Andre G. Cavalcanti

Penile fracture: experience in 56 cases

OBJECTIVE The aim of this work is to report the diagnostic and therapeutic options for 55 patients with clinical diagnosis of penile fracture. MATERIAL AND METHODS The patients were retrospectively assessed between 1982 and 2002. The primary diagnostic evaluation method for 55 patients (56 fractures) was clinical history and physical exam. Ten (17.8%) cases required complementary exams. Ultrasound (US) was performed in 2 cases, and magnetic resonance imaging (MRI) in 1 case. Retrograde urethrocystogram was performed in suspicious urethral injury, which happened for 7 patients. RESULTS Of 56 assessed cases, 49 (89.5%) were submitted to surgical exploration, and only 7 were conservatively conducted. Surgical treatment was performed in 48 patients (49 fractures), in these cases, 47 (95.9%) presented tunica albuginea disruption and solely 2 (4.1%) evidenced lesion of dorsal vein. Ultrasonography confirmed disruption of tunica albuginea in 1 (50%) case, and in the other it was not possible to determinate the origin of the lesion, and the patient was submitted to surgical exploration, which confirmed the condition. MRI was used only in 1 case, confirming the lesion. Among 7 patients submitted to conservative management, until now, 3 (42.8%) required surgical intervention to correct penile chordee. CONCLUSIONS Penile fracture is an entity of eminently clinical diagnosis, which management should be surgical and immediate, avoiding thus complications related to erectile dysfunction. When suspecting an associated urethral injury, Urethrocystogram is recommended. In cases where there is diagnostic uncertainty, ultrasound and/or MRI may be used to reveal the condition.

A morphometric analysis of bulbar urethral strictures.

In a beautifully descriptive paper, authors from Rio de Janeiro and San Francisco report a quantitative and qualitative histological analysis of spongiosal tissue in patients with bulbar urethral strictures. They found that stricture formation was characterised by major alterations in extracellular matrix features.

The effect of oestrogen and testosterone on the urethral seam of the developing male mouse genital tubercle

To describe the effects of exogenous oestrogens and androgens on urethral formation in the mouse, as the development of the mouse and human urethra have significant similarities, and understanding normal male urethral development may help to identify the causes of abnormal development, e.g. hypospadias.

Penile Fracture: Diagnosis, Treatment and Outcomes of 150 Patients

OBJECTIVE To report the diagnosis, treatment options, and outcomes of 150 patients with suspicion of penile fracture. MATERIALS AND METHODS We analyzed 150 patients with clinically suspected penile fracture (PF). The patients were divided into two groups: group 1 (G1) with low suspicion of penile fracture (n = 25), and group 2 (G2) with high suspicion of penile fracture (n = 125). Complementary image methods were conducted on 59 patients (39.3%), with ultrasonography (USG) performed on 37 (24.6%) patients and magnetic resonance imaging on only one (0.6%). Retrograde urethrocystogram was performed when urethral injury was suspected (21 patients, 14%). In G1, all patients underwent USG to complement diagnosis. In G2, 12 patients underwent USG owing to a doubtful diagnosis. Mean follow-up was 34.6 months. RESULTS All patients in G1 were able to achieve erection after the initial traumatic event and immediate penile detumescence did not occur in any of the cases. Of the 125 patients evaluated in G2, 110 (92%) presented with disruption of the tunica albuginea and 15 (8%) showed injury of the dorsal vein of the penis. Urethral injury was found in 20 (16%) patients and was always associated with corpus cavernosum injury. Among 110 cases of PF, 95 (86.3%) presented with unilateral and 15 (13.7%) presented with bilateral lesions. CONCLUSIONS Patients with high suspicion of PF should be treated surgically. However, in cases of low suspicion of corpora cavernosum injury, based on clinical criteria and imaging methods, conservative treatment is a feasible and safe option.

Treatment of Recurrent Priapism in Sickle Cell Anemia With Finasteride: A New Approach

OBJECTIVES To determine whether the use of finasteride controls recurrent priapism in patients with sickle cell anemia. METHODS Thirty-five patients with recurrent priapism because of sickle cell disease received finasteride during 120 days. The initial dose was decreased every 40 days, from 5 mg/d to 3 mg and then to 1 mg of finasteride until the end of 120 days. Five groups (G) were created based on priapism episodes in a month: G0, no episode; G1, 1-15 episodes; G2, 16-30; G3, 31-45; and G4, >45 episodes. RESULTS Records on day 0: G0, no patient; G1, 7 (20%); G2, 21 (60%); G3, 4 (12%); and G4: 3 (8%). After 40 days of using 5 mg/d finasteride we found the following results: G0, 5 patients (14%); G1, 19 (55%); G2, 8 (23%); G3, 3 (8%); and G4, none. At the end of the 40-day period, using 3 mg/d finasteride, the findings were as follows: G0, 19 patients (55%); G1, 14 (39%); G2, 2 (6%); G3, none; and G4, none. The findings after 120 days with 1 mg/d finasteride for the last 40 days were as follows: 16 patients (46%) and G1, 16 (46%). In 1 patient, the dose was increased to 3 mg and in 2 patients, to 5 mg, so as to achieve remission. CONCLUSIONS To our knowledge, this is the first study demonstrating that the use of finasteride could decrease and control the number of priapism recurrences in patients with sickle cell anemia, with fewer side effects than other drugs currently used.

