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Indwelling catheter placement is a modifiable risk factor for urethral trauma. We implemented a multidisciplinary Foley Project protocol in June 2015, which consisted of a system-wide catheter education program, difficult urinary catheterization (DUC) algorithm, and skilled catheter nursing team to improve patient outcomes. A retrospective review of male DUC consults between June 2014 and September 2015 was performed. The preprotocol group includes consults received from June 2014 to May 2015. The postprotocol group includes consults received from June 2015 to September 2015. There were 74 patients in the preprotocol and 18 patients in the postprotocol group. The overall incidence rates of catheter-associated trauma during placement were 41.1% in the preprotocol and 5.9% in the postprotocol groups (p = .005). In the preprotocol group, 53.4% required a procedure by a urologist, whereas only 11.8% of patients in the postprotocol group required a procedure (p = .002). The Foley Project protocol reduced the frequency of catheter-associated trauma and procedures.

Objective The objective of the study is to determine if tamsulosin initiated in the emergency department (ED) decreases the time to ureteral stone passage at 1 week or time to pain resolution, compared to placebo. Methods We performed a prospective, randomized, double-blinded, placebo-controlled trial of tamsulosin vs placebo in ED patients with ureterolithiasis on computed tomography. Patients were identified and enrolled between April 2007 and February 2009 and were randomized to either 0.4 mg of tamsulosin or placebo for 1 week. We contacted participants using a telephone survey on post-ED visit days 1, 2, 3, and 7. The primary outcome was time to stone passage, with secondary outcomes being maximum pain score and amount of pain medication required. Results Of the 127 patients enrolled during this study, 15 were lost to follow-up, and 12 required surgical interventions before the 7-day mark, leaving 100 patients for analysis. Of the 100 patients, 53 received tamsulosin and 47 received placebo. There was no difference between groups in percentage of male, mean age, initial serum creatinine, average stone size, stone location, and history of prior stone. The probability that the patient did not pass a stone at 7 days was not different between tamsulosin and placebo, 62.1% (95% confidence interval, 49.1%-75.1%) vs 54.4% (95% confidence interval, 40.3%-68.6%; P = .58). There was no significant difference in the high pain score ( P = .12) or hydrocodone/acetaminophen intake ( P = .76) between treatment groups at any of the time points. Conclusion This study reveals no difference in the proportion of stone passage or high pain score and pain medication utilization at 7 days between tamsulosin and placebo.

Robotic-assisted radical prostatectomy (RARP) has been rapidly adopted throughout the USA. The purpose of this study is to describe the prevailing RARP operative techniques and perceptions within the USA. An anonymous web-based survey was sent electronically to a list of 920 robotic urological surgeons. The survey assessed surgeon demographics, surgical technique, and postoperative care related to RARP. The study was comprised of urologists from community hospitals (76%) and university hospitals/specialty centers (24%). All geographic sections of the American Urological Association were represented. The most common neurovascular preservation techniques were ante/retrograde approach (48%), athermal (22%), and preservation of lateral pelvic fascia (17%). Surgeon choice of neurovascular preservation technique varied with the average number of procedures performed per year (P = 0.0065). High-volume surgeons tended to require a higher number of robotic cases in order to go through the learning curve of the “comfortable” (P = 0.001) and “expert” levels (P < 0.0001). The majority of surgeons reported that RARP (as compared with open surgery) improved urinary continence (77.2%), sexual function (65.6%), and surgical margin rates (53.8%). RARP is an evolving surgical procedure with significant variability in practice patterns among US surgeons. Further studies are necessary to compare the various techniques in order to improve surgical outcomes.

