[Extrapleural pneumonectomy for malignant pleural mesothelioma]

Standard treatment for malignant pleural mesothelioma (MPM) has not been proved yet. However, it has been recognized that extrapleural pneumonectomy (EPP) is a treatment of choice for epithelial MPM when combined with adjuvant therapies though EPP may frequently cause fetal complications. We report 5 cases of MPM with EPP, including 1 with good prognosis. Sixteen patients with MPM were admitted to our hospital between 1988 and 2003. Five patients underwent EPP, among which 4 were male and 1 female with ages from 46 to 61 years old. Histologically, 3 of them were epithelial and 2 were biphasic. Those with biphasic experienced acute respiratory failure and empyema, and died 81 days and 8 months after the surgery respectively. Among those with epithelial MPM, 2 are alive with no recurrence at 129 and 29 months after the surgery, and the other, followed by postoperative radiotherapy, died at 12 months. More cases with EPP or randomized controlled trials regarding EPP are necessary to evaluate efficacy of EPP for MPM.

Role of Glu318 at the putative distal site in the catalytic function of cytochrome P450d

Most microsomal P450s have a conserved "threonine cluster" composed of three Thrs (Thr319, Thr321, Thr322 for P450d) at a putative distal site. An ionic amino acid at 318 is also well conserved as Glu or Asp for most P450s. To understand the role of these conserved polar amino acids at the putative distal site in the catalytic function of microsomal P450, we studied how mutations at this site of P450d influence the activation of molecular oxygen in the reconstituted system. Catalytic activity (0.02 min-1) toward 7-ethoxycoumarin of the Glu318Ala mutant of P450d was just 6% of that (0.33 min-1) of the wild type, while those of Glu318Asp, Thr319Ala, and Thr322Ala were comparable to or even higher than that of the wild type. Consumption rates of O2 and formation rates of H2O2 of those mutants varied in accord with the catalytic activities. Especially, the efficiency (0.5%) of incorporated oxygen atom to the substrate versus produced H2O2 for the Glu318Ala mutant was much lower than that (3.7%) of the wild type, while that (58.8%) for the mutant Glu318Asp was 16-fold higher than that of the wild type. In addition, the autoxidation [Fe(II)---- Fe(III)] rate (0.074 s-1) of the Glu318Ala mutant was much lower than those (0.374-0.803 s-1) of the wild type and other mutants. Thus, we strongly suggest that Glu318 plays an important role in the catalytic function toward 7-ethoxycoumarin of microsomal P450d.

[Is the bronchoscopic criteria of early lung cancer valid?]

We studied the validity of the bronchoscopic criteria of the early lung cancer using the surgical specimen excised between 1980 and 1999. Twenty-four cases with squamous cell carcinoma of the lung of clinical stage I were located subsegmental or more proximal bronchi and trachea, and the size less than 20 mm in greatest dimension. We histopathologically investigated the endoscopic features in relation to the width of superficial extent, the depth of cancer invasion, and lymph node metastasis. Tumors of the thickened type lesions less than 20 mm in greatest dimension showed no invasion into the cartilaginous layer and no lymph node metastasis. On the other hand, in the nodular and polypoid types, invasion beyond the cartilaginous layer was observed more or less, and lymph node metastasis was observed in 1 case. These cases would not be suitable for bronchoscopic (photodynamic) therapy. In conclusion, the bronchoscopic criteria of early lung cancer is valid in the thickened type, but not in the nodular type or polypoid type.

A bridge between neuroscience and oncology: prostate cancer genesis. A 'negative' consequence of learning?

Prostate cancer has become the most commonly diagnosed cancer in men over recent years. The initiating mechanism for tumorigenesis within the prostate remains an unknown. The observation, that the cancer incidence in patients with chronic neurological disabilities is significantly lower than in the normal population lead to the hypothesis, that changed processing due to a barrage of aberrant sensory information within a healthy CNS can trigger events within the prostate cell, that cause malignant transformation. There is a broad overlap of cellular mechanism of gene expression, that lead to either long term potentiation, learning and memory storage or deregulated differentiation and malignant transformation.

Chronic perineal pain and lower urinary tract dysfunction--a clinical feature of the "Gulf War syndrome"?

A Persian Gulf War veteran presented to the University Neuro-Urology service for management of severe chronic perineal pain. The overall physical and neurological exam was unremarkable. However, the rectal exam and the urodynamic study revealed a severe pelvic floor dysfunction. A neuro-behavioral approach is recommended and discussed.

