Transrectal Prostate Biopsy Approach in Men Undergoing Kidney Transplant: A Retrospective Cohort Study at Three Referral Academic Centers.

BACKGROUND: Currently, there are no studies evaluating the feasibility of a prostate biopsy approach in men undergoing a kidney transplant (KT). Owing to this evidence, we planned a retrospective population-based study to evaluate our experience of a transrectal prostate biopsy (TR-PB) approach and studied the impact on the complication rate and outcomes in patients undergoing KT with suspected prostate cancer (PCa). METHODS: We collected data from KT patients who underwent PB with a transrectal approach. One week and two weeks after the PB, patients' information was collected regarding possible complications during the post-biopsy period. RESULTS: A total of 121 patients were included in this study. Among them, Group 1 was composed of 59 patients undergoing TR-PB with an ultrasound (US) standard technique, and Group 2 consisted of 62 patients undergoing TR-PB with an MRI-US cognitive technique. We observed a 28.9% Clavien-Dindo grade ≤ 2 of early side effect rates (mostly rectal bleeding and other minor hematuria), with a very low rate of hospital re-admission for acute urinary retention (3.3%); only one man required hospitalization for rectal bleeding, and there were no major complications. CONCLUSIONS: We can affirm that TR-PB can be a safe procedure with a low risk of severe complications when performed by skilled specialists with a standardized procedural pathway.

Serum Testosterone Concentration Influences the Response to Extracorporeal Shock Wave Treatment in Men With Peyronie's Disease.

OBJECTIVE: To assess the relationship between baseline total serum testosterone (T) and clinical outcomes in men affected by Peyronie's disease (PD) stable stage and treated by extra corporeal shockwave therapy (ESWT). METHODS: In this study, 168 patients affected by PD in stable stage (≥12 months) and treated with ESWT, were divided into 2 groups. Group 1 (G1) counted 71 patients with low T levels (≤ 300 ng/dL); group 2 (G2) consisted of 97 patients with normal T that received ESWT with the same protocol of G1 for 6 weeks. There were assessed at baseline and follow-up: Erectile dysfunction (ED), presence and severity of painful erections, penile plaque size, and penile curvature degree. The results were evaluated at baseline and 3, 6, 12, months after the treatment. RESULTS: Not statistically significant differences emerged between the 2 groups at baseline, except for higher presence of patients with ED in G1 (90%) vs G2 (52%). Three months after the treatment in G2 pain was resolved completely in 80.4% of the patients, compared with G1 (54.9%). G2 had a reduction of curvature degree after the 3-month treatment (P <.001). Mean plaque size decreased in both groups without statistically differences with baseline values. Mean ± SD International Index of Erectile Function-5 score progressively improved significantly in the eugonadal men. CONCLUSION: This study demonstrated greater efficacy for the treatment of PD in men with normal T concentrations compared with men with low T concentrations. The results obtained from this study suggest that may be valuable in considering T therapy in men with PD prior to ESWT.

Low-intensity laser diode plus extracorporeal shock wave therapy: a new treatment strategy in the management of Peyronie's disease.

PURPOSE: To assess the clinical effectiveness of extra corporeal shockwave therapy (ESWT) administration compared with ESWT plus a low-intensity laser diode therapy (LILDT) in the management of Peyronie's disease (PD) stable stage. METHODS: In this study, 214 patients affected by PD in stable stage (≥ 12 months), were divided into two groups. Group 1 (G1) counted 111 patients treated only with ESWT; Group 2 (G2) consisted of 103 patients that received ESWT with the same protocol of G1 plus LILDT for six weeks. The patients of both groups were assessed at baseline and follow-up for erectile function, painful erections, penile plaque size and penile curvature. The results were evaluated at baseline and 3, 6, 12 months after the treatment. RESULTS: Three months after the treatment in G2 pain in an erection or during intercourse was resolved completely in 78.6% of the patients, whereas in 55.8% cases of G1 (p < 0.003). G2 patients had a reduction of curvature degree after the 3 months treatment (p < 0.002). However, mean plaque size decreased in both groups without statistically differences with baseline values. Mean ± SD IIEF-5 score further improved significantly in the group treated with ESWT plus LILDT (p < 0.001). There were no permanent adverse sequelae after treatments. CONCLUSION: This study demonstrates an interesting therapeutic strategy when combined to the synergistic action of a shock wave therapy with low-intensity laser therapy on the stable plaques with significant benefits in terms of pain perception, penile curvature and sexual activity.

