Anti-Müllerian hormone: a novel biomarker for aggressive prostate cancer? Emerging evidence from a prospective study of radical prostatectomies

PURPOSE

Prostate cancer patients are a heterogeneous group as regards the aggressiveness of the disease. The relationship of steroid hormones with the aggressiveness of prostate cancer is unclear. It is known that the anti-Müllerian hormone (AMH) inhibits prostate cancer cell lines in vitro. The aim of this study is to investigate the relationship of AMH and steroid hormones with the aggressiveness of prostate cancer.

METHODS

This was a prospective study of consecutive radical prostatectomy patients. We measured the following hormones: total testosterone, sex hormone-binding globulin, albumin, luteinizing hormone, follicle-stimulating hormone, estradiol, dehydroepiandrosterone sulfate, androstenedione, and AMH. The minimum follow-up after radical prostatectomy was 5 years. For the aggressiveness of prostate cancer, we considered the following three variables: post-operative Gleason score (GS) ≥ 8, TNM pΤ3 disease, and prostate-specific antigen (PSA) biochemical recurrence (BCR).

RESULTS

In total, 91 patients were enrolled. The mean age and PSA were 64.8 years and 9.3 ng/dl, respectively. The median post-operative GS was 7. Low AMH blood levels were correlated with higher post-operative GS (p = 0.001), as well as with PSA BCR (p = 0.043). With pT3 disease, only albumin was (negatively) correlated (p = 0.008). ROC analysis showed that AMH is a good predictor of BCR (AUC 0.646, 95% CI 0.510-0.782, p = 0.043); a cutoff value of 3.06 ng/dl had a positive prognostic value of 71.4% and a negative prognostic value of 63.3% for BCR. Cox regression analysis showed that AMH is a statistically significant and independent prognostic marker for BCR (p = 0.013). More precisely, for every 1 ng/ml of AMH rise, the probability for PSA BCR decreases by 20.8% (HR = 0.792). Moreover, in Kaplan-Meier analysis, disease-free survival is more probable in patients with AMΗ ≥ 3.06 ng/ml (p = 0.004).

CONCLUSIONS

Low AMH blood levels were correlated with aggressive prostate cancer in this radical prostatectomy cohort of patients. Therefore, AMH could be a prognostic biomarker for the aggressiveness of the disease.

Nocturia due to nocturnal polyuria (NP). A common disorder

To the Editor, Nocturia is a significantly underestimated medical problem that affects seriously patients' quality of life, work engagement, productivity, and overall life conditions per se. Nocturia is a common condition, proven to be the most bothersome for patients with Lower Urinary Tract Symptoms (LUTS). People with two or more events of micturition per night have a significant increase in mortality rate and an increased risk of fall-related fractures if they visit the toilet two or more times per night [...].

Efficacy of fesoterodine fumarate (8 mg) in neurogenic detrusor overactivity due to spinal cord lesion or multiple sclerosis: A prospective study

AIMS

Antimuscarinic drugs are the first-line choice in the treatment of patients with neurogenic Detrusor Overactivity (nDO). Fesoterodine fumarate is the newest antimuscarinic drug. Limited data are published about the use of fesoterodine fumarate in patients suffering from neurogenic lower urinary tract dysfunction. Our study aims to determine the efficacy of fesoterodine fumarate on patients with nDO due to spinal cord lesion or multiple sclerosis (MS).

METHODS

This is an open-label prospective interventional study. Eligible patients were 18-80 years old with SCL or MS and nDO confirmed by a urodynamic study (UDS). At baseline, patients underwent a UDS to confirm nDO. Quality of life (QoL) was assessed by the Short-Form (SF) Qualiveen questionnaire. Patients received fesoterodine 8 mg/day for 3 months and were re-evaluated with UDS and SF-Qualiveen. The primary endpoint was the confirmation of the maximum detrusor pressure (P_detmax ) reduction after treatment. Secondary endpoints were: evaluation of maximum bladder capacity and compliance and QoL effect. Statistical analysis included Wilcoxon-test using SPSSv26.

RESULTS

One hundred and twenty-four patients completed the study. Ninety-five of them (76.6%) had SCL, while 29 (23.4%) had MS. P_detmax , maximum bladder capacity, and compliance had significant reduction after treatment (p < .001) in the whole group and each subgroup. SF-Qualiveen revealed a significant increase in QoL in each group (p < .001).

CONCLUSIONS

Fesoterodine fumarate (8 mg) is an efficacious drag in patients with SCL and MS, as it significantly decreases the detrusor pressure, increases the bladder capacity and compliance, and improves the QoL.

Translation and cultural adaptation of SF Qualiveen questionnaire in Greek

BACKGROUND

Most of neurologically impaired persons, who are suffering from spinal cord injury (SCI) or multiple sclerosis (MS), may face important lifestyle restrictions. Urinary disorders can further decrease their quality of life (QoL). SF Qualiveen is a validated questionnaire for the evaluation of QoL in this population related to neurogenic lower urinary tract dysfunction (NLUTD).

