Erectile function following high-energy thick loop prostatectomy.

OBJECTIVES: To evaluate the effects of the high energy cutting current that is used in conjunction with the thick loop on erectile function in patients with benign prostatic hyperplasia (BPH) undergoing prostatectomy. PATIENTS AND METHODS: Seventy patients with BPH were included in this prospective study. All patients underwent transurethral vaporization resection of the prostate (TUVRP) using the "Wing" thick loop and 250-Watt cutting current. Potency questionnaire to define if the patient was fully potent, partially potent or impotent was obtained both pre operatively and 3 months post-TUVRP. Adequate preoperative counseling on the procedure and its outcome particularly in relation to sexual activity was given to all patients that were sexually active. Age of the patients, size of the prostate, resectate weight and operation time was recorded for correlation with erectile function post-TUVRP. RESULTS: The mean age of patients was 70.1 +/- 6.3 years, the mean prostate size was 53.9 +/- 31.1 grams. Thirty-two patients (46%) were either impotent or sexually inactive at presentation. Thirty men were fully potent and 8 patients presented with reduced potency. Only 2 patients (5.2%) developed impotence post-TUVRP, both were partially impotent at presentation. CONCLUSIONS: Our results indicate that the frequency of erectile dysfunction following TUVRP may be low. It seems that the higher energy use in TUVRP does not adversely affect potency possibly because of the cooling effect of the circulating blood in the neurovesical bundles and the use of irrigation fluids intraoperatively.

Paramedian extraperitoneal approach for combined nephrectomy and augmentation ureterocystoplasty in children with neurovesical dysfunction.

OBJECTIVES: We describe and evaluate our approach to combined nephrectomy and augmentation ureterocystoplasty using a single paramedian extraperitoneal incision. PATIENTS AND METHODS: Three patients with neurogenic bladders (2 posterior urethral valves and 1 myelodysplasia) underwent nephrectomy and augmentation ureterocystoplasty. The mean age of the patients was 4.6+/-1.5 years. The indications for the procedure included control of urinary incontinence or preservation and stabilization of renal function. RESULTS: The integrity of the peritoneal cavity was easily preserved throughout the procedure using a paramedian incision. No complications were encountered in these patients. Early postoperative resumption of normal diet and activity was noted in all patients. CONCLUSION: The paramedian extraperitoneal approach through a single incision provides the advantages seen with other extraperitoneal techniques combining two incisions. The single paramedian incision has the potential to save on operative time and obviates the need to change the patient's position on the operating table while under anesthesia. Furthermore, the paramedian extraperitoneal approach provides the reconstructive surgeon with the chance to convert the procedure into a transperitoneal technique to incorporate bowel segments in order to complement ureterocystoplasty.

The 'Wing' versus the 'Vapor Cut' electrodes in transurethral electrovaporization-resection of the prostate: comparative changes in safety parameters.

We compared the early safety features of two-band resection devices used in transurethral vaporization-resection of the prostate (TUVRP). Ninety patients with prostatic outflow obstruction were prospectively evaluated in two open studies for the treatment using the 'Wing' cutting electrode in group 1 (Richard Wolf, Germany) and the 'Vapor Cut' electrode in group 2 (Karl Storz, Germany). Patients in both groups were comparable in age, presentation, prostate size and blood parameters. Safety features evaluated included changes in serum hemoglobin, hematocrit, sodium concentration and incidence of side effects. The mean drop in hemoglobin, hematocrit and serum sodium 1 h postoperatively for the Wing group were 0.54 g/dl, 2.04 ml/dl and 0.084 mEq/l respectively compared to a mean drop of 1.1 g/dl, 3.07 ml/dl and 3.1 mEq/l in the Vapor Cut group. These differences were statistically significant (p = 0.004, 0.03 and <0.0001 respectively). The mean resection weight was 24.78 +/- 10.4 and 24.46 +/- 14.79 g in groups 1 and 2, respectively; however, the mean operation time was significantly longer in the Wing group (47.7 vs. 37.1 min, p = 0.003). We conclude that both loops were safe and efficacious in the treatment of patients with prostatic outflow obstruction. Safety features that are related to the vaporization effect are influenced by the speed of resection.

