Surgical Treatment of Female Stress Urinary Incontinence with a Trans-Obturator-Tape (T.O.T.®) Uratape®: Short Term Results of a Prospective Multicentric Study

OBJECTIVE

The aim of the study was to assess the efficacy and safety of a new minimally invasive surgical procedure using the Trans-Obturator-Tape Uratape to treat female stress urinary incontinence.

PATIENTS AND METHODS

183 women with stress urinary incontinence (SUI) associated with urethral hypermobility, underwent the T.O.T. procedure (October 2001 to March 2003). 26 patients were previously operated for incontinence. 26 patients were operated at the same time for their genital prolapse. Mean age was 56 years (29-87). 50/183 patients were having mixed incontinence. A non-elastic, polypropylene tape (UraTape, Mentor-Porgès) with a silicon coated central part was placed under the mid-urethra. The surgical placement technique utilises a trans-obturator percutaneous approach. All patients underwent post-operative clinical examination, cough-stress test (full bladder), uroflowmetry, and post-voiding residual assessment.

RESULTS

Mean follow-up was 7 months (1-21). At 1 year follow-up 80.5% of the patients were completely cured and 7.5% were improved. The overall peri-operative complication rate was 2.2% with no vascular, nerve or bowel injury. 6 patients (3.3%) had post-operative urinary retention.

CONCLUSION

The present multicentric study confirms the results obtained by the instigator of the technique, E. Delorme, and allows us to consider T.O.T. as an effective and safe technique for the treatment of female stress urinary incontinence, alone or in combination with prolapse repair.

[Benign prostatic hyperplasia (BPH): prevalence in general practice and practical approach of French general practitioners. Results of a study based on 17,953 patients]

OBJECTIVES

To determine the elements taken into account by French general practitioners to establish the initial diagnosis of benign prostatic hyperplasia (BPH) and to estimate the prevalence of BPH.

MATERIAL AND METHODS

1,698 doctors answered a questionnaire on their medical practice, and kept a register for two consecutive weeks comprising all men between the ages of 55 and 70 years seen in their practice. Men with no known BPH completed the IPSS (International Prostate Symptoms Score) questionnaire. The doctors described the management of the first three patients with an IPSS score > 8.

RESULTS

The prevalence of BPH in the population of 33,077 men between the ages of 55 and 70 years consulting their general practitioner was 57.5%: 40.8% of patients had known BPH at the time of the visit and 29.9% of patients without known BPH reported voiding disorders (IPSS > or = 8). For the diagnosis of BPH, clinical interview was not systematically followed by digital rectal examination and urinalysis was rarely performed. Laboratory tests and ultrasound were the complementary investigations most frequently performed.

CONCLUSION

BPH is a frequent disease whose prevalence is underestimated. This diagnosis should be considered more frequently when patients over the age of 55 consult their general practitioner.

[Solitary fibrous tumours of the kidney]

Solitary fibrous tumours (SFT) are mesenchymal tumours that usually arise from the pleura. Renal SFT are exceptional (9 cases reported in the literature). The authors report a new case discovered during assessment of HT and treated by radical right nephrectomy. The histological appearance is characteristic: a tumour with a fibrous centre, composed of a monomorphic proliferation of spindle cells, with positive CD 34, CD 99, and bcl 2 labelling. The prognosis after complete resection is generally favourable.

[Calculous renal failure and pregnancy]

Obstructive renal failure is a rare but serious complication of pregnancy. Although most cases are due to extrinsic compression, renal tract obstruction can also be due to intraluminal precipitation of sulfadiazine prescribed for maternofoetal toxoplasmosis. The diagnosis is suggested by clinical history, ultrasound (radiolucent stones situated anywhere in the renal tract) and especially analysis of the urine pellet (wheat sheaf formation of yellowish crystals). Urinary drainage by double J stent or percutaneous nephrotomy is indicated in the absence of clinical improvement in response to symptomatic treatment and adequate alkaline rehydration. The risk of sulfadiazine crystallization must be systematically prevented by a sufficient water intake and urinary alkalinization right from the start of treatment.

