Preference for and adherence to oral phosphodiesterase-5 inhibitors in the treatment of erectile dysfunction

Sildenafil was the first orally administered phosphodiesterase-5 inhibitor approved for the treatment of erectile dysfunction. Its successful introduction into clinical practice was soon followed by the launch of two other phosphodiesterase-5 inhibitors: vardenafil and tadalafil. The plethora of choices made the question "which PDE-5 inhibitor?" relevant for patients and clinicians. Despite the lack of head-to-head comparative trials it is widely accepted that there are no significant differences in their safety and efficacy. Therefore a number of studies set out to determine which of the inhibitors patients would prefer and reasons for that preference. The majority of published trials show a preference for tadalafil. Others have argued that preference trials have several methodological flaws and data favoring tadalafil with its long duration of action do not reflect real-life prescription filling and sales figures. But even if one of the available PDE-5 inhibitors is chosen to treat erectile dysfunction what is the long-term compliance? A significant percentage of men initiating treatment switch between inhibitors or discontinue therapy. Reasons for that seem to often be unrelated to efficacy or tolerability and include emotional and social factors determining couples' and individuals' sexual and treatment seeking behavior.

Application of paclitaxel-eluting metal stents in renal artery of pig model

BACKGROUND AND PURPOSE

Recent reports concerning coronary, carotid, and femoral vasculature have proposed the use of drug-eluting metal stents (MS) to improve clinical and angiographic outcomes. Based on these reports, we used paclitaxel-eluting MS within an animal renal artery lumen and compared the results with those using a bare-metal stent.

MATERIALS AND METHODS

The experimental model in this study was the female pig renal artery. Ten pigs with weights ranging from 25 to 30 kg were used. Twenty stents were placed, two in each animal. The MS placement was randomly performed in either the right or left renal artery of each animal. In 10 arteries, a 3.5 x 18 mm R-stent (group A) was placed; in the remaining 10 arteries, a 3 x 32 mm paclitaxel-eluting coronary stent (T-stent, group B) was inserted. Patency was estimated with the use of digital subtraction angiography, CT angiography, and virtual endoscopy at 24 hours and 1 month poststent placement.

RESULTS

The positioning of the MS was successful in all cases. The initial angiographic result was maintained 24 hours after the intervention. No stent migration was seen, except for one paclitaxel stent that was acutely occluded. The one-month patency rate, as demonstrated by angiography, CT angiography, and virtual endoscopy, was 70% (8 arteries) in group A and 90% (9 arteries) in group B. The thickness of the endothelium and of the muscular coat was statistically significantly less in group B compared with group A (P = 0.0352 and P = 0.0046, respectively).

CONCLUSION

These preliminary experimental study results suggest that the paclitaxel-eluting MS is more efficient than the bare-metal stent when used within the pig renal artery. Further experimental and clinical studies are necessary to validate our preliminary encouraging results.

The effectiveness of a scientific symposium to change urologists’ attitude towards treatment of LUTS/BPH

PURPOSE

The use of interactive voting systems in continuing education helps to evaluate the alteration in the audience's views after a presentation. This study was designed to evaluate whether urologists' attitude towards management of benign prostate hyperplasia can be changed, and to estimate objectively the achievement of educational goals by using an interactive voting system.

METHODS

The audience attitude was repetitively estimated by responding to questions using wireless keypads. Educational goal achievement was calculated by adding the percentage of those changing their opinion from "wrong" to "right" and that of those insisting on their initial "right" opinion.

RESULTS

Giving a "wrong" answer and the probability of opinion change were independent of age and board certification. Being initially on the "wrong" side resulted in a greater probability of opinion change. The educational goals were achieved in 20.8-86.2% of cases.

CONCLUSION

Satellite symposia are helpful learning environments. The use of an interactive voting system may help to evaluate objectively the achievement of educational goals.

Does CPAP therapy improve erectile dysfunction in patients with obstructive sleep apnea syndrome?

OBJECTIVE

The aim of the study was to examine the quality of the characteristics of Erectile Dysfunction (ED) in men with Obstructive Sleep Apnea Syndrome (OSAS) and to investigate whether there is an improvement with the use of continuous positive airway pressure (CPAP) therapy.

