Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel.

Surgical treatments for ischemic priapism (IP) include shunts or penile implants. Non-ischemic priapism (NIP) is usually the result of penile/perineal trauma causing an arterial fistula and embolisation may be required. We conducted a systematic review on behalf of the EAU Sexual and Reproductive health Guidelines panel to analyse the available evidence on efficacy and safety of surgical modalities for IP and NIP. Outcomes were priapism resolution, sexual function and adverse events following surgery. Overall, 63 studies (n = 923) met inclusion criteria up to September 2021. For IP (n = 702), surgery comprised distal (n = 274), proximal shunts (n = 209) and penile prostheses (n = 194). Resolution occurred in 18.7-100% for distal, 5.7-100% for proximal shunts and 100% for penile prostheses. Potency rate was 20-100% for distal, 11.1-77.2% for proximal shunts, and 26.3-100% for penile prostheses, respectively. Patient satisfaction was 60-100% following penile prostheses implantation. Complications were 0-42.5% for shunts and 0-13.6% for IPP. For NIP (n = 221), embolisation success was 85.7-100% and potency 80-100%. The majority of studies were retrospective cohort studies. Risk of bias was high. Overall, surgical shunts have acceptable success rates in IP. Proximal/venous shunts should be abandoned due to morbidity/ED rates. In IP > 48 h, best outcomes are seen with penile prostheses implantation. Embolisation is the mainstay technique for NIP with high resolution rates and adequate erectile function.

What is the effectiveness of surgical and non-surgical therapies in the treatment of ischemic priapism in patients with sickle cell disease? A systematic review by the EAU Sexual and Reproductive Health Guidelines Panel.

Sickle cell disease (SCD) is an inherited hemoglobin disorder characterized by the occlusion of small blood vessels by sickle-shaped red blood cells. SCD is associated with a number of complications, including ischemic priapism. While SCD accounts for at least one-third of all priapism cases, no definitive treatment strategy has been established to specifically treat patients with SC priapism. The aim of this systematic review was to assess the efficacy and safety of contemporary treatment modalities for acute and stuttering ischemic priapism associated with SCD. The primary outcome measures were defined as resolution of acute priapism (detumescence) and complete response of stuttering priapism, while the primary harm outcome was as sexual dysfunction. The protocol for the review has been registered (PROSPERO Nr: CRD42020182001), and a systematic search of Medline, Embase, and Cochrane controlled trials databases was performed. Three trials with 41 observational studies met the criteria for inclusion in this review. None of the trials assessed detumescence, as a primary outcome. All of the trials reported a complete response of stuttering priapism; however, the certainty of the evidence was low. It is clear that assessing the effectiveness of specific interventions for priapism in SCD, well-designed, adequately-powered, multicenter trials are strongly required.

BK Virus Associated Haemorrhagic Cystitis. A systematic review of current prevention and treatment strategies.

BACKGROUND: BK virus is a major cause of late onset haemorrhagic cystitis in patients undergoing Haematopoietic Cell Transplantation (HCT). The evidence for the management of BK Virus Associated Haemorrhagic Cystitis (BKV-HC) is limited. Much of the published data consists of non-randomised case series and case reports. To our knowledge this is the first systematic review for the management of BKV-HC in both paediatric and adult populations. Our primary outcome was to examine the evidence for strategies of 1) prevention and 2) cessation of haematuria associated with BKV. Secondary outcomes were to assess the toxicity of treatment strategies and devise management recommendations for clinicians. MATERIALS AND METHODS: We performed a systematic review of the PubMed and Central databases to evaluate the current evidence. A search protocol was prepared and registered with the PROSPERO database (CRD42017082442). The review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Results were classified by treatment type. Qualitative analysis of included articles was performed, and grades of recommendations were devised for each treatment. RESULTS: Of 896 titles screened, 44 articles were included for qualitative analysis. The overall quality of evidence was low. There is insufficient evidence to recommend prophylactic quinolones. 40 studies evaluated treatments for established BKV-HC. There are no high-quality comparative studies. Cidofovir is the most studied treatment but quality of evidence is low, and grade of recommendation is weak. Hyperbaric oxygen therapy, Fibrin glue, Leflunomide, Sodium Pentosan Polysulfate, Intravesical Alum and Radiological embolisation have all been described but the effectiveness of these treatments is unclear. CONCLUSION: There remains no clear specific treatment for BKV-HC. An effective multi-disciplinary approach leading to early recognition and initiation of treatment is encouraged. The development of novel therapies followed by well-designed clinical studies are urgently needed.

Appearance of neuropeptides and NADPH-diaphorase during development of the enteropancreatic innervation.

