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Kaltsas A, Zikopoulos A, Dimitriadis F, Sheshi D, Politis M, Moustakli E, Symeonidis EN, Chrisofos M, Sofikitis N, Zachariou A. Oxidative Stress and Erectile Dysfunction: Pathophysiology, Impacts, and Potential Treatments. Curr Issues Mol Biol 2024; 46:8807-8834. [PMID: 39194738 DOI: 10.3390/cimb46080521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/01/2024] [Accepted: 08/13/2024] [Indexed: 08/29/2024] Open
Abstract
Erectile dysfunction (ED) is a prevalent condition affecting men's sexual health, with oxidative stress (OS) having recently been identified as a significant contributing causative factor. This narrative review aims to elucidate the role of OS in the pathophysiology of ED, focusing on impact, mechanisms, and potential therapeutic interventions. Key findings indicate that OS disrupts endothelial function and nitric oxide (NO) signaling, crucial for erectile function. Various sources of reactive oxygen species (ROS) and their detrimental effects on penile tissue are discussed, including aging, diabetes mellitus, hypertension, hyperlipidemia, smoking, obesity, alcohol consumption, psychological stress, hyperhomocysteinemia, chronic kidney disease, and sickle cell disease. Major sources of ROS, such as NADPH oxidase, xanthine oxidase, uncoupled endothelial NO synthase (eNOS), and mitochondrial electron transport, are identified. NO is scavenged by these ROS, leading to endothelial dysfunction characterized by reduced NO availability, impaired vasodilation, increased vascular tone, and inflammation. This ultimately results in ED due to decreased blood flow to penile tissue and the inability to achieve or maintain an erection. Furthermore, ROS impact the transmission of nitrergic neurotransmitters by causing the death of nitrergic neurons and reducing the signaling of neuronal NO synthase (nNOS), exacerbating ED. Therapeutic approaches targeting OS, including antioxidants and lifestyle modifications, show promise in ameliorating ED symptoms. The review underscores the need for further research to develop effective treatments, emphasizing the interplay between OS and vascular health in ED. Integrating pharmacological and non-pharmacological strategies could enhance clinical outcomes for ED patients, advocating for OS management in ED treatment protocols to improve patient quality of life.
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Affiliation(s)
- Aris Kaltsas
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | | | - Fotios Dimitriadis
- Department of Urology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Danja Sheshi
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Magdalena Politis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Efthalia Moustakli
- Laboratory of Medical Genetics, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Evangelos N Symeonidis
- Department of Urology II, European Interbalkan Medical Center, 55535 Thessaloniki, Greece
| | - Michael Chrisofos
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Nikolaos Sofikitis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Athanasios Zachariou
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
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Zhu B, Niu Y, Guo H, Jin X, Liu F. Pyroptosis and inflammation‑mediated endothelial dysfunction may act as key factors in the development of erectile dysfunction (Review). Mol Med Rep 2023; 28:165. [PMID: 37449500 PMCID: PMC10407613 DOI: 10.3892/mmr.2023.13052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/12/2023] [Indexed: 07/18/2023] Open
Abstract
Erectile dysfunction (ED) is a prevalent disease that causes sexual dysfunction in males. Inflammation‑induced endothelial dysfunction is a fundamental pathophysiological symptom of ED, which is impacted by cell death. Pyroptosis is a type of programmed cell death mediated by the inflammasome that was discovered in inflammatory disorders. The activation of nucleotide‑binding oligomerization domain‑like receptors, particularly downstream inflammatory factors, such as IL‑1β and IL‑18, is indicative of caspase‑dependent pyroptosis. Although the underlying mechanisms of pyroptosis have been investigated in several disorders, the role of pyroptosis in ED remains to be fully elucidated. At present, studies on pyroptosis have focused on improving the understanding of ED pathogenesis and promoting the development of novel therapeutic options. The present review article aimed to discuss the literature surrounding the mechanisms underlying pyroptosis, and summarize the role of pyroptosis in the development and progression of inflammation‑mediated ED.
