A mixture of cottonseed meal, soybean meal and animal byproduct mixture as a fish meal substitute: growth and tissue gossypol enantiomer in juvenile rainbow trout (Oncorhynchus mykiss)

Diets incorporating three different sources of extracted cottonseed meal (CM), soybean meal and an animal protein mixture were evaluated for juvenile rainbow trout. Fish averaging 0.96 g were divided into groups of 30; 3 groups per treatment, and each group was fed one of four diets for a 16-week period. Fish meal (FM) was replaced on a 25% protein basis by each of three different sources of CM from California (CA), Tennessee (TN), and Arkansas (AR), U.S.A. In the three CM-containing diets another 25% soybean meal protein and 50% animal protein mixture were also incorporated to completely replace FM protein. The results of growth rate and feed utilization showed that FM could be entirely replaced by a mixture of plant proteins (CM and soybean meal) and animal by-product proteins. Hematocrit levels were significantly lower in the group fed CM-containing diets than in the control. The findings suggest that CM can be used as a good protein source by the incorporation of at least 15% in diets (25% of fish meal protein replacement), and that the nutritive values of CM in juvenile trout can be different due to their different origin. Significantly higher concentrations of total gossypol were found in faeces of CM-TN (5.8 +/- 0.4 micromol/g) and CM-AR (5.6 +/- 0.6) groups than in that of CM-CA (3.7 +/- 0.4) group. It was documented that gossypol enantiomers, present in an equal proportion in diets, selectively accumulated in liver and bile, whereas equal proportions of (+)- and (-)-enantiomers were found in whole-body and faeces. Depending on CM source, fish can absorb approximately 35-50% of dietary gossypol, and the majority of the absorbed gossypol seemed to be excreted.

Reproductive efficiency and maternal-offspring transfer of gossypol in rainbow trout (Oncorhynchus mykiss) fed diets containing cottonseed meal

In a preceding study, complete substitution of fish meal protein with cottonseed meal (CM) protein did not affect the survival or growth rate of adult rainbow trout over a 6-mo period. Gossypol, a naturally occurring compound in cottonseeds, has an antifertility effect in terrestrial animals, but information regarding salmonid fish is lacking. Female rainbow trout in this experiment were fed diets with either 0, 25, 50, 75, or 100% (diets 1 to 5) of the fish meal protein replaced with CM protein until first maturation and spawning to study long-term effects on growth and reproduction. Feeding diets containing CM over a total period of 10 mo did not result in differences in growth and mortality compared to the control group (P > 0.05). Increased CM incorporation levels resulted in decreased (P < 0.05) blood hemoglobin (10.6 +/- 1.3, 8.4 +/- 1.8, 7.3 +/- 1.1, 6.9 +/- 0.8, and 5.6 +/- 1.4 g/dL) and hematocrit (49.6 +/- 3.9, 38.5 +/- 9.3, 34.4 +/- 3.7, 34.8 +/- 4.9 and 28.0 +/- 6.8%) levels in diets 1 to 5, respectively. The CM incorporation level had no effect (P > 0.05) on the number of eggs produced per female but led to a reduction (P < 0.05) in egg weight. Eyed stage survival of embryos was low in all dietary groups and did not show differences (P > 0.05). However, an increasing CM incorporation level led to a linear increase (P < 0.05) in the number of females that produced no viable embryos (23.1, 37.5, 42.9, 60.0, and 71.4%). Gossypol in the diet was absorbed by the female trout and transferred to the eggs (0, 2.2 +/- 0.5, 6.7 +/- 1.6, 10.6 +/- 4.2, and 20.0 +/- 2.6 micrograms/g in diets 1 to 5, respectively). A high concentration of gossypol remained in the juveniles at the swim-up stage (endogenous yolk-absorbed) (0.6 +/- 0.3, 2.4 +/- 0.3, 3.4 +/- 0.0, and 4.7 +/- 1.0 micrograms/g, diets 2 to 5, respectively). The findings suggest that replacement of the dietary fish meal protein with CM protein has no effect on fish growth and mortality but may lead to a reduction in reproductive performance in female rainbow trout.

Gossypol isomers bind specifically to blood plasma proteins and spermatozoa of rainbow trout fed diets containing cottonseed meal

We investigated the role of gossypol isomers binding to blood plasma, seminal plasma and spermatozoa to elucidate gossypol anti-fertility action in the teleost fish, rainbow trout (Oncorhynchus mykiss). Growth and hematological indicators of males were depressed when fish meal protein in diets was completely replaced with cottonseed meal. The cottonseed meal contained equal proportions of (-) (47.8+/-1.6%) and (+) gossypol isomers. Concentrations of spermatozoa were decreased with increasing proportions of gossypol in diets (from 0.22% to 0.95%); however, sperm motility and fertilizing ability were not affected. In contrast to mammals, steroid hormone concentrations were not suppressed in fish given diets with gradual increase of gossypol level. Gossypol concentrations were 100-fold higher in blood plasma than in seminal plasma, confirming a barrier in gossypol transfer between the general circulation and the testis. Spermatozoa accumulated predominantly (+) enantiomer (65-75%) with decreasing proportions as dietary gossypol concentrations increased. Spermatozoa bound most of the gossypol contained in the semen; however, this did not result in impairment of the sperm motility apparatus. Teleost fish sperm rely on ATP stores that accumulate during maturation as a source of energy during activation. In addition, the duration of sperm movement is short in these fish. As such, we hypothesize that the major action of gossypol on mammalian sperm, which is uncoupling of oxidative phosphorylation, does not impair the energy supply required for flagellar beating in fish spermatozoa.

