Rei K. Chiou

Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination.

OBJECTIVES Color Doppler ultrasound (CDU) diagnostic criteria for varicoceles are poorly defined, and the role of CDU in diagnosing varicoceles is controversial. The purpose of this study is to assess the diagnostic accuracy of CDU for varicoceles compared to physical examination. METHODS We prospectively studied 64 patients with CDU and collected the following data: maximum diameter of scrotal veins, the presence of a venous plexus, sum of the diameter of up to six veins of the plexus, and the duration and amplitude of flow change on Valsalva maneuver. To avoid interphysician variation, all patients were examined by one designated senior urologist with the sonographer remaining unaware of the findings. RESULTS CDU parameters of 127 testis units in 64 patients were analyzed and compared to the physical findings. Fifty-nine testis units were positive and 57 units were negative for varicocele on physical examination. In 11 testis units, results of physical examination were inconclusive regarding the presence of varicocele. The commonly accepted CDU criterion for varicocele (maximal vein diameter of 3 mm or greater) had a sensitivity of 53% and specificity of 91% compared to physical examination. We developed a new scoring system incorporating the maximal venous diameter (score 0 to 3), the presence of a venous plexus and the sum of the diameters of veins in the plexus (score 0 to 3), and the change of flow on Valsalva maneuver (score 0 to 3). Using a total score of 4 or more to define the presence of CDU-positive varicocele, we observed a sensitivity of 93% and a specificity of 85% when compared to physical examination. All moderate to large varicoceles found on physical examination were positive by CDU diagnosis using the scoring system, but the same group had only a 68% positive rate by traditional CDU diagnostic criteria. CONCLUSIONS Using the proposed new scoring system, CDU has been shown to be a reliable and accurate method of diagnosis for varicoceles compared to the current reference standard physical examination. CDU has the advantages of being able to objectively examine venous plexus and measure blood flow parameters and to be less observer-dependent than physical examination.

HEMODYNAMIC PATTERNS OF PHARMACOLOGICALLY INDUCED ERECTION: EVALUATION BY COLOR DOPPLER SONOGRAPHY

PURPOSE Penile erection is achieved through hemodynamic mechanisms that can be assessed best with color flow imaging and Doppler waveform analysis. We performed dynamic studies using computer assisted analysis to assess the hemodynamic patterns of pharmacologically induced erection. MATERIALS AND METHODS A total of 73 color Doppler ultrasound studies was performed in 66 patients with erectile dysfunction. Various blood flow parameters, including peak systolic velocity, end diastolic velocity, mean flow rate, resistive index and artery diameter, were observed continuously and recorded frequently for about 30 minutes after intracorporeal injection of papaverine/phentolamine/prostaglandin E1 mixture. A computerized Doppler waveform analysis of 3 curves or greater was performed for each recording to minimize error. A second injection was administered if the first injection failed to induce a rigid erection. Status of the erection was observed and recorded throughout the study. A computerized graph was generated for each corpus. RESULTS After intracorporeal injection the time to reach normal or peak velocity varied from 1 to 24 minutes. Among 146 corpus units in 73 color Doppler ultrasound studies we observed the following hemodynamic patterns: I-normal maximal peak systolic velocity (35 cm. per second or greater), sustained; Ia-end diastolic velocity 0 or less with complete erection response (19 units); Ib-end diastolic velocity greater than 0 or incomplete erection response (14 units); II-normal maximal peak systolic velocity (35 cm. per second or greater), transient; IIa-end diastolic velocity 0 or less with complete erection response (21 units); IIb-end diastolic velocity greater than 0 or incomplete erection response (12 units); III-borderline maximal peak systolic velocity (30 to 35 cm. per second); IIIa-end diastolic velocity 0 or less with complete erection response (10 units); IIIb-end diastolic velocity greater than 0 or incomplete erection response (8 units); IV-low maximal peak systolic velocity (less than 30 cm. per second); IVa-end diastolic velocity 0 or less with complete erection response (24 units); and IVb-end diastolic velocity greater than 0 or incomplete erection response (38 units). CONCLUSIONS Erection is a complex and dynamic process. A new classification of hemodynamic patterns is presented that aids in assessing and interpreting more thoroughly blood flow parameters to stratify more precisely the hemodynamic patterns of erectile dysfunction.

Treatment of recurrent vesicourethral anastomotic stricture after radical prostatectomy with endourethroplasty

We report our experience with successful treatment of 2 cases of severe recurrent vesicourethral anastomotic stricture after radical prostatectomy with endourethroplasty. Both patients had multiple failures of conventional treatments but have been free of stricture recurrence after endourethroplasty with 11 and 25 months follow-up, respectively. Follow-up urethroscopy showed open anastomotic segments with epithelialization after endourethroplasty in both patients. The patient who was continent prior to endourethroplasty remained continent afterward.

Placement of Large Suprapubic Tube Using Peel-Away Introducer

We describe a new method for placing a large suprapubic tube and report our experience with 56 patients. This method uses a specially designed fascial dilator and peel-away introducer to place an 18F Foley catheter suprapubically. In our experience the method is simple and effective for the exchange of a small suprapubic tube to an 18F Foley catheter, and for primary placement of a large suprapubic tube. It is easily performed at the bedside or during a minor procedure with the patient under local anesthesia.

