Indomethacin and symptomatic relief of benign prostatic hyperplasia.
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Administration, Rectal↗
Biomedical subjects
J C Presti
Publications and source records attributed to J C Presti.
The role of transrectal ultrasound-guided biopsy-based staging, preoperative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate cancer.
OBJECTIVES: To evaluate the role of ultra sound-guided systematic and lesion-directed biopsies, biopsy gleason score, preoperative serum prostate-specific antigen (PSA) as three objective and reproducible variables to provide a reliable combination in preoperative identification of risk of extraprostatic extension in patients with clinically localized prostate cancer. METHODS: The case records of 813 patients who underwent radical prostatectomy for clinically localized prostate cancer were analyzed. All had multiple systematic biopsies, two to three from each lobe, in addition to lesion-directed biopsies. Additionally, biopsies were done on seminal vesicles (SVs), if abnormal. Based on biopsy results, patients were classified as having stage B1 (T2a-T2b) or B2 (T2c) disease, depending on whether biopsies from one or both lobes were positive and stage C (T3) if there was evidence of SV involvement by biopsy of biopsies from areas of extracapsular extension as seen on transrectal ultrasound (TRUS) were positive. Logistic regression analyses with log likelihood chi-square test was used to define the correlation between individual as well as combination of preoperative variables and pathologic stage. RESULTS: On final pathologic examination, 473 (58%) patients had organ-confined disease, 188 (23%) had extracapsular extension (ECE), with or without positive surgical margins, and 72 (9%) had SV involvement. Eighty (10%) patients had pelvic lymph node metastases. Biopsy-based staging was superior to clinical staging in predicting final pathologic diagnosis. Logistic regression analyses revealed that the combination of biopsy-based stage, preoperative serum PSA, and biopsy Gleason score provided the best prediction of final pathologic stage. Probability plots constructed with these data can provide significant information on risk of extraprostatic extension in individual patients. CONCLUSIONS: This study demonstrates that TRUS-guided systematic biopsy in combination with preoperative serum PSA and biopsy Gleason score may provide a cost-effective approach for management decisions and prognostication in patients with prostate cancer.
Biopsy↗
Anterior bladder neck tube reconstruction at radical prostatectomy preserves functional urethral length--a comparative urodynamic study.
OBJECTIVE: To characterize the continence mechanism of anterior bladder neck tube reconstruction at the time of radical prostatectomy using urodynamic evaluation. PATIENTS AND METHODS: Prospective pre- and post-operative urodynamic profiles were performed in patients receiving conventional posterior 'racket handle' closures (control group--eight patients) and those receiving anterior bladder neck tube reconstruction at radical prostatectomy (study group--nine patients). Bladder neck tube reconstruction was performed by constructing 2 cm anterior bladder neck tubes over 22 F catheters. RESULTS: A significantly longer post-operative functional urethral length was demonstrated using urodynamic assessment in patients receiving an anterior bladder neck tube closure (4.6 vs 3.4 cm; P < 0.01). CONCLUSION: The anterior bladder neck tube reconstruction may promote urinary continence in patients undergoing radical prostatectomy by preservation of functional urethral length.
Anastomosis, Surgical↗
The use and accuracy of cross-sectional imaging and fine needle aspiration cytology for detection of pelvic lymph node metastases before radical prostatectomy.