AIM

The cross-cultural adaptation, the reliability check, and the validation of the SF Qualiveen in Greek.

DESIGN

The design of this study was the observational cohort study.

SETTING

Between November 2019 and May 2020, we addressed to 136 consecutive neurologic patients with MS or SCI from the outpatient clinic of the Unit of Neuro-urology of the National Rehabilitation Center in Athens.

POPULATION

The study was based on 124 patients (68 males and 56 females). There were 55 paraplegics, 16 tetraplegics and 53 MS patients.

METHODS

After a back forward translation of the SF Qualiveen between English and Greek, the patients completed the Greek version of SF Qualiveen and King's Health Questionnaire at baseline and 3 months later. Reliability check and validation were performed by factor analysis with the Explanatory Factor Analysis (EFA) method. Demographic data were collected as well.

RESULTS

The Greek version of the questionnaire showed good internal consistency with Cronbach's α >70 for the total score and most of the four sub-scales for the test and retest. Test-retest reliability showed that all domains of the SF-Qualiveen (test) were correlated with the SF-Qualiveen total score (test) and the same applies to the SF-Qualiveen (retest). Domains of SF-Qualiveen (test) were poorly correlated with the domains of SF-Qualiveen (retest). Construct and criterion validity were satisfactory and CFA found that the model had good fit [χ2 (14)=19.133, GFI=0.964, NFI=0.954, RMSEA=0.055, CFI=0.987].

CONCLUSIONS

This Greek version of the SF Qualiveen was tested following well-established guidelines on measurement properties and showed good validity and reliability. It is reproducible, reliable, and valid for the Greek population.

CLINICAL REHABILITATION IMPACT

This Greek version of the SF Qualiveen can be used as a tool to evaluate the impact of NLUTD on QoL in Greek-speaking patients with MS and SCI in research and clinical practice.

Combination Therapy with Alpha-blocker and Phosphodiesterase-5 Inhibitor for Improving Lower Urinary Tract Symptoms and Erectile Dysfunction in Comparison with Monotherapy: A Systematic Review and Meta-analysis

CONTEXT

The effects of combination therapy consisted of an α-blocker and a phosphodiesterase-5 inhibitor (PDE5I) for the treatment of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED).

OBJECTIVE

To systematically investigate the efficacy and safety of combination therapy in comparison with monotherapy.

EVIDENCE ACQUISITION

The study complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and the recommendations of the European Association of Urology Guidelines office. The study was registered in the PROSPERO database with ID CRD42018086619. Only comparative prospective studies, randomized or quasirandomized, with at least one control group with monotherapy were selected for the meta-analysis. The primary endpoint was the quality of life related to LUTS and ED, measured with the International Prostate System Score (IPSS), maximum flow rate (Qmax), postvoid residual (PVR), and International Index of Erectile Function (IIEF). Secondary endpoints included the adverse events rate. In the subgroup analysis of the influence of adding a PDE5I to the treatment of LUTS, the use of different PDE5Is was considered.

EVIDENCE SYNTHESIS

After the screening of 6687 publications, 25 randomized controlled trials were considered eligible to be included in the meta-analysis. In the combination group, IPSS was lower and Qmax was higher than in the α-blocker group, with mean differences (MDs) of 1.41 (95% confidence interval [CI]: 0.42, 2.41; I² = 71%, p =  0.005) and -1.01 ml/s (95% CI: -1.58, -0.43; I² = 58%, p =  0.0006), respectively. The mean change of the IPSS was bigger in the combination group, with an MD of -1.72 (95% CI: -2.55, -0.89; I² = 37%, p <  0.0001). The mean change of Qmax was insignificant, with an MD of -0.61 (95% CI: -1.57, 0.34; I² = 63%, p =  0.21), as well as PVR and the mean change of PVR, with MDs of 0.65 (95% CI: -5.37, 6.66; I² = 76%, p =  0.83) and -20.79 (95% CI: -48.94, 7.37; I² = 75%, p =  0.15), respectively. The IIEF and the mean change of the IIEF had no difference between the combination group and the PDE5I-monotherapy group, with MDs of 1.82 (95% CI: -0.91, 4.54; I² = 40%, p =  0.19) and 0.25 (95% CI: -1.11, 1.62; I² = 47%, p =  0.72), respectively. Regarding the adverse events, the meta-analysis was in favor of monotherapy. None of the studies reported any serious or severe adverse event.

CONCLUSIONS

Treatment with combination therapy is more effective for the improvement of the IPSS. Less significant improvement was shown in Qmax. The beneficial effect of combination therapy regarding ED remains equivocal. The combination therapy seemed to be safe and well tolerated.

