Biomedical subjects
Gerald H Jordan
Publications and source records attributed to Gerald H Jordan.
Reconstruction and management of posterior urethral and straddle injuries of the urethra.
Urethral stricture disease, once associated mainly with gonococcal urethritis, is now most frequently a consequence of trauma, such as a fall-astride injury or a pelvic fracture. This article discusses issues and approaches related to the treatment of strictures associated with perineal straddle trauma and pelvic fracture urethral distraction defects. The authors emphasize that endoscopic procedures seldom cure these strictures and in-dwelling stents are seldom useful in treatment. Primary anastomotic techniques are associated with success rates in the high 90% range and appear to be remarkably durable in most cases. In contrast, tubed reconstruction of the urethra is inevitably associated with diminished success rates and with problems of durability.
Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture.
PURPOSE: Treatment for urethral stricture disease often requires a choice between readily available direct vision internal urethrotomy (DVIU) and highly efficacious but more technically complex open urethral reconstruction. Using the short segment bulbous urethral stricture as a model, we determined which strategy is less costly. MATERIALS AND METHODS: The costs of DVIU and open urethral reconstruction with stricture excision and primary anastomosis for a 2 cm bulbous urethral stricture were compared using a cost minimization decision analysis model. Clinical probability estimates for the DVIU treatment arm were the risk of bleeding, urinary tract infection and the risk of stricture recurrence. Estimates for the primary urethral reconstruction strategy were the risk of wound complications, complications of exaggerated lithotomy and the risk of treatment failure. Direct third party payer costs were determined in 2002 United States dollars. RESULTS: The model predicted that treatment with DVIU was more costly (17,747 dollars per patient) than immediate open urethral reconstruction (16,444 dollars per patient). This yielded an incremental cost savings of $1,304 per patient, favoring urethral reconstruction. Sensitivity analysis revealed that primary treatment with urethroplasty was economically advantageous within the range of clinically relevant events. Treatment with DVIU became more favorable when the long-term risk of stricture recurrence after DVIU was less than 60%. CONCLUSIONS: Treatment for short segment bulbous urethral strictures with primary reconstruction is less costly than treatment with DVIU. From a fiscal standpoint urethral reconstruction should be considered over DVIU in the majority of clinical circumstances.
Role of laparoscopy in patients with previous negative exploration for impalpable testis.
OBJECTIVES: To evaluate the impact of laparoscopy in the treatment of patients with previous negative inguinal exploration for impalpable undescended testes. METHODS: A retrospective review was performed of patients who underwent laparoscopy after prior incomplete or "questionable" negative inguinal explorations for nonpalpable undescended testes. RESULTS: Twenty-seven males aged 1 to 22 years old, with 30 impalpable testes, underwent laparoscopy after prior negative open exploration. The operative notes were available for all patients. In 9 patients (33%), blind-ending spermatic vessels, vas deferens, and a closed ring were found. However, in the remaining 18 patients (67%), viable intra-abdominal or inguinal gonads (9 patients) and intra-abdominal remnants (9 patients) were identified. In 1 patient, seminoma of an intra-abdominal testis was present. CONCLUSIONS: When a patient is referred with an inconclusive previous open exploration for an impalpable gonad, laparoscopy has an important role in establishing or refuting the diagnosis of an absent testis. Moreover, therapeutic laparoscopy provides definitive options to standard open techniques when a viable testis or remnant is encountered. In this study, laparoscopy proved more accurate than open exploration with operative notes available defining the nature of the exploration.
Open reconstruction of pediatric and adolescent urethral strictures: long-term followup.
PURPOSE: Pediatric urethral stricture disease represents a significant surgical challenge. Published operative series of pediatric urethral reconstruction include small numbers or lack long-term followup. We examined the long-term outcome of open reconstructive techniques for pediatric urethral strictures. MATERIALS AND METHODS: From March 1987 through August 2002, 17 boys 7 to 17 years old underwent open urethral reconstruction with followup. Trauma was the etiology in 88% of cases. Nine patients had anterior urethral stricture and 8 had traumatic posterior urethral disruption. Strictures secondary to failed hypospadias correction were not included in analysis. In 10 patients (59%) previous management with open or endoscopic procedures had failed. Followup in all patients consisted of symptomatic evaluation, voiding cystourethrography and flexible urethroscopy. RESULTS: One-stage perineal urethral reconstruction was performed in all patients without retropubic or transpubic dissection. All patients were stricture-free and continent at a mean followup of 67 months. A total of 18 open surgical procedures were needed. A patient with posterior urethral disruption required reoperation for recurrent stricture disease but had excellent long-term results after the second operation. Chordee, penile shortening and urethral diverticula were not noted during followup. CONCLUSIONS: Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. When considering the importance of repair durability in the pediatric urethral stricture population, urethral reconstruction should be strongly considered the primary treatment option. Endoscopic procedures should be reserved for patients with short bulbar strictures associated with minimal spongiofibrosis. As in the literature, we do not advocate repeat direct vision internal urethrotomy.
The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption.
