Sexuality and management of benign prostatic hyperplasia with alfuzosin: SAMBA Thailand.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common condition among elderly men. The aim of therapy is to improve lower urinary tract symptoms (LUTS) and quality of life (QoL) and to prevent complications. AIM: The primary objective was to assess the effect on ejaculatory dysfunction (EjD) of 6 months treatment with alfuzosin (XATRAL) 10 mg once daily (OD) in men with LUTS suggestive of BPH in Thailand. Secondary objectives were to evaluate the efficacy of alfuzosin on LUTS, bother score (International Prostate Symptom Score [IPSS] 8th question), erectile dysfunction (ED), onset of action, and tolerability. METHODS: Overall, 99 men with moderate to severe LUTS suggestive of BPH (mean IPSS 18.9, bother score 4.3) were enrolled in an open-label study. Sexual function was evaluated at baseline and after 6 months treatment, using the International Index of Erectile Function-5 and the Male Sexual Health Questionnaire (MSHQ) ejaculation score, a new validated questionnaire assessing seven EjD symptoms. MAIN OUTCOME MEASURE: The main outcome measure is mean change from baseline to the end of treatment in the MSHQ Ejaculation score. RESULTS: MHSQ ejaculation score significantly improved from 23.09 at baseline to 21.54 at 6 months (P=0.022). Overall, 70% of patients perceived an improvement in LUTS within 1 week (36.3% within 3 days). IPSS total score significantly improved from 18.93 at baseline to 9.59 at 6 months (P<0.001). IPSS voiding and irritative subscores also significantly improved. The percentage of patients with moderate or severe ED decreased from 35.3% at baseline to 21.8% at 6 months. Most adverse events were dizziness (3%) and orthostatic hypotension (1%) with minor intensity. No significant change in blood pressure and heart rate was observed. CONCLUSIONS: Alfuzosin 10 mg OD administered for 6 months provides a marked and rapid (within 1 week) improvement in LUTS and bother score while improving both ED and EjD.

Increased prevalence of erectile dysfunction (ED): results of the second epidemiological study on sexual activity and prevalence of ED in Thai males.

OBJECTIVE: The aim of this study is to investigate changes in sexual activity and the prevalence of erectile dysfunction (ED) in Thai males. In addition, the treatment-seeking behaviour of Thai patients suffering from ED is also investigated. MATERIALS AND METHODS: In a cross sectional study using a standardized questionnaire with a multi-stage stratified random sampling, 2,269 men aged 40-70 were interviewed. The questionnaire was designed to investigate the effects of socioeconomic factors, medical conditions and unhealthy lifestyles on the development of ED. Furthermore, the questionnaire was designed to characterize the treatment-seeking behaviour of Thai patients suffering from ED. RESULTS: Compared to the first report dated the year 2000, the prevalence of ED has increased from 37.5% to 42.18%. In terms of socioeconomic factors, the highest prevalence of ED was observed among unemployed men (78.51%). Prostatism and/or prostatitis (Odd ratios (OR) = 2.02) and long histories of smoking (more than 30 years, OR = 2.36) were identified as statistically significant risk factors for ED, with p-values of <0.001. It is important to notice that 38.78% of the ED patients wanted to discuss their problem with spouses or partners. Three quarters of the ED patients (74.54%) preferred oral medication as therapy. CONCLUSIONS: The epidemiology of ED in Thailand is changing. An increased prevalence of ED does require further epidemiological studies on a regular basis in order to better understand the etiology of ED and look for measures (such as education) to counter the disease.

Surgical treatment of renal cell carcinoma with inferior vena cava thrombus: using liver mobilization technique to avoid cardiopulmonary bypass.

