Laparoscopy for the impalpable testes: experience with 80 intra-abdominal testes.

OBJECTIVE: To evaluate two-stage laparoscopic Fowler-Stephens (FS) orchidopexy for intra-abdominal testes. MATERIALS AND METHODS: A retrospective analysis was performed of the clinical findings, interventions and outcomes in 111 boys undergoing laparoscopy for 132 impalpable testes. RESULTS: The median age was 5.7 years (1.1-14.6 years). Twenty-seven testes were absent. Eighty testes were intra-abdominal, of which 10 were removed laparoscopically due to anatomical anomalies (4), short spermatic cord (5) or atresia (1). Twenty-five testes were located in the groin. Laparoscopic FS procedure was performed for 65 intra-abdominal testes: 60 two-stage operations and five where the testes were removed during FS second stage due to short vas or testicular atrophy. Outcome was successful in 80%. One-stage laparoscopic orchidopexy without vessel division was performed in five intra-abdominal testes with satisfactory results in three. In general, the success rate is higher in boys with bilateral intra-abdominal testes, probably due to younger age at operation. CONCLUSIONS: At our centre two-stage laparoscopic Fowler-Stephens orchidopexy for intra-abdominal testes showed results comparable to most other studies, but less satisfactory than a couple of recent studies. The median age at referral was higher than recommended. Operation at an earlier age may further improve the results.

Clearance and renal extraction of technetium-99m-L,L-ethylenedicysteine, I-131-ortho-iodohippurate and I-125-iothalamate in pigs.

99mTc-L,L-ethylenedicysteine (99mTc-EC) has been proposed as a 99mTc-labelled alternative to radio-iodinated ortho-iodohippurate (OIH) for renal imaging and evaluation of renal function. The kinetics of this new renal function agent were studied by a single-injection plasma clearance technique in pigs. 99mTc-EC, 131I-OIH and 125I-iothalamate were injected and the plasma concentration of the three tracers was followed for 240 min. Renal, hepatic and total plasma clearance were calculated. There was no difference between the renal plasma clearance of 99mTc-EC and 131I-OIH (175 +/- 9 versus 178 +/- 8 ml min-1, P = 0.43), whereas the difference between the total plasma clearance of 99mTc-EC and 131I-OIH was highly significant (268 +/- 16 versus 185 +/- 9 ml min-1, P = 0.0001). 99mTc-EC had a significant hepatic clearance of 83 +/- 10 ml min-1 whereas the hepatic clearance of 131I-OIH was negligible. Renal plasma extraction of both 99mTc-EC and 131I-OIH decreased significantly between 2 and 240 min post-injection from 0.85 to 0.45% for 99mTc-EC and from 0.93 to 0.57% for 131I-OIH. Red blood cell binding of 99mTc-EC and 131I-OIH was 6.1% and 20%, respectively. The protein binding of 99mTc-EC and 131I-OIH was 32% for both tracers. We conclude that 99mTc-EC is not a suitable tracer for measuring renal function by the single-injection plasma clearance technique in pigs. This is due to a decreasing renal extraction and a significant hepatic clearance.

[Evaluation of blood loss and absorption of irrigating fluid in transurethral resection of the prostate]. / Evaluering af blodtab og absorption af skyllevaeske ved transuretal resektion af prostata. En spørgeskemaundersøogelse.

A questionnaire was sent to all Danish departments performing transurethral resection of the prostate (TUR-P) concerning the use of irrigating fluids and methods to estimate peroperative blood loss and absorption of irrigating fluid. Fifty-six of 60 departments used glycine as an irrigant. Seventeen percent of the departments measured blood loss peroperatively (HemoCue). Only two departments (3%) measured absorption of irrigating fluid quantitatively by the expired breath ethanol method. The other departments estimated blood loss and absorption of irrigant from the colour of the irrigating fluid. From studies of the literature we suggest the use of sorbitol/mannitol as irrigating fluid instead of glycine, as this may have fewer adverse effects, and we recommend quantitative measurements of blood loss and absorption of irrigating fluid to minimise the potentially dangerous consequences of TUR-P.

