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Resumen Objetivo Comparar las lesiones ureterales intraoperatorias ocasionadas durante la CRIR con insercion de VAU con la tasa de infecciones postoperatorias tras la CRIR sin insercion de VAU. Pacientes y metodos En este ensayo aleatorizado los pacientes que recibieron una indicacion de una CRIR entre enero de 2017 y diciembre de 2017 se dividieron en 2 grupos. En el grupo A no se utilizo VAU y en el grupo B si se utilizo VAU. Se realizo la clasificacion de la escala Post-Ureteroscopic Lesion Scale (PULS) tras retirar la VAU o el ureteroscopio flexible. Las lesiones del ureter proximal, medio y distal se evaluaron y compararon segun la escala PULS. Ademas, los pacientes de ambos grupos recibieron seguimiento postoperatorio para evaluar el desarrollo de cualquier enfermedad infecciosa. Resultados El estudio incluyo a 181 pacientes, 89 del grupo A y 92 del grupo B. La tasa de ausencia de calculos global, los fragmentos residuales clinicamente insignificantes y la tasa de ausencia de calculos final fueron del 41,4%, 53,5% y 95%, respectivamente. Hubo 33 (37,1%) pacientes con lesiones ureterales en el grupo A y 42 (45,6%) pacientes con lesiones ureterales en el grupo B, sin diferencias estadisticamente significativas. Por otra parte, la tasa de infeccion postoperatoria fue mucho mayor en el grupo A (37,1% frente a 16,3% p = 0,03). Conclusiones No se ha visto un mayor numero de lesiones ureterales tras la insercion de la VAU. La insercion de una VAU durante la CRIR resulta en una tasa menor de infecciones postoperatorias. Numero de registro del ensayo clinico (numero de registro ISRCTN): 55546280.

Objective To compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion. Patients and methods In this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication. Results The evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P = 0.03). Conclusions UAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections. Clinical Trial Registration Number (ISRCTN registry number) 55546280.

Çalışmada 21 yazar bulunmaktadır. Bu yazarlardan sadece Bursa Uludağ Üniversitesi mensuplarının girişleri yapılmıştır. Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

A lot of interest has been recently attracted to miniaturized Percutaneous Nephrolithotomy (PCNL). Smaller diameter tracts and instruments, in comparison to standard PCNL are utilized to decrease the morbidity of PCNL. However, a debate is ongoing regarding the safety and efficacy of these methods. The growing enthusiasm toward miniaturized PCNL led to different techniques and instruments, and eventually generated confusion in the terminology of PCNL. In this review, we highlight the different modalities of miniaturized PCNL, their indication, their safety and efficacy, and the appropriate terminology is suggested. A comprehensive review of current literature was performed using PubMed(®). Publications relevant to the subject were retrieved and critically appraised. Miniaturized PCNL was introduced with the desire to reduce access-related complications and bleeding. Miniaturized PCNL has yet to prove clear advantage over the standard PCNL. Nevertheless, the current experience proves the safety of the miniaturized techniques. Advantages of the miniaturized PCNL suggested in the literature are the lower bleeding rate and decreased hospital stay. In addition, the miniaturized PCNL has been proven a safe and effective modality of renal stone treatment in pediatric population.

Context The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice. Objective Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice. Evidence acquisition Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified. Evidence synthesis Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure. Conclusions In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

To evaluate the efficacy of doxazosin in inducing spontaneous passage of stones in the distal ureter and to compare its efficacy according to the size of the stone.Seventy-three patients with a mean age of 46.38 +/- 10.17 years who presented with a distal-ureteral stone were divided into four groups according to stone size and drug treatment:5 mm without doxazosin (group A; n=15); 5-10 mm (group B; n=16);5 mm with doxazosin 4 mg/day for 4 weeks (group C; n=20); and 5-10 mm with doxazosin 4 mg/day for 4 weeks (group D; n=22). Groups A and B served as controls for groups C and D, respectively.Spontaneous stone passage was documented in 9 patients (60%) in group A v 17 (85%) in group C (P=0.047) and 7 (43.75%) in group B v 16 (72.73%) in group D (P=0.036). The average expulsion time was 8.78 +/- 1.09 days in group A v 7.59 +/- 0.80 days in group C (P=0.004) and 12.14 +/- 1.35 days in group B v 7.06 +/- 1.29 days in group D (P0.0001). The number of pain episodes in group D patients was significantly lower than in group B (P +/- 0.0078).Doxazosin treatment proved to be safe and effective for distal-ureteral stones, as determined by earlier expulsion, decreased colic frequency, and absence of side effects. The efficacy of doxazosin was significantly higher for 5-to 10-mm stones than for smaller ones.

