Brenda Eskenazi MA, PhD

• Brian and Jennifer Maxwell Endowed Chair in Public Health

https://publichealth.berkeley.edu/people/brenda-eskenazi/

Neoadjuvant and adjuvant alphablockade improves early results of high-energy transurethral microwave thermotherapy for lower urinary tract symptoms of benign prostatic hyperplasia: a randomized symptoms vaginitis cheap generic xalatan canada, prospective clinical trial symptoms 0f diabetes purchase generic xalatan on line. Tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia: results of a prospective symptoms yeast infection women generic xalatan 2.5 ml with mastercard, randomized medicine 801 generic xalatan 2.5 ml free shipping, single-blinded clinical trial symptoms pinched nerve neck safe xalatan 2.5 ml. Mortality symptoms 5 days past ovulation buy cheap xalatan 2.5ml on-line, morbidity and complications following transurethral resection of the prostate for benign prostatic hypertrophy. The efficacy and safety of perioperative low molecular weight heparin substitution in patients on chronic oral anticoagulant therapy undergoing transurethral prostatectomy for bladder outlet obstruction. Transurethral ethanol ablation of the prostate for symptomatic benign prostatic hyperplasia: long-term follow-up. New technologies for the surgical management of symptomatic benign prostatic enlargement: tolerability and morbidity of high energy transurethral microwave thermotherapy. Prevention of postoperative stricture from transurethral resection by preliminary internal urethrotomy: report of experience with 447 cases. Plasmakinetic resection of the prostate versus standard transurethral resection of the prostate: a prospective randomized trial with 1-year follow-up. Transurethral resection of prostate: technical progress by bipolar Gyrus plasma-kinetic tissue management system. Long-term followup of randomized transurethral microwave thermotherapy versus transurethral prostatic resection study. Sexual function following high energy microwave thermotherapy: results of a randomized controlled study comparing transurethral microwave thermotherapy to transurethral prostatic resection. Evaluation of fluid absorption during laser prostatectomy by breath ethanol techniques. High-energy transurethral microwave thermotherapy for large severely obstructing prostates and the use of biodegradable stents to avoid catheterization after treatment. Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up. Can histopathology predict treatment outcome following high-energy transurethral microwave thermotherapy of the prostate High energy thermotherapy versus transurethral resection in the treatment of benign prostatic hyperplasia: results of a prospective randomized study with 1 year of followup. Results of high-energy transurethral microwave thermotherapy in patients categorized according to the American Society of Anesthesiologists operative risk classification. High energy thermotherapy in the treatment of benign prostatic hyperplasia: results of the European Benign Prostatic Hyperplasia Study Group. Long-term risk of re-treatment of patients using alpha-blockers for lower urinary tract symptoms. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. Laser treatment of benign prostatic hyperplasia in patients on oral anticoagulant therapy: a review. Impact of oral anticoagulation on morbidity of transurethral resection of the prostate. Clinical response to transurethral microwave thermotherapy: is thermal dose dependent Plasma kinetic vaporization of the prostate: clinical evaluation of a new technique. Pretreatment prostate-specific antigen as an outcome predictor of targeted transurethral microwave thermotherapy. A novel intraurethral prostatic bridge catheter for prevention of temporary prostatic obstruction following high energy transurethral microwave thermotherapy in patients with benign prostatic hyperplasia. Temporary intraurethral prostatic bridge-catheter compared with neoadjuvant and adjuvant alphablockade to improve early results of high-energy transurethral microwave thermotherapy. Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia High-energy transurethral microwave thermotherapy in patients with acute urinary retention due to benign prostatic hyperplasia. Holmium laser ablation and enucleation of the prostate: a pilot study of the hybrid technique. Outcomes of radical prostatectomy for patients with clinical stage T1a and T1b disease. Transurethral needle ablation versus transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized, multicenter clinical trial. Bipolar transurethral resection of prostate in saline: preliminary report on clinical efficacy and safety at 1 year. Holmium laser enucleation of the prostate combined with electrocautery resection: the mushroom technique. Transurethral prostatic resection syndrome-a new perspective: encephalopathy with associated hyperammonemia. A 10-year follow-up after transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia; long-term results of a randomized controlled trial. A prospective, randomized trial comparing conventional transurethral prostate resection with PlasmaKinetic vaporization of the prostate: physiological changes, early complications and long-term followup. A study of the anatomy of the prostate, prostatic urethra and the urinary sphincter system. Impact of medical therapy on transurethral resection of the prostate: two decades of change. Transurethral incision versus resection of the prostate for small to medium benign prostatic hyperplasia. Effect of transurethral resection of the prostate on erectile function: a prospective comparative study. Insight into mechanism of neodymium: yttrium-aluminum-garnet laser prostatectomy utilizing the high-power contact-free beam technique. Laser vaporization of bovine prostate: a quantitative comparison of potassium-titanyl-phosphate and lithium triborate lasers. Transurethral electrovaporization of the prostate: a novel method for treating men with benign prostatic hyperplasia. Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-year follow-up. Maintenance of erectile function after photoselective vaporization of the prostate for obstructive benign prostatic hyperplasia. The long-term results of transurethral vaporization of the prostate using plasmakinetic energy. Removal of UroLume endoprosthesis: experience of the North American Study Group for detrusorsphincter dyssynergia application. