Minimally invasive treatment (MIT) options for relief of symptoms attributed to benign prostatic obstruction (BPO) are becoming a more commonly used option for patients failing medical therapy. These MIT utilize an endoscopic approach to either ablate the obstructing prostatic tissue by a variety of techniques or to place a urethral stent to relieve BPO. The uniting factor in all MIT is to decrease or eliminate the current morbidity and complications that accompany the standard surgical therapy such as transurethral resection of prostate (TURP). Clinical trials evaluating the efficacy and morbidity of these MIT modalities, either alone or in comparison to TURP are reviewed. Level I evidence (randomized controlled trials) are present for most of the MITs and provide the strongest support for overall conclusions. Symptomatic improvements and quality of life (QoL) improvements for all of the MIT follow a similar pattern with a more pronounced improvement in outcomes for the more ablative techniques. Uroflowmetry and durability of outcomes, however, seem to demonstrate little differences amongst the therapies. Disparities existed in the morbidity observed with the different techniques. Urinary retention and urinary infections were more common in the ablative technologies. Rates of blood loss, urinary incontinence, sexual dysfunction and urethral strictures were observed at a lower rate in the MIT groups when compared to the rates observed in TURP. The morbidity and durability of TURP is higher and longer than that of MIT, respectively.

Anesthesia for urology surgery poses special problems by way of patient factors and complexity of the procedure. Preoperative optimization of the patients with renal dysfunction and comorbidity; specific complications associated with the operative procedures, such as transurethral resection of prostate, laparoscopy surgery, percutaneous lithotripsy and renal transplantation; and the implications of the various positions that the patient may be subjected to during surgery are briefly presented. The purpose of this review article is to highlight the anesthetic implications of the renal and comorbid problems in a patient scheduled for genitourinary surgery.

OBJECTIVES: As the advancements, modifications and standardization of laparoscopy are taking place, there is a need for the reduction in morbidity associated with laparoscopic live donor nephrectomy. This study was performed to determine and reconfirm the advantages of laparoscopic donor nephrectomy over its open counterpart. MATERIALS AND METHODS: Two hundred open live donor nephrectomy (ODN) cases were compared to 264 cases of laparoscopic live donor nephrectomy (LDN). Pretransplant functional and radiological evaluation was done routinely by excretory urogram and renal arteriography. In case of vascular variations, CT angiography was preferred. Open cases were done by conventional method and laparoscopic group underwent certain technical and surgical modifications, including meticulous planning for the port placement. Operative time, analgesia requirement, start of the orals, hospital stay, blood loss, late allograft function, incidence of rejection, complications and technical problems were analyzed. RESULTS: Operative time was 135.8 ± 43 and 165 ± 44.4 min ( P <0.0001), requirement of analgesia was 60.5 ± 40 and 320 ± 120 mg ( P <0.0001), hospital stay was 4 ± 0.04 and 5.7 ± 2.03 days ( P <0.0001), warm ischemia time was 6.1 ± 2.0 and 4.1 ± 0.80 min ( P <0.0001) and time taken for the serum creatinine to stabilize in the recipient was 4.1 ± 1.6 and 4.32 ± 1.40 days ( P =0.06) for LDN and ODN groups respectively. There was a significant reduction in the blood loss in LDN group ( P =0.0005). Overall complications were 6.81 and 14.5% and ureteric injury was seen in 0.37 and 1% in LDN and ODN respectively. CONCLUSION: Laparoscopic live donor nephrectomy can now be performed with low morbidity and mortality to both donors and recipients and is proving to be the preferred operation to open donor nephrectomy. Our continued innovations in technical modifications have made this novel operation successful.

BACKGROUND: Benign prostatic enlargement (BPE) is the commonest cause of bladder outlet obstruction in men above 50 years of age. Though pressure-flow study is the gold standard in establishing outlet obstruction, it is associated with definite morbidity. Several noninvasive parameters are described to diagnose outlet obstruction due to BPE and evaluate treatment efficacy. AIM: We studied the role of transitional zone index (TZI) in assessing bladder outlet obstruction (BOO) due to BPE. SETTING AND DESIGN: Prospective hospital-based cross-sectional diagnostic study. MATERIALS AND METHODS: Thirty-five men aged between 50 and 77 years with untreated lower urinary tract symptoms due to BPE were studied. Patients with prostate cancer, prostatitis, active UTI urethral stricture, neurovesical dysfunction and diabetes mellitus were excluded. All patients underwent a standard assessment using the American Urological Association (AUA) symptom score, uroflow, pressure-flow (PF) study and transrectal ultrasound (TRUS) estimation of TZI. Investigators undertaking PF studies and TRUS were blinded to the investigation of others. From the PF studies, Abrams Griffith (AG) number was calculated. Based on this, patients were grouped into obstructed (AG>40) and unobstructed (AG<40) groups. STATISTICAL ANALYSIS: TZI was calculated and compared with PF studies using Mann-Whitney U test, logistic regression analysis and receiver operator characteristic curve (ROC). RESULTS: The mean age was 63.2 years (SD). The mean AUA scores and peak flow rate were 16.7 and 7.5 ml/sec, respectively. Of the 35 men, 21 were obstructed and 14 were unobstructed. TZI was not significantly different between the two groups, while the differences in age, AUA symptom score, prostate volume and TZ volume were statistically significant. Logistic regression model did not show any independent effect of TZI in predicting obstruction. ROC curve showed a poor overall accuracy in diagnosing obstruction due to BPE. CONCLUSION: Age, prostate volume and TZ volume are better indicators than TZI in diagnosis of BOO secondary to BPE.

