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Sexual medicine is unique in that it permeates throughout various medical specialties, without having its own defined borders. Urology, gynecology, primary care, endocrinology and cardiology are connected to sexual medicine to varying degrees. Should sexual medicine be a requisite part of the aforementioned teaching programs? Dr Martin Resnick, Lester Persky Professor and Chairman, Department of Urology, Case Western Reserve University, provides a perspective on this topic.

To determine if levels of inter-alpha-trypsin inhibitor (I alpha TI)-trimer differ in normal individuals based on age, gender or hormonal status, as the regulation of calcium oxalate (CaOx) crystallization inhibitors, e.g. by sex steroids, could be a mechanism contributing to the differences in CaOx urolithiasis between the sexes.Voided urine samples were collected from normal males and females. In Experiment 1 samples were grouped by gender and age, i.e. paediatric (PED)or = 10 years, male (M) 21, female (F) 14; young adult (YGAD) 20-30 years, M 23, F 18; adults (AD), 35-50 year, M 25, F 13; adults agedor = 60 years (60), M 24, F 16 (totals, M 93, F 61). In Experiment 2 samples were grouped by gender, age and hormonal status, i.e. PED, M 24, F 17; AD, M 24, F 22;60 and not on hormonal therapy, M 23, F 30; M60 and on androgen deprivation therapy (ANDEP) 18; and F60 on oestrogen supplementation, F+EST, 18 (total M 89, F 85). Levels of urinary I alpha TI-trimer were determined by immunoblotting and enhanced chemiluminescence, and relative densities of the bands determined.In both experiments the relative levels of I alpha TI-trimer were 2-7 times higher in M-PED than in all other groups of males (Por = 0.007). Among adult males, I alpha TI-trimer levels were similar in all groups, including ANDEP (Por = 0.9). There were no differences in the relative levels of I alpha TI-trimer among any of the groups of females, regardless of age or hormonal status (Por = 0.7).In males a decrease in I alpha TI-trimer was associated with the onset of adulthood and entry into the 'stone-forming years'. Females did not show this decrease, and neither sex showed an increase in I alpha TI-trimer in the60 group, when the incidence of CaOx urolithiasis is supposedly declining. While changes in urinary I alpha TI-trimer levels in males may reflect maturational changes in the kidney, overall these data do not support the hypothesis that the age-related changes in the incidence of urolithiasis are paralleled by changes in the expression I alpha TI-trimer. Additionally, the sex steroids do not appear to acutely regulate the expression of I alpha TI-trimer in adults, making differences in I alpha TI-trimer levels unlikely to be the reason for the disparity in the incidence of CaOx urolithiasis between the sexes.

Like all other medical and surgical practitioners, urologists are occasionally confronted with the unpleasant realization that they are being sued for medical malpractice. These suits are generated through any number of acts or failures to act during innumerable circumstances. We reviewed all urological claims presented to 1 representative insurance company and delineated the types of acts, settings, expenses and disposition of these claims. This review was performed to understand better the claims confronting urologists and provide future guidance to urologists in the medical malpractice setting.Working with The St. Paul Companies 259 medical malpractice claims against urologists consecutively closed from 1995 to 1999 were reviewed. Claims were defined as urological malpractice when the insured-defendant in a malpractice claim was a urologist. Each claim was reviewed in terms of disposition, patient age, geographic location, office-hospital setting, purported negligent act, procedure if applicable, litigation status and expenses incurred. Data ascertained were then compared to national practice statistics provided by the American Urological Association (AUA) and American Medical Association. In addition, a literature search with the key words urology and malpractice was performed. Related pertinent documents were reviewed and incorporated into this analysis.We reviewed 259 urological medical malpractice claims closed between 1995 and 1999. During this period The St. Paul Companies insured various numbers of private practice urologists. In the years ending 1995 to 1999, 489, 492, 438, 377 and 426 individual urologists, respectively, were insured with respective premiums paid in the amounts of $6.27, $6.23, $5.80, $5.15 and $3.87 million. Claims were analyzed by AUA section. The greatest incidence of claims occurred in the Southeastern section, followed by the North Central, South Central, Mid-Atlantic, New England, Western and New York sections. According to AUA statistics the greatest number of practicing urologists are in the Southeastern section, followed by the Western, North Central, South Central, Mid-Atlantic, New York, New England and Northeastern sections. When analyzing average expenses, the New England section had the most costly claims, followed by the Mid-Atlantic, North Central, Southeastern, South Central, Western and New York sections with respective mean expenses of $266,887, $145,031, $47,667, $41,843, $38,365, $30,037 and $1,065 per claim, respectively. The greatest percent of claims arose from the categories of inpatient, adult and surgical procedures. Endourological procedures resulted in the greatest incidence of surgical claims. However, claims related to prostatectomy involved the most expensive claims with a mean cost of $185,345. Of the surgical procedures incidents defined as postoperative complications were the most common acts of negligence generating a malpractice claim. The majority of malpractice claims were filed in court but subsequently voluntarily dismissed by the plaintiff.Medical malpractice persists as an issue confronting urologists. Urologists must strive to maintain open, honest, in-depth communications with their patients when occurrences with potential malpractice overtones arise.

