White's operation: the history of 19th century attempts to treat prostate disease with castration

To understand the roots of 19^th century hormonal treatments for BPH in the career of J. William White, a prominent surgeon scientist at the University of Pennsylvania. We reviewed primary and secondary literature available in PUBMED, the University of Pennsylvania Archives, and internet resources. In 1893, Dr. White presented a series of experiments demonstrating atrophy of the canine prostate following castration and advocated for this procedure in men suffering from prostatic hypertrophy. This approach was adopted by many of White's contemporaries. In 1895, White presented findings from 111 patients and reported improvement of urinary symptoms in three quarters of these patients. Improvements in surgical techniques for prostatectomy have predominantly eliminated castration as a clinical procedure for BPH treatment. These early experiments demonstrated the critical dependence of the prostate on testicular androgens and were the basis for subsequent hormonal therapies for BPH. In conclusion, the bold experiments of late 19^th century surgeons paved the way for our contemporary understanding of the important role of sex steroid hormones in BPH.

Women in Leadership in Urology: The Case for Increasing Diversity and Equity

There is a persistent male gender predominance in urology, especially with respect to female representation in leadership. We review the current status of women in urology leadership, discuss challenges women face in leadership positions, present the case for adopting inclusive practices that increase diversity and gender equity in urology leadership, and review the potential benefits of such an expansion. We discuss practical strategies to grow the role of women in urologic leadership, including increasing mentorship, modifying academic promotion criteria, and addressing implicit bias, while presenting a roadmap toward achieving equity and diversity at the highest ranks of urologic leadership.

Nephrolithiasis in Pregnancy: Treating for Two

OBJECTIVES

To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines.

METHODS

A structured literature review was performed to determine highest quality of evidence guiding care for pregnant patients with symptomatic nephrolithiasis. PUBMED and EMBASE databases were searched using terms "pregnancy," "nephrolithiasis," or "pregnancy" and "renal colic" alone and in combination with "stone", "kidney stone," "ultrasound," "MRI," "CT," "percutaneous nephrostomy," "ureteral stent," or "ureteroscopy." All English-language abstracts were reviewed for relevance and full-length articles were reviewed for content. Articles published prior to 1990 were excluded, and priority for inclusion was given to multi-institutional studies and larger institutional studies, reflecting the highest level of current available evidence and most contemporaneous practice patterns.

RESULTS

Symptomatic nephrolithiasis affects less than 1% of pregnancies but poses unique diagnostic challenges due to the physiologic changes of pregnancy and risks of ionizing radiation exposure to the fetus. Ultrasound remains the imaging modality of choice. Most patients may be managed non-operatively, but drainage with percutaneous nephrostomy or ureteral stent may be performed if warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment.

CONCLUSIONS

Though rare, symptomatic nephrolithiasis poses significant clinical challenges due to the need to minimize risk for both mother and fetus with diagnostic and therapeutic interventions. A multi-disciplinary approach is paramount, as is shared decision making with the patient at each step of care.

Injection molded open microfluidic well plate inserts for user-friendly coculture and microscopy

Open microfluidic cell culture systems are powerful tools for interrogating biological mechanisms. We have previously presented a microscale cell culture system, based on spontaneous capillary flow of biocompatible hydrogels, that is integrated into a standard cell culture well plate, with flexible cell compartment geometries and easy pipet access. Here, we present two new injection molded open microfluidic devices that also easily insert into standard cell culture well plates and standard culture workflows, allowing seamless adoption by biomedical researchers. These platforms allow culture and study of soluble factor communication among multiple cell types, and the microscale dimensions are well-suited for rare primary cells. Unique advances include optimized evaporation control within the well, manufacture with reproducible and cost-effective rapid injection molding, and compatibility with sample preparation workflows for high resolution microscopy (following well-established coverslip mounting procedures). In this work, we present several use cases that highlight the usability and widespread utility of our platform including culture of limited primary testis cells from surgical patients, microscopy readouts including immunocytochemistry and single molecule fluorescence in situ hybridization (smFISH), and coculture to study interactions between adipocytes and prostate cancer cells.