PATIENT SUMMARY

In this study, we review the effects of the combination therapy consisting of an α-blocker and a phosphodiesterase-5 inhibitor for the treatment of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). We found strong evidence to suggest the combination therapy for the improvement of LUTS. Benefits regarding the treatment of ED are less clear.

A Classification System for Urodynamic Evaluation of Lower Urinary Tract System Dysfunction

CONTEXT

A classification system for lower urinary tract system (LUTS) dysfunction, based on urodynamics, could support the evaluation and management of this pathological condition.

OBJECTIVE

A new alphanumerical classification system is proposed for staging neurogenic and non-neurogenic LUTS dysfunction, according to the urodynamic evaluation.

EVIDENCE ACQUISITION

This is a proposal based on experience from everyday clinical practice and represents an opinion open to discussion.

EVIDENCE SYNTHESIS

The purpose of this alphanumerical classification is the establishment of a simple, unified staging system describing all LUTS dysfunction situations, after a urodynamic evaluation, in a way that can help in diagnosis, treatment, health professionals' communication, education, and research.

CONCLUSIONS

This alphanumerical classification for LUTS dysfunction could become a unified standard and a prerequisite for ensuring the quality of care in all resource settings. Moreover, it would be useful for the future to include a classification as part of LUTS dysfunction registration.

PATIENT SUMMARY

A new alphanumerical classification system is presented. The purpose of this classification is the establishment of a simple, unified staging system describing entire lower urinary tract system dysfunction situations in a way that could help in diagnosis, treatment, health professionals' communication, education, and research.

Laparoscopic sacrocolpopexy using barbed sutures for mesh fixation and peritoneal closure: A safe option to reduce operational times

Introduction:

Laparoscopic sacrocolpopexy (LSC) has established itself as a safe method for the management of pelvic organ prolapse (POP). Laparoscopic suturing is a time-consuming intraoperative task during LSC. Self-retaining barbed sutures (SBSs) are known to reduce the operative time in laparoscopic cases. The current study aimed to evaluate the efficacy and safety of SBS during the performance of LSC.

Materials and Methods:

Twenty female patients with symptomatic POP were treated with LSC by an expert surgeon. The preoperative evaluation included the International Continence Society POP-quantification (POP-Q) and the prolapse-specific quality-of-life questionnaire Mesh fixation was performed with SBS anteriorly on the anterior vaginal wall and posteriorly on the levator ani muscle. A 5-mm titanium tacking device was used for promontofixation. The peritoneum was also closed with an SBS.

Results:

Mean patient's age was 63 years (range: 50–79 years). According to POP-Q, system 3 patients (15%) had Stage I, 12 patients (60%) had Stage II, 3 patients (15%) had Stage III, and 2 patients (10%) had Stage IV prolapse. Concomitant hysterectomy was performed in 14 patients, respectively. Mean operative time was 99.75 (range: 65–140) min, mean blood loss was 57.75 (range: 30–120) ml. One patient had a bladder perforation intraoperatively, and three patients developed transient fever postoperatively. One patient had a recurrent cystocele and three patients recurrent rectocele.

Conclusions:

The current study renders the use of SBS during LSC to be safe and efficient. Further comparative studies would elucidate the impact of the use of SBS in LSC.

Intravesical Therapies for Radiation Cystitis

Objective

The purpose of this study was to summarize developments during the last decade in intravesical treatments for radiation cystitis. Radiation used to treat pelvic malignancies inadvertently damages the urinary bladder leading to acute as well as chronic symptoms. Late sequelae may take years to develop and include storage symptoms and hematuria, which may be life-threatening in severe cases. Conservative measures, surgical interventions, and systematically or intravesically administered agents represent treatment choices.

Methods

MEDLINE and PubMed were searched to retrieve clinical data on the subject, published in peer-reviewed journals from 2002 onwards.

Results

Historically referenced intravesical treatments such as aluminium salts and formalin, were not investigated in recent studies. The replenishment of the glycosaminoglycan layer of the bladder mucosa shows promise in reducing acute symptoms and possibly long-term bladder damage, but needs further investigation. Botulinum toxin also represents a new alternative treatment for radiation cystitis but its mechanism of action and efficacy should be evaluated in future trials.

Conclusion

There is a paucity of data in recent literature regarding the management of radiation cystitis, at least by means of intravesical agents. The replenishment of the glycosaminoglycan layer of the bladder mucosa and the administration of botulinum toxin show promise, but need further investigation.

Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first-line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.

