Biomedical subjects
Publications and source records attributed to W J Hellstrom.
Histological examination of the radical nephrectomy and renal biopsy specimens in a 49-year-old woman revealed bilateral renal malacoplakia. The literature reports bilateral renal malacoplakia to be uniformly fatal. The preoperative diagnosis is based upon patient presentation and imaging studies. Insights into the bacterial etiology of this systemic disease are presented.
A comparison of the delivery of several antibiotics (vancomycin, gentamicin and aztreonam) to the tissue site of prosthesis implantation was studied using cavernous tissue levels for each antibiotic. A total of 32 patients underwent penile prosthesis implantation. Intravenous antibiotics were administered 1 to 2 hours preoperatively, with vancomycin and aztreonam given to patients at the Tulane University Medical Center, and vancomycin and gentamicin given to patients at the New Orleans Veterans Administration Hospital. At operation the urine, serum and cavernous tissue were concurrently sampled and later analyzed for antibiotic concentration. The mean cavernous tissue level for vancomycin was 55.5 +/- 5.5 ng./mg. (standard deviation) for 20 patients, while the mean cavernous tissue levels for aztreonam and gentamicin were 8.9 +/- 2.1 ng./mg. for 10 patients and 4.7 +/- 1.2 ng./mg. for 12 patients, respectively. When the delivery of antibiotic to cavernous tissue was compared (quantitated as ng. antibiotic per mg. tissue per mg. drug administered), a statistically significant value (p less than 0.01) was observed with vancomycin (0.11 ng./mg./mg.) greater than gentamicin (0.06 ng./mg./mg.) or aztreonam (0.01 ng./mg./mg.), and with no significant difference observed between aztreonam or gentamicin. These findings suggest that cavernous tissue levels may be used as a method to determine optimal antibiotic prophylaxis against penile prosthesis infection.
The U.S. Food and Drug Administration (FDA) lists vacuum constriction devices (VCD) as safe, nonsurgical therapy for erectile dysfunction. Our study compared the responses of 30 male (10 novice and 20 regular) VCD users of seven commercially available systems (Mentor Response, Mentor-Touch, Mentor-Piston, Dacomed Catalyst, Mission VED, Osbon ErecAid, and Pos-T-Vac). Variables evaluated included simplicity of instruction, ease of use, cost, instructional value of videotape, company follow-up, presence of a pressure-limitation gauge, and length of warranty. The results from our study show (1) 100 percent reported an additional cost to be of minor importance in determining choice of device, (2) 80 percent of novice and 95 percent of regular users stated the instructional videotape was essential, (3) 95 percent of the participants desired a twenty-four-hour hot-line, (4) 40 percent of novice users but only 25 percent of regular users wanted personalized company follow-up, (5) 100 percent of novice users preferred single-handed devices, while regulars showed no preference. (6) Regular users scored Mentor Response, Osbon ErecAid, and Mentor-Piston highest regarding ease of use. While the vacuum constriction devices are conceptually similar, there are subtle operational distinctions between the different brands. The clinical urologist should be aware of these nuances.
We used a retrospective case-control study design to compare sperm morphology in 50 varicocele patients and 50 patients with idiopathic infertility. Cases and controls were matched for the percentage of motile sperm and total sperm number per ejaculate. Varicocele patients had significantly more tapered sperm (36% +/- 3% versus 15% +/- 2%) and significantly fewer oval sperm (41% +/- 3% versus 47% +/- 2%). There was no significant difference between cases and controls in any other morphological type.
Platelet-activating factor is a naturally occurring molecule that does not appear to cause the detrimental effects to sperm as have been reported for other synthetic stimulatory agents. Incubation of freeze-thawed sperm with low motility with PAF at concentrations greater than or equal to 1.0 microM significantly improved a number of motion parameters (% motility, VSL and LIN). Optimal incubation conditions for PAF were defined at 1 hour and at 25 degrees C. The success of assisted reproductive techniques employing cryopreserved sperm with poor motility may be enhanced by stimulation protocols employing PAF.
