Penile haemodynamic changes in post-radical cystectomy patients.

The aim of this study was to assess the penile vascular changes in post-radical cystectomy patients. A prospective assessment took place between January 2003 and January 2005 of 45 potent men who underwent radical cystectomy and diversion for invasive bladder cancer. Nerve sparing (NS) technique was applied in 21 cases, while others were not subjected to NS (non-nerve sparing group; NNS = 24 cases). All patients were comparable in preoperative clinical and pathological parameters. A control arm was the preoperative normal indices of the same patients. Preoperative penile duplex ultrasounds (PDU) for all cases were carried out, and then follow-up 2, 6 and 12 months thereafter. On first postoperative visit, none of NS cases showed any arterial insufficiency, while two cases of NNS (8.3%) had peak systolic velocity (PSV) < 30 cm/sec. Moreover, all cases of both groups showed early increase of end diastolic velocity (EDV) > 5 cm/sec. In NS cystectomy group, the PSV showed statistically insignificant change [p > 0.05 (mean: 53.6, cm/sec)]. Shortly after surgery, the EDV values increased, followed by gradually significant improvement (decrease in EDV values) in comparison with control state (mean: 5.9 cm/sec). On the other hand, the NNS cases showed statistically insignificant changes in PSV (mean: 49.3 cm/sec), with deterioration in EDV that did not improve with time, in contrast to NS cases (mean: 13.15 cm/sec). The main significant penile vascular changes were in EDV (venogenic mechanism) in post-cystectomy patients. There was a gradual progressive improvement in venogenic competence mechanism in NS cases with insignificant deterioration of arteriogenic mechanism in both groups (NS/NNS).

Critical evaluation of the factors influencing erectile function after renal transplantation.

A total of 400 male renal transplant recipients (RTR) were investigated. Data on medical, sexual history, clinical examination and laboratory variables were collected. The severity of erectile dysfunction (ED) was assessed using the International Index of Erectile Function questionnaire. Univariate and multivariate logistic regression analyses were used to determine prognostic variables, which have independent impact on erectile function. ED was detected in 35.8% of the whole group. Current erectile function as compared to pretransplant status was improved, deteriorated or remained static in 44, 12.5 and 43.5% of the evaluated transplant recipients, respectively. After logistic regression analysis, age, hemoglobin level and presence of DM and/or peripheral neuropathy had significant and independent negative impact on erectile function. We concluded that renal transplantation has varying effects on erectile function. ED is highly prevalent among RTR and its pathogenesis is multifactorial.

The urethral Kock pouch: long-term functional and oncological results in men.

OBJECTIVE: To evaluate our experience with men who underwent radical cystectomy and urethral Kock pouch construction between January 1986 and January 1996. PATIENTS AND METHODS: Complications were classified as early (within the first 3 months after surgery) or late. Continence was assessed by interviewing the patient; they were considered continent if they were completely dry with no need of protection by pads, condom catheter or medication. The patients were followed oncologically and Kaplan-Meier survival curves constructed. Urodynamic studies were used to define the possible causes of enuresis. RESULTS: Three patients died after surgery from pulmonary embolism. There were 67 early complications in 63 patients. The mean (SD) follow-up was 87.8 (49.1) months. There were 111 treatment failures from cancer; of these, four men only had an isolated local recurrence in the urethra. Late complications included 72 pouch stones in 55 patients, and 36 deteriorated renal units caused by reflux (17), uretero-ileal stricture (11), nipple valve eversion (four) or stenosis (four). Interestingly, 65 renal units that were dilated before surgery improved significantly afterward. Ileo-urethral strictures occurred in seven men and anterior urethral strictures in six. Nine patients were totally incontinent and two had chronic urinary retention. Daytime continence was complete in 94% of men, with nocturnal enuresis in 55; the latter had significantly more residual urine, and a higher amplitude and duration of phasic contractions. CONCLUSIONS: Orthotopic bladder substitution after cystectomy for cancer is feasible, with good functional and oncological outcomes in properly selected patients. Nevertheless, the use of a hemi-Kock pouch is associated with many valve-related complications.

Paediatric penile trauma.

OBJECTIVE: To report our experience with paediatric penile trauma in a retrospectively evaluated series. PATIENTS AND METHODS: The records of 64 boys (mean age 7 years, sd 4) who were hospitalized over the last 20 years because of penile trauma were reviewed. The cause of trauma was circumcision in 43 (67%), a human hair-tie strangulation injury in 10 (16%), an animal attack in four (6%), a bicycle accident in four (6%), a zipper injury in two (3%) and electrical injury in one (2%). Patients were managed according to the severity of the injury. Eight (12%) with minimal skin loss or meatal injury underwent primary skin closure or meatoplasty; 40 (62%) with urethrocutaneous fistulae underwent repair and five (8%) with a glans hanging on a thin pedicle had the glans and the urethra reconstructed. Patients with partial or complete amputation of the glans (10) underwent primary haemostasis and meatoplasty; the penis was lengthened in one. One child with complete avulsion of the penis underwent perineal urethrostomy. RESULTS: Fifty-four patients (84%) were followed for a mean (sd) of 5.7 (4) years; there were good cosmetic and functional results in 45 (83%). Fifteen patients are now adults; 13 (86%) reported normal sexual function. Of the 40 patients assessed with circumcision-related injuries, six (15%) had functional disability (short penis in one and fistulae in five). Of the 10 patients with a hair-tie injury, none lost their glans. Of the four injuries caused by animal attacks, three had poor results (emasculation in one, short penis in one and severe curvature in the remaining patient). There was no functional disability in the remaining forms of trauma. CONCLUSIONS: In our region, ritual circumcision and hair-tie strangulation injuries are the most common causes of penile trauma in children. Good functional and cosmetic results are possible in most cases. However, animal attacks are associated with the highest rate of long-term functional and cosmetic disability.