Purpose: To measure the hardness of two types of urinary stones: calcium oxalate monohydrate (COM; CaC2O4 · H2O) and dicalcium phosphate dihydrate (brushite; CaHPO4 · 2H2O). Materials and Methods: The composition of 28 calcium oxalate monohydrate and 22 brushite stones was characterized by infrared spectroscopy (FT-IR). Stone specimens were embedded in crystallographic resin, polished, and subjected to indentation tests using a Vickers tester. The hardness was calculated from measuring the diagonal lengths of the residual indentation on the specimen using the appropriate equation. Results: The COM stones showed hardness values ranging from 15.3 to 64.2 HV with a mean of 35.8 ± 13.3, while brushite stones ranged from 10.1 to 46.1 HV with a mean of 26.5 ± 15.1. The results of ANOVA showed that there were significant differences (P < 0.05) between the two stone types. Conclusions: Calcium oxalate monohydrate stones exhibited greater hardness than brushite stones when assessed with Vickers studies.

Purpose To investigate the viscoelastic properties of plastic pigtail stents after removal from patients using the method of dynamic mechanical analysis (DMA). Materials and methods Dynamic mechanical analysis was performed in 12 polymeric pigtail stents left indwelling for various periods of time (0-120 days). The encrustations were characterized by infrared spectroscopy, and their morphology was observed using scanning electron microscopy. Results Softening and stiffening behavior was observed. Stiffening was found specifically in the stents with heavy mineral deposits. Conclusions Material degradation becomes obvious after certain periods of time. The effect of stent degradation appeared in two forms: softening of the stent polymer, possibly through interaction with urine, and stiffening of the stent secondary to the formation of various insoluble mineral deposits covered by layers of organic matrix.

Purpose: A detailed clinical management of the urological manifestations of multiple sclerosis (MS) is presented as it is practiced in our department, and therapeutic algorithms are constructed. Materials and methods: One hundred and ten patients were consecutively and prospectively studied with a clinical syndrome of MS, ranging in age from 32 to 65 years of age. Clinical diagnosis of the voiding dysfunction associated with MS was classified as a malfunction causing either problems of bladder evacuation, or storage, or a combination of both. Results: All patients were initially managed in a conservative way avoiding surgical procedures and following primarily pharmacologic treatment, because of the quite common reversibility of MS. The detailed management of the related voiding dysfunction is given by the proposed algorithms. Conclusions: Our purpose was to present the algorithms that can help the practicing physician to come to reasonable conclusions as to therapeutical choices directed to specific pathophysiologic characteristics of voiding dysfunction related to MS.

Purpose: In the present study we have performed a correlation of the most prevailing clinical conditions of multiple sclerosis (MS) with overall drug response and the grade of the disease. Materials and methods:One hundred and ten patients were consecutively and prospectively studied with a clinical syndrome of MS, ranging in age from 32 to 65 years of age. In the present study we evaluated the patients with DESD (n = 35), detrusor hyperreflexia (n = 32), and/or low compliance (n = 8). The latter three conditions were considered as the most threatening, and thus a correlation with the drug response and the grade of the disease was attempted. Results: All patients were initially managed in a conservative way avoiding surgical procedures and following primarily pharmacologic treatment, because of the quite common reversibility of MS. Our results suggest that there is no correlation between the prevailing clinical status and drug response (p = 0.06) or grade of the disease (p = 0.07). The only statistically significant correlation was seen between grade of the disease and overall drug response (p < 0.0001) Conclusions: Therapeutic responses were dependent upon the grade of the disease. The continuation of this study recruiting more patients into various subgroups of voiding dysfunction will further validate the statistical correlations among disease grade and therapeutic responses.

Purpose: In this study a detailed clinical management is presented as it is practiced in our department, and possible correlations between grade of the disease and therapeutic responses are examined. Materials and methods: One hundred and ten patients were consecutively and prospectively studied with a clinical syndrome of MS, ranging in age from32 to 65 years of age. Clinical diagnosis of the voiding dysfunction associated with MS was classified as a malfunction causing either problems of bladder evacuation, or storage, or a combination of both. Therapeutic responses of the voiding dysfunction were correlated with grade of the disease. Mean follow up period was 54 months. Results: All patients were initially managed in a conservative way avoiding surgical procedures and following primarily pharmacologic treatment, because of the quite common reversibility of MS. A possible correlation of response to treatment according to grade of the disease was studied. There was significant difference in the response to drug treatment among patients of different grades favoring grade 1 patients with both storage and evacuation voiding dysfunction. Conclusions: Our suggested treatment has secured the conversion of a high pressure into a low pressure vesicourethral system,thus obviating possible risk factors for the upper urinary tract and the bladder itself. Therapeutic responses were dependent upon the grade of the disease.