Granulosa cell tumor of the adult type: a case report and review of the literature of a very rare testicular tumor.

We report a case of testicular granulosa cell tumor of the adult type in a 48-year-old man. Microscopically, the tumor consisted of round to ovoid cells with grooved nuclei that were arranged in several patterns, including microfollicular, macrofollicular, insular, trabecular, gyriform, solid, and pseudosarcomatous. These cells demonstrated strong immunopositivity with MIC2 (O13) antibody, vimentin, and smooth muscle actin and focal positivity with cytokeratin. Although this type of sex cord-stromal tumor is relatively common in the ovaries, it is still extremely unusual in the testis, and it probably represents the rarest type of testicular sex cord-stromal tumor.

Prospective randomized study of transurethral vaporization resection of the prostate using the thick loop and standard transurethral prostatectomy.

OBJECTIVES: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral prostatectomy (TURP). The procedure uses one of the novel, thick resection loops coupled to augmented electrocutting energy. We evaluated the safety and efficacy of TUVRP in comparison with TURP. METHODS: Sixty-eight patients with prostatic outflow obstruction were prospectively randomized between equal TUVRP and TURP treatment groups. Safety parameters evaluated included changes in serum hemoglobin, hematocrit, and sodium 1 and 24 hours after resection. Operative time, catheterization time, and incidence of complications were noted. Efficacy parameters included evaluation by the International Prostate Symptom Score and maximum flow rate. RESULTS: Patients of both groups were balanced for the different baseline variables. One hour after TURP, patients had significantly lower levels of hemoglobin, hematocrit, and sodium (P = 0.03, 0.03, and 0. 01, respectively). The prostate resection weight was similar in both groups; however, the difference in the mean operative time was significant (TUVRP group 42.4 minutes and TURP group 35.9 minutes, P = 0.02). The postoperative catheterization time was significantly shorter for the TUVRP group (23.1 +/- 10.3 versus 36 +/- 17.3 hours, P <0.0001). All patients were followed up for an average of 9 months. The International Prostate Symptom Score was 4 +/- 3.4 and 5.6 +/- 3.1 and the maximum flow rate was 19 +/- 6.5 and 15.2 +/- 10 mL/s for the TUVRP and TURP groups, respectively; these differences were statistically significant (P = 0.03 and 0.01, respectively). Complications included urethral strictures (6 patients) and delayed hemorrhage with clot retention (2 patients); no differences in the incidence of complications were noted between the two groups. CONCLUSIONS: The results of the present study have demonstrated that TUVRP is as safe and efficacious as TURP in the treatment of men with prostatic outflow obstruction. The shorter catheterization time observed after TUVRP may be clinically significant, considering the demand for lower morbidity profiles by patients. The longer operative time in TUVRP was related to the slower motion of the Wing electrode needed to add the advantages of electrovaporization.

Transurethral vaporization-resection of the prostate versus standard transurethral prostatectomy: comparative changes in histopathological features of the resected specimens.

OBJECTIVES: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral resection of the prostate (TURP). TUVRP uses a band electrode coupled to a high electrocuting energy to achieve simultaneous resection, vaporization and coagulation of the prostate. We evaluated the histopathological resection specimens of patients treated with TUVRP to see whether the higher energy used will result in thermal artifacts that will interfere with the pathological evaluation of the prostate, and compared the results to TURP specimens. MATERIAL AND METHODS: The histopathological specimens of 50 patients that underwent TUVRP or TURP were reviewed. Artifactual pathological patterns that were identified in the specimens included: abnormal cellular orientation and spindling, artifactual cellular detachment from the underlying basement membrane, atypical cytological changes or areas of stromal coagulative necrosis. Each identified pattern was awarded 1 point. The severity of cautery artifact was graded into mild, moderate or severe according to the sum of points in each specimen. RESULTS: Mild cautery artifact changes were noted in 1 patient who underwent TURP. Moderate changes were noted in 21 patients in each TURP and TUVRP groups while severe changes were noted in 4 and 3 patients undergoing TUVRP and TURP respectively. There were no statistically significant differences between the groups with regard to the severity of the cauterization- induced changes. CONCLUSIONS: The quality of histopathological specimens produced by TUVRP is similar to the standard TURP. It seems that the higher energy use in electrovaporization technique does not result in greater thermal injury to the tissues possibly because of the cooling effect of the irrigation fluids used intraoperatively.

