Does hormonal therapy influence sexual function in men receiving 3D conformal radiation therapy for prostate cancer?

PURPOSE: We evaluated the effect of three-dimensional conformal radiation therapy (3D-CRT) with or without hormonal therapy (HT) on sexual function (SF) in prostate cancer patients whose SF was known before all treatment. METHODS AND MATERIALS: Between March 1996 and March 1999, 144 patients received 3D-CRT (median dose = 70.2 Gy, range 66.6-79.2 Gy) for prostate cancer and had pre- and post-therapy SF data. All SF data were obtained with the O'Leary Brief SF Inventory, a self-administered, multidimensional, validated instrument. We defined total sexual potency as erections firm enough for penetration during intercourse. Mean follow-up time was 21 months (SD +/- 11 months). The Wilcoxon signed-rank test was used to test for significance of the change from baseline. RESULTS: Before 3D-CRT, 87 (60%) of 144 men were totally potent as compared to only 47 (47%) of 101 at 1-year follow-up. Of the 60 men totally potent at baseline and followed for at least 1 year, 35 (58%) remained totally potent. These changes corresponded to a significant reduction in SF (p < 0.05). Patients who had 3D-CRT alone were more likely to be totally potent at 1 year than those receiving 3D-CRT with HT (56% vs. 31%, p = 0.012); however, they were also more likely to be potent at baseline (71% vs. 44%, p = 0.001). Although these two groups had a significant reduction in SF from baseline, their change was not significantly different from each other. CONCLUSION: These data indicate that 3D-CRT causes a significant reduction in total sexual potency as compared to pretreatment baseline. The addition of HT does not appear to increase the risk of sexual dysfunction.

Sildenafil citrate effectively reverses sexual dysfunction induced by three-dimensional conformal radiation therapy.

OBJECTIVES: We evaluated the response of sildenafil citrate in patients with prostate cancer treated with three-dimensional conformal radiation therapy (3DCRT) whose sexual function (SF) was known prior to therapy initiation. METHODS: From March 1996 to April 1999, 24 men with median age of 68 years (range 51 to 77) had 3DCRT for localized prostate cancer (median prescribed dose to the planning target volume of 70.2 Gy). These men started taking sildenafil for relief of sexual dysfunction at a median time of 1 year after completing 3DCRT. We used the self-administered O'Leary Brief Sexual Function Inventory to evaluate in series SF and overall satisfaction at three time points. These points were (a) before initiation of all therapies (3DCRT or hormonal treatment [HT]) for prostate cancer, (b) before starting sildenafil (50 mg or 100 mg) but after completion of all therapies, and (c) at least 2 months afterward. Rates of SF were based on the number of men responding to a given question. We tested for significance of these two interventions to change SF by applying the Wilcoxon sign rank test. RESULTS: Prior to all treatments, 20 (87%) of 23 men were sexually potent, with 8 (36%) of 22 fully potent (little or no difficulty for penetration at intercourse). After 3DCRT with or without HT and prior to sildenafil use, 13 (65%) of the 20 potent patients remained potent, with only 2 (11%) of 19 being fully potent. The use of sildenafil citrate resulted in 21 (91%) of 23 men being potent, with 7 (30%) being fully potent. In 16 men responding to the satisfaction question, 10 (63%) and 12 (75%) were mixed to very satisfied with their sex life before 3DCRT with or without HT and after sildenafil citrate use, respectively. This response corresponded to potency and satisfaction scores significantly decreasing and subsequently increasing on average by one unit after 3DCRT and sildenafil citrate use, respectively (P <0.05). CONCLUSIONS: In men receiving 3DCRT for prostate cancer, these data indicate that sildenafil citrate is effective for restoring SF and associated satisfaction back to baseline before treatment.

Transurethral microwave thermotherapy of the prostate without intravenous sedation: results of a single United States center using both low- and high-energy protocols. TJUH TUMT Study Group.

