The potential prolonged effect at one-year follow-up after 18-month randomized controlled trial of a 90 g/day low-carbohydrate diet in patients with type 2 diabetes.

OBJECTIVES: To evaluate the effect at a one-year follow-up after an 18-month randomized controlled trial (RCT) of 90 gm/day low-carbohydrate diet (LCD) in type 2 diabetes. RESEARCH DESIGN AND METHODS: Eighty-five poorly controlled type 2 diabetic patients with an initial HbA1c ≥ 7.5% who have completed an 18-month randomized controlled trial (RCT) on 90 g/day low-carbohydrate diet (LCD) were recruited and followed for one year. A three-day weighted food record, relevant laboratory tests, and medication effect score (MES) were obtained at the end of the previous trial and one year after for a total of 30 months period on specific diet. RESULTS: 71 (83.5%) patients completed the study, 35 were in TDD group and 36 were in LCD group. Although the mean of percentage changes in daily carbohydrate intake was significantly lower for those in TDD group than those in LCD group (30.51 ± 11.06% vs. 55.16 ± 21.79%, p = 0.0455) in the period between 18 months and 30 months, patients in LCD group consumed significantly less amount of daily carbohydrate than patients in TDD group (131.8 ± 53.9 g vs. 195.1 ± 50.2 g, p < 0.001). The serum HbA1C, two-hour serum glucose, serum alanine aminotransferase (ALT), and MES were also significantly lower for the LCD group patients than those in the TDD group (p = 0.017, p < 0.001, p = 0.017, and p = 0.008 respectively). The mean of percentage changes of HbA1C, fasting serum glucose, 2 h serum glucose, as well as serum cholesterol, triglyceride, low-density lipoprotein, ALT, creatinine, and urine microalbumin, however, were not significantly different between the two groups (p > 0.05). CONCLUSIONS: The one-year follow-up for patients on 90 g/d LCD showed potential prolonged and better outcome on glycaemic control, liver function and MES than those on TDD for poorly controlled diabetic patients.

Effect of a 90 g/day low-carbohydrate diet on glycaemic control, small, dense low-density lipoprotein and carotid intima-media thickness in type 2 diabetic patients: An 18-month randomised controlled trial.

AIM: This study explored the effect of a moderate (90 g/d) low-carbohydrate diet (LCD) in type 2 diabetes patients over 18 months. METHODS: Ninety-two poorly controlled type 2 diabetes patients aged 20-80 years with HbA1c ≥7.5% (58 mmol/mol) in the previous three months were randomly assigned to a 90 g/d LCD r traditional diabetic diet (TDD). The primary outcomes were glycaemic control status and change in medication effect score (MES). The secondary outcomes were lipid profiles, small, dense low-density lipoprotein (sdLDL), serum creatinine, microalbuminuria and carotid intima-media thickness (IMT). RESULTS: A total of 85 (92.4%) patients completed 18 months of the trial. At the end of the study, the LCD and TDD group consumed 88.0±29.9 g and 151.1±29.8 g of carbohydrates, respectively (p < 0.05). The 18-month mean change from baseline was statistically significant for the HbA1c (-1.6±0.3 vs. -1.0±0.3%), 2-h glucose (-94.4±20.8 vs. -18.7±25.7 mg/dl), MES (-0.42±0.32 vs. -0.05±0.24), weight (-2.8±1.8 vs. -0.7±0.7 kg), waist circumference (-5.7±2.7 vs. -1.9±1.4 cm), hip circumference (-6.1±1.8 vs. -2.9±1.7 cm) and blood pressure (-8.3±4.6/-5.0±3 vs. 1.6±0.5/2.5±1.6 mmHg) between the LCD and TDD groups (p<0.05). The 18-month mean change from baseline was not significantly different in lipid profiles, sdLDL, serum creatinine, microalbuminuria, alanine aminotransferase (ALT) and carotid IMT between the groups. CONCLUSIONS: A moderate (90 g/d) LCD showed better glycaemic control with decreasing MES, lowering blood pressure, decreasing weight, waist and hip circumference without adverse effects on lipid profiles, sdLDL, serum creatinine, microalbuminuria, ALT and carotid IMT than TDD for type 2 diabetic patients.

Does tunica anatomy matter in penile implant?

