Obesity Measures and Definitions of Sarcopenic Obesity in Singaporean Adults - the Yishun Study

OBJECTIVES

Due to the lack of a uniform obesity definition, there is marked variability in reported sarcopenic obesity (SO) prevalence and associated health outcomes. We compare the association of SO with physical function using current Asian Working Group for Sarcopenia (AWGS) guidelines and different obesity measures to propose the most optimal SO diagnostic formulation according to functional impairment, and describe SO prevalence among community-dwelling young and old adults.

DESIGN

Obesity was defined according to waist circumference (WC), percentage body fat (PBF), fat mass index (FMI), fat mass/fat-free mass ratio (FM/FFM), or body mass index (BMI). SO was defined as the presence of both obesity and AWGS sarcopenia. Muscle function was compared among phenotypes and obesity definitions using ANOVA. Differences across obesity measures were further ascertained using multiple linear regressions to determine their associations with the Short Physical Performance Battery (SPPB).

SETTING

Community-dwelling adults 21 years old and above were recruited from a large urban residential town in Singapore.

PARTICIPANTS

535 community-dwelling Singaporeans were recruited (21-90 years old, 57.9% women), filling quotas of 20-40 participants in each sex- and age-group.

MEASUREMENTS

We took measurements of height, weight, BMI, waist and hip circumferences, body fat, muscle mass, muscle strength, and functional assessments. Questionnaire-based physical and cognitive factors were also assessed.

RESULTS

Overall prevalence of SO was 7.6% (WC-based), 5.1% (PBF-based), 2.7% (FMI-based), 1.5% (FM/FFM-based), and 0.4% (BMI-based). SO was significantly associated with SPPB only in the FMI model (p<0.05), and total variance explained by the different regression models was highest for the FMI model.

CONCLUSIONS

Our findings suggest FMI as the most preferred measure for obesity and support its use as a diagnostic criteria for SO.

Malnutrition and Sarcopenia in Community-Dwelling Adults in Singapore: Yishun Health Study

OBJECTIVES

To determine the overlapping prevalence of malnutrition and sarcopenia and the association between parameters of malnutrition with muscle mass and strength in a community-dwelling Singaporean adult population.

DESIGN

This was a cross-sectional study.

SETTING

Large north-eastern residential town of Yishun in Singapore.

PARTICIPANTS

Random sampling of community-dwelling Singaporeans aged 21-90 years old (n=541).

MEASUREMENTS

Anthropometry, body composition and handgrip strength (muscle strength) were measured. Sarcopenia was identified using dual-energy x-ray absorptiometry scan (muscle mass). Nutritional status was measured using Mini Nutritional Assessment (MNA-SF). Other questionnaires collected included physical activity and cognition. Associations between nutritional status with sarcopenia as well as with muscle mass and strength were analysed using multinomial logistics and linear regressions.

RESULTS

The overall population-adjusted prevalence of those at nutritional risk and malnourished were 18.5% and 0.1% respectively. More than a third of participants (35%) who were at nutritional risk were sarcopenic. Malnourished participants were all sarcopenic (100%, N=2) whereas those who were sarcopenic, 27.0% (N=37) were at nutritional risk/malnourished. Being at nutritional risk/malnourished was significantly associated with 2 to 3 times increased odds of sarcopenia in multivariate analyses adjusting for age, gender, physical activity level and cognition, and fat mass index. Favourable MNA parameter scores on food intake and BMI were positively associated with greater muscle mass and handgrip strength (p<0.05).

CONCLUSION

Given the overlapping clinical presentation of malnutrition and sarcopenia, community screening protocols should include combination screening of nutritional status and sarcopenia with appropriate interventions to mitigate risk of adverse health outcomes.

L-theanine attenuates transport stress-induced impairment of meat quality of broilers through improving muscle antioxidant status

This study was to investigate the effect of dietary L-theanine (THE) supplementation (0, 600 mg/kg) on growth performance, carcass traits, immune organ indexes, meat quality, and muscle antioxidant status of transported broilers. A total of 180 one-day-old male Ross 308 broilers were randomly allotted to 2 treatment groups including a THE-free group with 12 replicates of 10 birds each and a THE group with 6 replicates of 10 birds each. On the morning of day 42, after a 9-h fast, the birds of THE-free group were divided into 2 equal groups, and then all birds in the 3 groups were placed into 18 crates and were transported according to the following protocols: 0-h transport of birds in the THE-free group (control group), 3-h transport of birds in the THE-free group (T group), and 3-h transport of birds in the THE group (T + THE group). Results showed that dietary THE supplementation improved feed conversion ratio and birds' final body weight (P < 0.05), while transport and dietary THE supplementation did not affect carcass traits of broilers (P > 0.05). Transport increased bird live weight loss, drip loss, L*24 h, muscle malondialdehyde (MDA), protein carbonyl (PC) and lactate contents, while it decreased thymus, spleen, and bursa of Fabricius indexes, pH24h, a*, and muscle total antioxidant capacity (T-AOC), catalase (CAT), and glutathione peroxidase (GSH-PX) activities and glycogen content (P < 0.05). Nevertheless, compared with birds in the T group, birds in the T + THE group exhibited increased thymus, spleen, and bursa of Fabricius indexes, pH24h, a*24 h, and muscle T-AOC, CAT, and GSH-PX activities and glycogen content, and decreased drip loss, L*24 h, and muscle MDA, PC, and lactate contents (P < 0.05). This study provided the first evidence that dietary THE supplementation prevented transport-stress-impaired immune organ indexes and meat quality of broilers, and the reason for maintenance of meat quality by supplementation of THE may be partly ascribed to the changed muscle glycolysis metabolism and antioxidant status.

Half a Century of Ephedrine

This presentation is a nostalgic account of ephedrine, an alkaloid of Ma Huang, Ephedra sinica. In 1923 C.F. Schmidt and I initiated the investigation on the product of our own isolation at Peking Union Medical College, and shortly concluded that we were dealing with one of the sympathomimetic amines. Clinical studies followed in the U.S., Canada and Europe. Thousands of patients with bronchial asthma have been benefitted by taking ephedrine per os. Similarly, hay fever sufferers derive symptomatic relief after oral doses and nasal spray. In spinal anesthesia, intramuscular injection of ephedrine before introduction of the local anesthetic into the spinal canal regularly prevents the fall of blood pressure. The drug by mouth can overcome the hangover of a phynotic. It is my earnest hope that present scholarly exchange (1) will reveal more developments from China.

Efficacy and safety of tadalafil for the treatment of erectile dysfunction: results of integrated analyses

PURPOSE

We conducted integrated analyses of the efficacy and safety of tadalafil, a potent, selective phosphodiesterase 5 inhibitor, for the treatment of erectile dysfunction.

MATERIALS AND METHODS

A total of 1,112 men with a mean age of 59 years (range 22 to 82) and mild to severe erectile dysfunction of various etiologies were randomized to placebo or tadalafil, taken as needed without food or alcohol restrictions, at fixed daily doses of 2.5 mg, 5 mg, 10 mg, or 20 mg up to a maximum of once daily [DOSAGE ERROR CORRECTED] in 5 randomized, double-blind, placebo controlled trials lasting 12 weeks. The 3 co-primary outcomes were changes from baseline in the erectile function domain of the International Index of Erectile Function and the proportion of "yes" responses to questions 2 and 3 of the Sexual Encounter Profile. Additional efficacy instruments included a Global Assessment Question.

