Penile ultrasound erectile dysfunction,ultra-che zinc 9 edta msds,basic survival english book pdf - Easy Way

Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Penile vascular anatomy……….? Internal pedundle artery through bulbar artery supplies ? Venous drainage is through base of the penis . Literature regarding both subjective and objective evaluations of erectile function following radical cystectomy is deficient.
To study the recoverability of erectile function in post–radical cystectomy patients on subjective and objective bases.
Between March 2003 and March 2005, 45 male patients with organ-confined invasive bladder cancer were prospectively enrolled in this study. Radical cystectomy and urinary diversion were offered to all patients (21 patients underwent a nerve-sparing [NS] surgical technique, and 24 patients underwent a non–nerve-sparing [NNS] surgical technique). Patients were evaluated preoperatively using the International Index of Erectile Function (IIEF) questionnaire and using penile Doppler ultrasound (PDU). The return of erectile function was better in the NS group on subjective and objective bases. The recoverability of erectile function in post–radical cystectomy patients was better when a nerve-sparing (NS) surgical technique was used on subjective and objective bases. Keywords: Radical cystectomy, Nerve sparing, Erectile Dysfunction, IIEF, Penile duplex ultrasound. Radical cystoprostatectomy is the current standard procedure for locally confined bladder cancer; however, a major drawback of this approach remains the frequently ensuing postoperative erectile dysfunction (ED). Recoverability of erectile function (EF) after radical cystoprostatectomy ranged between 14% and 80% [2], [3], [4], [5], [6], and [7].
Patients were evaluated subjectively (using the International Index of Erectile Function [IIEF] questionnaire) [11] and objectively (by penile Doppler ultrasound [PDU]) to alleviate the subjective bias. According to our knowledge, no studies in the literature (in English) have discussed objective and subjective evaluations of both surgical techniques within a short-term follow-up in post–radical cystoprostatectomy patients. The NS technique was applied to a group of 21 patients according to Schlegel and Walsh's [2] modifications of the standard technique that entails meticulous dissection of the anterior prostate and lateral aspect of the prostate-urethral junction with careful retrograde dissection of the posterior aspect from the rectum. After the first month, EF was assessed provisionally: complete recovery of spontaneous erectile function, mild tumescence unsatisfactory to intercourse, or complete loss of erectile function.
Nerve sparing was not performed in 24 patients (the NNS group) for several reasons: 8 patients had had previous pelvic surgery and had extensive pelvic adhesions, 6 patients presented technical difficulties (4 patients had bulky tumors and 2 patients had bleeding dorsal-vein complications), and 10 patients had a tumor at the bladder base or tumors close to the bladder neck.
The preoperative IIEF domains (EF, orgasm, desire, intercourse satisfaction, and overall satisfaction) were assessed.
Interestingly, the corresponding PDU showed that the PSV deterioration was insignificant during the course of follow-up in both groups (p=0.79). The comparison of the two methods of evaluation that were used in this study is shown in Table 6. Erectile dysfunction (ED) is a common complication in all patients treated by radical cystectomy. Various potency rates after NS radical cystoprostatectomy have been reported and have shown satisfactory results [2], [3], [4], [5], and [6], indicating that 49–80% of patients had erection after NS radical cystoprostatectomy. The variance in the results presented in the literature regarding the preservation of erectile function could be explained by differences in skills, differences in surgical techniques, and differences in patient-selection criteria among studies.
Table 1 shows the differences between the NS group and NNS group with regard to smoking, age at surgery, previous operations, and diabetes, even though they were not significant for the low number of patients in the two groups. The IIEF questionnaire is an applicable, previously tested, and amenable subjective tool for patients.
Our results show that there is significant progressive increase in EF, intercourse satisfaction, and overall satisfaction domains relative to the basal preoperative level during the follow-up period in the NS group.
From an objective point of view, PDU does not give reference to erectile response, but only to vascular parameters. In our study spontaneous erection was delayed in the NS group, but did progressively return over the following months. Spontaneous EF was absent for most patients in the NS group soon after surgery (only three patients had normal unaided erections postoperatively), but there was a progressive return in a variable proportion of these patients during the follow-up period.
Penile hemodynamic study on patients after NS radical prostatectomy who had no pharmacological support in the initial year after surgery revealed a progressive incidence of venous leakage varying from 14% at 4 mo to 50% at>12 mo [21].
