Prostatic infarction associated with aortic and iliac aneurysm repair

Very high levels of PSA in patients with cardiogenic shock: Report of four clinical cases

Prostate-specific antigen (PSA) is the tumor marker most widely used in conjunction with digital rectal examination (DRE) for the early detection of prostate cancer (PCa). Due to its limitations, especially the high rate of false positive (FP) results, PSA screening of transplant candidates is a controversial issue. Moreover, obtaining a FP result in the PCa screening of heart transplant candidates may lead to potentially harmful effects. Although most of the factors that may cause PSA FP results are well known, FP results related to cardiogenic shock, a common indication for heart transplant, are less known. We studied retrospectively four patients who suffered cardiogenic shock during their hospital stay and became heart transplant candidates. Their PSA serum levels were very high suggesting the presence of PCa. Our findings have shown that elevated PSA serum levels in these patients were not related to PCa and they might be associated with cardiogenic shock. This clinical case study adds evidences to the fact that cardiogenic shock is an important cause of PSA FP results, therefore it cannot be used as a reliable marker of PCa in this clinical condition and positive results should be properly interpreted.

PSA levels in men with spinal cord injury and under intermittent catheterization

AIM

To evaluate serum PSA levels of patients with spinal cord injury (SCI) submitted or not to CIC in comparison to those of the general population.

METHODS

We retrospectively studied 140 men with SCI admitted in our department from January 2005 to May 2009. Thirty-four SCI patients had PSA levels available, comprising 21 under CIC and 13 without CIC. Patients under CIC performed it 4-6 times a day and mean time of catheterization was 72.4 months (range 30-192). The most common etiology of SCI was fall from height (33%), followed by car/motorcycle crashes (15%). Control group was composed by 670 healthy men that were referred to our service to evaluation of Kidney donation or cancer prostate screening. We used Student's t-test and variance analysis (ANOVA) for age and PSA comparison between the groups.

RESULTS

Overall, patients with SCI and controls had similar mean age (54 vs. 57 years old, P = 0.11) and mean PSA level (1.81 vs. 1.95  ng/ml, P = 0.66). SCI patients were divided into with and without CIC. Patients without CIC had similar mean age (60 vs. 57 years old, P = 0.11) and similar PSA values when compared to controls (1.72 vs. 1.95  ng/ml, P = 0.89). Patients under CIC were compared to controls with similar age (50 vs. 47 years, P = 0.0332) and their PSA levels were greater (1.86 vs. 0.79  ng/ml, P = 0.026).

CONCLUSION

Clean intermittent catheterization increased PSA levels approximately doubling its value.

Influence of cardiopulmonary resuscitation on levels of tumour markers

Tumour markers (TM), including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 15-3 and prostate-specific antigen (PSA), are serum markers for malignant diseases. Previous studies investigating the effect of acute and chronic inflammation, cardiopulmonary bypass surgery and cardiopulmonary resuscitation (CPR) on levels of TM showed conflicting results. Cardiopulmonary resuscitation (CPR) may result in a profound inflammatory response, and is frequently associated with severe tissue hypoperfusion. The present study investigated whether AFP, CEA, CA 15-3 and PSA are influenced by CPR. Alpha-fetoprotein (AFP), CEA, CA 15-3 and PSA (only in male patients) were assessed immediately after hospital admission, 6 h, 12 h and 2 days after prolonged CPR in eight male and 12 female patients. Serum levels of AFP, CEA, CA 15-3 did not change significantly after CPR. Prostate-specific antigen (PSA) levels increased significantly with a highest level in the study period 48 h after CPR (3.3 +/- 3.1 and 28.3 +/- 30.5 ng/mL for baseline and 48 h levels, respectively; P < 0.001). Alpha-fetoprotein (AFP), CEA, CA 15-3 and PSA (in men) values above the normal range were observed in 0%, 13.8%, 3.8% and 46.9% of all measurements respectively. At least one value above the normal range were observed in 0%, 20%, 5% and 75% of all patients for AFP, CEA, CA 15-3 and PSA (in men) respectively. Baseline values of AFP, CEA, CA 15-3 and PSA (in men) were above the normal range in 0%, 15%, 5% and 10% of all patients respectively. Levels for all markers did not differ significantly between survivors and non-survivors. In conclusion, prolonged CPR does not influence AFP, CEA, CA 15-3 serum levels, but is frequently associated with increases of PSA. Thus, in contrast to PSA, interpretation of AFP, CEA, CA 15-3 serum levels is not influenced by recent CPR.