OBJECTIVE: To evaluate the results of surgical treatment of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus and describe the use of a transabdominal approach with liver mobilization to avoid cardiopulmonary bypass (CPB). METHODS: From February 2002 to January 2006, 109 patients with RCC were surgically treated at Siriraj Hospital. Twelve patients had an IVC thrombus, infrahepatic (level I), retrohepatic (level II), suprahepatic (level III) and intra-atrial (level IV) in one, two, eight and one patient, respectively. Patients' characteristics, pathological features, survival and morbidity were evaluated. RESULTS: Mean age was 58 years (range, 37-74 years). CPB was used in one patient with level IV thrombus. All patients (92%) with level I-III IVC thrombi underwent successful removal by transabdominal approach without any form of bypass. Mean operative time was 302 minutes (range, 195-420 minutes). The mortality rate was 16% (2 of 12) with sepsis and pulmonary embolism. One patient had colonic injury requiring primary repair. At the mean follow-up of 17 months (range, 3-35 months), of 10 patients, one died due to distant metastases, two were lost to follow-up and seven (60%) were still alive. Five patients (42%) were disease-free at the last follow-up. CONCLUSION: These results support the aggressive surgical removal of RCC with IVC thrombus as the initial treatment. Most of the thrombi can be approached and safely controlled by a transabdominal approach without any form of bypass. Tumour thrombus removal provides a high survival chance and offers improvement in quality of life.

Efficacy and tolerability of vardenafil in Asian men with erectile dysfunction.

AIM: To evaluate the efficacy and tolerability of vardenafil, a phosphodiesterase type-5 (PDE-5) inhibitor, in men of Asian ethnicity with erectile dysfunction (ED). METHODS: In this prospective, double-blind, multinational study, Asian men were randomized to receive vardenafil (10 mg) or placebo (4:1 ratio) for 12 weeks. The primary efficacy variables were the International Index of Erectile Function erectile function domain (IIEF-EF), and Sexual Encounter Profile (SEP) questions related to penetration and intercourse completion. Significant mean improvements were required in all three measures to show positive benefits of vardenafil treatment. Secondary efficacy variables included the Global Assessment Question (GAQ) on erection improvement. RESULTS: Least-squares mean baseline IIEF-EF domain scores (vardenafil 14.6, placebo 13.4) were consistent with moderate ED. After 12 weeks, vardenafil treatment was associated with significant increases from the baseline in IIEF-EF domain scores compared with the placebo (22.4 vs. 14.3; P<0.001). Vardenafil was associated with significant improvements from baseline in least squares (LS) mean success rates for SEP-2 (vardenafil 82.2 vs. placebo 43.6; P<0.001) and SEP-3 (vardenafil 66.1 vs. placebo 24.0; P<0.001). Positive GAQ responses were reported by 81.8% of vardenafil recipients vs. 24.3% of placebo recipients. Adverse events were reported by 25.4% of the vardenafil group, the majority mild and transient. CONCLUSION: Vardenafil (10 mg) is a highly effective and well-tolerated treatment for moderate ED in Asian men. These results add to the increasing amount of data demonstrating the safety and efficacy of vardenafil for the treatment of ED in a range of patient populations.

Outcomes of surgical treatment for upper urinary tract transitional cell carcinoma: comparison of retroperitoneoscopic and open nephroureterectomy.

OBJECTIVES: To determine the surgical and oncologic outcomes in patients who underwent retroperitoneoscopic nephroureterectomy (RNU) in comparison to standard open nephroureterectomy (ONU) for upper urinary tract transitional cell carcinoma (TCC). PATIENTS AND METHODS: From April 2001 to January 2007, 60 total nephroureterectomy were performed for upper tract TCC at Siriraj Hospital. Of the 60 patients, thirty-one were treated with RNU and open bladder cuff excision, and twenty-nine with ONU. Our data were reviewed and analyzed retrospectively. The recorded data included sex, age, history of bladder cancer, type of surgery, tumor characteristics, postoperative course, disease recurrence and progression. RESULTS: The mean operative time was longer in the RNU group than in the ONU group (258.8 versus 190.6 min; p = 0. < 001). On the other hand, the mean blood loss and the dose of parenteral analgesia (morphine sulphate) were lower in the RNU group (289.3 versus 313.7 ml and 2.05 versus 6.72 mg; p = 0.868 and p = 0.018, respectively). There were two complications in each group. No significant difference in p stage and grade in both-groups (p = 0.951, p = 0.077). One patient with RNU had lymph node involvement, three in ONU. Mean follow up was 26.4 months (range 3-72) for RNU and 27.9 months (range 3-63) for ONU. No port metastasis occurred during follow up in RNU group. Tumor recurrence developed in 11 patients (bladder recurrence in 9 patients, local recurrence in 2 patients) in the RNU group and 14 patients (bladder recurrence in 13 patients, local recurrence in 1 patient) in the ONU group. No significant difference was detected in the tumor recurrence rate between the two procedures (p = 0.2716). Distant metastases developed in 3 patients (9.7%) after RNU and 2 patients (6.9%) after ONU. The 2 year disease specific survival rate after RNU and ONU was 86.3% and 92.5%, respectively (p = 0.8227). CONCLUSION: Retroperitoneoscopic nephroureterectomy is less invasive than open surgery and is an oncological feasible operation. Thus, the results of our study supported the continued development of laparoscopic technique in the management of upper tract TCC.

