Experience with the long-term effect of microsurgical penile revascularization.

Fourty-two consecutive men underwent microsurgical penile revascularization for arterial insufficiency at least one year prior to this review. Data on the results of surgery were collected by questionnaire or telephone in 33 men (79%) with complete follow-up and by chart review in 9 men (21%) with partial follow-up. Success was measured as the ability to achieve successful intercourse on the majority of attempts without adjuvant therapy. Successful results are as follows: 19/36 (53%) at one year; 13/32 (41%) at two years; 14/26 (54%) at three years; 9/15 (56%) at four years; 4/10 (40%) at five years. Eight of 9 patients with partial follow-up functioned at last contact. Failures tended to occur early and successes appeared to remain stable over the time period studied. This long-term success rate speaks to a true benefit, and not a placebo effect, of penile revascularization in treating arteriogenic impotence.

Testicular hemodynamic changes after the surgical creation of a varicocele in the rat. Intravital microscopic observations.

The present study investigated the effect of a surgically induced varicocele on the dynamics of testicular blood flow. The surface vasculature of the normal and the varicocele-affected testis was examined utilizing intravital epi-illumination microscopy. Application of this technique to the study of the varicocele is new. Blood flow characteristics in surface veins were studied as the surface temperature of the testis was varied. Periodic, reproducible stoppages in blood flow, determined by direct observation of the red blood cells, were seen in seven of eight sham animals at the lower temperatures. These stoppages were abolished and blood flow increased at higher temperatures; stoppages reappeared at lower temperatures. The periodic stoppages were present in only one of eight rats with a proven varicocele (P less than 0.025) at any temperature studied. This loss of blood flow regulation may be the result of a loss of testicular arteriolar tone and may explain the increase in testicular blood flow and temperature elevation observed in association with a varicocele. These findings may provide new insights into the pathophysiology of the varicocele and highlight the need to study the microvascular sequelae of this vascular abnormality.

Transseptal crossed vasovasostomy.

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.

Effect of preoperative channel transurethral prostatectomy on complications of 125iodine implantation in carcinoma of prostate.

Patients receiving 125Iodine implantation and pelvic lymphadenectomy for clinically localized prostatic carcinoma were divided into two groups, with one group receiving a preoperative channel transurethral prostatectomy. The groups were matched according to clinical stage and histologic grade. Complications were classified as operative, short-term, and long-term. Although preoperative channel transurethral prostatectomy was associated with a greater incidence of surgical procedures after implantation, the overall complication rate did not differ between the two groups. The overall mortality rate and the incidence of progression of Stage C tumors did not differ between the two groups.

Varicocele: temporal considerations.

The pathophysiology of the abnormal spermatogenesis seen in the presence of the varicocele has not been elucidated in spite of extensive study. Furthermore, no satisfactory explanation exists for the bilateral abnormal spermatogenesis seen in a process which is felt to be unilateral in the majority of cases. The present study was designed to determine if a surgically produced unilateral varicocele would lead to ipsilateral testicular changes prior to the onset of contralateral testicular alterations. Utilizing the rat model and microsurgical techniques, the effects of the varicocele on ipsilateral and contralateral spermatogenesis was studied at intervals over 49 days. Mean seminiferous tubular diameter measurements and flow cytometric analysis of testicular tissue were utilized to assess spermatogenesis. A statistically significant decrease in mean seminiferous tubular diameter was seen between day 1 and day 49 in the left testicle. The right testicle tended to demonstrate similar changes but these were not significant by the method of analysis used. Flow cytometric analysis of testis DNA content also revealed a statistically significant difference in the percentage of haploid, diploid and tetraploid cells in the left testis on day 1 as compared to day 49. The right testis again tended to demonstrate similar but not significant changes. Though primarily a unilateral process, bilateral spermatic vein abnormalities were also visualized in some animals. This observation may contribute to the bilateral effect observed. These studies demonstrate that a surgically created left varicocele will result in bilateral testicular alterations. Within the time frame of the study, the ipsilateral alterations progressed to a greater degree.

