Jonathan E. Bernie

Sexual dysfunction in combat veterans with post-traumatic stress disorder

OBJECTIVES To evaluate the prevalence, clinical correlates, and severity of sexual dysfunction in combat veterans with and without post-traumatic stress disorder (PTSD) using a validated instrument for assessing sexual function. The results of recent studies have suggested that combat veterans with PTSD experience a higher rate of sexual dysfunction than do those without PTSD. METHODS We administered the International Index of Erectile Function (IIEF) and a demographic and health questionnaire to male combat veterans undergoing treatment for PTSD and to age-comparable male combat veterans without PTSD. RESULTS The mean total IIEF score was significantly lower in the 44 patients with PTSD than in the 46 controls (26.38 versus 40.86; P = 0.035). With respect to the individual IIEF domains, patients with PTSD had poorer scores on overall satisfaction and orgasmic function and showed trends toward poorer scores on intercourse satisfaction and erectile function. No statistically significant difference was observed for sexual desire. The rate of erectile dysfunction was 85% in patients with PTSD and 22% in controls. Moderate to severe erectile dysfunction was present in 45% of the patients with PTSD and in only 13% of controls. Significantly more patients with PTSD (57%) than controls (17%) were using psychotropic medications. CONCLUSIONS Combat veterans with PTSD experience a significantly higher rate of sexual dysfunction than do veterans without PTSD and show impairment in some, but not all, specific domains of sexual function. The IIEF may be useful in evaluating the response to treatment of erectile dysfunction. Clinicians should proactively address the sexual concerns of combat veterans with PTSD.

The intravesical potassium sensitivity test and urodynamics : Implications in a large cohort of patients with lower urinary tract symptoms

PURPOSE Bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH) is the most common diagnosis in older men with lower urinary tract symptoms. However, these symptoms also can occur with interstitial cystitis. We determine whether the potassium sensitivity test is useful for distinguishing BPH from possible intersitial cystitis in patients with lower urinary tract symptoms. We also test the hypothesis that patients with these symptoms who have a positive test will have urodynamic findings consistent with the diagnosis of interstitial cystitis. MATERIALS AND METHODS The potassium sensitivity test was performed in 526 (95%) males and 25 (5%) females with lower urinary tract symptoms undergoing urodynamic testing. Urodynamic parameters in the positive and negative potassium sensitivity test groups were compared. % RESULTS Of the patients 16% (89 of 551) had a positive potassium sensitivity test. Compared with patients who had a negative test, those who had a positive test were younger (61 versus 64 years, p = 0.03), had urgency at significantly lower volumes (108 versus 182 cc, p <0.0001), lower bladder capacity (343 versus 436 cc, p <0.0001) and lower post-void residual (49 versus 95 cc, respectively, p <0.001). Urodynamic parameters in the 24% (6 of 25) of women who had a positive potassium sensitivity test were similar to those in men who also had a positive test. CONCLUSIONS Urodynamic findings in patients with lower urinary tract symptoms who have a positive potassium sensitivity test are significantly different from those in patients who have a negative test, and are similar to those findings characteristic of interstitial cystitis. Interstitial cystitis should be considered in patients with lower urinary tract symptoms who have a positive test. The potassium sensitivity and urodynamic tests may be a useful combination for screening men with lower urinary tract symptoms to identify those symptoms that may be due to interstitial cystitis versus BPH.

Intraoperative mapping of renal lymphatic drainage: technique and application in a porcine model.

BACKGROUND AND PURPOSE The use of lymphadenectomy in renal-cell carcinoma (RCC) is controversial. Proponents argue that lymphadenectomy improves survival, whereas opponents challenge the procedure on the basis of its morbidity and the variable lymphatic drainage of the kidney. Intraoperative gamma probes have been used to guide resection of radiolabeled sentinel nodes in cancers of the breast, penis, and head and neck and in melanoma. Our goal in applying this technique to RCC is to improve detection and to limit sampling of lymph nodes during lymphadenectomy. This preliminary study in a porcine model evaluated the feasibility and transit time of radiolabeled tracer injected into the kidney. MATERIALS AND METHODS Data were collected on four 40-kg Yorkshire pigs. The right kidney was exposed through a flank incision. Using both blue dye and technetium-99m, mapping and resection of the sentinel lymph nodes was performed with the assistance of an intraoperative gamma probe (Neoprobe). Remote cervical lymph nodes were utilized as controls. Vascular counts along the carotid vessels were obtained to confirm that the radioisotope was not being dispersed systemically. RESULTS Within 10 minutes of renal injection of the tracer, excised sentinel lymph nodes demonstrated significant radioactive counts compared with controls. Vascular counts confirmed that radioisotope tracer did not enter the venous circulation. CONCLUSIONS Sentinel lymph node sampling using a gamma probe and blue dye appears to be feasible in the porcine kidney. Further studies using this technique in humans will evaluate the impact of selective lymphadenectomy on survival in RCC.

