Gianfranco Savoca

High-flow priapism: treatment and long-term follow-up

OBJECTIVES To determine the long-term follow-up of treatment of high-flow priapism, we reviewed the case records of 10 patients who were examined by the Urologic Clinic in Trieste from 1995 to 1998. High-flow or arterial priapism is a fairly rare dysfunction, generally resulting from penile or perineal trauma. In some cases, the etiology remains unknown. METHODS Trauma was reported in 6 of 10 cases. No etiologic causes were evident in the other patients. Nine patients underwent selective embolization during arteriography, and in 1 patient, corporotomy and ligature of the cavernous artery were performed. Color Doppler ultrasonography was repeated 1 day, 1 month, and 6 months after the operation. The determination of erectile function at a mean follow-up of 41 months (range 17 to 64) was performed using the International Index of Erectile Function. RESULTS Postoperatively, color Doppler ultrasonography revealed the absence of recurrence in 6 patients. Fistula recurrence was detected in 4 of 9 patients treated with selective embolization (44%). In three of these patients, a second embolization procedure was conclusive. In 1 case (11%), three consecutive embolizations were not conclusive and surgical ligature of the dorsal artery and collateral at the emergence of the penile root, out of the corpus cavernosum, was required. Sexual function was completely preserved in 80% of patients. CONCLUSIONS Pudendal angiography with superselective embolization is the treatment of choice. It is well tolerated and ensures a high preservation of premorbid erectile function.

Effect of Tadalafil on prostate haemodynamics: preliminary evaluation with contrast-enhanced US.

PurposePhosphodiesterase-5 (PDE-5) inhibitors have an established role in the treatment of erectile dysfunction, but there is increasing evidence that these drugs are effective also for the treatment of lower urinary tract symptoms and benign prostatic hyperplasia (BPH). The mechanism of action of PDE-5 inhibitors in the prostate, however, is poorly understood. It is conceivable that these drugs act by reducing the smooth muscle tone of the organ, but this effect could produce vascular changes as well. The aim of this study was to investigate whether administration of Tadalafil, a PDE-5 inhibitor, in patients with BPH produces haemodynamic changes in the prostate that can be assessed using contrast-enhanced US (CEUS).Materials and methodsTwelve consecutive patients with BPH underwent transrectal CEUS before and 90 min after administration of 20 mg Tadalafil. CEUS was performed during bolus injection of SonoVue (4.8 ml) using a nondestructive US mode. The same scan plane, imaging parameters and technique were used before and after Tadalafil administration. Digital clips were recorded and processed using dedicated software (QontraXt v.3.60. Signal intensity (SI) changes in a region of interest (ROI) encompassing the entire prostate were fitted to a gammavariate curve. Changes in enhancement peak, time to peak (TTP), sharpness of the bolus transit and area under the curve (AUC) were considered for further analysis.ResultsAfter Tadalafil administration, the enhancement peak and AUC increased significantly (p<0.01), reflecting changes in prostate vascularity. TTP and sharpness did not change significantly.ConclusionsIn patients with BPH, vascular changes are observed in the prostate after Tadalafil administration, which can be detected with CEUS.RiassuntoObiettivoGli inibitori della 5-fosfodiesterasi (PDE-5) hanno un ruolo ben definito nella terapia della disfunzione erettile, ma vi è una crescente evidenza che questi farmaci siano efficaci anche per il trattamento dei disturbi delle basse vie urinarie e dell’iperplasia prostatica benigna (IPB). Il meccanismo d’azione a livello prostatico degli inibitori delle PDE-5 è tuttavia scarsamente compreso. È verosimile che questi farmaci agiscano riducendo il tono della muscolatura liscia dell’organo, ma questo effetto può produrre anche variazioni della vascolarizzazione. Scopo di questo lavoro è valutare se nei pazienti con IPB la somministrazione di Tadalafil, un inibitore delle PDE-5, produce variazioni emodinamiche nella prostata valutabili con ecocontrastografia.Materiali e metodiDodici pazienti consecutivi con IPB sono stati studiati con ecocontrastografia prima e dopo la somministrazione di 20 mg di Tadalafil. L’ecocontrastografia è stata eseguita con un software contrastospecifico non distruttivo dopo somministrazione in bolo di SonoVue (4,8 ml). Prima e dopo la somministrazione di Tadalafil è stata utilizzata la stessa tecnica d’esame, sullo stesso piano di scansione e con gli stessi parametri. Gli esami sono stati registrati in forma digitale e analizzati con un software dedicato (QontraXt v.3.60, AMID, Roma, Italia). Le variazioni dell’intensità di segnale misurate in una regione di interesse (ROI) comprendente tutta la prostata sono state adattate ad una curva gamma-variata. Le variazioni del picco di enhancement, del tempo di picco (TTP), della ripidezza del transito del bolo e dell’area sotto la curva (AUC) sono state valutate statisticamente. Risultati. Dopo la somministrazione di Tadalafil si apprezza un aumento statisticamente significativo del picco di enhancement e dell’AUC, indice di una variazione nella vascolarizzazione della prostata. Non si sono apprezzate variazioni significative del TTP e della ripidezza del transito del bolo.ConclusioniNei pazienti con IPB dopo somministrazione di Tadalafil si osservano variazioni della vascolarizzazione prostatica rilevabili con l’ecocontrastografia.

