Biomedical subjects
Publications and source records attributed to C B Brendler.
Recent neuroanatomical findings making it possible to intraoperatively identify the branches of the pelvic plexus that innervate the corpora cavernosa have been used to modify standard radical prostatectomy and cystoprostatectomy to prevent postoperative sexual dysfunction.
We used Ulex europaeus agglutinin I (UEAI)-immunoperoxidase staining of endothelium to study the accuracy of hematoxylin and eosin (H&E) diagnosis, occurrence, and significance of lymphvascular invasion in transitional cell carcinoma (TCC) of the bladder invading the lamina propria (Stage T1). Original histologic slides from cases (1967 to 1985) with and without vascular invasion were destained and restained with UEAI-immunoperoxidase. Only 5 of 36 biopsies originally diagnosed with lymphvascular invasion had tumor nests within endothelium-lined spaces. The 31 negative biopsies had extensive retraction artifacts lined by connective tissue and fibroblasts around tumor nests. Thirty-five control biopsies remained negative for lymphvascular invasion. Clinical follow-up of the five patients with proven lymphvascular invasion found three without progression of disease 3 to 10 yr postbiopsy, one dead of a local recurrence of TCC 1.67 yr postbiopsy, and one lost to follow-up. Based on this study, we feel that lymphvascular invasion by TCC in Stage T1 tumors is unusual, is frequently misdiagnosed on H&E stain, and does not necessarily portend a poor prognosis.
A common affliction of older men is bladder outlet obstruction secondary to benign prostatic hyperplasia for which the standard treatment is surgical prostatectomy. We report on six men with urinary retention from benign prostatic hyperplasia who were not medically able to undergo surgical prostatectomy but were successfully treated with the luteinizing hormone-releasing hormone (LH-RH) agonist, leuprolide acetate. This therapy is exemplified by the case of a sixty-six-year-old man with hemophilia B and urinary retention. The patient was treated with daily subcutaneous injections of 1 mg of leuprolide acetate, and prostatic size decreased from 132 g to 42 g, with initiation of spontaneous micturition while on treatment. For patients with symptomatic benign prostatic hyperplasia who are not candidates for surgery, treatment with an LH-RH agonist, such as leuprolide acetate, should be considered as a possible alternative.
Eleven patients with persistent urge incontinence and frequent side effects on oral anticholinergic agents were treated with oxybutynin chloride administered intravesically. Five mg. tablets were dissolved in saline, and the solution was instilled twice daily and retained for 30 minutes. One patient was unable to retain the medication because of severe detrusor hyperreflexia and was eliminated from the study. The remaining 10 patients all reported subjective improvement following treatment and all became totally continent. No side effects were observed. In these 10 patients mean bladder capacity increased from 224 to 360 ml. (p less than 0.01) and mean maximum filling pressure decreased from 33 to 24 cm. water (p equals 0.17). Two additional patients with continent ileocecal urinary diversions were treated with topical oxybutynin chloride instilled directly into the intestinal reservoir. Both patients reported improved comfort with filling and 1 demonstrated a decrease in uninhibited contractions. These encouraging results suggest that treatment with topical oxybutynin chloride is an effective alternative in patients with voiding dysfunction who either are unresponsive to or have intolerable side effects on oral medications.
Although response to intracorporeal pharmacological erection testing has been proposed to determine the etiology of impotence, physiological criteria predicting this response have not been established and the literature includes conflicting results regarding which patients respond to pharmacological erection therapy. In this study 37 impotent patients underwent a diagnostic nocturnal penile tumescence evaluation (including measurements of rigidity, pulsations and bulboischiocavernosus muscle activity) and the results were correlated with subsequent response to intracorporeal pharmacological testing. Most but not all patients with psychogenic impotence and all with neurogenic impotence responded with good erections. For vasculogenic impotence response rate depended upon impairment severity determined from nocturnal penile tumescence measurements; none of the severe cases versus 90 per cent of the milder cases responded. The results indicate that response to intracorporeal pharmacological testing does not accurately distinguish psychogenic from organic impotence, is best for neurogenic impotence and worst for severe vasculogenic impotence, and can be predicted accurately by nocturnal penile tumescence measurements.
