Proper 6-branch suburethral autologous sling tensioning during robotic assisted radical prostatectomy with the intraopeartive use of retrograde perfusion sphincterometry: the technique.

The aim of this paper is to describe our surgical technique and results of proper 6-branch autologous sling tensioning during RALP employing intraoperatively the Retrograde Perfusion Sphincterometry (RPS). Between May 2016 and February 2020, 374 patients underwent RALP with the 6-branch suburethral autologous sling tensioned under intraoperative guidance of RPS. Surgical procedure: Retrograde Leak Point pressure (RLPP) was evaluated by means of RPS after pneumoperitoneum induction (RLPPp), after urethrovescical anastomosis (RLPPa) and during proper sling tensioning (RLPPs). The goal of the sling tensioning was to obtain at the end of the procedure similar pressures as after pneumoperitoneum induction (RLPPs ≅ RLPPp). Intraoperative variables, postoperative complications, and continence recovery outcomes were assessed. A descriptive statistical analysis was performed. Sling positioning and tensioning was feasible in all patients. Mean operative time was 215 min. Proper sling tensioning allowed for the possibility to restore sphincteric efficacy to preoperative value (RLPPs vs. RLPPp (42.5 vs. 42.6) cmH2O). Urinary continence was achieved, respectively, in 58%, 67%, 74%, 88% and 92% of patients after 24 h, 10 days, 1 month, 6 months and 1 year after catheter removal. In conclusion, RPS revealed a valid option for proper autologous 6-branch sling tensioning during RALP, offering the possibility to restore sphincteric apparatus efficiency to its preoperative status to improve EUC.

Ischemia of the glans 24 hours after circumcision: A case report and therapeutic solution.

INTRODUCTION:: Circumcision is a common surgical procedure, typically performed under local anesthesia and somehow also as outpatient clinic. Although complications are rare and most frequently related to the procedure itself, ischemia of the glans may occur as a major complication and can be related to local ischemia following dorsal penile nerve block. CASE DESCRIPTION:: We describe the case of a 33-year-old patient who underwent circumcision at our institution and, 24 h after the procedure, developed an acute ischemia of the glans; a re-intervention was performed in emergency setting to ensure a large, not-tightened circular suture under the glans, and low-molecular-weight heparin and antiplatelet therapy was introduced to achieve anti-coagulative/antiaggregant effects. After 48 h, the skin returned to its normal color and in 7 days the penile glans achieved complete remission of the ischemic aspect. A 6-month follow-up confirmed regular outcomes with normal erectile functions. CONCLUSION:: The treatment we proposed to treat acute post-circumcision ischemia of the glans is a simple and effective one, with a perfect aesthetic and functional outcome observed within 4 weeks and confirmed at 6-month follow-up.

Intraoperative Retrograde Perfusion Sphincterometry to Evaluate Efficacy of Autologous Vas Deferens 6-Branch Suburethral Sling to Properly Restore Sphincteric Apparatus During Robot-Assisted Radical Prostatectomy.

OBJECTIVE: The aim of this study is to describe (urodynamically) the effect of the use of a 6-branch autologous suburethral sling, made with absorbable sutures and vas deferens, to support the bladder neck and urethra during robot-assisted laparoscopic prostatectomy (RALP) to improve early urinary continence (EUC) recovery. MATERIALS AND METHODS: Retrograde leak point pressure (RLPP) was intraoperatively evaluated, by means of retrograde perfusion sphincterometry (RPS), in 77 patients (mean age ± standard deviation [SD]: 65.64 ± 7.23 years, mean body mass index ± SD: 26.69 ± 3.89) scheduled to undergo RALP at our institution. RLPP was evaluated before (RLPPb) and after pneumoperitoneum induction (RLPPp). RLPP was then evaluated after urethrovesical anastomosis (RLPPa) and after proper sling tensioning (RLPPs), with the aim to obtain the same pressure as after pneumoperitoneum induction. EUC recovery, defined as the use of no pad, was assessed 10 days, 30 days, and 6 months after catheter removal. RESULTS: RPS and proper autologous 6-branch sling positioning were feasible in all patients, without perioperative complications and negligible impact on overall operative time. Pneumoperitoneum induction increased, similarly, RLPP in all patients. An important decrease of sphincteric capability was evident after prostate removal and the following urethrovesical anastomosis, while proper sling tensioning allowed for restoration of sphincteric apparatus capability to its presurgical status (mean RLPPs 40.84 cmH2O vs RLPPp 40.39 cmH2O, p = 0.942). EUC recovery within 10 days after catheter removal was achieved in 59 (77%) patients and progressively improved over time. CONCLUSIONS: RPS, intraoperatively performed during RALP, allows for precise evaluation of the impact of the surgical procedure on sphincteric apparatus competence. Moreover, the use of the 6-branch suburethral sling, in association with RPS, allows for restoration of the proper supporting system to the urethral sphincter, similar to the preoperative condition, offering the basis for EUC recovery after radical prostate surgery.