Does using a laser improve outcomes of conventional circumcision in adult and children populations? Results from a systematic review and meta-analysis.

BACKGROUND: Male circumcision is a well-known old surgery, and several recently developed techniques have been scaled up, including the introduction of laser technology, as alternative approaches to overcome morbidity of conventional surgery scalpel/suture method OBJECTIVES: We aimed to perform a systematic review and meta-analysis of studies comparing laser circumcision versus conventional circumcision technique in terms of perioperative outcomes and efficacy (complications, unacceptable appearance, reoperation rate) both in children and adults. MATERIALS AND METHODS: This review was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were analyzed using the inverse variance of the mean difference with a random effect, 95% confidence interval (CI), and p-value. The incidence of complications, unacceptable appearance, and reoperation rate were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% CI, and p-value. Significance was set at p-value ≤0.05 and 95%CI. RESULTS: Seven studies were included. In comparison to the conventional circumcision, laser circumcision shoved lower visual analogue score at 24-h, and 7 days after surgery, a lower rate of overall complication rate (OR 0.33, 95% CI 0.24-0.47, p < 0.001), scarring (OR 0.09, 95% CI 0.02, 0.41, p = 0.002), and unacceptable appearance (OR 0.09, 95% CI 0.05, 0.15, p < 0.001). We found no statistically significant difference in surgical time, and incidence of bleeding, infection, wound dehiscence, and reoperation rate. DISCUSSION AND CONCLUSION: Our review infers that laser-assisted circumcision is certainly a safe and strong contender as the procedure of choice in both children and adult populations.

Hidden penis: a rare case of delayed complication after a pelvic blunt trauma.

Penile dislocation following a traumatic pubic bone fracture is a very rare condition. Only a few cases are reported in the literature and the presentation mechanism is still not completely understood. The impact energy on the pelvis usually causes a displaced fracture with concomitant withdrawal of the pubic bone. The retraction of the pubic bone pulls the penis by its suspensory ligament leading to penile dislocation. We describe a rare case of a "hidden" penis 2 months after a blunt pelvic trauma following a motor vehicle accident. Clinical examination revealed a retracted penile skin. The penis was not visible, neither palpable in the expected position. Micturition took place by dripping urine from the opening of the prepubic skin where urine got trapped in the surrounding skin. He also complained of not having erections. A magnetic resonance imaging that showed invaginated penis, located in the anterior pelvic wall, adjacent to the right inguinal canal. Surgical repair was performed trough an inverted "V" suprapubic incision that allowed exploring the pubic area. The degloved penile shaft was identified and isolated from fibrotic adhesions to the surrounding tissue. The invaginated penile skin that was thin and retracted. The point of fixation was located deeply in the right pubic area where the subcutaneous tissue and skin were firmly attached to a spike of the fractured pubic bone. This adhesion was sharply resected and the penis and its skin were restored in their anatomical position. The suspensory ligament was partially detached. Erection was simulated using saline solution injection into the corpora cavernosa to exclude penile curvature. Postoperative course was uneventful. One year after surgery, the penis had a normal appearance without retraction and sexual function was completely restored. Our case pointed out the importance of genitalia evaluation by practitioners involved in the care of pelvic trauma patients.

Scrotal trauma: interest of preoperative ultrasound in the prediction of the rupture of the tunica albuginea.

Aim Scrotal bruises are quite frequent injuries affecting young subjects, with psychological repercussions on body image and fertility. The interest of ultrasound in the context of the emergency remains controversial. The aim of our study was to investigate clinical, ultrasonographic and operative features of scrotal contusions, and to evaluate the contribution of ultrasound in the description of traumatic lesions. Methods In this retrospective and descriptive study 71 scrotal contusions operated from December 2015 to April 2020 were collected. We retrospectively analysed 26 patients (aged between 14 and 79 years) of 71 who sustained a scrotal ultrasound, where the latter was positive. The primary endpoint was albuginea rupture, whose concordance between ultrasound and surgery was assessed using the Kappa method. Positive and negative predictive values, sensitivity and specificity for the presence of albuginea rupture were evaluated for a set of ultrasound data: scrotal haematoma, haematocele, regularity of testicular contours, testicular fracture (specificity (93%), testicular haematoma, and Doppler signal intensity. Results Surgical treatment was necessary in 26 (37%) patients; only six orchiectomy were performed. Surgical exploration should be performed if haematocele is found in the genital examination without any ultrasound complement. Conclusion The ultrasonography is useful, detailed and accurate when the haematocele is not clinically evident.

