Angiodynography (color-coded duplex sonography) in the evaluation of vasculogenic impotence.

The penile arteries of 18 men with erectile dysfunction were examined by angiodynography (color-coded duplex sonography). Blood flow velocity was measured before and after intracavernous injection of papaverine/phentolamine. The angiodynographic findings were compared to arteriography. Normal values of peak flow velocity (after injection) were obtained from 6 men with normal arteriographic findings (deep artery greater than 25 cm/s, superficial artery greater than 30 cm/s). Angiodynography enables good imaging of the four penile arteries superior to duplex sonography. A strong correlation with the arteriographic findings could be found. Thus noninvasive angiodynography may replace penile arteriography for the routine evaluation of impotence.     

Measurement of penile brachial index (PBI) in patients with impotence

PBI was measured in 555 patients chosen at random from those who visited our impotence clinic between October 1984 and September 1986. Of 555 patients with impotence 29 (5.2%) showed a low PBI level of less than 0.6. On the basis of carefully taken history, risk factors causing the disturbance of penile blood flow were found in 13 (44.8%) of these 29 patients. They included diabetes mellitus, hypertension, surgery of pelvic organ, vertebral injury, vascular disorder of brain and gangliosympathectomy. Although penile angiography is necessary to make the definite diagnosis of vasculogenic impotence, hospitalization is usually required to perform the examination. Measurement of PBI is useful as a screening test to detect vasculogenic impotence at an outpatient clinic, because this examination is noninvasive and technically easy.     

Comparison of penile duplex ultrasonography with nocturnal penile tumescence monitoring for the evaluation of erectile impotence

A total of 50 patients with erectile dysfunction underwent comprehensive evaluation, including vascular evaluation with penile duplex ultrasonography and papaverine injection, as well as nocturnal penile tumescence monitoring. The latter was performed in a sleep laboratory setting in all patients. The results of penile duplex ultrasonography with papaverine injection were classified as 18 patients with normal vascular findings, 22 with arterial insufficiency, 3 with the pelvic steal syndrome and 7 with isolated venous leakage. Of the patients 15 had normal ultrasonographic and nocturnal penile tumescence findings, 29 had abnormal ultrasonographic vascular and nocturnal penile tumescence findings, 3 had abnormal ultrasonographic vascular findings and normal nocturnal penile tumescence (including 1 with the pelvic steal syndrome as evidenced by penile brachial index) and 3 had normal ultrasonographic vascular findings and abnormal nocturnal penile tumescence (including 2 with neurogenic erectile dysfunction). Penile duplex ultrasonography with papaverine injection appears to be a useful objective method to evaluate vasculogenic impotence and to correlate favorably with nocturnal penile tumescence monitoring. It also may have a higher yield than nocturnal penile tumescence monitoring in patients with the pelvic steal syndrome. While nocturnal penile tumescence is impaired in patients with neurogenic impotence, penile duplex ultrasonography with papaverine injection reveals, as expected, normal findings in patients with neurogenic impotence and normal vascular systems.     

Experience with intracorporeal injection of papaverine and duplex ultrasound scanning for assessment of arteriogenic impotence

We present our experience with the intracorporeal injection of papaverine and duplex sonography in the assessment of 47 patients with suspected vasculogenic impotence. Sonography and Doppler analysis were performed before and after the papaverine injection. The anatomy of the penis was easily seen. Flow in the deep arteries was obtained in most patients in both the flaccid and erect state. Patients with a good erectile response to papaverine injection had a larger increase in the inner diameter of the deep cavernosal artery than did those with a poor response. However, the percentage change in the diameter did not correlate with the degree of clinical response. Following injection, the systolic peak flow rates and diastolic minimum flow rates were higher in patients with some clinical response but only the increase in diastolic flow rates correlated in a stepwise fashion with the degree of clinical response. This technique provides a method for the objective assessment of response to intracorporeal papaverine injection. Its potential as a diagnostic test will only be determined after normal values are established. At present it appears most useful in patients responding poorly to papaverine injection by indicating the possible area of vascular impairment and the direction for further evaluation.     