[Safety notice for the use of drugs for intravesical instillations and cost analysis]. / Norme di sicurezza relative all'uso dei farmaci chemio e immunoterapici ad uso locale ed analisi dei costi

Among the objectives outlined in the National Health Plan 1998-2000 are some interventions to improve the safety of public and private health-care facilities. One of the significant risks in the health sector is the one resulting from exposure to chemotherapy drugs. The Health Surveillance must take into account that anticancer drugs are cytotoxic compounds, which can cause cancer. It is necessary that occupational exposure to antineoplastic agents be kept within the lowest possible level. The potential absorption due to exposure to chemotherapy may be significantly reduced by adopting preventive measures specific to particular concern in a centralization of structures and activities. To ensure an adequate system of protection for people who use these substances in professional health-care settings, there should be the establishment of a specific "Anticancer Drugs Unit" to entrust the working cycle. The places reserved for the preparation of cytotoxic chemotherapy must be equipped with floor and walls up to heights of appropriate plastic material easily washable. Inside the room there must be a "point of decontamination" for washing hands and eyes. The preparation of antineoplastic agents should be performed under hoods positioned away from heat sources and any air currents. It is advisable to use disposable surgical gowns with long sleeves with elastic cuffs or knitted sleeve to allow the gloves sticking above the gown itself. In the preparation of drugs the vial opening procedure must be implemented after verifying that no liquid is left at the top, and by wrapping the neck of the vial with a sterile gauze. Any accidental contamination must be reported to the Physician. All waste materials produced from the handling of cytotoxic chemotherapy should be considered as special hospital waste. To achieve high standards of safety and prevention for the personnel exposed to antineoplastic agents, it is necessary that workers are adequately informed about the risks and proper handling and disposal of anticancer drugs and contaminated materials.

Preoperative sex steroids are significant predictors of early biochemical recurrence after radical prostatectomy.

PURPOSE: We sought the association of preoperative serum total testosterone (tT), hypogonadism, 17ß estradiol (E2), and sex hormone-binding globulin (SHBG) with early biochemical recurrence (BCR) after radical prostatectomy (RP). METHODS: Sex steroids were assessed the day before surgery (7-11 a.m.) in a cohort of 605 patients with a median follow-up of 24 months following RP. Cox regression models tested the association between predictors [including age, body mass index (BMI), prostate-specific antigen (PSA), clinical stage, biopsy Gleason scores, tT, hypogonadism, E2, and SHBG] and early BCR (defined as a PSA ≥ 0.1 ng/ml that occurred within 24 months after RP). RESULTS: Early BCR was found in 34 (5.6 %) patients. Patients with BCR did not differ in terms of age, BMI, serum PSA, tT, E2, and SHBG levels, rate of hypogonadism, and clinical stage as compared with those without BCR (all p ≥ 0.05). Conversely, patients with BCR showed a greater prevalence of biopsy Gleason scores ≥4 + 3 (all p ≤ 0.001). At multivariable Cox regression analysis, tT [hazard ratio (HR): 1.43; p = 0.03] E2 (HR: 1.05; p = 0.04), SHBG (HR: 1.29; p = 0.02), and biopsy Gleason scores equal to 4 + 3 (HR: 3.37; p = 0.04) and ≥8 (HR: 20.06; p < 0.001) achieved independent predictor status for early BCR. Conversely, no significant associations were found for all the other predictors. CONCLUSIONS: Current findings show that preoperative serum sex steroids are independent predictors of early BCR in a homogeneous, large cohort of nonscreened patients treated with RP.

