Erectile dysfunction following Nd-YAG visual laser-assisted prostatectomy (VLAP).

We investigated if side fire Nd-YAG visual laser prostatectomy (VLAP) causes erectile dysfunction (ED) in patients who were sexually active prior to the procedure. The 36 study patients gave a detailed medical/sexual history: physical examination included bulbo-cavernous reflex (BCR) on rectal examination and routine blood tests. Lasing time, power of the applied laser beam (in watts), coagulation site and energy intensity were recorded. Patients with new onset ED during the one year study period underwent pudendal nerve conduction (PNC), color duplex Doppler ultrasonography, and NPT/RigiScan testing. In 6 out of 36 (16.7%) patients reporting significant post-operative ED, there was a tendency towards higher energy applied and longer lasing time but no correlation between prostate size or the site of energy application. Patients reported loss of night and/or morning erections (n = 5), retrograde ejaculations (n = 2), loss of ejaculate (n = 2), and decreased sensation of orgasm (n = 3). Three had abnormal PNC, duplex Doppler showed abnormal blood supply in four, and all six had abnormal NPT/RigiScan. We believe this is the first demonstration that VLAP may be associated with a high rate of ED and that the lasing time and intensity of applied laser energy may play a role in this outcome.

Does severity of ischemic coronary disease correlate with erectile function?

An association between diminution in the quality of male sexual function and ischemic coronary disease has been suggested. Patients with ischemic heart disease who underwent coronary angiography participated in this study which aimed to document the impact of the extent of coronary disease upon sexual function in 40 patients (mean age 56.6 y). The 11-questions accepted questionnaire addressing sexual drive, erectile function, and ejaculation was used. Information regarding, age, medications, hypertension, diabetes, relevant risk factors, medical history, and the number of occluded coronary vessels was retrieved from the patients' records. A statistically significant correlation was demonstrated between erectile function and the number of coronary vessels involved. Patients with one-vessel disease had more (P < 0.04) and firmer erections (P < 0.001) with fewer difficulties in achieving an erection (P < 0.007) than men with two- or three-vessel disease. Age, diabetes, and hypertension also had a negative effect on the quality of the erection (P < 0.05) in all patients.

Intraprostatic metal stents (Prostakath and Urospiral): more than 6 years' clinical experience with 110 patients.

We reviewed the long-term results of two different intraprostatic metal stents. Patients (N = 110) with either benign prostatic hyperplasia or prostatic cancer were included in a prospective study and treated by the insertion of one of two intraprostatic stents (Prostakath or Urospiral). The mean follow-up was 53 (range 36-80) months. Subjective and objective symptoms and signs were evaluated at each follow-up visit. The different complications and overall success rates were compared for the two intraurethral spirals. When considering both patient satisfaction and device functionality, the overall success rate was 65%. Stent migration, incrustation, failure to void, and clinical infections were the most common complications. Of 41 cases of late complications, removal of the stents was required in 35 patients. No difference in the rate of late complications was noted for the two stents. Intraurethral stents are well-tolerated by patients. The relatively low cost of spirals and the fact that they may be left in situ for long periods renders them highly cost efficient. There is a need for continued close follow-up when the stent is left in situ for prolonged periods. There was no significant difference between the two metal stents despite their different coating.

Effect of finasteride on free and total serum prostate-specific antigen in men with benign prostatic hyperplasia.

OBJECTIVE: To examine changes in the free-to-total (f/t) serum prostate-specific antigen (PSA) ratio among men treated with finasteride for benign prostatic hypertrophy. PATIENTS AND METHODS: Blood samples were taken from 20 men (mean age 71 years, range 61-87) before and after a minimum of 9 months of treatment with finasteride and the f/tPSA ratio determined using the Immulite assay system. RESULTS: Although mean total and free PSA levels decreased significantly, the mean f/tPSA ratio increased only slightly and not significantly; the ratios remained unchanged in men with an initially low or high (< > 10%) ratio. CONCLUSIONS: Concern has been expressed over the loss of the discriminatory power of serum PSA in a patient receiving treatment with finasteride. The f/tPSA ratio, currently used to help differentiate benign from malignant processes in the prostate, remains valid during treatment with finasteride; it does not affect the f/tPSA ratio.

