Surgical outcomes from limiting the use of nonabsorbable suture in tunica albuginea plication for Peyronie's disease.

Tunica albuginea plication (TAP) surgery for Peyronie's disease (PD) is classically described using nonabsorbable suture. Many patients are aware of nodularity at the suture sites (50-88%), and some find them painful (10-33%). We explore whether limiting permanent sutures provides a durable correction of curve and report the incidence of bothersome nodules. Beginning in 2007, we modified our TAP procedure to limit the use of permanent sutures. We reviewed all patients who underwent TAP procedures from 2007 to 2014 at our institution. Patients were contacted to complete a previously published survey regarding postoperative satisfaction. In total, 142 PD patients underwent the TAP procedure and 81/142 (57%) completed the postoperative survey. Mean office follow-up and survey follow-up were 17.3 and 56.3 months, respectively. Of the surveyed patients, 6.2% complained of a bothersome residual curve, 19.8% experienced nodularity and 4.9% reported bothersome nodules. Men with dorsal curves experienced less painful nodularity than those with ventral (P=0.047) or lateral curves (P=0.017). In total, 4/142 (2.8%) of men underwent repeat intervention. At long-term follow-up, limiting permanent sutures during TAP procedures for PD is durable with respect to curvature correction and has encouragingly low levels of nodularity and bother at suture sites.

Knowledge of AIDS among hospital workers: behavioral correlates and consequences.

Incidents of suboptimal care being rendered to AIDS patients have been documented. Using a voluntary anonymous questionnaire, we surveyed the employees of a large urban hospital in order to evaluate the knowledge, attitudes and professional behavior of the staff regarding AIDS. Responses were obtained from 1194 (60%) of the staff. Poor knowledge of the transmission of AIDS was documented, with 50% of workers stating that AIDS can be spread through ordinary non-sexual contact and 23% through the air by a cough or a sneeze. One-third of employees believed that they should be able to refuse to care for patients with AIDS. Extreme anxiety in dealing with AIDS patients was noted by 25% of employees, and only 16% of the employees would volunteer to work on an AIDS ward. Knowledge regarding AIDS was demonstrated to be a predictor of positive attitudes, appropriate professional behavior and lower anxiety in dealing with AIDS patients. The goal of hospital education programs on AIDS must be to ensure the incorporation of accurate information into the belief system of workers.

Diagnosis and treatment of erectile dysfunction.

Up to 30 million men in the United States are affected by some degree of erectile dysfunction (ED). In the Massachusetts Male Aging Study (MMAS) 52% of men between 40 and 70 years of age were found to have some degree of ED. The MMAS and other studies also found that the likelihood of developing ED increases significantly with age. The vast majority of ED is primarily of organic and vascular cause, although psychological factors also play a role in most cases. ED has been shown to compromise overall quality of life and is associated with depression, anxiety, and loss of self-esteem. It may also signal serious underlying disease, including diabetes, hypertension, and cardiovascular disease. Therefore, questions regarding sexual functioning should be a routine part of the medical history. In the early 1990s, with the growing number of nonspecific and effective as well as less invasive tests, a new algorithm was developed that tailored evaluation to the treatment goals of the patient and his partner. This "goal-directed" approach simplifies the management of ED in the primary care setting; the availability of an effective oral agent, as well as a range of other therapeutic options, allows men with ED of all causes to receive effective treatment.

Importance of asking questions about erectile dysfunction.

Cardiovascular disease and erectile dysfunction share many common risk factors. In fact, recent studies have demonstrated evidence of occult coronary artery disease, undiagnosed hyperlipidemia, and hypertension in men presenting with erectile dysfunction. It is therefore incumbent upon all physicians, especially cardiologists, to query their patients about their erectile function.

Conservative management of high-flow priapism.

High-flow priapism most frequently occurs as a result of penile trauma with subsequent unchecked arterial flow into the corpora cavernosa. An improved understanding of its underlying pathophysiology has allowed a more selective therapeutic approach, usually with preservation of potency. We report on 4 cases of traumatic high-flow priapism seen over a 5-year period. The patients were managed successfully with conservative treatment consisting of observation after arteriography or percutaneous duplex ultrasound-guided autologous clot embolization where tortuous vessels prevented selective embolization. No patient required surgical repair and hospitalization was brief (0 to 2 days). The use of color duplex ultrasonography provided a noninvasive modality for establishing the site of the injury and allowed serial follow-up evaluation. When conservative measures failed, the color duplex ultrasound study confirmed the presence of the ruptured cavernous artery and allowed percutaneous autologous clot embolization in 1 patient. Long-term follow-up (1 to 4 years) of these patients revealed a return to their preinjury state of erectile function.