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Affiliation(s)
- Bingbing Zhu
- Department of Human Anatomy, School of Basic Medical Science, Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
- Xinjiang Key Laboratory of Molecular Biology of Endemic Diseases, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
| | - Yangjiu Niu
- Department of Human Anatomy, School of Basic Medical Science, Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
- Xinjiang Key Laboratory of Molecular Biology of Endemic Diseases, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
| | - Haoqiang Guo
- Department of Human Anatomy, School of Basic Medical Science, Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
- Xinjiang Key Laboratory of Molecular Biology of Endemic Diseases, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
| | - Xiufang Jin
- Department of Human Anatomy, School of Basic Medical Science, Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
- Xinjiang Key Laboratory of Molecular Biology of Endemic Diseases, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
| | - Fengxia Liu
- Department of Human Anatomy, School of Basic Medical Science, Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
- Xinjiang Key Laboratory of Molecular Biology of Endemic Diseases, Urumqi, Xinjiang Uygur Autonomous Region 830011, P.R. China
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3
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Argiolas A, Argiolas FM, Argiolas G, Melis MR. Erectile Dysfunction: Treatments, Advances and New Therapeutic Strategies. Brain Sci 2023; 13:802. [PMID: 37239274 PMCID: PMC10216368 DOI: 10.3390/brainsci13050802] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Erectile dysfunction (ED) is the inability to get and maintain an adequate penile erection for satisfactory sexual intercourse. Due to its negative impacts on men's life quality and increase during aging (40% of men between 40 and 70 years), ED has always attracted researchers of different disciplines, from urology, andrology and neuropharmacology to regenerative medicine, and vascular and prosthesis implant surgery. Locally and/or centrally acting drugs are used to treat ED, e.g., phosphodiesterase 5 inhibitors (first in the list) given orally, and phentolamine, prostaglandin E1 and papaverine injected intracavernously. Preclinical data also show that dopamine D4 receptor agonists, oxytocin and α-MSH analogues may have a role in ED treatment. However, since pro-erectile drugs are given on demand and are not always efficacious, new strategies are being tested for long lasting cures of ED. These include regenerative therapies, e.g., stem cells, plasma-enriched platelets and extracorporeal shock wave treatments to cure damaged erectile tissues. Although fascinating, these therapies are laborious, expensive and not easily reproducible. This leaves old vacuum erection devices and penile prostheses as the only way to get an artificial erection and sexual intercourse with intractable ED, with penile prosthesis used only by accurately selected patients.
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Affiliation(s)
- Antonio Argiolas
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Monserrato, Italy; (F.M.A.); (M.R.M.)
| | - Francesco Mario Argiolas
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Monserrato, Italy; (F.M.A.); (M.R.M.)
| | - Giacomo Argiolas
- General Medicine Unit, Hospital San Michele, ARNAS“G. Brotzu”, Piazzale Ricchi 1, 09100 Cagliari, Italy;
| | - Maria Rosaria Melis
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Monserrato, Italy; (F.M.A.); (M.R.M.)
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Bernal J, Venkatesan K, Martins FE. Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options. J Clin Med 2023; 12:jcm12072697. [PMID: 37048780 PMCID: PMC10095222 DOI: 10.3390/jcm12072697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/18/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.
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Affiliation(s)
- Jose Bernal
- Department of Urology, Hospital Sotero del Rio/Clinica Indisa, Santiago 13123, Chile
| | - Krishnan Venkatesan
- Department of Urology, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Francisco E Martins
- Department of Urology, School of Medicine, University of Lisbon, Hospital Santa Maria, 1649-035 Lisbon, Portugal
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Kloner RA, Stanek E, Crowe CL, Singhal M, Pepe RS, Bradsher J, Rosen RC. Effect of phosphodiesterase type 5 inhibitors on major adverse cardiovascular events and overall mortality in a large nationwide cohort of men with erectile dysfunction and cardiovascular risk factors: A retrospective, observational study based on healthcare claims and national death index data. J Sex Med 2023; 20:38-48. [PMID: 36897243 DOI: 10.1093/jsxmed/qdac005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/23/2022] [Accepted: 09/12/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Treatment with phosphodiesterase type 5 inhibitors (PDE-5is) is effective in treating erectile dysfunction (ED). AIM The objective of this study was to determine the effect of PDE-5is on the incidence of major adverse cardiovascular (CV) events (MACE; composite outcome of CV death, hospitalization for myocardial infarction, coronary revascularization, stroke, heart failure, and unstable angina pectoris) and overall mortality. METHODS A retrospective observational cohort study was conducted in