BACKGROUND: Overall prosthesis survival is important in penile implant, which remains the final viable solution to many patients with refractory erectile dysfunction (ED). This paper is to retrospectively study the role of the anatomy of tunica albuginea (TA). METHODS: From March 1987 to March 1991 while the TA was regarded as a circumferential single layer, 21 organically ED men, aged from 27 to 77, received penile prosthesis implantation and were allocated to conventional group. From August 1992 to March 2013 while the tip of Hegar's dilator was categorically directed medial-dorsally during corporal dilatation derived from newfound TA as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat, 196 ED males, aged from 35 to 83, underwent penile implant and were categorized to advanced group. The model of prosthesis was recorded. Prosthesis loss rate and survival time were analyzed and the follow up period ranged from 22.4-26.4 (average 24.3) years and 0.4-20.6 (average 15.8) years to the conventional and advanced group respectively. RESULTS: To the conventional and advanced group, the number of inflatable and rigid type prosthesis used were 2, 19 and 15, 181 respectively, whereas the prosthesis loss was encountered in 50.0% (1/2), 15.8% (3/19) and 0.0% (0/15), 0.6% (1/181) respectively. And the prosthesis survival time were 5.1-6.3 (5.7) years, 1.3-26.4 (15.2) years and 6.1-16.2 (11.2) years, 0.4-20.6 (15.3) years to the conventional and advanced group respectively. Statistical significance was noted on prosthesis loss in groups (P=0.01) while the Mentor Acuform stood out in prosthesis survival. CONCLUSIONS: Anatomy-based managing maneuver appears to deliver better surgery success in penile implant. Tunica anatomy is significant in performing implant surgery.

Novel pilot films providing indispensable information in pharmaco-cavernosography.

BACKGROUND: Conventional pharmaco-cavernosography provides little information on penile venous anatomy, although it is indispensible in documenting veno-occlusive erectile dysfunction (ED). We propose an innovative method, which may provide additional insight into the penile venous structure. METHODS: From July 2010 to November 2012, 96 impotent men, aged 20 to 75 years, underwent this method of pharmaco-cavernosography in which two sets of 60 mL of 50% omnipaque solution administered intracavernously by themselves. The first set of pilot cavernosograms was taken at intervals of five, ten, twenty and thirty seconds after the commencement of the injection. The second set of cavernosograms was taken in the same intervals within 30 minutes following the pilot set, preceded by the injection of 20 µg prostaglandin E1 (PGE1). Analysis was conducted on the drainage veins including deep dorsal vein (DDV), cavernosal veins (CVs) and para-arterial veins (PAVs) accordingly. The veins demonstrated in the pilot cavernosograms, and the second set, were compared in terms of venous numbers and presentation percentage. RESULTS: There was a statistically significant difference (P<0.001) between the total number of independent venous drainage channels and the presentation percentage of DDV, CVs and PAVs observed in the pilot cavernosograms, and those in second set (4.5 vs. 2.1; 97.47%, 60.33%, and 38.91% vs. 57.06%, 29.34%, and 19.08%, respectively). CONCLUSIONS: Compared with conventional pharmaco-cavernosography methods, pilot cavernosograms are readily able to show detailed penile venous anatomy. It is therefore may be concluded that pilot cavernosograms is a valuable addition to conventional protocols of pharmaco-cavernosography.

Effectiveness of an e-learning curriculum on occupational health for music performers.

OBJECTIVE: The purpose of this study was (1) to evaluate the effectiveness of the e-learning curriculum and (2) to explore the type of questions raised by students through the "Health Promotion for Music Performers" (HPMP) e-learning curriculum. MATERIALS AND METHODS: This study was primarily a pedagogical research composed of a pre- and postintervention design coupled with a 1-month longitudinal knowledge retention measurement. The intervention, the HPMP e-learning curriculum, was implemented over 14 weeks, once a week, for a total of 14 classes. Each class consisted of a 60-min prerecorded lecture followed by a 40-min real-time interactive discussion. The interdisciplinary faculty panel consisted of experts from the field of music and medicine. The Self-Assessment Questionnaire (SAQ) was used to evaluate knowledge changes concerning (1) Practice and Performance issues and (2) Health and Life Style issues. RESULTS: Fifteen graduate-level music students participated in the study. The SAQ scores on the 1-month follow-up test for Practice and Performance issues were significantly higher than the pretest (t=2.731, p<0.05). On the other hand, no significant differences were found between the posttest and pretest or between the follow-up test and posttest. Regarding Health and Life Style issues, comparison at all three measurement points did not reveal any significant difference. Questions raised by students fell into four major categories: performance injury (45%), performance anxiety (22%), general physiology (22%), and general psychology (11%). CONCLUSIONS: The findings suggest that the HPMP e-learning course enhanced student awareness of Practice and Performance issues but did not have as significant an impact on student awareness of Health and Lifestyle issues.

