Antegrade subinguinal sclerotization with temporary clamping of the spermatic cord: a new surgical technique for varicocele.

OBJECTIVES: The purpose of our study was to evaluate the duration, effectiveness, and complications associated with a new operating technique for varicocele, using a subinguinal surgical approach and antegrade sclerotization of the spermatic veins. METHODS: A total of 756 varicocele patients who came under our care for infertility underwent surgical treatment with our technique. The diagnosis was based on clinical examination and confirmed by color-Doppler ultrasound of the spermatic cord. Only patients with continuous basal reflux inside the left spermatic vein detected in orthostatism underwent operation. The Colpi technique was used, which consists of a subinguinal incision with suspension of the spermatic cord; cord clamping for 8-10 minutes using two elastic bands; and injection of 1.5-3 mL of sclerosing agent during induced ischemia without any intraoperative radiological control. RESULTS: The average operating time was 25 minutes (range: 18-45 minutes). At the 3-month postoperative follow-up, there were 15 cases of persistent reflux (1.9%), 6 cases of hydrocele requiring surgical correction (0.7%), and 50 cases of fibrotic sequelae of penile lymphangiitis (6.6%). CONCLUSIONS: The new technique was more effective than the previous ones, with the exception of the microsurgical technique, which, however, takes 2-3 times longer to perform. The only significant complication was superficial single-vessel lymphangiitis of the penis, which resolved within 3 months with no apparent consequences. In conclusion, this new operating technique for varicocele is simpler to perform and may be effective compared with other techniques.

Evaluation of microalbuminuria in patients with erectile dysfunction.

INTRODUCTION: The recent sophisticated diagnostic procedures aimed at identifying the exact cause of erectile dysfunction (ED) are often complicated in clinical application, invasive, or highly expensive. Microalbuminuria, a test easy to perform and of low cost, is a marker of extensive endothelial dysfunction, and it has been suggested to be linked to ED. AIM: The aim of this study was to investigate the eventual role of microalbuminuria in differentiating patients with arteriogenic and non arteriogenic ED. METHODS: The diagnosis of ED was based on the International Index of Erectile Function 5-questionnaire, and patients were classified as arteriogenic (N = 29) and non-arteriogenic (N = 49) in relation to the results of echo-color-doppler examination of cavernosal arteries in basal conditions and after intracavernous injection of 10 microg prostaglandin E(1). MAIN OUTCOME MEASURES: The microalbuminuria of 78 males without the most common atheriosclerotic risks and with ED was measured. RESULTS: Microalbuminuria, defined as urinary albumin/creatinine ratio, was not significantly (P > 0.05) different between patients of the two groups. CONCLUSIONS: Our data show that in ED patients the cavernosal arteries damage, as assessed by dynamic echo-color-doppler, may be independent on or precede extensive endothelial dysfunction, and that microalbuminuria cannot be predictive of penile arteriogenic etiology.

Penile septoplasty for congenital ventral penile curvature: results in 51 patients.

PURPOSE: The technique most widely used to correct congenital ventral penile curvature is still corporoplasty as originally described by Nesbit. We present results in patients treated with a variation of Nesbit corporoplasty used specifically for congenital ventral penile curvature. MATERIALS AND METHODS: From June 2000 to June 2007 we treated 51 patients with congenital ventral penile curvature using modified corporoplasty (septoplasty), consisting of accessing the bed of the penile dorsal vein and excising 1 or more diamonds of tunica albuginea from it, extending in wedge-like formation 4 to 5 mm deep into the septum, until the penis is completely straightened. Patient history, clinical findings, self-photography results and the International Index of Erectile Function score were assessed. Curvature grade is expressed using the equation, 180 degrees - X, where X represents the deviation in degrees from the penis axis. Mean preoperative ventral curvature was 131.4 degrees (median 135, range 145 to 110). Of the patients 13 also had erectile dysfunction. RESULTS: At followup postoperative mean ventral curvature was 178.3 degrees (median 179.1, range 180 to 175). A total of 49 stated that they were completely satisfied. Penile shortening was 5 to 15 mm. Compared to preoperative values there were marked improvements in the International Index of Erectile Function score in the various groups. No major postoperative complications developed. In 4 patients wound healing occurred by secondary intent. CONCLUSIONS: This technique provides excellent straightening of the curved penis. By avoiding isolation of the whole dorsal neurovascular bundle there is no risk of neurovascular lesions. Suture perception is minimized.

Oxidative stress and antioxidant status in patients with erectile dysfunction.

INTRODUCTION: Erectile dysfunction (ED) is increasingly recognized as a public health problem. The interaction between nitric oxide and reactive oxygen species is one of the important mechanisms implicated in the pathophysiological process of ED. Plasma contains various antioxidant components to prevent free-radical injury. AIM: The aim of this study was to determine and compare the oxidative and antioxidant status of peripheral venous blood in patients with ED of arteriogenic and non-arteriogenic origin. METHODS: Oxidative stress and antioxidant status were assessed in 40 patients with ED and 20 healthy controls. MAIN OUTCOME MEASURES: Plasma reactive oxygen metabolite (ROM) concentrations were measured as an indicator of oxidative stress, and plasma total antioxidant status (TAS) to indicate antioxidant defense. RESULTS: Plasma ROM concentrations were higher (349.75 +/- 53.35 standard deviation [SD] U.Carr vs. 285.43 +/- 25.58 U.Carr, P < 0.001) and plasma TAS lower (0.54 +/- 0.16 SD mmol/L vs. 0.94 +/- 0.28 SD mmol/L, P < 0.0001) in patients with arteriogenic ED in comparison to those in patients with non-arteriogenic ED. Plasma ROM and TAS in controls were not significantly different from those in non-arteriogenic ED. Conclusions. This observation may be useful to better understand and distinguish arteriogenic from non-arteriogenic ED using laboratory tests. In addition, our findings provide important support for an antioxidant therapy to try to correct oxidative stress in arteriogenic ED patients.

