A transperitoneal laparoscopic approach to endourology.

Although endoscopic methods have become the preferred means of management for many diseases facing the genitourinary surgeon, a laparoscopic approach might be considered comparable or advantageous in select circumstances. In the literature, laparoscopists reporting their work have favored the transperitoneal approach; however, there are clear advantages and disadvantages to both transperitoneal and retroperitoneal laparoscopy. Intracorporeal suturing remains the most time-consuming aspect of reconstructive surgery, and research emphasis has been on suturing devices and novel anastomotic techniques. Laparoscopic pyeloplasty is efficacious and should be considered, particularly in the case of a capacious renal pelvis, crossing vessel, or failed previous endopyelotomy. Laparoscopic pyelolithotomy is uniquely suitable for patients with aberrant anatomy, such as a horseshoe kidney, and may be performed concurrently with pyeloplasty for ureteropelvic junction obstruction. The use of laparoscopic extravesical ureteral reimplantation awaits further development in both open and subtrigonal injection techniques. Its use in colposuspension is undetermined and requires further study as suturing technology improves. During laparoscopic exploration, it is possible to address intraoperative injuries to the ureter and bladder laparoscopically. In summary, laparoscopic surgery of the urinary tract is a "work in progress," but it offers promise for some of the most challenging of circumstances. As the technology advances and the clinical experience widens, the indications and contraindications for these techniques will be better established.

Priapism of ambiguous classification in a sickle cell patient.

We report a case of recurrent priapism in a sickle cell patient who had undergone physiological transformation from a low-flow state to a mixed high-flow/low-flow picture. An oral alpha-adrenergic agonist/histamine-1 antagonist combination maintained a balance of potency without stutter in the latter state, whereas an oral alpha-adrenergic agonist in the early part of his course did not prevent priapic progression. Concomitant use of a non-steroidal anti-androgenic agent rendered him impotent despite good libido. Other etiologies should be considered in the setting of recurrent priapism and failed standard therapies; duplex ultrasound is useful in order to delineate the hemodynamics. This case supports contentions that priapism is a spectrum phenomenon, and raises questions regarding the mechanism by which alpha-adrenergic agents prevent priapic progression.

Laparoscopic ureteral surgery.

The use of laparoscopy for ureteral surgery, currently in its relative infancy, is critically reviewed here as an alternative to traditional open and endoscopic methods. The technical aspects of laparoscopic ureteral surgery, clinical and experimental experience to date, and recent advances in anastomotic and substitutive technology are discussed.

Intraoperative electrical stimulation of cavernosal nerves with monitoring of intracorporeal pressure in patients undergoing nerve sparing radical prostatectomy.

OBJECTIVE: To explore the utility of intraoperative cavernosal nerve stimulation in facilitating atraumatic nerve dissection during radical prostatectomy, and thus help predict postoperative erectile function. PATIENTS AND METHODS: Fourteen patients (aged 51-72 years) underwent nerve-sparing radical retropubic prostatectomy (NSRRP); 10 were potent before surgery (group 1), and four had erectile dysfunction (group 2). A multi-acquisition system (MacLab/8e) with a Macintosh computer was used for real-time display and recording of intracavernosal pressure (ICP) during surgery. Nerves were stimulated with a bipolar probe (monophasic rectangular pulses, 10 mA, 20 Hz, 0.22 s) before and after removal of the gland. The follow-up consisted of interviews with patients and their partners' 12-18 months after treatment. RESULTS: The mean (sem) basal ICP of 8. 0 (2.0) cmH2O remained unchanged during nerve dissection. The mean increase in ICP during electrical stimulation was >50 cmH2O in seven potent patients (group 1) and was sustained as long as the nerve was stimulated. Postoperatively, these seven patients reported erections sufficient for sexual intercourse. However, the three remaining patients in group 1 had pressure rises of <30 cmH2O, of whom two reported partial erections and one reported total impotence postoperatively. The recovery time for erectile function was 6-12 months after surgery. Two patients from group 2 had transient increases in ICP to <40 cmH2O; one had an increase to 20 cmH2O and one had no response at all. All four patients remained totally impotent postoperatively. There were no complications. CONCLUSIONS: Intraoperative electrical stimulation of the cavernosal nerves with ICP monitoring before and after NSRRP is a safe and reliable method for documenting nerve continuity and its functional status. Patients who have normal preoperative erectile function and show an adequate rise in ICP upon electrical nerve stimulation during NSRRP will almost certainly be potent after surgery. This tool may be used to facilitate atraumatic nerve dissection during NSRRP.

Use of spiral computerized tomography in lieu of angiography for preoperative assessment of living renal donors.

