Relationship between penile fracture and Peyronie's disease: a prospective study.

Peyronie's disease is postulated to be initiated by repetitive minor traumas to the fully or partially erect penis. We investigated Peyronie's disease prospectively in cases treated for penile fracture (PF) within the last 20 years. Medical records of 63 cases treated for PFs were reviewed. Subjects were required to self-assess their current penile morphologies and sexual functions. Penile nodules and Peyronie's plaques were also evaluated with physical examination, ultrasonography and magnetic resonance imaging (MRI), and penile curvatures with auto-photography, and sexual function with international erectile function index (IIEF). Of the 63 cases (mean age 37 years), 46 who had mean follow-up of 63 months were re-evaluated. The mean IIEF-5 score was 23.2±3.1. Painful erections (n=5), penile nodules (n=5) and also penile curvatures <20° (n=2) were investigated. No Peyronie's plaque was palpated in any of the cases. Ultrasound and MRI showed fibrotic nodules of 5 mm in diameter, which extended into the subtunical area in the rupture site in 54% of the cases, although any thickening and Peyronie's plaque were not found in the tunica albuginea and intracavernosal septum of the cases examined. In PF patients treated surgically, the erectile function and penile morphology were preserved. In our cases PFs did not induce the development of Peyronie's disease.

Somatic angiotensin converting enzyme in varicocele.

The ACE is found as two isozymes in the body. A somatic isozyme found in blood and several other tissues, and a testis-specific isozyme found only in developing spermatids and mature sperm. In this study, we investigated the ACE activity in left spermatic vein blood samples of infertile patients with varicocele and its correlation to spermatologic parameters. The somatic ACE activities were determined in the peripheral and left spermatic vein blood samples from 31 infertile patients who underwent variococelectomy, and 11 fertile control subjects underwent left inguinal herniorraphy. The somatic ACE activity was measured by kinetic spectrophotometric assay. Semen analyses were performed according to WHO guidelines. The mean somatic ACE activities of peripheral and left spermatic veins of the varicocele group were 60.3 +/- 23.0 and 60.2 +/- 23.2 U/L, respectively. In control group, peripheral and left spermatic vein ACE activities were found as 56.8 +/- 17.1 and 56.5 +/- 15.5 U/L, respectively. There was no significant difference between the ACE activity in peripheral and left spermatic vein blood sample from the varicocele and control group. There was no statistically significant correlation between the spermatologic parameters and ACE activities in the spermatic and peripheral vein in both of varicocele and control groups. As a result, it may be suggested that the somatic ACE has no causative role in pathophysiology of varicocele and varicocele related infertility.

Laser-assisted fluoroscopic puncture: a new technique for accessing the kidney.

PURPOSE: We developed a laser pointer device that is mounted on the image intensifier of a C-arm fluoroscope. The laser-assisted fluoroscopic puncture technique (LAFPT) is an alternative method of accessing the kidney. MATERIALS AND METHODS: The LAFPT was assessed both in an in vitro model and in a series of cases. The in vitro model was composed of Foley balloons filled with contrast medium of different volumes (2-6 mL) embedded in silicone pads. The total fluoroscopy times and attempts required for a successful puncture with LAFPT were compared with those of conventional fluoroscopic access. RESULTS: The number of attempts required to puncture the 2-mL balloons was significantly greater with the conventional fluoroscopic technique than with LAFPT. The fluoroscopy time in vitro was reduced 50% with LAFPT. However, there was no statistically significant difference in the time required for the two techniques in the clinical series. CONCLUSION: The laser-assisted fluoroscopic puncture technique allows accurate positioning of a needle with reduced radiation exposure.

Is Bone-wax an injectable urologic material?

OBJECTIVE: Injection of endoscopic material for reflux and incontinence therapies became popular in urology because of its simplicity and repeatability. Research is going on to develop an ideal injectable material. In this experimental study we investigated whether the bone wax used for osteotomy hemostasis in orthopedic and neurosurgical operations could be used as an injectable material. MATERIALS AND METHODS: A total of 20 rabbits were included in the study: 6 underwent a sham operation, and in the remaining 14 rabbits, 0.5 ml bone wax liquefied with n-butyl acetic acid was injected submucosally via a 20-gauge needle at three different points on the anterior bladder wall. Cystectomy was performed on the 15th day in 2 rabbits (group I), on the 60th day in 2 (group II) and on the 150th day in 10 (group III). 0.20 ml bone wax was also injected subcutaneously and intramuscularly 7 days before cystectomy in group III. Bladders were examined macroscopically and histopathologically. All animals' lungs, livers, kidneys, spleens and brains were also removed and examined histologically. RESULTS: Submucosal swellings of bone wax maintained their localizations and shapes in all groups and all of the 42 bone-wax injection sites could be easily identified. Histologically, slight edema around the implant was seen in group I. In group II, collagen was increased around the implants and minimal hyperplasia of the epithelium overlaying bone wax was noted. 150 days after the injections, moderate collagen production and a mild increase in vascularity were seen around the implants. There was no macroscopic or microscopic evidence that implants migrated to locations other than the injection sites. CONCLUSIONS: When injected to the bladder submucosa, bone wax seems to be inert and biocompatible, encouraging further research to develop it as an alternative agent in the endoscopic treatment of vesicoureteral reflux and sphincteric incontinence.