Long-term results with Nesbit's procedure as treatment of Peyronie's disease

The objective was to assess sexual function at long-term follow-up after the Nesbit operation for Peyronies disease.One hundred and fifty seven out of 213 patients treated between 1986 and 1998 using the Nesbit procedure were reassessed by means of IIEF-5 questionnaire together with two questions about residual deformity and treatment satisfaction. The results from this questionnaire together with the patient case records constitute the basis of this paper.After an average 72-month follow-up subjective patient determination of satisfaction indicated that 87.9% were satisfied with the results of surgery, 136 patients (86.7%) had good erectile function (IIEF-5>21). Shortening of the penis (from 1.5 to 3 cm) occurred in 22 patients (14%), but only in 2 (1.3%) was intercourse difficult because of excessive shortening.In conclusion, the Nesbits operation results in the greatest amount of patient satisfaction about sexual function. When penile shortening occurs, it has not been a significant problem for patients who are properly counselled.

Percutaneous Ethanol Injection of the Prostate as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: Preliminary Report

Objective: To evaluate the feasibility, safety and efficacy of a minimally invasive treatment for benign prostatic hyperplasia (BPH) consisting of percutaneous ethanol injection inside the prostate under ultrasound surveillance. Material and Methods: Transperineal ethanol injection into the prostate was performed in 8 patients who were affected by obstructive BPH according to AUA symptom score, impaired urinary flow, and volume of postvoiding residual urine. Injections were performed under transrectal ultrasound surveillance at four sites of the prostate for an overall amount of 6 ml of ethanol per patient. The procedure was performed under local anesthesia. Results: The patients’ median age was 69.7 years (range 57–83). No major intraoperative or postoperative complications were encountered. The median symptom score decreased from 21±5.2 (range 14–28) to 10±4.4 (range 1–14) at 3 months postoperatively (p<0.0001). The median peak flow rate increased significantly from 11 ml/s (range 7–17) before the procedure to 16 ml/s (range 12–20) after it (p<0.001). The median volume of post–voiding residual urine dropped from 130 ml (range 36–200) before treatment to 27 ml (range 11–42) after it (p<0.01). The same parameters were assessed at 6 months without significant differences. A mild side effect was observed in 1 patient who reported severe urge incontinence and moderate perineal pain the first month after the procedure. Conclusion: Percutaneous ethanol injection therapy of the prostate is a safe, easy and minimally invasive procedure for treating BPH, especially when there is an high operative risk.

Patterns of prescription and adherence to European Association of Urology guidelines on androgen deprivation therapy in prostate cancer: an Italian multicentre cross-sectional analysis from the Choosing Treatment for Prostate Cancer (CHOICE) study

To evaluate both the patterns of prescription of androgen deprivation therapy (ADT) in patients with prostate cancer (PCa) and the adherence to European Association of Urology (EAU) guidelines for ADT prescription.

Sclerotherapy of hemangioma of the glans penis.

Penile hemangiomas are very rare, small lesions. Possible therapies include surgical excision, electrofulguration, cryotherapy, and sclerotherapy. We describe an extremely rare case of a large hemangioma of the glans that was treated by means of repeated injections of 2% polidocanol under local anesthesia (5% lidocaine-prilocaine cream). No complications were observed after the operation, and a satisfactory aesthetic result was obtained. No relapse was noted 18 months after the treatment. A therapeutic reference standard for the treatment of penile hemangiomas is still lacking because of the rarity of the disease. Sclerotherapy proved to be an effective, low-cost, and easy-to-perform procedure. Moreover, it is repeatable in case of failure.