Technology Meets Tradition: CO2 Laser Circumcision versus Conventional Surgical Technique.

PURPOSE: We wished to present the clinical applications and to evaluate the benefits of the use of a carbon dioxide (CO2) laser versus the conventional procedure for circumcision in adults, in terms of duration of surgery, surgical techniques, complications, pain and cosmetic appearance. PATIENTS AND METHODS: The medical records of 482 patients who had been circumcised were retrospectively evaluated. The patients were divided into two groups: 168 patients (Group A) were circumcised with traditional techniques; and 314 patients (Group B) were circumcised using a CO2 laser. All the patients were circumcised under local anesthesia. Pain was evaluated using a verbal numerical rating scale for pain assessment. Postoperative wound swelling, bleeding, infection and pain were assessed at 4 hours, 24 hours and 7 days after surgery. RESULTS: There were no significant differences between the two groups in terms of bleeding and infections. The difference in operating times between the groups was significant (p<0.001). Wound disruptions occurred in one patient in Group A at 3 days and two patients in Group B at 1 week. Pain scores were low and there was less pain in Group B than in Group A during the first 4 hours (1.8 vs 3.7; p<0.002). Compared with the conventional method, the CO2 laser technique was associated with much less pain at both 1 day (p<0.002) and 7 days (p<0.001) postoperatively. The cosmetic results were superior in Group B; a linear surgical scar developed in 94.9% of patients in Group B versus 61.3% in Group A (p<0.001). CONCLUSION: Our results show that the use of a CO2 laser was associated with a shorter operative time, less wound irritation and better cosmetic appearance compared with standard surgical techniques for circumcision.

Platelet-derived growth factor regulation of type-5 phosphodiesterase in human and rat penile smooth muscle cells.

INTRODUCTION: Relaxation of cavernous smooth muscle cells (SMCs) is a key component in the control of the erectile mechanism. SMCs can switch their phenotype from a contractile differentiated state to a proliferative and dedifferentiated state in response to a change of local environmental stimuli. Proliferation and contraction are both regulated by the intracellular second messengers cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP), which are degraded by phosphodiesterases (PDEs). The most abundant PDE present in corpora cavernosa is the electrolytic cGMP-specific phosphodiesterase type 5 (PDE5). AIM: We investigated the cellular localization of PDE5 in in vitro cultured corpora cavernosa cells and the effect of mitogenic stimulation on PDE5 expression. METHODS: Biochemical ad molecular techniques on cultured SMCs from human and rat penis. MAIN OUTCOME MEASURES: We studied the ability of the quiescent SMC phenotype vs. the proliferating phenotype in modulation of PDE5 expression. RESULTS: We demonstrated that PDE5 is localized in the cytoplasm, in the perinuclear area, and in discrete cytoplasmic foci. As previously demonstrated in human myometrial cells, the cytoplasmic foci may correspond to centrosomes. In corpora cavernosa, PDE5 protein levels are strongly regulated by the mitotic activity of the SMCs, as they were increased in quiescent cultures. In contrast, treatment with platelet-derived grow factor (PDGF), one of the most powerful mitogenic factors for SMCs, reduces the expression of PDE5 after 24 hours of treatment. CONCLUSION: We found that PDGF treatment downregulates PDE5 expression in proliferating SMCs, suggesting that PDE5 may represent one of the markers of the contractile phenotype of the SMCs of corpora cavernosa.

Ontogenetic profile of the expression of thyroid hormone receptors in rat and human corpora cavernosa of the penis.

