Erectile and ejaculatory functions changes following bipolar versus monopolar transurethral resection of the prostate: a prospective randomized study.

OBJECTIVES: To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) focusing on erectile and ejaculatory functions in a randomized trial. METHODS: Between January 2013 and December 2014, all consecutive TURP candidates with benign prostatic hyperplasia (BPH) were prospectively randomized 1:1 into M-TURP/B-TURP arms and followed up at 2, and 4 weeks, 6 and 12 months after surgery. All patients were assessed using IIEF-15 (International index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual-health inventory). Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between both intervention groups. RESULTS: Following M.TURP and B.TURP; 122 and 124 patients were included respectively and were considered for analysis at 1 year. Sexual function did not differ significantly between arms during follow-up (erectile function, P = 0.82; orgasmic function, P = 0.46; sexual desire, P = 0.29; intercourse satisfaction, P = 0.18; overall satisfaction, P = 0.92). There were no differences between arms in the distribution of EF evolution at any time compared with base line (at 12 months: M-TURP vs. B-TURP = improved, 24.5 vs. 26.6%; stable, 66.4 vs. 64.5%; deteriorated, 9.1 vs. 8.9%; P = 0.41). Newly developed erectile dysfunction (ED) was present in 8.2 and 7.3% of patients following M.TURP and B.TURP respectively and was related to presence of DM and obesity. Orgasm perception significantly reduced following M.TURP and B.TURP (P < 0.001). Newly reported ejaculatory dysfunction (Ej-MSHQ < 22) was significantly associated with low orgasm perception. CONCLUSIONS: There were no differences between M-TURP/B-TURP in any aspect of sexual function.

Erectile dysfunction post-perineal anastomotic urethroplasty for traumatic urethral injuries: analysis of incidence and possibility of recovery.

PURPOSE: To evaluate the incidence of erectile dysfunction (ED) and recoverability of erectile function (EF) after anastomotic urethroplasty for traumatic urethral injuries (TUIs) of different etiologies. METHODS: A retrospective review for patients' records underwent perineal anastomotic urethroplasty for TUIs from June 1998 to January 2014 was conducted. Those patients were contacted and evaluated using the International Index of erectile function questionnaire in sexually active men, and in unmarried men, the single-question self-report of ED was used. Patients with ED underwent penile color Doppler ultrasonography. RESULTS: Overall, 81 patients were included in the study. The incidences of ED following urethroplasty for TUIs were 72.3, 35.3 and 0% in cases due to pelvic fracture, straddle and iatrogenic injuries, respectively. None of the patients reported deterioration of EF after urethroplasty. Seven (13.5%) patients reported recovery of their EF within 2 years after trauma. The probability of recovery of EF after PFUI was 9% compared to 28.6 and 100% in patients with straddle and iatrogenic urethral injuries, respectively. Patients with type C pelvic fracture had no chance for EF recoverability. CONCLUSIONS: PFUIs have a probability of causing ED as much as 72% compared to 35 and 0% in men with straddle and iatrogenic urethral injuries, respectively. Anastomotic urethroplasty has no deleterious effect on EF. A tendency for higher recoverability of EF could be observed after iatrogenic urethral injuries followed by straddle injury then PFUIs. The probability of recovery decreased proportionally with severity of pelvic trauma.

Ejaculatory function after anastomotic urethroplasty for pelvic fracture urethral injuries.

