A retrospective analysis of risk factors for IPP reservoir entry into the peritoneum after abdominal wall placement.

Placement of an inflatable penile prosthesis (IPP) is the most effective treatment modality for men with ED refractory to medical management. We have previously demonstrated a protocol for IPP reservoir placement within the abdominal wall musculature, which was shown to be a safer location than traditional placement in the retropubic space of Retzius. The aim of this study was to review our complications with IPP reservoir entry into the peritoneum after abdominal wall placement of the reservoir. We retrospectively reviewed our two patients with peritoneal entry of the reservoir after posterior to transversalis fascia and anterior to transversalis fascia placement during virgin and compromised IPP cases, respectively. Our goal was to assess common inherent patient and surgical factors that resulted in this complication in order to develop a management algorithm to prevent future occurrence during alternative reservoir placement. Peritoneal reservoir entry was identified in two patients. These patients were both noted to be thin (mean body mass index (BMI) 18.5 kg/m2), current or former smokers. Peritoneal entry was identified early after reservoir placement. Neither of the patients suffered bowel injury and both subsequently underwent successful reservoir removal and IPP replacement. Both are currently doing well with functional IPPs on follow-up. Peritoneal entry of the reservoir occurs very rarely and, in our series, occurred in a cohort of patients with low BMI and tobacco use history. We recommend early identification of similar patients and subsequent reservoir placement anterior to transversalis fascia with caution to prevent peritoneal entry.

Intravesical penile implant reservoir: case report, literature review, and strategies for prevention.

To present a case of intravesical erosion of an infected multiple-component inflatable penile prosthesis (IPP) reservoir. We retrospectively reviewed a case of complete intravesical erosion of an infected IPP reservoir. We also reviewed the prior urologic literature concerning bladder-related reservoir complications, and formulated potential strategies to prevent these complications in the future. This patient was successfully managed with complete explantation of the cylinders and pump, along with cystotomy, intravesical reservoir removal and cystorraphy. Several months later, he was successfully reimplanted with a multiple-component IPP, and, with 7 months follow-up, has had no further complications. Management of intravesical placement or erosion of an IPP reservoir should be tailored to the clinical scenario. In cases with peri-prosthetic infection and subsequent intravesical reservoir erosion, complete explantation and delayed subsequent reimplantation has been successful. Inadvertent intravesical reservoir placement has been successfully managed via immediate cystotomy, reservoir repositioning and cystorraphy. Reservoir insertion via a counter-incision, an infrapubic approach and under direct vision can avoid this complication. Bladder laceration during reservoir reinflation has been successfully managed with cystorraphy and reservoir repositioning.

Inflatable penile prosthesis: site-specific malfunction analysis.

The purpose of this study was to analyze retrospectively the exact site(s) of device failure of a large series of Mentor Alpha I inflatable penile prostheses. The study consisted of 442 patients implanted over a 12-year period. Only those patients who developed a device malfunction and returned for re-evaluation by the author were included. The exact site(s) of device malfunction were obtained from a review of operative reports. The average length of follow-up in this series was 63 months, ranging from 1 to 138 months. In all, 22 (4.98%) patients developed device malfunction and returned for evaluation, including six (3.9%) of the 154 infrapubic devices and 16 (5.6%) of the 288 scrotal devices. Of these 22 patients, three declined revision and 19 were reoperated on by the author. The exact site of malfunction differed in the infrapubic vs scrotal implants. Most malfunctions of the scrotal device involved tubing fractures at the pump strain reliefs, whereas infrapubic device malfunctions typically involved the cylinders or the reservoir. A review of these malfunction patterns may assist the manufacturer in further improving the reliability of this prosthesis, and may assist implanting surgeons in planning operative procedures.

Does surgical approach affect the incidence of inflatable penile prosthesis infection?

