Biomedical subjects
Publications and source records attributed to A Morgentaler.
Gynecomastia is an unusual side effect associated with testosterone replacement therapy (TRT) that has been traditionally treated with surgery, radiation, or discontinuation of testosterone supplementation. We report here our experience with two cases of gynecomastia in men undergoing TRT who were successfully treated with the aromatase inhibitor anastrozole.
PURPOSE: We reviewed the experience with the 2-piece Ambicor penile prosthesis (American Medical Systems, Minnetonka, Minnesota) at 2 medical centers to investigate its mechanical reliability and complication rates as well as patient and partner satisfaction with the device. MATERIALS AND METHODS: From 1995 through 1999, 131 men underwent implantation of an Ambicor penile prosthesis at 2 medical centers. We performed a 3-part study consisting of a retrospective clinical record review, mailed patient and partner questionnaire, and mailed modified patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire. Mean followup was 43.4 months (range 12 to 73). RESULTS: All 131 men had a history consistent with an organic etiology of erectile dysfunction, including vascular disease in 62%, radical retropubic prostatectomy in 17%, Peyronie's disease in 15%, neophallus construction in 4% and radical pelvic surgery in 2%. Mean patient age was 56.8 years (range 22 to 76) at implantation. Overall there were complications in 10 cases (7.6%), including infection, hematoma and mechanical failure in 6 (4.6%), 1 (0.7%) and 3 (2.3%), respectively. A total of 112 men (85%) and 91 partners completed the questionnaire. All patient respondents still had an Ambicor prosthesis implanted and 96.4% had erection suitable for coitus. Overall patient and partner satisfaction was 96.4% and 91.2%, respectively. Of the respondents 92.9% of patients and 90.1% of partners would recommend the device to others. Of the 85 men (65%) and 46 partners who completed the modified Erectile Dysfunction Inventory of Treatment Satisfaction survey 90.6% and 82.6%, respectively, were satisfied or very satisfied overall with the penile prosthesis. CONCLUSIONS: The Ambicor penile prosthesis is associated with a low complication rate and reliable mechanical function. High satisfaction was reported by patients and partners.
PURPOSE: The association of free and total testosterone with prostate cancer is incompletely understood. We investigated the relationship of serum free and total testosterone to the clinical and pathological characteristics of prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of 117 consecutive patients treated by 1 physician and diagnosed with prostate cancer at our medical center between 1994 and 1997. Low free and total testosterone levels were defined as 1.5 or less and 300 ng./dl., respectively. RESULTS: After evaluating all 117 patients we noted no correlation of free and total testosterone with prostate specific antigen, patient age, prostatic volume, percent of positive biopsies, biopsy Gleason score or clinical stage. However, in patients with low versus normal free testosterone there were an increased mean percent of biopsies that showed cancer (43% versus 22%, p = 0.013) and an increased incidence of a biopsy Gleason score of 8 or greater (7 of 64 versus 0 of 48, p = 0.025). Of the 117 patients 57 underwent radical retropubic prostatectomy. In those with low versus normal free testosterone an increased mean percent of biopsies demonstrated cancer (47% versus 28%, p = 0.018). Pathological evaluation revealed stage pT2ab, pT2c, pT3 and pT4 disease, respectively, in 31%, 64%, 8% and 0% of patients with low and in 40%, 40.6%, 12.5% and 6.2% in those with normal free testosterone (p>0.05). CONCLUSIONS: In our study patients with prostate cancer and low free testosterone had more extensive disease. In addition, all men with a biopsy Gleason score of 8 or greater had low serum free testosterone. This finding suggests that low serum free testosterone may be a marker for more aggressive disease.
Erectile dysfunction can be devastating for men and for their partners. A good sexual history and focused physical examination can provide clues as to whether the underlying cause is psychogenic or organic. Diagnostic investigation should be tailored to the clinical picture. Oral medications now represent first-line therapy. Penile injection therapy and vacuum constrictive devices are reasonable choices for men in whom oral therapy falls or is contraindicated. The penile prosthesis provides a reliable long-term solution with high satisfaction rates. Psychotherapy may be indicated. Physicians can have a positive impact on the quality of life of patients by providing a non-judgmental and supportive environment for discussion and management of impotence.