have qualified instructors and an appropriate clinical learning environment. The spectrum of urological patients and procedures must be broad and include the multiple subspecialties of urology. The goal is to train residents to be competent to practice urology independently and without supervision within a 5or 6-year training program. The training program includes an initial year of internship in general surgery and all residents should have completed an M.D. degree or equivalent at an accredited institution. We are in a new era of training that emphasizes professionalism, communication skills and compassion for patients. Residents, attending physicians and related medical coworkers should work in an environment of mutual respect. Such an environment was not necessarily emphasized in the past. Guidelines founded through evidence-based study and a curriculum driven by the AUA University supports a more uniform outline for resident training. Competency-based training is now mandated and involves teaching and monitoring programs in the training of urology in six specified domains. (1) Medical Knowledge (2) Patient Care (3) System-Based Practice (4) Practice-Based Learning and Improvement (5) Interpersonal and Communication Skills and (6) Professionalism. A detailed discussion of these specific competencies is available at ACGME.org. Each resident must be evaluated with progress monitored by a competency committee formed of delegated instructors trained in evaluation. Resident progress and achievement of a competency in specific milestones of their training is documented with hope that the resident progresses toward complete competence by the end of their training. Progress in building a fund of urologic knowledge is monitored by an annual inservice exam, which simulates the experience of an actual board exam for graduates. The American public and government, which support residency training, mandate such Similar to the practice of urology, modern training of urologists has undergone dramatic evolution in the last three decades. The rapid pace of change is such that without continuous learning, the well-trained surgeon of 1990 might be incompetent today. To keep pace with these changes, training programs have embraced systematic learning modules and new technology along with more conventional teaching in the operating room to successfully prepare the next generation of urologists. The best training paradigm does not exist but is in continual evolution. The US paradigm for training and maintenance of skills as it currently exists is discussed so that training programs in other countries may compare and contrast for their best practice and development. Resident training in the USA is regulated and monitored by the Accreditation Council for Graduate Medical Education (ACGME) with each specialty having a Residency Review Committee (RRC), which establishes the requirements for certification of a residency training program. The ACGME is composed of member organizations representing physicians, hospitals and medical colleges for a coordinated program of graduated medical education. The RRC for urology is responsible for the monitoring and continued accreditation of urologic programs. The responsibility of running a urologic training program and the documentation of training and evaluating residents falls under a named Program Director who must be approved by the ACGME and have an appropriate academic portfolio and level of experience. The urology training program must

INTRODUCTION AND OBJECTIVES: The QoL in presence of urinary incontinence is significantly decreased after radical prostatectomy. ARGUS-T sling are currently employed for the treatment of SUI after radical prostatectomy but data on this device remain still limited. We report the short-term results of SUI treatment after radical prostatectomy with ARGUS-T. METHODS: From June 2008 since March 2013 161 patients affected by post-prostatectomy SUI and 21 patients affected by postTURP SUI were treated with ARGUS-T. The population was divided in 3 groups according to the incontinence degree: mild (1-2 pads/die), moderate (3-5 pads/die) and severe (>5 pads/die). The result was considered as satisfactory when the SUI was cured or improved. 21/182 patients (11.5%) were affected by mild SUI, 96/182 patients (52.7%) were affected by moderate SUI and 65/182 patients (35.7%) were affected by severe SUI. 49/182 patients (26.9%) were previously treated with adjuvant radiotherapy. In our study the QoL was evaluated using specific questionnaires (VAS score scale/QoL score scale) and the daily pad number was compared before and after ARGUS positioning. RESULTS: Median age of patients was 71 years old (range 5086 years) and median follow-up was 22 months (1-59 months). In our study the results were satisfactory in 157/182 patients (86.2%), 60/182 patients (33%) were cured and 97/182 patients (53.2%) were improved respectively. 37/49 patients (75.5%) previously treated with adjuvant radiotherapy showed satisfactory results. None complication was occurred during the intra-operative period while we observed in 26/182 patients (14.3%) a post-operative complication, such as infection (9/182), urethral erosion (1/182) and hypercontinence (16/182). The statistical analysis showed a significant reduction in the use of the number of daily pads and a substantial improvement in QoL after ARGUS-T implant (p