Extracorporeal shockwave lithotripsy for ureterolithiasis in patients with urinary bilharziasis: efficacy and variables that influence treatment outcome.

OBJECTIVES: Schistosomiasis affecting the ureter is commonly accompanied by ureteric dilatation with or without ureteric stricture and altered ureteric wall motility that can influence extracorporeal shockwave lithotripsy (ESWL) results. This study attempts to identify variables that may influence the outcome of ESWL in the treatment of ureterolithiasis in patients with urinary bilharziasis. PATIENTS AND METHODS: Forty-three patients with urinary schistosomiasis and ureterolithiasis treated with ESWL were reviewed. The study data include characteristics of patients, stones, urinary tract treated and details of ESWL treatment. RESULTS: Thirty-five patients (81.3%) were stone-free at 3 months. Multivariate analysis with logistic regression identified two significant variables that influenced treatment outcome, namely the presence of ureteric stricture (p = 0.004) and the ESWL voltage (p = 0.003). Ten ureteric strictures were encountered in 9 patients (21%), the majority of these were diagnosed post-ESWL when patients failed to pass well-fragmented stones in spite of pre-ESWL evaluation. CONCLUSIONS: In situ ESWL is a safe and effective first line of treatment for urinary stones in bilharzial ureters. The presence of concomitant bilharzial stricture is a significant variable which affects the treatment outcome. Every effort should be made to rule out and deal with possible complicating factors such as ureteric strictures in the pretreatment period.

Changes of serum prostate-specific antigen following high energy thick loop prostatectomy.

We evaluated the effect of the high electrocuting energy used with the thick loop, in transurethral vaporization resection of the prostate (TUVRP), on serum prostate-specific antigen (PSA). Forty-eight patients with benign protatic hyperplasia (BPH) were included in this prospective single arm sequential study. All patients had TUVRP using the 'Wing' thick resection electrode (Richard Wolf, Germany). Serum PSA was measured before, 1 day and 6 weeks in the morning post TUVRP. PSA values were correlated to preoperative prostate size and to prostatic resection weight. Serum PSA values (mean +/- SD) were 6.29+/-4.4 ng/ml, 14.9+/-11.1 and 2.3+/-1.9 before, 1 day and 6 weeks post TUVRP respectively. The mean increase in the PSA at 1 day over baseline value was 2.72, this was statistically significant (p < or = 0.0001). The PSA level returned to less than pre TUVRP value in all but 3 patients by 6 weeks. The PSA value 1 day post TUVRP correlated well with the pre PSA level, prostate size and prostatic resection weight (r = 0.58, r = 0.38 and r = 0.44 respectively) however, the PSA level at 6 weeks correlated only to pre TUVRP values (r = 0.53). We conclude that that serum PSA is not reliable within 6 weeks of TUVRP. The reversible increase in serum PSA value is similar to other forms of prostatectomy which, suggests that the increased level of electrosurgical energy that is used in TUVRP does not have an added adverse effect on the PSA levels.

Post traumatic high-flow arterial priapism. The need for increased awareness among health care professionals.

High flow arterial priapism is a rare urological emergency. Presentation, diagnosis and institution of definitive management are often delayed. We describe our experience with this diagnostic entity and reviewed the literature to define possible reasons for the delayed diagnosis and management. We report two patients (10 years and 35 years old) that presented following blunt perineal trauma. The presentation and diagnosis of arterial priapism were delayed in both patients. Selective angiogram of the internal pudendal artery revealed arteriocavernous fistula in each patient. Embolization of the fistulae by gel foam was carried out at the same sitting. Penile detumescence was noted in both patients at the conclusion of the angiographic embolization. Both patients regained erectile function 3 and 6 weeks post treatment. Awareness of the various etiologic factors in priapism is of paramount importance to establish the correct diagnosis and institute the appropriate treatment modalities. Absence of pain and preservation of potency in patients with arterial priapism are among factors that contribute to the delayed presentation, diagnosis and treatment. We reiterate the valuable role for selective internal pudendal artery angiography as a single investigation that provides both diagnostic and therapeutic means of management.

