Changes in female sexual function after pelvic organ prolapse repair: role of hysterectomy

INTRODUCTION AND HYPOTHESIS

Incontinence and pelvic organ prolapse (POP) have an impact on sexuality. Few studies evaluate the impact of hysterectomy on sexual function. We designed the present observational prospective longitudinal cohort study in order to evaluate the impact of uterus preservation after POP repair on sexual function.

METHODS

Between January 2006 and January 2011, 107 patients with POP, mean age 58 ± 8.9 years, underwent colposacropexy with or without hysterectomy. All the women without uterine disease were offered the chance to preserve the uterus. All patients gave written informed consent and completed the Female Sexual Function Index (FSFI) questionnaire, before and after surgery, provided detailed case history, underwent urogynaecological examination and urodynamic assessment and completed the Urogenital Distress Inventory short form (UDI-6) and Incontinence Impact on Quality of Life short form (IIQ-7) questionnaires, and the satisfaction Visual Analogue Scale (VAS). One year after surgery patients repeated the FSFI questionnaire and underwent a clinical check-up. The primary end-point was post-operative sexual function as evaluated by the FSFI, the secondary end-points were objective anatomical and subjective success, defined respectively as no prolapse and no incontinence-related symptoms.

RESULTS

Sixty-eight patients were included: 32 underwent uterus-sparing surgery and 36 hysterectomy plus colposacropexy. After surgery both groups had significant improvements in the total FSFI score and in the domains of desire, arousal and orgasm. The median post-operative scores of desire, arousal, and orgasm domains showed significant improvements in the uterus-sparing group compared with the hysterectomy group. None of the women had a uterine or vault prolapse recurrence.

CONCLUSIONS

Our data demonstrate that POP plays a role in female sexual dysfunction and uterus sparing surgery is associated with a greater improvement in sexual function.

Urgency, detrusor overactivity and posterior vault prolapse in women who underwent pelvic organ prolapse repair

INTRODUCTION

We investigated the relationship between posterior vault prolapse and overactive bladder (OAB) symptoms or detrusor overactivity (DO) and their changes after surgical repair.

METHODS

Forty-three patients with vault prolapse and prevalent posterior compartment prolapse underwent pelvic organ prolapse repair surgery: 28 received colposacropexy and 15 were treated by the vaginal approach. Subjective success was lack of prolapse-related symptoms or urgency. OAB symptoms, voiding symptoms and constipation were evaluated. Patient satisfaction was defined by a visual analog scale score (range 0-10). Objective anatomical success was defined as no vaginal prolapse of stage ≥2 at any vaginal site.

RESULTS

The median follow-up was 75 months (range 24-143). Preoperatively, 33/43 patients (76.74%) reported urgency. DO was found in 11/43 patients (25.6%), and 22/43 patients reported constipation. The anatomical outcome showed 2 persistent stage II rectoceles (6.9%). After surgery, OAB symptoms disappeared in 25/33 (75.88%) and persisted in 8 patients (24.2%); there was no de novo urgency. DO disappeared in 8/11 subjects (72.7%). Preoperative constipation was present in 17/33 patients with OAB symptoms (51.5%) and disappeared postoperatively in 13/17 patients (76.4%) (p < 0.013). De novo constipation appeared in 3 patients (associated with OAB in 2 patients).

CONCLUSIONS

Prevalent posterior compartment pelvic organ prolapse and OAB/DO were often associated. After surgery, OAB symptoms and DO were significantly reduced.

Correlation between age and Chromogranin A determination in prostate diseases

INTRODUCTION

Serum levels of Chromogranin A (CgA) were measured in consecutive patients with prostate diseases in order to evaluate the impact of age on CgA diagnostic significance.

MATERIALS AND METHODS

Serum levels of CgA were determinated in 217 consecutive patients immediately before prostate biopsy: CgA differences between cases (prostate cancer PC) and control (benign prostatic hyperplasia BPH) were analyzed, and CgA performance in prediction of PC was compared with age and standard diagnostic tools. CgA values were also analyzed in patients affected by PC, and compared with age and standard prognostic parameters.

RESULTS

At multivariate analysis, CgA approaches a statistically significant value as independent predictor of PC and positively correlates with age. In PC group, CgA positively correlates with age, while no correlations are found with PSA, Gleason score or stage of disease.

