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MINISTRY OF HEALTH OF UZBEKISTAN DEVELOPMENT CENTRE OF MEDICAL EDUCATION Tashkent Medical Academy "Approved" Prorector for educational proceedings of TMA Prof. Teshaev O.R. «_____»_________________ 2012 Department: UROLOGY Subject: Urology PEDAGOGICAL TECHNOLOGY SUBJECT: VARICOCELE, PEYRONIE'S DISEASE, ERECTILE DYSFUNCTION AND MALE INFERTILITY Educational-methodical course book (For teachers and students of medical institutes) Tashkent-2012 Compiled by: Mirkhamidov D.H. - TMA, Associate professor of Urology, MD, associate professor. Nuraliyev T.Yu. - Assistant of Urology department, TMA Reviewers: Gaybullaev A.A. - Head of Urology and Operative Nephrology department of TIAME, Ph.D. Fakirov A.Z. - TMA, Associate professor of Pediatric Surgery, MD, associate professor. Methodical course book approved: - by a meeting of ICC TMA, protocol № __ "___"_______ of 2012. - by the Academic Council of TMA, protocol № ___ of "___"____ 2012. 2 Pedagogic technology Topic 6 Varicocele. Peyronie's disease. Erectile dysfunction. Male infertility Amount of students: 10 Form of the practical occupation Plan of the practical occupation Purpose of educational occupation Occupation duration: 6 hours Practical class in a topic - Varicocele. Concept, an etiology and pathogenesis, classification, clinic symptoms, diagnostics and treatment. - Peyronie’s disease. Concept, an etiology and pathogenesis, classification, clinic symptoms, diagnostics and treatment. - Erectile dysfunction. Concept, an etiology and pathogenesis, classification, clinic symptoms, diagnostics and treatment. - Male infertility. Concept, an etiology and pathogenesis, classification, clinic symptoms, diagnostics and treatment. To generate general idea about: Varicocele. Peyronie's disease. Erectile dysfunction. Male infertility. To teach students to reveal the basic symptoms of varicocele. peyronie's disease, erectile dysfunction, male infertility. Acquisition and strengthening of the received theoretical knowledge. Acquisition of practical skills. Application acquisition of knowledge and skills in practice. Development of logical thinking of students. Formation structural thinking of students. Formation of own thinking of students The Pedagogical problems: Acquaint the reason and mechanism of the origin symptoms of varicocele. peyronie's disease, erectile dysfunction, male infertility. Results: The student should know an etiology, a pathogenesis, clinic, diagnostics, differential diagnostics, treatment and preventive maintenance of following diseases: varicocele. peyronie's disease, erectile dysfunction, male infertility; to palpate of male external genitals; to interpret laboratory, urodynamic, ultrasonic, X-ray, instrumental and other methods research results of this diseases; to evaluate the effectiveness of treatmen, criteria for cure; to carry out reabilitational and prophylactic medical examination Methods and technology of the education Practical education, demonstration, work in small groups – interactive game “a round table” or “spiderweb”. Facilities of the education Uniform methodical system on a topic of education, slides, banners, a distributing material, situational problems, examination of patients in department of urology, the case record. Face-to-face, collective and individual work. The educational room equip with means of training where probably to apply methods of training, “Erectile dysfunction” room Oral, written, the decision of situational problems and computer test problems, analysis of supervised patients, demonstration of Forms of the education Conditions of the education Monitoring and estimation 3 the master practical skills. Subject: Urology. Topic N6: Technological card of practical occupation “Varicocele. Peyronie's disease. Erectile dysfunction. Male infertility” Maintenance of activity: Activity of teacher Activity of the student 1 stage. Introduction (15 minutes) 1.1. Stated the name of a theme of practical employment, the Listened and wrote down. purpose, the maintenance and expect results are more its. Wrote down the name of a 1.2. Gave the short information on a theme of practical theme. employment. Acquainted students the plan of carrying out of Answered questions. employment. 1.3. Acquainted the list of the basic and additional literature. 1.4. For attraction of students to the vigorous activity asked questions. 2 stage. Basic process (150 minutes) 2.1. Showed visual materials on all questions of the plan of practical Listened, studied, wrote employment. By use of banners and razdaptochnogo of a material down, defined, asked interviewed on a theme of employment. Asked to write down high questions. lights of a theme of employment. Checked knowledge and degree of Wrote down high lights. development of a material students by use of stands in a thematic Answered questions. office. Actively participated in For definition of base knowledge interviewed. Popravalyaet and interactive games. rezumiruyet answers. Participated on kuratsiya of 2.2. In small groups spent interactive games us methods «a round patients, studied case records. table». Solved test problems. 