p53 and bcl-2 overexpression as associated risk factors in patients 40 years old or less with transitional cell carcinoma of the bladder.

OBJECTIVES: Transitional cell carcinoma (TCC) of the bladder in younger patients has historically a favourable prognosis. bcl-2 and p53 genes are implicated in cell cycle regulation with roles on programmed cell death. Presence of nuclear accumulation of p53 and cytoplasmic accumulation of bcl-2 were proposed to confer a growth advantage to tumour cells. In this study, we investigated the roles of p53 and bcl-2 as prognostic factors in TCC of bladder in patients younger than 40 years. PATIENTS AND METHODS: From 1986 to 1998, 25 patients younger than 40 years were treated for TCC of bladder in our hospital. Of the tumour specimens, 24 were adequate for evaluating p53 and bcl-2 oncoproteins (group I). As a control (group II), we randomly selected 30 patients older than 50 years treated for bladder cancer in this period. Two oncoproteins were detected by immunohistochemical analysis in paired tumour tissue specimens in both groups. Retrospectively obtained clinical follow-up data were available, with a mean follow-up of 44 and 25.5 months in groups I and II, respectively. Relations between tumour recurrences and progression with positivity of bcl-2 and p53 were investigated. RESULTS: Expression of bcl-2 was observed in 13 (54.1%) and 11 (36.7%) and nuclear p53 accumulation in 9 (37.5%) and 17 (56.7%) of groups I and II, respectively. In the presence of p53 expression, tumours showed significantly more progression in group I (55 vs. 6.7%) and group II (41.1 vs. 0%). Recurrence rates were not significantly different in tumours with and without nuclear p53 overexpression in both groups. Also, recurrence and progression rates were not significantly different in tumours with and without cytoplasmic bcl-2 overexpression in both groups. Grade (G) and stage appeared as important prognostic factors in both groups since 60% of GIII tumours showed progression in group I, but none of GI and GII tumours. Similarly, 75% of T3 tumours progressed, while these rates were 25 and 25% for T1-T2 tumours in group I. In group II, 31.2, 25 and 0% of GIII, GII and GI tumours progressed, while 50, 41.6 and 0% of T3, T2 and T1 tumours progressed, respectively. CONCLUSIONS: Nuclear p53 expression in TCC appears to be associated with a poorer prognosis in both younger and older patients. Although cytoplasmic bcl-2 overexpression is found in the majority of tumours in the younger group, it is not associated with tumour progression and recurrence.

Voiding and sexual dysfunctions after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment.

OBJECTIVE: The aim of this study is to evaluate the effects of the different immediate treatment modalities on the sexual and voiding functions in pelvic fracture urethral injuries. METHODS: The records of 38 male patients with traumatic posterior urethral injuries were reviewed, 18 of whom were treated by initial suprapubic cystostomy and delayed repair (Group 1), and 20 by primary urethral realignment (Group 2). Types of pelvic fractures and urethral injuries were classified according to surgical and radiological findings. Long-term voiding functions were determined by the patient questionnaire, residual urine and uroflow. Sexual functions were also determined by the patient questionnaire and a penile duplex ultrasound study. RESULTS: Mean follow-ups of Groups 1 and 2 were 37 and 39 months, respectively. Membranous urethral disruption extending to the urogenital diaphragm was the most frequent urethral injury (type 3), with incidences of 66.7% and 77.7%, respectively. There were no statistically significant differences in mean age, incidence of pelvic fracture types and urethral injury types between groups (p > 0.05). After the immediate treatments, 16.7% and 55% of the patients regained normal urination, and stricture developed in 83.3% and 45% of the patients, respectively. In 44.4% of the patients in Group 1 and 10% in Group 2, urethral strictures required open urethroplasty (p < 0.05). Erectile impotence before urethroplasty in 17.6% and 20%, anejaculation after urethroplasty in 17.6% and 15% and incontinence in 5.6% and 10% of the patients were found in Groups 1 and 2, respectively (p > 0.05). However, 88.8% and 90% of patients eventually achieved normal urination with complete continence. CONCLUSION: Sexual and voiding dysfunction after pelvic fracture posterior urethral injury seem to be the result of the injury itself, not of the immediate treatment modalities. In urethral disruption injuries, primary urethral realignment seems more favourable than suprapubic cystostomy and delayed repair.