a large US claims database in men with ≥1 diagnosis of ED without prior MACE within 1 year, from January 1, 2006, to October 31, 2020. The exposed group had ≥1 claim for PDE-5i and the unexposed group had no claims for PDE-5i, and the groups were matched up to 1:4 on baseline risk variables. OUTCOME The primary outcome was MACE and the secondary outcomes were overall mortality and individual components of MACE, determined by multivariable Cox proportional hazard modeling. RESULTS Matched plus multivariable analyses showed that MACE was lower by 13% in men exposed (n = 23 816) to PDE-5is (hazard ratio [HR] 0.87; 95% CI 0.79-0.95; P = .001) vs nonexposure (n = 48 682) over mean follow-up periods of 37 and 29 months, respectively, with lower incidence of coronary revascularization (HR 0.85; 95% CI 0.73-0.98; P = .029), heart failure (HR 0.83; 95% CI 0.72-0.97; P = .016), unstable angina (HR 0.78; 95% CI 0.64-0.96; P = .021), and CV death (HR 0.61; 95% CI 0.41-0.90; P = .014) with PDE-5i exposure. Phosphodiesterase type 5 inhibitor-exposed men had a 25% lower incidence of overall mortality (HR 0.75; 95% CI 0.65-0.87; P < .001). Men without coronary artery disease (CAD) but with CV risk factors at baseline showed a similar pattern. In the main study cohort, men in the highest quartile of PDE-5i exposure had the lowest incidence of MACE (HR 0.45; 95% CI 0.37-0.54; P < .001) and overall mortality (HR 0.51; 95% CI 0.37-0.71; P < .001) vs the lowest exposure quartile. In a subgroup with baseline type 2 diabetes (n = 6503), PDE-5i exposure was associated with a lower MACE risk (HR 0.79; 95% CI 0.64-0.97; P = .022). CLINICAL IMPLICATIONS PDE-5is may have cardioprotective effects. STRENGTHS AND LIMITATIONS Strengths are the large numbers of participants and consistency of the data; limitations include the retrospective nature of the study and unknown confounders. CONCLUSIONS In a large population of US men with ED, PDE-5i exposure was associated with lower incidence of MACE, CV death, and overall mortality risk compared to non-exposure. Risk reduction correlated with PDE-5i exposure level.
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Affiliation(s)
- Robert A Kloner
- Huntington Medical Research Institutes, Pasadena, CA, United States.,Keck School of Medicine, Department of Medicine, Division of Cardiovascular Medicine, Los Angeles, CA, United States
| | - Eric Stanek
- HealthCore Inc., Wilmington, DE, United States.,Anthem, Inc., Indianapolis, IN, United States
| | | | | | | | - Julia Bradsher
- Huntington Medical Research Institutes, Pasadena, CA, United States
| | - Raymond C Rosen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of California, San Francisco, CA, United States
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Mykoniatis I, Pyrgidis N, Zilotis F, Kapoteli P, Fournaraki A, Kalyvianakis D, Hatzichristou D. The Effect of Combination Treatment with Low-Intensity Shockwave Therapy and Tadalafil on Mild and Mild-To-Moderate Erectile Dysfunction: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Sex Med 2022; 19:106-115. [PMID: 34866029 DOI: 10.1016/j.jsxm.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Combination of different first-line treatments for erectile dysfunction (ED) has emerged as a promising therapeutic approach. AIM To conduct the first double-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy and safety of combination therapy with low-intensity shockwave therapy (LiST) and tadalafil vs LiST and placebo in patients with mild or mild-to-moderate vasculogenic ED. METHODS Fifty sexually active patients fulfilling the eligibility criteria were randomly assigned to 6 sessions of LiST twice weekly for 3 weeks and tadalafil (n = 25) or placebo (n = 25) once daily for 4 weeks. Patients were evaluated at 1, 3, and 6 months after completion of the treatment protocol. OUTCOMES The primary outcome was the mean change from baseline in the International Index of Erectile Function-Erectile Function (IIEF-EF) domain between the 2 groups at 3 months after treatment. Erectile function was also assessed at 1 and 6 months. The number of patients attaining a minimal clinically important difference (MCID) in the IIEF-EF, as well as the safety of combination therapy were evaluated. RESULTS Adjusting for the baseline values, IIEF-EF improved by 0.8 points more (95% confidence interval [CI] = -0.2 to 1.9, P = .12) at 1 month, 1 point more (95% CI = 0.1-1.9, P = .02) at 3 months and 1.7 points more (95% CI = 0.8-2.7, P < .001) at 6 months in patients treated with combination therapy compared to monotherapy. The number of patients attaining a MCID in the IIEF-EF between the 2 groups improved significantly only at the 3-month evaluation. No adverse events were reported during the whole study period. CLINICAL IMPLICATIONS Combination of LiST twice weekly for 3 weeks and tadalafil 5 mg once daily for 4 weeks may further ameliorate mild or mild-to-moderate vasculogenic ED compared to LiST monotherapy. STRENGTHS & LIMITATIONS We conducted the first randomized trial exploring the role of LiST and tadalafil in the management of ED. Conversely, our study lacks external validity due to its single-center design. CONCLUSION The addition of daily low-dose tadalafil during application of LiST may further improve erectile function compared to application of LiST as a standalone treatment in patients with mild or mild-to-moderate vasculogenic ED. Still, further high-quality studies are warranted to corroborate our findings.