Purpose: We performed a complete pathologic analysis examining extracapsular extension (ECE) and microscopic spread of malignant cells beyond the prostate capsule to determine whether and when clinical target volume (CTV) expansion should be performed. Methods and Materials: A detailed pathologic analysis was performed for 371 prostatectomy specimens. All slides from each case were reviewed by a single pathologist (N.S.G.). The ECE status and ECE distance, defined as the maximal linear radial distance of malignant cells beyond the capsule, were recorded. Results: A total of 121 patients (33%) were found to have ECE (68 unilateral, 53 bilateral). Median ECE distance = 2.4 mm [range: 0.05–7.0 mm]. The 90th-percentile distance = 5.0 mm. Of the 121 cases with ECE, 55% had ECE distance ≥2 mm, 19% ≥4 mm, and 6% ≥6 mm. ECE occurred primarily posterolaterally along the neurovascular bundle in all cases. Pretreatment prostrate-specific antigen (PSA), biopsy Gleason, pathologic Gleason, clinical stage, bilateral involvement, positive margins, percentage of gland involved, and maximal tumor dimension were associated with presence of ECE. Both PSA and Gleason score were associated with ECE distance. In all 371 patients, for those with either pretreatment PSA ≥10 or biopsy Gleason score ≥7, 21% had ECE ≥2 mm and 5% ≥4 mm beyond the capsule. For patients with both of these risk factors, 49% had ECE ≥2 mm and 21% ≥4 mm. Conclusions: For prostate cancer with ECE, the median linear distance of ECE was 2.4 mm and occurred primarily posterolaterally. Although only 5% of patients demonstrate ECE >4 to 5 mm beyond the capsule, this risk may exceed 20% in patients with PSA ≥10 ng/ml and biopsy Gleason score ≥7. As imaging techniques improve for prostate capsule delineation and as radiotherapy delivery techniques increase in accuracy, a posterolateral CTV expansion should be considered for patients at high risk.

awakening response (CAR) and baseline salivary cortisol samples were obtained in all participants prior to TSST and at defined intervals postTSST. Paired T-Tests were used to compare baseline cortisol (obtained 15minutesbeforeTSST) to stress responsecortisol (obtained50minutes after TSST) in OAB patients and controls. RESULTS: Eight patients with OAB and 5 controls completed the performance task and provided all requested salivary samples. No difference in CAR was detected between OAB women and controls. A trend toward greater physiologic responsiveness in women with OAB compared to controls was noted (Figure 1, p1⁄40.066). CONCLUSIONS: Women with OAB have similar baseline physiologic measures of stress response to controls. Women with OAB may have greater physiologic responsiveness to stress as measured by salivary cortisol following TSST. Evaluation of markers of stress response may provide targets for potential diagnostic and therapeutic interventions.

Background: Prostate cancer has classically been discovered in 10% of prostatectomy specimens from presumed benign disease. Our objective was to review incidental cancer in transurethral prostatectomy (TURP) specimens and to establish whether or not the incidence, presentation, and pathology have changed since the advent of prostate specific antigen (PSA). Methods: Five hundred and thirty patients underwent TURP for presumed benign disease at our institution in 1985 (before PSA), and 481 underwent TURP between 1994 and 1995. The charts of all patients with cancer were reviewed. Patients with known cancer preoperatively were excluded. Charts were reviewed with regard to indication for TURP, presentation, age, size of prostate, digital rectal exam, PSA, and pathology report. The most recent preoperative PSA value was utilized. Pathologic factors included the weight (grams resected), grade, and extent of tumors. Stage T1a tumors were defined as having Gleason scores of

Most patients with progressive MS will develop voiding dysfunction. In order to properly manage these patients, it is imperative to have a basic understanding of normal and abnormal bladder function. Based on history, physical examination, urinalysis, and renal function, diagnostic evaluation can be tailored to the individual. Empiric therapy without urologic consultation may be appropriate in some patients. In others, referral for full urodynamic evaluation will be necessary to best manage neurogenic voiding dysfunctions. Although there are many treatment options for patients with neurogenic bladders, it is imperative that therapy remain conservative and initially reversible because symptoms from MS tend to wax and wane over time. Long-term follow-up for patients with MS and neurogenic bladders is required to preserve renal function and avoid infections. A urologic program should be designed to promote continent, low-pressure bladder storage and controlled emptying while minimizing symptoms in a manner that promotes improved quality of life and self-esteem.

This article is devoted to the most common cause of outlet obstruction in the male geriatric population, benign prostate hyperplasia (BPH). The prevalence, pathophysiology, and natural history of BPH is discussed, along with the work-up and indications for medical or surgical intervention. The authors also focus on medical and surgical options now available for management of BPH.

