Reliability of efficacy in men with erectile dysfunction treated with tadalafil once daily after initial success.

The reliability of response to treatment is an important component of erectile dysfunction (ED) treatment. This study examined the reliability of tadalafil once daily (that is, successful attempts/total attempts) following initial successful intercourse. Data pooled from two randomized, double-blind, placebo-controlled trials of men with ED who received tadalafil 2.5 mg (N=96), tadalafil 5 mg (N=206) or placebo (N=148) once daily were analyzed to determine the first-attempt success rate and subsequent reliability of response. The first-attempt success rate (Sexual Encounter Profile question 3 (SEP3)) was significantly higher among men taking tadalafil 2.5 mg (45.7%) and 5 mg (55.2%) compared to placebo (28.5%; P<0.05 and P<0.001, respectively). Furthermore, following initial success, men taking tadalafil 5 mg had a significantly greater proportion of successful intercourse (SEP3) on subsequent attempts (85.9%, P<0.001) compared to men taking placebo (70.2%). Overall, men with ED taking tadalafil once daily experienced a high rate of reliability of efficacy.

Use of oral ketoconazole to prevent postoperative erections following penile surgery.

Analgesics and topical agents ineffectively inhibit painful erections after penile and urethral surgery. Oral ketoconazole reversibly inhibits testosterone production and has been used empirically at our institution to decrease postoperative erections. We performed a retrospective review of 38 patients who had undergone penile and urethral reconstructive surgery. In all, 31 patients received 400 mg of ketoconazole three times daily for 10-14 days postoperatively (the study group) and seven patients did not receive ketoconazole (the control group). The incidence of postoperative erections, pain, side effects, surgical outcomes and patient satisfaction in each group were compared. Of the control group, 71% reported erections in the immediate postoperative period, and all these patients reported the erections were painful. Only 23% of the patient taking ketoconazole reported postoperative erections, and only 16% reported the erections were painful. We conclude that ketoconazole effectively prevents painful postoperative erections with minimal side effects.

Characterization of patients presenting with male factor infertility in an equal access, no cost medical system.

OBJECTIVES: Demographic information on patients presenting for the diagnosis and treatment of male factor infertility has been limited in the past by the paucity of subspecialty trained providers and concentrated sequential patient information. Previously reported studies looking at the characteristics of patients being evaluated for male subfertility may represent a selected subset of patients able to access these services. The changes in the diagnostic modalities available in the 1990s and new diagnostic categories may also affect the characterization of patients seen with the diagnosis of male factor infertility. METHODS: A retrospective analysis was performed using a centralized database of patient records at a single military male infertility clinic. Seven hundred consecutive patients were studied to obtain information on patient and spouse age, race, length of subfertile period, medical history and examination, and laboratory evaluation. A single provider categorized the etiology of male factor infertility after the evaluation. RESULTS: The mean patient age was 36 years (range 17 to 68). The mean spouse age was 31.2 years (range 19 to 50). The mean subfertile period was 5.5 years (range 0.5 to 35). Of the 700 patients, 51% were white, 10% African American, 2% Hispanic, and 37% other/unknown. Eleven percent of the patients were active smokers. The most common etiologic category groups describing male subfertility were previous vasectomy (56%), varicocele (14%), idiopathic infertility (8%), and nonobstructive azoospermia (6%). CONCLUSIONS: An equal access, no cost medical system mirrors the demographics of the military population served. The clinical characteristics of patients presenting with male factor infertility have changed significantly during the past 30 years. Obstruction from a previous vasectomy is now the most common presenting complaint of patients visiting an infertility clinic. Vasectomy reversal may be more frequently requested when the cost is not a factor in providing fertility services. Idiopathic male factor infertility occurs in less than 10% of patients.

The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old.

