Luke S. Chang

Regulation of testosterone secretion by prolactin in male rats.

The goal of this study was to characterize the mechanism by which hyperprolactinemia alters testosterone production in rat testicular interstitial cells (TICs). Hyperprolactinemia was induced by grafting 2 anterior pituitary (AP) glands under the subcapsular space of the kidney in experimental rats. Control rats were grafted with brain cortex (CX). Six weeks post‐grafting, rats were challenged with human chorionic gonadotropin (hCG) then, the changes in either plasma testosterone or luteinizing hormone was measured. Additionally, TICs were isolated and challenged in vitro with hCG or prolactin, and the testosterone release measured by radioimmunoassay. Further investigation in signal transduction as intracellular 3′:5′ cyclic adenosine monophosphate (cAMP) production was observed under a regulation of forskolin or SQ22536. After the challenge of hCG or GnRH, the AP‐grafted rats showed a suppressed response in testosterone release as compared to those in the CX‐grafted group. The in vitro data from the AP‐grafted rats compared to the CX‐grafted animals showed a diminished response in testosterone release upon hCG stimulation. Administration of forskolin or SQ22536 disclosed dysfunction of adenylate cyclase in TICs from the AP‐grafted rats. When 8‐Br‐cAMP was incubated with TICs, the testosterone production was lower in the AP‐grafted compared to the CX‐grafted group. These results suggest that in addition to adenylate cyclase dysfunction, inefficiency of post‐cAMP pathways are also involved in the hypogonadism elicited by hyperprolactinemia in rats. J. Cell. Biochem. 74:111–118, 1999.

Changes in urinary output and electrolytes during gaseous and gasless laparoscopy

Urological laparoscopy has gained increasing acceptance recently. Alterations in renal water and electrolyte homeostasis by carbon dioxide peritoneal insufflation, retroperitoneal insufflation and abdominal wall lifting were measured in 30 well-hydrated pigs over a 2-h period. Oliguria was observed after gaseous insufflation but not after lifting the abdominal wall. Return to normal urinary output was observed at 30 min after release of pneumoretroperitoneum, and 60 min after pneumoperitoneum. Creatinine clearance declined, while the clearance rates of potassium, sodium and urea remained unchanged during peritoneal and retroperitoneal insufflation. An elevated serum aldosterone concentration was found which may mediate the increased urinary excretion of potassium and decreased urinary excretion of sodium found during peritoneal insufflation. Renal function remained stable, despite an elevation of serum creatine kinase being elicited after lifting the abdominal wall. In conclusion, significant changes in water and electrolyte homeostasis occurred during gaseous, not gasless, laparoscopy in pigs.

Direct needle insufflation for pneumoretroperitoneum: anatomic confirmation and clinical experience

OBJECTIVES The feasibility and safety of direct needle insufflation to create pneumoretroperitoneum was assessed by an imaging study and clinical experience. METHODS A total of 10 patients without previous retroperitoneal surgery or diseases received computed tomography scans of the retroperitoneum 2 cm above the iliac crest. Distances between quadratus lumborum and colon (Q-C distance) were measured in the supine and lateral positions. Changes of Q-C distance were calculated when the patient was changed from the supine to the lateral position. Operative charts on 38 retroperitoneoscopic procedures were collected prospectively to assess complications related to direct needle insufflation, which was performed by inserting a 14 G Veress needle blindly along the posterior axillary line 2 cm above the iliac crest. RESULTS Q-C distance increased from 8.7 to 27.3 mm (left side) and 4.6 to 18.1 mm (right side) when the patient was changed from the supine to the lateral position, both P values < 0.05. An average distance of 23 mm between colon and quadratus lumborum was found when patients were lying laterally. The misplacement of a Veress needle was encountered in 1 patient, in which a prefascia insufflation resulted in conversion of the endoscopic procedure. Needle puncture caused no visceral or great vessel injury. CONCLUSIONS Significant anterior movement of the colon was found when patients were changed from the supine to the lateral position. It provided a window for inserting the Veress needle blindly into the retroperitoneum. The high success rate (97%) and low complication rate of direct needle insufflation were found in actual clinical applications. We considered needle insufflation a safe and effective method of establishing a pneumoretroperitoneum for any retroperitoneoscopic procedure.

