Biomedical subjects
Publications and source records attributed to F C Lowe.
Epididymocutaneous fistula is a rare entity. A recent case in a patient with the acquired immunodeficiency syndrome and Marfan's syndrome led to this review. The patient's immunocompromised status as well as his past medical history necessitated special considerations in the diagnosis and management of his epididymocutaneous fistula.
Phytotherapeutic agents have enjoyed widespread use, especially in Europe, for the treatment of BPH. With the recent proliferation of nutrition and vitamin stores in the United States, use of these agents has greatly increased. Although SPB extract is the most extensively studied of the phytotherapeutic agents used for BPH, no well-defined mechanism of action has been proposed. Evidence for an antiandrogenic or antiestrogenic effect is conflicting, and there are no clinical data suggesting an effect on 5-alpha-reductase activity. Furthermore, clinical trials with SPB have largely been uncontrolled and are thus of limited value in ascertaining the true clinical impact of this agent. Double-blind, controlled studies with SPB also have limitations in that most were of very short duration (none longer than 3 months) and did not provide entry or exclusion criteria. In addition, standardized symptom scores were not utilized. Only two of seven studies showed an appropriate placebo response, and the results and conclusions of both these studies were contradictory. The best and most convincing study of the efficacy of phytotherapeutic agents (using Harzol) was recently published in the Lancet. This study was rigorous and matched in design and format with pharmaceutical industry trials. A mild but appropriate placebo response was detected, which further validates the study. However, a prior placebo-controlled study showed no efficacy of beta-sitosterol-beta-D-glucoside. This dichotomy of results possibly reflects the different composition of the agents tested. This is a major confounding factor in this field of study, especially because the active ingredients are unknown. Standardization of the compounds is needed to compare and assess accurately the effect of the different extracts.
This case of malignant fibrous histiocytoma of the testis/spermatic cord was found in a Holocaust survivor who was injected with an unknown substance in the left testicle while in Auschwitz concentration camp in 1943. Because malignant fibrous histiocytoma is a neoplasm rarely found in this location, with only 26 previously reported cases, a review of this entity was performed. A review of Nazi medical practices in the literature and through the Holocaust Museum research department was undertaken in an attempt to ascertain identification of the unknown substance injected into this patient; however, exact identification of the Auschwitz experiment or experimenter could not be determined. A left radical orchiectomy was performed, and subsequent histolopathologic review revealed a well-encapsulated 27 x 22 x 17-cm malignant fibrous histiocytoma. The left testis was not clearly identified due to necrosis of the tumor. This is the largest malignant fibrous histiocytoma of the spermatic cord/testis recorded in the literature to date. Based on the unusual location and size, the intratesticular injection probably contributed to the tumor development and certainly caused the patient's delay in seeking medical treatment.
PURPOSE: We determined whether early surgical intervention for ischemic penile gangrene in diabetics can be successful and limit morbidity. MATERIALS AND METHODS: A retrospective review was done of 7 diabetic patients with ischemic penile gangrene. RESULTS: Three patients underwent early distal penectomy without complications. All 4 patients initially observed suffered liquefaction and progression from dry to wet gangrene, and 2 underwent surgery (subtotal penectomy in 1 and distal penectomy in 1 who required reoperations for wound complications). CONCLUSIONS: With appropriate patient selection, surgical intervention can be successful and provide a better quality of life for those without terminal disease. Delaying intervention will usually require more extensive surgery and increase the risk of wound complications. However, observation is indicated for moribund hospitalized patients.
As the number of HIV-1 infected individuals and AIDS patients continues to increase, more cases involving the genitourinary tract will be encountered. Often, genitourinary manifestations will be the initial presentation of AIDS. Proper diagnosis will require awareness and a high index of suspicion. In addition to routine cultures, opportunistic infections with unusual organisms will require staining for fungi and acid-fast bacilli. Repeat cultures of blood, urine, seminal fluid, and abscess cavities may be required to establish a diagnosis. Prolonged courses of antibiotic treatment for prophylaxis and for relapses are usually required. Clinical understaging and rapid progression of tumors distinguish HIV-1-associated malignancies involving the genitourinary tract. Treatment for these malignancies will depend on the stage of HIV-1 infection. Any concomitant drug therapy and evidence of malnutrition will be important factors in selecting the proper timing and mode of therapeutic intervention. Although AIDS predominantly affects individuals between 30 and 50 years of age, an increasing percentage of patients over 50 years of age are being diagnosed. Common risk factors for acquisition of HIV include homosexuality or bisexuality and transfusion of blood or blood products. For the urologist, it is important to recognize that older patients more frequently present with AIDS at the time of diagnosis of HIV infection. A more rapid course of deterioration and high mortality is noted in this population. Clearly, protocols including surveillance, dosing regimens, and surgical intervention will need to be established and clarified to treat an anticipated increasing number of affected patients. In addition, it appears that adequate adherence to universal precautions is far from being achieved. Close monitoring and active surveillance of infection control may be needed to improve compliance.
