Ultrasonography is very sensitive in determining the size, location, and echogenicity of palpable testicular abnormalities, particularly if a hydrocele limits the physical examination.
Serum marker levels of α- fetoprotein (AFP) and β-human chorionic gonadotropin (HCG) are useful for diagnosis, for following the response to treatment, and for identifying recurrent disease. AFP may be elevated in patients with yolk sac tumors, embryonal carcinoma, and teratocarcinoma. β-HCG elevation may accompany choriocarcinoma and seminomas. Seminomas do not elaborate AFP; thus, an elevation in this marker confirms a nonseminomatous component.
Definitive diagnosis requires surgical exploration via an inguinal approach to avoid potential “contamination” of scrotal lymphatic draining during tumor manipulation. Similarly, trans-scrotal biopsies should be avoided.
Staging is shown in Table 25 -5.
Metastatic evaluation should include a CT scan of the abdomen and pelvis and either a chest radiograph or a chest CT scan.
Postorchiectomy serum markers should normalize within predictable time periods based on their half - lives (AFP, T1-T2 = 5 days; β-HCG, T1-T2 = 1 day). Failure to normalize virtually confirms disseminated disease.
Treatment of testicular tumors varies with the cell type and stage of disease.
Seminoma is uniquely radiosensitive and chemosensitive.
Stage I seminoma. Postorchiectomy treatment options include close observation or radiotherapy (2,500 rad) to para -aortic with or without the ipsilateral pelvic nodes. Survival is approximately 100%.
Stage II seminomas
Receive retropetal radiation α
Stage IIb and c are best treated by systemic chemotherapy.
Survival approaches 95%.
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|
|
|
TABLE 25-5 Staging of Germ Cell Tumors |
Stage |
Metastatic workup is negative; preoperative markers, if |
I |
positive, normalize. Tumor is isolated to the testicle. |
Stage |
Microscopic retroperitoneal disease. |
IIA |
|
Stage |
Minimal retroperitoneal disease on radiographic studies (<5 |
IIB |
mL). |
|
|
Stage |
Bulky retroperitoneal disease (>5 mL). |
IIC |
|
|
|
Stage |
Disease beyond retroperitoneal lymph drainage, or positive |
III |
markers after retroperitoneal lymph node dissection. |
|
|
Reprinted with permission from Lawrence PF, Bell RM Dayton MT:
Essentials of Surgical Specialties, 2nd ed. Baltimore, Williams &
Wilkins, 1993:393.
Stage III. Current recommendations include up to four courses of chemotherapy with cisplatin, etoposide, and bleomycin. Postchemotherapy radiation is considered occasionally for patients with a residual retroperitoneal mass. An 85% complete response rate to chemotherapy and an overall survival rate of 92% can be expected.
NSGCT
Stage I NSGCT. Treatment involves inguinal orchiectomy followed by either modified retroperitoneal lymphadenectomy (RPLND) or by an intense surveillance protocol.
Surveillance is generally reserved for compliant patients who are at low risk of micrometastatic disease. Risk factors of the primary testis tumor favoring RPLND include an embryonal carcinoma component, vascular or lymphatic invasion, and extension into peritesticular structures.
RPLND involves surgical removal of specific high-risk lymphatic tissue. Approximately 30% of stage I patients have nodal disease at RPLND. Most patients with micrometastases receive two cycles of adjuvant platinum -based chemotherapy.
Survival for both groups approaches 100%.
Stage II NSGCT. Patients with minimal nodal involvement radiographically or failure to normalize markers postorchiectomy should undergo either RPLND or chemotherapy alone. Survival is approximately 98%.