The male chronic pelvic pain syndrome

Suffering chronic pain is a common and debilitating problem that significantly impairs the quality of life of affected patients. Because we continue to struggle with chronic pelvic pain disorders both diagnostically and therapeutically, a neuro-behavioral perspective should be used in an attempt to explain pathways and neurophysiological mechanisms, and to improve diagnostics and treatment of male pelvic pain. First, however, malignant and acute/chronic bacterial disease has to be excluded as a cause of chronic pain in every single case. Then diagnostic approaches should screen for lower urinary tract dysfunction, pelvic floor functional disorders, and disturbed reflex integrity within the pelvic area. Treatment approaches for the male chronic pelvic pain syndrome could be divided into causal and symptomatic. Causal treatment approaches try to influence basic mechanisms generating and supporting chronic pain. In most cases a symptomatic approach is needed to relieve pain immediately. Because generally accepted treatment protocols and studies are missing, the following approach in the individual patient is recommended: (1) symptomatic treatment for immediate pain relief, (2) diagnostic work-up, (3) causal treatment trial.

Similarity of distributions of spinal c-Fos and plasma extravasation after acute chemical irritation of the bladder and the prostate

PURPOSE

Persistent pain in referred areas and voiding dysfunction are characteristic symptoms of chronic abacterial prostatitis. Since referred pain from visceral organs is considered a neurological event, it appeared reasonable to hypothesize that the persistent pain associated with prostatitis might also be explained by neural mechanisms. Neurogenic plasma extravasation and c-fos expression in the spinal cord, after chemical irritation of the rat prostate, was identified as a method to investigate the neurogenic aspect of prostatic inflammation.

MATERIALS AND METHODS

The distribution of plasma extravasation using Evans blue dye was determined after chemical irritation of the prostate and bladder of the rat, and the distribution of dye extravasation was analyzed. c-fos expression within the spinal cord was determined immunocytochemically after chemical irritation of the prostate, bladder and superficial somatic region determined by the dye extravasation as a referred pain area (tail root).

RESULTS

Chemical irritation of the prostate resulted in plasma extravasation in L5 to S2 dermatomes (primarily in L6 and S1). In rats receiving bladder irritation, the distribution of plasma extravasation showed a similar pattern to that observed in animals receiving prostatic irritation. Chemical irritation of the 3 structures resulted in expression of c-fos positive cells within the lumbosacral spinal cord. With each treatment the majority of c-fos positive cells were in the L6 and S1 segments. In all 3 groups the highest percentages of c-fos positive cells were observed in deeper laminae, including the dorsal commissure and sacral parasympathetic nucleus.

CONCLUSIONS

Our results strongly suggest that referred pain status in inflammation of the bladder and prostate is neurogenically mediated. Based on these studies, there should be significant overlaps of nociceptive neurons within the spinal cord, which receive nociceptive inputs from pelvic soma and viscera.

Pelvic arteriovenous aneurysm caused by transurethral resection of the prostate: successful management by intra-arterial embolization

We report a case of pelvic arteriovenous aneurysm caused by transurethral resection of the prostate. An abnormal vascular system was successfully managed by intra-arterial embolization using N-butyl cyanoacrylate in combination with platinum coil.

Perisphincteric injection of botulinum toxin type A. A treatment option for patients with chronic prostatic pain?

BACKGROUND

Chronic prostatic pain is still a diagnostic and therapeutic problem. The clinical observation that prostatic and pelvic pain is accompanied by motoric and sensoric disorders of the pelvic floor muscles led to the hypothesis that prostatic pain roots in a changed processing of afferent and efferent information with the central nervous system (CNS).

METHODS

Neuro-urological work-up of 11 male patients with chronic prostatic pain was completed. This included a clinical evaluation of pelvic floor function, urodynamic investigation of bladder and urethra function and a cystoscopy to exclude morphological aberrations. A transurethral perisphincteric injection of 200 units botulinum toxin type A (BTX) was followed by a 2- to 4-week visit to evaluate their influence on the neuro-urological symptomatology.

RESULTS

All chronic prostatic pain patients suffered from a pathological pelvic floor tenderness, an inability of sufficient conscious pelvic floor control, a urethral hypersensitivity/hyperalgesia and a urethral muscle hyperactivity. Basic parameters of bladder function (capacity, sensitivity, compliance) were normal. The BTX injection was followed by a pelvic floor muscle weakening and a relief of prostatic pain and urethral hypersensitivity/hyperalgesia. A botulinum-related decrease of the functional urethral length, the urethral sphincter closure pressure, the postvoid residual volume and an increase of the peak and average uroflow were objectivated.

CONCLUSION

A weakening of the urethral sphincter muscle via blocking acetylcholine release by BTX injection is followed by pain relief and symptom improvement. It can therefore be concluded that a barrage of nociceptive information from the dysfunctional pelvic floor overflood the CNS and induce a changed CNS processing. Interrupting the efferent branch of the disturbed central circle is one opportunity to treat chronic prostatic pain.

Central nervous system neurons labeled following the injection of pseudorabies virus into the rat prostate gland

BACKGROUND

The human prostate gland plays an important role in male fertility and is involved in different functional pathologies of the male lower urinary tract (LUT). The role of the prostate in these medical disorders is mainly unknown. Traditional surgical therapeutic attempts often fail to help these patients. For years, the clinical sciences have been stagnating due to a lack of basic science knowledge. Investigations into neuroanatomy and neurophysiology are urgently needed. Therefore, the neuroanatomy of the prostate gland in an experimental setup was explored. Recent progress in neuroscience methodology allows a transneuronal tracing by using a self-amplifying virus tracer, pseudorabies virus (PRV).

