Biomedical subjects
Publications and source records attributed to C F Donatucci.
A consecutive series of 18 patients underwent attempted direct vision internal urethrotomy (DVIU) under topical lidocaine anesthesia. The procedure was completed successfully in 15 of 18 (83%) patients. In these patients 12 of 15 (80%) reported either minimal or no discomfort. Direct vision internal urethrotomy using topical lidocaine anesthesia is a safe and cost effective procedure.
To evaluate the effectiveness and clinical outcome of patients treated by balloon dilatation of the prostate (BDP) compared with transurethral resection of the prostate (TURP) we performed a prospective, randomized clinical trial. Fifty-one men were randomized to either BDP or TURP. Both groups demonstrated a significant decrease in symptom score from preoperative levels (TURP 13.6 to 6.0 [p < 0.05]; BDP 14.1 to 8.1 [p < 0.01] at 1 year). The TURP group improved peak urinary flows; while, after initial improvement, the balloon group returned to pre-procedure levels. At twelve months 14 of 19 BDP patients (74%) and 14 of 18 TURP patients (78%) considered themselves improved. BDP results in symptomatic improvement; however, the effect may not persist. Objective improvement after BDP does not always occur. The morbidity of BDP is low and compares favourably to that of TURP. Thus BDP does not appear to be as effective as TURP and may offer only temporary relief of symptoms.
Retrograde and antegrade dissections from the penile hilum to the prostatic area and the glans penis were performed in 4 formalin-preserved adult male cadavers. In addition to the medial branches accompanying the urethra, the lateral branches of the cavernous nerves pierced the urogenital diaphragm 4 to 7 mm from the striated muscles of the external sphincter. At the penile region, multiple communications between the cavernous and dorsal nerves were noted that suggest that either the cavernous nerves use the dorsal nerve as a carrier to the distal portion of the penis or the dorsal nerve may itself contain autonomic fibers. These findings will improve our ability to preserve erectile function during pelvic, urethral, and penile surgery.
We describe the use of lidocaine as a topical anesthetic for 35 patients undergoing random bladder biopsies (bladder mappings) and cold-cup resection of small bladder lesions. Serum lidocaine levels were measured 7 to 10 minutes after instillation of the anesthetic using fluorescent polarization immunoassay. Adequate pain control was noted in 33 of 35 patients (94%), with negligible serum lidocaine levels noted in all 35. One patient had a 2 cm. tumor on the anterior wall of the bladder making resection with topical anesthesia suboptimal and 1 patient required 1 mg. supplemental intravenous midazolam hydrochloride to complete the procedure. We conclude that topical lidocaine is a safe, inexpensive and effective mode of anesthesia for bladder mappings and cold-cup biopsies of small bladder lesions. However, it may be inadequate for lesions large enough to require resection rather than cold-cup biopsy and those at poorly accessible regions of the bladder.
Because prostaglandin E1 causes erection by smooth muscle relaxation in a receptor-dependent manner, one would expect increasing dosages to cause a progressively greater response and that, at receptor saturation, further increases would not be beneficial. To test this hypothesis a single-blind, placebo-controlled study of increasing dosages of prostaglandin E1 injected intracavernously was done. In 16 men with vasculogenic impotence erections were monitored by the RigiScan device in real time for 2 hours after injection, and rigidity, tumescence and duration of erection were measured. Summary parameters to characterize erection with each dosage were developed: maximal rigidity, maximal rigidity sustained for 30 minutes and duration of greater than 60% rigidity. The dose-response curve was similar for all 3 parameters. The initial response to escalating doses of prostaglandin E1 from 2.5 to 20 micrograms. demonstrated a steep dose-dependent increase; at greater than 20 micrograms. a plateau was reached, indicating a nonlinear response. More than 80% of the patients attained the maximal response at doses of 20 micrograms. or less and less than 20% benefited from a further increase. Based on these results, the effects of prostaglandin E1 appear to be receptor-dependent and prostaglandin E1 monotherapy for impotence could be limited to 20 micrograms. or less, since larger amounts offer little additional benefit.