RESULTS

Compared with placebo, tadalafil significantly enhanced all efficacy outcomes. Patients receiving 20 mg. tadalafil experienced a significant mean improvement of 7.9 in International Index of Erectile Function erectile function domain score from baseline (p <0.001 versus placebo), 75% of intercourse attempts (Sexual Encounter Profile question 3, a secondary efficacy outcome) were successfully completed (p <0.001 versus placebo) and 81% reported improved erections at end point compared with 35% in the control group (p <0.001). Tadalafil was consistently efficacious across disease severities and etiologies, as well as in patients of all ages. Tadalafil was well tolerated, and headache and dyspepsia were the most frequent adverse events.

CONCLUSIONS

Tadalafil was effective and well tolerated in this patient population.

Efficacy and safety of tadalafil for the treatment of erectile dysfunction: results of integrated analyses

PURPOSE

We conducted integrated analyses of the efficacy and safety of tadalafil, a potent, selective phosphodiesterase 5 inhibitor, for the treatment of erectile dysfunction.

MATERIALS AND METHODS

A total of 1,112 men with a mean age of 59 years (range 22 to 82) and mild to severe erectile dysfunction of various etiologies were randomized to placebo or tadalafil, taken as needed without food or alcohol restrictions, at fixed daily doses of 2.5 mg, 5 mg, 10 mg, or 20 mg up to a maximum of once daily [DOSAGE ERROR CORRECTED] in 5 randomized, double-blind, placebo controlled trials lasting 12 weeks. The 3 co-primary outcomes were changes from baseline in the erectile function domain of the International Index of Erectile Function and the proportion of "yes" responses to questions 2 and 3 of the Sexual Encounter Profile. Additional efficacy instruments included a Global Assessment Question.

RESULTS

Compared with placebo, tadalafil significantly enhanced all efficacy outcomes. Patients receiving 20 mg. tadalafil experienced a significant mean improvement of 7.9 in International Index of Erectile Function erectile function domain score from baseline (p <0.001 versus placebo), 75% of intercourse attempts (Sexual Encounter Profile question 3, a secondary efficacy outcome) were successfully completed (p <0.001 versus placebo) and 81% reported improved erections at end point compared with 35% in the control group (p <0.001). Tadalafil was consistently efficacious across disease severities and etiologies, as well as in patients of all ages. Tadalafil was well tolerated, and headache and dyspepsia were the most frequent adverse events.

CONCLUSIONS

Tadalafil was effective and well tolerated in this patient population.

Involvement of L-arginine/nitric oxide pathway at the paraventricular nucleus of hypothalamus in central neural regulation of penile erection in the rat

The objective of this study is to investigate whether the L-arginine/nitric oxide pathway is involved in the neurotransmission of paraventricular nucleus of hypothalamus (PVN) activation-induced penile erection in the rat. Male adult Sprague-Dawley rats anesthetized with pentobarbital were used. The femoral artery was cannulated to measure systemic and mean arterial pressure (SAP and MAP), and heart rate (HR). A 26-gauge needle was inserted into corpus cavernosum to measure the intracavernous pressure (ICP) simultaneously with SAP, MAP and HR on a polygraph. Four groups of study were arranged: (1) stereotaxically delivery of L-arginine (500 nmol/500 nl) into PVN; (2) administration of a mixture (1 microl) containing N(G)-Nitro-L-arginine methyl ester (L-NAME) 500 nmol and L-arginine 500 nmol into PVN; (3) microinjection of saline 500 nl into PVN as a vehicle control; and (4) intracavernous injection of L-arginine (100 nmol/50 microl). The ICP, SAP, MAP and HR were monitored for at least 2 h after each administration of the experimental agents. Upon administration of L-arginine into PVN, there was a significant increase of ICP from resting 9.6+/-2.5 mmHg to peaked at 64.4+/-9.8 mmHg after a latency of 3016.0+/-1749.7 s and with a duration of 27.6+/-15.8 min. There was no change of resting ICP after administration of the mixture of L-NAME and L-arginine into PVN. Application of saline to PVN and intracavernous injection of L-arginine failed to increase ICP. Based on elicitation of penile erection upon administration of L-arginine into PVN, and elimination of this L-arginine induced penile erection by co-administration of L-NAME with L-arginine, the results of this study suggest that L-arginine/nitric oxide pathway may be involved in the neurotransmission of PVN activation-induced penile erection in the rat.

High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence

OBJECTIVES

To present our unfavorable experiences using allograft fascia lata. Allograft fascia lata is an attractive sling material providing less pain, a shorter operation time, and a reported effectiveness equal to autologous fascia.

METHODS

A total of 18 women (mean age 51.7 years, range 37 to 76) underwent pubovaginal sling surgery for stress urinary incontinence between March 1999 and July 1999 and were enrolled in this study. Solvent dehydrated gamma-irradiated human fascia lata with a size of 7 x 2 cm was used as the sling. The results were collected with a questionnaire survey.

RESULTS

All patients were followed up for a mean of 9.2 months (range 6.9 to 11.6). Thirteen patients considered the surgery successful or to have provided improvement, with a mean of 82.5% (range 50% to 100%) subjective improvement. Five patients (27.8%) had significant failure with full recurrence of incontinence within 3 to 6 months.

CONCLUSIONS

Solvent dehydrated gamma-irradiated allograft fascia is not reliable in pubovaginal sling surgery. The high failure rates within a short period prohibit its use in the operative management of stress urinary incontinence.

Fracture aspects of resin-dentin bonding in non-trimming microtensile test

Comparative studies on resin-dentin bond strength and failure mode were performed between the conventional tensile test and the microtensile test with non-trimming small specimens, 1 x 1 mm in cross-section, for two brands of dentin bonding systems. The fracture surface of the conventional large specimen showed a catastrophic cohesive failure in dentin at its center and a lesser adhesive failure, suggesting that the whole failure was due to the development of some major cracks. The non-trimming microtensile test showed significantly larger average bond strength with markedly larger standard deviation and significantly larger fraction of adhesive failure than the conventional test. Some small specimens were extremely strong and some were weak according to the heterogeneous distribution of tight bonding and defective or deficient bonding over the whole dentin surface. These results suggest that the non-trimming microtensile test may potentially provide more realistic aspects of resin-dentin bonding than the conventional bulk specimen.

ASSESS-3: a randomised, double-blind, flexible-dose clinical trial of the efficacy and safety of oral sildenafil in the treatment of men with erectile dysfunction in Taiwan

The efficacy and safety of sildenafil were evaluated in a randomised, double-blind, placebo-controlled, flexible-dose study in Taiwanese men aged 26 to 80 y with erectile dysfunction (ED) of broad-spectrum aetiology and more than 6 months' duration. A total of 236 patients were randomised at six medical centres in Taiwan to receive either sildenafil (50 mg initially increased if necessary to 100 mg or decreased to 25 mg depending on efficacy and toleration) (n=119) or matching placebo (n=117) taken on an 'as needed' basis 1 h prior to anticipated sexual activity for a period of 12 weeks. At the end of 12 weeks, the primary efficacy variables relating to the achievement and maintenance of erections sufficient for sexual intercourse, and the secondary efficacy variables, which included: (1) the five separate domains of sexual functioning of the IIEF (International Index of Erectile Function) scale, (2) the percentage of successful intercourse attempts; and (3) a global assessment of erections, were all statistically significantly improved by sildenafil in comparison with placebo (P<0.0001). Treatment-related adverse events occurred in 43.7% of patients receiving sildenafil and 18.8% receiving placebo. The most common adverse events with sildenafil were flushing, dizziness and headache (25.2, 6.7 and 5.9% of patients, respectively), and most were mild in nature. The efficacy and safety of sildenafil in the population of Taiwanese men appears similar to that reported in other studies in western populations.

