Effect of Ginkgo biloba Extract (EGb-761) on Recovery of Erectile Dysfunction in Bilateral Cavernous Nerve Injury Rat Model

OBJECTIVE

To investigate whether the therapeutic effect of Ginkgo biloba extract (GBE) in a rat model can improve erectile dysfunction after bilateral cavernous nerve injury.

METHODS

Forty-three male Sprague-Dawley rats underwent cavernous nerve crush injury and were randomized into 4 groups, including: vehicle only, high-dose GBE, medium-dose GBE, and low-dose GBE. Eight animals underwent sham operation. Four weeks later, erectile function was assessed by cavernous nerve electrostimulation, and penile tissue was collected for histologic analysis.

RESULTS

Significant recovery of erectile function was observed in the high-dose GBE group in a dose-dependent manner as compared with the vehicle-only group (P <.001). The high-dose GBE group had a significant increase in neurofilament-1 expression (P <.001), preservation of neural nitric oxide synthase nerve fibers of the dorsal penile nerve (P <.05), and increased smooth muscle cell content (P <.001) compared with the vehicle-only group. In addition, high-dose GBE markedly augments the smooth muscle-to-collagen ratio (P <.05) and reduces the apoptotic index.

CONCLUSION

Administration of GBE increases neuron survival and preserves the neural nitric oxide synthase nerve fiber and contents of the corpus cavernosum after bilateral cavernous nerve injury. These implications indicate the beneficial effects of GBE use in the repair of the cavernous nerve and recovery of erectile function after radical prostatectomy.

Efficacy and safety of intravesical onabotulinumtoxinA injection on elderly patients with chronic central nervous system lesions and overactive bladder

PURPOSE

Intravesical injection of onabotulinumtoxinA is an effective treatment for overactive bladder (OAB). Nonetheless, the treatment outcome is unclear in OAB patients with central nervous system (CNS) lesions. This study evaluated the efficacy and safety of intravesical onabotulinumtoxinA treatment in elderly patients with chronic cerebrovascular accidents (CVAs), Parkinson's disease (PD) and dementia.

MATERIALS AND METHODS

Patients with CVA, PD, dementia, and OAB refractory to antimuscarinic therapy were consecutively enrolled in the study group. Age-matched OAB patients without CNS lesions were selected to serve as a control group. OnabotulinumtoxinA (100 U) was injected into the bladder suburothelium at 20 sites. The clinical effects, adverse events, and urodynamic parameters were assessed at baseline and 3 months post-treatment. The Kaplan-Meier method was used to compare long-term success rates between groups.

RESULTS

A total of 40 patients with OAB due to CVA (23), PD (9), dementia (8) and 160 control patients were included in this retrospetive analysis. Improvement of urgency severity scale, increased bladder capacity and increased post-void residual volume were comparable between the groups at 3 months. Patients with CNS lesions did not experience increased risks of acute urinary retention and urinary tract infection; nonetheless, patients with CVA experienced a higher rate of straining to void. Long-term success rates did not differ between the patients with and without CNS lesions.

CONCLUSION

Intravesical injection of 100 U of onabotulinumtoxinA effectively decreased urgency symptoms in elderly OAB patients with CNS lesions. The adverse events were acceptable, and long-term effects were comparable to OAB patients in general. Nonetheless, the possibility of longstanding urinary retention and chronic catheterization need careful evaluation for this very vulnerable population before choosing intravesical onabotulinumtoxinA treatment.

Progression of lower urinary tract symptoms after discontinuation of 1 medication from 2-year combined alpha-blocker and 5-alpha-reductase inhibitor therapy for benign prostatic hyperplasia in men--a randomized multicenter study

OBJECTIVE

To investigate the treatment outcome of discontinuing 1 medication from 2-year combination therapy for male benign prostatic hyperplasia/lower urinary tract symptoms.

