Live surgery: highly educational or harmful?

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Evaluation of laparoscopic transperitoneal adrenalectomy: is it feasible for large masses?

AIM: The aim of this paper was to determine whether laparoscopic adrenalectomy (LA) is a safe and effective treatment for the management of large adrenal tumors. METHODS: We retrospectively evaluated the data of patients who underwent LA at our institution between September 2002 and September 2012. Seventy-six transperitoneal LA were performed by the same surgical team. Patients with invasive tumors to adjacent organs or distant metastasis were excluded from the study. All patients were operated using the 450 oblique position as transperitoneal approach. RESULTS: The mean age of the patients was 48.3 years (range 20-68 years). The mean tumor size was 5.37 cm (range 2-15 cm). Sixteen patients had tumor size over 8 cm. The mean tumor weight was 31.2 gr (range 2-156 g). The lesions were localized on the right side in 42 (55%) patients and on the left side in 34 (45%) patients. The mean intraoperative blood loss was 114 mL (range 20-400 mL) and the mean operative time was 112 min (range 55-300 min). Six patients (7%) required conversion to open procedure. The mean hospitalization time was 2.5 days (range 1-4 days). Five patients (6%) had post-operative minor complications. There were no incidents of capsular invasion or adverse cardiovascular events. CONCLUSION: LA is safe and feasible for both malign and benign adrenal lesions. Good preoperative assessment, surgical skills, team work and adherence to anatomical and surgical principles are the key to success for large adrenal masses.

Open, laparoscopic and robot-assisted laparoscopic radical prostatectomy: comparative analysis of operative and pathologic outcomes for three techniques with a single surgeon's experience.

OBJECTIVE: To compare outcomes of open (O-), laparoscopic (L-) and robot-assisted laparoscopic (RAL-) radical prostatectomy (RP) performed by the same surgeon. PATIENTS AND METHODS: From May 1999 to April 2012, 484 RPs were performed by a single surgeon. Patients' data including age, body-mass index, serum prostate specific antigen (PSA) level, Gleason score of prostate biopsy and prostatectomy specimen, preoperative prostate and specimen volumes, clinical and pathologic stages, operation time, estimated blood loss (EBL), catheterization time, blood transfusion rate were recorded. Prospectively collected data was evaluated retrospectively by statistical analyses. RESULTS: Of 484 radical prostatectomies, ORP (50), LRP (308) and RALRP (79) done by the same surgeon were included into study. Mean ages were 63.8, 62.7 and 60.3 years for ORP, LRP and RALRP respectively. Operation times for ORP, LRP and RALRP were 255, 208 and 242 minutes. EBL and hospitalization time were 602, 526, 234 mL, and 9.1, 3.2, 3.2 days for ORP, LRP and RALRP, respectively. While a significant advantage was found for EBL and complication rates in RALRP and for operation time in LRP, significant disadvantages were found in terms of catheterization time, hospitalization time, decrease in hemoglobin and blood transfusion in ORP. However, preoperative prostate volume and serum PSA level, oncologic outcomes and positive surgical margins were nearly similar in all operative techniques. CONCLUSIONS: Minimally invasive techniques such as LRP and RALRP are promising techniques with comparable outcomes with ORP. Shorter catheterization time, less blood loss and fewer complication rates can be provided by RALRP.

Indications for intraoperative frozen section in robot assisted radical prostatectomy: a pilot study.