PURPOSE: Previous studies have indicated that high-energy transurethral microwave thermotherapy (TUMT) requires intravenous (IV) sedation and/or narcotics for patient tolerance. This study was performed to determine tolerability, patient acceptance, and efficacy of TUMT using both low- and high-energy protocols in a single United States university setting. MATERIALS AND METHODS: Between August 11, 1997 and October 28, 1999, 210 men (mean age 64.9 +/- 9.1 years) presenting with symptomatic benign prostatic hyperplasia (BPH) received treatment with a Prostatron TUMT using either the low-energy Prostasoft 2.O or high-energy Prostasoft 2.5 software. Each patient had digital rectal examination and prostate-specific antigen level consistent with BPH, American Urological Association symptom score > or = 15, and Qmax <15 mL/s. Each patient received TUMT with only ibuprofen 400 mg by mouth (PO), lorazepam 1.0 mg PO, and ketorolac 30 mg intramuscularly (IM) prior to TUMT. A few patients who were concerned about limited pain threshold received oxycodone 5 mg/acetaminophen 325 mg PO. Of 210 patients treated, 12-month efficacy data were available for analysis in 80 patients. RESULTS: Forty-eight men (mean age 65 +/- 9.2 years) received low-energy 2.0 software TUMT, and 32 men (mean age 65.1 +/- 9.2 years) were treated with high-energy 2.5 software. Mean prostatic volume was 44.3 +/- 23.9 mL and 60.7 +/- 26.4 mL for the 2.0 and 2.5 groups, respectively. Mean energy delivered was 108.8 +/- 50.4 kJ and 173.1 +/- 41.1 kJ for the 2.0 and 2.5 treatment groups, respectively. International Prostate Symptom Score decreased from 23 pre-TUMT to 8 post-TUMT and 21 pre-TUMT to 10 post-TUMT at 12 months in the 2.0 and 2.5 groups, respectively. Mean peak flow rate improved 31.9% from 9.1 mL/s pre-TUMT to 12.0 mL/s post-TUMT and 45.8% from 9.6 mL/s pre-TUMT to 14.0 mL/s post-TUMT at 12 months in the 2.0 and 2.5 groups, respectively. All but two patients tolerated treatment without IV sedation. One patient experienced intolerable rectal spasm, and treatment was terminated in another patient because of poorly controlled hypertension. CONCLUSIONS: Patients can be treated safely with TUMT using either low or high energy, with almost universal patient tolerance and without the need for IV sedation or narcotics, if they premedicated effectively using a PO/IM regimen. Patients experience significant relief of symptoms whether low- or high-energy TUMT is used; however, high-energy TUMT improves flow rate to a greater extent than does low-energy therapy.

Glandular-tunical stabilization to repair SST deformity of the inflatable penile prosthesis.

Among the complications of penile prosthetic surgery, the SST deformity is uncommon. Nonetheless, this functional and cosmetic complication affects patient and partner. We describe a modified corrective technique of glandular stabilization and repositioning specifically designed for the inflatable penile prosthesis. The pericoronal glandular fascia is secured to the tunica albuginea by protecting the underlying inflatable cylinder and avoiding tunical plication. This technique minimizes the risk of cylinder perforation and penile sensory loss and foreshortening.

Testis biopsy findings in the spinal cord injured patient.