Atypical presentation of xanthogranulomatous pyelonephritis: diagnosis by ultrasonography and fine needle aspiration biopsy.

The diagnosis of xanthogranulomatous pyelonephritis may be difficult to make preoperatively. We describe a patient who had a nonfunctioning kidney with a normal collecting system on retrograde pyelography as well as normal angiography and venography. Preoperative diagnosis was xanthogranulomatous pyelonephritis by fine needle aspiration biopsy under ultrasonic guidance.

Progesterone receptors in the prostate.

The lateral prostate of the castrate rat has low levels of specific cytosol progesterone binding which can be increased by treatment of the animals with estradiol. Although progesterone alone is a relatively ineffective agonist in either the ventral prostate or the lateral prostate, treatment of animals with a combination of progesterone and estradiol caused selective growth of the lateral prostate. This response did not occur in the ventral prostate which had a very low or undetectable level of specific cytosol progesterone binding which did not respond to treatment with estradiol. The effects of progesterone in the lateral prostate were not mediated via the androgen receptor suggesting that the cytosol progesterone receptor is capable of mediating a growth response to an agonist in the lateral prostate. An endogenous agonist for the cytosol progesterone receptor in the prostate remains to be identified, and its relevance to BPH remains to be defined.

Acute leukemic infiltration of the prostate. Successful treatment with radiation.

Infiltration of the prostate by acute granulocytic leukemia can cause diagnostic and therapeutic difficulties. After stabilization of hematologic findings, the diagnosis can be made safely by needle biopsy of the prostate. The prostate may be one of the so-called sanctuary areas where chemotherapy does not affect the leukemic infiltrate. This process may be a source of reactivation of leukemia in patients who had achieved a hematologic remission. This report describes a patient who had successful eradication of acute myelomonocytic leukemia from the prostate by radiation therapy while in hematologic remission. Better surveillance for leukemic infiltrate of the prostate is needed, including needle biopsy when appropriate. Radiation may be an effective therapy for this manifestation of leukemia.

Current concepts in vasectomy reversal.

PIP: The most widely used vasovasostomy techniques and the patency and pregnancy results achieved are reviewed. The number of patients requesting vasectomy reversal is increasing. The usual reasons given for requesting the procedure are remarriage, death of a child, the original social motivation for the vasectomy is no longer meaningful to the patient and a change in economic status. In the macroscopic technique, 4-8 sutures are placed joining the cut ends of the vas. An absorbable stent may or may not be used. The microscopic technique emphasizes mucosal approximation. The cut ends of the vas deferens are resected and the penile end dilated. Resection is repeated until seminal fluid is observed. The anastomosis is performed utilizing a microvascular clamp to maintain approximation. 6 sutures are placed over a stent. The fascia is approximated to remove tension from the anastomosis. A review of the research literature suggests that surgeons obtain higher patency rates and pregnancy rates using magnification. In 1 study, the authors used direct vision and a monofilament nonabsorbable stent to achieve a patency rate of 90% and a pregnancy rate of 46%; and used an operating microscope and no stent to achieve a patency rate of 96% and a pregnancy rate of 54%. Modern techniques have resulted in significant improvements in patency rates, but a marked discrepancy in pregnancy rates remains. 2 factors that potentially contribute to low pregnancy rates are the formation of epididymal granulomas after the vasectomy and the stimulation of antisperm antibodies cause by absorption of sperm. Several factors can optimize the end results. At surgery, the vas deferens can be resected until fluid is seen, although the dissection should not be carried onto the epididymis unless the surgical team has the equipment and capability to perform an epididymovasostomy. Another factor which appears to affect the pregnancy rate is the duration between the vasectomy and reversal. Better results are achieved when the vasovasostomy is performed within 10 years of the vasectomy. Although no single procedure in vasectomy reversal has been proven statistically superior, modern techniques, e.g, absorbable stents and magnification, have led to an improved potential for pregnancy.^ieng