OBJECTIVES: To review retrospectively the rate of infection in 380 consecutive organically impotent men implanted with a Mentor Alpha I inflatable penile prosthesis, stratified by surgical approach (scrotal or infrapubic). METHODS: Data were obtained from review of medical records. One hundred percent of cases were available for a minimum postoperative follow-up of 6 months. RESULTS: Twenty patients had a prior penile prosthetic operation and were excluded, leaving 360 primary implants for review. Overall, 6 patients (1.7%) developed periprosthetic infection. Four of these 6 patients were diabetic. Four of 139 infrapubic cases (2.9%) and 2 of 221 scrotal cases (0.9%) developed periprosthetic infection. This difference was not statistically significant (P = 0.15). Equal proportions of the infrapubic (39.6%) and scrotal cases (40.3%) were diabetic patients. The infection rate in patients with and without diabetes was 4 of 144 (2.8%) and 2 of 216 (0.9%), respectively. This difference was not statistically significant (P = 0.18). CONCLUSIONS: This study indicates that there is no statistically significant difference in the infection rate when the scrotal and infrapubic approaches to inflatable penile prosthesis insertion are compared.

Outpatient inflatable penile prosthesis insertion.

OBJECTIVES: To assess the initial results of an ambulatory, outpatient, multiple-component inflatable penile prosthesis (IPP) insertion protocol. METHODS: Ninety-five consecutive men with organic impotence were implanted with a multiple-component IPP on an outpatient basis. Short-term complications were assessed by direct patient examination, phone interview, and office visits. RESULTS: Complications seen with this approach included 1 patient who required hospitalization for gross hematuria, 1 patient with a periprosthetic infection, and 4 patients who were unable to void and were sent home with a urethral catheter. CONCLUSIONS: Multiple-component IPP insertion is easily adaptable to the outpatient setting. The prosthetic infection rate (1%) was similar to that seen with inpatient implantation protocols. Urinary retention (4%) was the most frequent complication, and it was easily managed with temporary catheterization. Early results suggest that outpatient IPP insertion is a safe, effective treatment for men with organic impotence.

Intracorporal lengths of organically impotent men.

This report analyzes the intracorporal lengths of 236 consecutive organically impotent men who underwent insertion of a penile prosthesis. The average right or left intracorporal length in this series was 20.9 cm, with a standard deviation of 2.2 cm. Intracorporal length ranged from 14-27 cm. This data may be used as reference ranges for penile prosthesis manufacturers, and for Urologists who implant prostheses or perform penile lengthening procedures.

Inflatable penile prosthesis: results of 150 cases.

OBJECTIVES: To evaluate the reliability of the prosthesis and the rate of complications in organically impotent men who were implanted with an inflatable penile prosthesis. PATIENTS AND METHODS: A consecutive series of 150 men (mean age 60 years, range 25-90) were followed for a mean of 19 months (range 0-65) after implantation of the Mentor Alpha 1 penile prosthesis. Information was obtained from their medical records and by telephone interview, but the satisfaction of the patients was not assessed quantitatively. RESULTS: There were no complications in 145 of the patients and they currently have functioning prostheses. Complications occurred in five patients (3%), including two peri-prosthetic infections (1%) and two intra-operative and one post-operative cylinder aneurysm. Complications requiring re-operation occurred in three (2%) of patients; none of the implants leaked. CONCLUSIONS: These results suggest that for men with organic impotence, a Mentor Alpha 1 implant is an effective treatment option with acceptable morbidity and good mechanical reliability.

Mentor alpha-1 inflatable penile prosthesis cylinder aneurysm: an unusual complication.

This report describes the author's experience with Mentor Alpha-1 inflatable penile prosthesis cylinder aneurysms. In a series of 93 consecutive cases three implants developed a cylinder aneurysm. Two aneurysms developed intraoperatively and one developed 27 months postoperatively. Literature review suggests that the Mentor Alpha-1 penile prosthesis cylinders are very resistant to aneurysm formation under normal circumstances. However aneurysmal dilatation may occur if the cylinders are subjected to unusual stress.

Mentor Alpha 1 inflatable penile prosthesis: patient satisfaction and device reliability.