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. The development of benign prostatic hyperplasia among volunteers in the Normative Aging Study. Ethanol injection therapy of the prostate for benign prostatic hyperplasia: preliminary report on application of a new technique. Application of external microwave thermotherapy in urology: past, present, and future. A modified prostatic UroLume Wallstent for healthy patients with symptomatic benign prostatic hyperplasia: a European Multicenter Study. Cumulative prevalence of prostatism matches the autopsy prevalence of benign prostatic hyperplasia. Photoselective vaporization of prostate: five-year outcomes of entire clinic patient population. Transurethral microwave thermotherapy for benign prostatic hyperplasia: clinical outcome after 4 years. Suprapubic catheter following transurethral resection of the prostate: a way to decrease the number of urethral strictures and improve the outcome of operations. Cell death induced in a murine mastocytoma by 42-47 degrees C heating in vitro: evidence that the form of death changes from apoptosis to necrosis above a critical heat load. Dilutional hyponatremic shock: another concept of the transurethral prostatic resection reaction. The importance of the pressure in the prostatic fossa and absorption of irrigating fluid during transurethral resection of the prostate. National trends in surgical therapy for benign prostatic hyperplasia in the United States (2000-2008). Photoselective vaporization prostatectomy: experience with a novel 180 W 532 nm lithium triborate laser and fiber delivery system in living dogs. Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs. Bipolar versus monopolar transurethral resection of the prostate: a systematic review and metaanalysis of randomized controlled trials. A randomized doubleblind placebo-controlled phase 2 dose-ranging study of onabotulinumtoxinA in men with benign prostatic hyperplasia. Relief by botulinum toxin of voiding dysfunction due to benign prostatic hyperplasia: results of a randomized, placebo-controlled study. The 12-year outcome analysis of an endourethral wallstent for treating benign prostatic hyperplasia. The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery. Predictability of irritative voiding symptoms following photoselective laser vaporization of the prostate. Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. A multicenter, randomized, double-blind, placebo controlled study of onabotulinumtoxinA 200 u to treat lower urinary tract symptoms in men with benign prostatic hyperplasia. Transurethral resection of the prostate and transurethral incision of the prostate. The prostatron transurethral microwave device in the treatment of bladder outflow obstruction due to benign prostatic hyperplasia. Defining optimal laser-fiber sweeping angle for effective tissue vaporization using 180 W 532 nm lithium triborate laser. Urolume stent placement for the treatment of postbrachytherapy bladder outlet obstruction. Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Potassium-titanyl-phosphate laser vaporization of the prostate: a comparative functional and pathologic study in canines. Therapeutic effects of add-on botulinum toxin A on patients with large benign prostatic hyperplasia and unsatisfactory response to combined medical therapy. Randomized study of transurethral resection of the prostate and combined transurethral resection and vaporization of the prostate as a therapeutic alternative in men with benign prostatic hyperplasia. Baseline prostatic specific antigen does not predict the outcome of high energy transurethral microwave thermotherapy. Day-case holmium laser enucleation of the prostate for gland volumes of <60 mL: early experience. Temperature-correlated histopathologic changes following microwave thermoablation of obstructive tissue in patients with benign prostatic hyperplasia. The efficacy of transurethral resection of the prostate in men with moderate symptoms of prostatism. Minimally invasive treatments for benign prostatic enlargement: systematic review of randomised controlled trials. The clinical effectiveness of transurethral incision of the prostate: a systematic review of randomised controlled trials. Contemporary practice patterns of endoscopic surgical management for benign prostatic hyperplasia among urologists in the United States. PlasmaKinetic SuperPulse transurethral resection versus conventional transurethral resection of prostate. Thermo-expandable intraprostatic stents in bladder outlet obstruction: an 8-year study. Vaporization of prostates of > or =80 mL using a potassium-titanyl-phosphate laser: midterm-results and comparison with prostates of <80 mL. Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve. Ethanol promotes cytotoxic effects of tumor necrosis factor-related apoptosis-inducing ligand through induction of reactive oxygen species in prostate cancer cells. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. Transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia: a collaborative multicentre study. A novel transurethral microwave thermal ablation system to treat benign prostatic hyperplasia: results of a prospective multicenter clinical trial. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. The effect of increased maximum power output on perioperative and early postoperative outcome in photoselective vaporization of the prostate. Transurethral plasma vaporization of the prostate: 3-month functional outcome and complications. The incidence of benign prostatic hyperplasia and prostatic carcinoma in cirrhosis of the liver. Clinically significant prostate cancer is rarely missed by ablative procedures of the prostate in men with prostate specific antigen less than 4 ng/ml. Urethral strictures and bipolar transurethral resection in saline of the prostate: fact or fiction Transurethral resection versus minimally invasive treatments of benign prostatic hyperplasia: results of treatments. Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. Results of a 5-year multicenter trial of a new generation cooled high energy transurethral microwave thermal therapy catheter for benign prostatic hyperplasia.

