Michael F. Carter

Venogenic Impotence Following Dermal Graft Repair for Peyronie’s Disease

Peyronies plaque excision with dermal grafting generally offers good cosmetic results for patients who require surgical intervention for Peyronies disease. However, postoperative impotence has been reported in 12 to 100% of such patients. The mechanism of impotence in this setting is not well defined. We present 3 men who had venogenic impotence after plaque excision and dermal grafting for Peyronies disease. One patient has subsequently responded well to dorsal vein ligation, 1 has chosen an effective nonoperative method of management and 1 continues to consider the options. We report venous leak as an organic cause of impotence after plaque excision and dermal grafting for Peyronies disease, and its successful management by dorsal vein ligation. The implications of these findings in the surgical management of Peyronies disease are discussed.

Ureteroscopic Results and Complications: Experience with 130 Cases

Since its introduction for general use, the role of rigid ureteroscopy in the diagnosis and therapy of urological disease has been in evolution. We evaluated retrospectively the experience at our institution with rigid ureteroscopy from January 1983 to July 1986 in an attempt to identify clinical situations or techniques that tended to increase the incidence of either success or complications. We determined that ureteroscopic complications were rare in procedures performed for diagnosis compared to those performed for calculi (2 of 33 or 6 per cent versus 27 of 99 or 27 per cent, p less than 0.025). The likelihood of failure or complication was greater for stones above than for those below the pelvic brim (15 of 25 or 60 per cent versus 26 of 75 or 35 per cent, p less than 0.05). Major complications were more common early in our experience (9 of 63 or 14 per cent versus 2 of 69 or 3 per cent for the combined years 1983 and 1984 compared to 1985 and 1986, p less than 0.05). Our success rates in the treatment of calculous disease were similar to those reported previously, and they were somewhat better for stones located below (62 of 75 or 83 per cent) than for those above (17 of 25 or 68 per cent) the pelvic brim. Based on our findings we conclude that carefully performed diagnostic ureteroscopy has little potential for major complications, ureteroscopy for stones above the pelvic brim should be avoided when possible, and an increased rate of complications and failures is expected early in any series owing at least partly to the learning curve effect.

Penile Blood Pressure in the Evaluation of Erectile Impotence

Identification of specific etiologies of erectile impotence is hindered by a paucity of objective criteria needed to segregate organic from psychogenic varieties and to define specific organic causes. Simplified measurement of penile blood pressure was performed with a digital cuff and a portable ultrasound Doppler system for flow detection. An index relating penile-to-brachial systolic blood pressure was generated, and the results were compared in patients with impotence versus patients with normal erections. The mean indices for the two groups were significantly different (P less than 0.05). The penile-to-brachial index provides an additional diagnostic tool in the evaluation of potency, allowing us to identify those patients with decreased penile blood flow, and may be helpful in selecting patients for revascularization procedures.

Estimation of Prostatic Size by Suprapubic Ultrasonography

Previous ultrasonic scanning of the prostate primarily has involved the transrectal approach. In this study the suprapubic approach was chosen because it uses basic ultrasound equipment and is atraumatic. In 29 patients undergoing prostatectomy there was a highly significant correlation (r equals 0.95) between the prostatic weight determined by this method and the postoperative weight of the adenoma.

Effect of Local Alpha-Adrenergic Blockade on Human Penile Erection

Recent data suggest that selective local blockade of the alpha-adrenergic receptors of the sympathetic innervation within the corpora cavernosa of the penis will result in erection in normal and impotent subjects. To examine this hypothesis we studied in a randomized, double-blinded fashion 8 impotent patients and 2 normal controls. The organic nature of the impotence was documented with nocturnal penile tumescence testing, sacral latency examination, Doppler penile blood flow measurements, hormonal evaluation and psychological testing. The 2 normal controls had full erections for 5 to 7 minutes after the intracorporeal injection of 5 mg. phentolamine. All of the impotent subjects had tumescence without full erection after a similar injection. The tumescence was augmented by standing upright and diminished by assuming a supine posture, and lasted for several hours. Possible mechanisms, and diagnostic and therapeutic implications are discussed.