OBJECTIVE: This report describes a study of patient satisfaction and device reliability in 50 organically impotent males who were implanted with a Mentor Alpha 1 inflatable penile prosthesis. METHOD: Data were obtained from review of medical records, and patient-completed structured questionnaires. RESULTS: The average patient age was fifty-nine years (range: 25 to 90 years). Thirty-one patients (62%) had underlying medical conditions, and all tried at least one other treatment prior to implantation. All patients received perioperative prophylactic antibiotics, and all were drained with a closed suction drain for twenty-four hours. Follow-up ranged from two to forty-one months (av. 15 mos). Complications occurred in 2 patients (4%), including 1 periprosthetic infection and 1 intraoperative cylinder aneurysm. An average of one office visit was required for teaching inflation/deflation. Ninety-eight percent of the patients and 96 percent of their partners were satisfied with the device. Ninety-four percent and 96 percent thought the device was easy to inflate and deflate, respectively. Two patients (4%) reported partial cylinder inflation related to physical activity. All were satisfied with the girth and rigidity, but only 92 percent were satisfied with the length. Ninety-eight percent said they would undergo the procedure again and would recommend this implant to other impotent patients. CONCLUSIONS: These data indicate that the Mentor Alpha 1 device has good short-term mechanical reliability, and yields a high level of patient and partner satisfaction.

Masson's tumor of the kidney: a new renal lesion.

Intravascular papillary endothelial hyperplasia (Masson's tumor) is a rare benign reactive lesion usually found in thrombosed subcutaneous blood vessels. We report a case of Masson's tumor of the kidney, and discuss the relevant clinical, radiographical and pathological aspects.

Xanthogranulomatous pyelonephritis and amyloidosis: a rare association.

The coincidence of systemic amyloidosis and xanthogranulomatous pyelonephritis has been reported previously only once. Clinical findings, such as the nephrotic syndrome, cardiac and autonomic nervous system dysfunction, and adrenal insufficiency, are suggestive and a thorough investigation to rule out other causes of secondary amyloidosis is warranted. We report a case of xanthogranulomatous pyelonephritis associated with secondary systemic amyloidosis and the nephrotic syndrome. Treatment consisted of nephrectomy and intensive supportive care. The unique clinical, radiographic and pathological aspects of this case are discussed.

Effect of contractile activity on muscarinic receptor density and the response to muscarinic agonists.

Autonomic receptor density can be modulated by alterations in neuronal activity over a relatively short period of time (hours). The current study investigates whether increased in vivo stimulation of urinary bladder smooth muscle can alter muscarinic receptor density and response to muscarinic stimulation. A high degree of reflex stimulation of the urinary bladder (rabbits) was initiated by stricture of the external urethra. Intravesical pressure and intra-abdominal pressure were monitored continuously over a 4-hr time period. At the end of the 4-hr period, the rabbits were sacrificed and isolated strips of bladder body were either mounted in isolated smooth muscle baths for contractile studies or frozen and stored in liquid nitrogen for muscarinic receptor analysis. These studies demonstrated that over 4 hr of urethral stricture there was a significant reduction in muscarinic receptor density from a Bmax of 34 +/- 3.4 fmol/mg of protein in control bladder strips to 22 +/- 2.4 fmol/mg of protein in the experimental group. In association with the decreased muscarinic receptor density, there was a significant and selective decrease in the contractile response to muscarinic stimulation. Similar to the in vivo studies, repetitive field stimulation of in vitro strips resulted in a significant decrease in muscarinic receptor density and a significant and selective decrease in the contractile response to muscarinic stimulation. The results from these studies indicate that muscarinic receptor density, and response to muscarinic stimulation, can be modulated over a relatively short period of time by alterations in the level of neuronal stimulation.

Characterization of a Salmonella typhimurium mutant defective in phosphoribosylpyrophosphate synthetase.