Crypts in the lymphoid tissue occasionally may become obstructed treatment 6th feb cardiff order xalatan us, causing "cystic" dilation of the area medicine 003 discount xalatan 2.5ml with amex. Toward the end of the 12th week of gestation treatment trichomonas order cheap xalatan online, disruption of the dental lamina is evident symptoms for pregnancy 2.5ml xalatan with mastercard, with many fragments exhibiting central cystification and keratin accumulation medicine during pregnancy buy generic xalatan line. The gingival cyst of the adult is probably formed from remnants of the dental lamina (rests of Serres) within the gingival submucosa treatment of pneumonia purchase xalatan. Gingival cysts in a neonate appear as off-white colored nodules approximately 2 mm in diameter. A great deal of similarity has been noted between the gingival cyst in the adult and the lateral periodontal cyst, including the site of predilection, the age of occurrence, clinical behavior, and overall morphology. The gingival cyst presents as a painless growth in the attached gingiva, often within the interdental papilla. The neonatal gingival cyst is lined by bland stratified squamous epithelium and is filled with keratinaceous debris. Gingival cysts in adults are lined by a thin layer of cuboidal or flattened epithelium, with focal thickening that often demonstrates clear cell change. No treatment is indicated for gingival or palatal cysts of the newborn because they spontaneously rupture early in life. It is derived from an acute infection at the base of an occluded periodontal pocket or at the apex of a nonvital tooth. Pain is typical, but once the pus escapes to the surface, symptoms are temporarily relieved. Congenital hemangiomas and congenital vascular malformations appear at or around the time of birth and are more common in females. Congenital vascular malformations include lesions resulting from abnormal vessel morphogenesis. Separation of vascular lesions into these two groups can be of considerable significance relative to the treatment of patients. Unfortunately, in actual practice, some difficulty may be encountered in classifying lesions in this way because of overlapping clinical and histologic features. This lesion may exhibit a rapid growth phase that is followed several years later by an involution phase. They may represent arteriovenous shunts and exhibit a bruit or thrill on auscultation. Vascular morphology accounts for lesions exhibiting rapid flow versus those exhibiting slow flow. When they affect the mandible or the maxilla, a radiolucent lesion with a honeycomb pattern and distinct margins is expected. Differentiation between congenital hemangiomas and congenital vascular malformations can be difficult and occasionally impossible. A complete history, a clinical examination, and angiography or angiographic magnetic resonance imaging should be definitive in lesion identification and characterization. Laser therapy is another accepted form of primary treatment of selected vascular lesions. Encephalotrigeminal Angiomatosis (Sturge-Weber Syndrome) Encephalotrigeminal angiomatosis, or Sturge-Weber syndrome, is a noninherited neurocutaneous syndrome that includes vascular malformations with characteristic distribution. Spontaneous involution during early childhood is likely for congenital hemangiomas. If these lesions persist into the later years of childhood, involution is improbable and definitive treatment may be required. Port-wine stains may also occur as isolated lesions of the skin without the other stigmata of encephalotrigeminal angiomatosis. The vascular defect of encephalotrigeminal angiomatosis may extend intraorally to involve the buccal mucosa and the gingiva. Neurologic effects of encephalotrigeminal angiomatosis may include mental retardation, hemiparesis, and seizure disorders. Patients may be taking phenytoin (Dilantin) or similar drugs for control of the latter problem, with possible secondary development of drug-induced generalized gingival hyperplasia in relation to phenytoin. A differential diagnosis would include Parkes-Weber syndrome and angio-osteohypertrophy (Klippel-Trenaunay) syndrome, the latter characterized by vascular malformations of the face (port-wine stains), varices, and limb hypertrophy (bone and soft tissues). Lesions appear early in life, persist throughout adulthood, and often increase in number with aging. Intranasal telangiectasias are responsible for epistaxis, the most common presenting sign of hereditary hemorrhagic telangiectasia. Reactive Lesions Varix and Other Acquired Vascular Malformations A venous varix, or varicosity, is a type of acquired vascular malformation that represents focal dilation of a single vein. Varices involving the ventral aspect of the tongue are common developmental abnormalities. Thrombosis, which is insignificant in these lesions, occasionally occurs, giving them a firm texture. No treatment is required for a venous varix unless it is frequently traumatized or is cosmetically objectionable. Other acquired vascular malformations represent a more complex network or proliferation of thin-walled vessels than simple varices. These lesions present as red-blue discrete and asymptomatic tumescences that can be excised relatively easily. Clinically, this lesion is similar to peripheral giant cell granuloma, which also presents as a red gingival mass. Under these circumstances, multiple gingival lesions or generalized gingival hyperplasia may be seen. Pyogenic granulomas are typically red and smooth or lobulated with hemorrhagic and compressible features. They presumably arise from periodontal ligament or periosteum, and occasionally cause resorption of alveolar bone. Secondary ulceration caused by trauma may result in the formation of a fibrin clot over the ulcer. Scattered throughout the fibroblasts are abundant multinucleated giant cells believed to be related to osteoclasts. Microscopically, a peripheral giant cell granuloma is identical to its central or intraosseous counterpart, the central giant cell granuloma. Surgical excision is the preferred treatment for peripheral giant cell granulomas. Scarlet fever is an acute exanthematous condition caused by any of three exotoxin-producing, antigenically dissimilar streptococcal strains (A, B, or C), most commonly seen between 1 and 10 years of age. The characteristic effects of scarlet fever, a systemic bacterial infection, are the result of an erythrogenic toxin that causes capillary damage and that is produced most commonly by some strains of group A streptococci. All group A streptococcal infections are generally spread through droplets from contact with an infected individual or, less likely, a carrier. Crowded living conditions promote the spread of streptococcal infections, with the upper respiratory tract representing the most common portal of entry. Clinically, children are typically affected after an incubation period of several