METHODS

Sixty-two individual adult male Sprague-Dawley rats were used for retrograde transneuronal mapping of the spinal cord and brain stem after PRV-injection and control experiments. A PRV-tracer (5 microl, 1 x 10(8) pfu/ml) was injected into the prostate gland. After a survival time of 72, 96, or 120 hr, the animals were sacrificed. Brain and spinal cord were harvested via a dorsal laminectomy. After cutting on a freezing microtome, the tissue was immunostained for PRV.

RESULTS

PRV-positive cells were found within the sacral (S1-S2) and the thoracolumbar (T13-L2) spinal cord. At the supraspinal level, positive cells were found within the following regions: nucleus raphe, lateral reticular formation, nucleus gigantocellularis, A5 noradrenergic cell region, locus coeruleus, pontine micturition center, hypothalamus, medial preoptic region, and periaquaductal gray.

CONCLUSIONS

This is the first investigation on the central innervation of the prostate gland showing a broad central representation of neurons involved in the control of the prostate gland. It is obvious, comparing data from the literature, that there is a broad overlap in the innervation of pelvic visceral organs (bladder, rectum, and urethra). The appreciation of these neuroanatomical circumstances allows a growing understanding of common urological pathologies within the pelvis (pelvic pain, lower urinary tract, and bowel dysfunction).

Intra-arterial infusion chemotherapy for penile carcinoma with deep inguinal lymph node metastasis

From July 1994 to January 1999, three patients with penile squamous cell carcinoma with deep inguinal lymph node metastases without distant metastases were treated with multimodality treatment including intra-arterial infusion chemotherapy mainly with monthly courses of cisplatin, methotrexate and bleomycin. One patient achieved a complete response and 2 achieved a partial response. It appears to be reasonable to presume that intra-arterial chemotherapy has a beneficial effect in the management of penile cancer with fixed metastatic inguinal lymph nodes, but a larger number of patients and longer follow-up are required to confirm these results.

Area density of smooth muscle cells and response to endothelin 1 in human hyperplastic prostate

BACKGROUND

alpha-Agonists and endothelins (ETs) are the only agents that have been proved to induce significant contraction of the prostate. Although the response to phenylephrine (PE) is dependent on the quality of smooth muscle (SM) within the prostate, it is not clear whether the response to ET-1 is also influenced by SM density. We evaluate the relationship between contractile responsiveness to ET-1 and the area density of SM of the human prostate.

MATERIALS AND METHODS

Specimens were obtained from 17 patients with prostatic hyperplasia that underwent transurethral resection of the prostate. Specimens were used for isometric tension study (PE, KCl and ET) and also for quantitative morphometric analysis.

RESULTS

PE and ET-1 induced dose-dependent contractile responses. There were no significant differences in the average maximum response (E(max)) to these two agents. E(max) to KCl and PE showed direct positive correlations with the area density of SM. E(max) to ET-1 also showed a positive correlation with the SM density, although this relationship was weaker than those for the other two agents. Moreover, there was a strong positive relationship between E(max) to PE, KCl and that to ET-1.

CONCLUSIONS

The area density of SM appeared to significantly influence the contractile response to ET-1 as well as the response to PE and KCl.

[Surgical treatment for bilateral multiple lung cancers]

We reviewed 12 patients with contralateral bronchogenic carcinomas. Seven of them had metachoronous carcinomas and 5 had synchronous carcinomas. We treated 3 patients with lobectomy on both lungs, and 4 patients with lobectomy and segmentectomy, 2 patients with lobectomy and wedge resection, 2 patients with segmentectomy and thoracoscopic wedge resection, and one patient with lobectomy and ablation on each lung. Two patients who had lobectomy on both lungs were dead, one of whom of bronchofistula on operation and the other of respiratory failure 7 years and one month after second operation. The 5-year survival rate in 12 patients was 68.5% after first operation and 82.5% after second operation. We conclude that lobectomy on both lungs are not recommended because of high mortality rate and the limited resection should be considered to treat the other contralateral primary lung cancers. Because the patients with primary lung cancers have the possibility to suffer from new primary cancers in the different site of the lung, we need careful follow up of the patients after treatment on the first lung cancer.

Morphometric analysis of symptomatic benign prostatic hyperplasia with and without bladder outlet obstruction

To investigate the histological features of benign prostatic hyperplasia (BPH) with and without bladder outlet obstruction (BOO), 32 patients with symptomatic BPH, 22 with BOO and ten without BOO, were studied. The area density of smooth muscle, fibrous tissue, glandular epithelium, and glandular lumen in BPH adenoma resected by transurethral surgery was estimated using morphometric analysis. No differences were found in the area density of stromal and glandular components between the two groups. In the glandular component, neither the epithelium nor lumen differed between the two groups. However, the area density of smooth muscle in the obstructed group showed a decrease compared to that in the unobstructed group (P < 0.01). We conclude that a decreased proportion of smooth muscle in BPH adenoma may play an important role in BOO.

