activity have been extracted from the flagellar axonemes of demembranated bovine sperm. Electron microscopy of intact and salt-extracted sperm demonstrates a relatively selective removal of the outer dynein arms. The salt extract contains a specific ATPase activity of 55 nmoles inorganic phosphate (Pi)/min/mg protein. Sucrose density gradient centrifugation of this extract results in a 6-fold increase in specific activity of ATPase (333 nmole/Pi/min/mg protein), which sediments as a single 13S peak. Concomitant with the increase in specific activity, there is enrichment of three high molecular weight polypeptides (Mr greater than 300,000) characteristic of dynein heavy chains. ATPase activities in the initial extract and in the 13S peak are inhibited by concentrations of vanadate and erythro-9-[3-2-(hydroxynonyl)]adenine similar to those that inhibit ATPase activity in sea urchin sperm dynein. These findings indicate that outer arm dynein ATPase can be extracted and partially purified from bovine sperm.

Uncommon sites of recurrent seminoma and implications for therapy

Three patients with advanced seminoma that metastasized to the prostate, the kidney, and a lumbar vertebra are presented. The implications of such metastases regarding the management of residual lesions after chemotherapy are discussed.