LEFT RETROCAVAL URETER ASSOCIATED WITH INFERIOR VENA CAVAL DUPLICATION

Retrocaval ureter is a rare anomaly with an incidence of l / l ,OOO live births. Symptoms are associated with ureteral obstruction. Excretory urography (IVP) detects retrocaval ureter as hydronephrosis and dilatation of the proximal ureter with medial deviation. The diagnosis may be confirmed by retrograde pyelography or helical computerized tomography (CT). To our knowledge we report the first case of left retrocaval ureter associated with duplication of the inferior vena cava.

Bulbar urethroplasty using the dorsal approach: current techniques

INTRODUCTION The use of flaps or grafts is mandatory in patients with longer and complex strictures. In 1995-96 we described a new dorsal onlay graft urethroplasty. Over time, our original technique was better defined and changed. Now this procedure (also named Barbagli technique) has been greeted with a fair amount of enthusiasm in Europe and in the United States. SURGICAL TECHNIQUE The patient is placed in normal lithotomy position, and a midline perineo-scrotal incision is made. The bulbar urethra is then free from the bulbo-cavernous muscles, and is dissected from the corpora cavernosa. The urethra is completely mobilized from the corpora cavernosa, it is rotated 180 degrees, and is incised along its dorsal surface. The graft (preputial skin or buccal mucosa) or the flap is fixed and quilted to the tunica albuginea of the corporal bodies. The right mucosal margin of the opened urethra is sutured to the right side of the patch-graft. The urethra is rotated back into its original position. The left urethral margin is sutured to the left side of the patch graft and to the corporal bodies, and the grafted area is entirely covered by the urethral plate. The bulbo-cavernous muscles are approximated over the grafted area. A 16F silicone Foley catheter is left in place. COMMENTS Dorsal onlay graft urethroplasty is a versatile procedure that may be combined with various substitute materials like preputial skin, buccal mucosa grafts or pedicled flaps.

EARLY CATHETER REMOVAL AFTER ANTERIOR ANASTOMOTIC (3 DAYS) AND VENTRAL BUCCAL MUCOSAL ONLAY (7 DAYS) URETHROPLASTY

INTRODUCTION Physicians who perform urethroplasty have varying opinions about when the urinary catheter should be removed post-operatively, but research on this subject has not yet appeared in the literature. We performed voiding cystourethrogram (VCUG) on our anterior urethroplasty patients on days 3 (anastomotic) and 7 (buccal) in an effort to determine the earliest day for removal of the urethral catheter. MATERIALS AND METHODS Retrospective chart review of 29 urethroplasty patients from October 2002-August 2004 was performed at two reconstructive urology centers. 17 patients had early catheter removal (12 anastomotic and 5 ventral buccal onlay urethroplasty) and were compared to 12 who had late removal (7 anastomotic and 5 buccal). RESULTS Of those with early catheter removal, 2/12 (17%) of anastomotic urethroplasty patients had extravasation, which resolved by the following week and 0/5 (0%) of the buccal mucosal urethroplasty patients had extravasation. Patients with late catheter removal underwent VCUG 6-14 days (mean 8 days) after anastomotic urethroplasty and 9-14 days (mean 12 days) after buccal mucosal urethroplasty. 0% of the anastomotic urethroplasty had leakage after the late VCUG and 1/5 (20%) of the buccal patients had extravasation after the VCUG. Recurrences were low in all patient groups. CONCLUSION Catheter removal after anastomotic and buccal mucosal urethroplasty can be safely attempted on the 3rd and 7th post-operative days respectively, with a low rate of extravasation on VCUG. Eliminating the catheter as soon as possible should improve patient comfort without harming results and decrease the overall negative impact of surgery on the patient.

Relation between the area affected by Fournier's gangrene and the type of reconstructive surgery used: a study with 80 patients

OBJECTIVE To assess the affected skin area and the reconstructive techniques used in 80 patients affected by Fourniers gangrene. MATERIALS AND METHODS Eighty patients ranging in age from 19 to 85 years (mean = 51) affected by Fourniers gangrene were studied. When admitted to the emergency room the patients were submitted to clinical and laboratory examinations to analyze the gravity of the case. All patients were submitted to an extensive debridement of the lesion, urinary derivation by cystostomy and colostomy whenever necessary. RESULTS Only 13 patients (16.25%) died. From the 67 remaining patients, in 44 (65.6%) debridement was restricted to the scrotum, in 10 (14.9%) there has been scrotum and penile lesions and in 13 (19.3%) there has been a debridement of the scrotum and the perineal region. In 11 cases (16.4%) there was no need for reconstructive surgery with wound closing by second intention, in 16 cases (23.8%) reconstructive surgery was performed with mobilization of local skin, in 19 (28.3%) we have used skin grafts, 20 patients (29.8%) needed reconstructive surgery with the use of skin flaps and in 1 case (1.4%) there has been the use of skin flaps and grafts simultaneously. CONCLUSIONS Fourniers gangrene is a serious pathology and should be treated aggressively with an extensive debridement of the area with necrosis. The use of precocious reconstructive surgery of the genitals present good results and tends to greatly reduce the length of hospital stay and improve the psychological conditions of these patients.

Management of urethral lesions in penile blunt trauma

Background: Traumatic lesions to the penis may extend into the corpus spongiosum, causing laceration or complete transection of the urethra. Blunt penile trauma is usually related to sexual intercourse or manipulation. The aim of this paper was to report the authors experience with the management of urethral injuries in patients with penile blunt trauma.