Robert Kessler

Treatment of urinary incontinence by the periurethral implantation of glutaraldehyde cross-linked collagen.

Injectable materials have been used to augment the urethral sphincter and improve urinary continence with some success. However, none of these materials has received widespread use because they are difficult to inject and have been reported to migrate. We investigated the efficacy of transurethral implantation of glutaraldehyde cross-linked collagen, a highly purified bovine collagen. A total of 17 patients (16 men and 1 woman) with urinary incontinence resulting from a previous operation was selected for glutaraldehyde cross-linked collagen injection into the region of the urethral sphincter. Before and after implantation patients underwent urodynamic evaluation. Glutaraldehyde cross-linked collagen was injected into the area of the bladder neck or urinary sphincter under direct endoscopic vision. If no improvement occurred reinjection to increase the implant volume was performed at least 3 months after a previous injection. Of the 17 patients 9 were cured or improved. No complications have been reported. This investigation shows that glutaraldehyde cross-linked collagen can be injected into the urinary tract to correct urinary incontinence without observable or measurable morbidity.

Sildenafil (Viagra) and Ophthalmology

Sildenafil citrate (Viagra) is a new oral medication that inhibits phosphodiesterase-5 (PDE5) in the corpus cavernosum to facilitate penile erection for the treatment of male impotence. The drug also has a mild inhibitory effect on PDE6, which controls the level of cyclic guanosine monophosphate in the retina, and it may cause a perception of bluish haze or increased light sensitivity in some patients. Long-term retinal damage has not been reported, but long-term electroretinographic studies have not been performed. Sildenafil causes a mild lowering of blood pressure and is absolutely contraindicated in patients taking any form of nitrate medication. A number of cardiovascular deaths and retinal vascular events in patients taking sildenafil have been reported, but so far the rate of these complications does not exceed expectation for an elderly population. Ophthalmologists should alert patients to the ocular side effects and potential risks of this new drug until further clinical experience has been obtained.

Hydrocele Following Internal Spermatic Vein Ligation: A Retrospective Study and Review of the Literature

We reviewed 82 consecutive infertile men with varicoceles and 1 teenage boy with a painful varicocele, all of whom underwent a total of 111 internal spermatic vein ligations (55 unilateral and 28 bilateral) by the suprainguinal approach (Palomo method). Of these patients 3 who underwent unilateral and 3 bilateral internal spermatic vein ligations subsequently suffered a total of 8 hydroceles after an average postoperative interval of 18.2 months. The protein concentration of the hydrocele fluid in the 2 most recent patients was consistent with lymphatic obstruction.

Infectious Complications of Penile Prosthesis Surgery

Penile prosthetic surgery has become an increasingly common procedure. However, infection of the prosthesis remains a significant complication that almost always results in loss of the device. We present our 10-year experience with 9 infected prostheses among 417 total penile implants, for an over-all incidence of infectious complications of 2.2 per cent. A strict, broad-spectrum antibiotic schedule was adhered to rigidly by all patients, beginning preoperatively and continuing for a total of 10 days of perioperative coverage. Staphylococcus species were cultured in 56 per cent of the infected patients and in 100 per cent of the patients with positive cultures. Spinal cord injury patients showed a particular predisposition to prosthetic infection, with a 15 per cent incidence of infectious complications. Two other patients became infected after dental procedures and the need for routine antibiotic prophylaxis in the penile prosthesis patient is emphasized. Urinary tract instrumentation at the time of prosthetic implantation, whether planned or incidental, also appears to add a potentially avoidable risk for subsequent infection.

Renal arteriovenous fistulas

A review of the literature reveals that aggressive treatment of symptomatic intrarenal arteriovenous fistulas, whether by surgical or radiologic techniques, is generally indicated. The exception is those fistulas which result from closed renal biopsy since these usually heal spontaneously. The ultimate goal of any form of therapy is the maximal preservation of renal tissue. Methods of treatment are discussed, and a review of classification, etiology, incidence, symptoms, physiologic consequences, and means of diagnosis is given. A case of post-traumatic intrarenal arteriovenous fistula with ipsilaterally elevated renal vein renin and hypertension, cured by partial nephrectomy, is presented.

