A. Adil Esen

Ferritin: a tumor marker expressed by renal cell carcinoma.

Renal cell carcinoma (RCC) has been shown to secrete several hormones and biologically active substances that influence the host metabolism or induce paraneoplastic syndromes. Observation of anemia in 20% of patients with RCC and the spontaneous recovery of anemia following nephrectomy drew attention to the body iron metabolism. Ferritin was previously proposed as a tumor marker for RCC. In order to determine whether RCC cells actually produce ferritin, we studied ferritin levels in serum from peripheral and renal veins as well as from the tumor tissue and the healthy parenchyma from radical nephrectomy specimens of 22 patients with RCC. Ferritin levels both in sera and cytosols were measured by an enzyme immunoassay method. The mean serum ferritin level from the renal vein was 419.9 +/- 72.4 ng/ml, and it was 157.3 +/- 18.3 ng/ml from the peripheral vein (p < 0.05). Renal vein ferritin correlated with stage and had a significant impact on prognosis (p < 0.05). The mean cytosolic ferritin level of the cancer tissue was 705.6 +/- 56.9 ng/mg cytosol protein, whereas in the normal parenchyma it was 95.9 +/- 10.1 ng/mg cytosol protein. This was also highly significant (p = 1.15 x 10(-13)), suggesting that RCC cells probably express ferritin. As currently there exists no reliable tumor marker for RCC, the value of ferritin as a marker should be investigated further before drawing any clinical conclusions.

Effect of ejaculation on prostate-specific antigen levels in normal men.

While several manipulations such as digital rectal examination and cystoscopy have been shown to increase prostate-specific antigen (PSA) levels, lack of ejaculation for a period of time has been implicated as a cause of decreased serum PSA concentrations. However, the effect of ejaculation on the serum PSA concentration is not clear. This work determined the effect of ejaculation on serum PSA levels in normal men. Blood samples of 19 healthy subjects were taken before and 5 consecutive days after ejaculation. One subject was withdrawn from the study because of ejaculation during sleep, since another ejaculation was prohibited during the study. The mean PSA levels of the men before and 5 consecutive days after ejaculation were 0.79, 0.72, 0.63, 1.01, 0.71, and 0.74 ng/ml--not statistically significantly different. We conclude that ejaculation does not seem to affect the serum PSA concentration.

A NEW METHOD FOR THE EVALUATION OF ERECTILE DYSFUNCTION: SILDENAFIL PLUS DOPPLER ULTRASONOGRAPHY

PURPOSEnOf the various methods of hemodynamic studies performed to evaluate erectile dysfunction penile color Doppler ultrasound is currently considered the best. However, intracavernous injection is invasive and has adverse effects, such as prolonged erection. We evaluated whether sildenafil may be used as a substitute for intracavernous agents when assessing impotence on color Doppler ultrasound.nnnMATERIALS AND METHODSnA total of 42 patients with erectile dysfunction underwent color Doppler ultrasound before and after intracavernous injection of 60 mg. papaverine with genital and audiovisual sexual stimulation. Peak flow and end diastolic velocity were measured in the recorded waveforms obtained 0, 1, 5, 10 and 20 minutes after injection. The patients also underwent color Doppler ultrasound after a 50 mg. oral dose of sildenafil with genital and audiovisual sexual stimulation not before 3 days after the papaverine study. The same parameters were measured at 30, 45, 60, 75 and 90 minutes, and compared with the values obtained after papaverine injection.nnnRESULTSnMean peak flow velocity significantly increased after oral sildenafil starting at 30 minutes and achieving a maximum value at 60 minutes. There were no significant differences in the 2 methods in mean peak velocity 1, 5, 10 and 20 minutes after papaverine injection, and 30, 45, 60, 75 and 90 minutes after oral sildenafil administration. Penile color Doppler ultrasound with intracavernous papaverine injection is accepted as the gold standard but color Doppler ultrasound with sildenafil has 90% sensitivity and 100% selectivity for demonstrating arterial insufficiency. Due to prolonged erection 5 patients (11.9%) in the papaverine group required pharmacological detumescence by intracavernous injection. No adverse effects of sildenafil were observed.nnnCONCLUSIONSnSildenafil administration achieved increased peak flow velocity comparable to that after intracavernous papaverine injection. With no prolonged erection sildenafil emerges as a safer alternative compared to more invasive intracavernous injection.