Advances in understanding of mammalian penile evolution, human penile anatomy and human erection physiology: clinical implications for physicians and surgeons.

Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck's fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers.

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Usability evaluation of mobile medical treatment carts: another explanation by information engineers.

Healthcare services integration is a critical task as it attempts to reform the user practices. In response to the request of facilities upgrade, we perform a usability evaluation of the mobile medical treatment carts (MMTC) installed in the Emergency Medicine Department of our healthcare enterprise. A survey conducted in August 2006 identified that our experimental area needs some improvements to support the MMTC adoption. For example, the MMTC can accompany with several popular nursing care items. Follow-up several undertaken investigations indicated that our expectation of the MMTC solution had been reached. Given the evident heterogeneity of viewpoints, it is imperative for a healthcare enterprise to broadly ascertain the requirements of end users before investing in any information technologies.

An agile enterprise regulation architecture for health information security management.

Information security management for healthcare enterprises is complex as well as mission critical. Information technology requests from clinical users are of such urgency that the information office should do its best to achieve as many user requests as possible at a high service level using swift security policies. This research proposes the Agile Enterprise Regulation Architecture (AERA) of information security management for healthcare enterprises to implement as part of the electronic health record process. Survey outcomes and evidential experiences from a sample of medical center users proved that AERA encourages the information officials and enterprise administrators to overcome the challenges faced within an electronically equipped hospital.

Effects of using relaxation breathing training to reduce music performance anxiety in 3rd to 6th graders.

The current study examined the effects of applying relaxation breathing training (RBT) as a means to reduce music performance anxiety (MPA) in young, talented musicians. A group of 59 young musicians from 3rd to 6th grade participated in this study, and all of them started RBT twice a week for 2 months prior to the examination. Four tests--2 mos, 1 mos, half an hour and 5 min before the examination--were conducted to examine the level of MPA after the application of RBT. Results show that the degree of MPA 5 min before the trial was lower than the degree of performance anxiety half an hour before the jury (t = -3.683, p < 0.01), which indicated that the RBT was associated with a decrease in MPA. Although a series of RBT exercises was applied, results indicated that when approaching the date of examination, the degree of performance anxiety still increased and reached its maximum half an hour before the jury. The recommendation for future studies is to combine the application of RBT with other methods to expand its effect in reducing MPA.

The strategic use of standardized information exchange technology in a university health system.

This article illustrates a Web-based health information system that is comprised of specific information exchange standards related to health information for healthcare services in National Taiwan University Health System. Through multidisciplinary teamwork, medical and informatics experts collaborated and studied on system scope definition, standard selection challenges, system implementation barriers, system management outcomes, and further expandability of other systems. After user requirement analysis and prototyping, from 2005 to 2008, an online clinical decision support system with multiple functions of reminding and information push was implemented. It was to replace its original legacy systems and serve among the main hospital and three branches of 180-200 clinics and 7,500-8,000 patient visits per day. To evaluate the effectiveness of this system, user surveys were performed, which revealed that the average score of user satisfaction increased from 2.80 to 3.18 on a 4-point scale. Among the items, especially e-learning for training service, courtesy communications for system requests, and courtesy communications for system operations showed statistically significant improvement. From this study, the authors concluded that standardized information exchange technologies can be used to create a brand new enterprise value and steadily obtain more competitive advantages for a prestige healthcare system.

Salvage penile curvature correction surgery.