Kaposi's sarcoma (KS) of the penis is a well-recognized manifestation of the acquired immunodeficency syndrome. Extensive KS of the genitalia progressed and caused penile gangrene in 2 cases. Management is palliative with urinary diversion via percutaneous suprapubic cystostomy.
OBJECTIVES: We developed a decision analytic model to compare the costs of treatment for an initial 2-year period with finasteride, terazosin, and transurethral resection of the prostate (TURP) in men with at least moderate symptoms of benign prostatic hyperplasia (BPH). Outcome measures were BPH treatment costs, duration of symptomatic improvement, and lost productivity days (work or other customary activity). METHODS: Patterns of health care resource use associated with the treatment of moderate to severe BPH and BPH-related complications were evaluated by a survey of urologists and validated by a urology consensus panel. BPH safety and efficacy studies in the published literature were used to provide probabilities of treatment success. Both a national health care resource database (Systemetrics) and Medicare data were used to estimate the costs of specific health care services (such as physician services and laboratory tests). RESULTS: The probabilities of first-year success (defined as symptomatic improvement) for surgery, finasteride, and terazosin were 88%, 67%, and 74%, respectively. The most expensive intervention was surgery, followed by finasteride and terazosin, at estimated 24-month costs of $6411, $2860, and $2422 for private insurance and $3874, $2161, and $1820 for Medicare, respectively. Duration of symptom improvement was comparable for the three treatments. Estimates of usual activity days lost (work or other customary activity) were 22, 8, and 8 days for surgery, finasteride, and terazosin, respectively. CONCLUSIONS: As a primary intervention for patients considering conventional clinical approaches to BPH treatment, pharmacotherapy is expected to be less expensive than TURP over the initial 2 years of therapy.
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OBJECTIVE: To review and assess the management and evaluation of prostatic abscess in patients with the acquired immunodeficiency syndrome (human immunodeficiency virus [HIV]). METHODS: Retrospectively reviewed 7 cases of prostatic abscess in HIV-positive patients treated at our institution. RESULTS: All 7 patients presented with fever and irritative voiding symptoms. Only 1 patient had a positive initial urine culture; 3 of 5 operative cases only had positive intraoperative culture. Organisms cultured were Staphylococcus aureus, enterococcus. Mycobacterium tuberculosis, and Mycobacterium avium. CONCLUSIONS: Transrectal ultrasonography is the imaging modality of choice for diagnosing this condition; it also directs the appropriate surgical approach. Transurethral unroofing should be attempted whenever significant extension outside the prostate is not found. Intraoperative cultures for aerobes, anaerobes, fungi, and mycobacteria must be obtained.
OBJECTIVES: This study reviews and assesses the safety of terazosin for the treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS: Six placebo-controlled trials (including two unpublished series) involving 996 patients provide the database for this evaluation. Six hundred thirty-six patients received terazosin from 1 to 20 mg daily for a total of 229 patient-years of exposure to terazosin. The most common final dose of terazosin was 10 mg once daily. RESULTS: Side effects were generally mild or moderate in severity and resolved following cessation of therapy. Side effects resulted in premature withdrawal in 9% of terazosin-treated patients and 7% of placebo-treated patients (difference not significant). Dizziness (2.0%) and headache (1.1%) were the most common symptoms leading to premature withdrawal from the studies. Although postural symptoms and dizziness were slightly more common in those terazosin-treated patients 65 or more years old compared with patients less than 65 years old, this difference was not statistically significant. Only 4 of the 636 patients (0.6%) had syncopal episodes; 2 of these occurred at initiation of terazosin therapy or at dose escalation. Minimal reductions in blood pressure were observed in normotensive patients and patients with hypertension controlled by concomitant medication, whereas patients with untreated hypertension had substantial decreases in both systolic and diastolic blood pressures. Statistically significant increases in high density lipoprotein to cholesterol ratio and reductions in total cholesterol, low density lipoprotein, and triglycerides were also seen. CONCLUSIONS: This combined analysis suggests that terazosin can be safely administered to both normotensive and hypertensive patients with symptomatic BPH.
