Analysis of the consistency of intraurethral prostaglandin E(1) (MUSE) during at-home use.

OBJECTIVES: To determine the consistency of a successful response to intraurethral prostaglandin E(1) (MUSE), an effective treatment for a proportion of patients with erectile dysfunction, during at-home use in men who had a successful response in the office, to define the factors that correlated with the consistency of the response, and to determine whether patients continued long-term use. METHODS: The study group consisted of men with documented erectile dysfunction who had a successful response (grade 3 or 4 erection) to MUSE during an initial in-office dose. All enrollees completed a home diary assessing the treatment success during at least five medication administrations. Factors such as patient age, vascular risk factor status, and degree of in-office response were prospectively evaluated as correlates of response consistency. Finally, patient follow-up was conducted in an attempt to define how many patients were continuing to use this medication as a long-term treatment modality. RESULTS: Two hundred twelve patients underwent screening and 72 (34%) patients had in-office success. The overall per patient at-home consistency rate was 51%. None of the aforementioned factors correlated with the consistency of the response. At a mean of 9 months after beginning treatment, only 31% of the in-office responders were continuing to use MUSE. CONCLUSIONS: Although MUSE is an appropriate and safe treatment for many patients with erectile dysfunction, the lack of consistency is a significant consideration. Clinicians should pay close attention to patient education in an effort to promote realistic expectations for MUSE therapy. Furthermore, the lack of consistency may significantly lower the patient's interest in continuing this treatment long term.

The causes of patient dropout from penile self-injection therapy for impotence.

PURPOSE: Penile self-injection therapy, a second line treatment for erectile dysfunction, is the most efficacious means of reestablishing functional erections when first line therapies fail and the patient wants to avoid penile prosthesis implantation. Despite high efficacy rates, injection therapy has high dropout rates. To our knowledge studies to date analyzing patient attrition have reviewed small numbers of patients followed for only short periods. We elucidate the main reasons for patient dropout in a large penile self-injection program with long-term followup. MATERIALS AND METHODS: A questionnaire was mailed to 1,424 patients who completed the office training and home use phases of a penile self-injection program. RESULTS: The overall attrition rate was 31% of the 720 men who completed the questionnaire, with a mean followup of 38 months. The main reasons for dropout were cost of therapy, patient and partner problems with the concept of penile injection, lack of partner availability and spontaneous improvement in erections. Lack of efficacy of therapy was the primary reason for only 1 of 7 dropouts. Furthermore, adverse effects of penile injections (priapism, penile nodules, pain) appeared to be only minor contributors to dropout. CONCLUSIONS: To our knowledge this study is the largest published, single center cohort of patients treated with injection and followed for an analysis of dropout rates. Based on study data a reduction in dropout rates may be achieved by keeping the cost of therapy low, and ensuring patient and partner education as well as continued support throughout treatment.

Fibrin sealant inhibits connective tissue deposition in a murine model of peritoneal adhesion formation.

BACKGROUND: Postoperative peritoneal adhesion formation causes a multitude of disorders, including bowel obstruction and infertility. METHODS: To test whether fibrin sealant inhibits adhesion formation, mice were given an intraperitoneal injection of talc (to induce adhesions) after which sealant was administered. Seven and 14 days later, the thickness of connective tissue between the fragmented mesothelium and the abdominal muscle was measured. RESULTS: At both 7 and 14 days after talc administration, talc-treated mice had a 6-fold increase in connective tissue thickness over vehicle alone (P < .05). Although fibrin sealant alone failed to trigger peritoneal pathologic conditions, administration of sealant to talc-treated mice inhibited connective tissue deposition by 80% at 7 and 14 days (P < .05). Additionally, delaying fibrin sealant administration up to and including 72 hours after talc treatment results in comparable inhibition of connective tissue deposition, as does treatment immediately after talc exposure. CONCLUSIONS: This study demonstrates that fibrin sealant inhibits peritoneal inflammation and peritoneal adhesion formation with use of a quantitative assay of connective tissue deposition. In addition, this is the first report to document the administration of fibrin sealant into the closed abdomen. The success of these studies suggests that fibrin sealant will block peritoneal adhesions when administered laparoscopically. Finally, because fibrin sealant is therapeutic even when administered after the initiation of peritoneal inflammation, it suggests that it may be efficacious in patients who present with adhesions or those undergoing multiple operations.

Complications of acucise endopyelotomy.

Endoscopic management of ureteropelvic junction (UPJ) obstruction has a success rate of 80% to 86%. We have been performing a ureteral cutting balloon procedure under fluoroscopic control (Acucise endopyelotomy) for UPJ obstruction at Loyola University Medical Center since 1991. The overall success rate in 77 patients was 78%. All patients had a preoperative intravenous urogram or a retrograde pyelogram, but none had vascular imaging studies. Acucise endopyelotomy consisted of a posterolateral incision of the UPJ and placement of an endopyelotomy or double-J stent. Foley catheter placement at the end of the procedure demonstrated significant gross hematuria in three patients (4%). All three remained hemodynamically stable but with significant drops in postprocedure hemoglobin levels, which necessitated blood transfusion. Aggressive management included angiographic studies and embolization of lower-pole branching arteries in two patients (3%). One patient stopped bleeding after being given two units of blood. None of the patients required an open exploratory procedure. Although the risk of vascular injury is low with Acucise endopyelotomy, prolonged postoperative gross hematuria does mandate investigation and observation. Angiographic embolization appears to be the therapeutic modality of choice for patients with hemorrhagic complications after an Acucise endopyelotomy.

The laparoscopic cooling sheath: novel device for hypothermic preservation of kidney during temporary renal artery occlusion.

Hypothermia is commonly used to prevent ischemic renal damage during complex nephron-sparing surgical procedures requiring temporary renal artery occlusion. We developed a novel Cooling Sheath device, which is compatible with laparoscopy, to protect the kidney hypothermically during 60 minutes of temporary arterial occlusion in a laparoscopic swine model. Comparison of temperature curves and histology to control groups undergoing open slush surface cooling and laparoscopic warm ischemia for similar time periods was performed. Optimal hypothermic temperatures were reached rapidly and maintained with the use of the Cooling Sheath. Ischemic damage, present in all kidneys subjected to warm ischemia, was not found on histopathologic examination of the cooled kidneys. This new device provides hypothermic protection of the kidney during ischemia. The use of the Cooling Sheath combined with temporary arterial occlusion will allow more complex nephron-sparing renal surgery to be performed using laparoscopy.