Simultaneous diversion of the urinary and fecal streams utilizing a single abdominal stoma: the double-barreled wet colostomy.

A new technique to achieve simultaneous diversion of the urinary and fecal streams using a single abdominal stoma is described. The procedure consists of the construction of a diverting loop colostomy with division of the colon approximately 10 to 15 cm. distal to the stoma. The segment of colon distal to the stoma, the urine limb, acts as a urinary conduit. To date 3 patients have undergone the procedure with followup of 3, 13 and 18 months. Neither upper tract infection nor upper tract deterioration has occurred. The potential role of this procedure to treat a difficult group of patients is discussed.

Computerized Tomography in the Preoperative Staging for Pulmonary Metastases in Patients with Renal Cell Carcinoma

Computerized tomography (CT) is the state of the art technology for pulmonary staging of many extrathoracic malignancies. From 1976 to 1990, 120 of 330 patients with renal cell carcinoma treated at our hospital underwent chest radiography and chest CT. These patients were reviewed to evaluate the role of CT in examining the chest for staging of renal cell carcinoma. Median followup was 24 months. Agreement between the 2 imaging modalities was found in 105 patients. The results of chest radiography and chest CT were normal in 82 and abnormal in 23 patients. Of the 15 patients with disagreement between the 2 studies 13 had normal chest radiography with abnormal chest CT and 2 had abnormal chest radiography with normal chest CT. The 13 patients with normal chest radiography and abnormal CT were further divided into 2 groups: 8 patients with small borderline lesions seen on CT only and 5 patients with evidence of advanced, bulky disease outside the chest at presentation. A substantial agreement, more than chance alone, between chest radiography and CT existed (p < 0.0001). Followup records and survival data have shown no significant impact as a result of the disagreement between the 2 imaging modalities on the treatment decision or ultimate outcome. Based on this information, we believe that in patients with a relatively small tumor (stage T1) a normal chest radiograph suffices for pulmonary staging. The indications for additional chest CT would include solitary nodule on chest radiograph before salvage resection of metastasis, chest symptoms suggestive of endobronchial metastasis or extensive regional disease.

Fibroepithelial Polyps of the Ureter

We report a case of fibroepithelial polyps of the ureter, which are rare, benign mesodermal tumors. The advantage of ureteroscopic confirmation of this benign tumor is emphasized.

Urologic manifestations of von Recklinghausen neurofibromatosi

A sixty-seven-year-old white man was seen in February, 1981, with complaints of urinary frequency, incontinence, and gross hematuria of one-year duration. The patient had a history of von Recklinghausen neurofibromatosis since birth and had undergone multiple orthopedic procedures on his left leg for malformations secondary to his disease. Five months prior to admission, the patient had an inguinal herniorrhaphy with postoperative bladder hypotonia requiring a suprapubic catheter for two months. Physical examination was remarkable for innumerable pedunculated and subcutaneous neurofibromas covering the entire skin surface, and the previously noted left knee deformity and scarring. Intravenous pyelogram (IVP) demonstrated mild left hydroureteronephrosis. Cystoscopy revealed visual obstruction by the prostate gland, heavy trabeculation of the bladder wall, a laterally placed left ureteral orifice, and questionable left ureteral meatal stenosis, which was incised with an endoscopic scissors. A transurethral resection of 10 Gm of prostate was performed, but high post-void residual

Splenogonadal Fusion Associated with an Anaplastic Seminoma

A case of the rare anomaly of splenogonadal fusion is presented. The literature related to this anomaly is reviewed and the 2 principal classifications are discussed. To our knowledge this is the first reported case of splenogonadal fusion associated with an intra-abdominal testicular neoplasm.