Sonographic features of xanthogranulomatous pyelonephritis

PURPOSE

The purpose of this study was to describe the various sonographic features of xanthogranulomatous pyelonephritis (XGP).

METHODS

We retrospectively reviewed the CT, sonographic, and medical records of patients diagnosed with XGP from January 1981 to December 1998. Twenty-seven patients for whom XGP was histopathologically confirmed were included in the study. There were 12 men and 15 women, with an age range of 21-86 years (mean, 57 years). All patients had undergone sonography of the kidneys. The renal size, shape, and outline were recorded. The presence of perinephric fluid accumulation, of obstructive uropathy, or of internal echoes in the dilated collecting system and the echotexture of the renal parenchyma were documented.

RESULTS

We categorized the XGP into 4 groups on the basis of the sonographic features: (1) diffuse hydronephrotic, 12 patients (44%); (2) diffuse parenchymal, 9 patients (33%); (3) diffuse contracted, 4 patients (15%); and (4) segmental or focal, 2 patients (7%). A localized perinephric fluid collection was present in 4 patients (15%). The preoperative sonographic diagnoses were pyonephrosis (n = 14, 52%), renal pelvic tumor with possible associated infection (n = 5, 19%), renal parenchymal mass (n = 2, 7%), hydronephrosis (n = 2, 7%), and chronic pyelonephritis with renal atrophy (n = 4, 15%). XGP was considered a possible diagnosis in only 11 patients (41%).

CONCLUSIONS

XGP has no specific sonographic features but is suggested by parenchymal thinning and hydronephrosis, sonographic signs of chronic obstructive uropathy caused by stones; echoes in the dilated collecting system; and a perinephric fluid collection. CT, needle biopsy, or both are recommended to further evaluate and confirm sonographically suspected XGP.

Tamoxifen and colchicine-modulated vinblastine followed by 5-fluorouracil in advanced renal cell carcinoma: a phase II study

OBJECTIVES

Chemotherapy resistance of renal cell carcinoma (RCC) has been attributed in large part to multidrug resistance (MDR). Reported MDR-modulated chemotherapy for RCC, however, has resulted in only marginal response benefits. In this study, the MDR-modulated effect of paired tamoxifen and colchicine on vinblastine and the possible additive effect of 5-fluorouracil (5-FU) were investigated in the treatment of advanced RCC.

METHODS

Chemotherapy was administered every 4 weeks with biweekly vinblastine (4 mg/m(2)/day, intravenously on days 1 and 15) modulated by oral tamoxifen (100 mg/day) and colchicine (1 mg/day) from days -1 to 2 and from days 13 to 16. 5-FU (800 mg/m(2)/day from days 2 to 5) was administered after vinblastine administration as a continuous infusion.

RESULTS

Of 17 eligible patients with advanced RCC available for evaluation, 1 achieved a complete response (CR) and 3 a partial response (PR), with an overall response (CR plus PR) rate of 23.5%. The median overall survival time of all patients was 10 months (95% confidence interval [CI] 3.5 to 16.5); that of our patients with poor, intermediate, and favorable risks as stratified by Motzer's model was 6 (95% CI 1.7 to 10.3), 10 (95% CI 7.9 to 12.2), and 26 (95% CI 24.4 to 27.6) months, respectively. These results are encouraging in view of the poor efficacy of chemotherapy in RCC observed previously. Additionally, the treatment toxicity was limited: toxicity of grade 3 or greater occurred in only 1 patient with leukopenia, and no treatment-related mortality was found.

CONCLUSIONS

The encouraging response rates and overall survival with limited toxicity warrant further investigation of this combination therapy as an integrated part of immunochemotherapy for RCC.

Induction of CDK inhibitors (p21(WAF1) and p27(Kip1)) and Bak in the beta-lapachone-induced apoptosis of human prostate cancer cells

beta-Lapachone, a novel anti-neoplastic drug, induces various cancer cells to undergo apoptosis. In a previous report, we showed that beta-lapachone-induced apoptosis of HL-60 cells is mediated by oxidative stress. However, in the present study, we found that beta-lapachone-induced apoptosis of human prostate cancer (HPC) cells may be independent of oxidative stress. In contrast to the 10-fold beta-lapachone-induced increase in H(2)O(2) production seen in HL-60 cells, only a 2- to 4-fold increase was observed in HPC cells. N-acetyl-L-cysteine (NAC), a thiol antioxidant, inhibited the apoptosis in DU145 cells after 12 h exposure to beta-lapachone. Nonetheless, NAC, along with other antioxidants, failed to exert similar effect in HPC cells subjected to beta-lapachone treatment for 24 h. Under this premise, we suggest that the oxidative stress may not play a crucial role in beta-lapachone-mediated HPC cell apoptosis. Here we demonstrate that damage to genomic DNA is the trigger for the apoptosis of HPC cells induced by beta-lapachone. According to our results, beta-lapachone stimulates DNA dependent kinase expression and poly(ADP-ribose) polymerase cleavage in advance of significant morphological changes. beta-Lapachone promotes the expression of cyclin-dependent kinase (cdk) inhibitors (p21(WAF1) and p27(Kip1)), induces bak expression, and subsequently stimulates the activation of caspase-7 but not of caspase-3 or caspase-8 during the apoptosis of HPC cells. Taken together, these results suggest that the signaling pathway involving the beta-lapachone-induced apoptosis of HPC cell may be by DNA damage, induction of cdk inhibitors (p21 and p27), and then subsequent stimulation of caspase-7 activation.

Single agent paclitaxel as a first-line therapy in advanced urothelial carcinoma: its efficacy and safety in patients even with pretreatment renal insufficiency

BACKGROUND

Cisplatin-based chemotherapy is the mainstay of the treatment for advanced urothelial cancer, but patients with renal insufficiency before therapy are usually contraindicated to receiving platinum-based chemotherapy. Paclitaxel is one of the most promising agents against advanced urothelial carcinoma in recent trials and it can be easily tolerated even in patients with compromised renal function. We conducted a study in order to evaluate the efficacy and safety of paclitaxel as a first-line therapy in advanced urothelial carcinoma patients.

METHODS

Thirteen advanced chemo-naive urothelial carcinoma patients with a median age of 71 years were studied, seven of them demonstrating renal insufficiency (pretreatment serum creatinine > or = 1.5 mg/dl). All 13 patients received a minimum of two cycles of paclitaxel 175 mg/m2, delivered by intravenous infusion for 3 h every 3 weeks.

RESULTS

Four of the 13 patients responded to treatment, a response rate of 30.8%, with two of these achieving complete remission and two showing partial responses. The median overall survival period of all 13 patients was nine months (95% Cl: 6.51-11.49) and our study revealed a statistical tendency in the difference of median overall survival time between responders and non-responders (13 months versus 7.5 months, log-rank p = 0.038), although the number of cases was limited. The differences in response rate and median overall survival time, comparing patients with renal insufficiency and those with normal renal function, were not significant. Treatment-related toxicity was mild, with only two (15.4%) patients suffering from grade 3-4 leukopenia. No treatment-related mortality was noted.

