[High-resolution realtime sonography of varicoceles]. / Hochauflösende real-time-Sonographie der Varikozele.

An attempt has been made to classify varicoceles by means of real time sonography in accordance with the findings on palpation. The maximal diameter of the pampiniform plexus and of individual veins was determined sonographically and compared with the results of palpation in 74 patients with varicoceles. The sonographic findings are more accurate than is palpation. Fifteen subclinical varicoceles were discovered by sonography which could not be detected by palpation. It has been found convenient to classify the lesions in four sonographic stages. Maximal transverse diameter of the pampiniform plexus up to one centimetre is regarded as normal. A diameter of one to two centimetres corresponds to grade I, two to three centimetres corresponds to grade II and greater than three centimetres to grade III.

[Disorders of erectile potency in diabetes mellitus]. / Erektile Potenzstörung bei Diabetes mellitus.

The incidence of erectile dysfunction in patients with long-term diabetes mellitus can be as high as 50%. Diabetic microangiopathy is regarded as the most important pathogenic factor. In this review of a group of 210 impotent patients evaluated and treated at our centre we report on the examination data (angiopathy, neuropathy, psychogenic factors) in 36 patients with diabetes in comparison with the corresponding findings in 169 non-diabetic patients. In 5 patients erectile dysfunction had actually preceded the clinical manifestations of diabetes mellitus. Autoinjection therapy was started in 62% of all the diabetic patients, since this is effective, minimally invasive and, therefore, applicable to a large group of patients. This form of therapy was accepted by 90% of our patients' partners, which is in accordance to the reports in the literature. However, treatment had to be interrupted in 2 out of the 22 patients, owing to lack of cooperation on the part of the sexual partner. No complications were attributable to autoinjection therapy.

[Topical therapy in erectile dysfunction]. / Topische Therapie bei Erektionsstörung.

All forms of pharmacological therapy result in a relaxation of the corporeal smooth muscle. Intracorporeal injection of vasoactive drugs was introduced around 15 years ago and still is the most effective therapy in erectile dysfunction. Resulting in a consistent success rate of 70-80% this form of therapy will find numerous applications, even after the introduction of effective oral agents such as sildenafil. Prostaglandin E1 and--less frequently used--the combination of papaverine and phentolamine are the mainstay of intracorporeal injection therapy. Intraurethral prostaglandin (MUSE) has recently become available and is somewhat less effective than injection therapy. Externally applied drugs (nitroglycerin paste on the penile shaft and minoxidil solution on the glans penis) have not succeeded in the long run. Vacuum erection devices represent a form of physical topical therapy that is very versatile and also effective but rather infrequently applied.

Intracavernous injection of prostaglandin E1 in combination with papaverine: enhanced effectiveness in comparison with papaverine plus phentolamine and prostaglandin E1 alone.

We compared the erectile response to intracavernous injection of a combination of papaverine and prostaglandin E1 with that of a combination of papaverine and phentolamine (49 patients), and prostaglandin E1 alone (38). The degree of erection achieved was significantly better with papaverine plus prostaglandin E1 than with papaverine plus phentolamine and the duration of erection was less, although the incidence of prolonged erections (greater than 5 hours) was similar with both combinations. Papaverine with prostaglandin E1 likewise resulted in a significantly better degree of erection than prostaglandin E1 alone (prolonged erections occurred only after the drug combination). All erections subsided spontaneously and none required medical intervention throughout the study. Pain was noted only after injection of prostaglandin E1. The incidence was clearly lower (7 of 38 versus 13 of 38) after the injection of only 5 micrograms. prostaglandin E1 in combination with papaverine (although the difference is not statistically significant). Subjectively, the side effects caused by the drug combination were described as much less dramatic by the patients than after prostaglandin E1 alone. The combination of papaverine and prostaglandin E1 shows a clearly synergistic effect and might suitably replace papaverine plus phentolamine or prostaglandin E1 alone in patients who do not respond well or suffer side effects after high single doses.

Hyperhomocysteinemia in organ transplantation.

