Michaela H. Purcell

Deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage

Objective To report observations of semen parameters in men with untreated varicocele over time. Design Semen parameters in 13 men with varicoceles were obtained at initial presentation, and re-evaluated at a 9 to 96-month interval because of persistent infertility. Setting Outpatient male fertility clinic. Patients, Participants Thirteen men who presented for fertility evaluation and who were found to have varicocele(s) and normal semen parameters. Re-evaluation was performed because of continued fertility problems. Interventions None. Main Outcome Measure Semen parameters, especially sperm density, sperm mobility, and total sperm. Results Statistically significant deterioration was noted from normal to abnormal. Conclusion In males with varicocele(s), normal semen parameters should not routinely be expected to remain normal over time.

The inflatable penile prosthesis: failure of the rear tip extender in reducing the incidence of cylinder leakage.

Of 184 patients who have received an inflatable penile prosthesis at our institution since 1974, 43 per cent have undergone reoperation, the majority of which were owing to cylinder leakage. Comparison by life-table analysis of cylinders placed before and after introduction of the rear tip extender does not show an improvement in cylinder survival to date.

The Inflatable Penile Prosthesis, Reoperation and Patient Satisfaction: A Comparison of Statistics Obtained from Patient Record Review with Statistics Obtained from Intensive Followup Search

Of 179 patients who received the inflatable penile prosthesis 43 per cent have required reoperation, 60 per cent of which were performed for mechanical failure. An attempt to evaluate the adequacy of chart review in assessing current function and patient satisfaction was made by comparing reports obtained by chart review to those obtained by direct patient interview. Results showed that if chart review alone was used malfunction would have been underestimated by 13 per cent and patient satisfaction overestimated by 21 per cent. The importance of direct followup in evaluating patients with the inflatable penile prosthesis is demonstrated.

Intermittent Catheterization: Evaluation of Complete Dryness and Independence in Children with Myelomeningocele

We studied 46 children in active followup who have been managed by nonsterile intermittent catheterization to achieve continence. All patients were given maximum therapeutic doses of supplemental medication to improve dryness. Of the patients 33 per cent were noncompliant and, therefore, wet, 30 per cent were wet despite full compliance with the program, and only 24 per cent were completely dry and wearing regular underclothing. Nine children experienced side effects from the supplemental medications that were severe enough to warrant discontinuation of the drug. Of the 46 patients 19 have been removed from the catheterization program and currently are being managed by other modalities. Only 11 of the remaining 27 patients currently managed by catheterization perform the procedure independently. Results suggest that intermittent catheterization does not provide independence or social continence in many patients.

The Diagnosis and Surgical Management of Vasculogenic Impotence

Thirty-two patients have been treated for organic impotence at our institution during a 16-month period. Of these patients 5 were found to have penile vascular insufficiency and underwent a femorocavernosal bypass with an autogenous saphenous vein graft. Initial results were excellent but late failures occurred. At 28 months all shunts were occluded. Microscopic examination of the cavernous tissue revealed fibrous thickening of the septa and loss of cavernous spaces. These findings suggested that late failure in direct revascularization may be associated with fibrotic changes that occur under high pressure inflow to the corpora cavernosa.

Scott’s Inflatable Penile Prosthesis: Evaluation of Mechanical Survival in the Series 700 Model

The series 700 penile prosthesis was implanted in 131 patients. Actuarial analysis revealed survival of the cylinders to be 98 per cent at 1 year and 92 per cent at 36 months. The only additional failures were leaks in the reinforced tubing in 9 cases. No tubing leaks have occurred since revisions were made by the manufacturer in October 1983.

Penile prostheses: review of current models, mechanical reliability, and product cost

A fifty-year experience with the modern penile implant has led urologists to conclusions as to the reliability, applicability, and cost of these devices. Product evolution has led to a more physiologic erection. However, with increased sophistication, further potential for failure must be considered. Each modification must undergo the test of clinical experience in addition to classic bench testing in order to predict reliability accurately.

Aggressive Management of Bilateral Renal Cell Carcinoma

We review 4 cases of bilateral renal cell carcinoma. Treatment included extracorporeal surgery with subsequent autotransplantation in 2 patients and radical nephrectomy combined with contralateral partial nephrectomy in the remaining 2 patients. Absence of recurrence as well as length of patient survival supports this aggressive therapy.

Urinary incontinence in the elderly: Ways to relieve it without surgery

Few studies of incontinence have been done on the elderly as a specific population, although epidemiologic reports reveal that incontinence is a debilitating condition that affects 15% to 30% of the elderly population of the United States. In diagnosing the problem, we use the simplest procedure that can supply the required information. However, if the diagnosis is uncertain or the treatment being considered is risky, urodynamic testing is necessary. Several nonsurgical treatments are available and have varying degrees of success in reestablishing continence. Some, such as pharmacotherapy and intermittent self-catheterization, are effective for some patients and are replacing bladder drill and bladder distention in popularity. Less conventional techniques (electrotherapy, biofeedback, and periurethral injection) are useful only in select cases and have had fewer clinical trials. Clamps and external devices for men and pessaries for women are prone to complications and generally are avoided in our practice. Long-term use of indwelling catheters is a last resort, to be considered only when all other alternatives have been exhausted. Further clinical research that considers the particular problems of the elderly is needed so that practical, humane, and effective treatment becomes possible.

Correlation of antibody-coated bacteria with intravenous pyelogram in children with refluxing and nonrefluxing units

A fluorescent technique for detecting immune globulins on the surface of urinary bacteria has been used to differentiate upper from lower urinary tract infections. In an attempt to correlate positive fluorescence with deteriorative changes on the intravenous pyelogram, a total of 79 pediatric patients was studied. Twenty-three had ileal conduits with freely refluxing urine. The remaining 56 children had intact urinary tracts. Thirty of these had vesicoureteral reflux. Urine cultures were studied in conjunction with fluorescent antibody determinations. In patients with significant bacteriuria good correlation was seen with the presence of bacterial fluorescence and positive renal changes. This correlation was 88 per cent in patients with bowel conduits, 71 per cent in patients with vesicoureteral reflux, and 38 per cent in patients without reflux. Possible false positive and false negative results were relatively low, each occurred in 10 per cent of the specimens examined. It is concluded that the combindation of urinary tract infection and positive bacterial fluorescence is seen when upper tract deterioration has occurred and is seen most frequently in association with urinary reflux. In these instances aggressive therapy is often indicated.