Spontaneous germ cell death is a common cellular process in the mammalian testis, although the function of this process during spermatogenesis is unclear. An investigation was undertaken to determine whether p53 serves as a mechanism in germ cell quality control by causing spontaneous germ cell death. Using an annexin V assay, lower levels of spontaneous apoptosis were found in the testes of p53-/- mice compared to p53+/+ mice. Propidium iodine staining revealed that the greatest reduction in apoptosis and the largest increase in cell numbers occurred in the tetraploid germ cell population of p53-/- mice. Microscopic examination of sperm morphology showed an increased percentage of abnormal forms in p53-/- mice. Furthermore, p53-/- mice sired fewer offspring than p53+/+ mice did when both groups were mated with p53+/+ females. These results suggest that p53 mediates spontaneous testicular germ cell apoptosis and failure to remove defective germ cells by this mechanism results in increased percentages of abnormal sperm and reduced fertility. p53-mediated apoptosis may be an effector of cellular proofreading that acts to maintain the cellular integrity of germ cells during spermatogenesis.
Previous studies have demonstrated that testicular germ cell apoptosis can be induced both by heat stress and by withdrawal of androgens and gonadotrophins. To investigate whether heat-induced germ cell apoptosis occurs independently of the altered levels of hormones that occur with heat exposure, mouse testicular apoptosis was studied using an in vitro system with controlled levels of testosterone, FSH and LH. It was observed that cells underwent apoptosis sooner in the absence of hormones at the same temperature. Apoptosis also occurred earlier at abdominal temperature compared to scrotal temperature with the same hormonal levels. No somatic tissues studied underwent apoptosis at 37 degrees C under the same culture conditions. These results suggest that heat stress may independently activate an apoptotic pathway in the testis, and that hormone deprivation may induce apoptosis via a separate mechanism.
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Cryptorchidism is associated with male infertility: germ cell loss occurs by apoptosis in response to elevated temperature. Since the tumor suppressor p53 is highly expressed in the testis and is known to induce apoptosis, an investigation was undertaken to establish whether heat stress causes p53-mediated germ cell apoptosis. Using a mouse model of experimental unilateral cryptorchidism, it was observed that testicular weight reduction, germ cell loss, and DNA fragmentation all began in the cryptorchid testes on Day 6-7 in wild-type mice. In contrast, these changes were delayed by 3 days in p53-/- mice. These results suggest that abdominal heat stress induces germ cell loss through two apoptotic pathways: a p53-dependent pathway responsible for the initial phase of germ cell apoptosis, and a p53-independent pathway that accounts for subsequent apoptosis.
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p53 has been postulated to play a role in meiosis as well as in the regulation of germ cell numbers by apoptosis. This study investigated the subcellular localization of p53 in the testis, including conditions known to induce germ cell apoptosis. Western blot analysis showed that p53 was enriched in the nuclear envelope fraction, and confocal microscopy confirmed that p53 was associated with the nuclear envelope of germ cells. Exposure of the testis to heat stress induced translocation of p53 into the nucleus. Nuclear envelope binding provides an optimal site for rapid entry of p53 into the nucleus, where it may act as a DNA-binding protein to induce apoptosis or cell cycle arrest in response to appropriate stimuli. The nuclear envelope sequestration of p53 also provides a framework to understand how mitosis and meiosis in the testis may proceed despite high intracellular concentration of p53.
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OBJECTIVES: To evaluate the results of simultaneous placement of a penile prosthesis with radical prostatectomy. METHODS: From June 1993 to June 1996, 50 men underwent a combination procedure of non-nerve sparing radical retropubic prostatectomy and placement of a penile prosthesis. We performed a retrospective chart review of these patients, examining patient age, preoperative prostate-specific antigen level, Gleason score, operative time, estimated blood loss, analgesic use, length of hospital stay, time until intercourse, and complications. This group was compared with a group of 72 men undergoing radical prostatectomy alone during the same time interval. RESULTS: No significant differences were noted in preoperative patient variables. The mean operative time for prosthesis insertion was 82 minutes, and the mean time to sexual intercourse was 12.7 weeks. No prosthesis infections have occurred, with a mean follow-up of 1.7 years. Four men (8%) have required revision of their inflatable penile prosthesis. There were no significant differences between the combination procedure and radical prostatectomy alone with regard to estimated blood loss, length of hospital stay, or analgesic use. CONCLUSIONS: Simultaneous placement of a penile prosthesis during radical prostatectomy provides early return to sexual function, with no apparent increase in morbidity. Further study will be required to determine the impact of combination surgery on psychosocial adjustment and quality of life.
