Penile Self-amputation

Background A 24-year-old man was urgently transferred from an outside institution after self-amputating his penis.

Methods The patient was suffering from a paranoid schizophrenic delusional episode. Voices told him to amputate his own penis with a utility knife. He was taken emergently to the operating room by urology and plastic surgery. Cystoscopy was performed and a 14F percutaneous suprapubic catheter was placed. The amputated distal penis and the proximal stump were debrided. The urethra, dorsal artery, and neurovascular bundles were mobilized. The distal urethra was spatulated dorsally and the proximal urethra was spatulated ventrally. The urethra was reanastomosed over a 16F Foley catheter with interrupted, 4–0 absorbable, monofilament suture. The corpora were reanastomosed with interrupted, 2–0 and 3–0, absorbable, monofilament suture. The arteries and nerve were reanastomosed. Total ischemia time was between 4 and 5 hours.

Results The patient initially developed edema, ecchymosis, and mild incisional skin necrosis from the resulting reperfusion injury. However, the penile graft successfully maintained perfusion. He was discharged 2 weeks after his injury in stable psychiatric condition. His Foley catheter and suprapubic tube remained in place for 10 weeks. A voiding cystourethrogram (VCUG) demonstrated a patent urethra without evidence of urinary leakage or stricture. At the time of his VCUG, he experienced return of distal penile sensation and partial erections.

Conclusion Penile reimplantation after self-amputation is successful if ischemic time is minimized and a multidisciplinary approach with plastic surgery and microvascular anastomosis is performed.

Scrotal mesothelioma

A 67-year-old male patient presented with right scrotal swelling and underwent a right hydrocelectomy. A 1 cm paratesticular lesion was found within the hydrocele sac after entering the tunica vaginalis. Local excision grossly removed this in its entirety. Pathology returned as well differentiated papillary mesothelioma of the tunica vaginalis. Pathologic features and management options are discussed.

Urologic disease in a resource-poor country

BACKGROUND

Understanding the role that urologic disease plays within central Haiti could lead to the development of sustainable and regionally appropriate urologic care. We aim to document the prevalence of urologic surgical disease presenting for treatment in central Haiti.

METHODS

The present study is based on a retrospective review of surgical case logs at five Partners in Health and Zanmi Lasante hospitals in central Haiti. Data were collected from June 30, 2009, through July 29, 2010, and included patient demographics, disease processes, interventions required, surgeon name, and surgeon training (urologic trained versus non-urologic trained).

RESULTS

Urologic surgical disease comprised 498/5,539 (9.0 %) of all surgical cases in central Haiti from July 2009-July 2010. A total of 492 diagnoses and 498 urologic procedures on 469 patients were recorded. Most common diagnoses included hydrocele (33.3 %), phimosis (23.0 %), benign prostatic hyperplasia (10.8 %), and cryptorchidism (7.3 %). Hydrocelectomy was the most commonly performed procedure (160/498, 32.1 %), followed by circumcision (117/498, 23.4 %) and open prostatectomy (38/498, 7.6 %). Surgeon training (urologic versus non-urologic) was determined for 360/498 (72.3 %) of surgical cases. Urologic trained surgeons performed 55/360 (15.3 %) of all surgical procedures. Among patients who underwent prostatectomy, urology surgeons performed 14/31 (45.2 %) of open prostatectomies, and non-urology surgeons performed 17/31 (54.8 %). Urologists performed all transurethral resections of the prostate (9 vs. 0; p = 0.0051).

CONCLUSIONS

Urologic surgical diseases comprise a substantial source of morbidity for patients in central Haiti. Understanding the scale and scope of urologic disease is important in developing health systems to adequately address the regional burden of surgical disease in limited-resource settings.

Unidirectional barbed suture versus standard monofilament for urethrovesical anastomosis during robotic assisted laparoscopic radical prostatectomy

PURPOSE

V-Loc™180 (Covidien Healthcare, Mansfield, MA) is a new unidirectional barbed suture that may reduce loss of tension during a running closure. We evaluated the use of the barbed suture for urethrovesical anastomosis (UVA) during robotic assisted laparoscopic prostatectomy (RALP). Time to completion of UVA, post-operative anastomotic leak rate, and urinary incontinence were compared in patients undergoing UVA with 3-0 unidirectional-barbed suture vs. 3-0 Monocryl™ (Ethicon, Somerville, NJ).

MATERIALS AND METHODS

Data were prospectively collected for 70 consecutive patients undergoing RALP for prostate cancer between November 2009 and October 2010. In the first 35 patients, the UVA was performed using a modified running van Velthoven anastomosis technique using two separate 3-0 monofilament sutures. In the subsequent 35 patients, the UVA was performed using two running novel unidirectional barbed sutures. At 7-12 days postoperatively, all patients were evaluated with a cystogram to determine anastomotic integrity. Urinary incontinence was assessed at two months and five months by total daily pad usage. Clinical symptoms suggestive of bladder neck contracture were elicited.

