Edmund S. Sabanegh

INCIDENCE OF FECAL AND URINARY INCONTINENCE FOLLOWING RADICAL PERINEAL AND RETROPUBIC PROSTATECTOMY IN A NATIONAL POPULATION

PURPOSEnSince 1991 we have performed more than 300 anatomical radical perineal prostatectomies at Brooke Army and Wilford Hall Medical Centers, and were initially aware of 8 patients who presented with unsolicited postoperative fecal incontinence. We determined the incidence of fecal and urinary incontinence following radical prostatectomy, defined parameters to identify patients at risk for fecal complaints following radical prostatectomy, and estimated the impact of fecal incontinence on lifestyle and activities.nnnMATERIALS AND METHODSnInitially a validated 26-question telephone survey was used to evaluate 227 patients who had previously undergone radical prostatectomy at 1 of our 2 institutions. Based on results of the telephone survey a national survey was mailed to 1,200 radical prostatectomy patients randomly selected from a nationwide database of Department of Defense health care system beneficiaries. All patients had undergone radical perineal or retropubic prostatectomy at least 12 months before being contacted for the survey.nnnRESULTSnResponses to the telephone survey from 227 patients revealed that fecal incontinence was a problem after radical retropubic (5%) and perineal (18%) prostatectomy and less than 50% of those with fecal incontinence had told the physician. Our mail survey (response rate 80% and 78% usable for analysis, 784 radical perineal and 123 perineal) strongly indicated that fecal incontinence after radical prostatectomy is a problem nationwide. Frequency of fecal incontinence (daily, weekly, monthly or less than monthly occurrences) was significantly higher among radical perineal (3, 9, 3 and 16%) compared to retropubic prostatectomy (2, 5, 3, and 8%) patients (p=0.002). Fecal incontinence had a significant negative effect on patient social or entertainment activities (p=0.029), and travel and vacation plans (p=0.043). Radical perineal compared to retropubic prostatectomy patients were more likely to wear a pad for stool leakage (p=0.013), experienced more accidents (p=0.001), had larger amounts of stool leakage (p=0.002) and had less formed stools (p=0.001). Of radical perineal prostatectomy patients only 14% and of retropubic only 7% with fecal incontinence had ever told a health care provider about it, even when the incontinence was severe. Responses to our survey concerning urinary incontinence showed that radical perineal prostatectomy patients had a lower rate of urinary incontinence immediately after prostatectomy compared to retropubic (79 versus 85%, p=0.043). A higher proportion of perineal patients reported that all urinary leakage had ceased, that is full continence had returned (perineal 70%, retropubic 53%, p=0.001). A smaller proportion of perineal patients found it necessary to wear a pad to protect from urinary incontinence (perineal 39%, retropubic 56%, p=0.004).nnnCONCLUSIONSnFecal incontinence following radical prostatectomy occurs more frequently than previously recognized. In general fecal incontinence among radical perineal and retropubic prostatectomy patients surpasses the expected incidence rate of 4% for this age group (60 to 70 years) but incidence is significantly higher for radical perineal prostatectomy patients. However, radical perineal prostatectomy patients have a significantly lower incidence of urinary incontinence than those treated with retropubic prostatectomy. Surgeons who perform radical retropubic and perineal prostatectomy should be aware of the possibility of fecal and/or urinary incontinence and associated symptoms.

The effect of parenteral testosterone replacement on prostate specific antigen in hypogonadal men with erectile dysfunction