INTRODUCTION: To evaluate indications for intraoperative frozen section (IFS) during robot assisted laparoscopic radical prostatectomy (RALRP) in our series. PATIENTS AND METHODS: Prospectively documented 80 patients with prostate cancer (PCa) who underwent RALRP were evaluated between June 2010 and July 2012. Patients were divided into 2 groups according to whether systematically IFS was performed or not. Group 1 (n=66) consisted of patients on whom systematic IFS was performed, Group 2 (n=14) consisted of patients on whom IFS was not performed. All recorded data evaluated and statistical analyses were performed for determining indications and predictive factors for IFS during RALRP. All patients were operated by single surgeon and IFS, pathological assessments were performed by experienced uro-pathologist. Statistical significant p value was p < 0.05. RESULTS: Mean follow-up was 15±6 (25-4) months. Pre-operative prostate volume in trans- rectal ultrasonography (TRUS) was statistically higher in Group 1 than Group 2 (p = 0.037). The other parameters were statistically similar in both groups. According to outcomes of our study IFS was a dependent factor for positive surgical margin. Additionally, the cut off value of prostate volume in TRUS for IFS was 55.5 cc for IFS. CONCLUSIONS: Preoperative measured prostate volume in TRUS may be an indicator of IFS. Therefore, more accurate information may be given to patients with prostate cancer (Pca) before RALRP by using preoperative prostate volume in TRUS.

The consistency of Gleason scores may effect the operation outcomes for laparoscopic radical prostatectomy: a single surgeon and a single pathologist data.

INTRODUCTION: To evaluate the effects of consistency in preoperative and postoperative Gleason scores to the operation outcomes in patients who underwent laparoscopic radical prostatectomy. MATERIALS AND METHODS: 204 of 347 patients were included the study. 143 patients whose preoperative prostate biopsies were evaluated in the other Institute were not included into the study. The preoperative data of patients and operation outcomes were investigated from institute's files of patients. Patients were divided to three groups by using consistence of pre and postoperative Gleason scores. The tumor, node and metastasis classification were used for staging prostate cancer. RESULTS: Mean age was 63 and the mean PSA level was 11 ng/dl overall. In statistical analysis PSA levels, Gleason score and rate of positive score were significantly low in Group I (p < 0.05). As in operative data, nerve sparing surgical technique was performed statistical significance higher in Group 1 than other Groups. External bleeding rate of Group II was significantly lower than the other Groups. In univariate and multivariate analysis, postoperative pathologic stage was statistical significant for consistency of pre and postoperative Gleason scores. CONCLUSIONS: The modified Gleason scoring system is safe and usable for evaluating prostate biopsies and operative specimens. The consistency in pre and postoperative Gleason score effect the operation technique and also operation outcomes. Working with an experienced uro-pathologist provides to inform patients more accurate and better.

Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic.

OBJECTIVE: The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) performed by emergency physicians (EP) as a part of this algorithm. MATERIALS AND METHODS: This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55,000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The chi2 test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression. RESULTS: Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%. CONCLUSION: Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.

Relationship between mast cell and iNOS expression in testicular tissue associated with infertility.

The objective of this study was to investigate mast cells and iNOS expression in testis tissue, and to correlate these results with spermatogenic disorders. A total of 136 testicular biopsies were obtained from the testes of 80 patients with infertility. Their age ranged from 21 to 45 years. The biopsy specimens were immunohistochemically stained with antihuman tryptase for mast cells. In each section, all interstitial fields were evaluated for the total number of mast cells as well as the total number of Leydig cells. The number of mast cells per Leydig cell was calculated and recorded as mast cell index. Immunohistochemical iNOS staining was evaluated semiquantitatively according to intensity and the proportion of the stained cells. There was a significant increase of the mast cell index in all groups with testicular disorder compared with normal spermatogenesis group (p < 0.05). Increase of the index was in the order of hypospermatogenesis, maturation arrest and SCO, and index of SCO group was especially higher, i.e, more than twice than other groups. iNOS score was significantly higher in the SCO group than in the men with normal spermatogenesis, hypospermatogenesis, and maturation arrest (p < 0.05). Finally, a significantly statistical correlation was found between the iNOS score and mast cells index (r = 0.758, p = 0.001). Increase of mast cell index was observed in the groups of infertile testis, and high expression of iNOS in Leydig cells was associated with the highest mast cell index in SCO, the lesion with the most severe damage of the germ cell.

Transperitoneal laparoscopic radical prostatectomy: ascending technique.