Since the publication of the first genome screen for prostate cancer (CaP) 5 years ago, over a dozen linkage studies have appeared. Most attention has been directed to chromosome 1, where two separate regions have been identified as harboring a prostate cancer susceptibility locus: HPC1 in the 1q24-25 interval and PCaP in the 1q42.2-43 interval. Linkage analysis of chromosome 16 has also provided evidence of harboring two loci predisposing to CaP.We report on a replication linkage study of chromosomes 1 and 16 in 45 new and 4 expanded multiplex CaP families. Multipoint Z-scores were obtained for 30 highly polymorphic short-sequence tandem repeat markers spanning chromosome 1, and 22 markers spanning chromosome 16.The replication sample gave no evidence for a CaP susceptibility locus in the 1q24-25 interval and equivocal evidence for such a locus at 1q42.2-43. With respect to chromosome 16, positive Z-scores were obtained over a contiguous interval covering the entire p arm and the proximal half of the q arm.The linkage analysis of our replication sample does not support the existence of HPC1, and the evidence for the existence of PCaP remains equivocal. Evidence of a susceptibility locus on 16p remains strong, but the evidence for a susceptibility locus on 16q is weakened.

Neoadjuvant hormonal ablation therapy has been used to decrease the rate of positive surgical margins in patients treated with radical prostatectomy. We reviewed the available literature to determine whether this therapy is indicated and beneficial.We performed a MEDLINE key word search and assessed randomized prospective articles. Data were analyzed for the rate of positive surgical margins, seminal vesicle invasion and lymph node metastasis as well as surgical characteristics, including operative time, blood loss, hospital stay, rate of complications and difficulty of surgical dissection. In addition, these data were evaluated for prostate specific antigen-free survival.Neoadjuvant hormonal therapy decreased the rate of positive margins in 6 of the 7 randomized prospective studies. In none of 4 randomized prospective series was there an improved rate of seminal vesicle invasion with neoadjuvant hormonal therapy. Of 4 studies 3 showed no improvement in the rate of lymph node metastasis after neoadjuvant hormonal therapy compared with that in controls. Similarly there was no improvement in prostate specific antigen-free survival and no significant difference in operative time, operative blood loss, transfusion or hospital stay in patients treated with neoadjuvant hormonal therapy and controls. In addition, in 2 of 3 studies there was no difference in the complication rate.Analysis of the available literature revealed no significant improvement in outcome to support the routine administration of neoadjuvant hormonal therapy before prostatectomy.

Good models for the investigation of human prostate cancer are few. Cells from approximately 9.2-21 ml of peripheral blood from patients with metastatic prostate cancer or metastatic colon cancer were injected s.c. into nude mice. Prostate cancer from 2 of 11 patients and colon cancer from 1 of 3 patients were found to be growing as metastases in the lungs of the nude mice. To our knowledge, this is the first report of the formation of xenografts from carcinoma cells taken directly from the peripheral blood of patients. Expanding circulating cancer cells with this approach may have important translational applications including: (a) development of models of human cancers; and (b) sampling of cancers from specific patients for novel molecular and therapeutic approaches.