Saphenous vein harvesting by 'stripping' technique and 'W'-shaped patch covering after plaque incision in treatment of Peyronie's disease

Harvesting of the saphenous vein tract by means of leg stripping is proposed in the treatment of Peyronies disease. The technique of W-shaped saphenous vein after plaque incision to correct severe penile deformity associated with Peyronies disease is described. Graft material was obtained from the lower saphenous vein by means of distal ‘leg short stripping’ technique. The size and number of tunical incisions depended on the size of the plaque. A 15 cm venous segment is generally sufficient to cover the defect. The venous segment used was W-shaped, assembled with 6/0 polydioxanone (PDS) uninterrupted sutures and then sutured to the albuginea defect. In our preliminary series of eight patients, penile shortening and erectile dysfunction is absent. Complete correction of penile deformity was achieved in seven patients (87.5%). One patient had minimal residual curvature (<20°) which did not result in difficulty with intromission. Saphenous harvesting by the stripping technique is not an invasive procedure and is quick and simple to perform. The W-shaped assembling technique is safe because the piece of saphena is kept intact and may be suited properly to the albuginea defect.

Color Doppler appearance of penile cavernosal–spongiosal communications in patients with normal and impaired erection

Abstract. Our objective was to investigate prevalence and Doppler characteristics of penile cavernosal–spongiosal communications (CSC). These vessels are either anastomoses connecting the cavernosal arteries with the urethral arterial network or afferent vessels to the corpus spongiosum. Sixty-one consecutive patients underwent penile color Doppler US. Waveform changes in CSC were evaluated in comparison with changes in the cavernosal artery. Eighteen of 61 patients had normal erection, 17 of 61 had arterial insufficiency, and 26 of 61 had veno-occlusive dysfunction. Resistance index (RI) in CSC was significantly lower than in cavernosal arteries in all patients and increased during phases 1–2 (positive diastolic flow). Peak systolic velocity (PSV) in CSC was significantly higher in the patients with veno-occlusive dysfunction. During cavernosal phase 4 (diastolic flow reversal) CSC of patients with normal erection or with arterial insufficiency disappeared, underwent markedly reduced diastolic flow, or had systolic flow inversion. Conversely, low resistance flow was appreciable in CSC of patients with veno-occlusive dysfunction who reached phase 4. During phase 5 (systolic peak reduction) all CSC disappeared. Color Doppler US allows evaluation of CSC both in patients with normal and impaired erection.

Intrahepatic tumor thrombectomy through an abdominal diaphragmatic approach

Radical excision of renal cancer with propagation into the intrahepatic and intrapericardial inferior vena cava is an accepted surgical procedure.1.2 In a case of renal cancer with inferior vena caval suprahepatic involvement we verified the possibility of approaching the intrapericardial inferior vena cava through a limited diaphragmatic incision. CASE REPORT In a 75-year-old woman ultrasound and computerized tomography revealed a large solid mass in the left kidney and a vena caval thrombus extending above the suprahepatic veins. Magnetic resonance imaging and venacavography confirmed the diagnosis. The tumor was exposed through a Accepted for publication May 23, 1997. transverse abdominal approach combined with an epigastric vertical incision. The affected kidney was completely freed by ligation and section of the artery, ureter and vascular attachments. It remained attached only to the inferior vena cava and was transposed medially to the left mesocolon. The infrahepatic inferior vena cava was widely exposed by dividing the venous branches to the caudate and left lobes of the liver, and ligating the lumbar vessels. The diaphragm was exposed and incised in the midline at the level of its anterior insertion to the central tendon (fig. 1). The pericardial cavity was immediately entered. The upper extremity of the thrombus, placed at the diaphragm level, was evaluated by intraoperative ultrasound and its extension was confirmed by careful palpation under direct vision. A finger was then passed around the intrapericardial inferior vena cava above the thrombus and an umbilical tape was positioned. Other tapes were positioned around the hepatic hilum, infrarenal inferior vena cava, right renal vein and artery contralateral to the tumor. All tapes were clamped

LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE: 2 ADDITIONAL CASES

PURPOSE Microsurgical revascularization of the penis in vasculogenic impotence is an accepted surgical procedure in young men with a history of blunt pelvic or perineal trauma. Most penile revascularization techniques use the inferior epigastric artery in direct artery-to-artery revascularization or dorsal vein arterialization procedures. To obviate the wide pararectal incision laparoscopic mobilization of the inferior epigastric vessels has been recently proposed. We present 2 cases of successful laparoscopically assisted penile revascularization. MATERIALS AND METHODS With the patient under general anesthesia the first trocar was inserted in the umbilical region and pneumoperitoneum was induced. Two other trocars were positioned laterally. As soon as the inferior epigastric vessels were accessed, dissection was initiated below the level of the arcuate line. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level. The inferior epigastric pedicle was ligated with clips and transected at the cephalad edge of the dissection. It was then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels. RESULTS The anastomosis was patent and hemostasis was satisfactory. Operative time in the 2 cases was 4.3 and 5.2 hours, respectively. At 3 months both patients reported complete erections. CONCLUSIONS Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perform fast, accurate excision of the epigastric bundle. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided.