Venous drainage and functional control of the canine prostate gland.

The venous drainage of the canine prostate gland has been studied in nine dogs after post-mortem intravenous injection of a coloured suspension of latex. A submucosal cavernous plexus of the prostatic urethra continuous with that of the penis, and a previously unnamed vessel that drains this plexus into the prostatico-vesical vein are described. The eferential vein was found to open variably, but always into the prostatic venous system. The data support the concept that a very small retrograde blood flow would take androgen-rich blood from the deferential vein into the prostate gland.

Spontaneous rupture of a hydronephrotic kidney during pregnancy.

Acute abdominal pain during pregnancy can be of urologic origin. Hydronephrosis of pregnancy can be complicated by symptomatic renal colic, pyelonephritis, and secondary renal abscess formation. In this report, rupture of a hydronephrotic kidney with retroperitoneal urinoma formation was treated by retroperitoneal drainage and internal ureteral until a term delivery was achieved. However, if severe renal hemorrhage accompanies renal rupture, surgical exploration of the kidney with partial or complete nephrectomy may be necessary.

Penile implant for intractable priapism associated with sickle cell disease.

Intractable, therapy-resistant priapism in a patient with sickle cell disease is presented. The patient was managed with insertion of an inflatable penile prosthesis. He consequently maintained potency and remains free of priapitic episodes. To our knowledge, immediate penile prosthesis insertion for management of priapism has not been reported. We discuss the indications and advantages of this approach and review the current literature.

Penile calibration for nocturnal penile tumescence studies.

Artificial penile erections were created in 23 impotent patients by infusion of heparinized saline solution into the corpora cavernosa. Penile circumference as related to rigidity was accurately assessed. The increase in circumference necessary to produce erection adequate for vaginal penetration varied from 7.5 to 35 mm, whereas for maximum rigidity the penile circumference increase varied between 10 mm and 40 mm. These were then compared with the changes during nocturnal penile tumescence studies. Even though 5 patients in the series had erection greater than 15 mm, 40 per cent of them did not achieve rigidity adequate for vaginal penetration. One patient had nocturnal tumescence of only 12 mm; this, however, was an erection adequate for vaginal penetration. The approach discussed in this article may allow the rational use of portable home tumescence monitoring.

Effects of cyclophosphamide alone and scheduled methotrexate-5-fluorouracil combination chemotherapy on transplantable R-3327 prostatic adenocarcinoma in F1 hybrid male rat.

Male F1 hybrid rats bearing the R-3327 transplantable adenocarcinoma demonstrating similar growth patterns within the original sample of animals were carefully separated into control and treatment groups for each growth pattern. This assured treatment of tumors with similar cell kinetics within each group. In one group, cyclophosphamide (100 mg/kg) was injected intraperitoneally once every four weeks for eight weeks (total of two doses). In the second group, methotrexate (7.5 mg/kg) followed in ninety minutes by 5-fluorouracil (50 mg/kg) were injected intraperitoneally once each week for eight weeks (total of eight doses). These drug dosages did not depress the white cell count of the animals, and they tolerated the medicines well. Excellent suppression of tumor growth was obtained in each group with the cyclophosphamide treatment group being significant at the 0.01 level and the methotrexate-5-fluorouracil treatment group being significant at the 0.05 level.

Long-term mechanical reliability of multicomponent inflatable penile prosthesis: comparison of device survival.