Treatment of subclinical intraurethral human papilloma virus infection with interferon alfa-2b.

OBJECTIVES: Anogenital human papilloma virus (HPV) infection represents a growing concern among physicians in the United States. An intraurethral reservoir of the virus has been suggested as a possible source for reinfection between sexual partners, and may contribute to the increase in the number of affected individuals. Treatment reports of intraurethral HPV infection with adequate follow-up have been lacking. Our goals in this study were to identify the patients with cytologic evidence of HPV intraurethral infection, and to attempt treatment with intraurethral instillations of interferon alfa-2b. METHODS: Eighty-nine men with anogenital lesions or known exposure to HPV underwent cytologic examination using a urethral swab after all visible disease was adequately treated. Sixteen patients with positive cytology results were treated with weekly instillations of 25 million U of interferon alfa-2b solution for 6 weeks. Urethral cytology was monitored at 2 and 6 weeks post-treatment, as well as every 3 months thereafter up to a year. Those who had a recurrence during the study were retreated with a 6-week course using 50 million U per instillation. Patients were monitored for possible side effects. RESULTS: Seventeen (19%) of 89 patients who entered the study had urethral cytology positive for HPV infection with no evidence of visible disease. Seven (41%) of these 17 patients did not show external (meatal or skin) manifestations of the disease. Fourteen of 16 (88%) men who underwent the therapy were followed for an average of 11.8 months. Nine of those 14 (64%) remained disease free throughout the follow-up. Of the 5 who had a recurrence, 3 were successfully retreated, with a mean of 7.2 months of disease-free follow-up after the second course. No adverse effects of the treatment were noted by blood testing, semen analysis, and patient report. CONCLUSIONS: The urethra is a significant HPV reservoir and should be investigated in patients exposed to the virus. Interferon is a potentially safe and effective treatment option for intraurethral HPV.

Current and future roles of laparoscopic surgery in urology.

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.

Review of current nonsurgical management of Peyronie's disease.

The current nonsurgical treatment options for men with Peyronie's disease is reviewed. The treatments currently employed and published in the English literature are discussed. A wide variety of nonsurgical treatment options are available to the practicing physician, including oral and topical medications, intralesional injection therapy, as well as employing external energy sources to drive medicine into the tunica albuginea by iontophoresis or direct stimulation of plaque change by shock wave therapy. Nonsurgical treatment of Peyronie's disease clearly has a place in the armamentarium of the practicing urologist. Oral therapy appears to have little therapeutic benefit. Injection and topical approaches deserve further attention. Yet, no single treatment stands out as the most effective remedy for all men with Peyronie's disease. Further controlled, large-scale studies are necessary to establish the benefits of these nonsurgical approaches. In the meantime, combination therapy appears to make sense in the nonsurgical treatment of men with Peyronie's disease.

Intralesional verapamil for the treatment of Peyronie's disease: a review.

Multiple treatment options have been used for Peyronie's disease (PD) including intralesional injection of the calcium antagonist verapamil. The use of verapamil is based on its capacity to alter fibroblast function at several levels, including cell proliferation, extracellular matrix protein synthesis and secretion, as well as collagen degradation. Consequently, calcium antagonists may have the capacity to slow, prevent, or even reverse plaque formation and the progression of PD. The multicenter international experience with intralesional verapamil injection suggests that the majority of men with PD that receive treatment demonstrate durable reduction in pain, decrease in curvature, and improved sexual function. We review the scientific rationale, published literature, clinical experience, and technique of intralesional injection of verapamil.

Treatment of erectile dysfunction in patients with Peyronie's disease using sildenafil citrate.

