Penile size in adult men-recommendations for clinical and research measurements.

Data regarding the size of the adult penis is of great importance to both clinicians and researchers. Currently, there is no consensus regarding the preferred method for the evaluation of penile size. Various and conflicting methods are reported in the literature. We review the data on measurement methods of the flaccid, stretched, and erected penis with the aim of constructing a recommendation for best practice. A systematic search for articles on penile length and girth measurement techniques was performed using PubMed, Google Scholar, and Cochran Library. Only peer-reviewed articles published in English before August 2018 were reviewed. All authors evaluated the methods and results sections presented in each publication. Relevant, demonstrative publications are reported in this review. We did not find definitive evidence favoring one measuring method over the other. Therefore, we advocate the use of our recommendations for penile size measurement in future publications.

Long-term biochemical progression-free survival following brachytherapy for prostate cancer: Further insight into the role of short-term androgen deprivation and intermediate risk group subclassification.

INTRODUCTION: Brachytherapy is a well-established treatment of localized prostate cancer. Few studies have documented long-term results, specifically biochemical progression-free survival (bPFS) in men with brachytherapy alone, with or without short-term androgen deprivation therapy (ADT), or in combination with external beam radiotherapy (EBRT). Our aim was to analyze long-term bPFS of brachytherapy treated patients. MATERIALS AND METHODS: Retrospective analysis of 1457 patients with low and intermediate risk prostate cancer treated with brachytherapy alone (1255) or combined with EBRT (202). Six-months ADT was administrated for all EBRT combined patients and for prostate volume downsizing when >55 cc (328). Failure was by the Phoenix definition. Kaplan-Meier analysis and multivariate Cox regression estimated and compared 10-yr and 15-yr rates of bPFS. RESULTS: Median follow-up was 6.1 yr. Ten and 15-yr bPFS rates of the entire cohort were 93.2% and 89.2%, respectively. On multivariate analysis, PSA density (PSAD), ADT and clinical stage were significantly associated with failure. The most powerful independent factor was PSAD with a HR of 3.5 (95% CI, 1.7-7.4) for PSAD above 0.15. No significant difference was found between low and intermediate risks patients regardless of treatment regimen. However, comparison of two intermediate risk groups, Gleason score (GS) 7, PSA<20 ng/ml versus GS≤6 and PSA = 10-20 ng/ml, revealed 10- and 15-yr bPFS rates of 94.2% and 94.2% compared to 88.2% and 79.9%, (P = 0.022), respectively. ADT improved bPFS rates in low risk patients. The ten and 15-yr bPFS rates were 97.6% and 94.6% compared to 92.3% and 88.2%, (P = 0.020), respectively. CONCLUSIONS: Our retrospective large scale study suggests that brachytherapy provides excellent long-term bPFS rates in low and intermediate risk disease. Combination of brachytherapy with EBRT yields favorable outcomes in GS 7 intermediate risk patients and short-term ADT has a positive effect on outcomes in low risk patients. Further prospective studies are warranted to discriminate the role of adding either EBRT and/or ADT to brachytherapy protocols.

The pathophysiology of delayed ejaculation.

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1-4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

Comparison between preoperative and real-time intraoperative planning ¹²5I permanent prostate brachytherapy: long-term clinical biochemical outcome.

