Primary erectile dysfunction in a man with congenital isolation of the corpora cavernosa.

We report on a 33-year-old man with primary erectile dysfunction, isolated cavernous bodies, corporeal veno-occlusive dysfunction, and hypoplastic cavernous arteries. To our knowledge, this is only the second reported case of absence of communication between the corpora cavernosa.

Clinical outcome and cost comparison of percutaneous embolization and surgical ligation of varicocele.

We reviewed the records of 81 consecutive subfertile men with oligospermia and/or asthenospermia, treated for varicocele with either percutaneous embolization or surgical ligation between 1987 and 1991, and compared the outcomes and costs of the two procedures. All men had presented with infertility of at least 6 months duration, and in most cases female factors had been previously evaluated and treated. Patients were offered a choice of embolization or ligation of the internal spermatic vein. Forty-five men (56%) underwent ligation, and 36 men (44%) opted for embolization. The mean age, serum follicle-stimulating hormone, pretreatment sperm density, motility, and concentration of motile sperm were similar for the two groups. Seminal quality improved in 65% of all patients after varicocele ablation (46 of 71). Improvements were seen in postoperative sperm density (P < 0.01), motility (P < 0.002), and concentration of motile sperm (P < 0.001). Thirty-nine percent of the assessable patients established pregnancies during the study interval (26 of 66). The two treatment groups did not differ significantly with regard to the likelihood of postoperative improvement in sperm density (P = 0.64), motility (P = 0.33), concentration of motile sperm (P = 0.11), or pregnancy rate (P = 0.83). Percutaneous embolization and surgical ligation of varicocele are equally effective in improving male infertility and cost about the same. Embolization offers the potential advantage of shorter recovery to full activity as compared to surgical ligation. Where experienced interventional radiologists are available, percutaneous embolization should be offered as an alternative to open ligation.

Selective minimally invasive management of calculi in patients with urinary diversions.

We evaluate the efficacy of selectively applied minimally invasive management of calculi in 30 patients with urinary diversions (ileal/jejunal conduit in 23, cutaneous ureterostomy in 2, nonrefluxing colon conduit in 4 and ureterosigmoidostomy in 1). Upper tract calculi in 38 renal units were managed with extracorporeal shock wave lithotripsy or endo-urologically. Patients were divided into 3 treatment groups determined primarily by stone size and location: group 1-25 renal units with a mean stone burden of 1.78 cm.2 treated with extracorporeal shock wave lithotripsy alone, group 2-7 renal units with a mean stone burden of 12.75 cm.2 treated with percutaneous nephrostolithotomy alone and group 3-6 renal units with a mean stone burden of 19.03 cm.2 treated with a combination of both procedures. Stone-free results were 92%, 100% and 67% in groups 1 to 3, respectively. Total hospital stay averaged 4.3, 11.1 and 13.7 nights, while complications occurred in 1, 3 and 2 patients, respectively. We conclude that selective application of contemporary techniques for minimally invasive management of calculi in patients with a urinary diversion can provide acceptable results, even with progressively large and complex stone burdens, and that these results will be equivalent to those achieved in patients without urinary diversion.

Advances in noninvasive screening for renovascular disease.

BACKGROUND: Nearly 50 million Americans have hypertension, and renovascular hypertension accounts for perhaps 1% of them. PURPOSE: To review the current recommendations and the available screening tests for renovascular hypertension. SUMMARY: The presence of clinical clues increases the predictive value of screening tests for renovascular hypertension; these include abrupt onset of hypertension before age 30 or after age 55, severe hypertension, accelerated or malignant hypertension, hypertension refractory to a triple-drug regimen, moderate hypertension with diffuse vascular disease, an epigastric bruit, moderate hypertension with unexplained azotemia, and azotemia induced by an angiotensin-converting enzyme inhibitor. Captopril renography and duplex ultrasonography are clinically useful screening tools, but wide variation in accuracy exists among institutions. Magnetic resonance angiography may emerge as an effective clinical test. CONCLUSIONS: A thorough history and physical examination, coupled with judicious use of available screening technology, can help determine if a patient has renovascular hypertension and may benefit from intervention.