PURPOSE: Testicular microlithiasis is an imaging entity of the testicle thought to be a marker of testicular cancer. To our knowledge the prevalence of testicular microlithiasis in an asymptomatic population at risk for testicular cancer is unknown. We report an ultrasound screening study done to establish the prevalence of testicular microlithiasis in an asymptomatic population. MATERIALS AND METHODS: Healthy men 18 to 35 years old from the annual Army Reserve Officer Training Corps training camp volunteered for study. A screening genitourinary history was obtained, and physical examination and screening scrotal ultrasound were performed. We defined testicular microlithiasis as more than 5 high intensity signals on ultrasound with each signal larger than 2 mm. We categorized testicular microlithiasis into microcalcifications that were scant-5 to 25 per side, moderate-greater than 25 per side but no areas of near confluence and too numerous to count. In all subjects with testicular microlithiasis tumor markers were also measured. RESULTS: Of 1,504 evaluated men with a mean age of 22.4 years, 84 (5.6%) had testicular microlithiasis, including 45 of 1,053 white (4%), 21 of 149 black (14.1%), 6 of 71 Hispanic (8.5%), 3 of 54 Asian or Pacific Island (5.6%) men and 9 of 174 (5.2%) who claimed no race affiliation. Tumor markers were normal in all subjects with testicular microlithiasis. CONCLUSIONS: Testicular microlithiasis occurs in more than 5% of healthy young men. In contrast, testicular cancer develops in 3/100,000 to 5/100,000 men or 1,000-fold less often. The relative prevalence of testicular microlithiasis with respect to testicular cancer, increased prevalence in minorities, bilateral distribution, and inverse geographic distribution of men with testicular microlithiasis and testicular cancer represent evidence against an association of the 2 conditions. This study indicates that testicular microlithiasis is a common finding in asymptomatic men that may not be related to testicular cancer.

Surgical treatment of lung cancer invading chest wall: a retrospective analysis of 110 patients.

OBJECTIVE: To retrospectively assess the results of surgical treatment in a consecutive series of 110 patients with Stage IIb and IIIa non small cell lung cancer (NSCLC) invading chest wall. METHODS: A series of 110 patients underwent surgery for Stage IIb and IIIa NSCLC with involvement of chest wall. There were 101 male and 9 female patients, mean age was 61.4 (range 32--74), 52 (47.3%) of them complaining for chest pain. Surgical procedures were pneumonectomy in seven patients (6.4%), lobectomy in 73 (66.4%), bi-lobectomy in six (5.4%) and wedge resection in 24 (21.8%). In 63 patients (57.3%) an extrapleural resection was performed while in the other 47 (42.7%) an 'en bloc' resection of tumor with chest wall was required. In 22 patients (76.3%) repair was achieved by muscle flap while in 8 (26.7%) a prosthesis was required. Five-year survival was computed using the Kaplan--Meier method; P values correspond to the log-rank test. RESULTS: There were neither intraoperative nor postoperative deaths. Postoperative staging revealed 83 T3N0M0, 17 T3N1M0 and 10 T3N2M0. Mean postoperative hospital stay was 17.7 days (range 5--40). For N0 patients 5 year survival was 47% (39/83) and no significant difference was noted when extrapleural and 'en bloc' resection groups were compared (P = 0.08). In N1/N2 patients no survival was observed (0/27) and comparison between surgical procedures was not statistically significant (P = 0.41). Moreover when N0 patients were compared with N1 patients the difference in survival was significant for both extrapleural (P = 0.02) and 'en bloc' (P = 0.04) groups. No difference was noted when the two surgical procedures were compared independently form N status (P = 0.94). Within the group of patients undergone 'en bloc' resection survival was significantly better for N0 patients as in the group of extrapleural resection. CONCLUSION: Surgical treatment of Stage IIb and IIIa NSCLC invading chest wall by extrapleural or 'en bloc' resection is widely adopted and justified by the good results in terms of morbidity and relief of pain. Survival is always depending on the N status.

Changing trends in partial nephrectomy at Walter Reed Army Medical Center.

