Faculty Bibliography

Spontaneous renal artery dissection (SRAD) is a rare event, and thus may be a challenge for physicians to diagnose and treat. We report a case of SRAD in a healthy 56-year-old male who presented with flank pain, fever, and elevated white blood cell count. The patient was initially diagnosed with nephrolithiasis versus pyelonephritis and was admitted for observation. Multiple imaging modalities, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI) with gadolinium, CT angiogram, and intraoperative angiogram, were used to make the final diagnosis of SRAD. The patient was treated with endovascular stent placement and is currently free of pain with normal laboratory values and blood pressure

This article reviews the issues and controversies relevant to the treatment of advanced prostate cancer with androgen deprivation therapy. Initially, diethylstilbestrol was used for achieving androgen deprivation, but was replaced by luteinizing hormone-releasing hormone (LHRH). Adverse events associated with LHRH agonists include the flare phenomenon, hot flashes, loss of libido, erectile dysfunction, depression, muscle wasting, anemia, and osteoporosis. Intermittent therapy has been advocated to reduce morbidity of treatment. The addition of an antiandrogen provides maximum androgen blockade. There remains controversy regarding the timing of the addition of an antiandrogen. Secondary hormonal therapies include antiandrogens, adrenal androgen inhibitors, and estrogens

PURPOSE: We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy. MATERIALS AND METHODS: Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity. RESULTS: Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p = 0.059), 1.65 (p = 0.041) and 2.03 (p = 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. CONCLUSIONS: Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity

Prostate carcinoma and benign prostatic hypertrophy may both originate in stem cells, highlighting the importance of the characterization of these cells. The prostate gland contains a network of ducts each of which consists of a proximal (adjacent to the urethra), an intermediate, and a distal region. Here, we report that two populations of cells capable of regenerating prostatic tissue in an in vivo prostate reconstitution assay are present in different regions of prostatic ducts. The first population (with considerable growth potential) resides in the proximal region of ducts and in the urethra, and the survival of these cells does not require the presence of androgens. The second population (with more limited growth potential) is found in the remaining ductal regions and requires androgen for survival. In addition, we find that primitive proximal prostate cells that are able to regenerate functional prostatic tissue in vivo are also programmed to re-establish a proximal-distal ductal axis. Similar to their localization in the intact prostate, cells with the highest regenerative capacity are found in the proximal region of prostatic ducts formed in an in vivo prostate reconstitution assay. The primitive proximal cells can be passaged through four generations of subrenal capsule grafts. Together, these novel findings illustrate features of primitive prostate cells that may have implications for the development of therapies for treating proliferative prostatic diseases

OBJECTIVE: To determine the rate of anastomotic stricture (AS) after radical retropubic prostatectomy (RRP) performed by one experienced surgeon, and to identify factors predisposing to its formation. PATIENTS AND METHODS: In all, 708 men were prospectively monitored for the development of AS after RRP. Potential risk factors for AS were analysed. RESULTS: There were no significant differences in age, Gleason score, nerve-sparing status, intraoperative blood loss, degree of extravasation on initial cystography, or duration of the indwelling urinary catheter between men who developed AS and men who did not. The mean postoperative blood loss was significantly higher in men who developed AS. The incidence of AS was also significantly higher in men whose bladder necks were reconstructed more narrowly. CONCLUSION: The amount of bleeding and the calibre of the reconstructed bladder neck were significantly associated with AS formation after RRP. The development of a haematoma from bleeding might explain the increased likelihood of AS. The mechanism of AS formation is unrelated to the degree of urinary extravasation on cystography, providing that a urinary catheter is left indwelling until extravasation resolves

PURPOSE: We determined if the degree of postoperative bleeding predicts the extent of urinary extravasation on initial postoperative cystogram. MATERIALS AND METHODS: Between October 2000 to June 2004, 879 men underwent radical retropubic prostatectomy performed by a single surgeon. Of these men 97% underwent the initial postoperative cystogram 3 to 8 days following radical prostatectomy. Postoperative bleeding was expressed as the absolute change in hematocrit between hematocrit values measured immediately upon arrival into the recovery room and hospital discharge. Three hematocrit points were added to the change in postoperative hematocrit for every unit of blood transfused postoperatively. The relationship between the change in postoperative hematocrit and the extent of extravasation was examined. RESULTS: None, mild, moderate and marked extravasation was observed on the initial cystogram in 82.7%, 7.9%, 8.8% and 0.6% of cases, respectively. A significant relationship was observed between changes in postoperative hematocrit and the extent of extravasation on initial cystography (p <0.001). Postoperative changes in absolute hematocrit points of less than 2, 2 to 6 and greater than 6 identified clinically meaningful risk groups for urinary extravasation. The degree of extravasation was not significantly related to risk of anastomotic stricture or urinary incontinence. CONCLUSIONS: The extent of postoperative bleeding predicts the extent of urinary extravasation on initial cystography. It may be a useful measurement for identifying men who can safely undergo early catheter removal without cystography

Alpha-blockers have been evaluated for the treatment of benign prostatic hyperplasia (BPH) for 30 years, from early trials with the nonselective alpha-inhibitor phenoxybenzamine to short-acting (prazosin) then long-acting (terazosin, doxazosin, tamsulosin, alfuzosin) selective alpha(1)-antagonists. All of the alpha-blockers evaluated have demonstrated comparable effectiveness, and the evolution of alpha-blocker therapy for BPH has therefore focused primarily on improving convenience and tolerability. Although all of the long-acting alpha(1)-blockers are well tolerated, only tamsulosin and alfuzosin SR are administered without the requirement for dose titration. Alfuzosin has the additional advantage over tamsulosin of a lower incidence of ejaculatory dysfunction. Studies of subtype-selective alpha(1)-antagonists have not demonstrated superior efficacy or improved tolerability over the existing long-acting alpha(1)-blockers