Effect of elective prolonged urethral catheterization on serum prostate-specific antigen concentration.

OBJECTIVES: To determine the effect of an indwelling catheter on prostate-specific antigen (PSA) levels. PSA is an organ (prostate)-specific marker, and its level can be elevated in various pathologies as well as following urologic manipulations. An elevated marker may indicate the presence of prostate cancer. In the presence of an indwelling catheter, our inability to decide whether an elevated PSA value represents genuine pathology or is related to the catheter itself is often of great clinical importance. METHODS: A prospective study was conducted on 21 men with an indwelling catheter inserted electively for major nonurologic abdominal surgery to determine its influence on PSA concentration. Sera were collected before catheter insertion, 2 hours after, and then every day (average, 16 days). Catheters were left in place for an average of 5.5 days. RESULTS: Follow-up data compared to baseline and to the previous day's PSA concentrations revealed no significant change in any of the subjects. In 2 men with elevated preinsertion PSA levels (more than 10.0 ng/mL), the change over time did not differ in magnitude from changes in the other 19 men with normal pretreatment values. CONCLUSIONS: Inserting a urethral catheter and maintaining it for several days does not result in any clinically or statistically significant change in PSA levels. PSA values obtained in patients with an indwelling catheter are reliable and independent of its presence. An elevated level mandates prompt evaluation to exclude prostate cancer.

Functional melatonin receptors in human prostate epithelial cells.

Melatonin, secreted nocturnally by the pineal gland, affects gonadal growth and pubertal development in rodents and, presumably, in humans. Recently, we have found, using 125I-labeled melatonin as a probe, specific melatonin binding sites in the human benign prostate tissue; these sites were primarily associated with the microsomal fraction of the epithelial cells. In the present study, we have explored 125I-melatonin binding sites in human benign prostate epithelial cells in culture and investigated the effects of melatonin on growth and viability of these cells. 125I-melatonin bound to the prostate cells with high (K(d) = 68 pM) affinity. Competition experiments revealed that specific binding was inhibited by subnanomolar concentrations of melatonin and 2-iodomelatonin, whereas serotonin and 5-methoxytryptamine reduced the binding only partially. Melatonin (10 pM-10 nM) inhibited the incorporation of 3H-thymidine and 3H-uridine into the prostate epithelial cells in a dose-dependent manner. Inhibition was transient, and the incorporation recovered to control levels within less than 24 h. Protein synthesis as measured by the incorporation of 35S-methionine into cell proteins decayed to minimal levels about 2 h after addition of melatonin, and its recovery was slower compared with that of 3H-thymidine or 3H-uridine incorporation. Melatonin treatment (1 nM) for 2-7 days inhibited cell growth and markedly increased the percentage of non-viable cells in culture, measured by the trypan blue exclusion assay. The results demonstrate high affinity melatonin receptors in the human benign prostate epithelial cells, which may affect cell growth and viability.

Putative melatonin receptors in benign human prostate tissue.

Melatonin, secreted by the pineal gland at night, inhibits pubertal development of rats and presumably men. In addition, it may directly suppress prostate growth in the adult rat. To investigate the possibility for a causal relationship between the age-related decline in melatonin production and increase in prevalence of benign prostate hypertrophy (BPH) in man, the presence of melatonin binding sites in human BPH tissue was examined. In vitro autoradiography indicated specific 125I-labeled melatonin (125I-melatonin) binding in the prostate, localized to the glandular epithelium. Separation and subcellular fractionation indicated that these sites were associated with the microsomal fraction of the epithelial cells. Kinetic and equilibrium 125I-melatonin binding experiments revealed that the binding was time dependent and reversible, with an apparent half saturation at 140 pmol/L. Competition experiments indicated high and low affinity melatonin binding sites; binding was inhibited by melatonin (IC50 1 nmol/L and 1 micromol/L, respectively) and partially by the putative melatonin antagonist, N-(2,4 dinitrophenyl)-5-methoxytryptamine (ML-23; IC50 0.1 nmol/L). Serotonin and 6-hydroxymelatonin were less potent, whereas up to 0.1 mmol/Lol/L of 5-methoxytryptamine, 6-methoxymelatonin, and tryptamine caused only a partial reduction in specific binding. The guanine nucleotide analogs, guanosine 5'-O-[3-thiotriphosphate] and guanosine 5'-O-[2-thio-diphosphate, inhibited specific 125I-melatonin binding, whereas 5'-guanylyl imidodiphosphate was less potent. The results indicate putative melatonin receptors in the human prostate epithelium.