Long-term outcome of prostatic stent treatment for benign prostatic hyperplasia

OBJECTIVES To evaluate the long-term result of prostatic stent treatment for patients with benign prostatic hyperplasia (BPH). METHODS We reviewed our experience with prostatic stents in 24 patients with bladder outlet obstruction caused by BPH for whom up to 63 months of follow-up data were available. RESULTS Prostatic stents were successfully placed in 24 of 25 patients enrolled in the study. All 9 patients treated for urinary retention voided spontaneously after stent placement. In 14 (93%) of 15 patients with nonretention, voiding symptoms decreased by 50% or more. The stent was removed in 9 patients for persistence of symptoms, symptom recurrence, or stent migration. Nine patients died of unrelated causes during the follow-up period. The stents functioned adequately in these patients until death. In the remaining 6 patients, the stent was still in place at the last follow-up visit (range 12 to 52 months, average 35) after placement, and their Madsen-Iversen symptom scores ranged from 3 to 10. Fourteen patients underwent cystoscopy 1 to 37 months after stent placement. Epithelium did not completely cover the stent in any of these patients; however, no stone formation was noted. CONCLUSIONS Prostatic stents can be effective in relieving bladder outlet obstruction caused by BPH. They appear to be most useful in patients at high surgical risk and with a limited life expectancy. However, stent removal, which can be difficult, may be required in more than one-third of patients. We recommend prostatic stent placement primarily in patients who would otherwise be relegated to an indwelling catheter.

Comparative Analysis of Pain During Anesthesia and No-scalpel Vasectomy Procedure Among Three Different Local Anesthetic Techniques

OBJECTIVES To compare the pain during anesthesia and during the no-scalpel vasectomy procedure for local infiltration anesthesia (LIA), LIA supplemented with spermatic cord block (LIA + SCB), and no needle jet anesthesia. METHODS Bilateral no-scalpel vasectomy was performed in 323 patients during 2007. Of the 323 patients, 65 received LIA, 29 received LIA + SCB, and 227 received anesthesia using the no-needle technique with the MadaJet device. The level of pain during anesthesia administration and the subsequent procedural pain was documented for each technique using a pain scale of 0-10. RESULTS Pain during the LIA + SCB procedure (mean 1.7 +/- 1.6) was significantly less than the pain during LIA (mean 3.3 +/- 2.3; P < .01). No statistically significant difference was found between the levels of pain experienced during LIA + SCB and no-needle jet anesthesia (P >> .01 and P >> .05, respectively). Intraoperative pain after LIA + SCB (mean 0.64 +/- 1.2) was significantly less than the intraoperative pain after LIA (mean 2.7 +/- 2.6; P <<< .01). Also, the intraoperative pain after LIA + SCB was significantly less than the intraoperative pain after no-needle jet anesthesia (mean 2.13 +/- 2.0; P <<< .01). CONCLUSION LIA + SCB is an effective and better method of anesthesia compared with LIA alone or no-needle jet anesthesia for reducing the pain during vasectomy. Also, no difference was found in the pain levels during anesthesia for the LIA + SCB, LIA, and no-needle anesthesia techniques.

Clinical Experience and Sexual Function Outcome of Patients With Priapism Treated With Penile Cavernosal-Dorsal Vein Shunt Using Saphenous Vein Graft

OBJECTIVES To assess the outcome of new penile cavernosal-dorsal vein shunt using a saphenous vein graft. Traditional surgeries for priapism have high failure rate and subsequent impotence. METHODS We reviewed the medical records of, and administered a questionnaire and the International Index of Erectile Function to, 16 consecutive patients with priapism who had treated with the penile cavernosal-dorsal vein shunt from 1997 to 2007. Their age was 15-65 years. The duration of ischemic priapism was 32 hours to 8 days. Ten patients had previously undergone shunt surgery by other urologists. Of the 16 patients, 5 returned the questionnaires. RESULTS Priapism resolved or was improved after surgery in all 16 patients. One patient was lost to follow-up. One pediatric patient was excluded from the analysis. One patient with nonischemic priapism continued to have sexual intercourse. Of the 13 adult patients with ischemic priapism and follow-up for < or = 6.5 years, 3 patients had no erection, 1 had very little erection, and 9 (69%) had erection. Of the 9 patients with erections possible, six had had sexual intercourse (International Index of Erectile Function score 32-70) and 3 had not; 1 had a mental disorder, 1 was in prison, and for 1, the reason was unknown. After surgery, color Doppler ultrasound studies showed a patent shunt in all patients and restoration of cavernosal arterial flow in 12 of 13 patients studied. CONCLUSIONS A penile cavernosal-dorsal shunt appears effective for priapism. It resulted in priapism resolution even in patients who had experienced a previous failed cavernosal-glandular shunt or cavernosal-spongiosal shunt, with a high rate of sexual function preservation.

COLOR DOPPLER ULTRASOUND HEMODYNAMIC CHARACTERISTICS OF PRIAPISM PATIENTS BEFORE AND AFTER THERAPY AND ITS IMPACT ON SUBSEQUENT MANAGEMENT

the association between ED and the severity, duration and control of diabetes has not been clearly elucidated. METHODS: 634 men with type 2 diabetes (DM) who participated in the University of Michigan, Translating Research into Action in Diabetes (TRIAD) study provided information on erectile dysfunction using the validated single item question assessing the ability to maintain an erection satisfactory for sexual intercourse. Measures of diabetes severity including duration of disease, glycemic control, mode of therapy and presence of diabetic complications were examined by