Oner Sanli

Graft Materials in Peyronie's Disease Surgery: A Comprehensive Review

OBJECTIVE To discuss the currently used graft materials in Peyronies surgery. METHODS A MEDLINE search was conducted till the end of September 2006 on the surgical treatment of Peyronies disease, and all aspects of the graft materials used for Peyronies surgery were examined. RESULTS Currently available interposing graft materials may be classified in three categories: autologous tissues, extracellular matrix (ECM) tissues, and synthetic materials. Each grafting material in these categories has its own advantages and drawbacks in terms of tissue properties, antigenicity, availability, and cost-effectiveness. Saphenous vein grafts are the most widely used among autologous grafts, with acceptable functional outcomes in the long term. Other graft materials include tunica vaginalis, fascia lata, rectus fascia, and buccal mucosa, with variable results. Despite numerous advantages in terms of tissue compatibility, the major drawback of autologous grafts is tissue harvesting that to morbidities and longer operative durations. For this reason, the use of readily available ECM tissues as the products of tissue engineering is recommended by some authors. Among ECM grafts, cadaveric and bovine pericardia have satisfactory mid-term outcomes. However, longer follow-ups with an adequate number of patients are lacking. On the other hand, recent evidence suggests that small intestinal submucosa may be associated with high rate of operative failure and complications. Generally, synthetic materials are no longer used in grafting procedures in Peyronies surgery because of their antigenicity and inappropriate functional properties. For prosthesis surgery, pericardia as well as autologous rectus fascia grafts are probably the most suitable graft materials because of their suitable tissue characteristics that satisfy the mechanical demands of the prosthesis. CONCLUSION Saphenous vein grafting from autologous tissues and pericardium from ECM tissues have satisfactory results. However, further research and clinical studies are needed in order to determine the optimal graft material.

Does sexual dysfunction correlate with deterioration of somatic sensory system in diabetic women

To evaluate genital and extragenital somatic sensory system in diabetic women using biothesiometry and investigate the relation with sexual dysfunction. A total of 30 diabetic women and 20 normal sexually active women as a control group were evaluated with a detailed medical and sexual history including Index of Female Sexual Function (IFSF) questionnaire. Somatic sensory system of all women enrolled to the study was assessed by biothesiometry and threshold sensory values of nine genital sites and 14 extragenital sites were analyzed. The IFSF score in diabetic women was 23.6 while it was 38.3 in the control group (<0.0005). For each genital as well as extragenital sites, the mean biothesiometric values were significantly higher in diabetics. The sensation of introitus vagina, labium minora and clitoris were found to be the most deteriorated genital sites in diabetic women. The difference between diabetic women with or without female sexual dysfunction (FSD) was not significant for biothesiometric values. Our data indicate that, somatic sensory system is affected by diabetes however sexual dysfunction does not always manifest.

Obesity might not be a risk factor for female sexual dysfunction.

Study Type – Aetiology (case control)
Level of Evidence 3b

Incidentally diagnosed Peyronie's disease in men presenting with erectile dysfunction

The aim of this study was to analyze characteristics of patients with Peyronies disease (PD) diagnosed during a standart evaluation for erectile dysfunction (ED) and compare them with patients presenting with the classical complaints of PD. During a 10-y period, a total of 448 patients were evaluated at our two outpatient clinics, directed by the same author (AK). They were divided into two groups: group I consisted of patients, who presented with only ED and were unaware of their penile deformity, and group II consisted of patients with the classical features of the disease. The clinical characteristics, penile deformities, erectile status and the presence of comorbidities were determined in the two groups. Of 448 Peyronies patients, 16% (n=71) were detected during diagnostic work-up for ED. In this group of patients, ED was the presenting symptom for a mean period of 31.3±9.7 months. The mean age of men was 57.54±8.75 and 52.21±10.27 y in groups I and II, respectively (P=0.0001). The mean degree of deformity was 31.5±12.66° in group I and 41.16±19.14° in group II (P=0.0001). In group I (n=71), 69% (n=49) of the patients had a poor erectile response to the combined injection and stimulation (CIS) test. Also, in this group, the mean degrees of deformity in CIS-positive and -negative patients were 27.05±12.50 and 33.80±12.03°, respectively (P=0.033). Diabetes mellitus (40%) was the leading comorbidity in group I, while at least one comorbidity was observed in 73% of the cases (P=0.001). A remarkable percent of Peyronies patients (16%) were detected during a standard evaluation for ED. This study analyzed, for the first time, the frequency and the characteristics of incidentally diagnosed Peyronies patients who presented with only ED. Our data indicate that one should always consider the possibility of PD in older patients with diabetes, presenting with only ED.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Is Sexual Dysfunction in Women with Obstructive Sleep Apnea‐Hypopnea Syndrome Associated with the Severity of the Disease? A Pilot Study