Purpose : To improve results for locally advanced prostate cancer, a prospective clinical trial of concurrent external beam irradiation and fractionated iridium-192 (Ir-192) high dose rate (HDR) conformal boost brachytherapy was initiated. Methods and Materials : Between November 1991 and February 1994, 99 implants were performed on 33 patients with prostatic adenocarcinoma at William Beaumont Hospital. Using AJCC staging criteria, 9 patients had T2b tumors, 17 patients had T2c tumors, and 7 patients had T3 disease. Patients were treated with (a) 45.6 Gy whole pelvis external irradiation and (b) three HDR fractions of 5.5 Gy each (18 patients) or 6 Gy each (15 patients) to the prostate. Transperineal needle implants using real-time ultrasound guidance with interactive on-line isodose distributions were performed on an outpatient basis during weeks 1, 2, and 3 of external irradiation. Acute toxicity was scored using the Radiation Therapy Oncology Group (RTOG) morbidity grading system. Results : This technique of concurrent external pelvic irradiation and conformal HDR brachytherapy was well tolerated. No significant intraoperative or perioperative complications occurred. Three patients (9%) experienced Grade 3 acute toxicity (two dysuria and one diarrhea). All toxicities were otherwise Grades 1 or 2 and were primarily as expected from pelvic external irradiation. Persistent implant-related toxicities included Grades 1-2 perineal pain (12%) and hematospermia (15%). Median follow-up time was 13 months. Serum prostatic-specific antigen (PSA) levels normalized in 91% of patients (29 out of 32) within 1-14 months (median 2.8 months) after irradiation. PSA levels were progressively decreasing in the other three patients at last measurement. Prospectively planned prostatic rebiopsies done at 18 months in the first 10 patients were negative in 9 out of 10 (90%). Conclusions : Acute toxicity has been acceptable with this unique approach using conformal high dose rate Ir-192 boost brachytherapy with concurrent external irradiation. The initial tumor response as assessed by serial PSA measurement and rebiopsy is extremely encouraging. Dose escalation will proceed in accordance with the protocol guidelines. Further patient accrual and longer follow-up will allow comparison to other techniques.

This article discusses surgical procedures that may be useful in the management of patients with spinal cord injury and is intended to be of practical use to those in general practice. In addition to a discussion of the pros and cons of indwelling Foley and suprapubic catheters, useful reconstructive and diversionary procedures are reviewed.

Currently, the use of local anesthetic at the time of transrectal ultrasound-guided biopsy of the prostate is not universally accepted, as the needle injection itself causes pain. In prior studies, lidocaine was compared to placebo in separate patient groups. We present the first study to evaluate both lidocaine and placebo injected in each patient.Fifty patients received periprostatic injections of both lidocaine and placebo, randomized to separate sides of the prostate, in a randomized, double-blind, placebo-controlled trial design. Injections were delivered at the angle between the seminal vesicle and prostate on each side. Patients graded pain on a visual analog scale (VAS) (0-10) after injections and after each biopsy. Patients were surveyed to evaluate overall pain and discomfort before discharge. We used Student's t-test to compare the mean VAS scores between lidocaine and placebo.The mean (SD) VAS after biopsy was 1.9 (1.4) on the lidocaine side and 2.3 (1.4) on the placebo side (P = 0.202). Pain after the injection itself was similar to pain after biopsy, with the mean (SD) VAS of 2.4 (1.6) and 2.2 (1.7) after lidocaine and placebo injections, respectively (P = 0.546). None of the differences were statistically significant. Twenty-nine (59.2%) patients reported no pain at the time of discharge.Pain experienced during transrectal biopsy of the prostate is mild and is not significantly lowered with periprostatic nerve block. Pain from injection itself is similar to pain from core biopsies. Pain from transrectal ultrasound-guided biopsy of the prostate is well tolerated with no anesthesia.

We present a rare case of late renal allograft failure from ureteral obstruction resulting from inguinal herniation. A 72-year-old man presented with an elevated creatinine and hydroureteronephrosis of a transplanted kidney on ultrasound. Noncontrast computed tomography demonstrated an inguinal hernia containing ureter, and a nephrostomy tube was placed. The hernia and ureter were temporarily reduced during antegrade stent insertion. Creatinine normalized and we performed inguinal herniorrhaphy with polypropylene mesh. The ureter was not reimplanted. Renal function remained stable after nephrostomy tube removal. Simple herniorrhaphy without ureteral reimplantation may fix the case of ureteral obstruction from inguinal herniation.