An elevated total homocysteine plasma concentration is associated with an increased morbidity and mortality due to cardiovascular disease in the general population, in patients with renal failure and in recipients of kidney or heart transplants. The fasting or post-methionine loading plasma concentration of total homocysteine is elevated in 50-60% of renal transplant recipients with stable graft function and in the majority of heart transplant recipients. Fasting and post-methionine loading hyperhomocysteinemia can be normalized in virtually all renal transplant patients by a combination of folic acid (5 mg/d), vitamin B6 (50 mg/d) and vitamin B12 (0.4 mg/d). In individuals without renal failure much lower doses of folate and vitamin B12 are able to correct hyperhomocysteinemia. Currently, prospective studies are under way to clarify whether folate and vitamin therapy improves cardiovascular disease morbidity and mortality in the general population and in organ transplant recipients. While population wide screening for and treatment of hyperhomocysteinemia is generally not recommended, treatment of high risk patients, including renal failure patients and kidney and heart transplant recipients, can be considered but still represents an experimental therapy.

Hemodynamics of revascularization of the corpora cavernosa in an animal model. A preliminary report.

Numerous revascularization procedures are used for the treatment of vasculogenic impotence. In an animal model we created three different types of bypasses: inferior epigastric artery to dorsal penile artery, to dorsal artery and to dorsal vein (anastomotic arteriovenous fistula), and to dorsal vein alone. Epigastro-dorsal anastomoses remained fully patent without anticoagulants in 3 of 4 animals. With erection the flow in the inferior epigastric artery and the retrograde flow in the dorsal artery (towards the cavernous artery) increased significantly. In the 4 studies incorporating an anastomotic arteriovenous fistula we could not establish a clear reason to incorporate the artery; runoff was demonstrated only to the venous system. Arterial bypass to the dorsal vein with a simulated emissary vein increased outflow resistance as well as improved intracorporeal pressure during erection of the corpora in 4 animals. As resting pressure was also elevated, the penile smooth muscle might be at risk for further degeneration with this procedure.

Magnetic resonance imaging of renal calculi: an in vitro study.

Extracorporeal shock wave lithotripsy (ESWL) has been established as a standard method of urinary stone treatment. Poor fragmentation with an increased rate of complications has been noticed with certain calculi types (calcium oxalate monohydrate and cystine). In devising appropriate pre-operative strategies, it would be useful to know the calculi composition. We have investigated the in vitro utility of using magnetic resonance imaging (MRI) in analyzing urinary calculi. Our in vitro analysis found no difference in signal characteristics between calculi of varying composition. The absence of signal can be understood from a molecular basis. We conclude that MRI will not offer any assistance in characterizing the composition of urinary calculi.

Obstructive nephropathy: evaluation with dynamic Gd-DTPA-enhanced MR imaging.

The potential of dynamic gadolinium diethylenetriaminepentaacetic acid (DTPA)-enhanced magnetic resonance (MR) imaging for the examination of obstructive nephropathy was analyzed in 27 subjects (five healthy subjects, seven patients with dilated nonobstructed kidneys, six patients with acute obstruction, and nine patients with chronic obstruction) with use of a 1.5-T magnet. Morphologic findings were compared with quantitative analysis of temporal changes in signal intensity. Dynamic postcontrast images of the normal kidney demonstrated four phases of enhancement; cortical enhancement phase, early tubular phase, ductal phase, and excretory phase. The pattern of enhancement in dilated nonobstructed kidneys was similar to that in normal kidneys. In acutely obstructed kidneys, cortical enhancement was similar to that in normal kidneys (17% increase), but medullary enhancement was higher than normal, resulting in diminished corticomedullary differentiation. The early tubular phase was prolonged (until 2.5 minutes after injection), with delayed appearance of the ductal and excretory phases. In chronically obstructed kidneys, the increase in cortical intensity was less than that in normal kidneys (13% increase). The early tubular phase was prolonged, and the ductal phase was diminished or absent.

Electromagnetically generated extracorporeal shockwaves for fragmentation of extra-and intrahepatic bile duct stones: indications, success and problems during a 15 months clinical experience.

Electromagnetically generated extracorporeal shock waves (without waterbath) were applied after intravenous premedication with 10-15 mg diazepam and 100 mg tramadol in the treatment of 33 patients (aged 32 to 91 years) with multiple intrahepatic stones (n = 4) or huge common bile duct stones (n = 29, 18-30 mm in diameter), which could not be removed by conventional endoscopy. Stone disintegration was achieved in 70% of common bile duct stones and in all intrahepatic concrements after 800-7500 discharges, which were applied during one (n = 21), two (n = 6) or three sessions (n = 6). Apart from mild fleabite-like petechiae at the side of shock wave transmission no other side effects were observed for a total of 51 procedures. We believe electromagnetically generated shock waves are safe, easy to apply, and relatively effective in the therapy of common bile duct and intrahepatic stones.