Low-flow priapism: risk factors for erectile dysfunction.

OBJECTIVE: To evaluate our policy of managing priapism for the success rate of the treatments, potency afterward, complications, and the risk factors responsible for erectile dysfunction in these patients. PATIENTS AND METHODS: The study included 50 patients (mean age 37.1 years, range 22-66) with a diagnosis of priapism (1981-1999). Their records were reviewed; 35 patients were available for a long-term evaluation. Factors assessed were the duration of priapism, history of previous recurrent attacks, possible underlying causes (e.g. haematological disorders, medications or trauma), relation to sexual stimulation, pain, and any attempt at previous management. A complete blood screen and blood gases were assessed in corporal aspirates. Duplex ultrasonography was used in all impotent patients at their follow-up. Early and late complications were reviewed, and patients asked about their erectile function before priapism, and any recurrence. RESULTS: The median (range) duration of priapism was 48 (6-240) h; almost half the patients presented > 48 h after the onset of priapism. Sixteen patients (32%) reported a history of previous recurrent attacks, of whom seven had a history of previous treatments. The main cause of priapism was idiopathic or intracavernosal injection with papaverine. All patients were initially treated by corporal blood aspiration and injection with ephedrine; if this failed or if the priapism was prolonged (> 48 h) various shunts were used. The hospital stay was significantly shorter among patients with papaverine-induced or brief priapism. In the long-term follow-up of 35 patients (mean 66.4 months, range 3-220) only 15 (43%) reported preserved erectile function, and this was more likely in patients with brief priapism (< 48 h). Eight patients (23%) reported subsequent recurrent attacks of priapism; all were managed successfully as they presented shortly after their onset. Penile fibrosis was detected in 20 patients (57%), and was significantly more common in those with prolonged priapism (> 48 h) or from causes other than papaverine. The 20 impotent men evaluated by Doppler ultrasonography had severe echo-dense penile fibrosis and high end-diastolic velocities suggesting veno-occlusive incompetence in all except two. In five men with shunts cavernosography showed extensive venous leakage irrespective of site of the shunt. MRI in five patients with penile fibrosis showed heterogeneous areas of low signal intensity, corresponding with haemosiderin deposition and fibrosis. On univariate analysis the final result of management (complete detumescence or not), the duration of priapism and the presence of penile fibrosis significantly influenced erectile function. On multivariate logistic regression only the first remained significant. CONCLUSIONS: Low-flow priapism for > 48 h, failure to maintain complete detumescence after management, and marked penile fibrosis during the follow-up are the most significant risk factors responsible for erectile dysfunction, with failure to achieve complete detumescence the most detrimental.

Nocturnal enuresis in men with an orthotopic ileal reservoir: urodynamic evaluation.

PURPOSE: We evaluated the urodynamic features of enuretic and continent patients with an orthotopic neobladder. MATERIALS AND METHODS: Included in our study were 100 men with an orthotopic hemi-Kock or W neobladder and a minimum followup of 1 year. Of the patients 50 were completely continent day and night, and 50 had enuresis without evidence of an underlying organic etiology, such as stones, reflux or urethral stricture. RESULTS: Univariate analysis showed significantly higher pressure and a larger volume of post-void residual urine in the men with enuresis. In addition, maximum urethral pressure, maximum flow and compliance were decreased in the enuretic group compared to the continent group. Multivariate analysis revealed that post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions are the most critical parameters affecting nocturnal continence. CONCLUSIONS: The cystometric parameters significantly associated with nocturnal enuresis in patients with an orthotopic reservoir are post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions. Urethral pressure and flow parameters did not sustain significance on multivariate analysis.

Penile fractures: the successful outcome of immediate surgical intervention.

The data of 60 patients admitted to Mansoura Urology and Nephrology Center with penile fractures and treated by immediate surgical repair were reviewed with respect to their presentation, investigations, operative and post-operative details. Forty-nine patients were followed up regarding penile curvatures, plaques and erectile function. Patients reporting decreased erectile function were further assessed by evaluating their response to intracavernous injection of PGE1 and by penile color duplex Doppler ultrasonography. All of our patients had the classic clinical presentation of penile swelling and ecchymosis. Only five patients had accompanying urethral rupture. Penile ultrasonography was used to confirm the diagnosis in 23 patients. Immediate exploration was done using subcoronal circumferential incision in about two-thirds of the cases. All tunica albuginea ruptures were unilateral except one case which was bilateral. Interrupted absorbable sutures were used for repair in most of the patients. Urethral repair was done in five cases. Delayed complications were detected in only six cases (12.2%) in the form of mild penile curvature on erection, plaques and/or mild erectile dysfunction. Intracavernous injection (ICI) of PGE1 and penile duplex Doppler showed a normal pattern in three patients with erectile dysfunction while the fourth showed incompetent veno-occlusive mechanism. Psychosexual consultation was required for two of these patients while the third was successfully managed by self-ICI of PGE1. We conclude that the excellent outcome of our patients parallels other reports of early surgical repair regarding low morbidity, short hospital stay and rapid functional recovery. There is a low incidence and degree of erectile dysfunction among repaired patients; however, it should be thoroughly investigated and properly managed. Ultrasonography is easy and helpful; however, the more invasive cavernosography and/or magnetic resonance imaging are indicated when the case is atypical, or the diagnosis of rupture of tunica is suspicious.