CONCLUSIONS

Single-agent paclitaxel can be used as a first-line therapy in advanced urothelial carcinoma patients, and is especially suitable for those with pretreatment renal insufficiency, since the antitumor activity is significant while toxicity is well tolerated.

Klebsiella pneumoniae renal abscess

BACKGROUND

The clinical characteristics of renal abscess caused by Klebsiella pneumoniae have not been previously reported in case-series studies. The purpose of this study is to demonstrate the clinical characteristics of K pneumoniae renal abscess for early diagnosis and to identify the clinical risk factors associating with poor prognosis.

METHODS

We retrospectively reviewed the medical records of 24 patients with K pneumoniae renal abscess, from April, 1982 through February, 1998. The clinical presentations, including the demographic characteristics, predisposing disorders, initial signs and symptoms, laboratory test results, diagnostic radiology studies, therapeutic modalities and risk factors associated with mortality were studied.

RESULTS

The mean age was 58.7 years and the male to female ratio was 10:14. The most common predisposing factors were diabetes mellitus (58%), urolithiasis (25%) and immunosuppression (17%). Fever, chills and flank pain were the most common symptoms and signs, whereas pyuria, elevation of leukocyte count, glucose, blood urea nitrogen and creatinine were the common laboratory features. The distinct complications of K pneumoniae renal abscess were bacteremia in 13 (54%), emphysematous pyelonephritis in five (21%), and metastatic septic infection in three (12.5%). The cure rate was 52% (11/21) in patients treated with a combination of antibiotics and percutaneous drainage; however, six (35%) patients who survived required another surgical procedure for complete recovery. The overall mortality rate was 25%. The clinical factors of elderly age (>65 years) at presentation, lethargy, elevation of serum blood urea nitrogen and pulmonary complications were associated with poor prognoses.

CONCLUSIONS

Focusing on the early diagnosis of K pneumoniae renal abscess and recognition of the prognostic factors for a poor prognosis, we highlight the specific clinical characteristics that include elderly age, lethargy, impairment of renal function, metastatic septic lesions and pulmonary complications. All patients with K pneumoniae renal abscesses should receive empiric antibiotics and percutaneous drainage or aspiration, and surgical intervention as necessary for patients with intractable disease.

Mannitol facilitates rabbit urinary bladder recovery from overdistension injury

OBJECTIVES

To investigate the existence and functional significance of the enhanced lipid peroxidation in bladder overdistension injury and to explore the effect of mannitol, a free radical scavenger.

METHODS

Overdistension of rabbit bladders was induced and maintained for 3 hours by infusing normal saline into the bladder while keeping the intravesical pressure at 30 cm H(2)O. The bladders were then emptied and decompressed. Intravenous 20% mannitol was initiated 5 minutes before decompressing the overdistension. Detrusor tissue was obtained from the following groups: control, at the end of the overdistension period, and 30 minutes, 2 hours, and 7 days after decompressing the bladder. The tissue level of adenosine triphosphate (ATP) and phosphocreatine (PCr) and the lipid peroxidation product malondialdehyde (MDA) was assayed. Detrusor contractility was assessed by the response of the detrusor strips to KCl and bethanechol.

RESULTS

Decompressing the overdistended bladder led to a period of enhanced lipid peroxidation with an increase of MDA content from 225 to 384 pmol/mg protein 30 minutes after the decompression. Two hours later, the MDA content had recovered to the normal level. Mannitol abolished this period of enhanced lipid peroxidation. Overdistension impaired detrusor contractility and reduced the content of PCr (from 24.1 to 10.8 nmol/mg protein) and ATP (from 9.6 to 4.6 nmol/mg protein). Both detrusor contractility and the content of PCr and ATP further decreased 30 minutes after the decompression (PCr 5.4 nmol/mg, ATP 2.8 nmol/mg). They had recovered, but not fully, 7 days later. Mannitol prevented the further decrease in detrusor contractility and in the content of PCr and ATP during the initial decompression period (30 minutes after the decompression). In addition, the mannitol-treated group had quicker recovery in PCr and ATP levels, which returned to normal 7 days later.

CONCLUSIONS

Decompressing an overdistended bladder leads to enhanced lipid peroxidation, which is associated with an additionally decreased energetic metabolism and a more impaired contractile function. Mannitol effectively prevents enhanced lipid peroxidation and facilitates functional recovery. These results show that reactive oxygen species play a significant role in bladder overdistension injury.

Assessment of a three-dimensional operating system with skill tests in a pelvic trainer

OBJECTIVES

To compare the performance of laparoscopic skill assisted by a traditional two-dimensional (2D) and a three-dimensional (3D) endoscopic video system in a pelvic trainer.

MATERIALS AND METHODS

The 3D imaging system (DeepVision((R)), Automated Medical Products Corp.) consists of a traditional single lens optic laparoscope, a light source, an endoscopic camera (Stryker), a DeepVision processor and a DeepVision monitor. The 2D images could be obtained with the same system without turning on the DeepVision processor. Thirty-four medical personnel with no laparoscopic surgical experience were enrolled to perform two skill tests, the object-pick-up and spatial orientation test in a trainer box. They were randomly divided into two groups, one group performed the test under 2D conditions first and 3D later, and another group performed the test under 3D conditions first and 2D later. The duration needed to complete the skill tests was recorded and the differences on performance time under 2D and 3D conditions were calculated for each participant. Two-way ANOVA was used to analyze the statistic difference on the performance time in two conditions.

RESULTS

The duration needed to complete the initial skill tests was similar among 2D and 3D conditions. For both tests, the average performance time decreased significantly for the second attempt regardless of 2D or 3D conditions. Statistic analysis disclosed significant difference for learning factor (p < 0.001 for object-pick-up test and p < 0.01 for spatial orientation test), but no significant difference between 2D and 3D conditions (p = 0.276 for object-pick-up test and p = 0.327 for spatial orientation test).

CONCLUSION

A significant decrease of the performance time at the second attempt reflected the importance of a learning process in laparoscopic surgery. It appears that no significant benefits were obtained by this 3D operating system for surgeons without laparoscopic surgical experience.

Recovery of microvascular blood perfusion and energy metabolism of the obstructed rabbit urinary bladder after relieving outlet obstruction

We investigated the changes in urinary bladder microvascular blood perfusion and energy metabolism following outlet obstruction and after relieving the obstruction. We induced mild bladder outlet obstruction in male New Zealand White rabbits. Following 2 weeks of obstruction, one group of animals (n = 6) was sacrificed, while outlet obstruction was relieved in three additional groups, which were sacrificed 1 (n = 5), 2 (n = 5) and 4 (n = 5) weeks after relieving the obstruction. Seven sham-operated rabbits served as controls. Before obstruction, immediately before relieving the obstruction and preceding the sacrifice, the microvascular blood perfusion of the urinary bladder was measured using a laser Doppler blood flowmeter. The detrusor content of phosphocreatine and adenine nucleotides was determined by high-performance liquid chromatography. The results showed: (1) 2 weeks of outlet obstruction significantly decreased the bladder microvascular blood perfusion, which recovered gradually after relief of the obstruction and returned to the control level by 4 weeks of obstruction reversal; (2) outlet obstruction reduced detrusor energy charge and phosphocreatine content, which were restored in parallel after relieving the obstruction; by 4 weeks the bladder had regained their normal energy producing capability; (3) bladder microvascular perfusion has a very close correlation with detrusor energy charge (r = 0.791, p < 0.001). In conclusion, our findings of the close correlation between microvascular perfusion and energy production in bladder outlet obstruction suggest an important role for the decreased microvascular blood perfusion in reducing bladder energy production.

