Francesco Sasso

A Case-Control Study on Risk Factors for Peyronie’s Disease

The aim of this study was to investigate the relationship between history of selected diseases, genital traumas, and Peyronies disease. A hospital-based case-control study was conducted at the Andrologic and Surgical Outpatient Units of the Policlinico Gemelli, Rome, where 134 men with Peyronies disease and 134 male controls were interviewed. The association between Peyronies disease and selected characteristics was estimated by means of odds ratios (OR) and 95% confidence intervals (CI). Patients who underwent invasive procedures on the penis (i.e., urethral catheterization, cystoscopy, and transurethral prostatectomy) had a 16-fold increased risk for Peyronies disease (OR = 16.1, 95% CI: 1.8-142), while a nearly three-fold increase was observed among patients who had genital and/or perineal traumatisms (95% CI: 1.0-7.1). A history of urethritis, uricacidemia, and lipoma was also significantly associated with an increased risk for Peyronies disease. Twenty-one percent of the cases and none of the controls were affected by Dupuytrens contracture, and 4% of cases and none of the controls reported familial history for Peyronies disease. The frequency of inflammatory or fibromatous lesions of the genital tract of the partner was significantly higher in men with Peyronies disease than among controls. These results were consistent when performing a stratified analysis according to the type of controls (i.e., controls affected by urologic or by digestive conditions) to rule out the potential effect of recall bias. The findings of the study lend support to clinical reports stressing the importance of genital traumatisms and genetic conditions in the development of Peyronies disease.

Extracorporeal shockwave lithotripsy in pediatrics

Since its introduction in 1980, extracorporeal shockwave lithotripsy (SWL) has become the first therapeutic option in most cases of upper-tract urolithiasis, and the technique has been used for pediatric renal stones since the first report of success in 1986. Lithotripter effectiveness depends on the power expressed at the focal point. Closely correlated with the power is the pain produced by the shockwaves. By reducing the dimensions of the focus, it becomes possible to treat the patient without anesthesia or analgesia but at the cost of a higher re-treatment rate. Older children often tolerate SWL under intravenous sedation, and minimal anesthesia is applicable for most patients treated with second- and third-generation lithotripters. Ureteral stenting before SWL has been controversial. Current data suggest that preoperative stent placement should be reserved for a few specific cases. Stone-free rates in pediatric SWL exceed 70% at 3 months, with the rate reaching 100% in many series. Even the low-birth-weight infant can be treated with a stone-free as high as 100%. How can one explain the good results? Possible explanations include the lesser length of the childs ureter, which partially compensates for the narrower lumen. Moreover, the pediatric ureter is more elastic and distensible, which facilitates passage of stone fragments and prevents impaction. Another factor is shockwave reproduction in the body: there is a 10% to 20% damping of shockwave energy as it travels through 6 cm of body tissue, so the small body volume of the child allows the shockwaves to be transmitted with little loss of energy. There are several concerns regarding the possible detrimental effect of shockwaves on growing kidneys. Various renal injures have been documented with all type of lithotripters. On the other hand, several studies have not shown adverse effects. In general, SWL is considered to be the method of choice for managing the majority of urinary stones in children of all ages. Re-treatments improve the stone-free rate, often raising it to 100%. Among the predictors of success, stone size seems to be the most important. In the absence of guidelines, selecting the appropriate treatment modality for each child requires planning and depends on instrument availability and local expertise.

PATIENT SELECTION CRITERIA IN THE SURGICAL TREATMENT OF VENO-OCCLUSIVE DYSFUNCTION

PURPOSE We evaluated short and long-term results of simple and complex venous surgery in patients with veno-occlusive dysfunction unresponsive to maximum recommended doses of intracavernous alprostadil, who were selected with newly developed diagnostic indicators. MATERIALS AND METHODS A total of 23 impotent men with a mean age of 41 years (range 20 to 50) underwent complex penile venous surgery. Only patients fulfilling at least 3 criteria were included in study. The criteria were mild cavernous leak assessed by cavernosometry (grades 1 and 2), more than 30% cavernous smooth muscle tissue (histomorphometric analysis), normal analogical corpus cavernosum electromyography recordings according to international standards, cavernosal oxygen tension greater than 65 mm. Hg at erection and age younger than 50 years. RESULTS Of 23 patients 17 (74%) had normal erections within a year after surgery, and 5 of them (29%) complained of recurrent erectile dysfunction. At long-term followup 6 of 12 patients had spontaneous erections. CONCLUSIONS Careful selection with advanced diagnostic techniques should be mandatory before performing venous surgery in patients with high degree veno-occlusive dysfunction as the only alternatives are major therapeutical solutions.

