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Placement of the urethrostomy laterally allows exposure of the urethra while cutting through the corpus spongiosum erectile dysfunction psychological causes treatment purchase kamagra polo from india, where it is relatively thinner erectile dysfunction vitamin deficiency kamagra polo 100mg with mastercard, limiting bleeding and maximizing exposure erectile dysfunction drugs non prescription discount kamagra polo on line. The Monseur urethral reconstruction was applied in only a few select centers (Monseur, 1980). In this technique, the urethrostomy was made through the stricture on the dorsal wall. The edges of the stricture were sutured open to the underlying triangular ligament or corpora cavernosa, or both. In their modification, the urethrostomy is performed through the stricture on the dorsal wall. In the area of the urethrostomy, a graft is applied and spread fixed to the triangular ligament or corpora cavernosa, or to both. The edges of the stricturotomy are sutured to the edges of the graft and to the adjacent structures. The ventral and dorsal graft onlay techniques can be used with stricture excision and strip anastomosis (augmented Chapter40 SurgeryofthePenisandUrethra 925 A B C Figure40-24. A,Thecorpusspongiosum is detached from the triangular ligament and the corpora cavernosa. B, A two-layer floor strip anastomosis is performed,andthegraftisspreadfixedtothecorporacavernosa. Another option is the two-staged application of a mesh splitthickness skin graft, buccal mucosal graft, or posterior auricular full-thickness skin graft. In the first stage of the staged graft procedure, a medium-thickness split-thickness skin graft, a buccal mucosal graft, or a Wolfe graft is placed over the dartos fascia. If the graft is placed immediately onto the tunica albuginea or corpora cavernosa, the inability to mobilize the graft makes second-stage tubularization difficult. A, the appearance of the penis with the urethra (shadedareashowsthelocationofatight stenosis of the fossa navicularis that extendsintothedistalpendulousurethra). B,Thedistalnarrowstrictureofthefossa navicularis has been excised, and stricturotomyintothenormalurethraproximal totheexcisedtissuehasbeenperformed. A buccal graft has been applied to the defect,butthebolsterdressinghasnotyet beenapplied. The distalurethraisusuallycalibratedtocreate a urethral lumen of approximately 28 Fr. E,Glansreconstructionandclosureofthe distal shaft has been performed (shaded area shows the tunica dartos flap that carries a parietal tunica vaginalis island). Although Schreiter and Noll (1989), who first described the procedure of mesh split-thickness skin graft, often proceeded to the second stage within 3 to 4 months, we wait 12 months between the first-stage and second-stage surgeries if a splitthickness skin graft is used. This procedure has been found to be useful for select cases in the United States and Europe. In the United States, its use has mostly been confined to the most difficult cases, with single-stage reconstruction still applied to most cases. As already mentioned, staged graft techniques have been used effectively in complicated patients with hypospadias. In addition, in complicated patients with hypospadias, staged buccal grafts and posterior auricular skin grafts have been successfully employed. Numerous applications of genital skin islands, mobilized on either the dartos fascia of the penis or the tunica dartos of the scrotum, have been proposed for the repair of urethral stricture disease. We suggest that all these procedures are different applications of a single concept, as proposed by the microinjection studies of Quartey (1983). Skin islands can be viewed as passengers on fascial flaps, and the design of flaps for urethral reconstruction can be paralleled to the design of flaps for reconstruction in general.

