Erectile impotence as complication of direct vision cold knife urethrotomy

Erectile dysfunction in patients undergoing multiple attempts at hypospadias repair: Etiologies and concerns

INTRODUCTION

One-third of adult patients presenting for the repair of persistent penile defects after failing multiple hypospadias repair attempts during childhood will complain of erectile dysfunction (ED). The goal of this paper is to identify possible etiological causes of its onset.

MATERIALS AND METHODS

Five selection criteria were used for entrance into the study: 1) Patients had to have failed ≥ three prior hypospadias repair attempts. 2) Present for evaluation between 18 and 40 years of age. 3) No known congenital or medical anomaly could be present that could have predisposed to erectile dysfunction. 4) Sexual history inventory for men (SHIM-5 score) completed. 5) All patients with moderate to severe ED (SHIM scores ≤ 16) underwent psychological screening; individuals with good quality spontaneous or self-stimulated erections, experiencing major life events, or had documented psychological problems were excluded from the study. One hundred consecutive patients meeting these criteria were assessed. We evaluated multiple factors to discern if they were associated with the onset of ED: the initial location of the urethral meatus, if a corporoplasty was performed, the type of corporoplasty used, if the urethral plate was divided or resected, the use of a ventral corporal graft, the total number of open reparative procedures performed before referral, the number of direct visual internal urethrotomies (DVIU) performed, the length of a urethral stricture at the time of the referral and whether lichen sclerosus was present. Statistical evaluations used chi-square analysis, two-tailed t-tests, or a logistic regression model where indicated, p-values < 0.05 were considered significant.

RESULTS

37% (37/100) of our patients complained of moderate to severe ED (SHIM score ≤16). Statistical analysis comparing patients with ED to those without ED (63%:63/100), revealed patients with ED were older, median age 34 yrs (range 20-40) vs 26 yrs (range 18-40) p = 0.0212, had undergone division of the urethral plate 70.3% (26/37) vs 47.6% (30/63), p = 0.0276, had placement of a ventral corporal graft, 24% (8/33) vs 1.5% (1/67), p = 0.0003 or had undergone repetitive DVIU's to manage urethral stricture disease, median number 4 (range 0-15) vs 0 (range 0-6), p < 0.0001, see table.

CONCLUSIONS

The early onset of ED in patients that failed multiple attempts at hypospadias repair in childhood is associated with advancing age, division of the urethral plate, and prior ventral corporal grafting. Especially significant is the association of ED to the use of repetitive internal urethrotomy to manage urethral stricture disease.

Overcoming scarring in the urethra: Challenges for tissue engineering

Urethral stricture disease is increasingly common occurring in about 1% of males over the age of 55. The stricture tissue is rich in myofibroblasts and multi-nucleated giant cells which are thought to be related to stricture formation and collagen synthesis. An increase in collagen is associated with the loss of the normal vasculature of the normal urethra. The actual incidence differs based on worldwide populations, geography, and income. The stricture aetiology, location, length and patient's age and comorbidity are important in deciding the course of treatment. In this review we aim to summarise the existing knowledge of the aetiology of urethral strictures, review current treatment regimens, and present the challenges of using tissue-engineered buccal mucosa (TEBM) to repair scarring of the urethra. In asking this question we are also mindful that recurrent fibrosis occurs in other tissues-how can we learn from these other pathologies?

Male urethral strictures and their management

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

Physiology of penile erection and pathophysiology of erectile dysfunction

This article reviews the physiology of penile erection, the components of erectile function, and the pathophysiology of erectile dysfunction. The molecular and clinical under-standing of erectile function continues to gain ground at a particularly fast rate. Advances in gene discovery have aided greatly in working knowledge of smooth muscle relaxation/contraction pathways. The understanding of the nitric oxide pathway has aided not only in the molecular understanding of the tumescence but also greatly in the therapy of erectile dysfunction.

Recent trends of genitourinary endoscopy in children

Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.

Direct vision internal urethrotomy for the treatment of pediatric urethral strictures: analysis of 50 patients

PURPOSE

In an attempt to evaluate our experience with the treatment of pediatric urethral stricture disease we performed a retrospective review of patients undergoing direct vision internal urethrotomy (DVIU).