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We compared DNA flow cytometry to morphologic evaluation of routine testicular biopsies as methods of monitoring spermatogenesis. The study group consisted of 14 azoospermic men and 5 others who underwent testicular surgery unassociated with fertility problems. The findings for both studies were divided into three groups: normal, moderately abnormal, and markedly abnormal. Correlations between the findings from routine biopsy and flow cytometry were good. Of 9 patients having normal testicular morphology, 7 had normal ploidy classes by DNA flow cytometry while 2 had moderately abnormal histograms. Of 5 cases with moderately abnormal morphology, 1 had normal, 1 had moderately abnormal, and 3 had markedly abnormal ploidy distributions. In 5 cases described as Sertoli cell only, all DNA histograms were markedly abnormal, consisting almost exclusively of diploid cells. DNA flow cytometry of testicular biopsies and aspirates has been demonstrated to be a rapid, reproducible, and objective approach in evaluating the infertile male and is a promising method to investigate spermatogenesis in an outpatient clinic in lieu of formal testis biopsy.
Microsurgery, especially on an outpatient basis, is a growing part of urologic practice. A commercial table that matches the exacting requirements of urologic microsurgeons does not exist. We have developed a simple and inexpensive design that can be fabricated easily by a hospital workshop. Notable features include removable arm rests, table indentations, and an x-ray carriage assembly. The table is easy to maintain, transport, and store. Comfort and easy access to the operative field improve the surgeon's performance and ultimately translate into better operative results.
Deoxyribonucleic acid flow cytometry on testicular tissue is an established method to evaluate spermatogenesis. Needle aspiration is less invasive and permits sequential sampling as compared with open testis biopsy. Using seven primates, we examined the needle aspiration technique. There was no significant difference among locations aspirated; the Westcott needle (Bard Urological, Covington, GA) provided the most rapid analysis, and both the Biopty gun (Bard Urological) and Westcott needle were easy to use. Baseline means +/- SD for ploidy distributions were 1N: 65.73% +/- 7.1; 2N: 18.95% +/- 5.5; 4N: 11.4% +/- 2, Experimental data generated from primate models using testis aspiration and flow cytometry may elucidate human infertile conditions.
We compared two testing protocols designed to detect immunoglobulin (Ig) G antibodies on sperm surfaces: (1) SpermMar (Ortho, Raritan, NJ) and (2) Immunobead Testing (Biorad, Richmond, CA). The standard SpermMar (SPMAR) protocol (direct test of unwashed semen) was performed with 47 ejaculates and found to be more sensitive than Immunobead Testing (IBT) on washed sperm, detecting five samples with greater than or equal to 30% bead binding, all of which by IBT had less than 20% bead binding. In contrast, when SPMAR was performed on washed sperm or with an indirect antibody transfer from serum or seminal plasma, SPMAR results gave mostly low values for bead binding in comparison with IBT. Our data suggest that SPMAR be used only in direct assays employing unwashed ejaculates, that it can be easily incorporated into routine semen analysis as a screening test, and that positive results should be confirmed by IBT (IgG and IgA).
Flow cytometry can be performed on testicular aspirates of vasovasostomy candidates preoperatively. On the basis of ploidy ratios and debris components, DNA histograms can be classified as normal or abnormal. Using this method, the likelihood of the presence of sperm may be predicted.
For the neurologically impaired patient electroejaculation with a rectal probe can furnish sperm for artificial insemination. However, documentation of pregnancies in this patient group has been limited. Deoxyribonucleic acid flow cytometry has been shown to be a reproducible quantitative method with which to evaluate spermatogenesis. We assessed the ability of deoxyribonucleic acid flow cytometry on testicular aspirates to predict the quality of sperm production in 13 men undergoing electroejaculation. Semen analysis was performed on antegrade and retrograde specimens. Deoxyribonucleic acid histograms from testicular aspirates were evaluated for the relative proportions of haploid, diploid and tetraploid cells. These ratios were compared to the means reported for our own series of 25 patients who at vasovasostomy had sperm intraoperatively and to the similar figures from a group of 10 accident victims. Five patients had normal testicular ploidy compartments defined as within 2 standard deviations from control means. Of the 5 patients 4 had normal sperm counts and motilities (30 per cent or greater). Two patients have contributed sperm for artificial insemination; 1 has resulted in pregnancy. Three patients had moderately abnormal (2 to 4 standard deviations) testicular ploidy classes. These patients had adequate sperm counts but low motilities (5 per cent or less). Of the 5 patients with markedly abnormal (greater than 4 standard deviations) histograms 4 remained azoospermic despite repeated attempts at electroejaculation. Our data support the use of deoxyribonucleic acid flow cytometry on testicular aspirates as a predictor of which patients might succeed and those who are unlikely to succeed in an electroejaculation program.
