Testicular microlithiasis.

Testicular microlithiasis is an uncommon condition that is characterized by calcifications within the lumina of seminiferous tubules. It is usually an incidental finding on high frequency scrotal sonography. Testicular microlithiasis is a benign condition but is associated with testicular malignancies. Recent reports support this association and suggest regular follow-up in these patients.

Frère Jacques Beaulieu: from rogue lithotomist to nursery rhyme character.

PURPOSE: We discuss the history of Frère Jacques Beaulieu, a celebrated 17th century French lithotomist, and question the relationship of his name to a well-known nursery rhyme character. MATERIALS AND METHODS: We reviewed historical reports about Beaulieu and his career as a lithotomist. Nursery rhyme interpretations were also reviewed. RESULTS: Beaulieu was born in 1651 to a peasant family and learned the practice of lithotomy by apprenticeship. He was never formally ordained yet donned a monk habit and called himself Frère Jacques. He was the first person to use the lateral approach to perineal lithotomy and openly shared his surgical technique. His lithotomy procedure was observed by the high court in Paris on 3 separate occasions between 1697 and 1704. Unfortunately his patients had significant morbidity and mortality, and he was denied operating privileges. He performed approximately 5,000 lithotomies in 30 years and died in 1719 at age 68 years. The nursery rhyme "Frère Jacques" probably refers to a playful group of Jacobinic monks who often overslept. We found no direct association between Frere Jacques Beaulieu and the nursery rhyme character. CONCLUSIONS: Beaulieu was an early urologist who was the first to describe the lateral approach to perineal lithotomy. Unlike other lithotomists of the 17th century, he openly shared his surgical techniques and stimulated others to refine the procedure. Regardless of the exact derivation of the nursery rhyme, the name Frere Jacques will always be remembered in song.

Testicular microlithiasis is associated with testicular pathology.

OBJECTIVES: To evaluate the impact of testicular microlithiasis (TM) on male health by describing our experience. TM is an uncommon condition characterized by calcium deposits in the lumina of seminiferous tubules. These intratesticular calcifications appear as bright, 2- to 3-mm echogenic foci on testicular ultrasound (US). METHODS: Patients diagnosed with TM by high-frequency testicular US over a 4-year period from two separate institutions were included in this study. Approximately 1100 testicular USs were performed (both hospitals combined) over the 4-year period. Patients were clinically identified by the characteristic appearance of TM on testicular US. Pathologic specimens were obtained in 14 (64%) of 22 patients. RESULTS: Thirty-eight testicles (16 bilateral cases) in 22 patients were found to have TM. The incidence of TM was approximately 2%. Mean age at presentation was 29 years (range 8 to 63). Eight (36%) of 22 patients had testicular malignancies. Five (23%) of 22 patients were infertile. Three (14%) of 22 patients presented with unilateral necrosis of the testes due to spermatic cord torsion. Two patients had varicoceles, 1 patient had epididymitis, and another patient had torsion of an appendix testis. Previously unreported associations of TM and neurofibromatosis (1 patient) and acquired immunodeficiency syndrome (AIDS) (1 patient) were noted. No patient with TM later developed a testicular malignancy, yet the mean follow-up was only 31 months (range 1 to 108). One patient with unilateral TM developed bilateral TM, and 1 patient with bilateral TM subsequently developed unilateral TM. One patient developed spermatic cord torsion and testicular infarction 4 years after previously documented TM. CONCLUSIONS: TM is usually diagnosed by testicular US performed for various indications. TM is an uncommon condition that is found in testes with both malignant and nonmalignant conditions. The association of TM and testicular malignancy suggests regular follow-up with testicular US examinations.

Intra-abdominal pulmonary sequestration: a benign suprarenal mass.

A 34-year-old white woman presented with an 8.5-cm left suprarenal mass. Evaluation revealed normal adrenal hormone function. Pathologic examination after surgical removal revealed a rare benign condition, intra-abdominal extralobar pulmonary sequestration (accessory lung).

Primary adenocarcinoma of the epididymis: case report and review of the literature.

Primary epididymal malignancies are uncommon, and epididymal adenocarcinomas are exceedingly rare. We report a case of primary adenocarcinoma of the epididymis in a 62-year-old man and review the world literature on epididymal adenocarcinoma.

Schistosomiasis of the urinary bladder in an African immigrant to North Carolina.

A 30-year-old black man came to the emergency department with gross hematuria, prostatitis, and urethritis 4 months after immigrating to this country from the Sudan in Africa. Urinalysis revealed hematuria and no ova or parasites. An intravenous urogram showed normal kidneys and ureters. The patient had cystoscopy with biopsies of an inflamed and ulcerated bladder mucosa. The nematode Schistosoma haematobium and schistosome eggs were identified without evidence of urothelial malignancy. The patient was treated with praziquantel and is currently asymptomatic. Over 200 million people are infected with schistosomiasis worldwide, yet this disease is rarely encountered in this country. The differential diagnosis and assessment of patients must include exposure to uncommon diseases that are endemic to other geographic regions.