Erectile dysfunction (ED) has frequently been associated with Peyronie's Disease (PD) and may further compromise coitus. This is a retrospective analysis of ED in patients with PD since the release of sildenafil citrate (SC) focusing specifically on our patients' responses to SC. One-hundred seventy six patients with PD were evaluated between April 1998 and May 2001. All patients received a complete medical and sexual history, physical exam, penile duplex ultrasound (PDU, with 30-90 mg of papaverine) to assess penile vascular integrity, plaque dimensions, and erect penile deformity. Based on these findings, appropriate treatment options were offered for their PD and their ED including SC, which was offered to 73 men. Patient response to SC was specifically assessed during patient office interview and via a mailed EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) questionnaire. Seventy (39.8%) and 104 (59.1%) patients complained of decreased erectile capacity (ie rigidity) occurring before and after the onset of PD, respectively. Only two patients reported no change of erectile capacity. In all, 103 (58.5%) patients complained of significant reduction in sexual function due to diminished rigidity and sought treatment for their ED. Of the ED treatment options available, 73 (70.9%) patients were given a prescription for SC. Forty-eight (75.0%) patients returned the EDITS questionnaire while four of 73 (5.5%) patients did not fill their prescription and five of 73 (6.8%) did not engage in sexual activity following an initial trial of SC due to side effects (flushing, headaches). Based upon the EDITS response, 34 of 48 (70.8%) patients reported that they were either very satisfied or somewhat satisfied, five of 48 (10.4%) patients were neither satisfied nor dissatisfied, and nine of 48 (18.8%) patients were somewhat dissatisfied or very dissatisfied with the effectiveness of SC in enhancing their erectile response. No patient reported worsening of PD deformity or an increase in penile pain. The 30 patients who were not prescribed SC chose the following options to enhance rigidity: eight (7.8%) underwent prosthesis placement, four (3.9%) opted for vacuum constriction device (VCD), four (3.9%) chose intracorporal injections, and 14 (13.6%) used no adjunctive therapy. Erectile dysfunction is a problem associated with PD and all typical treatment options are acceptable. However, to our knowledge, there is no published study reviewing the efficacy of SC in patients with ED associated with PD. There appears to be no contraindication to using SC as being the least invasive and most convenient treatment option for ED with PD. Although the potential risk of coital trauma to the erect penis with PD is present, there is no evidence from this study that erections and coitus enhanced specifically by SC resulted in worsening deformity or progression of the PD. EDITS questionnaire results reveal that SC is an agent that allowed successful coitus in 70.8% of males with PD.

Establishing a standardized evaluation of the man with Peyronie's disease.

The goal of this article is to encourage development of a standardized approach to the evaluation of the man with Peyronie's disease. An additional aim is to identify those subjective and objective measures of change occurring as a result of treatment which would allow uniform reporting of treatment outcome. Systematic review of current clinical parameters used in assessing the man with Peyronie's disease including demographic data, physical findings, objective measures of penile deformity and erectile function as well as questionnaires employed to gain more reliable subjective data. As there is no accepted standard approach or previously published analysis of existing approaches, a survey of 68 recently published articles is included to query current outcome reporting on Peyronie's disease therapy. Results were as follows. An algorithm is suggested as an initial format for evaluation and outcome analysis. The pros and cons of subjective and objective measures of penile deformity is presented and a standardized questionnaire and penile duplex ultrasound report form is included for current use. The literature survey revealed the broad unscientific approach to outcome reporting making assessment of treatment quite difficult. In conclusion, it is clear that it is time to establish a standardized and globally acceptable evaluation and outcome reporting algorithm. There is interest to develop and validate a specific Peyronie's disease index questionnaire. In the meantime, this article presents specific recommendations to obtaining meaningful objective measures and methods to report them.

A surgical algorithm for penile prosthesis placement in men with erectile failure and Peyronie's disease.

