Urologists
31 years of experience
Video profile
Accepting new patients
Center City East
Jefferson Urology Associates
833 Chestnut St
Ste 703
Philadelphia, PA 19107
215-955-1000
Locations and availability (2)

Education ?

Medical School Score Rankings
New York University - Mount Sinai (1979)
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Erectile Dysfunction
Male Infertility
Appointments
Thomas Jefferson University Jefferson Medical College
Associations
American Urological Association
American Board of Urology

Affiliations ?

Dr. Hirsch is affiliated with 6 hospitals.

Hospital Affilations

Score

Rankings

  • Thomas Jefferson University Hospital
    Urology
    111 S 11th St, Philadelphia, PA 19107
    • Currently 4 of 4 crosses
    Top 25%
  • Methodist Hospital
    Urology
    2301 S Broad St, Philadelphia, PA 19148
    • Currently 3 of 4 crosses
    Top 50%
  • Wills Eye Hospital
    840 Walnut St, Philadelphia, PA 19107
  • Veterans Affairs Medical Center - Coatesville
    1400 Blackhorse Hill Rd, Coatesville, PA 19320
  • Veterans Administration Medical Center
  • VA Medical Center DE
  • Publications & Research

    Dr. Hirsch has contributed to 52 publications.
    Title Leukocyte Subtypes in Electroejaculates of Spinal Cord Injured Men.
    Date February 2002
    Journal Archives of Physical Medicine and Rehabilitation
    Excerpt

    OBJECTIVES: To determine the level of leukocytospermia and seminal leukocyte subtypes in men with spinal cord injury (SCI) and to compare the findings with those of fertile, able-bodied controls. DESIGN: Prospective, controlled clinical trial. SETTING: University infertility practice. PARTICIPANTS: Thirteen able-bodied fertile men age matched to 17 men with SCI seeking reproductive rehabilitation. INTERVENTIONS: Vibratory stimulation and antegrade electroejaculation for SCI group; manual ejaculation for controls. MAIN OUTCOME MEASURES: Immunoperoxidase technique on a panel of antileukocyte monoclonal antibodies to obtain the leukocyte subpopulations: B cells, T cells, neutrophils, and macrophages. Immunohistochemical staining and scoring to obtain the mean number of leukocytes and spermatozoa per high power field. The ratios of leukocyte to sperm and leukocyte subtype to sperm were tabulated. RESULTS: Total white blood cells, neutrophils, and macrophages in the SCI population were significantly higher than those in the ejaculates of controls. Although not significantly elevated, all the other evaluated subsets were higher in the SCI group then in the controls. CONCLUSIONS: Leukocytospermia appears to be a pervasive abnormality in the semen recovered from men with SCI. The SCI group had significant elevations of total seminal leukocytes after electroejaculation. Compared with controls, men with SCI had significantly more seminal neutrophils and macrophages. Asthenospermia, universally observed in men with SCI, may be attributable, among other causes, to leukocytospermia.

    Title Does Hormonal Therapy Influence Sexual Function in Men Receiving 3d Conformal Radiation Therapy for Prostate Cancer?
    Date June 2001
    Journal International Journal of Radiation Oncology, Biology, Physics
    Excerpt

    PURPOSE: We evaluated the effect of three-dimensional conformal radiation therapy (3D-CRT) with or without hormonal therapy (HT) on sexual function (SF) in prostate cancer patients whose SF was known before all treatment. METHODS AND MATERIALS: Between March 1996 and March 1999, 144 patients received 3D-CRT (median dose = 70.2 Gy, range 66.6-79.2 Gy) for prostate cancer and had pre- and post-therapy SF data. All SF data were obtained with the O'Leary Brief SF Inventory, a self-administered, multidimensional, validated instrument. We defined total sexual potency as erections firm enough for penetration during intercourse. Mean follow-up time was 21 months (SD +/- 11 months). The Wilcoxon signed-rank test was used to test for significance of the change from baseline. RESULTS: Before 3D-CRT, 87 (60%) of 144 men were totally potent as compared to only 47 (47%) of 101 at 1-year follow-up. Of the 60 men totally potent at baseline and followed for at least 1 year, 35 (58%) remained totally potent. These changes corresponded to a significant reduction in SF (p < 0.05). Patients who had 3D-CRT alone were more likely to be totally potent at 1 year than those receiving 3D-CRT with HT (56% vs. 31%, p = 0.012); however, they were also more likely to be potent at baseline (71% vs. 44%, p = 0.001). Although these two groups had a significant reduction in SF from baseline, their change was not significantly different from each other. CONCLUSION: These data indicate that 3D-CRT causes a significant reduction in total sexual potency as compared to pretreatment baseline. The addition of HT does not appear to increase the risk of sexual dysfunction.

    Title Transurethral Microwave Thermotherapy of the Prostate Without Intravenous Sedation: Results of a Single United States Center Using Both Low- and High-energy Protocols. Tjuh Tumt Study Group.
    Date May 2001
    Journal Techniques in Urology
    Excerpt

    PURPOSE: Previous studies have indicated that high-energy transurethral microwave thermotherapy (TUMT) requires intravenous (IV) sedation and/or narcotics for patient tolerance. This study was performed to determine tolerability, patient acceptance, and efficacy of TUMT using both low- and high-energy protocols in a single United States university setting. MATERIALS AND METHODS: Between August 11, 1997 and October 28, 1999, 210 men (mean age 64.9 +/- 9.1 years) presenting with symptomatic benign prostatic hyperplasia (BPH) received treatment with a Prostatron TUMT using either the low-energy Prostasoft 2.O or high-energy Prostasoft 2.5 software. Each patient had digital rectal examination and prostate-specific antigen level consistent with BPH, American Urological Association symptom score > or = 15, and Qmax <15 mL/s. Each patient received TUMT with only ibuprofen 400 mg by mouth (PO), lorazepam 1.0 mg PO, and ketorolac 30 mg intramuscularly (IM) prior to TUMT. A few patients who were concerned about limited pain threshold received oxycodone 5 mg/acetaminophen 325 mg PO. Of 210 patients treated, 12-month efficacy data were available for analysis in 80 patients. RESULTS: Forty-eight men (mean age 65 +/- 9.2 years) received low-energy 2.0 software TUMT, and 32 men (mean age 65.1 +/- 9.2 years) were treated with high-energy 2.5 software. Mean prostatic volume was 44.3 +/- 23.9 mL and 60.7 +/- 26.4 mL for the 2.0 and 2.5 groups, respectively. Mean energy delivered was 108.8 +/- 50.4 kJ and 173.1 +/- 41.1 kJ for the 2.0 and 2.5 treatment groups, respectively. International Prostate Symptom Score decreased from 23 pre-TUMT to 8 post-TUMT and 21 pre-TUMT to 10 post-TUMT at 12 months in the 2.0 and 2.5 groups, respectively. Mean peak flow rate improved 31.9% from 9.1 mL/s pre-TUMT to 12.0 mL/s post-TUMT and 45.8% from 9.6 mL/s pre-TUMT to 14.0 mL/s post-TUMT at 12 months in the 2.0 and 2.5 groups, respectively. All but two patients tolerated treatment without IV sedation. One patient experienced intolerable rectal spasm, and treatment was terminated in another patient because of poorly controlled hypertension. CONCLUSIONS: Patients can be treated safely with TUMT using either low or high energy, with almost universal patient tolerance and without the need for IV sedation or narcotics, if they premedicated effectively using a PO/IM regimen. Patients experience significant relief of symptoms whether low- or high-energy TUMT is used; however, high-energy TUMT improves flow rate to a greater extent than does low-energy therapy.