This study describes the isolation and characterization of a mutant (strain GP122) of Salmonella typhimurium with a partial deficiency of phosphoribosylpyrophosphate (PRPP) synthetase activity. This strain was isolated in a purE deoD gpt purin auxotroph by a procedure designed to select guanosine-utilizing mutants. Strain GP122 had roughly 15% of the PRPP synthetase activity and 25% of the PRPP pool of its parent strain. The mutant exhibited many of the predicted consequences of a decreased PRPP pool and a defective PRPP synthetase enzyme, including: poor growth on purine bases; decreased accumulation of 5-aminoimidazole ribonucleotide (the substrate of the blocked purE reaction) under conditions of purine starvation; excretion of anthranilic acid when grown in medium lacking tryptophan; increased resistance to inhibition by 5-fluorouracil; derepressed levels of aspartate transcarbamylase and orotate phosphoribosyltransferase, enzymes involved in the pyrimidine de novo biosynthetic pathway; growth stimulation by PRPP-sparing compounds (e.g. guanosine, histidine); poor growth in low phosphate medium; and increased heat lability of the defective enzyme. This mutant strain also had increased levels of guanosine 5'-monophosphate reductase. This genetic lesion, designated prs, was mapped by conjugation and phage P22-mediated transduction at 35 units on the Salmonella linkage map.

Immunochemical analysis of fibronectin using monoclonal antibodies.

Cloned hybrid cell lines secreting antibodies directed against human plasma fibronectin were prepared according to the methods of Kohler and Milstein (Kohler, G. and Milstein, C. (1975) Nature (London) 256, 495-497 and (1976) Eur. J. Immunol. 6, 511-519). The specificity of each monoclonal antibody for fibronectin was established from autoradiograms of radioimmunoprecipitates following SDS-polyacrylamide gel electrophoresis. The monoclonal antibodies were reactive with both native and SDS-denatured fibronectin. Ascites fluids obtained from infected isogenic mice precipitated 85-95% of the 125I-labelled fibronectin radioactivity in indirect radioimmunoprecipitation tests. Localization of specific epitopes to restricted regions of the fibronectin molecule was carried out by monitoring monoclonal antibody binding to proteolytic fragments. Of the five monoclonal antibodies analyzed in this study, three recognized determinants which resided in the terminal 35 kDa region of the fibronectin monomer. Furthermore, these epitopes were localized to fragments as small as 20 kDa. Competition studies carried out using plasma fibronectins isolated from different species revealed that three monoclonal antibodies recognized sites which were relatively conserved, while two monoclonal antibodies recognized epitopic sequences which were unique to the human protein. The corresponding anti-fibronectin serum also demonstrated discriminatory capabilities. Immunofluorescent analysis of human fibroblasts grown in vitro demonstrated that all the monoclonal antibodies tested were reactive with pericellular fibronectin.

3H-thymidine autoradiographic analysis of telencephalic histogenesis in the chick embryo: II. Dynamics of neuronal migration, displacement, and aggregation.

The movements of cells from their sites of origin in the proliferative neuroepithelium to their final positions in the chick telencephalon were traced by autoradiographic analysis of 3H-thymidine-labeled brains. A series of chick embryos were labeled on successive days of development between days 5 and 9 and fixed for autoradiography between days 6 and 10. Isochrone maps visualizing neuronal positions on each day of development between days 6 and 10 provided direct information concerning cell migrations, displacements, and aggregations leading to compartmentalization of the telencephalic wall and the generation of the "outside-in" pattern of histogenesis characteristic of the avian telencephalon. The topological divisions of the telencephalic wall appear to result from two factors: (1) the specification of neuronal precursors within the neuroepithelium and (2) the intrinsic associative and migratory properties of postmitotic neuronal populations expressed within the mantle layers. There was no evidence that glial cell barriers mediated the initial compartmentalization of neuronal populations.

3H-thymidine autoradiographic analysis of telencephalic histogenesis in the chick embryo: I. Neuronal birthdates of telencephalic compartments in situ.