MATERIALS AND METHODS

Fifteen men with OSAS and sexual dysfunction have been investigated in this follow-up study. The treatment period was for 12 weeks and the therapeutic CPAP levels were determined during the full night of the therapeutic titration.

RESULTS

In our 15 treated patients, the International Index Erectile Function (IIEF) total and all domain scores had increased after the CPAP treatment compared to the baseline, except for that of sexual desire domain.

CONCLUSIONS

CPAP therapy can improve the sexual function in ED patients with OSAS.

Non-steroidal anti-inflammatory drugs in the treatment of genitourinary malignancies: focus on clinical data

The antitumour activity of NSAIDs in preclinical trials has lead to their evaluation in the management of various malignancies in humans. Evidence regarding their use in the treatment of genitourinary tumours is reviewed here, focusing primarily on clinical data. The majority of available evidence comes from meeting abstracts and only a few published manuscripts were detected. The efficacy of selective COX-2 inhibitors, a subcategory of anti-inflammatory drugs, is promising in prostate cancer, in either biochemical recurrence after initial treatment or advanced disease. This does not seem to be the case for renal tumours in which efficacy in the advanced disease setting is not satisfactory. Despite the well-documented rationale for the application of NSAIDs in bladder cancer management, clinical evidence is not available. More studies are needed to assess the efficacy of anti-inflammatory agents in bladder cancer treatment and further clarify their therapeutic benefit in patients with prostate cancer, in which initial results are encouraging.

Safety of sildenafil in the treatment of erectile dysfunction in patients with obstructive sleep apnoea

Obstructive sleep apnoea, characterised by repetitive occlusion of the upper airway during sleep, is recognised as a risk or even an aetiological factor for erectile dysfunction. On the other hand, sleep-disordered breathing has been reported by many patients with erectile dysfunction. Sildenafil, a very commonly used erectile dysfunction treatment, could, at least theoretically, exacerbate sleep apnoea by interfering with pharyngeal muscle tone, nasal patency and gas exchange in the lung. A recent safety study suggested a detrimental effect of oral sildenafil on respiratory events in patients with obstructive sleep apnoea. Given the inconclusiveness of evidence on pathophysiological mechanisms and the paucity of relevant clinical data the safety risk of sildenafil administration in patients with obstructive sleep apnoea should be questioned. More clinical trials are needed to clarify this issue.

Digital subtraction angiography and computer assisted image analysis for the evaluation of the antiangiogenetic effect of ionizing radiation on tumor angiogenesis

PURPOSE

The aim of the present study was to evaluate and quantify the antiangiogenetic effect of ionizing radiation on tumor angiogenesis using digital subtraction angiography (DSA) in conjunction with computer assisted image analysis (CAIA).

METHODS

Walker 256 carcinosarcoma was inoculated in both glutei of 12 Wistar rats. When the tumors reached a diameter of 1.5 cm, local irradiation of the right gluteus was performed. The left gluteus of each animal served as a control. After 24 hours of irradiation, angiography was performed, and images where digitized and subsequently processed. The effect of irradiation was observed both in big and small vessels (smaller or greater than 200 microm).

RESULTS

Irradiated areas of both small and big vessels showed a statistically significant reduction in both total vessel area and length. Small vessels showed a greater trend toward suppression by irradiation (not statistically significant).

CONCLUSION

Irradiation had a deleterious effect in both macro- and micro-blood supply of a tumor. The use of CAIA enhanced the efficacy of DSA and enabled the in vivo identification of the effect of irradiation on various caliber vessels as well as the ratios of total length and total area of small and big vessels.

Application of Self-Expandable Metal Stents for Ureteroileal Anastomotic Strictures: Long-Term Results

PURPOSE

We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents.

MATERIALS AND METHODS

A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture.

RESULTS

The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation.

CONCLUSIONS

Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.

Endothelial dysfunction, erectile dysfunction and phosphodiesterase 5 inhibitors. An update of the current data and future perspectives

Endothelial dysfunction is a pathological entity that multiply affects the health status. Erectile dysfunction is being recognized as a condition that is strongly interrelated with endothelial dysfunction, being a vascular event itself. Oral pharmacotherapy for erectile dysfunction has provided us with a new armamentarium on this condition. Phosphodiesterase 5 inhibitors have been investigated and proved useful in clinical practice for erectile dysfunction but in addition to this, the results seem promising of a beneficial effect on endothelial dysfunction, as well.