Stage III NSGCT require induction chemotherapy employing platinum -based combinations for three to four cycles, with follow-up serum markers and radiographic re-evaluation. Markers and radiographs normalize in 70%–80% of patients, who can be followed without additional surgery. Those patients whose markers normalize but who have residual pulmonary, mediastinal, or retroperitoneal masses should undergo complete surgical resection of these masses. There is pathologic confirmation of carcinoma in approximately 20% of patients undergoing postchemotherapy surgery, and it dictates additional chemotherapy. Failure to normalize markers after chemotherapy portends a poor prognosis with or without additional surgery. Salvage chemotherapy or high-dose chemotherapy and autologous bone marrow transplantation may be considered in these cases.
Infertility issues in patients with testis cancer. Because testis cancer affects a population that is often interested in future fertility, counseling on this issue should be considered part of the treatment. Testis cancer itself adversely affects fertility, and the additional insults of surgical stress, orchiectomy, chemotherapy, and RPLND may further depress fertility. Men interested in future fertility should undergo preoperative semen analysis; if adequate parameters exist, sperm banking should be considered.
V Male Erectile Dysfunction
A The penis
Anatomy
Penile erectile tissue is contained within three erectile bodies–– two dorsally situated corpora cavernosa and one ventrally located corpus spongiosum.
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The urethra lies within the corpus spongiosum, which consists of cavernous, expansible spaces. Each of the three corpora is surrounded by the tunica albuginea , a thick, fibrous tissue layer. The thickness of the tunica around the cavernosa is much thicker, which is consistent with the increased pressure in these spaces.
Arterial supply is derived bilaterally from the internal pudendal artery, which is a terminal branch of the internal iliac artery. Branches to the penis are the bulbar artery, urethral artery, dorsal artery, and deep penile artery. The latter is the main blood supply to the corpora cavernosa.
Venous drainage is complex. A deep dorsal vein and a superficial dorsal vein exist as well as deep veins within the corpora cavernosa and the circumflex veins.
Innervation
Sympathetic innervation. The lower thoracic and upper lumbar regions of the spinal cord innervate the superior hypogastric plexus, which innervates the hypogastric nerve, which innervates the pelvic plexus.
Parasympathetic innervation. The sacral nerve roots (S2-S4) innervate the pelvic nerve, which innervates the pelvic plexus. The pelvic plexus sends nerve fibers to the penis via the cavernous nerve.
Somatic innervation of the penis is carried in the pudendal nerve (S2-S4).
B Penile erection and detumescence
are primarily hemodynamic events.
Arterial flow increases, and increased venous resistance also contributes.
The exact mechanism of neurovascular interaction is mediated by the cavernous nerves.
Neurophysiology
Erections with genital stimulation require only an intact sacral reflex.
The parasympathetic nervous system is of primary importance in penile erection. Nitric oxide released from nonadrenergic, noncholinergic neurons and the endothelium leads to vascular and corporal smooth muscle relaxation.
Hormonal factors are involved in both erectile function and sexual desire (libido). The exact nature of these factors is not fully understood.
Taking the patient's history is very important when evaluating the cause of erectile dysfunction.
The nature of onset and the duration of the problem are important. Psychogenic impotence may be abrupt in onset with a life stress.
An interview with the patient's sexual partner may prove beneficial.
The presence of nocturnal or early morning erections may suggest a psychogenic cause.
History of pelvic trauma, including vascular or neurogenic injury, is important to discern.
Risk factors include diabetes, hypertension, smoking, heart disease, and hypercholesterolemia.
Physical examination. There is a special emphasis on the neurologic and vascular examination. A DRE is performed to evaluate for prostate cancer with general evaluation of the genitalia. The penis should be examined for plaques and the testes for size and consistency.
Laboratory tests include:
Testosterone level
Serologic tests for systemic disease (e.g., anemia, renal insufficiency)
Diagnostic tests are not indicated in every patient. They include:
Nocturnal penile tumescence. Measurements are taken of nocturnal erections occurring during rapid eye movement sleep. Gauges are placed on the flaccid penis at bedtime and attached to a monitor overnight that evaluates the number, duration, and rigidity of erections.
Intracorporeal injections of vasoactive substances , such as papaverine, phentolamine, and prostaglandin E, have been used to elicit an erection. Response with a normal erection eliminates a significant “venous leak” etiology for erectile dysfunction.