PURPOSE: Azoospermia after electroejaculation in spinal cord injured men may be due to testicular failure or obstruction. These men can initiate pregnancy with assisted reproductive techniques, such as intracytoplasmic sperm injection, but only if sperm are present in the testis biopsy. We analyzed the histopathology of testis biopsies from spinal cord injured men and assessed whether patient factors were predictive of testis biopsy pathology. MATERIALS AND METHODS: A total of 50 paraplegic men undergoing testis biopsy were divided into 2 groups based on normal or abnormal testis histopathology. Patient age, post-injury years, level of lesion, hormonal status and semen analysis results were compared. RESULTS: Spermatogenesis was normal in 28 of the 50 patients. Hypospermatogenesis was exhibited in 15, maturation arrest at the spermatid stage in 6 and maturation arrest at the spermatocyte stage in 1 of the 22 abnormal cases. Nevertheless, mature sperm were identified in 43 of 50 biopsies (normal spermatogenesis and hypospermatogenesis). Men with normal spermatogenesis had better forward progression of sperm and a higher testosterone-to-luteinizing hormone ratio. Otherwise, there was no statistically significant correlation between study variables and testis biopsy results. No factors were predictive of testis biopsy histopathology. CONCLUSIONS: The documentation of mature sperm in 43 of 50 biopsies from spinal cord injured patients suggests that a high rate of sperm retrieval is possible using testicular sperm extraction if sperm cannot be retrieved from the ejaculate. With intracytoplasmic sperm injection techniques the majority of spinal cord injured men retain fertility potential, even if azoospermic following electroejaculation.

Gunshot wound to the penis: the need for corporal exploration.

Although the overall incidence of penetrating penile injuries is relatively low, these injuries may present complex management problems and should be managed with attention to long-term cosmetic and functional considerations. In this article we present an unusual case of a gunshot wound to the penis and emphasize the importance of bilateral corporal exploration and possible repair to avoid erectile dysfunction and penile deformity.

Are sperm motion parameters influenced by varicocele ligation?

OBJECTIVE: To document objectively, improvements in sperm motion parameters in subfertile men after varicocele ligation with the use of computer-aided sperm analysis. DESIGN: Retrospective chart review. SETTING: An academic clinical environment. PATIENT(S): Thirty-four men with varicocele as the primary cause of infertility who underwent a physical examination, hormonal profile, and Doppler ultrasound evaluation. INTERVENTION(S): Computer-aided sperm analysis was performed before and after either subinguinal or laparoscopic varicocele ligation. MAIN OUTCOME MEASURE(S): Patients were followed up for 3-18 months after operation, and average computer-aided sperm analysis values were obtained before and after operation. Computer-aided sperm analysis values were analyzed by paired Student's t-test, with special reference to motility and sperm motion parameters. RESULT(S): After varicocele ligation, patients demonstrated increases in mean sperm density and in the overall distribution of sperm with rapid velocity, although the increases were not statistically significant. Mean measures of straightness, linearity, and track speed also were increased after operation, but only progressive sperm velocity was increased to a statistically significant level. CONCLUSION(S): Because progressive velocity has been a primary computer-aided sperm analysis parameter predictive of male fertility and the success of assisted reproductive techniques, we conclude that varicocele ligation results in improvements in semen parameters, especially the key parameter of progressive sperm velocity.

Spermatogenesis in early and chronic phases of experimental spinal cord injury in the rodent model.

A rodent model was used to study the degree and dynamics of potential spermatogenic alterations during both acute and chronic phases after experimental spinal cord injury (SCI). Sexually mature Sprague-Dawley rats underwent controlled impact SCI by exposure of the thoracic spine, T-10 laminectomy, and intraoperative somatosensory-evoked potential latency and amplitude. A 50 gm-cm SCI was produced in 35 experimental subjects. Sham surgery was performed on 16 control subjects through exposure of the dura without weight drop. SCI was verified by obliteration of the somatosensory-evoked potential following injury and subsequent neurologic assessment (modified hindlimb Tarlov scale) 4 weeks after injury. Flow cytometry with acridine orange as the DNA probe was used to measure potential spermatogenic alterations in testicular cell development and integrity of epididymal sperm chromatin structure between 2 and 20 weeks following SCI. Flow cytometric analysis revealed that nine of the 35 SCI animals demonstrated altered spermatogenesis; it is not clear whether these effects are specific or nonspecific stress related. These responder animals contributed to dramatic differences in relative percent testicular haploid cells (spermatids) and concurrent differences in percent diploid cells at 2, 4, 8, 12, and 16 weeks. Percentages within the three spermatid populations (round, elongating, and elongated) also differed at these time points. The sperm chromatin structure assay (SCSA) revealed significant epididymal sperm nuclear structure differences at 2, 4, and 12 weeks (P < 0.001). These findings are in concordance with our clinical observations of spermatogenesis in spinal cord injured men and suggest that significant spermatogenic deficit may occur, even in the early phase of injury.

