Rainer M. Engel

Retroperitoneal teratoma. Review of the literature and presentation of an unusual case

A review of the literature reveals that 29 cases have been published since the reviews of Arnheim* and Palumbo.* These cases substantiate the preponderance in early life and the similarity of symptoms, site of origin, and low rate of malignancy; however, the previously reported sex difference is not substantiated and a marked improvement in operative mortality is noted. The case presented is of interest because of the radiographic abnormalities which it demonstrates, which led to the preoperative diagnosis of teratoma.

Comparison of RigiScan and formal nocturnal penile tumescence testing in the evaluation of erectile rigidity

Evaluation of male erectile function ideally should include measurement of axial rigidity expressed as grams force required to produce penile buckling. An axial rigidity more than 550 gm. is generally considered adequate for vaginal penetration. Unfortunately, this test cannot be done frequently and may disrupt sleep. An alternative method of determining rigidity is to use the RigiScan,* which makes repetitive measurements of radial rigidity at the base and tip of the penis expressed as per cent of normal maximum. Previous studies have demonstrated a positive correlation between axial and radial rigidity measurements but they have not been compared in patients with a wide range of erectile function. We performed a prospective study in a consecutive series of patients presenting with impotence comparing axial rigidity measured with a tonometer and radial rigidity measured by RigiScan. Erectile rigidity also was evaluated by a trained, blinded observer. Overall, RigiScan base and tip radial rigidity correlated well with axial rigidity (p < 0.002) and observer ratings (p < 0.003); axial rigidity similarly correlated well with observer ratings (p < 0.0001). However, when RigiScan base and tip radial rigidity exceeded 60% of maximum, there was a poor correlation with axial rigidity and observer ratings (p > 0.1). In this range, the RigiScan failed to discriminate axial rigidities between 450 and 900 gm. buckling force; however, axial rigidity in this same range again correlated well with observer ratings (p < 0.0001). Since an axial rigidity of more than 550 gm. is considered adequate for vaginal penetration, the RigiScan may not be able to detect mild abnormalities in erectile function. Further study is in progress to evaluate the significance of these findings but presently a RigiScan measurement of radial rigidity in excess of 60% of maximum should be interpreted cautiously and not necessarily regarded as normal. In this range further measurements of axial rigidity or observer ratings of rigidity may be necessary to establish the diagnosis.

Nephrogenic adenoma: clinical features and therapeutic considerations.

Nephrogenic adenoma is a benign metaplastic lesion that usually responds to endoscopic treatment. Although occasionally it has been present simultaneously with another malignancy there has been no evidence that a nephrogenic adenoma has ever transformed into a carcinoma. The symptoms of a nephrogenic adenoma can be severe but these lesions can be treated with transurethral surgery. The lesions can occur throughout the bladder and in the urethra. They usually are associated with trauma to the urothelium. Postoperative followup is needed because these lesions tend to have a symptomatic recurrence. An increased awareness of nephrogenic adenoma by urologists and pathologists may lead to its more frequent diagnosis.

Comparison of duplex ultrasonography and nocturnal penile tumescence in evaluation of impotence.

Duplex ultrasound is used commonly to evaluate vascular function in impotent men. There is evidence, however, that some men with normal vascular function may have falsely abnormal duplex ultrasound results because of suppression of response to pharmacological stimulation due to anxiety. We performed a prospective blinded study of 40 impotent men comparing duplex ultrasound to a formal nocturnal penile tumescence evaluation. Duplex ultrasound was done with a standard 10 MHz. color Doppler unit after intracorporeal pharmacological stimulation. Nocturnal penile tumescence was performed at a sleep laboratory, and included measurements of penile circumference, axial rigidity, arterial pulsations, and direct patient and observer evaluation of erections. Of 40 men 20 had an abnormal duplex ultrasound result (maximum arterial velocity less than 30 cm. per second), including 9 who had normal nocturnal penile tumescence with at least 1 rigid erection (greater than 550 gm. axial rigidity) lasting at least 5 minutes. All 9 men had evidence of psychogenic dysfunction on history and personality inventory, and only 1 had evidence of vascular disease. Of the other 11 patients with abnormal duplex ultrasound and nocturnal penile tumescence findings, only 2 had evidence of psychogenic impotence and 9 had evidence of vascular disease. In these 11 men there were significant correlations between maximum arterial velocity on duplex ultrasound, and maximum rigidity and arterial pulsations on nocturnal penile tumescence. Of 40 patients 20 had a normal duplex ultrasound finding (maximum velocity greater than 30 cm. per second). Nine of these patients had a normal nocturnal penile tumescence test, of whom 5 had evidence of psychogenic impotence and only 1 had evidence of vascular disease. Eleven men with normal duplex ultrasound had an abnormal nocturnal penile tumescence test, including only 2 with any evidence of psychogenic impotence, while 9 had vascular disease and 1 had a history of neurological disease. Based on this study 9 of 14 men (64%) with a normal nocturnal penile tumescence test and other evidence of psychogenic impotence had abnormal duplex ultrasound. Therefore, an abnormal duplex ultrasound study should be interpreted cautiously if there is evidence of psychogenic impotence. In men with vasculogenic impotence there is an excellent correlation and cross-validation between maximum velocity on duplex ultrasound, and axial rigidity and arterial pulsations on nocturnal penile tumescence.