The management of vesical calculi with combined optical mechanical cystolithotripsy and transurethral prostatectomy: is it safe and effective?

OBJECTIVES: To investigate the effectiveness and reliability of the combination of optical mechanical cystolithotripsy (OMC) and transurethral prostatectomy (TURP) for the treatment of bladder calculi and obstructive benign prostatic enlargement (BPE). PATIENTS AND METHODS: From December 1990 to December 1996, 61 patients who had bladder stones and BPE or bladder neck contracture were treated with combined OMC and TURP; 32 patients who had bladder stones with no infravesical obstruction were treated with OMC alone. The records of a random selection of 97 patients with obstructive BPE who were treated with TURP only in the same period were used as the control. The operative duration time, the length of hospital stay, the duration of urethral catheterization, outcome and complications of the procedures for each patients were reviewed. The Mann-Whitney U-test and chi-square tests were used for statistical analysis. RESULTS: The mean duration of surgery, hospital stay and urethral catheterization were significantly longer with combined OMC and TURP than with OMC alone (P<0.05). Stone-free rates were 94% after OMC alone and 93% after combined OMC and TURP. The postoperative mean peak flow rates were 14.3 mL/s after the combined procedure and 15.2 mL/s after TURP alone. The complication rates were 21% for the combined procedure and 13% for OMC alone. The complication rate of TURP was 5%, significantly lower than that for the combined procedure (P<0.05). CONCLUSION: Bladder stones were associated with infravesical obstruction in two-thirds of patients. Simultaneous treatment with OMC and TURP did not change the effectiveness of these procedures, but caused additional morbidity.

The effects of experimental varicocele on testicular histology and fertility in monorchic adult rats.

OBJECTIVE: To determine the effects of a left-sided experimental varicocele on testicular morphology and fertility in right hemicastrated adult rats. MATERIALS AND METHODS: A double-controlled experimental study was carried out using mature Sprague-Dawley rats, with 12 rats in each treated group and five corresponding controls. Group 1 underwent right orchidectomy, group 2 right orchidectomy and a left varicocele, and group 3 only a left varicocele; each control group underwent a corresponding sham operation. Two months after surgery each rat was placed with two mature female rats for one month to assess fertility. All the rats were then killed and their testes weighed; the mean testicular weight was calculated for each group and the mean seminiferous tubule diameter (STD) measured. Johnsen scores and histological abnormalities were evaluated for each testis using light microscopy. RESULTS: The mean (SEM) testicular weight and STD in group 2 were significantly lower, at 1311 (100) mg and 225 (11) microm, respectively, than in group 1, at 1771 (28) mg and 255 (4) microm (P<0.05). The mean weights of both testes in rats in group 3 were significantly lower than those in group 1 (P<0.05) and although both mean STDs were less than in group 1, the differences were not significant (P>0.05). There were no differences between the Johnsen scores in groups 2 and 3. There were severe histological abnormalities in the left testes in three of nine and two of eight animals in group 2 and 3, respectively; in group 3, changes in the right testis were detected in one rat. Six of nine and seven of eight rats were fertile in group 2 and 3, respectively. CONCLUSION: Experimental left varicocele decreased the left testicular weight and STD in both hemicastrated and intact adult rats. However, the presence of the right testis is important for preserving fertility.

Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application.

OBJECTIVES: Fournier's gangrene (FG) is an abrupt, rapidly progressive, gangrenous infection of the external genitalia, perineum or abdominal wall and is a real urologic emergency. In this study, the risk factors of FG and the effects of enzymatic debridements on wound healing were investigated. PATIENTS AND METHODS: We reviewed the records of 34 patients with FG to investigate the possible correlation between clinical outcome and infection focus, patient age, number of types of bacteria cultured, delay until presentation, predisposing diseases or accompanying conditions such as diabetes, neurologic deficit, chronic alcoholism and renal failure. Broad-spectrum triple antimicrobial therapy, aggressive and frequent surgical debridement, and if necessary urinary and colonic diversions were performed to control the infection. The effects of enzymatic debridements with topical lyophilized collagenase applications on the wound healing after the control of active infection were evaluated. RESULTS: The average age of the patients was 55 years. The sources of infections were urogenital in 12 (35.3%), anorectal in 10 (29.4%), dermal in 10 (29.4%) and undetermined in 2 (5.8%) of the patients. The average presentation time was 4.4 days and the number of isolated bacteria was 3.05 per case. The number of isolated bacteria and surgical debridements, the duration of hospital stay and the rate of mortality in patients with anorectal foci were higher than those of the patients with urogenital or dermal foci (p < 0.05). Diabetes, uremia and advanced age did not significantly affect the number of surgical debridements, the duration of hospital stay and control of active infection. Mortality was increased in chronic alcoholism, a finding of undetermined significance. Enzymatic debridements decreased the duration of hospital stay (p < 0.05). Five patients (14.7%) died despite prompt medical and surgical preventive measures. CONCLUSION: Chronic alcoholism, anorectal infection foci, neurological deficit and delayed presentation were found as risk factors in FG. Diabetes and advanced age did not affect the progression of disease in our cases. Enzymatic debridements decrease the number of surgical debridements and the duration of hospital stay.

