The impact of retrograde intrarenal surgery for asymptomatic renal stones in patients undergoing ureteroscopy for a symptomatic ureteral stone

BACKGROUND AND PURPOSE

In the era of rigid ureteroscopy (URS) for ureteral stones, asymptomatic renal stones were often left in place. With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Data are scarce regarding the impact of retrograde intrarenal surgery (RIRS) performed at the time of URS for a symptomatic ureteral stone in comparison with ureteral stone removal alone. The purpose of the study was to compare the outcomes of URS combined with RIRS with URS alone.

PATIENTS AND METHODS

A comparison between patients who underwent URS and RIRS (group A, n=47) and a matched control group of patients undergoing URS alone (group B, n=47) was performed. Matching was based on ureteral stone size and location, and preprocedural Double-J stent placement.

RESULTS

The median size of the largest ureteral stone in both groups was 8 mm with a mean total stone burden of 52.9 mm(2) (28.9) and 47 mm(2) (21.1) in groups A and B, respectively. Median renal stone size was 9 mm with a mean total stone burden of 84.1 mm(2) (40.3). Mean surgery time in groups A and B was 68 minutes (19.61) and 39 minutes (15.96), respectively (P<0.001). Median hospital stay was 1 day for both groups. The success rate for ureteral stone removal was 98% and 100% in groups A and B, respectively. Success rate for RIRS was 85% (40/47 cases). Hospitalization length and complications, mainly postoperative fever, did not differ significantly between the groups.

CONCLUSIONS

Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates. This combined approach reduces the need for future procedures and is probably more cost effective.

The evolution of orgasmic pain (dysorgasmia) following radical prostatectomy

INTRODUCTION

It is recognized that some patients experience painful orgasms known as dysorgasmia after radical prostatectomy (RP). This problem poses a barrier to satisfactory sexual relations for some couples. However, the natural history of this condition remains unknown.

AIM

To assess the evolution of dysorgasmia in patients who underwent RP.

METHODS

The study population included men who had been seen initially within 6 months after RP and complained of postoperative dysorgasmia and opted for no medical therapy with postoperative follow-up at least 24 months, and were seen at least twice over 2 years.

MAIN OUTCOME MEASURES

A proprietary dysorgasmia frequency scale and visual analog scale (VAS) for pain were used at each visit.

RESULTS

Data from 702 patients who had RP and presented for sexual function evaluation between 2002 and 2008 were prospectively collected and analyzed at Memorial Sloan-Kettering Cancer Center. Of the 702 patients, 84 (12%) complained of dysorgasmia. Mean patient age was 64 ± 16 years. Mean time interval since RP to initial sexual medicine interview was 2.2 ± 3.2 months. Mean number of visits was 4 ± 1.4. For the 84 patients who had dysorgasmia, mean dysorgasmia frequency and VAS score for pain at initial interview were 3.9 and 4.1, respectively. At 24 months, a statistically significant decrease in symptoms occurred, with 72%, 26%, and 7% of patients still complaining of pain at 12, 18, and 24 months, respectively. At 6 months, 26% of patients had a VAS score ≥6/10 and at 24 months this figure was 16%.

CONCLUSIONS

Our data provide evidence that dysorgasmia decreases in frequency and degree over time after RP. These data are in support of a surveillance strategy for all but the most bothered patients with dysorgasmia after RP.

Outcomes of clomiphene citrate treatment in young hypogonadal men

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Hypogonadism is a prevalent problem, increasing in frequency as men age. It is most commonly treated by testosterone supplementation therapy but in younger patients this can lead to testicular atrophy with subsequent exogenous testosterone dependency and may impair spermatogenesis. Clomiphene citrate (CC) may be used as an alternative treatment in these patients with hypogonadism when maintenance of fertility is desired. This study shows that CC is a safe and efficacious drug to use as an alternative to exogenous testosterone. Not only have we validated previous findings of other papers but have proven our findings over a much longer period (mean duration of treatment 19 months). This prospective study is the largest to date assessing both the objective hormone response to CC therapy as well as the subjective response based on a validated questionnaire.