Prostatic tissual distribution of alfuzosin in patients with benign prostatic hyperplasia following repeated oral administration

OBJECTIVES

The blood and prostatic concentrations of alfuzosin were determined in patients with benign prostatic hyperplasia (BPH).

METHODS

12 patients scheduled for BPH surgery were treated with alfuzosin 5 mg twice daily prior to surgery in an open trial. Seven doses were given over a 4-day period. Blood samples were drawn before the first and the last intake (day 3). On day 4 (surgery day), a blood and prostate tissue sample were taken simultaneously 12 hours after the last drug intake.

RESULTS

Mean trough blood levels were 6.0+/-4.6 ng/ml and 5.8+/-3.7 ng/ml on day 3 and day 4, respectively, indicating a stable alfuzosin concentration. The mean prostate concentration on day 4 was 12.3+/-5.6 ng/g. Alfuzosin prostate and blood concentrations at 12 hours post dosing on day 4 were significantly correlated (r=0.804, p=0.0016); the prostate-blood ratio was 2.4+/-0.7.

CONCLUSIONS

Oral administration of alfuzosin leads to a high diffusion of the drug into the prostate of BPH patients.

Quality of Sexual Life Questionnaire (QVS): a reliable, sensitive and reproducible instrument to assess quality of life in subjects with erectile dysfunction

A French quality of life questionnaire specific to erectile dysfunction (ED), 'QVS' for 'Questionnaire de Vie Sexuelle', has been developed. This paper describes its validation: item reduction and reliability (internal consistency and reproducibility), construct validity and criterion validity (clinical, discriminant and concurrent). The initial 40-item questionnaire was administered once to 316 ED and 117 control subjects, and twice (D0 and D7) to 104 ED and 29 control subjects. Item reduction gave a 27-item questionnaire with three scales (Sexual Life, Skills and Psychosocial Well-being) and four scores (one score for each scale and a Global Index). Psychometric analyses demonstrated the reliability and the validity of the QVS. The questionnaire was able to discriminate patients according to the presence or severity of ED. The Skills scale was the least sensitive. Analysis of responsiveness to change over time still needs to be addressed to consider the questionnaire as a fully validated instrument.

Multidimensional nature of apomorphine SL (Ixense) therapy

The aetiology of erectile dysfunction (ED) is multifactorial consisting of psychogenic and organic factors that must be considered in a multidisciplinary manner in order to treat effectively the disorder. New central initiators of erection such as apomorphine SL (Ixense) provide a pharmacologically multidimensional approach to the treatment of ED. When used in conjunction with a psychosexual counselling strategy designed to move patients at high risk of failure to high responder groups, it can provide an effective and safe pharmacological therapy for ED.

[Prostate cancer and acute disseminated intravascular coagulation. Therapeutic management based on three cases]

Acute DIC is a rare, but life-threatening complication of metastatic prostate cancer. The authors discuss the treatment modalities in the light of three cases and a review of the recent literature. The key to treatment of DIC is treatment anti of the tumour. Androgen blockade is indicated in hormone-dependent tumours. This treatment can sometimes be completed by low-dose oral anticoagulants. Chemotherapy is the treatment of choice of acute DIC during the hormone resistance phase.

[Erectile dysfunction: knowledge, wishes and attitudes. Results of a French study of 5.099 men aged 17 to 70]

OBJECTIVE

Although erectile dysfunction is today considered as a frequent disease, few patients actually seek for medical advice and take medication. The purpose of the study was therefore to analyse use and behaviour of men with erectile dysfunction.

MATERIAL AND METHODS

The study, performed between the 12th April and the 21st May 2002, involved 10,000 men 18 to 70 years old and consisted in self-administered questionnaires including 55 items (5099 questionnaires were eligible for analyse).