Desmopressin for the treatment of female storage lower urinary tract symptoms

Female storage lower urinary tract symptoms are prevalent and bothersome. They are usually attributed to an overactive bladder and treated with antimuscarinics. Nevertheless, failure of conventional treatment to alleviate nocturia in particular and epidemiological data suggesting that nocturnal polyuria is the only or a contributing factor to nocturia, has attracted interest in decreasing nighttime urine production as a method of managing nocturia. A reduction in urine production could also, at least temporarily, delay daytime storage symptoms by delaying bladder filling. Therefore, desmopressin, the synthetic analogue or naturally occurring antidiuretic hormone, could have a role in the management of female frequency, urgency and urgency incontinence. This work aims to review data on the use of desmopressin in females with storage symptoms. Available evidence indicates that desmopressin is efficacious in reducing nighttime urine production and episodes of nocturia, resulting in fewer sleep interruptions. This translates into improved quality of life. Desmopressin is also effective in postponing micturition, urgency and incontinence for several hours after being taken on demand. The tolerability profile of desmopressin is good and significantly improved compared to historical figures due to the introduction of new oral formulations, tailoring the dose according to gender and age and adhering to instructions for fluid restriction before administration. The incidence of hyponatremia, desmopressin’s most important side-effect, is less than 3% in recent trials. The efficacy of desmopressin, combined with its improved safety profile, makes it an interesting method for treating female storage lower urinary tract symptoms.

Correlation of ultrasound-estimated bladder weight to urodynamic diagnoses in women with lower urinary tract symptoms

OBJECTIVE

To test the hypothesis that the ultrasound-estimated bladder weight (UEBW) will correlate with the urodynamic diagnoses in women with lower urinary tract symptoms, in particular, detrusor underactivity and bladder outflow obstruction. Ultrasonography has been increasingly used in the assessment of lower urinary tract conditions.

METHODS

Adult women referred to the urodynamics suite for investigation of lower urinary tract symptoms were enrolled. After urodynamic evaluation, the portable BladderScan BVM 6500 device was used to calculate the bladder wall thickness and UEBW according to a standardized protocol. The patients were categorized according to the urodynamic findings. Women with normal findings, despite the symptoms for which they were referred, were used as the control group. The UEBW and bladder wall thickness measurements were compared between the groups and controls, using the Mann-Whitney and Kolmogorov-Smirnov tests. P <.05 was considered statistically significant.

RESULTS

A total of 187 women were enrolled. The UEBW was significantly lower in the patients with detrusor underactivity than in the controls (39.3 ± 3.0 g vs 45.7 ± 3.1 g, P <.001). Significant differences were also noted between the controls and patients with bladder outflow obstruction, with or without detrusor overactivity (45.7 ± 3.1 g vs 52.1 ± 3.9 g and 52.3 ± 6.2 g, respectively; P <.001 for both). The difference, in terms of the UEBW, between controls and patients with detrusor overactivity was not statistically significant (45.7 ± 3.1 g vs 45.3 ± 3.0, P > .05).

CONCLUSION

A significantly reduced UEBW in female patients with detrusor underactivity and a significantly increased UEBW in patients with bladder outflow obstruction were found. However, the finding of a significantly increased bladder weight in patients with detrusor overactivity was not confirmed in the present study.

The angiogenic switch for vascular endothelial growth factor-A and cyclooxygenase-2 in prostate carcinoma: correlation with microvessel density, androgen receptor content and Gleason grade

OBJECTIVE

Angiogenesis is essential for tumor growth and metastasis; however, angiogenic factors are not uniformly expressed in prostate carcinoma. Our aim was to determine the expression of vascular endothelial growth factor-A (VEGF-A) and cyclooxygenase-2 (COX-2) in prostate carcinomas in relation to intratumoral microvessel density (MVD), tumor grade and androgen receptor (AR) status.

MATERIALS AND METHODS

The expression of AR, VEGF-A and COX-2 was immunohistochemically evaluated in 24 benign prostatic hyperplasia (BPH) and 139 prostate carcinoma cases. MVD was evaluated by CD34 immunostaining.

RESULTS

Nuclear AR expression was inversely related to tumor grade (p < 0.001). MVD was strongly related to tumor grade, VEGF-A and COX-2 (p < 0.001 in all comparisons). VEGF-A expression increased with tumor grade (p < 0.01) and was inversely related to stromal AR expression. COX-2 was present in both BPH and prostate carcinoma, but its expression increased with tumor grade (p < 0.01). High-grade neoplasms presented low-to-moderate VEGF staining intensity compared to strong COX-2 expression.

CONCLUSIONS

Both VEGF-A and COX-2 expression is positively correlated with tumor grade and MVD. However, in Gleason 8-10 tumors, VEGF expression is moderate while COX-2 immunostaining is intense, suggesting a possible switch in the role of these two angiogenic factors in poorly differentiated neoplasms.

The role of antimuscarinics in the management of men with symptoms of overactive bladder associated with concomitant bladder outlet obstruction: an update

CONTEXT

This review focuses on the contemporary role of antimuscarinics in the management of men with symptoms of bladder outlet obstruction (BOO) and concomitant overactive bladder (OAB). Safety issues of antimuscarinics in this subpopulation of men are also reviewed.

OBJECTIVE

We reviewed the current literature and performed an analysis of the efficacy, suitability, and the safety of antimuscarinics in this subpopulation of men.