The role of cross-sectional pelvic imaging with computerized tomography or magnetic resonance imaging and fine needle aspiration in the assessment of pelvic lymph nodes in patients with prostate cancer is undefined. To address this issue we used formal decision analysis, comparing an imaging arm to a no imaging arm. Patient utility values were calculated, and test parameters and complication rates were extracted from the literature. Imaging was superior to no imaging only when the pretest probability of pelvic lymph node metastases was high. The most important parameter was the sensitivity of cross-sectional imaging for lymphadenopathy. When the sensitivity was 36%, which was the baseline figure derived from the literature, the probability of lymph node metastases required for imaging to be beneficial overall was 32%. We also performed a retrospective review of magnetic resonance imaging examinations at our institution in 174 patients with newly diagnosed prostate cancer and pathological confirmation of nodal status. The sensitivity for detecting nodal metastases was 25%. With this figure, the estimated probability of nodal metastases required to make imaging beneficial would be 45%, which is possible to achieve with highly selective clinical criteria. With a policy of imaging only in select patients the marginal cost is $794 per patient benefited (aborted radical prostatectomy because of nodal metastases detected with fine needle aspiration) compared to $50,661 per patient benefited if all patients are imaged. Thus, cross-sectional pelvic imaging before radical prostatectomy, solely for the purpose of detecting pelvic lymph node metastases, is not justified routinely. However, it is worthwhile on the basis of patient use values and cost-effectiveness in a select group of patients at high risk for nodal metastases.
Biopsy, Needle↗
Complete androgen blockade for metastatic prostate cancer.
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Androgen Antagonists↗
Allelic deletions in renal tumors: histopathological correlations.
Allelic loss on the short arm of chromosome 3 (3p) is considered to be one of the early detectable events in the pathogenesis of renal cell carcinoma (RCC). Conflicting reports, however, suggest that this event may be absent in some renal tumors. The present study attempts to further define subgroups of renal tumors associated with 3p deletions. In addition, we have also attempted to identify late genetic events associated with tumorigenesis and tumor progression. Eighty-two primary renal tumors (69 RCC and 13 oncocytic tumors) were analyzed by restriction fragment length polymorphism analysis directed at chromosomes 3, 11p, 17p, and 18q. Results were correlated with histopathological information. Deletions of 3p were seen in nonpapillary RCC of all cell types, but were absent in oncocytic and most papillary tumors. Among the 60 nonpapillary RCC, significant correlations were seen between deletion of 17p and tumor grade (P = 0.037), P stage (P = 0.027), and nodal metastases (P = 0.042). We therefore conclude that 3p deletions, although not specific to any cell type or histological pattern of RCC, are seen in a majority of clear cell nonpapillary RCC but are absent in oncocytic and most papillary tumors. Additional allelic losses on chromosome 17p are associated with advanced disease and, therefore, may be related to tumor progression. Further studies on larger series of patients with extended follow-up will be necessary to investigate the prognostic value of molecular genetic markers in RCC.
Alleles↗
Molecular genetic alterations of chromosome 17 and p53 nuclear overexpression in human bladder cancer.
We set out to define the alterations of chromosome 17 in human bladder tumors and to correlate p53 nuclear over-expression with 17p deletions in those neoplasms. We studied 60 bladder tumors by restriction fragment-length polymorphism analysis directed at five different loci on chromosome 17. The same tumors were studied with a panel of mouse monoclonal antibodies (PAb1801, PAb240, and PAb1620) to mutant and wild-type p53 proteins using immunohistochemistry. Deletion of 17p correlated with grade (p = 0.039), stage (p = 0.004), and the presence of vascular invasion (p = 0.056). None of the pathologic parameters correlated with 17q deletions. p53 nuclear overexpression correlated with grade (p = 0.027), stage (p = 0.008), vascular invasion (p = 0.021), and the presence of nodal metastases (p = 0.007). In superficial (Ta) lesions, 17p was not deleted, whereas 55% of T1 and T2-T4 tumors showed a loss of heterozygosity. Mutations of p53 as detected by immunohistochemistry were seen in superficial as well as invasive tumors, whereas loss of heterozygosity was seen only in invasive tumors. A strong correlation was found between the presence of mutation and the loss of heterozygosity of the remaining allele (p = 0.0003). Additional follow-up and further studies are required to better define the role of p53 nuclear overexpression and 17p deletions as markers of tumor progression in human bladder cancer.
Alleles↗
Fertility and testis cancer.
Patients with testicular cancer may demonstrate impaired spermatogenesis because of the disease process or as a direct consequence of treatment. For some patients, impaired spermatogenesis may resolve spontaneously, while in others, treatable etiologies may be identified and corrected.
