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The importance of surgery is related to the fact that teratoma and malignant transformation are inherently chemoinsensitive, and viable malignancy is usually present in the setting of prior chemotherapy (platin-resistant). Through this vascular complex, the human testis is provided with 9 mL of blood per 100 g of tissue per minute (Pettersson et al, 1973). Kaposi Sarcoma Kaposi sarcoma, first described in 1972, is a tumor of the reticuloendothelial system (Kaposi, 1982). Metastases to this node indicated the need for a complete superficial and deep inguinal dissection. This indicates that acquired epididymal dysfunction resulting from prolonged blockage may play an important role in the fertility potential of men after vasectomy reversal (Mui et al, 2014). Researchers have investigated a large number of potential male reproductive environmental toxicants. As it nears the urethral bulb, the artery divides into its three terminal branches, the bulbourethral artery, dorsal artery, and cavernosal artery. Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. B, Small crossing vessels are cauterized with bipolar cautery, and a pea-sized sample of seminiferous tubules is taken with a "no-touch" technique. PreparationoftheVasa the vas is grasped above and below the site of obstruction with two Babcock clamps. Inguinal Incision An inguinal incision is the preferred approach in men when obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy is strongly suspected. Psychogenic Previously, psychogenic impotence was believed to be the most common, thought to affect 90% of impotent men (Masters and Johnson, 1965). A subinguinal approach is easier in men with high, lax, capacious external rings and in men with long cords and low-lying testes. World Health Organization Task Force on Methods for the Regulation of Male Fertility. Study of the prevalence of female sexual dysfunction in sexually active women 18 to 40 years of age in Medellin, Colombia. An additional 5-mm port may be placed in the midaxillary line midway between the iliac crest and ribs for additional retraction if needed. Data from the National Social Life, Health, and Aging study indicated that 62%, 40%, and 17% of women aged 57 to 64, 65 to 74, and 75 to 85 reported having sex in the previous year, respectively. Plaque softening was noted in all patients, and 83% noticed that plaque-related changes in erectile function had arrested or improved. In most published series, pure seminoma accounts for less than 8% of late relapse events (Baniel et al, 1995; George et al, 2003; Ronnen et al, 2005; Sharp et al, 2008). Recently several groups have described the technique of glans resurfacing for penile squamous carcinoma of the glans penis. The perineal body receives fibers from the anterior portion of the anal sphincter and is the central point of insertion of the superficial transverse perinei muscles that arise at the ischial tuberosities. From the neurons in the spinal cord and peripheral ganglia, the sympathetic and parasympathetic nerves merge to form the cavernous nerves, which enter the corpora cavernosa and corpus spongiosum to modulate the neurovascular events during erection and detumescence. Efficacy of sildenafil as adjuvant therapy to selective serotonin reuptake inhibitor in alleviating premature ejaculation. All of the superficial lymph nodes within the described area are removed, as are the deep inguinal nodes that are located primarily medial to the femoral vein to the level of the inguinal ligament. Distribution of retroperitoneal metastases after chemotherapy in patients with nonseminomatous germ cell tumors. The basic aim of goal-directed management is to allow the patient or couple to make an informed selection of the preferred therapy for sexual fulfillment based on a sound understanding of all treatment options after completing a thorough discussion with the treating clinician. The dye (or radioactive tracer) is transported by the afferent lymphatics to a specific node in the regional nodal basin. Body morphology features such as increased height are observed in only 30% of Klinefelter males, and consequently the condition cannot be excluded by physical examination and physical inspection alone (Groth et al, 2013).