Duplex sonography evaluation can provide an objective measure of arterial penile blood flow as well as a relative assessment of venous drainage. Cavernosal arteries are evaluated for
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increased width and flow after intracorporeal vasoactive injection. Venous outflow during erections should diminish; if venous outflow is still high on duplex study, a venous leak phenomenon may be present.
Cavernosometry and cavernosography
Cavernosometry is a pressure flow evaluation of the penis during erection. After vasoactive injection, an erect penis requires little inflow infusion to maintain rigidity and high intracorporeal pressures. Cavernosometry evaluates the intracorporeal pressure and volume of necessary infusion to obtain and maintain an erection after a vasoactive injection.
Cavernosography is the injection of contrast material into the corpora to anatomically identify an abnormally excessive loss of venous blood during an erection.
Pudendal arteriography can identify isolated correctable lesions in a select population of postpelvic trauma patients.
Treatment
Counseling is required for men found to have a significant psychogenic component.
Oral therapy has revolutionized treatment. Selective phosphodiesterase type 5 inhibitors enhance erection through the nitric oxide/cyclic guanosine monophosphate (GMP) pathway. Three agents have been approved by the Food and Drug Administration (FDA).
A vacuum erection device is an external device that, under a pump mechanism, can draw blood into the penis to obtain an erection. The blood is retained by the placement of a constricting rubber ring at the base of the penis.
Vasoactive intracorporeal injections are self-administered, with risks comprised of bruising, mild scar formation, or priapism (erections lasting >4 hours).
A penile implant is a paired device that is surgically implanted into the corpora cavernosum. Several styles exist that are either malleable or inflatable. The main risk is infection associated with the prosthetic material.
VI Neurogenic Bladder
Voiding is a complex act involving detrusor contraction with sphincteric relaxation (the micturition reflex), which is coordinated in the pontine misturition center and controlled by cerebral input. Lesions occurring throughout the nervous system often profoundly affect voiding. As elsewhere, upper motor neuron lesions (suprasacral) tend to produce hyperreflexia (bladder overactivity), whereas lower motor neuron lesions (sacral nerve roots or cauda equina) cause areflexia (bladder flaccidity).
A Diagnosis
History. Detailed historical information regarding frequency, urgency, nocturia, sensation of fullness, straining, incontinence, erectile function, bowel habits, paralysis, paresthesias, history of neurologic and vertebral disease, pelvic surgery, and trauma as well as a review of medications are vital parts of diagnosis.
Physical examination includes an assessment of sensation, motor function, and reflexes of the lower extremities, perineum, and rectal areas. Anal sphincter tone should be assessed, as should the bulbocavernosal reflex (contraction of the anal sphincter with compression of the glans or clitoris or with traction on an indwelling urethral catheter).
Urodynamic studies (Fig. 25 -5)
Filling cystometry involves the creation of a pressure versus volume curve during bladder filling. Normal bladder sensation, high compliance (accommodation to increasing volumes with minimal increase in pressure), and the absence of uninhibited contractions during filling comprise a normal study.
The voiding phase assesses flow rate, contractility, and vesical pressure during voiding. Postvoid residual urine is recorded.
Electromyelography (EMG) of the striated sphincter can be used to demonstrate sphincteric function and to determine if appropriate sphincter relaxation occurs with voiding. Denervation of the sphincter may be elicited.
FIGURE 25-5 A: A normal cystometrogram. Note the normal compliance with filling and sphincteric relaxation during voiding. B: A cystometrogram study in a patient with a myelomeningocele. Note the poorly compliant bladder, uninhibited bladder contractions, and detrusor sphincter dyssynergia. EMG, electromyogram.
B Patterns of voiding dysfunction
Detrusor hyperreflexia (hypertonic neurogenic bladder) occurs with suprasacral lesions and is characterized by diminished bladder capacity and uninhibitable detrusor contractions.