INTRODUCTION Obstructive sleep apnea-hypopnea syndrome (OSAHS) may have a significant negative effect on sexual function. AIM To evaluate female sexual function in women with OSAHS. METHODS Twenty-six patients with OSAHS were evaluated in two groups according to apnea-hypopnea index as mild (5-15, Group I, N = 16) or moderate-severe (>or=15, Group II, N = 10). A third group (N = 10) of patients suspected of sleeping disorders other than OSAHS who also underwent polysomnographic studies served as the control group. All women were evaluated with a detailed sexual history including Female Sexual Function Index (FSFI) questionnaire and Beck Depression Inventory (BDI). Meanwhile, serum levels of estradiol, prolactin, total and free testosterone and dihydroepiandrostenedione-S were determined. MAIN OUTCOME MEASURES FSFI, BDI, and serum hormonal levels. RESULTS The mean ages and total FSFI scores of Group I, Group II and the control group were 46 +/- 7.1, 45 +/- 3.8, and 41 +/- 5.4 (P > 0.05); 24.7 +/- 5.3, 24.5 +/- 6.3, and 30.0 +/- 2.5 (P < 0.05), respectively. The mean FSFI domain scores were not statistically different between Groups I and II (P > 0.05) (desire, 3.18 +/- 1.2 vs. 2.92 +/- 1.6; arousal, 3.96 +/- 1.1 vs. 3.67 +/- 1.2; lubrication, 4.83 +/- 1.0 vs. 4.12 +/- 1.1; orgasm 4.0 +/- 1.1 vs. 5.15 +/- 2.9; satisfaction 3.96 +/- 1.1 vs. 4.05 +/- 1.4 pain; 4.84 +/- 1.2 vs. 4.65 +/- 1.3). However, the mean scores of desire (3.18 +/- 1.2 vs. 3.96 +/- 0.7), orgasm (4.0 +/- 1.1 vs. 5.0 +/- 1.1), and satisfaction (3.96 +/- 1.1 vs. 4.76 +/- 1.0) domains of Group I were significantly lower than the control group. Meanwhile, the mean scores of desire (2.92 +/- 1.6 vs. 3.96 +/- 0.7) and lubrication (4.12 +/- 1.1 vs. 5.22 +/- 0.9) domains were statistically different between Group II and the control group. The mean BDI scores of patients in Group I, Group II and the control group were 19.3 +/- 6.3, 20.2 +/- 6.6, and 11.0 +/- 7.1, respectively (P < 0.01). In addition, the mean levels of hormonal parameters were not significantly different from the control group (P > 0.05). CONCLUSIONS OSAHS is associated with a significant decrease in female sexual function. However, severity of OSAHS is not related with the degree of female sexual dysfunction (FSD). This situation reveals that both organic and psychogenic issues are being involved in FSD related with OSAHS.