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It is hypothesized that women are more likely than men to report flexibility in sexual attraction and behavior (Baumeister, 2000). One or both sides may be hypoplastic, indicating an absence of the scrotal contents since birth (Niederberger, 2011). Superimposed on this, there are annual and daily rhythms of testosterone production. Linder and colleagues (2006) demonstrated that penile erection requires association of soluble guanylyl cyclase with endothelial caveolin-1 in rat corpus cavernosum. This test is designed to assess afferent sensory mechanisms and stimulus processing at spinal and supraspinal nervous system levels. Retroperitoneal lymphadenectomy for clinical stage A testis cancer (1965 to 1989): modifications of technique and impact on ejaculation. Penile deviation remained stable in those receiving active drug; penile curvature deteriorated significantly in 32. It is important to recognize that medications may affect other components of the male sexual response cycle including sexual desire, arousal, and orgasm, which secondarily hampers erectile function. The direct effects of antihypertensives on male reproductive function is less clear. The foreskin is reduced, and a second incision is marked, following the outlines of the coronal margin and the V of the frenulum on the ventral side. Nonrandomized comparison of primary chemotherapy and retroperitoneal lymph node dissection for Chapter34 NeoplasmsoftheTestis 814. Patients who have undergone prior substitution urethral reconstruction, particularly where skin has been incorporated into the urethra, have been shown to be poor candidates for implantation with the UroLume stent because contact of the stent with the skin is associated with a virulent hypertrophic reaction. The spinous process projects posteroinferiorly, and the transverse processes project posterolaterally. The actual stricture repair involves elevation of the midline skin island, based on the dartos fascia of the penis and the tunica dartos of the scrotum. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk Vasoactive intestinal polypeptide/phentolamine for intracavernosal injection in erectile dysfunction. One of the most distressing problems we see is a patient who complains that the surgeon has removed too much skin. Patients are discharged on a regimen of oxybutynin and a suppressive antibiotic only if the preoperative urine culture was positive. Concomitant use of sildenafil and a vacuum entrapment device for the treatment of erectile dysfunction. Testicular cancer: marked birth cohort effects on incidence and a decline in mortality in southern Netherlands since 1970. It is also reserved for patients who refuse the procedure; for patients in places where technology is not available; and for patients in whom angioembolization has failed (Ji et al, 1994; Berger et al, 2001; Mulhall, 2006). Perturbation of genital response (thinning of vagina, dryness, rise in pH) is often attributable to hypoestrogenism from menopause (Bachmann et al, 1999). Although no standard evaluation for assessment of penile sexual sensitivity has been established, light touch and biothesiometry can be used (Levine and Burnett, 2013). The importance of retaining blood in the penis was stressed by Dionis (1718; quoted by Brenot, 1994), who attributed this to the muscles cramping the veins at the proximal end, and by Hunter (1787), who thought that venous spasm prevented the exit of blood. Sexual side effects of antidepressants in men and women are varied but are important factors governing compliance because these drugs are commonly prescribed to younger and middle-aged adults. However, no drugs have been approved by regulatory agencies for this purpose and most drugs that have been identified for potential use have limited efficacy, impart significant side effects, or are as yet considered experimental in nature. If the mediastinal disease is not contiguous, the timing of mediastinal dissection is guided in part by the pathology of the retroperitoneum. It has also been proposed that mesh grafts take readily because of increased levels of growth factors, possibly as a function of the slits. Intracavernous injection of prostaglandin E1 in combination with papaverine: enhanced effectiveness in comparison with papaverine plus phentolamine and prostaglandin E1 alone.
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Technologic advances in the way of interventional devices have rapidly gained interest. Sperm undergo many biochemical changes with passage through the epididymis (Brooks, 1983). In patients for whom multiple attempts at dilation or incision of these vesicourethral anastomotic stenoses have failed, Elliott and Boone (2001) proposed making an incision with placement of the UroLume endoprosthesis, followed at an interval by the placement of an artificial sphincter. Modifications of the Biemer design also include the glans construction technique that was originally described by Puckett and Montie (1978). A disadvantage of a retroperitoneal approach is the high incidence of varicocele recurrence, especially in children and adolescents, when the testicular artery is intentionally preserved. Severity of erectile dysfunction at presentation: effect of premature ejaculation and low desire. Patients with drug-eluting stents or a history of coronary artery disease are exceptions to this rule and should continue taking low-dose aspirin (81 mg) including on the day of the surgery. However, Mullhall and colleagues performed a series of simultaneous microsurgical vasovasostomies and varicocelectomies without intentionally preserving the cremasteric and periarterial network. Another trial randomizing patients to the use of sildenafil nightly or on-demand for 12 months with a 1-month washout showed that erection recovery was not different between patient groups (Pavlovich et al, 2013). A Pseudoepitheliomatous Micaceous and Keratotic Balanitis Pseudoepitheliomatous micaceous and keratotic balanitis is an unusual lesion that manifests as hyperkeratotic, micaceous growths on the glans and may have some of the microscopic features of verrucous carcinoma (see Chapter 16. With the successful cure of patients, an important treatment objective is minimizing treatment-related toxicity without compromising curability. Progressive skin extension: clinical and histological evaluation of a modified procedure using Kirschner wires. Women in the later stages of pregnancy may find some sexual positions uncomfortable; these may in some cases be resolved by use of alternative sexual positions or assistive cushions/furniture. As a result, men are often told by their physicians that nothing can be done during the acute phase and they should wait 6 months to a year, because there is a "good chance" that the disease process will resolve. The extent of the node dissection can be expanded based on intraoperative findings. They are glycoproteins composed of two polypeptide chain subunits, termed and, each coded by a