Jack H. Mydlo

Urethrography and Cavernosography Imaging in a Small Series of Penile Fractures: A Comparison with Surgical Findings

OBJECTIVESnTo compare our results of preoperative corporal cavernosography and retrograde urethrography in penile fractures with the clinical and intraoperative findings.nnnMETHODSnFrom January to October 1996, 7 cases of penile fracture were diagnosed at our inner city trauma center. All cases were associated with sexual activity and patients underwent preoperative retrograde urethrography and corpus cavernosography with immediate surgical intervention.nnnRESULTSnWe found that 2 patients who presented with blood at the meatus had intact urethras, whereas 2 of the 3 patients who had urethral lacerations did not have a bloody meatus. In 2 cases the urethrogram and cavernosogram revealed lacerations that were not initially detected surgically. However, in another 2 cases, the urethrogram and cavernosogram were falsely negative. Two of the seven corporal fractures were bilateral and five were unilateral.nnnCONCLUSIONSnOn the basis of this small sample, it appears that preoperative cavernosography and retrograde urethrography may show additional sites of tears in the corpora and urethra because hematoma formation may mask some ruptures. However, the presence or absence of a bloody meatus may not necessarily correlate with the status of the urethra, and the urologist also should be wary of a false-negative imaging study. We suggest that all cases of penile fracture be explored surgically, but preferably by a subcoronal degloving incision that allows careful examination of the urethra and corpora. Results of a larger series may determine if the routine use of these imaging modalities is justified intraoperatively.

LONG-TERM CONSEQUENCES FROM BLADDER PERFORATION AND/OR VIOLATION IN THE PRESENCE OF TRANSITIONAL CELL CARCINOMA: RESULTS OF A SMALL SERIES AND A REVIEW OF THE LITERATURE

PURPOSEnPerforation of the bladder during transurethral resection is a worrisome complication for most urologists. Little is known about the consequences of seeding of tumor cells into the peritoneum or retroperitoneum. We reviewed several hospital patient databases as well as the literature to determine the outcome of such situations.nnnMATERIALS AND METHODSnWe performed a local multi-institutional case and MEDLINE review using key words, such as bladder neoplasm, neoplasm seeding, perforation, rupture, transurethral resection, peritonitis and tumor. We also contacted several urologists and oncologists at major cancer centers in the United States and Europe regarding the incidence and followup of perforated/violated bladder cancer cases.nnnRESULTSnThere were 16 bladder violations in the presence of transitional cell carcinoma, including 2 partial cystectomies that had negative margins and no subsequent metastatic recurrences, a bladder tumor that was detected during suprapubic prostatectomy and perforations during transurethral resection (extraperitoneal in 4 cases and intraperitoneal in 9). Two patients died of sepsis and existing metastatic disease, respectively. The only recurrence among the remaining 11 patients developed after intraperitoneal bladder perforation during transurethral resection for Ta grade 2 tumor. Several anecdotal reports discussed local and distal tumor recurrences, suggesting that even superficial transitional cell carcinoma can behave aggressively if grown in an environment outside the bladder. However, these reports are rare. Any benefit of prophylactic chemotherapy was not proved.nnnCONCLUSIONSnWhile perforation of the bladder during transurethral resection for cancer and the possibility of tumor implantation are matters of concern, our review demonstrates that few patients return with an extravesical tumor recurrence either locally or distally compared to those with a nonruptured bladder after resection. Although our patient sample is small and there are a limited number of reports in the literature, the risk of recurrence still exists and the urologist should be aware of its possibility. Since recurrences are usually rapid, they may easily manifest to the urologist at followup. However, one should also consider chest x-rays and/or computerized tomography to rule out recurrences that are not clinically obvious.