A study of pelvic floor function pre- and postradical prostatectomy using clinical neurourological investigations, urodynamics and electromyography

OBJECTIVES

Incontinence after radical prostatectomy is addressed to sphincter damage and/or bladder dysfunction. Taking into account a high cure rate of incontinence by pelvic floor biofeedback treatment, the search for further mechanisms of a complex physiological concept seems feasible.

METHODS

To characterize pelvic floor function, 18 patients were prospectively evaluated before and after radical prostatectomy by clinical neurourological tests, urodynamics and needle/surface electromyography (EMG).

RESULTS

In all patients (mean age 62 years) investigations were completed successfully. The outcomes of neurourological investigations (sacral reflexes, voluntary pelvic floor contraction and relaxation) and needle EMG showed no significant changes in the pre-/postoperative comparison. Only by using surface EMG polygraphy change of activation patterns during pelvic floor contraction (decreased mean and medium frequency) could be found.

CONCLUSION

In patients without preexisting bladder dysfunction and with a basically normal operative and postoperative course, fine motoric changes of pelvic floor function are the main finding. This cannot be explained by a pure anatomical approach. Neurophysiological events, like a barrage of nociceptive information, caused by surgical dissection and an inflammatory reaction due to the healing process, contribute to altered processing within the central nervous system. The appreciation of these mechanisms, well studied in neuroscience and pain research, offers a better understanding of surgery-related short- and longterm morbidity after pelvic surgery, i.e., urinary incontinence and erectile dysfunction.

Sacral nerve stimulation and diurnal urine volume

OBJECTIVES

During a screening trial to determine candidacy for sacral nerve stimulation (SNS), several patients were required to repeat the baseline dietary because of discrepancies in the 24-hour urine output before and after successful stimulation. This raised a question regarding the relationship between urine production and neuromodulation. A more complete diary analysis of patients affected by urgency/frequency and/or urge incontinence was therefore carried out to evaluate the possibility of a direct modulatory influence of SNS on urine production.

METHODS

Voiding diaries of 40 patients (37 females and 3 males, average age 39.4 years) who underwent SNS were evaluated. Voiding diaries were obtained at baseline, during and after peripheral nerve evaluation (PNE) and after permanent implantation.

RESULTS

There was an increase in the average volume/void during PNE in 39 patients. Twenty-four-hour urine volume during PNE was statistically greater than that at baseline. Volume/void and diurnal volume were also significantly greater in follow-up periods after permanent implantation.

CONCLUSION

SNS appears to influence not only bladder function but also urine production. Increase in volume/void is paralleled by an increase in 24-hour urine output. The mechanism is unclear, but it is consistent with an altered release of antidiuretic hormone. This observation reflects the direct refractory involvement of the hypothalamus in micturition.

In vitro effect of amezinium on the rabbit urinary bladder: muscle strip and whole bladder evaluation

Dose-response studies for norepinephrine and amezinium were obtained for isolated muscle strips and in vitro whole bladder preparations to investigate the effect of amezinium on the bladder. Specimens (strips from the bladder base and body, and the whole bladder) were obtained from mature female rabbits. By the muscle strip study, amezinium showed a weak contractile effect (up to 40% of spontaneous contraction) on strips from the bladder base. Muscle strips from the bladder body presented no response to amezinium. In the whole bladder preparation, administration of norepinephrine showed an increase in intravesical pressure in 4 out of 7 rabbits, whereas administration of amezinium had negligible effect on intravesical pressure. Administration of amezinium showed no influence on strips from the bladder body and the whole bladder preparation. Direct contractile response in muscle strips from the bladder base by amezinium appeared to be a favourable effect considering urinary storage.

Relationship between urodynamic type of obstruction and histological component of the prostate in patients with benign prostatic hyperplasia

OBJECTIVES

This study was designed to compare urodynamic types of bladder outlet obstruction (BOO) and histological architecture of the prostate in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Twenty-four patients with symptomatic BPH, who underwent transurethral resection of the prostate (TURP), were included in the study. Before surgery, a pressure-flow (P-F) study was performed in all patients. According to the classification by Spanberg et al., they were divided into 5 normal type, 6 low-compliant, 6 compressive and 7 constrictive obstruction. The area density and total area of smooth muscle, fibrous tissue, glandular epithelium and glandular lumen in BPH specimens were estimated using morphometric analysis.

RESULTS

In all groups, the stromal component occupied about three fourths of BPH specimens, and fibrous tissue was the most prominent element. However, neither area density nor total volume of each histological component showed a significant difference among the four groups.