2.3. In common with students spent kuratsiya of patients in stationary branch (poll of patients, objective survey) and acquainted a material the case record. 2.4. Spent computer test poll in an educational room. 3 stage. Final stage (15 minutes) 3.1. Did the general conclusion on a theme. Listened, active students was 3.2. Otseniyevayet of knowledge and skills of actively participat estimat. Wrote down the task students. for independent work. Wrote 3.3. Declared the questions stud on the next employment and it down a theme of the asked to be prepar independently. following employment, 3.4. Gave the task for the following employment: prepared. 1) To draw an organizer "Pyramid" on varicocele. 2) Declared a theme of the following topic «Benign prostatic hyperplasia Varicocele, Peyroni desease, erectile dysfunction and man's infertility» and it asked to be prepar for practical employment. 3) Acquainted questions on control of the knowledge. 4) Acquainted the list of the necessary literature. 4 Subject: Varicocele. Peyronie's disease. Erectile dysfunction. Male infertility Occupation venue, equipment - Department of Urology; - A set of posters, computer slides, tables; - Computer. The duration of the lesson Occupation duration: 225 min Lesson purpose: - to create general idea about varicocele, Peyronie's disease, erectile dysfunction, male infertility - to give classification, - to explain an etiology and pathogenesis - to explain clinic symptoms - to explain diagnostics and differential diagnostics - to explain treatment(conservative and operative therapy) Objectives: The student should know: - classification varicocele, Peyronie's disease, erectile dysfunction, male infertility - diagnostics - modern methods of treatment The student should be able to: Should carry out independently practical skills: - palpation of male external genitals. - identify 3 form of varicocele - interpret sperm analysis - differentiate organic and psychotogen erectile dysfunction - define indications and contraindications for appointment of sildenafil citratis. Motivation Knowing the symptoms of urological diseases is the basis for the understanding of pathological processes occurring in the body of patients. Acquired knowledge of symptoms of urological diseases will allow general practitioners to correctly diagnose urological diseases, acute conditions to identify and assign an effective treatment. 5 Interdisciplinary communication and inside subject connections Teaching this topic is based on the knowledge bases of students of biochemistry, normal and abnormal anatomy, and topographic anatomy with operative surgery, histology, normal and pathological physiology of the genitourinary system. Besides, this subject is connected with therapy, surgery, obstetrix and gynecology Obtained in the course of training, knowledge will facilitate students to understand the aetiopathogenesis and clinic of urology, to carry out a differential diagnosis, to determine the tactics and treatment of urological patients. These diseases are widely widespread among a male. These patients can address to GP and the doctor must to direct patients correctly. The content of lessons Theoretical part Varicocele. Concept. Varicocele - a varicose veins grozdevidnogo plexus that develops mainly from the left side, sometimes a varicocele occurs on both sides or only on the right side. Varicocele develops most often between the ages of 14-15 years. Cause The idiopathic varicocele occurs when the valves within the veins along the spermatic cord do not work properly. This is essentially the same process as varicose veins, which are common in the legs. This results in backflow of blood into the pampiniform plexus and causes increased pressures, ultimately leading to permanent damage to the testicular tissue due to disruption of normal supply of oxygenated blood via the testicular artery. Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient is 15–30 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and it is the main cause of male infertility. 