A survey on the experience of 136 Italian urologists in the treatment of erectile dysfunction with PDE5 inhibitors and recommendations for the use of Avanafil in the clinical practice

Introduction: PDE5 inhibitors are the firstline treatment for erectile dysfunction. Although all these drugs share the same mechanism of action, each agent could have different characteristics in terms of selectivity, pharmacokinetics and tolerability profile. Materials and Methods: This manuscript illustrates a project, undertaken by the Italian Society of Urology in order to obtain a “snapshot” of the experience of Italian urologists with the use of PDE5 inhibitors in the clinical practice. This project included a survey, targeting a sample of 136 Italian urologists experienced in the treatment of ED, and the organization of a conference of experts who, based on the findings of the survey, the scientific literature and the clinical experience, would define some recommendations for the use of PDE5 inhibitors in clinical practice with a particular focus on Avanafil, the most recent drug in this class. Results: The following recommendations on the use of Avanafil were issued: 1) In patients who are candidates for the use of Avanafil, it is advisable to use the 200-mg dose from the first administration; 2) When used at the highest dose (200 mg), Avanafil shows a favourable tolerability profile with an efficacy similar to that of other agents; 3) The patient should be instructed to take Avanafil on an empty stomach, i.e., 30-45 minutes before or 2 hours after a meal; 4) The efficacy window of Avanafil is between 30 minutes and 6 hours after dosing, which qualifies this molecule as a new drug with an intermediate duration of action; 5) Avanafil at a dose of 50-100 mg/day may be a therapeutic option in chronic rehabilitation. Conclusions: Among PDE5 inhibitors, Avanafil is a new agent with an intermediate duration of action, characterized by high efficacy and good tolerability even at the highest dose (200 mg).

Genital Lichen Sclerosus in Male Patients: A New Treatment with Polydeoxyribonucleotide

Lichen sclerosus (LS) is an inflammatory and chronic disease that causes itching, pain, dysuria, urinary retention, dyspareunia and sexual dysfunction, in both men and women. The first line pharmacological treatment is based on the use of topical steroids, which have proved their efficacy in 60-70% of cases but with a high rate of relapses in time (50-80% of the patients of both sexes). The purpose of our non-randomised prospective pilot study was to evaluate the efficacy and tolerability of a new loco regional therapy with polydeoxyribonucleotides (PDRN) in the treatment of male genital LS. PDRN is an healing and anti-dystrophic drug with anti-inflammatory effects, through the reduction of cytokine. Twenty one male patients suffering from genital LS were recruited. All the patients were submitted to treatment using loco-regional intradermal injections with PDRN. Dermatology Life Quality Index (DLQI), International Index of Erectile Function (IIEF-5) and PGI-I questionnaires were administered at baseline and at the end of treatment in order to evaluate the results of this treatment. The statistical evaluation of the data obtained with the DLQI questionnaire showed a marked improvement of the overall conditions in terms of quality of life, with an average change of scores from 15 to 4 (p < 0.0001). PGI-I questionnaire showed that 80% of the patients treated considered their post-treatment conditions as 'improved'. There was no significant change in terms of sexual function according to the IIEF questionnaire (p = 0.189). The results obtained show the excellent tolerability and the therapeutic efficacy of PDRN, with clear improvement of the local symptoms and of the quality of life.

Androgen deprivation therapy (castration therapy) and pedophilia: What's new

Andrology is a constantly evolving discipline, embracing social problems like pedophilia and its pharmacological treatment. With regard to chemical castration, the andrologist may perform an important role as part of a team of specialists. At present, no knowledge is available regarding hormonal, chromosomal or genetic alterations involved in pedophilia. International legislation primarily aims to defend childhood, but does not provide for compulsory treatment. We reviewed international literature that, at present, only comprises a few reports on research concerning androgen deprivation. Most of these refer to the use of leuprolide acetate, rather than medroxyprogesterone and cyproterone acetate, which present a larger number of side effects. Current opinions on chemical castration for pedophilia are discordant. Some surveys confirm that therapy reduces sexual thoughts and fantasies, especially in recidivism. On the other hand, some authors report that chemical castration does not modify the pedophile's personality. In our opinion, once existing legislation has changed, andrologists could play a significant role in the selection of patients to receive androgen deprivation therapy, due in part to their knowledge about its action and side effects.