Immunohistochemical studies show that the -adrenergic receptors are expressed in both the smooth muscle and the urothelium of the human ureter (Matsumoto et al erectile dysfunction juice drink cheap kamagra polo 100mg, 2013) erectile dysfunction doctor orlando buy genuine kamagra polo. The ureter contains excitatory -adrenergic and inhibitory -adrenergic receptors (McLeod et al erectile dysfunction natural foods purchase 100mg kamagra polo with mastercard, 1973; Rose and Gillenwater, 1974; Weiss et al, 1978) that have been demonstrated with receptorbinding techniques (Latifpour et al, 1989, 1990). In the human ureter, renal pelvis, and calyces, 1D and 1A adrenoceptor subtypes are more prevalent than the 1B adrenoceptor subtype (Sigala et al, 2005; Itoh et al, 2007; Karabacak et al, 2013). The highest density of 1 adrenoceptors is found in the distal ureter, with the relative density being 1D higher than 1A, which is higher than 1B. This is in accord with the finding that phenylephrine, an -adrenergic agonist, induces a greater contractile force in isolated human ureteral segments obtained from the distal than the proximal ureter (Sasaki et al, 2011). The 1A adrenoceptor subtype is the primary receptor subtype that participates in the contraction of the mouse, hamster, and human ureter (Tomiyama et al, 2007; Sasaki et al, 2008; Kobayashi et al 2009c; Sasaki et al, 2011). It appears that 1A adrenoceptors are more involved in the maintenance of baseline ureteral tonus than in the potentiation of ureteral peristaltic activity (Morita et al, 1987a; Tomiyama et al, 2002). Edyvane and associates (1994) have provided evidence for at least four, and possibly six, different immunohistochemical populations of nerve fibers in the human ureter. These investigators demonstrated regional differences in the innervation of the ureter, with a more extensive innervation noted in the lower than in the upper ureter. Increases in renal pelvic pressure result in the release of substance P and a subsequent increase in afferent renal nerve activity. Intraluminal isoproterenol has been shown to lower renal pelvic pressures during ureteroscopy, with the presumption that this would decrease intrarenal backflow, which has potential harmful effects (Jung et al, 2008; Jakobsen, 2013). In rabbit renal pelvis, 2-adrenergic agonists inhibit contractile activity of the distal renal pelvis, and 1-adrenergic agonists potentiate contractile activity of the proximal renal pelvis (Kondo et al, 1989). Tyramine, whose adrenergic agonist effects are primarily the result of the release of norepinephrine from adrenergic terminals, also has a stimulatory effect on the upper urinary tract (Boyarsky and Labay, 1969; Finberg and Peart, 1970; Longrigg, 1974). The reported stimulatory effects of cocaine on ureteral activity (Boyarsky and Labay, 1969) may be explained by blockage of norepinephrine reuptake into adrenergic nerve endings, with a resultant increase in the magnitude and duration of the effect of norepinephrine. The -adrenergic antagonist doxazosin has been shown to slightly reduce spontaneous contractility of in vitro pig ureter and to inhibit the contractile effects of epinephrine and phenylephrine (Nakada et al, 2007), and tamsulosin inhibited the contractility of human ureters in vitro (Rajpathy et al 2008) and in vivo (Davenport et al, 2007). The -adrenergic antagonist propranolol has been shown to block or attenuate the inhibitory effects of -adrenergic agonists, such as isoproterenol, in a variety of preparations (McLeod et al, 1973; Vereecken, 1973; Longrigg, 1974; Rose and Gillenwater, 1974; Weiss et al, 1978). SensoryInnervationandPeptidergicAgentsintheControl ofUreteralFunction Sensory nerves can play both a sensory afferent and motor efferent role in a given tissue. Two classes of mechanosensitive afferent fibers have been identified in the guinea pig ureter (Cervero and Sann, 1989). It would appear that one group of fibers consists of tension receptors that respond to normal ureteral peristalsis, whereas the others are involved in the signaling of noxious events such as kidney stones and increased intraluminal pressures. Both groups are chemosensitive, being excited by K+, bradykinin, and capsaicin (Sann, 1998). One must consider input and output when predicting whether or not dilatation will occur; the effects of diuresis and obstruction appear to be complementary and additive with respect to the development of renal pelvic and calyceal dilatation. PropulsionofUrinaryBolus the theoretic aspects of the mechanics of urine transport within the ureter have been described in detail by Griffiths and Notschaele (1983); these are depicted in Figure 43-19. At normal flow rates, as the renal pelvis fills, a rise in renal pelvic pressure occurs and urine is extruded into the upper ureter, which initially is in a collapsed state. The contraction wave originates in the most proximal portion of the ureter and moves the urine in front of it in a distal direction. To propel the bolus of urine efficiently, the contraction wave must completely coapt the ureteral walls (Woodburne and Lapides, 1972; Griffiths and Notschaele, 1983), and the pressure generated by this contraction wave provides the primary component of what is recorded by intraluminal pressure measurements. The bolus that is pushed in front of the contraction wave lies almost entirely in a passive, noncontracting part of the ureter (Fung, 1971; Weinberg, 1974).