days. Neoplasms Erythroplakia Etiology Erythroplakia refers to a red patch on oral mucous membranes. The causes of this lesion are believed to be similar to those responsible for oral cancer. Erythroplakia is seen much less commonly than its white lesion counterpart, leukoplakia. Common sites of involvement include the floor of the mouth, the tongue, retromolar mucosa, and the soft palate. Individuals between 50 and 70 years of age are usually affected, and no gender predilection is apparent. Erythroplakia is usually supple to the touch unless the lesion is invasive, in which case induration may be noted. Approximately 40% of erythroplakias show severe dysplastic change; about 50% are squamous cell carcinoma and 9% mild or moderate dysplasia. A relative reduction in keratin production and a relative increase in vascularity account for the clinical color of these lesions. Microscopic features that separate this bowenoid change from the usual carcinoma in situ include marked disordered growth, multinucleated keratinocytes, large hyperchromatic keratinocyte nuclei, and atypical individual cell keratinization. Generally, it is more important to excise widely than to excise deeply in dysplastic and in situ lesions because of their superficial nature and the fact that dysplastic cells usually extend beyond the clinically evident lesion. Molecular biomarkers have not yet been identified to predict when (if) a lesion may undergo malignant transformation (see Chapter 2, Oral Cancer Pathogenesis). If, in fact, malignancy does develop, the conversion can range from months to years. Treatment Histopathology Erythroplakia Idiopathic Mucosal Red Patch Cause unknown-some related to tobacco Age-typically between 50 and 70 years High-risk sites-floor of mouth, tongue, retromolar mucosa, soft palate Histopathology Squamous cell carcinoma (50%) Severe dysplasia or in situ carcinoma (40%) Mild to moderate dysplasia (10%) Biopsy must be performed. The second pattern of Kaposi sarcoma was identified in Africa, where it is considered endemic. The third pattern of Kaposi sarcoma has been seen in patients with immunodeficiency status, including patients with organ transplants, and is commonly associated with a The clinical course is relatively rapid and aggressive, and the prognosis is correspondingly poor. In instances where Kaposi sarcoma (or other vascular neoplasm) is being considered, immunohistochemical studies may be beneficial. Clinical considerations include hemangioma, erythroplakia, melanoma, and pyogenic granuloma. Another remarkable look-alike, known as bacillary angiomatosis, mimics Kaposi sarcoma both clinically and microscopically. Bacillary angiomatosis is uncommon in the skin and is very rare in oral mucous membranes. Other types of chemotherapy directed against angiogenesis, and cytokine pathways may also be beneficial. Surgery has been useful on localized lesions, as well as low-dose radiation and intralesional chemotherapy. In various areas of the world, especially those with poor socioeconomic conditions, vitamin B deficiencies may be relatively common because of inadequate dietary intake. Decreased intake through malnutrition associated with alcoholism, starvation, or fad diets may lead to clinically apparent disease. Most of the vitamins classified under the B complex (biotin, nicotinamide, pantothenic acid, and thiamine) are Significant oral changes have been well documented in deficiencies of riboflavin (ariboflavinosis), niacin (pellagra), folic acid (one of the megaloblastic anemias), and vitamin B12 (pernicious anemia) (see the following section). Pernicious Anemia Pernicious anemia is essentially a deficiency of vitamin B12 (erythrocyte-maturing factor or extrinsic factor). This intrinsic factor is normally complexed to vitamin B12, making the vitamin available to mucosal cells for absorption. The lips may exhibit cracking and fissuring that are exaggerated at the corners of the mouth, in which case the condition is called angular cheilitis. The glossitis in this deficiency may be severe and may extend to other mucosal surfaces. The clinical signs of anemia, weakness, pallor, shortness of breath, difficulty in breathing, and increased fatigue on exertion, may be present. In more severe cases, central nervous system manifestations (headache, dizziness, and tinnitus) and gastrointestinal manifestations (nausea, diarrhea, and stomatitis) may be noted. Oral complaints center on the tongue, with patients reporting pain and burning as typical symptoms. The clinical picture of pernicious anemia can be only presumptive of this disease. Diagnosis is based on laboratory demonstration of a megaloblastic, macrocytic anemia. In addition to iron deficiency, the Plummer-Vinson (Paterson-Kelly) syndrome includes dysphagia, atrophy of the upper alimentary tract, and a predisposition to the development of oral cancer. Laboratory blood studies show slightly to moderately reduced hematocrit and reduced hemoglobin level.

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In general symptoms stomach cancer buy 2.5 ml xalatan fast delivery, prompt surgical reconstruction of most penile injuries usually leads to adequate and acceptable cosmetic and functional results treatment xyy buy xalatan master card. Penile fracture is the disruption of the tunica albuginea with rupture of the corpus cavernosum treatment wasp stings best 2.5ml xalatan. Fracture typically occurs during vigorous sexual intercourse medicine x stanford order xalatan american express, when the rigid penis slips out of the vagina and strikes the perineum or pubic bone symptoms 5 days after iui generic 2.5ml xalatan amex, producing a buckling injury symptoms 7 buy generic xalatan on line. The tunica albuginea is a bilaminar structure (inner circular, outer longitudinal) composed of collagen and elastin. The outer layer determines the strength and thickness of the tunica, which varies in different locations along the shaft and is thinnest ventrolaterally (Hsu et al, 1994; Brock et al, 1997). The tensile strength of the tunica albuginea is remarkable, resisting rupture until intracavernous pressures increase to more than 1500 mm Hg (Bitsch et al, 1990). When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure exceeds the tensile strength of the tunica albuginea, and a transverse laceration of the proximal shaft usually results. Although penile fracture has been reported most commonly with sexual intercourse, it also has been described with masturbation, rolling over or falling onto the erect penis, and other scenarios (Al Ansari et al, 2013). Penile fracture may occur more frequently in "stressful situations" such as extramarital sex (Kramer, 2011). In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence (Zargooshi, 2009). Mydlo (2001) reported that 94% of fractures in Philadelphia, Pennsylvania, were a result of sexual intercourse; Zargooshi (2009) described 76% of fractures in Kermanshah, Iran, as