Gerald H. Jordan

PROPOSAL: TRAUMA AS THE CAUSE OF THE PEYRONIE'S LESION

PURPOSE We define the cause of the occurrence of Peyronies disease. MATERIALS AND METHODS Clinical evaluation of a large number of patients with Peyronies disease, while taking into account the pathological and biochemical findings of the penis in patients who have been treated by surgery, has led to an understanding of the relationship of the anatomical structure of the penis to its rigidity during erection, and how the effect of the stress imposed upon those structures during intercourse is modified by the loss of compliance resulting from aging of the collagen composing those structures. Peyronies disease occurs most frequently in middle-aged men, less frequently in older men and infrequently in younger men who have more elastic tissues. During erection, when full tumescence has occurred and the elastic tissues of the penis have reached the limit of their compliance, the strands of the septum give vertical rigidity to the penis. Bending the erect penis out of column stresses the attachment of the septal strands to the tunica albuginea. RESULTS Plaques of Peyronies disease are found where the strands of the septum are attached in the dorsal or ventral aspect of the penis. The pathological scar in the tunica albuginea of the corpora cavernosa in Peyronies disease is characterized by excessive collagen accumulation, fibrin deposition and disordered elastic fibers in the plaque. CONCLUSIONS We suggest that Peyronies disease results from repetitive microvascular injury, with fibrin deposition and trapping in the tissue space that is not adequately cleared during the normal remodeling and repair of the tear in the tunica. Fibroblast activation and proliferation, enhanced vessel permeability and generation of chemotactic factors for leukocytes are stimulated by fibrin deposited in the normal process of wound healing. However, in Peyronies disease the lesion fails to resolve either due to an inability to clear the original stimulus or due to further deposition of fibrin subsequent to repeated trauma. Collagen is also trapped and pathological fibrosis ensues.

Laparoscopic Dismembered Pyeloplasty—The Method of Choice in the Presence of an Enlarged Renal Pelvis and Crossing Vessels

OBJECTIVE Herein we report our experience of 49 consecutive pyeloplasties that were all laparoscopically performed with an intracorporeally sutured anastomosis. We describe the operative technique, complications and outcomes during a follow-up period of 1-53 months (mean 23.2 months). PATIENTS AND METHODS Forty-nine patients (28 women and 21 men) with a mean age of 34 years (range 6-65 years) underwent a laparoscopic dismembered pyeloplasty because of primary ureteropelvic junction (UPJ) obstruction with hydronephrosis in each case. The preoperative evaluation included an evaluation for pain, an excretory urography (IVP), renal scan and sometimes CT angiography to evaluate for crossing vessels. Follow-up studies included an IVP, renal scan and renal ultrasound 4 weeks postoperatively and every 3 months thereafter. Success was considered as improvement of the pain score and IVP (less hydronephrosis, visible UPJ and/or normalization of drainage) or absence of an obstructive pattern during the washout phase of a renal scan. RESULTS There was no conversion to open surgery. The mean operative time was 165 min (range 90-240 min). Blood loss was negligible. Crossing vessels were noted in 57.1% of the patients (28/49). Postoperative hospital stay was 3.7 days (range 3-6 days). One patient had a leakage of the anastomosis on postoperative day 1 and needed to undergo laparoscopic repair. The mean follow-up is 23.2 months (range 1-53 months). There was one single late failure. This patient later underwent an open revision of the laparoscopic pyeloplasty. In all other patients (48/49), the obstruction was resolved or significantly improved. The long-term success rate is 97.7%. CONCLUSIONS The results of dismembered laparoscopic pyeloplasties compare favorably with those achieved by open pyeloplasties with less perioperative morbidity and discomfort. We do believe that laparoscopic dismembered pyeloplasty with an intracorporeal anastomosis is the method of choice in the treatment of the UPJ obstruction in the presence of an enlarged renal pelvis and crossing vessels.

Laparoendoscopic Upper Pole Partial Nephrectomy with Ureterectomy

A 14-year-old white girl presented with a history of recurrent urinary tract infections beginning at age 18 months. Anatomical evaluation revealed bilateral duplication of the collecting systems. On the right side of the upper pole moiety ended at an obstructing orthotopic ureterocele. On the left side the upper pole moiety was associated with an ectopic ureteral orifice. The patient underwent laparoendoscopic right upper pole partial nephrectomy with ureterectomy. To our knowledge this is the first report of a laparoendoscopic upper pole partial nephrectomy. Details of the procedure are discussed.

Laparoscopic single stage and staged orchiopexy.