Cardiac arrhythmias with external fixed-rate signal generators in shock wave lithotripsy with the Medstone lithotripter.

OBJECTIVES: To evaluate the incidence and outcome of cardiac arrhythmias associated with an external fixed-rate generator and the Medstone lithotripter with regard to stone location, anesthesia type, patient age, and gender. METHODS: Data were obtained on 933 patients who underwent shock wave lithotripsy (SWL) with the Medstone lithotripter. Patients were randomly divided into two study groups, including those with pre-existing cardiac disease, hypertension, and cardiac medications. Group 1 (576 patients) were treated with the external fixed-rate signal generator (cardiac simulator). Group 2 (357 patients) underwent electrocardiogram-gated SWL (no simulator). All patients were monitored for arrhythmias during SWL. Patients who developed arrhythmias on the simulator were converted to gated SWL. RESULTS: In group 1, 463 patients (80%) had no arrhythmias during treatment, whereas 113 patients (20%) developed cardiac arrhythmias (primarily premature ventricular contractions [PVCs]) and were successfully converted to gated SWL. Only 1 patient in group 2 (0.3%) had a documented arrhythmia (PVC). Group 1 patients who developed arrhythmias with a cardiac simulator were more likely to have renal rather than ureteral stones. Chi-square analysis showed a significant correlation between patients with and without arrhythmias in group 1 with regard to stone location (P <0.0001). In group 1, regional anesthesia, intravenous anesthesia, and general anesthesia had an arrhythmia rate of 14%, 27%, and 38%, respectively. The only patient in group 2 who developed arrhythmias was under general anesthesia. The differences between groups 1 and 2, with regard to anesthesia type and arrhythmia, were statistically significant (P <0.001). No patients required additional medical therapy or hospitalization for cardiac events, and all patients safely completed the SWL treatment. CONCLUSIONS: With careful monitoring and adequate precautions, external fixed-rate signal generators are safe, effective methods for pacing the Medstone shock wave lithotripter and probably other extracorporeal shock wave lithotripters.

Unusual complications of the vacuum erection device.

OBJECTIVES: The vacuum erection device (VED) is usually well tolerated and very effective for patients with erectile dysfunction. When used correctly, VEDs carry low morbidity and few recognized complications. We report on 5 patients who developed unusual complications associated with VED use, including two previously unreported complications of urethral bleeding and capture of scrotal tunica within the penile shaft. METHODS: Patient 1: a 38-year-old diabetic man with significant peripheral neuropathy and an 8-year history of erectile dysfunction developed penile skin necrosis at the ring site after leaving the penile ring on for an excessive length of time (6 hours). Patient 2: a 76-year-old diabetic man who used a VED correctly for 3 months developed severe urethral bleeding. Patient 3: a 75-year-old diabetic man who enjoyed satisfactory erections with a VED for 14 months developed a 3 x 3-cm penile cystic mass located on the proximal right side of the penile shaft. This mass was not present in the flaccid state and was seen only with VED use. Patient 4: a 65-year-old man developed Peyronie's disease after 4 years of correct VED use. Patient 5: a 62-year-old man with neurogenic impotence following a radical prostatectomy developed penile ecchymoses acutely following placement of a smaller constriction ring. He subsequently developed a dorsal penile plaque with mild dorsal curvature. RESULTS: Patient 1 did well with local skin care and no longer uses a VED. Patient 2 underwent cystoscopy and was found to have prominent urethral vessels (varicosities) in the midurethra, compared with a normal cystoscopy 9 months previously. This patient no longer uses a VED and now denies any urethral bleeding at 15-month follow-up. Patient 3 underwent corpora cavernosography and contrast injection of the cystic mass. These radiographic studies showed that the mass did not communicate with either corpora cavernosa or the corpus spongiosum. A retrograde urethrogram failed to show a urethral diverticulum. The patient was surgically explored, and the penile cystic mass was found to be scrotal tunica vaginalis. Subsequently, a hydrocele repair was performed, yet postoperatively the patient developed testicular migration into the ipsilateral penile shaft. Testicular fixation was not feasible secondary to a childhood herniorrhaphy, and an orchiectomy was performed. Patient 4 underwent implantation of a penile prosthesis and is doing well at 3-year follow-up. Patient 5 experiences mild dorsal penile curvature with erections induced by transurethral prostaglandin E1. The penile curvature does not interfere with intercourse and will be managed conservatively. CONCLUSIONS: We describe unusual side effects associated with VEDs. Although thousands of men use VEDs successfully and without morbidity, the urologist must be aware of unusual complications associated with VED use.