It is commonly believed that coarser suture materials should be used to provide sufficient tenacity in surgery for penile curvature correction. We report our 15-year experience of fine sutures in a second operation in 31 patients who underwent prior curvature correction elsewhere with coarser sutures, resulting in recurrent penile curvature. Suture materials used in prior surgeries in these patients were either 2-0 or 3-0 nylon sutures. In this series, all 31 patients underwent a modified Nesbit procedure at the level of the collagen bundles using finer sutures. Prior to July 1998, 10 men underwent salvage surgery using 4-0 polyglactin sutures. Thereafter, we adapted 6-0 nylon sutures for another 21 patients. We categorized the patients into the polyglactin (n = 10) and nylon (n = 21) groups respectively. Overall, 29 patients were available for follow-up while using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system, with 21 patients in the nylon group. We have found cavernosography a practical and reliable method to objectively assess penile morphology in these patients. The penile morphology both subjectively and objectively was excellent in all patients, except for 1 in each group. Erectile function restoration showed a trend of satisfaction in the polyglactin group and based on IIEF-5 was significantly improved in the nylon group (14.2 ± 3.6 vs 21.9 ± 2.1, n = 20, P < .001). These results suggest that in penile tunical surgery, fine sutures such as 6-0 nylon may result in better penile morphology and functional outcomes.

Clinical experience of a refined penile venous stripping surgery procedure for patients with erectile dysfunction: is it a viable option?

Penile venous surgery might not be considered an appropriate treatment for erectile dysfunction (ED) because of disappointing functional outcomes and unacceptable, seemly unavoidable, penile deformity. We report results of a refined penile venous stripping method in patients with veno-occlusive dysfunction (VOD). From 2000 to 2003, 341 of 467 men with ED were diagnosed with VOD via cavernosography and Doppler sonography. Patients were excluded from undertaking cavernosography if they had an untreated chronic systemic disease. Patients who had undergone the first penile venous surgery in other institutes were also excluded from this study because of the protracted surgical time and unpredictable functional outcomes, because severe fibrosis may prevent patients from completing penile venous removal. Of these 341 men, 178 were treated with a refined venous stripping surgical method (surgery group) and 163 patients were treated without this surgery (control group). In the surgery group, 167 were available for long-term follow-up using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system. The operative time ranged from 2.1 to 5.0 hours. The follow-up period ranged from 5.1 to 8.2 years, with an average of 7.7 +/- 1.4 years. The difference between the preoperative (9.7 +/- 3.9) and postoperative (21.6 +/- 2.8) IIEF-5 scores was significant (P < .001). Overall, 90.4% of the surgery group (151 of 167) reported improvements after surgery. A significant decrease in IIEF-5 scores (10.4 +/- 3.8 vs 7.9 +/- 3.2, P < .001, n = 121) during the same period of follow-up was, however, noted in the control group. This refined penile venous stripping surgery delivered favorable results and is a viable alternative for treating VOD.

Salvaging penile venous stripping surgery.

Disappointing functional outcome and penile deformity are major concerns of penile venous surgery. Consequently, it has been abandoned by most urologists. To explore whether penile deformity is correctable and erectile function can be improved, we report our experience in patients who had undergone surgery elsewhere. From 1986 to 2008, 16 consecutive patients sought our assistance because of poorer erectile capability or/and penile deformity from previous venous surgery elsewhere. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) was used to score the patients when it became available in 1998. Accordingly, 3 and 13 patients were categorized into the non-IIEF and IIEF groups, respectively. A median longitudinal pubic incision and a circumferential or semicircumcision were made to relieve the fibrotic tissues for accessing the deep dorsal veins, which were stripped thoroughly and ligated with 6-0 nylon sutures. The cavernosal veins were managed in a similar manner. The paraarterial veins were ligated only segmentally. Finally, the wound was approximated while an assistant consistently stretched the penile shaft. The operation time was 5.2 to 8.5 hours. The follow-up period ranged from 0.6 to 23.0 years. Overall, all patients reported satisfactory penile morphology postoperatively. In the IIEF group, the difference in preoperative and postoperative scores was significant (P < .001). In the non-IIEF group, 2 of the 3 patients reported natural coitus. This series of salvaging venous surgeries, although technically challenging, are helpful in correcting penile deformity and restoring erectile function in some patients who had poorer outcomes from prior venous surgeries.

U-Health: an example of a high-quality individualized healthcare service.