OBJECTIVES: To determine the mechanical reliability of multicomponent inflatable penile prosthesis, comparing five different types of devices, as well as the two-piece versus three-piece as a group. METHODS: We followed 83 patients with two-piece and 283 patients with three-piece inflatable penile prostheses for a mean time of 66 months. At a cutoff of 63 months, mechanical complication rates were reviewed and statistically analyzed. RESULTS: Thirty-one device-related complications occurred, and all were secondary to fluid leakage. The Mentor Alpha-1 prosthesis was significantly better than the Mentor Mark-II in terms of mechanical reliability (P = 0.01). A trend was noted toward the AMS 700 Ultrex inflatable penile prosthesis having fewer mechanical complications than the Mentor Mark-II (P = 0.06). In addition, a trend toward all three-piece prostheses being more mechanically reliable than the two-piece was noted (P = 0.08). The Mentor Alpha-1 device had a higher cumulative proportional survival (0.957) than all other devices (0.842 for AMS 700 Ultrex, 0.839 for AMS 700 CX, 0.783 for Mentor GFS, and 0.750 for Mentor Mark-II). CONCLUSIONS: As a group, a trend was noted toward the three-piece prosthesis having better mechanical reliability than the two-piece prosthesis. Comparisons between the individual types of prostheses showed thatthe Mentor Alpha-1 device was significantly more mechanically reliable than the Mentor Mark-II device, and a trend was noted toward the AMS 700 Ultrex device having fewer mechanical complications than the Mentor Mark-II. The Mentor Alpha-1 prosthesis had the highest cumulative proportional survival.

High flow malignant priapism with isolated metastasis to the corpora cavernosa.

Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.

Treatment outcome after radical prostatectomy is not adversely affected by a pre-existing penile prosthesis.

OBJECTIVES: To report on the safety of radical retropubic prostatectomy (RRP) in patients with a penile prosthesis presenting with clinically localized prostate cancer. METHODS: From January 1990 to December 1997, 8 consecutive men with a penile prosthesis underwent RRP for clinically localized prostate cancer. Retrospective data regarding patient population, operating time, estimated blood loss, length of hospital stay, and clinical outcome were evaluated. RESULTS: Mean patient age was 65.4 years (range 57 to 70) at the time of RRP, with a mean preoperative serum prostate-specific antigen level of 11.5 ng/mL. Mean duration of RRP surgery was 183.9 minutes, and the mean estimated blood loss was 1281.8 mL. No complication requiring penile prosthesis removal occurred. In 1 case, the reservoir tubing was punctured during closure of the abdominal fascia wall. This was immediately recognized and fixed. All patients had a functioning penile prosthesis after RRP. CONCLUSIONS: RRP can be safely and expeditiously performed in patients with a pre-existing penile prosthesis. The risk of prosthesis malfunction after RRP is very low. Patients with a penile prosthesis and prostate cancer should not be denied the option of undergoing RRP.

Assessment of psychosexual adjustment after insertion of inflatable penile prosthesis.

OBJECTIVES: To evaluate the psychosexual benefit obtained from multicomponent penile implant surgery in patients with erectile dysfunction. METHODS: A psychosexual questionnaire was given to 35 patients undergoing penile prosthesis implantation before surgery and at 3 months, 6 months, and 1 year after surgery. The questionnaire consisted of 13 questions scored on a scale from 1 through 5. Results of the questionnaire were statistically analyzed for differences among the preoperative, 3-month postoperative, 6-month postoperative, and 1-year postoperative period. RESULTS: The general linear model evaluation showed a significant difference for each overall combination of the following pairs: preoperative versus 3 months postoperative (P=0.0005) and 3 months postoperative versus 6 months postoperative (P=0.002). There was no overall difference between psychosexual total score at 6 months after surgery and 1 year after prosthesis implantation (P=0.85). The patients perceived improvement in their erectile ability and libido. Concern about obtaining and maintaining an erection during intercourse was significantly alleviated. There was an increase in the frequency of sexual activity and an improvement in satisfaction with sex life. A decrease in feelings of sadness, depression, anxiety, anger, frustration, and embarrassment related to sexual activity was also noted. CONCLUSIONS: The current study demonstrates significant improvement in the psychosexual well being of multicomponent penile implant recipients, with attainment of a high level of patient satisfaction up to 1 year after surgery.

Revision surgery for penile implants.

Over the last two decades, penile implants have been associated with a 81-97% patient satisfaction. Complications and revisions are inevitable sequelae of penile implant surgery. Between 1982 and 1992, a total of 47 patients were presented to us with complications related to penile implants who required surgical correction. Forty-two of 47 patients elected to do so. All 42 who opted for corrective surgery have functioning implants with 38 characterizing the result as good and four reporting them as fair. The corrective surgeries included corporal reconstruction with Goretex graft in five patients and use of rear tip extender for posterior crural repair in one patient. There was no increase in the incidence of infection or mechanical malfunction.

