Renal Tumor Invasion Depth and Diameter are the Two Most Accurate Anatomical Features Regarding the Choice of Radical Versus Partial Nephrectomy.

BACKGROUND AND AIMS: To evaluate simple tumor characteristics (renal tumor diameter and parenchymal invasion depth) compared with more complex classifications, that is, Renal Tumor Invasion Index (RTII) and Preoperative Aspects and Dimensions Used for an Anatomical classification, in predicting the type of nephrectomy (radical vs partial) performed. MATERIAL AND METHODS: A total of 915 patients who had undergone either partial nephrectomy ( n = 388, 42%) or radical nephrectomy ( n = 527, 58%) were identified from the Helsinki University Hospital kidney tumor database between 1 January 2006 and 31 December 2014. Tumor maximum diameter and depth of invasion into the parenchyma were estimated from computed tomography or magnetic resonance imaging images and compared with Preoperative Aspects and Dimensions Used for an Anatomical and Renal Tumor Invasion Index. Logistic regression and receiver operating curves were used to compare the parameters at predicting the type of nephrectomy. RESULTS AND CONCLUSION: All the anatomical variables of receiver operating curve/area under the curve analyses were significant predictors for the type of nephrectomy. Parenchymal invasion (area under the curve 0.91; 95% confidence interval, 0.89-0.93), RTII (area under the curve 0.91; 95% confidence interval, 0.89-0.93), and diameter (area under the curve 0.91; 95% confidence interval, 0.89-0.93) performed significantly better than Preoperative Aspects and Dimensions Used for an Anatomical classification (area under the curve 0.88; 95% confidence interval, 0.85-0.89). In multivariable analysis, invasion depth was the best predictor of nephrectomy type (percentage correct, 85.6%). Addition of one anatomic parameter into the model of non-anatomical cofactors improved the accuracy of the model significantly, but the addition of more parameters did not. Parenchymal invasion depth and tumor diameter are the most accurate anatomical features for predicting the nephrectomy type. All potential anatomical classification systems should be tested against these two simple characteristics.

Laparoscopic versus open nephrectomy for renal cell carcinoma?

Laparoscopic radical nephrectomy has become a well-standardized and reproducible, but technically demanding procedure. It is rapidly replacing the traditional open technique in radical nephrectomy with T1-2 tumours. Open operation will mainly be reserved for T3 tumours. Nephron-sparing surgery will play a major role in small (<4 cm) peripheral tumours. Open technique is still the standard for NSS, but with the refined techniques, laparoscopy may be soon coming.

A positive pharmacological erection test does not rule out arteriogenic erectile dysfunction.

PURPOSE: We tested the assumption that a positive pharmacological erection test implies normal penile vascular status. MATERIALS AND METHODS: From March 1991 to February 1995, 372 patients with erectile dysfunction were referred to our institutions. Penile hemodynamics were studied in 205 patients with color coded Doppler ultrasonography after intracavernous injection of 40 micrograms. prostaglandin E1. RESULTS: Of the 205 patients undergoing color coded Doppler utrasonography 92 had a rigid erection, that is a positive pharmacological erection test. Doppler wave analysis showed that 76 of the 92 patients (82%) had normal and 7 (8%) had borderline arterial function (peak systolic velocity greater than 35 and 25 to 35 cm. per second, respectively), while 9 (10%) had arterial insufficiency (peak systolic velocity less than 25 cm. per second). All 92 patients had a normal veno-occlusive mechanism (resistance index greater than 0.90). Of the 9 patients with pure arteriogenic erectile dysfunction 8 had risk factors for arterial insufficiency, such as aortoiliac occlusive disease (5), diabetes mellitus (3), longer than 20-year smoking history (8) and hypertension (7). CONCLUSIONS: Our study shows hemodynamically that a positive pharmacological erection test does not rule out arteriogenic erectile dysfunction.

Aortofemoral surgery and sexual function.