BACKGROUND: The purpose of the study is to evaluate the long-term clinical outcome through biochemical no evidence of disease (bNED) rates among men with low to intermediate risk prostate cancer treated with two different brachytherapy implant techniques: preoperative planning (PP) and real-time planning (IoP). METHODS: From June 1998 to July 2011, 1176 men with median age of 67 years and median follow-up of 47 months underwent transperineal ultrasound-guided prostate ¹²5I-brachytherapy using either PP (132) or IoP (1044) for clinical T1c-T2b prostate adenocarcinoma Gleason <8 and prostate-specific antigen (PSA) <20 ng/ml. Men with Gleason 7 received combination of brachytherapy, external beam radiation and 6-month androgen deprivation therapy (ADT). Biological effective dose (BED) was calculated using computerized tomography (CT)-based dosimetry 1-month postimplant. Failure was determined according to the Phoenix definition. RESULTS: The 5- and 7-year actuarial bNED rate was 95% and 90% respectively. The 7-year actuarial bNED was 67% for the PP group and 95% for the IoP group (P < 0.001). Multivariate Cox regression analyses identified implant technique or BED, ADT and PSA as independent prognostic factors for biochemical failure. CONCLUSIONS: Following our previous published results addressing the limited and disappointing outcomes of PP method when compared to IoP based on CT dosimetry and PSA kinetics, we now confirm the long-term clinical, bNED rates clear cut superiority of IoP implant methodology.

High detection rate of significant prostate tumours in anterior zones using transperineal ultrasound-guided template saturation biopsy.

UNLABELLED: Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Men with persistent suspicion for prostate cancer after previous negative standard transrectal biopsy series are offered saturation biopsy either transrectally or transperineally to increase cancer detection rate. A high-risk group of men with at least two previous negative transrectal biopsies underwent transperineal template-guided saturation biopsy. Prostate cancer was detected in 26%, predominantly in the anterior zones. PSA velocity or doubling time were the most powerful factors to predict cancer. OBJECTIVE: To evaluate the detection rate and the regional location of prostate cancer in men undergoing transperineal template-guided saturation biopsy (TTSB). PATIENTS AND METHODS: In all, 92 consecutive men with at least two previous negative transrectal biopsy series who underwent a multiple-core prostate TTSB at our centre were included in the study. • Univariable and multivariable logistic regression analyses were used to address the relationship between parameters before TTSB and prostate cancer-detection rate. • Covariates consisted of age at biopsy, free and total prostate-specific antigen (PSA), prostate volume, digital rectal examination findings, histological findings on previous biopsy, PSA velocity (PSAV), PSA-doubling time (PSADT) and the number of previous negative biopsy sets. RESULTS: Prostate cancer was diagnosed in 26% of the men. • A median of 30 cores was taken by TTSB. • Adenocarcinoma in >2 cores was detected in 58.5% and Gleason score ≥7 was detected in 46% of the diagnosed men. • Most of the tumours (83.3%) were found in the anterior zones of the gland, with a significantly higher number of positive cores vs the posterior zones (mean 4.9 vs 1.5, P= 0.015). • PSADT and PSAV were the only independent predictors of prostate cancer detection at multivariate analyses with odds ratios of 0.71 (P= 0.014) and 1.58 (P= 0.025), respectively. CONCLUSIONS: TTSB has a high prostate cancer-detection rate, especially in the anterior zones. • Men after at least two previous negative transrectal biopsy series and persistent suspicion of prostate cancer, as evidenced by rapid PSA dynamics, should be offered TTSB.

Endourological procedures and sexual dysfunction: a prospective multivariate analysis.

OBJECTIVE: To investigate whether endourological interventions are associated with postoperative sexual dysfunction. PATIENTS AND METHODS: The study comprises a consecutive and prospective series of patients, referred for endourological procedures. General anaesthesia was used and JJ stents were placed when required. Changes in sexual function, as assessed by the International Index of Erectile Function questionnaire that the participants filled in the day before the procedure and 1 month and up to 3 months afterwards, were analysed. RESULTS: The study group consisted of 50 men aged (mean ± SD) 45 ± 13 years, of whom 25 underwent ureteroscopy, 9 underwent retrograde intrarenal surgery (RIRS) and 16 underwent combined RIRS and percutaneous nephrolithotomy. JJ stents were postoperatively placed in 33 patients (66%). The study cohort self-reported a significant decrease in erectile function (P= 0.007), intercourse satisfaction (P < 0.001), orgasmic function (P= 0.001), sexual desire (P < 0.001) and overall satisfaction (P= 0.002) at 1 month following endourological procedures. This dysfunction was not related to chronic disease, age, smoking, preoperative or postoperative stenting, type of procedure, operative duration or surgeon expertise. The sexual function of all subjects returned to baseline within 3 months (P < 0.005). Postoperative erectile function in the stented group revealed a negative tendency that did not reach statistical significance. CONCLUSIONS: Endourological procedures are associated with temporary postoperative sexual dysfunction, which completely recovers within 3 months. The impact of postoperative stenting on sexual function was not significant. These findings contribute to enhanced preoperative patient counselling.