Follow-up with Mentor two-piece inflatable penile prosthesis.

Between October, 1987 and June, 1993, we implanted 50 Mentor two-piece inflatable penile prostheses with a mean follow-up of 52.18 months (6-72 months). In 7 pts (14%), the implants were removed for various reasons. One pt (2%) had total fluid leak due to breakage of the tube at its junction with the cylinder. One implant (2%) was replaced due to loss of rigidity. Two implants (4%) were removed due to infection and later replaced with semirigid prostheses. Three pts (6%) had pump erosion. There was loss of rigidity in seven implants (14%), which appears to be due to stretching of the tunica albuginea from repeated use. The limited amount of fluid in the resipump precludes compensation for the stretching, leading to loss of rigidity. The overall complication rate of 28% in this long-term series appears to be much higher than that in other reported short-term follow ups. Thirty-six pts (72%) are fully satisfied with the device and 7 pts (14%) are partially satisfied, with an overall satisfaction rate of 86%. In our series, 46/50 (92%) pts have functioning prostheses at the time of review.

Tissue ingrowth in penile implants and its effect on repeat penile surgery.

Penile implant malfunction is usually treated by removal of the original malfunctioning implant followed by replacement with a new device. During replacement, the original implant can be explanted without any difficulty, as it is not adherent to the surrounding tissue. Herein, we describe two cases of tissue ingrowth into the implant that produced difficulty during explantation and suggest ways in which this condition can be managed.

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.

Clinical versus subclinical varicocele: improvement in fertility after varicocelectomy.

OBJECTIVE: To assess the fertility after varicocelectomy in men with subclinical varicocele. DESIGN: We define subclinical varicocele as the varicocele detected by Doppler examination of the scrotum, in which no varicocele was found on clinical examination. Varicocelectomy was performed on subclinical varicocele, and fertility was assessed. SETTING: We reviewed the records of 54 men who underwent unilateral varicocelectomy at the Department of Urology, Wayne State University, between 1986 and 1987. PATIENTS: Records of 54 men were analyzed. Thirty-eight (70%) of the varicocele were diagnosed clinically (confirmed by Doppler examination) in group 1. In 16 (30%) men, the varicocele was diagnosed by Doppler examination only, with no varicocele detectable clinically, subclinical varicocele (group 2). RESULTS: Spermiograms improved in 76% of the patients in group 1 and in 81% of the patients in group 2. Fertility was assessed after 2 years of varicocelectomy. Eighteen (47%) of 38 patients in group 1 and 8 (50%) of 16 men in group 2 managed to impregnate their partners. Statistical analysis by chi 2 shows similar improvement in fertility potential between the two groups (P = 0.86). Multivariate repeated measure analysis showed significant improvement in sperm density (P = 0.0006) and sperm morphology (P = 0.0016) after varicocelectomy. CONCLUSIONS: These data suggest that varicocelectomy, in infertile men with subclinical varicocele, leads to fertility in 50% of the patient population as compared with 47% in clinical varicocele group. We suggest that the use of sophisticated, noninvasive techniques such as Doppler may have a place in the management of male infertility to detect subclinical varicocele.

Morphometric analysis of rat testis following chronic exposure to cigarette smoke.

PURPOSE: To assess the effect of chronic exposure to cigarette smoke on spermatogenesis in Sprague-Dawley rats. MATERIALS AND METHODS: Twenty 5-day-old Sprague-Dawley rats were exposed daily to cigarette smoke by the Walton smoking machine for a period of 15, 30, and 45 days. Age-matched Sprague-Dawley rats exposed to room air with the smoking machine served as controls. Rats were sacrificed from each group at 15, 30, and 45 days and the testes were removed. Fifty seminiferous tubules were assessed in each group. Morphometric and histopathologic analyses of the testes were carried out. The following parameters were studied: (1) Number of germ cells (step 7 spermatids), (2) seminiferous tubule diameter, (3) height of germinal epithelium, (4) presence of degenerating or sloughed cells, (5) failure of release of spermatids into the tubular lumen, and (6) degeneration of Leydig cells. Statistical analysis was performed using ANOVA followed by the t test. RESULTS: There was a significant decrease in the germ cell count (step 7 spermatids) in the rats exposed to cigarette smoke for 30 days (93.19 versus 98.15 step 7 spermatids in the control animals (p < 0.001). This decrease persisted in the rats exposed to cigarette smoke for 45 days (82.47 versus 103.01 step 7 spermatids in control animals, p < 0.001). The mean seminiferous tubule diameter was significantly reduced only in the rats exposed to cigarette smoke for 45 days (0.283 microm versus 0.299 microm in the control animals, p < 0.001). There was no significant difference in the height of the germinal epithelium, and no degenerating cells were noted in either group. CONCLUSIONS: Cigarette smoke adversely affects spermatogenesis in pubertal Sprague-Dawley rats.