Diagnosis and management of seminal vesicle cysts associated with ipsilateral renal agenesis: a pooled analysis of 52 cases

OBJECTIVE

Seminal vesicle cysts combined with ipsilateral renal agenesis represent a rare urological anomaly. We searched the literature to review the clinical presentation, diagnosis and therapeutic treatment options of this anomaly.

METHODS

A pooled analysis was performed of 52 cases of seminal vesicle cysts combined with ipsilateral renal agenesis, including our own observation. The evaluation included: patient age at diagnosis, race, laterality (R/L), presence of ureteral remnant in the cyst, presenting symptoms, diagnostic examinations, treatment and outcome.

RESULTS

The mean age at diagnosis was 30.2 years. The majority presented in the 2nd, 3rd and 4th decade of their lives. Only 2 patients (4%) were of African origin, all others were Caucasians. The distribution R:L was 2:1. Ureteral remnants were present in 14 patients (27%). The most common symptoms were: dysuria (37%), frequency (33%), perineal pain (29%), epididymitis (27%), pain following ejaculation (21%) and scrotal pain (13%). Infertility was found in 9 patients (17%). The cyst was palpable by digital rectal examination in 79%. All patients underwent intravenous urography, and 88% underwent cystoscopy. Other frequently performed investigations are: ultrasonography (27%), CT scanning (27%), vasovesiculography (46%) and urethrocystography (23%). The final treatment was open surgery in 74%, aspiration in 6%, transurethral deroofing of the cyst in 6% and spontaneous rupture in 4%. In 6% no treatment was given and in 4% the treatment is unknown. All patients were free of symptoms after open exploration. The success rates after transurethral deroofing and aspiration were 75 and 30% respectively.

CONCLUSION

Seminal vesicle cysts combined with ipsilateral renal agenesis are a rare urological anomaly, occurring in men in the 2nd to 4th decade of their life. They present with symptoms of bladder irritation and obstruction and with pain in the perineum and scrotum. Epididymitis is frequently found. The diagnostic work-up consists of a digital rectal examination, transrectal and abdominal ultrasonography, CT scan and a cystoscopy. Open surgery and transurethral deroofing of the cyst give excellent results (100 and 75% cure respectively). Aspiration of the cyst should only be used for diagnostic purposes.

Effects of diets containing gossypol on reproductive capacity of rainbow trout (Oncorhynchus mykiss)

We evaluated five practical diets in which 0%, 25%, 50%, 75%, and 100% (dietary treatments 1-5) of fish meal protein was replaced by solvent-extracted cottonseed meal protein. Adult rainbow trout (initial average weight 247 +/- 8 g) were fed the diets over a period of 131 days during which a general 2-fold body weight increase occurred. The total diet gossypol concentration (free and protein-bound) showed a gradual increase with increased cottonseed meal substitution. Blood samples were collected on Days 0, 64, 112, and 131 for hematological and steroid hormone determination in plasma of males and females. Hemoglobin content was significantly reduced in fish from treatment 5 (7.9 +/- 0.3 g/dl) in comparison to treatments 1-3 (10.3-10.9 g/dl). After 112 and 131 days of feeding, testis weights, concentrations of testosterone, and 11-ketotestosterone were elevated in fish from dietary treatments 2 and 3 in comparison to control and diets 4 and 5. On Day 71, sperm were collected from 6 fish per dietary treatment to assess sperm quality. No significant differences in sperm concentrations (7.2-9.8 x 10(9)/ml), motility (78-89%), and standardized (300 x 10(5) sperm/egg) fertilizing ability (18.9-22.6% hatched embryos) were found. Total gossypol concentrations in blood plasma differed significantly among treatments, and the levels were among the highest ever recorded in animals fed cottonseed-supplemented diets (2.9 +/- 0.2, 11.7 +/- 4.1, 21.7 +/- 1.4, and 29.9 +/- 3.9 microg/ml, for treatments 2-5, respectively). The major portion of gossypol in blood plasma was protein-bound (81-93%). This was in contrast to minute amounts of gossypol present in seminal plasma, mostly in free form (0.02-0.18 microg/ml), which indicates the presence of a barrier between general circulation and the testis with respect to gossypol distribution in lower vertebrates. Thus, the reproductive parameters of male rainbow trout examined in this study were not significantly affected by feeding cottonseed meal for 131 days.

Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. EORTC Genitourinary Group

OBJECTIVE

The authors present demographic and surgical data from a randomized phase III trial, instituted by the EORTC Genitourinary Group in 1988, the aim of which was to assess whether complete lymph node dissection in conjunction with radical nephrectomy for renal cell cancer is more effective than radical nephrectomy alone.