PURPOSE: To evaluate the change in indications, frequency, complications, and outcome in patients undergoing partial nephrectomy at a single institution during a 25-year period. MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent partial nephrectomy at Walter Reed Army Medical Center from 1970 to 1995. A total of 309 patient records were reviewed for patient age, sex, and primary diagnosis. A more detailed analysis was performed on 47 records of patients who underwent partial nephrectomy from 1986 to 1996. RESULTS: The number of partial nephrectomies declined from the 1970s to the 1990s, demonstrating the trend away from nephron-sparing surgery for benign disease. Partial nephrectomies for renal cell carcinoma increased during the same period. Fifty-seven percent (12 of 21) of patients from 1986 to 1996 underwent partial nephrectomy for incidentally discovered renal tumors. Complications occurred in 25% (11 of 44) of patients, with acute renal insufficiency occurring in 4.5% (2 of 44). Twenty-two of 25 patients who underwent partial nephrectomy for renal cell carcinoma were followed for a mean of 45.6 months. The cancer-specific 5-year survival rate for partial nephrectomy was 88.1%. CONCLUSION: Trends in nephron-sparing surgery showed a movement away from performing ablating surgery for benign disease and toward nephron-sparing surgery for renal masses. Despite a higher complication rate, the curative ability of partial nephrectomy is similar to that of radical nephrectomy.

The development of erectile dysfunction in men treated for prostate cancer.

PURPOSE: Erectile dysfunction is a common side effect in men treated for prostate cancer. Previously published studies document the incidence of erectile dysfunction in men treated for prostate cancer to be between 20% and 88%. To our knowledge a prospective evaluation focused on the development of erectile dysfunction in men treated for prostate cancer has not elucidated components of its chronology or risk factors. MATERIALS AND METHODS: A centralized prospective database of 2,956 patients diagnosed with prostate cancer at a single institution was studied in regard to pretreatment and posttreatment erectile dysfunction. Of these 2,956 patients 802 had sufficient information regarding erectile function and comprise our study population. Factors analyzed in regard to treatment and erectile dysfunction include treatment modality, that is radical prostatectomy, external beam radiation therapy and watchful waiting, and ethnicity, patient age, clinical stage and tumor histological grade. RESULTS: No significant difference was noted in the posttreatment erectile function between patients treated with radical prostatectomy or external beam radiation (10% versus 15%). Patients selecting watchful waiting had the lowest risk of erectile dysfunction. Clinical stage and race were significant predictors for the development of erectile dysfunction in the watchful waiting and external beam radiation treatment groups. CONCLUSIONS: Erectile dysfunction develops in greater than 80% of patients treated for prostate cancer. External beam radiation has the same risk for erectile dysfunction as radical prostatectomy.

Cancer and male sexual dysfunction.

Many men with cancer develop erectile dysfunction during treatment of their malignancy. Erectile dysfunction in these patients often has multiple causes, both physiologic and psychological. Various treatment options, including mechanical/surgical approaches and pharmacologic agents, are available to treat erectile dysfunction. Recent elucidation of the mechanism of erection at the organ, cellular, and molecular level have led to effective new local and systemic treatments. The successful treatment of erectile dysfunction depends on the provider's thorough knowledge of the mechanism of erection and the various available therapies. This article provides an overview of the pathophysiology and evaluation of erectile dysfunction, as well as useful treatment regimens.

Oral trazodone is not effective therapy for erectile dysfunction: a double-blind, placebo controlled trial.

PURPOSE: The unusual side effect of priapism associated with the antidepressant trazodone has led researchers to evaluate its use for the treatment of erectile dysfunction. Previous studies have shown nearly 70% efficacy in patients. Unfortunately, these studies have been anecdotal, retrospective or of combination therapy with yohimbine. A placebo controlled, fixed dose, double-blind crossover study was performed to evaluate the safety and efficacy of oral trazodone for the treatment of erectile dysfunction. MATERIALS AND METHODS: A total of 51 patients with at least 3 months of complete erectile dysfunction were randomized in a double-blind fashion to receive 50 mg. trazodone or placebo at bedtime. Evaluation consisted of a history, physical examination and laboratory studies, including hormonal evaluation, nocturnal penile tumescence evaluation, penile Doppler ultrasound and the Index of Sexual Satisfaction. Patients were followed at monthly intervals with an in clinic interview. After a 3-month treatment interval patients were reevaluated with index scores and crossed over after a 3-week washout period. Study end points included patient diary evaluations and index scores at the beginning of the study interval and the end of the first treatment period. RESULTS: Of the 51 patients who enrolled in the study 48 completed both phases. Mean patient age was 65 years (range 31 to 80). After the first 3-month treatment interval 19% of patients receiving trazodone had improved erections compared to 24% receiving placebo (p < 0.50). Of the trazodone group 35% had improvement in sex drive compared to 20% of the placebo group (p < 0.36). Mean Index of Sexual Satisfaction scores changed after treatment from 31.7 to 27.5 for the trazodone group (p < 0.50) and from 28.5 to 30.8 for the placebo group (p < 0.49). Side effects included drowsiness in 31% of the patients, dry mouth in 1% and fatigue in 19%. CONCLUSIONS: Trazodone is no more effective than placebo in improving erections and sexual function in patients with severe physiological erectile dysfunction.

