Intracavernous injection in the treatment of erectile dysfunction after radical prostatectomy: an observational study.

CONTEXT: Despite the recent improvements in performing radical retropubic prostatectomy that have led to a considerable decrease in the complication rate, erectile dysfunction still represents a major problem. Moreover, less invasive treatment options that are emerging for erectile dysfunction have not shown satisfactory results in managing these patients. OBJECTIVE: To study the efficacy and side effects of self-injection therapy in the treatment of men who had become impotent after undergoing radical prostatectomy due to prostate cancer, over a study period of 96 months. DESIGN: Observational study. SETTING: University Referral Center. PARTICIPANTS: 168 patients with erectile dysfunction, aged 43 to 78 years old, who underwent radical retropubic prostatectomy due to localized prostate cancer. PROCEDURES: The patients were treated with self-injection therapy using papaverine, phentolamine and prostaglandin E1, at home. RESULTS: This study showed an acceptable 94.6% success rate, with no life-threatening complications. In addition to this, our series presented a 13.1% cure rate with this therapy. CONCLUSION: Self-injection therapy with papaverine, phentolamine and prostaglandin E1 is effective and safe in the treatment of erectile dysfunction after radical prostatectomy.

Ureteroscopic stone removal in the distal ureter. Why change?

PURPOSE: We compared our experience with ureteroscopic stone basket manipulation under fluoroscopic guidance to ultrasound ureterolithotripsy for distal ureteral stone removal. MATERIALS AND METHODS: Retrospectively, we analyzed the medical records of 981 patients with ureteral calculi between January 1994 and December 1995, of whom 483 (49%) were treated for stones in the lower ureter and constituted our study group. The decision of when to perform lithotripsy (group 2) versus a basket procedure (group 1) was based on a prospective nonrandomized study and both groups were compared historically. All 322 patients in group 1 (mean age 49 years, range 14 to 86) primarily underwent ureteroscopic stone basket manipulation using the 4-wire Segura* basket. If the calculus could not be removed with the basket and another procedure was necessary, the case was considered a failure. The 161 patients in group 2 (mean age 37 years, range 14 to 74) underwent initially ultrasound ureterolithotripsy for stone fragmentation followed or not by removal of the fragments with the basket. Stone size did not differ significantly between groups 1 (mean 0.9 cm., range 0.6 to 1.7) and 2 (mean 0.8 cm., range 0.7 to 2.0). Ureteroscopy was performed in both groups with epidural anesthesia and on an outpatient basis in the majority of cases. RESULTS: The stone-free rate after 1 procedure was 98.1 and 95.6% in group 1 and 2, respectively. For group 2 versus group 1 the operative time was longer (mean 50, range 25 to 90 versus mean 19 minutes, range 11 to 40, respectively, p < 0.001), the complication rate was greater (16.1 versus 4.3%, respectively, p < 0.001) and average hospital stay was longer (2.1 versus 0.15 day, respectively, p < 0.001). CONCLUSIONS: Ureteroscopic stone treatment with basket manipulation under fluoroscopic guidance or ultrasound ureterolithotripsy provided a high stone-free rate. However, stone removal with the basket manipulation technique should be considered the first choice for treatment of small distal ureteral calculi based on the minimal morbidity, and short operative and recovery times.

The importance of the prostate weight in transurethral microwave thermotherapy.

OBJECTIVE: Transurethral resection of the prostate (TURP) is still the gold standard in the treatment of benign prostatic hyperplasia (BPH). Prostate weight could be of importance on the result of transurethral microwave thermotherapy (TUMT). The present study attempted to elucidate this point. MATERIAL AND METHODS: Transurethral microwave thermotherapy (TUMT) was administered to 106 men with BPH. The patients were classified into two groups according to the weight of the prostate. Group 1 comprised 69 patients, aged 52 to 84 years (mean 65 years), whose prostate weighed up to 50 gm. Group 2 comprised 37 men, aged 55 to 87 years (mean 68 years) whose prostate weighed more than 50 gm. Prostate weight was determined by transrectal ultrasound. The protocol included history and physical examination (particularly digital rectal examination), laboratory evaluation (particularly measurement of PSA), transrectal ultrasound and uroflowmetry. The post-void residual urine was measured by urethral catheterization and ultrasound examination. RESULTS: There were 5/106 (4.7%) failure; therefore, a total of 101 patients were followed from 3 to 27 months, mean 7.7 months. Postoperatively, both groups showed improvement of all the parameters analyzed, except PSA (p < 0.01). However, comparison of the two groups for irritative and obstructive symptoms score and uroflow showed no significant difference. The decrease of the post-void residual urine was statistically greater in group 1 (p < 0.01). Group 2 showed a larger reduction in weight in comparison to group 1 (p < 0.01). Complications were observed in 12/101 (11.9%) cases, with no statistical difference between groups. Of a total of 7 patients with ejaculatory disorders, 5 patients with smaller prostate were observed. Recovery was not seen at more than 6 months follow up. CONCLUSION: The results showed no correlation between the prostatic weight and the efficiency of TUMT in the treatment of BPH.

