Traumatic avulsion of the dorsal penile artery mimicking a penile fracture.
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Adult↗
Biomedical subjects
N A Armenakas
Publications and source records attributed to N A Armenakas.
Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double-blind, placebo controlled study.
PURPOSE: We performed a randomized, double-blind, placebo controlled study to assess the safety and efficacy of periprostatic anesthesia administration during prostate biopsy. MATERIALS AND METHODS: From May to November 2000 transrectal ultrasound guided prostate biopsy was performed in 132 consecutive men due to an abnormal digital rectal examination and/or elevated prostate specific antigen. During biopsy 66 patients each were randomly assigned to receive an injection of 1% lidocaine or normal saline. Immediately after biopsy the pain score was recorded independently by patients and the physician using a 10-point linear scale. In addition, patients were given a descriptive questionnaire to be completed at home and mailed back within 2 weeks of biopsy. RESULTS: Mean patient perceived pain scores plus or minus standard deviation of 2.7 +/- 0.21 in the lidocaine and 4.7 +/- 0.26 in the saline groups were significantly different (p <0.0001), as were mean physician perceived scores of 2.9 +/- 0.27 and 5.1 +/- 0.34, respectively (p = 0.0001). Mean questionnaire scores for pain during biopsy of 2.3 +/- 0.13 in the lidocaine and 3.1 +/- 0.18 in the saline groups were also significantly different (p = 0.0006), as were mean questionnaire scores for pain after biopsy of 1.8 +/- 0.11 and 2.3 +/- 0.13, respectively (p <0.006). There were no adverse effects of injection. CONCLUSIONS: Our results show a significant benefit of periprostatic anesthesia over placebo in a randomized double-blind trial. This safe, simple and rapid technique should be applied at transrectal ultrasound guided prostate biopsy to limit undue patient discomfort.
Aged↗
Relationship of prostate-specific antigen and prostate volume in patients with biopsy proven benign prostatic hyperplasia.
BACKGROUND: Emerging data suggest a direct correlation between prostate-specific antigen (PSA) and prostate volume in patients with lower urinary tract symptoms (LUTS) and clinical evidence of benign prostatic hyperplasia (BPH). We attempt to confirm that a similar correlation exists between PSA and prostate volume in patients with biopsy-proven BPH. METHODS: Over a 5 year period, 2,270 patients were confirmed to have BPH as the only histological diagnosis after evaluation with serum PSA, trans-rectal ultrasound (TRUS) biopsy, and prostate volume measurement. PSA and prostate volume were statistically analyzed by age-stratified cohorts, including multiple regression analysis and assessment of correlation using the Pearson correlation coefficient (r). RESULTS: Mean PSA and prostate volume increased with each advancing cohort of age, and the correlation of PSA and prostate volume was determined to be statistically significant (P < 0.001) in each cohort with a correlation coefficient ranging from 0.33 to 0.41. CONCLUSIONS: We confirm that the relationship between PSA and prostate volume in a large series of patients with biopsy-proven BPH provides a comparable correlation to data for patients with LUTS and clinical BPH. As such, PSA represents a valuable approximation of prostate volume, and may prove to be clinically useful in the management of patients with BPH.
Adult↗
The perioperative charge equivalence of interstitial brachytherapy and radical prostatectomy with 1-year followup.