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Bycommonusage most effective erectile dysfunction pills buy kamagra polo with paypal,thedivisions of the fossa navicularis erectile dysfunction natural remedies buy kamagra polo 100mg fast delivery, pendulous urethra erectile dysfunction treatment without side effects generic 100 mg kamagra polo otc, and bulbous urethra composetheanteriorurethra,andthedivisionsofthemembranous urethra,prostaticurethra,andbladderneckcomposetheposterior urethra. Emissary veins begin within the erectile space of the corpora cavernosa and, following a perpendicular or oblique course through the tunica albuginea, emerge from the lateral and dorsal surfaces of the corpora cavernosa to empty into the circumflex veins or the deep dorsal vein. The circumflex veins are channels, usually more prominently present in the distal two thirds of the penile shaft. They arise from the corpus spongiosum, on the ventrum of the penis, and often receive the emissary veins as they travel around the lateral aspect of the corpora cavernosa, passing beneath the dorsal arteries and nerves to empty into the deep dorsal vein. The circumflex veins can also become confluent ventrally, forming periurethral veins on each side. These may become important in the treatment of impotence caused by veno-occlusive incompetence. The deep dorsal vein is formed by five to eight small veins emerging from the glans penis to form the retrocoronal plexus, which drains into the deep dorsal vein that may consist of more than one vein lying in the midline groove between the corporeal bodies. In many patients, there is a connection between the superficial and deep dorsal veins. The vein gathers blood from the emissary and circumflex veins, and passing beneath the pubis at the level of the suspensory ligament, it leaves the shaft of the penis at the crus and drains into the periprostatic plexus. Normally, they are small and almost indiscernible, joining the deep dorsal vein or the periprostatic plexus. If the deep dorsal vein has been ligated or obliterated after trauma, striking development of these veins can be noted as the intracrural space is entered during the perineal dissection for urethral repair. Emissary veins in the proximal third of the crura, near their attachment to the ischial tuberosities, join to form several thin-walled trunks on the dorsomedial surface of each corpus cavernosum. Some pass medially, joining the dorsal or crural veins, or, extending proximally, enter the periprostatic plexus. Running in the penile hilum, deep and medial to the cavernosal arteries and nerves, they join to form a large venous channel that drains into the internal pudendal vein. Three or four small cavernosal veins emerge from the dorsolateral surface of each crus and course laterally between the bulbospongiosus and the crus of the penis for 2 to 3 cm before draining into the internal pudendal veins. These usually insignificant vessels become larger and can be noted more readily in patients with veno-occlusive erectile dysfunction. The internal pudendal veins (usually two) run together with the internal pudendal artery and nerve in the Alcock canal to empty into the internal iliac vein. Internal sphincter Smooth muscle Intrinsic sphincter External sphincter Volitional muscle of recruitment Figure 40-8. Distally, the skin of the penis is confluent with the glabrous skin covering the glans. At the corona, it is folded on itself to form the foreskin (prepuce) that overlies the glans. The dartos fascia, a layer of areolar tissue remarkable for its lack of fat, separates these two layers of skin and continues into the perineum, where it fuses with the layers of the superficial perineal (Colles) fascia. In the penis, the dartos fascia is loosely attached to the skin and the deeper layer of Buck fascia and contains the superficial arteries, veins, and nerves of the penis. Blood is supplied to the skin of the penis by the left and right superficial external pudendal vessels. At intervals, fine branches split off to the skin, forming a rich subdermal vascular plexus that can sustain the skin after its underlying dartos fascia has been mobilized. The arteries are accompanied by venous tributaries that are more prominent and more easily seen than the arteries.