Ultrasonography of the Adult Male Urinary Tract for Urinary Functional Testing

The incidence of clinical benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is increasing due to the aging population, resulting in a significant economic and quality of life burden. Transgenic and other mouse models have been developed to recreate various aspects of this multifactorial disease; however, methods to accurately quantitate urinary dysfunction and the effectiveness of new therapeutic options are lacking. Here, we describe a method that can be used to measure bladder volume and detrusor wall thickness, urinary velocity, void volume and void duration, and urethral diameter. This would allow for the evaluation of disease progression and treatment efficacy over time. Mice were anesthetized with isoflurane, and the bladder was visualized by ultrasound. For non-contrast imaging, a 3D image was taken of the bladder to calculate volume and evaluate shape; the bladder wall thickness was measured from this image. For contrast-enhanced imaging, a catheter was placed through the dome of the bladder using a 27-gauge needle connected to a syringe by PE50 tubing. A bolus of 0.5 mL of contrast was infused into the bladder until a urination event occurred. Urethral diameter was determined at the point of the Doppler velocity sample window during the first voiding event. Velocity was measured for each subsequent event yielding a flow rate. In conclusion, high frequency ultrasound proved to be an effective method for assessing bladder and urethral measurements during urinary function in mice. This technique may be useful in the assessment of novel therapies for BPH/LUTS in an experimental setting.

Evaluation of Thickened Fluids Used in Dysphagia Management Using Extensional Rheology

Recent studies show that understanding the rheological properties of thickened fluids, such as viscosity and yield stress, is advantageous in designing optimal thickened fluids for the treatment of dysphagia. To date, these studies have focused on the rheological behavior of thickened fluids in shear deformation, while limited information is available on the surface tension of thickened fluids or their rheological behavior in extensional deformation. Knowledge of the extensional properties of thickened fluids (extensional viscosity and cohesiveness) is important to fully understand the behavior of such fluids while swallowing. Our aim in this work, therefore, was to characterize water and skim milk thickened with a commercial thickener (xanthan gum based) to determine extensional deformation and surface tension properties. It was observed that the surface tension decreases as the thickener concentration increases due to the accumulation of the biopolymer at the surface of the fluid when it dissolves in water. In addition, the extensional viscosity of the fluid increased over time as the filament thinned (i.e., as the Hencky strain increased) until it reached a plateau. It was observed that the maximum extensional viscosity, which is related to the cohesiveness of the fluid, increases with the higher concentrations of thickener. However, the cohesiveness of thickened skim milk was lower than that of the thickened water at a given thickener concentration due to lower surface tension. This study confirms that by increasing the concentration of thickener, it will not only increase the shear viscosity (i.e., bolus thickness) of the fluid, but also the extensional viscosity (i.e., bolus cohesiveness).

Tissue-specific quantification and localization of androgen and estrogen receptors in prostate cancer

Androgens and estrogens, working together, promote prostate cancer (PRCA) initiation and progression, with androgens acting via androgen receptor (AR) and estrogens acting primarily through estrogen receptor α (ERα). While the interplay between these steroid hormones has been established, the interaction between steroid hormone receptors in prostatic disease remains unstudied. The goal of this study was to objectively determine the incidence, stage specificity, and tissue/cell type specificity of AR and ERα expression, both independently and simultaneously, during the progression of PRCA. Using multiplexed immunohistochemistry and multispectral imaging analysis, AR, ERα, and smooth muscle α-actin expression was detected and quantitated in benign prostate tissue (BPT), high-grade prostatic intraepithelial neoplasia (HGPIN), PRCA, and metastasis (MET) from patient specimens (n=340). Epithelial AR expression was significantly increased in HGPIN, PRCA, and MET compared with BPT, whereas ERα expression in epithelial and stromal cells was highest in HGPIN. With analysis of AR and ERα coexpression, we identified a unique population of double-positive (AR⁺/ERα⁺) cells that increased in HGPIN specimens in both the stroma and the epithelium. Double-negative (AR^-/ERα^-) cells significantly decreased across PRCA progression, from 65% in BPT to 30% in MET. Preliminary analysis of this AR⁺/ERα⁺ population indicates potential cell type specificity in smooth muscle α-actin-negative stromal cells. This study demonstrates stage-, tissue-, and cell type-specific AR and ERα expression changes during PRCA progression, both independently and coexpressed. A more complete understanding of steroid hormones and their receptors in the initiation and progression of prostatic disease may elucidate improved strategies for PRCA prevention or therapy.

