Differential therapies in various stages of penile induration.

OBJECTIVES: To evaluate the different therapies for penile induration. The results achieved in our series of 280 patients are described and the literature reviewed. METHODS: The study analyzed 2,752 cases of the literature that had been treated with Potaba, 1420 treated with radiotherapy, 117 cases treated with Orgotein injection and 93 cases that had been treated by surgery (a malleable prosthesis had been implanted 53 patients). RESULTS: In 2,752 cases of the literature that had been treated with Potaba, an improvement was seen in 60% (range 10%-82%) and the median failure rate was 40%. The overall success rate in 117 cases treated with Orgotein was 63%, with a median failure rate of 37%. In 1420 cases that had been treated with radiotherapy, the improvement and failure rates were 60% and 40%, respectively. In 93 patients that had undergone surgery, the improvement rate was 80%. Excellent results were achieved in all but 2 of the 53 patients in whom a malleable prosthesis had been implanted (infection required explantation of the prosthesis in these 2 patients). CONCLUSIONS: The importance of performing a detailed study of the plaque is underscored. A predisposition for abnormal scar tissue formation has to be considered. If surgery is indicated, the correct choice of surgical technique can achieve excellent results.

[Seminal tract reconstruction: 15 years experience]. / Reconstruction des voies séminales: 15 ans d'expérience.

Azoospermia in two spermiograms, normal FSH and normal testicle size are sufficient for the diagnosis of excretory azoospermia and constitute an indication for surgery. Over the last 15 years, in 642 men an epididymo-vasostomy was performed for inflammatory (51%), inborn (44%) or acquired (5%) epididymal obstruction. In 327 selected cases permeability ranged between 11 to 76% according to the location of the anastomosis and fertility followed in 0-52%. Vaso-vasostomy was done in 724 men. Depending on the time after sterilisation or herniotomy obstruction, permeability ranged between 52% and 92%, fertility between 38% and 74%. Double-layered anastomosis with sealing of the anastomoses by fibrin glue improved the results. Special operations for vas mobilisation and testicle elevation which avoid tension upon the anastomosis are outlined. In four men with long obstructions of the vas, testicle transposition into the inguinal area was performed; three of them had a positive postoperative spermiogram and two of them fathered a child. With increasing duration of obstruction the quality of postoperative spermiograms decreases. Sperm autoantibodies were significantly elevated in only 3% of 531 men, and in most cases normal values were seen after relief of obstruction. Reasons of seminal anastomoses are: defective technique, sperm leak, traction upon the anastomosis, infection and epididymal damage. The frequency with which the operation is performed is the main determinant of the competence of the surgeon and the chances of success.

Alloplastic spermatocele: 20 years experience and perspectives.

Reconstructive interventions on the seminal pathways are impossible in cases of vas aplasia, longer vas obstructions and ejaculatory disorders as paraplegia or diabetes mellitus. For these groups of patients there has been no further therapy until recently to fulfil their desire to father a child.

Microsurgical arterialization for vascular impotence.

Of 400 patients with erectile lesions Doppler flowmetry in combination with nitroglycerin stimulation showed a decreased penile arterial blood flow in 42 males. Dynamic cavernosography and cavernosometry showed a concomitant increase of venous drainage in 38 of them. Phallo-arteriography in 22 males demonstrated occlusion of the internal pudendal artery in 21 of them. In 15 patients penile arterialization was done by interposition of a saphenous vein graft between the iliac artery and deep dorsal penile vein. In 4 of these patients an additional venous leak was treated during the same operation by ligation of the internal iliac veins. Two years postoperatively two thirds of the patients are doing well. Failures in 5 of them included 4 diabetic neurovascular lesions and 1 postoperative priapism.

New treatment of increased venous drainage in organic impotence: ligation of internal iliac veins.

The internal iliac vein is the main confluent of the periprostatic and pudendal plexus. Therefore, it seems logical to ligate both internal iliac veins in impotent patients with increased venous drainage. The procedure was performed on 52 men and combined with ligation of collaterals to the saphenous and femoral veins in 32 of them. Erectile capacity improved in 36 patients (70%). Occasional papaverin injections and local nitroglycerin application were of help in 10 patients. Failures in 16 of 52 cases were mainly due to neurovascular lesions in diabetics.

Microsurgical arterialization for vascular impotence.

