A minimally invasive vasectomy with the no suture, inline method for vas occlusion.

OBJECTIVE: The current vasectomy methods, including the no scalpel vasectomy (NSV), have received considerable attention in recent years, because they are minimally invasive and utilize special instruments to expose the vas. However, at least 28 different methods for vas occlusion have been utilized with these procedures, and some postoperative complications have been attributed to the method of vas occlusion. Therefore, in this report we will critique the existing methods for vas occlusion and introduce a new and rapid method. PATIENTS AND METHODS: The NSV instruments were used to expose the vas, but, in addition, a fine skin hook, a short-bladed tenotomy scissors, and a hand-held, hotwire cautery were used for the new no suture, inline method of vas occlusion. No ligatures were placed around the vas, no portion of the vas was removed, and the mesentery behind the vas was not disturbed. The vas sheath was disrupted, there was luminal cautery on both the abdominal and testicular sides, a section of vas was detubularized and trimmed, and its epithelium was destroyed by cautery. This technique has been performed in 158 consecutive cases. RESULTS: All patients have demonstrated complete azoospermia on two follow-up semen analyses, with no pregnancies reported. CONCLUSION: This new method of vas occlusion seems to be rapid and compatible with the NSV instruments.

Evaluation of prostate volume by transrectal ultrasonography for use in a brachytherapy program.

OBJECTIVES: To evaluate two methods of measuring the prostate volume using transrectal ultrasonography. The measurements were performed in vivo at preplanning and again preoperatively in connection with brachytherapy. The accurate measurement of the prostate volume is important in a brachytherapy program for treatment planning. METHODS: A total of 43 patients with biopsy-proven prostate cancer underwent prospective determination of the prostate volume, by one physician, using transrectal ultrasonography. Volume calculations were made at the preplanning and preoperative settings, both by a hand-held rectal probe using the prolate ellipsoid formula and by a mounted probe in a stepping device using the planimetric method. RESULTS: The coefficient of variation between the preplanning and preoperative prostate volumes with the probe holder was less than 3% compared with the hand-held probe, which was greater than 10%. The difference between the median values at the preplanning and preoperative settings by serial planimetry was 2.5 cm(3) (range 0.2 to 9.4). The difference in the median volumes between the preplanning and preoperative ellipsoid calculations was 6.7 cm(3) (range 0.3 to 38.7). The difference between the median values with the ellipsoid volume was significant (P <0.001). The Pearson correlation coefficient for all values using the planimetric method was 0.92 versus 0.58 for the ellipsoid method. The correlation coefficient was significantly greater for the planimetric method (P <0.001). CONCLUSIONS: On the basis of these data, planimetric prostate volume determination, by a single ultrasonographer, is an accurate and reproducible method with applicability to a brachytherapy program.

The pathophysiology of varicoceles in the light of current molecular and genetic information.

Varicoceles are a common cause of male infertility, but despite data being obtained from animal models and human studies the pathophysiology remains unclear. Recently, molecular and genetic information has been reported on men with varicoceles which may shed new light onto the causes of decreased semen parameters and poor sperm function. Here, a number of studies are reviewed in an attempt to develop a working hypothesis for the relationship of varicoceles and infertility. New studies on testicular tissue of men with varicoceles have demonstrated increased apoptosis among developing germ cells, which may be the cause of oligospermia. Other studies with semen have shown increased levels of reactive oxygen species (ROS) in association with poor sperm motility. Recent studies of morphologically abnormal spermatozoa have demonstrated disruption of the sperm head actin by cadmium, a cation reported to be present in high concentrations among some men with varicoceles. Finally, microdeletions of the alpha-1 subunit of the sperm calcium channels in a proportion of men with varicoceles suggests a genetic defect leading to abnormal acrosomal function. The intent of this review was to explain the pathophysiology of varicoceles, and the findings seem to support a 'co-factor' hypothesis. In order for varicoceles to be associated with infertility, they exist as 'co-factors' along with other molecular/genetic problems.

The diagnosis and treatment of male infertility in the new millennium.

Treatment of male infertility accomplished far-reaching advances in the past decade. Semen analysis has given rise to sperm function tests. Microsurgery, e.g., reversal of vasectomy, has reached new heights in sperm retrieval directly from the testis/epididymis and in intracytoplasmic sperm injection (ICSI). Furthermore, genetic testing-for an ever-widening range of anomalies-is the norm in modern clinical practice. This review of what is possible, and now even common, in male infertility treatment focuses on sperm function, and then deficits/anomalies and their treatment; and testicular function and dysfunction, with descriptions of hormonal and surgical techniques that now offer fatherhood to men with types of infertility that strongly imply the need for genetic counseling.

