Hartmut E.H. Wegner

Treatment of Peyronie's disease with local interferon-alpha 2b.

Peyronies disease is an illdefined condition that often leads to severe penile deformity. Various conservative treatments have failed to have any impact, and surgery remains the mainstay of therapy in advanced cases. Recent reports of successful treatment of related diseases, notably keloid formation, with interferons (INF) have prompted us to use this biologic response modifier to alter the behavior of the myofibroblast, the cell most likely responsible for the development of Peyronies disease. From December 1992 to July 1994, 25 patients suffering from Peyronies disease were treated with five local injections of 1 million units of INF-alpha 2b each into a single designated and ultrasonographically measured plaque. The interval between the injections was 1 week. The patients were assessed clinically and ultrasonographically 1 and 6 months after the last injection. The condition improved clinically in only 1 case, but progressed in none. The measured plaque size decreased in 7 no or mildly calcified cases, remained stable in 12 cases, and increased in 6 patients, (solely calcified plaques). Side effects (myalgia, fever) occurred in 4 patients; of these 2 patients withdrew from treatment. INF-alpha 2b given according to our regimen is at best usefull for the treatment of Peyronies disease in the early, noncalcified stage during which it displays verifiable impact on the plaque treated and also helps alleviate the plaque-associated pain; but further dose-finding studies will have to be performed to identify clinically relevant treatment regimens.

Leydig Cell Tumor–Comparison of Results of Radical and Testis-Sparing Surgery in a Single Center

Between January 1981 and December 1995, 15 patients were treated for Leydig cell tumor at our institution -- 12 by radical orchiectomy, 3 by tumor enucleation. All patients were contacted to assess the long-term outcome depending on the treatment initially chosen. Follow-up ranged from 8 to 161 months (mean 56). In no case was progressive disease documented, in 1 case local recurrence was witnessed 4 months after tumor enucleation despite negative resection margins. We conclude that a small Leydig cell tumor can safely be managed by local enucleation alone.

Imaging Modalities in Peyronie’s Disease

Objective: Peyronie’s disease is an ill-understood condition afflicting men in their 40s with the reported age ranging from 18 to 68 years. It is characterized by a plaque in the tunica albuginea which leads to penile deformity making sexual intercourse difficult if not impossible and is often accompanied by severe pain upon erection in the early stage; erectile dysfunction is present in about 2% of cases. Diagnosis rests upon medical history, clinical examination with plaque palpation and autophotography in two planes. These diagnostic steps are not plaque-specific and therefore we wanted to assess which imaging modalities would allow for an objective determination of the plaque status. Materials and Methods: We evaluated 20 patients with Peyronie’s disease. All patients underwent clinical examination including autophotography and the subsequent use of the following imaging techniques: (1) ultrasound (US) using a 7.5-MHz transducer with a profile for semiquantitative density analysis; (2) X-ray in mammography technique in two planes; (3) computerized tomography (CT) with a density profile, and (4) magnetic resonance imaging (NMR). Results: (1) Degree of deviation: Penile deviation ranged from 15° to 63°. It was best assessed using radiography in mammography technique reflecting the results obtained by autophotography. (2) Calcifications: Plaque calcifications were seen in 12 patients, 8 had no calcifications but thickening of the tunica albuginea only, 2 also had a fibrosis of the corpus cavernosum distant to the plaque. Calcifications were visualized using ultrasound sonography (12/12), radiographically (12/12), CT (12/12), NMR (9/12). Thickening of the tunica albuginea only was visualized using ultrasound sonography (7/8), radiographically (0/8), CT (2/8), NMR (6/8). (3) Morphological pattern in ultrasound: Three distinct patterns could be detected: (type 1) the plaque appeared as a thickening of the tunica albuginea without acoustic shadowing and only minimal density increase in the histogram profile; (type 2) moderately calcified plaque with typical ultrasound shadow but minimal density increase in the density profile; (type 3) severely calcified plaque with typical acoustic shadowing and density increase in the histogram profile. (4) Plaque inflammation: Only NMR with gadolinium DTPA showed periplaque inflammation. Conclusions: High-resolution ultrasound sonography is the best imaging modality in assessment of plaques. NMR is the modality of choice to monitor the inflamed plaque. X-ray in mammography technique and CT are not necessary in daily routine.

EVALUATION OF PENILE ARTERIES WITH COLOR-CODED DUPLEX SONOGRAPHY: PREVALENCE AND POSSIBLE THERAPEUTIC IMPLICATIONS OF CONNECTIONS BETWEEN DORSAL AND CAVERNOUS ARTERIES IN IMPOTENT MEN

Penile revascularization for cases of arteriogenic impotence is based on the assumption of hemodynamically relevant connections between the dorsal penile and cavernous arteries. In 325 clinically impotent patients color-coded duplex sonography was performed with the penis flaccid and tumescent after intracavernous injection of 10 micrograms prostaglandin E1. We measured peak flow velocity, end diastolic flow velocity and resistance in the dorsal arteries, deep cavernous arteries and connections perforating the tunica albuginea between the 2 systems. Of our patients 14% had at least 1 such anastomosis with a peak flow velocity exceeding 25 cm. per second after stimulation. Peak flow velocities less than 20 cm. per second were noted only in arteriogenically impotent patients, while those exceeding 25 cm. per second without later rigid erection occurred only in patients with venous occlusive dysfunction and end diastolic flow velocity exceeded 5 cm. per second. We conclude that penile revascularization should be contemplated only if hemodynamically relevant connections are detected, peak flow velocity in the cavernous arteries is less than 20 cm. per second and end diastolic flow velocity is less than 5 cm. per second.