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome.

The Ultrex and Ultrex Plus penile prosthesis incorporate sequential design modifications that afford important functional advantages that reduce the potential for mechanical failure. This retrospective study reviews our experience with these models emphasizing innovations in surgical technique and postoperative results. Implantation of Ultrex (31%) and Ultrex Plus (69%) penile prosthesis was performed in 90 impotent men with organic erectile dysfunction following comprehensive multi-disciplinary evaluation. During a follow-up interval of 7-50 months, postoperative outcome was assessed. Of this group, 10% underwent simultaneous explant of another malfunctioning inflatable device or conversion from a semi-rigid prosthesis due to patient preference. Of the remainder, 20% selected implant surgery as their primary therapy while 73% were initially treated with various nonsurgical options prior to implantation. In all patients we employed a single peno-scrotal incision and applied the concept of controlled radial dilatation of all compartments. In our last 32 consecutive patients including eight with previous radical pelvic surgery, we utilized the preperitoneal distention balloon (PDB) facilitating safe and non-traumatic creation of the prevesical space for reservoir insertion. Post operative complications occurred in 8% of patients including pump infection and corporal deformity requiring reimplantation with AMS 700 CX cylinders, or self-contained unitarian prosthesis as a salvage procedure. Satisfactory, functional and anatomic outcome was reported in 95% of patients. Interim advances incorporated into the Ultrex and Ultrex Plus prosthesis have markedly reduced mechanical failure during our follow-up interval of up to 50 months. Importantly, controlled, non-traumatic radial dilatation of the prevesical space by the PDB may encourage broader use of the multicomponent inflatable models, particularly in a setting of pelvic fibrosis due to previous pelvic surgery or radiation.

Postsurgical outcomes assessment following varicocele ligation: laparoscopic versus subinguinal approach.

OBJECTIVES: To prospectively compare and objectively assess the postsurgical outcome parameters of both laparoscopic and open subinguinal techniques for varicocele ligation in infertile men. METHODS: A total of 41 evaluable patients with a history of infertility, abnormal semen analysis, and clinically diagnosed varicoceles underwent surgical ligation either by the insufflative intraperitoneal laparoscopic (n = 15), gasless laparoscopic (n = 7), or the open subinguinal (n = 19) approach. Most procedures (39 of 41) were performed in the outpatient setting, and patients were followed postoperatively for a minimum of 6 months. Postsurgical outcome was assessed by physical examination and review of a patient questionnaire quantifying the graded pain severity, analgesic requirements, and number of days to return to work. RESULTS: The average operative time was 82.3 +/- 26.5 minutes for insufflative intraperitoneal laparoscopic varicocelectomy, 170 +/- 55 minutes for gasless laparoscopic varicocelectomy, and 35.6 +/- 13.5 minutes for the open subinguinal approach. The analgesic requirement was 13.7 +/- 9.9 tablets for the insufflative laparoscopic group, 22.5 +/- 11 tablets for the gasless laparoscopic group, and 10.9 +/- 10.3 tablets for the open subinguinal group. The average number of days to return to work was 4.9 +/- 2.7 for the insufflative group, 6.6 +/- 2.6 for the gasless group, and 5.1 +/- 3.7 for the open subinguinal group. CONCLUSIONS: These results show no superiority of laparoscopic techniques over the standard open subinguinal technique with respect to hospital stay, analgesic requirements, or return to work. Laparoscopic techniques require excessive operative time, may have attendant complications, and require general anesthesia, limitations that preclude their routine application in varicocele ligation. However, the laparoscopic approach may have a role in the setting of other concurrently performed laparoscopic procedures.