PURPOSE: We compare the comprehensive 1-year charges in a consecutive group of patients undergoing radical prostatectomy and transperineal interstitial brachytherapy for clinically localized prostate cancer at a single urban institution. MATERIALS AND METHODS: A total of 60 consecutive men with clinically localized prostate cancer (T1-T2, N0, M0) were treated during a 15-month period with radical prostatectomy or interstitial brachytherapy. Hospital and outpatient records were analyzed for each patient in regard to preoperative, operative and postoperative charges. Parameters included number of encounters, diagnostic and therapeutic interventions, hospitalization and operative charges, and followup visits, diagnostic tests and interventions for 1 year. All charge calculations were based arbitrarily on the 1996 Medicare fee schedule, factoring in the mandated global charge reimbursement period of 90 days for both procedures. RESULTS: Of the patients 38 underwent radical prostatectomy (prostatectomy group) and 22 underwent interstitial brachytherapy (brachytherapy group). The brachytherapy group was older with higher pretreatment serum prostate specific antigen and clinical stage disease, and more frequently received neoadjuvant hormonal therapy compared to the prostatectomy group. The 2 groups were similar in Gleason score and, when applicable, duration of neoadjuvant hormonal therapy. Preoperative charges were 15.3% lower for prostatectomy than for brachytherapy (not statistically significant). Conversely, operative charges for prostatectomy were 13.5% higher (p = 0.04). The major difference among preoperative, operative and postoperative charges was for those incurred postoperatively by the brachytherapy group, which were 56.0% higher than those for the prostatectomy group ($2,285.20 versus $1,007.20, p = 0.0004). CONCLUSIONS: Transperineal interstitial seed implantation is perceived by many as more cost-effective than radical prostatectomy for patients with clinically localized prostate cancer. We demonstrated that when such patients were followed for 1 year, the comprehensive charges for radical prostatectomy and interstitial brachytherapy were equivalent.
Adult↗
Current methods of diagnosis and management of ureteral injuries.
A delay in diagnosis is the most important contributory factor in morbidity related to ureteral injury. The difficulty in making the diagnosis can be minimized by maintenance of a high index of suspicion and the timely performance of the appropriate radiographic and intraoperative evaluations. A decision on the timing of repair of the ureteral injury is based on the patient's overall condition, promptness of injury recognition, and proper injury staging. Ideally, when identified promptly, ureteral injuries should be repaired immediately. However, once there has been a delay in diagnosis or in the case of an unstable patient, temporizing measures can be used for urinary diversion. With the availability of simple, minimally invasive techniques to manage urinary extravasation and the absence of any risk of ureteral hemorrhage, ureteral reconstruction can be safely deferred until an opportune time during the recovery period. Successful surgical management requires familiarity with the broad reconstructive armamentarium and meticulous attention to the specific details of each procedure. Through adherence to the diagnostic and therapeutic principles outlined, complications can be minimized and renal preservation can be maximized in patients sustaining ureteral injuries.
Humans↗
Indinavir urolithiasis: an emerging cause of renal colic in patients with human immunodeficiency virus.
PURPOSE: We evaluate the clinical, diagnostic and radiographic findings in patients on indinavir therapy who presented with renal colic, and propose appropriate treatment options for indinavir urolithiasis. MATERIALS AND METHODS: A total of 16 patients positive for human immunodeficiency virus on indinavir were evaluated for 18 episodes of severe renal colic requiring hospitalization. Laboratory evaluation was performed in all patients followed by an imaging study. Conservative treatment included intravenous hydration, narcotic analgesics and temporary cessation of indinavir. Intervention was elected only in patients with persistent fever or intractable pain. A month after hospital discharge an excretory urogram and metabolic stone evaluation were performed. Mean followup was 9.3 months and 2 patients had recurrent symptoms. RESULTS: All patients presented with nausea or vomiting and hematuria. Imaging studies confirmed obstruction in all patients with 13 radiolucent (indinavir) and 3 radiopaque (calcium oxalate) stones. Patients with radiolucent and radiopaque stones demonstrated significant differences in urinary pH (p = 0.002) and serum creatinine (p = 0.03). Conservative therapy was successful in 11 patients (68.8%) within 48 hours and 4 patients (25%) with radiolucent calculi required endoscopic stenting for persistent fever. Metabolic stone evaluation demonstrated significant hypocitruria (less than 50 mg./24 hours) in all patients with radiolucent calculi. CONCLUSIONS: The urologist should be familiar with this growing cause of renal colic in patients on indinavir therapy. Pure indinavir stones are radiolucent and have a soft, gelatinous endoscopic appearance. Conservative treatment is successful in most patients and if intervention is deemed medically necessary, endoscopic stent placement should be the procedure of choice.
Acquired Immunodeficiency Syndrome↗
Changing testicular histology in AIDS: its implication for sexual transmission of HIV.