Renal functional reserve in pigs: renal haemodynamics, renal tubular function and salt and water homeostatic hormones during amino acid and dopamine stimulation.

The purpose of the study was to evaluate renal functional reserve [RFR is the difference between glomerular filtration rate (GFR) at rest and maximal GFR after stimulation] in a controlled study in normal pigs. Our basic hypothesis was that a decreased RFR may be used as an early indicator of renal deterioration, i.e. a test to disclose significant obstruction as opposed to simple dilatation in hydronephrosis. During various forms of stimulation (amino acids, captopril and dopamine), we measured changes in GFR, renal plasma flow (RPF), tubular reabsorption of sodium and water, net uptake from plasma to the kidney of three salt and water homeostatic hormones (angiotensin II, aldosterone and atrial natriuretic peptide) and of glucagon, which is thought to play a key role as mediator of the GFR increase during amino acid infusion. We found the largest GFR increase during combined infusion of amino acids and dopamine (+13%), but compared with a non-stimulated control group, the GFR increase was statistically non-significant. RPF increased by 57% during stimulation with amino acids plus dopamine (P < 0.001), while tubular reabsorption of sodium and water, and renal uptake of angiotensin II, aldosterone and atrial natriuretic peptide showed no significant differences between control and stimulation groups. The renal uptake of glucagon increased significantly during amino acid stimulation with no concomitant GFR increase. We conclude that in this experimental, non-obstructed model, RFR is a very insensitive measure, which cannot be used to discriminate between obstruction and simple dilatation in hydronephrosis. Further, our study does not support the hypothesis that glucagon is involved in GFR changes after amino acids.

[Anderson-Hynes pyeloplasty in hydronephrosis]. / Anderson-Hynes-pyeloplastik ved hydronefrose.

The purpose of the study was to evaluate pyeloplasty a.m. Anderson-Hynes in the treatment of hydronephrosis in a large series of patients. In 175 patients, consecutively operated for ureteropelvic junction obstruction, we found 24 (14%) with minor postoperative complications, mostly urinary tract infection. Six patients (3%) were reoperated because of continued pain and obstructed drainage postoperatively. There was a small, but statistically significant increase in renal functional share on the operated side. We found a highly significant correlation between postoperative changes in total GFR and single kidney GFR on the operated side, which suggests a real improvement in renal function, rather than a simple reallocation of function between the two kidneys. We conclude that newer treatment modalities known as "minimally invasive surgery" must give comparably good results in order to be an acceptable alternative to traditional dismembered pyeloplasty.

99mTc-MAG3 kinetics in the normal pig. A comparison to 131I-OIH and 125I-iothalamate after single injection and during continuous infusion.

An invasive comparative study of some pharmacokinetic aspects of 99mTc-mercaptoacetyltriglycine (MAG3), 131I-orthoiodohippurate (OIH), and 125I-iothalamate (iothalamate) was performed in six pigs 0-150 min after a simultaneous single injection (SI) and during a subsequent 90 min of continuous infusion (CI). The total plasma clearance and the renal clearance of MAG3 were about 75% that of OIH. The renal clearance of MAG3 was about 2 1/2 times the glomerular filtration rate. The distribution volume of MAG3 was 71% that of iothalamate and only 47% that of OIH. There was a significant hepatic plasma clearance of MAG3 of 5.9 ml min-1 and 3.9% of the injected dose was excreted in the bile. HPLC analysis revealed that technetium was excreted in urine and bile mainly labelled to MAG3. The average red blood cell (RBC) binding after single injection/during continuous infusion was 1.0%/2.3% for MAG3, 13.5%/9.0% for OIH, and 3.1%/5.3% for iothalamate. The binding of OIH to RBC in arterial blood increased from 8% at 1 min post-injection to 21% at 150 min post-injection. The RBC binding was higher in the renal vein, indicating incomplete back diffusion from RBC to plasma. The protein binding was 90% for MAG3, 49% for OIH and 16% for iothalamate. The renal plasma extraction of MAG3 was constant but significantly smaller after SI (0.54) than during CI (0.62). Following SI, the renal plasma extraction of OIH decreased continuously from 0.85 to 0.52, 3-150 min post-injection. On the average there was no significant difference in renal plasma extraction after SI and during CI of either OIH (0.72 versus 0.77) or iothalamate (0.26 versus 0.27). It is concluded that MAG3 is preferential to OIH as a tracer for renal function studies using a single injection technique mainly due to the constant renal extraction of MAG3.