Sex hormone-binding globulin is a significant predictor of extracapsular extension in men undergoing radical prostatectomy.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Previous reports showed controversial evidence supporting the role of sex steroids, mainly testosterone, in the etiology and pathogenesis of prostate cancer (PCa). The bioavailability of sex steroids is significantly regulated by sex hormone-binding globulin (SHBG). In this context, SHBG levels have been shown to be significantly higher in PCa patients than in controls. Likewise, SHBG was reported to serve as an independent predictor for extra-prostatic extension of tumour [defined as cancer (≥pT3) with capsular penetration, seminal vesicle involvement, or lymph node invasion (LNI)] in patients with clinically localized PCa. The presence of non-organ-confined disease is significantly associated with higher biochemical recurrence rates. This study provides novel evidence that SHBG might serve as a significant multivariate predictor of extra capsular extension (ECE) in PCa patients submitted to radical prostatectomy, after accounting for preoperative clinically available variables such as patient's age, total PSA, clinical stage, biopsy Gleason sum, and BMI. Moreover, a clinical cut-off for circulating SHBG allows using this easily quantifiable molecule as a novel clinical parameter in PCa patients. OBJECTIVE: • To examine the association between sex hormone-binding globulin (SHBG) and extracapsular extension (ECE) in men treated with retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: • Preoperative serum SHBG levels were measured in a cohort of 629 consecutive European Caucasian men [mean (range) age of 64 (41-78) years] who underwent RRP. • No patient received any hormonal neoadjuvant treatment. SHBG levels were measured the day before RRP (08:00-10:00 hours) in all cases at the same laboratory. • Logistic regression models tested the association between predictors [including age, prostate-specific antigen (PSA) level, clinical stage, biopsy Gleason sum, body mass index (BMI), and SHBG] and ECE. • Combined accuracy of predictors was tested in regression-based models predicting ECE at RRP. SHBG was included in the model both as a continuous and categorized variable (according to the most informative threshold level of 30 nmol/L). RESULTS: • In all, 92 patients (14.6%) had ECE. The mean (standard deviation; median) serum SHBG levels were significantly higher in men with ECE compared with those with no ECE at 41.1 (14.7; 37.5) vs 36.4 (16.7; 34) nmol/L (P= 0.007; 95% confidence interval -8.00, -1.29). • Univariate analyses indicated that continuously coded SHBG was significantly [odds ratio (OR) 1.01; P= 0.03] associated with ECE, with a predictive accuracy of 60.1%. • At multivariate analyses, both continuous (OR 1.01; P= 0.03) and categorical SHBG (OR 3.22; P < 0.001) were significantly associated with ECE, after accounting for age, PSA level, clinical stage, biopsy Gleason sum, and BMI. • Addition of continuously coded SHBG slightly increased the predictive accuracy of the base model based on clinically established predictors from 63.3% to 65.5% (2.0% gain; P= 0.48). • In contrast, a model based on categorized-SHBG showed bootstrap-corrected predictive accuracy of 68.4% (5.1% gain; P= 0.044). CONCLUSION: • This study shows that SHBG might serve as a significant multivariate predictor of ECE in men with prostate cancer that undergo RRP.

Surgery and erectile dysfunction.

OBJECTIVES: Erectile Dysfunction (ED) is one of the most negatively impacting complications associated with pelvic surgery. To date, several technical approaches and therapeutics options are available to limit the impact of pelvic surgical treatment on sexual health. The present article focuses on the short and long term outcomes of pelvic surgery in terms of erectile dysfunction. METHODS: A Medline search was conducted to identify original and review articles as well as editorials addressing the functional outcome after surgery. Keywords included radical prostatectomy, radical cystectomy, rectal cancer and erectile dysfunction. RESULTS: Erectile function impairment represents the most significant complication of pelvic surgery, negatively impacting the overall sexual health. The rates of ED range from 25-100%of patients, according to the extension of the pelvic dissection, the conservation of the neurovascular structures, as well as in consideration of the preoperative erectile function of the patients. Recent advances in the knowledge of pelvic anatomy resulted in an increase in the rates of erectile function recovery, especially in patients subjected to radical prostatectomy. The use of pro-erectile drugs significantly improves the outcomes of patients treated with nerve-sparing approach. Radical cystectomy for muscle-invasive bladder cancer is still associated with a high rate of erectile dysfunction. Similarly, pelvic surgery for rectal cancer is often a cause of ED in patients surviving to cancer treatment. Presence of urinary or faecal diversions surely represent a limitation to sexual activity in men. CONCLUSION: Recent advances in surgical technique and in the awareness of pelvic anatomy led to a better comprehension of the structures responsible for erectile function in pelvic surgery. New strategies are necessary in order to further reduce the rates of ED after this frequent surgical approach.

Cirugía y disfunción eréctil / Surgery and erectile dysfunction

OBJECTIVES: Erectile Dysfunction (ED) is one of the most negatively impacting complications associated with pelvic surgery. To date, several technical approaches and therapeutics options are available to limit the impact of pelvic surgical treatment on sexual health. The present article focuses on the short- and long term outcomes of pelvic surgery in terms of erectile dysfunction.METHODS: A Medline search was conducted to identify original and review articles as well as editorials addressing the functional outcome after surgery. Keywords included radical prostatectomy, radical cystectomy, rectal cancer and erectile dysfunction.RESULTS: Erectile function impairment represents the most significant complication of pelvic surgery, negatively impacting the overall sexual health. The rates ofArch. Esp. Urol. 2010; 63 (8): 640-648Keywords: Pelvic surgery. Erectil dysfunction.ED range from 25-100% of patients, according to the extension of the pelvic dissection, the conservation of the neurovascular structures, as well as in consideration of the pre-operative erectile function of the patients. Recent advances in the knowledge of pelvic anatomy resulted in an increase in the rates of erectile function recovery, especially in patients subjected to radical prostatectomy. The use of pro-erectile drugs significantly improves the outcomes of patients treated with nerve-sparing approach. Radical cystectomy for muscle-invasive bladder cancer is still associated with a high rate of erectile dysfunction. Similarly, pelvic surgery for rectal cancer is often a cause of ED in patients surviving to cancer treatment. Presence of urinary or faecal diversions surely represent a limitation to sexual activity in men . CONCLUSION: Recent advances in surgical technique and in the awareness of pelvic anatomy led to a better comprehension of the structures responsible for erectile function in pelvic surgery. New strategies are necessary in order to further reduce the rates of ED after this frequent surgical approach (AU)