OBJECTIVES: The understanding of testicular histology in acquired immunodeficiency syndrome (AIDS) is essential, because the sexual route is one of the main means of transmission of the human immunodeficiency virus, which is localized primarily in the germ cells of the testes. It is important to determine whether any changes have occurred in the testicular histologic patterns in the course of the AIDS epidemic. METHODS: One hundred forty testicular specimens were available from AIDS autopsies during the AIDS epidemic (1981 to 1998). The epidemic was divided into pre-zidovudine (pre-AZT) therapy (1981 to 1987) and antiviral therapy (1988 to 1998) periods; the latter period was further subdivided on the basis of the particular treatment used. Testicular histology was evaluated and correlated with patient age, CD4 T-cell counts, and pathologic findings in other parts of the body. RESULTS: Testicular histologic findings were categorized into three groups: hypospermatogenesis (group S), spermatogenic arrest (group A), and Sertoli cell only (group O). The percentage of AIDS patients with group S histologic findings remained constant throughout the study period: 26% in the pre-AZT and 28% in the antiviral therapy periods. However, there was a reversal in the percentages of patients in groups A and O: group A decreased from 48% (pre-AZT) to 28% (antiviral) and group O increased from 26% (pre-AZT) to 44% (antiviral). There was no correlation between testicular histologic results and patient age or CD4 count. Opportunistic infections and testicular neoplasms were also identified. CONCLUSIONS: This study demonstrates that current therapy and prolongation of survival in AIDS patients are associated with a shift in the histologic findings of testes toward a more pronounced loss of germ cells. However, 28% of patients still show significant spermatogenesis at the time of death from AIDS and this subgroup cannot be identified by age or CD4 T-cell counts. The presence of large numbers of residual germ cells in these patients suggests that they may continue to be infectious throughout their disease course.
Acquired Immunodeficiency Syndrome↗
Indications for nonoperative management of renal stab wounds.
PURPOSE: During the last 20 years 2,732 patients have presented to San Francisco General Hospital with renal trauma. Of these patients 198 sustained unilateral and 1 had bilateral stab wounds for a total of 200 renal injuries. We evaluated this subgroup of penetrating renal trauma cases to characterize the nature of the injuries and establish treatment guidelines for successful management. MATERIALS AND METHODS: Preoperative staging was performed in 143 cases (71.5%) with excretory urography or computerized tomography. Based on radiographic and clinical findings the injuries were graded according to the organ injury scaling system. There were 75 grade I (37.5%), 33 grade II (16.5%), 52 grade III (26%), 38 grade IV (19%) and 2 grade V (1%) injuries. Associated organ injuries in 122 patients (61%) involved primarily the liver, pleura, diaphragm and spleen. Mean injury severity score was 20.6 (range 4 to 50). RESULTS: Nonoperative treatment was selected in 108 patients (54%). In 3 patients initially treated nonoperatively delayed bleeding required surgical intervention. Of the 92 renal units explored 74 were reconstructed (80.4%) and 11 required nephrectomy (12%). The overall renal salvage rate was 94.5%. Complications included infection in 2 and hematoma in 2 patients each. Four patients died of nonurological complications. Followup imaging studies were obtained in 26 reconstructed kidneys (35.1%). None of the 107 patients who were followed demonstrated delayed sequelae of renal injuries or new onset of hypertension. CONCLUSIONS: Stab wounds are the most common penetrating trauma to the kidney. More than half of these injuries can be selectively treated nonoperatively. Management criteria are based on aggressive radiographic, laboratory, clinical and when indicated surgical staging. Meticulous attention to reconstructive techniques in renal exploration can ensure an excellent renal salvage rate.
Adolescent↗
Imaging characteristics of indinavir calculi.