The initial series of laparoscopic single stage orchiopexy for the abdominal or emergent impalpable undescended testis is reported. The first laparoscopic orchiopexy was performed at our institution in October 1991. Between October 1991 and January 1993, 14 patients (16 testes) underwent minimally invasive surgery with 6 months of followup in all cases. No evidence of testicular loss or acute atrophy has occurred, with the entire procedure being accomplished by laparo-endoscopic techniques in all cases. Treatment of 3 of the 16 testicles consisted of stage 2 of staged orchiopexy, and to our knowledge these cases represent the first stage 2 orchiopexy completed by laparoscopic techniques. In those cases stage 1 was performed by laparoscopic clipping of the vessels. The details of the procedure as we now perform it are described.

Complications of the exaggerated lithotomy position: a review of 177 cases.

To examine the incidence and nature of complications associated with placing patients in the exaggerated lithotomy position, a retrospective review of 177 procedures requiring the use of that position was done. Factors analyzed were patient age, height, weight and time in position. Height-to-weight ratio was calculated in an effort to establish a relationship between body habitus and common peroneal nerve neurapraxia, the most common complication (15.8%) noted in the study. Statistical analysis failed to show any relationship between these factors and the incidence of neurapraxic complications. The study demonstrates the safety of this highly useful surgical position for perineal operations. The technical points relative to positioning are emphasized.

Repair of the Complications of Hypospadias Surgery

In 1992 a retrospective review was conducted of 190 patients evaluated and treated for complications of hypospadias surgery during 1979 through 1990 at the Devine Center for Genitourinary Reconstructive Surgery of Sentara Norfolk General Hospital and Childrens Hospital of the Kings Daughters. We could not contact 13 patients and 8 are awaiting a second stage procedure. Of the 177 patients 167 (94.35%) have had a successful outcome, defined as a controllable urinary stream, functional erection and an acceptable cosmetic appearance, and 2 (1.13%) are considered failures. Details of presenting problems, surgical techniques and recent modifications of these procedures are presented.

Preoperative evaluation of erectile function with dynamic infusion cavernosometry/cavernosography in patients undergoing surgery for Peyronie's disease: correlation with postoperative results.

Most reports of surgical therapy for Peyronies disease to date have not included detailed preoperative assessment of erectile function. To evaluate the relationship between preoperative erectile function and postoperative success, we reviewed 25 consecutive patients with Peyronies disease who underwent surgery and evaluation with dynamic infusion cavernosometry and cavernosography preoperatively. Overall results of dynamic infusion cavernosometry and cavernosography revealed corporeal veno-occlusive dysfunction in 76% of the patients and inadequate arterial inflow parameters in 44%. Among 20 patients treated with plaque excision and dermal graft inlay, adequate postoperative erectile function for satisfactory intercourse occurred in 4 of 4 (100%) with an equilibrium accumulated intracorporeal pressure of greater than or equal to 70 mm. Hg, 9 of 12 (75%) with an equilibrium accumulated intracorporeal pressure of 40 to 65 mm. Hg and 1 of 4 (25%) with an equilibrium accumulated intracorporeal pressure of less than 35 mm. Hg. These data may be helpful to counsel patients before surgical therapy, and may explain some of the disparate results previously reported after plaque excision and dermal graft inlay on the basis of patient selection.

Management of recurrent anastomotic stenosis following radical prostatectomy using holmium laser and steroid injection

To present our experience with the management of recurrent and resistant anastomotic stenosis following radical prostatectomy (RP) using transurethral laser incision of the stenotic area and injection of steroids.

Penile Prosthesis Implantation in Total Phalloplasty

A series is presented of 8 patients who had undergone either total phalloplasty or free flap penile reconstruction. Our experience with prosthetic implantation is reviewed as is a brief history of phallic construction, including previously reported efforts at achieving rigidity with prosthetic implantation, autologous material implantation and so forth. We present in detail our current technique of implantation in these 8 patients, who underwent 10 attempts at implantation. In 4 patients infection necessitated removal of the prosthesis (2 have since undergone successful reimplantation). Of the 8 patients in whom implantation was attempted 6 (60%) currently have prostheses in place.

Preoperative Laparoscopic Localization of the Nonpalpable Testis

Laparoscopic examination was performed successfully on 14 patients with 17 nonpalpable testes. The procedure was successful in determining the location in 16 of 17 nonpalpable testes, and this information was beneficial for selecting the subsequent operative approach. Laparoscopy was safe in the younger child (10 patients were 3 years old or less and 7 patients were less than 2 years old), and it added an insignificant increase in operative time.