BACKGROUND AND PURPOSE: To demonstrate the operative steps of transperitoneal laparoscopic radical prostatectomy with the ascending approach (Heilbronn technique). PATIENTS AND METHODS: The technique is based on our experience with more than 1000 cases of clinically localized prostate cancer from March 1999 to April 2004. The technical steps, instrumental requirements, patient data, complications, and reintervention rate were reviewed. RESULTS: The principles of the technique include the routine use of a voice-controlled robot (AESOP) for the camera, exposure of the prostatic apex with 120 degree retracting forceps, free-hand suturing for Santorini plexus control, application of 5-mm clips during the nerve-sparing technique, control of the prostatic pedicles by 12-mm Hem-o-Lock clips, the bladder neck-sparing technique in patients with stage T1c and T2a tumors, and use of interrupted sutures for the urethrovesical anastomosis. A considerable improvement was observed when comparing the first 300 with the most recent 300 cases (mean operating time 280 v 208 minutes; conversion rate 2.7% v 0.3%; reintervention rate 3.7% v 1.0%). CONCLUSIONS: Through our experience with more than 1000 cases, transperitoneal access for laparoscopic radical prostatectomy has proven to be feasible and transferable with results comparable to those of the original open approach. Besides the well-known advantages of minimally invasive surgery, the video endoscopic approach may offer further benefits in permitting optimization of the technique by video assessment.

Penile scintigraphy with 99mTc-human immunoglobulin G: a novel method for distinguishing the unstable and stable phases of Peyronie's disease.

OBJECTIVE: To investigate the value of penile scintigraphy using 99mTc-human immunoglobulin G (IgG) to differentiate the unstable (acute) and stable (chronic) phases of Peyronie's disease (PD). PATIENTS AND METHODS: Thirty-two consecutive patients (25 with PD and seven without) were evaluated using a detailed sexual history, serum chemistry panel, colour Doppler ultrasonography during simultaneous intracavernosal injection of 50 mg papaverine and stimulation, and 99mTc-IgG scanning. When indicated, nocturnal penile tumescence monitoring, dynamic infusion cavernosometry, cavernosonography and cavernosal artery systolic occlusion pressure were measured. After administering 370 MBq of 99mTc-IgG, images were taken at 30 min, 1, 2, 3 and 4 h. The scans were considered positive if there was any focal accumulation of radiopharmaceutical consistent with PD plaque formation. RESULTS: Eleven of the 25 patients with PD (mean age 56 years, sd 8) were in the unstable phase, the remaining 14 being in the stable phase. There was a localized increase in 99mTc-IgG activity in 10 patients who had unstable PD. There was complete resolution of increased activity in two patients at 12 and 13 months of follow-up. Of the 14 patients in the stable phase, 12 (at > 1 year) showed neither increased nor decreased 99mTc-IgG activity. In the remaining two patients there was increased activity on the plaque side. There was no local increase in activity in the control group. CONCLUSION: Inflammatory reactions can develop at various intervals during the unstable phase of PD. Medical methods should be used during the unstable phase and surgery delayed until the stable phase of the disease begins. An objective method of differentiating between the phases is therefore important. Penile 99mTc-IgG imaging is a new diagnostic approach for confirming the unstable phase of PD.

Effect of experimental varicocele in rats on testicular oxidative stress status.

The present experiments were undertaken to determine the levels of MDA, SOD and catalase in the testis of adolescent rats with experimental left varicoceles. Male Wistar rats, 7 weeks old and weighing 160-170 g, were randomly allocated into three groups. The first group of rats underwent partial ligation of the left renal vein (n = 15). The second group of rats underwent a sham operation (n = 7) and the third group acted as controls (n = 7). Animals were sacrificed 6 weeks after surgery and dilatation of the internal spermatic veins was observed. Levels of MDA, SOD and catalase activity were measured in testis. The experimental left varicocele group showed severe testicular changes compared to other groups. The mean MDA (SEM) levels in right and left testicular tissues of varicocele bearing rats, sham-operated rats, and control rats were 0.48 +/- 0.24 and 0.31 +/- 0.11, 0.22 +/- 0.02 and 0.35 +/- 0.12, 0.62 +/- 0.29 and 0.13 +/- 0.05, respectively (P > 0.05). The mean SOD (SEM) levels in right and left testicular tissues of varicocele bearing rats, sham-operated rats, and control rats were 7,790 +/- 606 and 6,974 +/- 574, 7,475 +/- 1,517 and 7020 +/- 1,106, 8,727 +/- 1,188 and 9,019 +/- 1,129, respectively (P > 0.05). The mean catalase (SEM) levels in right and left testicular tissues of varicocele bearing rats,sham-operated rats, and control rats were 75.77 +/- 11.5 and 53.82 +/- 10.1, 91.94 +/- 14 and 94.90 +/- 32, 65.40 +/- 5.7 and 90.93 +/- 16.4, respectively (P > 0.05). Our results suggest that oxidative status, which reflects a relative balance between reactive oxygen species (ROS) generated and ROS scavenged, may not be responsible for the testicular dysfunction associated with experimentally induced varicocele during adolescence in rats.