To elucidate the neuropharmacology of erection, we undertook an in vivo canine study to examine the role of cholinergic and nonadrenergic, noncholinergic (NANC) neuroeffectors and the sinusoidal endothelium in erection induced by electrostimulation. We also examined the effect of adenylate cyclase and guanylate cyclase blockers by intravenous injection of N-ethylmaleimide and methylene blue, respectively. In addition, the effects of intracavernous injection of the nitric oxide-releasing substance, nitroprusside, and bromocyclic adenosine monophosphate (AMP) and bromocyclic guanosine monophosphate (GMP) were also studied. In contrast to in vitro results, atropine reduced the increase of intracavernous pressure after neurostimulation (p = 0.029). Intracavernous injection of CHAPS to destroy the sinusoidal endothelium abolished the response to acetylcholine (p = 0.001), but only partially inhibited the response to electrostimulation (mean = 75% pressure increase, p = 0.022), indicating that neuronal nitric oxide plays a major role in penile erection. Methylene blue, a guanylate cyclase inhibitor, significantly inhibited the erectile response to both neurostimulation and sodium nitroprusside (p = 0.000 and 0.017, respectively). However, N-ethylmaleimide, an adenylate cyclase inhibitor, could not reduce the response to neurostimulation (p = 0.078). The erectile response to intracavernous injection of cGMP was significantly better than that induced by cAMP (p = 0.025). Our results suggest that both the cholinergic and NANC neuroeffectors and the sinusoidal endothelium are involved in erection. In addition, our data imply that the neuronal nitric oxide/cyclic GMP system is the most likely pathway for penile smooth muscle relaxation and erection.
A prosthetic penile venous compression device was surgically placed in 14 dogs to assess the effects of chronic device implantation and repeated device cycling on cavernous tissue. Duration of device implantation ranged from 37 to 224 days; total number of device cycles ranged from 8 to 59. At recovery, erection was induced by electrostimulation of the pelvic nerve. The device successfully prolonged intracavernous elevation for as much as 30 minutes after inflation. Histologic examination of representative tissue sections through the corpora revealed no evidence of neural injury, vascular compromise, or tissue atrophy. The implantable venous compression device may offer an improved method of treatment of venogenic impotence.
We performed a retrospective analysis of 101 impotent patients using intracavernous self-injections as primary therapy for vasculogenic impotence. A total of 70 patients used an average of 5.58 micrograms prostaglandin E1 (95% confidence interval 4.83 to 6.34 micrograms) as a single agent, and 31 injected 0.40 ml. (95% confidence interval 0.342 to 0.457 ml.) of a combination of papaverine (12 mg./ml.), phentolamine (1 mg./ml.) and prostaglandin E1 (9 micrograms/ml.). We describe the procedure to establish the dosage for home use and discuss the implications of the low dosages relative to previous reports.
We undertook a retrospective review of 100 impotent men under age 40 to determine the underlying etiologic factors in the group and to evaluate the role of surgery in their care. Although patients ranged in age from 18 to 40 (mean--32.2 years), the number of patients increased steadily with advancing years. The majority of patients (72) had vasculogenic impotence (arteriogenic--15, venogenic--46, mixed--11), followed by psychogenic (13), neurogenic (12) and other causes (4). The differential diagnosis did not correlate with age. Contributing factors were present in 76%, trauma and substance abuse being most common. Essentially equal numbers of patients were treated surgically (40) and with intracavernous injection of vasoactive agents (39). Considerably fewer had a vacuum constriction device (5), oral medication (5), psychotherapy (4), other therapy (4), and none (3). The majority of patients referred to our tertiary urologic practice for treatment of vasculogenic impotence were sent by other urologists. Although the referral source did not appear to influence the choice of treatment, it probably has accounted for the preponderance of vasculogenic impotence in this series.
We report our experience with the use of transrectal ultrasound and ultrasound-guided needle biopsy in the diagnosis of 4 cases of malakoplakia of the prostate. Prostatic malakoplakia is rare with a total of 25 cases reported in the literature. It may simulate carcinoma on digital rectal examination and transrectal ultrasound. Herein are 4 additional cases in which transrectal ultrasound of the prostate was compatible with carcinoma. Subsequent needle biopsy of the suspicious regions revealed the classic pathologic features of malakoplakia. Malakoplakia is a difficult pathologic diagnosis, and the prevalence of this disease may be underestimated. As the use of transrectal ultrasound becomes more common in diagnosing carcinoma of the prostate, and due to the difficulty in diagnosing malakoplakia pathologically, we recommend maintaining a high index of suspicion for malakoplakia to avoid possible unnecessary radical surgery.
