Robert S. Davis

Vasovasostomy: Current state of the art

Multiple techniques have been used for reanastomoses of the vas deferens after partial bilateral vasectomy. These procedures may be divided into 3 categories: macroscopic surgical loupe magnification and microscopic. At the University of Rochester Medical Center in Rochester New York vasovasostomy is performed with a surgical operating microscope and includes a 2-layer closure. All patients are hospitalized for 1 day. 2 separate upper vertical hemiscrotal incisions are made. If inguinal extensions are required the incisions are extended cephalad. The entire scrotal contents are delivered out of the wound and after the vasectomized ends of the vas are identified and carefully mobilized the occluded ends including the granuloma are sharply excised with a scalpel or fine sharp scissors. The presence of sperm in the semen at the time of vasovasostomy favors a good result but its absence is not an absolute prognosticator for failure. Once the presence of sperm is confirmed the proximal end of the vas canal may be irrigated with saline to decrease sperm concentration at the level of the anastomosis discouraging formation of a sperm granuloma. 87 vasovasostomies were performed at Strong Memorial Hospital of the University of Rochester School of Medicine and Dentistry. The overall patency rate was 75% with pregnancy rate of 46%. All those cases lost to follow-up were not included. The patency rate is based on 66/87 (75%) and the pregnancy rate 32/69 (46.3%). The average sperm count 6 months postoperatively was 21 million/ml; the mean motility score was 46% with an average 51% of normal forms. A table lists the results of 943 vasovasostomies performed by 19 surgeons using 6 techniques over the last 6 years. The best technical results (90% patency) were obtained with the microscopic 2-layer unstented technique. The best pregnancy rates were obtained with loupe magnification and a 1-layer stent technique. This discrepancy brings up the subject of a possible immunologic factor in the final results of vasovasostomy. Analysis of current information available leads to the following conclusions: the results of vasovasotomy have improved; the best technique for vasovasostomy appears to be the microscopic 2-layer unstented procedure; discrepancy in the results between patency and pregnancy indicate other factors are involved and antibodies are probably the major cause affecting pregnancy; and vasovasostomy results should be standardized to allow comparisons between surgeons. The role of sperm antibodies must be included in future prospective reports.

Penile fracture: Operative management and cavernosography

Three cases of acute penile injury are presented. Corpus cavernosography at the time of presentation was obtained, confirming the diagnosis. Radiologic evaluations including cavernosography and when indicated urethrography are discussed. Management modalities are reviewed including our preference for surgical exploration when a cavernosal tear has been documented.

Doppler evaluation of erectile dysfunction -Part 2

Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED. The advantages of penile Doppler and pharmacologic duplex ultrasonography include objective, minimally invasive evaluation of penile hemodynamics at a relatively low cost. Arteriogenic ED may be secondary to peripheral vascular disease and diabetes, or may be seen in association with coronary artery disease. Various parameters, such as diameter of the cavernosal artery, peak systolic flow velocity, degree of arterial dilatation and acceleration time, have been suggested for the diagnosis of arteriogenic ED, but peak systolic flow velocity is the most accurate indicator of arterial disease. This second part of the review article describes the various causes of ED and the interpretation and evaluation of color flow Doppler examination in ED.

Doppler evaluation of erectile dysfunction |[ndash]| Part 1

Erectile dysfunction (ED) is the consistent inability to achieve and maintain an erection sufficient for satisfactory sexual activity. Erectile dysfunction affects as many as 30 million men in America, with an increasing prevalence with age. Erectile dysfunction is secondary to organic, psychogenic and combined causes. The first part of this review article describes the guidelines for evaluation and treatment plans for men with ED. It also describes the normal sonographic anatomy of the penis, sonographic technique for evaluation of ED and the normal phases of erection.

Percutaneous Nephropyelostomy in the Management of Acute Pyohydronephrosis

Percutaneous nephropyelostomy using the posterolateral approach was employed together with antibiotics and other supportive therapy as the initial step in the treatment of acute pyohydronephrosis, with gratifying results. Percutaneous nephropyelostomy is recommended as the procedure of choice for this specific clinical emergency.

Extracorporeal shock-wave lithotripsyin patients with spinal cord dysfunction

Patients with spinal cord dysfunction are at an increased risk for urolithiasis. A retrospective study was undertaken to determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) in this population. Thirteen kidneys received 19 treatments averaging 2,350 shocks per renal unit. All but one of the stones showed good fragmentation; however, none of the patients was stone-free at three months. Four of 9 patients with long-term follow-up were stone-free at five to fifteen months. Our poor stone-free rate is similar to that found in other studies of patients with spinal cord dysfunction. ESWL was well tolerated in this population, however, the clearance of stones is poor and delayed.

Peritonitis and abdominal free air due to intraperitoneal bladder perforation associated with indwelling urethral catheter drainage.

Perforation of the bladder related to long-term indwelling Foley catheter drainage is a rare and serious complication. We report 2 cases of bladder perforation leading to generalized peritonitis and free intraperitoneal air. These cases re-emphasize the importance of considering bladder perforation in the differential diagnosis of the acute abdomen and of performing a complete abdominal exploration when the site of perforation is not easily detectable.

Recent Advances in the Diagnosis and Management of Blunt Renal Trauma

Experience with 207 cases of blunt renal trauma is reviewed. We have found that renal scans and selective renal arteriography are the most informative diagnostic tests. However, in a small community setting we suggest use of an infusion urogram and a retrograde pyelogram. Our accuracy rates with these 4 diagnostic tests are listed and selected cases are illustrated. We believe that if exploration is warranted, kidney salvage rates will be improved because of an accurate assessment of the extent of renal injury.

Bacillus Calmette-Guerin and Interleukin-2 for Treatment of Superficial Bladder Cancer

A total of 22 patients with bladder cancer received bacillus Calmette-Guerin (BCG) and interleukin-2. Significant bladder tumor remissions were noted in 15 of 17 patients (88%). Of 5 patients with carcinoma in situ 1 was noncompliant and he died of carcinoma in situ. The other 4 patients are in remission. BCG alone was instilled in 22 additional patients with superficial bladder cancer. The remission rates were encouraging. Of the 22 patients 13 (59%) had remission of the bladder tumor. A half dose of BCG (60 mg.) is adequate when given weekly for 6 weeks. Maintenance therapy is important as noted in both of our clinical arms. BCG and interleukin-2 therapy results in a higher remission rate.

Ureteral injury associated with lumbar disk surgery

Abstract A case of ureteral injury during lumbar laminectomy treated successfully by retrograde endoscopic ureteral stenting is reported. This case and a review of previously reported cases support the use of ureteral stents for the treatment of partial ureteral transection occurring during lumbar laminectomy.