Sildenafil versus continuous positive airway pressure for erectile dysfunction in men with obstructive sleep apnea: a comparative study of their efficacy and safety and the patient's satisfaction with treatment

AIM

To assess the efficacy of sildenafil and continuous positive airway pressure (CPAP) in the treatment of concurrent erectile dysfunction (ED) with obstructive sleep apnea (OSA), and to gauge the level of treatment satisfaction in patients and their partners.

METHODS

Forty men were treated for 12 weeks with sildenafil 100 mg (20 men) or CPAP during nighttime sleep (20 men). Treatment efficacy was assessed by the rate of successful intercourse attempts, and satisfaction with treatment was assessed by patients' and partners' answers to question 1 of the Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

Under sildenafil, 128 of 249 (51.4%) intercourse attempts were successful; under CPAP, 51 of 193 (26.9%) attempts were successful ((c)P < 0.001). Erectile function was improved in both groups. After sildenafil and CPAP treatment, the mean International Index for Erectile Function domain scores were 14.3 and 10.8, respectively ((b)P = 0.025), compared to 7.8 and 7 at baseline, respectively. CPAP and sildenafil were well tolerated. Sporadic episodes of nasal dryness under CPAP and transient headache and flushing under sildenafil were not significant. Fifty percent of patients treated with sildenafil and 25% with CPAP were satisfied with the treatment, and their partners were equally satisfied. The satisfaction scores for both patients and partners under sildenafil were superior to those under CPAP ((c)P < 0.002).

CONCLUSION

Both sildenafil 100 mg and CPAP, used separately, had positive therapeutic impact but sildenafil was superior. Patients and their partners were more satisfied with sildenafil for the treatment of ED. However, because of the high proportion of dissatisfied men and partners, new therapeutic agents or a combination of the two methods must be studied further.

Doxazosin for the Management of Distal-Ureteral Stones

PURPOSE

To evaluate the efficacy of doxazosin in inducing spontaneous passage of stones in the distal ureter and to compare its efficacy according to the size of the stone.

PATIENTS AND METHODS

Seventy-three patients with a mean age of 46.38 +/- 10.17 years who presented with a distal-ureteral stone were divided into four groups according to stone size and drug treatment: <5 mm without doxazosin (group A; n=15); 5-10 mm (group B; n=16); <5 mm with doxazosin 4 mg/day for 4 weeks (group C; n=20); and 5-10 mm with doxazosin 4 mg/day for 4 weeks (group D; n=22). Groups A and B served as controls for groups C and D, respectively.

RESULTS

Spontaneous stone passage was documented in 9 patients (60%) in group A v 17 (85%) in group C (P=0.047) and 7 (43.75%) in group B v 16 (72.73%) in group D (P=0.036). The average expulsion time was 8.78 +/- 1.09 days in group A v 7.59 +/- 0.80 days in group C (P=0.004) and 12.14 +/- 1.35 days in group B v 7.06 +/- 1.29 days in group D (P<0.0001). The number of pain episodes in group D patients was significantly lower than in group B (P +/- 0.0078).

CONCLUSIONS

Doxazosin treatment proved to be safe and effective for distal-ureteral stones, as determined by earlier expulsion, decreased colic frequency, and absence of side effects. The efficacy of doxazosin was significantly higher for 5-to 10-mm stones than for smaller ones.

Ureteral injuries during gynecologic surgery: treatment with a minimally invasive approach

PURPOSE

To report the safety and efficacy of percutaneous nephrostomy and primary antegrade recanalization for treatment of iatrogenic ureteral strictures after gynecologic surgery.

PATIENTS AND METHODS

Ten women had symptoms suggestive of ureteral obstruction during the immediate postoperative period (5 days-1 week after surgery). Under analgesia and conscious sedation, standard percutaneous nephrostomy was performed, and a long 7F sheath was placed in the upper ureter. The obstructions were traversed with the aid of a 0.0035-inch Glidewire and a 5F angled Glide catheter (Terumo, Japan). Subsequently, the areas were dilated with angioplasty balloons to a maximum diameter of 7 mm. Finally, an 8F percutaneous internal/external nephroureteral drainage stent was inserted to secure ureteral patency. Follow-up was carried out by serial nephrostomography until removal of the stent and by renal ultrasonography thereafter.