Expression of cAMP-responsive element modulator (CREM) in rat testes following chronic cocaine administration.

OBJECTIVE: c-AMP-responsive element modulator (CREM), one of the nuclear factors involved in the regulation of gene expression by cAMP, has an important role in spermatogenesis. Our recent study has shown that chronic administration of cocaine to male rats results in disruption of spermatogenesis, including reduction of germ cells. As a further step toward understanding this process, we have studied the role of CREM in cocaine-induced testicular damage. MATERIALS AND METHODS: Sprague-Dawley rats were administered cocaine hydrochloride subcutaneously daily for 90 days. Control animals received equal volumes of normal saline daily for 90 days. Testes were removed after 15, 30, 90 days of cocaine administration. Total RNA was extracted from the testes and subjected to RT-PCR. Testicular tissue was also homogenized in a lysis buffer, and Western blotting was performed using anti-CREM antibody. RESULTS: RT-PCR analysis detected a single fragment of approximately 520 base pairs (bp) in control testes at all time points. The cocaine-treated testes showed reduced expression of CREM fragment. Western blot analysis using CREM antibodies confirmed the RNA data. There were reduced CREM proteins in the cocaine-treated testes compared with controls. CONCLUSIONS: The CREM gene is essential for spermatogenesis. Our results indicate that the reduction in testicular CREM expression may be one of the mechanisms responsible for disruption or impairment of spermatogenesis in the testes following chronic cocaine administration.

Chronic cigarette smoking induces an oxidantantioxidant imbalance in the testis.

OBJECTIVES: We have previously demonstrated the harmful effect of chronic inhalation of cigarette smoke on the testis in Sprague-Dawley rats. The aim of the present study was to investigate the role of free oxygen radicals and reactive oxygen species in inducing testicular damage in Sprague-Dawley rats following exposure to cigarette smoke. MATERIALS AND METHODS: Sprague-Dawley rats, 25 days old, were exposed daily to cigarette smoke by the Walton smoking machine for a period of 15, 30, and 45 days. Age-matched Sprague-Dawley rats were exposed to room air with the smoking machine and served as controls. Rats were sacrificed from each group at 15, 30, and 45 days and the testes were removed. The testicular tissue levels of glutathione and lipid peroxidation product malonaldehyde (MDA) were measured colorimetrically using the Bioxytech GSH-400 and LPO-586 kits, respectively. The activity of glutathione peroxidase was assessed colorimetrically using the Bioxytech GPx-340 kit. Statistical analysis was performed using ANOVA followed by the t test. RESULTS: There was a 47.8% increase in the MDA in the treated rat testis compared with the control rat after 45 days of exposure to cigarette smoke or air, respectively (p < 0.05). This was associated with a parallel significant decrease in the level of glutathione and glutathione peroxidase activity in the treated rat testis, 38.2% and 29.1%, respectively, after 45 days of cigarette smoke exposure (p < 0.05). No significant difference was noted in the levels of glutathione, glutathione peroxidase, and lipid peroxidation end products after 15 and 30 days of treatment. CONCLUSIONS: Chronic cigarette smoke inhalation is associated with an increase in the level of oxidants and a simultaneous decrease in the level of antioxidants in the rat testis. This abnormality of the oxidant-antioxidant balance may be one of the mechanisms leading to testicular tissue damage and abnormal spermatogenesis in the rat testis following chronic inhalation of cigarette smoke.