Endocrine disruptor bisphenol A is implicated in urinary voiding dysfunction in male mice

Estrogens, acting synergistically with androgens, are known from animal experiments to be important in lower urinary tract symptoms (LUTS) and benign prostate enlargement. Human exposure to environmental estrogens occurs throughout the life span, but the urologic health risks in men are largely unknown. Bisphenol A (BPA) is an endocrine disruptor implicated in male urogenital malformations. Given the role of estrogens in male LUTS, we studied the effects of BPA administered in combination with testosterone (T) on the urinary voiding behavior of adult male mice. Adult male mice underwent subcutaneous implantation with slow-release pellets of 25 mg BPA or 2.5 mg estradiol-17β (E2), plus 25 mg T, and were compared with untreated (UNT) mice that underwent sham surgery. We studied urinary voiding behavior noninvasively for 1 mo before treatment and for 4 mo after treatment. After euthanasia, we evaluated bladder volume and mass. Mice treated with T+BPA had increased bladder volume ( P < 0.05) and mass ( P < 0.01) compared with UNT mice. After 4 mo of treatment with T+BPA, three of five mice developed voiding dysfunction in the form of droplet voiding or an intermediate pattern of voiding different from both UNT and T+E2-treated mice. Treatment of male mice with BPA or estradiol induces voiding dysfunction that manifests at later time points, implicating the endocrine disruptor, BPA, as a contributor to male LUTS.

Estrogen receptor-α is a key mediator and therapeutic target for bladder complications of benign prostatic hyperplasia

PURPOSE

Estrogens are important in prostate growth and have a role in benign prostatic hyperplasia. However, to our knowledge no current therapy directly targets estrogen action. Estrogens act primarily via estrogen receptors α and β. In a mouse model we evaluated the relative contribution of these receptors to bladder complications of benign prostatic hyperplasia. We also evaluated the prevention of these bladder complications using the selective estrogen receptor modulators raloxifene and tamoxifen (estrogen receptor-α selective antagonists), and R,R-THC (estrogen receptor-β selective antagonist).

MATERIALS AND METHODS

Adult male C57bl/6 mice received implants of 25 mg testosterone and 2.5 mg 17β-estradiol slow release pellets. Untreated controls underwent sham surgery. We evaluated the contributions of the estrogen receptor subtypes in ERαKO and ERβKO mice compared to their respective wild-type litter mates. Wild-type mice treated with testosterone plus 17β-estradiol were compared to mice treated with testosterone plus 17β-estradiol and 25 mg selective estrogen receptor modulators to evaluate the prevention of benign prostatic hyperplasia complications by selective estrogen receptor modulators.

RESULTS

Large bladders with urinary retention developed in ERαWT and ERβWT litter mates treated with testosterone plus 17β-estradiol but such bladders did not develop in ERαKO mice treated with testosterone plus 17β-estradiol. ERβKO mice treated with testosterone plus 17β-estradiol had large bladders with urinary retention and increased bladder mass. Cotreatment with the estrogen receptor-α antagonist raloxifene resulted in decreased bladder mass compared to that in wild-type mice treated with testosterone plus 17β-estradiol. Bladders in mice treated with the estrogen receptor-β antagonist R,R-THC were similar to those in testosterone plus 17β-estradiol treated mice.