Prospective comparison of PSA kinetics following two different prostate cancer brachytherapy planning methods: preoperative and real-time intraoperative dosimetry planning.

OBJECTIVES: Preoperative planning (PP) and intraoperative planning (IoP) are established (125)I-brachytherapy techniques for the treatment of localized prostate cancer. We prospectively compared the effects of each method on reducing PSA levels. MATERIALS AND METHODS: One hundred eighty patients treated with brachytherapy as monotherapy without neoadjuvant androgen deprivation therapy or external beam radiation using PP (75) or IoP (105) methodologies and with ≥ 5 years of follow-up were included in the study. CT-based dosimetry was calculated 1 month postoperatively. PSA was obtained every 3 months for the first year and semiannually thereafter. Available PSA and dosimetric data from both groups were analyzed and compared. RESULTS: At 5 years after brachytherapy, the probability of having a nadir PSA value < 0.5 ng/ml was 90% in the IoP group compared with 60% in the PP group (P < 0.0001). The rate of PSA decline was 3-fold faster in the IoP group than in the PP group. Dosimetry results highly favored the IoP method: mean V(100) (%) and D(90) (Gy) were 95 and 180 vs. 60 and 81 (P < 0.001), respectively. CONCLUSIONS: Our initial finding of highly superior postimplant CT dosimetry calculations of the IoP method are now substantiated by the biochemical favorable results (PSA kinetics) of this method.

Validation and comparison of the two Kattan nomograms in patients with prostate cancer treated with (125) iodine brachytherapy.

UNLABELLED: Study Type - Prognostic (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Nomograms are based on large patient population. Their applicability should be externally validated. Among 747 brachytherapy patients we evaluated two Kattan nonograms and conclude that they have limited value to predict PSA-free survival. OBJECTIVE: To validate and compare the preoperative and postoperative Kattan prediction nonograms for prostate cancer recurrence after brachytherapy. PATIENTS AND METHODS: Patients (n= 747) treated with (125) I-brachytherapy were evaluated. Both nomograms were used to calculate the prediction of 5-year biochemical-freedom from failure (BFFF) based on clinical stage, Gleason score, prostate-specific antigen (PSA) level, receipt of androgen deprivation therapy and the post-implant dosimetry variable D90 (values of the minimal dose received by 90% of the prostate volume). The predicted values using the Kattan nomograms and the observed values were compared. Predictive accuracy was determined using the concordance index. RESULTS: The 5-year BFFF probability was 94% (95% confidence interval [CI], 92-96%) for the modified American Society for Radiation Oncology (ASTRO) definition and 97% (95% CI, 95-98%) for the Phoenix definition using Kaplan-Meier analysis. The predicted values of BFFF using both Kattan nomograms were lower than the observed rates in our cohort. The concordance index values were 0.51 and 0.52 for preoperative and postoperative nomograms, respectively. Concordance correlation coefficient between the two nomograms was 0.15. CONCLUSIONS: In our population, the 5-year BFFF outcomes rates were superior to nomogram predictions. Neither nomogram predicted outcomes after (125) I-brachytherapy in this non-US cohort. The postoperative nomogram was also a poor predictor, although it included D90 dosimetry values, as a variable of treatment quality. Strict inclusion criteria, perhaps more favourable than the ones on which the Kattan nomograms were based, could be the explanation for these discrepancies.

The controversial role of phosphodiesterase type 5 inhibitors in the treatment of premature ejaculation.