Multiphasic diagnostic evaluation of arteriogenic, venogenic, and sinusoidogenic impotency. Value of noninvasive tests compared with penile duplex ultrasonography

Fifty patients with a mean age of fifty-five years (range 25 to 75 years) in whom vasculogenic impotency was suspected clinically were evaluated to determine the type of vascular lesion involved: arterial insufficiency, venous leak, or sinusoidal dysfunction. All patients underwent first, noninvasive diagnostic tests including penile brachial index, penile brachial subtraction index, and penile plethysmogram, followed by penile duplex ultrasonography with papaverine and phentolamine injection. Patients with abnormal ultrasonography were divided into two groups: One group with suspected sinusoidal dysfunction and those with either arteriogenic or venogenic insufficiency but not considered candidates for surgery; they were not subjected to further studies. Another group with suspected proximal arteriogenic lesions and those with suspected venous leakage considered candidates for surgical correction were subjected to angiography and cavernosometry-cavernosography, respectively. The findings of the noninvasive tests were compared with those provided by the invasive tests. The results indicated that noninvasive tests can predict whether or not impotency is arteriogenic in approximately 90 percent of cases. The noninvasive tests, however, were less accurate in predicting venogenic and sinusoidogenic impotency, for which penile duplex ultrasonography seems to be the choice.     

The assessment of pelvic circulation after internal iliac arterial reconstruction: a retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients' ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

The assessment of pelvic circulation after internal iliac arterial reconstruction:—A retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients’ ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.     

Application of computerised penile arterial waveform analysis in the diagnosis of arteriogenic impotence. An initial study in potent and impotent men

A new method is described for evaluating arteriogenic impotence by means of noninvasive quantification of penile Doppler arterial waveforms using computerised analysis based on the Laplace Transform model. The haemodynamic changes occurring during a papaverine-induced erection in healthy potent volunteers have been recorded by this technique, which has also been shown to be capable of discriminating between a normal and an abnormal penile arterial supply in an initial study of potent and impotent men.     

Diagnostic tests for impotence: a comparison of papaverine injection with the penile-brachial index and nocturnal penile tumescence monitoring

The diagnostic usefulness of nocturnal penile tumescence monitoring, penile-brachial index and intracorporeal injection of papaverine (60 mg. in 20 ml. normal saline) was compared in 43 impotent men. Intracorporeal pressure was measured with a pressure transducer. Based on turgidity, and the time of onset and duration of erection, we classified the impotence as psychogenic/neurogenic (normal vascular competence), mild or severe arteriogenic, or venogenic. The intracorporeal injection of papaverine was useful as a functional diagnostic test for impotence. The penile-brachial index, an indirect measurement of the flaccid penis, did not correlate well with the results of the papaverine test. A poor response to papaverine injection documents organic impotence and, under these circumstances, nocturnal penile tumescence monitoring is not necessary. We conclude that the intracorporeal injection of papaverine currently is the best screening technique for the differential diagnosis of vasculogenic impotence.     

Prospective evaluation of scrotal ultrasound and intratesticular perfusion by color-coded duplex sonography (CCDS) in TESE patients with azoospermia

Purpose

The objective of this study was to assess whether CCDS might improve the outcome of testicular sperm retrieval in patients with azoospermia. Furthermore, we evaluated potential sonographic alterations of the testis before and after trifocal and Micro-TESE.

Methods

78 patients were enrolled prospectively: 24 with obstructive azoospermia (OA) and 54 with non-obstructive azoospermia (NOA). 31 of 54 patients in the NOA group had negative surgical sperm retrieval. Testicular volume, hormonal parameters and sonographical findings were compared before and after TESE. The spermatogenetic score was determined for all retrieval sites. CCDS was performed at the upper, middle and lower segment of the testis. Ultrasound parameters and peak systolic velocity (PSV) were measured pre- and post-operatively.

Results

Testicular volume and epididymal head size were significantly increased in OA patients compared to NOA patients. Ultrasound parameters were comparable between NOA patients with and without successful sperm retrieval. A higher intratesticular PSV was significantly correlated with a better spermatogenic score in the corresponding sonographic position. However, after adjustment for other clinical confounders, PSV does not show a significant influence on the spermatogenic score. Testicular volume decreased significantly in all patients post-operatively after 6 weeks (p < 0.001). Finally, the PSV significantly increased in all patients 24 h after surgery and nearly returned to baseline levels after 6 weeks (p < 0.001).

Conclusions

A higher intratesticular PSV may be helpful as a pre-operative diagnostic parameter in mapping for better sperm retrieval, but CCDS does not help to predict successful testicular sperm retrieval after adjustment for other clinical confounders.