METHODS

Before surgery, the renal cell carcinoma was staged and judged to be nonmetastatic and resectable. The patients were randomized prior to surgery into those having radical nephrectomy combined with complete lymph node dissection or into those having radical nephrectomy alone. Postoperatively all patients were followed until progression of disease or death.

RESULTS

Of the 772 randomized patients, 41 were not eligible. 383 had a complete lymph node dissection together with a radical nephrectomy. 389 had a radical nephrectomy alone. The complication rate did not differ significantly between the two groups. A complete lymph node dissection in 336 patients revealed absence of lymph node metastases in 325 of them.

CONCLUSIONS

The present study shows that complete lymph node dissection does not add morbidity to the radical nephrectomy. After proper preoperative staging, the incidence of unsuspected lymph node metastases is low (3.3%).

Continuous of "pulse-and-withdraw" supply of ascorbic acid in the diet: a new approach to altering the bioavailability of ascorbic acid, using teleost fish as a scurvy-prone model

In scurvy-prone animals ascorbic acid uptake is regulated by the number of intestinal "brush-border" carriers available for transport. The number of carriers is negatively affected by an increasing dietary ascorbic acid intake, thus limiting the maximum attainable uptake. We tested a new approach towards manipulating the accumulation of ascorbic acid in rainbow trout by repeatedly feeding a 10 day ascorbic acid allowance in a 1 or 3 day "pulse" followed by withdrawal, rather than spread out over the entire 10 day period. Pulse dosing led to initially increased mortalities compared to continuous dosing, but this was reversed after 55 days. Although individual weight and cumulative mortality were not significantly different after 88 days, total liver ascorbic acid levels were significantly higher in the 1-day pulse group (16.3 +/- 3.9 micrograms/g) than in the 3-day pulse (9.8 +/- 0.9 micrograms/g) or continuous (9.3 +/- 0.9 micrograms/g) groups. This led us to conclude that after an initial adaptation phase a feeding profile with intermittent ascorbic acid withdrawal results in a compensatory increase in uptake of ascorbic acid from the diet and/or a better conservation of the body pool of ascorbic acid, opening interesting new avenues for ascorbic acid dosing and therapy.

Relationship between vitamin C and plasma concentrations of testosterone in female rainbow trout, Oncorhynchus mykiss

Two-year old rainbow trout females were fed diets containing 0, 30, 110, 220, 440 and 870 mg kg(-1) ascorbyl-2-monophosphate Mg(+) salt (groups 1, 2, 3, 4, 5, and 6, respectively) from August until March. At the time of spawning (February-March) blood was sampled and the ovulating females were hand stripped. Estradiol (E2) and testosterone (T) concentrations in plasma, and ascorbic acid (AA) concentrations in plasma and eggs were determined. The mean plasma concentrations of T were higher in group 4, 5, or 6 than in group 2 or 3 (p < 0.05). Moreover, the average plasma concentration of T in fish fed the diets with AA level below National Research Council (NRC) recommendations (groups 1, 2 and 3) was significantly lower (p<0.01) than the average plasma concentration in fish fed diets with AA level above NRC recommendations (groups 4, 5, and 6). These data are consistent with the hypothesis that AA can influence production of steroids in female rainbow trout.

Reproductive success of female rainbow trout (Oncorhynchus mykiss) in response to graded dietary ascorbyl monophosphate levels

Ascorbic acid is an essential nutrient in rainbow trout diets and has been shown to play an important role in fish reproduction. Recommended dietary levels are based on immature fish, and the specific requirements for brood stock are unknown. To establish the optimum dietary level for mature rainbow trout, six graded levels of ascorbyl-2-monophosphate were fed to groups of female fish over a period of 10 mo until spawning. Increasing dietary levels of ascorbyl monophosphate resulted in significantly increased ascorbic acid concentrations in liver, kidney, ovaries, and ovulated eggs. Liver and egg concentrations were saturable at 109.3 and 266.6 micrograms ascorbic acid/g tissue, respectively. Tissue saturation levels of 83.7% and 91.2%, respectively, were reached at the highest dietary level (870 mg ascorbyl monophosphate/kg diet) tested. Both fecundity and embryo survival increased significantly with dietary ascorbyl monophosphate levels. The results indicated that the present National Research Council recommended dietary level of 50 mg ascorbic acid/kg diet for rainbow trout is inadequate for brood stock fish. An amount 8 times higher is necessary to optimize tissue ascorbic acid levels and achieve maximum reproductive success.

The influence of age on treatment choice and survival in 735 patients with renal carcinoma

OBJECTIVE

To determine whether age is related to treatment choice and survival in patients with renal carcinoma.

PATIENTS AND METHODS

In this retrospective study 735 patients with renal carcinoma, diagnosed between 1982 and 1990 in one of the hospitals connected to the Rotterdam Cancer Registry, were evaluated with respect to treatment choice and survival.