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Affiliation(s)
- Ioannis Mykoniatis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Nikolaos Pyrgidis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Filimon Zilotis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paraskeui Kapoteli
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Agrippina Fournaraki
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kalyvianakis
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Dimitrios Hatzichristou
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
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Pyrgidis N, Mykoniatis I, Haidich AB, Tirta M, Talimtzi P, Kalyvianakis D, Ouranidis A, Hatzichristou D. The Effect of Phosphodiesterase-type 5 Inhibitors on Erectile Function: An Overview of Systematic Reviews. Front Pharmacol 2021; 12:735708. [PMID: 34557099 PMCID: PMC8452927 DOI: 10.3389/fphar.2021.735708] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Multiple systematic reviews explore the effect of phosphodiesterase type 5 (PDE5) inhibitors on erectile dysfunction (ED), with each study addressing specific outcomes. However, physicians and policymakers require a holistic approach of this topic. Objective: To summarize the current evidence regarding the efficacy and safety of PDE5 inhibitors for the management of ED through an overview of systematic reviews. Methods: Studies were identified by searching PubMed, Web of Science, Cochrane Library and Scopus databases, as well as sources of grey literature until June 12, 2021 (PROSPERO: CRD42020216754). We considered systematic reviews, meta-analyses or network meta-analyses of randomized trials that provided outcomes about the efficacy and safety of any approved PDE5 inhibitor (avanafil, sildenafil, tadalafil and vardenafil). We constructed forest plots for meta-analytic effects regarding the change in erectile function, adverse events and dropouts after administration of PDE5 inhibitors in the general population and in specific patient groups. Results: We included 23 studies with 154,796 participants and a total of 258 meta-analytic effects. Sildenafil 25 mg [Weighted Mean Difference (WMD): 13.08, 95% Confidence Interval (CI): 10.1-16.06] seemed to be statistically superior to all interventions in improving erectile function compared to placebo, but studies with low-dose sildenafil are lacking. Moreover, comparing among different PDE5 inhibitors, sildenafil 50 mg or sildenafil 100 mg were considered the most effective compounds in the general population. The latter derived, however, predominantly from indirect comparisons among different PDE5 inhibitors. Still, sildenafil 100 mg was associated with more treatment-related adverse events and dropouts. Interestingly, low-dose daily tadalafil may be more effective than high-dose on-demand tadalafil (WMD: 1.24, 95% CI: 0.03-2.44). Furthermore, testosterone and PDE5 inhibitors in patients with ED and hypogonadism seem to further improve symptoms, while the addition of a-blockers in patients with urinary symptoms treated with PDE5 inhibitors does not provide additional benefits (WMD: −0.8, 95% CI: −1.65-0.06). Conclusion: Although the efficacy and safety of PDE5 inhibitors, compared to placebo, is well-documented, the existing evidence comparing different PDE5 inhibitors is low. Therefore, high-quality, head-to-head, trials comparing different PDE5 inhibitors are necessary to determine their ideal dosage and formulation based on their safety and efficacy profile. Systematic Review Registration: PROSPERO, identifier [CRD42020216754].
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Affiliation(s)
- Nikolaos Pyrgidis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Mykoniatis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Tirta
- Institute for the Study of Urological Diseases, Thessaloniki, Greece
| | - Persefoni Talimtzi
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kalyvianakis
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Ouranidis
- Department of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Department of Chemical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Hatzichristou
- Institute for the Study of Urological Diseases, Thessaloniki, Greece.,Urology Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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