CONCLUSIONS

Age, correlating with CgA values in overall population and in PC subgroup, emerged as a confounding factor in CgA determination. Serum CgA has not been demonstrated as a diagnostic marker of PC being only a marker of neuroendocrine differentiation. Cga values did not correlate with other clinical prognostic factors, except age, in untreated-naive PC.

A review of penile metastasis

Penile cancer as primary disease is relatively rare in developed countries. The penis is a rare site of metastases in spite of its rich vascularization. Approximately 500 cases have been reported in the literature; almost 70% of primary lesions are of pelvic origin (from genitourinary or recto-sigmoid primary tumors). We describe a case of penile metastasis from lung cancer. The rarity of the event prompted us to also explore related reviews and discuss the incidence, physiopathology, diagnosis and therapy of penile secondary cancer.

A review of penile metastasis

Penile cancer as primary disease is relatively rare in developed countries. The penis is a rare site of metastases in spite of its rich vascularization. Approximately 500 cases have been reported in the literature; almost 70% of primary lesions are of pelvic origin (from genitourinary or recto-sigmoid primary tumors). We describe a case of penile metastasis from lung cancer. The rarity of the event prompted us to also explore related reviews and discuss the incidence, physiopathology, diagnosis and therapy of penile secondary cancer.

Corporoplasty for induratio penis plastica with soft axial tutors, single relaxing albugineal incision and safenous grafting. A 3-year follow up

OBJECTIVES

Etiological and pathogenic mechanisms of Peyronie's disease (PPI) are today better known than in the past, but till now therapeutic options are not completely satisfactory. In fact several therapeutic alternatives were suggested, but none demonstrated its superiority. Surgery is the preferred option in chronic stable disease with the following goals: penile straightening, penile lengthening and recovery of penetrative coital activity. Aim of this paper was to present a personal experience with modifications of the original surgical technique.

MATERIALS AND METHODS

From September 2005 to December 2008, a total of 58 patients (mean age 44.7 years) underwent corrective penile surgery for PPI. All patients had a single plaque with dimensions ranging 1.2-2.6 cm in length. Simple dorsal recurvatum >50 degrees was observed in 38 patients, dorsolateral left recurvatum >45 degrees in 8, ventral recurvatum >40 degrees in 6, lateral left recurvatum >45 degrees in 4, dorsolateral right recurvatum >45 degrees in 2. Forty patients were implanted with a 7 F Virilis II prosthesis, 7 with a 7 F Virilis I, 8 with 10 F Virilis I and 3 with 9.5 F SSDA prosthesis. Implanted tutor length ranged between 16.6 and 20 cm, measuring from crura to corpora apex. In 46 patients we implanted a safena graft and in 12 with recurvatum >60 degrees we used bovine pericardial collagen patch (Veritas-Hydrix).

RESULTS

At long term follow up (1-3 years) we observed a penile elongation from 1.2 to 2.3 cm with complete correction of penile recurvatum in all the patients. After 12-36 months excellent penetrative sexual activity was referred by 75% of the patients, satisfactory in 20% and disappointing in 5%. Major complaints were "cool glans" feeling, delayed ejaculation, unnatural penis appearance due to permanent hyperextension. None developed lower urinary tract symptoms.

CONCLUSION

According to such results, the described technique should be considered as a gold standard for all cases of PPI associated to recurvatum > 35-40 degrees (lateral, ventral and dorsal) associated to a plaque with mild-moderate erectile dysfunction.

Long-term results of the surgical treatment of Peyronie's disease with Egydio's technique: a European multicentre study

The long-term outcomes of 157 patients affected by Peyronie's disease (PD) who underwent penile straightening with Egydio's technique between January 2004 and December 2008 are reported. Only patients with PD who were stable for at least 6-12 months prior to surgery were enrolled in this study. Preoperative assessment included a dynamic echo colour Doppler ultrasound scan to evaluate the degree of penile deformity and the peak systolic velocity in the cavernosal arteries and an assessment of erectile function with the administration of the International Index of Erectile Function 5 (IIEF-5) questionnaire. Stretched penile length was recorded pre- and postoperatively. Surgical complications, cosmesis and sexual function, patient satisfaction and postoperative erectile function were assessed postoperatively at 3 months, 1 year and 2 years, respectively. After a median follow-up period of 20 months (range: 12-24 months), we found that mild residual curvature (12%) and glans hypoesthesia (3%) were the only causes of partial dissatisfaction. No rejection of the graft was observed. All patients recovered their ability to penetrate with no difficulty. In addition, an intraoperative average increase of 2.5 cm (range: 1.7-4.1 cm) in stretched penile length was recorded, with all patients engaging in penetrative sexual intercourse. In conclusion, this procedure represents a safe and reproducible technique for the correction of penile curvature resulting from PD and yields excellent cosmetic and functional results.