CONCLUSION

The type of BOO in patients with BPH cannot be explained by histological architecture alone.

Effect of immobilization stress on testicular germ cell apoptosis in rats

The influence of immobilization stress on testicular germ cell apoptosis was investigated in rats. A transient increase in serum corticosterone and a transient decrease in serum testosterone were observed during each period of immobilization stress. Twenty-four hours after the last immobilization session, the testicular weight and serum concentrations of corticosterone and testosterone were the same between the immobilization stress and control groups. However, the percentages of apoptotic tubules and apoptotic cells in the stress group were significantly higher than those in controls (P < 0.001). These facts suggest that immobilization stress can enhance testicular germ cell apoptosis in rats.

Relation between urethral elasticity and bladder outlet obstruction and histologic composition of the prostate in patients with benign prostatic hyperplasia

OBJECTIVES

In benign prostatic hyperplasia (BPH), bladder outlet obstruction is caused by mechanical blockage resulting from an enlarged prostate, and by the increased tone of prostatic smooth muscle. In patients with obstructive BPH, the prostatic urethra urodynamically corresponds to the flow-controlling zone (FCZ). We sought to investigate the relation between the obstruction and elastic properties of the FCZ and the histologic composition of the prostate in symptomatic patients with BPH.

METHODS

The grade of infravesical obstruction was classified according to preoperative pressure-flow data from 30 men with symptomatic BPH, and the elastic properties of the FCZ were evaluated as the mean elastance, which was calculated using the three-parameter model. The area densities of smooth muscle, fibrous tissue, epithelium, and lumen were determined by quantitative morphometry, using BPH tissue obtained by transurethral resection.

RESULTS

The area density of smooth muscle had a negative correlation with mean elastance (p = -0.50, P <0.01), the linear passive urethral resistance relation (p = -0.43, P <0.05), and the group-specific urethral resistance factor (p = -0.39, P <0.05). No other histologic element was correlated with these variables.

CONCLUSIONS

Our results suggest that urethral elasticity and bladder outlet obstruction grade are influenced by the relative content of smooth muscle within the prostate in patients with BPH.

Neurourological insights into the etiology of genitourinary pain in men

PURPOSE

Pelvic pain remains a challenging urological problem. Because antimicrobial therapy is often unsuccessful for relieving symptoms, it is reasonable to question whether pelvic pain is the result of microbiological versus functional pelvic disease. We analyzed clinical and urodynamic findings to evaluate the role of pelvic floor dysfunction in patients with pelvic pain.

MATERIALS AND METHODS

We retrospectively evaluated history, physical examination and urodynamic studies in 103 men with an average age of 47 years who presented with pelvic pain between August 1994 and August 1997. In all patients microbiological tests were negative before study entry.

RESULTS

The reported locations of pain were the prostate and/or perineal region in 45.6% of cases, scrotum and/or testis in 38.8%, penis in 5.8%, bladder in 5.8%, and lower abdomen and lower back in 1.9% each. Previous treatment consisted of 1 to 12 courses of antibiotics in the preceding 6 to 36 months. In 88.3% of the patients there was pathological tenderness of the striated muscle with poor to absent pelvic floor function. Urodynamics were performed in 84 cases. Cystometry was normal except for decreased compliance in 5 patients. Abnormal findings were mostly evident in the coordination of voiding and in dynamic sphincter-pelvic floor activity. Average sphincter pressure was increased to 104.9 cm. water in 72.6% of the patients, average peak urine flow was decreased to 9.9 ml. per second in 61.9% and functional urethral length was increased to greater than 35 mm. in 79.8%. Urethral profile pattern was dysfunctional, obstructed, and combined dysfunctional and obstructed in 52.4, 11.9 and 21.4% of the cases, respectively, while in 88.1% urethral sensitivity was minimally or markedly increased.

CONCLUSIONS

Since activity is a reflection of neural control, the apparent association of pelvic floor dysfunction with pelvic pain raises the probability of a primary or secondary central nervous system breakdown in the regulation of pelvic floor function. This hypothesis is supported by the improvement in symptoms caused by therapy aimed at modulating the pelvic floor, such as biofeedback, medication and sacral anterior root stimulation.

Effects of estrogen and progesterone on urinary bladder in female rabbit: evaluation by quantitative morphometric analysis

OBJECTIVES

To investigate possible effects of estrogen and/or progesterone on the histologic characteristics of female rabbit urinary bladders, we carried out quantitative morphometric analysis of the rabbit bladders.

METHODS

Mature female rabbits were treated by ovariectomy with and without successive estrogen and/or progesterone administration. Area densities of the connective tissue (CT) and smooth muscle (SM) cells, the area of single SM cells, and the thickness of the bladder wall were determined by computer-assisted quantitative morphometric analysis.