Synchronous ipsilateral renal adenocarcinoma, transitional cell carcinoma of the renal pelvis and metastatic renal lymphoma.

Synchronous ipsilateral renal tumors are rare. To our knowledge we report the first case of synchronous ipsilateral renal cell carcinoma, transitional cell carcinoma of the renal pelvis and renal lymphoma. Although the collision of these tumors has been suggested by some to be more than coincidental, there is no conclusive evidence that patients with renal cell carcinoma are at higher risk for any of the aforementioned malignancies. A 72-year-old man was referred for an incidental 4 cm. hypervascular right renal mass, which had been revealed on abdominal ultrasound initially performed to assess for splenomegaly. He had a 3-year history of IgM paraproteinemia associated with neuropathy and an IgM level of 524 mg./dl. (normal 34 to 213), and a long-standing history of cigarette smoking but no history of antecedent urothelial carcinoma. Laboratory values were significant for an elevated creatinine of 1.8 mg./dl. (normal 0.5 to 1.5), which 1 year earlier had been 1.2 mg./dl. Urinalysis and physical examination were normal. Before our evaluation, gadolinium enhanced magnetic resonance imaging obtained by the hematologist had confirmed the 4 cm. lower pole mass in the right kidney. There was no intravascular tumor thrombus or lymphadenopathy. The left kidney appeared normal. Peripheral blood flow cytometry at that time indicated a monoclonal B-cell lymphoma (B lymphocytes: IgM br 66%, IgD 62%, K/CD19 br 65%, L/CD19 3%, CD19 67%, CD20 br 64%, CD23 62%. Right radical nephrectomy was performed through a flank incision without incident (part A of figure). Pathological examination revealed renal cell carcinoma (part B of figure), transitional cell carcinoma (part C of figure) and B-cell lymphoma (part D of figure). Distal ureterectomy and cystoscopy were performed 6 weeks after nephrectomy. Pathological examination failed to identify the presence of disease. Convalescence was uneventful and no treatment has been planned for lymphoma.

Tubeless Barcat: a patient-friendly hypospadias procedure.

OBJECTIVES To determine whether the distinct advantages of a catheter-free hypospadias repair can be obtained with a Barcat procedure without an adverse effect on surgical outcome. METHODS A retrospective review was performed on consecutive patients who had undergone a catheter-free Barcat repair from July 1998 to May 2002. Patient records were examined for information regarding age, meatal location, primary or secondary procedure, operative time, postoperative follow-up, and complications. RESULTS Thirty-six consecutive catheter-free Barcat hypospadias repairs were performed in the review period. Patient age ranged from 6 months to 9 years (mean 26 months). All patients either had a coronal meatus or a subcoronal meatus. Thirty-three patients (92%) underwent a primary repair. Three patients (8%) underwent the repair as a secondary procedure after a previous failed procedure. The mean follow-up was 25 months. One patient required a single catheterization in the immediate postoperative period for urinary retention. Another patient had glans separation and meatal retrusion requiring a revision procedure. All the other patients achieved a satisfactory cosmetic result with an orthotopic slit-like meatus. CONCLUSIONS The Barcat hypospadias repair may be performed in patients with distal hypospadias without the use of a postoperative urethral catheter. Foregoing a catheter had no adverse effect on the surgical outcome with reduced patient discomfort.

Ileal conduit perforation-iatrogenic injury and conservative management.

The ileal conduit was popularized by Bricker in the 1950s. Since then, surveillance of the upper urinary tract has been accomplished with intravenous urography, ultrasonography, or loopography. Loopography is used as an imaging modality at our institution because of its safety and avoidance of intravenous contrast. We report the first case of an iatrogenic rupture of an ileal conduit during loopography.