separate gene. A double-blind, placebo-controlled study of the use of methylprednisolone in infertile men with sperm-associated immunoglobulins. In one method, dye was injected into the seminal vesicles until it could be visualized with a cystoscope flowing from the ductal orifices at the verumontanum, and the pressure at that point was measured (Eisenberg et al, 2008). The dopamine agonists bromocriptine and cabergoline may be prescribed for in nanograms per deciliter (ng/dL) to picograms per milliliter (pg/ mL) of less than 10: 1 indicates aromatase overactivity that would benefit from inhibitory therapy (Raman and Schlegel, 2002; Gregoriou et al, 2012; Schlegel, 2012). Conditions that result in anejaculation are primarily neurologic and include retroperitoneal lymph node dissection, pelvic surgery, multiple sclerosis, transverse myelitis, congenital neural tube defects, diabetes mellitus, and spinal cord injury (Brackett et al, 2009; Phillips et al, 2014). Proximal sharp dissection of the urethral bulb is carried out posteriorly and laterally, staying close to the bulb but avoiding entry, if possible, because bothersome bleeding will result. The postmenopausal ovary produces T; women who are surgically menopausal after oophorectomy experience a more marked decline in T compared to women who are naturally menopausal (Davison et al, 2005). Three nonresponders underwent salvage surgery and eventually died of their disease. Suprahilar resections are thought to carry a higher risk for chylous ascites because of disruption of the cisterna chyli and its contributing lymphatics. Capsule formation improves over time, whereas inflammation persists or becomes more pronounced. Effects of ageing and streptozotocin-induced diabetes on connexin43 and P2 purinoceptor expression in the rat corpora cavernosa and urinary bladder. UroLume has been taken off the market and is currently not available for implantation. Jordan and colleagues (2007) first reported the use of a vesselsparing excision and reanastomosis of the bulbar urethra. Low levels of total testosterone and bioavailable testosterone have been reported as predictive of an increased incidence of cerebral vascular accidents or transient ischemic attack, even after adjusting for conventional risk factors for cerebral vascular disease (Yeap et al, 2009).
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The unique vascular qualities of the penis allow careful repeated debridement as opposed to aggressive debridement. Circumcision is indicated in a young boy who has had recurrent urinary tract infections thought to be associated with the redundant preputial skin. Expression of caveolin-1 in penile cavernosal tissue in a denervated animal model after treatment with sildenafil citrate. If clear evidence of obstruction is found-that is, an epididymal sperm granuloma with dilated tubules above and collapsed tubules below-vasoepididymostomy is performed. Dubey and colleagues (2005) showed the extent of luminal narrowing to be a predictor of success with internal urethrotomy: the narrower the percent of narrowing, the worse the outcome, with a cutoff of 74% narrowing. Almost all of the reports showed high prevalence rates for men in their 70s and 80s, ranging from 50% to 75%. If the patient presents with the distal part having been disposed, or otherwise unavailable, the wound should be closed. The clinician may use brief checklists or questionnaires for the purpose of recognizing the problem and initiating its evaluation, although he/she should routinely perform a detailed interview to understand the nature of the sexual complaint. Without question, tubularized flaps provide better results than tubularized grafts. The mini-micro-epididymal sperm aspiration for sperm retrieval: a study of urological outcomes. However, some patients present with only lateral curvature, with the right side larger than the left, and curvature to the left. The block is bivalved for ease of application, which admittedly becomes more difficult as the course of radiotherapy progresses. Risk Factors Common risk factor categories associated with sexual dysfunction include the following: general health status, diabetes mellitus, cardiovascular disease, concurrence of other genitourinary disease, psychiatric/psychological disorders, other chronic diseases, and sociodemographic conditions. Although this report is one of the few with a consistent patient population and treatment regimen, further study of this approach is needed to confirm the findings of this singleinstitution series. Inflammatory strictures associated with gonorrhea were the most commonly seen in the past and are less common now. Previous studies have demonstrated no positive nodes deep to the fascia lata unless superficial nodes were also positive (Pompeo et al, 1995; Puras-Baez et al, 1995), which supports the efficacy of this procedure in surgical staging. Sympathetic fibers innervate the smooth muscle of the capsule and stroma for contraction. The differential distribution of these adenosine receptor subtypes largely determines whether a particular vessel relaxes or contracts as a result of adenosine stimulation (Tabrizchi and Bedi, 2001). Pathophysiology of varicocele in nonhuman primates: long-term seminal and testicular changes. Successful pregnancy and birth after intrauterine insemination using caput epididymal sperm by percutaneous aspiration. The assessment of whether or not sperm are living is essential if near or total asthenospermia is Secondary Semen Assays the haploid male gamete expresses different surface antigens than the remainder of diploid cells in the male body and consequently must be protected from the immune system by tight junctions between Sertoli cells (Walsh and Turek, 2009). They may arise from the urethra and protrude from the meatus in women (Yamashita et al, 2004; Aita et al, 2005). Laparoscopic surgery versus antegrade scrotal sclerotherapy: retrospective comparison of two different approaches for varicocele treatment. Whether such testing changes the management of such responses is unclear (Woodard and Diamond, 2009). The effect of temperature on epididymal function may help explain how varicocele and cryptorchidism affect male infertility. I believe these recurrences are likely the result of recanalization through the coils because, unlike with surgical repair, the veins are not ligated and divided. High prevalence of hypogonadotropic hypogonadism in men referred for obesity treatment. Disruption of endothelial function is an early indicator of the development of vascular disease (Triggle et al, 2012). The lymphatics of the glans join Symptoms Pain does not develop in proportion to the extent of the local destructive process and usually is not a presenting complaint. Animal studies demonstrate that the stimulation of sympathetic nerves or systemic infusion of epinephrine causes detumescence of the erect penis (Diederichs et al, 1991a, 1991b). In healing by secondary intention, epithelialization progresses from the wound edges.