INTRODUCTION: In the last few years, various studies have underlined a correlation between thyroid function and male sexual function, hypothesizing a direct action of thyroid hormones on the penis. AIM: To study the spatiotemporal distribution of mRNA for the thyroid hormone nuclear receptors (TR) alpha1, alpha2 and beta in the penis and smooth muscle cells (SMCs) of the corpora cavernosa of rats and humans during development. METHODS: We used several molecular biology techniques to study the TR expression in whole tissues or primary cultures from human and rodent penile tissues of different ages. MAIN OUTCOME MEASURE: We measured our data by semi-quantitative reverse transcription polymerase chain reaction (RT-PCR) amplification, Northern blot and immunohistochemistry. RESULTS: We found that TRalpha1 and TRalpha2 are both expressed in the penis and in SMCs during ontogenesis without development-dependent changes. However, in the rodent model, TRbeta shows an increase from 3 to 6 days post natum (dpn) to 20 dpn, remaining high in adulthood. The same expression profile was observed in humans. While the expression of TRbeta is strictly regulated by development, TRalpha1 is the principal isoform present in corpora cavernosa, suggesting its importance in SMC function. These results have been confirmed by immunohistochemistry localization in SMCs and endothelial cells of the corpora cavernosa. CONCLUSIONS: The presence of TRs in the penis provides the biological basis for the direct action of thyroid hormones on this organ. Given this evidence, physicians would be advised to investigate sexual function in men with thyroid disorders.

Urodynamic parameters after solifenacin treatment in men with overactive bladder symptoms and detrusor underactivity.

AIMS: To describe the changes in urodynamic parameters and to assess patients' perceptions of voiding difficulties and improvements in symptom bother after solifenacin treatment in men with overactive bladder (OAB) and detrusor underactivity (DUA). METHODS: In this prospective study, 49 neurologically intact men were enrolled. DUA was defined as a bladder contractility index (BCI) <100. All subjects received 5 mg of solifenacin once a day for 120 days. A complete urodynamic study was carried out on the day before to the first dose of solifenacin and at day 120. RESULTS: Solifenacin treatment resulted in a decrease in Q(max) during UDS (-0.6 ml/sec; P = 0.007), P(det)Q(max) (-6.4 cmH(2)O; P < 0.001), BOOI (-7.5; P < 0.001), BCI (-3.8; P = 0.001), BVE (-4.4%; P = 0.006), and voided volume (-7.5 ml; P = 0.09). On the contrary, PVR (+6 ml; P = 0.152), and maximum cystometric capacity (+22.9 ml; P = 0.001) increased. The regression analysis suggested that changes in urodynamic parameters after solifenacin treatment were limited for BOOI (9.4%), P(det)Q(max) (8.4%), and BCI (6.5%), with no significant impact on Q(max) during UDS, BVE, volume voided and PVR. No significant change in subjective perception of voiding difficulties was found. The incidence of AUR was 2.2% and improvement in patient's experience of OAB symptoms bother after solifenacin treatment was observed. CONCLUSIONS: Solifenacin treatment results in changes of urodynamic parameters. These changes, however, seem not to be of clinical significance as suggested by the lack of subjective deterioration in voiding difficulties and by the low incidence of AUR.

Surgical and biologic outcomes after neoadjuvant bicalutamide treatment in prostate cancer.

OBJECTIVES: To perform a randomized, prospective, controlled, intention-to-treat study to determine the usefulness of bicalutamide as a neoadjuvant hormonal therapy regimen to surgery in reducing positive surgical margins and modulating epidermal growth factor receptor (EGFR) member's in men with prostate cancer. METHODS: From April 2002 to December 2003, 430 men were diagnosed with prostate cancer. Of these men, 119 with clinical Stage T2-T3a were enrolled. Of the 119 men, 61 were assigned to receive 150 mg/day bicalutamide for 120 days before radical prostatectomy (bicalutamide plus surgery group) and 58 to radical prostatectomy alone (surgery group). Logistic regression analysis was performed to determine the relationship between bicalutamide and EGFR/Her2/neu levels. P <0.05 was considered to indicate significance. RESULTS: Patients treated with bicalutamide had a 3.5-fold increase in negative surgical margins (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.4 to 8.74; P = 0.011). In particular, in Stage pT3a tumors, bicalutamide treatment was associated with a fivefold increase in negative surgical margins (OR 5.4; 95% CI 1.9 to 15.5; P = 0.002). In those with Stage pT2, no difference for this surgical outcome was noted. Immunohistochemical analysis revealed that bicalutamide increased EGFR levels 2.8-fold (OR 2.8; 95% CI 1.3 to 6.2; P = 0.014) and of 2.7-fold Her2/neu (OR 2.7; 95% CI 1.2 to 5.8; P = 0.022). When EGFR and Her2/neu were overexpressed, they were also active. In this regard, bicalutamide increased p-EGFR levels 3.3-fold (OR 3.3; 95% CI 1.3 to 8.2; P = 0.0016) and increased p-Her2/neu 2.8-fold (OR 2.8; 95% CI 1.2 to 6.3; P = 0.025). CONCLUSIONS: Bicalutamide appears to reduce the prevalence of positive surgical margins. The upregulation of Her2/neu and EGFR and their phosphorylated forms was an early event after bicalutamide treatment. We hypothesized that the benefits of neoadjuvant hormonal therapy might be overwhelmed by the capacity of the residual tumor to acquire compensatory survival pathways and to grow and progress.