Laparoscopic ligation of bilateral spermatic varices under epidural anesthesia

Feasibility and safety of laparoscopic ligation of bilateral internal spermatic varices under epidural anesthesia were assessed in 11 patients. Another 11 patients undergoing the same procedure under ventilation-assisted anesthesia served as controls. Patients in both groups belonged to the American Society of Anesthesia functional class I. Arterial blood analyses were obtained (1) in the horizontal supine position; (2) in the 15 degrees Trendelenburg position; (3) at 15 min after carbon dioxide pneumoperitoneum insufflation, and (4) at 15 min after desufflation in the supine position. In the epidural anesthesia group arterial blood parameters and respiratory rate remained stable in the Trendelenburg position. After intraperitoneal insufflation of carbon dioxide for 15 min, the arterial carbon dioxide level increased from 40.1 +/- 2.2 to 42.1 +/- 2.6 mm Hg, the respiratory rate increased from 17.0 +/- 1.4 to 20.6 +/- 1.2/min, the blood pH value decreased from 7.386 +/- 0.027 to 7.355 +/- 0.034, all values showing statistically significant differences. These changes returned to the preinsufflation level 15 min after release of the pneumoperitoneum. The above-mentioned parameters remained unchanged under the pneumoperitoneum by assisted ventilation in the control group. The mean time of surgery was similar in both groups: 82 and 90 min for the groups having general and epidural anesthesia, respectively. All laparoscopic procedures were accomplished successfully under general anesthesia. However, failure to ligate the internal spermatic varices occurred in 3 patients under epidural anesthesia, mainly due to patient intolerance to abdominal distension. The operation was continued under intubated general anesthesia for relaxing the abdominal muscle to provide an adequate working space. In 8 patients being successfully operated under epidural anesthesia, 5 experienced mild but tolerable abdominal distension; 2 complained of shoulder pain intraoperatively. Although laparoscopic ligation of internal spermatic varices could be accomplished in some patients under epidural anesthesia, it carried a high failure rate, more intraoperative morbidity, and significant arterial blood gas alterations. Routine ventilation-assisted anesthesia is suggested for therapeutic laparoscopy even for an easy procedure such as the ligation of the internal spermatic varices.

Metastatic Tumors Involving the Testes

From 1979 to 1999, totally 200 cases of testicular tumor were diagnosed and treated at Taipei Veterans General Hospital. With the exception of lymphoma and leukemia, a total of 14 cases with metastatic tumor to the testis was collected. Eight cases(51.7%)were derived from adenocarcinoma of the prostate, 2 cases(13.6%) from lung cancer, 2(13.6%) from cancer of the gastrointestinal tract, 1(7.1%) from carcinoma of the seminal vesicles and 1(7.1%) from undetermined origin. There were 2 cases with bilateral testicular involvement(13.6%), and another 12 cases were unilateral involvement as well as all cases combined with multiple metastases. Nine cases(64.3%) presented with a scrotal mass without elevation of AFP or B-HCG clinically, and 5 cases were discovered incidentally ofter therapeutic orchiectomy due to adenocarcinoma of the prostate. One of the 14 cases was still alive. In the 13 expired cases, the average survival was 12.8 mo for the 7 patients with prostate cancer after orchiectomy and 7.4 mo for the 6 non-prostate cancer patients. Prognosis was very poor in metastatic carcinoma to the testis due to the late stage.

Tuberculosis of the Prostate

OBJECTIVE: To evaluate the clinical manifestations and management of tuberculous prostatitis at Taipei Veterans General Hospital. PATIENTS AND METHODS: Nine adult males presented to the urology clinic with an enlarged prostate. Clinically, a malignant tumor was suspected after digital rectal examination (DRE). Core needle biopsy was performed for further diagnosis at Taipei Veterans General Hospital during a period of over 10 years (from January 1989 to October 1999). They were well identified histologically. RESULTS: The histopathological sections depicted chronic inflammation in all cases and caseous necrosis in 7 patients (78%). Acid-fast stain revealed positive acid-fast bacilli (AFB) in 7 patients (78%). These cases were diagnosed as tuberculosis of the prostate and were treated with an antituberculous drug regimen. CONCLUSIONS: Tuberculosis of the prostate is sometimes difficult to differentiate from carcinoma of the prostate. Transrectal ultrasound-guided biopsy of the prostate allows a reliable diagnosis in tuberculous prostatitis. Therefore, it is recommended as the method of choice for diagnosis and follow-up, as has been advocated for the diagnosis of prostate cancer.

Kidney Trauma - A Review of 28 Cases

From March 1979 to ,28 patients with renal injuries seen at Veterans General Hospital-Teipei were reviewed. Sixteen injuries (57.1%) were caused by traffic accident, 4 (14.3%) by falling accident and 4 (14.3%) by stab wounds. Two of 24 patients (8.3%) had a normal urinalysis. One of 11 patients who received intravenous urography (IVU) normal finding. Computerized tomography (CT) was performed in 18 patients to find all with abnormalities. The most common one was perirenal hematoma (44.4%). Associated injuries were found in 17 of 28 patients (60.7%), and the most common were spleen rupture and hemothrax. Among 14 stable renal injuries initially treated conservatively, there were 4 complications including 3 cases of renal function deterioration and I case of elevation of blood pressure. The 14 injuries that were explored included 7 with shattered kidney (50.0%), 1 with renal pedicle injury (7.1%), 4 with renal laceration (28.6%) and 2 with renal contusion (14.3%). Two patients (7.6%) expired due to severe shock CT was more accurate than IVUin the diagnosis of renal trauma and the surgical treatment for renal laceration or fragmentation provides a satisfactory outcome.