Computerized tomography (CT) of the abdomen and pelvis is often routine in the preoperative staging assessment of invasive transitional cell carcinoma of the bladder. We determine the accuracy of staging CT findings, usefulness before planned extirpative surgery and impact on surgical management of this disease.We retrospectively reviewed the medical records, including radiographic, operative and pathological reports, of 82 consecutive cases. All patients presented with muscle invasive bladder tumors, were considered candidates for radical cystectomy and underwent preoperative staging CT of the abdomen and pelvis between July 1994 and June 1998. The ability of CT to provide additional staging information in terms of depth of tumor invasion, local extent of tumor, pelvic lymph node involvement and distant metastases was examined. We determined whether CT findings altered surgical management for individual patients.CT was able to discriminate depth of invasion in only 1 patient (1.2%) and correctly identified extravesical tumor spread in 4 (4.9%). Lymph node and distant metastases were accurately determined in 4 (4.9%) and 2 (2.4%) cases, respectively. The overall accuracy of CT was 54. 9%, with an under staging and over staging rate of 39.0% and 6.1%, respectively. CT provided accurate, additional staging information in only 8 cases (9.8%). Surgical management was altered in 3 cases (3.7%) and only 1 (1.2%) avoided an unnecessary operation as a result of CT findings.Staging CT of the abdomen and pelvis in patients with invasive bladder carcinoma has limited accuracy, mainly because of its inability to detect microscopic or small volume extravesical tumor extension and lymph node metastases. CT tends to under stage advanced disease and failed to alter surgical management in nearly all of our cases.

The Internet is changing the way medicine is being practiced and challenging our notions of the doctor-patient relationship. We analyze the development of online prescriptions and propose guidelines for the sale of sildenafil over the Internet.Using MEDLINE, Medscape and Lexis-Nexis search engines we reviewed pertinent materials from January 1996 to July 1999 focusing on the keywords Viagra, prescription and Internet. The review included press releases, law review articles, case law, medical literature, pending litigation, proposed legislation, and federal and state statutes.Online prescriptions are an outgrowth of the mail order drug business. This development continues the historic innovations in communications and transportation that have enabled physicians to practice medicine over long distances while maintaining ties to hospitals and other specialists. While the sale of sildenafil over the Internet may be profitable and convenient, it raises a variety of legal, ethical and safety concerns. Many federal and state organizations have addressed the issue without establishing a clear standard.A clear distinction exists between online prescriptions and pharmacies. While it may be acceptable for sildenafil to be sold over the Internet given current technologies, it must be done within the confines of a traditional doctor-patient relationship. Online prescriptions must be limited to patients who live in states in which the prescribing physician is licensed. Failure to establish a doctor patient relationship in this context breeches ethical standards, and may give rise to potential civil and criminal liabilities.

There is debate over whether the recent increases seen in prostate cancer are due to lead-time bias from screening, or identification of clinically insignificant lesions.Population-based incidence rates for 1973-1996 were calculated, based on the Surveillance, Epidemiology, and End Results Program (SEER) tumor registries. Relative incidence rates for prostate cancer by stage, fatal incidence, and lymph nodes were calculated, adjusted for age.Localized and regional stage prostate cancer increased through 1992 and then dropped. The rate of distant-stage disease was relatively stable from 1973-1991, with a decrease in distant stage starting in 1992. The 2-year mortality rates were constant for 1973-1989. A decline in the 2-year mortality among cases (fatal incidence) also began in 1992.These data show large increases in early disease, followed by a drop and leveling off along with a decrease in advanced disease (distant stage, 2-year mortality, positive lymph nodes). This indicates that the increasing incidence rates for prostate cancer are largely due to lead-time bias from increased early detection and treatment of prostate cancer. However, since incidence rates have not declined to rates seen in the 1970s, the additional cases may also reflect length bias from insignificant lesions or a true increase in incidence over time.