PURPOSE: The effect of anastomotic urethroplasty for pelvic fracture urethral injuries (PFUIs) on ejaculatory profile is under-reported in the literature. There is controversy as regards the effect of bulbocavernous muscle splitting during surgery on ejaculatory function (EjF). We evaluated the effects of anastomotic urethroplasty on EjF using a validated questionnaire. METHODS: We retrospectively reviewed the computerized surgical records to identify patients who underwent anastomotic posterior urethroplasty for PFUIs from June 1998 to January 2014. Those patients were retrieved and evaluated for their EjF using the EjF component of the Male Sexual Health Questionnaire (MSHQ). RESULTS: Overall, 58 patients were included in the study with a mean age of 31.6 years. All patients except one have antegrade ejaculation, and according to the overall ejaculatory score, only 5 patients (8.6%) reported ejaculatory dysfunction and the remaining 53 (91.4%) had good or average EjF. Ten men (17.2%) reported decreased volume and force of ejaculate. Decreased pleasure during ejaculation was the commonest ejaculatory disorder (39.6%). The score of each of the seven ejaculatory questions among the study patients was in harmony to the previous study of anterior urethroplasty except that men in this study had higher ejaculatory frequency and latency. CONCLUSIONS: Nearly all men maintained antegrade ejaculation after posterior urethroplasty for PFUIs. The risk of urethral reconstruction and splitting the bulbocavernous muscle on ejaculation seems to be minimal.

Predicting the resected tissue weight from a digital rectal examination and total prostate specific antigen level before transurethral resection of the prostate.

OBJECTIVE: To determine the use of the prostate specific antigen (PSA) level and digital rectal examination (DRE) findings to estimate the resected tissue weight (RTW) before transurethral resection of the prostate (TURP). PATIENTS AND METHODS: We retrospectively analysed 983 patients who underwent TURP between December 2006 and December 2012. The primary outcome was the RTW required for clinical improvement, and was not associated with re-intervention. Age, PSA level, body mass index (BMI) and DRE findings were correlated and modelled with the RTW. The DRE result was defined as DREa (small vs. large) or DREb (small vs. moderate vs. large) according to the surgeon's report. Equations to calculate RTW were developed and tested using receiver operating characteristic (ROC) curve analyses. RESULTS: There were significant correlations between PSA level (r = 0.4, P < 0.001) and RTW, whilst BMI and age showed weak correlations. The median (range) RTW was 45 (7-60) vs. 15 (6-60) g for small vs. large prostates (DREa) (P < 0.001), respectively. Similarly, the median (range) RTW was 11 (6-59) vs. 26.2 (6-60) vs. 42 (7-60) g in small vs. moderate vs. large prostates (DREb) (P < 0.001), respectively. Using PSA level and DREb (model 3) there was a significantly better ability to estimate RTW than using PSA and DREa (model 2) or PSA alone (model 1) based on ROC curve analyses. The equation developed by model 3 (RTW = 1.2 + (1.13 × PSA) + (DREb × 9.5)) had a sensitivity and specificity of 82% and 71% for estimating a RTW of >30 g, and 84% and 63% for estimating a RTW of >40 g, respectively. CONCLUSIONS: The PSA level and DRE findings can be used to predict the RTW before TURP.

Weekly intravesical bacillus Calmette-Guerin (BCG) alternating with epirubicin in Ta and T1 urothelial bladder cancer: An approach to decrease BCG toxicity.

CONTEXT: Bacillus Calmette-Guerin (BCG) therapy is the standard treatment for nonmuscle-invasive bladder cancer (NMIBC). However, its toxicity is a major concern. AIM: If we reduce the number of BCG doses by half and replace the second half with epirubicin, we may have a lower toxicity while maintaining the same efficacy of BCG. To test this hypothesis, we conducted this study as an update of our previous report. SETTING AND DESIGN: The study included 607 patients with Ta and T1 NMIBC between January 1994 and December 2008. MATERIALS AND METHODS: After transurethral resection of bladder tumor (TURBT), the patients received weekly doses of 120 mg BCG alternating with 50 mg epirubicin for six weeks (three weekly doses of each). Maintenance was given. Recurrence, progression rates, and toxicity were assessed. End points were progression, recurrence, and cancer-specific survival. RESULTS: A total of 532 patients were eligible for evaluation (mean age: 58 years; median follow-up: 45 months). Of these, 291 (55%) were free, 157 (29.5%) showed recurrence, and 84 (15.8%) showed muscle-invasive progression. Toxicity developed in 221 patients. These were mild in the majority (167), whereas 10 developed hematuria, 30 severe cystitis, and five systemic complications. The rate of permanent therapy discontinuation was 3.8%. STATISTICAL ANALYSIS USED: SPSS package version 16 and Kaplan-Meier curves were used to evaluate survival. CONCLUSIONS: Reducing the frequency of BCG instillations by half and replacing the second half with epirubicin results in a similar efficacy and a lower toxicity compared with historical cases receiving BCG alone. However, further trials are required to support these results.