Out of 400 patients with erectile lesions, Doppler flowmetry in combination with nitroglycerin stimulation showed a decreased penile arterial blood flow in 42 males. Dynamic cavernosography and cavernosometry showed a concomitant increase of venous drainage in 38 of them. Phalloarteriography in 22 males demonstrated an occlusion of the interna pudendal artery in 21. In 15 patients penile arterialization was done by interposition of a saphenous vein-graft between the iliac artery and the deep dorsal penile vein. In four of these patients an additional venous leak was treated during the same operation by ligation of the internal iliac veins. Two years postoperatively, two of three of the patients are doing well. Failures in five included four diabetic neurovascular lesions and one postoperative priapism.

[Impotence in diabetes mellitus. Etiological factors and therapeutic possibilities]. / Impotenz bei Diabetes mellitus. Atiologische Faktoren und Behandlungsmöglichkeiten.

The neurovascular causes of diabetic impotence are presented. 55 men presenting impotence and diabetes mellitus were examined in an extended diagnostic program. Nocturnal penile tumescence and Papaverin-test showed psychogenic impotence in 10 of these men, which lead to psychosexual therapy of the couple. Because of regional erectile lesions (Mb. Peyronie, penile trauma, inborn penile deviation, Priapism) 8 further diabetics were successfully operated. The remaining 37 patients with diabetes mellitus showed vascular erectile lesions (increased venous drainage in 7 and decreased arterial inflow in 30 men) and were operated upon with the following methods: Microsurgical arterialisation of the penile vein via a V. saphena-graft to the iliaque artery was done in 4 patients. There was an amelioration in 2 and a longterm failure in the remaining 2 men. Vein ligation of both internal iliaque veins and lateral penile veins in 7 patients resulted in 2 short term improvements and 5 failures. Flexible penile prostheses (AMS- and Jonas-prostheses) in 26 patients showed good results in 24 and infectious complications in 2 of them (Explanation of both prostheses, ones partial penile amputation). Vascular interventions for diabetic impotence seem to be of questionable value and therefore the implantation of penile prostheses should be preferred. In diabetics, infection of the alloplastic implants is particularly dangerous and may lead to septicemia and penile amputation.

Ureteral endosplints: a quiet revolution of urological treatment.

During the last decade ureteral endosplints have dramatically changed the management, urgency and risks of urinary drainage for benign and malignant hydronephrosis. In 38 cases with retroperitoneal fibrosis effective urinary drainage with endosplints was combined with cortisone/azathioprin-therapy and practically excluded the need for surgery. In 30 pregnant women with hydronephrosis, splints prevented surgery and abortion. During surgery, postoperatively and before ESWL splints solved various drainage problems. In 25 patients with tumour-induced hydronephrosis splints generally allowed for a comfortable survival time. The prerequisits and limits of medical decisions in respect to urinary drainage of malignant hydronephrosis are outlined.

[Diagnosis and therapy of organic impotence]. / Diagnostik und Therapie bei organischer Impotenz.

A stepwise diagnosis using objective and reproducible methods of examination makes it possible to distinguish between psychogenic and organic causes of impotence. Among 104 men who had organic disorders of erection half were due to local penile disease, the remainder to vascular disease (diabetic angiopathy, arteriosclerosis, abnormal venous drainage). Cavernosal through-flow measurements revealed differences among the various groups of disorders with regard to the flow rates required for achieving and maintaining an artificial erection and made it possible, in conjunction with other tests (Doppler perfusion measurements and papaverine response), to arrive at a precise diagnosis and plan for surgical intervention. Of 91 men who had been operated upon 79 had good results (87%). Largely noninvasive diagnostic measures thus achieved effective treatment and thus contributed to an improved feeling of self-esteem.

Alloplastic spermatocele: poor sperm motility in intraoperative epididymal fluid contraindicates prosthesis implantation.

After vasectomy reversal by vasovasostomy or vasoepididymostomy motile sperm appear commonly in the semen even when only nonmotile sperm are present in the intraoperative vasal or epididymal fluid. We studied patients with bilateral congenitally absent vasa deferentia to see if relief of obstruction by implantation of an alloplastic spermatocele also benefits sperm motility in such patients. A total of 130 alloplastic spermatoceles was implanted in 91 patients. Of 21 patients with only nonmotile sperm in the epididymal fluid intraoperatively only 1 had motile sperm in the postoperative aspirates from the alloplastic spermatocele. The quality of sperm motility in the intraoperative epididymal fluid was predictive of the quality of sperm motility in the postoperative aspirates. Conception postoperatively did not occur whenever less than 20 per cent of the intraoperative epididymal sperm was motile. Thus, poor or absent sperm motility in the epididymal fluid during planned alloplastic spermatocele implantation predicts a poor postoperative result and, therefore, contraindicates implantation of the prosthesis. Pregnancy, which occurred postoperatively in 7 of 91 wives, ended in spontaneous abortion in 3 and progressed to full-term delivery in 4.