PURPOSE: We evaluate whether spiral computerized tomography (CT) can be used in lieu of renal angiography for preoperative assessment of living renal donors, with special attention to multiplicity of renal vasculature. MATERIALS AND METHODS: A total of 47 living renal donor candidates were evaluated with spiral CT and all but 2 underwent donor nephrectomy. Patients were divided into early and late groups because there was a learning curve with spiral CT. In the early group 18 donors underwent renal angiography as well as spiral CT and 10 underwent nephrectomy after spiral CT only. In the late group 5 had dual radiographic evaluation for ambiguities in spiral CT interpretation and 12 underwent nephrectomy after spiral CT only. Spiral CT was performed and interpreted blind to angiographic results, and vice versa. RESULTS: Spiral CT identified 50 of 52 renal arteries (96%) found at surgery overall and 23 of 25 (92%) found at surgery after spiral CT only. Two accessory arteries were missed in the 10 early group donors evaluated with spiral CT only, yielding an early negative predictive value of 80%. Renal angiography identified another accessory artery missed by spiral CT in the early group. All 3 missed vessels were identified retrospectively. No arteries found at surgery were missed in the late group (negative predictive value 100%), although there were 2 false-positive results detected by spiral CT relative to renal angiography in 1 candidate renal unit. Overall accuracy to predict early renal artery division relative to surgical findings was 93% for spiral CT and 91% for renal angiography. However, early renal artery division was clinically significant for only 1 of 11 vessels found at surgery. Spiral CT demonstrated 4 anomalous venous returns and renal angiography identified none. However, spiral CT missed 2 accessory veins and identified only 1 of 2 fibromuscular dysplasia cases. Total cost for spiral CT and renal angiography was $886 and $2,905, respectively. CONCLUSIONS: Spiral CT is a reasonably good alternative to renal angiography for living renal donor assessment but there is a profound learning curve for performance and interpretation. Renal angiography is still the gold standard with respect to the identification of arterial multiplicity and fibromuscular dysplasia, and it should be used adjunctively in cases with spiral CT ambiguity. Neither spiral CT nor renal angiography is ideal for the assessment of early renal artery division which is seldom an issue. The benefits of spiral CT over renal angiography are potentially lower morbidity, improved donor convenience and reduced cost.

Modification of sexual behavior of Long-Evans male rats by drugs acting on the 5-HT1A receptor.

Modulation of the sexual behavior of male rats by the anxiolytic buspirone (S-20499) and its analog gepirone were compared to the effects of 8-OH-DPAT (or DPAT, a selective 5-HT1A reference agonist), and BMY-7378 (a selective 5-HT1A partial agonist). Long-Evans rats were used; modulation of copulatory behavior and alteration of penile reflexes were examined. Modulation of copulatory behavior was assessed by three indices: frequency and length of intromission, and latency of ejaculation. DPAT, at doses of 1-8 mg/kg, reduced these three indices in a time dependent manner such that the effects peaked at 45 min and normalized at 90 min. The dose-effect relationship (assessed 45 min after DPAT injection) is bell-shaped with an ED50 approximately 1 mg/kg on the ascending limb of the curve. The effects of buspirone (2 mg/kg) and gepirone (2 mg/kg) on copulatory behavior were indistinguishable from control. BMY-7378 alone and in combination with these other 5-HT1A agonists reduced copulatory behavior, though not statistically significant. Penile reflexes, including number of erections, cups and flips, were inhibited by these agents: DPAT>buspirone>gepirone (inactive at 2 mg/kg). Furthermore, the latency period to erection was at least doubled by DPAT (2 mg/kg). Buspirone and gepirone, however, reduced the latency period to erection. BMY-7378 inhibited penile reflexes when administered alone and even more in combination with DPAT or buspirone. Two butyrophenone analogs, spiperone (a 5-HT1A and dopamine D2 antagonist) and haloperidol (a D2 antagonist), were also tested for their interaction with DPAT. Both of these drugs (at 0.25 mg/kg, 60 min after administration) reduced all indices of penile reflexes and copulation. Furthermore, in combination with DPAT (2 mg/kg, 45 min), the effects were synergistic such that sexual activity came nearly to a standstill. These opposing effects on putatively brain originated copulatory behavior and spinal mediated penile reflexes indicate that the effects of buspirone and DPAT on sexual behavior in the male rat may be possible at different parts of the central nervous system. If a tentative shared target site by DPAT and buspirone is the 5-HT1A receptor, than the same 5-HT receptor sub-type at different locations (brain, raphe nuclei, spinal cord and autonomic ganglia) may modulate rat sexual behavior in opposing ways.

Aorto-caval fistula: a clinical spectrum.

Ten cases of aortocaval fistula (ACF) associated with abdominal aortic aneurysm (AAA) were reviewed. In 5 cases the ACF became apparent after evacuation of the thrombus; only 5 patients presented with features of patent ACF. Four patients in addition presented with extra-caval rupture of the aneurysm. Based on these variables, a classification relating ACF and AAA was developed. In this series all patients were male with a mean aneurysm size of 8.5 cm. All patients required bifurcation grafts for reconstruction. A multifactorial etiology related to enlargement and rupture of all aneurysms seems to apply to ACF. Eight of 10 patients survived. Awareness of this entity and proper preparation allow for successful outcome in the treatment of this condition.

Arteriovenous fistula following punch-graft hair transplantation.

Arteriovenous fistula is a rarely reported complication of punch-graft hair transplantation. Two cases seen at our institution are presented and the nature, etiology, and prevention of this entity are discussed.

Tc-99m colloid lung uptake in a rare case of toxoplasmosis with liver involvement.

Intensive lung accumulation of colloid (Tc-99m phytate) was demonstrated in a child suffering from acquired toxoplasmosis with a rare manifestation of severe liver damage. The possible mechanism and clinical importance of colloid lung concentration in this case is briefly discussed, including a review of the literature on this subject.

Dopamine and the aged.

Regardless of the age of the patient, dopamine is a valuable agent for treating shock associated with an abdominal catastrophe. However, when the time is appropriate for withdrawal of dopamine, the aged do not react as do younger patients. Despite apparent adequate hydration, additional volume loading is required to avert renal failure, and the dosage of dopamine has to be decreased gradually until withdrawal is complete.