Cesar Ercole

The Value of Serum Prostate Specific Antigen Determinations Before and after Radical Prostatectomy

We evaluated serum prostate specific antigen before and after radical prostatectomy. In 100 consecutive patients who underwent radical prostatectomy, preoperative prostate specific antigen levels tended to increase with the increasing severity of pathological stage. However, even at levels of greater than 10 ng. per ml. the positive and negative predictive values (78 and 61 per cent, respectively) of prostate specific antigen to predict extracapsular disease were not sufficient to make this test useful alone for staging. In theory, after radical prostatectomy prostate specific antigen should be zero if no remaining prostatic tissue is present. Tests of precision and analytical sensitivity in our laboratory using a commercial prostate specific antigen assay revealed that a value of 0.4 ng. per ml. or more is different from zero at a greater than 95 per cent confidence level. With this guideline we evaluated the meaning of prostate specific antigen levels 3 to 6 months after radical prostatectomy in 59 men. Among men whose prostate specific antigen level was less than 0.4 ng. per ml. only 9 per cent demonstrated recurrence as evidenced by the development of positive bone scan or progressively elevated prostate specific antigen levels within 6 to 50 months. Alternatively, in men whose 3 to 6-month prostate specific antigen level was 0.4 ng per ml. or more there was evidence of recurrence in 100 per cent within 6 to 49 months (p less than 0.0001). Progressively elevated (more than 0.4 ng. per ml.) prostate specific antigen levels preceded recurrence from 12 to 43 months in all 6 patients who had positive bone scans, while increasing prostate specific antigen levels since radical prostatectomy have continued from 9 to 65 months in the 11 patients who have no radiological evidence of recurrent disease to date. Prostatic acid phosphatase serum values after radical prostatectomy were not useful to predict persistent disease. Prostate specific antigen values 3 to 6 months after radical prostatectomy are a sensitive indicator of persistent disease after radical prostatectomy and often precede other evidence of this occurrence by many years. This fact may alter concepts about surgical results, and possibly shorten and sharpen clinical studies involving adjuvant therapy after radical prostatectomy.

Prostatic Specific Antigen and Prostatic Acid Phosphatase in the Monitoring and Staging of Patients with Prostatic Cancer

Serum prostatic specific antigen and prostatic acid phosphatase levels were measured retrospectively and evaluated in 357 men with benign prostatic hypertrophy and in 209 men with various stages of prostatic carcinoma. Although prostatic specific antigen values were elevated in 21 per cent of the patients with benign prostatic hypertrophy, the elevations usually were low and did not interfere with clinical interpretation. Prostatic specific antigen was elevated in 98 per cent of 86 men with active stage D2 disease; in 22 per cent of the men prostatic specific antigen was the only elevated marker. In contrast, prostatic acid phosphatase was the only elevated marker in 1 per cent of the patients with stage D2 disease and neither marker was elevated in 2 per cent. Among 74 patients in whom prostatic specific antigen and prostatic acid phosphatase determinations were made before radical prostatectomy, prostatic specific antigen was elevated substantially (greater than 10 ng. per ml.) in 59 per cent (26 of 44) with extracapsular disease and in only 7 per cent (2 of 30) without extracapsular disease. More importantly, of those 28 patients with substantially elevated prostatic specific antigen levels 26 (93 per cent) had extracapsular disease. Serial serum measurements showed that prostatic specific antigen either reflected or predicted clinical status in more than 97 per cent of the patients. We conclude that prostatic specific antigen is an excellent serum tumor marker for monitoring patients with prostatic carcinoma and that it surpasses prostatic acid phosphatase in this regard. Prostatic specific antigen also may be useful in staging prostatic carcinoma and it may change our attitudes significantly about the therapeutic responses to this cancer.