A modified acrosome induction test.

Many types of acrosome induction tests require special equipment and reagents that are not available to most clinicians; thus, simpler tests seem desirable. A modified acrosome induction test has been developed that uses basic reagents and a light microscope, which are available in most office settings. A hypoosmotic swelling test and a double stain (Bismark brown and rose Bengal) were combined to evaluate the viable acrosome reaction (AR) among 74 infertile men and 42 control men. The study included 34 infertile males without varicoceles, 20 with nonrepaired varicoceles and 20 with repaired varicoceles. On each test day, a specimen from a fertile donor was run as a control. The spontaneous acrosome reaction was recorded in semen before and after capacitation. The final % viable acrosome reaction equaled the capacitated value minus the spontaneous value for whole semen. The mean % viable AR among the control specimens was 16% with no values less than 10%. This mean value for controls was significantly greater than the mean % viable AR in each patient group. There were no overlaps in the 95% confidence intervals. When the study group was stratified according to normal acrosome induction tests or >10% viable AR, 30 patients had a normal test and 44 had abnormal tests. Six patients with varicoceles and an abnormal acrosome induction test had a varicocelectomy, and 2 (33%) converted their acrosome induction test to normal after at least 6 months of follow-up. Nine patients had in vitro fertilization (IVF), 3 had a poor result, and all had an abnormal acrosome induction test. Six had a good result with IVF and all 6 had a normal acrosome induction test. Thus, the acrosome induction test described in this report may be performed in any office laboratory to detect subtle male factor problems. The results may be helpful for planning IVF, intracytoplasmic sperm injection, or varicocele surgery for infertile men.

Modified vasoepididymostomy with simultaneous double needle placement, tubulotomy and tubular invagination.

PURPOSE: Recently a new technique for vasoepididymostomy was described which included tubular invagination by the triangulation method with a patency rate of 92%. Although these early data were encouraging, some technical problems were noted with the technique. After placing the first suture there was often tubular leakage and collapse. The tubulotomy was difficult and in some cases a suture was inadvertently cut. A modified technique is presented for vasoepididymostomy with tubular invagination, including some methods described in rat models. Only 2 sutures are used with simultaneous double needle placement. MATERIALS AND METHODS: The 2-suture technique was used on 19 men who had undergone at least 1 vasoepididymostomy during vasectomy reversal procedures. RESULTS: Patency was demonstrated in 7 of 9 men (77.7%) who underwent modified bilateral vasoepididymostomy and 6 of 7 (85.7%) who underwent unilateral vasoepididymostomy and unilateral vasovasostomy. Pregnancies were reported in both groups. The overall operating time for the modified technique was about 35 to 45 minutes per side. CONCLUSIONS: Modified vasoepididymostomy with simultaneous needle placement, tubulotomy and invagination resulted in early patency in a high percentage of patients. Tubular invagination may have advantages compared to other conventional methods of vasoepididymostomy but more followup is needed.

Use of diuretic renogram in evaluation of patients before and after endopyelotomy.

OBJECTIVES: Endopyelotomy is a widely accepted alternative in the treatment of ureteropelvic junction (UPJ) obstruction, with success rates between 63% and 88%. However, various methods have been used to evaluate patients with UPJ obstruction, making it difficult to compare results. Diuretic renography has the potential to unify the evaluation if performed in standard ways. In this report, we present a standardized protocol for diuretic renography. METHODS: Nineteen endopyelotomies were performed by one surgeon (E.B.K.) at our institution. The 16 patients were evaluated with technetium 99m MAG-3 diuretic renography. The presence or absence of obstruction was classified according to the differential renal function, time activity curves, and Tmax to T 1/2max time. Three patients had a postoperative Whitaker's test. RESULTS: Eight patients had pre- and postoperative diuretic renograms at our institution. This group was stratified by their differential renal function. Among 4 patients with differential renal function greater than 35%, 3 of 4 showed progressive improvement in renal function postoperatively, 4 of 4 had a Tmax to T 1/2max time less than 10 minutes, and 3 of 4 ha d unobstructed time activity curves. Five patients had postoperative renograms only. Of these 5 patients, 4 had differential renal function greater than 35% and 3 of 5 had normal-appearing curves and normal Tmax to T 1/2max time. Three patients required a second endopyelotomy and 2 of these underwent a dismembered pyeloplasty. CONCLUSIONS: Standardized diuretic renography should be used as an objective test for the evaluation of patients with UPJ obstruction. The successful outcome of an endopyelotomy depends on the preoperative renal function of the involved kidney. Whitaker's test may be used for equivocal cases.