Gefitinib and bicalutamide show synergistic effects in primary cultures of prostate cancer derived from androgen-dependent naive patients.

We previously demonstrated that the inhibition of the epidermal growth factor receptor (EGFR) signalling affects the endocrine therapy responses of prostate cancer (PCa) cells and that bicalutamide (BCLT) is able to reinforce PI3K activity through mechanisms involving PTEN decrement and EGFR and Her2 activities. The aim of this study was to evaluate if the hormonal therapy with BCLT can affect the EGFR-targeted therapy using primary cultures obtained from 22 human PCa tissues harvested after radical prostatectomy (RP) in patients who received (n=10) BCLT and those that did not (n=12) as neoadjuvant hormone therapy (NHT). We demonstrated that cultures derived from PCa tissues harvested after NHT presented significantly higher EGFR and Her2 levels compared to cultures derived from control patients. However, cultures derived from patients with NHT were less sensitive to gefitinib when compared to cultures derived from control patients. Conversely, BCLT effectiveness did not seem to be different in the two groups and was partially additive with gefitinib in the NHT group and additive/synergistic in the control group. Cultures (8/22) were negative for the expression of the PTEN gene and we observed no differences in the two groups. Thus the different IC50 values observed for gefitinib and the partial additivity in the combination treatment with gefitinib and BCLT is influenced by EGFR/Her2 ratio because it was shown that EGFR inhibition was lower when Her2 is overexpressed. Taken together, our results indicate that anti-EGFR targeted therapies and a possible combination therapy involving gefitinib and BCLT should be performed early in naive patients when Her2 is not overexpressed and before the anti-androgenic hormone therapy induces such an undesirable effect.

Urodynamic obstruction in women with stress urinary incontinence--do nonintubated uroflowmetry and symptoms aid diagnosis?

PURPOSE: We estimated the prevalence of urodynamic obstruction in women with stress urinary incontinence and determined which clinical indicator (nonintubated uroflowmetry or urinary symptoms) better predicts urodynamic obstruction. MATERIALS AND METHODS: From December 2004 to June 2005, 101 women with urodynamic stress urinary incontinence were enrolled. Adjunctive lower urinary tract symptoms were also observed. Of 101 women with stress urinary incontinence 27 had abnormal and 74 had normal nonintubated uroflowmetry. Normal nonintubated uroflowmetry was defined as a bell-shaped curve with maximum flow more than 15 ml per second and post-void residual urine less than 50 ml. Urodynamic obstruction was diagnosed based on maximum urine flow less than 12 ml per second and maximum detrusor pressure at maximum flow more than 25 cm H(2)O. RESULTS: In our stress urinary incontinence population the prevalence of urodynamic obstruction was 15.7%. In urodynamically obstructed women storage symptoms were most common (56.3%), while voiding and post-micturition symptoms were less common (31.3% and 6%, respectively). A good correlation between abnormal nonintubated uroflowmetry and urodynamic obstruction (phi = 0.718, p <0.0001) was found. lower urinary tract symptoms correlated weakly with urodynamic obstruction. The diagnostic performance of abnormal nonintubated uroflowmetry for predicting urodynamic obstruction showed that it had relatively low positive predictive value (51.8%) with high negative predictive value (97.3%), sensitivity (87.5%) and specificity (84.1%). The diagnostic performance of lower urinary tract symptoms was weak. CONCLUSIONS: Our study confirms the coexistence of obstruction and stress urinary incontinence. In this population abnormal nonintubated uroflowmetry cannot always confirm the presence of urodynamic obstruction and complete urodynamic study might be indicated. Conversely normal nonintubated uroflowmetry seems to accurately predict normal urodynamic study and might render the execution of this test not essential. Symptoms represent a poor clinical indicator of voiding disorder.

