Tadalafil monotherapy in management of chronic prostatitis/chronic pelvic pain syndrome: a randomized double-blind placebo controlled clinical trial.

PURPOSE: In this placebo-controlled trial, we aimed to evaluate the clinical results of using PDE-5 inhibitor, tadalafil 5 mg OD, for management of CP/CPPS. PATIENTS AND METHODS: 140 patients ≤ 45 years old with moderate/severe CP/CPPS associated with ED (IIEF-5 < 22) were randomly divided and received either tadalafil 5 mg OD (tadalafil-group) or placebo (control-group) for 6 weeks. Post-treatment CPSI scores were compared to baseline and to placebo. Clinically significant responders (≥ 25% reduction from baseline score) were calculated. Tadalafil-induced changes in IIE-5 were evaluated in correlation to that of CPSI scores. RESULTS: By the 6th week, 59 and 56 patients were available in both groups respectively. Compared to baseline, tadalafil-group patients showed significant improvement in total, pain, urinary and Qol domains of CPSI (19.1 ± 5.26, 10.42 ± 3.55, 4.2 ± 1.72 and 4.47 ± 1.64 vs. 24.21 ± 5.05, 12.14 ± 3.57, 6.08 ± 1.53 and 6.22 ± 1.76), p < 0.5. When compared to placebo, all 6th week CPSI domains scores, except for pain, were significantly better in tadalafil-group (p < 0.05). Post-treatment pain score didn't significantly differ between both groups (10.42 ± 3.55, vs. 11.71 ± 3.9, p > 0.05). Clinically significant responders were 30 patients (50.8%) in tadalafil-group vs. 3 patients (5.4%) in control. Tadalafil-induced changes in IIEF-5 score had weak but significant correlation to Qol domain (r = - 0.28, p < 0.05). CONCLUSION: Tadalafil 5 mg OD can significantly improve all CPSI domains as compared to baseline. Post-treatment CPSI scores, except for pain, were better than placebo. About 50.8% of patients can develop ≥ 25% reduction in their total CPSI scores after treatment. Apart from Qol domain, these changes are not significantly correlated to tadalafil-induced IIEF-5 scores changes.

Dorsal onlay urethroplasty using lingual mucosal grafts for lichen sclerosis anterior urethral strictures repair: Long-term outcomes.

OBJECTIVE: To evaluate the long-term outcomes of dorsal onlay urethroplasty using lingual mucosal graft for repairing urethral strictures associated with genital lichen sclerosis. METHODS: This study included 36 patients who had lichen sclerosis long anterior urethral strictures that were managed with dorsal onlay urethroplasty using lingual mucosal graft, and were followed up ≥5 years. Preoperatively, we measured the maximum urinary flow rate and the International Prostate Symptom Score, then every 3 months in the first year, and annually thereafter. During follow up, patients with obstructive symptoms were subjected to urethrography and/ or urethroscopy. A successful urethroplasty was defined as normal voiding and no need for further intervention. RESULTS: Of the 36 patients, two were lost during the follow up, thus 34 patients were involved in the assessment. After lingual mucosal graft urethroplasty, there were significant improvements in maximum urinary flow rate and International Prostate Symptom Score (P < 0.0001). This improvement was sustained during the 5-year follow-up period. The median follow-up period was 66.5 months (interquartile range 64-70 months). The overall success rate in this study was 88.2%. Postoperative complications that required intervention were reported within the first year in four (11.8%) patients. Oral site complications were mild in the early postoperative period with no long-term complications. CONCLUSIONS: Dorsal onlay urethroplasty using lingual mucosal graft is a reliable and durable procedure for repairing lichen sclerosis urethral stricture. It provides a long-term success rate with few failures occurring within the first year. Lingual mucosal graft harvesting is associated with minor, immediate oral complications, and no long-term morbidity.

The long-term results of lingual mucosal grafts for repairing long anterior urethral strictures.

OBJECTIVE: To evaluate the long-term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts. PATIENTS AND METHODS: This study included 23 patients (mean age 36.3 years, range 21-62) who had a lingual mucosa onlay graft for managing a long anterior urethral stricture, and who were followed up for ⩾5 years. The mean length of the stricture was 4.6 cm. The International Prostate Symptom Score and uroflowmetry values were obtained before surgery, and at 3, 6 and 12 months afterwards, and annually thereafter. A retrograde urethrogram with a voiding cysto-urethrogram was taken before surgery, at catheter removal, after 3 and 6 months, and selectively thereafter. RESULTS: The mean (range) follow-up was 66 (60-72) months. The cause of the stricture was trauma in nine patients, instrumentation in seven, idiopathic in four, urethritis in two and previous hypospadias repair in one. The surgery was successful in 20 of the 23 patients (87%), and a recurrent stricture developed in the remaining three. There were no fistulae or clinically perceptible graft sacculations, and no long-term donor-site complications. CONCLUSIONS: With a long-term follow-up, our series confirms the durability of lingual mucosal onlay grafts for treating long anterior urethral strictures. This procedure results in a long-term high success rate with few of the complications that occur primarily during the first year.

Dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of penile torsion: a prospective randomized study.

PURPOSE: To compare the results of dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of congenital penile torsion. PATIENTS AND METHODS: Seventeen patients with congenital penile torsion were evaluated and managed from 2006 to 2010. On a random basis, 9 patients underwent surgical repair using a dorsal dartos flap rotation technique (group 1), and 8 patients by suturing tunica albuginea to the pubic periosteum (group 2). All were followed up every 6 months. RESULTS: The mean age in group 1 was 52.3 ± 24.8 months, while in group 2 it was 53.4 ± 33.6 months. Mean follow up was 22.3 ± 10.2 and 21.5 ± 7.2 months in group 1 and group 2 respectively. Torsion was corrected in 6 (66.7%) patients of group 1; 3 (33.3%) had residual torsion < 10°. In group 2, correction was achieved in 6 (75.0%) patients and 2 (25.0%) had residual torsion < 10°. The mean operative time was significantly less for group 1 than for group 2: 45.3 ± 7.1 and 74.5 ± 5.3 min, respectively (P < 0.0001). CONCLUSIONS: In short-term prepubertal follow up, both dorsal dartos flap rotation and suturing tunica albuginea to the pubic periosteum are effective for correction of congenital penile torsion. The former technique is easier to perform as it requires much less dissection.

The value of measuring the prostatic resistive index vs. pressure-flow studies in the diagnosis of bladder outlet obstruction caused by benign prostatic hyperplasia.

OBJECTIVE: To compare the prostatic resistive index (RI) and measurements from pressure-flow studies (PFS) for the diagnosis and follow-up of bladder outlet obstruction (BOO) in patients with benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: In all, 338 men (aged 55-82 years) presenting with lower urinary tract symptoms were evaluated prospectively for BOO secondary to BPH. In all patients, the prostatic RI was measured by transrectal power Doppler ultrasonography. PFS were assessed in all patients and depending on the results the patients were divided into an obstructive and an unobstructive group. The receiver operating characteristic (ROC) curve was used to determine the prostatic RI threshold value for predicting BOO secondary to BPH. Patients who were confirmed to have BOO secondary to BPH received either medical or surgical treatment, and they were re-evaluated after 3 and 6 months with prostatic RI measurements. RESULTS: According to the PFS the obstructive group included 158 patients and the unobstructive group 180 patients. The mean (SD) prostatic RI was significantly higher in the obstructive group, at 0.73 (0.04), than in the unobstructive group, 0.65 (0.05) (P < 0.001). Using the ROC curve a prostatic RI of â©¾ 0.71 predicted BOO secondary to BPH, with 84.6% sensitivity, 78.4% specificity and 83.8% overall predictability. After management, the prostatic RI of the obstructive group, 0.69 (0.08), was significantly lower than before treatment, 0.73 (0.04) (P < 0.05). CONCLUSIONS: The prostatic RI can predict BOO with high specificity and sensitivity. We believe that the prostatic RI could be a useful variable for the diagnosis and follow-up of patients with BPH.

Evaluation of intravesical potassium sensitivity test and bladder biopsy in patients with chronic prostatitis/chronic pelvic pain syndrome.

AIM: We evaluated the possibility that patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) might have similar histological and physiological bladder changes as that documented in patients with painful bladder syndrome/interstitial cystitis (PBS/IC). METHODS: Thirty-five known patients of CP/CPPS according to the clinical criteria of National Institutes of Health (NIH) were evaluated. The severity of the symptoms was evaluated according the NIH-Chronic Prostatitis Symptom Index. All patients underwent a potassium sensitivity test (PST) and bladder cystoscopy. Bladder biopsy was obtained from 17 patients with prostatitis and four control patients. RESULTS: Urinary symptoms were present in 31 (88.6%) patients. Pelvic pain was reported in all patients. PST was positive in 26 (84%) of 31 patients that presented with urinary symptoms in its filling phase. In the voiding phase, 10 (28.5%) patients experienced urethral pain. Of these patients, five had negative filling PST. There were only two (5.7%) patients that had negative PST in both of its phases for an overall positive PST rate of 94.3%. The severity of PST was not correlated with the total symptom score (P = 0.37). However, patients with severe urinary symptoms were more likely to score higher grades with PST (P = 0.01). Of the 17 patients who underwent bladder biopsy, a significant increase in the number of mast cells (MC) was present in 11 (64.7%) patients. Glomerulations with bladder cystoscopy was observed in 24 (68.6%) patients. CONCLUSIONS: The data of the present study support the opinion that PBS/IC is under-diagnosed in male patients that present with urgency, frequency and/or pain. In some patients diagnosed as CP/CPPS, the symptoms might be related to bladder dysfunction rather than prostatic inflammation.

Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow up.

OBJECTIVES: We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. PATIENTS AND METHODS: Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). RESULTS: Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. CONCLUSIONS: The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.