MATERIALS AND METHODS

The computerized surgical logs at 2 pediatric hospitals were reviewed to identify patients who underwent DVIU between 1992 and 2001. Hospital and clinical charts were then reviewed. Many variables were analyzed, including patient age, etiology of stricture, technique and clinical outcomes. Minimum followup to be included in clinical outcome analysis was 12 months.

RESULTS

A total of 50 patients were identified (mean age 7.7 years, range 6 months to 17 years). The most common etiology for stricture formation was previous hypospadias repair (20 patients [40%]). Forty patients met the 12-month minimum followup requirement for clinical outcome analysis. Of these patients 20 (50%) had no symptoms to suggest recurrent stricture at a median of 2.0 years (mean 2.7 years, range 12 months to 7 years). Seventeen patients (42.5%) had symptoms of recurrent stricture at a median of 8 months (mean 13 months, range 2 months to 5 years). Technical factors did not influence the ultimate success or failure of the procedure.

CONCLUSIONS

DVIU provides a therapeutic option that successfully treats approximately half of the patients with a reasonably low complication rate. Complications following DVIU should not preclude its use as a therapeutic modality for the treatment urethral strictures in children. If the child fails the initial DVIU, repeat attempts at endoscopic correction of urethral stricture should be abandoned in favor of definitive urethroplasty.

Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients

PURPOSE

We reviewed our experience with anastomotic urethroplasty for anterior urethral stricture.

MATERIALS AND METHODS

A chart review revealed 168 patients 6 to 82 years old (mean age 38) with at least 6 months of followup (mean 70, range 6 to 291) after anastomotic urethroplasty.

RESULTS

Average stricture length was 1.7 cm. Of the 168 patients stricture recurred in 8 (5%) but was managed by direct vision internal urethrotomy or a single dilation in 5, while repeat urethroplasty was required in 3 (2%). In these 3 cases extenuating circumstances included patient dislodgment of the catheter with attempts to replace it that disrupted repair, a history of urethrocutaneous fistula and periurethral abscess, and previous irradiation complicating the stricture in 1 each. Other complications were uncommon, such as transient thigh pain or numbness in 3 patients (2%), small wound dehiscence in 2 (1%), and scrotal hematoma, erectile dysfunction and self-limited pulmonary edema in 1 (less than 1%) each.

CONCLUSIONS

Anastomotic urethroplasty for anterior stricture has a high success rate of 95%. It is technically straightforward and complications are uncommon. Cure by anastomotic urethroplasty should be strongly favored over long-term management by direct vision internal urethrotomy or dilation.

Neural pathways and central sites involved in penile erection: neuroanatomy and clinical implications

Penile erection occurs in response to tactile, visual, and imaginative stimuli in humans. In animals olfactory and auditory cues are particularly important. The participation of multiple sites with the brain and spinal cord, and coordination of somatic and autonomic pathways make sexual behavior in general, and erection in particular, vulnerable to neurologic injury and disease. Sites within the brain and spinal cord act in concert to process, coordinate, then distribute the neural inputs necessary for sexual behavior including erection. Activation of neurons in some of these regions either pharmacologically or by electrical stimulation has been associated with penile tumescence. This review will provide a geographic framework for understanding the neuroanatomical basis of penile erection based primarily on animal data. Following discussion of the anatomical substrates, a clinical correlation is then provided to confirm and reinforce these experimental observations.

Sexual function after transurethral prostatectomy

The potency of 98 men who underwent transurethral resection for benign prostatic enlargement was assessed before and after operation in a prospective study. Preoperatively, 38 could not maintain their erections long enough to achieve coitus. Three months after operation a decrease in erectile ability had been experienced by three of the remaining 60 patients, while two reported an improvement. At the six-month follow-up two of these patients stated that they had recovered their preoperative potency, while the third patient still experienced reduced erectile function. Examination showed normal penile blood pressure but testing with papaverine showed reduced tumescence.