Mitochondrial DNA deletion of the human detrusor after partial bladder outlet obstruction-correlation with urodynamic analysis

OBJECTIVES

To investigate mitochondrial DNA (mtDNA) mutations in human detrusor after partial bladder outlet obstruction (BOO) and correlate the findings with the results of urodynamic studies.

METHODS

Sixty-two male patients with and without BOO were recruited and assessed by the International Prostate Symptom Score, a quality-of-life assessment index, and sonography. The severity of partial BOO was determined by pressure-flow study with an International Continence Society (ICS) nomogram. Random detrusor biopsies obtained cystoscopically were analyzed by polymerase chain reaction (PCR) techniques to detect possible mtDNA deletions. Primer-shift PCR and DNA sequencing were then performed to characterize specific mtDNA deletions. A semiquantitative PCR method was used to determine the proportion of the deleted mtDNA in detrusor. Finally, the mtDNA deletion and the urodynamic results were compared statistically.

RESULTS

A 4977-bp mtDNA deletion was identified in the human detrusor. Its incidence and proportion were found to increase after partial BOO (P = 0.005 and 0.012, respectively). The incidence of the mtDNA deletion was 4.2% (1 of 24) in the unobstructed group, 27.8% (5 of 18) in the equivocal group, and 40% (8 of 20) in the obstructed group. The mean proportion of the 4977-bp deleted mtDNA was 23.7 and 12.7 times higher in the obstructed and equivocal groups, respectively, compared with that of the unobstructed group.

CONCLUSIONS

We found mtDNA with the 4977-bp deletion in human detrusor and an increase of this deletion after partial BOO. This molecular change might account for the previous observations of mitochondrial functional impairment and voiding dysfunction after partial BOO.

Morphological and morphometric analysis of human detrusor mitochondria with urodynamic correlation after partial bladder outlet obstruction

PURPOSE

We correlated ultrastructural changes in mitochondria in the human detrusor with the severity of partial bladder outlet obstruction on urodynamics.

MATERIALS AND METHODS

We recruited into the study 52 men with and without bladder outlet obstruction symptoms. The severity of partial bladder outlet obstruction was determined by pressure flow study. Random detrusor biopsy specimens obtained by cystoscopy were fixed immediately and processed for transmission electron microscopic observation. Random areas were photographed for further morphological and morphometric analysis using mitochondrial damage score and stereological principles.

RESULTS

Mitochondrial damage score and mean mitochondrial volume strongly correlated with the urodynamic severity of partial bladder outlet obstruction, while mitochondrial volume density, surface density of the mitochondrial outer membrane and number of mitochondria per unit of cytoplasm area did not significantly correlate with severity.

CONCLUSIONS

Detrusor mitochondrial swelling and structural destruction increased with the severity of partial bladder outlet obstruction. These changes may be associated with impaired mitochondrial function and oxidative metabolism after partial bladder outlet obstruction. Detrusor mitochondrial damage may explain voiding dysfunction after partial bladder outlet obstruction develops.

Dopaminergic neurotransmission at the paraventricular nucleus of hypothalamus in central regulation of penile erection in the rat

PURPOSE

To investigate whether the paraventricular nucleus of hypothalamus (PVN) is involved in the central regulation of apomorphine-induced penile erection in the rat, and to decipher dopamine receptor subtypes in the PVN that are involved in apomorphine-induced penile erection.

MATERIALS AND METHODS

Male adult Sprague-Dawley rats (200 to 300 gm.) anesthetized with pentobarbital sodium were used. The intracavernous pressure (ICP), recorded along with systemic and mean arterial pressure (SAP, MAP) as well as heart rate (HR), was measured via a 26-gauge needle inserted into one corpus cavernosum. The PVN was activated by stereotaxically delivered apomorphine hydrochloride (0.1 nmol./100 nl.). Injection of saline into PVN served as a vehicle control. To investigate the participation of dopamine receptor subtypes in the PVN on apomorphine-induced penile erection, D1 or D2 receptor antagonist, SCH-23390 (100 pmol./100 nl.) or sulpiride (100 pmol./100 nl.) respectively, was administered into the PVN prior to subcutaneous application of apomorphine (80 microg./kg.). The effects on ICP of microinjection of D1, D2 or D3 receptor agonist, SKF-38393 (200 pmol./100 nl.), lisuride (200 pmol./100 nl.) or 7-hydroxy-DPAT (200 pmol./100 nl.) respectively, into the PVN were also evaluated.

RESULTS

The mean resting ICP was 5.2+/-0.4 mm. Hg. Upon administration of apomorphine into the PVN, there was a significant increase in ICP that peaked at 50.7+/-5.3 mm. Hg and persisted for 45.2+/-18.0 minutes after an onset latency of 677.7+/-311.6 seconds. Yawning and teeth gnashing were also observed in most of animals during the period of ICP increase. There was no significant change in SAP, MAP or HR. In addition, there was no elevation in ICP after administration of saline to the PVN or direct injection of apomorphine into the cavernous tissue. Microinjection of D1 or D2 receptor antagonist into the PVN blocked the increase in ICP after subcutaneous administration ofapomorphine. Direct application of D2, but not D1 or D3 receptor agonist into the PVN, on the other hand, increased the ICP.

CONCLUSIONS

Our results demonstrate that application of apomorphine to the paraventricular nucleus of hypothalamus elicited penile erection in the rat. Such an increase in ICP to apomorphine was due mainly to activation of the D2 receptor subtype in the PVN. These observations indicate that PVN may be involved in the central regulation of apomorphine-induced penile erection in the rat.

Immunohistochemical analysis of nm23-H1 protein in bladder cancer

BACKGROUND

The nm23 gene was first identified from murine K-1735 melanoma cell lines and possesses metastasis-suppressor activity. However, conflicting results concerning the metastasis-suppressor activity of nm23-H1 gene product have been reported in human solid tumors. The significance of nm23-H1 protein in bladder cancer remains to be determined. Therefore, we examined nm23-H1 protein expression immunohistochemically in bladder cancer.

METHODS

Formalin-fixed, paraffin-embedded tissue specimens were obtained from 39 patients with primary bladder cancer who had undergone radical cystectomy between 1987 and 1994. The specimens were examined immunohistochemically using a monoclonal antibody to nm23-H1, and the results of immunostaining were compared with clinicopathologic factors and patient survival.

RESULTS

Positive nm23-H1 protein expression was confined primarily to the cytoplasm of bladder cancer cells. A higher frequency of nm23-H1 positive expression was seen in higher stage tumors. There was a positive trend for the expression of nm23-H1 protein with the progression of the tumor (p < 0.025). No relationship was found between nm23-H1 protein expression and patients' clinicopathologic factors including age, tumor size, tumor morphology and tumor grade. Furthermore, nm23-H1 protein expression was not correlated with patient survival.

CONCLUSIONS

These results suggest that in bladder cancer nm23-H1 protein expression may play an important role in tumor progression rather than in metastasis suppression.

Observations after orchiectomy in clinical stage I nonseminomatous germ cell tumors of the testis

BACKGROUND

The optimal management of clinical stage I nonseminomatous germ cell tumor (NSGCT) of the testis remains controversial. For years, retroperitoneal lymph node dissection in combination with orchiectomy, has been the standard treatment in patients with clinical stage I NSGCT. Recently, with advancement of effective cisplatin-based chemotherapy and clinical staging procedures, a new approach of observation after orchiectomy is being evaluated. We reviewed cases of orchiectomy and observation for clinical stage I NSGCT of the testis in order to evaluate the treatment outcome.