Spontaneous rupture of the kidney or collecting system during pregnancy is an unusual condition. We report the sixteenth such case and, to our knowledge, the first case managed successfully with temporary insertion of a ureteral catheter. Based on our experience in this case, we recommend a modified approach to therapy for this condition.
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The usefulness of prostate specific antigen to predict final pathological stage was studied in 178 consecutive patients. Prostate specific antigen was determined preoperatively in all patients by a monoclonal immunoradiometric assay. All pathological specimens were examined for capsular penetration, seminal vesicle involvement and lymph node involvement. Prostate specific antigen correlated directly with capsular penetration (p less than 0.002), seminal vesicle involvement (p less than 0.02) and lymph node involvement (p less than 0.05). However the diagnostic accuracy of an elevated serum antigen level on an individual basis was only 55 per cent for capsular penetration and 50 per cent for seminal vesicle involvement and lymph node involvement. With a log-linear regression model, the half-life of prostate specific antigen was calculated to be 3.15 +/- 0.09 days. From the equation PSA (t) equals PSA (2) e[-0.2197(t-2)], prostate specific antigen can be used to detect residual cancer on day t in the immediate postoperative period. With respect to long-term followup, 127 patients have been monitored for longer than 2 months postoperatively with prostate specific antigen (mean followup 2 years, range 2 months to 8.6 years). Of the 101 patients who had favorable pathological findings at operation (organ-confined cancer or capsular penetration only) 92 (91 per cent) had a followup antigen concentration in the female range (0.0 to 0.2 ng. per ml.), whereas only 5 of 26 men (19 per cent) with either seminal vesicle involvement or lymph node involvement had an antigen value that was less than 0.2 ng. per ml. All patients with a documented clinical recurrence (8 of 127, 6 per cent) had an elevated followup serum prostate specific antigen concentration. These findings suggest that preoperative levels of prostate specific antigen are not sufficiently reliable to predict final pathological stage on an individual basis in patients with early prostatic cancer, and that the antigen is a sensitive tumor marker for the detection of residual disease after radical prostatectomy and subsequent recurrence of tumor on long-term followup.
We report on a 63-year-old man with persistent urinary retention owing to a large bladder diverticulum. To our knowledge this is the second case reported in the literature. A simple technique for excision of large vesical diverticula is described.
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The usefulness of clinical stage, serum prostatic acid phosphatase and preoperative Gleason grade in predicting final pathological stage in patients with adenocarcinoma of the prostate remains controversial. To determine the predictive value of these 3 preoperative variables we reviewed 275 patients with clinically localized disease who were treated between April 1982 and February 1986. All patients were examined preoperatively and subsequently were operated upon by 1 urologist. Serum prostatic acid phosphatase was determined in all patients by the Roy method using thymolphthalein monophosphate as the substrate. The Gleason grade of each prostatic biopsy specimen was determined preoperatively by 1 pathologist, who also examined the final pathological specimen with respect to capsular penetration, and seminal vesicle and pelvic lymph node involvement. Using logistic regression analysis with the likelihood ratio chi-square test, clinical stage and Gleason grade had a direct correlation with capsular penetration (p less than 0.0001 and less than 0.0001, respectively), seminal vesicle involvement (p less than 0.0001 and less than 0.0001, respectively) and positive lymph nodes (p less than 0.0001 and less than 0.0002, respectively). Within the normal range of values (0.0 to 0.8 IU/l.) serum prostatic acid phosphatase correlated directly with capsular penetration (p less than 0.003) and seminal vesicle involvement (p less than 0.01) but not with lymph node involvement (p equals 0.08). Again with logistic regression analysis we determined that the best predictors of final pathological stage are not individual variables but models that use combinations of preoperative variables. The models generated are as follows: capsular penetration--serum prostatic acid phosphatase and Gleason grade (p less than 0.00001), seminal vesicle involvement--clinical stage and Gleason grade (p less than 0.00001), and lymph node involvement--clinical stage and Gleason grade (p less than 0.00001). With these models probability plots have been constructed so that the final pathological stage in patients with clinically localized prostatic cancer can be predicted preoperatively.