OBJETIVO: La Disfunción Eréctil (DE) es una de las complicaciones asociadas con la cirugía pélvica que impactan más negativamente. Hasta el momento actual, varias técnicas de abordaje y opciones terapéuticas están disponibles para limitar el impacto del tratamiento quirúrgico pélvico sobre la salud sexual. El presente artículo está enfocado en los resultados de disfunción eréctil a corto y largo plazo de la cirugía pélvica.METODOS: Realizamos una búsqueda en Medline para identificar artículos originales y revisiones así como editoriales que trataran sobre los resultados funcionales de la cirugía. Las palabras clave incluían prostatectomía radical, cistectomía radical, cáncer de recto y disfunción eréctil.RESULTADOS: El empeoramiento de la función eréctil representa la complicación màs significativa de la cirugía pélvica, afectando negativamente la salud sexual global. Las tasas de DE tienen un rango entre el 25-100% de los pacientes, según la extensión de la disección pélvica, la conservación de las estructuras neurovasculares, así como la consideración de la función eréctil preoperatoria de los pacientes. Avances recientes en el conocimiento de la anatomía han tenido como resultado una mejoría de las tasas de recuperación de la función eréctil, especialmente en pacientes sometidos a prostatectomía radical. La utilización de fármacos pro-erectiles mejora significativamente los resultados de los pacientes tratados con un abordaje conservador de bandeletas neurovasculares. La cistectomía radical para el cáncer vesical músculo infiltrante se asocia todavía con una alta tasa de disfunción eréctil. De forma similar, la cirugía pélvica del cáncer rectal causa frecuentemente DE en los pacientes que sobreviven al tratamiento del cáncer. La presencia de una derivación urinaria o fecal representa seguramente una limitación para la actividad sexual en hombres. CONCLUSION: Los avances recientes de la técnica quirúrgica y el conocimiento de la anatomía han llevado a una mejor comprensión de las estructuras responsables de la función eréctil en la cirugía pélvica. Son necesarias nuevas estrategias para reducir más aun las tasas de DE después de este abordaje quirúrgico frecuente (AU)

Is extended and saturation biopsy necessary?

Prostate biopsy (PBx) techniques have significantly changed since the original Hodge's 'sextant scheme', which should now be considered obsolete. The feasibility of carrying out a biopsy scheme with a high number of cores in an outpatient setting is a result of the great improvement and efficacy of local anesthesia. Peri-prostatic nerve block with lidocaine injection should be considered the 'gold standard' because it provides the best pain relief to patients undergoing PBx. The optimal extended protocol should now include the sextant template with an additional 4-6 cores directed laterally (anterior horn) to the base and medially to the apex. Saturation biopsies (i.e. template with > or = 20 cores, including transition zone) should be carried out only when biopsies are repeated in patients where there is a high suspicion of prostate cancer. Complementary imaging methods (such as color- and power-Doppler imaging, with or without contrast enhancement, and elastography) could be used in order to increase the accuracy of biopsy and reduce the number of unnecessary procedures. Nevertheless, the routine use of these methods is still under evaluation.

Postoperative orgasmic function increases over time in patients undergoing nerve-sparing radical prostatectomy.