RESULTS

Nephrectomy was performed less often in elderly patients, both with and without distant metastases. The resection rate for patients aged 70 years and older was 63% against 82% for younger patients (P < 0.001). Crude 5-year survival rates for patients aged 20-59, 60-69 and 70+ were 54, 38 and 22% respectively. For patients with tumours restricted to the kidney (Robson stage 1), corrected survival rates were 80, 70 and 48% respectively. The overall post-operative mortality was 3.8% and was not related to age (P = 0.73).

CONCLUSION

Treatment choice and outcome in patients with renal carcinoma were affected by age. As the proportion of patients aged 70 years and older, now 38%, will inevitably increase in the next decades, more attention is needed with respect to contra-indications for surgical treatment in the elderly.

Deoxyribonucleic acid ploidy of core biopsies and metastatic lymph nodes of prostate cancer patients: impact on time to progression. The European Organization for Research and Treatment of Cancer Genitourinary Group

We studied 98 patients with locally confined but lymph node positive prostatic cancer (1 stage T1, 29 stage T2, 55 stage T3 and 2 stage T4) who were not treated by radical prostatectomy. A retrospective analysis was done of deoxyribonucleic acid (DNA) ploidy of pretreatment core biopsies of the primary tumor and lymph node metastases. While DNA ploidy has been shown to be an important prognostic factor if applied to radical prostatectomy specimens, core biopsy specimens and nodal metastases have rarely been studied. Of the 98 patients 87 were evaluable for DNA ploidy: 45 (52%) had diploid, 13 (15%) had tetraploid and 29 (33%) had aneuploid tumors. The ploidy of the primary tumor and of the lymph node metastases correlated significantly with the rate of progression and interval to progression. Also, significant correlations were noted between the percentages of cells in the S phase or S plus G2 phases of the cell cycle and interval to progression. Most patients in this study are part of the European Organization for Research and Treatment of Cancer protocol 30846, a prospective randomized study of early versus delayed treatment in lymph node positive, otherwise locally confined prostate cancer. This study is ongoing. Early endocrine treatment was associated with a significantly longer interval to progression. In a Cox regression analysis of the prognostic factors involved in this study, early endocrine treatment was more important than ploidy or proliferation patterns. Stage (T category) and histopathological grade did not show a correlation with progression. Followup is still too short and the numbers of patients are too small for relevant subgroup analysis. DNA ploidy measurement by flow cytometry on archival (paraffin embedded) core biopsy and lymph node material is possible, and produces meaningful results in predicting the prognosis of prostatic cancer. Since this information can be made available before treatment decisions, its exact value in the management of locally confined prostate cancer can be determined.

Effects of estrogen deprivation on human benign prostatic hyperplasia

Sex steroids are thought to play an essential role in the pathogenesis of human benign prostatic hyperplasia (BPH). Since recent studies in animal models and in men have shown that estrogens might be causally linked to the onset and maintenance of BPH, we examined the effect of 1-methyl-androsta-1,4-diene-3,17-dione (Atamestane), a newly developed aromatase inhibitor, in men with BPH. In an open multicenter study 49 men (mean age 70.1 years, range 55 to 84) with obstructive BPH were treated with atamestane (3 x 200 mg/day) for 3 months. Of the 49 patients 44 completed the treatment period; the other patients discontinued the study for reasons unrelated to treatment. With treatment BPH-related symptoms such as daytime voiding frequency, nycturia, peak flow and residual urine improved considerably; however, these parameters did not reach statistical significance. The mean prostatic volume decreased significantly from 74.2 +/- 31.7 to 64.0 +/- 31 ml (mean +/- SD). Serum estrogen levels decreased markedly during treatment. In addition intraprostatic estrogen concentration decreased with treatment as compared to estrogen levels in hyperplastic prostates from untreated patients. The following conclusions can be drawn from this study: first, estrogens appear to have an important supportive role in established BPH, and second, estrogen deprivation improved BPH-related symptoms and reduced significantly prostatic volume.

Penile sensitivity in men with premature ejaculation and erectile dysfunction

Previous research indicates that penile sensitivity is typically lower in men with erectile dysfunction than in age-matched controls. On the assumption that sensitivity might be greater in men with short ejaculation latency (premature ejaculation), the present research investigated penile threshold (sensitivity) to vibrotactile stimulation in men with premature ejaculation, erectile dysfunction, or a combination of the two. Premature ejaculators showed thresholds commensurate with controls, while men with erectile dysfunction, or combined erectile dysfunction and premature ejaculation, showed significantly elevated thresholds. Although premature ejaculators did not show penile hypersensitivity, there was a significant correlation in this group between ejaculation latency and threshold. Overall, these findings argue against a primary role for penile sensitivity in ejaculation latency, and suggest that other somatic factors or cognitive factors may play the more critical role in premature ejaculation.