Comparison of the effects of on-pump versus off-pump coronary artery bypass surgery on serum prostate-specific antigen levels

AIM

To compare the effects of coronary artery bypass operation with or without extracorporeal circulation on serum total prostate-specific antigen levels.

METHODS

Seventy-six men with a mean age of 57.04+/-9.27 years (range 44-77 years), who underwent coronary artery bypass surgery were enrolled to the study. In 50 patients (Group I), coronary revascularization was performed using extracorporeal circulation, and in 26 patients (Group II) coronary bypass grafting was performed on the beating heart without using extracorporeal circulation. All the patients had serum total prostate-specific antigen levels measured preoperatively and twice postoperatively in the first and fifth postoperative days. Differences in mean total prostate-specific antigen levels between the two groups in the postoperative period were analysed.

RESULTS

The mean preoperative total prostate-specific antigen levels in Group I and Group II were 1.28+/-1.13 ng/mL and 1.11+/-0.93 ng/mL, respectively, and there was no significant difference in the preoperative total prostate-specific antigen values between the two groups (P=0.519). In Group I, postoperative means were 4.96+/-6.29 ng/mL and 5.86+/-9.09 ng/mL in the first and fifth days, respectively (P=0.0001, P=0.0001). Total prostate-specific antigen means in the same postoperative period for Group II were 2.13+/-2.72 ng/mL and 2.00+/-2.20 ng/mL, respectively (P=0.014, P=0.024). The comparison of total postoperative prostate-specific antigen levels between the groups showed significantly higher elevation in Group I (postoperative day 1: P=0.013; day 5: P=0.05).

CONCLUSIONS

Coronary revascularization can cause a statistically significant rise in serum total prostate-specific antigen levels. This rise is more marked in patients undergoing conventional coronary revascularization.

Does ischemia-induced prostate damage during cardiac surgery involving cardiopulmonary bypass cause bladder outlet obstruction?

OBJECTIVE

This study sought to investigate whether ischemia-induced prostate damage during cardiac surgery involving cardiopulmonary bypass causes bladder outlet obstruction.

MATERIALS AND METHODS

The study involved 37 men who underwent elective cardiac surgery involving cardiopulmonary bypass. Prostate-specific antigen (PSA) levels were determined preoperatively (baseline) and on postoperative days 1, 5, and 30. In 4 cases, the PSA level after the operation was unchanged from the preoperative level, so these 4 men were excluded from the study. In the remaining 33 patients, symptoms of bladder outlet obstruction were assessed using the International Prostate Symptom Score. Each subject completed this test preoperatively and 3, 6 and 9 months postoperatively, and the means scores at these time points were compared. The effects of patient age, operative time, CPB time, and aortic clamping time on postoperative increases in PSA levels were investigated.

RESULTS

Thirty-three (89.2%) of the 37 men exhibited increased postoperative PSA levels compared to baseline. The mean PSA level for the 33 cases on day 5 was significantly higher than the baseline mean, but the mean levels on postoperative days 1 and 30 were comparable to baseline. Nine (24.3%) of the 33 men had postoperative PSA levels greater than 4.0 ng/dl (the upper normal limit). There was no significant difference between preoperative and postoperative International Prostate Symptom Scores.

CONCLUSION

The study indicates that men's PSA levels are, indeed, increased after cardiac surgery with cardiopulmonary bypass. However, in 9 months of follow-up, there was no association between this PSA rise and development of BOO, according to International Prostate Symptom Scores.