OBJECTIVES: To determine the incidence and pathophysiology of erectile dysfunction (ED) in patients with aortoiliac occlusive disease (AIOD) and the effects of aortofemoral surgery, including endarterectomy (E) and reconstruction (R), on erectile function (EF). DESIGN: Evaluation of EF before and 3 months after surgery. METHODS: 31 out of 40 male patients scheduled for aortofemoral surgery were given multiple choice questionnaires and penile dynamic Colour Doppler Ultrasonography. RESULTS: Of the 31 who agreed to enter the study five (16%) were found to be potent and 26 (84%) to suffer from ED. This was purely arteriogenic in 8% of the cases, purely venogenic in 23%, combined arteriogenic and venogenic in 53%, and neurogenic in 16%. Twenty patients returned for postoperative evaluation of EF, nine who had undergone E and 11 who had undergone R. Improvement of EF, in terms of increased penile arterial inflow, occurred in seven patients, six who had undergone E and one who had undergone R. EF remained unchanged in nine patients, three who had undergone E and six who had undergone R. Deterioration of EF occurred in four patients, all who had undergone R, and was attributable to decreased arterial inflow in two cases and to neurogenic surgical injury in the other two. CONCLUSIONS: The majority of patients with AIOD suffers from ED. Reduced penile arterial inflow and cavernovenous leakage are equally important in the pathophysiology of ED in patients with AIOD, suggesting that atherosclerosis may also compromise the penile veno-occlusive mechanism. Endarterectomy seems more likely than reconstruction to improve or maintain EF.

Etilefrine in the prevention of prolonged erection after diagnostic pharmacological stimulation.

The aim of this study was to verify the efficacy and safety of intracavernous injection of etilefrine hydrochloride in the prevention of pharmacologically induced prolonged erection. Two hundred rigid erections due to diagnostic pharmacological stimulation were treated with immediate intracavernous injection of 5 to 10 mg etilefrine hydrochloride. Penile response and general side effects after the injection were recorded. Patients were interviewed after 1-2 weeks about possible side effects. Detumescence occurred within 10 minutes in 194 (97%) cases. In the remaining six (3%), detumescence occurred after cavernous aspiration and additional injection of 5 mg etilefrine. Thirteen patients (6.5%) had transitory palpitations. None of the patients had hypertensive crisis, cardiac arrythmia or ischaemic events. Intracavernous injection of etilefrine is effective and safe in preventing prolonged erection after diagnostic pharmacological stimulation.

Duplex Doppler scanning with prostaglandin E1 in the diagnosis of cavernovenous leakage.

The aim of this study was to find out the normal response of the duplex Doppler (DD) parameter resistance index (RI) during a high dose prostaglandin E1 (40 micrograms) induced erection and to evaluate the clinical usefulness of DD scanning in the diagnosis of cavernovenous leakage (CVL). The results of DD scanning and cavernometry were compared in 10 potent control subjects and 82 impotent patients RI was > or = 1 in all control subjects later than 10 min after the intracavernous injection and RI at 20 min after the injection (RI20) was chosen as a clinical parameter. An inverse correlation (r = -0.69, p < 0.001) between RI20 and the maintenance flow (MF) at 150 mm Hg (MF150) was demonstrated. Sensitivity and specificity of RI20 (values < 1 indicating CVL) as a test of CVL (MF150 > 18 ml/min) were 89% and 86%, respectively. In conclusion, the measurement of RI20 in DD scanning after an adequate pharmaco-stimulation is a reliable, noninvasive method in the diagnosis of CVL.

Cardiovascular reflexes in the neurological evaluation of impotence.

Testing of the autonomic cardiovascular reflexes (single breath beat-to-beat variation and orthostatic blood pressure change) was performed in 542 patients with erectile dysfunction who were grouped according to aetiological factors and their response to visual sexual stimulation and the papaverine test. Age-related normal values for autonomic tests were determined in the group of 124 patients with psychogenic impotence. Abnormal cardiovascular reflexes were associated with ageing and organic impotence, indicating autonomic dysfunction as a major contribution to impotence. Single breath beat-to-beat variation, as a simple non-invasive test, is useful in the clinical evaluation of impotence, especially in patients with diabetes and a history of alcohol abuse.