Increased bladder apoptosis with alpha-1 adrenoceptor antagonists in benign prostatic hyperplasia.

OBJECTIVE: To determine whether preoperative usage of alpha-1 adrenoceptor antagonists (alpha-1ARA) prevents the alterations in bladder wall components due to obstruction via changing apoptotic and/or proliferative activity and provides an advantage for improvement of irritative symptoms following removal of bladder outlet obstruction. MATERIAL AND METHODS: A total of 39 patients were enrolled to the present study. According to preoperative medical treatment, patients were divided into 2 groups as preoperative untreated (n = 15) and medically treated patients with alpha-1ARA (n = 24). Apoptotic and proliferative indices of bladder wall were determined with TUNEL assay and proliferating cell nuclear antigen immunoreactivity, respectively. RESULTS: While the mean apoptotic indexes (AI) of lamina propria were 0.293 +/- 0.163 vs 0.978 +/- 0.194 in untreated and treated patients, the mean AI of myofibroblast cells were 0.10 +/- 0.06 and 0.90 +/- 0.23 in untreated and treated patients, respectively. There were statistically significant differences between lamina propria (p = 0.0067) and myofibroblast cells (p = 0.0280) AI in the two groups. However, there were no significant differences between postoperative symptom indices in preoperatively treated and untreated groups. CONCLUSIONS: alpha 1-ARA treatment might have an effect on hypertrophy and supersensitivity of bladder wall due to increased outlet obstruction via prevention of the imbalance between cell proliferation and apoptosis, providing normal homeostatic control mechanisms, through the interval between the onset of the lower urinary tract symptoms and time surgical intervention. However, further studies should be organized to demonstrate the impact of long-term alpha 1-ARA medication for post-operative significant improvement on irritative symptom index.

Impact of chronic renal failure and peritoneal dialysis fluids on advanced glycation end product and iNOS levels in penile tissue: an experimental study.

OBJECTIVES: To investigate the impact of chronic renal failure (CRF) on advanced glycation end product and inducible nitric oxide synthase (iNOS) in penile tissue, we examined the advanced glycation end product 5-hydroxy methyl furfural (5-HMF) content and iNOS expression in rats in which uremia had been produced by greater than 85% nephrectomy. In addition, the contribution of peritoneal dialysis (PD) fluids to the elevation of penile tissue 5-HMF levels and iNOS staining scores has been investigated. METHODS: Adult male Wistar rats, aged between 10 and 12 weeks and weighing 200 to 330 g, were divided into five groups that each included 6 animals. The first group served as a control group. In the second group, CRF was induced and a peritoneal catheter was implanted, but PD was not performed. In group 3, CRF was induced and PD was performed using dialysis fluids containing 1.36% glucose and icodextrin. In group 4, CRF was also induced and PD was performed using 3.86% glucose and icodextrin. Finally, in group 5, without CRF, an indwelling catheter was implanted, and the PD procedure was performed using dialysis fluids containing 3.86% glucose and icodextrin. RESULTS: The elevation in 5-HMF levels and iNOS staining scores in penile tissue from groups 2, 3, 4, and 5 was significant compared with group 1 (P <0.05). The elevation in 5-HMF levels and iNOS staining scores was also significant between groups 2 and 3, 2 and 4, 3 and 4, 3 and 5, and 4 and 5 (P <0.05). Moreover, the correlation between the 5-HMF levels and iNOS staining scores was statistically significant (r = 0.525, P = 0.003). CONCLUSIONS: In the present experimental study, we found that 5-HMF levels and iNOS staining scores were significantly elevated in rat penile tissue in which uremia had been produced compared with the groups without CRF. Additionally, PD fluids containing glucose had an effect on the elevation of penile tissue 5-HMF levels and iNOS staining scores.

