Ö. Atahan

MULTIFACTORIAL EVALUATION OF DIABETIC ERECTILE DYSFUNCTION

We determined arterial venous and sinusoidal factors in 20 patients with insulin dependent diabetes mellitus and erectile dysfunction by performing dynamic infusion cavernosometry (DIC), colour flow Doppler ultrasonography, penile biothesiometry and corpus cavernosum electromyography (CCE).DIC, colour flow Doppler ultrasonography and penile biothesiometry were done in standard fashion except for CCE. Paradoxical increase in the electrical activity of corpus cavernosum after intracavernous (IC) papaverine was called a discoordination that was due to cavernous smooth muscle contraction instead of relaxatoon.Arterial and accompanying pathologies were found in 10 (50%) patients. In 3 (15%) of them pure arterial pathology, in 6 (30%) patients arterial and veno-occlusive dysfunction (VOD) and in one patient arterial pathology with abnormal biothesiometry were found.VOD and accompanying pathologies were found in 12 (60%) patients. In 6 (30%) of them VOD and arterial, in 4 (20%) patients VOD and discoordination and in 2 (10%) patients VOD and abnormal biothesiometric values were present. A higher frequency and coexistence of VOD and discoordination pattern were observed.In conclusion, patients with diabetic impotence show a wide range pathophysiology of erection and the evaluation of these patients must include multistep techniques.

Electromyographic Changes of Corpus Cavernosum Due to Papaverine and Nitroprusside in Veno-Occlusive Dysfunction

PURPOSE We compared electrical activity of the corpus cavernosum after intracavernous papaverine and nitroprusside injections. Some aspects of the androgen modulator system in patients with veno-occlusive dysfunction are discussed. MATERIALS AND METHODS Electromyography of the corpus cavernosum was performed before and 1 day after intracavernous injection of 60 mg. papaverine and 400 micrograms. sodium nitroprusside in 22 patients with veno-occlusive dysfunction. Changes in duration and amplitude of electromyographic potentials were compared in groups with and without incoordination patterns. RESULTS The decreases in electrical amplitude and duration in 15 patients with a negative incoordination pattern, and increases in 7 with a positive pattern were more significant with intracavernous sodium nitroprusside than with papaverine injections. CONCLUSIONS Electromyographic changes were more prominent with nitroprusside than with papaverine, which demonstrates the use of nitroprusside when performing corpus cavernosum electromyography.

Electrical Activity of Corpus Cavernosum in Vasculogenic and Non-vasculogenic Erectile Dysfunction

We aimed to compare the electrical activity of corpus cavernosum before and after intracavernous papaverine injection and to determine the blood lipid profile in vascular and non-vascular erectile dysfunction, and also to assess whether vascular pathology and abnormal blood lipid levels impair cavernosal smooth-muscle relaxation. We determined total cholesterol (TC), triglyceride (TG) and high-density lipoprotein (HDL) levels in peripheral and cavernosal blood in 39 patients with erectile dysfunction. Electromyography of the corpus cavernosum was performed before and after an intracavernous injection with 60 mg of papaverine in all patients. Thirty-nine impotent patients have been divided into two groups: vasculogenic erectile dysfunction (VED) and non-vasculogenic erectile dysfunction (NVED), according to colour Doppler ultrasonic flowmetry, dynamic infusion cavernosometry and the pressure difference between the brachial arterial systolic pressure and cavernosal arterial systolic pressure measurements. Biochemical values and amplitude changes were compared in both groups. The TC level was higher in both peripheral and cavernosal samples of the VED group than in the NVED group (p = 0.000), with no differences between peripheral and cavernosal blood levels within the same groups (p > 0.05). There were no significant changes in TG and HDL levels in any of the groups (p > 0.05). The mean amplitude differences before and after papaverine injection (delta A) were found to be 2.05 +/- 0.78 microV in the VED group and 4.68 +/- 2.53 microV in the NVED group, showing that the relaxation response to papaverine was more significant in the NVED than in the VED group (p = 0.003). The moderate decreases in the amplitude of electrical activity of corpus cavernosum and the higher TC levels found in the VED group can be accepted as the parameters of impairment in the relaxation of corpus cavernosum, showing the role of hypercholesterolaemia and vascular pathologies in erectile dysfunction.

Is apolipoprotein-(a) an important indicator of vasculogenic erectile dysfunction?

We aimed to investigate whether high peripheral and cavernosal plasma levels of apolipoprotein-(a) [Lp (a)] is an indicator for vasculogenic erectile dysfunction. We determined Lp (a), total cholesterol (TC), triglyceride (TG) and high density lipoprotein (HDL) levels in peripheral and cavernosal blood in 39 patients with erectile dysfunction. Thirty-nine impotent patients have been divided into two groups: vasculogenic erectile dysfunction (VED) and nonvasculogenic erectile dysfunction (NVED), according to colour Doppler ultrasonic flowmetry, dynamic infusion cavernosometry, and the pressure difference between the brachial arterial systolic pressure and cavernosal arterial systolic pressure measurements. Biochemical values were compared in both groups. Lp (a) and TC levels were higher in both peripheral and cavernosal samples of VED group than in NVED group, with no differences between peripheral and cavernosal blood levels within the same groups. There were no significant changes in TG and HDL levels in either group. The detection of more than 31 mg/dl in Lp (a) level solely shows the vascular origin with a sensitivity and specificity of 95 and 82.3%, respectively. High Lp (a) levels can be considered an indicator of vasculogenic erectile dysfunction.

Dynamic infusion cavernosometry and cavernosography in diagnosing and classifying venoocclusive dysfunction.

