Treatment of congenital penile curvature due to disparate corpora cavernosa by the Nesbit technique: a rule of thumb for the number of wedges of tunica required to achieve correction.

Treatment of pure congenital penile curvature due solely to asymmetry of the corpora cavernosa as described by Nesbit lacks precision. Intraoperative verification of Nesbit correction by artificial erection after wedge excision may be impossible because leakage through the sutured corporeal incisions prevents full erection. We present a rule of thumb to calculate the number of 1 cm. wedges of tunica albuginea to be excised to correct an individual deformity. The number of such wedges required is equal to the measured difference in centimeters between the lengths of the asymmetric, concave and convex surfaces of the affected penis, between the pubis and mid glans. Results of application of this principle in 6 patients are presented.

Trends in urological manpower in the United States in 1986.

Estimated urological manpower needs for the United States are reviewed and correlated with the nationwide urological work load. In addition, a limited attempt is made to assess the ideal urological work load. On the basis of this study a decrease in the production of urologists appears to be less necessary than has been proposed to date. If the present trend of increasing the length of urology residency training to 2 pre-urology years plus 4 years of urology continues, and if the influx of foreign trained graduates continues to decrease the problem of overproduction of urological specialists may be solved, since these 2 measures by themselves would reduce the annual certification in the United States to about 280 diplomates, which is 20 less than the estimated annual attrition of 300 practicing urologists. The 8,236 urologists in the United States counted by the American Medical Association in 1983 performed an average of 204 hospital procedures each, including 43 transurethral prostatic resections. The average load per urologist seems to be adequate to maintain diagnostic, therapeutic and surgical skills.

Quantitation of corporeal venous outflow resistance in man by corporeal pressure flow evaluation.

We describe a technique that allows us to quantify intracorporeal penile venous resistance in papaverine-induced erections. By increasing intracorporeal pressure to greater than the mean arterial pressure by cavernous perfusion with Ringer's lactate solution we can control and measure cavernous flow and pressure, and, therefore, calculate venous resistance. We evaluated 78 impotent men and 6 controls with this method. The most important measure of the integrity of the venous resistance mechanism and of the ability to obtain an adequate erection was a post-distension steady state pressure of 50 mm. Hg or more and a venous outflow resistance of 20 mm. Hg minute per cc or more. Our method aids in the clinical evaluation of the etiology of erectile impotence.

Urinary calculous disease in Southeast Asian immigrants.

Recent immigrants from Southeast Asia accounted for 39 of 149 hospital admissions for treatment of urinary tract stones. Presumptive diagnosis of a urinary calculus was possible in only 19 per cent of the refugees compared with 60 per cent of other patients treated at the same hospital (p less than 0.005). Calculi in Southeast Asian immigrants were larger (p less than 0.001), and surgical procedures were required more often (p less than 0.05) than for other patients with calculi. Urinary stones should be considered a likely cause of abdominal or urinary tract complaints in recent immigrants from Southeast Asia.

The artificial bladder: a historical review.

The search for the ideal surgical replacement for all or part of the urinary collecting system continues. A wide variety of biologic and nonbiologic substitutes have been tried. Even though much experience has been gained in this area, the use of artificial material remains at an experimental level and needs further development. This review presents the history, problems, and developments of the replacement of the urinary bladder by nonbiologic materials.

Urological trauma in the Pacific Northwest: etiology, distribution, management and outcome.

A computer-assisted review identified 184 patients with genitourinary tract injuries among 5,400 hospitalized for trauma. Particular attention was directed to the controversial groups of patients with blunt renal and posterior urethral injuries. Management of renal injuries was based on clinical criteria. Subsequent renal exploration was necessary in only 1 of 115 patients with renal contusions, or simple or deep lacerations who underwent initial expectant management. Followup was available in all patients with severe renal injuries and in 53 per cent with renal contusions or simple lacerations. Parenchymal loss was noted on an excretory urogram in only 1 patient and none suffered hypertension, hydronephrosis or other sequelae. A staged approach was preferable to immediate repair of posterior urethral injuries. Seven patients managed by initial cystostomy drainage followed by secondary urethral repairs did well. Primary realignment was complicated by stricture, incontinence or impotence in 3 of 6 patients.

Sexually transmitted diseases and carcinogenesis.

Issues related to the development of cancer of the urogenital system in men and women and the possible role played by agents of sexually transmitted diseases are discussed. Research evidence supporting the role of specific viral agents in the etiology of cancer of the uterine cervix, penis, testis, prostate, and urinary bladder is presented. Also included is a discussion of the current speculations about the role played by agents of sexually transmitted diseases in acquired immune deficiency syndrome (AIDS).

Ureteropelvic junction obstruction in infants and children: functional evaluation of the obstructed kidney preoperatively and postoperatively.

We evaluated 14 children with primary ureteropelvic junction obstruction, using preoperative excretory urography and renal imaging with the renal cortical labeling agent 99mtechnetium dimercaptosuccinic acid. All children with a reduction in function of 10 per cent or more in the obstructed kidney had severe calicectasis; others with severe calicectasis had minimal functional loss. Renal scanning with dimercaptosuccinic acid discourages surgery in the questionably obstructed kidney and encourages repair in the severely obstructed kidney. In 10 children who had followup renal imaging after repair relative function was not significantly different.

A new and simplified method for concealing the hypertrophied clitoris.

Current surgical procedures that are utilized in the management of patients with an enlarged clitoris are both complex and challenging. We report a new method of concealing the hypertrophied clitoris between the labia majora instead of resorting to the more difficult clitoral amputation or recession. This concealment of the clitoris is simple, may be done on an outpatient basis, and accomplishes the goal of creating normal-appearing female external genitalia.

Vesicoureteral reflux in children with uremia. Prognostic indicators for treatment and survival.

To define factors related to renal prognosis in children with vesicoureteral reflux and renal insufficiency, we reviewed 908 children with vesicoureteral reflux. Twenty-five patients were found who had initial creatinine clearances of less than 60 mL/min/sq m and had five-year follow-up examinations. All had severely dilated ureters. Renal function improved in eight, remained stable in ten, and deteriorated in seven. Probability of deterioration of renal function in these children was related to factors measurable at clinical presentation: (1) a corrected creatinine clearance of less than 25 mL/min/sq m; (2) 2r greater reaction for protein on urinalysis that disclosed no infection; and (3) being in less than the fifth percentile of body length. The total number of the three factors present in each patient was more significantly related to prognosis than any one factor.

The use of self-retained ureteral stents in the management of urologic complications in renal transplant recipients.

Nineteen self-retaining ureteral stents were used to manage postoperative ureteral obstruction and fistulas in 12 renal transplant recipients. In 3 patients with ureteral obstruction and 2 with a fistula placement of the self-retaining stents for 4 to 6 weeks allowed the complication to resolve. In 3 patients with ureteral obstruction placement of the self-retaining stents allowed for stabilization of the condition and reduction of immunosuppression therapy before an open surgical repair. In 6 patients self-retaining ureteral stents were used to protect the high risk anastomosis done at an open surgical repair of a complication. Placement of a self-retaining ureteral stent may be the best choice in the early management of ureteral obstruction and fistulas in transplant recipients.

The effect of bladder function on the dynamics of the ureterovesical junction.

Upper tract perfusion studies in suspected ureterovesical junction obstruction should always be performed with measurement of intravesical pressure and with variation in bladder volume. Obstruction observed with increasing bladder volumes may be related to a non-compliant bladder wall, mechanical obstruction at or near the junction itself or a combination of both factors.

Lack of agreement between subjective ratings of instructors and objective testing of knowledge acquisition in a urological continuing medical education course.

Objective scores from multiple-choice questions before and after a postgraduate course were compared to subjective ratings of the instructors at a 3-day seminar. The objective mean scores after the course were significantly higher than the scores before the course (p less than 0.0001). There was no correlation between test results and subjective ratings of instructors.

Urolithiasis associated with pregnancy.

Of 34,081 deliveries in a 12-year period 20 were complicated by urinary calculi during the pregnancy. Of the 20 deliveries 3 required intervention either during pregnancy or immediately postpartum. There were no maternal deaths and only 1 stillborn secondary to erythroblastosis. Analysis of symptoms, findings, procedures and outcome is presented in this uncommon but serious problem.

Urodynamic assessment of incontinence after prostatectomy.

There were 15 men with incontinence after prostatectomy who were assessed with a urethral pressure profile and a multichannel filling and voiding study with sphincter electromyography. Of these 15 patients 7 had sphincter weakness alone, 7 had sphincter weakness and detrusor hyperreflexia, and 1 had detrusor hyperreflexia alone. Full urodynamic assessment is essential before treatment can be recommended for incontinence after prostatectomy.

Comparison of wound strength in normal, radiated and infected tissues closed with polyglycolic and chromic catgut sutures.

Wound strength in the rectus muscle of rabbits is greater at any measured time interval when sutured with polyglycolic acid than when sutured with chromic catgut. This is true for both irradiated and nonirradiated tissues. No significant advantage is seen for either suture in nonirradiated bladder, although the trend favors polyglycolic acid. In irradiated bladders, a significant advantage is seen for polyglycolic acid at 15 days. In measuring repaired ureteral orifice size, only chronic catgut suture in nonirradiated rabbits caused marked edema and unreteral obstruction. Postoperative ureteral dilation with both materials resolved over a 90 day period. In the irradiated ureter, however, resolution of this obstruction appears to occur earlier and more dependably when polyglycolic acid suture has been used. Polyglycolic acid showed a trend for superior strength in urothelial wounds tested. The healing of bladder epithelium is usually completed in ten to 14 days. The entire bladder wound gains strength rapidly until day 21 and gains little strength thereafter. A suture material that does not increase the inflammatory response but lasts long enough for complete bladder healing is advisable. Using the criterion of wound breaking strength in our experimental work, polyglycolic acid was shown to be superior to chromic catgut suture material.

Transurethral urethrotomy under vision.

Transurethral urethrotomy under vision with the Sachse urethrotome is a new surgical procedure for the treatment of urethral strictures. The chief advantage of the urethrotome is the fact that the surgeon can cut strictures selectively and accurately under clear vision. The procedure is less painful than blind internal urethrotomy and less extensive cases can be done in the office with the patient under local anesthesia. We report on 36 cases with at least 6 months of followup. In 20 cases the strictures were distal to the prostate and the results were considered good in 16, improved in 3 and a failure in 1. The other 16 cases involved vesical neck contractures and all patients had good results. The technique for urethral strictures distal to the prostate and for vesical neck contractures is described and postoperative treatment is emphasized and discussed.

Results of large-caliber internal urethrotomy.

Thirty-five patients undergoing internal urethrotomy for urethral stricture disease were reviewed retrospectively. Eight patients had conventional urethrotomies (less than 36 F) while 27 had large-caliber urethrotomies (greater than 40 F). Large-caliber urethrotomy tends to give longer symptom-free intervals immediately postoperatively, but long-term results show little difference between the two groups.