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The results with split-thickness skin grafts are so good that full-thickness grafts are rarely used for coverage of the penis. Preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging penile cancer: results with pathological correlations. It is important to limit the excursion of the scissors to a 1-cm depth and to maintain the scissors on the pubic ramus. Autocrine regulation of Leydig cell differentiated functions by insulin-like growth factor I and transforming growth factor beta. Improved clinical outcome in recent years for men with metastatic nonseminomatous germ cell tumors. Although Schreiter and Noll (1989), who first described the procedure of mesh split-thickness skin graft, often proceeded to the second stage within 3 to 4 months, we wait 12 months between the first-stage and second-stage surgeries if a splitthickness skin graft is used. However, the association of cavernosal veno-occlusive dysfunction and trauma of the penis continues to be seen, and some patients have significant problems with erectile dysfunction after fracture-type injuries of the penis. The paternal age effect appears to increase the fraction of sperm with sex chromosomal aneuploidies (Wyrobek et al, 1996). Ackerman (1948) described a histologically similar tumor occurring in the oral cavity. Suggesting that a man consume locally grown produce to avoid ill effects of pesticides may not be in his best interest. Cadaveric dura mater graft for correction of penile curvature in Peyronie disease. Initial series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage 1 nonseminomatous germ cell testicular cancer. Patients with physical abnormalities had a variety of neurologic, arterial, and veno-occlusive dysfunction. Etilefrine is available as an oral or injectable treatment in some European countries. Endothelium-derived nitric oxide and cyclooxygenase products modulate corpus cavernosum smooth muscle tone. In this series, 100% of the nonirradiated fistulae were successfully closed with a mean follow-up of 20 months, 85% of the irradiated fistulae were closed in a single stage, and 12% required an additional procedure, with an ultimate closure rate of about 97%. The majority of men with lifelong premature ejaculation prefer daily drug treatment: an observation study in a consecutive group of Dutch men. Testis-Sparing Surgery Testis-sparing surgery (or partial orchiectomy) is highly controversial and has no role in the treatment of a patient suspected to have a testicular neoplasm with a normal contralateral testis. Blunt finger dissection through the external ring will free the vas to the internal inguinal ring if additional abdominal side length is necessary. It is important to note that most lubricants have spermatotoxic properties and may interfere with conception (Vargas et al, 2011). Treatment of symptomatic and/or infected lymphoceles includes percutaneous drainage with systemic antibiotics reserved for infected lymphoceles. Most relapses occur within 2 years of completing initial treatment, and these are classified as early relapse (de Wit et al, 1998; Nichols et al, 1998; Michael et al, 2000; Culine et al, 2007; Motzer et al, 2007). It is generally believed that bilateral node dissection in this setting is not necessary. An integrated analysis of alprostadil topical cream for the treatment of erectile dysfunction in 1732 patients. Cytokines cause cellular and local arterial wall inflammation and may lead to vascular smooth muscle apoptosis, degradation of the fibrin cap, and plaque rupture, thereby leading to platelet adhesion, thrombus formation, and ultimately angina or myocardial infarction (Malkin et al, 2003). Psychobehavioral intervention to reduce anxiety surrounding sexual activity is crucial (Rosenbaum, 2011). Thus sperm fertility maturation is, for the most part, achieved at the level of the late corpus or early cauda epididymis. The role of the levator ani muscle in evacuation, sexual performance and pelvic floor disorders. Several cycles of spermatogenesis coexist within the germinal epithelium at any one time, and they are described morphologically as stages. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of the North American Menopause Society. Prevalence of testicular size discrepancy in infertile men with and without varicoceles.