    Title Sildenafil Citrate Effectively Reverses Sexual Dysfunction Induced by Three-dimensional Conformal Radiation Therapy.
    Date May 2001
    Journal Urology
    Excerpt

    OBJECTIVES: We evaluated the response of sildenafil citrate in patients with prostate cancer treated with three-dimensional conformal radiation therapy (3DCRT) whose sexual function (SF) was known prior to therapy initiation. METHODS: From March 1996 to April 1999, 24 men with median age of 68 years (range 51 to 77) had 3DCRT for localized prostate cancer (median prescribed dose to the planning target volume of 70.2 Gy). These men started taking sildenafil for relief of sexual dysfunction at a median time of 1 year after completing 3DCRT. We used the self-administered O'Leary Brief Sexual Function Inventory to evaluate in series SF and overall satisfaction at three time points. These points were (a) before initiation of all therapies (3DCRT or hormonal treatment [HT]) for prostate cancer, (b) before starting sildenafil (50 mg or 100 mg) but after completion of all therapies, and (c) at least 2 months afterward. Rates of SF were based on the number of men responding to a given question. We tested for significance of these two interventions to change SF by applying the Wilcoxon sign rank test. RESULTS: Prior to all treatments, 20 (87%) of 23 men were sexually potent, with 8 (36%) of 22 fully potent (little or no difficulty for penetration at intercourse). After 3DCRT with or without HT and prior to sildenafil use, 13 (65%) of the 20 potent patients remained potent, with only 2 (11%) of 19 being fully potent. The use of sildenafil citrate resulted in 21 (91%) of 23 men being potent, with 7 (30%) being fully potent. In 16 men responding to the satisfaction question, 10 (63%) and 12 (75%) were mixed to very satisfied with their sex life before 3DCRT with or without HT and after sildenafil citrate use, respectively. This response corresponded to potency and satisfaction scores significantly decreasing and subsequently increasing on average by one unit after 3DCRT and sildenafil citrate use, respectively (P <0.05). CONCLUSIONS: In men receiving 3DCRT for prostate cancer, these data indicate that sildenafil citrate is effective for restoring SF and associated satisfaction back to baseline before treatment.

    Title Glandular-tunical Stabilization to Repair Sst Deformity of the Inflatable Penile Prosthesis.
    Date December 2000
    Journal Techniques in Urology
    Excerpt

    Among the complications of penile prosthetic surgery, the SST deformity is uncommon. Nonetheless, this functional and cosmetic complication affects patient and partner. We describe a modified corrective technique of glandular stabilization and repositioning specifically designed for the inflatable penile prosthesis. The pericoronal glandular fascia is secured to the tunica albuginea by protecting the underlying inflatable cylinder and avoiding tunical plication. This technique minimizes the risk of cylinder perforation and penile sensory loss and foreshortening.

    Title Sonographically Guided Transurethral Laser Incision of a Müllerian Duct Cyst for Treatment of Ejaculatory Duct Obstruction.
    Date October 2000
    Journal Ajr. American Journal of Roentgenology
    Title Integrative Urology: a Spectrum of Complementary and Alternative Therapy.
    Date August 2000
    Journal Urology
    Title Testis Biopsy Findings in the Spinal Cord Injured Patient.
    Date March 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Azoospermia after electroejaculation in spinal cord injured men may be due to testicular failure or obstruction. These men can initiate pregnancy with assisted reproductive techniques, such as intracytoplasmic sperm injection, but only if sperm are present in the testis biopsy. We analyzed the histopathology of testis biopsies from spinal cord injured men and assessed whether patient factors were predictive of testis biopsy pathology. MATERIALS AND METHODS: A total of 50 paraplegic men undergoing testis biopsy were divided into 2 groups based on normal or abnormal testis histopathology. Patient age, post-injury years, level of lesion, hormonal status and semen analysis results were compared. RESULTS: Spermatogenesis was normal in 28 of the 50 patients. Hypospermatogenesis was exhibited in 15, maturation arrest at the spermatid stage in 6 and maturation arrest at the spermatocyte stage in 1 of the 22 abnormal cases. Nevertheless, mature sperm were identified in 43 of 50 biopsies (normal spermatogenesis and hypospermatogenesis). Men with normal spermatogenesis had better forward progression of sperm and a higher testosterone-to-luteinizing hormone ratio. Otherwise, there was no statistically significant correlation between study variables and testis biopsy results. No factors were predictive of testis biopsy histopathology. CONCLUSIONS: The documentation of mature sperm in 43 of 50 biopsies from spinal cord injured patients suggests that a high rate of sperm retrieval is possible using testicular sperm extraction if sperm cannot be retrieved from the ejaculate. With intracytoplasmic sperm injection techniques the majority of spinal cord injured men retain fertility potential, even if azoospermic following electroejaculation.

    Title Gunshot Wound to the Penis: the Need for Corporal Exploration.
    Date July 1999
    Journal Techniques in Urology
    Excerpt

    Although the overall incidence of penetrating penile injuries is relatively low, these injuries may present complex management problems and should be managed with attention to long-term cosmetic and functional considerations. In this article we present an unusual case of a gunshot wound to the penis and emphasize the importance of bilateral corporal exploration and possible repair to avoid erectile dysfunction and penile deformity.

    Title Spermatogenesis in Early and Chronic Phases of Experimental Spinal Cord Injury in the Rodent Model.
    Date July 1999
    Journal Journal of Andrology
    Excerpt

    A rodent model was used to study the degree and dynamics of potential spermatogenic alterations during both acute and chronic phases after experimental spinal cord injury (SCI). Sexually mature Sprague-Dawley rats underwent controlled impact SCI by exposure of the thoracic spine, T-10 laminectomy, and intraoperative somatosensory-evoked potential latency and amplitude. A 50 gm-cm SCI was produced in 35 experimental subjects. Sham surgery was performed on 16 control subjects through exposure of the dura without weight drop. SCI was verified by obliteration of the somatosensory-evoked potential following injury and subsequent neurologic assessment (modified hindlimb Tarlov scale) 4 weeks after injury. Flow cytometry with acridine orange as the DNA probe was used to measure potential spermatogenic alterations in testicular cell development and integrity of epididymal sperm chromatin structure between 2 and 20 weeks following SCI. Flow cytometric analysis revealed that nine of the 35 SCI animals demonstrated altered spermatogenesis; it is not clear whether these effects are specific or nonspecific stress related. These responder animals contributed to dramatic differences in relative percent testicular haploid cells (spermatids) and concurrent differences in percent diploid cells at 2, 4, 8, 12, and 16 weeks. Percentages within the three spermatid populations (round, elongating, and elongated) also differed at these time points. The sperm chromatin structure assay (SCSA) revealed significant epididymal sperm nuclear structure differences at 2, 4, and 12 weeks (P < 0.001). These findings are in concordance with our clinical observations of spermatogenesis in spinal cord injured men and suggest that significant spermatogenic deficit may occur, even in the early phase of injury.

    Title Are Sperm Motion Parameters Influenced by Varicocele Ligation?
    Date May 1999
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To document objectively, improvements in sperm motion parameters in subfertile men after varicocele ligation with the use of computer-aided sperm analysis. DESIGN: Retrospective chart review. SETTING: An academic clinical environment. PATIENT(S): Thirty-four men with varicocele as the primary cause of infertility who underwent a physical examination, hormonal profile, and Doppler ultrasound evaluation. INTERVENTION(S): Computer-aided sperm analysis was performed before and after either subinguinal or laparoscopic varicocele ligation. MAIN OUTCOME MEASURE(S): Patients were followed up for 3-18 months after operation, and average computer-aided sperm analysis values were obtained before and after operation. Computer-aided sperm analysis values were analyzed by paired Student's t-test, with special reference to motility and sperm motion parameters. RESULT(S): After varicocele ligation, patients demonstrated increases in mean sperm density and in the overall distribution of sperm with rapid velocity, although the increases were not statistically significant. Mean measures of straightness, linearity, and track speed also were increased after operation, but only progressive sperm velocity was increased to a statistically significant level. CONCLUSION(S): Because progressive velocity has been a primary computer-aided sperm analysis parameter predictive of male fertility and the success of assisted reproductive techniques, we conclude that varicocele ligation results in improvements in semen parameters, especially the key parameter of progressive sperm velocity.