Relationship of costs and real advantages of microsurgery in urology.

The cost-advantage relationships in the use of microsurgical equipment and techniques in various medical fields are examined. Cost-effectiveness in clinical urology appears to support the use of microsurgery. Specific applications to urethroplasty, pyeloplasty, renal stone surgery, and renal trauma, are discussed.

[Cavernosography]. / Kavernosographie.

Cavernosography can be useful in the investigation and follow-up of induratio penis plastica, tumours, trauma, priapism, impotence and in planning surgery. The examination is easily carried out. In the small series so far undertaken, no complications have been reported.

[Surgical results of epididymovasostomy and vaso-vasostomy]. / Operationsresultate der Epididymo-Vasostomie und der Vaso-Vasostomie.

In the Urology Clinic of the University of Hamburg 326 epididymo-vasostomies have been done. A follow-up of 241 men was possible. Bilateral anastomosis resulted in a 47% permeability; after unilateral recanalisation a patency-rate of 32% was obtained. Vaso-vasotomy after vasoresection was performed in 56 men. Following a splinted one-layer anastomosis, which we abandoned in the meantime, patency was obtained in 64% of patients. Current techniques in one or two-layers without a splint resulted in a 88% permeability. The double layer anastomosis does not offer an advantage over the one-layer method.

Vas deferens aplasia: clinical and anatomical features of 90 cases.

Out of 531 patients with excretory azoospermia, scrotal exploration for attempted epididymo-vasostomy showed vas aplasia in 90 of them (= 17%). In the latter group complete bilateral agenesis of the vas was seen in 64 cases while the remaining showed partial vas aplasia or different findings on both sides. The anatomical findings were classified into various groups of frequency. The typical peroperative picture included extensive paraepididymal bodies of fat, venous conglomerations at the place of missing epididymal structures and frequent Morgagni's hydatides and spermatoceles. Preoperative palpation and surgical findings did not correlate. Laboratory examination of the ejaculate showed volume and fructose values below the norm in the majority of cases. Electron- and light-microscopy showed dissolution of spermatozoa and sperm-phagocytosis within the dilated epididymal canal as well as within the bordering tissue. Since laboratory- and physical examinations are misleading in some cases with vas aplasia surgical exploration is necessary. A cup-shaped Silicone-Dacron reservoir was implanted upon the remaining epididymal structures in 16 men with vas aplasia, but insemination of the aspirated material in their wives did not lead to any lasting pregnancy. In other centers 3 conceptions and normal births were obtained by this method.

Vasography - Clinical and experimental investigations.

In order to examine the effect of contrast mediums of different concentration and composition upon the vas, experiments in 90 rats were done. In comparison to three control groups of 10 animals each (surgery only, vas ligation only, saline injection) six contrast mediums caused a varying degree of damage to the vas deferens. The latter included irritation of the epithelium, inflammation, cellular infiltration, fibrosis of the wall, septum-formation and fenestration within the vas and actual obliteration. According to these experiments only hydrophilic contrast mediums of low concentration should be used in humans for vasography.

[Inspection of the urinary tract by flexible instruments (author's transl)]. / Inspektion der Harnwege mit flexiblen Instrumenten.

A flexible choledochoscope of 5.7 mm diameter and a bronchoscope of 4.8 mm diameter were used in 60 patients for intraoperative pyeloscopy and stone removal. Intrarenal inspection ensures that a kidney is free of stones. In a further six patients small calculi were removed via a nephrostoma or ureterostoma. Flexible urethro-cystoscopy may be indicated particularly in the intensive care patient, following trauma or surgery upon the pelvis or the hips, and in cases with coxarthrosis, following implantation of semirigid penile prostheses and for urethral stricture. A flexible endoscope of 2.3 mm may be used via a 24 Fr. cystoscope for inspection of the ureter and the upper renal calix. This procedure allowed for preoperative differential diagnosis between tumor, stone, papilla or vascular compression within the ureter or upper calix in seven patients.