EVIDENCE ACQUISITION

We performed a systematic search of Medline/PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews for relevant articles published between 1990 and September 2010, restricted to studies in humans published in English. In addition, published abstracts presented at the annual meetings of the European Association of Urology, the American Urological Association, and the International Continence Society in the last decade (2000-2010) were hand-searched and evaluated. Each article's title and abstract were reviewed for their appropriateness and relevance to the use of antimuscarinics in patients with BOO and concomitant OAB. Relevant articles were fully reviewed and included in the final data acquisition.

EVIDENCE SYNTHESIS

Treatment options include combination treatment with α-blockers and antimuscarinics, sequential use of α-blockers and antimuscarinics, monotherapy with antimuscarinics, and a combination of antimuscarinics and 5α-reductase inhibitors. The sequential use of α-blockers and antimuscarinics seems to be the most appropriate approach, and the use of antimuscarinics and α-blockers appears generally to be safe and efficacious. Data are insufficient for a possible stratification of patients for a specific sequence of the drugs reviewed.

CONCLUSIONS

This review infers that the existing data confirm the safety of antimuscarinics administered for the treatment of these patients. The efficacy of antimuscarinics has been proven in different trials regarding different storage symptom end points, but not all end points regarding OAB reached significance. All the reported trials are of short duration (4-12 wk) and include only men with low postvoid residual urine volumes at baseline (<200ml). Overall, the addition of an antimuscarinic to the treatment of a patient with BOO and concomitant OAB seems to offer an amelioration of the symptoms and a moderate improvement in quality of life.

The pharmacotherapy of overactive bladder

Urinary urgency is the key symptom of overactive bladder (OAB) and often forces patients to modify their lifestyle or daily routine. The impact of OAB on quality of life is significant. Antimuscarinics, an established pharmaceutical treatment for OAB, were originally thought to affect parasympathetic efferents to the bladder; however, there is increasing evidence of an important effect on afferent pathways. Dry mouth and constipation are the most common undesirable events resulting from the use of these agents. Imipramine, a tricyclic antidepressant, is a useful drug for the treatment of OAB, especially when combined with antimuscarinic agents, although this has not been adequately assessed as yet. One result of research in this field is the upcoming introduction of beta-3 agonists in the treatment of OAB. Botulinum toxin, a minimally invasive medical treatment, represents a new era for the treatment of refractory OAB. Despite the fact that this is currently an off-label treatment, it actually represents a widespread alternative method of therapy when conventional medical treatment fails. Pharmacotherapy will continue to play a major role in the treatment of OAB in the future.

Antimuscarinics and bladder outlet obstruction: From a contraindication to an indication?

AIM

To review if the existing data support the new concept that antimuscarinic agents can be used for the treatment of bladder outlet obstruction (BOO) with coexisting overactive bladder (OAB).

METHOD

A literature search of Medline publications (up to 2008) on use of antimuscarinic agents for treatment BOO was performed and all data were presented. All relevant data from published studies in congress abstracts were as well included.

RESULTS

The existing data show that this treatment effectively improves patient quality of life. Concerns about the possibility of urinary retention were shown to be unfounded. It seems that antimuscarinic agents do not affect voiding pressures and the use of antimuscarinic agents for BOO seems safe.

CONCLUSIONS

The combination of an alpha-blocker and antimuscarinic agent for the treatment of BOO with concomitant OAB seems promising.

Efficacy of the InVance™ male sling in treating stress urinary incontinence: a three-year experience from a single centre

INTRODUCTION

The aim of this study was to evaluate the efficacy of the InVance™ male sling in treating stress urinary incontinence.

PATIENTS AND METHODS

We retrospectively reviewed operative logs from a single surgeon of 43 patients treated over a 3-year period (Feb. 2004 to Nov. 2006) for stress incontinence by implantation of a male bulbourethral bone-anchoring sling (InVance™). The mean follow-up time was 24.2 months (range 4-38). Radical prostatectomy was the most common cause of incontinence in this group (33/ 43 cases; 76.7%). Efficacy was evaluated objectively in terms of the number of pads used per day, while subjective patient satisfaction was also recorded. We also investigated a possible correlation between preoperative parameters and outcome.

RESULTS

Twenty-two patients (51.2%) were cured (totally dry: 30.2%; the remainder: 1 pad per day), while 8 (18.6%) patients improved but still required two pads per day. Overall, 30 of 43 patients (69.6%) were satisfied with the outcome of the operation. Postoperative infection was the most common complication (11.6%). The severity of preoperative incontinence correlated with the outcome of the operation, with mild incontinence giving better results.

CONCLUSIONS

The bone-anchored male sling is an effective and minimally invasive treatment for mild-to-moderate male urinary incontinence.

Long-term stability of the hydrochlorides of tramadol and alizapride in dextrose 5% polyolefin bag at 5+/-3 degrees C

OBJECTIVE

To investigate the stability of tramadol hydrochloride 100mg associated with alizapride 50mg in 100ml of 5% dextrose solution stored at 5+/-3 degrees C.