Current status of the surgical management of Peyronie's disease

Surgery is the standard treatment for patients in the chronic phase of Peyronies disease. Reconstructive surgeries function by either shortening the convex side of the tunica albuginea (Nesbit procedure, Yachia technique and penile plication) or lengthening the concave side by incision of the plaque with subsequent grafting. Tunical shortening procedures are ideal for men with good erectile capacity, penile curvatures less than 60° and predicted postprocedural length loss of less than 20% of erect penis length. Tunical lengthening procedures with grafting are indicated in patients with severe penile length loss, curvatures greater than 60° and prominent hourglass deformities. Saphenous vein and tunica albuginea are the most commonly used autologous graft materials. Cadaveric or bovine pericardium and 4-layer small intestinal submucosa are promising nonautologous tissues. Penile implantation of a prosthesis is the standard procedure in men with erectile dysfunction who do not respond to conservative treatment. If residual penile curvature is less than 30° after implantation, no further treatment is required. However, residual curve of greater than 30° can be straightened with manual modeling. Additional procedures such as penile plication, the Nesbit procedure, or grafting can be performed if modeling fails to correct the residual deformity.

Posttraumatic nonischemic priapism treated with autologous blood clot embolization.

INTRODUCTION High-flow arterial priapism is rare and characterized by a prolonged nonpainful erection. Autologous clot embolization allows complete resolution of the problem in most of the cases. AIM To review our experience with superselective transcatheter embolization in the treatment of nonischemic priapism. MAIN OUTCOME MEASURES Advances in the understanding of the nonischemic priapism with the aid of newer techniques have altered the current management of nonischemic priapism. MATERIALS AND METHODS Between 2002 and 2006, 11 patients underwent superselective transcatheter embolization of nonischemic priapism with blunt trauma to the penis or perineum. All patients underwent diagnostic evaluation with color-flow Doppler ultrasound and superselective pudendal arteriography, revealing bilateral arteriocorporal fistula and pseudoaneurysm in two cases, bilateral arteriocorporal fistula in one case, unilateral arteriocorporal fistula in one case, and unilateral arteriocorporal fistula and pseudoaneurysm in seven cases. Autologous blood clot was used as an embolization agent in all cases combined with microcatheter guidance. RESULTS The procedure was technically successful in all cases. In three (27.2%) cases, a second embolization was required due to recurrence of priapism. In all patients, erectile function was restored within 6 weeks of the procedure. Follow-ups at 6 and 12 months after the last procedure revealed that full erectile capacity was restored in 10 of 11 patients, and these patients did not experience further recurrence of priapism. One patient reported a slight decrease in the quality of his penile erection. CONCLUSIONS Our experience revealed that superselective transcatheter embolization and transient occlusion of the fistula with autologous blood clot is an effective therapy for the treatment of nonischemic priapism. Furthermore, recovery of erectile function due to recanalization of the occluded vessel occurred weeks after the procedure.

Increased preoperative levels of plasma fibrinogen and D dimer in patients with renal cell carcinoma is associated with poor survival and adverse tumor characteristics

BACKGROUND AND OBJECTIVE The relationship between renal cell carcinoma (RCC) and coagulation/fibrinolysis system has been described in several studies. The aim of this study was to investigate the role of 4 different coagulation/fibrinolysis factors on the prediction of histopathologic and survival prognosis in patients with RCC. PATIENTS AND METHODS Data from 128 patients who underwent surgical intervention between March 2006 and January 2011 for RCC were evaluated in this prospective study. Blood samples were collected from all patients on the morning of the operation to measure the plasma fibrinogen, D-dimer, coagulation factor VII, and antithrombin 3 levels. The relationships of these factors in the demographic, clinical, and histopathologic outcomes were analyzed using the Student t, Mann-Whitney U, Kruskal-Wallis, and one-way analysis of variance tests. Receiver operating curve analyses were performed to determine the optimal cutoff level for fibrinogen and d dimer, both of which had a strong relation with the clinical and histopathologic parameters. Disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) were assessed using the Kaplan-Meier method. Multivariate Cox regression analyses (forward stepwise logistic regression) were performed to examine the independent prognostic values on survival outcomes. RESULTS Increased plasma fibrinogen and d-dimer levels were associated with tumor size (P = 0.004 and 0.106), nuclear grade (P<0.001 and<0.001), TNM category (P<0.001 and 0.029), and metastasis (P<0.001 and 0.032). Both increased plasma fibrinogen and d-dimer levels predicted decreased DFS (P = 0.027 and 0.04), CSS (P = 0.007 and 0.043), and OS (P = 0.014 and 0.001) rates based on Kaplan-Meier analyses. Furthermore, multivariate analyses demonstrated that fibrinogen independently predicted poor DFS (hazard ratio [HR] = 2.52; 95% CI: 1.04-6.31; P = 0.029) and CSS (HR = 3.89; 95% CI: 1.13-13.40; P = 0.032), whereas d dimer had negative independent prognostic value on OS (HR = 4.01; 95% CI: 1.54-10.50; P = 0.005). CONCLUSIONS Increased plasma fibrinogen levels accurately predict poor histopathologic and survival outcomes and may be an effective independent prognostic factor in patients with RCC. Moreover, d dimer may serve as a copredictive factor in conjunction with fibrinogen.