The fate of cryopreserved sperm acquired during vasectomy reversals.

PURPOSE: Intraoperative sperm banking has been recommended during vasectomy reversal. These specimens are maintained as insurance for possible future intracytoplasmic sperm injection. We evaluated the fate of specimens collected intraoperatively from 48 vasectomy reversal patients. MATERIALS AND METHODS: Of 75 men 48 (64.0%) agreed to intraoperative sperm banking during vasectomy reversal. A total of 135 vials of epididymal sperm, 81 vials of testicular tissue and 13 vials of vasal sperm were cryopreserved. RESULTS: Among couples who stored sperm 10 (20.8%) voluntarily discarded the specimens within 4 months of vasectomy reversal. Specimens from 31 couples (64.5%) remain in storage. Seven couples (14.6%) have used frozen sperm for intracytoplasmic sperm injection. In 3 of these couples the men were azoospermic after surgery, 2 men had 10,000 to 15,000 sperm per ml. in the ejaculate with limited motility and 2 had 1 to 2 million sperm per ml. with limited motility. The 7 women who underwent intracytoplasmic sperm injection ranged between 37 and 39 years old, which was older than the mean age of the remaining study group (32.7 years). With intracytoplasmic sperm injection fertilization was achieved in all cases and 20 of 47 eggs (42.5%) developed into embryos. Of 7 women 4 achieved biochemical pregnancies (57.1%) and 2 (28.6%) delivered newborns with epididymal sperm. Natural pregnancy occurred in 7 of 16 vasectomy reversal couples (43.7%) who were followed at least 18 months postoperatively but the time to pregnancy averaged 1 year. CONCLUSIONS: Cryopreservation of sperm collected at vasectomy reversal is recommended for patients undergoing vasoepididymostomy or vasovasostomy. The couples who used the cryopreserved sperm for intracytoplasmic sperm injection included husbands whose postoperative ejaculate remained azoospermic or severely oligospermic and wives who were approaching 40 years old. Only a limited number of couples (14.6% of the study group) have used the cryopreserved sperm but the delivered newborn rate (28.6%) was comparable to other intracytoplasmic sperm injection data. The natural pregnancy rate after vasectomy reversal was 43.7% but the time to pregnancy after surgery was lengthy (average 1 year). These findings may be helpful for counseling couples who are planning vasectomy reversal surgery and may be considering intraoperative sperm banking.

PIP: This is a follow-up study on the cryopreserved sperm specimens acquired during vasectomy reversal. The sample was composed of 75 men from whom 48 (64%) agreed to intraoperative sperm banking during vasectomy reversal. A total of 135 vials of epididymal sperm, 81 vials of testicular tissues, and 13 vials of vassal sperm were cryopreserved. The result indicates that among the couples who stored sperm, 10 (20.8%) voluntarily discarded the specimens within 4 months of vasectomy reversal. Specimens from 31 couples (64.5%) remain in storage. 7 couples (14.6%) have used frozen sperm for intracytoplasmic sperm injection. In 3 of these couples, the men were azoospermazoic after surgery, 2 men had 10,000-15,000 sperm/ml in the ejaculate with limited motility, and 2 had 1-2 million sperm/ml with limited motility. Intracytoplasmic sperm injection fertilization was achieved in all cases and 20 of 47 eggs (42.5%) developed into embryos. Of the 7 women, 4 achieved biochemical pregnancies (57.1%) and 2 (28.6%) delivered newborns with epididymal sperm. Natural pregnancy occurred in 7 of 16 vasectomy reversal couples (43.7%), but the time to pregnancy ranged from 4-18 months with an average of 1 year. Therefore, intraoperative collection and cryopreservation of epididymal and testicular sperm are recommended during vasectomy reversal surgery.

The emergence of specialized procedures for the acquisition, processing, and cryopreservation of epididymal and testicular sperm in connection with intracytoplasmic sperm injection.