MATERIALS AND METHODS

Patients with International Prostate Symptom Score ≥ 8, total prostatic volume (TPV) >30 mL, and maximum flow rate (Qmax) <15 mL/s were randomly assigned to the 5α-reductase inhibitor (5ARI) discontinue (DC-5ARI) or α-blocker discontinue (DC-α-blocker) group. All patients received combination therapy with dutasteride (0.5 mg QD) and doxazosin (4 mg QD) for 2 years and then discontinued either one drug for 12 months. The primary endpoint was the occurrence of resuming medication. The secondary endpoints were the net parameters changed or the need of transurethral resection of the prostate (TURP).

RESULTS

A total of 117 patients in DC-5ARI and 113 in DC-α-blocker group completed the study. The baseline TPV and Qmax were similar between groups before combination therapy. Resumption of combination therapy was significantly more in DC-5ARI than DC-α-blocker group (51.3% vs 31.0%; P = .005). The mean duration from discontinuing to resuming medication was 5.0 ± 4.4 months in DC-α-blocker and 7.8 ± 3.8 months in DC-5ARI group (P <.05). The TPV progression (29.1% vs 8.0%; P <.001) and the need for TURP (14.5% vs 7.1%; P = .043) were significantly higher in DC-5ARI than DC-α-blocker group. Patients with larger TPV (45.8 ± 18.1 mL) had significantly greater need for resuming 5ARI than smaller TPV (36.3 ± 16.9 mL; P = .007), and a lower Qmax might predict resuming α-blocker.

CONCLUSION

After a 2-year combination therapy, discontinuation of either one drug induced benign prostatic hyperplasia progression in either group. Greater risk of resuming medication and needing TURP were noted in patients who discontinued 5ARI.

5α-Reductase inhibitor is less effective in men with small prostate volume and low serum prostatic specific antigen level

BACKGROUND/PURPOSE

Large total prostate volumes (TPVs) or high serum prostate-specific antigen (PSA) levels indicate high-risk clinical progression of benign prostatic hyperplasia. This prospective study investigated the treatment outcome of combined 5α-reductase inhibitor and α-blocker in patients with and without large TPVs or high PSA levels.

METHODS

Men aged ≥ 45 years with International Prostate Symptom scores (IPSS) ≥ 8, TPV ≥ 20 mL, and maximum flow rate ≤ 15 mL/s received a combination therapy (dutasteride plus doxaben) for 2 years. Patients with baseline PSA ≥ 4 ng/mL underwent prostatic biopsy for excluding malignancy. The changes in the parameters from baseline to 24 months after combination therapy were compared in those with and without TPV ≥ 40 mL or PSA levels ≥ 1.5 ng/mL.

RESULTS

A total of 285 patients (mean age 72 ± 9 years) completed the study. Combination therapy resulted in significant continuous improvement in IPSS, quality of life index, maximum flow rate, and postvoid residual (all p < 0.0001) regardless of baseline TPV or PSA levels. However, only patients with baseline TPV ≥ 40 mL had significant improvements in IPSS-storage subscore, voided volume, reduction in TPV, transitional zone index, and PSA levels. In addition, patients with baseline TPV < 40 mL and PSA < 1.5 ng/mL had neither a reduction in TPV nor a decrease in serum PSA level.

CONCLUSION

A high TPV indicates more outlet resistance, whereas elevated serum PSA level reflects glandular proliferation. Thus, patients with TPV<40 mL and low PSA levels has less benefit from 5α-reductase inhibitor therapy. The therapeutic effect of combined treatment may arise mainly from the α-blocker in these patients.

Body mass index and buttock circumference are independent predictors of disintegration failure in extracorporeal shock wave lithotripsy for ureteral calculi

BACKGROUND/PURPOSE

Effective stone disintegration by extracorporeal shockwave lithotripsy (ESWL) may depend on patient- and stone-related factors. We investigated predictors of disintegration failure in ESWL for a solitary ureteral calculus.

