Study of cavernosal arterial anatomy using color and power Doppler sonography: impact on hemodynamic parameter measurement.

PURPOSE: We report on color and power Doppler ultrasound to study cavernosal arterial anatomy, and evaluate the impact of vascular anatomy on the measurement of hemodynamic parameters. MATERIALS AND METHODS: Cavernosal arterial anatomy of 42 patients with erectile dysfunction was evaluated using color and power Doppler ultrasound. A computerized waveform analysis was used to measure peak systolic velocity, end diastolic velocity and resistive indexes at various sites, including the penile crura, and proximal mid and distal penile shaft. Hemodynamic parameters were measured in each artery in cases of bifurcated or multiple cavernosal arteries. RESULTS: A total of 80 corpora were adequately evaluated. We observed a single artery without major proximal branches in 37 corpora, a single artery with major proximal branches in 17, bifurcated arteries in 15, 2 cavernosal arteries in 4 and marked arterial tortuosity in 1. In 6 corpora the main cavernosal artery arose from the superficial dorsal artery. The peak systolic velocity was highest at the proximal and decreased progressively at the distal site. The peak systolic velocity plus or minus standard deviation at the mid shaft averaged 69.3+/-30.0% of that at the proximal penile shaft. Of the 15 corpora with bifurcated arteries 67% had a 40% or greater difference in peak systolic velocity between the branches. Complete or partial occlusion of the cavernosal artery was identified in 3 corpora, and a dramatic difference in peak systolic velocity proximal and distal to the stenotic area was demonstrated. CONCLUSIONS: Cavernosal arterial anatomy is variable and hemodynamic parameters differ at various sites of measurement. Parameters should be measured at a consistent proximal site to obtain a reliable assessment. Variations in vascular anatomy and cavernosal artery pathology should be considered when interpreting color Doppler sonography and before penile vascular surgery.

Tumor localization and systemic absorption of intravesical instillation of radio-iodinated iododeoxyuridine in patients with bladder cancer.

PURPOSE: We evaluated tumor uptake and systemic distribution of intravesically instilled iododeoxyuridine (IUdR) in patients with superficial bladder cancer. MATERIALS AND METHODS: We performed 24 intravesical instillation studies in 11 patients with a mean age of 71 years. Radio-iodinated IUdR was administered through a Foley catheter. Gamma camera imaging was done after instillation and after 5 to 7 bladder irrigations. Tumor uptake was estimated by region of interest analysis. Bladder biopsy samples and surgical tumor specimens were tested for acid insoluble (deoxyribonucleic acid incorporated) radioactivity. Blood samples were obtained and analyzed for systemic absorption. RESULTS: Imaging was positive in all patients with bladder cancer. Average tumor uptake plus or minus standard deviation was 0.185+/-0.120% of the instilled dose. Preferential uptake of IUdR in the tumor was observed in all 6 patients undergoing tissue analysis. The tumor-to-normal bladder ratio ranged from 3.2 to 74,000 (median 202). Systemic absorption of IUdR was minimal. Blood sample analysis performed after intravesical instillation in all 11 cases revealed an average uptake of 3.2x10(-5)% instilled dose per ml. (range 0.69x10(-5) to 6.7x10(-5)) in the systemic circulation. Instillation within 24 hours after transurethral bladder tumor resection in 5 cases resulted in a higher but not dangerous average systemic uptake of 7.3x10(-4)% instilled dose per ml. (range 1.3x10(-5) to 2.6x10(-3)). Instillation 1 to 4 weeks after transurethral surgery in 8 cases resulted in no increased systemic absorption with an average blood level of 3.4+/-1.8x10(-5)% instilled dose per ml. There was no detectable distribution of radioactivity into other organs, including the thyroid. We noted no evidence of systemic toxicity in the study. CONCLUSIONS: Intravesical instillation of radio-iodinated IUdR achieves selective localization in the bladder tumor with minimal uptake by the normal bladder and minimal systemic absorption. The use of intravesical IUdR therapy for bladder cancer appears to be promising and requires further study.

Color Doppler ultrasound assessment of urethral artery location: potential implication for technique of visual internal urethrotomy.