RESULTS

Age, PSA, Gleason score, prostate size, estimated blood loss, body mass index, and clinical and pathologic stage between the 2 groups were similar. Comparing the monofilament group and V-Loc™180 cohorts, average time to complete the anastomosis was similar (27.4 vs. 26.4 minutes, p = 0.73) as was the rate of urinary extravasation on cystogram (5.7 % vs. 8.6%, p = 0.65). There were no symptomatic bladder neck contractures noted at 5 months of follow-up. At 2 months, the percentage of patients using 2 or more pads per day was lower in the V-Loc™180 cohort (24% vs. 44%, p < 0.02). At 5 months, this difference was no longer evident.

CONCLUSIONS

Time to complete the UVA was similar in the intervention and control groups. Rates of urine leak were also comparable. While the V-Loc™180 was associated with improved early continence, this difference was transient.

A candidate gene analysis of methylphenidate response in attention-deficit/hyperactivity disorder

OBJECTIVE

This study examines the potential role of candidate genes in moderating treatment effects of methylphenidate (MPH) in attention-deficit/hyperactivity disorder (ADHD).

METHOD

Eighty-two subjects with ADHD aged 6 to 17 years participated in a prospective, double-blind, placebo-controlled, multiple-dose, crossover titration trial of immediate release MPH three times daily. The subjects were assessed on a variety of parent and clinician ratings and a laboratory math test. Data reduction based on principal components analysis identified statistically derived efficacy and side effect outcomes.

RESULTS

Attention-deficit/hyperactivity disorder symptom response was predicted by polymorphisms at the serotonin transporter (SLC6A4) intron 2 VNTR (p = .01), with a suggested trend for catechol-O-methyltransferase (COMT) (p = .04). Gene × dose interactions were noted on math test outcomes for the dopamine D4 receptor (DRD4) promoter (p = .008), DRD4 exon 3 VNTR (p = .006), and SLC6A4 promoter insertion/deletion polymorphism (5HTTLPR) (p = .02). Irritability was predicted by COMT (p = .02). Vegetative symptoms were predicted by 5HTTLPR (p = .003). No significant effects were noted for the dopamine transporter (SLC6A3) or synaptosomal-associated protein 25 (SNAP25).

CONCLUSIONS

This article confirms and expands previous studies suggesting that genes moderate ADHD treatment response. The ADHD outcomes are not unitary but reflect both behavioral and learning domains that are likely influenced by different genes. Future research should emphasize candidate gene and genome-wide association studies in larger samples, symptom reduction as well as side effects outcomes, and responses over full therapeutic dose ranges to assess differences in both gene and gene × dose interactive effects.

Polymorphisms in the hANP (human atrial natriuretic peptide) gene, albuminuria, and hypertension

Atrial natriuretic peptide (ANP) jointly affects kidney function and blood pressure homeostasis and is a candidate susceptibility gene for both essential hypertension and kidney disease. We evaluated the relation between the ScaI and BstXI polymorphisms of the human ANP (hANP) gene, hypertension, and albuminuria in a clinical cohort of 1033 subjects, including type 1 and type 2 diabetic patients, nondiabetic subjects with essential hypertension, and nondiabetic normotensive control subjects. Microalbuminuria was present in 15%, 29%, and 2%, respectively, of type 1 diabetic, type 2 diabetic, and nondiabetic patients. Macroalbuminuria was present in 9% of type 1 diabetics, 21% of type 2 diabetics, and 31% of nondiabetics. Prevalence of hypertension was 31%, 58%, and 61% in normoalbuminuric, microalbuminuric, and macroalbuminuric subjects, respectively (P<0.0001). Genotype distributions were in Hardy-Weinberg equilibrium in all 4 patient subgroups. The frequency of the ScaI mutated allele (A(1)) was significantly lower in hypertensive than in control subjects (11% versus 19%, P=0.018) and in patients with macroalbuminuria (5%) as compared with normoalbuminuric subjects (16%; P<0.0001). In a nominal logistic model adjusting for gender, age, obesity, diabetes, micro/macroalbuminuria, and hypertension, the A(1) allele was independently associated with macroalbuminuria (odds ratio, 0.57; confidence interval, 1.39 to 3.59; P=0.003) but not with hypertension. In the same model, the frequency of the BstXI mutated allele (T(708)) was increased in the presence of microalbuminuria (odds ratio, 2.25; confidence interval, 1.39 to 3.59; P<0.001). We conclude that the mutated genotypes of the ScaI polymorphism are negatively associated with overt nephropathy, whereas the mutated genotypes of BstXI polymorphism are positively associated with microalbuminuria. hANP gene variants may exert a protective effect against the development and progression of kidney damage in diabetes.