INTRODUCTION: Postprostatectomy orgasmic function (OF) remains poorly defined. AIMS: To assess OF over time in patients who underwent bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP) for organ-confined prostate cancer (PCa). METHODS: Baseline data were obtained from 334 consecutive preoperatively sexually active PCa patients at hospital admission; data included a medical and sexual history, IIEF domain scores, and ICIQ-SF. Questionnaire were then completed every 12 months postoperatively, and patients participated in a semistructured interview at the 12-month (191/334 [57.2%] patients), 24-month (95/334 [28.4%] patients), 36-month (42/334 [12.6%] patients), and 48-month (19/334 [5.7%] patients) follow-up (FU). MAIN OUTCOME MEASURES: IIEF-OF domain values throughout the FU. Multivariate linear regression analysis (MVA) of the association between predictors (patient's age, IIEF-erectile function [EF], ICIQ-SF, and the use of postoperative proerectile pharmacological treatments) and the IIEF-OF at 12-month, 24-month, and 36-month FU. RESULTS: Preoperative mean (median) IIEF-OF was 7.6 (10). The anova analysis showed an increase of the IIEF-OF values (P = 0.008; F = 4.009) throughout the FU (namely, IIEF-OF 12-month: 6.1 [6]; 24-month: 7.2 [8]; 36-month: 7.3 [8]; and 48-month: 7.7 [9.50]). The 12-month MVA showed that while proerectile oral therapy did not affect postoperative OF (P = 0.150; Beta 0.081), IIEF-OF linearly increased with IIEF-EF (P < 0.001; Beta 0.425). Conversely, IIEF-OF linearly decreased with patient's age (P < 0.001; Beta -0.135) and with ICQ-SF scores (P < 0.001; Beta -0.438). The 24-month and 36-month analyses showed that IIEF-OF still linearly increased with IIEF-EF (P < 0.001; Beta 0.540, and P < 0.001; Beta 0.536 respectively at the 24- and 36-month FU), whereas pharmacological therapy, rate of urinary continence, and patient's age did not significantly affect postoperative OF. CONCLUSIONS: Postoperative OF significantly ameliorates over time in patients undergoing BNSRRP. The higher the postoperative EF score, the higher the OF throughout the FU time frame.

Unsuccessful investigation of preoperative sexual health issues in the prostate cancer "couple": results of a real-life psychometric survey at a major tertiary academic center.

INTRODUCTION: Investigating preoperative sexual function of patients with prostate cancer (PCa) and their partners is needed for realistic functional outcome analyses after radical prostatectomy (RP). AIM: To assess pre-RP sexual health issues of PCa patients and their partners in a stable heterosexual relationship. METHODS: Data were analyzed from 3,282 consecutive patients who underwent RP over a three-period survey. During Period 1, on admission to the hospital the day prior to surgery, 1,360 patients were asked to complete the International Index of Erectile Function (IIEF). During Period 2, 1,171 patients were asked to complete the preoperative IIEF; similarly, patients' partners were invited to complete the Female Sexual Function Index (FSFI). Lastly, during Period 3, only candidates for RP were asked to fill in the IIEF. MAIN OUTCOME MEASURES: To assess the rate of patients who completed the questionnaire during the three-period survey. To detail the proportion of patients' partners who filled in the questionnaire, along with the partners' reasons for non-adherence to the proposed investigation during Period 2. RESULTS: A small rate of men completed the IIEF during Period 1 (583 in 1,360 [42.9%]), Period 2 (290 in 1,171 [24.8%]), and Period 3 (261 in 751 [34.8%]) (chi(2) trend: 13.06; P = 0.0003). In this context, a significantly lower proportion of patients completed the questionnaire during Period 2, as compared with both Period 1 (chi(2): 95.13; P = 0.0001) and Period 3 (chi(2): 21.87; P < 0.0001). Only 82 in 1,171 (7.0%) partners completed the FSFI over Period 2. Moreover, only 6 in 82 (7.3%) of women provided complete data. CONCLUSIONS: The investigation of sexual health issues of both partners prior to RP is largely unsuccessful. In this context, the prevalence of incomplete data collection is high, and these results demonstrate that contemporaneously investigating the sexual health issues of both partners significantly increases the prevalence of incomplete data collection.

Acceptance of and discontinuation rate from paroxetine treatment in patients with lifelong premature ejaculation.

INTRODUCTION: Selective serotonin reuptake inhibitors are the most widely used agents for delaying ejaculation in patients with premature ejaculation (PE). AIM: The aim of this study was to assess the acceptance of and the discontinuation rate from paroxetine treatment in patients with lifelong PE. METHODS: We analyzed the acceptance of and discontinuation rates of 93 consecutive potent patients (mean age, 37.6 years) seeking medical treatment for lifelong PE. The patients were assessed with detailed medical and sexual history, self-reported intravaginal ejaculatory latency time, self-administered International Index of Erectile Function, complete physical examination, and the Meares-Stamey test. The patients received a paroxetine prescription (10 mg daily for 21 days and then 20 mg as needed) for the first 3 months. Thereafter, the patients could either stay with the same on-demand treatment or take paroxetine 10 mg daily for 3 months. The patients were evaluated at 3 and 6 months, and requested to complete multiple-choice global assessment questions regarding specific reasons for eventual therapy discontinuation. MAIN OUTCOME MEASURES: The primary end point was acceptance and discontinuation rates for paroxetine treatment in patients seeking medical treatment for lifelong PE. The secondary end point was the reasons for nonacceptance of treatment or discontinuation. RESULTS: Twenty-eight (30.10%) patients decided not to start paroxetine. Fear of using an "antidepressant drug" was the main reason (42.9%) for treatment nonacceptance. Twenty (30.8%) patients who initiated therapy eventually discontinued it. Treatment effect below expectations was the main reason of treatment dropout (75%) during the first 3 months, followed by temporary loss of interest in sex because of relationship issues (15%) and side effects (10%). Of the patients who continued treatment, 77.8% preferred daily paroxetine, while 22.2% continued as-needed therapy. CONCLUSIONS: Thirty percent of lifelong PE patients seeking medical treatment for complaints of early ejaculation freely decided not to start any paroxetine treatment, and roughly 30% of patients who started therapy eventually discontinued it.