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The correlation between the amount and location of antisperm antibody binding to the sperm surface and the level measured in the serum has not been previously reported. Hence, the value and limitations of screening blood sera from men with suspected immunologic infertility are not currently known. In this study 70 paired sera and semen samples were assayed by the immunobead test (IBT). A screening protocol for blood sera was constructed to be 100% sensitive for detecting semen specimens with 20% or more of sperm binding IgG or IgA immunobeads. The specificity of this screening protocol was determined to be 79%. Serum IgA was not a good predictor of IgA on the sperm surface. The true positive predictive rate for antisperm antibodies on the sperm surface using circulating antisperm antibodies as a screening assay was estimated to be as low as 35%. There was little correlation between the site of immunobead binding following passive antibody transfer from patients' sera to donor sperm and the site of naturally occurring antibodies on the patients' sperm surface. Although direct assessment of antibodies on the sperm surface is preferred, these data suggest that serum IgG alone can be used as a sensitive screening assay for antisperm antibodies in men. A positive screen dictates that a direct assay on semen should be performed.
Although chronic nonbacterial prostatitis is common, the condition remains poorly understood and refractory to treatment. Another approach, i.e., a urodynamic explanation, seems warranted. The underlying cause of the symptoms may be an inappropriate spasm of of the distal urethra/external sphincteric unit, leading to increased pressure in the prostatic urethra with a resultant reflux of urine into the prostatic ducts. The presence of urine (sterile or infected) could induce ductal and periductal inflammation, which could further aggravate spasm of the involved pelvic musculature, exacerbating the voiding dysfunction. We present 3 patients in whom this sequence of events was documented radiographically and urodynamically. Consequently, treatment involved modulation of the dysfunction of the distal urethra/external sphincteric unit: (1) reeducation by reassurance and biofeedback was the initial line of therapy; (2) pharmacologic manipulation using alpha-blockers (to affect smooth and striated muscle irritability) and striated muscle relaxants was next tried; (3) finally, in unremitting symptoms, we used selective sacral-root electro-stimulation, successfully fatiguing the involved muscles and relieving the voiding dysfunction.
We believe that, without evidence of inflammation (greater than 5 WBC on VB1), there is no indication for routine culture or antibiotic treatment of infertile men. In the presence of active inflammation and positive cultures for chlamydia, treatment with antibiotics is appropriate. However, active inflammation and positive chlamydial cultures were rare findings in our population (2 of 52 and 1 of 52, respectively). Thus, we find no evidence for a role of current asymptomatic mycoplasma or chlamydial infection in male infertility.
Immunologic infertility is an important area of current clinical research. The immunobead test is a laboratory method that identifies the classes of antisperm antibodies and their binding sites on the sperm surface. In this study we have investigated the variability in the pattern of antibody binding to spermatozoa after passive transfer from blood serum. Serum from a single donor containing antisperm antibodies of the IgG class was used in all experiments. The spermatozoa from 27 semen donors were found to differ significantly in the degree and location of immunobead binding after exposure to this serum. There was substantial day-to-day variability in the results for individual semen donors and the overall variability in test results was significantly greater when a number of semen donors was used rather than a single donor. These data suggest that details of antisperm antibody binding after passive transfer from body fluids may depend on the sperm donor. The design of research studies involving antibody transfer must take this source of variability into account.
The recent introduction of intracorporeal injections of papaverine and phentolamine for the diagnosis and treatment of impotence has resulted in an increased incidence of iatrogenic priapism. Based on our research into penile hemodynamics we propose a refined approach to all types of priapism. Intracorporeal blood gas and pressure monitoring should be used to differentiate ischemic (low flow) from nonischemic (high flow) types. Most cases of papaverine-induced or phentolamine-induced priapism will respond to aspiration alone or in combination with intracorporeal instillation of a diluted alpha-adrenergic agent. In spontaneous priapism alpha-adrenergic agents can be tried first if patients have only mild or no ischemia. In patients with severe ischemia stagnant blood should be evacuated and a shunt procedure should be performed to allow metabolic replenishment of tissue. Intracorporeal pressure monitoring will help to determine the size and number of shunts needed to re-establish corporeal circulation.