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The pathophysiology of urethral prolapse has never been clearly elucidated. Following en bloc removal of the urethra, bladder, vagina, uterus and pelvic floor tissues from a 4-year-old burn victim with urethral prolapse at the time of death and from a female newborn cadaver, careful step-sectioning of the specimens at 5 mm. intervals for histological examination was performed. The anatomical defects of urethral prolapse noted were marked eversion of the urethral mucosa, vascular congestion of the "corpus spongiosum urethrae muliebris", and a cleavage plane between the inner longitudinal and outer circular-oblique smooth muscle layers of the urethra. We propose that urethral prolapse results from poor attachments between the smooth muscle layers of the urethra in association with episodic increases in intra-abdominal pressure. A clinical review of 12 cases revealed that at least 8 (67 per cent) had antecedent episodes of marked increases in intra-abdominal pressure. Obliteration of the cleavage plane between the smooth muscle layers is important for successful treatment of this lesion.
A relative enzymatic index has been developed which differentiates normal, hyperplastic (BPH) and malignant human prostatic tissues. Enzymatic activities have been calculated at Vmax conditions in 10 normal, 14 BPH and 11 carcinoma samples. Five enzymes have been assayed: 1) 5 alpha-reductase, 2) 3 alpha-hydroxysteroid oxidoreductase, 3) 3 beta-hydroxysteroid oxidoreductase, 4) 17 beta-hydroxysteroid oxidoreductase and 5) acid phosphatase. The following observations were made when comparing individual enzymatic activities between the 3 tissue groups: 1) mean 5 alpha-reductase activity was lower in carcinoma than in both normal prostate and BPH (p less than 0.05), 2) mean 3 alpha-hydroxysteroid oxidoreductase and 3 beta-hydroxysteroid oxidoreductase activities were greater in carcinoma than in BPH (p less than 0.05) and 3) mean acid phosphatase activity was higher in BPH than in both normal prostate and carcinoma (p less than 0.01). The absolute enzymatic activities were then expressed as relative activities by dividing each absolute value by the mean value for that enzyme in normal prostatic tissue. Relative enzymatic activities were used to derive the ratio: (Formula: see text) The mean value of this ratio was statistically different in normal, BPH and carcinoma tissue (p less than 0.01). The mean value was 3.6 times higher in BPH than in normal tissue, and was 3.8 times higher in normal tissue than in carcinoma. This suggests that BPH and carcinoma diverge in opposite directions biochemically from normal prostatic growth and supports histologic evidence that the 2 neoplastic conditions have a different pathogenesis rather than being part of the same disease spectrum.
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A unique form of acquired renal cystic disease occurs commonly in the end stage kidneys of patients with chronic renal failure. Recent experience with 3 cases of acquired renal cystic disease has made us aware that the condition has significant urological implications. The pathogenesis of this disease is unknown but may be related to tubular obstruction, ischemia or the accumulation of toxic products. The diagnosis of acquired renal cystic disease is established by either ultrasound or computerized tomography, both of which demonstrate bilateral multiple small cysts scattered throughout the cortex and medulla of the contracted end stage kidney. Acquired renal cystic disease usually is asymptomatic but may be associated with either hemorrhage or neoplasia. Autopsy studies have revealed renal tumors in up to 45 per cent of the patients with acquired renal cystic disease. These tumors usually are small but our case 3 was a renal cell carcinoma that measured 4 cm. in diameter. Also, there have been other recent reports of large tumors and deaths of metastatic renal carcinoma in patients with acquired renal cystic disease. Patients with chronic renal failure should undergo periodic examination of the native kidneys by either ultrasound or computerized tomography. It may be difficult to distinguish benign from malignant lesions radiologically, and nephrectomy may be indicated when the diagnosis is uncertain.