Presenting symptoms are irritative, such as urgency and frequency. If intravesical pressures become elevated, vesicoureteral reflux and upper tract deterioration may occur.
Treatment includes anticholinergics; intermittent bladder catheterization; and, sometimes, surgical bladder augmentation.
Detrusor -areflexia (atonic bladder) occurs with lesions of the sacral cord, nerve roots, or cauda equina, resulting in loss of the sacral reflex arc. Increased capacity, decreased intravesical pressure, absence of efficient bladder contractions, and urinary retention with overflow incontinence may result. Medical therapy is generally ineffective. Catheterization (indwelling or intermittent) and urinary diversion are often used.
Detrusor external sphincter dyssynergia (DSD) involves contraction of the external sphincter during bladder contraction, causing a “functional” outlet obstruction. This condition results from lesions of the spinal cord and may occur alone or may complicate a hyperreflexic or atonic picture. Treatment involves medication to promote urinary retention (anticholinergics) and intermittent catheterization to overcome DSD.
C Voiding dysfunction in specific diseases
Spinal cord injury associated with suprasacral lesions usually causes hyperreflexia with DSD, and injury with sacral lesions usually causes areflexia.
Cerebrovascular accidents result in loss of cortical inhibition with detrusor hyperreflexia, manifested by urgency with urge incontinence. DSD is not featured, and patients often contract the sphincter voluntarily.
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Parkinsonism causes detrusor hyperreflexia, resulting in urgency, frequency, incontinence, and failure of the external sphincter to relax, which may complicate the picture.
Multiple sclerosis leads to voiding dysfunction in 50%–80% of those affected, most commonly, urgency; frequency; incontinence; and, occasionally, retention. Urodynamic studies reveal detrusor hyperreflexia in most cases. Approximately 70%–80% exhibit features of DSD.
Myelodysplasia describes various abnormal conditions of vertebral development that affect spinal cord function. Myelomeningocele is the most common. Findings may include a poorly compliant bladder with high intravesical pressure, weak detrusor contractions, and DSD. Management includes use of anticholinergic agents to diminish bladder pressures and intermittent catheterization to overcome failure of the bladder to empty.
Lumbar disc disease causes detrusor acontractility and decreased sphincteric activity; obstructive voiding symptoms predominate. Urinary retention may occur.
Diabetic cystopathy is an autonomic neuropathy manifested by diminished bladder sensation, increased capacity, decreased contractility, and elevated postvoid residual.
D Treatment
Pharmacologic treatment allows manipulation of bladder contractility (by way of cholinergic receptors in the bladder) and allows changes in outlet resistance (via α-adrenergic receptors in the bladder neck, prostatic capsule, and urethra).
Catheterization. An indwelling catheter can be used. Intermittent catheterization frees the patient from continuous appliance usage and lowers the incidence of UTIs, meatal erosion, urethral stricture, and epididymitis. Patients develop bacterial colonization, which requires no treatment unless symptoms of infection occur.
Urinary diversion away from the bladder by formation of an ileal conduit or catheterizable reservoir may be necessary in patients with recurrent urosepsis or renal insufficiency caused by a detrusor problem.
Bladder augmentation to increase capacity and decrease intravesical pressure may be required in patients with hyperreflexia or in those with contracted, poorly compliant bladders secondary to long-standing neurologic disease (e.g., myelomeningocele), radiation cystitis, or chemically induced bladder fibrosis. Intermittent catheterization is usually required.
E
Autonomic dysreflexia is an outpouring of sympathetic activity in response to afferent visceral stimulation in patients with spinal cord injuries with lesions above T6. Bladder, urethral, or rectal stimulation may produce profound hypertension, bradycardia, diaphoresis, headache, and piloerection in these patients. Treatment consists of withdrawing the stimulant and medication directed at the hypertensive crisis. Prophylaxis with various medications (e.g., chlorpromazine, nifedipine) is sometimes useful in affected patients who require urologic manipulation.
VII Urologic Trauma
A Evaluation