Surgical management of renal carcinoma with extensive involvement of the vena cava and right atrium

Between 1988 and 1990, 8 patients with a renal tumour extending into the vena cava and with supradiaphragmatic extension were treated by an operative technique involving extracorporeal circulation and deep hypothermic circulatory arrest. In 4 patients the thrombus extended into the right atrium. Six patients appeared to have a renal carcinoma. Intra-operatively one patient's tumour proved to be a metastasis of a squamous cell carcinoma of the lung and another patient was found post-operatively to have a leiomyosarcoma of the vena cava. Two of these 6 patients died from metastases 6 weeks and 8 months post-operatively. Four patients are symptom-free, although 3 of them have liver or lung metastases 10, 20 and 37 months post-operatively. One has no evidence of disease 18 months post-operatively. The use of extracorporeal circulation and deep hypothermic circulatory arrest provides optimal surgical exposure and gives the patients a considerable complaint-free interval post-operatively. How often cure is also achieved is as yet unclear.

Mitomycin C and aminoglutethimide in the treatment of metastatic prostatic cancer: a phase II study

In a phase II study, 24 patients with metastatic prostatic cancer were treated with mitomycin C 15 mg/m2 i.v. every 6 weeks, combined with aminoglutethimide 250 mg twice a day. A low dose of 37.5 mg cortisone acetate was supplied daily to compensate for adrenal cortical suppression. A partial response was demonstrated in 4 of 24 evaluable patients with bi-dimensionally measurable metastases. Stable disease occurred in 8 patients over a period of more than 6 months. Within the maximum cumulative dose limit of 2 mg/kg body weight mitomycin C, toxicity was observed in 21 cases, including 2 deaths due to treatment toxicity. The poor response rate and high toxicity suggest that the addition of aminoglutethimide does not enhance the effect of mitomycin C in these patients.

[Epidemiology and natural course of benign prostatic hyperplasia]

Benign prostatic hyperplasia (BPH) is a frequent condition in men over 50 years of age. At autopsy the histological characteristics of BPH are seen in 80% of all men older than 80 years. Although BPH is so frequent, its precise etiology is still unknown. Each of the various sources from which epidemiological data on BPH can be obtained has its own specific problems in terms of potential errors and biases, which have to be taken into account in interpretation of the data from these sources. There are clear differences in the incidence of BPH in various races. In negroids BPH is more frequent than in Caucasians, while in Asiatic races BPH is less frequent. However, in Asiatics BPH occurs more frequently in men who have immigrated into western countries. Age and hormonal status are well known to be involved in the development of BPH. Other factors, such as marital status, socioeconomic class, smoking, diet, diabetes, hypertension, and liver cir-rhosis have been implicated, but their relation with the risk of developing BPH has never been proven. The natural history of BPH is characterized by an age-dependent increase in histological changes and an increase in prostate size. The histological changes compatible with BPH are found in men below the age of 30 with an incidence of less than 10%. During the 6th decade, 42% of prostatic specimens have histological signs of BPH and during the 8th decade of life more than 80% of prostatic specimens. The histological changes of BPH precede prostatic enlargement by roughly 1 decade. There is an initial spurt of prostate growth during the period of maturation and puberty.(ABSTRACT TRUNCATED AT 250 WORDS)

Androgens and androgen-receptors in prostate tissue from patients with benign prostatic hyperplasia: effects of cyproterone acetate

Testosterone, 5 alpha-dihydrotestosterone and cyproterone acetate (CPA) were estimated in samples of prostate tissue, obtained from benign prostatic hyperplasia (BPH) patients who were or were not pretreated with CPA. Furthermore, these steroids were estimated in various fractions of the BPH tissue, and the number of nuclear androgen-receptor sites was determined. CPA-treatment caused a 4-fold, significant suppression of 5 alpha-dihydrotestosterone levels in total prostate tissue and its subfractions, without affecting testosterone levels or the androgen-receptor contents of the nuclear extracts. Nuclear concentrations of CPA were twice as high as those of 5 alpha-dihydrotestosterone. It is concluded that effects of CPA may have been caused through a combination of the following mechanisms: (1) suppression of peripheral androgen levels; (2) competition with androgens for (nuclear) androgen-receptors; and (3) suppression of prostatic 5 alpha-reductase.

Changes in penile sensitivity following papaverine-induced erection in sexually functional and dysfunctional men

To understand more clearly the role of penile sensitivity in sexual functioning, changes in penile thresholds resulting from papaverine-induced tumescence were studied in men who were either sexually functional or suffering from erectile dysfunction. Variable vibratory tactile stimulation was applied to 2 different sites, the base and tip of the underside of the penis. With standard psychophysical methodology, subjective thresholds were determined from a minimum of 5 threshold crossings. Results indicated a significant elevation in threshold after intracavernous papaverine injection, even though only partial erection was induced in most subjects. Men with erectile dysfunction had higher thresholds than control subjects but no difference in sensitivity was found between the base and tip of the penis. These findings indicate that low penile sensitivity is characteristic of some, although not all, men experiencing erectile problems and that this sensitivity is even lower during tumescence.

[A patient with a wide aorta and 2 wide kidney pelves: retroperitoneal fibrosis]

The case is discussed of a patient with renal insufficiency due to severe stenosis of both ureters brought about by a periaortic inflammatory process. Such periaortitis is seen in severe atherosclerosis; the condition allegedly occurs in 5 to 23% of all patients with an abdominal aortic aneurysm. The literature on this form of retroperitoneal fibrosis is reviewed.