RESULTS

Six weeks after each treatment, ovariectomy alone resulted in a decrease in CT density of the bladder. Successive estrogen treatment increased the bladder wet weight and SM cell density within the bladder wall. Progesterone treatment reduced CT degradation in ovariectomized rabbits. Sex steroids did not significantly influence the area of each SM cell. There was no significant difference in histologic characteristics between the rabbits treated by estrogen alone and those treated by combination (estrogen and progesterone) therapy.

CONCLUSIONS

Ovariectomy and successive hormonal replacement therapy resulted in morphologic changes within the rabbit urinary bladder. Cotreatment with progesterone did not significantly change the morphologic findings produced by estrogen treatment alone.

[Superior vena cava reconstruction combined with resection of mediastinal-pulmonary malignant tumors]

From 1988 to 1997, we experienced 5 cases of the superior vena cava (SVC) replacement with expanded polytetrafluoroethylene (ePTFE) grafts combined with resection of mediastinal or pulmonary malignant tumors. Two patients had lung cancer and three had invasive thymoma. Resection and reconstruction of the superior vena cava (SVC) were performed by application of a bypass graft between the innominate vein and the right atrium in two cases and a temporary bypass using a heparin-coated tube in three cases. Except in one patient who died of acute respiratory failure, no complication or occlusive symptom were observed postoperatively. Two patients remain healthy for 5 years 4 months and 2 years 7 months after operation. Three died 9 years, 5 months, and 110 days after operation respectively. In conclusion, ePTFE graft replacement or patch angioplasty of the SVC should be part of planning and execution of radical excision with curative intent of mediastinal or pulmonary malignant tumors.

Central autonomic innervation of the lower urinary tract--a neuroanatomy study

Knowledge about the central innervation of the lower urinary tract is limited. The spinal cord and the pontine micturition center have been investigated most thoroughly, whereas high centers have received little attention. Pseudorabies virus (PRV), a self-amplifying and transneuronal tracer was injected into the bladder trigone of 21 Sprague-Dawley rats. The animals were killed after 72, 96, and 120 h. The whole CNS was sectioned and immunostained for PRV. CNS centers directly connected to the bladder include the intermedio lateral cell column, the central autonomic nucleus, and the nucleus intercalatus at the spinal cord levels T12-L2 and L6-S2. The raphe pallidus et magnus, the A5 nor-adrenergic area, the pontine micturition center, the locus coeruleus, the periaquaductal gray, the nucleus para- et periventricularis of the hypothalamus, the red nucleus, the medial preoptic area, and the cortex are supraspinal centers connected to the bladder. Lower urinary tract function is a complex multilevel and multineuronal interaction. It involves facilitation and inhibition at many levels of the CNS.

Renal cell carcinoma with renal artery aneurysm

We describe a patient who was diagnosed as renal cell carcinoma with renal artery aneurysm in the contralateral kidney. Right aneurysmectomy followed by simple arteriorrhaphy with termino-lateral anastomosis, and then left radical nephrectomy were performed in one session. The patient did well postoperatively. Generally, surgical indication of renal artery aneurysm itself has been yet a matter of debate. In such case like this, however, it seems better to resect any kind of aneurysm of the opposite side, taken into consideration the haemodynamic changes after nephrectomy. Surgical indications are commented on.

Round spermatids from hybrid sterile mice can initiate normal embryo development

Fertilization and embryo development following intracytoplasmic injection of round spermatids collected from hybrid sterile mice (BALB/c) were investigated. The rates of oocyte activation, blastocyst formation and development into live offspring were compared with those after intracytoplasmic injection of round spermatids from fertile mice (B6D2F1). The injection of oocytes with round spermatids from hybrid sterile or sterile males resulted in similar rates of normal fertilization and embryo development. The rates of development to term of 2-cell embryos were also similar, regardless of the origin of the round spermatids injected. This finding suggested that round spermatids from hybrid sterile mice have the ability to fertilize normally and to allow normal embryo development.

Botox-induced prostatic involution

BACKGROUND

A simple approach to induced prostatic atrophy was explored. Surgical denervation is known to produce profound atrophy of the rat prostate. Because Botulinum toxin type A (Botox) produces a long-term chemical denervation, the potential to induce atrophy of the rat prostate was explored.

METHODS

Thirty rat prostates were injected with varying doses of Botox. Single and serial injections were used, and rats were subsequently sacrificed after either 1 or 4 weeks, respectively. The prostate glands were harvested, weighed, and histologically studied for morphologic and apoptotic changes.

RESULTS

The total prostate volume and weight were found to be reduced in all Botox-injected animals. Histologically, a generalized atrophy of the glands was observed with the H&E stain. There was also diffuse glandular apoptosis evident with the Tunel stain. There were no significant complications (e.g., urinary retention, weight loss, or hind/limb weakness).

CONCLUSIONS

Botulinum toxin type A injection into the prostate gland induces selective denervation and subsequent atrophy of the prostate. Apoptosis was seen diffusely throughout the gland. It may be possible that in the future, this long-acting neurotoxin could be used for the treatment of common pathologies of the human prostate.