BACKGROUND: We investigated the efficacy of oral clonidine 150 mg to prevent perioperative shivering in patients undergoing transurethral resection of prostate under subarachnoid block. Geriatric patients who undergo transurethral resection of prostate are prone to perioperative shivering during spinal anesthesia. Use of prophylactic oral clonidine, which is known to reduce shivering, could lead to decrease in the morbidity and mortality of such patients. MATERIALS AND METHODS: In this prospective double blinded placebo-controlled study, 80 patients scheduled for transurethral resection of prostate surgery under subarachnoid block were randomized into two groups. Group I (n=40) received oral clonidine 150 mg, while Group II (n=40) were given placebo tablet. After achieving subarachnoid block, the incidence, severity and duration of shivering was recorded and compared in both the groups. The body temperature (axillary, forehead and tympanic membrane), hemodynamic parameters and arterial saturation were recorded at regular intervals. RESULTS: Incidence of shivering was significantly less in patients who were given oral clonidine when compared with that of the placebo group (5 vs. 40% respectively; P value of <0.01). Clonidine did not lead to any collateral clinically significant side effects. CONCLUSION: We conclude that as a prophylaxis oral clonidine 150 mg is effective in reducing the incidence, severity and duration of perioperative shivering in patients undergoing transurethral resection of prostate surgery under spinal anesthesia.

Sexual dysfunction and more specifically erectile dysfunction (ED) can be a harbinger of serious occult medical conditions. ED can be considered a clinical manifestation of generalized vascular disease and therefore shares similar risk factors: aging, hypertension, diabetes mellitus, hypercholesterolemia and smoking. The initial evaluation of men with ED should be thorough. Studies of normal and abnormal penile tumescence have led to the discovery of many important pathways. The greatest medical advance in the management of male sexual dysfunction since the identification of androgens have been the discoveries that nitric oxide (NO) is the primary neuro-modulator of penile smooth muscle relaxation and that oral phosphodiesterase type 5 inhibitors enhance erection quality through the NO mechanism. As a consequence of oral pharmacotherapies, the role of invasive diagnostics has diminished. Most guidelines recommend only history, physical exam and limited laboratory testing prior to instituting oral therapies for ED. In 2006 we still have unanswered questions about ED and these will frame the role of future diagnosis and therapy: can lifestyle changes alone improve erectile function; is ED a marker for the development of atherosclerotic heart disease, do lower urinary tract symptoms of benign prostatic hypertrophy and ED share a common pathway?

The National Institute of Health defined erectile dysfunction as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual performance. Erectile dysfunction must be considered a public health problem for its high prevalence worldwide. Aetiology of erectile dysfunction can be classified as organic, psychogenic or mixed. Erectile dysfunction must be considered the first sign of many diseases. Thus, a correct diagnostic approach is essential before starting an effective therapeutic regimen. Current guidelines concerning management of erectile dysfunction agree on the great importance of anamnesis as being the basis of a correct diagnosis of erectile deficit. First level diagnostic tests, including anamnesis, validated questionnaire, routine laboratory tests and hormonal profile seem enough to make an aetiological diagnosis of erectile dysfunction and to identify and remove any erectile dysfunction (ED) risk factors in most cases. First level tests should be performed, so than urologists can accurately diagnose ED and prescribe relevant treatment. Second level diagnostic evaluation includes specialistic instrumental exams that can be helpful for accurate aetiological diagnosis of erectile dysfunction. These exams, including Penile dynamic colour-duplex. Doppler ultrasonography, nocturnal penile tumescence recording, cavernosometry/cavernosography and neurological investigation, should be performed when first level diagnostic assessment is not clear, when the presence of an underlying organic pathology should be excluded in young patients with persistent ED, when veno-occlusive or neurogenic ED is suspected and when a better definition of the disease is needed.