Acute idiopathic scrotal oedema: Rare disorder or difficult diagnosis?

This study reports our experience in 6 cases of acute idiopathic scrotal oedema. Although children were the primary targets, this pathologic condition was also encountered in adults.Specific diagnosis of acute idiopathic scrotal oedema, opposed to other causes of scrotal swelling, is based on history, an objective examination, velocimetric Doppler exam and echography. Correct diagnosis is important in order to avoid unnecessary surgery.We are inclined to consider acute idiopathic scrotal oedema as an allergic disorder and recommend a follow-up within two days.

Sexual outcomes after organ potency-sparing surgery and glans reconstruction in patients with penile carcinoma.

Introduction: Radical surgery is the “gold standard” for treatment of invasive penile carcinoma but very poor aesthetic, functional and psychological outcomes have been reported. Our purpose was to assess the impact of organ potency-sparing surgery in locally confined carcinoma of the penis. Materials and Methods: We evaluated retrospectively 42 patients with early penile cancer (Ta,T1,T2), treated with glandulectomy and glanduloplasty with urethral mucosa and sparing of cavernosal apexes, or glandulectomy and limited apical resection in cases of Stage T2. Sexual function, ejaculation and libido were evaluated with an IIEF-15 questionnaire before the appearance of neoplasia (about three months before the surgery) and six months after surgery. Quality of life was evaluated by the Bigelow-Young questionnaire. The scores relating to two weeks prior to the surgery have been compared to those obtained six months after surgery. The statistical analysis was conducted using t-Student for repeated measures and analysis of variance. Results: Six months after surgery 73% of patients reported spontaneous rigid erections, 60% coital activity while 76% of the group treated with urethral glanduloplasty reported normal ejaculation and orgasm, regained an average of 35 days after surgery. The average IIEF-15 scores reported in the entire series in the domains of erection, libido and coital activity of the pre-cancer period were not statistically different than those recorded six months after surgery. In the group treated with glandular reconstruction, pre-and postoperative IIEF-15 mean scores related to ejaculation and orgasm domains were not significantly different. Mean scores of Bigelow-Young questionnaires related to sexual pleasure, familial, social and professional relationships showed significant improvement after surgery. Conclusions: Potency sparing-sparing surgical treatments have a positive impact on a wide spectrum of the patients life including family relationships, and social and working conditions.

Corpus cavernosum electromyography (CC-EMG): A new technique in the diagnostic work-up of impotence

We have studied cavernous electrical activity in 42 subjects, healthy volunteer controls and groups of impotent, patients using a nonspecific electromyographic device (PICO-MENFIS) and a specific one, the SPACE-recorder 7500 designed to achieve electric recordings from the corpora cavernosa. In all of the patients, we detected under basal conditions a mean amplitude of 583±323 μV, a mean duration of 4.9±7 s,a mean polyphasicity of 3.5±1.4. It should be emphasized that a significant reduction of potential amplitudes was recorded after pharmacological stimulation in both the controls and the impotent patients. The healthy controls showed amplitudes significantly higher than the impotent patients after radical cystectomy (715±141 μV versus 381±227 μV, p<0.01).The patients after a “nerve-sparing” radical cystectomy with a mean amplitude similar to the controls (500–700 μV) reacted well to the intracavernous drugs in a high percentage of cases.In our experience, CC-EMG seems to be a reliable method which can pinpoint directly lesions to the cavernous smooth muscle and penile autonomic nerves. It has also been able to assess the effects of stress, anxiety and pain on the erectile mechanisms.

Refluxes in orthotopic neobladders: Canthe ileocecal sphincter be considered an adequate antireflux mechanism?