Endocrinological and pathological entities of the pre-Cushing's syndrome

The purpose of the study was to clarify the disease entity of pre-Cushing's syndrome. The authors report on the pathological findings and contents of various steroids in the adenomas of three cases of pre-Cushing's syndrome. Oncocytes were found in one adenoma and others were pure clear cell dominant adenomas. All the adenomas contained higher concentrations of precursor steroids than those of five cases of Cushing's syndrome. However, the patterns of increased precursors were quite different among the three cases. Pre-Cushing's syndrome appeared to include several different kinds of disease entities.

Postoperative chronic pain and bladder dysfunction: windup and neuronal plasticity--do we need a more neurological approach in pelvic surgery?

PURPOSE

Cases of combined symptoms of dysfunctional voiding and associated pelvic discomfort are difficult diagnostic and therapeutic challenges. Surgical solutions not uncommonly fail to relieve those symptoms. We determine why these symptoms persist postoperatively.

MATERIALS AND METHODS

Four cases of ureteral injury during gynecological laparoscopic procedures for pelvic/menstrual pain are presented. The cases are reviewed for their severity and similarity in presenting symptoms, complications and long-term consequences.

RESULTS

In all cases light pain symptoms and/or dysfunctional voiding problems that existed before the initial surgery escalated severely after corrective pelvic surgery.

CONCLUSIONS

There are established neurophysiological mechanisms that would explain the observed increase in pain after surgical manipulation of the pelvis. Windup and changes in neuronal plasticity are direct consequences of wounding and/or neural injury to the central nervous system. These principles are important for surgeons to appreciate due to the impact they can have on the outcomes of surgery. Blocking the sensory input into the spinal cord, inherent to every surgical procedure, through use of local anesthetics, that is preemptive anesthesia, before creation of a wound provides the greatest protection against escalation of symptoms. Thorough evaluation of all patients before pelvic surgery is recommended to identify high risk groups (preexisting pain, voiding syndromes).

Pericentric inversion of chromosome 9 in infertile men

Reproductive condition was studied in 6 infertile men with pericentric inversion of chromosome 9. Semen analyses revealed one azoospermia, one oligozoospermia, three asthenozoospermias and one normozoospermia. Four cases showed normal levels of plasma gonadotropins and testosterone. The response of plasma testosterone to human chorionic gonadotropin was within the normal range in all cases. However, the administration of LH-RH resulted in abnormal response of plasma gonadotropin in all patients. These results indicate that infertile males with pericentric inversion of chromosome 9 have an abnormality in the hypothalamic-pituitary-testicular axis.

The effect of triathlon on urinary excretion of enzymes and proteins

In order to investigate the effect of triathlon and renal function of normal subjects, we evaluated the excretion of urinary enzymes and proteins before and after triathlon. From 6 subjects samples were obtained 24 hours after the first urine collection. We performed quantification of urinary total protein, beta2-microglobulin (beta2-M), N-acetyl-beta-D-glucosaminidase activity (NAG), and concentration of urinary creatinine from each participant. There was a significant increase in urinary total protein excretion immediately after triathlon (p<0.01). The urinary beta2-M and NAG excretions after triathlon were higher than the initial values. Post-exercise proteinuria in one subject persisted until the next morning, whereas the increased excretion of urinary beta2-M and NAG returned to the pre-exercise level at least 24 hours after triathlon. It appears to be reasonable to presume that glomerular damage may persist in some subjects who do heavy exercise.

Schwannoma of the penis: report of a case and review of the literature

A case of schwannoma located in the penile shaft in a 65-year-old male is described. Special stain using S-100 immunoperoxidase was useful in establishing the diagnosis in this case. We reviewed the literature on penile schwannoma and focussed on the diagnosis of this rare ailment.

Serum level of carboxyterminal propeptide of type I procollagen in haemodialysis patients

Serum concentrations of carboxyterminal propeptide of type I procollagen (PICP) and carboxyterminal parathyroid hormone (C-PTH) were measured in 33 haemodialysis patients. Serum levels of PICP and C-PTH in the haemodialysis group were significantly higher than those in the controls. Although there was no correlation between serum C-PTH and creatinine, a positive correlation was found between PICP and creatinine. This indicates that the measurement of PICP in serum is useful for monitoring metabolic bone diseases in haemodialysis patients.

Correlations between urethral elastance and histological architecture in patients with benign prostatic hyperplasia

To investigate whether the properties of the flow-controlling zone (FCZ) in obstructive benign prostatic hyperplasia (BPH) would be affected by differences in the histological architecture of the prostate, we evaluated relationships between morphometric and urodynamic data. BPH specimens from 14 patients undergoing transurethral surgery were analysed by quantitative morphometry. The cross-sectional area and mean elastance of FCZ, together with other parameters, were calculated on a preoperative pressure-flow study. Correlations between these parameters and tissue composition were determined. Our study group comprised men with clinical and urodynamic evidence of infravesical obstruction secondary to BPH. No correlations were found between the area density or total volume of each histological element and the cross-sectional area of FCZ at peak flow rate. Neither area density nor total volume of each element correlated with the mean urethral elastance. Our results indicate that the histological architecture of the prostate in patients with obstructive BPH cannot predict the urethral elastance.