    Title Using a Colonoscopy Snare to Safely Remove Large Papillary Bladder Tumors.
    Date March 1999
    Journal Techniques in Urology
    Excerpt

    A standard 22F rigid cystoscope with a 6.9F Bard colonoscopy snare connected to an Erbe power source at 25 W was utilized to remove bladder tumors. A loop was used to resect the base of the lesion and underlying muscle. Snare resection of papillary vesical tumors is a safe, easy method that can complement standard loop resection and be a valuable asset to urologists. No interference with histopathologic examination was encountered with this technique.

    Title Experience with the Ultrex and Ultrex Plus Inflatable Penile Prosthesis: New Implantation Techniques and Surgical Outcome.
    Date December 1998
    Journal International Journal of Impotence Research
    Excerpt

    The Ultrex and Ultrex Plus penile prosthesis incorporate sequential design modifications that afford important functional advantages that reduce the potential for mechanical failure. This retrospective study reviews our experience with these models emphasizing innovations in surgical technique and postoperative results. Implantation of Ultrex (31%) and Ultrex Plus (69%) penile prosthesis was performed in 90 impotent men with organic erectile dysfunction following comprehensive multi-disciplinary evaluation. During a follow-up interval of 7-50 months, postoperative outcome was assessed. Of this group, 10% underwent simultaneous explant of another malfunctioning inflatable device or conversion from a semi-rigid prosthesis due to patient preference. Of the remainder, 20% selected implant surgery as their primary therapy while 73% were initially treated with various nonsurgical options prior to implantation. In all patients we employed a single peno-scrotal incision and applied the concept of controlled radial dilatation of all compartments. In our last 32 consecutive patients including eight with previous radical pelvic surgery, we utilized the preperitoneal distention balloon (PDB) facilitating safe and non-traumatic creation of the prevesical space for reservoir insertion. Post operative complications occurred in 8% of patients including pump infection and corporal deformity requiring reimplantation with AMS 700 CX cylinders, or self-contained unitarian prosthesis as a salvage procedure. Satisfactory, functional and anatomic outcome was reported in 95% of patients. Interim advances incorporated into the Ultrex and Ultrex Plus prosthesis have markedly reduced mechanical failure during our follow-up interval of up to 50 months. Importantly, controlled, non-traumatic radial dilatation of the prevesical space by the PDB may encourage broader use of the multicomponent inflatable models, particularly in a setting of pelvic fibrosis due to previous pelvic surgery or radiation.

    Title Postsurgical Outcomes Assessment Following Varicocele Ligation: Laparoscopic Versus Subinguinal Approach.
    Date June 1998
    Journal Urology
    Excerpt

    OBJECTIVES: To prospectively compare and objectively assess the postsurgical outcome parameters of both laparoscopic and open subinguinal techniques for varicocele ligation in infertile men. METHODS: A total of 41 evaluable patients with a history of infertility, abnormal semen analysis, and clinically diagnosed varicoceles underwent surgical ligation either by the insufflative intraperitoneal laparoscopic (n = 15), gasless laparoscopic (n = 7), or the open subinguinal (n = 19) approach. Most procedures (39 of 41) were performed in the outpatient setting, and patients were followed postoperatively for a minimum of 6 months. Postsurgical outcome was assessed by physical examination and review of a patient questionnaire quantifying the graded pain severity, analgesic requirements, and number of days to return to work. RESULTS: The average operative time was 82.3 +/- 26.5 minutes for insufflative intraperitoneal laparoscopic varicocelectomy, 170 +/- 55 minutes for gasless laparoscopic varicocelectomy, and 35.6 +/- 13.5 minutes for the open subinguinal approach. The analgesic requirement was 13.7 +/- 9.9 tablets for the insufflative laparoscopic group, 22.5 +/- 11 tablets for the gasless laparoscopic group, and 10.9 +/- 10.3 tablets for the open subinguinal group. The average number of days to return to work was 4.9 +/- 2.7 for the insufflative group, 6.6 +/- 2.6 for the gasless group, and 5.1 +/- 3.7 for the open subinguinal group. CONCLUSIONS: These results show no superiority of laparoscopic techniques over the standard open subinguinal technique with respect to hospital stay, analgesic requirements, or return to work. Laparoscopic techniques require excessive operative time, may have attendant complications, and require general anesthesia, limitations that preclude their routine application in varicocele ligation. However, the laparoscopic approach may have a role in the setting of other concurrently performed laparoscopic procedures.

    Title Laparoscopic Urologic Surgery Outcome Assessment.
    Date February 1998
    Journal Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A
    Excerpt

    Laparoscopic surgery is an evolving technique that began to be applied widely in urology in the early 1990s. We have conducted an ongoing multicenter study of laparoscopic urologic surgery to identify any changes in utilization, complications, and short- and long-term outcomes. Laparoscopic urologic surgical procedures were assessed in three successive phases: retrospective initial experience [P1] (before 1991), and prospectively, an intermediate phase [P2] (1991-1992) and a late phase [P3] (1993-1994). The late phase group was followed for 1 year through 1995 to identify any delayed complications. In the P1 group, 114 patients are included; 105 underwent laparoscopic pelvic lymph node dissection (LPLND), 7 underwent laparoscopic variocele ligation (LVL), and 2 underwent other procedures. The complication rates in P1 are 21% (total): 10.5% (major) and 10.5% (minor). The P2 group includes 148 patients; 132 underwent LPLND, 10 underwent LVL, and 6 underwent other procedures. The complication rates decreased to 16.2% (total): 6% (major) and 10.1% (minor). The latest group (P3) includes 326 subjects; 245 had LPLND, 39 had LVL, and 42 had other procedures. More improvement in outcome is shown in this phase with a 7.98% total complication rate: 0.92% major and 7.05% minor. In addition, other parameters such as operative time and hospital stay show improvement through the successive phases. There were no significant long-term complications in the latest study group. This study demonstrates a continual improvement in outcome and changes in utilization patterns as urologists become more experienced with laparoscopic surgery. The complexity of the procedures performed has increased with a decrease in the complication rates overall.

    Title Gasless Laparoscopic Varicocele Ligation: Experience with New Instrumentation and Technique for Retroperitoneal and Intraperitoneal Approaches.
    Date February 1998
    Journal Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A
    Excerpt

    Laparoscopic access to the retroperitoneum without abdominal insufflation has recently been made possible by devices designed to create a dilated laparoscopic cavity maintained by a fixed retraction system. This technique was applied in 10 patients undergoing laparoscopic ligation of the internal spermatic vein via extraperitoneal and intraperitoneal approaches. Gasless laparoscopic varicocelectomy was completed in 7 of 8 men by the extraperitoneal route and in neither of the 2 men approached intraperitoneally. The mean operative time was 170+/-55 min and postoperative pain exceeded the norm for standard insufflative laparoscopic varicocelectomy. Whereas certain theoretical advantages are offered by the gasless extraperitoneal approach to varicocele ligation, exposure through the gasless technique is currently suboptimal. Further development of "retraction" technology is required, prior to its routine application for varicocele ligation.