PURPOSE: Indinavir sulfate is an effective protease inhibitor of the human immunodeficiency virus type 1. Use is associated with a significant incidence of crystallization and stone formation in the urinary tract, and these calculi are not visible on plain radiographs. Previously all urinary stones, including uric acid and matrix, were believed to be radiodense on computerized tomography (CT). We conducted a retrospective study to evaluate the radiographic appearance of indinavir calculi. MATERIALS AND METHODS: Retrospective chart review of 36 patients taking indinavir sulfate and presenting with renal colic was performed with attention to presentation, urinalysis, radiographic evaluation and management. Specifically, imaging characteristics on CT were addressed. RESULTS: All patients complained of ipsilateral flank pain and 35 had nausea and/or vomiting. Of 30 patients with dysuria or urgency the majority had hematuria, and most had pyuria and/or proteinuria. No stones were visualized on abdominal radiography. Diagnosis was confirmed on 1 of 13 excretory urograms and 4 of 11 renal ultrasounds. None of 12 CT scans was diagnostic of renal lithiasis. CONCLUSIONS: Indinavir sulfate is a protease inhibitor with poor solubility and significant urinary excretion. Crystallization and stone formation are demonstrated in as many as 20% of patients taking the medication. Most patients present with flank pain, nausea or vomiting and hematuria. Previously CT was thought to identify all urinary calculi with clarity but it cannot reliably confirm the presence of indinavir calculi.
Adult↗
Cost-effective hydrocele ablation.
PURPOSE: The surgical repair of hydroceles can be relatively expensive in some cases in terms of costs and initial limitation of activity. We ascertain whether aspiration and sclerotherapy of hydroceles is a safe, efficient, cost-effective treatment modality in select patients. MATERIALS AND METHODS: In 47 patients 51 hydroceles were treated in the office with aspiration and instillation of a sclerosing solution based on a sodium tetradecyl sulfate preparation. One treatment was done in 14 cases and 2 in the remainder. Medicare data for 1995 were used for charge analysis. RESULTS: The overall success rate was 61% (34 of 51 cases) with success defined as no perceptible ipsilateral scrotal fluid reaccumulation on palpation by a physician and complete patient satisfaction. The failure rate was 39% (17 cases) with failure defined as perceptible ipsilateral scrotal fluid reaccumulation on palpation by a physician and/or patient dissatisfaction. The charge differential of surgery versus aspiration and sclerotherapy was greater than 9:1. CONCLUSIONS: The aspiration and sclerotherapy technique that we used appears to be an efficacious, safe, cost-effective treatment modality in select patients with idiopathic hydroceles.
Aged↗
Reconstruction of resistant strictures of the fossa navicularis and meatus.
PURPOSE: We evaluate the long-term efficacy of an integrated 1-stage approach for the reconstruction of resistant strictures of the fossa navicularis and meatus. MATERIALS AND METHODS: In 19 men with resistant glanular urethral strictures of varied origin reconstruction was tailored to the individual characteristics of the urethral stricture and glans. Urethral reconstruction was performed with a ventral transverse island fasciocutaneous penile flap in 16 cases, resection and primary end-to-end anastomosis in 2, and a buccal mucosal graft in 1. The glanuloplasty was completed as a glans cap in 15 patients and as glans wings in 4. In the latter group the glans was significantly scarred from the causative process and previous failed procedures. RESULTS: The patients were followed for a mean of 42.7 months. Transient urinary splaying and mild glans torsion were observed postoperatively but resolved within 8 weeks. Overall, a durable, functional and cosmetic result was achieved in 18 patients (94.7%), and only 1 had an anastomotic stricture that required reoperation. CONCLUSIONS: Although the management of resistant glanular urethral strictures can be difficult, the appropriate reconstructive techniques can permanently correct these strictures. We describe a logical 1-stage approach to reconstructing the fossa navicularis and meatus, allowing a functionally successful and cosmetically appealing long-term outcome.
Adult↗
PSA divergence. A new parameter for the accurate longitudinal assessment of prostatic disease.
