Retrospective review of flow patterns following retropubic prostatectomy.

AIM OF THIS STUDY: We retrospectively evaluated penile inflows in 103 previously potent individuals who underwent standard nerve sparing radical retropubic prostatectomy (RRP) for the treatment of prostate cancer. No effort to identify or spare the accessory pudendal artery (APA) was made in any case. Our goal was to investigate the role of the accessory internal pudendal artery (APA) in the maintenance of erections in this population. We hypothesize that if the APA is present in a significant number of men, and its ligation significantly contributes to post-RRP impotence, then there should be an increased incidence of asymmetry between R/L cavernous arterial flows among post RRP patients with vascular impotence. MATERIALS AND METHODS: One hundred and three previously potent individuals complaining of persistent erectile dysfunction for at least six months after RRP were studied with color duplex Doppler, following age specific dosing of PGE1. Vascular assessment was performed before and after self-stimulation, measuring peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI). Erections were visually rated as inadequate (INA), adequate (ADE) for penetration, or excellent (EXC) with sustained rigidity for at least 20 min. Cavernous artery asymmetry (CAA) was defined as a >10 cm/s difference between right and left sided arterial flows. RESULTS: Mean duration between surgery and Doppler study was 14.7 months. 27 out of 103 (26%) of patients developed excellent rigidity consistent with isolated neurogenic impotence (PSV=32.0 cm/s, mean RI=0.95); 24 out of 103 (23%) had adequate vascular responses making it impossible to infer presence or absences of neurogenic impotence; 52 out of 103 (51%) had inadequate rigidity consistent with vascular insufficiency (PSV=23.7 cm/s, mean RI=0.66). We noted that of patients with EXC response, 48% (13 out of 27) had CAA. Among patients with severe inflow disease (INA responders), CAA was seen in only 21% of cases (11 out of 52). CONCLUSIONS: The incidence of APA has been reported as being from 4-70%, and its significance in the maintenance of erections has been questioned. Assuming that the APA provides significant inflow in some patients, we expected an increase in CAA in individuals in whom it was sacrificed. We found a higher incidence of CAA among post-RRP patients with normal vascular erectile responses to PGE1 (48%) compared to men with true vasculogenic impotence post-RRP (21%). These data do not support the importance of the APA in the maintenance of erections in the post-RRP patient.

Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes.

PURPOSE: To compare the success of percutaneous varicocele embolization to surgical ligation with regard to changes in semen characteristics and pregnancy outcome. MATERIALS AND METHODS: Infertility records from 346 men who underwent correction of their varicocele for infertility (surgical ligation 149; embolization 197) were reviewed retrospectively. Preprocedural and postprocedural semen analyses and pregnancy outcomes were obtained with use of chart and telephone follow-up. RESULTS: In men who successfully impregnated their partners, there were significant improvements in sperm density, percent total improvement, motility, and progression. Postprocedural (embolization vs surgery) percentage increases in seminal parameters were density, 156.8% versus 138.5%; total, 168.8% versus 157.91%; and motility, 2.7% versus 3.2%. The percent of individuals who had a change in sperm progression was 31% versus 41%. There was no statistical difference between the techniques based on t tests. The pregnancy rates were similar for the two groups, 39% and 34% for embolization and surgery, respectively. CONCLUSION: There is no significant statistical difference in seminal values or pregnancy outcome between the two techniques.

Development of prostate cancer after pituitary dysfunction: a report of 8 patients.

OBJECTIVES: Eight patients with a history of pituitary dysfunction were seen in the Department of Radiation Oncology at the Hospital of the University of Pennsylvania for evaluation of their prostate carcinoma. Because prostate cancer is a hormonally responsive cancer, hormonal abnormalities from pituitary dysfunction may have played a role in its development. In addition, many patients with pituitary dysfunction receive exogenous hormonal replacement. The histories of these 8 patients were reviewed to look for any common underlying factor in the development of their prostate cancer. METHODS: The radiation oncology charts, hospital charts, and pathology reports were reviewed. The cause and treatment of the pituitary disorder were reviewed. Hormonal dysfunction, hormonal replacement, and treatment duration were recorded. The interval to the development of prostate cancer, stage at diagnosis, prostate-specific antigen level, Gleason score, treatment, and treatment outcome were also investigated. RESULTS: We found a variety of pituitary disorders and treatments. However, all patients received testosterone replacement therapy prior to the development of their prostate cancer (median of 30 months). The time to the development of the cancer ranged from 26 to 250 months (median 98). Patients had Stage T2 or T3 tumors at diagnosis. Patients were treated either with radical prostatectomy or radiation therapy. Six of the 8 patients were alive and doing well at their last follow-up examination. CONCLUSIONS: Prostate cancer has been shown to be androgen responsive. All the patients in this series were placed on physiologic testosterone replacement for pituitary dysfunction. The role of testosterone in the initiation of prostate cancer has been debated. However, at the present time, it seems appropriate to establish close monitoring for prostate cancer in patients receiving androgen therapy for pituitary dysfunction.

A multivariable analysis of clinical factors predicting for pathological features associated with local failure after radical prostatectomy for prostate cancer.