Pancreatic ganglia are formed by neural crest-derived precursors, are innervated by enteric neurons, and contain neuropeptides. In addition, the enzyme NADPH-diaphorase is located in a subset of enteric and pancreatic neurons. The expression of neural markers (GAP-43 and NC-1), neurotransmitter-related markers (including neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), gastrin-releasing peptide (GRP), galanin (GAL), dopamine beta hydroxylase (DBH), substance P (SP), calcitonin gene-related peptide (CGRP)), and NADPH-diaphorase was studied in the fetal and neonatal rat gut and pancreas (E12-P28) in situ and in vitro. NC-1, GAP-43 and DBH-immunoreactive cells were found in the primordial stomach on day E12, and in the pancreas on day E13, along with NPY in endocrine cells. Pancreatic NPY-immunoreactive neurons were detected by day E18. CGRP was seen in the foregut at day E12 but not in the pancreas until day E14. Other neuropeptides (SP, GAL, GRP and VIP) all appeared in the foregut earlier than in the pancreas. NADPH-diaphorase activity was first found in situ in foregut neurons on day E13, and in the pancreas on day E14, but seen in explants a day earlier. These observations show that development of neurons occurs earlier in the gut than in the pancreas, and that NADPH-diaphorase activity appears earlier than the immunoreactivities of the neuropeptides.

Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature.

This study was conducted to evaluate the role of antepartum laparoscopic cholecystectomy (LC). Patients who underwent LC were identified from a hospital database with the use of CPT/ICD codes. Of 2093 cases performed at a major center (October 1991 to November 1997), only six were performed during pregnancy. On reviewing the English literature, gestational age at surgery and delivery and outcome of delivery were provided in only 69 of 105 patients (33 papers with 1-10 cases) and we tabulated different variables from the cases in this review. In this series, two patients who had LC in the first trimester underwent elective termination of pregnancy. Of the seven published cases of first trimester LC followed to delivery, one had preterm delivery. First trimester open cholecystectomy (OC) has a 12 percent spontaneous abortion rate. The four patients who had second trimester LC had normal deliveries at term. Of the 43 published cases of second trimester LC followed to delivery, 39 ended in uncomplicated, full-term deliveries. Three of four second trimester cases at one institution had spontaneous abortions. None of our patients underwent LC in the third trimester. Of the 12 published cases of third trimester LC followed to delivery, one had preterm delivery. Third trimester OC is reported to have a 40 percent rate of preterm delivery. There were no intraoperative cholangiograms (IOC), prophylactic or postoperative use of tocolytics, or intraoperative fetal monitoring in our series. We added six cases of LC during pregnancy to the previously reported 105 cases. The successful outcome in all trimesters suggests that LC is a safe procedure throughout pregnancy; however, surgery in the second trimester is preferable. Compared with OC, there is a decreased risk of spontaneous abortion in the first trimester and preterm labor in the third trimester.

Perinatal mortality in diabetic patients undergoing antepartum fetal evaluation: a case-control study.

OBJECTIVE: To identify changing trends, if any, of fetal loss in diabetic patients undergoing antepartum fetal evaluation in a case-control study. METHODS: Fetal assessment (non-stress test and/or biophysical profile) logbooks from January 1981 to June 1998 were reviewed and the patients with diabetes were identified. The study group comprised patients with pregnancy loss. Each case was matched by year of delivery and class of diabetes with four randomly selected controls with no pregnancy loss. All patients in both groups were at > 26 weeks' gestation. RESULTS: Thirteen stillbirths and four neonatal deaths occurred in 1,935 diabetic patients who underwent fetal evaluation. There was no significant difference in age, race, gravidity, parity, clinic or private service, or the type of delivery in the two groups. Losses were more likely (p < 0.001) to occur before 32 weeks, with birth weights < 2,500 g, with a greater time interval from their last fetal evaluation, with poor glycemic control and with congenital malformations (six of seven occurred before 1990). In this study, perinatal losses were associated with non-compliance and other associated problems in the mother. Overall perinatal mortality in these patients was 17 per 1935 and corrected 11 per 1935 or 5.6 per 1,000. CONCLUSION: In the 1980s suboptimal glycemic control with major fetal malformations emerged as the major contributory factor to perinatal loss and, in the 1990s, this was associated medical problems. With a better awareness of the adverse effect of suboptimal glycemic control at the time of organogenesis and advances in fetal diagnosis and evaluation, fetal loss due to diabetes has become a rarity. Patients with associated medical problems and those at risk for abruptio placentae should be managed more aggressively.

Alpha-fetoprotein in diabetic pregnancy. A reassessment.