Results of chimney modification technique in ureterointestinal anastomosis of Hautmann ileal neobladder in bladder cancer.

BACKGROUND: To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. METHODS: Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. RESULTS: At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. CONCLUSION: New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.

Novel technique to prevent lymphocele recurrence after laparoscopic lymphocele fenestration in renal transplant patients.

PURPOSE: To describe the use of nonabsorbable polymer ligating (NPL) clips to prevent recurrence after laparoscopic lymphocele fenestration and to determine the efficacy and safety of this treatment in renal-transplant patients at our center. PATIENTS AND METHODS: From December 2000 to October 2005, nine patients with a mean age of 38.5 years (range 26-54 years) and symptomatic lymphoceles were treated laparoscopically among 144 renal-transplant patients. The overall incidence of symptomatic lymphocele was 6.2% (9/144). The mean time from transplantation to diagnosis was 55.5 days (range 20-98 days). Patient and lymphocele characteristics, complications, recurrence rate, and outcomes of this procedure were analyzed retrospectively. RESULTS: Laparoscopic treatment was successful in eight patients; the other was converted to open surgery. One patient sustained an allograft-ureteral injury. The mean operative time was 90.7 minutes (range 75-120 minutes), and the mean postoperative stay was 4.1 days (range 1-7 days). Lymphocele recurrence was found in the first two patients after laparoscopic surgery without NPL clips. With a mean follow-up of 42.3 months (range 31-51 months), no recurrence was observed in patients in whom NPL clips were used to maintain the patency of the peritoneal window. No late laparoscopy-related complications occurred. CONCLUSION: Laparoscopic lymphocele fenestration with NPL clips is a safe, technically easy, and efficacious procedure for the treatment of symptomatic lymphoceles after renal transplantion.

Prevalence of prostate cancer in aging males receiving PSA (prostate specific antigen) screening test (A campaign for celebration of Siriraj Established Day).

UNLABELLED: Prostate cancer is a potential men's health problem. The prevalence of prostate cancer continues to rise. Serum PSA (Prostate Specific Antigen) can be used as a screening tool for detection of early prostate cancer However, a screening program for prostate cancer has not yet been accepted as cost-effective and long term survival benefits have not been shown. Nevertheless, some doctors request PSA testing in men who present with lower urinary tract symptoms (LUTS) to detect prostate cancer OBJECTIVE: To study for prevalence of prostate cancer in healthy men seeking medical check-up for prostate cancer. MATERIAL AND METHOD: During the anniversary celebration of Siriraj established day (26/07/1888), a cohort study of Prevalence of prostate cancer in aging males using PSA Screening Test was carried out, 200 men over 45 years of age were invited to PSA testing and prostate glands check-up including, IPSS (international prostatic symptoms score), QOL (quality of life score) and DRE (digital rectal examination). Patients with elevated PSA were advised to undergo transrectal-ultrasound-guided-biopsy of the prostate (TRUS-biopsy). Cancer detection rate was calculated according to symptoms described by patients, IPSS and age groups. Data was compared using Chi-Square test. RESULTS: Median values from data of men's ages, IPSS, QOL and PSA were 63 years, 11, 2, and 1.23 ng/ml, respectively. 9 of 200 patients (4.5%) were found to have prostate adenocarcinoma on biopsy. Most of the cancer cases showed a localized lesion. Prostate cancer was found more common in patients who described themselves as having abnormal urination. There was no prostate cancer found in patients with a mild degree of LUTS (IPSS less than 8). Prostate cancer tended to be more common in men with high IPSS. CONCLUSION: Screening prostate cancer by PSA testing detected the cancer in 4.5%. Most cancers were found on symptomatic patients. Patients with LUTS should be made aware of prostate cancer and PSA testing may be offered in such patients. However screening of prostate cancer in all men regardless of symptoms must wait for a larger study looking at long term survival benefit, cost-effectiveness of screening, and lastly, quality of life of patients on a screening program.