METHODS

From July 2008 to May 2010, 203 patients who underwent ESWL for a solitary ureteral calculus were enrolled. Clinical and radiologic data were collected, and factors related to ESWL failure were analyzed.

RESULTS

Fifty-two patients (25.6%) showed ESWL failure, with a mean follow-up of 41 days. Forty patients (19.7%) required retreatment, including 12 who underwent repeat ESWL and 28 who underwent curative ureteroscopy. Patients with ESWL failure had significantly higher body weight, body mass index (BMI), and buttock circumference (BC) than patients for whom ESWL was successful. Univariate analysis showed that stone burden (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.06) and BC (OR, 1.06; 95% CI, 1.01-1.11) were predictors of ESWL failure, while BMI was a potential predictor with borderline significance (OR, 1.09; 95% CI, 0.99-1.20). Multivariate analysis showed that stone burden (OR, 1.04; 95% CI, 1.03-1.06) was a significant predictor for all patients. On stratifying patients according to the level of ureteral calculi, BC was found to be an independent predictor (OR, 1.35; 95% CI, 1.02-1.80) for ESWL failure for middle/lower ureteral calculi and BMI (OR, 1.47; 95% CI, 1.13-1.91) for upper ureteral calculi.

CONCLUSION

Stone burden is the main predictor of ESWL failure for all patients with ureteral calculi. BC and BMI are independent predictors for ESWL failure for middle/lower and upper ureteral calculi, respectively.

International Prostatic Symptom Score-voiding/storage subscore ratio in association with total prostatic volume and maximum flow rate is diagnostic of bladder outlet-related lower urinary tract dysfunction in men with lower urinary tract symptoms

OBJECTIVES

The aim of this study was to investigate the predictive values of the total International Prostate Symptom Score (IPSS-T) and voiding to storage subscore ratio (IPSS-V/S) in association with total prostate volume (TPV) and maximum urinary flow rate (Qmax) in the diagnosis of bladder outlet-related lower urinary tract dysfunction (LUTD) in men with lower urinary tract symptoms (LUTS).

METHODS

A total of 298 men with LUTS were enrolled. Video-urodynamic studies were used to determine the causes of LUTS. Differences in IPSS-T, IPSS-V/S ratio, TPV and Qmax between patients with bladder outlet-related LUTD and bladder-related LUTD were analyzed. The positive and negative predictive values (PPV and NPV) for bladder outlet-related LUTD were calculated using these parameters.

RESULTS

Of the 298 men, bladder outlet-related LUTD was diagnosed in 167 (56%). We found that IPSS-V/S ratio was significantly higher among those patients with bladder outlet-related LUTD than patients with bladder-related LUTD (2.28±2.25 vs. 0.90±0.88, p<0.001). TPV was similar between the two groups; however, in contrast to patients with bladder-related LUTD, patients with bladder outlet-related LUTD had higher detrusor voiding pressure, lower Qmax values, and greater postvoid residual volumes. The combination of TPV≥30 ml and Qmax≤10 ml/sec had a PPV of 68.8% and a NPV of 53.5% for bladder outlet-related LUTD. When IPSS-T≥12 or IPSS-T≥15 was considered as an additional criterion, PPV increased to 75.0% and 78.5%, respectively, and the NPV decreased to 50.9% and 50.2%, respectively. When IPSS-V/S>1 or >2 was factored into the equation instead of IPSS-T, PPV were 91.4% and 97.3%, respectively, and NPV were 54.8% and 49.8%, respectively.

CONCLUSIONS

Combination of IPSS-T with TPV and Qmax increases the PPV of bladder outlet-related LUTD. Furthermore, including IPSS-V/S>1 or >2 into the equation results in a higher PPV than IPSS-T. IPSS-V/S>1 is a stronger predictor of bladder outlet-related LUTD than IPSS-T.

Predictors of successful first-line antimuscarinic monotherapy in men with enlarged prostate and predominant storage symptoms

OBJECTIVE

To identify predictors of successful first-line antimuscarinic monotherapy for patients with enlarged prostate and predominant storage symptoms.