Quantitative sensory testing of peripheral thresholds in patients with lifelong premature ejaculation: a case-controlled study.

INTRODUCTION: The main functional factors related to lifelong premature ejaculation (PE) etiology have been suggested to be penile hypersensitivity, greater cortical penile representation, and disturbance of central serotoninergic neurotransmission. AIMS: To quantitatively assess penile sensory thresholds in European Caucasian patients with lifelong PE using the Genito-Sensory Analyzer (GSA, Medoc, Ramat Yishai, Israel) as compared with those of an age-comparable sample of volunteers without any ejaculatory compliant. METHODS: Forty-two consecutive right-handed, fully potent patients with lifelong PE and 41 right-handed, fully potent, age-comparable volunteers with normal ejaculatory function were enrolled. Each man was assessed via comprehensive medical and sexual history; detailed physical examination; subjective scoring of sexual symptoms with the International Index of Erectile Function; and four consecutive measurements of intravaginal ejaculatory latency time with the stopwatch method. All men completed a detailed genital sensory evaluation using the GSA; thermal and vibratory sensation thresholds were computed at the pulp of the right index finger, and lateral aspect of penile shaft and glans, bilaterally. MAIN OUTCOME MEASURES: Comparing quantitatively assessed penile thermal and vibratory sensory thresholds between men with lifelong PE and controls without any ejaculatory compliant. RESULTS: Patients showed significantly higher (P < 0.001) thresholds at the right index finger but similar penile and glans thresholds for warm sensation as compared with controls. Cold sensation thresholds were not significantly different between groups at the right index finger or penile shaft, but glans thresholds for cold sensation were bilaterally significantly lower (P = 0.01) in patients. Patients showed significantly higher (all P < or = 0.04) vibratory sensation thresholds for right index finger, penile shaft, and glans, bilaterally, as compared with controls. CONCLUSIONS: Quantitative sensory testing analysis suggests that patients with lifelong PE might have a hypo- rather than hypersensitivity profile in terms of peripheral sensory thresholds. The peripheral neuropathophysiology of lifelong PE remains to be clarified.

Anatomical radical retropubic prostatectomy in patients with a preexisting three-piece inflatable prosthesis: a series of case reports.

INTRODUCTION: Only few reports addressed the outcome of patients submitted to anatomical radical retropubic prostatectomy (RRP) with an indwelling inflatable penile prosthesis (IPP). AIM: To assess the feasibility and safety of RRP in patients with clinically localized prostate cancer and a previously implanted with an IPP. MAIN OUTCOME MEASURES: We evaluated the surgical parameters and the follow-up functional results in this particular patient population. METHODS: Four patients previously submitted to IPP implant for severe erectile dysfunction underwent RRP for organ-confined prostate cancer. Patients' charts were carefully reviewed to investigate pre- and perioperative details. Patients were evaluated by the International Index of Erectile Function (IIEF) preoperatively and at 6 months postoperatively. Patients were then contacted to assess long-term functional and oncological outcome. RESULTS: The outcome of the procedures was comparable to a normal population in terms of operating time, estimated blood loss, hospitalization time, and pathological outcome. No injury to the preexisting penile implant was reported. Continence was obtained in 3 (75%) patients at catheter removal, and in 1 (25%) patient at the 1-month follow-up. No major intra- and postoperative complications were reported. All patients were able to use their prosthesis after RRP. No statistical difference in pre- and post-RRP EF domain scores was found. CONCLUSION: The presence of an IPP in patients with prostate cancer is not a contraindication to perform an anatomical RRP. Surgery can be performed safely without injuring the implant and the clinical outcome in these patients is satisfactory. Postoperative implant use is not affected by RRP.

Holmium laser enucleation of the prostate and holmium laser ablation of the prostate: indications and outcome.