Corpus cavernosum electromyography (CC-EMG) has been intensively studied as a potential clinical tool for evaluating the function of the cavernous smooth muscle and its autonomic innervations since 1989. Both basic and clinical studies have shown promising results. However, its application as a diagnostic tool with clinical relevance was hindered by insufficient knowledge of cavernous smooth muscle electrophysiology and a series of technical and practical difficulties. Recently, major progress has been made to overcome these difficulties. Multichannel monopolar recording method has been proved to be superior to traditional one or two-channel bipolar recording. Correlation techniques have been applied as a comprehensive, objective and easy-to-use method to analyze CC-EMG recordings. Using these newly developed techniques, CC-EMG has been demonstrated to be discriminative in erectile dysfunction patients with conditions that are associated with cavernous smooth muscle degeneration and/or autonomic neuropathy from men with normal erectile function. However, before CC-EMG can be used as a robust method for erectile dysfunction-diagnostics, some basic and clinical issues are still to be solved. This review presents an overview of the latest advances in CC-EMG studies, mainly focusing on the clinical application of this method as a diagnostic tool. Furthermore, the background knowledge of cavernous electrophysiology, the problems to be overcome and future perspectives are also discussed.

Erectile response in mammals is centrally and peripherally regulated by androgens. Severe hypogonadism in men usually results in loss of libido and potency which can be restored by androgen administration. The original insights into the mechanisms of action of androgens on sexual function indicated that androgens particularly exert effects on libido and that sleep-related erections were androgen-sensitive but erections in response to erotic stimuli were relatively androgen-independent. There are a number of recent developments which shed new light on testosterone treatment of erectile dysfunction in aging men. There is growing insight that testosterone has profound effects on tissues of the penis involved in the mechanism of erection and that testosterone deficiency impairs the anatomical and physiological/biochemical substrate of erectile capacity, reversible upon androgen treatment. Several studies have indicated that the administration of PDE-5-inhibitors is not always sufficient to restore erectile potency in men and that administration of testosterone improves the therapeutical response to PDE-5-inhibitors considerably. There is increasing insight not to view erectile dysfunction (ED) as a single entity but as part of the aging process. Circulating levels of testosterone are closely related to manifestations of other etiological factors in ED, such as atherosclerotic disease and diabetes mellitus. The latter are correlated with lower-than-normal testosterone levels.

Pharmacotherapy is currently the therapeutic option of choice for erectile dysfunction. Comprising mainly intracavernosal injection therapy using alprostadil or alprostadil combined with phentolamine and/or papaverine and oral phosphodiesterase-5 inhibitors, it is safe and effective if appropriately prescribed and administered. The medications in current use produce satisfactory erectile responses by enhancing cavernosal vasodilatation mainly through their ability to promote relaxation of the smooth muscle cells in the corpora cavernosa involving the synthesis and activity of nitric oxide via the cyclic guanosine monophosphate and cyclic adenosine monophosphate biochemical pathways. The main side-effects and complications of intracavernosal injections are postinjection pain, prolonged erections, priapism and penile fibrosis. There may be a variety of side-effects with phosphodiesterase-5 inhibition but these are usually inconsequential. Recent serious ill health and the need for ongoing long-acting nitrate therapy or frequent use of short-acting nitrates for angina are absolute contraindications to the use of phosphodiesterase-5 inhibitors. Caution has to be exercised in prescribing phosphodiesterase-5 inhibitors for patients with impaired renal or hepatic functions or receiving multi-drug therapy for any systemic disease. All patients presenting with erectile dysfunction should be investigated and treated for cardiovascular risk factors. They should also be counseled regarding lifestyle factors particularly healthy balanced diet, regular physical exercise and inappropriate social habits.

Erectile dysfunction is one of the important health problems affecting man and his partner. Recently, many treatments have evolved for the treatment of erectile dysfunction or sexual health. Of the available treatments several are pharmacologically proven and tested medications. However, in Asia, there are significant users of unproven medications for sexual health. These medications are traditionally used by the folklore living in the countryside. These untested medications may have a profound effect on the body system and their interactions with other medications may be harmful. However, comprehensive accounts of such medications are unavailable. This paper descriptively highlights the common medications used for sexual health in Asia.