Microsurgical TESE versus conventional TESE for ICSI in non-obstructive azoospermia: a randomized controlled study.

In a population of non-obstructive azoospermia patients, the efficacy of microsurgical testicular sperm extraction (microTESE) and conventional TESE was evaluated in a randomized controlled study on 138 testicles, classified and paired in a 48-square table according to the different classes of the following three variables: patient plasma FSH concentration, orchidometry and testicular histology. Sperm retrieval was positive in 21/22 testicles with hypospermatogenesis (11/11, 10/11; microTESE, TESE respectively), in 12/14 with maturation arrest (6/7, 6/7), in 16/22 with incomplete Sertoli cell-only syndrome (8/11, 8/11), and in 16/80 with complete Sertoli cell-only syndrome (11/40, 5/40). Sperm recovery was positive in 5/24 patients with FSH concentration > or = 3 x maximum value of normal range (N) (4/12, 1/12), in 17/40 patients with 2N < or = FSH < 3N (9/20, 8/20), in 30/48 patients with N < FSH < 2N (17/24, 13/24), and in 13/26 patients with FSH = N (6/13, 7/13). Regarding orchidometry, sperm recovery was positive in 11/18 testicles with volume (V) > or = 12 ml (6/9, 5/9), in 27/56 testicles with 8 ml < or = V < 12 ml (15/28, 12/28), and in 27/64 testicles with V < 8 ml (15/32, 12/32). FSH value and the surgical procedure were the two variables significantly (P < 0.05) predicting positive sperm retrieval.

Surgical treatment of varicocele by a subinguinal approach combined with antegrade intraoperative sclerotherapy of venous vessels.

OBJECTIVE: To evaluate the efficacy, in terms of recurrences, complications and operative duration, of a new technique for treating varicocele. PATIENTS AND METHODS: Between September 1999 and December 2002 we evaluated 307 men aged 17-51 years with varicocele. In all of the men the clinical diagnosis was confirmed by ultrasonography. The men were treated by a variant of the microsurgical technique described in 1994. A 2-3 cm distal subinguinal incision was made at the level of the superficial inguinal ring and the spermatic cord was exposed. The largest vein in the spermatic cord fat was cannulated. A 7-9 cm segment of the spermatic cord was clamped for 8-10 min; at the start of the ischaemia time, 1.5-3 mL of 3% atoxysclerol was injected into the cannulated vein. After sclerotherapy, the vein was ligated at the injection site, and the blood flow to the cord was restored. RESULTS: The mean operative duration was 25 min. Follow-up at 3 and 6 months after surgery, with objective examination and scrotal ultrasonography, revealed one case of clinical recurrence/persistence. The most common complication was penile lymphangitis (nine men) that regressed spontaneously; three men had temporary orchialgia. There were no cases of secondary hydrocele or testicular atrophy. CONCLUSIONS: The modified technique appears to be relatively easy and safe, and to of low cost. Given the promising results in terms of complications and persistence, the treatment appears to be a suitable first-line approach for the surgical treatment of varicocele.

Premature ejaculation. 1. Definition and etiology.

There is no general agreement on the definition of premature ejaculation, therefore scientific studies often reach discordant results depending on whether they assess the increase in ejaculatory latency or the couple's sexual satisfaction. Etiological theories can be divided into psycho-sexual (anxiety-related, behavioral) and biological (pelvic floor alteration, hypersensitivity of the glans penis, accelerated conduction and cortical amplification of the genital stimuli), both sharing the neurobiological assumption of serotonergic mediation. Premature ejaculation can be iatrogenic (amphetamine, cocaine, dopaminergic drugs) or secondary to urological diseases (prostatovesiculitis, frenulum breve) or to neurological diseases (multiple sclerosis, peripheral neuropathies, medullary expansion processes).

Premature ejaculation. 2. Classification and diagnosis.

A classification of premature ejaculation must distinguish between hyper-orgasmic or hypo-orgasmic, between situational or global; furthermore, it must define whether it occurs during vaginal penetration only or also in masturbation, and must study its latency periods and its relationships to the erectile dysfunction, with which it is often associated. Tests with local anesthetics, biothesiometry and penile vibrotactile stimulation, integrated with a thorough study of the general and psycho-sexual history, provide a good diagnostic classification that makes the therapeutic approach appropriate.

Premature ejaculation. 3. Therapy.

Serotonergic drugs (SSRIs) are the most commonly used, but they are characterized by relapse some time after medication interruption as well as by sexual side effects. The efficacy of phosphodiesterase-5 inhibitors seems excellent, but the risk of tachyphylaxis has been reported. The former (fluoxetine, paroxetine, sertraline, clomipramine) should be used in young patients with hyper-orgasmic forms, while the latter (sildenafil, tadalafil, vardenafil) should be used in hypo-orgasmic forms, in old age or when PE is associated with erectile dysfunction. Topical anesthetics provide satisfactory results in premature ejaculation due to hypersensitivity of the glans, and physiotherapy of the pelvic floor muscles proves successful in cases associated with pelvic floor dysfunction. Therapeutic associations and psycho-sexual therapy techniques may improve results, particularly in the long term.