We herein report a case of a female embryo who died in utero and at autopsy she was found to have bilateral renal agenesis with the extrarenal manifestations of Potter's syndrome together with mermaid syndrome which is a rare combination. From all the anomalies of the upper urinary tract bilateral renal agenesis seems to have a cardinal role in the survival of the embryo afflicted with the spectrum of associated anomalies.

An unusual case of a 15-year-old male who presented with a characteristic clinical syndrome of testicular torsion one week prior to our observation, is reported. During our intervention the testicle was not removed but, on the contrary, restoration of a satisfactory testicular albugineal appearance was achieved.

Purpose: We investigate the association of clinical and urodynamic findings with corresponding clinical grade and possible predictors of clinical grade of multiple sclerosis (MS).Materials and Methods: A total of 90 patients, 28 to 62 years old (mean age 45.8 +/− 12.1), with the clinical syndrome of MS were consecutively and prospectively studied. All patients were subjected to detailed video urodynamic evaluation and electromyography of the external urethral sphincter.Results: Urodynamic evaluation revealed detrusor hyperreflexia in 52 patients (57.7%), detrusor external sphincter dyssynergia in 27 (30%) and hypocontractility or areflexia of the detrusor in 15 (16.6%). Residual urine varied widely from 50 to 900 ml. Decreased compliance with areflexia was seen in 5 patients (5.5%) and nonrelaxing sphincter (but not contracting) with bladder hypercontractility was noted in 9 (10%). Statistical analysis followed comparison of 2 proportions. When patients with a less severe form (grades 1 and 2) wer...

Purpose: This study was undertaken to evaluate the immediate and long-term effects of the combination of alpha-blockers and antibiotics in the treatment of chronic prostatitis.Materials and Methods: The patients eligible for study were assigned to 3 groups: group 1-nonprostatodynia, abacterial prostatitis (134), group 2-prostatodynia (72) and group 3-chronic bacterial prostatitis (64). alpha-Blockers were administered to all patients of groups 1 and 2 with demonstrable high maximal urethral closure pressure and typical clinical complaints irrespective of the presence of inflammatory findings in expressed prostatic secretion. alpha-Blockers were given to 50% of patients with bacterial prostatitis. Antibiotics were administered to all patients with positive expressed prostatic secretion cultures, and in half of those with abacterial prostatitis and inflammatory expressed prostatic secretion. Mean followup was 22 months (range 6 months to 3 years). The sign 1-tailed test was used for statistical anal...

A case of isolated, bilateral, adrenal tuberculosis is presented. A 25-year-old male was admitted to the hospital due to lumbar pain, fever, weight loss and anorexia. Abdominal ultrasonography and computed tomography demonstrated bilateral adrenal enlargement. Laboratory investigations were remarkable for adrenal insufficiency. The Mantoux reaction was positive but there was no evidence of lung or urinary infection. CT-guided biopsy of the left adrenal gland was performed and established the diagnosis of adrenal tuberculosis.

The authors prospectively evaluated 24 consecutive female patients with type III stress urinary incontinence, ranging in age from 36 to 70 years (mean 55 years). All patients were operated upon and had a vesicourethral suspension by a Gore-Tex suburethral sling. All were evaluated urodynamically 6 and 30 months after surgery. In this group of patients clinical cure of incontinence was observed in 83.3% (20) and in the remaining 4 patients it was significantly improved. In 2 patients there was an erosion of the urethra and the sling had to be removed 3.5 years later. Five other women remained dry but complained of occasional irritative symptoms, and several urinary tract infections were recorded (2-3 per year), which were documented by positive urine cultures. In the remaining 17 patients no erosion was observed and no irritative symptoms were reported. The urodynamic evaluation revealed an excellent postoperative result both 6 months and 30 months after surgery.