Histological grading of prostatic carcinoma in prostatectomy specimens. Comparison of prognostic accuracy of five grading systems

The prognostic accuracy of 5 histological grading systems (Broders, Anderson, Mostofi, Gleason and Mostofi-Schroeder) was compared. Grading was performed on 50 prostatectomy specimens by 5 pathologists. The results were averaged so as to reduce the impact of inter-observer variation. The Cox proportional hazards model was used to estimate the relationship between average grading scores and both time-to-recurrence and time-to-death by prostatic carcinoma. Age at surgery was considered to be a possible confounding factor and adjusted accordingly. The prognostic impact of the 5 grading systems (related to both recurrence and death caused by prostatic carcinoma) was judged by the likelihood ratio (LR) test score (chi 2 distributed with 1 df); for time-to-recurrence for the Mostofi-Schroeder score the LR was 6.54 and for the Gleason system it was 1.79. A stepwise procedure demonstrated that the best prognostic performance was reached with the Mostofi-Schroeder and Broders systems used together (with Mostofi-Schroeder weighted 1.5 times larger than Broders). For time-to-recurrence the median grading result was also used, giving results similar to the mean grading result. For time-to-death from prostatic carcinoma the LR test scores for all grading systems were relatively low. In this analysis the outcome of the Gleason system showed a minimum of prognostic ability, whereas the Broders and Mostofi-Schroeder systems had a reasonable predictive ability. Since the inter-observer variation of the Mostofi-Schroeder system was large, the Broders system is preferable. The restrictions and implications of this study are discussed and a brief review of the prognostic importance of grading of prostatic carcinoma is presented.

Prolonged treatment with the GnRH analogue buserelin does not affect alpha-subunit production by the pituitary gonadotroph

Seven patients with metastatic prostatic cancer were treated with biodegradable implants of the GnRH analogue buserelin and six were treated with buserelin intranasally. After 4-24 weeks of treatment mean serum testosterone concentrations were significantly lower in the patients treated with implants than in those treated intranasally (0.7 vs 1.7 nmol/l respectively; P less than 0.01). Also, serum LH concentrations were significantly lower in the group treated with implants. Serum alpha-subunit concentrations were significantly higher than pretreatment values during buserelin treatment. However, the sum of the concentrations of alpha-subunit present either as free alpha-subunit or as a part of LH did not differ significantly from pre-treatment values after 8 weeks or more of buserelin treatment. During buserelin treatment serum LH concentrations measured by radioimmunoassay (RIA) were higher than those measured by immunoradiometric assay (IRMA). Cross-reactivity of alpha-subunit in the LH RIA accounted for many, but not all, of the observed discrepancies. We conclude that: (1) the principal long-term effect of prolonged buserelin administration on the pituitary gonadotroph is the suppression of LH beta production, while alpha-subunit production is not affected; (2) the serum concentrations of bioactive LH are better reflected by LH concentrations measured by IRMA than by those measured by RIA. (3) Subcutaneous application of biodegradable buserelin implants is more effective in suppressing serum LH and testosterone concentrations than intranasal buserelin application.

Morphometrically estimated variation in nuclear size. A useful tool in grading prostatic cancer

At present there are several grading systems for prostatic carcinoma. Most are difficult to reproduce. An objective method of grading seems to be necessary and could make comparisons between various groups of patients easier and grading more reliable. In the present study morphometrically estimated nuclear size and variation in nuclear size are matched with the survival rates of 207 patients who underwent total perineal prostatectomy for cancer. On the basis of morphometrically estimated variation in nuclear size the patients could be divided into two groups with significantly differing survival rates. In this way it was possible to split the group of patients with grade 2 carcinoma (Mostofi's grading system) into two groups of patients with significantly different survival rates. The survival rates in these two groups did not differ significantly from those in the patients with Grade 1 and Grade 3 tumors respectively. The results are discussed in the light of the recent literature on the subject. Morphometry seems to be a valuable tool in grading prostatic cancer.

Hearing loss and radiotelephony intelligibility in civilian airline pilots

Airline pilots with a mild to moderate hearing loss are regularly examined in the Netherlands National Aerospace Medical Centre. If this hearing loss exceeds the national hearing standards not only a tone-audiometric test but also routine speech-audiometry is performed. The maximal discrimination of phonetically balanced monosyllable words (20 word lists) in 16 airline pilots (32 ears) with such a hearing loss varies between 65%-100%. However, none of these pilots complains of a bad speech-intelligibility in the cockpit. This may indicate that there is a poor relation between the routine speech discrimination and the speech intelligibility in the working situation. We developed a "speech-audiometric" test (RT-test) which is completely based on the aviation jargon used in radiotelephony (RT) communications. In our group of 16 pilots the maximal discrimination in the RT-test was excellent. Even for ears with a maximal discrimination of 65%-70% in the routine speech-audiometric test the maximal RT-discrimination was 99%-100%. These pilots were all very experienced (average: 14,360 flying hours). Undoubtedly, this experience is of great importance in radiotelephony-intelligibility.