METHODS

Men aged ≥ 50 years with total International Prostate Symptom Score (IPSS-T) ≥ 8, total prostate volume (TPV) ≥ 20 mL, IPSS quality of life (QOL) index ≥ 2, IPSS voiding to storage (IPSS-V/S) subscore ratio ≤ 1, and post-void residual (PVR) ≤ 250 mL were recruited into a prospective open-label study. All men received tolterodine ER (4 mg) daily. Global response assessment (GRA) ≥ 1 after treatment was considered successful treatment and an indication for continued antimuscarinic monotherapy.

RESULTS

One hundred ninety-seven men aged 50-89 years (average TPV 44.4 mL) received first-line tolterodine monotherapy. Mean IPSS-T, IPSS storage (IPSS-S) subscore, and QOL improved significantly at 2, 4, and 12 weeks. Average PVR increased significantly; no patient developed acute urinary retention. One hundred thirty-six patients (69.0%) showed improvement (GRA ≥ 1) at both 2 and 4 weeks. Regression analysis showed that IPSS-S (P = .039) and maximum urine flow (Qmax, P = .033) were significant predictors of therapeutic success. Patients with smaller baseline TPV, higher IPSS-S, and higher Qmax had significantly higher treatment success rates.

CONCLUSION

First-line antimuscarinic monotherapy is safe and effective within 12 weeks in selected patients with benign prostatic hyperplasia (BPH) Higher baseline IPSS-S, higher baseline Qmax, and lower TPV were predictors of successful antimuscarinic monotherapy.

Androgens inhibit tumor necrosis factor-α-induced cell adhesion and promote tube formation of human coronary artery endothelial cells

Endothelial cells contribute to the function and integrity of the vascular wall, and a functional aberration may lead to atherogenesis. There is increasing evidence on the atheroprotective role of androgens. Therefore, we studied the effect of the androgens-testosterone and dihydrotestosterone-and estradiol on human coronary artery endothelial cell (HCAEC) function. We found by MTT assay that testosterone is not cytotoxic and enhances HCAEC proliferation. The effect of testosterone (10-50 nM), dihydrotestosterone (5-50 nM), and estradiol (0.1-0.4 nM) on the adhesion of tumor necrosis factor-α (TNF-α)-stimulated HCAECs was determined at different time points (12-96 h) by assessing their binding with human monocytic THP-1 cells. In addition, the expression of adhesion molecules, vascular cell adhesion molecule-1 (VCAM-1) and intracellular adhesion molecule-1 (ICAM-1), was determined by ELISA and Western blot analysis. Both testosterone and dihydrotestosterone attenuated cell adhesion and the expression of VCAM-1 and ICAM-1 in a dose- and time-dependent manner. Furthermore, androgen treatment for a longer duration inhibited cell migration, as demonstrated by wound-healing assay, and promoted tube formation on a Matrigel. Western blot analysis demonstrated that the expression of phosphorylated endothelial nitric oxide synthase (eNOS) increased, whereas that of inducible nitric oxide synthase (iNOS) decreased following the 96-h steroid treatment of TNF-α-stimulated HCAECs. Our findings suggest that androgens modulate endothelial cell functions by suppressing the inflammatory process and enhancing wound-healing and regenerative angiogenesis, possibly through an androgen receptor (AR)-dependent mechanism.

Change in intraoperative rectal temperature influencing erectile dysfunction following transurethral resection of the prostate

BACKGROUND/PURPOSE

In this study, we assessed the relationship between changes in intraoperative rectal temperature and erectile function in patients who have undergone transurethral resection of the prostate.

METHODS

Eighty-six potential patients with benign prostatic hyperplasia-induced lower urinary tract symptoms were studied. Patients were divided into two groups: group 1-small prostates (<40 ml) and group 2-large prostates (≥ 40 ml), as determined by transrectal ultrasound measurement. The intraoperative rectal temperature was evaluated using a transrectal thermosensor and the differences between the highest intra- and preoperative temperatures were recorded. The erectile function at baseline, at three months and at one-year postoperatively was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire.