To report the results of a retrospective study of 2290 ProstaScint scans of 2154 patients with prostate carcinoma done at 15 institutions.The results were analyzed by logistic regression after stratification of the patients into four groups: group 1, newly diagnosed; group 2, after radical prostatectomy with a rising prostate-specific antigen (PSA) level; group 3, after radiation therapy with a rising PSA level; and group 4, after hormonal therapy.The PSA level and ProstaScint scans positive in the prostate bed (P0.001) and for pelvic metastases (P0.001), but not for extrapelvic metastases, correlated significantly in group 1 patients. In group 2, the association for detecting fossa recurrence was weaker (P = 0.033) and was insignificant for pelvic and extrapelvic metastases. Patients in group 3 also exhibited a weak PSA-ProstaScint association for detecting fossa recurrence (P = 0.038), and was insignificant for pelvic and extrapelvic metastases. No significant PSA-ProstaScint correlation was found in patients in group 4 for fossa recurrence, pelvic or extrapelvic metastases. The distribution of positive ProstaScint results among the prostate/prostate bed, pelvic nodes, and extrapelvic nodes was nearly equal for all groups, except that a significantly greater percentage of extrapelvic metastases was found in the hormonal group (group 4). The ProstaScint results were independent of the Gleason score for 260 patients before and 285 patients after therapy.The results of this study underscore the complementary diagnostic value of ProstaScint to PSA level and Gleason score as an independent indicator of prostate cancer recurrence and metastases and in identifying extrapelvic metastases in both newly diagnosed and recurrent prostate cancer.

Prostate cancer (PCA), the most commonly diagnosed cancer in males in the United States, is the second leading cause of cancer-related deaths of males in this country. Because of the poor success rate in the treatment of PCA, an intervention at an early stage may reduce the progression of small carcinoma to large metastatic lesion, thereby reducing PCA-related deaths. Concerted efforts are needed to establish mechanism-based approaches to develop: (a) the markers for early detection of the disease as well as toward monitoring the efficacy of treatment(s); and (b) novel chemopreventive strategies against PCA. Using unique samples of pair-matched benign and cancer tissue obtained from the same PCA patient, we showed that ornithine decarboxylase (ODC) activity is significantly (P0.001) elevated in PCA (1142 +/- 100; mean +/- SE) than in paired benign tissue (427 +/- 51; mean +/- SE). The immunoblot analysis also showed a significant elevation in the protein expression of ODC in the PCA tissues as compared with the paired benign tissue. Furthermore, our data showed that the ODC activity in the prostatic fluid obtained by a digital rectal massage from the patients with PCA (3847 +/- 162; mean +/- SE) was significantly higher than in the patients with benign prostatic hyperplasia (2742 +/- 167; mean +/- SE) or normal individuals (1244 +/- 67; mean +/- SE). This observation might be of significance because the prostatic fluid could be obtained noninvasively by digital rectal massage. We suggest that ODC could serve as a target for early detection of human PCA as well as for monitoring the efficacy of treatment(s). The development of ODC as a target for novel chemopreventive strategies against PCA is an intriguing possibility.

The current study was designed to compare the interpretation of the individual performing transrectal ultrasound examination (operator) with experienced individuals who interpreted the examination with and without the availability of clinical data. Inter-observer and intra-observer variability was compared to determine the reproducibility and reliability of the study.All patients undergoing radical prostatectomy for treatment of localized carcinoma of the prostate underwent a transrectal ultrasound examination before the procedure. The sonogram was interpreted by the operator and reviewers. The radical prostatectomy specimen was examined pathologically and the staging as determined by ultrasound was compared with the pathological findings.Ultrasound operator accuracy for extracapsular extension and seminal vesicle invasion was 0.70 and 0.74, respectively, compared with the accuracy of the reviewers, which ranged from 0.59 to 0.75 and 0.44 to 0.74 for extracapsular extension and seminal vesicle invasion, respectively. In general, blinded reviews were less accurate than unblinded reviews but this was only statistically significant for 2 reviewers.Although for most reviewers the addition of clinical data did not improve the accuracy of the interpretation, an advantage was noted for the operator, that is, the individual performing the examination. In general, the technical quality of the examination was related to the accuracy of the readings.

We describe the use of absorbable mesh for closure of a large parenchymal defect created by partial nephrectomy.A circular piece of polyglycolic acid mesh was measured to approximate the diameter of the parenchymal defect and the edges were sutured to the renal capsule in a running fashion.This technique has been used in 3 patients without complications. This approach has been particularly helpful for repairing large and irregular renal parenchymal defects.Use of polyglycolic acid mesh is effective for rapid, hemostatic closure of the kidney in association with partial nephrectomy.

