Engin Kandirali

Peyronie's disease in men under age 40: characteristics and outcome.

Peyronies disease is most commonly seen in the fifth decade of life. However, a wide range of age (20–83 y) is reported. During a 6-year period, men with Peyronies disease presenting under the age of 40 were reviewed retrospectively and followed-up. The prevalence of Peyronies patients presenting under age 40 was 8.2%. Their mean age was 32.47±5.37 (range: 23–39) y and 78.9% of them presented during the acute phase of the disease. Pain on erection was a part of presenting symptom complex in 52.6% and the majority (84%) had a degree of penile curvature <60°. Erectile dysfunction (ED) was present in 21% of patients, who responded well to intracavernous injection test. After a minimal 2-year follow-up, improvement in penile deformity was observed in 36.8%, and 42.1% had stable disease while 21% experienced deterioration of the penile curvature. The onset of Peyronies disease is clinically more noisy and acute in patients presenting under age 40 and this forces the physicians to treat them more vigorously.

Microsurgical inguinal varicocele repair in azoospermic men.

OBJECTIVES To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome. METHODS After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy. RESULTS After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them. CONCLUSIONS Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

Incidentally diagnosed Peyronie's disease in men presenting with erectile dysfunction

The aim of this study was to analyze characteristics of patients with Peyronies disease (PD) diagnosed during a standart evaluation for erectile dysfunction (ED) and compare them with patients presenting with the classical complaints of PD. During a 10-y period, a total of 448 patients were evaluated at our two outpatient clinics, directed by the same author (AK). They were divided into two groups: group I consisted of patients, who presented with only ED and were unaware of their penile deformity, and group II consisted of patients with the classical features of the disease. The clinical characteristics, penile deformities, erectile status and the presence of comorbidities were determined in the two groups. Of 448 Peyronies patients, 16% (n=71) were detected during diagnostic work-up for ED. In this group of patients, ED was the presenting symptom for a mean period of 31.3±9.7 months. The mean age of men was 57.54±8.75 and 52.21±10.27 y in groups I and II, respectively (P=0.0001). The mean degree of deformity was 31.5±12.66° in group I and 41.16±19.14° in group II (P=0.0001). In group I (n=71), 69% (n=49) of the patients had a poor erectile response to the combined injection and stimulation (CIS) test. Also, in this group, the mean degrees of deformity in CIS-positive and -negative patients were 27.05±12.50 and 33.80±12.03°, respectively (P=0.033). Diabetes mellitus (40%) was the leading comorbidity in group I, while at least one comorbidity was observed in 73% of the cases (P=0.001). A remarkable percent of Peyronies patients (16%) were detected during a standard evaluation for ED. This study analyzed, for the first time, the frequency and the characteristics of incidentally diagnosed Peyronies patients who presented with only ED. Our data indicate that one should always consider the possibility of PD in older patients with diabetes, presenting with only ED.

TGF-β1 neutralizing antibodies decrease the fibrotic effects of ischemic priapism

The objective of this study was to evaluate the possible role of transforming growth factor beta 1 (TGF-β1) antibodies (ab) for the prevention of fibrotic effects of priapism in a rat model. In total, 30 adult Sprague–Dawley rats were divided into five groups. Priapism with 6 h (group 1), priapism with 6 h+ab (group 2), priapism with 24 h (group 3), priapism with 24 h+ab (group 4) and control (group 5). Priapism was induced with a vacuum erection device and a rubber band was placed at the base of the erect penis. At 1 h after the initiation of priapism, TGF-β1 antibodies were given intracavernosaly. All rats underwent electrical stimulation of the cavernous nerve after 8 weeks. Intracavernous and systemic blood pressures were measured during the procedure. Rats in group 1 showed significantly higher (intracavernosal pressure (ICP) pressures to cavernous nerve stimulation and had higher ICP/BP ratios when compared to other groups. Similarly, histopathologic examination revealed less fibrosis in group 2, compared with the other groups. Consequently, TGF-β1 antibodies antagonise the fibrotic effects of TGF-β1, especially in cases with duration of priapism less than 6 h.