OBJECTIVES To evaluate the usefulness of the ileocecal sphincter in preventing ureteral refluxes in ileocecal orthotopic neobladder, thus avoiding the use of antireflux technique for ureteroileal anastomosis. METHODS From 1980 to 1992, 95 patients underwent orthotopic bladder substitution. In 30 our detubularized ileal reservoir was used and in 65 first only an integral ileocecal segment was used and subsequently multiple transverse teniamyotomies on the cecal portion to increase the capacity and reduce the pressure. The upper urinary tract was indirectly protected in the ileal reservoir technique by leaving an integral 8 to 10 cm long afferent segment folded behind the reservoir and in the ileocecal technique by the ileocecal sphincter, thus keeping the anastomosis between ureters and ileum simple and direct. RESULTS The mean follow-up of the 65 patients with ileocecourethrostomy is 37 +/- 33 months (range, 2 to 141 months); in 13.8% of the patients (9/65) monolateral refluxes appeared, but without any evident clinical consequences. The appearance of monolateral stenosis on the ureterointestinal anastomosis requiring treatment occurred in 4 patients (6%): 3 underwent an endoscopic treatment and 1 a surgical one. Modifications of renal function with respect to the preoperative status were not verified in any of the patients. CONCLUSIONS The ileocecal sphincter is an effective antireflux mechanism for an orthotopic neobladder in which multiple transverse teniamyotomies (5 to 7) increase the capacity of the neobladder itself, reduce its internal pressure, and confer a nearly spherical configuration. Moreover, a correct anastomosis between the cecum and membranous urethra decisively reduces the resistance to emptying of the neobladder, thus avoiding too strong pressures against the ileocecal sphincter. The integrity of the circular muscular layer maintains a healthy tonic wall: this fact, combined with the low peripheral resistances, ensures good emptying and a stable capacity. The procedure is easy to perform and not time-consuming; these considerations lead us to consider the ileocecal unit an excellent structure for bladder substitution.

Sport, infertility and erectile dysfunction

In the last decades a growing interest has been dedicated to prevention, diagnosis and therapy of male genital pathologies, such as varicocele, infertility and erectile dysfunction in the population involved in sport activities. High incidence (up to 30%) of varicocele has been reported in a population of athletes and up to 60-80% in the subgroup of body-builders. The incidence of varicocele specifically increases with hours of training, in a linear model. Controversial data come from literature about the effects of physical activity on fertility, with prevalence of trials demonstrating worsening of seminal parameters. Furthermore, it has been demonstrated that physical stress in healthy male athletes can interfere with LH levels. Bicycling is one of the major risk factors for erectile dysfunction, with incidence of 13-24%. This is due to the prolonged compression of perineal arteries leading to reduced chronic penile perfusion. Bioengineering studies have been the basis for industry to produce specifically shaped saddles that significantly reduce and minimize compressive effects. Finally, high frequency of lower urinary tract symptoms (LUTS) in cyclists has been related to increased incidence of erectile dysfunction in comparison with normal population.

PRIMARY SYNOVIAL SARCOMA OF THE PENIS

Primary synovial sarcoma of the penis is rare. We report a case of a painful penile mass associated with dysuria in which the histological evaluation revealed a synovial sarcoma while imaging studies demonstrated no evidence of skeletal or visceral metastasis. CASE REPORT A 27-year-old man presented with a painful mass on the right side of the penis associated with dysuria. Urological and medical history were unremarkable. Laboratory investigations were negative. On clinical examination the mass appeared to be confined to the distal third of the right corpus cavernosum with irregular edges and a firm consistency. No inguinal node was palpable. Magnetic resonance imaging (MRI) showed a dishomogeneous oval lesion (2.6 1.5 1.7 cm. in diameter) close to the right corpus cavernosum (fig. 1). We administered an intracavernous injection of prostaglandin E1 to investigate the possibility of vascular disease. Subsequently, a penile tumor surrounded by a pseudocapsule was isolated. The mass was biopsied and was found to be an endothelial tumor without infiltration of the surrounding tissues. The mass was then excised completely and the corpus cavernosum was closed with an absorbable continuous suture (fig. 2). The definitive histological diagnosis was synovial sarcoma of the penis consisting of spindle cell tumor with a high nucleus-tocytoplasm ratio and irregular edges without high mitotic activity. Since synovial lesions are multifocal with a high prevalence in the skeleton and abdomen, abdominal MRI and a total body x-ray were performed. Both tests were negative for metastasis and/or nodes. The patient was subsequently referred to the oncology unit, and considering his age it was decided that he should be followed with an abdominal MRI every 6 months and a total body x-ray annually.

Urethrospongiosal fistulas : clinical and therapeutic considerations

From 1986 to 1990, 8 cases of urethrospongiosal fistulas were observed. All the patients had a history of bleeding after a difficult catheterization. The symptoms were not pathognomonic but the fistulas were visible only by X-ray examination. The authors suggest that urethrospongiosal fistulas are more common than one expects, especially in cases of bleeding after complicated catheterization. This is more frequent when coexistent urethral strictures or prostatic hypertrophy make the maneuver difficult. The authors also suggest that the urinary extravasation in the corpus spongiosum could explain the pathophysiology of the urethral manipulation syndrome according to Kelamy.