     

Comparison of digital subtraction angiography, CT angiography, and ultrasonic Doppler examination in the evaluation of penile arterial lesions]

BACKGROUND: CT angiography reconstructed by a multidetector-row helical CT scanner is a newly developed form of imaging. We compared CT angiography and ultrasonic Doppler examination with digital subtraction angiography (DSA) in the diagnosis of arterial lesion. METHOD: Eighteen patients with arteriogenic erectile dysfunction (ED) underwent color Doppler study, DSA, and CT angiography after providing informed consent. The CT angiography images were obtained by a multidetector-row helical CT scanner, Asteion TSX021A (TOSHIBA). We injected prostaglandin E1 into the penile cavernous body, and then rapidly infused nonionic contrast medium into the antecubital vein. DSA and CT angiography images of the bilateral internal pudendal arteries and cavernous arteries were examined for stenotic lesions or occlusion. We also compared the peak systolic blood flow velocity in the cavernous artery measured by color Doppler ultrasound with CT angiography and DSA. RESULTS: The CT angiography and color Doppler studies were performed on an outpatient basis, but DSA required hospitalization. In the 36 internal pudendal arteries, DSA represented 22 normal arteries and 14 stenosis or occlusions. CT angiography showed 15 normal arteries and 21 occlusions. For the diagnosis of stenosis or occlusion in the internal pudendal artery, the CT angiography image had a good agreement, with a sensitivity of 1.00, specificity of 0.68, and accuracy of 0.81. For diagnosis in the cavernous artery, CT angiography image also showed a good agreement with DSA; however, the quality of the images of fine arteries was better in the DSA images. The inferior view and internal view of the pelvis in CT angiography were helpful for visualizing the internal pudendal artery, especially at the pubic bone. There was insufficient correlation between peak systolic blood flow velocity and DSA findings. There were no serious complications involved in either examination. CONCLUSIONS: CT angiography has not yet reached the same level as DSA in the evaluation of fine arteries. However, CT angiography can produced images sufficient for the diagnosis of arteriogenic ED with some advantages. We believe that with improvement, CT angiography will become an adequate replacement for DSA in the diagnosis of penile arterisl lesion.     

Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.

OBJECTIVE: Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes. DESIGN: Retrospective study. MATERIALS: From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral). METHODS: We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length. RESULTS: In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity. CONCLUSIONS: A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.     

Predictive value of patient history and correlation of nocturnal penile tumescence, colour duplex Doppler ultrasonography and dynamic cavernosometry and cavernosography in the evaluation of erectile dysfunction

AIMS: The results of history and physical examination, nocturnal penile tumescence testing (NPT), colour flow duplex Doppler ultrasonography and dynamic infusion cavernosometry and cavernosography (DICC) were retrospectively correlated in 207 patients with erectile dysfunction. METHODS AND MATERIALS: The predictive value of the patient's own subjective assessment of early morning and nocturnal erections, history of cigarette smoking, the presence of vascular risk factors was correlated to the outcome of investigations. The result of Rigiscan NPT was correlated to the peak systolic velocity (PSV) and the resistance index (RI) determined at colour flow duplex Doppler ultrasonography, and the maintenance flow rate (Qm) determined at DICC. RESULTS: Eighty-five out of two hundred and seven patients (41%) had normal NPT comprising 48 out of 85 patients (56%) who described rigid early morning and nocturnal erections, 15 out of 85 patients (18%) who smoked cigarettes and 9 out of 85 patients (11%) with other positive vascular risk factors. 72 out of 85 patients (85%) had a normal PSV (>30 cm/s), 80 out of 85 patients (94%) had a normal RI (>0.85) and 82 out of 85 patients (96%) had a normal Qm), (<10 ml/min). Vascular investigations in this group identified 71 out of 85 patients (84%) with no penile vascular disease, 11 out of 85 patients (13%) with arteriogenic impotence, 2 out of 85 patients (2%) with mixed vasculogenic impotence and 1 out of 85 patients (1%) with cavernosal venous leakage (CVL). One hundred and twenty-two out of two hundred and seven patients (59%) had an abnormal NPT comprising 18 out of 122 patients (15%) who continued to experience rigid early morning erections, 65 out of 122 patients (53%) who smoked cigarettes, 59 out of 112 patients (48%) with other positive vascular risk factors, 36 out of 112 patients (29%) had an abnormal PSV (<30 cm/s), 49 out of 122 patients (40%) had an abnormal RI (<0.85) and 55 out of 122 patients (45%) had an abnormal Qm (>10 ml/min). Vascular investigations in this group identified five patients with no penile vascular disease, 51 out of 122 patients (41%) with arteriogenic impotence, 31 out of 122 patients (25%) with cavernosal venous leakage (CVL) and 35 out of 122 patients (29%) with mixed vasculogenic impotence. CONCLUSIONS: (1) a history of cigarette smoking and positive vascular risk factors are good predictors of organic impotence whereas the patient's subjective assessment of his own early morning erections is unreliable; (2) normal NPT correlates well with normal PSV, RI and Qm but does not exclude organic impotence; (3) abnormal NPT correlates well with abnormal PSV, RI and Qm.     