We developed an algorithm for surgical management and placement of penile prostheses in patients with erectile failure (ED) and Peyronie's disease (PD). We identified 46 men ages 40 to 77 y with PD who could not attain an adequate erection with sexual stimulation and pharmacotherapy. All men were candidates for penile straightening and inflatable prosthesis placement using the following algorithm. Manual molding was attempted initially, followed by tunica incision for insufficient straightening. For tunical defects greater than 2 cm, polytetrafluoroethylene (PTFE) patch grafting was performed to prevent prosthesis cylinder herniation and recurrent deformity from cicatrix contraction. Mean preoperative penile curvature was 53 degrees (0-90). Prosthesis implantation with manual molding, implant with plaque incision, and implant with plaque incision and PTFE grafting were successfully accomplished in 25 (54%), 12 (26%), and nine (20)% respectively. Mean follow-up was 39 months (range 1-74). Full erectile capacity with a straight phallus was achieved in all patients. Complications included temporary (< 8 months) decreased penile sensation in four (9%), mild (< 2 cm) penile shortening in three (7%), delayed ejaculation in one (2%), and infection requiring explanation in one diabetic male (2%). All of the implanted prostheses provided satisfactory rigidity with no mechanical failures or recurrent curvature. We conclude that inflatable penile prosthesis implantation is a safe and effective therapy with a high satisfaction rate in men with ED and PD. The developed algorithm helps define prosthesis placement and straightening techniques to obtain optimal results with minimal complications.

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism.

PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Preoperative semen analysis as a predictor of seminal improvement following varicocelectomy.

OBJECTIVE: To determine the predictive role of preoperative semen analysis on both seminal improvement and pregnancy rates following varicocelectomy. DESIGN: Retrospective data analysis. SETTING: Two academic medical center infertility clinics. PATIENT(S): One hundred ten consecutive patients who underwent varicocelectomies. Seminal improvement data were available for 84 patients, and pregnancy data were available for 58 patients. INTERVENTION(S): Stratification of patients based on preoperative total motile sperm count (TM). Varicocelectomy was performed on all patients. MAIN OUTCOME MEASURE(S): TMs, pregnancy rates, and conception techniques following varicocelectomy of each preoperative group. RESULT(S): Men with mild to moderate oligoasthenospermia (TM >5 million) had significantly better seminal improvement following varicocelectomy. While preoperative stratification showed no difference in pregnancy rates (when assisted reproductive techniques were included), men who achieved a postoperative TM >20 million were more likely to achieve conception by less invasive techniques (natural and intrauterine insemination vs. in vitro fertilization [IVF]). CONCLUSION(S): Varicocelectomy may be the most cost-effective initial intervention in males with TM >5 million. Patients with TM <5 million and concomitant female factor infertility may be better initial candidates for IVF.

Identification of seminiferous tubule aberrations and a low incidence of testicular microliths associated with the development of azoospermia.

OBJECTIVE: To evaluate the use of percutaneous testicular sperm aspiration in the assessment of azoospermia and its association with seminiferous tubule microliths. DESIGN: Case report. SETTING: Tertiary care fertility center in a university hospital. PATIENT(S): Male undergoing infertility evaluation. INTERVENTION(S): Testicular biopsy and percutaneous testicular aspiration. MAIN OUTCOME MEASURE(S): Serum hormone analysis, sperm concentration in semen, spermatogenesis in samples from testicular biopsies and aspirations, and microlith composition. RESULT(S): A patient presented for infertility evaluation with a history of severe oligospermia that progressed to azoospermia. The serum testosterone concentration (357 ng/dL) and LH concentration (9.2 mIU/mL) were normal and the serum FSH concentration (18.3 mIU/mL) was elevated. Testicular biopsy results indicated spermatogenic hypoplasia with limited spermatozoa. Seminiferous tubules obtained by percutaneous testicular aspiration were structurally aberrant, with multiple diverticula. Microliths averaging 120 microm in diameter were observed within and blocking the seminiferous tubules. The microliths were composed of calcium phosphate (hydroxyapatite) in both the core and peripheral regions. Electron microscopy revealed a high degree of collagen-like material within the peripheral zone. CONCLUSION(S): The presence of seminiferous tubule microliths is associated with the development of azoospermia. In patients with a low incidence of seminiferous tubule microliths and aberrant seminiferous tubule architecture, percutaneous testicular aspiration may provide a diagnostic advantage over testicular biopsy.

Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction.

The role of nocturnal penile tumescence monitoring in helping to distinguish psychogenic from organic impotence has been the subject of research for several decades. Tumescence monitoring alone, while it does provide useful information, imposes limitations on the diagnostic inferences that can be drawn concerning the adequacy of erectile function. This led to the development of nocturnal penile tumescence and rigidity monitoring (NPTR). Although there is no single test that enables physicians to diagnose the precise etiology and degree of impotence, NPTR provides useful information in a rather noninvasive and inexpensive manner allowing one to direct patients to the appropriate treatment.