Prevalence and effect of varicoceles in an elderly population

OBJECTIVES The prevalence of a varicocele in the adolescent and young adult populations is approximately 15%. Because other varicose veins increase in prevalence with advanced age, we hypothesized that the incidence of varicoceles in the elderly population would be greater and might affect testicular size, consistency, and function. METHODS As part of a prostate cancer screening program, we prospectively evaluated 354 men (mean age 60.7 years) by physical examination for the presence of a varicocele, testicular size, and consistency, and measured the serum testosterone level. RESULTS A varicocele was present bilaterally in 19.8% (70 of 354), left sided only in 22.0% (78 of 354), and right sided only in 1.1% (4 of 354) of patients. Decreased testosterone levels correlated with older age (P = 0.001) and the presence of bilaterally soft testes (P = 0.02) but not the presence of a varicocele. Testes in men with bilateral varicoceles were significantly smaller (P = 0.001) and softer (P = 0.001) than in men without varicoceles. Higher grade varicoceles were more likely to be associated with soft testes (P = 0.001) than were lower grade varicoceles. CONCLUSIONS The 42% prevalence of varicoceles in our elderly population was greater than that for historic control younger populations, suggesting either an increase with age or examiner sensitivity bias. Varicoceles in the elderly, especially when bilateral, significantly affect testicular consistency (softer) and testicular size (smaller), but do not directly decrease serum testosterone levels. The presence of bilaterally soft testes in elderly men indicates bilateral gonadal dysfunction and may be a physical examination finding associated with decreased serum testosterone.

Testicular Trauma: Potential Impact on Reproductive Function

PURPOSE The long-term effects of testicular trauma on reproductive function are unknown. In an effort to define the relationship between testicular injury and fertility in humans, we identified patients with a history of testicular trauma and assessed parameters commonly associated with fertility. MATERIALS AND METHODS We reviewed 15 patients 23 to 59 years old who underwent immediate exploration after testicular trauma between 1972 and 1991. Of the patients 11 were contacted and 8 returned for prospective followup. Reproductive and sexual histories, physical examination, measurements of serum hormones and antisperm antibodies, semen analysis and scrotal ultrasound were done. RESULTS Of the 8 patients 1 (13%) achieved and 7 (87%) did not attempt conception. Hormonal status was normal in all 8 patients. Six men had objective evidence of subfertility by semen analysis only, although none had severe oligospermia or asthenospermia and only 1 had severe teratospermia. Five of 9 traumatized testes were atrophic. Interestingly, only 1 patient had antisperm antibodies, the levels of which were probably low enough to be clinically insignificant. CONCLUSIONS There was definite evidence of subfertility as assessed by abnormal semen analyses and atrophic testes following testicular trauma. However, the subfertility did not appear to be immune mediated nor did the patients present with infertility. Since only 1 patient had severely compromised fertility according to semen analysis we conclude that early repair can help preserve hormonal function as well as fertility.

Changing surgical concepts in the treatment of priapism.

The treatment of priapism has changed significantly because of better understanding of the physiology of erection and of the pathophysiology of the disease. Several operative procedures have been advised to provide better venous drainage to the corpora. Herein we describe our experience with 20 patients. In 7 cases a modification of the cavernospongiosum shunt was used. This shunt is done under direct vision at the level of the proximal glans, thus, providing a better cavernosum-spongiosum shunt.

Nonintubated Anderson-Hynes Repair of Ureteropelvic Junction Obstruction in 60 Patients

We reviewed our experience with 68 consecutive Anderson-Hynes ureteropyeloplasties. The 64 infants, children and young adults ranged from 2 days to 28 years old (median age 2 years), and 28 were less than 1 year old. Intubation was used in only 4 patients: 2 who also underwent ureteral reimplantation for vesicoureteral reflux, 1 with stones in the renal pelvis and 1 with pyonephrosis. We successfully repaired 60 of 64 nonintubated renal units (93.4 per cent). Temporary postoperative ureteral stenting was required for extravasation from 8 renal units (12.5 per cent). Two patients later underwent repeat ureteropyeloplasty for recurrent obstruction. Nephrectomy was performed for pyonephrosis in 1 patient and for a nonfunctioning kidney that had exhibited poor function preoperatively in 1. Prolonged ileus necessitated extended hospitalization in 3 patients (4.6 per cent). We conclude that nonintubated dismembered ureteropyeloplasty for uncomplicated, primary ureteropelvic junction obstruction can be performed safely and successfully, and should be considered the standard treatment. Positioning of the Penrose drain is critical to avoid urinoma formation. When persistent urinary leakage occurs temporary diversion is easy and well tolerated. Hospital stay averaged 12.1 days for patients with extravasation compared to 4.3 days when no extravasation occurred. Immediate preoperative retrograde pyelography did not seem to contribute to postoperative urinary extravasation by causing edema of the ureteral orifice.