METHODS

Solutions of 5% dextrose 100ml in polyolefin bags (n=5) containing approximately tramadol hydrochloride 100mg associated with alizapride 50mg were prepared under aseptic conditions and stored about 32 days at 5+/-3 degrees C. The tramadol hydrochloride and alizapride concentrations were measured by high-performance liquid chromatography (HPLC). Visual inspection was performed and pH was measured periodically during the storage. Stability of the solutions was defined as the common regression line 95% lower confidence limit of the concentration remaining superior to 90% of the initial concentration as recommended by the Food and Drug Administration (FDA).

RESULTS

No color change or precipitation in the solutions was observed. Tramadol hydrochloride 100mg associated with alizapride 50mg in 100ml of 5% dextrose infusions was stable when stored at 5+/-3 degrees C during 32 days. Throughout this period, the lower confidence limit of the estimated regression line of concentration-time profile remained above 90% of the initial concentration. There was no significant change in pH during storage.

CONCLUSION

Under the conditions of this study, tramadol hydrochloride 100mg associated with alizapride 50mg in 100ml of 5% dextrose infusions stored up to 32 days at 5+/-3 degrees C remain stable and may be prepared in advance by a Centralized Intravenous Additive Service (CIVAS) to improve safety and management.

The use of a ureteral access sheath for the urethral dilatation and catheterization of difficult urethral strictures

BACKGROUND

Urethral catheterization can often be technically demanding due to the presence of obstructing segments within the urethra. Conventional methods attempting to restore urethral patency often are unsuccessful and traumatize the urethral lumen.

METHOD

We present an innovative technique by using a hydrophilic guidewire and a hydrophilic ureteral access sheath for the 'first-line' catheterization and management of 'difficult' urethral strictures. We used this technique in 10 extremely difficult cases of strictures present in all the urethral segments.

RESULT

The dilation was successful and atraumatic in all the cases due to the hydrophilic nature of the access sheath. In all patients, larger sizes of urethral catheters were gradually inserted within the next couple of days.

CONCLUSION

We propose 'access sheath'-assisted urethral dilatation as a safe and simple alternative for the 'first-line' catheterization and, possibly, management of 'difficult' urethral strictures.

Urethral Diverticulum: A New Complication Associated with Tension-Free Vaginal Tape

A case of a urethral diverticulum following the insertion of a tension-free vaginal tape (TVT) is presented. The patient was a woman with stress urinary incontinence who underwent surgery to correct intrinsic sphincter deficiency. Three cases of urethral diverticula have been published thus far as complications of TVT insertions, but this is the first complication associated with intrinsic sphincter deficiency. The high pressures in the proximal urethra that result from positioning the TVT in the middle urethra, especially when obstruction co-exists with an open bladder neck, can be a predisposing factor for this complication. The possibility of a urethral diverticulum when postvoid incontinence occurs after the insertion of a TVT should be carefully evaluated.

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.

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.

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.

Long-term treatment with intracavernosal injections in diabetic men with erectile dysfunction

AIM

To assess the behavior of patients with diabetes mellitus (DM) and erectile dysfunction (ED) during 10 consecutive years of treatment with self-injection of vasoactive drugs.

METHODS

Thirty-eight diabetic men, including 12 with type I and 26 with type II diabetes, were followed up regularly for 10 years after they began self-injecting for severe ED. Real time rigidity assessment was used for the objective determination of the initial dosage and then doses were regulated in order to introduce an erection suitable for penetration and maintenance of erection for approximately 30 min. Patients were followed up every two months, and doses were increased only when the treatment response was not satisfactory.

RESULTS

The number of injections used per year by the patients was reduced each year (mean numbers: 50 in the first year and 22.5 in the 10th) and treatment shifted towards stronger therapeutic modalities (mixtures of vasoactive drugs instead of prostaglandin E1 alone). Type I diabetic men were standardized to a level of treatment as early as 5 years after the initiation of treatment. That level was finally reached by type II patients after another 4-5 years.

CONCLUSION

Treatment with self-injections of vasoactive drugs in diabetic men with severe ED is a safe and effective alternative in the long term. Diabetic men of both types show the same preferences in quality and quantity of treatment after 10 years. The key point for maintenance in treatment is the adjustment of the therapeutic method and dosage to optimal levels for satisfactory erections.

Case report: laparoscopic adrenalectomy in a patient with primary adrenal malignant melanoma

We report a case of laparoscopic management of a primary malignant melanoma of the left adrenal gland. A 42-year-old male presented a 55 x 60-mm round, inhomogeneous, noninvasive mass of the left adrenal gland. Hormone-activity values were within normal range. The mass was removed laparoscopically en bloc along with the left adrenal gland, and its histopathologic evaluation was consistent with the features of a malignant melanocytic tumor. Postoperatively, the patient presented no signs of fever or remarkable blood loss and was discharged on the third day in good clinical condition. He is free of disease 1 year later.