硅橡胶银丝阴茎假体植入治疗阳萎

采用硅橡胶银丝假体治疗阳萎６４例，５２例患者术后性生活双方满意，有效率８１％。术后并发症有假体感染４例，持续性疼痛５例，包皮水肿３５例，急性尿潴留１例，误伤尿道１例，假体过短２例，银丝折短４例。术后随访６～３０个月，４例因感染取出假体，８例因假体过短和持续性疼痛者性交欠满意。     

Comparison of international index of erectile function with nocturnal penile tumescence and rigidity testing in evaluation of erectile dysfunction

We tried to compare the parameters of nocturnal penile tumescence and rigidity (NPTR) testing with erectile function (EF) domain score of International Index of Erectile Function (IIEF), which is used in diagnosis and determining the severity of erectile dysfunction (ED), and to assess the sufficiency of IIEF in the diagnosis of ED. A total of 90 men, mean age 46 years (24-75), presenting with ED to our clinic between January 2001 and March 2003 were included in the trial. All the men answered the standard IIEF (15 questions) forms and was divided into four groups as mild ED, moderate ED, severe ED and no ED according to the EF domain score that is obtained from 1st, 2nd, 3rd, 4th, 5th and 15th questions. Then NPTR testing with the RigiScan Plus monitoring device was performed for two consecutive nights on those men. The distribution of the six parameters of NPTR testing (number of erections, duration of erections, TAU base, RAU base, TAU tip, RAU tip) among the four groups and the correlation with IIEF-EF domain score were evaluated. Additionally, the distribution of the risk factors (diabetes mellitus, hypertension, atherosclerotic heart disease, dyslipidemia and smoking) was analyzed both among the four groups and in each group. According to IIEF-EF domain scores of 90 patients, 16 (18%) had severe ED, 21 (23%) moderate ED, 41 (46%) mild ED and 12 (13%) no ED. There was no statistically significant difference between the risk factors among the men in these groups (P > 0.05). When the IIEF-EF domain scores were compared with parameters of NPTR testing, no statistically significant difference was obtained among ED groups (mild, moderate, severe) (P > 0.05). However, we observed a statistically significant difference between three ED groups and no ED group (P < 0.05). If NPTR testing is considered as a gold standard test, sensitivity, specificity, positive predictive value and negative predictive value of IIEF-EF domain score in ED diagnosis are 100, 17.9, 29.4 and 100% respectively. In conclusion, we did not observe a clinical correlation between IIEF-EF domain scores and NPTR parameters in the whole population; however, we observed that if IIEF-EF domain scores were normal, NPTR parameters were also normal. In other words, we can say that if the initial IIEF-EF domain scores are normal, then we do not have to perform NPTR testing. This could be helpful to make a cost-effective diagnosis.     

Correlation of invasive Doppler flow wire with renal duplex ultrasonography in the evaluation of renal artery stenosis: the Renal Artery Stenosis Invasive Doppler (RAIDER) study