Penile prostheses represent an important treatment modality for erectile dysfunction. A review of the design considerations for penile prostheses is presented, using the American Medical Systems, Inc., product line as a practical example. Current models include both inflatable hydraulic and solid malleable designs. The challenge for the future is to develop devices with improved durability while optimizing ease of use and cosmetic appearance.
The dependence of spermatogenesis on the relatively cool environment of the scrotum is well known, and recent work has shown that germ cells undergo apoptosis upon exposure to abdominal temperature. p53 is a potent inducer of apoptosis and regulator of cell growth, and is found in high concentrations in the testis. The purpose of this study was to determine whether exposure of the testes to suprascrotal temperature was associated with alterations in testicular p53 expression. Male adult CD-1 mice were rendered unilaterally cryptorchid by surgically fixing one testis to the anterior abdominal wall while leaving the contralateral tests in the scrotum to serve as the euthermic control. p53 expression was evaluated in the cytoplasmic, soluble nuclear, and insoluble fractions by Western blot analysis with the monoclonal p53 antibody pAb240. The weights of the scrotal testes were unchanged over the 15 day study period. The weights of the cryptorchid testes remained stable for 7 days and then decreased by approximately 40% over the next two days. Histological evidence of germ cell loss was evident only after day 7. Altered expression of p53 protein in the cryptorchid testis was noted beginning on day 7, and consisted of the expression of a new 47 kD isoform of p53 in the cytosolic form and a 30 kD isoform in the soluble nuclear fraction. Scrotal testes showed no changes at any time point. These results demonstrate altered expression of the regulatory protein p53 beginning 1-2 days prior to the onset of germ cell loss following experimental unilateral cryptorchidism. Given the known function of p53 as an inducer of apoptotic cell death, these observations suggest a significant role for p53 in temperature-mediated germ cell loss.
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OBJECTIVE: To determine the prevalence of occult prostate cancer in men with low serum total testosterone or free testosterone levels. DESIGN: Retrospective analysis of a consecutive series of men. SETTING: Academic teaching hospital. PATIENTS: Seventy-seven men with low total testosterone or free testosterone levels, with normal results of digital rectal examination and prostate-specific antigen (PSA) levels of 4.0 ng/mL or less. The mean age was 58 years. INTERVENTIONS: Sextant prostate needle biopsies with ultrasound guidance. MAIN OUTCOME MEASURES: Results of prostate needle biopsies, transrectal ultrasound, prostate volume, PSA level, PSA density, total and free testosterone levels. RESULTS: Prostate cancer was identified in 14% (11/77) of the entire group and in 10 men (29%) aged 60 years or older. The median age for men with cancer was 64 years. Histologic examination showed Gleason scores of 6 or 7 for all cancers. No significant differences were noted between the cancer and benign groups with regard to PSA level, PSA density, prostate volume, total testosterone level, or free testosterone level. CONCLUSIONS: A high prevalence of biopsy-detectable prostate cancer was identified in men with low total or free testosterone levels despite normal PSA levels and results of digital rectal examination. These data suggest that (1) digital rectal examination and PSA levels are insensitive indicators of prostate cancer in men with low total or free testosterone levels, and (2) PSA levels may be altered by naturally occurring reductions in serum androgen levels.
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Ureteral pseudodiverticula are small outpouchings along the length of the ureter diagnosed primarily by the retrograde urogram. They are associated with hematuria and urinary tract infections, although it is now known whether they cause these associated symptoms or are a result of them. Herein we report 2 cases that highlight the characteristic clinical correlates of ureteral pseudodiverticulosis and review the pertinent literature.