Erection problems in medical practice: differential diagnosis with relatively simple method

Functional sexual potency can be assumed when penile erection occurs during visual erotic stimulation, and to a lesser degree with normal nocturnal penile tumescence. Erection, increase in circumference as well as rigidity, can be measured with a simple device consisting of a calibrated felt band with a sliding collar fastened to 1 end. Subjects were 58 consecutive patients, mainly from a urology outpatient department, with erection problems and 67 healthy control men. Changes in penile circumference were measured during viewing of an erotic videotape and during sleep. Functional sexual potency, at least partially, was presumed to exist in 41 patients (71%), many of whom had a somatic pathological condition that might easily have been believed to be the cause of the erectile dysfunction. During the latter half of the study nocturnal penile tumescence also was measured. This group included 7 patients who did not respond to the visual stimuli, 5 of whom had normal nocturnal penile tumescence. We conclude that the erection meter, in conjunction with an erotic video test and nocturnal penile tumescence measurements, is a useful and simple device in the differential diagnosis of erectile difficulties in men. This is true especially when elaborate sleep laboratory facilities and neurophysiological equipment are not available.

Pharmacokinetics and endocrine effects of the LHR analogue buserelin after subcutaneous implantation of a slow release preparation in prostatic cancer patients

The pharmacokinetics and endocrine effects of the LHRH analogue buserelin [D-Ser(TBU)6-LHRH], released from biodegradable implants, were studied in 14 patients with stage C and D prostate cancer. Six patients received a subcutaneous implant of 3.3 mg buserelin monthly, and 8 patients received a subcutaneous implant of 6.6 mg buserelin every two months. Serum levels of buserelin decreased rapidly immediately after implantation. After 1-2 weeks a more gradual decline occurred, while in the two-monthly treated group a third phase of the elimination curve started after 5 weeks. Mean serum buserelin levels just before the next implantation in the two groups were not different. Urinary excretion of buserelin followed the same pattern. Serum LH levels in both groups became non-detectable 2 weeks after the first implant. This decrease of LH levels was accompanied by a suppression of serum testosterone to concentrations below 1 nmol/l (castration level). Side effects were not different from those observed with the intranasal application of buserelin. It is concluded that the subcutaneous application of buserelin is an easily administered form of treatment which has more profound and more reliable endocrine effects when compared with the intranasal administration of the drug. The greatest advantage of the new preparation is that the intervals between applications may be prolonged to at least 2 months.

Natural history of benign prostatic hyperplasia (BPH)

The natural history of a disease describes its course without treatment. Description may be related to anatomy, pathology, changes on physical examination, symptoms of the disease under discussion, and the changes of all these parameters with time. Most information related to morphology and prostatic size resulted from autopsy series. Histological changes compatible with BPH may be present in the human prostate as early as age 30 years. The normal weight of an adult prostate is in the range of 15-20 g (autopsy specimens). The human prostate undergoes two kinds of growth: the first one is related to puberty, the second one to the development of BPH. The first increase of prostatic weight is clearly related to the endocrine changes occurring with puberty; the reasons for prostatic growth with the development of BPH are unknown as yet but seem to be related to endocrine factors. BPH rarely or never develops in early castrates. The scarce available information also shows that BPH is present at ages 70-80 in 50-75% of males studied. Only a fraction of those males showing benign prostatic enlargement actually become symptomatic. The natural history of the symptoms and their development in time and in relation to prostatic mass or other related factors is largely unknown. The available information on this subject is reviewed. In Europe, the symptomatology of BPH is described commonly in stages I-IV. Death resulting from BPH is usually related to severe infection in combination with obstructive uropathy of the upper urinary tract. Death is rare and is prevented by timely treatment. BPH and prostatic carcinoma frequently occur in the same prostatic specimen. Considering the different location of both entities within the gland, their different incidence, the difference in morphology of their early manifestations within the fine structure of the prostate, and other factors suggest that both disease entities have a different etiology. The incidence of BPH and prostatic carcinoma increases steadily with age. It is likely that age-related endocrine factors contribute to the pathogenesis of this disease.

Treatment of benign prostatic hyperplasia by androgen deprivation: effects on prostate size and urodynamic parameters

The possible effect of medical androgen deprivation in the treatment of benign prostatic hyperplasia has been studied in 12 patients. Six patients received the luteinizing hormone-releasing hormone agonist buserelin and 6 others received the antiandrogen cyproterone acetate. The treatment resulted in an average decrease in prostatic size of 29 per cent after 12 weeks as measured by ultrasonography. This decrease led to an increase in peak urinary flow rate, a reduction in residual urine volume and a decrease in daytime voiding frequency. However, it caused no decrease in urethral resistance but only an increase in the bladder contraction strength. After discontinuation of the treatment the prostates showed regrowth to the initial sizes within 6 to 36 weeks. The urodynamic changes were reversed as well. Although statistically significant, the urodynamic changes were minimal from a clinical viewpoint and did not lead to an unobstructed state after 12 weeks of treatment. For this reason the clinical indication for use of medical androgen deprivation in benign prostatic hyperplasia patients will remain limited for the time being.