The outcome of varicocelectomy in subfertile men with an absent or atrophic right testis.

OBJECTIVES: To determine the effects of varicocelectomy on semen quality, testicular volumes and serum hormone levels in subfertile men with an absent or atrophic right testis. PATIENTS AND METHODS: Seventeen patients whose wives were gynaecologically normal were evaluated with at least two semen analyses and measurements of serum hormone levels and antisperm antibodies. Scrotal ultrasonography was used to determine testicular volumes and spermatic vein diameters. Varicocelectomy was performed by high ligation via an inguinal approach. All patients were seen at a follow-up 3 months later, and after 6, 9 and 12 months the scrotal ultrasonography, hormone assessment and semen analyses were repeated. Any pregnancies in their wives were recorded over a median follow-up of 19 months. RESULTS: After surgery, all patients had significant improvements in sperm motility, morphology and concentration (P<0.01) but the differences in pre- and post-operative testicular volumes and plasma hormone levels were not statistically significant (P>0.01). No patients had immunological infertility. Eleven of the wives became pregnant during the follow-up. CONCLUSION: Higher pregnancy rates can be achieved by left varicocelectomy in subfertile men with an absent or atrophic right testis. Sperm concentration, motility and morphology are significantly improved by varicocelectomy.

Chronic nephrotic syndrome and chronic renal failure by amyloidosis secondary to xanthogranulomatous pyelonephritis.

The association of xanthogranulomatous pyelonephritis (XPN) and systemic amyloidosis is extremely rare. This association has been described in only six cases. We present a 4-year-old male admitted with a history of anuria and abdominal pain. Investigations revealed multiple calculi in both kidneys. A right pyelolithotomy and left nephrectomy were performed. Histological examination demonstrated XPN and amyloidosis. At discharge serum creatinine had dropped to 1.1 mg/dl but after being lost to follow up for 9 years, the child was readmitted because of edema. Laboratory examination revealed a nephrotic syndrome and serum creatinine of 2.3 mg/dl. Rectal biopsy showed the presence of amyloid. A treatment by colchicine was unsuccessful. Fifteen months later, at the age of 15 years, the patient developed terminal renal failure (serum creatinine 14 mg/dl).

Effects of intracavernous calcium channel blockers in dogs.

Intracavernous injection of smooth muscle relaxing agents can induce penile erection. In this experimental study, we compared the effects of intracavernously injected calcium channel blockers (CCBs) and papaverine in dogs, and investigated their clinical applicabilities. We administered 30 mg papaverine, 10 mg nifedipine, 10 mg nitrendipine and 2.5 mg verapamil to 10 adult male dogs intracavernously, each at different times. Intracavernous pressure values, systemic arterial pressure values and heart rate values were recorded for 45 minutes after the intracavernous injections. We used the paired Student t-test for statistical analysis. Papaverine induced full erection in all of the 10 dogs. Nifedipine induced full erection in 4, nitrendipine in 5, and verapamil in 6 of the 10 dogs. Nifedipine and nitrendipine caused significant decreases in blood pressure and increases in heart rate. In conclusion, the effects of intracavernous CCBs are not superior to those of papaverine. We cannot recommend nifedipine and nitrendipine for intracavernous injection, but verapamil may be included in intracavernous pharmacotherapeutic combinations.

Rare complication of circumcision: penile amputation and reattachment.

We report a case of traumatic penile amputation which occurred accidentally during a ritual circumcision in a 10-year-old boy. A successful penile reattachment was accomplished. Additionally, we discussed the causes and prevention of this condition.

Reappraisal of antibiotic susceptibility tests in the management of chronic bacterial prostatitis.

In view of 50 cases of chronic bacterial prostatitis the efficacy and limitations of antibiotic susceptibility tests have been evaluated and factors affecting passage of drugs across the prostatic cell membrane have been discussed.