PURPOSE OF REVIEW: Holmium laser enucleation of the prostate (HoLEP) has been proposed as an alternative to transurethral resection of the prostate and to open prostatectomy for patients with lower urinary tract symptoms because of large benign prostatic enlargement. The aim of this review is to critically analyze currently available evidence-based reports regarding HoLEP, with particular interest in long-term follow-up results. RECENT FINDINGS: The use of holmium laser for the treatment of benign prostatic hyperplasia was first reported in 1996. HoLEP seems to represent a valid alternative to both transurethral resection of the prostate and open prostatectomy, with valid long-term functional results, a low rate of short-term and long-term complications, and very low rates of reintervention. SUMMARY: HoLEP represents a valid alternative to both transurethral resection of the prostate and open prostatectomy for treatment of patients suffering from lower urinary tract symptoms due to benign prostatic enlargement. The recently published long-term follow-up data demonstrate the durability of functional results. HoLEP can be offered as the size-independent gold standard treatment of patients with lower urinary tract symptoms because of benign prostatic enlargement.

Sex hormone-binding globulin: a novel marker for nodal metastases prediction in prostate cancer patients undergoing extended pelvic lymph node dissection.

OBJECTIVES: To examine the association between sex hormone-binding globulin (SHBG) and lymph node invasion (LNI) in patients treated with radical retropubic prostatectomy and extended pelvic lymph node dissection (ePLND). METHODS: The preoperative serum SHBG level was measured in a cohort of 168 consecutive patients (mean age 63.9 years, range 48-77) who underwent radical retropubic prostatectomy with ePLND for clinically localized prostate cancer. Logistic regression models tested the association between the predictors (including prostate-specific antigen, clinical stage, primary and secondary biopsy Gleason grades, and SHBG) and LNI. Logistic regression coefficients were used to calculate the predictive accuracy, which was subjected to 200 bootstrap resamples to reduce overfit bias. RESULTS: Thirteen patients (7.7%) had LNI. The mean serum SHBG level was significantly greater in the patients with LNI than in those without LNI (50.0 vs 35.1 nmol/L, respectively; P < .001). Univariate analysis indicated that preoperative SHBG was the single most informative predictor of LNI (77.8% vs 71.7% for prostate-specific antigen, 63.9% for clinical stage, and 63.1% and 54.2% for primary and secondary Gleason grade, respectively). On multivariate analysis, preoperative SHBG was still significantly associated with LNI (P < .001), after accounting for the other variables. The addition of preoperative SHBG increased the predictive accuracy of the base model using clinically established predictors from 72.7% to 82.8% (10.1% gain; P < .001). CONCLUSIONS: The results of this study provide novel evidence that SHBG might serve as a significant multivariate predictor of LNI in patients with prostate cancer undergoing ePLND. The use of preoperative serum SHBG could help to identify patients at risk of LNI who should undergo ePLND.

Does educational status affect a patient's behavior toward erectile dysfunction?

INTRODUCTION: Educational status has been investigated rarely as a potential factor affecting the behavior of patients with new onset erectile dysfunction (ED) toward seeking first medical help and subsequent compliance with prescribed phosphodiesterase type 5 inhibitor (PDE5) therapy. AIM: To test whether the educational status of patients with new onset ED and naïve to PDE5 therapy may have a significant impact on the delay before seeking first medical help (DSH) and compliance with the suggested PDE5. MAIN OUTCOME MEASURES: Assessing DSH and compliance with PDE5 in new onset ED patients according to their educational status by means of detailed logistic regression analyses. METHODS: Data from 302 consecutive patients with new onset ED and naïve to PDE5s were comprehensively analyzed. Patients were segregated according to their educational status into low (elementary and/or secondary school education) and high (high school and/or university degrees) educational levels. Complete data were available for 231 assessable patients. Univariate (UVA) and multivariate (MVA) logistic regression analyses addressed the association between educational status and DSH after adjusting for age, relationship status, and Sexual Health Inventory for Men score. Likewise, UVA and MVA were performed to test the association between educational status and patient compliance with PDE5 at the 9-month median follow-up. RESULTS: Median DSH was 24 months (range 1-350; mean 38.1 +/- 42.8). The lower the educational status, the shorter the DSH (P = 0.03). In contrast, a significantly (P < 0.0001) greater proportion of patients with a higher educational status showed compliance with the suggested PDE5 at the 9-month follow-up. Overall, educational status was not an independent predictor of either DSH or patient compliance with PDE5 therapy. CONCLUSIONS: After adjusting for other variables, our findings suggest that in new onset ED patients, educational status does not independently affect the DSH and patient compliance with PDE5 therapy.

Menstrual cycle-related changes in circulating androgens in healthy women with self-reported normal sexual function.