Long-term efficacy of the trans-obturator and retropubic mid-urethral slings for stress urinary incontinence: update from a randomized clinical trial

PURPOSE

To report the extended long-term results of the use of tension-free vaginal tape(TVT) and trans-obturator tape (TOT) for the treatment of female stress urinary incontinence (SUI).

METHODS

A prospective, multicentre randomized clinical trial comparing the use of TVT and TOT was used to evaluate 87 patients. The inclusion criteria were stress or mixed UI associated with urethral hyper mobility (the stress component was clinically predominant), while the exclusion criteria were previous anti-incontinence surgery and/or pelvic organ prolapse. The objective cure criteria were a negative provocative stress test and a negative 1-h pad test, with no further treatment for SUI. The subjective cure criteria were a 3-day voiding diary, quality-of-life questionnaires (UDI6-IIQ7), and patient satisfaction on a scale from 0 to 10.

RESULTS

Eighty-seven patients were evaluated (47 TOT and 40 TVT) at a median follow-up of 100 months. Subjective and objective cure rates were 59.6 and 70.2 % in the TOT group and 75 and 87.5 % in the TVT group. The mid-to-long-term trend was a decreasing continence rate in patients who underwent TOT, compared with a stable rate for TVT. The Kaplan-Meier survival curve showed that continence rate decreased for up to 25 months after surgery, with stabilization thereafter for the TVT group while continuing to drop in the TOT group, with no inter-group difference.

CONCLUSION

The patients in both groups were highly satisfied at long-term follow-up. The overall continence rate worsened for both groups within 25 months. While the results tend to stabilize in the TVT group, a further decline in the TOT was observed.

Reconstructive surgery in Peyronie’s disease: What’s new?

Surgical treatment of Peyronie’s disease (PD) is still a challenge and a gold standard approach does not exist; however the main goal is to straight penile shaft, and to restore penetrative and coital capacity. The less invasive approach aims to correct curvature without intervening directly on the fibrous plaque while the more complex “corporoplasty” applies specific geometric criteria and uses different autologous and heterologous grafts. Each approach has its pros and cons and decision-making should be tailored to the individual patient’s expectations. Other surgical options include different use of patches to cover the tunica albuginea defect, with the choice depending on the surgeon’s personal experience. Despite the wide range of autologous (buccal mucosa, vein, dermis, etc.) and heterologous grafts (bovine pericardium, swine intestinal submucosa, porcine dermis, etc.) none currently represents the real “gold standard” because the data are extremely variable and frequently not representative. Several factors seem to favor buccal mucosa grafts over inert biocompatible materials: as vital tissue, buccal mucosa tends to heal rapidly, immediately integrating with the surrounding albuginea tissue. This translates into a more rapid resumption of spontaneous erections (after 3/4 d) and sexual activity and into a reduced risk of curvature relapse and erectile dysfunction after surgery. Another advantage of the buccal mucosa graft is its low cost. In conclusion, despite the recent development of some exciting new surgical techniques we are still unable to deliver a definitive take-home message about reconstructive surgery in PD because the majority of the studies reported insufficient data. However, since it is clear that major outcomes, besides the cosmetic result, are the patient’s and partner’s satisfaction and the economic impact of each technique, we recommend they be included among the outcome assessment parameters in further studies

Can daily intake of aspirin and/or statins influence the behavior of non-muscle invasive bladder cancer? A retrospective study on a cohort of patients undergoing transurethral bladder resection

Background

This study aimed to evaluate the behavior of non-muscle-invasive bladder cancer (NMIBC) in patients submitted to transurethral bladder resection (TURB) comparing subjects in chronic therapy with aspirin, statins, or both drugs to untreated ones.