METHODS

We retrospectively reviewed the records of 13 patients with clinical stage I NSGCT of the testis treated at our hospital from February, 1981 to August, 1996. The patient age at diagnosis ranged from 0.6 to 44 years. Nine patients had yolk sac tumors, and four had mixed germ cell tumors. Median follow-up was 42 months (range, 20-132 months).

RESULTS

Prior to orchiectomy, serum beta-human chorionic gonadotropin and alpha-fetoprotein (AFP) were raised to abnormal concentrations in four and in 13 patients, respectively. With a median follow-up of 42 months, three of 13 patients relapsed at a median of three months after orchiectomy. Two patients showed elevated AFP and radiographically identifiable tumors simultaneously, and one patient showed elevated AFP as the only evidence of relapse. Following treatment with cisplatin-based chemotherapy, the three patients who relapsed responded successfully and the elevated AFP returned to normal. The patients are currently alive and disease free.

CONCLUSIONS

Observation after orchiectomy is a reasonable approach for patients with clinical stage I NSGCT of the testis.

Testicular yolk sac tumors in children

BACKGROUND

Testicular tumors in children are uncommon, comprising about 1% of pediatric malignancies. Yolk sac tumor is the most common malignant testicular tumor in children. Because yolk sac tumor in children is rarely seen, its treatment has been controversial. We reviewed the records of 15 children with testicular yolk sac tumor treated at our hospital in order to evaluate optimal management and treatment outcome.

METHODS

From February, 1981, to August, 1996, 15 children with testicular yolk sac tumor were treated. Mean patient age at diagnosis was 15.8 months (range, 7-22 months). Fourteen patients presented with stage I disease and one presented with stage III disease. Mean follow-up was 88 months (range, 2-156 months).

RESULTS

All 15 patients received radical inguinal orchiectomy as initial treatment. Serum alpha-fetoprotein (AFP) concentrations were measured in 14 stage I patients preoperatively and were elevated in all of them. During follow-up, the one stage III patient died of the disease. Of the remaining 14 patients, two (14.3%) had recurrence with elevated AFP at three months and 10 months postorchiectomy, respectively. These patients were managed with cisplatin-based combination chemotherapy. To date, they are both alive with no further recurrence, and AFP concentrations returned to normal after chemotherapy. Overall, of the 15 patients with testicular yolk sac tumor, 14 (93.3%) survived without disease.

CONCLUSIONS

Our results suggest that testicular yolk sac tumor in children is a tumor with a favorable prognosis. Serum AFP concentration is extremely useful in diagnosis and monitoring of treatment response. Radical inguinal orchiectomy alone seems adequate for patients with stage I disease if serum AFP concentrations return to normal postoperatively. Cisplatin-based combination chemotherapy should be administered in patients with tumor recurrence or metastasis.

Life-threatening germ cell tumor arising in cryptorchidism: a case report

We report a case of life-threatening germ cell tumor in abdominal cryptorchidism. A 32-year-old man presented with a three-month history of dyspnea, loss of appetite, general weakness and a large abdominal mass. Physical examination revealed vacancy of the right scrotal contents. Chest radiograph showed massive left pleural effusion. Abdominal ultrasound revealed ascites, right hydronephrosis and the presence of an 18 x 15-cm heterogeneous echogenic mass in the upper abdomen and right iliac fossa. Abdominal computerized tomography (CT) revealed the presence of a large heterogeneous tumor and an enlarged (4 x 4-cm) retroperitoneal lymph node. Sonoguided needle biopsy of the abdominal mass demonstrated malignant cells of an uncertain type and origin. Serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) concentrations were elevated. Under the diagnosis of metastatic nonseminomatous germ cell tumor in abdominal cryptorchidism, the patient received three cycles of cisplatin-based combination chemotherapy followed by resection of the abdominal residual cryptorchid tumor. Histologically, the tumor showed marked necrosis without viable cancer. The patient had remained free of disease for seven months following surgery.

Postchemotherapy retroperitoneal residual mass in infantile yolk sac tumor

BACKGROUND

Persistent postchemotherapy retroperitoneal residual mass with normalization of alpha-fetoprotein (AFP) in infantile yolk sac tumor is rare.

METHODS/RESULTS

A 38-month-old boy with recurrent yolk sac tumor was treated with cisplatin-based combination chemotherapy. After chemotherapy, the retroperitoneal lymph node metastasis, 7 x 6 cm in size, decreased to 2 x 2 cm. Serum AFP levels returned to normal. The retroperitoneal residual mass was resected and histologically showed complete necrosis without viable cancer cells.

CONCLUSION

The patient has remained free of disease for 36 months after operation.

Clinical experiences of germ cell tumor in cryptorchid testis

The increased risk of malignancy occurring in the cryptorchid testis is well established. In order to investigate the management and outcome of germ cell tumor in cryptorchid testis, we retrospectively reviewed the records of 11 patients with cryptorchid tumor treated at our hospital between January 1973 and December 1996. Mean patient age at diagnosis was 47.6 years (range, 22-80). Of these patients, 3 were found in the inguinal area and 8 in the abdomen. Six occurred in the right cryptorchid testis and 5 in the left. Four patients presented with stage I disease, 4 with stage II, and 3 with stage III. Median follow-up period was 48.0 months (range 1-163). All 3 inguinal cryptorchid tumors and 6 of 8 abdominal cryptorchid tumors were seminoma. The remaining 2 abdominal cryptorchid tumors were nonseminomatous germ cell tumor. Of the 3 patients with inguinal cryptorchid seminomas, 2 with stage I disease were treated with prophylactic radiotherapy to nodal areas and 1 with stage III disease was treated with chemotherapy. Eight patients with abdominal cryptorchid tumors were treated with multidisciplinary approaches, including radiotherapy, cisplatin-based combination chemotherapy, and surgery. The overall survival rate for patients with inguinal and abdominal cryptorchid tumor was 81.8%. Two patients with stage III disease died during treatment and the remaining 9 patients are still alive without evidence of disease.

Effects of outlet obstruction and its reversal on mitochondrial enzyme activity in rabbit urinary bladders

PURPOSE

This study investigated the effects of outlet obstruction and its reversal on mitochondrial enzyme activity in the rabbit urinary bladder.

MATERIALS AND METHODS

We induced mild bladder outlet obstruction in male New Zealand White rabbits. Following two weeks of obstruction, one group of animals (n = 6) was sacrificed, while outlet obstruction was relieved in three additional groups of animals, which were sacrificed one (n = 5), two (n = 5) and four (n = 5) weeks after relieving the obstruction. Seven sham operated rabbits served as controls. We extracted mitochondria from fresh detrusor and assayed activities of key mitochondrial enzymes in the citric acid cycle, citrate synthase and malate dehydrogenase, as well as those in the electron transport chain, succinate cytochrome c reductase, NADH-cytochrome c reductase and cytochrome c oxidase. With high performance liquid chromatography (HPLC) we determined the tissue content of phosphocreatine and the adenine nucleotides (ATP, ADP and AMP), which was used for calculating energy charge. Responses of detrusor strips to 500 microM bethanechol and 120 mM KCl provided the assessment of detrusor contractility.