[Varicocele of the testis. A comparison between laparoscopic and conventional surgery]. / Varicocele testis. En sammenligning mellem laparoskopisk og konventionel operation.

We compared the results of laparoscopic varicocelectomy in 11 patients with those of 11 conventional varicocelectomies. There was a significantly longer operating time for laparoscopic surgery (45 versus 35 minutes), but a shorter hospital stay (one versus two days) and a quicker return to normal activity (two versus four days). There was no statistically significant difference in the outcome of surgery in the two groups concerning symptomatology and objective findings, but three patients, all conventionally operated, had no effect of the operation. One patient, operated laparoscopically, had signs of genitofemoral nerve injury. We conclude that laparoscopic varicocelectomy may be superior to conventional surgery, but further evaluation in larger, prospective studies is warranted.

[Infusion cavernosography and erectile dysfunction]. / Infusionskavernosografi og erektiv dysfunktion.

Infusion cavernosography with the object of quantitating the rate of venous drainage from the penis and localization of possible abnormities in drainage was employed as a routine investigation in examination of erectile dysfunction in 46 patients. "Infusion to obtain erection" (IOE) and "infusion to maintain erection" (IME) were determined. In five patients, IOE was found to be greater than 180 ml/minute which was considered to be diagnostic of venous leakage. Infusion cavernosography could be assessed in 31 patients. Filling of the glans with the radio-opaque medium was found before rigidity was obtained in 27 whereas, in 19 filling of the glans occurred after rigidity was obtained. No localizing fistulae were demonstrated. It is concluded that routine employment of infusion cavernosography in investigation of impotence is unnecessary. Filling of the glans with the radio-opaque medium in infusion cavernosography does not appear to be a sign of a cavernoso-spongious fistula but rather a physiological phenomenon.

[Burns. An epidemiologic casualty ward study]. / Brandsår. En epidemiologisk skadestueopgørelse.

Four hundred eighty five persons were treated for burns at the casualty ward of Aarhus County Hospital between 1 January and 31 December 1986. Compared to a previous study from the municipality of Copenhagen only minor differences were found concerning the distribution of patient sex and age, and the cause and scene of accident. Small children aged 0-5 years constituted a high risk group, representing more than 18% of all burn injuries. Ninety one per cent of the accidents in this group took place in the home, and the need for further prophylactic measures is evident. Our suggestions include better insulation of oven doors, and protective shields at the front of electric stoves. Further, we emphasize that children should never be left alone in the kitchen without proper supervision.

[Priapism. New diagnostic and therapeutic methods]. / Priapisme. Nye diagnostiske og terapeutiske metoder.

Priapism (P) may develop from unknown causes or may occur secondary to other disease or as a side effect of medication. The occurrence of pharmacologically induced erection by intracavernous injection of drugs has resulted in a number of cases of iatrogenic priapism. Priapism may be ischaemic or non-ischaemic and determination of the acid-base status in the cavernous blood may be of value in the choice of treatment. The non-ischaemic cases should be treated primarily by aspiration of blood, possibly followed by intracavernous injection of a vaso-constrictive agent, eg 15 micrograms adrenaline or noradrenaline, repeated if necessary. Cases which do not respond to this and severe ischaemic cases should be treated with glando-cavernous anastomosis.

Urodynamic effect of acute alpha-receptor blockade in patients with bladder neck dysfunction.