Cost implications of antimuscarinic drugs in the treatment of overactive bladder syndrome

Overactive bladder syndrome is highly prevalent, particularly among the elderly. As well as the consequent morbidity, such as urinary infections, skin irritation and bone fractures, almost all aspects of quality of life, personal and social, are influenced. Therefore, the associated cost is substantial. Pharmacotherapy with antimuscarinics is the mainstay of treatment. Because of the good balance between efficacy, safety and tolerability, these drugs seem to be cost-effective therapeutic modalities for overactive bladder. In the milieu of a constantly ageing population, rising demand for the treatment of health conditions and the need for rational use of healthcare resources, further studies with long-term antimuscarinic drug treatment and follow-up are needed to redefine their therapeutic value.

The relationship between the perineal length measurements and the urodynamic stress incontinence

OBJECTIVE

The purpose of this study was to assess the relationship between the length of perineal body, the anal position index, the total fourchette-coccyx distance and the anal-coccyx length and female urodynamic stress urinary incontinence (USUI).

PATIENTS AND METHODS

The study included 57 women with USUI (group A) and 45 women without USUI as control (group B). All patients underwent a urodynamic evaluation and measurement of the length of perineal body (PB) and the distance between the fourchette and the inferior margin of coccyx (FC). PB is the distance between the fourchette and the center of anal orifice. The ratio PB/FC is the anal position index. Subtracting the PB length from FC distance equals the anal-coccyx (AC) length.

RESULTS

The student's t-test showed no significant statistical difference between any of the measured lengths in the two groups. Moreover, in the USUI group, ANOVA did not show any significant relationship between the urodynamic parameters and the measured lengths. Regarding to the investigated urodynamic parameters only the maximum urethral pressure (Pura max) presented a significant statistical difference between the two groups (P = 0.009).

CONCLUSION

Theoretically, a differentiation of perineal distances probably brings to the surface a laxity of the pelvic floor, a factor predisposing to USUI. Furthermore, the anterior position of anus can be a cause of constipation which also contributes to USUI. However, our study did not reveal any relationship between the perineal length measurements and USUI. Further investigation with longer series of patients is needed to show if this simple, inexpensive and non-invasive test could be added in the armamentarium of the diagnostic and prognostic investigation of USUI. Regarding to the urodynamic parameters, our results emphasize the importance of the Pura max parameter in the urodynamic evaluation of USUI.

Efficacy of the combination of an α1-blocker with an anticholinergic agent in the treatment of lower urinary tract symptoms associated with bladder outlet obstruction

The combination of an alpha1-blocker with an anticholinergic is a new and promising therapeutic approach for bladder outlet obstruction and detrusor overactivity. Both placebo-controlled and comparative studies have demonstrated that the addition of an anticholinergic in the conventional treatment of patients with bladder outlet obstruction is safe, as the likelihood of acute urinary retention is low. Although the pathophysiology of detrusor overactivity is unknown and most probably multifactorial, it is not expected that the voiding phase is influenced by regular doses of anticholinergics, although high doses may affect detrusor contraction. However, safety issues must be studied further. The combination of tamsulosin with propiverine or tolterodine, and of doxasosin with tolterodine has been shown to cause a significant improvement of lower urinary tract symptoms when compared with alpha1-blocker monotherapy. Indisputably, the existing literature provides clear evidence that the combination of an alpha1-blocker with an anticholinergic extends physicians ability to manage lower urinary tract symptoms caused by bladder outlet obstruction and overactive bladder syndrome.

Comparison of the efficacy of tolterodine and oxybutynin in different urodynamic severity grades of idiopathic detrusor overactivity

OBJECTIVE

To compare the efficacy of tolterodine and oxybutynin in the treatment of specific, according to their urodynamic grade of severity, populations with overactive detrusor.

METHODS

In this open, randomized, two-way crossover study 128 women with urodynamically confirmed, idiopathic detrusor overactivity were recruited. Patients were categorized in 4 grades of severity groups, according to the characteristics of the first overactive detrusor contraction during filling cystometrogram: high volume-low pressure (grade-group I), high volume-high pressure (grade-group II), low volume-low pressure (grade-group III) and low volume-high pressure (grade-group IV). The primary outcome measure was average volume of voided urine per micturition.

RESULTS

107 patients successfully completed the study protocol and were included in the analyses: 40 in group IV, 36 in III, 25 in II and 6 in group I. In groups IV and III both oxybutynin and tolterodine significantly increased the average volume of voided urine per micturition but the differences between the drugs were not significant (p > 0.05). In group II neither of the drugs achieved significant changes in the outcome measure (p > 0.05).

CONCLUSIONS

Tolterodine and oxybutynin are clinically equipotent in treating detrusor overactivity in specific severity groups of patients, although urodynamic effects are somewhat different.