Prostate-specific antigen (PSA) and the various parameters derived utilizing this marker have increased our ability to diagnose early prostatic disease; however, their accuracy in identifying the etiology of the disease remains somewhat limited. We propose a new PSA derivative, termed "PSA divergence" (PSADI), defined as the change in serum PSA over time (years) divided by the change in prostatic volume over time (years), to more accurately distinguish benign, premalignant, and malignant prostatic diseases. In this study, we evaluated 160 subjects with a PSA >4.0 ng/ml who were found by transrectal ultrasound-guided biopsy (TRUS) to have either benign prostatic hyperplasia or prostatic intraepithelial neoplasia. These men were followed at 6 or 12 months with serial PSA, digital rectal exam (DRE), and TRUS with rebiopsy. Data analysis demonstrated a statistically significant (p < 0.05) correlation between PSADI and each final pathologic outcome, suggesting that PSADI is useful in distinguishing among intraepithelial neoplasia and benign and malignant prostatic disease.
Aged↗
Evaluation of asymptomatic microhematuria.
OBJECTIVES: The purpose of this study was to evaluate a comprehensive urine cytodiagnostic assay to assist in localizing the site of origin and the etiology of asymptomatic microhematuria. This analysis, which assesses various qualitative and quantitative aspects of the voided urine, is compared simultaneously with controls obtained from the established routine urologic evaluation. METHODS: One hundred consecutive subjects who presented solely for the evaluation of asymptomatic microhematuria were evaluated by the established routine urologic evaluation and a refined urine cytodiagnostic assay. For the purpose of this study, only calculi and neoplasms were considered significant findings. RESULTS: The incidence of significant urologic disease was 13% (3 renal neoplasms, 2 urothelial bladder carcinomas, and 8 urinary calculi). The refined urine cytodiagnostic assay identified both uroepithelial vesical neoplasms, 7 of the 8 urinary calculi, and none of the 3 renal neoplasms. The presence of dysmorphic urinary red blood cells (RBCs) and RBC casts was strongly suggestive of renal parenchymal bleeding. Overall, 43 of 44 subjects (98%) with dysmorphic RBCs and RBC casts failed to demonstrate any significant urologic etiology. CONCLUSIONS: These preliminary results suggest that the refined cytodiagnostic urine assay may be helpful in distinguishing whether a given patient's microhematuria is of a significant urologic or a renal parenchymal cause. The addition of this specialized urinalysis may prove a useful adjunct in improving the diagnostic yield in patients with asymptomatic microhematuria.
Adolescent↗
Posttraumatic impotence: magnetic resonance imaging and duplex ultrasound in diagnosis and management.
In 15 patients, impotent as a result of prostatomembranous urethral disruption consequent to pelvic crush injuries, magnetic resonance imaging (MRI) and duplex ultrasound were used to establish anatomical and pathophysiological criteria for accurate diagnosis and appropriate management. All patients were initially treated by suprapubic cystostomy diversion for at least 3 months, after which urethral reconstruction was performed. All men were potent before the pelvic trauma, with loss of sexual function immediately thereafter. Preoperative MRI demonstrated prostatic displacement in 13 cases (86.7%) and cavernous injury in 12 (80%). Duplex ultrasound revealed the cause of erectile failure as vasculogenic in 12 patients (80%) and neurogenic in 3 (20%). Treatment of impotence was deferred for at least 18 months after injury. Of the neurogenic group 2 patients were started on intracavernous injection therapy and 1 refused treatment. Of the vasculogenic group 3 patients underwent successful revascularization, 2 are on injection therapy and 1 had a penile prosthesis inserted. The detailed anatomical information obtainable with pelvic MRI and the functional data provided by duplex ultrasonography enabled us to identify the individual organic components of posttraumatic impotence and to select effective cause-specific therapy.
Adolescent↗
MR imaging of traumatic posterior urethral injury.
To assess the role of magnetic resonance (MR) imaging in defining the surgical approach and in predicting permanent erectile dysfunction in patients with traumatic posterior urethral injury, 27 patients underwent MR imaging before open urethral reconstruction. MR findings were correlated with surgical findings, surgical approach, and sexual potency at 12-month follow-up. MR imaging correctly revealed the length of the urethral injury (allowing for 0.5-cm discrepancy) in 23 of 27 (85%) patients and displacement of the prostatic apex in 19 of 21 (90%) patients. MR findings prompted a change in the clinically planned surgical approach from perineal to combined perineal and transpubic in seven (26%) cases. Significant variables affecting permanent impotence were avulsion of the corpus cavernosum, (P < .001), separation of the corporeal body (P < .05), and superior and/or lateral prostatic displacement (P < .05). When MR imaging findings of both cavernous avulsion and superior and/or lateral prostatic displacement were present, the probability of permanent impotence was 95%. In the absence of these findings, the probability of normal potency was 83%. MR imaging can be performed to help select the most effective surgical approach and to assess permanent erectile dysfunction.