INTRODUCTION: It is controversial whether or not the most frequent male sexual dysfunctions, premature ejaculation (PE) and erectile dysfunction (ED), share pathogenetic mechanisms and treatments. METHODS: Three scientists (C.McM., J.C., and A.A.), together with the Controversy's Editor (E.A.J.), with expertise in the area of medical treatment of PE, present different perspectives on the use of phosphodiesterase type 5 inhibitors (PDE5is) in PE. The psychological point of view is discussed by an expert in sexology (M.P.). MAIN OUTCOME MEASURE: Outcome measures used are expert opinions supported by the critical review of the currently available literature. RESULTS: This Controversy examines the role of nitric oxide (NO) as a neurotransmitter involved in the central and peripheral control of ejaculation, the adherence of methodology to the contemporary consensus of ideal PE drug trial design, the impact of methodology on treatment outcomes, and the role of PDE5i drugs (sildenafil, tadalafil, and vardenafil) in the treatment of PE. CONCLUSIONS: While it is evident that PDE5is are the first choice in patients with comorbid ED and PE (where one may be secondary to the other), well-designed studies on the possible use of PDE5is in PE patients without ED are still limited. The issue will be less controversial when further evidence on the role of NO and PDE5 in the mechanism of ejaculation is available.

Disorders of orgasm and ejaculation in men.

INTRODUCTION: Ejaculatory/orgasmic disorders are common male sexual dysfunctions, and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia. AIM: To provide recommendations and guidelines concerning current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men. METHODS: An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 25 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge of disorders of orgasm and ejaculation represent the opinion of seven experts from seven countries developed in a process over a 2-year period. MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. RESULTS: Premature ejaculation management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin re-uptake inhibitor [SSRI] and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. Behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Retrograde ejaculation is managed by education, patient reassurance, pharmacotherapy, or bladder neck reconstruction. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic atiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal. CONCLUSIONS: Additional research is required to further the understanding of the disorders of ejaculation and orgasm.

Detection of prostate specific transcripts in the peripheral blood during brachytherapy predicts postoperative PSA kinetics.

BACKGROUND: We evaluated whether detection of prostate-specific antigen (PSA) and human kallikrein 2 (hK2) transcripts in the peripheral blood during brachytherapy could predict biochemical outcome. METHODS: Eighty-one patients who underwent (125)Iodine-based brachytherapy for localized prostate cancer (Gleason score <8, PSA <20 ng/ml, stage

Is there a place for conservative treatment in Peyronie's disease?

INTRODUCTION: Peyronie's disease (PD) is a relatively common disorder affecting middle aged men. Conservative nonsurgical treatments include oral, topical, and intra-lesional pharmacotherapies, vacuum stretching, and mechanical traction. METHODS: Four people with expertise and/or interest in the area of PD were asked to contribute their opinions with regard to the safety and efficacy of nonsurgical conservative treatments. MAIN OUTCOME MEASURE: To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. RESULTS: Of the four experts writing on the topic, one believes a combination of medical therapy and penile traction has positive potential for curvature. Another feels that although medical therapies have potential to alleviate pain, there is little evidence to show that they help with curvature or that penile traction helps. A third expert proposes dividing the disease into phases, where patients in the acute phase may benefit from conservative therapy, whereas patients whose disease is stable require surgical intervention. The last expert agrees that the therapy should depend on the stage of the disease, but believes like the first expert that there is a role for traction therapy for patients with stable disease. CONCLUSION: There is a need for guidelines for nonsurgical therapies for patients with PD, but there is a paucity of evidence as to their efficacy.

Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills.

INTRODUCTION: Vulvar vestibulitis syndrome (VVS) is a diverse, multifactorial phenomenon. Its precise etiology is unknown. AIM: To define the association between oral contraceptive (OC) estrogen dosage and VVS. Methods. Women diagnosed as having VVS participated in the study. MAIN OUTCOME MEASURES: Data on type and usage of oral contraceptive pills (OC) were obtained by a questionnaire, and they were compared for the data on OC usage in the general population. RESULTS: Available commercial data on Israeli women taking OC showed that 51% of them use low-dose estrogen (

Extending the application of tubeless percutaneous nephrolithotomy.