Purpose: For proper indications at university hospitals laparoscopic nephrectomy is often considered the standard of care. At community hospitals past surveys have not demonstrated this change. We describe the changing practice patterns of performing laparoscopic nephrectomies in indicated patients at our community hospital. We reviewed our data on monitoring our training program. Materials and Methods: A retrospective chart review was performed of 381 consecutive complete nephrectomies performed at our institution from February 2000 to December 2003, including 62 live donor nephrectomies. Patient age, pathological size, operative time, estimated blood loss, duration to solid food intake and duration of hospitalization were compared between open nephrectomy and laparoscopic nephrectomy groups using the Wilcoxon 2-sample test. Surgical practice and surgeon characteristics were also described. Results: Patients who underwent laparoscopic nephrectomy demonstrated superior postoperative recovery with earlier return to solid diet and shorter hospitalization. The 2 groups were similar in regard to major complication rates. The number of laparoscopic nephrectomies increased annually, while the number of open nephrectomies decreased. The number of laparoscopic urologists increased annually. More importantly laparoscopic urologists performed an increasing number of nephrectomies, while nonlaparoscopic urologists faced a decrease in the number of nephrectomies performed. There appeared to be little evidence of hand assisted laparoscopic nephrectomy as a bridge to learning standard laparoscopic nephrectomy. Conclusions: Our training paradigm has safely and effectively trained community urologists to perform laparoscopic nephrectomies. Laparoscopic nephrectomy is now considered a standard treatment option along with conventional open surgery and it should be offered to the patient in the medical setting. Although fellowship trained urologists can certainly add expertise to any program, community based hospitals do not have to depend on them.

During a 5-year period 32 children and adolescents 4 to 18 years old underwent 35 extracorporeal shock wave lithotripsy (ESWL*) treatments for 37 calculi. The unmodified Dornier HM3 lithotriptor was used in 21 cases (60%) while the remaining cases were treated with the Siemen Lithostar lithotriptor. The HM3 necessitated general anesthesia in 67% of patients and the Lithostar necessitated intravenous sedation in 86%. The majority of pediatric lithotripsy treatments were performed on an outpatient basis (24) or during an overnight hospital stay (3) while 8 were done on an inpatient basis. Of the 37 stones treated with 1 ESWL session 68% resolved, 19% had residual fragments less than 4 mm., 8% had residual fragments greater than 4 mm. and 5% required an endoscopic procedure for resolution. When success rates by lithotriptor were examined no significant difference between the 2 machines was identified although the HM3 treated larger stones (p = 0.0499). There were no statistical differences in regard to success and the use of stents, patient age or stone location between the 2 lithotriptors. Three patients required adjuvant procedures, and complications and morbidity developed in 2 and 5, respectively. All children or parents were contacted for followup (range 7 to 67 months). One child required ESWL for a new stone while another passed a stone without intervention. Only 1 child with a residual fragment less than 4 mm. became symptomatic but needed no intervention while 1 of 3 with fragments greater than 4 mm. needed intervention. No patients required open or percutaneous intervention.

Trauma to the lower genitourinary tract often presents with clear signs and symptoms. Failure to properly diagnose injuries to this region can lead to significant long-term morbidity. Approximately 7.5–16.0% of patients with a pelvic fracture sustain an injury to the lower genitourinary tract.1–5 Attempts should be made to optimize the initial management of a patient with a lower genitourinary injury in order to minimize future sequelae.