National Taiwan University Hospital (Taipei, Taiwan), which is one of the largest hospitals in Taiwan, is undergoing healthcare service reforms: it is combining the home healthcare service network and sensors network into a new service known as the Ubiquitous Healthcare (U-Health) service system in order to continually provide a personalized healthcare service to patients who live in remote areas. The U-Health service system is comprised of six service components that are introduced in an integrated manner: tele-education, telediagnosis, telemonitoring, teleconsultation, teletherapy and lifetime health. The target patient segments are postdischarge patients, patients suffering from cardiovascular diseases, patients suffering from chronic diseases and patients in hospice care. Since its launch in October 2009, the U-Health service system has effectively reduced the rehospitalization rate from 12% in October 2009 to 6% in May 2010 and the rate of visiting the emergency room from 21% in October 2009 to 9% in May 2010, during the 14-day postdischarge follow-up period.

An evaluation of a weight-loss program incorporating E-learning for obese junior high school students.

Obesity in adolescents is continuing to rise at an alarming rate and is becoming an important public health problem in Taiwan. Therefore, the aims of this study were (1) to evaluate the effectiveness of a Weight-loss E-learning Program (WEP) on obese Chinese adolescents and (2) to gauge this group's satisfaction with the WEP. The design was quasi-experimental, using purposive samples from two junior high schools in Taipei, Taiwan. Obese adolescents between 12 and 14 years of age with body mass indexes (BMI) over 25 kg/m2 were recruited. A 14-week WEP was developed to expedite weight loss for the selected adolescents. Data such as BMI, waist-to-hip ratio, waist circumference, hip circumference, mid-arm circumference, triceps skinfold, blood pressure, and physical fitness were collected through standardized instruments and methods before and after the WEP. The satisfaction of the subjects and four psychosocial variables were evaluated and taken into account by authoritative scales and questionnaires. In total, 37 adolescents participated in this study. After the WEP, we found significant decreases in BMI (p < 0.05), waist circumference (p < 0.05), and triceps skinfold (p < 0.001) in the sample population. Improvements were found in three of four tests of physical fitness (p < 0.001, p < 0.05, and p < 0.01, respectively). All psychosocial variables showed significant favorable changes (p < 0.01 for self-esteem scores, p < 0.001 for the other three variables) and satisfaction levels for the WEP ranged from 56.6% to 83.8% in four different criteria. The WEP was effective in helping obese Chinese adolescents lose weight. However, there is still room for improvement.

Application of tele-ultrasound in emergency medical services.

In emergency medical services, portable ultrasound scanners have the potential to become new-age stethoscopes for emergency physicians. For trauma cases in particular, portable ultrasound scanners can scan the chest and abdomen of emergency patients both rapidly and conveniently. This study describes the development of tele-ultrasound for pre-diagnosis in a medical emergency setting as a part of the updated Mobile Hospital Emergency Medical System (MHEMS). An emergency medical technician can provide an emergency physician with a patient's ultrasound images and medical information during the patient's pre-hospitalization and transportation period using a combination of the MHEMS, the portable ultrasound scanner, and the onboard 3G communication capabilities. The MHEMS includes a Dispatch and Mission Control Center that facilitates the communication between the Emergency Department of a specified hospital, the systems aboard the ambulance. Early receipt of information relevant to the patient will enhance pre-diagnosis options for on-duty emergency physicians and allow for a hospital's emergency department to promptly prepare necessary surgical instruments or beds. Furthermore, emergency medical technicians can also obtain instructions from on-duty physicians to enhance damage and disaster control ability in critical moments.

Long-term results of autologous venous grafts for penile morphological reconstruction.

In order to evaluate the long-term results of autologous venous grafts, we present an overview of patients who underwent a procedure utilizing a venous patch from the deep dorsal vein with or without combination of the cavernosal vein in treating penile deformity. From March 1995 to March 2005, a total of 85 consecutive patients with Peyronie disease or congenital penile deviation underwent venous grafting. Tunical corporotomy was covered using transplanted venous wall sutured microscopically to collagen bundles of the inner circular and outer longitudinal layer of the tunica albuginea. The vein was sutured with the serosal side outward, after it had been detubularized, properly constructed, and spliced together. In this cohort, 48 patients with Peyronie disease and 37 with congenital penile deviation were respectively categorized as belonging to the Peyronie and congenital groups. All patients were evaluated preoperatively and postoperatively with the International Index of Erectile Function (IIEF-5) scoring, angle measurement of erectile penis, satisfaction with the penile shape, and a cavernosogram which was further available for 15 patients. Histological confirmation in 5 cases was followed up for up to 10 years. The mean angle improvement was 44.8 +/- 3.6 degrees for the Peyronie group and 37.6 +/- 3.8 degrees for the congenital group. A satisfactory penile shape was achieved in 77 (90.6%) patients, although 8 men (9.4%) complained of mild deviation of the penis (<15 degrees). Erectile function was good in 81 patients, although 6 of them had to use oral sildenafil/tadalafil postoperatively. Overall, they had a mean preoperative IIEF-5 score of 19.7 +/- 2.8, which increased to a mean postoperative score of 21.6 +/- 2.2. The cavernosograms consistently disclosed a good penile shape. The histological confirmation showed that the donor vein retained its histological character despite the fact that perfect coalescence and lining up with the tunica albuginea were noted. The autologous vein appears to be an acceptable graft material, and the transplanted vein may have a modeling action rather than a scaffolding role in venous patch surgery on the penile tunica albuginea. Careful microsurgical manipulation is required to achieve a satisfactory, sustainable outcome.