Functional and histologic alterations in growing solitary rat kidney as result of extracorporeal shockwaves.

The long-term effects of extracorporeal shockwave lithotripsy (SWL) on children treated for renal calculi are unclear. To study the effects on the immature animal, we evaluated 31 Wistar white rats that underwent right nephrectomy at 30 days of age. At 40 days of age they were divided into three groups: a control group of 10 rats that received no shockwaves; Group I (9 rats) that received 1000 shockwaves at 16.0 kV, and Group II (12 animals) that received 1000 shock waves at 17.2 kV. Six months later at maturity (7 months and 10 days of age), the following parameters were measured: (1) body and renal weight; (2) blood lithium, sodium, potassium, and creatinine; (3) fractional lithium, sodium, and potassium excretion; and (4) clearances of lithium and creatinine. The kidneys were studied grossly and histologically. We found no significant changes in overall animal and renal growth between the post-SWL and control groups. However, there were significant changes in renal function. The animals in Groups I and II presented significant increases in blood potassium compared with the control group. Furthermore, the 1000 x 17.2 kV group showed permanent histologic renal changes, including red cells in Bowman's capsule and glomerular congestion. The disorders caused by SWL are compatible with hyporeninemic hypoaldosteronism, inappropriately low plasma renin activity, and aldosterone deficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

Ejaculatory dysfunction after transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia.

The possibility of retrograde ejaculation or impotence after transurethral resection of the prostate has led to searches for other treatments for benign hyperplasia (BPH). Transurethral microwave thermotherapy (TUMT) was administered to 100 men with a mean age of 61 years and moderate to severe BPH in one 60-minute outpatient session without anesthesia. A urethral catheter was frequently maintained for 5 to 7 days to avoid urinary complaints. Of the 100 original patients, 79 were followed from 3 to 24 months (mean 7.3 months). The prostate volume, irritative and obstructive symptoms, residual urine volume, and urinary flow improved (P < 0.01). No systemic complications were encountered. There were minor complications such as epididymitis, urethral bleeding, and severe micturition discomfort within the first 30 days postoperatively. A total of 7 ejaculatory disorders occurred among 64 patients (11%), 6 complete absences and 1 retrograde ejaculation without recovery for more than 6 months. As TUMT is a fairly new method, further studies must be done to define its effectiveness and safety.

Effects of extracorporeal shockwave lithotripsy on renal growth and function: an animal model.

The long-term effects of extracorporeal shockwave lithotripsy (SWL) on children are unclear. At 40 days of age, with an average weight of 166 g, 34 Wistar white rats were divided into three groups: 9 rats (control group) received no shockwaves, 10 rats (Group 1) received 1000 shockwaves at 16.0 kV, and 15 animals (Group 2) received 1000 shockwaves at 17.2 kV. Six months later, at maturity, body weight; lithium and creatinine; fractional sodium, potassium, and lithium excretion; and the clearances of lithium and creatinine were measured, and the kidneys were studied grossly and histologically. We found no significant changes in overall animal or renal growth between the post-SWL groups and the control group. However, there were significant changes in renal function, mainly in Group 2; the animals of this group presented a significant increase in blood lithium and potassium, besides a significant decrease in the fractional potassium excretion compared with the control group. Furthermore, the animals in Group 2 showed permanent histologic renal changes, including red cells in Bowman's capsule and glomerular congestion. The disorders caused by SWL are compatible with hyporeninemic hypoaldosteronism, an inappropriate low plasma renin activity and aldosterone deficiency. We conclude that SWL does not affect either overall animal or renal growth but may cause permanent histologic damage and significant changes in renal function.