    Title Noninsufflative Extraperitoneal Laparoscopic Varicocele Ligation.
    Date July 1997
    Journal Techniques in Urology
    Excerpt

    Currently, most laparoscopic procedures are performed through the intraperitoneal route utilizing standard insufflative technique to create a working space. We report our experience with the new technique of gasless extraperitoneal varicocelectomy performed in eight subfertile men, in which we effectively dissect the retroperitoneum by using a trocar balloon device (peritoneal distention balloon) and maintain the working cavity with a motorized abdominal wall retractor (Laparofan/Laparolift retraction system). In addition to the primary trocar, two valveless secondary trocars are placed, through which either laparoscopic or standard surgical instruments may be used. The spermatic veins are doubly clipped while the artery is preserved in all cases. The mean operative time was 150 +/- 51 min with no intraoperative complications, and all patients were discharged within 24 h. The average days to return to work was 6.5 +/- 3.0 and the average postoperative analgesic requirement (pain pills) was 23.5 +/- 9.9. There were no significant postoperative complications. Exposure and working space provided by the gasless technique are not as satisfactory as the standard insufflative technique, and operative time is far more extensive. To surmount these limitations in gasless laparoscopy, significant developments are required in retraction technology.

    Title Experience with Intracavernous Pge-1 in the Treatment of Erectile Dysfunction: Dose Considerations and Efficacy.
    Date July 1997
    Journal International Journal of Impotence Research
    Excerpt

    The recommended dose of PGE-1 as treatment for erectile dysfunction has ranged from 10-60 mcg in various studies. We conducted the present study to identify factors that influence dose tritration and maintenance. From 96 patients who presented to our institution with erectile impotence, 40 elected self injection with PGE-1. Erectile response to intracavernous injection was assessed in the course of office-based dose titration. Patients were stratified into different groups based on age and etiology of erectile dysfunction. The mean maintenance dose was calculated in each group. Patients were evaluated quarterly by physical palpation of the penis, complete blood count, serum electrolytes, and liver function tests in order to assess safety of therapy. The average maintenance dose varied with the etiology of erectile dysfunction and age of the patient. The central neurogenic group was the most responsive to PGE-1 therapy, requiring an average maintenance dosage of 5 mcg. Men with vascular etiologies required the largest maintenance dosage of 20 mcg. Furthermore, dosage requirement increased linearly with age. We conclude that dosing considerations vary widely in a clinical setting and their determination is greatly facilitated if primary and associated causes of erectile dysfunction and the age of the patient are considered.

    Title New Prostatectomy Technique: Transurethral Electrovaporization of the Prostate.
    Date April 1997
    Journal Techniques in Urology
    Excerpt

    Major health and economic concerns have caused urologists to seek alternative forms of treatment for benign prostatic hypertrophy (BPH). The goal of these newer treatments is to decrease morbidity, reduce health care cost, and improve overall outcome for the patients with symptomatic bladder outlet obstruction. Transurethral resection of the prostate (TURP) is the gold standard treatment for BPH. One factor associated with the relative higher cost of a TURP is the average 4-day postoperative stay needed to clear the hematuria. Techniques have evolved that have allowed immediate tissue removal through "vaporization" of the prostate with a decrease in the postoperative stay. These techniques have primarily relied upon the use of lasers to vaporize tissue. A new transurethral prostatectomy technique called transurethral electrovaporization of the prostate (TVP) has been recently introduced. This relies upon a newly developed resectoscope electrode (VaporTrode) that allows vaporization of the prostate tissue in the "cutting" mode. The potential advantage of TVP is the reduction in postoperative hematuria and the utilization of equipment and techniques that are already familiar to the practicing urologist.

    Title Epidemiology of Current Treatment for Sexual Dysfunction in Spinal Cord Injured Men in the Usa Model Spinal Cord Injury Centers.
    Date December 1996
    Journal The Journal of Spinal Cord Medicine
    Excerpt

    This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

    Title Noninsufflative Laparoscopic Access.
    Date October 1996
    Journal Journal of Endourology / Endourological Society
    Excerpt

    Standard laparoscopic surgery requires maintenance of the working cavity by continual carbon dioxide insufflation and exaggerated Trendelenburg positioning. Both cardiopulmonary and metabolic adverse effects may result from these maneuvers, which may be avoided by a gasless approach to laparoscopic surgery. We investigated a new mechanical retraction system designed to maintain exposure of either intraperitoneal or retroperitoneal contents in a gasless laparoscopic cavity and assessed its performance in both laparoscopic approaches. Gasless laparoscopic surgery was attempted using the Laprolift/Laparofan system for retroperitoneal procedures: left varicocele ligation (three cases), renal biopsy (one case), extraperitoneal pelvic lymph node dissection (one case), and intraperitoneal bilateral varicocelectomy (two cases). Renal biopsy and varicocelectomy were accomplished successfully with the gasless approach and with technical ease comparable to that of the standard insufflative laparoscopic approach. Gasless pelvic lymph node dissection and intraperitoneal varicocelectomy were converted to insufflative laparoscopic or open procedures because of inadequate exposure of the pelvic contents. This early experience with gasless laparoscopy indicates that it may best be reserved for retroperitoneal urologic procedures.

    Title Radial Dilatation in the Insertion of the Multi-component Inflatable Penile Prosthesis.
    Date August 1995
    Journal British Journal of Urology
    Title Sequential Penile Ultrasound Monitoring of Patients Treated with Chronic Intracavernous Prostaglandin E1.
    Date June 1995
    Journal Urology
    Excerpt

    OBJECTIVES. Clinical outcome studies of prostaglandin E1 (PGE1) have shown a markedly decreased rate of palpable fibrosis and plaque formation. In this prospective study we investigate the potential of this agent to produce subclinical fibrotic changes. METHODS. Real-time high-resolution ultrasound scanning of the corpora was performed using a 7.5 to 10 MHz linear array transducer in 80 men on initiation of treatment with self-administered PGE1 and at quarterly intervals during the course of following (3 to 28 months). The dorsal portion of the penile shaft was scanned in the transverse and sagittal planes from base to glans for a side by side comparison of the cavernosal tissue, evaluating local abnormalities of tissue echogenicity. RESULTS. Palpable lesions were not detected in any men on quarterly follow-up examination. Thirteen (16.5%) men developed new echogenic foci not present on pretreatment scanning at the following locations: proximal corpus cavernosum, subcutaneous tissues, and corpus spongiosum. These changes were observed both as single and multiple lesions ranging in size from 1 to 10 mm. The presence of these findings was independent of the etiology of impotence, dose frequency, and duration of intracavernous therapy. CONCLUSIONS. The significance of these subclinical changes is unknown but their low incidence should be recognized when considering long-term intracavernous therapy.

    Title Erectile Dysfunction in Systemic Sclerosis.
    Date June 1995
    Journal Urology
    Excerpt

    Systemic sclerosis (SSc, scleroderma), a connective tissue disorder involving multiple organ systems, can be a causal factor in erectile dysfunction. We present a case report and a review of the literature. Awareness of this association can hasten the detection of this disorder and influence management choices.

    Title Evaluation of Sperm Morphology of Electroejaculates of Spinal Cord-injured Men by Strict Criteria.
    Date May 1995
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To compare sperm morphology of electrostimulated ejaculates of spinal cord-injured (SCI) men with that of manual ejaculates of an able-bodied population. DESIGN: Retrospective study. PATIENTS: Spinal cord-injured men (n = 21) participating in a reproductive rehabilitation program and able-bodied men (n = 163) attending a male fertility clinic. SETTING: Male fertility clinic of a university urology practice. MAIN OUTCOME MEASURES: Morphological characteristics of sperm evaluated by strict criteria. RESULTS: Electroejaculates of SCI men had significantly higher percentages of small sperm heads, vacuolated sperm heads, and sperm with tail defects than found in manual ejaculates of able-bodied men. Cellular elements of nongerminal origin (white blood cells, red blood cells, epithelial cells) were also more likely to be present in electroejaculates. CONCLUSION: When evaluated by strict criteria, electroejaculates exhibit specific defects in sperm morphological profile. A pervasive pattern of teratozoospermia exists that may reflect underlying defects contributing to decreased fertility in SCI men.