PURPOSEnParenteral testosterone supplementation is a common treatment for erectile dysfunction in hypogonadal men. Despite its frequent use, the effect of testosterone on prostate specific antigen (PSA) in these patients has not been documented previously. In this study we determined the effect of parenteral testosterone replacement on PSA and PSA velocity in a group of men being treated for erectile dysfunction.nnnMATERIALS AND METHODSnA retrospective analysis of 48 patients (mean age 65.9) was performed and 2 study groups were identified. Group 1 consisted of 27 patients with a serum PSA level before and after initiating testosterone replacement therapy, and group 2 consisted of 27 men with a minimum of 3 PSA measurements (intervals of 6 months or greater) while on testosterone replacement. Each man had erectile dysfunction, a normal digital rectal examination and a low or low-normal total serum testosterone level before initiating therapy. Testosterone replacement was discontinued if no subjective improvement in erectile function was obtained, or if prostate adenocarcinoma was suggested by digital rectal examination or PSA.nnnRESULTSnThe mean increase in PSA after initiating testosterone replacement was 0.29 ng./ml. representing a mean change of 37% from baseline (mean interval 12.8 months). The mean PSA velocity was 0.05 ng./ml. per year. Pretreatment testosterone level, age and testosterone dose did not independently alter the PSA during testosterone replacement. Eleven men required prostate biopsies during treatment. Biopsies were indicated for abnormal digital rectal examination in 10 men and an elevated PSA in 1. All biopsies were benign.nnnCONCLUSIONSnParenteral testosterone replacement in hypogonadal men with normal pretreatment digital rectal examination and serum PSA levels does not alter PSA or PSA velocity beyond established nontreatment norms. Thus, any significant increase in PSA or PSA velocity should not be attributed to testosterone replacement therapy and should be evaluated.

Outcomes for vasectomy reversal performed after obstructive intervals of at least 10 years.

OBJECTIVESnTo determine the outcomes for vasectomy reversal performed after at least 10 years of obstruction.nnnMETHODSnWe performed a retrospective review of three surgeons experience with microsurgical vasectomy reversal for obstructive intervals of at least 10 years.nnnRESULTSnThe overall pregnancy rate was 37%. The patency/pregnancy rate for an obstructive interval of 10 to 15, 16 to 19, and 20 or more years was 74%/40%, 87%/36%, and 75%/27%, respectively. The overall ongoing/delivered rate was 35%. The ongoing/delivered rates equaled the pregnancy rates, except in the 16 to 19-year group, for which the ongoing/delivered rate was 27%. Assuming a live delivery rate per cycle of 25% for intracytoplasmic sperm injection (ICSI), the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 20 years. Assuming a live delivery rate of 28.6% per cycle for ICSI with obstructive azoospermia, the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 15 years.nnnCONCLUSIONSnEven after prolonged obstructive intervals, vasectomy reversal offers better or comparable success rates to ICSI. For each center, depending on their success rates, a threshold obstructive interval exists at which ICSI surpasses vasectomy reversal. Depending on their wishes, couples who have an obstructive interval that exceeds this threshold may be better served by ICSI. As with all infertile couples, close collaboration between the urologists and gynecologists is essential to provide the most appropriate care.

REPEAT VASECTOMY REVERSAL AFTER INITIAL FAILURE: OVERALL RESULTS AND PREDICTORS FOR SUCCESS

PURPOSEnWe review the treatment outcomes for microsurgical reconstruction following failed vasectomy reversal and identify predictors for success.nnnMATERIALS AND METHODSnWe performed a retrospective review of our experience with microsurgical reconstruction in 41 men who underwent 1 or more prior unsuccessful vasectomy reversal procedures. Of these patients 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy, 11 underwent bilateral (7) or unilateral (4) vasovasostomy and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Postoperative followup consisted of serial semen analyses and telephone interviews.nnnRESULTSnPatency and pregnancy followup data were available in 33 and 31 patients, respectively. Five couples had ongoing uncorrected female factor infertility problems and were not included in pregnancy rate calculations. Mean obstructive interval was 10.6 years. Overall patency and pregnancy rates were 79 and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at followup was 38.0 million. History of conception with the current partner was predictive of future conception with 4 of 5 nonremarried couples (80%) initiating a pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Other factors, including smoking history and obstructive interval, did not correlate with postoperative success. Reconstruction with vasovasostomy on at least 1 side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15), although they did not assume statistical significance.nnnCONCLUSIONSnMicrosurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term followup. In our series previous conception with the current partner was predictive of future conception after reconstruction. Urologists performing repeat vasectomy reversal must be familiar with microsurgical techniques, since almost three-quarters of patients will require at least unilateral vasoepididymostomy.