OBJECTIVE

• To prospectively assess the andrological outcomes of long-term clomiphene citrate (CC) treatment in hypogonadal men.

PATIENTS AND METHODS

• We prospectively evaluated 86 men with hypogonadism (HG) as confirmed by two consecutive early morning testosterone measurements <300 ng/dL. • The cohort included all men with HG presenting to our clinic between 2002 and 2006 who, after an informed discussion, elected to have CC therapy. CC was commenced at 25 mg every other day and titrated to 50 mg every other day. The target testosterone level was 550 ± 50 ng/dL. • Testosterone (free and total), sex hormone binding globulin, oestradiol, luteinizing hormone and follicle stimulating hormone were measured at baseline and during treatment on all patients. Once the desired testosterone level was achieved, testosterone/gonadotropin levels were measured twice per year. • To assess subjective response to treatment, the androgen deficiency in aging males (ADAM) questionnaire was administered before treatment and during follow-up.

RESULTS

• Patients' mean (standard deviation [sd]; range) age was 29 (3; 22-37) years. Infertility was the most common reason (64%) for seeking treatment. The mean (sd) duration of CC treatment was 19 (14) months. • At the last evaluation, 70% of men were using 25 mg CC every other day, and the remainder were using 50 mg every other day. • All mean testosterone and gonadotropin measurements significantly increased during treatment. • Subjectively, there was an improvement in all questions (except loss of height) on the ADAM questionnaire. More than half the patients had an improvement in at least three symptoms. • There were no major side effects recorded and the presence of a varicocele did not have an impact on the response to CC.

CONCLUSION

• Long-term follow-up of CC treatment for HG shows that it appears to be an effective and safe alternative to testosterone supplementation in men wishing to preserve their fertility.

Peyronie's disease in teenagers

INTRODUCTION

Peyronie's disease (PD) is commonly seen in middle-aged men, and little is known about this condition in teenagers.

AIM

To investigate the characteristics of PD in teenagers.

METHODS

The findings were compared between patients with the disease who were teenagers with those over 40 years of age. Statistical analyses were conducted to define differentiating features between these two groups.

MAIN OUTCOME MEASURES

The demographics, clinical features, and associated comorbidities of patients with PD were reviewed.

RESULTS

Thirty-two teenaged males were evaluated for PD in a single institution over a 10-year period. The median age for our cohort was 18 (15-19) years. Forty-five percent of patients had already been seen by another urologist, and 28% had been told they did not have PD. The mean duration of PD before seeking medical care in our cohort was 3 ± 1 months. Sixteen percent of patients reported antecedent penile trauma, half of which happened during coitus or masturbation, and 18% of patients had hemoglobin (Hb) A1c levels > 5%. Dupuytren's contracture was not seen in this population. Twenty-two percent of patients presented with penile pain. Subsequent ED was seen in 37% of patients. Multiple noncontiguous plaques were seen in 37% of patients. Twelve percent were previously treated with vitamin E, while another 12% had previous intralesional verapamil. High distress was reported by 94% of patients. Thirty-four percent sought medical attention for anxiety/mood disorder, and 28% had a negative encounter with a sexual partner related to PD. All of the 32 patients had penile curvature with a mean of 32 ± 12 degrees. Seventy-two percent of the patients had dorsal curvature while 22% had an associated deformity. Using duplex Doppler ultrasound, 12% had a calcified plaque, while none of the patients had abnormal hemodynamics. When compared with PD in adults, teenagers had greater than seven times the prevalence of multiple noncontiguous plaques (37% vs. 5%). Also, the prevalence of HbA1c level > 5% was higher in the teenagers as well (18% vs. 5%).

CONCLUSIONS

PD does occur in teenagers often causing high distress levels. Compared to older adults, teenagers often present earlier, and more commonly have elevated HbA1c level and increased number of plaques at presentation.

