Extirpative surgery for chronic orchialgia: is there a role?

Chronic orchialgia is a difficult and frustrating condition for both the patient and clinician. Determining appropriate course of therapy should require extensive conservative measures and consideration of alternative surgical options prior to concluding an orchiectomy is warranted. This manuscript aims to provide the clinician with the information currently available to determine if the anticipated success rate is warranted to consider extirpative surgery for idiopathic chronic orchialgia.

Optimizing outcomes in vasectomy: how to ensure sterility and prevent complications.

Vasectomy provides a long-term effective sterilization for men and is performed on nearly 500,000 men annually in the United States. Improvements in technique have led to a decreased failure rate and fewer complications, although significant variations in technique exist. Use of cautery occlusion with or without fascial interposition appears to have the least failures. A no-scalpel approach lowers risk of hematoma formation, infection and bleeding post-operatively. A patient can be considered sterile when azoospermia is achieved or the semen analysis shows less than 100,000 non-motile sperm per milliliter. Incorporating these principles may allow the physician to optimize outcomes in vasectomy.

Rethinking the value of sending vasectomy specimens for histologic examination: an analysis of arterial vasculature and failure to transect the vas deferens.

OBJECTIVES: The testicular, deferential, and cremasteric arteries and their branches surround the vas deferens (VD), leaving them susceptible to injury during vasectomy. Literature describing the caliber of arteries seen in vasectomy specimens is lacking, making it difficult to categorize the significance of an observed artery. We aimed to establish reference values for arterial size typically encountered in vasectomy specimens and assess our institutional experience with failure to transect the VD. METHODS: The luminal diameter of the largest artery in 231 consecutive VD specimens from 116 patients was measured microscopically. For comparison, the diameter of the largest artery within 10 spermatic cord cross-sections from inguinal orchiectomies was obtained. The immediate vasectomy failure rate based on histologic assessment was calculated using specimens from 2008 to 2012. RESULTS: The luminal diameter of the largest artery encountered in a vasectomy specimen was 1.00 mm or less in 96.5% of cases. Artery sizes greater than or equal to 2.50 mm were only seen in spermatic cord resections. From 2008 to 2012, three (0.36%) of 837 patients undergoing vasectomy had specimens that showed failure to transect both VD. CONCLUSIONS: Although the American Urologic Association and European Association of Urology state that histologic evaluation of vasectomy specimens is not required, we encourage the surgeon to send VD specimens for histologic examination. Doing so allows early identification of the failure to transect the VD and the resection of surrounding vasculature, providing quality control feedback to the surgeon.

A catalog of magnetic resonance imaging compatibility of penile prostheses.

INTRODUCTION: Erectile dysfunction has been successfully treated with penile prosthesis implantation for over 50 years. Ferromagnetic implants or devices may create a potentially hazardous or painful situation during magnetic resonance imaging (MRI). A modern catalog of the MRI compatibility of penile prostheses is not available. AIM: Evaluate the safety profile of implanted, penile prostheses during MRI. MAIN OUTCOME MEASURE: Review available in vitro safety data and reported patient complications experienced during MRI with a penile prosthesis in place. METHODS: A search of PubMed™ for articles documenting a penile prosthesis present during MRI was performed. Radiology texts and product information from manufacturers' producing a penile prosthesis were reviewed. Direct discussion with product manufacturers was also performed to obtain additional safety and compatibility information. RESULTS: Nine clinical articles noted the presence of a penile prosthesis at the time of magnetic resonance imaging. No articles documented a complication from MRI of a man with a penile prosthesis. A single patient with an unnamed malleable prosthesis was noted to have twisting of the device during MRI which did not result in discomfort or malfunction of the device. In vitro studies support the safety of most prostheses during MRI. CONCLUSION: The available data suggests there is little risk for most patients with a penile prosthesis who undergo MRI. Notable exceptions include Dacomed's Omniphase and Duraphase device and the MRI-conditional Spectra device manufactured by AMS. Current manufacturers of penile implants provide wallet cards and medical letters to support safety when undergoing an MRI. Prior prosthesis implantation should not preclude patients from having an MRI.

Prostate-specific antigen response after definitive radiotherapy for Skene's gland adenocarcinoma resembling prostate adenocarcinoma.