Outcomes of radical prostatectomy in clinically locally advanced N0M0 prostate cancer

INTRODUCTION

Radical prostatectomy (RP) in patients with locally advanced (cT3) prostate cancer (PCa) is considered an optional therapy.

AIM

To evaluate outcomes of surgery for cT3 disease and to compare results with those of patients treated for cT1-T2 PCa.

PATIENTS AND METHODS

Data of 74 consecutive patients with cT3 N0M0 PCa who underwent RP were compared to those of 425 consecutive unselected patients who underwent surgery for cT1-T2 N0M0 disease.

RESULTS

cT3: The pathological report showed a pathological downstaging in 16.3% of cases. Continence rate was 65.5%, potency rate was 38.8%, 5-year PSA-free survival was 61.9%, 5-year cancer-specific survival was 95.2%. cT1-T2: The pathological report showed a clinical downstaging in 39.1%. Continence rate was 70.8%, potency rate was 56.2%, 5-year PSA-free survival was 67.4%, 5-year cancer-specific survival was 96.0%.

CONCLUSIONS

cT3 PCa presents challenges for the uro-oncologist since standard treatment is still under debate. RP in well-informed patients is a procedure with acceptable morbidity and should be at least a first part of a multimodality approach.

Patients of surgical educational course may have a poorer outcome for pelvic organ prolapse repair and higher complication rate: a case-control study in urogynecology

INTRODUCTION AND HYPOTHESIS

To investigate the outcome of the surgical educational course setting in patients undergoing urinary incontinence (UI)/pelvic organ prolapse (POP) repair.

METHODS

A case-control study of patients who underwent surgery for UI and/or POP during educational post-graduate courses (group A) or during routine hospital work (control--group B). The primary outcome measures were changes in the incontinence rate, presence/absence of POP, and complications. For 2 x 2 tables, chi (2) test was used. Multivariate logistic regression models were developed.

RESULTS

One hundred eighty-six patients belonged to group A and 158 to group B; median follow-up was 46.7 months. Failure, complication, and re-operation rates for UI repair were not significantly different in the two groups: p = 0.162, p = 0.110, p = 0.188, respectively. The logistic regression analysis for POP repair showed that group A has higher risk for failure (OR = 2.71; 95% CI: 1.31-5.61) and higher complication rate (OR = 2.38; 95% CI: 1.31-4.32).

CONCLUSION

Patients who underwent surgery during educational course developed a poorer outcome after POP repair and higher complication rate.

Iatrogenic trapped penis in adults: new, simple 2-stage repair

PURPOSE

We present a new, 2-stage functional and cosmetic reconstruction of concealed penis in adults with short-term subjective outcomes.

MATERIALS AND METHODS

Patients with excess penile skin removal, shaft tissue scarring and penile retraction with poor functional and cosmetic results underwent 2-stage repair. At stage 1 after a coronal incision and penile degloving an intrascrotal tunnel was formed and the penis was transposed through the scrotum. Three or 4 zero or 2-zero nonresorbable sutures were applied ventral to the penis, crossing through the entire scrotum to ensure complete scrotal skin adhesion to the penis (penile scrotalization). At stage 2 after 6 to 12 weeks the scrotal skin at the penile base was incised bilaterally to separate the skin around the penis from the remaining scrotal skin (penile descrotalization). Evaluation was scheduled 3, 6 and 9 months postoperatively, and annually thereafter.

RESULTS

Ten men with concealed penis underwent this 2-stage penile repair, including 8 who were circumcised and 2 who underwent conservative surgery for penile cancer. Mean +/- SD operative time was 75 +/- 15 minutes for stage 1 and 45 +/- 10 minutes for stage 2. No major intraoperative or perioperative complications occurred except superficial scrotal hematoma in 1 patient. At a median followup of 20 months (range 6 to 72) all men were in satisfactory clinical condition and the median patient satisfaction visual analog score was 97 (range 85 to 100). All patients recovered normal spontaneous erection with regular sexual intercourse 4 to 8 weeks after operation 2.