Renal function, serum calcium and magnesium during treatment of advanced bladder carcinoma with cis-dichlorodiamineplatinum: impact of tumour site, patient age and magnesium suppletion

In a group of ten patients, treated with cisplatin for advanced or metastatic urothelial cancer, renal function deteriorated in six. In a group of 28 patients, treated with cisplatin for tumours outside the urinary tract, renal function was impaired in 14 (50%). Renal function deterioration occurred more frequently in later life. Localization of the primary tumour in the urinary tract does not seem to predispose to renal function impairment. In contrast with reports in the literature, there was a significant decrease in serum calcium levels in spite of magnesium suppletion and normal serum magnesium levels. These calcium levels spontaneously returned to normal some months after the last treatment course with cisplatin.

Grading of prostatic cancer: II. The prognostic significance of the presence of multiple architectural patterns

This second report in a series of three deals with the prognostic importance of the presence of multiple, histologically identifiable architectural patterns in prostatic carcinomas. In the previous paper three of 12 parameters studied were identified as being prognostically significant in patients with single architectural patterns (formations) present in their tumors. The three parameters are nuclear anaplasia, architecture ("glands"), and mitoses, if present. The questions of whether "the worst part of a tumor determines prognosis" or "the presence of differentiated formations improves prognosis" are investigated by applying these parameters to patients with multiple tumor formations. Overall and corrected survival served as parameters. It was shown that the parameters shown to be of importance for prognosis in tumors with single formations also have significant influence in patients with multiple formations. The worst formation determines prognosis, but patients with poorly differentiated tumors do significantly worse if their tumor is homogeneous. The presence of better-differentiated formations improves the prognosis of the worst formation. The observations made are discussed in view of the histopathogenesis of prostatic cancer.

Grading of prostatic cancer: III. Multivariate analysis of prognostic parameters

This work is based on the two previous publications which are concerned with grading prostatic carcinoma. In the present communication the technique of multivariate analysis is applied to quantify the prognostic importance of parameters which were earlier identified as contributing in a significant manner to grading. The results of this analysis are used to construct a scoring system which differentiates five significantly different prognostic groups. When compared to the results of grading, the new system is shown to be superior. The large group of 228 patients with G2 tumors can be split into three groups, each with a significantly different prognosis. The correlation of the scoring system to local tumor extension (pT category) is described. Recommendations for grading of prostatic carcinoma resulting from this work are the following: Only three independent parameters are of significance for grading prostatic cancer: tumor architecture, nuclear anaplasia, and the presence or absence of mitoses. The combination of these parameters in a scoring system identifies five separate prognostically different groups. The separation achieved by this new system is superior to conventional grading and is suggested for grading prostatic cancer.

Grading of prostatic cancer (I): An analysis of the prognostic significance of single characteristics

This paper contains the first part of an attempt to quantitate the impact on prognosis of various parameters used in grading of prostatic cancer. Out of 346 patients of Elmer Belts series, 113 were identified whose tumors showed homogeneity with respect to single characteristics of a total of 12 parameters applied for grading in Mostofi's system. By this procedure it was possible to eliminate the possible influence on prognosis of the presence of several tumor formations within the same tumor. By using overall and intercurrent death corrected survival as end points, the impact of each of the 12 parameters on prognosis was studied. Only the architecture of the tumor (the parameter "glands"), variation in size and shape of the nucleus (anaplasia), and grade significantly influenced overall survival. In addition, corrected survival was significantly dependent on the amount of tumor seen and on the presence of mitoses. Subsequently, an attempt was made to replace "grade" by single parameters which had been shown previously to be of prognostic significance. It turned out that this was not possible. Grade is largely dependent on architecture and nuclear pleomorphism, but neither one of these parameters alone can reproduce "grade." Multivariate analysis was next used to further determine the prognostic weight of the individual parameter, and, if possible, to construct a new, more efficient grading system. These results will be reported separately [8]. It is unknown at the present time what the impact of several architectural formations within the same tumor on prognosis may be. The number of different formations found ranges from 1 to 4 in this material; 668 different formations belonging to 346 tumors were graded. The results of this analysis will be reported in part two of this series of papers [7].

Transrectal ultrasonography in the followup of prostatic carcinoma patients

Prostatic volume was determined by transrectal ultrasonography before and after castration in 13 patients, and after radiotherapy in 24. Measurements were done after 1, 2 and 3 months, and subsequently at 3-month intervals. Significant volume reductions occurred in the castration and radiation groups within 3 months. The decrease in prostatic volume was significantly more pronounced in the castration group during the entire study (p less than or equal to 0.01). Patients with enlargement of the prostate predominantly owing to benign prostatic hypertrophy also had a decrease in volume. No increase in prostatic volume after initial reduction was encountered for up to 9 months. In several cases progression of metastases occurred with no increase in the volume of the primary tumor. Followup may be too short to encounter local recurrence after radiotherapy or hormone-independent growth after castration. Proctitis after radiotherapy created artifacts that probably led to inaccurate measurements with ultrasonography. The technique provides a new, accurate parameter for followup of conservatively treated prostatic cancer patients. The clinical importance of the technique still remains to be determined.