Infarct of the prostate gland: experience on needle biopsy specimens

Prostatic infarcts are uncommon and in the past have only been reported on transurethral resections of the prostate. We reviewed 13 consults and 2 nonconsult cases of needle biopsies showing prostatic infarcts from two institutions. The incidence of infarcts on biopsy were 2 in 2958 (0.07%) and 1 in 108,586 (0.0009%) in our nonconsult cases. Men averaged 71 years of age (range, 57-84 yrs). No relationship was seen with histories of hypertension, diabetes, atherosclerotic coronary vascular disease, recent surgery, and steroid use. Four of 12 men with available information had acute urinary retention, with markedly enlarged prostates in three (90 cc, 92 cc, 94 cc); two of these men had hematuria. An additional two men also had large glands (84 cc, 150 cc), one also with hematuria. Of eight men without acute urinary retention, three had sudden prostate-specific antigen (PSA) rises (increases of 199 ng/mL, 219 ng/mL, 287 ng/mL). Infarcts were usually an isolated focus on one core and varied from 1 mm to 11 mm (mean, 6.3 mm). Six cases showed earlier-aged infarcts with coagulative necrosis and recent hemorrhage and six showed intermediate-aged infarcts with reactive stroma and epithelium without necrosis. In the remaining three cases, there were remote infarcts characterized by replacement of the stroma by dense fibrosis with metaplastic glands. Adjacent tissue revealed reactive nests of immature squamous metaplasia in 14 of 15 cases with visible nucleoli (12 cases), squamous atypia (7 cases), and mitoses ranging from 1-10 (7 cases). Pathologists sent in 10 of 13 consult cases (77%) for problems with interpretation of the infarcts; remaining consults had other pathology of concern. One case was misdiagnosed as urothelial cancer. Features helpful in recognizing infarcts' benign nature were cyst formation containing cellular debris with or without neutrophils (73%), corpora amylacea (20%), and rings of collagen around squamous islands (40%). Infarcts are typically, although not exclusively, found in large prostates and may result in sudden rises in serum PSA. Infarcts' distinctive histology must be recognized and distinguished from necrosis resulting from infection and prior cryotherapy, as we have seen such misdiagnoses. Pathologists' awareness of prostatic infarcts on needle biopsy and their potential for atypical histology can prevent the misdiagnosis of cancer.

Elevation of prostate-specific markers after cardiopulmonary resuscitation

BACKGROUND-Prostate-specific antigen (PSA), acid phosphatase (AP), and prostatic acid phosphatase (PAP) are serum markers for adenocarcinoma of the prostate gland. Previous studies indicated that prostatic ischemia may also produce elevations of PSA. Cardiopulmonary resuscitation (CPR) is frequently associated with profound tissue hypoperfusion. The present study investigated whether PSA, AP, and PAP are influenced by prolonged CPR. METHODS AND RESULTS-PSA, AP, and PAP were assessed immediately, 12 hours, 24 hours, 2 days, 3 days, 5 days, and 7 days after prolonged CPR (>5 minutes) in 14 male and 5 female patients. No changes were noted in women. In men, serum levels increased significantly after CPR and gradually decreased to near baseline values after 7 days. PSA, AP, and PAP values above the normal range were observed in 63%, 71%, and 64% of all patients, respectively. Compared with survivors, nonsurvivors exhibited higher peak serum levels of PSA (98.6+/-14.3 versus 1.1+/-2.2 mcg/L; P<0.03), AP (57.0+/-71 versus 8.6+/-8.8 U/L; P<0.05), and PAP (47.0+/-62 versus 5.7+/-8.0 U/L; P=NS). Patients with poor neurological outcome exhibited higher peak serum levels of PSA (86.4+/-135.5 versus 12.0+/-23.8 mcg/L; P<0.05), AP (50.9+/-68.1 versus 8.7+/-9.6 U/L; P=NS), and PAP (41.6+/-59.5 versus 5.8+/-8.8 U/L; P=NS) than patients with good neurological outcome. CONCLUSIONS-Prolonged CPR is frequently associated with increases of PSA, AP, and PAP serum levels. Therefore, PSA cannot be used for diagnosis of adenocarcinoma of the prostate during the first weeks after CPR. Further evaluation of these parameters as additional prognostic markers after CPR is warranted.

Ischemic damage to the prostate during cardiac surgery: a clinical model

BACKGROUND

To determine if altered tissue perfusion during cardiac surgery results in ischemic tissue damage to the prostate, as suggested by a rise in prostatic-specific antigen (PSA).

METHODS

Twenty-nine male patients undergoing elective coronary artery bypass grafting were studied. Ten male patients undergoing elective gastrointestinal surgery served as controls. PSA levels were determined preoperatively and six hourly intervals postoperatively for 48 hr. All patients underwent urethral catheterization at induction of anesthesia.

RESULTS

All patients (100%) who had undergone cardiac bypass surgery showed rises in serum PSA during 48 hr of postoperative follow-up. At the 6-hr postoperative interval, the mean PSA was significantly different from the mean baseline value (paired two tailed Student's t test, P < 0.001) in 27 of the 29 (93%) patients. In contrast, the PSA values in the 10 gastroenterological controls did not change at 6 hr (P > 0.2) or during the next 48 hr. One patient in the cardiac group showed a very marked elevation in serum PSA of greater than 50 times normal preoperative levels.

CONCLUSIONS

Statistically significant rises in PSA levels are seen following coronary bypass surgery. This rise may be caused by ischemic nontrauma related damage to the prostate and suggests a possible pathophysiological mechanism for the clinically episodic symptoms of prostatism seen in elderly men.