PURPOSE: Erectile dysfunction is a common sequel of pelvic fractures, particularly those associated with posterior urethral injury when it can be neurogenic or arteriogenic due to damage to the cavernous nerves or branches of the pudendal arteries. We studied erectile function of patients with posterior urethral injuries due to pelvic fractures. MATERIALS AND METHODS: Patients referred for posterior urethral reconstruction and strictures due to pelvic fractures were evaluated before reconstruction. All patients underwent nocturnal penile tumescence testing, and if those results were abnormal, penile duplex ultrasound with intracavernous injection was performed. Patients with normal vascular function on duplex ultrasound were diagnosed with neurogenic erectile dysfunction. Those patients with abnormal arterial function on duplex ultrasound underwent arteriography to further define the extent and location of arterial damage. RESULTS: The study included 25 consecutive patients with posterior urethral strictures and a mean age of 28.6 years. Of the patients 18 (72%) had erectile dysfunction as demonstrated by nocturnal penile tumescence and all underwent penile duplex ultrasound. Ultrasound confirmed normal vascular response in 13 of the 18 patients and they were diagnosed with probable neurogenic erectile dysfunction. The remaining 5 patients (28%) with erectile dysfunction had an abnormal arterial response, and significant arterial pathology was confirmed by arteriography. CONCLUSIONS: Erectile dysfunction is common in patients with pelvic fractures associated with urethral injury. We believe that erectile function should be assessed and documented in such patients before attempting urethroplasty. In the majority of these patients erectile dysfunction is caused by disruption of the cavernous nerves with sparing of arterial inflow.
Total phallic construction, option to gender reassignment.
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Laparoscopic live donor right nephrectomy: a new technique with preservation of vascular length.
PURPOSE: We report our initial experience with right laparoscopic live donor nephrectomy using a modified vascular clamp for achieving maximal length of the renal vein. MATERIALS AND METHODS: Since 1999, 34 patients have undergone laparoscopic live donor nephrectomy at Charité Hospital in Berlin, including 30 on the left and 4 on the right side. The right technique involves a 4-port transperitoneal laparoscopic approach with a muscle splitting lumbar incision for kidney extraction. To duplicate completely the comparable open operation a modified Satinsky atraumatic vascular clamp (Aesculap, Inc., Center Valley, Pennsylvania) was introduced through a 1 cm. lateral incision and placed across the vena cava, enabling harvest of the full length of the renal vein flush with the vena cava. The vena cavotomy is closed with a running suture placed in intracorporeal fashion. RESULTS: All procedures were successfully accomplished without technical or surgical complications. Mean operative time was 170 minutes. Mean renal warm ischemia time from endoscopic cross clamping of the renal vessels to cold perfusion on the bench was 2.1 minutes. In all 4 kidneys it was possible to harvest the whole length of the renal vein, so that the recipient operation was performed under optimal vascular conditions. All 4 kidneys were transplanted successfully in the recipients and showed immediate function. CONCLUSIONS: Right laparoscopic live donor nephrectomy is technically feasible, safe and a viable option for minimally invasive organ donation when left kidney donation is not desired. The Satinsky atraumatic vascular clamp enabled harvest of the whole right renal vein. We believe that this laparoscopic technique effectively duplicates the open operation with less morbidity.
Treatment of recurrent idiopathic priapism with oral baclofen.
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Scrotal and perineal flaps for anterior urethral reconstruction.
The use of scrotal and perineal flaps for anterior and posterior urethral reconstruction has been unfairly maligned with claims of poor waterproofing qualities, formation of diverticula, and the potential to import hair into the urethra. Actually, scrotal and perineal skin do not appear to differ from other genital skin with regards to permeability to surface liquids, and although these islands are difficult to tailor, when properly prepared they are no more likely to create diverticula than other genital skin islands. Similarly, if the flap is prepared from hirsute skin, hair will be imported into the urethra; however, hairless scrotal areas can be mobilized as skin islands, and the skin overlying the perineal artery is non-hirsute or nearly non-hirsute in many individuals.
Principles of tissue transfer techniques in urethral reconstruction.
Many reconstructive surgical techniques require tissue transfer, or movement of tissue from a donor to a recipient site. The techniques of tissue transfer in reconstructive urologic surgery assume knowledge of skin anatomy, the basic principles of tissue transfer, and the composition and characteristics of the donor and recipient tissues. These topics will be addressed in this article.
Laparoscopic dismembered pyeloplasty--the method of choice in the presence of an enlarged renal pelvis and crossing vessels.
OBJECTIVE: Herein we report our experience of 49 consecutive pyeloplasties that were all laparoscopically performed with an intracorporeally sutured anastomosis. We describe the operative technique, complications and outcomes during a follow-up period of 1-53 months (mean 23.2 months). PATIENTS AND METHODS: Forty-nine patients (28 women and 21 men) with a mean age of 34 years (range 6-65 years) underwent a laparoscopic dismembered pyeloplasty because of primary ureteropelvic junction (UPJ) obstruction with hydronephrosis in each case. The preoperative evaluation included an evaluation for pain, an excretory urography (IVP), renal scan and sometimes CT angiography to evaluate for crossing vessels. Follow-up studies included an IVP, renal scan and renal ultrasound 4 weeks postoperatively and every 3 months thereafter. Success was considered as improvement of the pain score and IVP (less hydronephrosis, visible UPJ and/or normalization of drainage) or absence of an obstructive pattern during the washout phase of a renal scan. RESULTS: There was no conversion to open surgery. The mean operative time was 165 min (range 90-240 min). Blood loss was negligible. Crossing vessels were noted in 57.1% of the patients (28/49). Postoperative hospital stay was 3.7 days (range 3-6 days). One patient had a leakage of the anastomosis on postoperative day 1 and needed to undergo laparoscopic repair. The mean follow-up is 23.2 months (range 1-53 months). There was one single late failure. This patient later underwent an open revision of the laparoscopic pyeloplasty. In all other patients (48/49), the obstruction was resolved or significantly improved. The long-term success rate is 97.7%. CONCLUSIONS: The results of dismembered laparoscopic pyeloplasties compare favorably with those achieved by open pyeloplasties with less perioperative morbidity and discomfort. We do believe that laparoscopic dismembered pyeloplasty with an intracorporeal anastomosis is the method of choice in the treatment of the UPJ obstruction in the presence of an enlarged renal pelvis and crossing vessels.
Treatment of Peyronie's disease.
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