The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable?

Although topical anesthetic blockage for penile surgeries has been substantially reported in the medical literature, its methodology, reliability, and reproducibility have not been consistent. We report on several methods of topical blocks for local anesthesia in patients with indications for penile surgeries. From March 1993 to March 2003, a total of 1131 men, ages 19 to 87, underwent penile surgeries in which 165, 203, 708, 45, and 10 patients received penile implantation, modified Nesbit procedure, venous surgery, venous patches, and arterial revascularization respectively, under pure local anesthesia on an outpatient basis. They were categorized into the implant, Nesbit, venous, patch, and arterial groups respectively. Proximal dorsal nerve blockage, peripenile infiltration, and topical injection, although challenging, were sufficient local anesthesia for patients in the last 4 patient groups. A new method of crural blockade, however, was also required for optimal anesthesia of the cavernous nerve for implantation purposes. The anesthetic effects and postoperative results were satisfactory. Common immediate side effects included puncture of the corpus spongiosum or the deep dorsal vein as well as the innominate vessel, subcutaneous ecchymosis, transient palpitations, and acceptable low level of pain. There were no significant late complications. In the implant group, however, 6.1% of patients (10/165) had experienced pain over the perineum for 1 to 2 weeks postoperatively. Overall there were statistical differences in scoring between the 5 groups in which the implant group stood out when a visual analog scale of 100 mm was used. Topical nerve blockades proved to be reliable, simple, and safe, with minimal complications. They offer the advantages of less morbidity, reduced effects of anesthesia, protection of privacy, and a rapid return to preoperative daily activity.

Insufficient response to venous stripping surgery: is the penile vein recurrent or residual?

There is currently controversy on whether the insufficient response to penile venous surgery done in an attempt to restore erectile function is due to recurrent or residual veins. In order to elucidate this issue, we report a study on those patients who failed to respond to the first venous surgery and subsequently underwent or declined a second operation. From July 1996 to July 2003, a total of 83 patients, aged 25 to 83, who were dissatisfied with their first venous surgery and were later diagnosed with a persistent veno-occlusive dysfunction via our dual cavernosography, were recruited into our study. Subsequently, 45 men underwent penile venous stripping surgery for a second time and were assigned to the surgery group, whereas the remaining 38 men were subject to follow-up and routine management and were assigned to the control group. All were evaluated with the abridged 5-item version of the international index of erectile function (IIEF-5) every 6 months for 1 to 5 years and cavernosogram, if necessary. In the surgery group their preoperative IIEF-5 score was 10.1 +/- 3.7, which increased to 17.1 +/- 3.2 (P < .001) after the first surgery and further increased to 20.7 +/- 3.1 (P < .001) after a second venous stripping of the cavernosal vein that was consistently demonstrated on the cavernosogram. Overall, 41 men (91.1%) reported a positive response to further venous surgery, with more satisfactory coitus, after the residual veins were stripped thoroughly, although eventually 4, 3, and 3 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. The follow-up period ranged from 12 months to 72 months, with an average of 37.0 +/- 11.5 months. In the control group, however, their corresponding IIEF-5 score changed from 17.4 +/- 2.9 to 16.9 +/- 3.2 (P > .05). Finally, 11, 7, and 8 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. Although there was no statistical significance between the 2 groups in the first postoperative IIEF-5 scores, there was a significant difference in their IIEF-5 after further venous surgery. In this study, we propose that the clinical relapse of erectile dysfunction is a result of "residual" veins rather than "recurrent" ones.