Is Aspiration DNA Histogram a Feasible Method for Diagnosing Testicular Spermatogenesis

It often needs open testicular biopsy to get adequate tissue for daignosis by tradi-tional pathologic technique. Since the advent of flow cytometry, the deoxyribonucleic acid (DNA) histogram can be used to evaluate the spermatogenesis with the advantage of less specimen needed. The DNA histogram of testicular aspirate is performed on testes of 17 male Sprague Dawley rats by needles of three different size, 21G, 23G and 26G. These aspirates are incubated into phosphate bufgfer saline immediately, pro-pidium iodide (PI) staining is done within 4 hours. The success rates of aspiration to get adequate cells for analysis are 100%, 88.2%, and 76.5% by 21G, 23G and 26G needles respectively. The DNA histogram reveals characteristic pattern of normal sper-matogenesis in all of these aspirates. Another 17 specimens aspirated by 21G needle are incubated into normal saline instead. Although all these aspirates can get adequate cells, there is a decrement of the percentage of haploid cell (1C) compartment as compared with those incubated with Dulbeccos Modified Eagles Medium (72.1% vs. 62.7%,P value = 0.04). This may be caused by the gradual death of haploid cells such as spermatid or spermatozoae in normal saline before analysis. These testes are reeval-uated with traditional pathology and DNA histogram one month after the aspiration. Both of them show normal spermatogenesis. In conclusion, WE CONSIDER THE USAGE OF 21G needle for testis aspiration and culture medium incubation is a feasible and safe method for evaluating spermatogenetic function.(J UROL R.O.C., 2:359-364, 1991)

Changes of Serum Prostate-Specific Antigen before and After Transurethral Vaporization of Prostate for Benign Prostatic Hyperplasia

We conducted this prospective study in order to assess the effect of transurethral vaporization of the prostate(TUVP) on the serum level of prostate-specific antigen(PSA). Thirty patients (average age: 70.5 yr, range: 62-80) with symptomatic benign prostatic hyperplasia(BPH) and negative rectal examination for hard nodule were included for evaluation. Transrectal ultra-sonography(TRUS) and serum PSA were checked in every patient before surgery. Biopsy was done if PSA was greater than 10 ng/ml or f suspicious lesion was detected by TRUS. Serum PSA in the morning(ELISA PSA II method-monoclonal antibody) was checked before TUVP, and at 20 h, 2, and 4 weeks after TUVP. Serum PSA values(mean±SD) were 5.3±4.2, 20.5±9.1, 5.1±3.1, and 3.6±2. 3 ng/ml, respect-tively. Estimated prostate weights were 33.8±14.0g. PSA was elevated 3.85 times at 20 h after TUVP and then decreased gradually after that. Of the 30 patients, the PSA level returned to less than pre-operative level 2 wk after surgery in 10 cases (33.3%), and 4 weeks after surgery in the other 26 cases (86.7%). PSA level at 20 h after TUVP correlated well with the estimated weight of the prostate(by TRUS) and preoperative PSA status (r=0.83 and 0.82, respectively, p＜0.05). Serum PSA increased significantly at 20 h after TUVP then decreased gradually. The degree of postoperative PSA increase was higher for larger prostates and for patients with higher preoperative PSA levels. We recommend that checking serum PSA is preferably done at least 4 wk after TUVP to avoid influence from the surgical procedure.

Clinical Experiences of Primary Urothelial Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) is an unusual cancer in the urinary tract. In order to investigate the clinical status of primary urothelial SCC, we retrospectively reviewed the records of 12 patients treated at Veterans General Hospital-Taipei between January 1979 and April 1998. Mean age at diagnosis was 70 yr (range 48 to 84). Of these patients, SCC in 11 (92%) was found in the urinary bladder, and 1 (8%) in the ureter. The original specimen of I patient was not available. Of the other 11 patients, 4 (36%) had well-differentiated cancer, 4 (36%) moderately differentiated cancer, and 3 (2 7%) poorly differentiated cancer. Four patients (36%) presented with stage T2N0, 2 (18%) with stage T3N0, 3 (2 7%) with stage T4NQ, and 2 (18%) with stage N1. Mean follow-up period was 9.2 mo (range I to 23). Of 12 patients, 10 underwent surgery, I radiotherapy only, and I no treatment. The postoperative adjuvant treatments were added in 10 patients which included radiotherapy in 4 patients (40%), chemoradiotherapy in 2 (20%), and chemotherapy in 2 (20%). Six patients expired during the follow-up period. Their average survival time from diagnosis was only 5.5 mo. The cumulative survival rate at 23 mo was 40.9%. In conclusion, primary urothelial SCC is a rare cancer. Because most patients have advanced disease as well as moderately to poorly differentiated tumors at the time of diagnosis, the prognosis is grim.