98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein connects to the renal vein (and does so at a 90-degree angle), while the right testicular vein drains at less than 90-degrees directly into the significantly larger inferior vena cava. Isolated right sided varicoceles are rare. A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a right-sided varicocele is newly diagnosed in a patient older than 40 years of age. One non-malignant cause of a secondary varicocele is the so-called "Nutcracker syndrome", a condition in which the superior mesenteric artery compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus. The most common cause is renal cell carcinoma (a.k.a. hypernephroma) followed by retroperitoneal fibrosis or adhesions. Pathophysiology The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. This network of 6 veins coalesces into the gonadal, or testicular, vein. The right gonadal vein drains into theinferior vena cava, while the left gonadal vein drains into the left renal vein at right angle to the renal vein, which then drains into the inferior vena cava one of the main function of the plexus is to lower the temp to the testicles, during vericocele this function is lost, hence the most common complication of untreated vericocele is higher temp to testes resulting in testicular atrophy causing infertility. The small vessels of the pampiniform plexus normally range from 0.5–1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele. Recent studies have shown that the detrimental effect of varicocele on the sperm production is progressive and due to reduction in supply of oxygenated blood and nutrient material to the sperm production sites, which persistently reduces the quality and the quantity of the sperms, leading to reduction in their fertility capacity with time. Diagnosis. Symptoms and signs. Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt. Palpating a varicocele can be likened to feeling a bag of worms. When lying down, gravity may allow the drainage of the pampiniform plexus and thus make the mass not obvious. This is especially true in primary varicocele, and absence may be a sign for clinical concern. The testicle on the side of the varicocele may or may not be smaller compared to the other side. Varicocele can be reliably diagnosed with ultrasound, which will show dilatation of the vessels of the pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver, such as Valsalva's maneuver (straining, like he is trying to have a bowel movement) or standing up during the exam, both of which are designed to increase intra-abdominal venous pressure and increase the dilatation of the veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva, increasing the sensitivity of the examination. Recent studies have shown that varicocele is a bilateral disease and the diagnosis of the right side is missed by physical examination and even by ultrasonography. The examination should be performed by ultrasonography — color flow doppler performed by highly experienced sonographer or radiologist that will diagnose varicocele by demonstrating back-flow in the right and in the left spermatic veins. Tactics. In the presence of symptoms and objective signs of the disease the patient should be referred to a urologist or invite a specialist for advice. Peyronie's Disease Peyronie's Disease (also known as "Induratio penis plastica", or more recently chronic inflammation of the tunica albuginea, is aconnective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis affecting up to 10% of men. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening. A variety of treatments have been used, but none have been especially effective. A certain degree of curvature of the penis is considered normal, as many men are born with this benign condition, commonly referred to as congenital curvature. 7 The disease may cause pain; hardened, big, cord-like lesions (scar tissue known as "plaques"); or abnormal curvature of the penis when erect due to chronic inflammation of the tunica albuginea. Although the popular conception of Peyronie's Disease is that it always involves curvature of the penis, the scar tissue sometimes causes divots or indentations rather than curvature. The condition may also make sexual intercourse painful and/or difficult, though many men report satisfactory intercourse in spite of the disorder. Although it can affect men of any race and age, it is most commonly seen in Caucasian males above the age of 40, especially those of blood type A+, but has been seen in men as young as 18. The disorder is confined to the penis, although a substantial number of men with Peyronie's exhibit concurrent connective tissue disorders in the hand, and to a lesser degree, in the feet. About 30 percent of men with Peyronie's Disease develop fibrosis in other elastic tissues of the body, such as on the hand or foot, including Dupuytren's contracture of the hand. An increased incidence in genetically related males suggests a genetic component. Diagnosis A urologist can diagnose the disease and suggest treatment, although it is easily diagnosed by general practitioners or family doctors. An ultrasound can provide conclusive evidence of Peyronie's disease, ruling out congenital curvature or other disorders. Symptoms: - painful erections - curved erection - erectile dysfunction - palpation of small knot and scar tissue forms in the tunica albuginea Causes The underlying cause of Peyronie's Disease is not well understood, but is thought to be caused by trauma or injury to the penis usually through sexual activity although many patients often are unaware of any traumatic event or injury.