Thermoreceptor mediated bladder sensation in patients with diabetic cystopathy

Urinary bladder sensation to ice water instillation was evaluated in 32 patients with diabetes mellitus. Sixteen patients were urodynamically normal (group 1) and the remaining 16 were diagnosed as having diabetic cystopathy (group 2). Eleven out of 16 patients in group 2 could be considered as having impairment of sensation to urinate. Two out of 16 (12.5%) subjects in group 1 could not perceive ice water infusion, whereas 25% of patients in group 2 did not feel the ice water sensation. In group 2, patients with impaired urinary sensation showed relatively high incidence of negative ice water test (36.4%), although there were no statistical differences between the other groups. There was no apparent relationship between prevalence of peripheral neuropathy and that of negative ice water test. Impairment of ice water perception was less frequent than that of mechanoreceptor sensation in patients with diabetic cystopathy.

The American Urological Association Symptom Index: early postoperative evaluation of irritative and obstructive symptoms due to benign prostatic hyperplasia

In order to evaluate the acute effects of two different treatments on changes in the American Urological Association symptom score, we divided 23 men with benign prostatic hyperplasia into 2 groups. Group 1 (n = 16) and group 2 (n = 7) were treated with transurethral resection of the prostate and visual laser ablation of the prostate, respectively. Twice before and about 1 week after surgery, patients completed the AUA symptom questionnaire and underwent urodynamic evaluation. The symptom indexes were subcategorized as obstructive and irritative symptoms. All symptom scores were identical in groups 1 and 2 preoperatively. Postoperatively, significant improvement was found in obstructive scores, the total score, maximum and average flow rates only in group 1. This outcome is probably the reflection of an essential dissmilarity in both therapies. Clinically, the obstructive subscore appears reactive to changes in obstruction and seems meaningful in follow-up even in the early postoperative days.

Functional property, norepinephrine content and morphometric findings in human hyperplastic prostate

BACKGROUND

Although alpha-adrenergic blockers are widely used as a treatment of benign prostatic hyperplasia (BPH), it is not clear whether contractile property of hyperplastic prostate to alpha-adrenergic agonist depends upon an area of density of smooth muscle within the respective BPH tissue.

METHODS

Functional study and quantitative morphometric analysis were performed on human prostatic specimens obtained by transurethral resection from 22 men with symptomatic BPH. Tissue norepinephrine content was also evaluated.

RESULTS

There was a linear correlation between the area of density of smooth muscle and maximum response to phenylephrine (r = 0.457, P = 0.0362). Although the area of density of smooth muscle showed a positive correlation with norepinephrine content (r = 0.437, P = 0.0471), norepinephrine content was not correlated with maximum phenylephrine response.

CONCLUSIONS

Contractile response to alpha-adrenergic agonist was directly influenced by the area of density of the smooth muscle within an individual prostate.

Short-arm dicentric Y chromosome associated with Sertoli-cell-only tubule

We report a case of a short-arm dicentric Y chromosome associated with Sertoli-cell-only tubule. Chromosomal analysis, using G- and C-banding techniques, revealed: 45,X/46,X psu dic(Y) (pter-->q11::q11-->pter)/46,X + mar. Staining by fluorescence in situ hybridization using a Y chromosome centromere-specific DNA probe showed two bright spots in the pseudodicentric Y chromosome and one in the marker chromosome. It is assumed that Sertoli-cell-only tubule is caused by deletion or disruption of the azoospermic factor gene located distal in Yq11.

[A case of primary malignant melanoma of the esophagus]

A case of primary and malignant melanoma of the esophagus was reported. A 64-year-old male complaining of discomfort of anterior chest pain was admitted to our hospital for operation. Findings of upper G-1 X-ray and endoscopic examination revealed suspiciously malignant melanoma. Subtotal thoracic esophagectomy with R III dissection was performed. Operative findings included A0 N2 Pl0 M0 Stage III. Macroscopically it showed black-grayish colored polypoid tumors, 7 cm in size. The typical finding of junctional activity adjacent to the tumor mass and melanocytes were microscopically found. The patient received postoperative systemic chemotherapy, but was died of multiple liver and bone metastases 125 days after surgery. Malignant melanoma of the esophagus has extremely poor prognosis and none of effective therapies has been reported.

A case of primary giant calculus in female urethra

Urinary calculus is rarely seen in the urethra and is usually encountered in men with urethral stricture or diverticulum. Primary urethral calculi are extremely rare in females. We describe a case of a giant urethral stone impacted in the urethra of a 103-year-old female.