Bladder outlet obstruction index and maximal flow rate during urodynamic study as powerful predictors for the detection of urodynamic obstruction in women.

AIMS: To evaluate whether bladder outlet obstruction index (BOOI), a mathematical index of outlet resistance, in association with maximal flow rate (Qmax) obtained during multichannel urodynamics (UDS) or detrusor pressure at maximal flow rate (PdetQmax) could help the identification of obstruction in women. METHODS: From January 2004 to February 2005, 401 women were assessed in our urodynamic unit. Of these, 133 were neurologically intact women, referred symptoms suggestive of voiding disorders and had an abnormal non-intubated uroflussometry (NIF) (BOO group). A normal NIF was defined as a bell-shaped curve in presence of a Qmax >15 ml/sec and a PVR <50 ml. Symptoms of voiding disorders were ascertained by interview and rated positive if they occurred more than occasionally. Thirty-seven women were enrolled as unobstructed if they presented a normal NIF and symptoms suggestive of voiding disorders less than occasionally (unobstructed group). RESULTS: ROC curve demonstrated similar diagnostic accuracy in the diagnosis of urodynamic obstruction for Qmax obtained during UDS (AUC = 0.908; P < 0.0001; CI99% = 0.831 to 0.985) and BOOI (AUC = 0.879; P < 0.0001; CI99% = 0.794 to 0.918) and the least was seen for PdetQmax (AUC = 0.706; P = 0.001; CI99% = 0.620 to 0.830). A Qmax obtained during UDS cut-off < or =15 ml/sec provides specificity of 85.9% and sensitivity of 78.9%. A BOOI cut-off > or = -8 provides a sensitivity of 80.8% and specificity of 86.1%. The weakest sensitivity (64.2%) and specificity (64.6%) was recorded for PdetQmax > or =28 cmH(2)O. CONCLUSIONS: BOOI and Qmax obtained during UDS appears to be the most discriminating urodynamic parameters of female BOO. The use of these cutoff might facilitate the identification of women with functional and anatomical obstruction.

Tamsulosin treatment increases clinical success rate of single extracorporeal shock wave lithotripsy of renal stones.

OBJECTIVES: To design a randomized, no-treatment, controlled, prospective study to determine whether the administration of tamsulosin, as adjunctive medical therapy, increases the efficacy of one extracorporeal shock wave lithotripsy (ESWL) session to treat renal stones and decreases the use of analgesic drugs after the procedure. METHODS: A total of 130 patients underwent a single ESWL session to treat solitary radiopaque renal stones 4 to 20 mm in diameter. After treatment, all patients were randomly assigned to receive our standard medical therapy alone (controls) or in association with 0.4 mg tamsulosin daily for a maximum of 12 weeks. All 130 patients were followed up for 3 months or until an alternative treatment was given. RESULTS: Of the 130 patients, 78.5% of those receiving tamsulosin and 60% of controls had achieved clinical success at 3 months (P = 0.037). When we stratified patients according to stone size, for those with a stone size larger than 10 mm, the success rate was significantly greater in the tamsulosin group (P = 0.028). Renoureteral colic occurred in 76.9% of patients treated with standard therapy but in only 26.1% of those receiving tamsulosin (P < 0.001). The mean cumulative diclofenac dose was 375 mg per patient in the tamsulosin group and 675 mg per patient in the control group (P < 0.001). CONCLUSIONS: The results of our study have demonstrated that tamsulosin therapy, as an adjunctive medical therapy after ESWL, is more effective than lithotripsy alone for the treatment of patients with large renal stones and is equally safe. In addition, our results also indicated that adjunctive treatment with tamsulosin could decrease the use of analgesic drugs after ESWL.