[9] There is also an association that a class of anti-hypertensive drugs known as calcium channel blockers may be a possible cause of or exacerbate the disease, although it has not been proven. However, all beta blocker drugs list Peyronie's disease as a possible side effect. In some cases, medications may help. Surgery to treat Peyronie's disease is generally only recommended if the curvature and pain are severe enough to prevent sexual intercourse. Surgery, such as the "Nesbit operation", is considered a last resort and should only be performed by highly skilled urological surgeons knowledgeable in specialized corrective surgical techniques. MALE INFERTILITY Introduction. The European Association of Urology (EAU) consensus group on male infertility consider that male infertility is an interdisciplinary subject in its own right, with paternity in a sterile 8 partnership being the primary clinical objective. This understanding of male infertility implies cooperation with non-urologists in all aspects of infertility in daily work, and knowledge of other pertinent guidelines, issued by well-accepted authorities such as the World Health Organization (WHO), the ESHRE Andrology Special Interest Group [1] and the European Academy of Andrology. Accepting these recommendations, the EAU consensus group on male infertility is convinced that the following guidelines will help European urologists in their interdisciplinary situation to focus on their special skills and knowledge and to achieve a better understanding of the outcome for the male patient and the couple. Definition Infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year’ [WHO] Epidemiology and aetiology About 25% of couples do not achieve pregnancy within 1 year, of whom 15% seek medical treatment for infertility and less than 5% remain unwillingly childless. Infertility affects both men and women. Male causes for infertility are found in 50% of involuntarily childless couples. If there is a single factor, the fertile partner may compensate for the less fertile partner. In many couples, however, a male and a female factor coincide. Infertility usually becomes manifest if both partners are sub-fertile or have reduced fertility. Reduced male fertility can be the result of congenital and acquired urogenital abnormalities, infections of the genital tract, increased scrotal temperature (varicocele), endocrine disturbances, genetic abnormalities and immunological factors [2]. No causal factor is found in 60-75% of cases (idiopathic male infertility). These men present with no previous history associated with fertility problems and have normal findings on physical examination and endocrine laboratory testing. Semen analysis reveals a decreased number of spermatozoa (oligozoospermia), decreased motility (asthenozoospermia) and many abnormal forms on morphological examination (teratozoospermia). Usually, these abnormalities come together and are described as the oligo-astheno-teratozoospermia (OAT) syndrome. Table 1: Aetiology and distribution (%) of male infertility among 7,057 men [2] • Sexual factors 1.7 • Urogenital infection 6.6 • Congenital anomalies 2.1 • Acquired factors 2.6 • Varicocele 12.3 • Endocrine disturbances 0.6 • Immunological factors 3.1 • Other abnormalities 3.0 • Idiopathic abnormal semen (OAT syndrome) or no demonstrable cause 75.1 The unexplained forms of male infertility may be caused by several factors, such as chronic stress, endocrine disruption due to environmental pollution, reactive oxygen species and genetic abnormalities. 9 Prognostic factors The main factors influencing the prognosis in infertility are: • Duration of infertility • Primary or secondary infertility • Results of semen analysis • Age and fertility status of the female partner. When the duration of infertility exceeds four years of unprotected sexual intercourse, the conception rate per month is only 1.5%. At present, in many Western countries, women postpone their first pregnancy until they have finished their education and have started a professional career. However, the fertility of a woman of 35 years of age is only 50% of the fertility potential of a woman aged 25 years. By the age of 38 years, this has reduced to only 25%, and over the age of 40 years it is less than 5%. Female age is the most important single variable influencing outcome in assisted reproduction. Investigations Routine investigations include semen analysis and hormonal determinations. Other investigations are described according to the special situation. Semen analysis In non-obstructive azoospermia, semen analysis shows normal ejaculate volume and azoospermia after several centrifugations have been performed. A recommended method is semen centrifugation at 600 g for 10 min and thorough microscopical examination of the pellet (x600). The upper fluid is then re-centrifuged (8000 g) for an additional 10 min and examined. All samples can be stained and re-examined under the microscope. Hormonal determinations Generally, the levels of FSH are mainly correlated with the number of spermatogonia. When these cells are absent or markedly diminished, FSH values are usually elevated. When the number of spermatogonia is normal but there is complete spermatocyte or spermatid blockage, FSH values are within normal range. However, on an individual patient basis, FSH levels do not provide an accurate prediction of the status of spermatogenesis [9-11]. Preliminary data indicate a stronger correlation between low inhibin B level and spermatogenic damage. At present, the routine determination of inhibin B is not suggested. Combination obstructive/non-obstructive azoospermia. Some azoospermic patients may present with a combination of obstructive and spermatogenic pathologies and increased serum FSH levels [9]. It is therefore advisable to perform testicular biopsy in azoospermic patients with elevated FSH levels, who are known or suspected of having seminal duct obstruction, or when the size and/or consistency of one testis has decreased. Testicular biopsy Testicular biopsy is indicated in patients without evident factors (normal FSH and normal testicular volume) to differentiate between obstructive and non-obstructive azoospermia. Testicular biopsy can also be performed as part of a therapeutic process in patients with clinical evidence of nonobstructive azoospermia who decide to undergo ICSI. Spermatogenesis may be focal. In these cases, 10 one or more seminiferous tubules are involved in spermatogenesis while others are not [15-17]. About 50-60% of men with non-obstructive azoospermia have some seminiferous tubules with spermatozoa that can be used for ICSI. Most authors recommend taking several testicular samples given the possible regional differences. Other authors support the hypothesis that a single sample is demonstrative of the total histological pattern [15,20]. Many authors find a good correlation between diagnostic biopsy histology and the likelihood of finding mature sperm cells during testicular sperm retrieval and ICSI. Semen analysis Andrological examination is indicated if semen analysis shows abnormalities (Table 2). Since semen analysis still forms the basis of important decisions concerning appropriate treatment, standardization of the complete laboratory work-up is highly desirable. Ejaculate analysis has been standardized by the WHO and propagated by continuing work and publications in the WHO Laboratory Manual for Human Semen and Sperm-Cervical Mucus Interaction (4th edition) [1]. The consensus is that modern spermatology has to follow these guidelines without exclusions. Overview of standard values for semen analysis according to the 1999 WHO criteria • Volume ≥ 2.0 ml • pH 7.0-8.0 • Sperm concentration ≥ 20 million/ml • Total no. of spermatozoa ≥ 40 million/ejaculate • Motility ≥ 50% with progressive motility or 25% with rapid motility within 60 min after ejaculation • Morphology ≥ 14% of normal shape and form* • Viability > 50% of spermatozoa • Leukocytes < 1 million/ml • Immunobead test (IBT) < 50% spermatozoa with adherent particles • MAR test** < 50% spermatozoa with adherent particles Changes in a spermogram Normozoospermiya of- 40 million and more in sperm, 50% and more with progressive movement, 50% and above normal forms spermatozoa, 75% and more from number of live spermatozoa. All parameters have normal level. Oligozoospermiya — concentration of spermatozoa less than 20 million/ml or less than 40 million spermatozoa in sperm. Teratozoospermiya — less than 50% of spermatozoa with normal morphology Astenozoospermiya — less than 50% of spermatozoa have progressive advance movement Nekrozoospermiya — lack of mobile spermatozoa Oligoastenoteratozoospermiya — a combination of 3 options of deviations Polizoospermiya — quantity of spermatozoa more than 200 million/ml Azoospermiya — absence in sperm spermatozoa, but is possible existence of cages spermatogenesis. Aspermiya — absence of sperm. Gematospermiya – presence of blood at seed liquid 11 Used in this lesson, new teaching technologies: "Round Table". The method provides for joint activities and active participation in the classroom each student, the teacher works with the entire group. Embarks on a circle piece of paper with the job. Each student writes his answer sheet and passes the other. All write down their answers, followed by discussion: crossed out the wrong answers, the number of correct - evaluate the student's knowledge. To think about each answer the student is given 3 minutes. Then, the answers are discussed. At the end of the method of teacher comments on your answer is correct, its validity, the activity level of students. This methodology promotes student speech, forming the foundations of critical thinking as In this case, the student learns to assert his view, analyze responses band members - participants of the contest. Questions: 1. At what age does varicocele meet more often? 