Construction of predictive models for recurrence and progression in >1000 patients with non-muscle-invasive bladder cancer (NMIBC) from a single centre.

OBJECTIVE: To construct predictive models based on the objectively calculated risks of progression and recurrence of non-muscle-invasive bladder cancer (NMIBC) in a large cohort of patients from a single centre. PATIENTS AND METHODS: Between October 1984 and March 2009 a cohort of 1019 patients (877 males; 142 females; median age 44 years) with histologically confirmed NMIBC was included in this study. Among these patients, 74% received bacillus Calmette-Guérin (BCG)-based therapy. Complete transurethral resection of bladder tumour of all visible tumours was carried out in all patients, and the stage and grade were determined. Univariate analysis and multivariate Cox regression were used to identify predictors of recurrence and progression. The studied predictors included age, sex, stage, grade, associated carcinoma in situ, tumour size, multiplicity, macroscopic appearance of the tumour, history of recurrence and type of adjuvant intravesical therapy. Multivariate logistic regression models were used to develop the 12- and 60-month recurrence and progression predictive models. The predictive accuracy of the models was assessed for discrimination as well as calibration. RESULTS: The median (range) follow-up was 44 (6-254) months. On multivariate analysis, stage, multiplicity, history of recurrence and adjuvant intravesical therapy were significantly associated with recurrence, whereas for progression only tumour grade and size were significant independent predictors. The constructed nomograms had a 64.9% and 69.4% chance of correctly distinguishing between two patients, one destined to have a recurrence and one not at 12 and 60 months, respectively. The constructed nomograms had a 70.2% and 73.5% chance of correctly distinguishing between two patients, one destined to progress and one not at 12 and 60 months, respectively. All predictive models were well calibrated. CONCLUSIONS: Based on multivariate analysis of the studied prognostic factors nomograms for predicting recurrence and progression in NMIBC were constructed. Most of the studied patients had received BCG-based therapy, making these models more closely applicable to contemporary practice than others. These predictive models have reasonable discriminative ability and are well calibrated, but require external validation before they can be applied to other populations.

Survival after primary and deferred cystectomy for stage T1 transitional cell carcinoma of the bladder.

CONTEXT: The optimal time of cystectomy for nonmuscle invasive bladder cancer (NMIBC) is controversial. AIM: This study aims at comparing cancer-specific survival in primary versus deferred cystectomy for T1 bladder cancer. SETTINGS AND DESIGN: Between 1990 and 2004, a retrospective cohort of 204 patients was studied. MATERIALS AND METHODS: Primary cystectomy at the diagnosis of NMIBC was performed in 134 patients (group 1) and deferred cystectomy was done after failed conservative treatment in 70 (group 2) Both groups were compared regarding patient and tumor characteristics and cancer-specific survival. STATISTICAL ANALYSIS USED: Cancer-specific survival was calculated using the Kaplan-Meier method. RESULTS: Mean follow-up was 79 and 66 months, respectively, in the two groups. Tumor multiplicity was more frequent in group 2; otherwise, both groups were comparable in all characteristics. The definitive stage was T1 in all patients. Although the 3-year (84% in group 1 vs. 79% in group 2), 5-year (78% vs. 71%) and 10-year (69% vs. 64%) cancer-specific survival rates were lower in the deferred cystectomy group, the difference was not statistically significant. In group 2, survival was significantly lower in cases undergoing more than three transurethral resections of bladder tumors (TURBT) than in cases with fewer TURBTs. CONCLUSIONS: Cancer-specific survival is statistically comparable for primary and deferred cystectomy in T1 bladder cancer, although there is a non-significant difference in favor of primary cystectomy. In the deferred cystectomy group, the number of TURBTs beyond three is associated with lower survival. Conservative treatment should be adopted for most cases in this category.