RESULTS

Despite a high prevalence of erectile dysfunction (25%), increased with age (44% in the men aged 45 and over), the study showed that only 22.2% of men with erectile dysfunction take medical advice with 36.9% of them take medication. Men generally think erectile dysfunction is not very common in comparison to other diseases, and correlate it with stress and tiredness. However, men with erectile dysfunction (particularly those over 45) mention diseases as hypertension, prostatic and cardiovascular diseases. 94% of men would take medical advice if their problems should repeat. However, obstacles to consultation still remain for men presenting with erectile dysfunction and especially the difficulty to talk about sexuality with their physician (for 63% of men).

CONCLUSION

This study confirms the high prevalence of erectile dysfunction and that few men concerned actually seek for professional assistance and take medication. Moreover, it demonstrates the major contribution of the physician in opening the dialogue on sexual problems because men are frequently embarassed or afraid to discuss this sensitive topic.

Early experience with sildenafil for the treatment of erectile dysfunction in renal transplant recipients

BACKGROUND

Erectile dysfunction (ED) is common in men with renal failure, but is not always alleviated following kidney transplant. The objective of the present study was to assess the feasibility in renal transplant patients of sildenafil citrate treatment, an agent with proven efficacy in the management of ED.

METHODS

This was a phase IV, open, multicentre, 3 month, dose-escalation study. All patients meeting the inclusion criteria were prescribed a dose of 50 mg sildenafil at the first visit. Thereafter the dose could be increased to 100 mg or reduced to 25 mg based on efficacy or tolerability. The primary efficacy parameter assessed the ability of patients to achieve erections sufficient for intercourse and to maintain erections after penetration. Secondary endpoints assessed patient satisfaction with sildenafil and the effect of sildenafil on their quality of life. Patients were carefully monitored throughout the study for adverse events, interactions with immunosuppressive therapy and effect on graft function.

RESULTS

The study included 50 patients in the intent-to-treat population. Sildenafil significantly improved patient's erection ability and the frequency of their erection maintenance. Analysis of the secondary efficacy parameters revealed that 66% of patients believed treatment had improved their erections. Patients reported improvements in their sexual life and partner relationships and a high level of satisfaction with treatment. There were no interactions between sildenafil and the immunosuppressive drugs and there was no significant adverse effect of sildenafil on graft function.

CONCLUSIONS

Sildenafil is an effective and well-tolerated agent for the treatment of ED in renal transplant recipients.

Evaluation of mathematical models describing drug release from estradiol transdermal systems

The in vitro release profiles of 13 patches of estradiol (from five marketed products) were determined by the paddle-over-disk method. The transdermal systems were membrane-controlled type or matrix diffusion-controlled type. The estradiol content of test aliquots of the dissolution medium was determined by HPLC. To analyze the release mechanism, several release models were tested such as zero order, first order, Higuchi, Weibull, Korsmeyer-Peppas, and Makoid-Banakar. The release profiles showed that the drug was released at a constant rate for three patches. The drug-release rate from the other 10 patches was not constant, and diminished with the square-root of time (Higuchi model).

[Efficacy of suburethral TVT in cases of stress urinary incontinence associated with severe sphincter insufficiency. Report of 22 cases]

INTRODUCTION

The TVT system has revolutionized the management of female stress urinary incontinence (SUI). Less favourable results have been observed in patients with urinary incontinence associated with a low maximum urethral closing pressure (MUCP). The objective of this prospective study was to evaluate the efficacy of TVT in this situation.

MATERIAL AND METHODS

From October 1999 to June 2001, 22 patients between the ages of 53 and 84 years (median: 66.7 years) were operated for SUI with an MUCP < 25 cm H2O (mean: 17.6 cm H2O, range: 6 to 22 cm H2O) present for more than 8 months (range: 8 to 48 months). Three patients also had associated urgency. The Ulmstem manoeuvre was positive in every case and the Bonney manoeuvre was positive in 19 patients. Insertion of TVT was associated with sacral colpopexy in two patients. Success of treatment was defined by complete absence of incontinence and voiding disorders after the operation.