Although both groups received erectogenic aids to maintain their erectile and sexual activity, the improvement in EF over time in the NS group was proven by both IIEF and PDU findings, whereas similar improvement was absent in the NNS group. Although we aimed from the start to do NS and orthotopic diversions for all patients, who were carefully selected to be comparable even in pathological aspects, the intra-operative surgical findings played an effective role in neurovascular-bundle preservation and in the choice of diversion modality. The recoverability of erectile function in post–radical cystoprostatectomy patients is mainly related to improvement in veno-occlusive mechanism.
Critical revision of the manuscript for important intellectual content: El-Assmy, Mosbah, Shaaban.
Ritesh Mahajan, I'm an italian student, could you answer a question about the penile anatomy?



The most significant change was in veno-occlusive function, which improved rapidly and progressively in the NS group during 1 yr of follow-up. The most significant difference was in veno-occlusive function, which improved rapidly and progressively in the NS group during 1 yr of follow-up. This aspect represents a frequent cause of fear and concern for patients and their partners and has a significant impact on the choice of therapy.
This could be explained by differences in surgeon skill level, surgical technique, or patient selection criteria; however, the methods of evaluation could also cause the results to be misleading. The aim of this study was to evaluate the recoverability of EF in a group of patients who underwent either nerve-sparing (NS) or non–nerve-sparing (NNS) cystectomy by comparing the preoperative IIEF questionnaire results and PDU results with their postoperative counterparts. The study included 45 potent males with organ-confined bladder cancer who were treated with radical cystectomy and urinary diversion.
In a group of 24 patients a NS technique could not be applied (NNS group) for several reasons: surgeon's judgment, bulky mass, basal tumor or tumor near the bladder neck, pelvic adhesions, or other intraoperative complications hindering the possibility of preventing dissection of the neurovascular bundle.
The latter two groups were given phosphodiesterase type 5 inhibitor (PDE5-I; sildenafil citrate, 50mg) on demand, to be increased to 100mg after a failed 50-mg response. Statistical analysis of continuous-variable means were performed using student t tests (paired and unpaired, when appropriate). The preoperative comorbidity parameters of both groups were comparable with no statistical significance (Table 1). The comparison was carried out between the EF domain of IIEF and the EDV of PDU because both of them showed significant changes during follow-up.
In 1982, Walsh and Donker [1] suggested that ED was produced by injury to the pelvic nerve plexus, which provides autonomic innervation to the corpora cavernosa. Nightly erectile function measurements (nocturnal penile tumescence test [NPT]), vibration-provoked, or video-provoked EF measurement should be performed. This may indicate that radical cystoprostatectomy did not compromise the penile arterial inflow, in this group of patients, at least. Similarly, in the study of Montorsi et al [22], 8 of 15 patients who did not self-inject with alprostadil in the first 4 mo after surgery had a color-PDU diagnosis of venous leakage, compared with only 2 of 12 patients from the treatment group.
No patients in the NNS group showed spontaneous erection, and all of them needed intracavernous self-injection of PGE1.
This signifies the crucial role of nerve preservation for the recoverability of EF even if a complete loss of erection occurs during the early postoperative period. Moreover, the subjective tools could not reflect the normal objective findings in the PDU study. The veno-occlusive mechanism was better and progressively returned to normal in the NS group on subjective and objective bases within 1 yr of follow-up. Hekal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Physiology of erection, pathophysiology of impotence and implications of PGE1 in the control of collagen synthesis in the corpus cavernosum. Clinical and duplex US assessment of effects of sildenafil on cavernosal arteries of the penis: comparison with intracavernosal injection of vasoactive agents-initial experience. Corresponding PDU findings were comparable in peak systolic velocity during the course of follow-up in both groups. ED in postcystectomy patients is attributed to the injury to the pelvic nerve plexus, which provides autonomic innervations to the corporae [1]. Subjective methods may give false higher success rates [8] and [9], whereas objective tests may give false lower results [10]. Those patients with tumors at the bladder base or tumors close to bladder neck had frozen section biopsies from the urethra that were negative for cancer before the decision for a neobladder urinary diversion procedure was made. A total of eight doses were tried before PDE5-I was considered to have failed and a shift to intracorporeal injection (ICI) of prostaglandin E1 (PGE1; 20 mcg) was made. No patients had neurological or peripheral vascular diseases; all patients had normal renal and liver functions.
On the basis of these observations, the operative procedures of radical prostatectomy [1] and radical cystoprostatectomy [2] were modified to avoid injury to the cavernosal nerves and, thus, preserve potency in most patients undergoing these operations.