OBJECTIVES: To assess prostate-specific antigen response after definitive radiotherapy in a patient with localized Skene's gland adenocarcinoma resembling prostate adenocarcinoma. MATERIALS AND METHODS: A 71-year-old patient was evaluated for a 2 year history of painless hematuria and found to have a localized Skene's gland adenocarcinoma resembling prostate adenocarcinoma with a pre-therapy PSA of 54.52 ng/ul. She elected to undergo definitive radiotherapy holding radical surgery for salvage. She received 73.8 Gy of intensity modulated radiotherapy in 41 fractions. Serum PSA, imaging, and cystoscopy were followed at 6 month intervals for 2.5 years. RESULTS: The PSA decreased to 0.65 ng/ul 32 months after treatment, her clinical symptoms resolved, and on imaging and exam she has no evidence of residual disease. The PSA half life was 6.16 months (r(2) = 0.97). CONCLUSIONS: For this rare tumor we show that PSA is a reliable marker for disease response and also show that definitive radiotherapy can be an option for organ and functional preservation in patients with localized disease. Cases of periurethral adenocarcinomas should be pathologically screened to assess if they are of Skene's gland origin, as our results suggest a radiotherapy treatment paradigm may be appropriate management in a select subgroup of women with periurethral adenocarcinoma.

10-Year analysis of adverse event reports to the Food and Drug Administration for phosphodiesterase type-5 inhibitors.

INTRODUCTION: To ensure public safety all Food and Drug Administration (FDA)-approved medications undergo postapproval safety analysis. Phosphodiesterase type-5 inhibitors (PDE5-i) are generally regarded as safe and effective. AIM: We performed a nonindustry-sponsored analysis of FDA reports for sildenafil, tadalafil, and vardenafil to evaluate the reported cardiovascular and mortality events over the past 10 years. METHODS: Summarized reports of adverse events (AEs) for each PDE5-i were requested from the Center for Drug Evaluation and Research within the FDA. These data are available under the Freedom of Information Act and document industry and nonindustry reports of AEs entered into the computerized system maintained by the Office of Surveillance and Epidemiology. MAIN OUTCOME MEASURE: The data were analyzed for the number of AE reports, number of objective cardiovascular events, and reported deaths. RESULTS: Overall, 14,818 AEs were reported for sildenafil. There were 1,824 (12.3%) reported deaths, and reports of cardiovascular AEs numbered 2,406 (16.2%). Tadalafil was associated with 5,548 AEs and 236 deaths were reported. Vardenafil was associated with 6,085 AEs and 121 reports of deaths. The percentage of reported severe cardiovascular disorders has stabilized at 10% to 15% of all AE reports for sildenafil and tadalafil and 5% to 10% for vardenafil. Only 10% of AE reports sent to the FDA for PDE5-i were from pharmaceutical manufacturers. CONCLUSION: Reports of deaths associated with PDE5-i remain around 5% of total reported events. Despite inherent limitations from evaluating FDA reports of AEs, it is important that these reports be reviewed outside pharmaceutical industry support in order to provide due diligence and transparency. Lowe G and Costabile RA. 10-year analysis of adverse event reports to the Food and Drug Administration for phosphodiesterase type-5 inhibitors. J Sex Med 2012;9:265-270.

Phosphodiesterase type 5 inhibitor abuse: a critical review.

Abuse of sildenafil has been reported since its introduction in 1999 and commonly documented in combination with illicit drugs among men and women of all ages. Increased risks of sexually transmissible diseases including HIV have been associated with sildenafil use in men who have sex with men. Recognizing the abuse potential of phosphodiesterase type 5 inhibitors (PDE5), we aim to summarize the current knowledge of this abuse. An investigation of EMBASE, PubMed, the Food and Drug Administration (FDA) website, MedWatch, and search engines was performed to evaluate information regarding sildenafil, tadalafil, and vardenafil abuse. The EMBASE search provided 46 articles fitting the search criteria and evaluation led to 21 separate publications with specific information regarding PDE5 abuse. A PubMed search found 10 additional publications. MedWatch reported 44 separate warnings since 2000, most of which reported contamination of herbal products with active drug components. Few reports of abuse were among the 14,818 reports in the FDA AERS for sildenafil. A search for "internet drug store" revealed 6.4 million hits and of 7000 internet pharmacies identified by the Verified Internet Pharmacy Practice Sites Program (VIPPS) only 4% were in proper compliance. The role internet pharmacies play in counterfeit PDE5 or abuse is not well documented; however based on easy access, direct patient marketing, and low advertised cost it is likely this role is underreported. Currently the best recommendation for providers is to recognize the possibility of abuse and to educate patients on risks of this behavior.

Feasibility and adequacy of robot-assisted lymphadenectomy for renal-cell carcinoma.