PURPOSE: A multivariate analysis is used to determine the predictive value of pretreatment clinical indicators on pathologic features associated with local failure after radical prostatectomy in patients with prostate cancer. METHODS AND MATERIALS: A retrospective review of the pathologic findings of 235 patients with adenocarcinoma of the prostate treated between 1990 and 1993 with a radical retropubic prostatectomy was performed. The preoperative clinical data including the serum prostate specific antigen, clinical stage, Gleason sum, and endorectal magnetic resonance scan findings are used to identify patients prior to definitive treatment who would be at high risk for having pathologic features associated with local failure at radical prostatectomy. Outcome prediction curves are constructed from a logistic regression multivariate analysis displaying the probability of pathologic involvement of the seminal vesicle, extracapsular disease, or positive surgical margins as a function of the preoperative prostate specific antigen and Gleason sum for the cases when the endorectal magnetic resonance scan is positive, negative, or not included in the multivariate analysis. RESULTS: Factors identified on multivariate analysis as significant predictors of seminal vesicle invasion include endorectal magnetic resonance scan findings (p < 0.0001), and preoperative prostate specific antigen (p = 0.017). Endorectal magnetic resonance scan findings (p = 0.0016), preoperative prostate specific antigen (p = 0.0002), and Gleason sum (p < 0.0001) were significant predictors of extracapsular extension and preoperative prostate specific antigen (p < 0.0001) and Gleason sum (p = 0.03) were significant predictors of disease extending to the margins of resection. Clinical stage was not a significant predictor (p > 0.05) of pathologic features associated with local failure on multivariate analysis. As a single modality, endorectal surface coil magnetic resonance imaging was accurate 93%, 69%, and 72% of the time for predicting seminal vesicle invasion, transcapsular disease, and final pathologic stage, respectively. Failure to recognize microscopic penetration of the capsule found at the time of pathologic evaluation in a prostate gland with a grossly intact capsule accounts for the majority (70%) of the staging inaccuracies. CONCLUSIONS: The use of the endorectal surface coil magnetic resonance scan findings in conjunction with both the serum prostate specific antigen and Gleason sum improves the clinical accuracy of predicting those patients at high risk for clinically unsuspected extraprostatic disease. In particular, for the subgroup of patients with moderately elevated prostate specific antigen (> 10-20 ng/mL) and intermediate grade clinically organ confined prostate cancer [Gleason sum: 5-7] where the specificity of these tests to predict for occult extraprostatic disease is suboptimal, the additional information obtained from the endorectal coil magnetic resonance scan allows the physician to definitively subgroup these patients into low and high risk for seminal vesicle invasion or transcapsular disease.

Interstitial emphysema associated with epidural anesthesia for extracorporeal shock-wave lithotripsy.

Interstitial emphysema was noted on abdominal radiographs in 38 (15%) of the first 150 patients treated by extracorporeal shock-wave lithotripsy at our hospital. All 38 patients had undergone successful or attempted epidural anesthesia for the lithotripsy. This finding was not seen in any patient who had not undergone epidural puncture. The emphysema is the result of the introduction of air into the paraspinal and back muscles or subcutaneous tissues during attempted or actual puncture of the epidural space. This air was apparent on abdominal radiographs taken after lumbar puncture in 38 (23%) of 167 patients who underwent attempted or actual puncture of the epidural space. The emphysema decreases over the ensuing days, is of no clinical significance, and bears no direct relationship to extracorporeal shock-wave lithotripsy. This finding should not be mistaken for emphysema caused by gas-producing or gas-containing retroperitoneal diseases.

Kidney changes after extracorporeal shock wave lithotripsy: CT evaluation.

Computed tomography (CT) was performed in 50 patients before and after extracorporeal shock wave lithotripsy (ESWL) to determine the effects of ESWL on the kidney and perinephric tissues. Bilateral treatments were performed in three patients. Post-ESWL scans demonstrated subcapsular hematomas in eight (15%) patients (two large, six small, none symptomatic) and intrarenal hematomas in two (4%) patients. In three (6%) patients small subcapsular fluid collections of uncertain cause were seen. Treated kidneys showed a statistically significant mean increase in size (9%) after ESWL, as measured at the axial level of the major stone fragment. Perinephric soft-tissue stranding and fascial thickening were seen in 37 (70%) of 53 treated renal fossae, with the changes ranging from mild to severe. The authors conclude that while most patients undergoing ESWL will show some posttreatment abnormality on CT scans, the procedure appears to be associated with a low frequency of serious renal trauma.

Erectile failure following pelvic trauma: a review of pathophysiology, evaluation, and management, with particular reference to the penile prosthesis.

Twenty-five inflatable and two semi-rigid rod type penile prostheses have been implanted in 27 patients with erectile failure following pelvic trauma. Reoperation was required in 13 patients in the inflatable prosthesis group but ultimate success and satisfaction were achieved in 92%. The etiology of erectile failure following various types of trauma is reviewed, as well as the approach to the evaluation of erectile failure in such a patient. Where etiology-specific corrective therapy is not possible, the penile prosthesis has proven to be an acceptable form of substitution therapy.

The contractile and metabolic effects of acute ischemia on the rabbit urinary bladder.

The present study determined the effect of 1 hour of in vivo ischemia on the response of the rabbit urinary bladder to specific autonomic agonists and on the intracellular adenosine triphosphate content. A 48 per cent decrease in the contractile response of the base to the alpha agonist methoxamine was noted. A 42 per cent decrease in the response of the bladder body to bethanechol was found. Neither tissue improved significantly after a 1-week recovery period. Ischemia caused an immediate 80 per cent decrease in the intracellular adenosine triphosphate content that improved to 50 per cent of control with a 1-week recovery period. Although the site of the defect is not definitely identified, acute ischemia resulted in a decreased contractile response that could result in bladder dysfunction.

Transureteroureterostomy in spinal cord injury patients for persistent vesicoureteral reflux: 6 to 14-year followup.

We did a long-term followup for spinal cord injury patients who had undergone transureteroureterostomy for persistent reflux after failed vesicoureteroplasty. Particular attention was paid to the complications that are unique to these patients and include the trapping of ureteral calculi, recurrent vesicoureteral reflux and bladder hypertrophy with vesicoureteral junction obstruction. Caution is advised in using this procedure in the spinal cord injury patient because of these problems despite the over-all success in maintaining the patency of the anastomosis.