Do reported micturition symptoms on the American Urological Association Questionnaire correlate with 24-hour home uroflowmetry recordings?

PURPOSE: Patient subjective descriptions of micturition habits using the American Urological Association (AUA) symptom index were compared with uroflowmetry recordings obtained during a 24-hour period. MATERIALS AND METHODS: In a prospective study, the AUA questionnaire was given twice to 42 men. All micturitions during a typical 24-hour period were continuously recorded by a home uroflowmetry system. Daytime frequency, strength and intermittency of the stream, and nocturia were calculated from the recorded data, which were correlated with the matching questionnaire answers. RESULTS: Except for nocturia, there was no correlation between the answers and recorded findings. CONCLUSIONS: Men are unable to quantify correctly their own clinical status. The study results cast doubt on the validity of the self-administered AUA survey to reflect clinical micturition.

Cardiac arrhythmias during nonsynchronized extracorporeal shock wave lithotripsy.

PURPOSE: We evaluated the occurrence of cardiac arrhythmias during nonsynchronized extracorporeal shock wave lithotripsy. MATERIALS AND METHODS: A total of 125 nonsynchronized shock wave lithotripsy treatments was performed using a spark plug lithotriptor. RESULTS: Asymptomatic unifocal ventricular premature contractions occurred during 23 treatments (18.4%) and were more frequent during therapy on the right side (p < 0.05). Among patients undergoing multiple sessions only 1 exhibited ventricular premature contractions during treatment. No correlation was demonstrated between ventricular premature contractions and patient age, gender, presence of heart disease, stone size and location within the collecting system (kidney or ureter), presence of a ureteral catheter or nephrostomy tube, mode of anesthesia or number of shock waves. CONCLUSIONS: Nonsynchronized shock wave lithotripsy can be accomplished safely in most patients.

Use of automatic insulin injector for intracorporeal injection in erectile dysfunction.

Intracorporeal injection of vasoactive drugs for the treatment of impotence may be problematic in patients with limited dexterity or psychogenic inhibitions of self-injection. Already in common use for diabetic patients is an easy-to-use automatic injector device, with rapid and simple loading and operating. This economical and handy gadget is adapted to accept standard disposable syringes. We have found it useful also for painless self-injection of intracorporeal vasoactive drugs for the treatment of erectile dysfunction.

[Finasteride (Proscar) for benign prostatic hypertrophy].

Several alternatives to surgery for benign prostatic hypertrophy (BPH) were studied during the past few years. Finasteride (Proscar), a 4-azosteroid, is an inhibitor of the enzyme 5-alpha reductase, which is responsible for the conversion of testosterone to the biologically more active dihydrotestosterone (DHT). We report 3 years of experience with the drug in 23 men. Persistent significant decreases in serum DHT and prostate-specific antigen (PSA) were documented. Prostatic volume decreased by about 25% after 1 year, and remained fairly constant thereafter. Urination improved, as evidenced by increased maximal flow rate and decreased volume of residual urine. Symptoms were affected favorably, but only mildly. One of the main advantages of the drug is its lack of side-effects. More data on a larger number of patients with a longer follow-up are needed before finasteride can be established as having a role as an alternative treatment for BPH.

How reliable is a single measurement of urinary flow in the diagnosis of obstruction in benign prostatic hyperplasia?