Is percutaneous monotherapy for staghorn calculus still indicated in the era of extracorporeal shockwave lithotripsy?

Staghorn stones can be treated by percutaneous nephrolithotomy (PCNL) or by extracorporeal shockwave lithotripsy (SWL); however, the combination of the two techniques appears as the most frequent treatment. In a previous study, the investigators noted that staghorn calculi treated with PCNL monotherapy have a good clearance rate. Herein, we have reviewed 102 staghorn stones that underwent PCNL before (1984-1986) (Group 1; n = 51) and after (1987-1990) (Group 2; n = 45) the introduction of SWL. The stone burden has increased in both size and complexity: there were 27 complete staghorn calculi (60%) in Group 2 compared with 19 (37%) in Group 1. Despite the higher number of kidney punctures, blood urea nitrogen and serum creatinine measurements demonstrated improvement of renal function postoperatively. The stone-free rates were 78% and 89% and the retreatment rates 31% and 18% in Groups 1 and 2, respectively. Complications (29% and 38%) were a function of the technical factors that become more apparent in the more difficult cases. Our data support the concept that the surgeon should have no previous intention to use the lithotripter and, therefore, should try to remove the entire stone percutaneously safely and economically.

Blood pressure changes after extracorporeal shock wave lithotripsy in normotensive patients.

To evaluate the blood pressure changes caused by extracorporeal shock wave lithotripsy 102 patients 5 to 81 years old (mean age 40 years) with normal blood pressure and kidney lithiasis were monitored during a mean period of 22 months. There were 61 male (group 1) and 41 female (group 2) patients. Patients were evaluated by measurement of the diastolic pressure and the average arterial pressure before and after lithotripsy. Hypertension was considered when the diastolic pressure was greater than 90 mm. Hg for 2 weeks. The amount of shock waves applied in each case ranged from 1,250 to 6,000, with a mean of 4,000 shock waves at a median intensity of 18.1 kv. The incidence of hypertension after extracorporeal shock wave lithotripsy was 3.92%, which is similar to that of a normal population, although the diastolic pressure was statistically higher after treatment in both groups. In the male patients the diastolic pressure increased from 79.26 (+/- 9.7) to 81.47 (+/- 10.1) mm. Hg and in female patients it ranged from 76.58 (+/- 8.3) to 79.26 (+/- 9.9) mm. Hg. Similarly, the average arterial pressure was equally higher in the female group, ranging from 89.88 to 91.75 mm. Hg. In the male group the difference was not statistically significant, despite an increase from 94.5 to 95.8 mm. Hg.

The importance of hyperprolactinemia in impotence.

The role of serum prolactin in sexual dysfunction has not yet been clarified. Moderate elevations of prolactin levels, without any associated disorder, occur frequently. A random group of 600 patients was studied to determine the level of prolactin in which medical treatment was necessary. Among these patients 23 (3.8%) presented hyperprolactinemia and were divided into two groups: Group 1--Twelve patients with prolactin levels ranging from 20 to 40 ng/ml, and Group 2--Eleven patients with levels higher than 40 ng/ml. In Group 1, prolactin of all patients returned to normal levels after treatment, but only one patient (8.3%) achieved full erection; on the other hand, in Group 2, nine out of eleven patients prolactin returned to normal after treatment and 77.7% achieved full erection.

Surgical treatment of veno-occlusive dysfunction: evaluation of short-term and long-term results.

The abnormal venous drainage of the penis is an important cause of erectile dysfunction. Until recently the best choice for treatment was the venous surgery. We studied 21 patients submitted to radical vein ligation due to venous leakage. Their age ranged from 27 to 69 years (mean 53 years). A total of 14 patients evaluated after a mean follow-up of 13 months showed a 64% success rate. At a mean follow-up of 25 months the success rate of the 21 patients operated on, decreased to 38%. Therefore, we concluded that in a long-term follow-up the results are not quite satisfactory, which brings us much concern about the efficacy of the operation.