The role of expression of extracellular matrix proteins and epidermal growth factor receptor activity on fertilization capacity of testicular harvested spermatozoa.

It has been suggested that multiple growth factors are crucial for spermatogenesis. We analyzed whether alterations on epidermal growth factor receptor activity and different expression pattern of extracellular matrix proteins had an impact on the fertilization capacity of spermatozoa and pregnancy rate after testicular sperm extraction and intracytoplasmic injection. Extracellular matrix proteins and epidermal growth factor receptor were immunohistochemically evaluated in testis of 88 patients with nonobstructive azoospermia. Testicular sperm extraction and intracytoplasmic injection procedure was also performed in 32 of the patients for whom mature sperm could be harvested from the testicular tissue. While collagen Type-IV and laminin activity percentages were 33.1% and 86.4% in motile sperm harvested testicular tissue, these activities were 23.3% and 89.3% in immotile sperm harvested testicular tissue, respectively. In addition, the mean epidermal growth factor receptor expression was higher in immotile than motile sperm obtained tissue (56.4% vs. 51.1%, P=0.4928). There was no statistically significant relationship between the extracellular matrix protein and epidermal growth factor receptor expression patterns and sperm motility, fertilization and pregnancy rates in testicular sperm extraction and intracytoplasmic injection. However, further studies are required to investigate the relationship between other growth factors and sperm fertilization capacity.

Cavernosal arterial anatomic variations and its effect on penile hemodynamic status.

OBJECTIVE: With continuous improvements in ultrasound technology, small vessels with remarkably slow blood flow that may not be assessed by color Doppler ultrasonography, can be evaluated using power Doppler ultrasonography. In the present study, penile arterial anatomic variations were determined with power Doppler ultrasonography and its impact on penile hemodynamic status. METHODS: A total of 54 patients with erectile dysfunction were evaluated with power Doppler ultrasonography. The effects of vascular anatomic variations and the structure of the corpora cavernosa and tunica albuginea on vascular status were assessed on both sides. RESULTS: A normal penile vascular system was observed in 35.2% and 25% of 54 patients (mean age: 46.6+/-11.5 years) at the radix and mid-shaft of the penis, respectively. Pure arterial component was observed in 40.7% (22/54) and 47.2% (17/36) of the patients at the base and mid-shaft of the penis, respectively. Penile arterial insufficiency was severe in 9.2 and 5.5% of the patients at the base and mid-shaft of the penis, respectively, whereas intrapenile truncus was found in six patients (5.5%), the ratio of single cavernosal artery, intrapenile and extrapenile bifurcations were 69.4, 7.4 and 12.0%, respectively. Twenty (18.5%) dorso-cavernosal perforators, 15 (13.9%) cavernoso-dorsal and 30 (27.8%) intercavernosal branches were found. Peak systolic blood flow velocity values were decreased in 12 of 36 patients (33.3%) distally, while increased blood flow was observed in 11 (30.5%). CONCLUSIONS: Hemodynamic parameters might be variable at either side of the penis and depend on intrapenile arterial anatomic variations. Parameters determined using power Doppler ultrasonography should be evaluated from the proximal to distal side of the penis to obtain reliable and standard results. However, variations of penile arterial anatomy and its effect on penile hemodynamic changes should not be overlooked especially in the patients who are candidates for penile reconstructive or vascular surgery.

Relationship between apoptosis regulator proteins (bcl-2 and p53) and Gleason score in prostate cancer.