BACKGROUND AND PURPOSE: The role of lymph node dissection (LND) for renal-cell carcinoma (RCC) is evolving. When clinically negative, nodal disease is rare, but LND remains important in selected patients. Earlier identification of micrometastasis may become beneficial with emerging systemic agents. The ability to perform an adequate LND laparoscopically is uncertain. Open surgical data suggest a minimum of 12 nodes needed to identify most nodal metastases. Robotics may improve adequacy of laparoscopic LND. We report our results with the first reported robot-assisted LND series for RCC. PATIENTS AND METHODS: Robot-assisted LND was performed in 36 patients with RCC by a single surgeon. For right-sided tumors, LND included paracaval, retrocaval, and interaortocaval nodes, and left-sided tumors included interaortocaval and periaortic nodes. RESULTS: Mean patient age was 58 years (22-79) with a mean body mass index of 32 kg/m(2) (20-54). Mean tumor size was 7.3 cm with 16 T(3) tumors, including 4 vena caval tumor thrombi. Mean time for LND was 31 minutes, and mean estimated blood loss was 74 mL with no transfusions. Discharge was postoperative day (POD) 1 in 94% and POD 2 in 6%. A mean of 13.9 nodes was obtained with 1 pN+ (2.8%) patient. Mean nodal yield from the first to second half of cases rose from 11 to 16.8 nodes (P=0.02) with 77% having a minimum of 12 nodes in the second half. CONCLUSIONS: Robot-assisted LND for RCC is feasible with adequate nodal yield. Increased yield in later cases may reflect a learning curve. The positivity rate was low as expected, but higher yield was obtained than in the limited laparoscopic literature.

Complete transurethral bladder eversion 3 months after hemipelvectomy.

A 46-year-old white female underwent a left hemipelvectomy for chondrosarcoma. She presented with total incontinence and a bulging vaginal mass. Exam confirmed complete transurethral bladder eversion that was addressed with transvaginal multilayer bladder neck closure and suprapubic tube placement. Eventually she underwent abdominal hysterectomy, mesh sacral colpopexy, and catheterizable stoma creation. Patient is continent of urine 3 months postoperatively. We present the first reported case of bladder eversion after hemipelvectomy and propose possible pathophysiologic mechanisms.

Urethral triplication with meatuses terminating on the penis: a rare case presenting with bifid urinary stream.

Urethral duplication is an uncommon clinical finding, and classification systems have been described to explain the clinical findings. Urethral triplication is an extremely uncommon diagnosis, with few published case reports. We present the rare case of an infant noted to have a bifid urinary stream and found to have urethral triplication on voiding cystourethrography.

Ultrasonic, pneumatic and combination intracorporeal lithotripsy for percutaneous nephrolithotomy.

INTRODUCTION: Refinements in ultrasonic and pneumatic lithotriptors, as well as the development of new dual-modality lithotriptors, have increased the options available for the endourologist. Studies comparing the efficiency of the devices in both bench and clinical models help provide the endourologist with guidance in selecting the most appropriate lithotrite. METHODS: A review of the literature was performed reviewing the current status of pneumatic, ultrasonic, and dual-modality lithotriptors. RESULTS: Performance characteristics of currently available lithotriptors differ. Dual-modality lithotriptors offer superior efficiency compared to separate ultrasonic and pneumatic lithotriptors but durability may be a concern with some models. CONCLUSIONS: Ultrasonic and pneumatic devices are the lithotriptors of choice for PCNL. Dual-modality lithotriptors have been shown to be the most efficient in both bench and limited clinical trials.

Non-invasive management of primary phosphodiesterase type 5 inhibitor failure in patients with erectile dysfunction.

Phosphodiesterase type 5 inhibitors (PDE5-i) have become first line therapy for the treatment of erectile dysfunction. Most initial prescriptions for PDE5-i are by primary care practitioners. Urologists must now routinely manage the patient who has failed initial therapy with PDE5-i. Lifestyle modifications can be of benefit to patients. Patient education and optimization of the PDE5-i can result in a successful response. Interestingly, there are reports of up to 60% salvage after changing the PDE5-i utilized. Daily PDE5-i have shown benefit, and treatment of hypogonadism can enhance response to PDE5-i. We review the management of PDE5-i failures with emphasis on noninvasive approaches to gaining improved erectile response to these medications. An algorithm based on the reviewed strategies is proposed to guide clinicians in the treatment of erectile dysfunction.

Launching a successful robotic surgery program.