In recent years, many investigators have devised innovative urinary diversions to improve the quality of life of patients requiring urinary diversions after cystectomy. In this article, we report a literature review in which we compare the outcomes of patients receiving an ileal conduit to those receiving either a continent cutaneous diversion or an orthotopic neobladder. In this discussion, we analyze the data in the literature that pertains to quality of life, incontinence rates, and metabolic complications. We conclude that although the newer urinary diversions are promising, randomized prospective trials comparing patients receiving these diversions to those receiving an ileal conduit need to be performed.

The establishment of extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy, and ureteroscopy as the primary treatment modalities for almost all renal and ureteral calculi has greatly diminished the role of open stone surgery. We reviewed our most recent experiences with open stone surgery to determine the current indications and to establish what role open surgery plays in the management of urolithiasis. We conducted a retrospective review of all patients undergoing open stone surgery during a consecutive 60-month period from 1991 through 1995 at three university-affiliated hospitals. Hospital and office charts, operative notes and records, and pertinent radiographic studies were reviewed. Of the 780 therapeutic stone procedures performed, 42 were open surgical procedures (5.4%), including pyelolithotomy [15], anatrophic nephrolithotomy [14], ureterolithotomy [7], and radial nephrolithotomy [6]. The most common indications for open stone surgery were complex stone burden, previous treatment failures with less-invasive modalities, anatomical abnormalities involving the renal collecting system, and patient comorbid medical problems. The stone-free rate following open surgery was 93%. There were five complications. Based on our experience, we discuss our current indications for open stone surgery.

We evaluated the efficacy of finasteride for the treatment of gross hematuria secondary to benign prostatic hyperplasia in a prospective fashion.Twelve patients with recurrent episodes of gross hematuria secondary to benign prostatic hyperplasia were treated with finasteride 5 mg/day. Before initiating treatment, we excluded other sources of hematuria using intravenous urography, cystoscopy, and urine culture.Bleeding subsided within 2 weeks of treatment in all 12 patients. Minimum follow-up was 6 months. Finasteride was well tolerated by all 12 patients.Finasteride appears to be effective in treating recurrent gross hematuria secondary to benign prostatic hyperplasia. This therapy should be considered an alternative to transurethral resection of the prostate or hormonal ablation in patients with recurrent hematuria and no significant obstructive uropathy or adenocarcinoma of the prostate.

We evaluated gamma-glutamyl transpeptidase as an indicator of metastatic disease in patients with renal cell carcinoma.We reviewed the records of 53 patients with metastatic renal cell carcinoma, and compared serum alkaline phosphatase and gamma-glutamyl transpeptidase with the site of metastases. These results were then compared to those in 29 patients with clinically localized renal cell carcinoma.Overall gamma-glutamyl transpeptidase was elevated in 37 patients (69.8%) with metastatic disease, while alkaline phosphatase was elevated in 16 (30.2%, p0.025). Gamma-glutamyl transpeptidase was increased in more patients with hepatic metastases only than alkaline phosphatase (p0.025) and in all groups it was a better predictor of metastases than alkaline phosphatase. Gamma-glutamyl transpeptidase was also increased in significantly more patients with metastatic renal cell carcinoma (37 of 53) compared to 1 of the 27 with localized renal cell carcinoma (p0.001).Gamma-glutamyl transpeptidase was increased in a large percent of patients with metastatic renal cell carcinoma, and it was normal in the majority with localized renal cell carcinoma. We conclude that gamma-glutamyl transpeptidase should be included as well as alkaline phosphatase in the preoperative metastatic evaluation of patients with renal cell carcinoma. Elevated gamma-glutamyl transpeptidase should prompt a search for bone as well as liver metastases.