RESULTS

One patient was lost to follow-up. The median follow-up was 7.5 months (range: 3 to 27 months). The mean duration of bladder catheterization was 1.3 days (range: 1 to 5 days). Fifteen patients were completely cured by TVT (71.4%). In these cases, uroflowmetry and post-voiding volume were not affected by the operation. Treatment was ineffective in 6 patients (4 cases of uncontrolled leaks, one case of de novo urge incontinence, one case of postoperative dysuria with a post-voiding residue of 120 ml).

CONCLUSION

The TVT system appears to be an effective method for the treatment of most patients with SUI associated with severe manometric sphincter incompetence. However, these favourable results need to be confirmed by a longer follow-up.

[Non-typhus Salmonella urinary tract infections]

Non-typhus Salmonella urinary tract infections are rare. Based on a clinical case and a review of the recent literature, the authors analyse the diagnostic setting and discuss the necessary investigations and treatment modalities. Non-typhus Salmonella urinary tract infections generally occur in a predisposed clinical setting, such as immunodepression or acquired (stones, schistosomiasis) or congenital uropathy. As in the present case, it can also be the first clinical expression of AIDS, which must be systematically investigated. Antibiotic therapy must be continued for at least two weeks and consists of a third generation cephalosporin or fluoroquinolones, but the prognosis is directly related to the underlying clinical condition.

Simple method for determination of paraquat in plasma and serum of human patients by high-performance liquid chromatography

A simple and fast HPLC system is presented for quantifying paraquat in human plasma and serum using 1,1'-diethyl-4,4'-bipyridyldiylium (diethyl paraquat) as an internal standard. An octadecyl-silica column is used with an eluent of 10% acetonitrile (v/v) containing sodium 1-octanesulphonic acid (3.0 mM) and a diethylamine-orthophosphoric acid buffer (pH 3). Unlike with other techniques, sample treatment requires only the precipitation of protein contents by 6% perchloric acid (v/v) in methanol. The method has a limit of detection of 0.1 microg/ml and is linear up to 10 microg/ml. The serum of four patients and the plasma of one patient with paraquat intoxication's were analysed and positive identification and quantification was readily achieved. One of those patients survived, partially given the rapid disclosure of his levels of paraquat. Therefore, this method is suitable for quantification of paraquat in toxicological samples. It may be used as a prognostic tool in critical case detoxification and to quickly identify potentially salvageable patients for enrollment in new hemofiltration studies.

A shared care approach to the management of erectile dysfunction in the community

Erectile dysfunction (ED) affects men of all ages and results in considerable distress and impact on quality of life for those who suffer from it. As ED is associated with a wide variety of under-lying conditions and cardiovascular co-morbidities, there is a requirement for diversity of treatment options and several factors must be considered to customise and optimise therapy. In the ideal holistic approach to management of the ED patient, both primary care and specialist physicians have an important role to play. This article reports on a sequential approach for the diagnosis and treatment of ED, with an emphasis on 'shared care'. The deliberations are based on a pan-European inter-disciplinary group that met at the Lygon Arms, UK on 22 February 2002.

Identification, molecular cloning and functional characterization of NKp46 and NKp30 natural cytotoxicity receptors in Macaca fascicularis NK cells

Natural killer (NK) cell recognition and function in humans is regulated by multiple cell surface receptors. The "on" signal leading to NK cell triggering is primarily mediated by natural cytotoxicity receptors (NCR). Analysis of NK cells in primate animal models is of particular relevance because NK cells may play an essential role in host defenses against infections. We analyzed Macaca fascicularis PBMC and in vitro-derived NK cell populations and clones by cytofluorometry, using a wide panel of mAb, and by cytolytic activity assays. In addition, RT-PCR strategy and transient transfections were used to isolate M. fascicularis NCR. NCR-specific mAb reactivity (anti-NKp46 and anti-NKp30) was present on M. fascicularis PBMC and on NK cell cultures. Macaque NCR were functional in both redirected killing and in mAb-mediated masking assays. Cloning of macNKp46 and macNKp30 NCR homologous genes showed a high sequence similarity (86 % and 88 %, respectively) with their human counterparts. Attempts at identifying NKp44 surface reactivity and at cloning the macaque homologue were unsuccessful. NKp46 and NKp30 NCRs, but not NKp44, are highly conserved in M. fascicularis NK cells. This suggests the possibility of a staged appearance of the NCR during phylogenesis and provides a useful tool for the study of natural immunity correlates of protection in primate SIV/SHIV infection models.

