L. Dean Knoll

Use of porcine small intestinal submucosal graft in the surgical management of Peyronie's disease.

OBJECTIVES To report the use of a new acellular, xenographic porcine jejunal submucosal graft as a closure material for the tunica albuginea after plaque incision. METHODS Twelve patients with at least a 12-month history of Peyronies disease with a penile curvature of 70 degrees or greater were evaluated. Patient age ranged from 39 to 61 years (mean 50). Preoperatively, all underwent Doppler ultrasound after an intracavernous injection. Lyophilized (freeze-dried) small intestinal submucosa immersed in normal saline was used to graft the tunical deficit after the plaque incision using a subcoronal incisional approach. RESULTS Surgical correction of the penile curvature was achieved in 11 of 12 patients. At a mean follow-up of 11 months (range 5 to 20), all patients were potent, with one requiring intracavernous injection therapy. One patient developed a 60 degrees curvature 6 months postoperatively and required reoperation. No reports of penile shortening, pain, infection, hematoma, bulging at the graft site, or evidence of a local immunogenic rejection reaction have been noted. CONCLUSIONS At this early stage, acellular porcine jejunal submucosal grafts for coverage of cavernosal defects after Peyronies plaque incision allow for satisfactory clinical results. The ease of surgical handling and placement and no associated comorbidities from harvesting techniques, coupled with no adverse reactions, make this material an anatomic and functional tunical substitute.

Leiomyoma of the bladder.

We report 5 cases of leiomyoma of the bladder and review the literature. Because of its size and location, this tumor usually is asymptomatic unless urinary tract function is affected. Excretory urography and computerized tomography were useful in identifying the location, consistency and size of the lesions. Small lesions can be managed with transurethral resection and large lesions require segmental resection. Cystectomy is not indicated.

Long-term followup in patients with cystine urinary calculi treated by percutaneous ultrasonic lithotripsy

From February 1983 through 1986, 15 patients (17 renal units) with cystine urinary lithiasis were treated by percutaneous ultrasonic lithotripsy. Three patients were lost to followup. Of the 13 renal units in the remaining 12 patients 7 (54 per cent) had retained stone fragments and 6 (46 per cent) were free of stones. While on medical management 7 of the 13 renal units (54 per cent) had new stones, 5 (38 per cent) remained unchanged and in 1 (8 per cent) the retained stones dissolved. The rate for reoperations was 43 per cent for the group with retained stones (3 of 7) and 17 per cent for the group that was free of calculi after percutaneous ultrasonic lithotripsy (1 of 6). Our study suggests that the optimal treatment with percutaneous ultrasonic lithotripsy should result in a patient who is free of stones.

Use of porcine small intestinal submucosal graft in the surgical management of tunical deficiencies with penile prosthetic surgery

OBJECTIVES To report the use of a new acellular xenographic porcine jejunal submucosal graft as a closure material for tunica albuginea deficiencies (distal erosion, attenuation) after penile prosthesis insertion. METHODS Seventeen patients with at least a 36-month history of having an indwelling three-piece inflatable penile prosthesis developed tunica albuginea deficiencies. Nine patients with unilateral distal erosion of the tunica and eight with attenuation of the tunica underwent penile prosthesis revisionary surgery and tunical reconstruction using lyophilized small intestinal submucosa (Surgisis). The reconstructive techniques used a suprapubic and subcoronal incisional approach and a new three-piece inflatable prosthesis. RESULTS Reconstructive surgical correction of the tunical defect was achieved in all 17 patients. At a mean follow-up of 21 months (range 6 to 34), no patient had had separation of the graft from the tunica or recurrence of the deficiency. All patients had a satisfactorily functioning prosthesis. Infection, pain, bulging, or evidence of a local inflammatory response at the graft site has not occurred. No patient required any additional surgery. CONCLUSIONS At the initial long-term follow-up, acellular porcine jejunal submucosal grafts for coverage of tunical deficiencies with penile prosthetic surgery allow for satisfactory clinical results. The ease of surgical handling and placement, elimination of nonabsorbable synthetic grafting materials, and no associated comorbidities from graft harvesting techniques, coupled with no adverse reactions, make this graft an anatomic and functional tunical substitute.

Management of Nondilatable Cavernous Fibrosis With the Use of a Downsized Inflatable Penile Prosthesis

The basic underlying cause of inability to implant a penile prosthesis is cavernous fibrosis resulting in unsatisfactory cavernous dilation. During the last 3 years, 20 patients with severe cavernous fibrosis underwent penile prosthetic implantation with a downsized inflatable penile prosthesis, obviating the need for additional cavernous reconstruction. After a mean followup of 20 months 19 of the 20 patients had a functional device with only 1 requiring explantation for infection. We believe that this downsized penile prosthesis is a valuable addition to the urological armamentarium when considering reimplantation or implantation in a patient with intracavernous fibrosis and scarring.