Transcatheter Embolization of Large Idiopathic Renal Arteriovenous Fistula

Renal arteriovenous fistulas are unusual lesions with a variety of clinical manifestations. Congenital and acquired forms have been treated successfully with transcatheter embolization for 2 decades. In the case of large aneurysmal lesions the risk of inadvertent pulmonary embolism has traditionally precluded this approach and necessitated open surgery. However, with refinements in angiographic equipment and technique, such an approach is now feasible and desirable.

Long-segment ureteral replacement with expanded polytetrafluoroethylene grafts

OBJECTIVESnTraumatic loss of significant lengths of ureter all too often results in nephrectomy when vascularized pedicles of bowel or bladder fail or are not available for substitution. Historically, alloplastic replacement of ureters has failed due to obstruction, bioincompatibility, or graft migration. This study was undertaken to test the performance of ringed expanded polytetrafluoroethylene (PTFE) tube grafts as ureteral replacements in a canine model.nnnMETHODSnEight female dogs underwent partial ureteral replacement with ringed PTFE tube grafts. An involuting anastomosis was used to anchor the graft to the bladder. The dogs were followed with intravenous urograms and Whitaker infusion pressure tests for up to 12 months.nnnRESULTSnSix of 8 animals (75%) had preservation of excellent renal function with normal intravenous urograms and low Whitaker infusion pressures. One animal had mild hydronephrosis with an elevated infusion pressure. One animal died of spontaneous renal rupture secondary to obstruction at the ureteral-graft anastomosis. All other grafts were patent by histologic examination without encrustation or infection.nnnCONCLUSIONSnAlthough not suggested as first-line therapy after ureteral loss, expanded PTFE may have a use as a prosthetic ureteral replacement in situations where conventional surgical therapies are unsuccessful. This material appears to be biocompatible, and the technique of bladder anastomosis described here prevented migration of the prosthesis.

Fertility in men after treatment for stage 1 and 2A seminoma

The purpose of this article is to assess the long-term fertility and attitudes towards fecundity in men after radical inguinal orchiectomy and radiation therapy (RT) for seminoma, and also to assess how often sperm cryopreservation is being offered to patients with seminoma prior to treatment. A retrospective review was conducted at 3 institutions (Wilford Hall Air Force Medical Center, Brooke Army Medical Center, and Fitzsimmons Army Medical Center) to identify patients who had undergone treatment of stage 1 or 2A seminoma during the period from 1975 to 1997. Seventy-three of 212 (34%) patients meeting the selection criteria of stage 1 or 2A seminoma provided information for this analysis. This was thought to be a good response rate, given that many of the patients had changed duty stations or had separated from the military by the time this study started. We performed a review of RT and tumor board records of 73 patients who were treated for testicular seminoma at selected treatment facilities from 1975 to 1997. Patients completed questionnaires and phone interviews that focused on prior fertility, the desire to father (more) children, other fertility-affecting factors (varicocele, cryptorchidism, infection, and erectile dysfunction), and incidence of physician counseling with regard to cryopreservation. All patients were asked to obtain a current semen analysis (SA). Eleven (15%) patients reported that they had tried to father children since completion of their RT. Seven of 11 (64%) successfully achieved pregnancy within a mean time of 3.5 years since RT (range: 1 month to 5 years). Of the 4 couples that were not successful, 1 had severe female factor infertility problems and a second had organic erectile dysfunction. A third had a past surgical history remarkable for vasectomy with subsequent vasectomy reversal. Nine patients provided SA. Mean sperm count and motility were 24.2 Mil/mL (range: 5–81 Mil/mL) and 63.1% (range: 30–90%), respectively (normal SA values: count = 20–250 Mil/mL, motility >50%, and volume = 1.5–5.0 mL). No patients were azoospermic. Overall mean time interval from radiation therapy was 7.9 years. Radiation dose and time since RT did not correlate with either SA results or conception. Only 16 of 73 (22%) men had been offered pretreatment sperm cryopreservation by their counseling physician. It is concluded that (1) patients who are treated for early stage seminoma by orchiectomy and RT have greater than a 50% chance of regaining normal semen parameters, and all regain at least some spermatogenesis; 2) recovery of spermatogenesis is not related to therapeutic radiation dose with the use of modern shielding and RT portals; (3) the majority of treated patients who desire children can conceive; and (4) sperm cryopreservation remains an underutilized option for seminoma patients.