Epididymal and testicular spermatozoa have been used widely for ICSI among men with obstructive azoospermia and NOA. New aspiration and biopsy techniques are available, and several sperm preparation methods have been described to isolate sperm. Most samples have sufficient sperm for cryopreservation. Accordingly, clinicians must sort through these new procedures to develop treatment plans that best suit their practices. In the future, other methods will be developed, and clinicians will have to critically review them prior to use.

Complete replication of human sperm genome in egg extracts from Xenopus laevis.

To examine the ability of Xenopus egg extracts to support a complete replication cycle of human sperm genome, demembranated human spermatozoa were incubated with the extract from activated Xenopus laevis eggs. Most sperm heads were decondensed within 15 min. The heads became round within 30 min with diameters of 10-30 microns. The process of DNA replication in the pronuclei was monitored by two methods, bromodeoxyuridine incorporation and flow cytometry. The results indicate that DNA replication was initiated approximately 1.5 h after membrane structure formation and that it lasted up to 9 h. The amounts of DNA in most pronuclei were doubled by 4-9 h, depending on which donor toad was the source of the egg extract. Inclusion of the protein synthesis inhibitor, cycloheximide (100 micrograms/ml), had no obvious effect on human sperm DNA replication but appeared to prevent the pronuclei from degradation after a prolonged period (> 6 h) of incubation. After storage in liquid nitrogen for > 1.5 mo, the efficiency of the egg extracts in supporting sperm head decondensation and DNA replication was reduced for human sperm but not for Xenopus sperm. Possible applications of the use of Xenopus egg extract for human sperm activation and DNA replication are discussed.

Management of the epididymal tubule during an end-to-side vasoepididymostomy.

Microsurgical repairs of epididymal obstruction have improved because of specific tubule anastomoses. However, these techniques require considerable microsurgical skills and any modifications to organize and simplify these procedures seem desirable. Four modifications are described for the management of the epididymal tubule during end-to-side vasoepididymostomy, including closed tubule fixation, micro-tubulotomy, micro-suction and placement of double-armed sutures through the epididymal tubule before attachment of the vas. These procedures have been performed on 51 patients. "Mixed procedures," or a modified vasoepididymostomy on 1 side and a vasovasostomy on the other, were done in 32 cases and "pure procedures," which included bilateral modified end-to-side vasoepididymostomy (16) and unilateral procedures (3), were done in 19. The semen and pregnancy data for the 19 cases of pure procedures were patency rate 58% in 11 and pregnancy rate 42% in 8. These modifications appeared to be helpful to organize and simplify several aspects of the procedure, and the results were improved compared to other techniques.

Urethral stricture and semen quality.

OBJECTIVE: To study the relationship between urethral stricture and infertility, which has not been well studied in the past. PATIENTS AND METHODS: In this study in West Africa, the mean semen values from 90 fertile controls and 32 infertile controls were compared to 40 men with incomplete urethral strictures (IUS) and 56 men with complete urethral strictures after treatment. Testicular biopsies were performed on 30 patients. Sexually transmitted urethritis accounted for 79% of the strictures within this group of patients. Repair of the strictures restored ejaculate in 39 men, and 22 men had normospermia (20 million/mL); however, the remainder had either azoospermia or oligospermia. The biopsies revealed normal spermatogenesis in 5 men, which suggested ductal obstruction, but 14 patients had destruction of seminiferous tubules suggesting end organ failure. Eleven other men had hypospermatogenesis, maturation arrest, or premature sloughing of cells, which may be amenable to treatment. CONCLUSIONS: These data suggest that early medical treatment and repair of urethral stricture may improve fertility for men with urethral strictures, especially strictures following infectious urethritis. Testicular biopsies may aid in the diagnosis of persistent infertility among these men, and should be considered as part of the work-up.

Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data.