Using a colonoscopy snare to safely remove large papillary bladder tumors.

A standard 22F rigid cystoscope with a 6.9F Bard colonoscopy snare connected to an Erbe power source at 25 W was utilized to remove bladder tumors. A loop was used to resect the base of the lesion and underlying muscle. Snare resection of papillary vesical tumors is a safe, easy method that can complement standard loop resection and be a valuable asset to urologists. No interference with histopathologic examination was encountered with this technique.

Gasless laparoscopic varicocele ligation: experience with new instrumentation and technique for retroperitoneal and intraperitoneal approaches.

Laparoscopic access to the retroperitoneum without abdominal insufflation has recently been made possible by devices designed to create a dilated laparoscopic cavity maintained by a fixed retraction system. This technique was applied in 10 patients undergoing laparoscopic ligation of the internal spermatic vein via extraperitoneal and intraperitoneal approaches. Gasless laparoscopic varicocelectomy was completed in 7 of 8 men by the extraperitoneal route and in neither of the 2 men approached intraperitoneally. The mean operative time was 170+/-55 min and postoperative pain exceeded the norm for standard insufflative laparoscopic varicocelectomy. Whereas certain theoretical advantages are offered by the gasless extraperitoneal approach to varicocele ligation, exposure through the gasless technique is currently suboptimal. Further development of "retraction" technology is required, prior to its routine application for varicocele ligation.

Noninsufflative extraperitoneal laparoscopic varicocele ligation.

Currently, most laparoscopic procedures are performed through the intraperitoneal route utilizing standard insufflative technique to create a working space. We report our experience with the new technique of gasless extraperitoneal varicocelectomy performed in eight subfertile men, in which we effectively dissect the retroperitoneum by using a trocar balloon device (peritoneal distention balloon) and maintain the working cavity with a motorized abdominal wall retractor (Laparofan/Laparolift retraction system). In addition to the primary trocar, two valveless secondary trocars are placed, through which either laparoscopic or standard surgical instruments may be used. The spermatic veins are doubly clipped while the artery is preserved in all cases. The mean operative time was 150 +/- 51 min with no intraoperative complications, and all patients were discharged within 24 h. The average days to return to work was 6.5 +/- 3.0 and the average postoperative analgesic requirement (pain pills) was 23.5 +/- 9.9. There were no significant postoperative complications. Exposure and working space provided by the gasless technique are not as satisfactory as the standard insufflative technique, and operative time is far more extensive. To surmount these limitations in gasless laparoscopy, significant developments are required in retraction technology.

Laparoscopic urologic surgery outcome assessment.

Laparoscopic surgery is an evolving technique that began to be applied widely in urology in the early 1990s. We have conducted an ongoing multicenter study of laparoscopic urologic surgery to identify any changes in utilization, complications, and short- and long-term outcomes. Laparoscopic urologic surgical procedures were assessed in three successive phases: retrospective initial experience [P1] (before 1991), and prospectively, an intermediate phase [P2] (1991-1992) and a late phase [P3] (1993-1994). The late phase group was followed for 1 year through 1995 to identify any delayed complications. In the P1 group, 114 patients are included; 105 underwent laparoscopic pelvic lymph node dissection (LPLND), 7 underwent laparoscopic variocele ligation (LVL), and 2 underwent other procedures. The complication rates in P1 are 21% (total): 10.5% (major) and 10.5% (minor). The P2 group includes 148 patients; 132 underwent LPLND, 10 underwent LVL, and 6 underwent other procedures. The complication rates decreased to 16.2% (total): 6% (major) and 10.1% (minor). The latest group (P3) includes 326 subjects; 245 had LPLND, 39 had LVL, and 42 had other procedures. More improvement in outcome is shown in this phase with a 7.98% total complication rate: 0.92% major and 7.05% minor. In addition, other parameters such as operative time and hospital stay show improvement through the successive phases. There were no significant long-term complications in the latest study group. This study demonstrates a continual improvement in outcome and changes in utilization patterns as urologists become more experienced with laparoscopic surgery. The complexity of the procedures performed has increased with a decrease in the complication rates overall.