RESULTS

Twelve obstructions with a mean length of 1.4 cm (range 0.4-1.9 cm) were managed. The technical success rate was 100%. No major complications occurred, and normal renal function was restored. The mean follow-up was 12 months. In 60% of the patients, a patent ureter was depicted at 1 week, whereas in four patients, repeat dilation of the obstructed segment was required. The stents were removed after a mean period of 4.8 weeks.

CONCLUSION

Percutaneous nephrostomy and primary antegrade ureteral balloon dilation is safe and efficacious for treating ureteral injury after pelvic surgery and obviates open surgical manipulations.

Sildenafil combined with continuous positive airway pressure for treatment of erectile dysfunction in men with obstructive sleep apnea

OBJECTIVES

To assess efficacy and safety of the combination of sildenafil and continuous positive airway pressure (CPAP), and satisfaction with treatment for erectile dysfunction (ED) in men with obstructive sleep apnea (OSA).

PATIENTS AND METHODS

Forty men suffering from OSA and concurrent ED were treated with CPAP after a thorough investigation. After a 4-week run-in period, the patients were randomly allocated to treatment for 6 weeks; 20 men to the combination group, receiving additionally 100 mg sildenafil on demand for intercourse, and 20 men to CPAP alone. After a 1-week washout phase, the two groups switched to the other treatment arm for an additional 6 weeks period. End points for efficacy evaluation were the percentage of successful attempts for intercourse based on an event log and the overall satisfaction with sildenafil in the treatment of ED.

RESULTS

The patients recorded a total of 149 attempts for intercourse during the run-in phase with a success rate of 19.5%. During the 12 weeks of treatment, the success rate of intercourse attempts was 24.8% when only on CPAP and 61.1% when in combination with sildenafil (P < 0.001). Of the studied men, 70% were satisfied with the use of sildenafil while 30% remained unhappy with this additional treatment.

CONCLUSIONS

Sildenafil in combination with CPAP appears clearly superior to CPAP alone. The efficacy of this combination is superior to that of sildenafil alone, as reported in previous studies. Both treatment modalities are safe and well tolerated. However, approximately one-third of the patients remain unsatisfied even from the combination treatment. Further treatment options are needed.

The impact of long-term conventional treatment for overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease) on concurrent erectile dysfunction

PURPOSE

To assess the improvement of concurrent erectile dysfunction (ED) in men with overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease), treated with continuous positive airway pressure (CPAP) and bronchodilators.

MATERIAL AND METHODS

We evaluated 48 men of a mean age of 52.8+/-10 years suffering from both obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), and concurrent ED. They were treated with conventional for pulmonary obstruction therapy (CPAP and bronchodilators) for 6 months and then their erectile function (EF) status was reassessed. ED was considered as improved, if ED intensity score increased for at least five points compared to that of baseline. The determinants for improvement of ED were also evaluated, as well as patient's personal degree of satisfaction with the treatment they received as far as the disorder was concerned.

RESULTS

EF was improved in 12 patients (25%), but only two thirds of them were satisfied with the grade of improvement after treatment. ED improvement was related positively with age and apnea/hypopnea index and negatively with ED duration. ED intensity score, O(2) saturation at night and BMI were not significantly related to the outcome of EF improvement.

CONCLUSIONS

Conventional treatment for OSA and COPD, has a positive effect on concurrent ED on the minority of patients. This effect is possibly due to the improvement of respiration during sleep with CPAP and of oxygenation with bronchodilators continuously. Of the improved men, one third was not satisfied with the impact of this treatment modality on their EF. It is likely that specific for ED treatment is needed in these individuals.

Injectables for the treatment of stress urinary incontinence: current use and future perspectives

Stress urinary incontinence is a prevalent symptom among women. It also affects men, primarily those operated on for prostate disease. Even though it is not life threatening, it seriously impacts quality of life. Bulking agents have been used in the treatment of incontinence for many decades, offering a treatment option for both women and men. Their short-term efficacy is satisfactory, but there is concern regarding durability of effect. Despite concerns regarding efficacy, the minimally invasive nature of the technique, with uncommon and self-limited complications, has made injectables quite popular among both physicians and patients. In light of recent developments in the surgical treatment of incontinence, resulting in highly efficacious, but also easy and safe-to-perform, procedures, the role of injectables must be re-evaluated. In these cost-conscious times, health economics is also an important issue, and comparative cost-effectiveness assessment of available treatment options is becoming imperative.