Erectile dysfunction following direct vision internal urethrotomy

A total of 104 evaluable patients 20-90 years old treated by direct vision internal urethrotomy a.m. Sachse for urethral strictures reported retrospectively via a questionnaire their sexual potency before and after internal urethrotomy. Eleven patients (10.6%) experienced partial or total erectile dysfunction following the operation, most of whom had distal and long strictures. Eight were evaluated for impotence and on grounds of a comprehensive history, physical examination, penile Doppler investigations, and papaverine tests it was concluded that 3 patients might have achieved an abnormal communication between the corpus cavernosum and corpus spongiosum. In two of the patients cavernosographies were carried out and in one total opacification of the corpus spongiosum was demonstrated, but the exact location of the leak could not be pinpointed, and surgical treatment therefore not rendered feasible. Possible factors in the development of erectile dysfunction following internal urethrotomy are analyzed.

Sexual dysfunction after prostatectomy

One of the major and disconcerting complications of prostatectomy is impotence. Several studies have reported only a small reduction in potency rates following prostatectomy but have not examined the effect of surgery per se on a group of men in whom one could expect a significant incidence of reduced potency. In order to rectify this defect, a prospective study was undertaken to assess the effect of transurethral resection of the prostate (TURP) and other general surgical procedures on two age-matched populations. In all cases potency and ejaculatory function and frequency of intercourse were assessed pre- and post-operatively. Potency was retained in 86% of men undergoing TURP and in all of the men undergoing general surgical procedures (p less than 0.01). Of those men who indicated that they were capable of having sexual intercourse prior to operation, 88% were unaffected by TURP. In the general surgical group 97% were unaffected. Thus it would appear that TURP has a significant effect on sexual function which cannot be accounted for by the stress of surgery or the age of the population undergoing operation.

Excisional repair of urethral stricture. Follow-up of 90 patients

One hundred five patients with urethral stricture of various causations were treated with excision of the stricture and oblique end-to-end anastomosis. Fifty-two patients (49%) had had one or more previous operations and dilatations, respectively. The immediate postoperative complication rate was 9 per cent. Ninety patients could be followed for one to eight years. The success rate was 93 per cent. Five patients had recurrent strictures. The failures were due to abscess formation, perineal hematoma, and excessive length of stricture.

Neuroanatomy of penile erection: its relevance to iatrogenic impotence

The neuroanatomy of erection in men is not well defined. Recently, we isolated successfully the cavernous nerves for acute and chronic neurostimulation to induce penile erection in dogs and monkeys. We then investigated the anatomy of these nerves in humans by cadaveric dissection and serial histologic sectioning. Our experience in tracing the spinal nuclei responsible for vesical and urethral function by transportation of horseradish peroxidase enabled us to explore the location and organization of the spinal center for erection. Thus, systemic knowledge of the neuroanatomy of erection was accumulated. The spinal nuclei for control of erection are located in the intermediolateral gray matter at the S1 to S3 and T12 to L3 levels in dogs, and the S2 to S4 and T10 to L2 levels in humans. From these sacral nuclei axons issue ventrally and join the axons of the nuclei for the bladder and rectum to form the sacral visceral efferent fibers. These fibers emerge from the anterior root of S2 to S4, and join the sympathetic fibers to form the pelvic plexus, which then branches out to innervate the bladder, rectum and penis. The fibers innervating the penis (cavernous nerves) travel along the posterolateral aspect of the seminal vesicle and prostate, and then accompany the membranous urethra through the genitourinary diaphragm. These fibers are located on the lateral aspect of the membranous urethra and ascend gradually to the 1 and 11 o'clock positions in the proximal bulbous urethra. Some of the fibers penetrate the tunica albuginea of the corpus spongiosum, while others spread to the trifurcation of the terminal internal pudendal artery and innervate the dorsal, deep and urethral arteries. Shortly before the 2 corpora cavernosa merge the cavernous nerves penetrate the tunica albuginea along with the deep artery and cavernous vein. The terminal branches of these nerves innervate the helicine arteries and the erectile tissue within the corpora cavernosa. Because of the intimate relationship of the cavernous nerves to the rectum, prostate and urethra, they can be damaged easily during urological and pelvic procedures. This systemic knowledge of the human cavernous nerves from the spinal center to the erectile tissue should permit a better understanding of erection and impotence. Furthermore, with the aid of intraoperative neurostimulation, the cavernous nerves may be identified and preserved, thereby preventing iatrogenic impotence.