Vacuum constriction and external erection devices in erectile dysfunction.

The development of external erection devices has evolved as the social stigma surrounding the treatment of erectile dysfunction has gradually disappeared during the late twentieth century. Although the success of surgical and medical therapy for erectile dysfunction has been documented, especially since the introduction of sildenafil citrate, patient demand for an effective, noninvasive, drug-free management of erectile dysfunction has remained. As the population continues to age, acquiring the comorbidities commonly associated with erectile dysfunction, such as hypertension, diabetes mellitus, and atherosclerotic vascular disease, the demand for such treatment should persist. This article examines the development, mechanism of action, efficacy, and patient satisfaction with regard to vacuum constriction and external erection devices.

Flap reconstruction in patients with head and neck cancer: techniques and results.

Patients who are treated by surgery, radiotherapy, or any combination thereof may suffer from complications in wound healing or tumor recurrence which necessitate reconstruction of repair utilizing tissue brought in from other parts of the body. The majority of patients, who required flap reconstruction for primary repair or for a complication of their surgery, had their primary lesion in the supraglottic larynx or inferior hypopharynx. More than two-thirds of the flaps elevated were for fistula repair. Five year survival in this group of patients was lower than in those patients with uncomplicated postoperative courses, although the quality of life for the survivors in both groups was not significantly different.

High-grade malignancies of the parotid gland: effective use of planned combined surgery and irradiation.

The trend toward treatment of parotid gland malignancies with planned combined surgery and postoperative radiation therapy is currently being followed by many centers, although prospective studies confirming the efficacy of this treatment regimen have only recently begun. We have reviewed only our "high-grade" histologic types: adenocarcinomas, malignant mixed tumors, high-grade mucoepidermoid carcinomas, squamous cell carcinomas, and undifferentiated carcinomas. Acinic cell carcinomas, adenoid cystic carcinomas, and low-grade mucoepidermoid carcinomas were excluded from study because of their different biologic behavior. Since 1974, we have employed the approach of surgical extirpation with preservation of the facial nerve when possible for all parotid tumors, combined with planned postoperative radiation therapy (50-70 Gy). We reviewed the 37 cases of "high-grade" parotid gland malignancies and compared the patients treated with the combined modality approach with our historical patients treated initially with surgery alone. Despite an apparent higher stage at presentation, our combined treatment group ultimately had significantly better local control (70% vs. 20%), and an equivalent survival rate at five years. Tumor was present at the margin of resection in 14 (74%) cases treated with combined surgery and irradiation. The facial nerve was preserved in six of these patients with positive margins, and only one of these patients developed a local or regional treatment failure. In conclusion, our data confirms the efficacy of surgical exploration to determine the extent of disease and surgical resection, preserving facial nerve function if possible, followed by postoperative radiation therapy at adequate doses. Control of local-regional disease was much improved by combined modality therapy as opposed to surgical resection alone, despite the prevalence of residual microscopic disease in the resection margins. Facial nerve function is optimally preserved by this approach of conservative surgery combined with postoperative radiation therapy.

Adenoid cystic carcinoma of major and minor salivary gland origin.

The records of 76 patients with adenoid cystic carcinoma of major and minor salivary gland origin seen at the Washington University Medical Center from 1963-1980 were reviewed to determine factors involved in local control, development of distant metastasis, and survival. Twenty-four (32%) patients were initially treated with surgery alone, 36 (47%) with combined surgery and irradiation, and 16 (21%) with irradiation alone. Local control after treatment was determined for all patients and was analyzed with respect to extent of surgery and dose of irradiation. Of 75 patients evaluable for local control, 30 (40%) failed with a median time of less than 5 years. There was no significant difference for patients treated vigorously for local recurrences after surgery. Patients who had a complete surgical resection (i.e., negative margins) survived significantly longer than patients treated by incomplete resection or biopsy alone followed by irradiation. Distant metastases developed in 50% of patients regardless of local control. Median survival after development of distant metastases was 40 months. There was no difference between major and minor gland sources for development of metastases. Lymph node involvement was rare. Our data indicate that complete and radical surgery results in the best survival. Combined modality therapy with surgery and irradiation optimizes the control of local disease. However, since distant metastases develop in spite of local control, in most instances we cannot recommend mutilating surgery for this disease entity.