Dynamic infusion cavernosometry and cavernosography (DICC) were performed in 22 patients who were referred with symptoms of partial erection and transient erection and who were diagnosed as deep dorsal venous leakage by means of colour Doppler ultrasonography. We reached the diagnostic values for corporovenous leakage (CVL), also classified them and showed the veins that need to be ligated. With these advantages, DICC is a very cost-effective and safe technique that can be performed routinely in the diagnosis of corporovenous leakage.

Late Glans Hypervascularization Subsequent to Penile Prosthesis Implantation After Revascularization Operation

Since the introduction of corpus cavernosum revascularization Merent modifications of microsurgical techniques have been performed for the treatment of vasculogenic impotence in select patients.’ Specific complications, including graft failure, graft occlusion, priapism, glanular hypervascularization and urinary retention with glanular hypervdarization, have been reported.”4 Glans hypervascularization is associated with glanular pain, swelling and ulceration and, if left unchecked, it can develop into capillary occlusion and scar formation. In most cases hypervascularization is managed with banding and ligation of the graR artery.3.4 We present a case in which penile prosthesis implantation caused glanular hypervdarization subsequent ta previously performed deep dorsal vein arterialization. CASE REPORT A 42-year-old man presented to our clinic with erectile dysfunction. Color flow Doppler examination and dynamic infusion cavernosometry revealed pure veno-occlusive dysfunction with normal penile biothesiometric and corpus cavernosum electromyographic findings. End-to-side anastomosis was performed between the left inferior epigastric artery and deep dorsal vein. Unlike the Furlow-Fisher procedure, the circumflex collaterals were preserved and the deep dorsal venous valves were not disrupted. ARer completion of the anastomosis the deep dorsal vein was ligated proximal to the arteriovenous anastomosis. Spontaneous erections started postoperatively and evaluation with an ultrasonic deep blood flow detector (vasculoscope) showed a patent anastomosis. After 4 months, despite the patent anastomosis, the patient was not able to achieve erections adequate for intercourse. Therefore, a Marc I1 penile prosthesis without ligation of inferior epigastric artery was implanted. Seven months after revascularization the patient had pain and tenderness of the glans and parameatal superficial ulceration (see figure). Graft ligation was then performed and the patient improved in 2 weeks. DISCUSSION Deep dorsal vein arterialization could produce a retrograde arterial flow into the cavernous bodies through the collateral deep dorsal venous network, allowing retrograde arterial filling of the cavernous bodies and reduction of the venous leak. Glanular hypervascularization results from high spongiosal flow due to arterialized circumflex veins. This complication is usually present in the early postoperative period but delayed hypervascularity of the glans penis has been reported.3 The rate of penile hypervascularity has been between 7 and 22%, and the condition has been treated with graft ligation, transcatheter graft embolization and banding of the graft artery.3.4

Modified four corner bladder neck suspension in anatomical stress incontinence with moderate cystocele

We aimed to evaluate the efficacy and the short- and long-term results of the modified four corner bladder neck suspension (FCBNS) procedure in the correction of type 2 stress urinary incontinence with moderate cystocele. We studied retrospectively 26 consecutive patients who underwent modified FCBNS procedure during a 2-year period at our institution. The modifications that were made were the distal sutures starting from the midurethra as a coil fashion of three centimetres to the bladder neck and its fixation to the pubic bone. Preoperative questionnaires, hospital and clinical records, and postoperative questionnaires were reviewed to assess comparative outcome among the patients. Patient follow-up ranged from 22 to 47 months (mean 33.5). The mean age at the time of surgery was 55.3±11.6, and mean parity was 3.2±1.3. Twenty-five of 26 women (96%) were cured after six months and 24 of 26 (92%) were cured after twenty-one months. Cystoceles were completely reduced. Complications occurred in 15% of the patients. The modified FCBNS is a useful and effective operation in treating anatomical stress urinary incontinence and an associated moderate cystocele since it elevates and supports midurethra as well in selected patients and it is associated with a low incidence of postoperative complications.

Experiences with clam ileocystoplasty

Clam ileocystoplasty was performed in 18 patients with urge incontinence, total incontinence or enuresis with instable detrusor. Although the persistence of detrusor instability was observed in 33.33% of the patients, complete clinical cure was found in 72.23 and symptomatic improvement was 22.22%.

IMPORT CATHETER IN ERECTILE DYSFUNCTION

PURPOSE We propose an alternative technique for intracavernous self-injection of sodium nitroprusside for erectile dysfunction by inserting a Medtronic ImPort* catheter with a valved tip. MATERIALS AND METHODS A silicone catheter was implanted in 3 patients with psychogenic impotence. The reservoir, which is used for vasoactive agent injection, was implanted laterally to the anterosuperior iliac spine and the distal tip of the catheter was inserted into the corpora cavernosa via a subcutaneous tunnel. The injection technique was taught to the patient and the initial injection was performed 1 week later. RESULTS All patients and partners were satisfied with the technique and quality of erections at a mean followup of 14 months. There were no major local complications due to catheter implantation and no systemic complications due to sodium nitroprusside injection. CONCLUSIONS An alternative technique for intracavernous pharmacotherapy of inserting an ImPort catheter prevented the complications of intracavernous injections in patients with erectile dysfunction.

Urinary Glycosaminoglycan Excretion in Bladder Carcinoma

The urinary glycosaminoglycan (GAG) excretion in 35 patients with bladder cancer was significantly greater than that in 30 normal persons. In the cancer patients, the results were analysed according to tumour characteristics. Statistically significant differences were found, with increased GAG levels paralleling tumour size, multifocality, stage and grade. These preliminary data suggest that, parallel with established clinical parameters, measurement of urinary GAG excretion provides an indicator of repair of the bladder epithelium.