Twenty-six elderly patients with obstructive symptomatology and an initial low peak urinary flow rate (< 15 ml/s) were observed for 6 to 12 months. Repeated assessments were made of flow rates and residual volumes. Within patients variation of the maximal urinary flow was significant; the standard deviation (SD) varied from 0.8 to 5.5 ml/s. The SD varied with the mean peak flow rates and this suggests that the precision of a single determination of a patient's peak flow is inversely related to the peak flow itself. In all, 333 determinations of peak flow were obtained. Only 80% were below 2 SD of the mean Siroky nomogram. Multiple determinations were used to estimate the sensitivity rate for each patient, i.e. the proportion of peak flows that were less than 2 SD below the mean of Siroky's nomogram. The average sensitivity for all of the flow values was 0.813 when applied to voided volumes and increased only slightly to 0.838 when applied to total bladder volume. Given a prevalence of 0.70 of obstruction ascribed to benign prostatic hyperplasia (BPH) among elderly men, the positive predictive value of an abnormally low peak flow was 0.97. A single low peak flow based on assessment of voided volume may serve as an almost sure indication of obstruction. If a patient has a single normal peak flow rate, he still has a 0.31 probability of having evidence of obstruction in his following uroflow determinations. Using total bladder volume does not make a difference in most patients and is not worth the effort and discomfort. The only patients who require accurate residual measurements are those with a normal uroflow but clear-cut obstructive symptomatology or with borderline peak flow. The results of this study are relevant to everyday clinical practice and to the evaluation of studies on alternatives to surgery in BPH.

The role of the radionuclide renal study in the management of renal colic.

If renal colic is suspected in the patient presenting with acute flank or lower abdominal pain it must be established whether or not the affected kidney is obstructed and whether there is functional impairment that may require urological intervention. The radionuclide renal study developed in this hospital and used routinely for over 10 years can reveal obstruction when the results of commonly used tests are negative. It also provides information on renal function, morphology and blood flow. It is a cost-effective, safe and reliable procedure for the initial investigation of patients presenting with suspected renal colic.

Posthernioplasty urinary retention: a noninvasive work-up for prediction.

The prognostic value of various subjective and objective noninvasive urological parameters was evaluated for their possible role in the prediction of post-hernioplasty urinary retention. In a prospective study, 35 patients aged 55-85 years without previous micturition complaints or urological surgery were evaluated 1 day prior to inguinal hernioplasty. This included medical history for modified Madsen subjective scoring profile, physical examination and uroflowmetry. Bladder capacity, residual urine and prostatic volume were measured by ultrasound. All patients underwent a similar method of hernioplasty, were closely followed 48 h postoperatively and any voiding difficulties or urinary retention were noted. Urinary retention occurred in 12 patients. None of the remaining 23 patients had urination difficulties. Comparing these two groups, we concluded that patient age, bladder capacity and prostatic volume have no prognostic value for potential postoperative urinary obstruction. On the other hand, obtaining a good anamnesis of obstructive and irritative symptoms for scoring, measuring maximal flow rate on urinary flowmetry and estimating residual urine volume may predict patients who are potentially at high risk for posthernioplasty urinary retention.

Prolonged treatment with finasteride (a 5 alpha-reductase inhibitor) does not affect bone density and metabolism.

OBJECTIVE: Since it is not clear whether testosterone or dihydrotestosterone is the active hormone in bone metabolism, we wished to assess the effect of finasteride, a 5 alpha-reductase inhibitor, or vertebral bone mineral density and parameters of bone and mineral metabolism. DESIGN: Patients were treated in a randomized, double-blind controlled study with either placebo, 1 or 5 mg/day finasteride. PATIENTS: Twenty-three men with benign prostatic hyperplasia (BPH) were included in this study; eight received placebo, seven were allocated to treatment with 1 mg/day, and eight to 5 mg/day finasteride for 12 months. MEASUREMENTS: Vertebral bone mineral density was measured at the lumbar spine by dual energy X-ray bone densitometry. Serum calcium, phosphorus, parathyroid hormone, osteocalcin and vitamin D metabolites were measured regularly. Urinary calcium and creatinine excretion were monitored as well. RESULTS: Finasteride caused a significant decrease in serum dihydrotestosterone after 6 and 12 months, but no effect on serum testosterone. Vertebral bone mineral density remained unaltered. None of the other parameters monitored were affected except for a small unexplained increase in 1.25-dihydroxyvitamin D in the group receiving 5 mg finasteride/day. CONCLUSIONS: Testosterone is probably the active hormone in bone metabolism. However, oestradiol, the product of testosterone aromatization (which remains unaltered under finasteride) may yet be another possible responsible steroid in the maintenance of bone density. We can also not rule out that the small amount of dihydrotestosterone remaining under finasteride administration is sufficient for maintaining normal bone metabolism.