2. What is the difference idiopathic and symptomatic varicocele? 3. Tell about varicocele’s form. 4. Tell about treatment of varicocele. 5. What is the Peyronie's disease? 6. Clinic symptom’s of the Peyronie's disease Definition of childless marriage 8. The form of male infertility. 9. Characteristic of normal sperm 7. Analitical part: Situational tasks: 27 years old man has infertility last 3 years. At inspection it is revealed reduction of the sizes left testis, dilation of gonodal veins 1. Preliminary diagnose 2. What diagnostic methods must be use? 3. With what diseases it is necessary to differentiate 4. Your recommendation 5. Your treatment Answers: 1. Varicocele, left side, 3 stage 2. Orchidometry. Sperm analyze 3. Hydrocele. Orchoepididimitis. Testis cancer. 12 4. Phlebography, phlebomanomery 5. Sclerotherapy or operation of Ivanisevich Practical part The interview with the patient in the urology department, conducting physical examination 7. Forms of control knowledge, skills and abilities - Viva voice examination; - Writing; - Solution of tasks; - Tests. 8. Criteria for evaluating the current control № Achievement as a 1. Achievement as a Achievement as a percentage (%) and percentage (%) and scoring the student's knowledge level rating percentage (%) and scoring the student's knowledge level rating scoring the student's knowledge level rating 86-100 Excellent "5" Independently analyses Uses in practice Shows high activity, a creative approach to the conduct of interactive games Correctly solves the case studies with full justification for the answer Understands the subject matter Knows, says confident Has a faithful representation 2. 71-85 Uses in practice Good "4" Shows high activity during the interactive games Correctly solve situational problems, but the rationale for the answer not full enough Understands the subject matter Knows, says confident 13 Has a faithful representation 3. 4. 55-71 54 and less Knows, says not sure Satisfactorily "3" Has a partial view Unsatisfactorily "2" It does not accurately represent Do not know 9. Chronological map of classes № Stages of training Forms employment of Continued resident a of Property in the minutes. 225 1. Lead-in tutor (study subjects). 2. Discussion topics practical training, assessment of The survey, baseline knowledge of students with new explanation educational technologies (round table, case studies, slides), as well as checking the source of students' knowledge, the use of visual aids (slides, models, phantoms, ultrasound, x-ray, etc.). 3. Summing up the discussion. 15 4. Giving students tasks to perform the practical part of training. Cottage explanations and notes for the task. Self-Supervision. 30 5. The assimilation of skills a student with a teacher Medical history, 40 (Supervision thematic patient) clinical role-playing case studies 6. Analysis of the results of laboratory and work with the clinical 30 instrumental studies thematic patient, differential laboratory diagnosis, treatment plan and rehabilitation, instruments 10 an 50 prescriptions, etc. 7. Talk degree goal classes on the basis of developed Oral questioning, test, 30 theoretical knowledge and practical experience on debate, discussion of the results of the student, and with this in mind, the practical work evaluation of the group. 8. Conclusion of the teacher on this lesson. Information, Assessment of the students on a 100 point system questions for and its publication. Cottage set students the next training. class (a set of questions) 14 20 self- Questions 1. What is varicocele? 2. Tell 3 stages of varicocele. 3. Tell complications of varicocele. 4. Tell indications for operative treatment of varicocele. 5. What is the Peyronie's disease? 6. What is reason curve of penis in Peyronie's disease? 7. Modern treatment of Peyronie's disease 8. What is the erectile dysfunction 9. The form of erectile dysfunction 10. What kind of drugs may be reason of erectile dysfunction 11. What kind of type of male infertility do you know? 12. Tell normal characteristic of sperm 13. What do you known about extracorporal fertilization Recommended literature 1. Tutorial: "Urology." M. Medicine, 2004 2. Manual of Urology in 3 volumes. Ed. Acad. NA Lopatkina M, 1998. 3. Emergency urology. A. Pytel, II Zolotarev. M. Medicine, 1985. More: 1. Martin I. Resnick. Secrets of Urology. 1998. 2. Directory of GP. J. Mert. M. practice. 1998. 3. Urology and Andrology at the questions and answers. Ed. OA Tiktinsky, V. Mickle. "Peter". St. Petersburg, 1998. - 377s. 4. Urology by Donald Smith. Ed. E. Tanago and Dzh.Makanincha. Translated from English. "Practice." M. 2005. - 819s. 5. Internet: (www.uroweb.ru; www.uro.ru; www.medscape.com; www.medicalstudents.com; www.uroweb.org; www.bju.org; www.europeanurology.com). 15