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A thorough review of 46 such tumors from the Armed Forces Institute of Pathology revealed an equal number of benign and malignant lesions (Dehner and Smith, 1970). Compared to white women, African-American women were less likely to express concerns about vaginal lubrication and attractiveness but were more likely to be concerned about sexually transmitted diseases. Any fluid exuding from the lumen is placed on a slide, mixed with a drop of saline, and sealed with a coverslip for microscopic examination. In our series of 1500 microsurgical operations, 43% of couples had achieved pregnancy at 1 year (Goldstein and Tanrikut, 2006) and 69% at 2 years when couples with female factors were excluded. In older boys and men, the vessels are more substantial and not easily sealed by compression, no matter how vigorous. In a doubleblinded, placebo-controlled trial of men with severe burn (40% to 70% of body surface), patients treated with a testosterone analogue, Oxandrolone, were found to decrease significantly both weight and net nitrogen loss while improving donor-site wound healing compared to the placebo group (Demling and Orgill, 2000). Evaluation of the genitals should start with careful inspection of the external genitalia including mons pubis, labia majora, labia minora, clitoris, and vulvar vestibule. Chylous Ascites Chylous ascites refers to the accumulation of chylomicroncontaining lymphatic fluid in the peritoneal cavity. Histologic classification of penile carcinoma and its relation to outcome in 61 patients with primary resection. Prostate Cancer Prostate cancer has become the most common nonskin malignancy in men in Western countries. Finally, testis volume may be more directly measured by ultrasonography of the scrotum (Sakamoto et al, 2007a, 2007b; Abdulwahed et al, 2013). Operative scars in the inguinal or scrotal region should alert surgeon to the possibility of iatrogenic inguinal obstruction (hernia repair) or vasal or epididymal obstruction (hydrocelectomy, orchiopexy) (Sheynkin et al, 1998a; Hopps and Goldstein, 2006). Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection. The distinction is significant, as the pathophysiologic basis of each is different. Transverse and longitudinal orientations are used to measure the length, width, and height of the prostate. In one study, penile length, measured from the pubopenile junction to the meatus, was 8. Diabetes and vascular impotence: does insulin dependence increase the relative severity Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes. The latter enters the spinal cord via the S2-S4 roots to terminate on spinal neurons and interneurons in the central gray region of the lumbosacral segment (McKenna, 1998). There are three important considerations for the use of flaps in urethral reconstruction: the nature of the flap tissue, the vasculature of the flap, and the mechanics of flap transfer. However, intravenous or intracavernous injection of atropine failed to abolish erection induced in animals by electrical neurostimulation (Stief et al, 1989a) and in men by erotic stimuli (Wagner and Uhrenholdt, 1980). Conversion to a cutaneous urinary conduit with use of reconfigured bowel from the existing orthotopic diver sion is another option (Bissada et al, 2004). In adults, circumcision can be done with local anesthesia, by blocking the dorsal nerves at the base of the penis and circumferentially infiltrating the superficial layers of the penile base. Investigators have studied the effects of Coenzyme Q10, or ubiquinone, a component of the mitochondrial electron transport chain, on semen analysis parameters in several small controlled trials, with improvement in sperm density and motility observed compared with placebo (Balercia et al, 2009; Safarinejad, 2009; Safarinejad et al, 2012; Lafuente et al, 2013). Comparison of selective internal iliac pharmaco-angiography, penile brachial index and duplex sonography with pulsed Doppler analysis for the evaluation of vasculogenic (arteriogenic) impotence. Many cellular elements contribute to the reshaping process, including chromosome structure, associated chromosomal proteins, the perinuclear cytoskeletal theca layer, the manchette of nuclear microtubules, subacrosomal actin, and Sertoli cell interactions. Chapter40 SurgeryofthePenisandUrethra 921 Dilation Urethral dilation is the oldest and simplest treatment of urethral stricture disease, and for a patient with an epithelial stricture without spongiofibrosis, it may be curative. Clinically detectable distant metastatic lesions to the lung, liver, bone, or brain are uncommon and are reported to occur in 1% to 10% of patients in most large series (Staubitz et al, 1955; Riveros and Gorostiaga, 1962; Beggs and Spratt, 1964; Derrick et al, 1973; Johnson et al, 1973; Kossow et al, 1973; Puras et al, 1978, reviewed in Pettaway et al, 2010). Patients are directed to stop taking oxybutynin 24 hours before the voiding trial. Prevalence of sexually transmissible pathogens in semen from asymptomatic male infertility patients with and without leukocytospermia. Inferior pubic rami resection with en bloc radical excision for invasive proximal urethral carcinoma. Having accomplished this task, redundant fibroblasts and myofibroblasts are eliminated by apoptosis. Graft techniques for correction of curvature are used but with far less frequency than in years past.