Five-Year Followup of the Scott Inflatable Penile Prosthesis and Comparison with Semirigid Penile Prosthesis

The Scott inflatable penile prosthesis remains one of the most popular devices available for the surgical treatment of impotence despite high complication and reoperation rates. We present our 5-year followup of 116 inflatable prostheses placed before 1981 in 85 patients, with a 61 per cent overall 5-year complication rate. The incidence of complications by year after operation showed that most (22 per cent) devices failed within 1 year after implantation, with failure rates gradually decreasing to 6 and 7 per cent during years 4 and 5, respectively. Of 85 patients receiving an inflatable prosthesis 61 per cent underwent reoperation during the 5-year followup. A 5-year overall complication rate of only 14 per cent was seen in 29 Small-Carrion semirigid prostheses implanted during the same time. The results of numerous recent improvements in the design and structure of the Scott inflatable penile prosthesis to prevent mechanical device failure remain to be tested over the long term.

Complications of inflatable penile prostheses

Abstract From February, 1974, to June, 1979, 128 patients underwent insertion of an inflatable penile prosthesis at our medical center. Major complications (a complication requiring device removal or a secondary surgical procedure) occurred in 21 patients (16 per cent), and 18 were successfully repaired. The most common complication was fluid leak which occurred in 12 patients. Of the 128 patients, 125 presently have a normally functioning prosthesis and satisfactory intercourse.

LONG-TERM EXPERIENCE WITH CONTROLLED EXPANSION CYLINDERS IN THE AMS 700CX INFLATABLE PENILE PROSTHESIS AND COMPARISON WITH EARLIER VERSIONS OF THE SCOTT INFLATABLE PENILE PROSTHESIS

UNLABELLED OBJECTIVEs. To determine complication and survival rates of the AMS 700CX penile prosthesis and to compare its reliability with earlier versions of the Scott inflatable penile prosthesis. METHODS Retrospective chart review and telephone interviews were used. RESULTS Actual 4-year survival of the AMS 700CX device was 85%, whereas earlier versions of the device had actual 4-year survival of 46% (p < 0.0001). The observed difference in prosthesis reliability could not be accounted for by differences in patient population, surgical technique, or incidence of infections. The most significant factor that contributed to improved prosthesis survival was the lack of cylinder complications (leaks and aneurysms). CONCLUSIONS The controlled expansion cylinders of the AMS 700CX penile prosthesis are a significant advance in reliable, low-morbidity surgical therapy for impotence.

Penile Implants in the Treatment of Peyronie’s Disease

The treatment of Peyronies disease remains controversial. Patients who fail conservative therapy may require surgical intervention to restore the ability to have sexual intercourse. Plaque excision and dermal grafting have not been universally successful, and alternate procedures that rely on the placement of a penile prosthesis have gained in popularity. We reviewed our experience with 35 patients with advanced Peyronies disease treated with a penile prosthesis. Preoperatively, 55% of the patients were unable to engage in intercourse due to pain or angulation of the penis and 25% were unable to achieve any erection at all. Postoperatively, with a mean followup of 6.9 years, 88% of the patients were able to engage in intercourse and were satisfied with the results obtained. In selected patients with advanced disease the implantation of a penile prosthesis remains a highly successful and satisfying alternative for the treatment of Peyronies disease.

Endothelium Dependent Relaxation of Human Corpus Cavernosum by Bradykinin

Abstract The release of endothelium-derived relaxing factor (EDRF) from human corpus cavernosum (CC) tissue was confirmed by demonstrating that bradykinin produces endothelium dependent relaxation of human CC tissue. Human CC strips were set in a tissue bath and isometric tension changes were recorded. All strips showed spontaneous contractions and produced tonic contractions by both high potassium solution and noradrenaline (NA) (10 −9 to 10 −4 M) in a dose dependent manner. In preparations precontracted with NA, relaxation was produced by bradykinin (10 −7 to 2 × 10 −6 M). Strips lacking endothelium were contracted by NA but no relaxation was observed with the addition of bradykinin. More direct evidence of the release of EDRF from human CC was demonstrated by a “sandwich” mount. We conclude that bradykinin relaxes human CC by releasing EDRF and that this EDRF may be a factor in erectile function. ( J. Urol., 144: 1015–1017, 1990 )