Robotic-assisted laparoscopic prostatectomy is rapidly becoming the most commonly performed surgical approach to treat clinically localized prostate cancer. The establishment of a robotic surgery program at any institution requires a structured plan and certain key elements to be in place to allow successful development. At least five essential phases are necessary for successful implementation of a robotics program. A thorough initial design and implementation lead to the execution of clinical services that meet previously established goals. Once the execution phase is established, the next step is to focus on maintenance and growth to maximize the benefits of the program. In this paper, we discuss the necessary phases for creating a successful robotic program, paying special attention to the aspects that allowed our facility to create a profitable robotic-assisted laparoscopic prostatectomy program in year 1.

Laparoscopic reconstructive options for obstruction in children with duplex renal anomalies.

OBJECTIVE: To present our initial experience of laparoscopic reconstructive surgery in children with upper urinary tract obstruction associated with duplex anomalies, as although there is much information on ablative procedures such as laparoscopic heminephrectomy, there is little available about minimally invasive reconstructive options for duplex renal anomalies in children. PATIENTS AND METHODS: We retrospectively reviewed four consecutive patients (aged 6-11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at our institution. The port placement and surgical exposure were analogous to that for transperitoneal laparoscopic pyeloplasty. A JJ stent was placed retrogradely into the ureter immediately before each procedure. The procedures performed were pyelo-ureterostomy for incomplete duplication and lower pole pelvi-ureteric junction (PUJ) obstruction, lower pole pyeloplasty for lower pole PUJ obstruction and complete duplication, and ipsilateral uretero-ureterostomy and distal ureterectomy for an obstructed, ectopic upper pole. Foley catheters were left indwelling for 36-48 h and stents were removed at 4-6 weeks. Postoperative imaging included either ultrasonography or intravenous urography. RESULTS: Three children presented with intermittent flank pain due to lower pole PUJ obstruction. The other child presented with pyonephrosis and purulent drainage from her vagina due to an ectopic ureter associated with a functioning upper pole segment. All procedures were successfully completed. The only complication was in the first patient (pyelo-ureterostomy) who had transient urinary extravasation that resolved with bladder decompression for 10 days. With a follow-up of 6-18 months, all had resolution of symptoms with improvement in radiographic variables. CONCLUSIONS: This series shows that children with duplex anomalies and obstruction can undergo successful reconstruction using techniques learned with laparoscopic pyeloplasty.

Which is better--retroperitoneoscopic or laparoscopic dismembered pyeloplasty in children?

PURPOSE: Groups at multiple institutions have documented the efficacy of minimally invasive repair of ureteropelvic junction obstruction with a retroperitoneoscopic or laparoscopic approach. To our knowledge no group has compared the 2 operative procedures directly at a single institution. MATERIALS AND METHODS: The records of 49 consecutive patients with a history of retroperitoneoscopic pyeloplasty or transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction were reviewed retrospectively, of whom 29 underwent attempted retroperitoneoscopic pyeloplasty and 20 underwent laparoscopic pyeloplasty. Retroperitoneoscopic pyeloplasty cases were performed first in the series before changing to the laparoscopic pyeloplasty approach. Retroperitoneoscopic pyeloplasty was performed using an anterolateral approach with retroperitoneal balloon distention. Laparoscopic pyeloplasty repair was performed using a transmesenteric approach for left ureteropelvic junction obstruction or after right colon mobilization for right repairs. Dismembered pyeloplasty was performed over a stent using 5-zero polydioxanone suture. Stents were placed antegrade or retrograde based on anatomy and presenting symptoms. Parameters studied were patient age, operative time, postoperative analgesic requirement during hospitalization, hospital stay and success rate. RESULTS: No difference was observed between the 2 groups in patient age, success rate, hospital stay or analgesic narcotic requirement. Average operative time for retroperitoneoscopic pyeloplasty was significantly longer than for laparoscopic pyeloplasty (239.1 vs 184.8 minutes). Overall success rates were also statistically equivalent (25 of 27 retroperitoneoscopic and 19 of 19 laparoscopic pyeloplasties) with incomplete followup in 1 patient in the retroperitoneoscopic pyeloplasty group and 1 in the laparoscopic pyeloplasty group. Three children, including 2 with retroperitoneoscopic and 1 with laparoscopic pyeloplasty, had transient urinary extravasation postoperatively, which was related to poorly positioned stents. Five patients in the retroperitoneoscopic group and 1 in the laparoscopic group underwent balloon dilation for indistinct but persistent postoperative flank pain with equivocal radiological findings. There were no major complications following either technique. CONCLUSIONS: In our experience no major difference exists between the retroperitoneoscopic and laparoscopic approaches for correcting ureteropelvic junction obstruction. The difference in operative time likely reflects the learning curve for laparoscopic suturing and dissection. Currently we prefer the laparoscopic approach because of the larger working space for suturing, the perceived ease of antegrade stent placement and the subjective improvement in cosmetic outcome. The 2 techniques should be considered equal with regard to the successful correction of ureteropelvic junction obstruction.