Also, the 5-yr actuarial local recurrence rate of 7.5% suggests that the technique does not compromise cancer control. Schoenberg et al [17] demonstrated that recovery of sexual function was age-dependent: 62% in patients younger than 50 yr, 47% in patients between 50 yr and 60 yr, and 20% in patients older than 60 yr. Authors who evaluated EF using a questionnaire before surgery reported a relatively high potency rate [8] and [9], whereas those who assessed EF with objective tests did not [10]. In spite of a low number of patients in this study, there is no statistical difference shown. In spite of this, the questionnaire may be influenced by some preoperative factors, for example, depression after clinical diagnosis or surgical decision or presence of hematuria that might compromise patient mood and libido. However, we selected the PDU for objective assessment because it gives more data about the underlying vascular causes of ED, and the etiology of post–radical cysto-prostatectomy ED attributed to veno-occlusive disease requires PDU for assessment.


Moreover, low-oxygen tension in cavernosal tissue due to hypoxia following surgery leads to vasoconstriction, corporeal fibrosis, and subsequent ED [20]. This can be explained by cavernous tissue fibrosis that occurs secondary to low-oxygen tension on cavernosal tissue due to a decrease of nitric oxide that results in progressive venous incompetence and subsequent ED [18]. On the other hand, the chance of regaining EF even with early erectile rehabilitation is nil when non–nerve sparing techniques are used.
To attain conclusive results a randomized clinical trial over a large patient group with a single type of diversion and for long follow-up period should be undertaken.
The NS cystectomy technique can ensure good oncologic and sexual outcome (based on the short follow-up period). With rise in the? Tumescent cavernosal pressure – distended sinusoids abut the? Rigid tunica albuginea and this? Detumescence leads to cessation of the venous egress and leads to rigid erection. Although the end diastolic velocity was significantly more deteriorated postoperatively than preoperatively in both groups, gradual improvement in patients in the NS group was more evident 12 mo after surgery.
The patients were followed up regularly at 2 mo, 6 mo, and 12 mo using the same evaluation methods.
Furthermore, both groups did not receive preoperative chemotherapy, radiotherapy, or psychotropic drugs. Furthermore, all patients in the NNS group failed to respond to sildenafil therapy, and they required intracorporeal PGE1 injection as an erectogenic aid (the mean of the EF domain was 7).
Schoenberg et al demonstrated that following NS radical cystoprostatectomy for organ-confined cancer, the disease-specific 10-yr survival rate for all stages treated was 69%, and the 10-yr survival rate and freedom from local recurrence was 94% [17].
Therefore, we evaluated our patients subjectively (using the IIEF questionnaire) and objectively (using PDU) to alleviate the subjective bias.
Postoperative factors such as postoperative stress and diversion type may also play a role. Therefore, every attempt should be made to preserve the neurovascular bundle during cystoprostatectomy.
Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function.
Autoinjection of the corpus cavernosum with a vasoactive drug combination for vasculogenic impotence.
Color-coded duplex sonography in impotence: significance of different flow parameters in patients and controls.
With rigid erection ,this diastolic component of the cavernosal arterial flow is lost and at times reverses also . Repeated ANOVA tests were applied to identify the significance of the effect of time on both surgical groups and on each group (NS and NNS) separately. To overcome this, patients were asked 1 wk or 2 wk before surgery about their sexual behavior 1 mo before the diagnosis, and they were also questioned again 2 mo after hospital discharge. Those PDU findings correlate with the results of other reports on radical prostatectomy [18] and [19]. Use of subjective and objective tools in assessment of the patients is mandatory and conclusive.
Voiding function and sexual activity in patient following Hautmann neobladder construction.
Prostatic capsule- and nerve-sparing cystectomy in organ-confined bladder cancer: preliminary results.
The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. The potency-sparing radical cystectomy: does it compromise the completeness of the cancer resection?.
Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-yr follow-up.
General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. Recovery of spontaneous erectile function after nerve-sparing radical reteropubic prostatectomy with and without early intracavernous injections of alprostadil: Results of a prospective randomized trial.
On the other hand, during the course of follow-up, patients in the NNS group showed a deterioration in all domains compared with preoperative values.
A randomized clinical study using a single type of diversion over a large group of patients for long-term follow-up should be done to confirm our conclusion. Potency, continence, and complication rates in 1,870 consecutive radical retropubic prostatectomies.




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