Adolescent↗
Renal gunshot wounds: methods of salvage and reconstruction.
Over the past 14 years, 2079 patients have been seen at our institution with renal trauma. Of these, 84 sustained gunshot wounds (81 unilateral, 3 bilateral; a total of 87 renal units). We evaluated this group to characterize the nature of their injuries and establish a methodology for renal salvage and reconstruction. Preoperative radiographic staging was performed with excretory urography (IVP) or computed tomographic (CT) scanning. The injuries were classified into five categories: 16 contusions (18.4%), 12 minor lacerations (13.8%), 44 major lacerations (50.5%), six vascular injuries (6.9%), and nine combination laceration and vascular injury (10.3%). Most patients had multiple organ injuries, with 79 requiring associated surgical procedures (94%). The mean injury Severity Score (ISS) was 26.7 (range, 4-59). Based on radiographic and clinical staging criteria, 69 renal injuries were surgically explored (79.3%), and 12 patients underwent nephrectomy (13.8%). Forty-six renal units were reconstructed (66.6%) by various methods, including renorrhaphy, omental pedical flaps, mesh or peritoneal patch grafts, partial nephrectomy, and vascular repair. Overall, 75 renal units were salvaged (86.2%). Early renal vascular control was achieved in all patients who underwent renal exploration. Follow-up functional studies were done in 24 (28.5%): none had delayed nephrectomy or postinjury hypertension. Overall, 79 patients survived (94%); however, mortality was not related to renal injury. These findings suggest that aggressive radiographic staging coupled with early vascular control and careful selection of reconstructive techniques can ensure a high renal salvage rate in patients with renal gunshot injuries.
Adult↗
AIDS presenting as primary testicular lymphoma.
A case of AIDS presenting as a primary testicular lymphoma is reported. Despite the lack of evident systemic disease, such a presentation in a young patient should alert the physician to the possible presence of an underlying human immunodeficiency virus infection.
Adult↗
Detection of HIV-related protein in testes and prostates of patients with AIDS.
The testes and prostates of 14 patients with acquired immune deficiency syndrome (AIDS) for whom autopsies were performed were examined for the presence of human immunodeficiency virus (HIV) and the pathologic alterations seen in AIDS. Histologically, the testes contained peritubular fibrosis and variable spermatogenic arrest, which were inconsistent with the young age of these patients. There were also numerous foci of germ cell degeneration and occasional germ cell loss. The Leydig cells were atrophic and decreased in number. The prostates contained increased numbers of concretions. Sections of testis and prostate were stained with an anti-HIV P17 monoclonal antibody with the use of the avidin-biotin technique. Small scattered foci of positive staining were identified in 8 of 14 testes (57%). They were located over one or several degenerating germ cells and the surrounding Sertoli cells. In addition, in 9 of 14 prostates (64%) there were a few minute foci of positive staining in several adjacent glandular epithelial cells. In one case the testis was positive and the prostate was negative, whereas in two cases the testes were negative and the prostate positive. In contrast, 22 testes and 22 prostates of control non-AIDS patients, read double-blind, were negative. The positive controls were HIV-infected tissue culture HUT 78 lymphoma cells in which there were many scattered positive cells. The results indicate the presence of focal HIV-associated protein in the testes and prostates of patients with AIDS, particularly within the foci of germ cell degeneration. The present observations are in accordance with previous research demonstrating the presence of HIV in the seminal fluid of patients with AIDS and appears to indicate the presence of an infection of the male genital tract by the HIV virus.
Acquired Immunodeficiency Syndrome↗