OBJECTIVE: To assess the need for obtaining radionuclide bone scans in the staging evaluation of patients with newly diagnosed, untreated prostate cancer. This determination was made on the basis of presenting prostate-specific antigen (PSA) levels. DESIGN: Retrospective review. PARTICIPANTS: The medical records of 2064 consecutive patients with prostate cancer who were evaluated at the Mayo Clinic in Rochester, Minn, from January 1989 through December 1990 were reviewed. Eight hundred fifty-two patients with newly diagnosed, untreated disease and a serum PSA concentration less than 20.0 micrograms/L at presentation comprised the study population. MAIN OUTCOME MEASURE: The rate of false-negative results associated with using the serum PSA concentration to predict bone scan findings. RESULTS: Five hundred sixty-one patients had a serum PSA concentration of 10.0 micrograms/L or less; only three had an abnormal bone scan result, and one had an indeterminate scan result. Of the 467 men whose PSA value was 8.0 micrograms/L or less (two times the upper limit of the reference range), none had bone scan results that were either abnormal or indeterminate. The rate of false-negative results for an abnormal bone scan result was 0% with a serum PSA value of 8.0 micrograms/L or less and 0.5% with a cutoff level of 10.0 micrograms/L. The 95% upper confidence limit for the rate of false-negative results for all PSA cutoff levels less than 20.0 micrograms/L was less than 2%. CONCLUSIONS: For patients with newly diagnosed, untreated prostate cancer, a serum PSA concentration of 10.0 micrograms/L or less, and no skeletal symptoms, a staging radionuclide bone scan does not appear to be necessary. This clinical situation applies to 39% of all patients presenting with newly diagnosed prostate cancer. Since more than 130,000 new cases are diagnosed each year, approximately 50,000 patients are affected annually. If the $600 staging bone scan were eliminated for these patients, a significant economic savings to the health care system in this country would be effected.
Prolonged erections, priapism, secondary to pharmacologic stimulation are usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmacologically induced (prostaglandin E1) prolonged erections were randomized to receive terbutaline, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections.
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The principal role of PAP determinations in 1993 with the ready availability of reproducible serum PSA determinations would be in the identification of those patients with clinically localized prostate cancer who will not be candidates for surgical cure because of the high likelihood of having pathologic stage C or D disease. However, if you believe that radical prostatectomy offers good local control and palliation for clinically localized but pathologic stage C or D disease, then preoperative PAP determinations are not necessary. Also, if you believe that radical prostatectomy in conjugation with androgen deprivation therapy is appropriate for clinically localized but pathologic stage D1 disease, then, again, preoperative PAP determinations are not necessary. However, if you believe that radical prostatectomy is indicated only for those patients with organ-confined cancer, then ordering a preoperative staging Roy enzymatic PAP assay is indicated. Therefore, every urologist must know the type of assay and the substrate being used by his/her laboratory to interpret the PAP results properly; otherwise, patients with potentially curable cancer will not be offered a radical prostatectomy. In conclusion, PSA is superior to PAP for diagnosis, screening, and monitoring prostate cancer. Even though there are three assays for PSA, there is less confusion in interpreting the results than for PAP. The only specific area where the enzymatic PAP assay can be useful is in the identification of those patients with clinically localized disease but pathologically extensive disease; this is not important if you believe that radical prostatectomy offers good local control and palliation for pathologic stage C and D1 disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Computed tomographic (CT) evaluation of an abdominal mass diagnosed a huge 2-L congenital bladder diverticulum that caused urinary retention and ureteral compression leading to renal failure. The patient's renal failure resolved with decompression. His voiding dysfunction and retention resolved following diverticulectomy.
Squamous-cell carcinoma of the scrotum has a poor prognosis unless locally confined. Patients with stage A1 disease have approximately a 75% or better chance for long-term survival. Occupation-related and -induced scrotal carcinomas are less frequent now because of better hygiene, protective clothing, and awareness of the carcinogenicity of industrial oils. A rise in the incidence of the disease might result from the HPV epidemic. The basic treatment of squamous-cell carcinomas of the scrotum still depends on wide local excision of the primary lesion. Patients should be treated with a broad-spectrum antibiotic for 4 to 6 weeks prior to sentinel node biopsy or ilioinguinal lymphadenectomy. Sentinel node biopsy should be performed to rule out micrometastasis and to establish the need for a formal ilioinguinal lymphadenectomy. Radiation therapy has little therapeutic benefit in the management of squamous-cell carcinoma of the scrotum. Bleomycin might be useful as adjuvant therapy for widespread ilioinguinal disease before attempted resection, although this has yet to be proved.
AIDS is clearly the most lethal of all the STDs. The universal adherence to "safe" sexual practices is required in order to try to limit this epidemic. Unfortunately, the other forms of transmission of HIV, intravenous injection and via the fetal-placental circulation, have ensured that simply altering the sexual practices of society would not be sufficient to end this epidemic quickly.
The acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC) can be associated with nephropathy and renal failure. As the number of AIDS and ARC patients continues to increase dramatically, urologists will be called upon more frequently to help evaluate these patients for reversible causes of renal failure and to obtain tissue for pathologic diagnosis. Eight patients with ARC and renal failure were recently evaluated. Renal biopsies in 4 patients revealed focal and segmental glomerulosclerosis while 2 others showed proliferative and necrotizing glomerulonephritis with crescents. The implications of this study are that ARC patients with renal failure should be fully evaluated and be considered for long-term dialysis. However, the results of renal biopsies in these patients are unlikely to affect patient treatment.