Erectile function rehabilitation after radical prostatectomy: practice patterns among AUA members

INTRODUCTION

Despite a growing body of evidence supporting erectile function (EF) rehabilitation after radical prostatectomy (RP), there are no guidelines on this subject.

AIM

To explore EF rehabilitation practice patterns of American Urological Association (AUA) urologists.

METHODS

A 35-question instrument was constructed assessing physician demographics, training, and EF rehabilitation practices after RP, and was e-mailed to AUA members by the AUA Office of Education. Data were acquired by the AUA and analyzed by the investigators.

MAIN OUTCOME MEASURE

Percentage of responders who recommend EF rehabilitation practices following RP, characterization of prevalent rehabilitation practices.

RESULTS

Of the 618 urologists who completed the survey, 71% were in private practice, 28% considered themselves as sexual medicine specialists, although only 4% were fellowship-trained, 43% were urologic oncology specialists (14% fellowship-trained), 86% performed RP, and 86% of responders recommended rehabilitation practices. Being a sexual medicine or a urologic oncology specialist was not predictive of rehabilitation employment. Forty-three percent rehabilitate all patients, 57% only selected patients. Selection for rehabilitation was dependent upon preop EF by 66%, nerve-sparing status by 22%, and age by 5%. Eleven percent started rehab immediately after RP, 97% within 4 months. 24%, 45% and 18% ceased rehab at <12, 12-18, and 18-24 months, respectively. Eighty-nine percent of RP surgeons performed rehabilitation vs. only 66% who do not perform RP (P < 0.0001). Eighty-seven percent prefer phosphodiesterase type 5 inhibitors (PDE5i) as their primary strategy followed (in order) by vacuum erection device (VED), intracavernosal injection (ICI), and urethral suppositories.

CONCLUSIONS

Among the respondents, penile rehabilitation is a common practice. Urologic oncologists and RP surgeons are more likely to use rehabilitation practices. The most commonly employed strategy is regular PDE5i use for 12-18 months after RP. .

Peyronie's disease following radical prostatectomy: incidence and predictors

INTRODUCTION

Both prostate cancer and Peyronie's disease (PD) are prevalent in men after their fifth decade of life. The evidence to support or refute a link between radical prostatectomy (RP) and PD is limited.

AIMS

To define the incidence of PD in men who had RP and determine possible predictors of PD development after RP.

METHODS

A review of a prospectively built sexual medicine database, years 2002-2008, looking at subjects who had RP as a monotherapy for localized prostate cancer. We identified and characterized subjects who developed PD within 3 years after RP and compared them with subjects who did not.

MAIN OUTCOME MEASURES

The incidence of PD among men who attended a sexual medicine clinic after they had RP, predictors of PD development after RP.

RESULTS

The study population included 1,011 subjects, and PD incidence in this population was 15.9%. Mean time to develop PD after RP was 13.9 +/- 0.7 months. Mean curvature magnitude was 31 + 17 degrees. On univariate analysis, younger age (mean age of 59 + 7 in men with PD vs. 60 + 7 years in men without PD, P = 0.006) and white race (vs non-white, 18% vs. 7%, P < 0.001) were predictive of PD development after RP, but post-op erectile function was not a predictor of PD development. On multivariate analysis, younger age (odds ratio (OR) = 1.3, for 5-year decrease in age) and white race (OR = 4.1, vs. non-white) remained independent significant predictors.

CONCLUSIONS

Men presenting with sexual dysfunction after RP have higher PD incidence then the general population. Therefore, they should be routinely evaluated for PD. Younger men and men of white race are at increased risk for PD. Prospective controlled studies are needed to elucidate the incidence of PD following RP and to conclude if RP has a causative role in the pathogenesis of PD.

Persistent erectile dysfunction following radical prostatectomy: the association between nerve-sparing status and the prevalence and chronology of venous leak

INTRODUCTION

. Failure to recover erectile function after radical prostatectomy (RP) may result from venous leak as a sequela of neuropraxia-induced erectile tissue damage. Venous leak portends a poor prognosis for erections recovery as well as phosphodiesterase type 5 inhibitor (PDE5i) response.