Objective Double-Blind Evaluation of Erectile Function with Intracorporeal Papaverine in Combination with Phentolamine and/or Prostaglandin E1

We performed a double-blind, crossover study using objective measurements to compare maximum rigidity and duration of erections with papaverine hydrochloride in combination with phentolamine mesylate and/or prostaglandin E1. The rationale for the protocol was to combine a smooth muscle relaxant (papaverine) with either or both vasodilating agents (phentolamine and prostaglandin E1) commonly used for injection therapy. The 7 volunteer patients with organic impotence documented by abnormal nocturnal penile tumescence testing were injected with 0.5 to 1.0 ml. papaverine (30 mg./ml.) in combination with phentolamine (0.5 mg./ml.) and/or prostaglandin E1 (5 micrograms./ml.). Each patient received 2 injections on each of 2 testing dates; injection 2 was given after tumescence resulting from injection 1 had subsided completely. The medications were given in a randomized, counterbalanced order following double-blind procedures. Patients evaluated the erections subjectively. In addition, the RigiScan device was used to measure maximum rigidity and duration of erections. All patients observed increased duration of erections with both combinations containing prostaglandin E1. Analysis of RigiScan measurements showed no statistically significant differences for maximum rigidity (p greater than 0.1) but significantly greater duration of erections with papaverine plus prostaglandin E1, and papaverine plus phentolamine plus prostaglandin E1 compared to papaverine plus phentolamine (p less than 0.001). There was no statistical difference in rigidity or duration of erections between papaverine plus prostaglandin E1 and papaverine plus phentolamine plus prostaglandin E1. No patient reported significant penile pain with any of the injections. We conclude that the combination of papaverine and prostaglandin E1 produces erections of longer duration than papaverine plus phentolamine and that no additional benefit is gained by adding phentolamine to a combination of papaverine and prostaglandin E1. Further studies are in progress to define optimal dose response curves for papaverine and prostaglandin E1 as individual agents and in combination.

BLADDER EXSTROPHY: VESICOPLASTY OR URINARY DIVERSION?

Abstract Forty-seven patients with bladder exstrophy are analyzed with postoperative follow-up available in 38 and histologic data in 29. No bladder was free of significant histologic changes. Malignant degeneration was seen in 4 patients; the exstrophy had been previously closed in 2. The functional results of cystoplasties were disappointing. No patient was continent, and repeated episodes of pyelonephritis made urinary diversion necessary. Ureterosigmoidostomy did not sufficiently protect the upper tract leading to deterioration and urinary tract infections and necessitating diversion with ileal loop in more than half of the patients. Primary ileal loop urinary diversion gave the most satisfactory results, the least clinical problems, and is the surgical procedure of choice.

Concurrent renal cell and transitional cell carcinoma in a single kidney: a case report.

Abstract We report a case of 2 concurrent primary renal tumors of differing histology within the same kidney. A review of the literature to date indicates this event to be rare. With 1 exception, all previous cases have been combined renal cell and transitional cell carcinomas.

Prostatic Needle Biopsy: Comparison of Needles

To clarify the advantages of the 2 most commonly used biopsy needles results of 100 routine needle biopsies of the prostate are evaluated. The series includes patients selected for study concerning the medical treatment of benign prostatic hyperplasia.

Anecdotas y "coincidencias" de la Urología Americana: Hugh Hampton Young

Resumen es: Breve revision sobre la vida y logros de Hugh Hampton Young, inventor, defensor de las artes, gran cirujano y profesor ademas de gran innovador. Urologo ...

Permanent urinary diversion in childhood: Indications and types

Abstract Pathologic conditions of childhood requiring permanent urinary diversion range from the rare malignant diseases to neurogenic bladder, as from meningomyelocele. New techniques of self-catheterization and bladder evacuation by electric pumps and devices are being evaluated. At present permanent urinary diversion is the treatment of choice, and this should be performed before upper tract deterioration occurs. A temporary urinary diversion, loop cutaneous ureterostomy, should be done in patients where eventual reconstruction of the urinary tract is feasible. Types of permanent urinary diversions and indications for each are discussed.Pathologic conditions of childhood requiring permanent urinary diversion range from the rare malignant diseases to neurogenic bladder, as from meningomyelocele. New techniques of self-catheterization and bladder evacuation by electric pumps and devices are being evaluated. At present permanent urinary diversion is the treatment of choice, and this should be performed before upper tract deterioration occurs. A temporary urinary diversion, loop cutaneous ureterostomy, should be done in patients where eventual reconstruction of the urinary tract is feasible. Types of permanent urinary diversions and indications for each are discussed.