Methods

This retrospective study was conducted on 574 patients diagnosed with NMIBC who underwent TURB between March 2008 and April 2013. The study population was divided into two main groups: treated (aspirin and/or statins) and untreated. The treated group was further divided into three therapeutic subgroups: Group A (100 mg of aspirin, daily for at least two years); Group B (20 mg or more of statins, daily for at least two years); and Group C (100 mg of aspirin and 20 mg of statins together). The mean follow-up of patients was 45.06 months.

Results

No significant differences were observed among the different groups at baseline. On multivariate analysis, statin treatment, smokers and high stage disease (T1) achieved the level of independent risk factor for the occurrence of a recurrence. When patients were stratified according to the different treatment; patients treated with statins (Group B) presented an higher rate of failure (56/91 patients; 61.5%) when compared to Group A (42/98 patients; 42.9%), Group C (56/98; 57.1%) and (133/287 patients; 46.3%). This difference corresponds to a significant difference in recurrence failure free survival (p = 0.01).

Conclusions

Our results suggest that long-term treatment with aspirin in patients with NMIBC might play a role on reducing the risk of tumor recurrence. In contrast, in our investigation data from statins and combination treatment groups showed increased recurrence rates. A long-term randomized prospective study could definitively assess the possible role of this widely used drugs in NMIBC.

Micro-RNA-155-mediated control of heme oxygenase 1 (HO-1) is required for restoring adaptively tolerant CD4+ T-cell function in rodents

T cells chronically stimulated by a persistent antigen often become dysfunctional and lose effector functions and proliferative capacity. To identify the importance of micro-RNA-155 (miR-155) in this phenomenon, we analyzed mouse miR-155-deficient CD4(+) T cells in a model where the chronic exposure to a systemic antigen led to T-cell functional unresponsiveness. We found that miR-155 was required for restoring function of T cells after programmed death receptor 1 blockade. Heme oxygenase 1 (HO-1) was identified as a specific target of miR-155 and inhibition of HO-1 activity restored the expansion and tissue migration capacity of miR-155(-/-) CD4(+) T cells. Moreover, miR-155-mediated control of HO-1 expression in CD4(+) T cells was shown to sustain in vivo antigen-specific expansion and IL-2 production. Thus, our data identify HO-1 regulation as a mechanism by which miR-155 promotes T-cell-driven inflammation.

Corporoplasty using buccal mucosa graft in Peyronie disease: is it a first choice?

OBJECTIVE

To assesses the surgical and functional efficacy of corporoplasty with buccal mucosa graft, patients and partner's satisfaction, and the low cost of this operation. Biocompatible tissues are frequently used during corporoplasty, but they are expensive and often do not match the thickness and elasticity of the tunica albuginea, leading to fibrosis and scar retraction. Buccal mucosa graft is not usually emphasized in many review articles and clinical studies are limited.

METHODS

Thirty-two patients with stable disease and normal erections were included in this retrospective study. All patients underwent corporoplasty with plaque incision and buccal mucosa graft. Preoperative International Index of Erectile Function (IIEF) questionnaire and penile duplex ultrasonographies with measurement of curvature were conducted. At 6 and 12 months postoperatively, patients answered the IIEF and the Patient Global Impression of Improvement questionnaires. Patient and partner satisfaction were recorded at all subsequent visits.

RESULTS

Thirty-two patients underwent corporoplasty between 2006 and 2013, and no major complications developed in any patient. After 1 year, curvature relapse was present in 1 patient (3.5%), and 1 patient had slight erectile dysfunction. IIEF values had significantly improved 1 year after surgery (P = .031). Patient satisfaction was 85% on the Patient Global Impression of Improvement questionnaire. Twenty-five of 28 partners were satisfied (90%). Data analysis confirmed the stability of the IIEF score in 16 patients after 2 years (mean IIEF score, 21.3).

CONCLUSION

Corporoplasty with buccal mucosa graft is easy to perform and represents a good treatment choice for most forms of Peyronie disease with curvature preventing penetration and sexual intercourse.