Biochemical control using serial posttreatment serum prostate specific antigen (PSA) levels is being increasingly used to assess treatment efficacy for localized prostate cancer. However, no standardized definition of biochemical control has been established. We reviewed our experience treating patients with localized prostate cancer and applied three different commonly used definitions of biochemical control to determine if differences in therapeutic outcome would be observed.Between January 1987 and December 1991, 480 patients with clinically localized prostate cancer received external beam irradiation (RT) using localized prostate fields at William Beaumont Hospital. The median dose to the prostate was 66.6 Gy (range 58-70.4) using a four-field or arc technique. Pretreatment and posttreatment serum PSA levels were recorded. Over 86% (414 of 480) of patients had a pretreatment PSA level available. Three different definitions of biochemical control were used: (a) PSA nadir1 ng/ml within 1 year of treatment completion. After achieving nadir, if two consecutive increases of PSA were noted, the patient was scored a failure at the time of the first increase; (b) PSA nadir1.5 ng/ml within 1 year of treatment completion. After achieving nadir, if two consecutive increases of PSA were noted, the patient was scored a failure at the time of the first increase; (c) Posttreatment PSA nadir4 ng/ml without a time limit. Once the nadir was achieved, if it did not rise above normal the patient was considered to be biochemically controlled. Clinical local control was defined as no palpable prostate nodularity beyond 18 months, no new prostate nodularity, or a negative prostate biopsy.Median follow-up was 48 months (range 3-112). Pretreatment PSA values were correlated with treatment outcome using the three definitions of biochemical control as well as clinical local control. Pretreatment PSA values were stratified into five groups (Group 1: PSA4; Group 2: PSA 4-10; Group 3: PSA 10-15; Group 4: PSA 15-20; and Group 5: PSA20), and 5-year actuarial rates of biochemical control were calculated using the three biochemical control and one clinical local control definitions. For Group 1, 5-year actuarial rates of biochemical control were 84%, 90%, 91%, and 96% for Definitions 1-3 and clinical local control, respectively. For Group 2, 5-year actuarial control rates were 45%, 54%, 74%, and 92% for the four definitions, respectively. For Group 3, 5-year actuarial control rates were 26%, 31%, 63%, and 100% for the four definitions, respectively. For Group 4, 5-year actuarial control rates were 24%, 24%, 50%, and 100% for the four definitions, respectively. Finally, for Group 5, 5-year actuarial control rates were 5%, 14%, 15%, and 89% for the four definitions, respectively. Depending on the definition used, statistically significant differences overall in outcome rates were observed. Differences between all four definitions for all pairwise comparisons ranged from 5 to 53% (p0.001).When different definitions of biochemical control are used in assessing treatment outcome, significantly different rates of success are noted. Until a standardized definition of biochemical control is adopted, differences in treatment outcome cannot be meaningfully compared.

A 30-year-old man presented with a 7-month history of chronic partial priapism and sexual dysfunction following blunt perineal trauma. Duplex penile ultrasound confirmed high flow priapism and color flow Doppler ultrasound diagnosed an arteriovenous fistula within the left corpus cavernosum. This lesion was corrected via corporeal exploration and ligation of the artery feeding the fistula. The use of color flow Doppler ultrasound to diagnose this unusual condition obviated the need for angiographic studies. This rare condition of posttraumatic priapism may be diagnosed by noninvasive means. The pathophysiology, diagnosis and treatment of posttraumatic priapism and review of the literature are discussed.

One hundred seventy-two patients on a pharmacologic erection program for male erectile dysfunction were sent a detailed questionnaire regarding their satisfaction using intracorporeal injection with vasoactive drugs. Sixty-seven percent of patients responded. Eighty-five percent of respondents said their sex life was improved. Eighty-eight percent would recommend penile self-injection to a friend whose complaint is impotence. Despite this, 49 percent of respondents were no longer using self-injections. The results from our detailed questionnaire suggest that the majority of the patients are quite satisfied with the erections achieved with intracorporeal injection of vasoactive drugs. The high dropout rate associated with such a program may be due to reasons other than the quality of erection achieved and sexual satisfaction derived from pharmacologic erections.

Spinal-cord injury (SCI) is usually associated with multiple-organ injuries, all of which must immediately be attended to upon institution of medical care. Total rehabilitation of the spinal-cord-injured patient is begun as soon as the acute process is stabilized. As part of any such program, sexual functionality must be explored to determine, among other things, whether erectile ability has been preserved. During the investigation, one should be aware that erectile fonction may be evolving just as would any other function that depends upon the integrity of the spinal cord. Significant recovery of erectile function may be observed within the first 12 mo and occasionally several months there after. In addition, since erection is in itself a multifactorial process, numerous factors besides the neurogenic component should be considered. A thorough knowledge of the various etiologies of impotency is necessary if one is to be accurate in pinpointing the exact mechanism of this dysfunction.