OBJECTIVE: Determining renal resistive index (RI) in the setting of renal artery stenosis may predict which patients benefit from revascularization. Renal duplex ultrasonography (RDUS) is the traditional method of assessing RI, but it is not available in most invasive endovascular laboratories. Conversely, endovascular techniques to assess RI are available but not well validated. The primary goal was to determine if an invasive approach using an endovascular Doppler flow wire correlates with RI assessment using traditional noninvasive RDUS. METHODS: In a single-center prospective trial, patients were enrolled if they had known or suspected renovascular disease. A Doppler flow wire was placed in multiple segments of the renal artery, and peak (PSV) and end-diastolic velocities (EDV) were measured. RI was calculated using the formula: RI = [1 - (EDV/PSV)] x 100. Similarly, RI was also derived using standard RDUS. All patients underwent both RI techniques before any revascularization procedure. Secondary end points included assessing the correlation for pole-to-pole renal length assessment and PSV and EDV velocities using both invasive and noninvasive techniques. Pearson correlation coefficient calculations were used to determine degree of correlation. RESULTS: The study enrolled 20 patients, and 35 renal arteries were studied. Overall, Pearson correlation coefficient for invasive vs noninvasive RI assessment was 0.86 (95% confidence interval [CI], 0.73 to 0.93). The r values were 0.43 (95% CI, 0.11 to 0.67) for pole-to-pole renal length, 0.66 (95% CI, 0.54 to 0.76) for PSV, and 0.61 (95% CI, 0.48 to 0.72) for EDV determination. No major complications occurred during this study. Average time to perform invasive Doppler assessment was 10.4 +/- 7.4 minutes per artery. CONCLUSIONS: Invasive RI assessment using an endovascular flow wire technique correlates well with traditional noninvasive RDUS. A moderate statistical correlation also exists for pole-to-pole renal length, PSV, and EDV determinations. The procedure is safe and can be performed rapidly.     

Gray scale and color Doppler sonography with extended field of view technique for the diagnostic evaluation of anterior urethral strictures

PURPOSE: We compared the clinical relevance of radio urethrography with that of sonourethrography for evaluating male urethral strictures. MATERIALS AND METHODS: From 2002 to 2004, 93 men were referred to our institution for urethral strictures. Patients were evaluated by conventional voiding cystourethrography, retrograde urethrography, and gray scale and color Doppler sonourethrography. For sonourethrography the extended field of view technique was used to obtain 1 image of the whole anterior urethra. In all cases the urethra was evaluated cystoscopically or at open surgery. Radio urethrography and sonourethrography findings were compared with cystoscopy or surgery findings. RESULTS: All strictures were evaluated and treated cystoscopically with visual internal urethrotomy (34%) or at open operation (66%), which allowed comparison of the ability of each study to predict operative stricture length. Sonourethrography correctly identified the stricture and its site in all cases, whereas radio urethrography yielded 2 false-negative results. There was a significant difference between stricture length measured by radio urethrography compared to that measured by sonourethrography (correlation coefficient 0.72 vs 0.92, p<0.005). Mean+/-SD stricture length measured by radio urethrography was 1.5+/-1.3 cm and by sonourethrography it was 2.1+/-0.9 cm. Comparison of radio urethrography and sonourethrography stricture length with operative lengths demonstrated a good correlation in the penile urethra (correlation coefficient 0.91 vs 0.98), whereas a poor correlation was found in the bulbar urethra (correlation coefficient 0.65 vs 0.92). CONCLUSIONS: Gray scale and color Doppler sonourethrography using the extended field of view technique with a Siemens Sonoline Elegra is a promising tool for defining male urethral strictures. It seems to be superior to radio urethrography for treatment planning.     

Comparison of noninvasive continuous arterial waveform analysis (Nexfin) with transthoracic Doppler echocardiography for monitoring of cardiac output

Study ObjectivesTo compare the Nexfin cardiac output (CO) with the CO obtained from transthoracic Doppler echocardiography (TTE) during routine cardiac function screening.DesignObservational clinical study.SettingEchocardiography laboratory.Patients40 ASA physical status 1 and 2 patients scheduled for routine TTE examination.InterventionsNone.Measurements and Main ResultsIn 40 patients scheduled for routine TTE examination, we obtained simultaneous CO measurements with Doppler ultrasound and derived from Nexfin blood pressure measurements. Correlation and level of agreement between Nexfin and TTE were analyzed using Pearson correlation coefficient and Bland-Altman plots. The Pearson correlation coefficient for Nexfin versus TTE was 0.68 (CI: 0.46 - 0.82, P < 0.0001). Bland-Altman analysis showed a bias of 0.51 ± 1.1 L/min and limits of agreement of -1.6 to 2.6 L/min, with a percentage error of 39%.ConclusionsConsidering limits of precision of CO measurements with Doppler echocardiography (± 30%), the agreement between noninvasive CO measurement with the Nexfin and TTE is reasonable.