Early sildenafil dose optimization and personalized instruction improves the frequency, flexibility, and success of sexual intercourse in men with erectile dysfunction.

We investigated the effect of early sildenafil dose optimization and personalized instructions on sexual intercourse success in 1109 men beginning sildenafil therapy for erectile dysfunction. In phase 1 (4 weeks), patients followed the instructions contained in the sildenafil (50 mg) sample pack and had 1.4 sexual intercourse attempts per week with 82% success. Patients (17%) had a second intercourse attempt (80% successful): 58% occurred within 4 h, 20% within 5-8 h, and 22% within 9-24 h of the first attempt. In phase 2 (4 weeks), sildenafil was adjusted as needed (53% to 100 mg, and 2% to 25 mg), and investigators provided personalized instructions to facilitate patient success. Sexual intercourse attempts increased to 1.7 per week, with 91% success, and 18% were followed by a second attempt, of which 91% were successful. Most patients requested the 100-mg dose, which helped improve sexual intercourse frequency, flexibility and success.

Transurethral resection of the prostate versus open prostatectomy: long-term mortality comparison.

To determine whether transurethral prostatectomy results in higher long-term mortality rates than open prostatectomy, we reviewed retrospectively 1,125 patients treated by transurethral and 190 treated by nonperineal open prostatectomy for benign disease at 1 institution from 1978 through 1987. Patients in whom prostatic cancer was found were excluded. We identified age, preoperative medical illnesses and urinary retention, American Society of Anesthesiologists category, type of anesthesia, length of followup, health status and cause of death. For statistical analysis the study cohort consisted of 527 patients in whom the charts were complete and followup was adequate (421 in the transurethral prostatectomy and 106 in the open prostatectomy groups). Mean age for the 2 groups was 66.3 and 67.5 years, respectively. With an average followup of 70.7 months 77% of the transurethral prostatectomy group were alive, compared to 78% of the open prostatectomy group at an average followup of 71.4 months. We found no supportive evidence that transurethral prostatectomy results in higher long-term mortality rates than does an open operation (log-rank test p = 0.74). Also, there was no significant survival difference in patients who required a preoperative Foley catheter. We also examined a subset of patients with adequate followup who had no significant medical history (for example hypertension, diabetes, heart disease and so forth) and compared them to patients with medical illnesses at prostatectomy. There was a significant survival difference between those with and without preoperative medical conditions (Wilcoxon test p = 0.047) in the transurethral prostatectomy group but not in the open group (p = 0.58). However, there was no significant survival difference between procedures among the healthiest subset of patients (p = 0.16).

The effect of acute obstruction on ureteral function.

In an effort to understand the physiologic processes which contribute to, or hinder the transport of stones through the ureter, we examined the intraluminal ureteral pressures and peristaltic activity above and below the acutely obstructed site. Because of patient differences, variability in stone size, shape and composition, an in vivo animal model was developed to study acute ureteral obstruction. Five adult mongrel dogs were anesthetized. A midline celiotomy was made and an open-ended ureteral catheter was inserted through a distal ureterotomy and advanced up the ureter. An angiographic balloon catheter was inserted through a small nephrotomy and directed down the ureter. The experiment was divided into phases: control, ureteral obstruction (balloon inflation) and release of obstruction (balloon deflation). Compared to control values, peristaltic rate above the obstruction increased significantly (p less than 0.05), as well as baseline, peak, and delta (peak minus baseline) pressures. In contrast, the peristaltic rate below the obstructed site remained approximately the same as its control, despite the significant decreases in baseline, peak, and delta (p less than 0.05) pressures. Failure of transmission of effective peristalsis across the obstructed site may hinder stone passage; however, this remains to be proven. Moreover, the failure of transmission of the increased rate of peristalsis past the balloon and persistence of peristaltic activity below the site of obstruction despite absence of urine flow suggest segmental forces influence peristaltic activity.

Percutaneous management of renal pelvic tumors: a treatment option in selected cases.

Nine patients with renal pelvic transitional cell carcinomas were selected for treatment with percutaneous resection because of a solitary kidney (3), bilateral synchronous disease (1), renal insufficiency (1), poor surgical risk (2) or preoperative evidence of a single, low grade, superficial tumor (2). Eight patients underwent second-look procedures 2 to 28 days postoperatively, at which time 6 received neodymium: YAG laser irradiation. Supplemental intracavitary therapy through the nephrostomy tube was given in 6 patients (mitomycin C in 1 and bacillus Calmette-Guerin in 5). Of those patients 2 had third-look procedures. Five patients remain free of recurrence with a followup of 3 to 28 months (mean 9.5 months). In the other 4 patients there was recurrent disease in the renal pelvis (3) or reappearance of positive cytology studies (1) 4 to 5 months postoperatively. Extrarenal tumor recurrence was not observed. Percutaneous surgery provided adequate information to assess tumor architecture, grade, invasiveness and multifocality, and the presence of contiguous mucosal abnormalities, which, along with positive cytology and a history of or concurrent tumors in other segments of the urinary tract, increased the likelihood of tumor recurrence. Second-look procedures appeared to be useful to assess the effectiveness of the initial procedure and to remove any residual disease. Our results suggest that percutaneous surgery can provide results similar to those of an open conservative operation, although further investigation is needed to determine the ultimate place of this technique.