Disappointing initial results with transurethral alprostadil for erectile dysfunction in a urology practice setting.

PURPOSE: We evaluate the response to intraurethral alprostadil administration using the Medicated Urethral System for Erection (MUSE) in unselect men with a history of erectile dysfunction. We determine the effects on blood pressure during in office monitoring and assess safety of this form of treatment. We compare the efficacy of MUSE in an office setting with the placebo controlled pivotal study. MATERIALS AND METHODS: A total of 115 men with erectile dysfunction underwent in office testing with MUSE following the algorithm recommended by the manufacturer and outlined in the original pivotal study. Patients were asked to rate the rigidity of erection from 1 to 5 with scores 4 and 5 for erections sufficient for intercourse, and level of discomfort from 1 (very uncomfortable) to 5 (very comfortable) at 15-minute intervals. Patients who did not achieve a sufficient erection were scheduled to return for in office testing using the next higher dose up to 1,000 microg. Patient supine and sitting blood pressures were recorded by a nurse before and every 15 minutes after administration. Telephone contact with patients 2 to 3 months after the last in office testing was made to determine whether they were using the system. RESULTS: Mean plus or minus standard deviation rigidity scores independent of dosage increased from 2.34+/-0.99 at 15 minutes to 2.49+/-0.96 at 30 minutes and decreased thereafter. Although the 1,000 microg. dosage resulted in highest mean score at all times, the differences between dosages were not significant. Rigidity score 4 or 5 was achieved in 13.2% (500 microg.) and 30% (1,000 microg.) of patients at 30 minutes. Mean level of discomfort was 3.6+/-1.2 at 15 minutes and improved thereafter. Comfort levels were not significantly different among dosages. Overall, at 15 minutes 16.8% of patients were uncomfortable (score 1 or 2) and 41.3% were somewhat uncomfortable (1, 2 or 3). For all dosages supine and sitting systolic and diastolic blood pressures decreased significantly from before treatment to 15 minutes and stayed lower during monitoring. Defined by strict criteria 41.2% of patients experienced orthostatic hypotension during in office testing. A total of 21 patients had adverse events, including pain, discomfort and burning in the penis (the most common), dizziness and chest pain. One patient had a syncopal episode and fell in the office. At last followup only 18.6% of the tested patients continued to use MUSE at home, while the remainder discontinued treatment due to pain, insufficient erections for intercourse and cost. CONCLUSIONS: We were unable to achieve similar results to the pivotal study following manufacturer instructions and the algorithm provided by that study. Independent of age and etiology no more than 30% of patients at any given time using any dose achieved erections sufficient for intercourse during in office testing. Because of this limited efficacy, discomfort, pain and burning associated with treatment, and cost, more than 80% of patients did not continue to use MUSE at home.

Is selective therapy of recurrent nephrolithiasis possible?

We evaluated, in 128 patients with recurrent nephrolithiasis, the efficacy of special treatment programs for some of the common causes of nephrolithiasis, chosen on the basis of their ability to correct underlying physicochemical and physiologic derangements. Therapy included sodium cellulose phosphate for 18 patients with absorptive hypercalciuria, thiazide diuretics for 27 patients with absorptive hypercalciuria and for 10 with renal hypercalciuria, orthophosphate for eight patients with hypophosphatemic absorptive hypercalciuria, allopurinol for 21 patients with hyperuricosuric calcium oxalate nephrolithiasis, thiazide and allopurinol for 26 patients with absorptive hypercalciuria with hyperuricosuria, and high fluid intake and/or low calcium diet for 22 patients with normocalciuric nephrolithiasis. Patients in all seven groups had a significant reduction in stone formation during 1.70 to 3.37 years of treatment, as compared with the pretreatment period of three years. Remission was found in 70 to 91 percent of patients and reduced stone formation rate was encountered in 88 to 100 percent. Each treatment program produced a significant decline in stone formation rate from 1.90 to 2.28 stones per year to 0.09 to 0.55 stones per year. The actual number of stones formed during treatment was significantly lower than the number predicted from the pretreatment frequency of stone formation (less than 26 percent). The results provide evidence supporting a selective approach to therapy of nephrolithiasis.

Private practice experience with radical surgical treatment of cancer of prostate.

This private practice series of 255 men with adenocarcinoma of the prostate was evaluated with regard to the efficacy of radical prostatectomy in controlling disease. Sixty-seven men underwent radical surgery: 77 per cent are surviving longer than ten years post-operatively with several of these individuals now in their fifteenth year, 9 per cent died of their disease, and 10 per cent are totally incontinent. The survival in this series are compared with those of other series and the differences discussed.

A private practice experience with adenocarcinoma of the prostate in men less than 50 years old.

We have found a sharp increase in the number of men less than 50 years old with adenocarcinoma of the prostate. In the last 4 years we have found 9 new patients less than 50 years old, which far exceeds the expected number. Prompted by this increase we reviewed our experience with prostatic carcinoma in young men. Our findings of 11 of 256 patients (4 per cent) and good survival from 6 months to 15 years (90 per cent) are at variance with previously published reports. We attribute the increased number of patients with adenocarcinoma of the prostate to our willingness to biopsy small "unimportant" nodules in the prostate. Whether these findings reflect an actual increase in the incidence of prostatic carcinoma in young men or simply an increase in the frequency of diagnosis of previously unrecognized lesions is not clear.