Unilateral traumatic hematocele--an unusual presentation of bilateral testicular rupture.

The case of a young male patient with penile laceration and right hematocele following blunt trauma to the genitalia is presented. Both testes were found ruptured at exploration and were repaired. The value of early surgical intervention in scrotal trauma is reiterated and indications for bilateral testicular exploration in cases of unilateral traumatic hematocele are suggested.

Transurethral electrovaporization-resection of the prostate using the "wing" cutting electrode: preliminary results of safety and efficacy in the treatment of men with prostatic outflow obstruction.

OBJECTIVES: Transurethral vaporization-resection of the prostate (TUVRP) is a modification of the standard transurethral prostatectomy (TURP). The technique uses the "Wing" resection loop with electrovaporization current to achieve simultaneous resection, vaporization, and coagulation of prostatic tissue. We evaluate the early safety and efficacy results of TUVRP in the treatment of patients with prostatic outflow obstruction. METHODS: The first 31 patients treated with TUVRP since September 1997 are reported. The group included 19 patients with urinary retention and 12 patients with lower urinary tract symptoms (LUTS). Patients with symptoms were assessed at baseline with the International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax). The same parameters were evaluated at 3 months for the entire group. Safety parameters included changes in serum hematocrit and sodium concentration, incidence of side effects, and changes in sexual function. RESULTS: All patients with retention were voiding spontaneously with an IPSS of 3.9+/-3.1 and Qmax of 21.3+/-10.2 mL/s. In the patients who presented with LUTS, the IPSS decreased from 24.3+/-8.3 to 4.1+/-4.9 at 3 months and Qmax increased from 5.2+/-4.5 mL/s to 16+/-7.5 mL/s at 3 months (P <0.001). Mean resection weight was 27.9+/-18.4 g. Mean postoperative catheter time was 24.1 hours. Mean change in hematocrit concentration was 2.5 mL/dL and the change in sodium concentration was 0.8 mEq/L. Complications included 1 patient with a bladder neck contracture, 1 with a urethral stricture, and 1 with clot retention; 1 patient developed transurethral syndrome. No change in sexual function was noted in this group. CONCLUSIONS: TUVRP is a promising new modification of TURP. This procedure combines the excellent debulking capabilities of TURP (with preservation of the entire specimen for histopathologic examination) and adds the benefits of electrovaporization, resulting in minimal blood loss and electrolyte disturbance.

Augmentation ureterocystoplasty with ipsilateral renal preservation in the management of patients with compromised renal function secondary to dysfunctional voiding.

We evaluated the role of ureterocystoplasty with ipsilateral renal preservation in the management of patients with neurovesical dysfunction and impaired renal function. The procedure was carried out on 6 patients with a mean age of 8.5 years. All patients had vesicoureteric reflux (VUR) secondary to neuropathic bladders, recurrent urinary tract infections, day time incontinence, impaired and deteriorating renal function. All patients were followed up with a mean of 22.5 months (range 6-30). Renal function stabilized in 4 patients and improved in 2 patients. Adequate urinary bladder capacity was achieved in all patients. Bladder volume increased from a mean of 210+/-71 to 382+/-66, this increase was statistically significant (p<0.001). All patients were dry by day including the children who at presentation were in diapers. We conclude that the results of this operative intervention are satisfactory and promising in the management of this difficult group of patients while avoiding the side effects of enterocystoplasty procedures.

Prevalence of intratubular germ cell neoplasia of the testis.

Full text is available as a scanned copy of the original print version.

Extracorporeal shock wave lithotripsy for lower pole nephrolithiasis: efficacy and variables that influence treatment outcome.