Pharmacotesting with high dose prostaglandin E1 in impotence.

The diagnostic value of pharmacotesting in impotence is controversial. The results of high dose prostaglandin pharmacotesting were compared with those of colour duplex Doppler scanning and pharmacocavernometry in 82 impotent patients and 10 control subjects. Based on the results of 10 control subjects, the prostaglandin test was defined as positive if intracavernous pressure 200 minutes after injection of 40 micrograms prostaglandin E1 was > or = 42 mm Hg and negative if intracavernous pressure was < 42 mmHg. The test was repeated in 29 subjects and classified results were consistent in 24 subjects (86%, k = 0.65). The test was negative in 52 out of 56 patients (sensitivity 93%) with vasculogenic impotence (arteriogenic and/or cavernovenous factor involved) and the test was positive in 21 out of 26 patients (specificity 81%) with non-vasculogenic impotence (arteriogenic or cavernovenous factor not involved). The majority, 27 out of 31 patients (87%) with arteriogenic impotence showed simultaneous dysfunction of cavernovenous occlusion mechanism. In conclusion, pharmacotesting with high dose prostaglandin is a useful screening test of vasculogenic impotence.

Cavernous auto-injection therapy with prostaglandin E1.

During 1990-1992, 176 consecutive patients (aged 18-83 years, mean 53 years) with erectile dysfunction were personally investigated by the author in the private office setting at Eira Hospital. Pharmacotesting with 20 micrograms prostaglandin was positive in 89 of 138 patients (64%) tested. Eleven per cent of the patients complained of pain during erection. Of 131 patients, who initially were offered auto-injections as a primary treatment modality, 99 (76%) began the therapy. Seventy-four per cent of the patients continued auto-injections after three months. The overall efficacy of prostaglandin E1 to induce adequate erections for sexual intercourse was estimated to be 71%. One prolonged erection without medical intervention and no penile fibrotic lesions were recorded. In conclusion, cavernous auto-injection therapy with prostaglandin E1 is a well accepted, effective and safe treatment alternative in psychogenic as well as organic impotence. Every impotent patient should be informed of this therapy.

Duplex Doppler scanning with high-dose prostaglandin E1 stimulation in the diagnosis of arteriogenic impotence.

The aim of this study was to find out the normal range of penile duplex Doppler parameters with pharmacostimulation of 40 micrograms prostaglandin E1 and to assess the repeatability and clinical value of the method. Maximal systolic velocity increase (SVImax) is presented as a new flow parameter. 10 potent and 82 impotent patients were investigated. Peak systolic velocity values were significantly higher when recorded at proximal than at distal penis. Repeatability of SVImax was fairly good (coefficient of variation = 0.18). SVImax ranged from 32 to 100 cm/s in 10 control subjects. The distribution of SVImax values in patients grouped according to the number of arteriosclerotic risk factors indicates that this parameter may be useful in the diagnosis of arteriogenic impotence.

Pharmacocavernometry with prostaglandin E1.

The aim of this study was to define the normal response of cavernometry parameters with high-dose pharmacostimulation, to investigate repeatability of the method and to find out the incidence of cavernovenous leakage in impotence. 82 consecutive impotent patients and 10 potent control subjects underwent pharmacocavernometry with 40 micrograms of prostaglandin E1. In control subjects, the maintenance flow at 150 mm Hg (MF150) was 3-22 ml/min with an average of 6 ml/min (SD = 6 ml/min). Cavernometry was repeated in 17 patients, but the repeatability of quantitative parameters was disappointing. Cavernovenous leakage was estimated to be present in 55-67% of all impotent patients. Cavernometry with a high-dose prostaglandin E1 pharmacostimulation is a useful method in selected patients, but the consistency of the method should be improved.