Cellular proliferation programmed cell death (apoptosis) are associated with tumor growth in general, and prostate cancer growth in particular. The aim of this study was to examine the expression of the apoptosis regulating genes bcl-2 and p53 and Gleason score in core needle biopsy specimens of prostate cancer using immunohistochemistry. We studied bcl-2 and p53 expression in 12 cases of low grade (Gleason score 2-5), 12 cases of intermediate grade (Gleason score 6-7) and 8 cases of high grade (Gleason score 8-10) prostate cancer. Overexpression of bcl-2 was noted in 3 of 32 patients (9.32%). One of them was high grade; others were intermediate grades. Expression of p53 was observed in 3 of low grades; others were high grade. The statistical analysis of present data suggest that there is no significant relation between p53 and bcl-2 expression and Gleason score in prostate cancer.

Are normal hemodynamic responses invariably associated with normal penile rigidity and potency?

The existence and importance of patients with low penile buckling pressure and normal penile hemodynamic status have been recently recognized. We assessed the ratio of inadequate erection for vaginal penetration (low buckling pressure) in patients with normal penile vascular system proved with penile Doppler ultrasonography. A total of 101 patients with normal penile vascular status were retrospectively scrutinized dependent on penile axial rigidity (buckling pressure). Ninety patients had sufficient penile axial rigidity (> or = 550 g) whereas in the remaining 11 patients (11%) inadequate penile buckling pressure for vaginal penetration (< 550 g) was determined. Penile geometric and mechanical properties should not be overlooked during the evaluation of penile vascular system lest the patient be incorrectly diagnosed as having psychogenic impotence.

Honeymoon impotence: psychogenic or organic in origin?

OBJECTIVES: Honeymoon impotence is the inability to perform successful sexual intercourse during the initial experience, especially during the first nights of marriage, and it is relatively frequent in Turkey. We investigated the underlying penile vascular abnormalities in patients presenting with honeymoon impotence and sought to differentiate between psychogenic and organic etiologies. METHODS: Between 1989 and 1999, 90 patients sought urologic help for honeymoon impotence. Patient age ranged from 18 to 39 years (mean 28.06 +/- 3.4). All patients were given an intracavernous injection of 60 mg papaverine combined with self-manual genital stimulation (CIS test) to assess the degree of tumescence. Patients with a positive response to the CIS test were later evaluated with nocturnal penile tumescence (NPT) monitoring. Patients with a negative response to the CIS test and/or NPT monitoring were evaluated further using penile color Doppler ultrasound. RESULTS: A psychogenic etiology was found in 61 patients (67.7%), 50 (55.5%) of whom achieved satisfactory sexual intercourse after intracavernous injection. Twenty-five patients (27.7%) exhibited penile vascular abnormalities by color Doppler ultrasound. Neurogenic erectile dysfunction was considered in the remaining 4 patients (4.4%) with a positive response to the CIS test, abnormal findings on NPT monitoring, and a normal vascular system with color Doppler ultrasound. CONCLUSIONS: The present study is the first to report penile vascular abnormalities in patients presenting with honeymoon impotence, which was previously believed to be exclusively psychogenic in origin. The evaluation of the penile vascular system in patients with honeymoon impotence may reveal underlying penile vascular abnormalities, allowing the choice of the appropriate therapeutic option.

Evaluation and therapeutic approaches of voiding and erectile dysfunction in neurological Behçet's syndrome.