OBJECTIVES: Extracorporeal shock wave lithotripsy (ESWL) for the treatment of lower caliceal stones (LCS) tends to have a poor success rate, prompting many urologists to advocate alternative treatment modalities. This study attempts to identify variables that may influence the outcome of ESWL treatment for LCS to help in selecting patients that are likely to benefit from the treatment. METHODS: One hundred forty-two patients with isolated LCS treated with the Dornier HM3 lithotriptor were reviewed. The study data include characteristics of patients, stones, urinary tract treated, previous treatment of stones in the same kidney, and details of the ESWL treatment. RESULTS: Eighty patients (56%) were stone free 3 months after ESWL. Multivariate analysis with logistic regression identified six independent and significant variables that influenced treatment outcome: these included number of stones (P = 0.001), previous percutaneous nephrostolithotomy (PNL) treatment (P = 0.001), side of the stone (P = 0.002), presenting stone type (P = 0.004), number of ESWL sessions (P = 0.01), and maximum kilovoltage setting of ESWL at treatment (P = 0.02). Stone size did not influence the treatment outcome in this study. CONCLUSIONS: ESWL provides an acceptable first line treatment for patients with LCS. Patients who fail ESWL and have poor prognostic features (ie, multiple LCS, hard stones requiring high voltage and multiple ESWL sessions, lower caliceal stone formation secondary to ESWL treatment of stones in other locations of the renal unit, or previous treatment with PNL) should be counseled for alternative treatment modalities.

Extracorporeal shock wave lithotripsy for the rescue of post-endoscopic or surgically retained biliary duct stones: does saline irrigation affect the outcome?

Extracorporeal shock wave lithotripsy (ESWL) has been found valuable in situations where obstructing stones in the common bile or intrahepatic ducts are retained following surgery or attempted endoscopic removal. However, success rates are dependent on the type of ESWL system employed and upon a high frequency rate of repeated treatment sessions. We outline our experience with 23 cases of retained, obstructing bile duct stones, ranging in size from 10 to 40 mm diameter, treated with Dornier HM3 ESWL. In the initial 12 patients in the series, successful stone fragmentation occurred in 83% of cases with a median 1.6 treatment sessions. In the latter 11 cases in the series, patients were treated prone and the stone-bearing biliary duct was irrigated with saline solution during ESWL delivery. With this technique, successful stone break up was achieved in all patients (100%) with a single treatment session. Endoscopic sphincterotomy is, however, a prerequisite for extracorporeal lithotripsy and, despite the high success rates now available with new techniques, we believe the ESWL should continue to be employed in support of primary endoscopic methods of management for obstructing bile duct stones.

Rare association of unilateral renal oncocytoma and angiomyolipoma.

A 65-year-old woman presented to the hospital with left loin pain and haematuria, radiological diagnostic studies demonstrated left renal mass suggestive of renal cell carcinoma and radical nephrectomy was performed. Pathological examination demonstrated the very rare association of renal angiomyolipoma and oncocytoma.

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia.

OBJECTIVES: To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys. METHODS: Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented. RESULTS: All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 +/- 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients: in 1 of them, ureteroscopy was needed. CONCLUSIONS: ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.

Renal tumors in adult Saudi patients: A review of 43 cases.

Seventy-nine patients with renal tumors were seen at King Khalid University Hospital (KKUH) over a 10-year period from 1985 through November 1995. In a retrospective study, we analyzed the records of 43 Saudi patients from all over the Kingdom; they represented 54% of all patients encountered. Fourteen percent of the patients had benign renal tumors in the form of angiomyolipoma and oncocytoma. Eighty-six percent of the patients had malignant renal tumors.

Anephric state after graft nephrectomy in a patient treated with renal autotransplantation for bilateral metachronous loin pain/hematuria syndrome.

We report a case of bilateral consecutive renal autotransplantation for the loin pain/hematuria syndrome. Initial good response was followed by recurrent consecutive pain in the transplanted kidneys, necessitating bilateral graft nephrectomy and renal hemodialysis.