Place of double-J stents in extracorporeal shock wave lithotripsy.

Although double-J stents (DJS) are used to reduce complications following extracorporeal shock wave lithotripsy (ESWL), there has recently been a tendency to limit their use because of complications. We retrospectively reviewed 351 patients with renal stones larger than 30 mm to determine the effectiveness and the complications of DJS. While DJS were inserted prior to ESWL in 85 patients, 266 patients were treated without. The stone-free rate in the stented group was not significantly different from the non-stented group (31 and 30%). While the auxiliary treatment rate for the steinstrasse was 15% in the stented group, it was 18% in the non-stented group. Additionally, 4 of the stented patients (5%) were treated endoscopically because of encrustation or migration of the stent. Half of the patients in the stented group complained of mild bladder discomfort and disturbances which were relieved after removal of the DJS. We believe that DJS neither enhance stone passage nor reduce complications following ESWL, and therefore suggest their use only under certain conditions such as patients with solitary kidneys.

Faculty Development Program in Dokuz Eyl?l School of Medicine: In the process of curriculum change from traditional to PBL

Abstract Introduction: In Dokuz Eylül School of Medicine (DESM) a faculty development program is being carried out by the “Trainers’ Training Committee?. DESM made a fundamental change in its curriculum from traditional to Problem-based Learning (PBL) in 1997. This was the first implementation of a PBL curriculum in Turkey. Faculty development activities were initiated in the same year. This paper describes the faculty development activities with a special emphasis on PBL courses. Program description: Between 1997-2000 27 four-day long PBL courses were held for 343 participants. The curriculum consisted of PBL philosophy, PBL steps, role of the tutor and students in PBL process, effective case design, assessment principles and group dynamics. PBL simulations enabled the participants to play the roles of both tutors and students. Process evaluation: At the end of the program most of the participants stated that length of the program, content, training methods and the course organization was appropriate. The majority of the participants (89.5%) found the program very useful. PBL steps, PBL practices and PBL philosophy were found as the most useful sessions. Discussion: These courses gave medical staff the opportunity to develop their understanding of PBL methodology and theory. PBL courses and continuous educational activities such as weekly tutor meetings are being held and new courses on advanced tutoring skills are being planned for the near future in DESM.

THE PREDICTION OF PAPAVERINE INDUCED PRIAPISM BY COLOR DOPPLER SONOGRAPHY

PURPOSEnWe identified color Doppler sonography findings that are useful for predicting priapism in patients after the intracavernous injection of diagnostic papaverine.nnnMATERIALS AND METHODSnWe evaluated 72 men with erectile dysfunction by color Doppler sonography after the diagnostic injection of papaverine. Cavernous artery waveforms were recorded, and peak systolic and diastolic velocity of the recorded waveforms was measured. In cases of priapism color Doppler sonography findings were retrospectively evaluated to identify any finding that would predict priapism.nnnRESULTSnPriapism was observed in 8 of the 72 patients (11.1%). In 6 of 8 priapism cases there was no blood flow in the cavernous artery during or after adequate erection, including after minutes 5, 10 and 20 in 3, 1 and 2, respectively. This absence of encoding was not relieved even after all stimuli were removed. In 2 patients who later presented with complaints of priapism the Doppler study was completed normally and all parameters were acquired without any cessation of blood flow in the cavernous artery. The persistent disappearance of color and pulse encoding in the cavernous artery predicted priapism with 75% sensitivity, 100% specificity, a positive and negative predictive value of 100% and 96.9%, respectively, and 97% accuracy.nnnCONCLUSIONSnThe persistence of absent blood flow in the cavernous artery even after the elimination of all stimuli during penile color Doppler ultrasound is a reliable predictor of priapism. The finding is accurate enough to initiate treatment for priapism to avoid further delay.

Analysis of premature ejaculation in hemodialysis patients using the International Index of Erectile Function.