Objective: To evaluate the use of Goretex pubovaginal sling and compare the results with a typical indigenous material graft made of rectal fascia. Methods: We have prospectively evaluated 48 consecutive patients in a randomized fashion in whom a sling procedure was performed to treat their type III incontinence. Sixteen women had a vesicourethral suspension (VUS) by a Goretex sling and another group of 32 patients, comparable in age range and medium age with the previous group, had a similar VUS by a sling from the rectus abdominis fascia. Both groups were evaluated urodynamically 6 and 30 months later. Results: In the first group, cure of incontinence was observed in 87.5% and in the remaining patients it was significantly improved. In 2 patients there was an erosion of the urethra and the Goretex sling had to be removed 3.5 years later. Three other women remained dry but complained of occasional irritative symptoms. In the remaining It there was no erosion and the excellent postoperative result was maintained. In the group with fascial slings there was no erosion observed and in general they had less irritative symptoms. Cure or improvement of incontinence was comparable with the first group when studied 6 months after surgery, but there was a significant difference in the 30 months postoperative evaluation. Conclusions: Use ofa Goretex sling provides better long-term results even though it is associated with somewhat increased morbidity.

Optical coherence tomography (OCT) images and histology images of metal stents (MSs) inserted in animal ureters were compared, and the reliability of an OCT-based automated method for the performance of quantitative evaluation of ureteral MSs was evaluated. A zotarolimus-eluting metal stent (ZES) and a bare metal stent (BMS) were inserted in each ureter of ten pigs and six rabbits. OCT was performed in unobstructed stented ureters. Histopathologic examination of the stented ureters embedded in glycol-methacrylate took place. Quadrants of OCT images were compared to their respective histologic images by employing two independent observers who delineated different layers in the quadrants of OCT images and correlated them to the respective histologic quadrants. Manual (integrated OCT device software) and automated measurements of the OCT images using an automated strut detection method were compared. The observers highly agreed on the delineation of urothelium from the lamina propria and the lamina propria from the muscle layer of the ureteral wall. The algorithm measurements were similar to the manual measurements, and the algorithm proved to be reliable in the evaluation of ureteral MSs. Significantly higher endothelial hyperplasia of the BMSs in comparison to the ZESs was also quantitatively demonstrated by the strut detection method. OCT proved to be a reliable method for the evaluation of ureteral MSs. OCT provided images of the stented ureteral lumen similar to light microscopy quality. Measurements of the stented ureter are reliably performed by the automated strut detection method.

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches. To present LESS and NOTES in its historical context and to clarify the associated terminology. Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT). The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4 years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that ‘laparoendoscopic single-site surgery’ (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy. The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.

The aim of this study was to investigate the patterns of renal function recovery during partial nephrectomy (PN) on an experimental solitary kidney rabbit model and establish the upper tolerable time limits of applied ischemia. Forty-eight New Zealand rabbits underwent an open right nephrectomy and after 30 days, the animals were clustered into five groups (A, B, C, D, E). The first four groups received an open left PN, under different types of ischemia. Groups A (n = 8) and B (n = 10) were subjected to 90 and 60 min of warm ischemia (WI), respectively, while groups C (n = 10) and D (n = 10) received 90 and 120 min of cold ischemia (CI) with ice-slush cooling. Group E (n = 10) served as sham group. Serum determinations of creatinine (SCr) and BUN were recorded preoperatively and on postoperative days (POD) 1, 3, 6 and 15. The animals were euthanized and the remaining kidneys were harvested and evaluated microscopically. The type and duration of ischemia were statistically significant parameters (P < 0.001). Groups B, C and D exhibited a similar pattern of recovery from trial initiation to the 15th POD (P = 0.788 and P = 0.068, respectively). Group A was extremely differentiated, with 100% mortality caused by uremia. The microscopic findings were consistent to the serum biochemistry. In our solitary kidney rabbit model, the upper limits of tolerable WI seem to be set on 60 min. CI can safely preserve the model’s renal function—even up to 120 min.