We correlated glycosylated hemoglobin (HbA1) with maternal serum alpha-fetoprotein (MSAFP) in 92 and amniotic fluid AFP (AFAFP) in 27 patients with pregestational and gestational diabetes. MSAFP and AFAFP were measured between 15 and 20 weeks and correlated with HbA1. In group 1, HbA1 was measured at < or = 12 weeks' gestation; in group 2, it was measured 0-6 weeks before MSAFP measurement; and in group 3, it was measured within 6 weeks after MSAFP. Mean MSAFP was 1.02 +/- 0.77 multiples of the median (MOM) (+/- SD) in all diabetics, 1.1 +/- 0.93 MOM in gestational diabetics and 0.89 +/- 0.33 MOM in pregestational diabetics (P = NS). There was no correlation between MSAFP and HbA1 in groups 1-3. Patients with HbA1 > 9 g% had a mean MSAFP of 0.84 MOM as compared to 0.85 MOM in those with HbA1 < 9 g% (P = NS). AFAFP values were within normal limits even in patients with HbA1 > 9 g% in early pregnancy (n = 8). No significant decrease in MSAFP was seen in pregestational diabetics, and no correlation was seen with HbA1 levels. AFAFP levels were unchanged in diabetics.

Fetal faciocervical teratoma with anemia and thrombocytopenia. A case report.

A massive teratoma in the faciocervical region was found in a fetus at 21 weeks, with laboratory evidence of anemia and thrombocytopenia. Vaginal delivery was achieved by cardiocentesis followed by Laminaria tent insertion, dilation and evacuation.

Transvaginal ultrasonography in gynecologic office practice: assessment in 663 premenopausal women.

OBJECTIVES: We describe transvaginal ultrasonographic evaluation of 663 premenopausal women with signs or symptoms of gynecologic problems and compare the findings of transvaginal ultrasonography with those of antecedent bimanual examination. STUDY DESIGN: In this retrospective descriptive study, data on age, menstrual history, results of bimanual examination, and subsequent surgical and pathologic findings were abstracted from the medical record and linked to indications and results on transvaginal ultrasonography reports from May 1991 through October 1993. RESULTS: The result of bimanual examination of the uterus was normal in 125 of 347 women with transvaginal ultrasonography-diagnosed fibroids (36.0%). Findings were normal at bimanual examination of the corresponding adnexa in 134 of the 190 adnexa with transvaginal ultrasonography findings (70.5%). Among the subjects with normal results of bimanual examination of the adnexa, surgical procedures documented 12 endometriomas, 2 adnexal abscesses, and 5 benign and 1 malignant neoplasm. CONCLUSION: Given the apparent considerable limitations of the bimanual examination, the utility of routine in-office transvaginal ultrasonography screening of both women with and women without symptoms should be prospectively investigated.

Sonographic neuroembryology of the central nervous system.

In the last decade, strong emphasis has been placed on the structural evaluation of the fetus. Central nervous system anomalies are among the most common malformations affecting the developing fetus. As ultrasound equipment has improved, our demand for more resolute pictures has increased. The high-frequency, transvaginal ultrasound probe allows us to access the fetal fontanel and produce high-resolution fetal brain images. When such transducer probes are aligned with the fetal anterior fontanel (much like neonatal brain scans), clear and clinically useful images in the sagittal and coronal planes are generated. In this article, we review the technique of transvaginal transfontanel scanning, discuss pertinent neuroembryology, and apply this information to the sonographic diagnosis of neural tube defects.

Protein S deficiency in pregnancy: a case report.

Protein S deficiency is uncommon, may cause recurrent thrombosis, and may complicate pregnancy. A patient with protein S deficiency presented with a stillbirth followed by postpartum pulmonary embolism. She then had a successful pregnancy managed by anticoagulation and close fetal monitoring.

Is induction of labor with continuous release dinoprostone vaginal pessary a viable option in patients with preeclampsia?

Objective: To evaluate the role of dinoprostone vaginal pessary (DVP) for induction of labor in preeclampsia.Methods: This is a prospective review of 94 patients with preeclampsia, who delivered from July 1995 to December 1996 at a university center. Of these, 25 received DVP, 22 oxytocin, 11 intracervical prostaglandin E(2), and 36 received no pharmacologic agents. Patients receiving DVP and oxytocin induction were compared for outcome of pregnancy and cesarean section rate. Statistical analysis was carried out by Student t test, chi(2) test with Yates correction.Results: The two groups were comparable with respect to parity and 5-minute Apgar scores.Three patients in the DVP group developed complications-one episode of seizure, one atonic postpartum hemorrhage, and one cervical laceration. One patient in the oxytocin group developed HELLP syndrome.Conclusion: DVP is at least as effective as oxytocin in achieving vaginal delivery in preeclampsia, despite lower Bishop scores. Future larger studies are needed to better assess DVP in patients with preeclampsia.