Objective: We have conducted the following study to determine the prevalence of premature ejaculation in male hemodialysis patients and its impact on sexual quality of life. Methods: This study was performed in hemodialysis facilities. Patients were asked to complete the International Index of Erectile Function (IIEF) questionnaire and also to report their ejaculation status. 98 male hemodialysis patients with normal potency were included in the study. The IIEF domain scores were determined, and the overall and relationship satisfaction rates were calculated for the patients with and without premature ejaculation separately. Results: The mean age was 45.9 (range 30–69) years and the duration of hemodialysis was 37.8 (range 7–84) months. Premature ejaculation was determined in 31 (31.6%) patients. Patients with premature ejaculation experienced significantly lower overall satisfaction scores. Items of satisfaction with overall sexual life and sexual relationship with partner were responded to with a score of ‘moderately satisfied’ or ‘very satisfied’ in 47 and 53% of patients with premature ejaculation and 84 and 86% of patients without premature ejaculation, respectively. Conclusions: Premature ejaculation is a prevalent disorder in hemodialysis patients and seems to affect the satisfaction rate and sexual quality of life of these patients.

CONTRACTILITY CHANGES OF THE DEEP DORSAL PENILE VEIN DUE TO SEROTONIN

PURPOSEnPenile erection is a complex neurovascular phenomenon that takes place with the active contribution of arterial and sinusoidal structures. However, some authors claim that larger veins including the deep dorsal veins that produce contractions, might be involved in the physiology of erection. This study was designed to clarify the contractile properties of deep dorsal penile veins (DDPV).nnnMATERIALS AND METHODSnThe effect of serotonin (5-HT), noradrenaline (NA), adenosine triphosphate (ATP) and acethylcholine (Ach) on the isolated DDPVs of 16 impotent men, 9 with veno-occlusive dysfunction and 7 without venous leakage, and 5 potent men (controls) who underwent radical prostatectomy, were examined in vitro.nnnRESULTSnAlthough NA, ATP and Ach had no effect, 5-HT produced concentration-dependent contractions. Emax and pEC50 of 5-HT were 411 +/- 10 mg., 5.92 +/- 0.25; 1020 +/- 260 mg., 5.83 +/- 0.24 and 160 +/- 40 mg., 6.4 +/- 0.22 in controls and patients who had venous leakage and no venous leakage, respectively. Samples of controls were contracted only with 5-HT2 agonist, DOI (pEC50 = 5.63 +/- 0.02), and these contractions were antagonized with 5-HT2 antagonist ketanserin. On the other hand, both DOI (pEC50 = 6.30 +/- 0.77) and 5-HT1 agonist, 5-CT (pEC50 = 6.23 +/- 0.21) produced venoconstriction in patients with veno-occlusive dysfunction.nnnCONCLUSIONSnThe present findings suggest that 5-HT receptor functions in the DDPVs are of 5-HT2 subtype in potent men and the altered response to 5-HT in patients with veno-occlusive disease may play a role in the pathophysiology of impotence.

Early Catheter Removal following Transurethral Prostatectomy:Overnight Catheterization

Objective: Our aim was to determine the safety and feasibility of catheter removal on the first morning after transurethral prostatectomy. Methods: Fifty-four patients who underwent transurethral prostatectomy were included in a prospective study. The decision to remove the catheters on the first morning after surgery was based on the color of the catheter effluent, absence of clots, normal vital signs and adequate urine output. Patients who voided successfully were discharged on the same day as catheter removal. Results: Catheters were removed in 43 (79.6%) patients on postoperative day 1. Of these patients 40 (93%) voided successfully, however 3 of them required recatheterization due to bleeding or urinary retention. The criteria for catheter removal were not met in 11 patients and their catheters were removed on postoperative day 2 in 2 and on postoperative day 3 in 9. The mean length of hospital stay after surgery was 1.74 days for the entire group and 1.41 days for those in whom the catheter was removed on postoperative day 1. Conclusion: Overnight catheterization after transurethral prostatectomy seems to be a feasible approach without leading to significant morbidity in selected patients.

Concealed Penis:Rare Complication of Circumcision

A man presented with a concealed penis which developed after circumcision. In addition to anatomic variations in penile skin attachment and obesity, circumcision is an iatrogenic cause in the etiology of a concealed penis. Although it is a frequent and simple operation, it may lead to uncommon complications due to a lack of experience and poor technique.