In man the penile corpora cavernosa have vascular continuity via channels passing through the penile septum. To our knowledge we report the first case of a complete penile septum resulting in corporeal vascular dissociation. The patient presented with primary sexual dysfunction. CASE REPORT A 38-year-old white man presented with a lifelong history of sexual dysfunction described as erections that were never fully rigid. Sexual intercourse was suboptimal because of buckling of the erection. Medical history and physical examination were unremarkable. A Rigiscan* evaluation demonstrated 3 or 4 erectile episodes with reasonable tumescence and duration but rigidity was less than 70%. Injection of 15 mcg. prostaglandin El into the right corporeal body resulted in full rigidity of the right corporeal body only and left curvature of the penis while the left corporeal body remained flaccid. The left corporeal body was then injected with prostaglandin El, resulting in a full straight erection that exceeded those previously experienced. Duplex ultrasonography demonstrated unilateral tumescence of the corpora after injection of prostaglandin El (fig. 1 ). Cavernosal -arterial flow velocity -was normal and increased only on the injected side. Cavernosography revealed unilateral corporeal opacification when contrast medium was

In Reply. —Since my answer to the question of fluoxetine and sexual dysfunction, JAMA has received numerous letters disputing my statement that sexual dysfunction occurs in "up to 1.9% of patients." I wish that I could claim a typing error, but I chose to quote the Physicians' Desk Reference in search of a rate of sexual dysfunction to explain the patient's delayed orgasm. Clearly, the rate of delayed ejaculation or anorgasmia is much higher than 1.9%. Indeed, drugs that inhibit serotonin reuptake may have a therapeutic effect in patients with premature ejaculation. At this time, the letters I have received from JAMA quote rates of 7.8% to 75% of patients having problems with sexual dysfunction. 1,2 Many articles address overall sexual dysfunction, including anorgasmia in patients receiving fluoxetine, but careful perusal shows small numbers of men studied. Zajecka et al 1 suggest a 7.8% incidence of sexual dysfunction in men

Endoscopic evaluation of bowel conduits used for urinary diversion can be a cumbersome and untidy endeavor. We present a simple technique that facilitates this type of examination using an ostomy bag connected to a urinary drainage bag.

This study is designed to explore the patient's point of view on success with penile prosthesis. Detailed questionnaires were sent to 57 penile prosthesis recipients, 38 of whom responded. Overall, 89 per cent claimed improved sexual satisfaction, and 76 per cent noted improved self-image with their prostheses. Seventy-six per cent claimed their partners approved of the prosthetic device. Prosthetic appearance was satisfactory to 87 per cent. Five patients, knowing what they now know, would not have had the prosthetic implantation. A significant factor in 4 of the 5 patients was lack of partner approval. We conclude penile prosthesis implantation is successful in returning satisfactory sexual intercourse to impotent men and their partners. Partners of those desiring penile prosthesis should be included in the preoperative evaluation process.

Ureteroarterial fistulas are uncommon. We report a patient who developed a spontaneous fistula between the right iliac artery aneurysm and the right ureter. The diagnosis was made by a retrograde pyelogram and body computed tomography. The fistula was ultimately treated by simple transvesical ligation of the distal ureter. A brief description of the case is provided and the cause and management of ureteroarterial fistula are discussed.

Bladder neck obstruction in women is rare. Recently, we encountered 3 cases with similar findings. Clinically, the patients had chronic bladder symptoms of obstruction and irritation. The bladder showed trabeculation, diverticula and/or vesicoureteral reflux. Urinary flow rates were poor or absent. Endoscopy was unreliable in evaluating the outlet. The voiding pressure-flow cystourethrography study established the diagnosis. Specific operations to relieve bladder neck obstruction may be justified with proper urodynamic documentation.

A retrospective review of our experience with the artificial urinary sphincter in 32 women is presented. All patients had a history of recurrent urinary incontinence after failed bladder suspension procedures. Of 32 devices 31 were functioning, with an average followup of 2.5 years, and 91 per cent of the patients were dry without pads. Mechanical complications requiring surgical repair occurred in 21 per cent of the patients. Indications for artificial urinary sphincter implantation in the female patient and technical aspects of the procedure are discussed. The artificial urinary sphincter appears to be an acceptable treatment modality for urethral sphincter deficiency resulting in recurrent urinary stress incontinence in female patients.

Uniform uric acid calculi were treated in an unmodified Dornier HM3 lithotripter to map the effectiveness in breaking up stones at measured distances from the focal point (F2). Clinical application of the findings is suggested for stones which cannot be focused at F2.

A case report of triamterene bladder calculus is presented. Triamterene containing antihypertensives should be used with caution in patients with predisposition to form stones.

A case of scrotal fat necrosis is presented. The clinical presentation usually is characteristic and the condition can be managed nonoperatively.