The remaining intact nephrons are hypertrophied erectile dysfunction doctor houston kamagra polo 100mg online, and there RenalDrainage Prompt drainage of the obstructed kidney is important to relieve pain and prevent functional decline erectile dysfunction clinic raleigh discount kamagra polo 100mg line. Minimally invasive endourologic and interventional radiologic techniques allow for temporary drainage until a definitive procedure can be performed erectile dysfunction treatment injection buy generic kamagra polo 100 mg, and in some circumstances it may be a permanent management option. In humans, delayed relief of obstruction (>2 weeks) has been demonstrated to decrease long-term renal function and increase the risk for hypertension (Lucarelli et al, 2013). Other factors that influence the return of renal function after relief of obstruction include a lesser degree of obstruction, greater compliance of the collecting system, and the presence of pyelolymphatic backflow (Shokeir et al, 2002). Conversely, older age and decreased cortical thickness are predictors of diminished recovery of renal function after relief of obstruction (Lutaif et al, 2003). The presence of increased collagen deposition in renal parenchyma at the time of pyeloplasty has been shown to have a negative impact on recovery of renal function, because it demonstrates a more advanced state of renal fibrosis (Kim et al, 2005; Kiratli et al, 2008). Mag3 was found to underestimate the potential of the kidney for recovery and was associated with a large variation in accuracy. ClinicalManagementofPostobstructiveDiuresis the majority of patients do not demonstrate a clinically significant postobstructive diuresis after relief of urinary tract obstruction, and those who are susceptible typically exhibit signs of fluid overload, including edema, congestive heart failure, and hypertension (Loo and Vaughan, 1985). Most commonly, postobstructive diuresis develops after relief of urinary retention, and the speed at which the bladder is drained has not been shown to have any effect on the development of postobstructive diuresis or hematuria (Nyman et al, 1997). Patients with normal renal function, normal electrolytes, no evidence of fluid overload, and a normal mental status should have their vital signs and urine output monitored regularly, and they should be given free access to oral fluids. If evidence of a postobstructive diuresis develops, vital signs, urine output, and electrolytes should be monitored more frequently, and patients should continue to have free access to oral fluids. This is a physiologic diuresis that, in the majority of cases, resolves when free water and excess solutes are eliminated. In patients with impaired renal function, altered mental status, and signs of fluid overload, more intense monitoring is indicated. A urine osmolality should be checked, and vital signs and urine output should be checked frequently. If pathologic diuresis ensues, the patient can become hypovolemic as a result of excess water loss, and electrolyte abnormalities may develop as result of salt or potassium wasting. Very intense monitoring and careful fluid and electrolyte replacement are indicated in these patients. A number of different endoscopic, open, laparoscopic, and robotically assisted ablative and reconstructive options are available and are discussed elsewhere in this text. The decision to remove a kidney, however, should be made only after the kidney has been adequately drained for a sufficient period to allow maximal recovery and an accurate assessment of renal function (Kerr, 1954). In the setting of global renal insufficiency, the decision is more complicated and patients may elect management with a chronic indwelling stent or nephrostomy tube to prevent more rapid progression to dialysis. ExperimentalModulationofPostobstructiveDiuresis Experimental data suggest the potential for pharmacologic manipulation of postobstructive diuresis. It remains unclear, however, what role pharmacologic manipulation might play in clinical practice. Clearly, further research is required to identify effective management strategies for postobstructive diuresis and to determine which patients would benefit from pharmacologic manipulation. PostobstructiveDiuresis Mechanism of Postobstructive Diuresis Postobstructive diuresis, defined as a period of significant polyuria, may develop after the relief of urinary tract obstruction. The diuresis is generally a physiologic response to the accumulated solutes and volume expansion that have occurred during obstruction. Sodium, urea, and free water are eliminated, and the diuresis subsides after homeostasis is achieved (Loo and Vaughan, 1985). Pathologic postobstructive diuresis may ensue, characterized by inappropriate renal handling of water and/or solutes.