Effect of elective prolonged urethral catheterization on serum prostate-specific antigen concentration

OBJECTIVES

To determine the effect of an indwelling catheter on prostate-specific antigen (PSA) levels. PSA is an organ (prostate)-specific marker, and its level can be elevated in various pathologies as well as following urologic manipulations. An elevated marker may indicate the presence of prostate cancer. In the presence of an indwelling catheter, our inability to decide whether an elevated PSA value represents genuine pathology or is related to the catheter itself is often of great clinical importance.

METHODS

A prospective study was conducted on 21 men with an indwelling catheter inserted electively for major nonurologic abdominal surgery to determine its influence on PSA concentration. Sera were collected before catheter insertion, 2 hours after, and then every day (average, 16 days). Catheters were left in place for an average of 5.5 days.

RESULTS

Follow-up data compared to baseline and to the previous day's PSA concentrations revealed no significant change in any of the subjects. In 2 men with elevated preinsertion PSA levels (more than 10.0 ng/mL), the change over time did not differ in magnitude from changes in the other 19 men with normal pretreatment values.

CONCLUSIONS

Inserting a urethral catheter and maintaining it for several days does not result in any clinically or statistically significant change in PSA levels. PSA values obtained in patients with an indwelling catheter are reliable and independent of its presence. An elevated level mandates prompt evaluation to exclude prostate cancer.

Molecular aspects of bladder outlet obstruction

In an animal model of obstruction, increasing load induces significant smooth muscle hypertrophy which is associated with a down-regulation of myosin heavy chain expression. This undoubtedly contributes to the decreased smooth muscle contractility seen in this model. Moreover, obstruction-induced hypertrophy leads to the development of a dedifferentiated smooth muscle phenotype, as evidenced by a revision of the cell to fetal (of non-muscle) gene expression patterns. Similar alterations are seen in atherosclerotic vessels and other pathologic smooth muscle systems. In these systems, dedifferentiation is also associated with significant alterations in extracellular matrix expression. It seems likely that obstruction in the bladder induces dedifferentiation of the smooth muscle cell which alters contractility as well as extracellular matrix expression, leading to altered bladder performance and decreased compliance.

Nontraumatic elevation of prostate specific antigen following cardiac surgery and extracorporeal cardiopulmonary bypass

We recently treated a number of patients with markedly elevated prostate specific antigen (PSA) levels associated with acute urinary retention in a post-cardiac surgery setting. A controlled study was conducted to determine if this elevation is secondary to trauma from urethral catheterization or more directly associated with the cardiac surgery and extracorporeal bypass. In 68 patients undergoing cardiac surgery serum PSA levels were determined preoperatively and 12 to 18 hours postoperatively (after urethral catheterization). The control patients were 23 men undergoing evaluation for chest pain in the cardiac care unit. The serum PSA level was markedly elevated in 38 patients (56%) after cardiac surgery. In contrast, only 1 control patient (4.3%) had an elevated level after urethral catheterization (p = 0.0001). The mean post-cardiac surgery PSA concentration was 9.14 +/- 16.08 ng./ml. (range 0.1 to 94.8) with a mean elevation of 528% (range -50 to 5,155%). This finding was statistically different from the mean post-catheterization level of 1.86 +/- 2.26 ng./ml. (range 0.2 to 9.1, p = 0.034) and mean elevation of 6% (range -50 to 100%, p = 0.0001) in the control patients. We conclude that cardiac surgery and extracorporeal cardiopulmonary bypass can cause a marked elevation in serum PSA that appears to be unrelated to urethral catheterization. Presently, the etiology of this elevation is unknown, although PSA measurements may eventually find use as a marker for prostatic damage associated with acute urinary retention in the postoperative setting.

Acute arterial insufficiency of the male genitalia

Three patients developed severe ischemia of the penis or scrotum from acute arterial occlusion. In one case, nonhealing ulceration of the glans developed after atheroembolism to the dorsal penile artery. One patient had penile ischemia after ligation of pelvic and femoral collateral circulation during repair of an aorto-bilateral-iliac artery aneurysm. A third patient had ischemia of the penis and scrotum from thromboembolism to the iliac arteries during repair of an aortoenteric fistula. Only seven patients have been described with acute arterial occlusion and severe ischemia of the male genitalia. A rare phenomenon because of rich collateral circulation, acute ischemia of the genitalia nevertheless must be recognized as a sign of severe vascular disease and a consequence of major arterial ligation or occlusion in the pelvis and groins.