PURPOSE: We assessed the location of urethral arteries in patients with urethral stricture using color Doppler ultrasound. MATERIALS AND METHODS: We performed 41 color ultrasound studies of the urethra in 33 patients 17 to 76 years old. The linear array transducer was placed on the ventral surface of the penis and perineum to image the urethra and periurethral structures. In addition to evaluating the extent of stricture disease, color Doppler ultrasound determined the location of the urethral arteries at the segment with stricture. RESULTS: The number and site of the urethral arteries vary among individuals. Contrary to the common belief that these arteries are located at the 3 and 9 o'clock positions, we have found that in the bulbous urethra the arteries are at the 1 to 2 o'clock positions in 14% of cases, 3 to 4 in 22%, 5 to 6 in 17%, 7 to 8 in 18%, 9 to 10 in 18% and 11 to 12 in 11%. The arteries may be close to the surface of the urethral lumen, especially in patients who have undergone previous urethral procedures. Preoperative evaluation of urethral artery location may be helpful for preventing arterial bleeding at visual internal urethrotomy. CONCLUSIONS: Color Doppler ultrasound can effectively assess the extent of stricture disease and urethral artery sites. Because the location of the urethral arteries varies among patients, individual preoperative assessment is advisable. Color Doppler ultrasound is currently our imaging method of choice for evaluating strictures of the pendulous and bulbous urethra.

Hemodynamic patterns of pharmacologically induced erection: evaluation by color Doppler sonography.

PURPOSE: Penile erection is achieved through hemodynamic mechanisms that can be assessed best with color flow imaging and Doppler waveform analysis. We performed dynamic studies using computer assisted analysis to assess the hemodynamic patterns of pharmacologically induced erection. MATERIALS AND METHODS: A total of 73 color Doppler ultrasound studies was performed in 66 patients with erectile dysfunction. Various blood flow parameters, including peak systolic velocity, end diastolic velocity, mean flow rate, resistive index and artery diameter, were observed continuously and recorded frequently for about 30 minutes after intracorporeal injection of papaverine/phentolamine/prostaglandin E1 mixture. A computerized Doppler waveform analysis of 3 curves or greater was performed for each recording to minimize error. A second injection was administered if the first injection failed to induce a rigid erection. Status of the erection was observed and recorded throughout the study. A computerized graph was generated for each corpus. RESULTS: After intracorporeal injection the time to reach normal or peak velocity varied from 1 to 24 minutes. Among 146 corpus units in 73 color Doppler ultrasound studies we observed the following hemodynamic patterns: I-normal maximal peak systolic velocity (35 cm. per second or greater), sustained; Ia-end diastolic velocity 0 or less with complete erection response (19 units); Ib-end diastolic velocity greater than 0 or incomplete erection response (14 units); II-normal maximal peak systolic velocity (35 cm. per second or greater), transient; IIa-end diastolic velocity 0 or less with complete erection response (21 units); IIb-end diastolic velocity greater than 0 or incomplete erection response (12 units); III-borderline maximal peak systolic velocity (30 to 35 cm. per second); IIIa-end diastolic velocity 0 or less with complete erection response (10 units); IIIb-end diastolic velocity greater than 0 or incomplete erection response (8 units); IV-low maximal peak systolic velocity (less than 30 cm. per second); IVa-end diastolic velocity 0 or less with complete erection response (24 units); and IVb-end diastolic velocity greater than 0 or incomplete erection response (38 units). CONCLUSIONS: Erection is a complex and dynamic process. A new classification of hemodynamic patterns is presented that aids in assessing and interpreting more thoroughly blood flow parameters to stratify more precisely the hemodynamic patterns of erectile dysfunction.

Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination.

OBJECTIVES: Color Doppler ultrasound (CDU) diagnostic criteria for varicoceles are poorly defined, and the role of CDU in diagnosing varicoceles is controversial. The purpose of this study is to assess the diagnostic accuracy of CDU for varicoceles compared to physical examination. METHODS: We prospectively studied 64 patients with CDU and collected the following data: maximum diameter of scrotal veins, the presence of a venous plexus, sum of the diameter of up to six veins of the plexus, and the duration and amplitude of flow change on Valsalva maneuver. To avoid interphysician variation, all patients were examined by one designated senior urologist with the sonographer remaining unaware of the findings. RESULTS: CDU parameters of 127 testis units in 64 patients were analyzed and compared to the physical findings. Fifty-nine testis units were positive and 57 units were negative for varicocele on physical examination. In 11 testis units, results of physical examination were inconclusive regarding the presence of varicocele. The commonly accepted CDU criterion for varicocele (maximal vein diameter of 3 mm or greater) had a sensitivity of 53% and specificity of 91% compared to physical examination. We developed a new scoring system incorporating the maximal venous diameter (score 0 to 3), the presence of a venous plexus and the sum of the diameters of veins in the plexus (score 0 to 3), and the change of flow on Valsalva maneuver (score 0 to 3). Using a total score of 4 or more to define the presence of CDU-positive varicocele, we observed a sensitivity of 93% and a specificity of 85% when compared to physical examination. All moderate to large varicoceles found on physical examination were positive by CDU diagnosis using the scoring system, but the same group had only a 68% positive rate by traditional CDU diagnostic criteria. CONCLUSIONS: Using the proposed new scoring system, CDU has been shown to be a reliable and accurate method of diagnosis for varicoceles compared to the current reference standard physical examination. CDU has the advantages of being able to objectively examine venous plexus and measure blood flow parameters and to be less observer-dependent than physical examination.