Treatment of Recurrent Urinary Incontinence After Artificial Urinary Sphincter Placement Using the AdVance Male Sling

OBJECTIVES We report on the use of the AdVance male sling to treat men who had an artificial urinary sphincter placed and subsequently developed recurrent urinary incontinence. METHODS Nineteen men who had undergone placement of an artificial urinary sphincter for post prostatectomy urinary incontinence, and who had developed recurrent incontinence, were treated by placing an AdVance sling. Self-reported pad use preoperatively was 2-5 pads per day. RESULTS All 19 patients (100%) reported improvement in their incontinence as documented by decreased pad use. Of these men, 15 (79%) became dry, using no further pads, and four (21%) decreased pad use to 1 pad per day. Of the 15 dry patients, 8 remained dry without reactivation of the artificial sphincter (53%); the other 7 maintained complete continence with a combination of the sling and an activated artificial sphincter. CONCLUSIONS Men who suffer from recurrent urinary incontinence secondary to cuff compression atrophy can be made continent by the placement of a male sling. The technique of sling placement requires no special modification in these patients. By not revising the artificial urinary sphincter the capsule surrounding the device is not violated, which may decrease the risk of postoperative infection. In addition, the patient may not need to rely upon the use of his artificial sphincter to maintain continence.

Prospective multicenter study of transperineal prostatic block for transurethral needle ablation of the prostate

The choice of anesthesia during thermal therapy of the prostate plays a significant role in the morbidity profile, patient convenience, and cost. We report 39 men with symptomatic benign prostatic hyperplasia who underwent transurethral needle ablation of the prostate under transperineal prostatic block. This method of local anesthesia proved safe, convenient, and satisfactory during the procedure.

Application of nocturnal electrobioimpedance volumetric assessment: a feasibility study in men without erectile dysfunction.

PURPOSE Electrobioimpedance volumetric assessment is based on the principle of delivering a constant, nondetectable alternating current to a tissue segment. A potential difference measured between the electrodes is converted to impedance. Since impedance changes with variations in blood flow, penile volumetric change is measured noninvasively. We applied this procedure to the development of a new device to evaluate erectile activity nocturnally, and we report our findings in men with no history of erectile dysfunction. MATERIALS AND METHODS Our study group comprised 10 men with a mean age of 44 years who had no history of erectile dysfunction. The NEVA device consists of a small recording device attached to the upper thigh, and 3 small adhesive electrode pads placed over the hip and on the penile base and glans, respectively. Each subject used the NEVA device for 2 nights. RESULTS Overall 20 nights of electrobioimpedance volumetric assessment were recorded. Tumescence monitoring revealed 3 to 6 erections per night per subject (mean 3.45) lasting 10 to 50 minutes (mean 17). As determined from the impedance measurements, mean volume change was 14.4 ml. with a 213% mean volume change over baseline. CONCLUSIONS The new NEVA device is small, comfortable to wear and easy to use. It determines the number and duration of erectile events and percentage increase of blood volume changes during these events in normal men in a noninvasive manner. Future directions of study include a comparison to men with erectile dysfunction and analysis of the dynamic information of the NEVA data.

A Randomized Crossover Study Using Yohimbine and Isoxsuprine Versus Pentoxifylline in the Management of Vasculogenic Impotence

PURPOSE We evaluated the efficacy and safety of yohimbine and isoxsuprine or pentoxifylline in the management of vasculogenic erectile dysfunction. MATERIALS AND METHODS A total of 20 patients diagnosed with arterial insufficiency and cavernous venous leakage by pharmacological penile duplex scanning underwent nonhormonal oral therapy. A randomized crossover study was performed using 5.4 mg. yohimbine plus 10 mg. isoxsuprine or 400 mg. pentoxifylline 3 times daily. Response to therapy was assessed by a sexual questionnaire and repeat penile duplex ultrasonography. RESULTS No patient in either phase of the study in either group had a complete response to the oral regimen(s) and there was no improvement in the pre-injection or post-injection cavernous arterial peak systolic flow velocities or resistance indexes. CONCLUSIONS Our study suggests that these oral agents, although well tolerated, were not effective in the management of these patients with mixed vasculogenic erectile dysfunction.

Bowenoid papulosis of the penis: successful management with neodymium: YAG laser

Bowenoid papulosis of the penis is a recently described entity that clinically resembles benign verruca-like papular lesions but, histologically, it is identical to carcinoma in situ, Bowens disease or erythroplasia of Queyrat. Although a few cases of spontaneous regression of bowenoid papulosis in men have been reported, conservative therapy, consisting of topical 5-fluorouracil, electrodissection or excision, is recommended. With these treatment modalities recurrences are not uncommon. We report 2 cases of extensive bowenoid papulosis of the penis treated successfully without scarring with the neodymium-yttrium-aluminum-garnet laser.