Humans↗
Comparison of plicated and stapled continent ileocecal stoma.
Tapered terminal ileum and an intact ileocecal valve have been shown to be an effective efferent continence mechanism in patients with continent ileocecal urinary reservoirs. The terminal ileum can be tapered by simple suture plication or with linear gastrointestinal stapling devices. We used precise urodynamic techniques to study 21 continent urinary reservoirs constructed from ileocecal bowel segments: 14 with plicated segments and 7 with stapled segments. Mean contraction pressures tended to be higher in the latter (P = 0.054), although maximum contraction pressures were similar (P = 0.48). Terminal ileum tapered with the gastrointestinal stapling device and an intact ileocecal valve provide for an effective efferent continence mechanism that is easy to construct and catheterize.
Evaluation Studies as Topic↗
Multicenter, randomized, double-blind, placebo controlled study to investigate the effect of finasteride (MK-906) on stage D prostate cancer.
A total of 28 untreated patients with asymptomatic, stage D prostate cancer was randomized in a double-blinded fashion to receive finasteride (10 mg. per day), a 5 alpha-reductase inhibitor or placebo. Patients were evaluated at 3-week intervals by rectal examination, and serum prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) levels, and at 6-week intervals by bone scan and transrectal ultrasound determinations of prostatic volume. Patients stopped the medication at week 6 at the discretion of the investigator when PSA levels increased from baseline. After 12 weeks all patients were reevaluated. Of the patients 13 received finasteride and 15 received placebo. The 2 groups did not differ statistically with respect to patient age, initial PSA and PAP level, or the extent of metastases on initial bone scan. A statistically significant decrease in the median percentage change from baseline in PSA at weeks 3 and 6 occurred in the finasteride group compared to the placebo group (-22.9% versus -2.9% and -15.1% versus +11.7%, respectively, p less than 0.05). Finasteride had no effect upon PAP, serum testosterone, prostatic volume or appearance of bone scans. A decrease in serum PSA in the finasteride treatment group suggests that finasteride exerts a minor effect in patients with prostate cancer. This effect does not approach that seen with medical or surgical castration yet because of the potency preserving feature and the lack of toxicity finasteride may warrant further study in the treatment of prostate cancer.
5-alpha Reductase Inhibitors↗
Continence after radical cystoprostatectomy and total bladder replacement: a urodynamic analysis.
Urodynamic evaluation was performed in 10 patients after radical cystoprostatectomy and continent urethral diversion with detubularized ileum and in 13 patients continent after radical prostatectomy. In both groups surgical techniques were modified to optimize preservation of the periurethral tissue at the prostatic apex. For the ileal neobladder group 9 patients (90%) were completely continent and 1 (10%) noticed moderate nocturnal incontinence. The urethral sphincteric mechanism was well preserved in these patients, with no significant difference between the 2 groups in mean functional urethral length (3.8 +/- 0.6 versus 3.6 +/- 0.8 cm., p = 0.55) or maximal urethral closure pressure (87 +/- 34 versus 74 +/- 20 cm. water, p = 0.26). Tubularization of the bladder or neobladder above the level of the external sphincter was noted in both groups. Continence after radical cystoprostatectomy with continent urethral diversion and after radical prostatectomy is dependent upon an intact urethral sphincteric mechanism as well as a compliant, low pressure reservoir, either bladder or a bladder substitute. Urinary incontinence after total bladder replacement with detubularized ileum can be minimized by preserving as much of the distal urethral sphincter as possible. This can be done by careful dissection of the prostatic apex, performed under direct vision, with an understanding of the anatomy of the urethral sphincter and its innervation.
Aged↗
Molecular genetic alterations in superficial and locally advanced human bladder cancer.