INTRODUCTION: There is currently neither a clinically useful, reliable and inexpensive assay to measure circulating levels of free testosterone (T) in the range observed in women, nor is there agreement on the serum free T threshold defining hypoandrogenism that is associated with female-impaired sexual function. AIM: Following the Clinical and Laboratory Standards Institute guidelines, we generated clinically applicable ranges for circulating androgens during specific phases of the menstrual cycle in a convenience sample of 120 reproductive-aged, regularly cycling healthy European Caucasian women with self-reported normal sexual function. METHODS: All participants were asked to complete a semistructured interview and fill out a set of validated questionnaires, including the Female Sexual Function Index, the Female Sexual Distress Scale, and the 21-item Beck's Inventory for Depression. Between 8 am and 10 am, a venous blood sample was drawn from each participant during the midfollicular (day 5 to 8), the ovulatory (day 13 to 15), and the midluteal phase (day 19 to 22) of the same menstrual cycle. MAIN OUTCOME MEASURES: Serum levels of total and free testosterone, Delta(4)-androstenedione, dehydroepiandrosterone sulphate and sex hormone-binding globulin during the midfollicular, ovulatory and midluteal phase of the same menstrual cycle. RESULTS: Total and free T levels showed significant fluctuations, peaking during the ovulatory phase. No significant variation during the menstrual cycle were observed for Delta(4)-androstenedione and dehydroepiandrosterone sulphate. Despite the careful selection of participants that yielded an homogeneous group of women without sexual disorders, we observed a wide range of distribution for each of the circulating androgens measured in this study. CONCLUSIONS: This report provides clinically applicable ranges for androgens throughout the menstrual cycle in reproductive-aged, regularly cycling, young healthy Caucasian European women with self-reported normal sexual function.

Remembered International Index of Erectile Function domain scores are not accurate in assessing preoperative potency in candidates for bilateral nerve-sparing radical retropubic prostatectomy.

INTRODUCTION: The reliability of reported postoperative data in patients undergoing nerve-sparing radical retropubic prostatectomy is often limited because the degree of sexual function (SF) has not been assessed objectively both before and after treatment. Most reports include only a retrospective chart review, and there is a question of whether such data are accurate. AIM: To test the agreement between a remembered International Index of Erectile Function (IIEF) score, which targeted SF regarding a period preceding the surgery by 6 months and a real-time IIEF, 4 weeks prior to surgery, in candidates for bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP). METHODS: From May 2005 to May 2006, 333 consecutive patients were candidates for BNSRRP at our institution. Upon admission on the day prior to surgery, each patient was asked to complete a set of validated questionnaires including both a remembered and a real-time IIEF. Two-tailed Student's t-test, chi2 test, Pearson correlation coefficient, multivariate regression analyses, and interrater agreement (kappa) were used to test the agreement between the two assessments. MAIN OUTCOME MEASURES: Assessing the preoperative SF characteristics of candidates for a BNSRRP, and testing the reliability of a remembered IIEF with the interrater agreement (kappa) test. RESULTS: Mean scores for the remembered IIEF were overall better than the real-time IIEF scores, as supported by direct comparison of the mean IIEF domain scores. Univariate correlation analysis and multivariate regression analysis indicated a significant correlation in the quality of the SF during the two periods. However, the remembered IIEF scores did not show a good statistical agreement with those of the real-time assessment, as demonstrated by the interrater agreement analysis. CONCLUSIONS: Because of the lack of significant agreement between remembered and real-time IIEF scores, the present findings indicate that remembered IIEF should not be used to assess SF in a real-life clinical setting in candidates for BNSRRP.

Acceptance of and discontinuation rate from erectile dysfunction oral treatment in patients following bilateral nerve-sparing radical prostatectomy.

OBJECTIVES: Assess acceptance of and discontinuation rate from erectile dysfunction (ED) treatment in patients after bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP). METHODS: We analyzed acceptance and discontinuation data of 100 consecutive, age-comparable, preoperatively self-reported potent BNSRRP patients who at the discharge from the hospital received a phosphodiesterase type 5 inhibitor (PDE5-I) prescription. Patients were informed of the pharmacokinetic properties of the available compounds and the option of on-demand versus rehabilitative therapy. Thereafter, patients did not receive any specific counseling throughout the entire follow-up period and freely decided to use or not use any ED therapy. Complete preoperative data were obtained on hospital admission and included a medical and sexual history and the International Index of Erectile Function (IIEF). The IIEF was completed every 6 mo postoperatively, and patients participated in a semi-structured interview about the treatment adherence at the 18-mo follow-up. RESULTS: Forty-nine (49%) patients freely decided not to start any ED therapy (group 1). Of the remaining patients, 36 (36%) opted for an as-needed PDE5-I (group 2), whereas 15 (15%) decided to use a daily PDE5-I (group 3). At the 18-mo follow-up, the overall discontinuation rate from both treatment modalities was 72.6% (eg, 72.2% vs. 73.3% in group 2 vs. group 3; p=0.79). Treatment effect below expectations was the main reason for treatment discontinuation, followed by loss of interest in sex due to partner's causes. CONCLUSIONS: Almost 50% of BNSRRP patients freely decided not to start any ED treatment postoperatively. Roughly 73% of patients who started therapy eventually discontinued it.