Human prostatic cell line PNT1A, a useful tool for studying androgen receptor transcriptional activity and its differential subnuclear localization in the presence of androgens and antiandrogens

The human immortalized prostatic cell line PNT1A has been proved to be a good model for analysis of cellular processes such as the prostatic epithelium proliferation in response to androgens and growth factors. Here we used this cell line for studying the transcriptional activity and trafficking of the androgen receptor (AR) by analyzing several actions of antiandrogens. Transient transfection experiments with PNT1A cells were performed with wild type human AR and an androgen-responsive gene reporter. We demonstrated that the transcription of reporter gene could be triggered by natural androgens (testosterone and dihydrotestosterone) in PNT1A cells as well as in the prostatic carcinoma cell line DU-145. With competitive experiments in the two cell lines, we observed no difference between the antagonistic capacity of cyproterone acetate (CPA) and hydroxyflutamide at 10(-7) M. At this concentration, bicalutamide antagonist activity was lower. In parallel, we compared the subcellular localization of the modified green fluorescent protein (EGFP)-AR in COS-7, PNT1A and DU-145 cell lines under fluorescence microscopy: we found different distributions between nucleus and cytoplasm, depending on the cell line and the culture medium. Androgen induced cluster formation within the nucleus of the PNT1A and DU-145 cells. However, the cytonuclear trafficking of androgen bound EGFP-AR in the same living cell and nuclear foci were easier to examine in the PNT1A cells. The antiandrogen capacity of bicalutamide was manifested by a slower androgen-dependent nuclear transfer of EGFP-AR and a homogeneous nuclear localization. A delayed advent of nuclear clusters was observed in presence of CPA. We conclude that the PNT1A cell line is a better model than the DU-145 cell line to analyze the trafficking of AR and the association of AR on the nuclear matrix, as well as to observe the action of antiandrogens on these critical steps in prostate cells.

Divisability of diltiazem matrix sustained-release tablets

The objective of this work was to study the possibility of a solid sustained-release dosage form, like a tablet, be divided without changing its release characteristics. Diltiazem hydrochloride Sustained-Release (SR) tablets with a standard groove on one face, were tested and the following dissolution parameters were evaluated: t10%, t25%, and t50% dissolution time, and dissolution efficiency at t120, and at t360. To analyze the release mechanism, several release models were tested such as Higuchi, zero order, first order, Baker-Lonsdale, Hixson-Crowell, Weibull, and Korsmeyer-Peppas. The similarities between two in vitro dissolution profiles were assessed by the difference factor (f1), the similarity factor (f2) and the Rescigno index (xi(i)). The in vitro release kinetics of diltiazem hydrochloride tablets were evaluated using USP apparatus 4. Using a one-way ANOVA (a = 0.05), statistically significant differences were found for t10%, t25%, and t50% dissolution times with a constant and with a variable pH dissolution fluid. The variation coefficient for the divisibility assay (Portuguese Pharmacopoeia VI) was lower than the limit value of 10%. The diltiazem release rate from this pharmaceutical system was not constant, and diminished with the square root of time (Higuchi model) showing that the phenomenon controlling drug release was the diffusion occurring inside the swelled polymeric matrix. Diltiazem release rate was a function of the area in direct contact with the dissolution fluid and not of the pharmaceutical matrix volume. The results obtained permit us to conclude that the division, in this case, affects the drug release characteristics.