A total of 606 modified subinguinal microscopic varicocelectomies was performed on 466 outpatients using local anesthesia and sedation. The patients selected for these procedures were infertile for at least 12 months and had at least 1 semen parameter below threshold level: less than 20 million per ml., less than 50% motility or less than 40% normal morphological forms. The lymphatics, spermatic artery and vas were preserved, whereas all refluxive veins were transected or obliterated. Postoperative complications were limited to transient epididymal discomfort in 5.5% of the patients, ecchymosis at the wound site in 3.4% and wound inflammation in 2.4%. There was only 1 permanent hydrocele. The palpable recurrence rate was 0.82% per procedure. The median values for each semen parameter were compared preoperatively and postoperatively by the Wilcoxon signed rank test. The differences in the median values were significant for all parameters. As an alternative statistical model, the average preoperative semen value was subtracted from the average postoperative semen value for each parameter. The median differences were 10.8 million sperm per ml. for sperm density, 13.9% for motility and 3.8% for normal morphological forms. These differences were significantly greater than zero by the Wilcoxon signed rank test. The intra-quartile ranges for these differences suggested that postoperatively more than 75% of the patients had a difference of greater than zero for sperm density and per cent motility, and 63% had a difference of greater than zero for normal morphology. The 1-year pregnancy rate was 35.6% for 186 varicocelectomy patients compared to 15.8% for 19 medically treated men with varicocele. The difference between the true 1-year pregnancy rates was 19.8% and the 95% confidence intervals estimated bounds of 1.91 to 37.5%. These data suggest that outpatient subinguinal microscopic varicocelectomy has minimal morbidity and recurrence, and may be beneficial for select patients.

Microsurgical aspiration of sperm from the epididymis: a mobile program.

We report data from 25 microsurgical aspirations of the epididymis on 22 men. There were 14 men with congenital absence of the vas, 6 with failed vasoepididymostomy, 1 with adult cystic fibrosis and 1 with a childhood hernia repair. The specimens were used for assisted reproductive technologies, including in vitro fertilization and tubal embryo transfer. The protocol for aspiration, ovulation induction and sperm processing evolved during the course of these studies, and the patients were classified into 2 groups on the basis of methodology. Seventeen procedures were performed for the in-house in vitro fertilization team but 8 other procedures were done for nearby in vitro fertilization centers, and the final prepared sperm samples were transported as part of our mobile program. Group 1 patients underwent standard aspiration techniques, standard ovulation induction and sperm processing by wash and swim up. Among this group there were no fertilizations or pregnancies with 8 in-house and 2 transported specimens. Group 2 patients had leuprolide suppression before ovulation induction, direct intratubular aspiration and a complex sperm preparation, including pentoxifylline stimulation, mini-Percoll filtration and incubation with human follicular fluid. Among this group there were 2 fertilizations and 1 pregnancy with 9 in-house cases, and 3 fertilizations and 2 pregnancies with 6 transported specimens. These results suggest that a mobile program for microsurgical aspirations of sperm from the epididymis and in vitro fertilization or tubal embryo transfer is feasible within the framework of a strict protocol.

Insemination data on men with varicoceles.

OBJECTIVE: To determine possible benefits of sperm processing and intrauterine insemination (IUI) for a group of men with a varicocele history who had not achieved a pregnancy by natural coitus (mean duration of infertility 42.2 months). DESIGN: A retrospective study including infertile men with varicoceles who were classified by their semen analyses and sperm penetration assays (SPAs). SETTING: Private practice of infertility. PATIENTS: Seventy-one infertile couples. The husbands had a varicocele history and were grouped into four clinical categories (14 untreated, 5 medical treatment, 34 varicocelectomies, and 18 varicocelectomies plus medical treatment). The wives were studied or treated before IUI. INTERVENTIONS: Varicocelectomies were performed on the males when indicated. Female studies included laparoscopies as indicated intrauterine insemination with Tomcat catheter (Sherwood Medical, St. Louis, MO) was performed in all cases. MAIN OUTCOME MEASURES: Overall pregnancy rates (PRs) and fecundity rates with sperm processing and IUI. RESULTS: Six pregnancies occurred with 66 cycles of sperm processing and IUI among 28 men with normal SPAs (PR 21%, fecundity rate = 0.09). In contrast, there were no pregnancies with 121 cycles among 43 varicocele patients with abnormal SPA results or with low values for all three semen parameters. CONCLUSIONS: Sperm processing and IUI may be beneficial for selected patients with varicoceles who had not achieved a pregnancy by coitus.

The status of vasectomy reversals.

Vasectomy reversals are being requested in increasing numbers. Non-urologists are often the first physicians consulted about such procedures. In some instances, these physicians know very little about the procedures, and the consultation leads to confusion and frustration. In this report, current facts on vasectomy reversals will be provided for the benefit of non-urologists.