being due to self-manipulation. The tunical tear is usually transverse and 1 to 2 cm in length (Asgari et al, 1996; Mydlo, 2001). The injury is usually unilateral, although tears in both corporeal bodies occur in 10% of injuries (Mydlo, 2001; El-Taher et al, 2004). Bilateral corporeal injuries are more commonly associated with urethral injury (Koifman et al, 2010). Although the site of rupture can occur anywhere along the penile shaft, most fractures are distal to the suspensory ligament. Injuries associated with coitus are usually ventral or lateral (Mydlo, 2001; Lee et al, 2007), where the tunica albuginea is the thinnest (Hsu et al, 1994). The diagnosis of penile fracture is often straightforward and can be made reliably by history and physical examination. Patients usually describe a cracking or popping sound as the tunica tears, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft. If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical "eggplant deformity. The swollen, ecchymotic phallus often deviates to the side opposite the tunical tear because of hematoma and mass effect. Given that urethral injury occurs frequently, preoperative urethrography should be considered when urethral injury is suspected. However, because urethrography can be time-consuming and inaccurate (Kamdar et al, 2008), intraoperative flexible cystoscopy is now often performed routinely just before catheter placement at the time of penile exploration when urethral injury is suspected. The typical history and clinical presentation of penile fracture usually make adjunctive imaging studies unnecessary. However, when the history and physical examination are equivocal for penile fracture, ultrasonography can establish the diagnosis (Koifman et al, 2010). Penile ultrasound is most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision (El-Assmy et al, 2011). Cavernosography is discouraged in the evaluation of a suspected penile fracture because it is time-consuming and unfamiliar to most urologists and radiologists (Beysel et al, 2002; Morey et al, 2004). False fracture has been reported in patients who present with penile swelling and ecchymosis, and some even describe the classic "snap-pop" or rapid detumescence typically associated with fracture (Feki et al, 2007). Physical examination may be inadequate for definitive diagnosis of a corporeal tear in these circumstances (Shah et al, 2003). Another condition that may mimic penile fracture is rupture of the dorsal penile artery or vein during sexual intercourse (Armenakas et al, 2001; Bar-Yosef et al, 2007). Multiple contemporary publications recommend that suspected penile fractures be promptly explored and surgically repaired. Alternatively, small lateral incisions may be used for localized hematomas or palpable tunical defects (El-Bahnasawy and Gomha, 2000; Nasser and Mostafa, 2008). The distal circumcising incision may be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments. Closure of the tunical defect with interrupted 2-0 or 3-0 absorbable sutures is recommended; deep corporeal vascular ligation and excessive debridement of the delicate underlying erectile tissue should be avoided. Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration (Shaeer, 2006). Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter. Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter. Therapy with broad-spectrum antibiotics and 1 month of sexual abstinence are recommended. In uncircumcised patients, the distal circumcising incision may place the distal prepuce at risk for ischemia. Although a ventral vertical incision is preferred, if a distal circumcising incision is required, performing limited circumcision at the conclusion of the repair should be strongly considered. B, During surgical exploration and repair, urethral laceration with an exposed Foley catheterisnoted(large arrow). Transverse laceration of left corpus cavernosum (arrow)associatedwithpenilefracture,successfullyrepairedthrough acircumcisionincision. Although repair results in penile curvature in less than 5% of patients (El Atat et al, 2008), conservative management of penile fracture has been associated with penile curvature in more than 10% of patients, abscess or debilitating plaques in 25% to 30%, and significantly longer hospitalization times and recovery (Meares, 1971; Nicolaisen et al, 1983; Kalash and Young, 1984; Orvis and McAninch, 1989). Zargooshi (2009) reported in a surgical series of 352 patients that surgical management of penile fractures resulted in erectile function in nearly all patients. Although surgery is better than conservative management, surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair (El-Assmy et al, 2011; Kozacioglu et al, 2011). Most penetrating wounds to the genitalia are due to gunshots (Mohr et al, 2003; Phonsombat et al, 2008; Bjurlin et al, 2013), and most require surgical exploration. Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure. Gunshot injuries to the phallus are rarely isolated wounds- nearly all victims have significant associated injuries, including abdominal, pelvic, lower extremity, vascular, or additional genitourinary injuries (Bandi and Santucci, 2004; Kunkle et al, 2008; Najibi et al, 2010). Excellent cosmetic and functional outcomes can be expected with immediate reconstruction (Gomez et al, 1993; Cavalcanti et al, 2006). An artificial erection may be induced to ensure penile straightness, and plication techniques may be used to correct any curvature resulting from closure of a large corporeal injury (Kunkle et al, 2008). Urethral injuries have been reported in 15% to 50% of penile gunshot wounds (Miles et al, 1990; Goldman et al, 1996; Mohr et al, 2003; Cinman et al, 2013). Retrograde urethrography should be strongly considered in any patient with penetrating injury to the penis, especially with high-velocity missile injuries, blood at the meatus, or difficulty voiding and when the trajectory of the bullet was near the urethra (Goldman et al, 1996; Mohr et al, 2003; Bandi and Santucci, 2004, Phonsombat et al, 2008; Cerwinka and Block, 2009). Alternatively, intraoperative retrograde urethral injection of methylene blue or indigo carmine may identify the site of injury and the adequacy of closure. If a catheter has already been placed, pericatheter injection may help to ascertain urethral integrity. Urethral injuries resulting from penetrating trauma should be closed primarily by use of standard urethroplasty principles whenever possible-excellent results have been reported (Miles et al, 1990; Bandi and Santucci, 2004). Patients with urethral injury and extensive tissue damage from high-velocity weapons or closerange shotgun blasts may require staged repair and suprapubic urinary diversion (Bandi and Santucci, 2004), especially injuries located in the penile urethra (Cavalcanti et al, 2006). The morbidity of animal bites is directly related to the severity of the initial wound. Most