    Title Use of Intracavernous Injection of Prostaglandin E1 for Neuropathic Erectile Dysfunction.
    Date February 1995
    Journal Paraplegia
    Excerpt

    The administration and suitability of intracavernous PGE-1 in men with neuropathic erectile dysfunction is reported herein. Twenty-seven men with neuropathic erectile dysfunction (SCI, 14; multiple sclerosis, 7; discogenic disease, 6) were evaluated and treated with intracavernous PGE-1. An average of 3.2 office sessions were required to learn adequate self-injection technique and determine optimal dosage requirement. Initial dosage for SCI men was 2.5 micrograms and increased in 2.5 micrograms increments to a mean maintenance dose of 6.2 micrograms. Quarterly monitoring up to 28 months demonstrated satisfactory erectile rigidity and duration of erection in all patients electing to pursue home administration of PGE-1. During this interval, over 40% of patients dropped out of the treatment program. No priapism or changes in serum chemistries, CBC, or platelets were observed during this period. Corporal fibrosis although not palpable, was detected subclinically by penile ultrasound in two men. This study confirms the safety and efficacy of self-administered intracavernous PGE-1 for neuropathic impotence. However, because of a significant rate of voluntary cessation, patients should be counseled regarding the full range of therapeutic alternatives to intracavernous therapy.

    Title Controlled Balloon Dilatation of the Extraperitoneal Space for Laparoscopic Urologic Surgery.
    Date December 1994
    Journal Journal of Laparoendoscopic Surgery
    Excerpt

    Laparoscopic urologic surgery has become increasingly more popular, with the majority of procedures and techniques that have been described based on intraperitoneal experience and anatomic considerations. Urologic surgery, traditionally confined mostly to the extraperitoneal space, has followed these intraperitoneal descriptions when undertaken laparoscopically. Our experience of controlled, laparoscopically monitored dilatation of the extraperitoneal space using a new trocar-mounted balloon dissector can create a working space in a surgical environment familiar to traditional open urologic surgery. We report our initial experience with the preperitoneal distention balloon in 15 patients, emphasizing the technique of extraperitoneal access and the laparoscopic visualization of anatomy relevant to pelvic lymph node dissection, varicocele ligation, nephropexy, and renal biopsy. In this early experience, laparoscopic pelvic lymph node dissection was performed successfully in 7 of 11 patients and in all other patients undergoing the retroperitoneal procedures. Patients with a prior history of hernia repair or appendectomy do not appear to be suitable to this approach when used for pelvic lymphadenectomy. The trocar-mounted balloon device allows direct visualization and control of the dissection process. Avoiding the transperitoneal approach may eliminate many of the complications associated with the transperitoneal access and procedure completion. We conclude that the extraperitoneal technique using this device merits further investigation and more widespread application in the laparoscopic approach to conventional extraperitoneal urologic procedures.

    Title Office Based Screening of Sperm Autoimmunity.
    Date December 1994
    Journal The Journal of Urology
    Excerpt

    Sperm autoimmunity has been reported as a contributory cause of male factor infertility in up to 10% of subfertile men. The standard laboratory technique for the determination of sperm bound antisperm antibodies is the direct immunobead test. However, because of its complex methodology this test does not readily lend itself as a screening tool for this diagnosis. We describe a simple office based procedure, the sperm mixed antiglobulin reaction, for the detection of antisperm antibodies and compare its diagnostic accuracy with the standard direct immunobead test. Both assays were simultaneously performed on each of 102 semen specimens from men with male factor infertility. The rate of detection of sperm autoantibodies was 16.6% and 19.6% by the direct immunobead test and sperm mixed antiglobulin reaction, respectively. Compared to the direct immunobead test, sperm mixed antiglobulin reaction demonstrated a sensitivity and specificity of 100% and 96%, respectively. The positive predictive value was 85% and the negative predictive value was 100%, emphasizing its particularly useful role as a screening tool for office based detection of sperm autoantibodies in men who present for evaluation of fertility potential.

    Title Complications of Teflon Injection for Stress Urinary Incontinence.
    Date October 1994
    Journal Neurourology and Urodynamics
    Excerpt

    Four significant complications of Teflon injections for stress urinary incontinence are reported in 22 women and eight men. Three of the complications included periurethral abscess, urethral diverticulum, and periurethral Teflon granuloma with urethral wall prolapse occurred in women. These complications needed surgical excision and further surgery for stress incontinence, in two patients the outcome was good. Among the female patients the cure rate for stress incontinence with Teflon injection was only 18% in the 5-year follow-up. One other complication, a Teflon cyst, occurred in a male who had previously undergone radical retropubic prostatectomy. Only two of the eight men (25%) who received Teflon injections had maintained improvement after 1 year.

    Title Endoscopic Urethroplasty of Posterior Urethral Avulsion.
    Date August 1994
    Journal Urology
    Excerpt

    OBJECTIVES. Traumatic avulsion of the posterior urethra represents a challenging reconstructive problem that traditionally has been managed by the transpubic or transperineal approach. We report the advantages of endourologic techniques to reconstruct short posterior urethral disruptions based on the principles of establishing proximal urethral control and balloon dilation of the newly constructed urethra. METHODS. Endourologic urethroplasty consists of: (1) antegrade flexible cystoscopy or antegrade passage of a Goodwin sound, (2) retrograde urethrotomy to light or to tip of Goodwin sound, facilitated by C-arm fluoroscopy, (3) establishment of urethral continuity by passage of a guide wire, (4) balloon dilation of the newly established urethra to 24 to 30 F over a length of 4 cm, and (5) long-term urethral stenting (4 to 8 weeks) with a silicone Foley catheter. RESULTS. In four men initially managed by suprapubic cystostomy, endourologic reconstruction was performed. The mean blood loss was 250 mL, and mean length of hospitalization was 5.4 days. All patients were continent and three were potent over a mean follow-up of 10.5 months. Uroflowmetric monitoring showed satisfactory voiding patterns with subsequent minor endoscopic revisions required in three patients. CONCLUSIONS. The technical advantages of this method include stabilization and identification of the proximal urethra, intraoperative shortening of the urethral gap to facilitate the urethrotomy, and radial distention of the urethra by balloon dilation. We conclude that endourologic methods provide a safe and effective initial treatment of urethral avulsion.

    Title Objective Assessment of Spermatogenesis in Men with Functional and Anatomic Obstruction of the Genital Tract.
    Date July 1994
    Journal International Journal of Andrology
    Excerpt

    Experimental rodent models simulating the condition of neurogenic infertility have drawn attention to the role of potential epididymal dysfunction as an underlying cause. This functional obstruction of the genital tract is comparable to the outcome of genital tract obstruction after vasectomy, and may explain the common finding of asthenospermia in both groups following either stimulated semen recovery or vasovasostomy, respectively. Since spermatogenic dysfunction has been reported in spinal cord injury, the relative roles of defective sperm production and sperm transport remain to be determined in men with neurogenic infertility. The objective of this study was to compare the levels of spermatogenesis in groups of vasectomized men and those with spinal cord injury, using objective measurement criteria for spermatogenesis. Groups of 10 spinal cord-injured and six vasectomized men matched for age and duration of disease, underwent incisional testicular biopsy. The specimens were divided equally for parallel quantitation of spermatogenesis by both quantitative cytometry and DNA flow cytometric analysis. Quantitative parameters showed similar values for both groups with reference to mean tubular wall thickness, mean tubular concentration of spermatids and Sertoli cells, as well as the mean spermatid: Sertoli cell ratio per tubule. Additionally, similar percentages of 1N, 2N and 4N cells, were found in both groups. Based on these preliminary findings this study provides a clinical correlation supporting the experimental observation that both anatomical and functional obstruction of the male genital tract exert a similar although minor spermatogenic insult, and that in both the putative cause for neurogenic infertility is more likely to be at the post-testicular level.