CONCLUSIONS

Estrogen receptor-α but not β is a key mediator of bladder complications of benign prostatic hyperplasia and a potential target for future therapies.

Renal capsule xenografting and subcutaneous pellet implantation for the evaluation of prostate carcinogenesis and benign prostatic hyperplasia

New therapies for two common prostate diseases, prostate cancer (PrCa) and benign prostatic hyperplasia (BPH), depend critically on experiments evaluating their hormonal regulation. Sex steroid hormones (notably androgens and estrogens) are important in PrCa and BPH; we probe their respective roles in inducing prostate growth and carcinogenesis in mice with experiments using compressed hormone pellets. Hormone and/or drug pellets are easily manufactured with a pellet press, and surgically implanted into the subcutaneous tissue of the male mouse host. We also describe a protocol for the evaluation of hormonal carcinogenesis by combining subcutaneous hormone pellet implantation with xenografting of prostate cell recombinants under the renal capsule of immunocompromised mice. Moreover, subcutaneous hormone pellet implantation, in combination with renal capsule xenografting of BPH tissue, is useful to better understand hormonal regulation of benign prostate growth, and to test new therapies targeting sex steroid hormone pathways.

Sex steroid receptor expression and localization in benign prostatic hyperplasia varies with tissue compartment

Androgens and estrogens, acting via their respective receptors, are important in benign prostatic hyperplasia (BPH). The goals of this study were to quantitatively characterize the tissue distribution and staining intensity of androgen receptor (AR) and estrogen receptor-alpha (ERα), and assess cells expressing both AR and ERα, in human BPH compared to normal prostate. A tissue microarray composed of normal prostate and BPH tissue was used and multiplexed immunohistochemistry was performed to detect AR and ERα. We used a multispectral imaging platform for automated scanning, tissue and cell segmentation and marker quantification. BPH specimens had an increased number of epithelial and stromal cells and increased percentage of epithelium. In both stroma and epithelium, the mean nuclear area was decreased in BPH relative to normal prostate. AR expression and staining intensity in epithelial and stromal cells was significantly increased in BPH compared to normal prostate. ERα expression was increased in BPH epithelium. However, stromal ERα expression and staining intensity was decreased in BPH compared to normal prostate. Double positive (AR and ERα) epithelial cells were more prevalent in BPH, and fewer double negative (AR and ERα) stromal and epithelial negative cells were observed in BPH. These data underscore the importance of tissue layer localization and expression of steroid hormone receptors in the prostate. Understanding the tissue-specific hormone action of androgens and estrogens will lead to a better understanding of mechanisms of pathogenesis in the prostate and may lead to better treatment for BPH.

Testosterone and 17β-estradiol induce glandular prostatic growth, bladder outlet obstruction, and voiding dysfunction in male mice

Benign prostatic hyperplasia (BPH) and bladder outlet obstruction (BOO) are common in older men and can contribute to lower urinary tract symptoms that significantly impact quality of life. Few existing models of BOO and BPH use physiological levels of hormones associated with disease progression in humans in a genetically manipulable organism. We present a model of BPH and BOO induced in mice with testosterone (T) and 17β-estradiol (E(2)). Male mice were surgically implanted with slow-releasing sc pellets containing 25 mg T and 2.5 mg E(2) (T+E(2)). After 2 and 4 months of hormone treatment, we evaluated voiding patterns and examined the gross morphology and histology of the bladder, urethra, and prostate. Mice treated with T+E(2) developed significantly larger bladders than untreated mice, consistent with BOO. Some mice treated with T+E(2) had complications in the form of bladder hypertrophy, diverticula, calculi, and eventual decompensation with hydronephrosis. Hormone treatment caused a significant decrease in the size of the urethral lumen, increased prostate mass, and increased number of prostatic ducts associated with the prostatic urethra, compared with untreated mice. Voiding dysfunction was observed in mice treated with T+E(2), who exhibited droplet voiding pattern with significantly decreased void mass, shorter void duration, and fewer sustained voids. The constellation of lower urinary tract abnormalities, including BOO, enlarged prostates, and voiding dysfunction seen in male mice treated with T+E(2) is consistent with BPH in men. This model is suitable for better understanding molecular mechanisms and for developing novel strategies to address BPH and BOO.