Forty-nine male patients, median age 35 years (range 16-59) with bladder neck dysfunction (BND) were investigated before and after intravenous administration of phentolamine to evaluate the effect of acute alpha-blockade on micturition parameters and to identify patients, who might benefit from alpha-blocking therapy. Under the influence of phentolamine we found a significant decrease in the mean values of maximal urethral closure pressure (MUCP), pressure at the bladder neck and prostatic profile length (PPL), a decreased bladder capacity, a more complete bladder emptying, and a small but significant improvement in peak flow rate (PFR). However, according to a flow-rate nomogram analysis with correction for voided volume, only two patients significantly improved their PFR. A subgroup of 20 "responders", defined as patients with any improvement of PFR after phentolamine, not caused by increased detrusor pressure was characterized by significantly longer opening time and lesser maximal flow rate before phentolamine (more severe BND). All other pressure-flow parameters as well as the static pressure at bladder neck niveau were not different. We conclude that it is not possible before phentolamine administration to select a group of patients, which might benefit from alpha-blockade and it is suggested that this procedure might be included in the evaluation of patients with suspected BND.

Urethral pressure variations in healthy male volunteers.

Urethral pressures are usually considered to be static and only few authors have emphasized time-related pressure changes. We conducted a study on 10 healthy male volunteers, monitoring the urethral pressures at maximal urethral closure pressure, 2.5 cm proximal (bladder neck) and 2.5 cm distal (pars bulbosa) respectively over 30 min periods. At the bladder neck only sporadic waves were seen. At maximal closure pressure almost permanent oscillations were found, the wavelengths and amplitudes showing big differences. At the pars bulbosa 2 persons showed only sporadic oscillations and in 7 we found permanent pressure variations. The pressure variations are proposed to represent peristaltic activity with the ability of expelling the last drops of urine after micturition and posing a mechanical barrier to ascending microorganisms.

Short- and long-term reproducibility of cystometry.

We investigated 8 male patients, age 28-51 years, mean 35, with symptoms of bladder neck dysfunction by means of repeated water-cystometry. We made four cystometries with different patient positions and filling rates followed by a further two cystometries after an interval of 8 days. We found no difference in bladder volumes at first sensation and maximal capacity between the different investigations, irrespective of patient position and filling rate. It was concluded that data obtained by water cystometry may be regarded as absolute.

Vesico-ureteral reflux. I. Renal function and morphology in relation to anamnestic and urodynamic parameters.

Hundred and one children aged 12 years or less were consecutively referred with non-neurogenic vesico-ureteral reflux. None of the patients were previously operated for reflux. Based on the degree of reflux and the degree of nephropathy judged from urograms or renoscintigrams the patients were assigned an index defined as the sum status of both nephro-ureteric units. We found no correlation between VUR index, nephropathy index and GFR on one side, and bladder function parameters (spontaneous voiding, cystometry, bladder activity during sleep) on the other. Further, no correlation was found to history concerning urinary tract infections or enuresis the year before admittance. Possible reasons for the lack of correlation are discussed.

Vesico-ureteral reflux. II. The longterm outcome of kidney function in non-surgical treatment.

Seventy one patients were included in a prospective study of non-surgical treatment of vesico-ureteral reflux (VUR). We found 111 refluxing ureters, with 20 grade 1, 4 grade 2, 41 grade 3, 5 grade 4 and 1 grade 5. There was no correlation between presenting symptoms and degree of VUR or nephropathy, or between renal function in terms of glomerular filtration rate. During followup the patients were treated with long-term low-dose antibiotic prophylaxis and voiding disorders were corrected pharmacologically or by micturitional training. With a median follow up time of 6 years (3-10) 63% of the patients had cessation or down grading of VUR, irrespective of initial VUR degree. There was no correlation between cessation rate and urodynamic parameters, GFR, history of enuresis or previous urinary infections. The study supports a non-surgical attitude towards VUR patients irrespective of VUR degree, with prophylaxis of urinary infections and possibly correction of voiding disorders.