    Title Facilitated Implantation of the Inguinal Reservoir of the Multicomponent Inflatable Penile Prosthesis.
    Date June 1994
    Journal The Journal of Urology
    Excerpt

    We present a method of implantation of the inguinal reservoir of the multicomponent inflatable penile prosthesis that permits safe 1-step creation of an adequate prevesical space. The preperitoneal distention balloon is inflated in the prevesical space to produce a compartment of adequate volume to avoid back pressure on the reservoir and minimize potential bladder injury in the setting of previous pelvic surgery.

    Title Flexible Cystoscopy During Urodynamic Evaluation of Spinal Cord-injured Patients.
    Date April 1994
    Journal Journal of Endourology / Endourological Society
    Excerpt

    Eighty-one consecutive flexible cystoscopic examinations were performed on 69 patients with spinal cord injury (SCI) at the time of their urodynamic study. The indications for cystoscopy included hematuria, recurrent urinary tract infections, symptoms of bladder outlet obstruction, the presence of an intraurethral sphincter stent requiring evaluation, neurogenic vesical dysfunction requiring endourodynamic study (cystometrogram through the working port of the flexible cystoscope), or bladder calculi. Flexible cystoscopy was accomplished in all patients, whether lying supine or seated in a wheelchair (N = 16). Only 6 of 39 patients with previous episodes of autonomic dysreflexia became hypertensive during cystoscopy. When a urodynamic catheter could not be inserted, the flexible cystoscope was particularly useful in defining the urethral anatomy or obstruction and in performing endourodynamic evaluation. The only complication was the development of febrile urinary tract infection in four patients. The flexible cystoscope is a valuable tool in the urodynamic laboratory caring for patients with SCI and is effective for use in endourodynamics, especially when patient positioning or catheter placement is difficult. The procedure is well tolerated, causes minimal stimulation leading to the development of autonomic dysreflexia, and provides accurate cystometric data.

    Title Simplified and Objective Assessment of Spermatogenesis in Spinal Cord Injured Men by Flow Cytometry Analysis.
    Date March 1994
    Journal Paraplegia
    Excerpt

    Deterioration of the germinal epithelium of the testis is a known sequela of spinal cord injury (SCI) that may influence the outcome of male reproductive rehabilitation efforts. Quantitative testicular biopsy, currently regarded as the standard of assessing the integrity of spermatogenesis, has not gained wide-spread clinical use because of its invasive nature and relative technical complexity. Alternatively, aspiration DNA flow cytometry analysis of the testis has offered a potential method of spermatogenic assessment that meets both the requirements of simplicity and objectivity. The objective of this study is to determine the capability of flow cytometry to assess spermatogenesis following SCI. Eleven SCI men underwent incisional testicular biopsy with the specimen simultaneously submitted for quantitative evaluation of the germinal epithelium by both quantitative histometry and DNA flow cytometry. The haploid percentage of cells showed highly significant levels of correlation with key micrometric parameters of the quantitative testicular biopsy: spermatid/tubule (p < 0.002) and the spermatid/Sertoli cell ratio (p < 0.0005). Since tissue procurement is accomplished less invasively for flow cytometry analysis, we recommend this method as the modality of assuring integrity of the germinal epithelium in candidates for reproductive rehabilitation.

    Title Prospective Evaluation of Terazosin for the Treatment of Autonomic Dysreflexia.
    Date January 1994
    Journal The Journal of Urology
    Excerpt

    Terazosin was evaluated in 21 normotensive spinal cord injured patients with autonomic dysreflexia. The patients were followed for 3 months during which the autonomic dysreflexia severity and frequency were evaluated. Autonomic dysreflexia severity mean score was significantly improved when measured at baseline and at 1 week, 1 month and 3 months (10.3 +/- 4.2, 5.08 +/- 2.3, 3.83 +/- 2.5 and 4.5 +/- 1.4, respectively, p < 0.0005). No statistically significant change was seen in erectile function and blood pressure. Three patients complained of fatigue, 1 of whom had the dosage reduced from 5 to 2.5 mg. daily. Terazosin appears to be effective in preventing serious harm from autonomic dysreflexia without erectile function impairment. The effectiveness is significant in the first week and remains for at least 3 months.

    Title Soluble Fc Gamma Riii (cd16) and Immunoglobulin G Levels in Seminal Plasma of Men with Immunological Infertility.
    Date October 1993
    Journal Journal of Andrology
    Excerpt

    Receptors for the Fc region of the immunoglobulin G (IgG) (Fc gamma R) have been recognized as a link between humoral and cellular immune responses. A soluble form of Fc gamma RIII (CD16) has been found in seminal plasma (SP), which may modulate immunosuppression of antisperm immune responses in the male and female reproductive tracts. SP from some individuals apparently have lower levels of Fc gamma RIII, but it is not known whether the diminished activities are due to low receptor concentration or steric interference from IgG. To test the hypothesis that different levels are due to steric interference, relative levels of Fc gamma RIII were measured in SP using monoclonal antibody 3G8 in an amplified enzyme-linked immunosorbent assay (ELISA) system. Men who were positive for antisperm antibodies (ASA) by Sperm Mar and direct immunobead assay (N = 26) and negative for ASA (N = 26) were tested. Individuals who were ASA positive had lower detectable levels than those who were ASA negative (t = 1.99, P = 0.05). Therefore, variation in Fc gamma RIII levels may be due to steric interference from IgG. IgG subclass concentrations in SP of both groups were determined using an ELISA method and compared to Fc gamma RIII levels. Slight correlations were seen for IgG1 (r2 = 0.237, P < 0.001), IgG2 (r2 = 0.204, P < 0.001), and total IgG (r2 = 0.299, P < 0.001) in relation to Fc gamma RIII levels in ASA-negative SP specimens.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Validation of Flow Cytometry Analysis in the Objective Assessment of Spermatogenesis: Comparison to the Quantitative Testicular Biopsy.
    Date August 1993
    Journal The Journal of Urology
    Excerpt

    Objective determination of spermatogenesis has been accomplished by quantitative testicular biopsy, which, although laborious, has served as the standard for spermatogenic assessment. Aspiration deoxyribonucleic acid (DNA) flow cytometry of the testis, however, has simplified this determination, and has correlated with indirect hormonal parameters of spermatogenesis and qualitative observations of the seminiferous epithelium. Nevertheless, this important modality has yet to be validated against quantitative micrometry of the testis. To determine this correlation we submitted 29 incisional testicular biopsies for simultaneous quantitative analysis and DNA flow cytometry. Micrometric parameters included the mean tubular wall thickness, and the mean tubular concentration of late spermatids and Sertoli cells. The percentage of haploid, diploid and tetraploid cells was determined for each patient. For the entire patient population a statistically significant correlation was observed between the percentage of haploid cells and the tubular concentration of late spermatids (r = 0.784, p < 0.0005) as well as the mean tubular spermatid-to-Sertoli cell ratio (r = 0.824, p < 0.0005). A similar correlation was noted for various etiological subsets of patients: spinal cord injury (r = 0.809, p < 0.002), genital tract obstruction (r = 0.705, p < 0.02) and miscellaneous diagnoses (r = 0.828, p < 0.02). For the group with testicular failure quantitative micrometry and flow cytometry demonstrated severe impairment in all patients although a statistically significant correlation could not be shown because of the small range of values. DNA flow cytometry analysis correlates strongly with the current standard of quantitative spermatogenic assessment and, therefore, it may be validated as a simplified and highly objective method of determining spermatogenesis.