We determined the accuracy of transrectal ultrasonography versus digital rectal examination in staging the local extent of biopsy proved carcinoma of the prostate.A National Institutes of Health funded network was developed to perform prospective, multi-institutional trials. A total of 386 patients judged by the investigators to be candidates for radical prostatectomy underwent transrectal ultrasonography with recording of data according to a numerical analog for construction of receiver operating characteristic curves. The results of digital rectal examination were similarly recorded. After radical prostatectomy whole mount histology was performed on all surgical specimens, and pathological findings were correlated with preoperative transrectal ultrasound and digital rectal examination results.The calculated area under the curve for transrectal ultrasound in predicting extracapsular tumor extension was 0.69 compared to 0.72 for digital rectal examination (p = 0.64), while that for predicting seminal vesicle invasion was 0.74 and 0.69, respectively (p = 0.36). There was a nonstatistically significant trend for improved accuracy of both examinations as tumor volume increased. Transrectal ultrasound was more accurate for staging posterior cancers than for those in the anterior portion of the prostate.Neither transrectal ultrasound nor digital rectal examination proved to be superior to each other for staging the local extent of prostate cancer. No imaging modality or examination that depends on gross architectural changes is likely to have a high degree of accuracy in detecting microscopic extension of extracapsular tumor frequently observed in radical prostatectomy specimens.

The genetics, pathophysiology, diagnosis, and treatment of cystinuria are discussed in this article. Newer chemotherapeutic and surgical options that are used to treat this disease process also are reviewed. The authors suggest a multimodal approach in the treatment of cystinuria and cystine calculi.

High-resolution profiles of the reflections of a broad-band 4 MHz ultrasound pulse from radical prostatectomy and autopsy specimens in vitro have been captured and analyzed. An attempt was made to correlate the histopathology of each prostate reflection site with the profile of the pulse reflected from that site. Reflections from 125 sites on 22 prostate specimens were studied. Although the reflected pulse from each site displayed a distinctive profile, we could find no obvious correlation between the shape of that profile and the histologic findings at that site.

Most patients' prostate cancers respond to androgen deprivation but relapse after periods of several months to years. Only two prostate cancer xenografts, LNCaP and PC-346, have been reported to be responsive to androgen deprivation and to relapse subsequently. Both of these tumors shrink slightly, if at all, and relapse less than 5 weeks after androgen withdrawal. After androgen withdrawal, the human primary prostate cancer xenograft CWR22 regresses markedly, and prostate-specific antigen (PSA) falls up to 3000-fold in the blood of mice. PSA usually returns to normal. In some animals, the tumor relapses and is then designated CWR22R. In these animals, PSA starts to rise approximately 2-7 months, and tumor begins to grow 3-10 months after castration. Animals with CWR22 need to be euthanized because of large tumors 6-12 weeks after the transplantation of CWR22. Androgen withdrawal prolongs life approximately 3-4-fold.

We determined whether cystic fibrosis patients are at increased risk for the development of urolithiasis.Telephone interviews were conducted with 201 cystic fibrosis patients older than 15 years to identify those with a history of urolithiasis. Histories were confirmed by chart review, and only patients with urolithiasis documented by excretory urography, renal ultrasound or spontaneous passage of a stone were included.A total of 11 patients (5.5%) had documented urolithiasis, with 2 or more episodes in 7. Mean age at initial episode was 27.0 years (range 19 to 33).Cystic fibrosis patients may be at increased risk for urolithiasis compared to age-specific prevalence rates for stone disease in the general population.

The American Urological Association convened the Prostate Cancer Clinical Guidelines Panel to analyze the literature regarding available methods for treating locally confined prostate cancer, and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit.The panel searched the MEDLINE data base for all articles from 1966 to 1993 on stage T2 (B) prostate cancer and systematically analyzed outcomes data for radical prostatectomy, radiation therapy and surveillance as treatment alternatives. Outcomes considered most important were survival at 5, 10 and 15 years, progression at 5, 10 and 15 years, and treatment complications.The panel found the outcomes data inadequate for valid comparisons of treatments. Differences were too great among treatment series with regard to such significant characteristics as age, tumor grade and pelvic lymph node status. The panel elected to display, in tabular form and graphically, the ranges in outcomes data reported for each treatment alternative.In making its recommendations, the panel presented treatment alternatives as options, identifying the advantages and disadvantages of each, and recommended as a standard that patients with newly diagnosed, clinically localized prostate cancer should be informed of all commonly accepted treatment options.