Pulmonary embolism: increased ventilation in areas of decreased perfusion.

An abnormal finding that is considered characteristic of large or extensive pulmonary embolism has been observed on ventilation-perfusion (V-P) lung scans. This observation is a regional area of increased ventilation radioactivity in the embolized region of the lung that is more than the normal ventilation radioactivity in the adjacent or contralateral normally perfused lung. It has been designated the "enhanced V-P mismatch sign." This sign was noted in 15 cases among approximately 700 routine V-P lung scans interpreted by a nuclear radiologist. Of these, large or extensive emboli were confirmed in only 10 cases, nine by means of angiography and one by means of autopsy studies. The remaining five cases demonstrated clinical correlation only and are not included in this report. Of the 10 confirmed cases with enhanced V-P mismatch sign, increased ventilation radioactivity involved unilateral lung distribution in five and zonal or lobar distribution in five. The Westermark sign was seen in only seven of the 10 cases. It is hoped that this observation will prove useful in the diagnosis of large or extensive pulmonary emboli.

Renal pseudoenlargement secondary to retroperitoneal liposarcoma.

A case of renal pseudoenlargement caused by a large retroperitoneal mass is reported. An intravenous urogram showed apparent enlargement of the right kidney and a normal left kidney. Computed tomography showed a normal-sized right kidney. The discrepancy was due to magnification produced by marked anterior displacement of the right kidney by a retroperitoneal liposarcoma.

In vivo evaluation of iophendylate-cyanoacrylate mixtures.

Cyanoacrylate glue is a rapidly polymerizing agent used for vascular embolization. Polymerization occurs when the glue comes into contact with ions in the blood or on the vascular endothelium. Mixing iophendylate with cyanoacrylate causes slowing of polymerization, allowing flow-directed embolization into the nidus of an arteriovenous malformation (AVM) or the central neovascularity of a tumor or hemangioma. The authors attempted to define the relationship between the iophendylate-glue ratio and polymerization time with an in vivo swine model. In this model, glue setup occurred much more rapidly than predicted on the basis of in vitro studies. This appeared to be due to glue polymerizing on the endothelium at vessel bifurcations and at areas of acute angulation or marked vessel narrowing. On the basis of these data, the authors substantially increased the iophendylate-glue ratio in their most recent AVM embolization procedures and achieved nidus occlusion in each case. With use of the authors' guidelines, it is possible to achieve optimal distal flow-directed embolization with cyanoacrylate.

Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT.

The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.

Renal artery stenosis: evaluation with color Doppler flow imaging.

Renal artery stenosis (RAS) is the most common correctable cause of hypertension. The current study was undertaken to evaluate the usefulness of color Doppler flow imaging as a screening examination in the detection of significant RAS. Fifty-five kidneys in 30 patients were examined with aortography and color Doppler flow imaging in a double-blind fashion. The peak systolic velocity (PSV) in the renal artery, the renal-aortic ratio (RAR) (ie, the ratio of the PSV in the renal artery to the PSV in the aorta), and the renal artery resistive index were determined and compared with the percentage of stenosis as determined with angiography. Ultrasound (US) criteria used to diagnose RAS were (a) an RAR of 3.5 or greater and/or (b) a renal artery PSV of greater than 100 cm/sec. Doppler tracings were obtained in 25 (69%) of 36 kidneys with a patent single renal artery. RAR and PSV each yielded a sensitivity of 0% in the diagnosis of RAS. Doppler tracings were obtained in three (50%) of six occluded renal arteries. Accessory arteries were present in 13 (24%) of 55 kidneys, but none were visualized with color Doppler flow imaging. The authors conclude that with current technical capability, color duplex US is not an adequate screening method for the detection of RAS.