AIMS

To define the impact of RP nerve-sparing status on venous leak prevalence and chronology.

METHODS

STUDY POPULATION

men who underwent RP for localized prostate cancer, had functional erections prior to RP, developed postoperative erectile dysfunction (ED), had a Doppler ultrasonography within 6 months of RP, and did not receive any ED treatment for the first 6 months after RP other than on-demand PDE5i.

MAIN OUTCOME MEASURES

Venous leak prevalence and erectile function recovery at different time-points.

RESULTS

Data on 142 patients were analyzed, mean age: 58 +/- 16 years. Sixty percent had bilateral nerve-sparing (BNS) surgery, 20% unilateral nerve-sparing (UNS) surgery, and 20% non-nerve-sparing (NNS) surgery. Eleven percent and 21% had venous leak by 3 and 6 months, respectively. Venous leak prevalence by 6 months was 7%, 11%, and 75% for BNS, UNS, and NNS surgery (P < 0.001). Mean end-diastolic velocity was 1.8, 2.1, and 7.2 cm/second for the three groups (P < 0.01). The only patients developing venous leak prior to 3 months were NNS patients, one-third of NNS-associated venous leak occurring before this time-point. At 18 months, the proportion of men having return of unassisted erections was 49%, 42%, and 7% with mean erectile function domain scores of 21, 18, and 12, and PDE5i response rates were 72%, 64%, and 12% for the three groups, respectively.

CONCLUSIONS

Nerve-sparing status impacts heavily upon the prevalence and the chronology of venous leak development post-RP. NNS RP is associated with early development of venous leak, increased prevalence of venous leak, and reduction in return of natural erections.

Erectile function recovery rate after radical prostatectomy: a meta-analysis

INTRODUCTION

Erectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied.

AIM

To conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP.

MAIN OUTCOME MEASURES

EFR rate after RP.

METHODS

An EMBASE and MEDLINE search was conducted for the time range 1985-2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population >or=50 patients, >or=1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups.

RESULTS

A total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17-1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting >or=18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients >or=60 years, 77% vs. 61%, RR = 1.26, P = 0.001.

CONCLUSIONS

These data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident.

Impact of prostate weight on radical prostatectomy outcomes

BACKGROUND

The management of localized prostate cancer in patients with large prostates is controversial.

OBJECTIVES

To investigate the impact of prostate weight on radical prostatectomy outcomes.

METHODS

The files of 244 patients who underwent radical prostatectomy were reviewed. Data were collected on patient and tumor characteristics and on oncological, urinary and erectile function outcomes. Results were compared between patients with prostates weighing < or = 60 g or > 60 g.

RESULTS

A prostate weight of > 60 g was documented in 25% of the patients. There was no difference in clinical stage distribution between patients with smaller and patients with larger prostates. Patients with a larger prostate were characterized preoperatively by higher levels of prostatespecific antigen (9.8 vs. 7.3 ng/ml, P = 0.009), lower tumor grade (biopsy Gleason score < or = 6: 77.6% vs. 90.2% P = 0.04), and a higher incidence of moderate-severe urinary symptoms (69.8 vs. 38.8%, P = 0.0003). Analysis of pathological stage distribution yielded a higher proportion of lower stage disease and a lower incidence of positive margins in the large-prostate group (11.7 vs. 25.8%, P = 0.024). There were no statistically significant between-group differences in the rate of persistent postoperative detectable PSA, biochemical recurrence, urinary incontinence and erectile function.

CONCLUSIONS

The outcomes of radical prostatectomy in patients with large prostate are favorable in terms of cancer characteristics despite their higher preoperative PSA levels, and comparable to that in patients with small prostate in terms of urinary continence and erectile function. Surgery may be particularly beneficial in patients with preoperative urinary symptoms. Hence, radical prostatectomy should not be discouraged as a treatment for localized prostate cancer in patients with sizeable prostates.