Renal trauma from recreational accidents manifests different injury patterns than urban renal trauma

PURPOSE

The majority of blunt renal trauma is a consequence of motor vehicle collisions and falls. Prior publications based on urban series have shown that significant renal injuries are almost always accompanied by gross hematuria alone or microscopic hematuria with concomitant hypotension. We present a series of blunt renal trauma sustained during recreational pursuits, and describe the mechanisms, injury patterns and management.

MATERIALS AND METHODS

Database review from 1996 to 2009 identified 145 renal injuries. Children younger than age 16 years, and trauma involving licensable motor vehicles, penetrating injuries and work related injuries were excluded from analysis. Grade, hematuria, hypotension, age, gender, laterality, mechanism, management, injury severity score and associated injuries were recorded.

RESULTS

We identified 106 patients meeting the criteria and 85% of the injuries were snow sport related. Age range was 16 to 76 years and 92.5% of patients were male. There were 39 grade 1 injuries, 30 grade 2, 22 grade 3, 12 grade 4 and 3 grade 5 injuries. Gross hematuria was present in 56.7%, 77.2% and 83.3% of grade 2, grade 3 and grade 4 injuries, respectively. None of the patients with grade 2 or greater injuries and microscopic hematuria had hypotension except 1 grade 5 pedicle injury. The nephrectomy and renorrhaphy rate for grade 1 to grade 4 injuries was 0%.

CONCLUSIONS

Compared to urban series of blunt renal trauma, recreationally acquired injuries appear to follow different patterns, including a paucity of associated injuries or hypotension. If imaging were limited to the presence of gross hematuria, or microscopic hematuria with hypotension, 23% of grade 2 to grade 4 injuries would be missed. Men are at higher risk than women. However, operative intervention is rarely helpful.

Androgens and estrogens in benign prostatic hyperplasia: past, present and future

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are common clinical problems in urology. While the precise molecular etiology remains unclear, sex steroids have been implicated in the development and maintenance of BPH. Sufficient data exists linking androgens and androgen receptor pathways to BPH and use of androgen reducing compounds, such as 5α-reductase inhibitors which block the conversion of testosterone into dihydrotestosterone, are a component of the standard of care for men with LUTS attributed to an enlarged prostate. However, BPH is a multifactorial disease and not all men respond well to currently available treatments, suggesting factors other than androgens are involved. Testosterone, the primary circulating androgen in men, can also be metabolized via CYP19/aromatase into the potent estrogen, estradiol-17β. The prostate is an estrogen target tissue and estrogens directly and indirectly affect growth and differentiation of prostate. The precise role of endogenous and exogenous estrogens in directly affecting prostate growth and differentiation in the context of BPH is an understudied area. Estrogens and selective estrogen receptor modulators (SERMs) have been shown to promote or inhibit prostate proliferation signifying potential roles in BPH. Recent research has demonstrated that estrogen receptor signaling pathways may be important in the development and maintenance of BPH and LUTS; however, new models are needed to genetically dissect estrogen regulated molecular mechanisms involved in BPH. More work is needed to identify estrogens and associated signaling pathways in BPH in order to target BPH with dietary and therapeutic SERMs.