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The pathognomonic arteriographic finding is an arteriolacunar fistula; a characteristic intracavernosal coneshaped blush of contrast is seen at the site of the cavernous artery or arteriole laceration. Multiple factors are suspected to associate obesity with male infertility, and hypogonadotropic hypogonadism may or may not be involved (Hammoud et al, 2006; Aggerholm et al, 2008; Pauli et al, 2008; Hofny et al, 2010; Paasch et al, 2010; Teerds et al, 2011). The striated sphincter is anterior to the dorsal vein complex and lateral to the levator ani. Morphologic analysis of the various germ cells reveals at least 13 recognizable germ cell types in the human testis (Clermont, 1963; Heller and Clermont, 1964). Why some plaques undergo mineralization and others do not remains unknown, but it does appear that the extent of mineralization may have a bearing on a successful response to nonsurgical therapy; men with more extensive calcification are less likely to benefit from nonsurgical treatment (Chung et al, 2011a). This relation has also been demonstrated in postmenopausal women (Montalcini et al, 2007). This finding and the technical difficulty with lymphangiography make aspiration less practical as a staging technique for patients with no palpable lymph nodes. Although the location of the distraction injury has been shown to be an important factor in continence after reconstruction, this information should be a factor only in counseling of patients before the reconstruction and not in the treatment approach. The media layer of veins is significantly smaller than that of arteries and contains less vascular smooth muscle. We do not use pericatheter retrograde urethrography to evaluate patients who have undergone urethral reconstruction. Other than necessitating caution during evaluation, these diverticula do not usually cause problems or require treatment unless they are very large. Surgical procedures that compromise the bladder neck closure mechanism may result in retrograde ejaculation. Testis-sparing surgery may be considered for tumors less than 3 cm if the diagnosis is suspected preoperatively. In addition, prolactin may have a direct effect on the penis through its contractile effect on the cavernous smooth muscle (Ra et al, 1996). With extensive involvement, the inelastic dartos can be sufficient to restrain the penis and conceal the penile shaft. Long-term followup and selection criteria for penile revascularization in erectile failure. Oliver and colleagues (1994) first described the use of one to two cycles of carboplatin in 78 patients and reported only two relapses and no deaths. In the aforementioned Korean study, the adjusted odds for kidney stones increased with an increasing quintile of waist circumference (P <. In general, this type of assessment is preferred by andrology laboratories at present because it appears to more effectively correlate with clinical outcomes (Sakkas and Alvarez, 2010). The investigators found that patients with grade 3, or the most extensive, calcification (>1. Hematogenous metastases occur by means of the vascular structures of the corporeal bodies; lymphatic spread to the regional inguinal and pelvic nodes occurs by lymphatic permeation. It is interesting to note that 60% to 70% of plaques are located on the dorsal aspect of the penis and are usually associated with the septum (Pryor and Ralph, 2002). Late relapse of testicular germ cell neoplasms: a descriptive analysis of 122 cases. Use of a Dacron or Gore-Tex sleeve should be avoided because of the markedly increased risk of infection and ingrowth into the graft, which makes it impossible to remove. From animal studies, it is clear that the plasma membrane covering the sperm-head region harbors specialized proteins that participate in sperm-egg interaction (Saling, 1989). Because normal human testicular sperm are immotile as they enter the epididymis, and remain relatively immotile within the caput, mechanisms other than sperm motility must exist to transport sperm through the epididymis. The clitoris (both glans and bulbs) is composed of erectile tissue with large dilated vascular spaces. Reply by authors: Melanoma of the penis, scrotum and male urethra: a 40-year single institution experience. Relationship between cavernosal ischemia and corporal veno-occlusive dysfunction in an animal model. Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Leiomyomas also may be discovered incidentally during routine pelvic examination or an unrelated surgical proce dure (Cornella et al, 1997).