We attempted to define the role of tumor suppressor genes in the pathogenesis of human bladder cancer through a combined molecular genetic and immunohistochemical approach. Thirty-four bladder tumors (1 Pis, 6 Pa, 5 P1, 3 P3a, 18 P3b, 1 P4; 8 low grade and 26 high grade tumors) have been analyzed. Restriction fragment length polymorphism analysis directed at 5 suspected or established tumor suppressor gene regions (3p21-25, 11p15, 13q14, 17p11-13, and 18q21) was combined with immunohistochemical using Rb-PMG3-245 monoclonal antibody directed at the retinoblastoma (Rb) gene product. Tumor grade correlated with deletions of 3p (P = 0.004) and 17p (P = 0.063). Tumor stage correlated with deletions of 3p (P = 0.010), 17p (P = 0.015) and altered Rb expression (P = 0.054). Vascular invasion correlated only with deletions of 17p (P = 0.038). No marker correlated with positive lymph nodes. Our results suggest that altered Rb expression occurs in all grades and stages of bladder cancer but is more commonly associated with invasive tumors. Genetic alterations of 3p, 11p, 17p, and 18q are rare events in low grade, superficial tumors, whereas they are more common in high grade and invasive bladder cancer. The role of these genetic alterations in the prognosis of bladder cancer will require additional follow-up and further studies.
Blotting, Southern↗
Histopathological, cytogenetic, and molecular characterization of renal cortical tumors.
We used cytogenetic and restriction fragment length polymorphism (RFLP) analysis methods to define genetic alterations and also correlate the changes with histopathology in renal cortical tumors. The study series is comprised of 50 renal tumors in 4 histological categories: (a) clear cell, nonpapillary, renal cell carcinoma (RCC) (n = 32); (b) nonclear cell, nonpapillary RCC (n = 10); (c) papillary RCC (n = 3); and (d) oncocytic tumors (n = 5). Successful karyotypes were obtained from 28 tumors (56%), of which 17 (61%) were abnormal. Abnormalities of chromosome 3p were seen in 9 tumors, which included unbalanced translocations and terminal or interstitial deletions. Abnormalities of chromosome 5 were identified in 11 tumors, 8 of which were due to unbalanced translocations between 3p and 5q, resulting in an extra copy for the region 5q22----ter. In addition, trisomy or tetrasomy of chromosome 17 was seen in 6 (5 with normal chromosome 3 and one with 3p deletion), trisomy or more copies of chromosome 7 in 8 (4 with 3p deletion, 2 with trisomy or tetrasomy 17, and 2 with trisomy alone), and trisomy 12 in 3 (all with trisomy 17) tumors. Furthermore, relative deficiency of chromosome 17p was seen in 3 (all with deletion 3p) and chromosome 18 in 4 (all with deletion 3p) tumors. RFLP analysis with four chromosome 3 specific probes detected 3p deletions in 19 tumors with the most common breakpoint located between 3p14-21. The 19 3p deletions detected by RFLP included tumors that also showed rearrangement of 3p by cytogenetics (n = 4) and those that showed normal karyotypes (n = 3) in addition to cytogenetic failures (n = 12). Deletions of 17p were seen in 5 of 31 informative cases. Thus, deletions of 3p were seen in a total of 24 tumors by cytogenetic and/or RFLP analysis, 21 of which were clear cell, nonpapillary RCC, whereas 3 had a minor clear-cell component. Oncocytic and nonclear, nonpapillary tumors, on the other hand, did not demonstrate 3p deletions by either technique, whereas trisomy 17 was seen in 3 of the 3 papillary tumors. The loss of alleles from chromosome 17p and 18 and an increased dosage of gene or genes on chromosomes 5q and 7 as seen in high-stage tumors of various histological subtypes may be associated with progression of disease.
Adult↗
Bilateral spontaneous renal hemorrhage due to polyarteritis nodosa.
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Adult↗
Pathophysiology of urinary incontinence after radical prostatectomy.