OBJECTIVES: Tubeless percutaneous nephrolithotomy (PCNL) has been successfully performed in selected patients. We assessed its applicability for use without imposing preoperative restrictions. METHODS: The study consisted of a prospective and consecutive series of 126 patients. Tubeless PCNL was performed when perforation, residual stones, and significant bleeding had been intraoperatively excluded by fluoroscopy, nephroscopy, and hemodynamic assessment. Staghorn stones, supracostal and/or multiple access, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications. The demographic, clinical, and intraoperative and postoperative data were statistically analyzed. RESULTS: Using this protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The average patient age (54 years versus 52 years), stone burden (924 versus 1044 mm2), operative time (116 versus 130 minutes), complication rate (9% versus 13%), hemoglobin decrease (1.2 versus 1.1 mg/dL), and immediate stone-free rate (92% versus 90%) were similar for the tubeless and regular PCNL groups, respectively (P >0.05). The reasons for performing standard PCNL were an expected second-look procedure (n = 35, 58%), an impression of active bleeding (n = 16, 27%), significant extravasation (n = 5, 8%), and suspected hydrothorax (n = 4, 7%). The overall transfusion rate was 3%. The average analgesia requirement (pethidine HCL) was 0.4 and 1.2 mg/kg (P <0.01), the median hospital stay was 1 and 4 days (P <0.0001), and the median back-to-work time was 7 and 15 days (P <0.001) for the tubeless and regular PCNL groups, respectively. CONCLUSIONS: The results of our study have shown that tubeless PCNL can be safely and effectively performed based on intraoperative factors, without preoperative contraindications. Compared with the standard procedure, tubeless PCNL was associated with reduced postoperative pain, hospital stay, and recovery time.

Preimplant predictive factors of urinary retention after iodine 125 prostate brachytherapy.

OBJECTIVES: To assess the rate and predictive factors of urinary retention after iodine 125 brachytherapy for localized prostate cancer. METHODS: Between 1998 and 2006, 655 patients with localized prostate cancer (T1-2, Gleason score 7 or less) were treated with brachytherapy at our institution. 42% received neoadjuvant hormonotherapy for prostate downsizing or when brachytherapy was combined with external beam radiation (10%). They underwent real-time interactive implantation (79%) or a preplanned technique (21%). Clinical, treatment-related and dosimetric factors were evaluated for catheterization requirement because of urinary retention. All patients received alpha1-blockers before and throughout at least 30 days posttreatment. RESULTS: Twenty-one (3.2%) patients required catheterization because of urinary retention. Median time to retention onset was 1 day postimplantation. Univariate and multivariate analyses demonstrated that preimplant ultrasound (US)-based prostate volume and preimplant international prostate symptom scores (IPSS) were significant independent predictive factors for urinary retention (odds ratio [OR] = 6.8 and 3.1, 95% CI = 2.3-11.4 and 0.2-5.9, P = 0.02 and P = 0.03, respectively). Eight catheterized patients were successfully relieved from their catheter by nonsurgical means and 13 underwent minimal (channeling) transurethral resection of the prostate (TUR-P) not earlier than 6 months postimplant. Mean volume of resected prostate tissue was 9.9 mL (range 4.5-15). The perioperative and postoperative courses were uneventful. There was no TUR-P-related incontinence. CONCLUSIONS: Catheterization for acute urinary retention after brachytherapy is an uncommon event. Our data suggest that preimplant US-based prostate volume and IPSS are the strongest predictors for catheterization. Catheterized patients who are refractory to medical therapy can safely undergo a minimal TUR-P.

The role of phosphodiesterase type 5 inhibitors in the management of premature ejaculation: a critical analysis of basic science and clinical data.