Is Only Perianal Anesthesia with Lidocaine-Prilocaine Cream Sufficient to Decrease the Pain during Transrectal Ultrasound-Guided Prostate Biopsy? A Prospective Randomized Study

Aims: To determine the optimal place to apply the local anesthetic agent and to investigate the efficacy of lidocaine-prilocaine cream on the perianal and intrarectal region during prostate biopsy. Methods: The study included 80 patients. Patients were randomized into four groups: group 1 served as the control group and was administered no anesthesia; group 2 received 5 ml lidocaine-prilocaine cream perianally; group 3 received 5 ml lidocaine-prilocaine cream intrarectally, and group 4 received lidocaine-prilocaine cream perianally and intrarectally. Pain scores during probe insertion, biopsy procedure, and the overall pain score were assessed. Mean pain scores in each group were compared statistically. Results: In group 1, the mean pain score was significantly higher during probe insertion than that during biopsy (p < 0.001). For the mean overall pain scores, there was no significant difference between groups 1 and 3 (p = 0.942), but the results of group 1 were statistically different from groups 2 (p = 0.001) and 4 (p < 0.001). When we compared the biopsy pain scores, there was no significant difference among the groups (p > 0.05). During probe insertion, subjects in groups 2 and 4 reported significantly lower pain scores than the control group (p = 0.002, p = 0.001, respectively). Conclusions: Perianal anesthesia with lidocaine-prilocaine cream may solely be sufficient to decrease the pain during prostate biopsy.

Reliability of the 34βE12, keratin 5/6, p63, bcl-2, and AMACR in the diagnosis of prostate carcinoma.

OBJECTIVE In this study, we aimed to investigate which basal cell marker should be used with α-methylacyl coenzyme A racemase (AMACR) to increase diagnostic accuracy in the diagnosis of prostate carcinoma. MATERIALS AND METHODS A total of 98 cases of prostate biopsy, comprising 65 cases with prostate adenocarcinoma and 33 cases without adenocarcinoma, were included in this study. Prostate-specific antigen (PSA) serum levels before biopsies were obtained. The number of cores with malignant glands and Gleason scores for each case were determined. Paraffin sections were stained immunohistochemically with 34βE12, keratin 5/6, p63, bcl-2, and AMACR. RESULTS According to staining pattern, extensiveness, and intensity of basal cell markers in benign glands, 34βE12 gave the best results. As negative markers for prostate adenocarcinoma, the best markers were p63 and 34βE12. According to the AUC values in ROC curves for both extensiveness and intensity, the arrangement from the best to the worst was 34βE12, p63, bcl-2, and keratin 5/6. The 34βE12 had the best sensitivity and specificity values (95% and 98%, respectively). Staining extensiveness and intensity of keratin 5/6 in malignant glands, and those of bcl-2 in benign glands had statistically significant positive correlation with serum PSA levels. Even though AMACR is a negative marker for benignity, some of the benign glands also had positive immune reaction with AMACR. However, AMACR positivity was usually focal and weak. Nevertheless, intensively stained subjects were also present. No correlation was present between AMACR and basal cell markers. CONCLUSIONS As a result, we suggest that keratin 5/6 and bcl-2 should not be used to identify benign glands in prostate biopsy since they show high positivity in malignant glands and high negativity in benign glands. 34βE12 should be the first choice as a basal cell marker. p63 can be used together with 34βE12, but it may not give additional diagnostic information. When we evaluated the correlation of basal cell markers, we did not find any complementary staining results among basal cell markers. Our study showed that 34βE12 is the most appropriate negative marker to combine with AMACR as a positive marker for the diagnosis of prostate adenocarcinoma.

Detection of a retained epidural catheter fragment.