CONCLUSIONS

This simple, new 2-stage technique seems feasible and effective, and it is well accepted by patients. Further studies are mandatory to confirm preliminary results.

Open-label, longitudinal study of tamsulosin for functional bladder outlet obstruction in women

OBJECTIVES

To investigate the clinical effect of tamsulosin for the treatment of functional bladder outlet obstruction (BOO) in adult women.

METHODS

In a prospective, longitudinal open-label study, 63 women affected by functional BOO were treated with tamsulosin. Inclusion criteria were: age >18 years, reporting voiding symptoms (intermittent stream, hesitancy, straining and/or a feeling of incomplete emptying), uroflowmetry maximum flow rate (Q(max)) under 12 ml and/or presence of postvoid residual greater than 50% of the voiding volume. Exclusion criteria were: patients suffering from any other anatomical or functional disorder such as urethral stenosis, pelvic organ prolapse, neurological disturbances, or systemic diseases that could impact upon bladder voiding. Tamsulosin was administered in a single daily dose of 0.4 mg for at least 30 days. Primary outcomes were clinical efficacy and Q(max) improvement; secondary outcomes were tolerability and safety. Voiding and storage symptoms and uroflowmetry results were assessed before and at the end of the alpha-blocker therapy.

RESULTS

Tamsulosin therapy was well tolerated. After therapy voiding symptoms improved in 71.4% of patients (45/63; p < 0.0001), and if associated with storage symptoms in 66.67% (26/39; p < 0.00001). Recurrent infections were reduced by 50% in 81% (21/26) of patients. Uroflowmetry parameters improved in 36/63 patients (57.1%). Postvoiding residue improved in 62.5% (10/16) and disappeared in 25% (4/16) with no significant changes in voided volume. An improvement was observed in 66% (16/24) of patients with isolated voiding symptoms, in 51.2% (20/39) with associated storage symptoms and in 65% (17/26) of women with associated recurrent urinary infections.

CONCLUSIONS

These results suggest that alpha-blocker may be an effective treatment option in women with voiding dysfunction due to functional BOO.

Surgical treatment of Peyronie's disease by plaque incision and grafting with buccal mucosa

BACKGROUND

Plaque incision and tunical grafting is widely used to correct penile curvatures secondary to Peyronie's disease (PD), but there is no consensus on the ideal graft to be used.

OBJECTIVE

To evaluate the efficacy, safety, and reproducibility of plaque incision and buccal mucosa grafting (BMG) in the correction of severe penile curvatures secondary to PD.

DESIGN, SETTING, AND PARTICIPANTS

Fifteen patients reporting normal erections and stable curvature (>12-mo duration) entered this prospective study carried out at two university hospitals.

INTERVENTION

All patients underwent plaque incision and BMG.

MEASUREMENTS

Preoperative evaluation included the International Index of Erectile Function (IIEF-5) and penile duplex ultrasounds with measurement of curvature and length of affected side. Follow-up visits were scheduled at 1, 3, 6, and 12 mo postoperatively, then yearly. Three-mo postoperative evaluation included IIEF-5, patient and partner satisfaction, and intracavernous injection test with evaluation of penile rigidity, straightness, and length; patient and partner satisfaction was recorded at all subsequent visits.

RESULTS AND LIMITATIONS

Mean patient age was 56.3 yr and mean penile curvature 72 degrees ; five patients had a two-sided curvature with mean second curvature of 37 degrees . There were no complications. All patients resumed unassisted intercourse 1 mo after surgery. Three-mo postoperative evaluation showed 100% penile straightening, 1.8-cm mean increase in length of affected side, no curvature recurrence or de novo erectile dysfunction, 1.6 mean increase in IIEF-5 score, and patient and partner satisfaction of 93.3% and 100%, respectively. Although results remained stable at subsequent follow-up (mean 13.1 mo), a greater number of patients and longer follow-up are needed before drawing any definite conclusions.

CONCLUSIONS

BMG provided excellent short-term results, probably because its prompt revascularisation, suggested by the fast return of spontaneous erections, prevented shrinkage, which is the main cause of graft failure. It also proved to be safe and reproducible, thus representing a valuable treatment option for PD.