Retroperitoneal seminoma with 'burned out' phenomenon in the testis

The rare 'burned out' phenomenon in germ cell tumors is known as the presence of an extragonadal germ cell tumor without traces of neoplasm in the testis. This condition is different and less common from the primary extragonadal germ cell malignancies. These malignancies are treated surgically with or without adjuvant chemotherapy or radiotherapy and their prognosis is better than that of other types of primary extragonadal tumors.

Vardenafil (Levitra) for erectile dysfunction: a systematic review and meta-analysis of clinical trial reports

Trials of the efficacy and safety of vardenafil in the treatment of male erectile dysfunction (ED) were meta-analysed. All available databases were searched (January 1, 2001-November 30, 2003). Trials were eligible if they included men with ED, compared vardenafil with placebo, were randomized, were at least of 12 weeks duration, and assessed clinically relevant outcomes. Two reviewers independently evaluated study quality and extracted data in a standardized fashion. Nine trials (6809 men) met the inclusion criteria. In results pooled from seven fixed-dose trials, vardenafil increases the Erectile Function domain of the International Index of Erectile Function questionnaire by 6.18 units (weighted mean difference (WMD)). Vardenafil also increases the percentage of erections firm enough to allow vaginal penetration (WMD: 26) and the percentage of sexual attempts that were successful per participant (WMD: 29.8). The percentage of men agreeing with the statement that 'the treatment they have been taking over the past 4 weeks improved their erections', is also in favour of vardenafil (relative risk (RR): 3). These efficacy variables appeared greater at higher doses, although there are no significant differences between 10 and 20 mg dose. The same results were extracted for the two flexible 'as needed' dosing trials. Discontinuations are greater at the vardenafil groups compared to placebo (RR: 2.25). Specific adverse events with vardenafil included flushing, dyspepsia, headache, and rhinitis. Vardenafil was not significantly associated with serious cardiovascular events or death. Vardenafil, in all treatment regimens, shows to possess superior efficacy to placebo in the treatment of patients with erectile dysfunction. More data is needed on patients' subgroups.

Paranephric Abscess during Pregnancy: A Case for a Low-Dose Interventional CT

A young pregnant woman hospitalized in our department with sepsis due to a paranephric abscess, and treated successfully with a nephrostomy under the guidance of low-dose CT, is presented. Based on this successful and safe treatment for the fetus, it is proposed that low-dose CT can be applied without any risk to pregnant women with special urological problems such as paranephric and splenic abscesses, dysmorphic and ectopic or horseshoe kidneys.

Efficacy of apomorphine and sildenafil in men with nonarteriogenic erectile dysfunction. A comparative crossover study

To compare the efficacy of apomorphine and sildenafil in men with nonarteriogenic erectile dysfunction (ED), 40 men were studied. Post-injection penile peak systolic velocity was greater than 25 cm s(-1). Twenty men started on apomorphine 2 mg and 20 on sildenafil 50 mg, the doses titrated up to 3 and 100 mg, respectively, if necessary. After a 1-week washout period each group switched to the other treatment mode. Efficacy was the percentage of attempts resulting in erections firm enough for intercourse, based on an event log data. The majority (85%) of the men had concomitant diseases, risk factors for ED and 95% were heavy smokers. The overall success rate of apomorphine was 62.7%, compared with 73.1% of sildenafil (Yates-corrected chi-square, P < 0.0004). The response to apomorphine 2 mg and sildenafil 50 mg was age related. Sildenafil was statistically more effective than apomorphine in impotent men with normal penile Doppler. Given the contraindication of sildenafil in men taking nitrates and the quick time of action of apomorphine, the two drugs are satisfactory first line therapeutic tools in such individuals and the choice should be based on patient's needs and preferences.

Erectile dysfunction in men with obstructive sleep apnea syndrome: a randomized study of the efficacy of sildenafil and continuous positive airway pressure

The aim of this study was to compare the efficacy of sildenafil and continuous positive airway pressure (CPAP) in men with erectile dysfunction (ED) and obstructive sleep apnea syndrome (OSAS). In all, 30 men were randomly treated for 12 weeks either with sildenafil 100 mg before intercourse (15 men) or CPAP during night time sleep (15 men). Under sildenafil, 97/180 (53.9%) of attempted intercourses were successful compared to 33/138 (23.9%) under CPAP. The mean IIEF (erectile function domain score) was 12.9 and 9.3 after sildenafil and CPAP treatment, respectively (P=0.007), compared to 7.9 and 7 at baseline. In all, 53.3% of patients were satisfied with sildenafil and 20% with CPAP for ED treatment (P=0.058). Although sildenafil was superior to CPAP, comorbidities and OSAS per se possibly resulted in a lower effectiveness of sildenafil compared to that in the general population of ED men. While about half of the patients were not satisfied even with the more effective treatment, we conclude that a combination of the two therapeutic tools or a different therapeutic mode should be studied further.