    Title The Value of Quantitative Testicular Biopsy and Deoxyribonucleic Acid Flow Cytometry in Predicting Sperm Recovery from Electrostimulated Ejaculates.
    Date May 1993
    Journal The Journal of Urology
    Excerpt

    Spermatogenic abnormalities have been reported in the majority of men following spinal cord injury, and they contribute to the multifactorial etiology of reproductive dysfunction. Thus far, few have studied the seminiferous epithelium in this group of patients by objective criteria. While quantitative micrometry and flow cytometric analysis are accurate and reproducible methods of quantitating spermatogenesis, the latter is simpler and permits needle aspiration for tissue recovery. The objective of this study is to determine the value of quantitative micrometry and flow cytometric analysis as methods of predicting total sperm yield in electrostimulated ejaculates. Incisional testicular biopsy was performed in 12 anejaculatory men, and the tissue specimens were divided for analysis by quantitative micrometry and flow cytometric analysis. Quantitative micrometry consisted of determining the mean tubular wall thickness, mean tubular concentration of the Sertoli cells and mature spermatids in a minimum of 10 round seminiferous tubules per patient. Specimens were prepared for flow cytometric analysis and the deoxyribonucleic acid histogram was analyzed to determine the percentage of cells in each ploidy compartment. Of the quantitative micrometry parameters analyzed a significant correlation resulted between the total sperm yield per electroejaculate and the mean tubular concentration of late spermatids (p = 0.001) as well as with the mean tubular ratio of late spermatids to Sertoli cells (p = 0.003). The tubular concentration of spermatids resulted in a sensitivity and specificity of 100% and 75%, respectively, to predict adequate sperm yield in semen. Likewise, the mean tubular ratio of spermatids to Sertoli cells resulted in a sensitivity and specificity of 75% and 87.5%, respectively, in its ability to predict normal sperm yield in the recovered ejaculate. Deoxyribonucleic acid flow cytometry analysis showed a normal haploid compartment in all 6 specimens studied, and each was associated with high numbers of sperm in recovered semen. Quantitative histometric parameters correlate significantly with the total sperm yield obtained in electrostimulated ejaculates and may have a role in the selection of candidates for treatment in reproductive rehabilitation programs.

    Title Transurethral Balloon Dilation of the External Urinary Sphincter: Effectiveness in Spinal Cord-injured Men with Detrusor-external Urethral Sphincter Dyssynergia.
    Date May 1993
    Journal Radiology
    Excerpt

    The authors investigated balloon dilation as a minimally invasive alternative to transurethral external sphincterotomy for the treatment of detrusor-external urethral sphincter dyssynergia (DESD). Seventeen spinal cord-injured men with voiding pressures greater than 60 cm H2O underwent balloon dilation of the external sphincter to 90 F at 4 atm of pressure for 10 minutes. The mean voiding pressures before and 12 months after dilation were 83 cm H2O +/- 35 and 37 cm H2O +/- 15, respectively (P = .008). There was a significant decrease in residual urine volume, from 163 mL +/- 162 to 68 mL +/- 59 (P = .05), whereas bladder capacity remained relatively unchanged at 253 mL +/- 181 and 230 mL +/- 97 (P = .30). Complications included one case of postoperative bleeding necessitating transfusion, two treatment failures, and one bulbous urethral stricture. Fourteen of the 17 patients (82%) now void without the aid of an indwelling catheter or alternative therapy. Balloon dilation has no detrimental effect on erectile function and may improve fertility.

    Title Urinary Dysfunction in Lyme Disease.
    Date January 1993
    Journal The Journal of Urology
    Excerpt

    Lyme disease, which is caused by the spirochete Borrelia burgdorferi, is associated with a variety of neurological sequelae. We describe 7 patients with neuro-borreliosis who also had lower urinary tract dysfunction. Urodynamic evaluation revealed detrusor hyperreflexia in 5 patients and detrusor areflexia in 2. Detrusor external sphincter dyssynergia was not noted on electromyography in any patient. We observed that the urinary tract may be involved in 2 respects in the course of Lyme disease: 1) voiding dysfunction may be part of neuro-borreliosis and 2) the spirochete may directly invade the urinary tract. In 1 patient bladder infection by the Lyme spirochete was documented on biopsy. Neurological and urological symptoms in all patients were slow to resolve and convalescence was protracted. Relapses of active Lyme disease and residual neurological deficits were common. Urologists practicing in areas endemic for Lyme disease need to be aware of B. burgdorferi infection in the differential diagnosis of neurogenic bladder dysfunction. Conservative bladder management including clean intermittent catheterization guided by urodynamic evaluation is recommended.

    Title Technique of External Sphincter Balloon Dilatation.
    Date November 1992
    Journal Urology
    Excerpt

    We report on our technique and early experience with balloon dilatation of the external sphincter in 7 spinal cord-injured men with detrusor external sphincter dyssynergia and elevated voiding pressure. Following dilatation, bladder emptying into condom catheters was achieved in all patients without dribbling incontinence.

    Title Lyme Cystitis and Neurogenic Bladder Dysfunction.
    Date June 1992
    Journal Lancet
    Title Antisperm Antibodies in Seminal Plasma of Spinal Cord-injured Men.
    Date April 1992
    Journal Urology
    Excerpt

    Central to the problem of reproductive rehabilitation of spinal cord-injured men treated by assisted ejaculatory techniques is the consistent observation of deficient semen quality. Most studies have reported asthenospermia despite the presence of normal sperm concentration in most men undergoing these procedures. To date little attention has been given to the incidence and relevance of sperm autoimmunity in this group. In 9 anejaculatory spinal cord-injured men, electroejaculation was performed. Antegrade ejaculates were obtained in 7 men and analyzed. Mean sperm antegrade concentration was 74.4 +/- 113 x 10(6)/mL with a mean motile sperm concentration of 28.6 +/- 54.0 x 10(6)/mL. Enzyme-linked immunosorbent assay (ELISA)-determined antisperm antibody response was positive in the seminal plasma of 5 of 7 patients. Because of the disproportionately high incidence of an immunologic factor in men with neurogenic infertility, sperm autoimmunity should be considered among the important causes underlying their seminal dysfunction.

    Title The Relative Distribution of Viable Sperm in the Antegrade and Retrograde Portions of Ejaculates Obtained After Electrostimulation.
    Date March 1992
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To determine the relative concentration, motility, and viability of spermatozoa in the antegrade and retrograde portions of the ejaculate after electroejaculation in spinal cord injured men. DESIGN: Retrospective. SETTING: University outpatient clinic providing tertiary care in reproductive rehabilitation. PATIENTS: The antegrade and retrograde portions of 22 ejaculates obtained from five spinal cord-injured men were analyzed for sperm density, mean sperm motility, and percentage of total motile and viable sperm yield. RESULTS: The number of spermatozoa were uniformly distributed between the antegrade (54.4%) and retrograde (45.6%) ejaculates. However, of the total sperm yield in both compartments, 66.3% of the motile spermatozoa and 71% of the viable sperm were found in the antegrade compartment (P less than 0.05). Additionally, mean sperm motility was significantly higher in the antegrade ejaculate (P less than 0.05). CONCLUSIONS: Significantly impaired sperm motility and viability are noted in the retrograde ejaculate. Efforts should therefore be directed to maximizing the antegrade portion of the electro-ejaculate and optimizing the technique of preserving functional sperm in the intravesical compartment.

    Title Quantitative Testicular Biopsy in Spinal Cord Injured Men: Comparison to Fertile Controls.
    Date August 1991
    Journal The Journal of Urology
    Excerpt

    Spermatogenic abnormalities have been reported in the majority of spinal cord injured men on routine testicular biopsy. However, given the interim advances in their urological and rehabilitative care, a quantitative assessment of the germinal epithelium after spinal cord injury and comparison of these parameters to normal controls are warranted. Incisional testicular biopsy was performed in 14 spinal cord injured men. Quantitative micrometric techniques were applied to assess spermatogenesis and the results were compared to a normative data base of testicular biopsies previously obtained from a group of 15 fertile volunteers. From a minimum of 10 randomly selected round seminiferous tubules per subject the mean number of Sertoli cells, mature spermatids, tubular diameter and tubular wall thickness were determined in both groups and statistically analyzed. In the spinal cord injury group the mean number of spermatids per tubule was significantly lower and the mean number of Sertoli cells per tubule was significantly higher than in fertile controls (p less than 0.05). Moreover, the mean Sertoli cell-to-spermatid ratio per seminiferous tubule was significantly higher in the spinal cord injury group and discriminated between spinal cord injured men and controls, with a sensitivity of 93% and specificity of 100% (p less than 0.0001). Half of the spinal cord injury group showed a mean tubular spermatid density of less than 10. Compared to the fertile population, spinal cord injured men show significant differences in quantitative parameters of the germinal epithelium that may contribute to the reproductive dysfunction.