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In almost all parameters studied, including erection, ejaculation, and libido, patients scored less than controls (reduction in orgasm, in libido, and interest in sex). Care is taken to avoid pressure on the lateral aspects of the lower extremities and calf muscles. The elastin content allows tunical expansion and helps to determine stretched penile length. The role of surgery continues to evolve owing to advances in chemotherapy regimens, clinical staging modalities, and continued surgical innovation (Sheinfeld and Herr, 1998; Allaf et al, 2005; Albers et al, 2008). Conservative measures include ice applied to the perineum and site-specific compression. This scale may be of greater use in assessing the subjective components of sexual problems in women but it still cannot be used as a substitute for careful and meticulous history and physical examination. With experience, these tissues can be readily identified as more fibrous compared with lymphatic tissue. However, other researchers have observed no significant negative effects on sperm in fertile men exposed to high heat at work, and postulated that in the normal state, compensatory mechanisms protect the testis when a prolonged rise in ambient temperature occurs (Momen et al, 2010). Clinical parameters that predict successful outcome in men with premature ejaculation and inflammatory prostatitis. Objective responses were noted in 12 (57%), including 2 of 5 with distant metastases. The labia minora are thinly or not at all keratinized and consist of vascular tissue in a fibrous stroma (Yang et al, 2006). If not meticulously performed, vasography can cause stricture or even obstruction at the vasography site, which can complicate subsequent reconstruction (Howards et al, 1975b; Poore et al, 1997). It is important to clarify that many early studies characterized sexual desire in terms of spontaneous sexual interest and desire. The aneuploidy status and polyploidy status of sperm were first investigated owing to concern that advanced paternal age was associated with increased cases of trisomy, especially trisomy 21 or Down syndrome, in offspring. Because these meatotomies were seldom successful in the longterm, techniques were developed that allowed the spatulation of random penile skin flaps into the meatotomy defects. False-negative results may occur in aging patients and in patients with depression or anxiety, which may conditionally affect the physiology of sleep-related erectile phenomena. At our center, we perform neonatal circumcision with a penile block for anesthesia. In an attempt to standardize and improve reproducibility of assessment of sperm interaction with cervical mucus, investigators devised model systems in which sperm and mucus could be observed ex vivo (Niederberger et al, 1993). If the patient is circumcised, the sleeve of skin between the amputation injury and the old circumcision scar should not be discarded. Diagnosis and treatment of erectile dysfunction for reduction of cardiovascular risk. Radiotherapy of localised prostate cancer: analysis of late treatment complications-a prospective study. Prediction of necrosis after chemotherapy of advanced germ cell tumors: results of a prospective multicenter trial of the German Testicular Cancer Study Group. PostoperativeManagement Sterile fluff gauze dressings are held in place with a snug-fitting scrotal supporter. The cylinders are inflated with saline solution to produce penile rigidity during sexual activity and are deflated after intercourse. Schiller-Duval bodies, which resemble endodermal sinuses, are a characteristic feature and are seen in roughly half of cases. Two limitations of such an approach are clear: First, the data are derived from a fertile population and not an infertile one, and second, the clinician cannot rely on descriptive statistics to predict outcomes. Because structures such as the sperm tail share similar microtubular construction with cilia, conditions that affect this architecture frequently result in a variety of other clinical manifestations such as immotile sperm, congenital heart disease, chronic respiratory and otolaryngologic infections, and laterality defects (Ferkol and Leigh, 2012). As with the gonadal veins in males, the left ovarian vein enters the left renal vein, and the right ovarian vein empties into the anterolateral wall of the vena cava. The septal area, site for the central regulation of penile erection during waking and rapid eye movement sleep in rats: a stimulation study. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. They concluded that small lesions (smaller than 2 cm) were best managed with local resection, whereas deeperseated tumor often necessitates partial or total amputation.
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At 3 months, the capsule that forms around the reservoir typically protects it from any pressure increase and decreases the incidence of autoinflation (Wilson and Mulcahy, 2006). The testis is returned to the tunica vaginalis, which is closed with a continuous suture of 5-0 Vicryl. Such evaluation may confirm or define etiologic medical conditions associated with the sexual dysfunction. However, several authors have raised the issue that this causes a significant delay and could affect survival, especially among patients who are likely to be truly positive by virtue of the stage or grade of the primary tumor (Kroon et al, 2005b; Pettaway et al, 2007). The theory is that certain cancers typically do not spread to other lymph nodes without the necessary and stepwise involvement of the sentinel node first. Confirmatory biochemical testing should be performed to support any clinically suspected cases. Dermoid cysts are differentiated from epidermoid cysts by the presence of adnexal structures such as glandular elements, adipose tissue, and cartilage. Subsequent procedures in this setting depend on the results of frozen-section analysis. A septum separates the corpora cavernosa but is permeable distally to allow for free communication between their vascular spaces. The external spermatic fascia is closed with interrupted 5-0 Vicryl, facilitated by the previously placed suture at the apex of the external spermatic fascia. In addition, it is not always necessary, and usually not beneficial, to dilate the stricture at the time of the initial endoscopic evaluation. T levels rise during the follicular phase to a peak around the time of ovulation (Roney and Simmons, 2013). The retroperitoneal pathology in this group revealed active cancer in 80% and teratoma in 20%. Careful attention to retroperitoneal lymphatic anatomy with ligation of large-caliber lymphatics is thought to minimize the risk of this complication. Traction has been shown in nonpenile tissue models to induce cellular proliferation by several pathways (Ilizarov, 1989; Sun et al, 1996; Molea et al, 1999; Assoian and Klein, 2008; Bueno and Shah, 2008). Initially, semirigid prostheses were more popular than inflatable devices, primarily because they were easier to implant and rarely required mechanical revision (Wilson and Mulcahy, 2006). Viability of the skin flaps raised during the dissection depends on anastomotic vessels in the superficial fatty layer of the Camper fascia that course lateral to medial along the natural skin lines. Patients do report additional engorgement with sexual stimulation, with return to partial erection after climax. The patient is maintained on bed rest for 2 or 3 days, and pneumatic compression stockings are used. Relapses occurring more than 2 years after completion of initial therapy are classified as late relapse and differ substantially in terms of prognosis and therapy (discussed later). The superficial group is composed of 4 to 25 lymph nodes that are situated in the deep membranous layer of the superficial fascia of the thigh (Camper fascia). In one study, sensitivity was greatest in men with transitional cell carcinoma (80%) and in those with tumors involving the pendu lous urethra (73%) (Touijer and Dalbagni, 2004). Another approach, especially when the female partner is young, is to do the vasovasostomy or vasoepididymostomy first. In most case reports of metastatic priapism, the primary malignancy is genitourinary (prostate and bladder). The anterior urethra and labia drain to the superficial and then to the deep inguinal lymph nodes (Carroll and Dixon, 1992). Women with neuroproliferative vestibulodynia will have marked pain with even light contact against the vestibular tissue (Goldstein and Burrows, 2008). Until recently, treatment options have been limited to behavioral and psychological procedures. Routine cardiac assessment is not necessary for all patients with erectile dysfunction. In these patients, serum 17-hydroxyprogesterone, 4-androstenedione, renin, and testosterone can be used to assess response to therapy (Pierre et al, 2012). The main side effect is a reduction of sexual desire, which occurs in up to 70% (Iversen et al, 2001). Limited data support that sperm parameters may concurrently improve (Raman and Schlegel, 2002; Gregoriou et al, 2012; Schlegel, 2012).