The efficacy and safety of oral sildenafil in Thai men with erectile dysfunction: a randomized, double-blind, placebo controlled, flexible-dose study.

OBJECTIVE: To evaluate the efficacy and safety of sildenafil citrate (Viagra) in a randomized, double-blind, placebo-controlled, flexible-dose study in Thai men with erectile dysfunction of broad-spectrum etiology and more than 6 months' duration. MATERIAL AND METHOD: 125 patients aged 26 to 77 years were randomized at 4 centers in Thailand to receive either sildenafil citrate (50 mg initially, increased if necessary up to 100 mg or decreased to 25 mg depending on efficacy and/or tolerability) (n = 63) or a matching placebo (n = 62) taken on an 'as needed' basis approximately 1 hour prior to anticipated sexual activity for a period of 12 weeks. Efficacy was assessed by the patients' responses to the 15-question International Index of Erectile Function (IIEF), to questions on the event log of sexual activity, and to the global efficacy assessment question concerning improvement in erections. RESULTS: At the conclusion of the study, both the primary efficacy variables relating to the achievement and maintenance of erections sufficient for sexual intercourse and the secondary efficacy variables, which included the 5 separate domains of sexual functioning of the IIEF, the percentage of successful attempts at sexual intercourse, and the global efficacy assessment question concerning improvement in erections, were all significantly improved statistically by sildenafil in comparison with placebo except in the sexual desire domain which showed no difference. The percentage of successful attempts at sexual intercourse in the sildenafil group was 66.16 per cent while in the placebo group it was 33.05 per cent. The percentage of global efficacy assessment was improved in the sildenafil group by 82.5 per cent compared to 36.1 per cent in the placebo group. Adverse events considered treatment-related occurred in 19 patients (30.2%) receiving sildenafil and 7 (11.3%) receiving placebo. The most common adverse events with sildenafil were vasodilatation (flushing), headache, and dizziness, which occurred in 14.3 per cent, 6.3 per cent, and 6.3 per cent of patients respectively. All events were mild in nature. CONCLUSIONS: Sildenafil is a safe and effective treatment for erectile dysfunction of broad-spectrum etiology in Thai men. Its efficacy appears similar to that reported in other studies in Western populations.

The prevalence of prostate cancer screening in Thai elderly.

PROBLEM: Prostate cancer is the most common cancer in elderly men in Western countries. In the future, it may be an important problem in Thailand. At present, there is no evidence about the prevalence and the outcome of screening in this disease. OBJECTIVES: To determine the prevalence of prostate cancer in elderly Thai men and to identify the most appropriate screening method for detection of prostate cancer in Thailand. MATERIAL AND METHOD: 928 elderly men from communities around Siriraj Hospital were evaluated for prostate cancer by Digital Rectal Examination (DRE) and/or Prostate Specific Antigen (PSA). Transrectal ultrasound guided biopsy (TRUS-Bx) which is the gold standard for definitive diagnosis was performed in cases with an abnormal DRE and/or PSA. If biopsy could not be performed, intermittent follow-up with DRE and/or PSA were recommended. RESULT: The prevalence of prostate cancer in Thai elderly men in the urban community was more than 0.75 per cent and the prevalence of abnormal DRE and PSA was 8.7 and 17.3 per cent respectively. The Positive Predictive Value (PPV) of both tests was 60 per cent and higher than the PPV of an individual test. A screening program for prostate cancer starting with DRE may be more cost effective. CONCLUSION: The prevalence of prostate cancer, abnormal DRE and abnormal PSA in Thai elderly men were more than 0.75, 8.7 and 17.3 per cent respectively which are comparable to the prevalence in Western countries. It is important that we take an interest in this disease.