Alprostadil for the treatment of erectile dysfunction.

Erectile dysfunction (ED) is a common medical condition affecting over 20 m men in the United States. Efficacious medical therapy for the treatment of erectile dysfunction has been available since the early 1980s and can be divided into local pharmacotherapy and systemic therapy. Alprostadil, a synthetic form of prostaglandin E1, is a useful local pharmacotherapeutic agent for the treatment ED. Alprostadil is presently available for administration as an intracavernosal injection or an intraurethral suppository. Local alprostadil therapy is effective at restoring the ability to participate in intercourse in up to 70% of men with ED. The principle side-effects of alprostadil are local, with few systemic reactions. The mechanism of alprostadil, its efficacy in clinical trials and side-effects are examined to outline the utility of alprostadil for the treatment of ED.

Endoscopic and surgical palliation of esophageal cancer.

BACKGROUND: Esophageal carcinoma is frequently diagnosed at an advanced stage. Therefore for most patients either surgical or endoscopic palliation with or without radiochemotherapy may be taken into consideration. This retrospective study analyzes immediate and long term results of perendoscopic treatment in patients with unresectable esophageal cancer. Moreover a comparative analysis has been made with a group of patients who underwent palliation surgery. METHODS: From 1982 to 1998 458 patients with esophageal cancer underwent palliation perendoscopic disobstructive treatment (427 patients), palliation surgery (29 patients) and dis-obstruction followed by perendoscopic gastrostomy (2 patients). Among patients treated by perendoscopic procedures, 18 underwent dilation, 53 dilation and radiotherapy, 236 stent implantation, respectively of the plastic (102) and self-expandable metallic (134) type. 120 patients underwent NdYAG laser treatment. RESULTS: The results for patients who underwent perendoscopic procedures are referred to as regards the first 30 days after treatment and on the long run in terms of grade of dysphagia according to Visick's scale. For the group of patients undergoing simple dilation we had an improvement (from Visick III-IV to I-II) in 33% of cases and in 54.7% when radiotherapy was added. Far better results were achieved in all groups undergoing stent implantation, with or without brachytherapy, and NdYAG laser treatment with or without previous chemical necrolysis (range 90.3-100%). Most frequent complications were obstruction and stent displacement. Mean survival was better for patients undergoing laser recanalisation (7.2 months) while among stents the metallic type has given better results than plastic ones both for survival (6.2 vs 5.9 months) and mortality (2.4 vs 4.9%). Comparison with the group undergoing palliation surgery has shown that mean survival is the same for patients undergoing jejunostomy or gastrostomy while it is significantly better for patients undergoing palliation resection or by-pass surgery compared with those treated by stent implantation or laser recanalisation. CONCLUSIONS: The palliation treatment of patients with esophageal and cardial carcinoma is still a complex problem as far as therapeutic strategy is concerned. The best palliation is surgery even though characterized by a greater morbidity and mortality compared with perendoscopic techniques that may represent, in selected cases, a suitable alternative.

Successful treatment of stutter priapism with an antiandrogen.

Recurring periods of prolonged erections in patients with sickle cell disease (stutter priapism) are uncommon, yet troubling sequelae of hemoglobinopathies. Medical or surgical therapy is variably successful in these men. We report a case of stutter priapism successfully treated with an oral antiandrogen.

Efficacy and safety of transurethral alprostadil in patients with erectile dysfunction following radical prostatectomy.