PIP: This report provides current facts about vasectomy reversal, hoping to inform non-urologists, who are often the first physicians consulted by patients seeking the procedure. The author explain that an increasing number of men are requesting vasectomy reversals, and unless non-urologists are informed about the subtleties involved in the procedure, they may provide patients with confusing and frustrating information. The article begins by discussing patient selection, operative choices, scheduling and anesthesia. Since all men continue to produce sperm in the testes after a vasectomy, they are all potential candidates for reversal. The procedure, however, involves thoughtful intraoperative evaluation, as well as the use of improved microsurgical techniques in some cases. The old vasectomy site may not be the only place of obstruction, since over time there may be engorgement, leaking, or scarring in the epididymis. The 2 operative procedures available are vasovasostomy and vasoepididymostomy. The decision of which procedure is required is made only at the time of the surgery, based upon certain intraoperative findings. The article goes on to explain the intraoperative findings that influence the operative choice, and discusses the success ratios of reversals. In 61 vasovasostomies performed by the author, more than 80% were considered successful, with 31 (50.8%) pregnancies reported. And in 16 vasoepididymostomies performed, 62.5% achieved patency and resulted in a pregnancy rate of 25%. The author then addresses the possible causes of postoperative failure, including sperm antibodies. Finally, the author briefly mentions options other than reconstructive microsurgery, such as intraoperative sperm aspiration and micromanipulation.

A modified vasoepididymostomy performed with the sling and blanket technique.

A modification is presented for the end-to-end type of vasoepididymostomy known as the sling and blanket. We have exploited the differences in size between the vas and epididymis to gain a mechanical advantage. When the epididymis is transected the redundant tunic is preserved. The sling is created from the tunic, which is drawn forward and sutured to the vas posteriorly about 1 cm. from its cut end. The sling provides support so that the end-to-end anastomosis between the vas lumen and specific epididymal tubule may be completed in 1 plane and without rotation. The blanket is created from the remaining epididymal tunic, which is sutured anteriorly to cover the anastomosis and stabilize the vas. The procedure was performed on 8 patients with primary epididymal obstruction. The patency rate was 50% and the pregnancy rate was 25%. Although vasoepididymostomy remains a difficult microsurgical operation, this modification seems to be beneficial in selected cases.

The use of a vacuum constrictor device to augment a partial erection following an intracavernous injection.

Intracavernous injections and vacuum constrictor devices have been used for the nonoperative management of impotence and sexual dysfunction. Although most men are able to use these methods successfully, it currently is well known that up to 30 to 35 per cent of the patients may have only a partial response to the injections. We observed 22 men with partial tumescence after an intracavernous injection of papaverine (15 to 30 mg.) and phentolamine (0.5 to 1.0 mg.). The penis was not rigid and the buckling pressures never exceeded 50 mm. Hg after 20 minutes of observation. In each case we immediately applied a vacuum constrictor device because these devices had been used successfully by other men with similar diagnoses. A total of 21 men responded within 30 to 60 seconds and achieved a rigid erection with buckling pressures of greater than 100 mm. Hg (16) and 60 mm. Hg (5). These findings indicate that a vacuum constrictor device may be used to augment a partial response to an intracavernous injection and that the availability of injections and vacuum constrictor devices provides these men with a more complete nonoperative program.

Penile plethysmography on impotent men using vacuum constrictor devices.

Vacuum constrictor devices achieve an erection-like state of the penis by means of a clear plastic cylinder, a vacuum pump, and a constrictor ring. Although these devices are noninvasive compared with penile injections and implants, they have been used less often in clinical practice. Part of the hesitancy to prescribe these devices has been related to the lack of published data concerning the effects of constriction on penile blood flow. In this report, we utilized penile plethysmography to estimate penile blood flow on 51 men before, during, and after the use of the constrictor ring. All patients demonstrated a 70-75 percent decline in the amplitude of the pulse-volume curve during constriction, but continuous blood flow was maintained in each case. Within sixty seconds after removal of the ring, the amplitude returned to baseline values for all men, including 12 patients with a penile brachial index of less than 0.7. Among 33 patients, there was evidence of a transient increase of amplitude following constriction, which was consistent with a postischemic hyperemia. These findings suggest normal penile blood flow, and indicate that the use of constrictor rings may be safe for patients with these tracings. Penile plethysmography appears to be a useful technique to help with patient selection and constrictor ring fit. Follow-up tracings probably should be scheduled at periodic intervals for men utilizing these rings and devices.