Epidermolysis bullosa is a group of rare genetic disorders characterized by noninflammatory blistering lesions of the skin occurring after minor mechanical trauma. In association with junctional epidermolysis bullosa, a syndrome of pyloric atresia has occasionally been noted in the literature. Several infants who had this combined disorder have been reported to have severe genitourinary tract involvement. Most of these patients have died at an early age because of severe urinary tract involvement. We describe a rare survivor who was initially treated with urinary diversion. Subsequent attempts at undiversion of this patient were unsuccessful. He is presently stable following rediversion. The entities of e. bullosa and e. bullosa/pyloric atresia are reviewed with emphasis on urologic associations.
A retrospective review was done of the results of the combined intracavernous injection and stimulation test, an office based functional test for impotence. In this procedure the quality of erection is assessed 15 minutes after injection of a vasoactive drug. In our series 90 patients did not achieve full rigidity and were instructed to perform genital self-stimulation for 5 minutes before reevaluation. Of the 90 patients 67 (74%) improved with stimulation and 23 (26%) showed no improvement. At 5 minutes after stimulation a decrease in the quality of the erection was found in 25 patients--a finding suggestive of venogenic impotence. When cavernosometry and cavernosography were performed 21 patients (84%) had moderate to severe venous leakage and 4 (16%) showed none. Self-stimulation after diagnostic injection of intracavernous agents can improve patient response, and may better predict the potential success of a therapeutic self-injection program and the diagnosis of suspected venogenic impotence.
Sexual dysfunction resulting from penile deformity is amenable to surgical correction. We describe a simplified technique in which surgical plication with nonabsorbable sutures is assisted by intraoperative erection induced by intracavernous papaverine. This procedure can be performed in an ambulatory surgery center with the patient under local anesthesia with minimal postoperative morbidity. To date we have treated 6 patients and followup ranges from 12 to 24 months. All patients have straight erections and retain normal erectile function.
The use of lidocaine as a topical anesthetic in bladder biopsies is described. Lidocaine was used in 7 patients undergoing random bladder biopsies and serum lidocaine levels were measured 7 to 10 minutes after instillation. Adequate pain control was noted in each patient with negligible serum lidocaine levels even in the face of denuded bladder mucosa.
Furosemide remains the drug of choice for patients with the transurethral resection syndrome. Furosemide is often used intraoperatively to treat patients suspected of having excessive irrigant absorption. To examine the efficacy of such therapy, a randomized study was performed in which furosemide was administered to patients undergoing routine transurethral resection of the prostate (TURP) to determine the effect of furosemide on electrolyte and fluid volume conservation in these patients. Seven patients treated with furosemide on completion of TURP had a statistically significant delayed drop in serum sodium values after normal initial values (139 mEq/L to 134 mEq/L). Seven untreated control patients did not have a similar drop in sodium values, and the difference between groups was significant. We suggest that furosemide be used with caution in patients undergoing routine TURP, and when given it should be accompanied by the infusion of an isotonic balanced salt solution.
A case of mucinous adenocarcinoma of the prostate that was diagnosed with the aid of prostate-specific antigen immunoperoxidase staining is reported. Focal areas of the tumor, which were morphologically similar to the remainder of the tumor, stained with neuron-specific enolase by an immunoperoxidase technique and with the Grimelius stain. This tumor is best thought of as a variant of the classic acinotubular adenocarcinoma of the prostate with well-differentiated cells that secrete mucin, rather than as a completely different type of cancer, as proposed previously.
The occasional concurrence of junctional epidermolysis bullosa and pyloric atresia has been documented in the literature. Several infants reported as having this combined disorder were also noted to have significant genitourinary disease. We treated a 4 1/2-year-old boy with mild cutaneous manifestations of junctional epidermolysis bullosa, corrected pyloric atresia, and significant renal disease secondary to recurrent obstruction of the ureterovesical junction.
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