victims are boys, and dog bites are the most common injury (Gomes et al, 2001; Van der Horst et al, 2004). Initial management of dog bites includes copious irrigation, debridement, and immediate primary closure along with prophylactic use of broadspectrum antibiotic (Wolf et al, 1993; Cummings and Boullier, 2000; Bertozzi et al, 2009). Because of the risk of polymicrobial infection and the antimicrobial susceptibilities of typical organisms, recommended empirical antimicrobial therapy choices include a -lactam antibiotic with a -lactamase inhibitor. Human bites produce contaminated wounds that often should not be closed primarily. Most individuals with human bite injuries seek medical attention after a substantial delay and are more likely to present with gross infection. Empirical antibiotic administration is warranted with amoxicillin/clavulanic acid or moxifloxacin (Talan et al, 2003). Amputation Traumatic amputation of the penis, although rare, is usually the result of genital self-mutilation. Psychosis is present in 65% to 87% of patients performing genital self-mutilation (Greilsheimer and Groves, 1979; Aboseif et al, 1993; Romilly and Isaac, 1996). Reconstruction of the urethra and reanastomosis of the corporeal bodies with microsurgical repair of dorsal penile vessels and nerves achieves remarkably good results. Patients should be transferred to a facility with microsurgical capabilities; however, if such a facility is unavailable, macroscopic anastomosis of the urethra and corporeal bodies can be performed with good erectile results, albeit with potential compromise of sensation and skin loss (Bhanganada et al, 1983; Razzaghi et al, 2009). Every attempt should be made to locate, clean, and preserve the severed portion in a "double bag" technique. Also, a screwdriver may be placed between the upper and lower shields of the slider, and a twisting action separates the two shields from the median bar and unravels the zipper (Raveenthiran, 2007). Another technique involves cutting the anterior shield with a wire cutter (Maurice and Cherullo, 2013). Some children may require more than local anesthesia or sedation; circumcision or an elliptical skin excision can be performed in the operating room under anesthesia (Yip et al, 1989; Mydlo, 2000). Hypothermic injury to the amputated segment can occur if it is in direct contact with ice for a prolonged period. Successful reimplantation is possible after 16 hours of cold ischemia time or 6 hours of warm ischemia (Lowe et al, 1991). If the severed part is unavailable, the penile stump should be formalized by closing the corpora and spatulating the urethral neomeatus, similar to a partial penectomy procedure for malignant disease. Microvascular reconstruction of the dorsal arteries, vein, and nerves is the preferred method of repair for an amputated penis. Adequate erectile function is possible with microvascular reanastomosis and macroscopic replantation, with more than 50% of men able to achieve erection with either technique (Bhanganada et al, 1983; Lowe et al, 1991; Aboseif et al, 1993). However, complications such as urethral strictures, skin loss, and sensory abnormalities all are less common with microvascular repair (Jezior et al, 2001). Normal penile sensation returns in 0% to 10% of patients after macroscopic replantation (Bhanganada et al, 1983; Lowe et al, 1991), whereas sensation is present in more than 80% of patients with microscopic replantations (Jordan and Gilbert, 1989; Lowe et al, 1991; Jezior et al, 2001). Penile skin necrosis, sometimes complete, is often a troublesome problem, although it is less common with microsurgical repair. This is because the blood supply of the skin is independent of the corporeal bodies and because without repair of the superficial vascular structures, the penile skin is essentially a free graft (Jezior et al, 2001). Split-thickness skin grafts are applied when the native skin becomes necrotic (Ozturk et al, 2009). An alternative strategy is to denude the phallus of all skin and bury it in the scrotum, leaving the glans exposed, followed by separation of the structures after 2 months (Bhanganada et al, 1983; Jordan and Gilbert, 1989). Strangulation Injuries Accidental injuries with thread, hair, or rubber bands occur in children, but child abuse must be considered in such cases. Any child with unexplained penile swelling, erythema, or difficulty voiding should be examined closely for a hidden strangulating hair or string. Adults may place objects around the shaft as a means of sexual pleasure or to prolong an erection. The constricting device can reduce blood flow, cause edema, and induce ischemia; gangrene and urethral injury may develop in delayed presentations. Emergent treatment requires decompression of the constricted penis to allow blood flow and micturition. Depending on the constricting device, significant resourcefulness may be required of the physician. Initial attempts to remove a solid constricting device causing penile strangulation involve lubrication of the shaft and foreign body and attempted direct removal. A string or latex tourniquet can be wrapped around the distal shaft to decrease swelling and to improve the odds of removing the device with lubrication. If the constricting object cannot be severed or removed, a string technique should be considered (Browning and Reed, 1969; Vahasarja et al, 1993; Noh et al, 2004). A thick silk suture or umbilical tape is passed proximally under the strangulation object and wound tightly around the penis distally toward the glans. The tag of suture or tape proximal to the ring is grasped; unwinding from the proximal end pushes the object distally. Glanular puncture with a needle or blade allows escape of dark trapped blood and improves the odds of removing the object with the string method (Browning and Reed, 1969; Noh et al, 2004). Plastic constricting devices can be incised with a scalpel or an oscillating cast saw (Pannek and Martin, 2003), but metal objects present a more difficult challenge. Readily available hospital equipment (ring cutters, bolt cutters, dental drills, commercially available rotary tools, orthopedic and neurosurgical operative drills) may be inadequate to cut through heavy iron or steel items. The use of industrial drills, steel saws, hacksaws, saber saws, and high-speed electric drills has been reported (Perabo et al, 2002; Santucci et al, 2004). Occasionally, fire department and emergency medical services equipment may be required to cut through iron and steel rings. The phallus should be protected from thermal injury, sparks, and the cutting blade by use of tongue depressors, sponges, or malleable retractors; continuous saline irrigation may be used for cooling. Such elaborate undertakings are best accomplished in the operating room under anesthesia. If decompression is delayed and the patient is distended and unable to void, a suprapubic bladder catheter should be placed.