PURPOSE: Behçet's syndrome is a progressive inflammatory disease which involves multiple systems. It is characterized by 3 main symptoms of iridocyclitis, and oral and genital ulcerations. Nervous system involvement is seen rarely in this clinical entity and is known as neurological Behçet's syndrome. Inflammation usually occurs in the brain stem, cerebellum and medulla spinalis. Voiding and erectile dysfunction can be due to progressive inflammatory reactions in the nervous and vascular systems. We prospectively evaluated the dysfunctional bladder and penis, and therapeutic options were evaluated prospectively. MATERIALS AND METHODS: A total of 24 consecutive patients diagnosed with neurological Behçet's syndrome after neurological evaluation were enrolled in this study. Neurological involvement and localization of the nervous system were proved on evaluation. Voiding and erectile dysfunction was evaluated regardless of the presence of related symptoms, and the results were compared with those of controls. Patients with voiding dysfunction on urodynamic study were treated and reevaluated symptomatically after 3 and urodynamically after 6 months. RESULTS: The rate of erectile dysfunction in neurological Behçet's syndrome was 63%. Mixed type vasculogenic impotence, arterial insufficiency, veno-occlusive dysfunction and neurogenic impotence were identified in 7, 2, 2 and 1 patient, respectively. Detrusor instability was demonstrated in 12 patients with urgency incontinence, including 3 with detrusor-sphincter dyssynergia. Brain stem localization was determined in these patients on neurogenic evaluation. Significant improvement was observed with anticholinergic treatment and clean intermittent catheterization in 3 patients with detrusor-sphincter dyssynergia. Hypersensitive and hypocompliant detrusor was noted in patients with neurological Behçet's syndrome who had normal voiding habits. CONCLUSIONS: Incontinence or irritable bladder symptoms should not be considered innocuous clinical findings in neurological Behçet's syndrome. Lower urinary tract function should be evaluated in all patients with this neurological syndrome. The incidence of erectile dysfunction is approximately 65% and the therapeutic approach should be determined according to lower urinary tract function.

Does the positive intracavernous papaverine test always indicate a normal penile vascular system?

OBJECTIVE: A positive intracavernous papaverine test has been presumed to determine normal erectile hemodynamics. Recently, positive erectile responses to intracorporeal injection tests were reported in patients with penile arterial insufficiency. METHODS: This hypothesis was assessed by obtaining hemodynamic data using color Doppler ultrasonography in 417 patients with erectile dysfunction aged between 20 and 73 years (mean 43.06 +/- 13.66). A normal penile vascular system was found in 95 patients (22.79%), veno-occlusive dysfunction in 76 (18.22%), arteriogenic erectile dysfunction (ED) in 113 (27.10%) and mixed-type ED in 133 (31.89%). RESULTS: A positive erection response was achieved in 176 patients with combined intracavernosal injection of 60 mg papaverine and self-manual genital stimulation (CIS) test, while a negative response was observed in the remaining 241 (57.79%). Color Doppler ultrasonography combined with pharmacological erection has proved a normal penile vascular system in 94 (53.41%) and penile arterial insufficiency in 82 (46.59%) patients of those who gave a positive response to the CIS test. Also, a positive CIS test response was observed in all patients with unilateral arterial insufficiency (n = 31) and in 51 patients (62.19%) out of 82 with bilateral arterial insufficiency. CONCLUSION: A positive intracavernous papaverine test indicates veno-occlusive dysfunction competence but does not necessarily signify a normal penile arterial system. The CIS test should be combined with color Doppler ultrasonography in order to determine the vascular component of ED, since the differentiation is not possible between slight penile arterial insufficiency and psychogenic or neurogenic impotence with the CIS test.

The correlation of end-diastolic flow velocity and cavernosometry results in the diagnosis of venous leakage.

OBJECTIVES: Cavernosometry is a conventional and reliable method used in the diagnosis of caverno-venous incompetence. Recently, cavernosal artery end-diastolic blood flow velocity more than 5 cm/sec during the rigid phase and after 10 minutes with duplex ultrasonography has been considered as veno-occlusive dysfunction. METHODS: Fifteen patients with erectile dysfunction aged 20 to 56 years (mean age 35.8) were evaluated by dynamic infusion cavernosometry and duplex ultrasonography which measured end-diastolic blood flow velocity during the rigid phase of erection and after 10 minutes. RESULTS: Dynamic cavernosometry was considered the gold standard during this comparative study. The sensitivity of duplex ultrasonography was found to be 100%, its specificity was 71.42%, positive predictive value 80% and its negative predictive value was 100% in the detection of caverno-venous incompetence.