To define the origin of urinary incontinence after radical prostatectomy urodynamic studies in 24 incontinent patients were compared to those of 13 continent patients. A statistically significant difference between incontinent and continent patients was found for the mean functional profile length (2.1 versus 3.6 cm., respectively, p less than 0.001), maximal urethral closure pressure (39 versus 74 cm. water, respectively, p less than 0.001) and maximal urethral closure pressure during voluntary contraction of the external sphincter (107 versus 172 cm. water, respectively, p less than 0.002). The differences among maximal detrusor pressure, initial bladder volume at which a detrusor contraction occurs, maximal cystometric capacity and residual urine were not statistically significant between the 2 groups. Urethral instability was present in 1 of the 24 incontinent patients (4.2%) and in none of the 13 continent patients, while detrusor instability was present in 6 (25%) and 3 (23.1%), respectively. Urethral and detrusor instability correlated poorly with incontinence (correlation coefficients 0.123 and 0.021, respectively). The appearance of the bladder outlet on voiding cystourethrography was correlated with urodynamic parameters and the presence or absence of continence. Tubularization above the level of the external sphincter was present in continent but absent in incontinent patients. Continence after radical prostatectomy is dependent upon sphincteric efficiency, which may be influenced by the anatomical configuration of the reconstructed bladder outlet and the integrity of the distal urethral sphincteric mechanism.
Aged↗
Functional characteristics of the continent ileocecal urinary reservoir: mechanisms of urinary continence.
We evaluated urodynamically 14 patients with a continent ileocecal urinary reservoir. Reservoirs were constructed of detubularized right colon alone (4 patients), or augmented with ileum (2) or with a U-shaped ileal patch (8). All reservoirs were placed in the abdomen and used plicated terminal ileum as the efferent continence mechanism. Twelve patients are completely continent with intermittent catheterization at 4 to 8-hour intervals. Two patients suffer mild nighttime incontinence. Mean reservoir volume was 675 ml. Intermittent intestinal contractions were noted in the plicated ileal segment and reservoir but they occurred more frequently in the former and were either synchronous with or preceded those in the reservoir. Mean and maximal contraction pressures were 24 and 47 cm. water, respectively, in the reservoir and 40 and 151 cm. water, respectively, in the plicated ileal segment (p equals 0.043 and less than 0.001, respectively). The highest reservoir contractions occurred in the 2 patients with nocturnal incontinence. The method of construction bore no consistent correlation with mean or maximal contraction pressures, contraction frequency or continence. Careful urodynamic assessment suggests that the ileocecal urinary reservoir is a relatively low pressure, nonrefluxing and continent bladder substitute. The plicated terminal ileal segment acts as an effective sphincter that responds to pressure elevations in the reservoir. Its simple construction and easy catheterization make it an attractive alternative to intussuscepted ileal segments.
Adult↗
Ureteral and renal pelvic injuries from external trauma: diagnosis and management.
To define the optimal methods of diagnosis and repair of ureteral and renal pelvic injuries, we reviewed the records of 18 patients with 19 collecting system injuries (16 penetrating, three blunt). Hematuria was absent in five of 16 patients. Intravenous urography was diagnostic of ureteral injury in three and normal or nondiagnostic in eight. Retrograde pyelography was performed in only one patient and was diagnostic of bilateral ureteral injury. Treatment consisted of primary repair (minimal or no debridement and closure) in 11 injuries, ureteroureterostomy (debridement and reanastomosis) in six, ureteroneocystostomy in one, and transureteroureterostomy in one. Ureteral stents were placed in 12 injuries, nephrostomy catheter in one, and both in two. Four patients had no form of diversion. Followup was available for 14 patients; serum creatinine values were normal in each. Results of imaging studies in 13 were normal in 11; one showed mild caliectasis and one a resolving urinoma. Both intravenous urography and initial urinalysis may be unreliable indicators of ureteral and renal pelvic injury, and high suspicion mandates exploration. Usually the urinary tract can be satisfactorily reconstructed. Satisfactory urinary diversion can be achieved in most cases with an internal ureteral stent.
Adult↗
Lumbar herniation of the kidney.
We report a case of lumbar herniation of a kidney, resulting in intermittent ureteropelvic junction obstruction. Surgical repair of the lumbodorsal fascial defect resulted in resolution of the uretero-pelvic junction obstruction.
Adult↗