Effect of cocaine on testicular blood flow in rats: evaluation by percutaneous injection of xenon-133.

PURPOSE: Cocaine abuse has reached epidemic proportions in the United States. Our recent study has shown that cocaine has adverse action on spermatogenesis and fertility in male rats. The indirect action of cocaine occurs by blocking the reuptake of neurotransmitter, which causes local vasoconstriction. In this study we evaluate blood flow to the testes after subcutaneous injection of cocaine to male rats. METHODS: Male Sprague-Dawley rats were divided into two main groups. The treatment group received subcutaneous cocaine (30 mg/kg body weight) and the control animals received normal saline. Xenon-133 wash out experiments were carried out on testes at 5, 10, 15, 20, 30, 45, 60, 90 min and 4.5 hours after injection of cocaine or normal saline. Statistical analysis was done by SPSS V. 7.S for windows. P < 0.05 was considered statistically significant. RESULTS: There was a reduction in testicular blood flow after cocaine administration to male rats. This vasoconstrictor effect was most pronounced at 15 min after injection of cocaine and persisted up to 60 min. At 90 min, the early restitution of blood flow to ischemic tissue occurred. There was a significant increase in testicular blood flow in cocaine-treated groups than in the control group during restitution phases at 90 min. At 4.5 hours, there was no difference in blood flow in both groups. CONCLUSION: This study demonstrates that cocaine, when given subcutaneously at a 30 mg/kg body weight dose, results in prolonged vasoconstriction of the blood vessels to the testes. Adverse effects of cocaine on the testes may be in part due to ischemic and postischemic reperfusion injury to the organ.

Histopathological changes in the testes of prepubertal male rats after chronic administration of cocaine.

PURPOSE: This study was conducted to evaluate histopathologic findings in the testes of prepubertal male rats after long-term cocaine exposure. METHODS: At 25 days of age, male Sprague-Dawley rats were administered cocaine hydrochloride daily (15 mg/kg body weight corresponding to an average single dose for a heavy cocaine user). The treatment was continued for 100 days when all the rats were sacrificed. Morphological analysis of the testes were assessed by qualitative and quantitative histological means. RESULTS: In all the groups, a minimum of 5 to 10 representative seminiferous tubules were examined. The mean diameter of the seminiferous tubules was less in the treated group than in their respective controls (p < 0.05). The thickness of the germinal epithelium was much reduced in the cocaine-treated groups when compared with their controls (p < 0.05). The number of degenerating germ cells was greater in the treated group than in the controls. There was evidence of failure to release the mature spermatids in the treated groups. There was no evidence of sloughed Sertoli cells or germ cells in the tubular lumen or the epididymis. CONCLUSION: There were distinct histopathological changes noted after chronic administration of cocaine. These changes are characteristic of toxic effects on the testes, but the exact mechanism is not clear. Further studies are underway in our laboratory to delineate the exact mechanism of action by cocaine on the testes.

Cigarette smoking induces apoptosis in rat testis.

In a previous studywe demonstrated the deleterious effect of cigarette smoke on spermatogenesis in the testis of peripubertal Sprague-Dawley rats. In this study we investigated the development of apoptosis as a possible contributing factor to the pathogenic mechanism underlying these effects. Peripubertal rats were exposed to cigarette smoke with the Walton Horizontal Smoking Machine. Similarly, age-matched control rats were exposed to room air with the smoking machine. Rats from both groups were sacrificed after 45 days of treatment and the testes were removed. Testes were stained utilizing the terminal deoxynucleotidyl transferase dUTP nick end-labeling (TUNEL) staining technique. DNA fragmentation was further evaluated using gelectrophoresis. There was a significant increase in the incidence of apoptosis in the treated group compared to the control group as demonstrated by the larger amount of tubules containing > or = 3apoptotic bodies in the smoke-exposed group, that is, 36% versus 14% in the control group (p < 0.05). Agarose gel electrophoresis demonstrated the DNA ladder in the treated group but not in the control animals. In conclusion, chronic cigarette smoke induces apoptosis in the rat testis. Apoptosis may be one of the pathogenic mechanisms responsible for defective spermatogenesis in the rat following chronic cigarette smoking.