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This is the least invasive procedure but often requires 10 to 20 passes to obtain an adequate yield. This procedure can be accomplished as a Y-V-plasty after the excision of any scarred ridge of neourethra. Pathologic features of epidermoid carcinoma of the penis: a prospective study of 66 cases. These arteries vary in number and location with the most common variant being the middle adrenal artery arising from the aorta and the inferior adrenal arising from the renal artery. Cryptorchidism As described elsewhere in this text, during the fifth week of gestation, cells destined to become gonads arise in the posterior abdominal wall of the developing embryo (Lewis and Kaplan, 2009). Partial pubectomy can be performed with the reciprocating attachment of the Aesculap surgical drilling device (Aesculap, Tuttlingen, Germany); this makes placement of the sutures technically straightforward and improves the exposure for the dissection and resection of the distraction fibrosis. PreoperativeEvaluation Before attempted surgical reconstruction of the reproductive tract, adequate spermatogenesis should be documented. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. The cholinergic supply does not appear important for motor activity of the vas deferens (Baumgarten et al, 1975). In genitourinary reconstructive surgical procedures, we tend to use the term island flap. Association between viral hepatitis and erectile dysfunction: a population-based case-control analysis. However, until additional long-term studies become available, laser ablation should be performed with the understanding that local recurrences may develop and that close surveillance and patient self-examination are necessary for early detection. It is important for the urologist to have a medical oncology partner who possesses the clinical ability to assess bleomycin toxicity, to limit the dose when necessary and to obtain pulmonary function testing when appropriate before sending the patient to surgery to minimize risk of postoperative acute respiratory distress syndrome. When performed with the patient under local anesthesia, a cord block is necessary to minimize pain. The semantic variations in published reports on female pelvic muscle anatomy can complicate interpretation of published research. The gonadal vein is placed on gentle traction and bluntly dissected down to the internal ring. In my opinion, the reservoir should always be placed through a separate incision (if the implant is performed via a penoscrotal approach) and placed in a submuscular position. With the widespread prescribing of opioid analgesics, their use as a cause of hypogonadotropic hypogonadism should be suspected in all such hypoandrogenic men. A review of studies focusing on penile prosthetic infection between 2000 and 2012 suggested that the most important factors to minimize the risk of device infection include the use of antibiotic-coated prostheses and procedures that decrease inoculating bacteria into the surgical wound. In the event of a sympathetic outflow (autonomic dysreflexia), termination of the procedure should be sufficient to break the response; however, intravenous access allows for delivery of sympatholytic agents should they become necessary. Subclinical disease may be detected by the application of 5% acetic acid solution to the penis, followed by inspection with a magnifying glass. Deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage. Systemic diseases such as morbid obesity, chronic malnutrition, and type 2 diabetes may also be associated with hypogonadotropic hypogonadism (Dhindsa et al, 2004; Sokol, 2009). Before the electroejaculation sequence, a digital rectal examination and anoscopy are performed. Intralesional administration of large doses of human leukocyte interferon for the treatment of condylomata acuminata. Chapter37 TumorsofthePenis 851 agent that produces calciuria, such as calcitonin, to rapidly lower serum calcium levels. Data suggest that diminishing the glans sensitivity may inhibit the spinal reflex arc responsible for ejaculation (Wieder et al, 2000). Vaginal suppositories containing the benzodiazepine drug diazepam (10 mg) have been advocated by some experts for pelvic pain syndromes including dyspareunia.