Severe obstructive sleep apnoea syndrome and erectile dysfunction: a prospective randomised study to compare sildenafil vs. nasal continuous positive airway pressure

BACKGROUND

A high incidence of erectile dysfunction (ED) among patients with obstructive sleep apnoea syndrome (OSAS) has been reported, with a strong correlation between obstructive sleep apnoea, ED, and quality of life (QOL), and it has been estimated that 10-60% of patients with OSAS suffer from ED. In this prospective randomised controlled trial, we investigated 82 men with ED consecutively who were referred to the outpatient clinic for sleep disorders and had severe OSAS (AHI> 30 events/h) without any other comorbidities as a possible cause of ED. The aim of this study was to evaluate and compare the efficacy of sildenafil vs. continuous positive airway pressure (CPAP) in men with ED and severe OSAS.

METHODS

Eighty-two patients were randomised to two main treatment groups: group 1 patients (n = 41) were treated with 100-mg sildenafil 1 h before sexual intercourse without CPAP, and group 2 patients (n = 41 men) were treated with only nasal CPAP during night time sleep. Both groups were evaluated with the same questionnaires (International Index of Erectile Function-EF domain; Sex Encounter Profile; Erectile Dysfunction Inventory Treatment Satisfaction) 12 weeks after treatment.

RESULTS

In patients receiving sildenafil treatment, 58.2% of those who attempted sexual intercourses were successful compared to 30.4% in the CPAP group. The mean number of successful attempts per week was significantly higher in the sildenafil group compared with the CPAP group (2.9 vs. 1.7, respectively; p < 0.0001). The mean IIEF-EF domain scores were significantly higher in the sildenafil group compared with the CPAP group (p < 0.0001). The overall satisfaction rate was 68% with sildenafil treatment and 29% with CPAP treatment.

CONCLUSIONS

This study confirms that severe OSAS is strongly associated with erectile dysfunction. CPAP and sildenafil (100 mg) are safe and effective therapies for OSAS-related ED patients. In the present study sildenafil was more effective than CPAP in treating ED associated with OSAS, as indicated by a significantly higher rate of successful attempts at intercourse and higher IIEF-EF domain scores. Our study, to date, is the only that has investigated sildenafil in patients with severe OSAS.

Managing female urinary incontinence: A regional prospective analysis of cost-utility ratios (curs) and effectiveness

Introduction: To evaluate the cost-utility of incontinence treatments, particularly anticholinergic therapy, by examining costs and quality-adjusted life years. Materials and methods: A prospective cohort study of women who were consecutively referred by general practitioners (GPs) to the Urology Department because of urinary incontinence. The primary outcome was evaluation of the cost-utility of incontinence treatments (surgery, medical therapy and physiotherapy) for stress and/or urgency incontinence by examining costs and quality-adjusted life years. Results: 137 consecutive female patients (mean age 60.6 ± 11.6; range 36-81) were enrolled and stratified according to pathologies: SUI and UUI. Group A: SUI grade II-III: 43 patients who underwent mid-urethral sling (MUS); Group B: SUI grade I-II 57 patients who underwent pelvic floor muscle exercise and Group C: UUI: 37 patients who underwent antimuscarinic treatment with 5 mg solifenacin daily. The cost utility ratio (CUR) was estimated as saving more than €1200 per QALY for surgery and physiotherapy and as costing under € 100 per QALY for drug therapy. Conclusions: This study shows that appropriate diagnosis and treatment of a patient with incontinence lowers National Health Service costs and improves the benefits of treatment and quality of life.

Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach

OBJECTIVES

Premature ejaculation is the most common male sexual disorder. The aim of the study was to evaluate the possible therapeutic role of pelvic floor muscle rehabilitation in patients affected by lifelong premature ejaculation.

METHODS

We treated 40 men with lifelong premature ejaculation, reporting, a baseline intravaginal ejaculatory latency time (IELT) ≤ 1 min, with 12-week pelvic floor muscle rehabilitation.

RESULTS

At the end of the rehabilitation, mean IELTs were calculated to evaluate the effectiveness of the therapy. At the end of the treatment, 33 (82.5%) of the 40 patients gained control of their ejaculatory reflex, with a mean IELT of 146.2 s (range: 123.6-152.4 s). A total of 13 out of 33 (39%) patients were evaluated at 6 months follow up, and they maintained a significant IELT (112.6 s) compared with their initial IELT (mean 39.8 s).