    Title Biochemical Analysis of Electroejaculates in Spinal Cord Injured Men: Comparison to Normal Ejaculates.
    Date January 1991
    Journal The Journal of Urology
    Excerpt

    To address the consistent finding of asthenospermia in spinal cord injured men we compared the biochemical constituents of antegrade fractions of electroejaculates of 6 such patients with the manual ejaculates of 6 volunteers. Semen samples in each group were analyzed for 19 biochemical parameters, pH and osmolality. Organic components included triglycerides, glucose, fructose, uric acid, creatinine, urea, total protein, albumin and cholesterol. Metabolic enzymes, including glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase, lactate dehydrogenase and alkaline phosphatase, were measured. Inorganic constituents included chloride, sodium, potassium, zinc and phosphorous. Although not significant, higher levels of blood urea nitrogen and creatinine were demonstrated in most electroejaculates suggesting urinary contamination of the antegrade specimens. In electroejaculates significantly lower levels (p less than 0.05) of fructose, albumin, GOT and alkaline phosphatase as well as significantly higher levels (p less than 0.05) of chloride were noted. No significant difference in osmolality or pH was found. Moreover, in the electroejaculates the levels of glucose, uric acid and all inorganic constituents approached their corresponding levels in serum. We conclude that biochemical abnormalities of the seminal plasma may contribute to seminal dysfunction of spinal cord injured men and may result from neurological injury to the accessory sex glands or from the electroejaculation procedure itself.

    Title Systemic Sperm Autoimmunity in Spinal-cord Injured Men.
    Date September 1990
    Journal Archives of Andrology
    Excerpt

    Historically, spinal-cord injured men have been considered virtually sterile because of ejaculatory dysfunction commonly resulting from their injury. Assisted ejaculatory techniques, however, have overcome the problem of sperm transport and have allowed both the establishment of pregnancy through artificial insemination and the assessment of their semen quality. Most studies have noted the presence of asthenozoospermia in the setting of normal sperm concentration following electroejaculation or vibratory stimulated ejaculation. Thus far, little attention has been given to the basis for the frequent finding of asthenozoospermia, and the possibility of sperm autoimmunity in this group has not been adequately studied. In nine spinal-cord injured men, reproductive evaluation was performed consisting of hormonal measurements, testicular biopsy, and indirect immunobead tests for sperm autoimmunity. A mean sperm concentration was 144 +/- 185 x 10(6)/ml. However, the mean motile concentration was 33 +/- 62 x 10(6)/ml. Indirect serum immunobead showed positive IgG or IgA titers in 3 of 8 patients. Because of the disproportionately high incidence of an immunologic factor in spinal-cord injured men compared to able-bodied infertile men, sperm autoimmunity should be considered among the important causes underlying seminal dysfunction following spinal cord injury.

    Title Quantitative Testicular Biopsy in Congenital and Acquired Genital Obstruction.
    Date February 1990
    Journal The Journal of Urology
    Excerpt

    To determine if congenital obstruction of the genital tract is associated with significant testicular histopathological conditions compared to acquired forms of obstruction we performed testicular biopsy in 8 vasectomized men and 5 men with vasal agenesis. Quantitative analysis of the seminiferous tubular and epithelial parameters demonstrated a statistically significant increase in tubular wall thickness in the vasectomized group. There was no significant difference among the groups with reference to the mean number of late spermatids per seminiferous tubules, mean number of Sertoli cells per seminiferous tubules, mean number of seminiferous tubules per field (100 times) or mean seminiferous tubular diameter. We conclude that despite a lifelong duration of obstruction, men with vasal agenesis demonstrate a more favorable testicular histological status compared to men after vasectomy. This finding may have therapeutic implications when considering assisted pregnancy techniques as a method of treatment of male genital tract atresia.

    Title Electroejaculatory Stimulation of a Quadriplegic Man Resulting in Pregnancy.
    Date February 1990
    Journal Archives of Physical Medicine and Rehabilitation
    Excerpt

    Reproductive rehabilitation of men after spinal cord injury has been made possible by the application of assisted ejaculatory techniques such as electroejaculation. Although this technique may predictably overcome the barrier of semen recovery, the problem of seminal dysfunction still remains. This report describes one of the few pregnancies established by a quadriplegic man using electroejaculatory stimulation for semen acquisition and standard in vitro semen preparation methods for intrauterine insemination.

    Title Pharmacologic Therapy of Male Infertility: Specific Treatment.
    Date September 1989
    Journal Comprehensive Therapy
    Excerpt

    Pharmacotherapy of male reproductive disorders is applicable to the majority of men seeking treatment for infertility. Since a favorable prognosis is associated with specific medical measures directed toward enhancing sperm quality, a comprehensive clinical and laboratory assessment of the infertile male is essential. This treatment may consist of replacement therapy for pituitary or hypothalamic dysfunction (i.e., exogeneous gonadotropins or GnRH), suppression of prolactin excess, antimicrobial therapy, sympathomimetic agents for ejaculatory disorders, or immunosuppressive treatment of sperm autoimmunity. Finally, the possibility of multiple causes of male reproductive dysfunction and their specific forms of treatment should be considered.

    Title Medical Treatment of Male Infertility.
    Date June 1987
    Journal The Urologic Clinics of North America
    Excerpt

    After an appropriate clinical and laboratory assessment of a patient's fertility status, the clinician must often decide whether specific and empiric treatment is indicated. Specific treatment may take the form of replacement therapy (exogenous gonadotropins or GnRH) for pituitary or hypothalamic failure, inhibition of prolactin secretion, antimicrobial therapy, or immunosuppressive therapy for demonstrable immunologic infertility. Finally, ejaculatory dysfunction often requires sympathomimetic agents. Alternatively, in the normogonadotropic oligospermic patient, the major form of empiric therapy relies on the enhancement of physiologic hormone levels that influence spermatogenesis. Such "stimulation" therapy may be achieved by GnRH analogues, antiestrogens, exogenous gonadotropins, or androgens.

    Title Endourological Reconstruction of Posterior Urethral Disruption.
    Date March 1987
    Journal The Journal of Urology
    Excerpt

    While conventional methods of urethroplasty for posterior urethral disruption usually are successful technically, they may be associated with complications and often require the expertise of a specialist. Therefore, the option of an endourological approach to the treatment of the obliterated posterior urethra would be highly desirable if a comparable surgical outcome could be achieved. We describe a closed controlled method of posterior urethral reconstruction following traumatic avulsion of the posterior urethra. Urethral continuity was re-established by endoscopic identification of the true prostatic outlet, its fixation with an angiography wire and a Goodwin sound, retrograde visual urethrotomy through the fibrotic segment and balloon dilation of the entire posterior channel. Postoperative anatomical and functional results were excellent, and were achieved with much less risk and cost to the patient than those of a perineal or transpubic urethroplasty.


    Similar doctors nearby

    Dr. Deborah Glassman

    Urology
    15 years experience
    Philadelphia, PA

    Dr. Gaurav Bandi

    Urology
    10 years experience
    Philadelphia, PA

    Dr. Demetrius Bagley

    Urology
    40 years experience
    Philadelphia, PA

    Dr. Kelly Healy

    Urology
    5 years experience
    Philadelphia, PA

    Dr. Costas Lallas

    Urology
    12 years experience
    Philadelphia, PA

    Dr. S Mulholland

    Urology
    48 years experience
    Philadelphia, PA
    Search All Similar Doctors