Intermittent azoospermia associated with epididymal sarcoidosis

OBJECTIVEnTo report an unusual case of intermittent azoospermia associated with epididymal sarcoidosis.nnnDESIGNnRetrospective case analysis.nnnSETTINGnWilford Hall Medical Center.nnnPATIENT(S)nA 36-year-old male with secondary infertility and epididymal sarcoidosis.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURES(S)nAn analysis of sperm count in relation to steroid courses.nnnRESULTS(S)nEpididymalgia, and to a lesser extent, sperm counts were noted to fluctuate temporally around steroid courses given for pulmonary flares of sarcoidosis. Epididymal sarcoidosis can be associated with intermittent azoospermia. Presumably, epididymal granulomas undergo exacerbations and remissions and cause intermittent ductal obstruction.nnnCONCLUSIONS(S)nBecause of the unpredictable effect of sarcoidosis on the male genital tract, all patients interested in paternity should obtain a semen analysis at the time of disease diagnosis. If oligospermia is noted or if there is clinical evidence of epididymal involvement, the patient should be offered sperm banking for possible future assisted reproductive techniques.

Vasovasostomy: multiple children and Long-term pregnancy rates

PURPOSEnTo determine the long-term patency and pregnancy rates after vasovasostomy and to determine the likelihood of having more than 1 child after this procedure.nnnMATERIALS AND METHODSnWe performed a retrospective examination of 73 patients that were at least 4 years out from vasovasostomy at our institution. Patients and their partners completed questionnaires that focused on their pre- and post-procedure fertility, vasal obstructive interval, time to pregnancy, and the number of children conceived. All patients were asked to obtain a current semen analysis.nnnRESULTSnFrom a population of 73 patients with proven prior fertility, 43 could be contacted for data collection. Of the 43 men, 39 (91%) reported that they had actively tried to father children. These 39 men are a mean of 84.8 months (range, 4 to 10 years) out from their surgery, with a mean vasal obstructive interval of 87 months (7.4 years). All men denied using assisted reproduction techniques except the father of the only twins, who reported the use of ICSI for female-factor infertility. He was excluded from further pregnancy calculations. Forty-five percent of couples achieved at least 1 pregnancy, whereas 6 of 17 (35%) conceived 2 children. Mean time to conception was 14.7 months for the first child and 51 months for the second (range, 13 to 108 months). In those that did not conceive (n = 21), the mean obstructive interval was 106 months versus 81 months for those that did conceive. This time interval was not statistically different (P > 0.05). Mean maternal age was significantly less in those that did versus those that did not conceive (32.2 vs 36.6 years) (P < 0.01). We also noted that 10 of 21 were with a different spouse that had never been pregnant. Three of these 10 had known female-factor fertility problems. Semen analyses were obtained in 6 of the 21 patients that did not father children. Only 1 of the 6 was azoospermic. Thirteen (33%) desired more than 1 child at the time of vasectomy reversal.nnnCONCLUSIONSnAfter vasovasostomy in patients with a vasal obstructive interval of 7 years, up to 45% of couples may achieve pregnancy and up to 35% could go on to conceive a second child. Long-term anastomosis patency after the procedure is estimated to be approximately 60%. Maternal age is a significant factor in predicting a couples success in conceiving a child. Vasovasostomy remains a highly effective option for restoration of fertility in vasectomy patients, while offering the opportunity for multiple pregnancies with only a single intervention.

Dressing for surgical wounds of the penis

We describe a simple tubular elastic gauze dressing for surgical wounds of the penis. The amount of pressure placed on the penis is consistent and reproducible. The material is elastic enough to avoid vascular occlusion and is easily applied with a plastic tube. The dressing stays in place, can be used with stents or catheters, and is easily removed by the patients at home.