Neutron-Mapping Polymer Flow: Scattering, Flow Visualization, and Molecular Theory

Flows of complex fluids need to be understood at both macroscopic and molecular scales, because it is the macroscopic response that controls the fluid behavior, but the molecular scale that ultimately gives rise to rheological and solid-state properties. Here the flow field of an entangled polymer melt through an extended contraction, typical of many polymer processes, is imaged optically and by small-angle neutron scattering. The dual-probe technique samples both the macroscopic stress field in the flow and the microscopic configuration of the polymer molecules at selected points. The results are compared with a recent "tube model" molecular theory of entangled melt flow that is able to calculate both the stress and the single-chain structure factor from first principles. The combined action of the three fundamental entangled processes of reptation, contour length fluctuation, and convective constraint release is essential to account quantitatively for the rich rheological behavior. The multiscale approach unearths a new feature: Orientation at the length scale of the entire chain decays considerably more slowly than at the smaller entanglement length.

Preference for NaCl solutions in sham drinking Sprague-Dawley rats: water deprivation, sodium depletion, and angiotensin II

Male Sprague-Dawley rats were fitted with closable gastric fistulas and were then tested under closed fistula (real intake) and open fistula (sham intake--fluids drain from the stomach without appreciable absorption) conditions in one of three states: fluid deprivation, sodium depletion, and infusion of angiotensin (Ang) II. Water and various concentrations of NaCl were offered to drink in 1-h one- or two-bottle intake tests. In Experiment 1, water-deprived rats with closed fistulas drank more 0.15 M NaCl than either water or 0.3 M NaCl, offered in one-bottle tests. In sham drinking tests, the intake decreased monotonically as NaCl concentration increased. In two-bottle tests, water was greatly preferred over NaCl solutions. In Experiment 2, sodium-depleted rats preferred NaCl over water, again demonstrating a peak intake at 0.15 M in closed fistula conditions. However, with the fistula open the intakes of 0.05 and 0.15 M were similar, and 0.45 M considerably lower. In Experiment 3, Ang II-infused rats consumed both water and NaCl in two-bottle tests in both open and closed fistula trials. The quantity ingested on sham trials was only modestly elevated over real intake trials with Ang II compared with sham tests in Experiments 1 and 2.

Effect of desalivation on water and sodium chloride intake in rats

Desalivate rats consumed significantly less water than sham-operated rats in response to acute challenges with a variety of dipsogens, including polyethylene glycol (PEG), isoproterenol, serotonin, and an angiotensin I converting enzyme inhibitor (CEI). Nonsignificant reductions were recorded after treatments with either angiotensin II or hypertonic NaCl. Meal-related hyperdipsia, and resultant possible hyperhydration, of desalivate rats does not account fully for these reductions in experimental thirsts. The mean 24-h intake of three concentrations of NaCl, in choice with water, showed no difference in the preferences for NaCl of desalivate and sham-operated animals. During chronic administration of CEIs, both desalivate and sham-operated rats showed comparable induction of NaCl appetite.

Angiotensin-converting enzyme inhibition and Na appetite: microbehavioral analysis and nycthemeral physiology

The present experiments describe a marked nycthemeral rhythm in both the appetite for 0.3 M NaCl solution and components of the renin-angiotensin-aldosterone axis stimulated in Sprague-Dawley rats by chronic administration of enalapril, an angiotensin I-converting enzyme inhibitor. Continuous recording of water, NaCl, and food intakes shows that the sodium appetite is manifest as discrete bouts of salt ingestion in temporal proximity to meals and is partially independent of water bouts. In particular, salt bouts occur without water bouts in the late afternoon of a 12:12-h light-dark cycle and continue periprandially with water bouts during the night. Intake of all three commodities is minimal in the morning. In a second experiment, it was determined that plasma renin activity (PRA) was maximally elevated by chronic enalapril in the daytime and that plasma aldosterone was reduced by enalapril but continued to show nycthemeral rhythm peaking in the afternoon. The concurrent maxima in PRA and aldosterone in the afternoon in enalapril-treated rats thus coincides with NaCl intake in the absence of water intake.