To the Editor: We thank the editor for a chance to respond to comments by Drs. Rocco and Philip1 concerning our paper.2 The idea that our study corroborates the findings of Rocco et al.3 is not correct. We measured epidural space pressure as saline was infused at several different flow rates in each animal and found a linear flow-pressure relation with a calculated Y-axis intercept that was within 1 to 2 mm Hg of the actual pressure obtained in the absence of flow. These data argue strongly against the presence of “Starling resistor (SR)” anatomy in the normal pig’s epidural space. If an SR were present, the calculated Y intercept would have been higher than observed, or the relation would have curved down, which indicates recruitment of additional exit pathways with critical opening pressures for fluid leaving the epidural space. In comparison, Rocco et al.3 measured epidural space pressure only at a single flow rate in each patient and, thus, cannot determine whether or not an SR is present. Their best evidence for an SR is the fact that “visible flow” of fluid passively leaving a syringe barrel and entering the epidural space “did not start” until the syringe had been raised some 10 to 15 cm above the spine—not a very scientific approach, because flow rates were not measured and low infusion pressures may have resulted in flow that escaped notice. Thus, the two studies differ in their methods, results, and interpretation. Rocco et al.3 determined their “initial pressure” after infusing small volumes of saline into the epidural space (legend to their Figure 1) and determined their “critical opening pressure” after infusing 3 to 9 mL; hence, to criticize us for doing the same is disingenuous. Their initial pressures were reported as 12 to 15 mm Hg, but these numbers come from only 13 of 25 patients studied. What were the pressures in the other 12 patients, and why were they excluded from analysis? Of additional note, the technique used by Rocco et al.3 for calculating “pressure at zero flow” was invalid because they extrapolated epidural space pressure versus time, rather than versus flow. On the other hand, we are pleased to note the similarity between our Figure 1 and their Figure 4, a tracing of pressure recorded during constant-flow volume infusion in an apparently healthy patient scheduled for surgery. The feature that is common to the two figures is a plateau in epidural space pressure as flow continues. We believe this plateau means that saline leaves the epidural space through pathways with constant resistance and enters a system with large capacitance. Otherwise, pressure would continue to increase rather than plateau. Our study was done in normal pigs, and finding similar results in a human is encouraging. Rocco et al.3 think certain technical aspects of our study precluded demonstration of SR-type hydrodynamic behavior. The linearity of our flow-pressure relations (R2 0.98 1.0) means that extrapolation to determine the Y-axis intercept is reasonable and accurate; hence, we would have found evidence of a critical opening pressure had it been present. The linearity of the relation adequately rules out recruitment of additional pathways with higher opening pressures as well. Rocco et al.3 are correct that infused fluid needs to reach the pressure-sensing needle before a reliable measurement can be made, but this distance was only 2 to 3 cm in our study because the needles were located at adjacent interspaces. They miss the bigger picture, however, which is that fluid spreads up and down the epidural space and through a variety of exit pathways, all of which might well demonstrate SR behavior. Rocco et al.3 confuse terms when they state that “once the critical opening pressure (initial pressure) is reached. . .” We strongly disagree with the concept that pressure measured in the absence of flow (initial pressure) corresponds to a critical opening pressure, and Rocco et al.3 make this distinction in Table 2 of their previous publication. Frankly, we were surprised to observe a pressure plateau during fluid infusion and that our flow-pressure relations were linear. We think the situation is more analogous to the flow of saline into a vein than into a “space” with limited capacitance and run off. Further studies are necessary to determine the location and nature of the exit pathways from the spinal epidural space that influence the hydrodynamics we have observed.

Does the Testicular Apoptotic Index Vary with Serum Gonadotropins and Testicular Histopathology in Infertile Men

Aims: Testicular apoptosis has been shown in human specimens, but its correlation with serum gonadotropins and testosterone levels has not been studied. The aim of this study was to evaluate the relationship of apoptosis with serum hormone levels and testicular histopathological findings in infertile men. Methods: Testis biopsy specimens were obtained for routine clinical purposes from 41 azoospermic men. The biopsy material was divided into two parts: one part was fixed in Bouin’s solution and processed using paraffin embedding and HE staining, and the other was fixed in 10% neutral buffered formalin and embedded in paraffin for the detection of apoptosis using TUNEL. To determine the apoptotic index, the number of apoptotic cells was divided by the total number of the counted cells and multiplied by 100 to calculate the percentage. Results: The apoptotic index was significantly higher in specimens with maturation arrest than in those with normal spermatogenesis (p = 0.016), hypospermatogenesis (p = 0.05), and Sertoli-cell-only specimens (p < 0.001). A significant negative correlation was found between serum follicle-stimulating hormone levels and the apoptotic index (r = –0.356, p = 0.01). Conclusion: Our results demonstrate there is a relationship between increased apoptosis and testicular dysfunction, and indicate a prominent role for apoptosis in human male infertility.

Isolated renal hydatıc cyst; from an unusual course to diagnosis

An isolated renal cyst hydatic in a 65 year old man with unusual symptomatology, course and complications were presented.

Surgical Removal of an Unrecognized Tapestry Needle from the Urethra.

The variety of intraurethral foreign bodies has been reported in literature. Most of them tend to be self-inserted because of sexual or erotic reasons. We report a 23-year old male patient who had tapestry needle into his urethra, which was not self-inserted. The patient was referred to our institution with dysuria and hematuria. There was microscopic hematuria in urine analysis and no pathologic sign in sonography. The needle was detected in proximal urethra in pelvic X-ray and endoscopic visualization revealed that it was trapped in mucosa. The needle was successfully removed by open surgery. Main treatment for the removal of urethral foreign bodies is usually endoscopic but open surgery may be required in some cases especially cutting foreign bodies.