The authors believed that either tube was reliable and that each had its own unique advantages and disadvantages symptoms 97 jeep 40 oxygen sensor failure generic xalatan 2.5 ml otc. In general symptoms 0f pregnancy buy xalatan 2.5ml fast delivery, the full-thickness bowel wall tube was more adaptable owing to the ability to create a longer tube treatment 0f ovarian cyst buy xalatan overnight. The decreased distal blood supply might be improved by creating a wider base on the tube symptoms 24 hour flu buy cheapest xalatan. The seromuscular tube was equally reliable but could be anastomosed only to the umbilicus symptoms 2 order xalatan amex, owing to the short adit tube medicine dosage chart xalatan 2.5 ml online. Either tube was believed to be indicated as a continence mechanism in the Mainz I pouch when the appendix was not available or as a continence mechanism for reservoirs created from other large intestinal segments. Either the late complication rate was 37% and was predominantly attributable to the pouch. Stomal failure requiring open revision occurred in 45 patients (8%) and was directly related to the continence mechanism. The developers of this procedure were innovative in their attempts to bring the incontinence rate down to an acceptable level. To this end they tried multiple techniques, with variable success: an alloplastic stoma (4 of 4 incontinent); sutured intussusception (8 of 8 incontinent); stapled intussusception (5 of 22, 23% incontinent); and stapled ileocecal intussusception (10 of 204, 4. The stapled ileocecal intussusception described previously is the current recommendation, and the long-term incontinence rate among the patients undergoing the stapled nipple valves was reduced to 10%. Other late complications included the need for ureteral reimplantation in 28 patients (4. Despite the loss of the terminal ileum, no significant decrease in serum vitamin B12 levels has been reported, and no patient has developed macrocytic anemia or neurologic symptoms. Since the inception of this procedure, the overall complication rate has been considered high (31%). However, as Stein and associates (1995) pointed out, 50% of the complications were manageable with percutaneous techniques. Gerharz and associates (1997) from Marburg, Germany, reported their single-institution experience with the Mainz I ileocecal pouch. From 1990 to 1996, 202 consecutive patients underwent continent diversion, 96 with a submucosally embedded in situ appendix and 106 with an intussuscepted ileal nipple. In 17 of 96 patients (18%) with an appendiceal stoma, 23 revisions were performed for stomal stenosis. In contrast, only 13 of 106 patients (12%) with an intussuscepted ileal nipple developed problems with their stoma. The continence mechanism is created by placing the tube into the adjacent taenial trough. A mucosal window is opened at the base of the U, and the tube sutured to the mucosa with interrupted sutures. Another novel Mitrofanoff continence mechanism was described by Montie (1997), who conceived of a procedure in which a 2- to 3-cm segment of terminal ileum is isolated on its blood supply. The width of the segment was chosen to correspond to the circumference of the tube to be created. Once isolated, the segment is opened near one of its mesenteric junctions to create a longitudinal reconfiguration. When longer tubes are necessary, two adjacent segments can be isolated, reconfigured, and joined together. Although the technique was originally described in dogs, Montie (1997) has used it in humans without complication. Montie (1997) reported on a high rate of stomal stenosis in dogs, but this may have been secondary to infrequent catheterizations. Other groups have used tapered ileum to create a tunneled access into the right colon. Using tapered ileum for this purpose has the advantage of a blood supply independent of the reservoir and no length restrictions while having the disadvantage of further limiting intestinal absorptive surface. Wiesner and colleagues (2007) recently compared their longterm results in 458 patients who underwent Mainz I pouch construction. The anastomosis was made using a submucosal tunnel in 809 renal-ureteric units, and using a serosa-lined extramural tunnel in 74 units. At 17 months postoperatively they found a significantly higher occurrence of anastomotic obstruction in the submucosal tunnel group compared with the extramural group (7. It is important to note that they found a much higher rate of obstruction in patients with previously dilated upper tracts (14%) or with a history of neurogenic bladder (17%). In another comparison of patients with a Mainz I pouch, Wiesner and colleagues (2006) reported on 800 patients with almost 8 years of follow-up. Newtechniques for construction of efferent conduits based on the Mitrofanoff principle. Ischemic degeneration of the continence mechanism occurred almost three times more often in the appendiceal group. Right Colon Pouches with Intussuscepted Terminal Ileum Additional pouches using nipple valve technology for the continence mechanism include those right colon pouches in which intussusception of the terminal ileum and ileal cecal valve is employed. These are variations on the continent cecal reservoir initially described by Mansson (1987) that employ an intact cecal segment. These surgeries differ from one another by only a few features, mainly related to the technique employed for stabilizing the nipple valve. Unless the appendix is being used as a continence mechanism, appendectomy should be performed in all cases because an in situ appendix would serve as a nidus for infection and abscess formation. Since that edition was published, no new modifications to these procedures have been reported, and they are not further described here. The reader is referred to the prior edition of this text for an in-depth description of these operations. This operation, which involved the partial spatulation of the cecal segment and attachment of an ileal patch, represented major contributions to the original ileocecal reservoir as described by Gilchrist and associates (1950), in which the intact bowel reservoir was employed and no attempt was made to strengthen the ileocecal valve. Originally, strengthening the ileocecal valve consisted of making a double row of imbricating sutures to the entire ileal segment (Rowland et al, 1985, 1987). It soon became apparent that this was necessary only in the region of the ileocecal valve. The remaining "neourethra" could be tapered and brought through an abdominal or perineal stoma. At Indiana University as well as other institutions it became clear that the concept of marsupializing only a portion of the ascending colon segment left enough peristaltic integrity in the cecal region to generate pressures sufficiently high to overcome the continence mechanism in some patients. A number of groups contributed to the concept of using the entire right