Application of Paclitaxel-Eluting Metal Mesh Stents within the Pig Ureter: An Experimental Study

OBJECTIVE

The purpose of the present study is to compare the standard bare metal stents (BMS) with the Paclitaxel-Drug Eluting Stent (DES) in the ureter of a pig model.

MATERIALS AND METHODS

We report on an experimental study with ten female pigs weighing between 25 and 30 kg. The stents were randomly placed in either the right or left ureter in each of 10 study animals, for a total of 20 stented ureters. Ten ureters were stented with an R-Stent (Orbus Medical Technologies, Hoevelaken Netherlands), and ten with a Paclitaxel-Eluting Coronary Stent (Boston Scientific, Natick, MA, USA). Patency was measured by radiograph of the nephrostomy tract, intravenous urography and virtual endoscopy at 24 hours and 21 days after the initial procedure, respectively.

RESULTS

Free flow of urine through the stents into the bladder was documented in all stented ureters 24 hours after stent insertion by radiograph of the nephrostomy tract. At the 21 day follow-up examination, 5 R-Stents were found to be completely occluded and two partially stenosed, whereas no occluded stent was detected in the Paclitaxel-DES group. Pathology examination of the stents at 21 days follow-up showed that the obstructed R-Stents generated severe inflammation with metaplasia of the urothelium. The Paclitaxel-Eluting MS generated a mild inflammatory response within the ureteral lumen at the site of the stent, without hindering ureteral patency. R-stents proved to develop more hyperplasia compared to the Paclitaxel-Eluting MS.

CONCLUSIONS

Paclitaxel-DES, when compared with the standard R- Stent BMS, generated less inflammation and/or hyperplasia of the surrounding tissues, thus maintaining ureteral patency. Long-term animal trials are required to further validate our results.

Versican but not decorin accumulation is related to metastatic potential and neovascularization in testicular germ cell tumours

AIMS

To investigate the expression of versican and decorin in patients with testicular germ cell tumours (GCTs) and to correlate this with the clinicopathological findings. Matrix proteoglycans versican and decorin are frequently overexpressed in various malignancies and are involved in the progression of cancer.

METHODS AND RESULTS

Overexpression of versican and decorin was detected in GCTs by immunoblotting. Immunohistochemical staining for proteoglycans was performed on 71 cases of paraffin-embedded tissues. In most of the cases increased decorin and versican stromal staining was demonstrated. In both seminomas and non-seminomatous germ cell tumours (NSGCTs) strong staining of decorin was not found to be related to any of the clinicopathological variables. Accumulation of versican was found to be associated with vascular and lymphatic invasion, nodal metastasis and disease stage in seminomas and NSGCTs and, in addition, with tumour size and distant metastasis only in NSGCTs. Additionally, only the deposition of versican was linearly correlated with the number of microvessels in the tumour stroma in GCTs.

CONCLUSIONS

Ectopic versican and decorin expression is a frequent feature in GCTs. Versican but not decorin accumulation in GCTs is related to metastatic potential and neovascularization and might be a useful marker for testicular malignancy.

Primary adrenal tuberculosis: role of computed tomography and CT-guided biopsy in diagnosis

A case of isolated, bilateral, adrenal tuberculosis is presented. A 25-year-old male was admitted to the hospital due to lumbar pain, fever, weight loss and anorexia. Abdominal ultrasonography and computed tomography demonstrated bilateral adrenal enlargement. Laboratory investigations were remarkable for adrenal insufficiency. The Mantoux reaction was positive but there was no evidence of lung or urinary infection. CT-guided biopsy of the left adrenal gland was performed and established the diagnosis of adrenal tuberculosis.

Case report: Leiomyosarcoma of the renal pelvis

We present a new case of leiomyosarcoma, a very rare clinical entity, arising from the renal pelvis. The primary diagnosis, based on asymptomatic gross hematuria and imaging findings, was tumor of the left kidney. After a left radical nephro-ureterectomy, histology confirmed a leiomyosarcoma of the renal pelvis. No adjuvant treatment was provided and the patient remains healthy 3 years after surgery.