Benign prostatic hyperplasia in elderly Thai men in an urban community: the prevalence, natural history and health related behavior.

PROBLEM: Although benign prostatic hyperplasia (BPH) is a common disease in elderly Thai men the prevalence in the community and its natural history is unknown. OBJECTIVES: To determine the prevalence of symptomatic BPH and its natural history. To determine the health related behaviors which have an impact on the voiding symptoms. MATERIAL AND METHOD: 879 elderly men aged > or = 60 years from communities around Siriraj Hospital were studied. The International Prostate Symptom Scores (IPSS) and Quality of Life (QOL) scores were evaluated in the participants at the beginning of the study and 1 year later. The overall assessment, complications and health related behaviors were also evaluated. RESULT: The prevalence of symptomatic BPH in the community was 41.3 per cent. In terms of overall assessment at 1 year follow-up, symptomatic BPH patients (IPSS 8-35), the rate of "improved", "same" and "worse" was 10.6, 70.2 and 19.2 per cent respectively. The complication rate was about 10 per cent. Three quarters of the elderly men had health related behavior at risk. CONCLUSION: The prevalence of symptomatic BPH was high. Its natural history was unpredictable and some BPH symptoms may be influenced by their behaviors.

The risk and effectiveness of transurethral resection of prostate.

BACKGROUND: To advise a patient to have transurethral resection of prostate (TURP) needs information on the benefit and complications of the procedure. Quality assurance also needs present results to be compared with future ones. OBJECTIVES: The authors wanted to know: 1. Whether TURP can decrease theInternational prostate symptom score (IPSS) and improve the Quality of Life (QOL) scores concerning urination at 1.5 months post-operatively for at least 25 per cent of the pre-operative scores?; 2. What are the common medical diseases in this type of patient?; and 3. What are the mortality and immediate complications of TURPF? METHOD: This was a prospective, before-after design trial. All patients who came to have TURP at a tertiary care hospital were studied. IPSS and QOL scores were recorded before surgery and again when the patients came back to follow up at 1.5 months after discharge. Patients were evaluated for cardiopulmonary reserve and congestive heart failure. Anesthetic technique of choice was spinal anesthesia with 0.5 per cent bupivacaine. Anesthetic and surgical complications were recorded if the definitions were met. ANALYSIS: Pre-operative and 1.5 months post-operative scores were compared using paired t-test and 95 per cent confidence interval. RESULTS: During the 13 months there were 269 consecutive males who received TURP. The mean +/- SD age was 70.4 +/- 8.8 years (range 35-97). The mean difference between pre- and post-operative IPSS was 6.7 +/- 9.1 (95% CI 5.2-7.8). Quality of Life also improved, the mean difference between pre- and post-operative QOL was 3.2 +/- 1.6 (95% CI 2.9-3.5). Most patients had ASA class 2. Common pre-operative existing diseases were hypertension (31.6%), ischemic heart disease (18.2%), diabetes (15.6%), and COPD (7.1%). Anesthetic techniques were spinal block (77.3%), epidural block (5.9%), continuous epidural (11.2%), and general anesthesia (5.6%). Intra-operative complications were reported and T URsyndrome occurred in 1 patient (0.37%). There was one surgical death 3 days post-operation, due to septic shock probably from bowel perforation. CONCLUSION: The patients' symptoms and quality of life significantly improved, but there was 1 surgical death and 1 TUR syndrome among 269.