The birthdates of neuronal populations comprising the chick telencephalon were determined by 3H-thymidine labeling and were mapped with respect to their terminal positions in the 16-day embryo. Essentially all neurons were generated between four and nine days of embryonic development. Each telencephalic structure (based on terminology used by Karten and Hodos, '67) was characterized by a specific range of birthdates: some regions such as the core of the ectostriatum or the paleostriatum primitivum, were generated within a single day, while others, such as the hyperstriatum accessorium, required up to five days for generation of the complete population. Spatial-temporal gradients of neuronal birthdates, lateromedial and ventrodorsal, were seen in the telencephalon as a whole and within individual subcompartments as well. An "outside-in" pattern of histogenesis predominated throughout the entire telencephalon, including the dorsolateral cortex. However, notable exceptions pertaining to the paleostriatum augmentatum, hyperstriatum intercalatus and field "L" were observed. Glial cells, generated for the most part after day ten, were found to be distributed homogeneously throughout all areas of the telencephalon. These data provide the first birthdating data for an avian telencephalon and bring greater resolution to previous analyses of the histogenesis of this brain region. Further, the compartmentalization of the proliferative neuroepithelium is revealed by these data, and the possibility of a common time of origin in the neuroepithelium for neurons of related function is discussed.

Target neuron-specific process formation by embryonic mesencephalic dopamine neurons in vitro.

Mesencephalic dopamine neurons from the embryonic mouse brain were dissociated, aggregated in vitro in the presence of dissociated cells from appropriate or inappropriate target neuron areas, and visualized by the Falck-Hillarp histofluorescence technique after exposure to 1 microM exogenous dopamine. When aggregated with the surrounding rostral mesencephalic tegmentum cells only or with the addition of rostral tectum cells, the dopamine neurons formed a dense dendritic arborization, but no axons were observed. In the presence of dopamine-neuron target cells from the corpus striatum, a dense axonal plexus characteristic of that formed in this area in vivo was observed. In contrast, in aggregates formed with target cells from the frontal cortex, branching fluorescent axons bearing irregularly spaced and shaped varicosities were found coursing through the neuropil, as is characteristic of the dopaminergic innervation to the frontal cortex in vivo. Only proximal dendrites were observed in the presence of these axonal target cells. Dopamine neurons cultured with inappropriate target cells from the occipital cortex did not form either extensive axonal or dendritic processes. Thus, the presence, type, and distribution of dopamine neuronal processes are dependent on the presence of appropriate target cells. The formation of unique patterns of neuronal processes by dissociated neurons in vitro suggests that the information necessary for this differentiation is intrinsic to the dopamine neurons and their target cells. This system provides a useful model with which to study basic mechanisms underlying neuronal recognition.

Separation and characterization of neuronal and glial cell populations from embryonic chick cerebra in culture.

A new procedure of separation of glial and neuronal cell population from embryonic chick cerebra has been described and their morphology in vitro was examined by SEM. This technique used the differential adhesive properties of the glial and neuronal cells to obtain an initial separation in primary monolayer culture. The neuronal fraction was then further purified by treatment with cytosine arabinoside. The homogeneity of the glial and neuronal cultures produced by this technique was examined by phase contrast and scanning electron microscopy, liquid scintillation counting of incorporation of radioactive precursors into the cultured cells and autoradiographic study of the cultures. The purity of the neuronal culture was estimated to be better than 97 and 98% based on LSC and autoradiography respectively. The purity of glial culture was assessed by phase contrast and SEM and was estimated to have a purity of over 99%. The viability of the both cultures was good following initial separation. The glial cells were typically epitheloid and formed confluent monolayer 7--10 days after initial separation. These cells have a smooth upper surface and are typically hexagonal in shape. The neuronal cultures formed small aggregates interconnected with compound neuronal processes. It was noted that the neuronal differentiation was closely related to the glial cells. In the presence of a glial carpet, the aggregates became flattened and well differentiated neuronal cells were found. On the contrary, round neuronal aggregates were found. In the case of mixed cultures of glial and neuronal cells neurites were seen grown mainly on the surface of glial carpet. Only in rare occasions, neurites were seen bridging over the bare glass surface.