colon or more, marsupializing the entire structure and refashioning it in a Heineke-Mikulicz configuration (Lockhart, 1987; Bejany and Politano, 1988; Benson et al, 1988; Rowland, personal communication, 1989). These variations have been entitled the Florida pouch (Lockhart, 1987) and the University of Miami pouch (Bejany and Politano, 1988). However, they represent relatively minor variations on the theme of the Indiana pouch. The Indiana pouch in its present form involves isolating a segment of terminal ileum approximately 10 cm in length along with the entire right colon to the junction of the right and middle colic artery blood supplies. After bowel continuity is reestablished, appendectomy is performed and the appendiceal fat pad obscuring the inferior margin of the ileocecal junction is removed by cautery. The entire right colon is opened along its antimesenteric border, and ureteral-taenial implants are fashioned. With nonabsorbable sutures, interrupted Lembert sutures are taken over a distance of 3 to 4 cm in two rows for the double imbrication of the ileocecal valve as described at Indiana University. The second row of sutures should attempt to bring the opposite mesenteric edges of ileum together, usually over a 12- to 14-Fr catheter. These two rows of sutures should be placed approximately 8 mm from one another, and the initial suture in each row may be taken in a purse-string fashion around the cecal margin as well. Alternatively, the University of Miami group suggests placing purse-string sutures in the same ileal region (Bejany and Politano, 1988). Finally, the Tampa group suggests placement of apposing Lembert sutures on each side of the terminal ileum. The remaining ileum can be tapered over the catheter and excess ileum removed with a stapling technique. It is important to carry out the imbrication while the cecal reservoir is still open (Rowland, 1996) so that the gradual closure of the ileocecal valve can be closely observed. The pouch is then closed in a Heineke-Mikulicz configuration with a running absorbable suture. Ureteral stents and a suprapubic tube are taken through a stab wound in the pouch and led through the right lower abdominal quadrant. The pouch is rotated so as to bring the ileal neourethra as close as possible to the selected stoma site. A fingerbreadth-wide skin button is transected along with a similar button from the anterior and posterior fascia. The ileal neourethra is advanced between bundles of the rectus muscle through the stoma and excess ileum is transected. The ileal edges are sewn to skin with interrupted sutures so as to create a flush stoma. In addition to the differences in the technique of ileocecal valve imbrication, both the University of Miami and the Florida pouches differ in the amount of colon used. The entire ascending colon and the right third or half of the transverse colon is isolated along with 10 to 12 cm of ileum. The entire upper extremity of the large bowel is mobilized laterally in the fashion of an inverted U. The medial limbs of the U are sutured to each other after the bowel has been spatulated. This inverted-U closure, however, is exactly the same as a HeinekeMikulicz reconfiguration. There have been recent modifications to the Indiana reservoir that allow for more rapid construction and a lower complication rate (Rowland, 1996). The modifications incorporate the use of metal staples to create the efferent limb and absorbable staples to fashion the reservoir. Carroll and Presti (1992) reported on the urodynamic features of the stapled and plicated terminal ileum and found that the stapled limb performed equally well and was easier to construct. The use of absorbable staples to create this and other types of reservoirs is described later in the chapter. The postoperative care of the patient with an Indiana pouch or its variants is not substantially different from that used in patients with other right colon catheterizable diversions. In early reports, Rowland recommended discharging the patient with the suprapubic tube in place until readmission to the hospital 3 weeks later for tube removal and instruction in self-catheterization. In the current medical climate, which places a premium on outpatient procedures, tube removal and catheterization instruction are now ambulatory procedures at most institutions, including Indiana University (Bihrle, 1997). Average pouch capacities of 400 to 500 mL have been reported by the Indiana group (Rowland et al, 1987). Combining the partially and totally spatulated bowel procedures, this group reports a reoperation rate of 26%. Very elegant urodynamic studies were conducted in Indiana pouch variants by Carroll and colleagues (1989). However, their pouch capacities exceeded 650 mL, and peak contractions of 47 cm H2O were recorded at capacity. The last 81 patients operated on by Rowland underwent construction of a stapled efferent limb, and in the last 20 the reservoir was created with absorbable staples (Rowland, 1996). Two patients experienced a pouch leak that was managed conservatively, and 1 patient required open revision of the efferent limb owing to difficulty with catheterization. Early complications not directly attributable to the pouch occurred in 7 patients (8. Transient small bowel obstruction was the most common complication, occurring in 4 patients (4. One patient developed a superficial wound infection, and 1 patient developed an abdominal abscess requiring surgery (1. A, A segment of terminal ileum approximately 10cm in length along with the entire right colon is isolated. B, Appendectomy is performed and the appendiceal fat pad obscuring the inferior margin of the ileocecal junction is removed by cautery. Pouch stones occurred in 3 patients: 1 underwent open removal, and 2 had endoscopic extraction. The most common late complication not related to the pouch was small bowel obstruction; this was seen in 6 patients and was managed conservatively in 5. At 1 year, daytime and nighttime dry intervals of 4 hours or longer were achieved in 98% of patients. Eighty-four percent of patients stated that they slept through the night without the need to awake for catheterization. In 165 patients and 326 ureters, no attempt was made to create a tunneled reimplantation. This approach was adopted owing to the high incidence of ureteral obstruction encountered in the first 30 ureters that were tunneled into a Florida pouch (43 patients, 13. All patients are being followed conservatively, and no renal deterioration has been demonstrated. The appendix is folded cephalad into the tunnel (B), and seromuscular sutures are placedthroughthemesoappendix(C). Reservoir capacities ranged from 400 to 1200 mL, and maximal reservoir pressures at capacity ranged from 18 to 55 cm H2O (Lockhart, 1987). The reason why these authors experienced such a high incidence of ureteral obstruction with both nontunneled and tunneled ureteral colonic anastomoses is not clear.