Is Type 2 Diabetes Mellitus a Predictive Factor for Incontinence After Laparoscopic Radical Prostatectomy? A Matched Pair and Multivariate Analysis

PURPOSE We evaluated the effect of diabetes mellitus on incontinence after laparoscopic radical prostatectomy. MATERIALS AND METHODS From a series of 2,071 patients 135 with type 2 diabetes mellitus undergoing laparoscopic radical prostatectomy without radiotherapy and with a minimum followup of 24 months were identified. These patients were randomly matched with 135 nondiabetic controls for age, body mass index, preoperative prostate specific antigen, clinical stage, neoadjuvant hormonal therapy, prostate volume, previous surgery, surgeon skills, surgical approach, presence of bladder neck sparing, lymphadenectomy, technique of urethrovesical anastomosis and attempted nerve sparing surgery. RESULTS Using multivariate analysis age, diabetes mellitus and duration of diabetes mellitus were independent factors for post-prostatectomy incontinence in the whole group. Early continence (0 to 3 months) was observed in 43.7% of patients with diabetes and in 57.8% of nondiabetic controls which was statistically significant (p = 0.02). The rates of continence in patients with diabetes mellitus for 5 or more years at 3, 12 and 24-month evaluations were less than those in patients with diabetes mellitus for less than 5 years, and the difference was statistically significant (36% vs 50%, p = 0.001; 63.9% vs 82.4%, p = 0.02; 91.8% vs 98.6%, p = 0.03, respectively). CONCLUSIONS Patients with type 2 diabetes mellitus need longer to recover continence than nondiabetics after laparoscopic radical prostatectomy. However, type II diabetes mellitus did not affect overall return to continence. Patients with diabetes mellitus for 5 or more years have an almost 5 times increased risk of post-prostatectomy incontinence compared to those with diabetes mellitus for less than 5 years. Diabetic patients should be counseled for the potential negative impact of diabetes mellitus on the recovery of continence after laparoscopic radical prostatectomy.

Grading of Classical Testicular Microlithiasis Has No Effect on the Prevalence of Associated Testicular Tumors

Aim: To evaluate the role of further grading of classical testicular microlithiasis (CTM) on the prevalence of associated testicular tumors. Methods: Patients diagnosed with CTM using scrotal ultrasound over a 5-year period from a referral radiology clinic were included in this study. Patients with CTM were categorized as group 1 (grade I; 5–10 microliths/image), group 2 (grade II 10–20 microliths/image), and group 3 (grade III > 20 microliths/image). Other pathological findings were also recorded. The prevalence of testicular cancer was compared statistically between groups using the χ2 test. Results: Seventy-eight of 4,310 (1.8%) patients were found to have CTM. Of these, 17 (21.7%) had ultrasonographically detected testicular cancer. In patients without CTM (n = 4,232), 58 (1.1%) testicular cancers were found. This accounted to a 19.7-fold increase in the detection rate of testicular cancer in patients with CTM compared to patients without CTM. The rates of testicular cancer detected in groups 2 and 3 were 25 (6/24) and 26.6% (4/15), respectively (p > 0.05), while it was 17.9% (7/39) in group 1. Conclusions: CTM is an uncommon incidental finding in patients undergoing testicular ultrasonography, and grading of CTM plays no role in the prevalence of testicular cancer.