RESULTS

Contractile response of the detrusor strips to bethanechol stimulation was significantly reduced by outlet obstruction, nevertheless, it recovered gradually toward the control level after the relief of outlet obstruction. Outlet obstruction reduced the detrusor content of phosphocreatine, ATP and energy charge. After relieving the obstruction, however, these recovered gradually, reaching control levels 4 weeks later. The activities of all assayed enzymes were reduced by two weeks of outlet obstruction. Relieving the obstruction restored enzyme activity gradually but at different rates for different enzymes. Activities of the citric acid cycle enzymes citrate synthase and malate dehydrogenase recovered and were similar to control levels four weeks after relief of the obstruction. Of the enzymes in the electron transport chain, NADH cytochrome reductase activity recovered most quickly by one week after relief of the obstruction. The activity of cytochrome c oxidase improved more slowly, but 4 weeks after relieving the obstruction it, also, was restored and was similar to the control level. Succinate cytochrome reductase activity remained lower than the control over the entire four weeks of recovery.

CONCLUSIONS

The close association between mitochondrial enzyme activity, energy metabolism and contractility of the detrusor indicates the important role of mitochondrial enzyme damage in decreasing energy production and impairing contractile function of the urinary bladders following outlet obstruction. Our findings also show that various mitochondrial enzymes exhibit different susceptibilities and reversibilities to pathological stress.

Complicated urinary tract infection: analysis of 179 patients

BACKGROUND

The aim of our study was to investigate the incidence, bacteriology, management and outcome of complicated urinary tract infections (UTIs) at the Veterans General Hospital-Taipei.

METHODS

Between June, 1993, and July, 1994, medical records of 2,566 patients admitted to the Division of Urology, Veterans General Hospital-Taipei, were retrospectively reviewed. Of these patient, 1,322 had a diagnosis of benign prostatic hyperplasia (BPH), 607 were admitted for renal stones, 496 for ureteral stones, 75 for transitional cell carcinoma (TCC) of the urinary bladder, 47 for renal tumors and 19 for TCC of the ureter. Among all patients studied, 179 (6.98%) acquired a complicated UTI. Of these, 81 were admitted for BPH, 46 for renal stones, 42 for ureteral stones, five for TCC of the urinary bladder, three for renal tumors and two for TCC of the ureter.

RESULTS

Of the 179 patients with complicated UTIs, 155 were men and 24 were women. The urine culture positive rate was 76.0% (136/179) and the most common bacteria were Escherichia coli, Proteus mirabilis and Pseudomonas aeruginosa. The principle mode of treatment included parenteral antibiotics and urinary diversion (percutaneous nephrostomy and Foley catheterization), when necessary. The infection control rate for these complicated UTIs was 96.3% for BPH, 95.5% for renal stone, 97.6% for ureteral stone, 80% for TCC of the urinary bladder, 100% for renal tumor and 100% for TCC of the ureter. Mortality due to complicated UTI was 3.9% (7/179).

CONCLUSIONS

We concluded that the prognosis of complicated UTI is good if diagnosis and appropriate treatment are given promptly. Early drainage to relieve obstruction and intravenous antibiotics are initially necessary. Surgical intervention is required to resolve functional or structural abnormalities after the UTI has been controlled.

Successful treatment of a bulky seminoma in an abdominal undescended testis: a case report

An undescended testis is a major risk factor for the development of testicular malignancy. Herein we report the case of a 40-year-old man with a bulky seminoma arising in an uncorrected abdominal undescended testis. The definitive diagnosis was established by results of sonoguided biopsy and tumor marker studies. The patient was successfully treated with initial cisplatin and etoposide combination chemotherapy followed by resection of the residual tumor. The optimal diagnosis and treatment of this rare disease is discussed.

Prostate cancer: local staging with endorectal magnetic resonance imaging

BACKGROUND

Prostate cancer has received increasing attention during the past decades. Staging of tumors before treatment is imperative for planning appropriate therapy. The purpose of this study is to assess the role of endorectal magnetic resonance imaging (MRI) in local staging of prostate cancer.

METHODS

Endorectal MRI was performed in 31 patients with histologically-proven prostate cancer. MRI was done three to 100 days (mean, 32.1 days) after either transrectal ultrasonography (TRUS) with biopsy or transurethral resection of the prostate (TURP). Radical prostatectomies were performed within two weeks after MRI. The diagnostic accuracy of endorectal MRI for local tumor staging, specifically for extracapsular extension (ECE) and seminal vesicle invasion (SVI), was evaluated by correlating MRI results with histopathologic findings of whole-mount specimens.

RESULTS

The accuracy of endorectal MRI for the detection of tumor presence and estimation of tumor volume was 48%. Sensitivity, specificity and positive predictive value for evaluation of ECE were 88%, 69% and 80%, respectively, and for SVI, were 66%, 84% and 50%, respectively. The overall accuracy of MRI in local tumor staging (using the TMN system) was 61%. Accuracy in differentiating localized from invasive cancer was 84%.

CONCLUSION

Endorectal MRI is not accurate enough to detect tumor presence or estimate tumor volume. Diagnostic accuracy for local tumor staging is unsatisfactory. However, endorectal MRI is highly accurate in differentiating localized (stage B) from invasive (stage C) cancer.

Is renal function at the tumor side a prognostic factor in ureteral transitional cell carcinoma?

OBJECTIVES

To evaluate whether the ipsilateral renal function on the tumor side is a prognostic factor in transitional cell carcinoma (TCC) of the ureter.

PATIENTS AND METHODS

We retrospectively reviewed 129 consecutive patients with ureteral TCC between September 1973 and July 1993 at our hospital. There were 98 males and 31 females aged from 31 to 84 years (mean 64.9). Of them, 126 patients who received intravenous pyelography (IVP) were divided into 3 groups according to their radiological findings (group 1: nonvisualization of kidney at tumor side; group 2: hydronephrosis or hydroureter; group 3: no obstruction). Eighty patients receiving radionuclide (131I-hippuran) renal function test (RRFT) with available effective renal plasma flow (ERPF) were divided into 2 groups using ipsilateral ERPF 50 ml/min as a cutoff value (group 1: < 50 ml/min; group 2: > or = 50 ml/min). The mean survival of each group was estimated by the Kaplan-Meier method.

RESULTS

For patients receiving IVP, the mean survivals were 61.7, 99.7 and 83.8 months for groups 1, 2, and 3, respectively, and the differences between each 2 of the 3 groups were statistically significant (p < 0.05). For patients having RRFT, the mean survivals were 65.8 months for group 1 and 89.2 months for group 2 patients, and the difference between them was statistically significant (p < 0.05). When renal function, tumor number, grade, stage and type of treatment were analyzed using a multivariate method, only tumor stage was statistically significant as a prognostic factor.

CONCLUSION

Ipsilateral renal function at the tumor side is not a good prognostic factor for patients with ureteral TCC. However, when the stage of tumor is not available, renal function at the tumor side may provide an implication of the patient's prognosis.

Immunoreactivity of nm23-H1 protein in renal cell carcinoma

Formalin-fixed, paraffin-embedded tissue blocks from 25 surgical specimens of renal cell carcinoma (RCC) including 13 adjacent normal renal tissues were investigated. The specimens were examined by immunohistochemistry using the monoclonal antibody, nm23-H1. The positive immunostaining of nm23-H1 protein was confined primarily to the cytoplasm of both normal renal tubular epithelial cells and renal tumor cells. Immunostaining of nm23-H1 protein was reduced significantly in RCC as compared to the normal renal tissues (P = 0.003). The positive immunostaining of nm23-H1 protein was seen in 92% (12/13) of normal renal tissues and in 60% (15/25) of RCC. No relationship was found between immunostaining of nm23-H1 protein and the patient's clinicopathological factors including age, tumor size, tumor location, tumor grade and tumor stage. Furthermore, immunostaining of nm23-H1 protein was not correlated with patient survival. Although immunoreactivity of nm23-H1 protein in patients with RCC was not correlated with survival, nm23-H1 protein may play a role in human renal tubular tumorigenesis.