Cyclophosphamide associated bladder cancer : A highly aggressive disease : Analysis of 12 cases

PURPOSE We gained knowledge of the etiology, treatment and prevention of cyclophosphamide associated urothelial cancer. MATERIALS AND METHODS The medical records of 6 men and 6 women (mean age 55 years) with cyclophosphamide associated bladder cancer were reviewed. RESULTS All tumors were grade 3 or 4 transitional cell carcinoma. Of the 5 patients initially treated with endoscopic resection alone only 1 is alive without disease. Of the 6 patients who underwent early cystectomy 4 were alive at 24 to 111 months. The remaining patient with extensive cancer underwent partial cystectomy for palliation and died 3 months later. CONCLUSIONS Cyclophosphamide associated bladder tumor is an aggressive disease. However, long-term survival is possible when radical cystectomy is performed for bladder tumors with any sign of invasion and for recurrent high grade disease, even when noninvasive.

Prostate specific origin of dipeptidylpeptidase IV (CD-26) in human seminal plasma.

PURPOSE A number of peptidases which can metabolize certain bioactive peptides and growth factors have been identified in seminal plasma. Our goal in this study was to determine molecular properties and the tissue source(s) for one of these peptidases, dipeptidylpeptidase IV (DPP IV), in human seminal plasma. MATERIALS AND METHODS We measured the activities of DPP IV with the dipeptide glycylprolyl-p-nitroanalide and its molecular forms using immunoblotting of seminal plasmas of men who were vasectomized or with different sperm concentrations, and in prostatic and seminal vesicle secretions of men undergoing prostatic surgery. RESULTS DPP IV in seminal plasma of vasectomized men was a membrane associated dimer comprised of subunits of approximately 110 kDa. Its activity did not differ in seminal plasmas of vasectomized, azoospermic, oligozoospermic and normozoospermic men indicating no correlation with the concentration of sperm originally present in the semen. The DPP IV antigen (CD -26) and enzymic activity were present in prostatic secretion, but absent from that of the seminal vesicles. These data indicate that the prostate gland is the primary source of DPP IV activity in seminal plasma. There was little variation in its activities in repeat seminal plasma samples from the same individual, and there was no change in its activity with age to 50 years. CONCLUSIONS DPP IV in seminal plasma was derived from the prostate gland and it may be useful as a bioindicator of prostate function and/or disease with age in men.

Transurethral resection of prostate immediately after renal transplantation

The subject of transurethral resection of the prostate (TURP) after renal transplantation has not been evaluated in the urologic literature. We retrospectively compared the outcome of renal transplantation in 8 patients who underwent transurethral resection of the prostate within ten days of renal transplantation with 8 patients who did not undergo prostate surgery. Patients were computer-matched for seven parameters. There was no statistically significant difference in patient survival (6 vs 7) and graft survival (56% vs 88%) between the two groups. However, there was a 25 percent incidence of major perioperative complications (including one mortality) in the TURP group directly attributable to the procedure. Transurethral resection of the prostate can be safely performed immediately after renal transplantation only if urine is sterile, antibiotics and steroids are carefully administered perioperatively, low-gravity irrigation is used, and hemostasis is meticulous.

Modified Benchekroun Technique for Continent Ileal Stoma

The Guzman continent ileal stoma is constructed by a modification of the Benchekroun technique, which is based on the principle of the inkwell and collapse of the inner tube through retrograde filling of the valve. We used this procedure in 7 patients, all of whom are continent. During a followup of 6 months to 2 years no major complications developed. The stoma is easy to construct, has a low risk of evagination because the inner tube is stabilized with sutures and is easy to catheterize. It does not require staples, which reduces the chance of stone or fistula formation. The terminal ileum in continuity with the cecum or an isolated ileal segment can be used.