Objective: The purpose of this study was to assess the relationship between the length of perineal body, the anal position index, the total fourchette-coccyx distance and the anal-coccyx length and female urodynamic stress urinary incontinence (USUI). Patients and methods: The study included 57 women with USUI (group A) and 45 women without USUI as control (group B). All patients underwent a urodynamic evaluation and measurement of the length of perineal body (PB) and the distance between the fourchette and the inferior margin of coccyx (FC). PB is the distance between the fourchette and the center of anal orifice. The ratio PB/FC is the anal position index. Subtracting the PB length from FC distance equals the anal-coccyx (AC) length. Results: The student’s t-test showed no significant statistical difference between any of the measured lengths in the two groups. Moreover, in the USUI group, ANOVA did not show any significant relationship between the urodynamic parameters and the measured lengths. Regarding to the investigated urodynamic parameters only the maximum urethral pressure (Pura max) presented a significant statistical difference between the two groups (P = 0.009). Conclusion: Theoretically, a differentiation of perineal distances probably brings to the surface a laxity of the pelvic floor, a factor predisposing to USUI. Furthermore, the anterior position of anus can be a cause of constipation which also contributes to USUI. However, our study did not reveal any relationship between the perineal length measurements and USUI. Further investigation with longer series of patients is needed to show if this simple, inexpensive and non-invasive test could be added in the armamentarium of the diagnostic and prognostic investigation of USUI. Regarding to the urodynamic parameters, our results emphasize the importance of the Pura max parameter in the urodynamic evaluation of USUI.

To determine the composition and the extent of crystalline (and other) encrustation on ureteral catheters inserted under sterile conditions in stone formers, in comparison with catheters of the same type inserted in nonstone formers for the same time but for different clinical reasons.Forty consecutive self-retained polyurethane pigtail ureteral catheters removed by cystoscopy between November 2000 and February 2002 were studied, 30 from stone formers and 10 from patients without stone histories. The mean dwelling time was 55 days for the stone formers and 79 days for the other patients. The encrustations were collected and analyzed with Fourier-transform infrared spectroscopy, powder X-ray diffraction, or both. The stones from nine of the patients were also subjected to the same spectroscopic analysis. Representative sections of the catheters were investigated by scanning electron microscopy and energy-dispersive X-ray analysis.The most common encrustation in stone formers was calcium oxalate monohydrate. In patients without stones, deposits of organic compounds were found consistently. The mean mass of encrustation of stone formers was larger (71.05 mg) than that of patients without stones (1 mg).Calcium oxalate is the predominant type of encrustation on ureteral catheters in stone formers. Prevention of heavy encrustation should be directed to therapeutic measures concerning calcium oxalate lithiasis and development of new materials by the medical industry that are less prone to encrustation.

To compare the efficacy of apomorphine and sildenafil in men with nonarteriogenic erectile dysfunction (ED), 40 men were studied. Post-injection penile peak systolic velocity was greater than 25 cm s(-1). Twenty men started on apomorphine 2 mg and 20 on sildenafil 50 mg, the doses titrated up to 3 and 100 mg, respectively, if necessary. After a 1-week washout period each group switched to the other treatment mode. Efficacy was the percentage of attempts resulting in erections firm enough for intercourse, based on an event log data. The majority (85%) of the men had concomitant diseases, risk factors for ED and 95% were heavy smokers. The overall success rate of apomorphine was 62.7%, compared with 73.1% of sildenafil (Yates-corrected chi-square, P < 0.0004). The response to apomorphine 2 mg and sildenafil 50 mg was age related. Sildenafil was statistically more effective than apomorphine in impotent men with normal penile Doppler. Given the contraindication of sildenafil in men taking nitrates and the quick time of action of apomorphine, the two drugs are satisfactory first line therapeutic tools in such individuals and the choice should be based on patient's needs and preferences.

To evaluate the results of four currently used approaches for the treatment of clinically diagnosed varicoceles, and compare their influence on semen parameters.We prospectively evaluated 88 patients, 23-39 years old (mean age 31), with a clinically diagnosed varicocele. Patients were allocated randomly to be treated either by a retroperitoneal (group A), inguinal (group B), subinguinal (group C), or percutaneous venous embolization approaches (group D). All patients were evaluated 6 and 12 months postoperatively.Clinical recurrence of varicocele occurred in 4 patients of group A (18.2%), 1 patient of group B (4.5%), and 2 patients of group D (9.1%). Hydrocele formation was seen in 1 patient of group B (4.5%), and 2 patients of group C (9.1%). In all groups statistically significant improvement as to the sperm concentration was found in both the 6- and 12-month follow-up. This significance was more prominent in group C followed by groups B and D, and finally by group A. As to sperm motility, in group C there was a statistical significance in both follow-up evaluations, and in group B statistical difference was reached only in the 12-month evaluation. Sperm morphology did not differ in any of the groups postoperatively compared to the preoperative values.The subinguinal approach disclosed a more prominent improvement in both semen concentration and motility in the 6- and 12-month follow-up evaluation when compared to the other techniques. Furthermore, due to its simplicity and avoidance of opening the external oblique fascia, we believe it represents the more plausible approach when treating clinical varicocele.