Initial Results Utilizing Combination Therapy for Patients with a Suboptimal Response to Either Alprostadil or Sildenafil Monotherapy

Objective: Intraurethral alprostadil and oral sildenafil are useful in selected patients. However, there continues to be a significant treatment failure rate. Since their mechanisms of action are different, we wanted to evaluate the effectiveness of combination therapy.Materials and Methods: Of 214 patients treated for erectile dysfunction (ED), 65 were not fully satisfied with the firmness of their erections via monotherapy. Responses were evaluated using the International Index for Erectile Function (IIEF) questionnaire before and after treatment. Group I consisted of 33 patients who tried maximal dose intraurethral alprostadil monotherapy initially, followed by the maximal dose of sildenafil monotherapy, and were still unsatisfied. Group II consisted of 32 patients who tried the maximal dose sildenafil monotherapy initially, followed by the maximal dose of alprostadil monotherapy, and were also unsatisfied. There 65 patients then underwent combination therapy.Results: 60 out of the 65 patients stated they were satisfied with combination therapy. Questionnaire scores for erectile function were 23.1±2.0 (114%) for combination therapy vs. 19.2±1.8 (77%) and 15.2±1.6 (41%) for sildenafil and alprostadil monotherapies (p<0.05). There were no significant differences in responses between the two groups. The men also reported improvement in intercourse and overall satisfaction.Conclusions: Combination therapy may be an option for motivated patients who have a suboptimal response from monotherapy.

An analysis of microvessel density, androgen receptor, p53 and HER-2/neu expression and Gleason score in prostate cancer preliminary results and therapeutic implications

Objectives: To investigate relationships between microvessel density (MVD), androgen receptors (AR), mutant p53 and HER-2/neu expression and Gleason score (GS) to further understand the tumor biology of prostate cancer (CAP). Methods: Slides of CAP from patients who underwent radical prostatectomy or channel transurethral resection of the prostate (TURP) were tested for androgen receptors by immunocytochemical assay and MVD was analyzed by staining with antibodies to the endothelial cell membrane molecule PECAM-1/CD-31. The p53 monoclonal antibody D07 and HER-2 9G6 mouse monoclonal antibody were used to assess p53 and HER-2/neu expression, respectively. The results were correlated with GS and clinical stage by multivariate analysis. Results: We found a fourfold greater expression of MVD in prostate cancer specimens compared to neighboring normal prostate tissue. We observed a greater concentration of MVD in the higher Gleason scores (r = 0.40, p = 0.06), and a correlation of Gleason score with mutant p53 expression (r = 0.57, p <0.05). We did not observe any associations between AR or HER-2/neu to Gleason score. More than half of the patients with specimens with 50% or greater expression of mutant p53 were in stage D2 (T4NxM1b) at the time of biopsy. Conclusions: We observed a correlation between mutant p53 and GS, and a greater concentration of MVD in the higher GS. Since the neovascularity of prostate tumors can be attenuated by radiation and hormones, while mutant p53 may confer resistance to such treatment, it appears that p53 expression may also play an important role in addition to angiogenesis in the virulence of prostate cancer. These data may aid in allocating patients to different treatment modalities.

Results from different patient populations using combined therapy with alprostadil and sildenafil: predictors of satisfaction.

Objective To evaluate the outcome of combined therapy (using intraurethral alprostadil and oral sildenafil) in private and clinic patients with erectile dysfunction, and thus assess predictors of satisfaction.

IS THERE A DIFFERENCE IN OUTCOME WHEN TREATING TRAUMATIC INTRAPERITONEAL BLADDER RUPTURE WITH OR WITHOUT A SUPRAPUBIC TUBE

PURPOSEnPrimary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury.nnnMATERIALS AND METHODSnWe reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed.nnnRESULTSnPenetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group.nnnCONCLUSIONSnThese data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.

Early CT findings of fournier’s gangrene in a healthy male

Early clinical identification of Fourniers gangrene is imperative to avoid delay in the aggressive surgical debridement, antibiotic therapy, and sometimes hyperbaric oxygen treatments. We report on the early computed tomography findings of a non-gas-forming Fourniers gangrene in a healthy male to aid urologists, surgeons, and radiologists in the recognition of this rapidly progressive and often fatal infection.