RESULTS

Intraoperative rectal temperature differences were 0.54 ± 0.24°C for group 1 (n=45) and 0.44 ± 0.20°C for group 2 (n=41), (p=0.04). The IIEF-5 scores for group1 and group 2 were, respectively, 20.9 ± 1.6 and 20.6 ± 1.6 at baseline (p=0.32), 17.3 ± 2.9 and 18.7 ± 3.2 (p=0.037) at 3 months, 17.9 ± 2.7 and 18.7 ± 3.0 (p=0.17) at 1 year postoperatively. The deterioration of erectile function at 3 months post-operatively was observed for both groups. The percentage of retrograde ejaculation between two groups was not significantly different (p=0.33) at 1 year postoperatively.

CONCLUSION

Our study revealed that a higher intraoperative rectal temperature difference caused by transurethral resection of the prostate might affect the postoperative erectile function, particularly in patients with a small prostate.

Testosterone and sex hormone-binding globulin have significant association with metabolic syndrome in Taiwanese men

OBJECTIVES

To investigate the relationship between sex hormones and metabolic syndrome (MS) in an Asian population.

METHODS

A cross-sectional study was conducted in 237 men aged 20-88 years (mean age 52 years). Serum lipids, glucose, insulin, total testosterone (TT), estradiol (E2), sex hormone-binding globulin (SHBG), and dehydroepiandosterone sulfate (DHEA-S) were measured along with body height, weight, waist circumference, and blood pressure. Free testosterone (FT) and bioavailable testosterone (BT) were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Men with MS had lower levels of TT, BT, FT, SHBG and DHEA-S than men without MS. Multivariate analysis, after adjusting for age and smoking status, indicated that TT (OR: 0.909, 95% CI: 0.836-0.988, p = 0.003) and SHBG (OR: 0.948, 95% CI: 0.913-0.985, p = 0.006) were significantly associated with MS (R(2) = 0.314). TT was associated with waist circumference (p = 0.008) and abnormal triglycerides level (p = 0.006); SHBG was associated with blood pressure (p = 0.003), blood glucose (p = 0.043) and abnormal triglycerides (p = 0.048). A significant trend was observed between decreasing levels of TT, BT, FT, and SHBG and increasing numbers of MS components.

CONCLUSION

Results show that serum testosterone and SHBG levels inversely correlate with MS in an Asian population applying the Asian MS definition.

Significant association between serum dihydrotestosterone level and prostate volume among Taiwanese men aged 40-79 years

INTRODUCTION

We evaluated the association between serum sex hormone levels and prostate volume in Taiwanese men.

METHODS

A cross-sectional study was conducted in 505 men (aged 40-79 years, mean age 58 years). Serum total testosterone (TT), free testosterone (FT), dihydrotestosterone (DHT) and estradiol (E2) levels were measured. Total prostate volume (TPV) and transition zone volume (TZV) were measured by transrectal ultrasonography. Body mass index (BMI), DHT/TT and E2/TT were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Apart from DHT, an age-dependent change of sex hormone levels were observed. On univariate analyses, age, BMI, serum DHT level and DHT/TT ratio, as well as serum E2 level and E2/TT ratio, but not serum TT and FT levels showed a significant association with prostate volume. On multivariate analysis, however, only serum DHT level and DHT/TT ratio remained significant. Logistic regression analysis showed that the odds ratios (95% confidence interval) of the second, third, and fourth quartiles of serum DHT levels for benign prostatic hyperplasia (defined as TPV ≥ 20 ml) risk were 2.06 (1.21-3.51), 2.66(1.56-4.53) and 7.15(4.0-12.6), respectively (p < 0.001).

CONCLUSIONS

Higher serum DHT level and DHT/TT ratio were associated with larger prostate volume and higher prevalence of BPH in Taiwanese men.