Xanthine urolithiasis.

Xanthine calculi are uncommonly encountered stones. When they occur, they typically do so in association with inborn metabolic disorders such as hereditary xanthinuria or Lesch-Nyhan syndrome. They may also occur in association with states of profound hyperuricemia such as myeloproliferative disease after treatment with allopurinol. If the underlying disorder is not addressed, a high risk of stone recurrence exists. Therefore, to raise clinical awareness, we reviewed and report our experience in the treatment of patients with these stones, discussing the underlying pathophysiology and approach to treatment.

Lung-protective ventilation in neurosurgical patients.

PURPOSE OF REVIEW: Concepts of ventilator-induced lung injury have revolutionized our approach to the ventilatory management of patients with acute lung injury and acute respiratory distress syndrome over the past 10 years. The extension of these principles to patients with brain injuries is challenging, as many of them are out of keeping with usual brain-protective management. RECENT FINDINGS: Many patients with acute lung injury or acute respiratory distress syndrome and an acute brain injury may in fact be managed safely within the confines of a lung-protective strategy. Elevated levels of positive end-expiratory pressure in head-injured patients with acute lung injury or acute respiratory distress syndrome also appear to be safe, particularly when the level is set below that of the intracranial pressure, when patients have a low respiratory system compliance, or when positive end-expiratory pressure results in significant lung volume recruitment. Several novel therapies to minimize ventilator-induced lung injury are currently in the early stages of investigation in neurosurgical patients. SUMMARY: In many patients with brain injuries and acute lung injury the goals of lung protection can be achieved without threatening cerebral perfusion. In patients with more refractory raised intracranial pressure the optimal balance between brain and lung is not well established. Further research is needed on lung-protective strategies in this vulnerable population.

Local impairment of anti-neutrophil elastase capacity in community-acquired pneumonia.

Protease-antiprotease balance in 17 patients with unilateral community-acquired pneumonia (CAP) was characterized (day 6+/-0.8). Levels and activities of alpha-1 antitrypsin (A1AT), secretory leucoprotease inhibitor (SLPI), and neutrophil elastase (NE) were quantified. Lobes were designated as infected or uninvolved according to the presence of an infiltrate on chest radiograph. NE levels in infected lobes were higher than those in uninvolved lobes, and NE levels were significantly elevated in both, compared with that in control lobes (n=18; P<.01). A1AT and SLPI levels were similar in infected and uninvolved lobes and were significantly elevated, compared with those in control lobes (P<.05 and P<.005, respectively). Anti-NE activity in infected lobes was less than that in control or uninvolved lobes (P<.05); values in the latter 2 were similar. Free NE was detected in 7 of the infected samples, indicating that anti-NE capacity is impaired. Both A1AT and SLPI were cleaved or complexed in infected lobes, and A1AT was oxidized in infected lobes. We conclude that mean elastase levels are increased and that mean anti-elastase capacity is decreased in pneumonic lobes.

Tumor necrosis factor-alpha-converting enzyme: its role in community-acquired pneumonia.

Bronchoalveolar lavage fluid recovered from infected and uninvolved lungs of patients with community-acquired pneumonia (CAP; n=16) on day 6+/-0.8 was analyzed for cytokine, soluble receptor, and antagonist levels. The role of tumor necrosis factor (TNF)-alpha-converting enzyme (TACE) in the resolution of the local inflammatory response was investigated. TNF-alpha, interleukin (IL)-1beta, and IL-6 were elevated in the infected versus uninvolved lobe, whereas IL-10 was not. Epithelial lining fluid (ELF) cytokine levels correlated with intracellular cytokine expression. Levels of proTNF-alpha were reciprocally related to TNF-alpha ELF levels. Levels of soluble receptors, generated by TACE cleavage of membrane-bound precursors, were compartmentalized to infected ELF. TACE was down-regulated by internalization in cells from the site of infection. These data demonstrate that, in vivo during CAP, TACE has a role in regulating resolution of the local inflammatory response by modulating levels of pro- and counterinflammatory mediators.