Differences in prostate and adipose tissue basic fibroblast growth factor : Analysis of preliminary results

OBJECTIVESnBasic fibroblast growth factor (bFGF or FGF-2) is mitogenic to human prostate epithelial and stromal cells, and it is reported to be elevated in the serum and urine of patients with various cancers, including prostate cancer. Obesity, with increased body fat, is a risk factor for prostate cancer through unknown mechanisms. Because adipose tissue is a source of FGF-2, we determined the quantity and quality of activity of FGF-2 in omental adipose tissue and compared it with normal and cancerous prostate tissues.nnnMETHODSnUsing heparin-Sepharose chromatography, we extracted proteins from human omental adipose tissue, adenocarcinoma of the prostate, and benign prostatic hypertrophic (BPH) tissues. Each of the mitogenic proteins eluted with NaCl concentrations between 1.4 M and 1.8 M, similar to control FGF-2. Using FGF-2 antisera (which inhibited the mitogenic activity of the proteins), we performed Western blot analysis to confirm their homology to FGF-2. We also assessed recovery, mitogenicity, and angiogenicity of each of the proteins using thymidine incorporation into human umbilical vein endothelial cells and the chorioallantoic membrane assay.nnnRESULTSnThere was greater recovery of FGF-2 from omental adipose tissue compared with cancerous or BPH homogenates (40 micrograms [2.0 micrograms/g] versus 25 micrograms [1.25 micrograms/g] and 20 micrograms [1.0 microgram/g], respectively). Moreover. FGF-2 from adipose tissue had greater mitogenic activity (96.2% versus 74.8% and 54%; P < 0.05) and a greater angiogenic activity (5.1 vessels versus 2.9 and 1.8 vessels; P < 0.05) on the chorioallantoic assay.nnnCONCLUSIONSnWe suggest that human omental adipose tissue FGF-2 may demonstrate greater mitogenic and angiogenic activity than either BPH or prostate cancer tissue FGF-2. It is not known whether FGF-2 from adipose tissue qualitatively or quantitatively may underlie the relationship between obesity and prostate cancer.

Growth factors in urologic tissues : detection, characterization, and clinical applications

During the last two decades, enormous strides have been made in understanding cellular and molecular biology. The direction of treatment of many neoplasms and other diseases are starting at the microscopic level. Growth factors are polypeptides that play a part in the development and maintenance of living tissues. We, as well as others, have investigated the role that growth factors play particularly in urologic tissues, both benign and malignant. We review several well-known growth factors and their function in prostate, kidney, and bladder tissues, as well as their functions in other regulating processes of the human body, and also the use of growth factors as tumor markers, and antibodies to growth factors as possible treatment of disease.

PRELIMINARY RESULTS COMPARING THE RECOVERY OF BASIC FIBROBLAST GROWTH FACTOR (FGF-2) IN ADIPOSE TISSUE AND BENIGN AND MALIGNANT RENAL TISSUE

PURPOSEnBasic fibroblast growth factor (bFGF or FGF-2) is mitogenic to numerous epithelial, mesodermal and endothelial cells, and thus may play a role in the neovascularity and progression of several tumors. Furthermore, FGF-2 is reported to be elevated in the serum and urine of patients with various cancers, including renal cancer. Obesity, with increased body fat, is a risk factor for renal cancer through unknown mechanisms. Since adipose tissue is a source of FGF-2, we determined the quantity and quality of activity of FGF-2 in omental adipose tissue and compared it to normal and cancerous renal tissue.nnnMATERIALS AND METHODSnUsing heparin-Sepharose chromatography we extracted proteins from human omental adipose tissue, renal cell carcinoma (RCC) and benign renal tissue (BRT). Using FGF-2 antisera we performed western blot analysis to confirm their homology to FGF-2. We also assessed recovery, mitogenicity and angiogenicity of each of the proteins using thymidine incorporation into human umbilical vein endothelial cells (HUVEC) and the chorioallantoic membrane (CAM) assay.nnnRESULTSnEach of the three purified mitogenic proteins eluted with NaCl concentrations between 1.4 M. and 1.8 M., similar to control FGF-2. There was greater recovery of FGF-2 from omental adipose tissue compared with renal cell carcinoma or benign renal tissue (42 microg. vs. 24 microg. and 18 microg., respectively; ANOVA p <0.05). Moreover, FGF-2 from adipose tissue had greater mitogenic activity (96.% versus 68% and 38%; p <0.05) and greater angiogenic activity (5.5 vessels versus 2.7 and 1.6 vessels; p <0.05) on the CAM assay.nnnCONCLUSIONSnWe suggest that human omental adipose tissue FGF-2 may demonstrate greater mitogenic and angiogenic activity than either benign or cancerous renal tissue FGF-2. It is not known if FGF-2 from adipose tissue may play a role in the relationship between obesity and renal cancer.