PURPOSE: A retrospective analysis of the MUSE clinical trial was performed to evaluate the efficacy and safety of transurethral alprostadil in patients with erectile dysfunction after radical prostatectomy. MATERIALS AND METHODS: Patients received doses of transurethral alprostadil in the clinic and those for whom a suitable dose was determined were treated at home with active drug or placebo for 3 months. Patients had undergone radical prostatectomy no less than 3 months before study entry. RESULTS: Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction 70.3% had an erection believed sufficient for intercourse in the clinic and 57.1% on active medication had sexual intercourse at least once at home. The product of clinic and home success rates (70.3 x 57.1%) was an overall success rate (the likelihood of active treatment to lead to intercourse at home) of 40.1%. The frequency of most adverse effects of radical prostatectomy was comparable to that of other organic etiologies of erectile dysfunction (1,127 patients). The percentage of patients with hypotension in the clinic was lower after radical prostatectomy compared to other erectile dysfunction etiologies (0.8 versus 4.2%, p < 0.001) but the percentage of patients with urethral pain/burning was higher (18.3 versus 10.4%, p = 0.027). No urinary tract infection, fibrosis or priapism occurred in the post-radical prostatectomy patients. CONCLUSIONS: Transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy, although psychological changes associated with cancer and surgery may limit home response. The severe neurovascular deficit associated with prostatectomy neither limits the efficacy of transurethral alprostadil nor increases the risks.

Cancer and male factor infertility.

With the increasing success of multimodality anticancer therapy, most men of reproductive age will survive their malignancy. Reproductive function is a principal concern of these men. Health-care providers are shifting the focus of oncologic care toward improving the quality of life in cancer patients, particularly with regard to fertility. For unknown reasons, fertility and sexual function are adversely affected in men with germ cell tumors and Hodgkin's disease prior to the initiation of therapy. Despite these pretreatment abnormalities, fertility potential remains good. Cancer therapy utilizing physical and chemical treatment methods can temporarily or permanently damage spermatogonia, resulting in azoospermia and infertility. Recovery of spermatogenesis can take up to 10 years after therapy. Alternative treatment regimens can preserve reproductive function while maintaining high therapeutic efficacy. Surgical treatment should be directed toward maintaining the neurovascular mechanisms responsible for seminal emission and ejaculation. With new developments in assisted reproductive techniques, even cancer patients with severe oligoasthenospermia can father children. These techniques have not been found to increase the incidence of major or minor birth defects.

The effect of human chorionic gonadotropin on methotrexate concentration in the rat testes.

PURPOSE: We analyzed the effect of human chorionic gonadotropin (hCG) on drug concentrations in testicular interstitial fluid and whole testis tissue samples in rats receiving hCG prior to methotrexate (MTX) administration and in animals that did not receive hCG. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were injected subcutaneously with 200 i.u. hCG (Goldline Laboratories, Ft. Lauderdale, FL.). Controls were injected subcutaneously with normal saline (0.2 cc). Sixteen hours after injection, each rat was given methotrexate (Methotrexate LPF, Immunex Corp. Seattle WA.) via a carotid artery cannula in a dose of 30 mg./kg. Methotrexate (MTX) levels were collected 60 minutes post infusion time in 27 rats and 90 minutes post infusion in 27 rats. MTX levels were measured in serum, testicular interstitial fluid and testicular tissue. MTX levels were measured using high performance liquid chromatography (HPLC). RESULTS: A significantly higher concentration of MTX was found in testicular interstitial fluid (TIF) in rats injected with hCG when specimens were collected 60 minutes post infusion. MTX levels in TIF had reversed 90 minutes post infusion with higher levels found in control rats. Tissue levels of MTX demonstrated no significant difference at either 60 or 90 minutes in the hCG treated animals or controls. CONCLUSION: Our results suggest that hCG effects the tissue distribution of MTX within the testis. Human chorionic gonadotropin may have this effect on the testicular microvasculature by 1) selectively increasing capillary permeability, 2) increasing lymphatic flow within the testes or 3) increasing testicular blood flow.

Intracranial metastatic adenocarcinoma of the prostate presenting as visual disturbance.

We report two cases of intracranial metastatic adenocarcinoma of the prostate that presented with visual disturbance. The two patients had no prior history of prostate cancer and both underwent invasive neurosurgical procedures. Progressive neurological decline mandated craniotomy in one patient and the other patient underwent transphenoidal surgery for biopsy. Androgen deprivation therapy was instituted postoperatively for both patients when prostate cancer was determined to be the source of the metastatic lesions.