Symptomatology and urodynamic findings in younger males with bladder neck dysfunction.

We studied consecutively 46 males, median age 36 years (range 16-59), diagnosed as bladder neck dysfunction (BND) according to a urodynamic investigation. The diagnosis was based on a prolonged opening time (greater than 04 sec) in the pressure-flow investigation and absence of organic obstruction and neurologic disease. Median duration of symptoms was 24 months (range 1-240). The most frequent symptoms were poor stream (in 70%), frequency (50%) and dribbling (37%), while 30 % had nocturia, and 20% urgency, dysuria or perineal pain during voiding. Thirty-two % had one or more urinary tract infections. We found no correlation between urodynamic findings and symptomatology in terms of total symptom-score or -duration. Median opening time was 10 sec. Patients with shorter opening time were found to have significantly greater Qmax, while the rest of the parameters did not differ. Concerning single symptom-items we found a significant correlation between small bladder capacity and frequency and nocturia but no correlation between obstructive symptoms and the pressure at the bladder neck or the urethral resistance factor. Previously used classifications of BND patients on basis of micturition pressure or response to acute alpha-blockade were not found to be of use and it is concluded that future research should be directed towards a better definition of outflow resistance which then may be used both diagnostically, prognostically and as a therapeutic aid.

Combined pressure and drainage studies in hydronephrosis.

Current evaluation of hydronephrosis includes pressure-flow studies as well as isotope renography with induced diuresis. A case is presented where a new approach of combining these two methods gave opposing results concerning the significance of obstruction. Some of the implications are discussed.

[Nocturnal erectile activity in erectile dysfunction. An examination of nocturnal penile tumescence and rigidity]. / Natlig erektiv aktivitet ved erektiv dysfunktion. Udredning vha. natlig penistumescens og rigiditet (NPTR).

The historical background for the use of sleep-related erections (nocturnal penile tumescence) to distinguish organogenic from psychogenic impotence is reviewed. A commercially available system for continuous, non-invasive measurement of penile tumescence and rigidity is presented.

Erectile dysfunction in multiple sclerosis.

In a sample of 29 impotent men with multiple sclerosis and erectile problems, penile arterial inflow and venous outflow were within normal limits. In 26 patients, the pudendal evoked potential (PEP) was abnormal, and eight of these also had abnormal bulbocavernous reflex (BCR). Three patients had abnormal PEP and normal BCR, and of these, two had normal and one had abnormal nocturnal erectile activity. The validity of PEP/BCR testing was supported by normal findings in six patients with MS and without erectile problems. Nocturnal erectile activity was normal in 11 patients, of whom nine had abnormal PEP and/or BCR. A high disability score corresponded poorly with both reduced sexual function, insufficient nocturnal erectile activity, and abnormal PEP and/or BCR. Intracavernous injection of papaverine gave erection in 27 patients, the dose needed to create an erection being inversely related to the level of disablement. PEP and BCR testing may be more sensitive in defining neurogenic erectile dysfunction (ED) than nocturnal erectile activity. We considered 26 of the cases to have a neurogenic cause of ED and three to have mainly a psychogenic cause.

Pharmacologically induced erection in patients with multiple sclerosis.

Intracavernous injection of papaverine was tested in a group of 29 patients with multiple sclerosis and erectile dysfunction. Acceptable rigidity was obtained in 27 patients of whom 23 started to use self-injections as treatment. During an observation period of 5-12 months (mean 8.5 months) a total of 297 injections (3-35 per patient) were reported and 272 injections (92%) produced rigidity in 8-480 min. One case of priapism was seen. Minor haematomas or ecchymoses were reported in 16 cases. Two patients developed penile indurations after 6 and 19 injections respectively; one of these indurations resolved spontaneously. Self-injection with papaverine was found to be a safe and well-accepted treatment of erectile dysfunction in multiple sclerosis but long term side effects need further elucidation before the treatment is to be used as a routine procedure.