CONCLUSIONS

The results obtained in our subjects treated with pelvic floor rehabilitation are promising. This therapy represents an important cost reduction compared with the standard treatment (selective serotonin reuptake inhibitors). Based on the present data, we propose pelvic floor muscle rehabilitation as a new, viable therapeutic option for the treatment of premature ejaculation.

Prulifloxacin vs fosfomycin for prophylaxis in female patients with recurrent UTIs: a non-inferiority trial

INTRODUCTION AND HYPOTHESIS

This multicentre, randomised, non-blinded, parallel group study is designed to assess the null hypothesis that a 3-month prophylactic schedule with fosfomycin is not inferior to prulifloxacin in reducing the number of urinary tract infection episodes during and after prophylaxis in female patients with recurrent urinary tract infections (rUTIs).

METHODS

One hundred and fifty-two patients with rUTIs who were candidates for prophylaxis therapy were enrolled and randomised to prulifloxacin (group 1) or fosfomycin (group 2). The prophylaxis regimen included a single dose of fosfomycin (one 3-g cachet) per week, or a single dose (600 mg) of prulifloxacin (one tablet) a week for 12 weeks. The inclusion criteria were female patients over 18 years, urine culture responsiveness to drugs at patient recruitment and history of rUTI. Exclusion criteria were pregnancy and counter-indications to this drug therapy. Patients were prospectively randomised. Check-ups were scheduled at 2 weeks, 1 month and 3 months from the beginning of the study and 3, 6, and 12 months after suspension of the therapy. The primary end-points were the reduction of the number of UTIs (negative urine culture) during and after prophylaxis.

RESULTS

Final data analysis included 67 patients in group 1 and 57 in group 2. Nine out of 76 patients (group 1) and 19 out of 76 (group 2) dropped out. UTI episodes were significantly reduced in number compared with before prophylaxis (p < 0.0001) at all study end-points in both groups. No significant differences were found in disease-free duration, as achieved by the two therapy groups (log-rank test; p = 0.41), in the reduction of UTI episodes during and after prophylaxis, in the adverse effects or improved quality of life.

CONCLUSIONS

Both drugs provided adequate prophylaxis in patients with rUTIs, with no difference in efficacy.

Evaluation of electrospun bioresorbable scaffolds for tissue-engineered urinary bladder augmentation

Tissue engineering represents a potential and valuable approach for the treatment of urologic pathologies. Bioresorbable polymeric scaffolds can be regarded as effective platforms to surgically treat bladder diseases and subsequently guide the formation of novel tissue after implantation. To this aim, the evaluation of electrospun scaffolds made up of poly(ε-caprolactone) blended with poly(3-hydroxybutyrate-co-3-hydroxyvalerate) is presented here. Firstly, the microstructure and the viscoelastic/mechanical properties of the electrospun fabrics were investigated. Then, the in vivo response was assessed by performing a urinary bladder augmentation using female Wistar rats as an animal model. 15 days after the surgical procedure, the scaffolds were covered by regenerative urothelium up to 50%, which increased to 50-100% after 30 days. These encouraging results, collected in the 90-day follow-up, clearly showed the potential applications of tissue engineering in the urologic field. A longer in vivo evaluation is currently underway.

Glans reconstruction with the use of an inverted urethral flap after distal penile amputation for carcinoma

Restoration of adequate cosmesis and preservation of sexual and urinary function are the main goals of penile reconstructive surgery following amputation for carcinoma. Split thickness skin grafts and oral mucosa grafts have been widely used for the creation of a pseudoglans with excellent cosmetic and functional results. The main drawbacks associated with the use of grafts are donor site morbidity, the lack of engorgement of the pseudoglans and the risk of poor graft take, which may lead to contracture and poor cosmetic results. In the present series the long term cosmetic and functional outcomes of glans reconstruction with an inverted distal urethral flap are described.