Renal cell cancer and concomitant transitional cell cancer of the renal pelvis and ureter in the same kidney--report of 4 cases and review of the literature.

Three patients (1 man, 81 years old; 2 women, 56 and 61 years old) had renal cell cancer and transitional cell cancer in the same kidney, and another patient (female, 77 years old) had renal cell cancer and transitional cell cancer in the ipsilateral ureter. Simultaneous occurrence of renal cell cancer and transitional cell cancer is an extremely rare entity with only 15 cases having been reported.

Paratesticular Epidermoid Cyst and Ipsilateral Spermatic Cord Dermoid Cyst: Case Report and Discussion of Pathogenesis, Diagnosis and Treatment

We report a case of a paratesticular epidermoid cyst with a concurrent dermoid cyst of the ipsilateral spermatic cord at the internal inguinal ring. The patient presented for evaluation of a presumed testicular neoplasm. Epidermoid and dermoid cysts were confirmed histologically after local excision. To our knowledge concomitant occurrence of these lesions has not been reported previously. We discuss the pathogenesis, diagnosis and treatment.

Leydig cell tumor recurrence after enucleation

Leydig and Sertoli cell tumors are the primary nongerm cell tumors of the testis, comprising approximately 1 to 3% of all testicular tumors. While only 10% of all Leydig cell tumors are malignant, the histological specimen does not allow accurate assessment of potentially malignant behavior. Since the preoperative diagnosis is difficult and clinical course is unpredictable, radical orchiectomy has been the standard treatment. However, tumor enucleation has been reported, usually with excellent results. To our knowledge we report the first case of local tumor recurrence after resection with tumor-free margins.

Nitroxergic innervation of the human ureterovesical junction

Nitric oxide synthase (NOS) immunohistochemistry and nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) histochemistry were used to investigate the distribution of nitroxergic, i.e., nitric oxide-synthesizing, neuronal perikarya and processes in the human ureterovesical junction (UVJ). Tissue specimens obtained from two cadaver kidney donors and two patients undergoing radical cystectomy for bladder cancer were examined. Clusters of NOS-immunoreactive neurons were localized in extramural ureterovesical ganglia. NOS-containing nerve fibers traveled within large extramural nerve trunks and marched among smooth muscle bundles. Extramural and intramural blood vessels were encircled by varicose NOS-positive axonal processes. The distribution of NOS immunoreactivity paralleled the staining pattern for NADPH-d activity. Urothelium stained strongly for NADPH-d activity but showed no NOS immunolabeling. Specimens from all four patients investigated showed similar staining patterns. Our results suggest that nitric oxide, a potent smooth-muscle-relaxing neurotransmitter in the autonomic nervous system, plays a physiologic role in opening the human UVJ.

Ultrasound and Soft-Tissue Radiography to Monitor Local Interferon-α2B Treatment in Peyronie's Disease

Purpose: We attempted to assess objectively the response of Peyronies disease plaques to local interferon-α2B. Material and Methods: Twenty patients were treated with 5 local injections of 1 million units of IFN-α2B into a single designated plaque. Before treatment, and 4 weeks and 6 months after treatment, the plaques were examined ultrasonographically. Each time, a histogram profile was performed. All patients also underwent soft-tissue radiography in 2 planes using the mammography technique before and 6 months after treatment. Results: We found that with ultrasonography the plaques could be classified into 3 groups depending on degree of calcification, from nil to complete. Radiography detected calcifications better than ultrasonography but failed to detect plaques without calcification. The degree of calcification was negatively correlated with the response to treatment, since noncalcified plaques responded best, while fully calcified plaques failed to respond. Conclusion: In Peyronies disease, ultrasonography is an important tool for non-invasive monitoring treatment response and for preselecting patients for medical treatment.

TESTICULAR NECROSIS AFTER ANTEGRADE SCLEROTHERAPY OF VARICOCELE

A 26-year-old man who had been evaluated for male factor infertility presented with a left sided varicocele. Antegrade sclerotherapy was performed. Under local anaesthesia the pampiniform plexus was dissected. A 24gauge plastic venflon | sheath was inserted. Blood dripped from the venflon | Two ml of saline were easily injected. Under fluoroscopy 10 ml of a mixture of contrast and normal saline (5 ml Omnipaque | were injected. Fluoroscopy showed excellent opacification of the spermatic vein (Fig. 1). A mixture of 3 ml ethoxysclerol and 2 ml of air were injected and the procedure was terminated.