Long-term outcome of prostatic stent treatment for benign prostatic hyperplasia.

OBJECTIVES: To evaluate the long-term result of prostatic stent treatment for patients with benign prostatic hyperplasia (BPH). METHODS: We reviewed our experience with prostatic stents in 24 patients with bladder outlet obstruction caused by BPH for whom up to 63 months of follow-up data were available. RESULTS: Prostatic stents were successfully placed in 24 of 25 patients enrolled in the study. All 9 patients treated for urinary retention voided spontaneously after stent placement. In 14 (93%) of 15 patients with nonretention, voiding symptoms decreased by 50% or more. The stent was removed in 9 patients for persistence of symptoms, symptom recurrence, or stent migration. Nine patients died of unrelated causes during the follow-up period. The stents functioned adequately in these patients until death. In the remaining 6 patients, the stent was still in place at the last follow-up visit (range 12 to 52 months, average 35) after placement, and their Madsen-Iversen symptom scores ranged from 3 to 10. Fourteen patients underwent cystoscopy 1 to 37 months after stent placement. Epithelium did not completely cover the stent in any of these patients; however, no stone formation was noted. CONCLUSIONS: Prostatic stents can be effective in relieving bladder outlet obstruction caused by BPH. They appear to be most useful in patients at high surgical risk and with a limited life expectancy. However, stent removal, which can be difficult, may be required in more than one-third of patients. We recommend prostatic stent placement primarily in patients who would otherwise be relegated to an indwelling catheter.

Radiolabeled iododeoxyuridine: safety evaluation.

UNLABELLED: The emphasis of radiolabeled iododeoxyuridine (*IUdR) research at our institution to date has been to assess its safety as a potential therapeutic agent. Toward this goal, we have performed preclinical and clinical studies, using various routes of administration, to detect adverse changes in normal tissues in both humans and animals. As IUdR is rapidly dehalogenated by the liver, the intravenous route is unlikely to be successful in therapeutic efforts. We have therefore focused our attention on more "protected" routes: intra-arterial and intravesicular administration. METHODS: Studies were performed in farm pigs after multiple administrations of [125I]IUdR into the aorta, carotid artery and bladder. IUdR and metabolites were measured in venous blood samples at appropriate time intervals after administration, after which histologic examination of tissues was performed. Studies in human have been performed after intra-arterial administration of [123I]IUdR in patients with liver metastases and intravesicular administration in patients with bladder carcinoma, initially using [123I]IUdR and currently using both [123I]IUdR and [125I]IUdR. Blood samples for pharmacokinetics and metabolite analysis and tissue for autoradiography (when feasible) have been obtained. RESULTS: To date, no evidence of adverse effects on normal tissue or alteration of hematologic or metabolic indices have been seen in pigs or humans. When instilled in the bladder, there is little leakage of IUdR in the circulation. CONCLUSION: When [125I]IUdR is used as a therapeutic agent, we anticipate little or no effect on normal tissues.

Treatment of recurrent vesicourethral anastomotic stricture after radical prostatectomy with endourethroplasty.

We report our experience with successful treatment of 2 cases of severe recurrent vesicourethral anastomotic stricture after radical prostatectomy with endourethroplasty. Both patients had multiple failures of conventional treatments but have been free of stricture recurrence after endourethroplasty with 11 and 25 months follow-up, respectively. Follow-up urethroscopy showed open anastomotic segments with epithelialization after endourethroplasty in both patients. The patient who was continent prior to endourethroplasty remained continent afterward.

Evaluation of urethral strictures and associated abnormalities using high-resolution and color Doppler ultrasound.

OBJECTIVES: To study the role of urethral sonography and color Doppler imaging in the evaluation of patients with urethral strictures and associated abnormalities. METHODS: We reviewed our experience with 41 urethral sonographic studies in 35 patients and compared them to 33 retrograde urethrograms. For 6 recent cases, we also used color Doppler imaging to assess spongiosal tissue blood flow and the location of urethral arteries. RESULTS: Both retrograde urethrography and urethral sonography assessed the caliber and length of the strictures well. Urethral sonography provided additional information about stricture involvement of the spongiosum, location of urethral arteries, and associated abnormalities (that is, periurethral abscess and urethrocutaneous fistula). This information was useful for the clinical stratification of urethral stricture disease and the planning of treatment. CONCLUSIONS: With the advantages of avoiding radiation to testis, providing real-time evaluation of the distensibility of the urethra, and having the capacity of assessing spongiosum and periurethral tissue involvement and urethral artery location, urethral sonography appears to offer more than retrograde urethrography for the evaluation of anterior urethral stricture.

Repair of extensive traumatic membranous urethral disruption with endourethroplasty and artificial sphincter: case report.

We report a case of extensive traumatic membranous urethral obliteration with a 4-cm gap that was successfully treated with a transperineal-transurethral puncture technique to reestablish urethral continuity in association with endourethroplasty to repair the long fibrotic gap. The injury also involved the bladder neck, and the patient had subsequent stress urinary incontinence. Because endourologic treatment of his stricture did not require mobilization of the bulbous urethra, an artificial sphincter was placed 13 months later without difficulty. The patient is continent and remains stricture free at 3 years. This case illustrates the potential of endourologic treatment for severe membranous urethral disruptions.

Placement of large suprapubic tube using peel-away introducer.

We describe a new method for placing a large suprapubic tube and report our experience with 56 patients. This method uses a specially designed fascial dilator and peel-away introducer to place an 18F Foley catheter suprapubically. In our experience the method is simple and effective for the exchange of a small suprapubic tube to an 18F Foley catheter, and for primary placement of a large suprapubic tube. It is easily performed at the bedside or during a minor procedure with the patient under local anesthesia.

Long-term experience utilizing a new balloon expandable prostatic endoprosthesis: the Titan stent. North American Titan Stent Study Group.

OBJECTIVES: To determine the long-term safety and efficacy of the Titan endoprosthesis as a therapeutic alternative in the management of men with bladder outlet obstruction. METHODS: One hundred forty-four patients (mean age, 73.5 years +/- 4.2) had placement of the Titan stent. The stents were inserted under direct vision and expanded to 33 F using a balloon catheter. Of the 144 patients, 59 (41%) were in urinary retention and 85 (59%) presented with moderate to severe symptoms of prostatism. Patients were assessed at baseline and in follow-up at 1, 3, 6, 12, 18, and 24 months. Parameters of evaluation included the Madsen-Iversen symptom questionnaire, peak flow rate (Qmax), postvoid residual urine volume (PVR), and incidence of adverse events. RESULTS: At 24 months, for the retention cohort, symptoms, Qmax, and PVR were 5.21 +/- 0.81, 11.34 +/- 1.12 mL/s, and 31.00 +/- 12.8 mL, respectively (P < 0.002). For patients with symptoms of bladder outlet obstruction, the results were as follows at 24 months: (1) symptoms decreased from 15.89 +/- 0.47 to 9.33 +/- 0.86 (P < 0.001); (2) Qmax increased from 8.59 +/- 0.41 mL/s to 11.43 +/- 1.12 mL/s (P < 0.001); and (3) PVR decreased from 116.94 +/- 19.95 mL to 74.4 +/- 36.2 mL (P < 0.03). There were minimal complications; stents were removed from 28 patients (19%) because of migration, 10 of which were placed by one investigator. CONCLUSIONS: When properly placed, the Titan stent was an effective therapeutic alternative to prostatectomy or long-term catheterization in high-risk obstructed patients or those in urinary retention.

Randomized comparison of balloon dilation and transurethral incision for treatment of symptomatic benign prostatic hyperplasia.

The concept of relieving the symptoms of benign prostatic hyperplasia (BPH) by dilating the urethral has existed for centuries. Thirty patients with a clinically estimated prostate gland size of 25 g or less were randomized to either balloon dilation (BDP) or transurethral incision of the prostate (TUIP). The mean pretreatment Madsen-Iverson symptom scores in the two groups were 15.0 +/- 4.9 (SD) and 15.4 +/- 4.4, respectively. The early response rates were 87% fo BDP and 86% for TUIP, with the mean symptom scores declining to 3.4 +/- 2.8 after dilation and 4.2 +/- 6.6 after incision. Among the 14 patients who initially responded to BDP, 2 have been lost to follow-up, 1 died of unrelated causes at 17 months with no urinary symptoms, 2 remain in response at 32 and 38 months, and the other 9 (75% of those available for evaluation) have developed recurrences. Among the 12 patents who responded to TUIP, 2 have been lost to follow-up, 8 remain in response at 14 to 48 months, and 2 (20%) developed recurrences by 44 months of follow-up. In the short term, both BDP and TUIP are effective for treating bladder outlet obstruction in men with relatively small prostates. However, the effect of dilation appears to be less durable than that of incision.