Peyronie's disease is a physically and psychologically devastating disorder affecting close to 10% of adult men. It is currently believed to be a form of wound healing disorder where there is excessive scar formation in response to a triggering process, most commonly following trauma to the erect penis. In this circumstance, the plaque which is an inelastic scar of the tunica albuginea develops which causes a variety of penile deformities including curvature, indentation, loss of girth and shortening. Frequently pain will accompany erection or direct palpation of the plaque in the early, active phase of this disease, but pain does tend to resolve over time but the deformities tend to remain. In up to 90% of patients there is associated diminished erectile capacity. Fifty percent of the time, men note evidence of erectile dysfunction prior to developing the Peyronie's disease. A variety of factors may contribute to erectile dysfunction in this patient population. Most commonly there is an underlying vascular insufficiency, which may be due to the same processes that result in accelerated atherosclerosis including diabetes, hypertension, smoking, and dyslipidemia. There may also be a substantial psychogenic effect, as we know that the majority of men with Peyronie's disease are significantly psychologically distressed by the changes to their penis. Lastly, there has been some suggestion that the abnormal geometry of the penis may contribute to a reduction of intracavernosal pressure resulting in diminished rigidity. This article briefly reviews what is currently understood about the etiology and presentation of the patient with Peyronie's disease and tries to clarify several of the widely held misconceptions. In addition, there are recommendations for evaluation and a more detailed discussion of the erectile dysfunction associated with Peyronie's disease, as well as appropriate treatment options.

PURPOSE: The purpose of this review was to examine the role of penile prosthesis implantation in the era of multiple treatment options for erectile dysfunction (ED). METHODOLOGY: A literature search was performed to identify reports of three-piece inflatable penile prosthesis survival, free of mechanical failure in which results were given as Kaplan-Meier projections. Patient and partner satisfaction articles were also identified and reviewed. CONCLUSIONS: With multiple treatment options for ED, the percentage of men going on to penile prosthesis implantation is decreasing. However, because of the attractiveness of new treatment options and increased public awareness, more men with ED are presenting today for treatment. Penile prosthesis implantation is the only option which is applicable to nearly every man with ED and thus penile prosthesis implantation continues to play an important role in the management of ED. Patient and partner satisfaction with penile prosthesis implantation, particularly with three-piece inflatable devices, is higher than for any other treatment option.

Penile reconstructive surgeries are performed mainly as radical treatment for conditions associated with congenital abnormalities of the urethra or penis, after penile trauma, penile cancer, short penis, corporal fibrosis and in cases of gender reassignment. In this article, we review the controversial penile augmentation topic, clarifying how most workers disagree with its scientific basis. We also highlight recent advances in surgical techniques in treatment of penile injuries and those employed for female-to-male sex reassignment procedures. We also propose a practical approach for evaluating and counseling patients complaining of a small sized penis.

Multicystic renal dysplasia is an extremely uncommon cause of hypertension in children. Ipsilateral duplication anomalies associated with multicystic kidney have rarely been reported. Hypertension associated with multicystic kidney has been reported previously in a few cases but on Medline search no report was found where hypertension was associated with segmental multicystic dysplasia in a duplicated system. We report a one-year-old girl in whom hypertension was associated with left partial duplicated system and lower moiety multicystic dysplasia. After lower pole heminephrectomy the hypertension resolved and remained so at six months follow-up. In our knowledge this is the first report of its type.

We report a case of acute urinary retention in a 13-month-old boy, secondary to a perforate Cowper's syringocele. Diagnosis was established with voiding cystourethrogram, transperineal ultrasound and urethroscopy; definitive management involved endoscopic unroofing of the syringocele and resolution of the patient's obstructive signs and symptoms followed. Although novel diagnostic and therapeutic options have been reported, standard urethrographic imaging and endoscopic management is appropriate for the majority of symptomatic Cowper's syringoceles.

We report a rare case of Wegener's granulomatosis involving the prostate gland in a 45-year-old male who presented with acute urinary retention. Treatment was initiated with oral cyclophosphamide and steroids. The prostate size regressed in four weeks and patient voided well after removal of catheter.

We report two cases of inadvertent ureteric catheterization by cystometry catheter causing acute loin pain. Ultrasound of kidneys in the first patient showed the presence of air in the pelvicalyceal system. In the second patient, injection of contrast media confirmed the presence of contrast in the ureter. In both patients, further investigations did not show any evidence of vesico-uretric reflux.

Involvement of the genitourinary organs is the most common site of extra-pulmonary tuberculosis. Genitourinary tuberculosis (GUTB) almost always starts from the kidney. A wide spectrum of complications can arise from the kidney being affected by GUTB. A rare complication of GUTB in the form of renogluteal fistula is described. Excision of the fistula with nephroureterectomy combined with anti-tubercular treatment has resulted in cure.

Lymphangioma of epidydimis is a very rare cause of scrotal swelling. We report a case of lymphangioma of epidydimis in a 24 year old male. This case is being presented in view of its rarity.

We report a rare case of localized unilateral perirenal involvement in retroperitoneal fibrosis in a man presenting with left upper abdominal discomfort and generalized weakness. The increased diagnostic capabilities and imaging characteristics of computed tomography and magnetic resonance imaging are emphasized. Multiple tissue sampling for histopathological study should be done to rule out malignancy in cases of atypical site involvement.