Paraneoplastic elevation of serum alkaline phosphatase in renal cell carcinoma: incidence and implication on prognosis

PURPOSE

We investigated the incidence and prognostic significance of paraneoplastic elevation of serum alkaline phosphatase in patients with renal cell carcinoma.

MATERIALS AND METHODS

Clinical data of 365 pathologically proved renal cell carcinoma cases were reviewed. Serum alkaline phosphatase level greater than 100 units per 1., but without obvious conditions that may cause phosphatase elevation, including metastasis to or disease of liver or bone and pregnancy, was regarded as paraneoplastic serum alkaline phosphatase elevation. Survival was evaluated using the Kaplan-Meier method.

RESULTS

Of 365 patients 77 (21.1%) had paraneoplastic serum alkaline phosphatase elevation. The respective incidence from stage I to IV cases was 9.9% (16 of 161), 31.9% (15 of 47), 34.3% (23 of 67) and 25.6% (23 of 90). Patients with stage I disease had the lowest incidence but there were no statistically significant differences among stages II, III and IV disease. Of 77 patients with elevated serum alkaline phosphatase 48 had additional paraneoplastic manifestations. The disease specific 5-year survival rate in patients with normal serum alkaline phosphatase was significantly better than in patients with isolated phosphatase elevation, which in turn was better than in patients with multiple paraneoplastic syndromes (70.7 versus 50.5 versus 30.8%). Patients with persistent or recurrent elevation of serum alkaline phosphatase after radical nephrectomy had metastatic lesion or local recurrence. In some patients serum alkaline phosphatase returned to normal after nephrectomy but metastasis developed later without recurrent phosphatase elevation.

CONCLUSIONS

Paraneoplastic serum alkaline phosphatase elevation in renal cell carcinoma patients implies an unfavorable prognosis, and additional paraneoplastic syndromes further worsen the prognosis. Recurrent or persistent serum alkaline phosphatase elevation after radical nephrectomy suggests distant metastasis or residual tumor. However, the return of serum alkaline phosphatase to normal does not guarantee cure of the disease. Identification of paraneoplastic serum alkaline phosphatase elevation is valuable in the prediction of outcome and postoperative followup of renal cell carcinoma patients.

Clinical outcome at 3 months after transurethral vaporization of prostate for benign prostatic hyperplasia

OBJECTIVES

To evaluate the clinical outcome of transurethral vaporization of the prostate (TUVP) for the management of benign prostatic hyperplasia (BPH).

METHODS

Between March and June 1995, 30 patients with symptomatic BPH treated by TUVP were enrolled in this study. Transrectal ultrasonography (TRUS) was done preoperatively. American Urological Association (AUA) symptom score determination, pressure flow study, and questionnaire (for evaluating potency) were done preoperatively and 3 months postoperatively.

RESULTS

The average age was 70.5 years (range 60 to 83) and estimated prostate size by TRUS before surgery was 33.8 +/- 14.0 g. The average AUA symptom score decreased significantly 3 months after TUVP (6.2 +/- 7.8 versus 18.2 +/- 9.0; P < 0.01). The maximum urine flow rate (Qmax) was 11.1 +/- 3.7 mL/min before TUVP (mean +/- SD) and 17.0 +/- 6.5 mL/min 3 months after TUVP, whereas the detrusor pressure at maximum urine flow (Pdes at Qmax) was 61.0 +/- 23.9 and 41.2 +/- 15.2 cm H2O, respectively. Qmax increased and Pdes at Qmax decreased significantly 3 months after TUVP. Of the 30 patients, 3 (10%) developed bladder neck contracture. Of the 24 patients who were potent sexually before operation, 3 (12.5%) developed impotence 3 months after surgery.

CONCLUSIONS

TUVP is an effective alternative surgical procedure to relieve obstruction for patients with symptomatic BPH. However, cautious attitude on its usage is advocated based on our preliminary results indicating the occurrence of late complication such as impotence and bladder neck contracture.

Participation of paraventricular nucleus of hypothalamus in central regulation of penile erection in the rat

PURPOSE

To investigate the possible participation of the paraventricular nucleus of hypothalamus in central regulation of penile erection.

MATERIALS AND METHODS

Male adult Sprague-Dawley rats were anesthetized and maintained with pentobarbital sodium. The intracavernous pressure (ICP) was used as an experimental index for penile erection, and was recorded alongside systemic arterial pressure and heart rate. The effect on ICP of electrical (30-s train of 30-120 microA, 40-160 Hz, 1-ms rectangular pulses) or chemical (L-glutamate, 0.5 nmol/50 nl.) activation of the paraventricular nucleus of hypothalamus (PVN) or hippocampal formation was evaluated.

RESULTS

Electrical activation of the PVN elicited both multiple and single episodes of elevation in ICP, along with visible erection and ejaculation. The former pattern exhibited an increase in ICP that was more sustained, with higher peak amplitude and longer latency. Chemical stimulation of neuronal perikarya in the PVN also resulted in similar patterns of rise in ICP and visible erection. These effects were, nonetheless, not accompanied by significant alterations in systemic arterial pressure and heart rate. Activation of the hippocampal formation, as we reported previously, similarly elicited multiple and single episodes of increase in ICP. These erectile responses, however, were substantially reduced or eliminated upon electrolytic lesion of the ipsilateral PVN.

CONCLUSION

These observations suggest that the PVN may be an important nucleus that participates in central neural regulation of penile erection in the rat. Furthermore, an efferent pathway(s) from the hippocampal formation to PVN may constitute part of the neural circuitry in the forebrain in the regulation of erectile functions.

The route of seminal vesicle involvement in adenocarcinoma of prostate: lymphaticovascular or local extension?

BACKGROUND

Adenocarcinoma of the prostate with seminal vesicle involvement indicates a rather poor prognosis. The aim of this study is to evaluate the route of seminal vesicle involvement via lymphaticovascular or local extension, as a possible way which may determine the extent of disease as systemic or local.

METHODS

In a retrospective study of 32 patients who underwent radical prostatectomy for localized cancer of the prostate, medical records and imaging studies were reviewed, and the histopathological slides of the resected specimens were rechecked.

RESULTS

Of 32 patients, 12 (37.5%) had seminal vesicle involvement. Seven patients had involvement of bilateral seminal vesicles and five had unilateral involvement. Tumor cells invaded the muscle portion of seminal vesicle from the adjacent prostatic tissues in all 12 patients. Four of the seven patients with involvement of bilateral seminal vesicles developed bony metastasis 7 to 12 months after operation. No patient with unilateral involvement of seminal vesicle was found to have disease progression to bony metastasis during follow-up for as long as 39 months.

CONCLUSIONS

The route of seminal vesicle involvement in prostate cancer was through local extension in all of our patients. Involvement of bilateral seminal vesicles may have more chances to develop bony metastasis than unilateral involvement. Further study with a large number of patients is necessary to clarify the issue regarding the route of seminal vesicle involvement in adenocarcinoma of prostate.