OBJECTIVES: To assess the usefulness of the phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of premature ejaculation (PE) and to describe possible mechanisms to explain their effect. METHODS: A MedLine search was performed for peer-reviewed articles on the role of PDE5-Is in managing PE. No meta-analysis method was used. RESULTS: Five manuscripts that examined the efficacy of PDE5-Is in the treatment of PE were retrieved. Three studies used sildenafil as monotherapy and two used it in combination with a serotonin selective reuptake inhibitor (SSRI). Three studies demonstrated a beneficial effect of sildenafil in the treatment of PE, as measured by intravaginal ejaculatory latency time (IELT) and by different questionnaires assessing the patients' subjective feelings of ejaculatory control, sexual satisfaction, and anxiety. One study showed the superiority of sildenafil compared to other modalities. Two studies showed that combination therapy of paroxetine and sildenafil was better than paroxetine alone. One study did not demonstrate a beneficial effect of sildenafil in prolonging IELT, but showed that sildenafil improved patients' perception of ejaculatory control. Another study showed that topical anesthetics were better than sildenafil in the treatment of PE but did not use IELT or a validated questionnaire to measure the efficacy of treatment. Several possible mechanisms could explain effectiveness of the PDE5-Is for treatment of PE: centrally, through the effect on the nitric oxide/cyclic guanosine monophosphate pathway; peripherally by causing relaxation of smooth muscle in the vas deferens, seminal vesicles, prostate, and urethra and inhibition of adrenergic transmission; or locally by inducing peripheral analgesia. Another possibility might be prolongation of the duration of erection. CONCLUSIONS: Encouraging evidence supports the role of PDE5-Is for treating PE. Possible therapeutic mechanisms of action of PDE5-Is are multiple and complex and include central and peripheral effects. A large population, multicenter, randomized, double-blind, placebo-controlled study is needed to elucidate the efficacy of PDE5-Is in the treatment of PE.

A three-dimensional model of the penis for analysis of tissue stresses during normal and abnormal erection.

Approximately half of the males between the ages of 40 and 70 suffer erectile dysfunction. Because adequate mechanical interactions in the penis are necessary for functional erection it is important to analyze stresses in the erect penis. Previous penis models were limited to simplified or two-dimensional geometry. Here we developed a three-dimensional model for structural analysis of normal erection as well as erections of a penis with substantial asymmetry of the corporal bodies, and Peyronie's disease. The model was constructed based on anatomical images and included skin, tunica albuginea, corpus cavernosa, and spongiosum. The mechanical behavior of the tunica and skin were assumed to be three-dimensional-orthotropic, and other tissues as well as Peyronie's plaque was taken as linear elastic. Stresses and deformations during erection were analyzed using a commercial finite elements (FE) solver. Erection was simulated by raising blood pressure in the corporal bodies to 100 mmHg. The tunica was found to be the most highly loaded tissue in the erect penis. Peak von Mises stresses in the healthy tunica, tunica of the asymmetric corpora model, and tunica with Peyronie's disease were 114 kPa, 167 kPa, and 830 kPa, respectively. The angles of distortion of the penis with respect to the vertical axis were approximately 4.5 degrees and approximately 2 degrees , for the asymmetric and Peyronie's cases, respectively. The model's ability to determine internal stresses in the erect penis offers a new point of view on the mechanical factors involved with erection, and enables us to relate these data with different penile pathologies.

Holmium laser ureteroscopic treatment of various pathologic features in pediatrics.