Experience with intracavernous PGE-1 in the treatment of erectile dysfunction: dose considerations and efficacy.

The recommended dose of PGE-1 as treatment for erectile dysfunction has ranged from 10-60 mcg in various studies. We conducted the present study to identify factors that influence dose tritration and maintenance. From 96 patients who presented to our institution with erectile impotence, 40 elected self injection with PGE-1. Erectile response to intracavernous injection was assessed in the course of office-based dose titration. Patients were stratified into different groups based on age and etiology of erectile dysfunction. The mean maintenance dose was calculated in each group. Patients were evaluated quarterly by physical palpation of the penis, complete blood count, serum electrolytes, and liver function tests in order to assess safety of therapy. The average maintenance dose varied with the etiology of erectile dysfunction and age of the patient. The central neurogenic group was the most responsive to PGE-1 therapy, requiring an average maintenance dosage of 5 mcg. Men with vascular etiologies required the largest maintenance dosage of 20 mcg. Furthermore, dosage requirement increased linearly with age. We conclude that dosing considerations vary widely in a clinical setting and their determination is greatly facilitated if primary and associated causes of erectile dysfunction and the age of the patient are considered.

Epidemiology of current treatment for sexual dysfunction in spinal cord injured men in the USA model spinal cord injury centers.

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

Noninsufflative laparoscopic access.

Standard laparoscopic surgery requires maintenance of the working cavity by continual carbon dioxide insufflation and exaggerated Trendelenburg positioning. Both cardiopulmonary and metabolic adverse effects may result from these maneuvers, which may be avoided by a gasless approach to laparoscopic surgery. We investigated a new mechanical retraction system designed to maintain exposure of either intraperitoneal or retroperitoneal contents in a gasless laparoscopic cavity and assessed its performance in both laparoscopic approaches. Gasless laparoscopic surgery was attempted using the Laprolift/Laparofan system for retroperitoneal procedures: left varicocele ligation (three cases), renal biopsy (one case), extraperitoneal pelvic lymph node dissection (one case), and intraperitoneal bilateral varicocelectomy (two cases). Renal biopsy and varicocelectomy were accomplished successfully with the gasless approach and with technical ease comparable to that of the standard insufflative laparoscopic approach. Gasless pelvic lymph node dissection and intraperitoneal varicocelectomy were converted to insufflative laparoscopic or open procedures because of inadequate exposure of the pelvic contents. This early experience with gasless laparoscopy indicates that it may best be reserved for retroperitoneal urologic procedures.

New prostatectomy technique: transurethral electrovaporization of the prostate.

Major health and economic concerns have caused urologists to seek alternative forms of treatment for benign prostatic hypertrophy (BPH). The goal of these newer treatments is to decrease morbidity, reduce health care cost, and improve overall outcome for the patients with symptomatic bladder outlet obstruction. Transurethral resection of the prostate (TURP) is the gold standard treatment for BPH. One factor associated with the relative higher cost of a TURP is the average 4-day postoperative stay needed to clear the hematuria. Techniques have evolved that have allowed immediate tissue removal through "vaporization" of the prostate with a decrease in the postoperative stay. These techniques have primarily relied upon the use of lasers to vaporize tissue. A new transurethral prostatectomy technique called transurethral electrovaporization of the prostate (TVP) has been recently introduced. This relies upon a newly developed resectoscope electrode (VaporTrode) that allows vaporization of the prostate tissue in the "cutting" mode. The potential advantage of TVP is the reduction in postoperative hematuria and the utilization of equipment and techniques that are already familiar to the practicing urologist.