OBJECTIVES: To assess the outcome of pediatric patients treated by ureteroscopy for various pathologic findings. METHODS: A total of 31 children (median age 5 years, range 0.3 to 14) were ureteroscopically treated for ureteropelvic junction obstruction (UPJO) (n = 6, 1 primary and 5 secondary), ureteral strictures (n = 4), and calculi (n = 21). Miniscopes with a holmium laser were used for lithotripsy and ureterotomy. RESULTS: The average age in the UPJO group was 1.8 years (range 0.3 to 4), the operative time was 40 minutes (range 30 to 50), and the hospitalization was 1.2 days (range 1 to 2). A successful clinical and functional outcome was maintained after an average follow-up of 16 months (range 8 to 30). The 4 cases of ureteral stricture included two located in the middle ureter and two at the ureterovesical junction. No failures had occurred in this group after an average follow-up of 25 months (range 8 to 40). The calculi cases comprised 10 lower ureteral, 2 upper ureteral, and 9 renal stones, with an average stone burden of 11 mm (range 5 to 20). Three patients (14%) underwent preoperative stenting. Two patients (10%) required ureteral orifice dilation. Postoperatively, 4 patients (18%) had a ureteral catheter left in place, 15 (71%) had an internal stent with an externalized string, and 2 (10%) did not require drainage. The average operative time was 39 minutes (range 15 to 90), and the hospitalization was 1 day (range 0.5 to 2). All patients were rendered stone free. CONCLUSIONS: The results of our study have shown that the ureteroscopic approach in children with UPJO, ureteral strictures, and urinary calculi is safe and highly effective. Routine preoperative stenting and intraoperative ureteral dilation are not necessary. Stents with external strings were well tolerated and easily removed without anesthesia.

Dorsal vein injuries observed during penile exploration for suspected penile fracture.

INTRODUCTION: Penile fracture is a rare injury, bearing potential impairment of erectile function if not treated. Patients with clinical presentation of a penile fracture commonly undergo early surgical exploration with the intention to repair a tunica albuginea tear. AIM: We present a group of men who presented with a penile hematoma following trauma to the erect penis. Exploration revealed an intact tunica albuginea and a dorsal vein tear. METHODS: Eighteen men (mean age 38 years, range 20-55) presented with suspected penile fracture during an 8-year period. One man presented twice. Two of the patients were managed expectantly and the remaining 16 patients underwent 17 immediate surgical explorations. Explorations were performed under general anesthesia, using a circumferential subcoronal incision and degloving of the penile skin. The tunica albuginea of both penile sides as well as the penile urethra were examined for injuries. MAIN OUTCOME MEASURES: Medical records were retrospectively reviewed for etiology, symptoms, signs of physical examination, and information on findings of surgical exploration. Data on erectile function, medical treatment for erectile dysfunction, and penile curvature were obtained during follow-up. RESULTS: In nine of the 17 procedures the tunica albuginea was intact and the only pathological finding was a ruptured dorsal vein. One procedure was negative for both tunical and vascular injury. A tunical tear was detected in the remaining seven procedures. At a mean follow-up of 40 months (range 4-91), five patients required medical treatment for erectile dysfunction, including the two who were managed expectantly, two with a tunical tear, and one with a venous tear. CONCLUSIONS: Dorsal vein tears may mimic penile fracture. Suggestive findings following trauma to the erect penis prompted exploration for suspected tunica albuginea tear. In less than half of the men was the diagnosis of penile fracture established and treated at surgery.

Hyperoxaluria in women with vulvar vestibulitis syndrome.

OBJECTIVE: To determine whether evaluation and treatment of hyperoxaluria in vulvar vestibulitis syndrome (VVS) is justified. STUDY DESIGN: Forty women (mean age, 24.5 years; range, 18-35) diagnosed with VVS at a sex therapy clinic participated. Diagnosis of VVS relied upon Friedrich's criteria: (1) severe vulvar vestibular pain upon touch or attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) physical findings confined to vulvar erythema of various degrees. Oxalate was measured in 24-hour urine samples. Women with hyperoxaluria (urine oxalate >50 mg/24 h) were placed on a low-oxalate diet and oral calcium citrate as single therapy and reevaluated 3 months later. RESULTS: Hyperoxaluria was diagnosed in 7 women (17.5%), of whom 1 demonstrated an objective improvement and could have pain-free vaginal intercourse following treatment, yielding a 2.5% benefit from the evaluation and treatment of hyperoxaluria. CONCLUSION: There is no justification for evaluation and treatment of hyperoxaluria in women with VVS due to its low yield and economic burden.