Does timing of presentation of penile fracture affect outcome of surgical intervention?

OBJECTIVE: To assess the effect of timing of presentation of cases with penile fracture on the outcome of surgical intervention. PATIENTS AND METHODS: Between January 1986 and May 2010, 180 patients with penile fracture were treated surgically in our center. To assess the effect of timing of presentation, patients were classified into 2 groups: group I with early presentation (≤24 hours) and group II with delayed presentation (>24 hours). All patients were contacted by mail or phone and were re-evaluated. All patients were reevaluated by questionnaire and local examination. Patients with erectile dysfunction were evaluated by color Doppler ultrasonography. RESULTS: Group I included 149 patients (82.8%) and group II included 31 (17.2%). In group I, patients presented to the emergency department from 1-24 hours (mean, 11.8) after occurrence of the penile trauma. Although patients in group II presented from 30 hours to 7 days (mean, 44.7 hours). Both groups were similar regarding etiology of injury, clinical presentation, surgical findings, and incidence of associated urethral injury. Mean follow-up period for group I was 105 months, and for group II it was 113 months. After such long-term follow up, 35 (19.4%) patients had complications; however, there was no statistically significant difference between both groups. CONCLUSIONS: Cases of penile fracture with early or delayed presentation up to 7 days should be managed surgically. Both groups have comparable excellent outcome with no serious long-term complications.

False penile fracture: value of different diagnostic approaches and long-term outcome of conservative and surgical management.

OBJECTIVES: We determined the value of clinical and radiological findings in diagnosis of false penile fracture. Also, the long-term outcome of conservative and surgical treatment of such patients was evaluated. METHODS: Seventeen patients with false penile fracture were treated conservatively (3 patients) and surgically (14 patients) at our center. Medical records were retrospectively reviewed for etiology, symptoms, signs of physical examination, and information on findings of surgical exploration. Data on erectile function and penile sequelae were obtained during follow-up using the Sexual Health Inventory for Men (SHIM) questionnaire and local examination. RESULTS: The most common cause of false penile fracture is sexual intercourse (76.5%). False fracture was suspected in 3 patients who presented with small hematoma and slow post-trauma detumescence; intact tunicas were diagnosed by magnetic resonance imaging (MRI) in all of them and were managed conservatively. Surgical penile exploration was performed in 14 cases, in whom preoperative ultrasound was done in 6, and it was false positive for presence of tunical tear in 50%. Exploration revealed nonspecific dartos bleeding in 9 cases and avulsed superficial dorsal vein in 5. Long-term follow-up (mean=93 months) was available for 16 patients, among whom there was no complications. CONCLUSIONS: In most cases, false penile fracture is indistinguishable from true penile fracture either clinically or radiologically. In atypical cases, MRI seems to be a promising modality for diagnosis of such patients. The long-term outcome of conservative and surgical treatment is excellent.

Long-term outcome of surgical treatment of penile fracture complicated by urethral rupture.

INTRODUCTION: The combination of lesions of the penile urethra and the corpus cavernosum is rare and is likely to worsen the immediate and long-term prognosis. AIM: To assess the late effects of penile fractures complicated by urethral rupture treated by immediate surgical intervention. METHODS: Fourteen patients with concomitant urethral rupture were treated surgically at our center. Those patients were seen in the outpatient follow-up clinic and were re-evaluated. MAIN OUTCOME MEASURES: Sexual Health Inventory for Men questionnaire, local examination, uroflowmetry and penile color Doppler ultrasound. RESULTS: The most common cause of penile fracture is sexual intercourse (50%). The site of tunical tear was in the proximal shaft of the penis in 3 patients (21%) and in the mid of the shaft in 11 patients (79%). Urethral injury was localized at the same level as the corpus cavernosum tear in all cases; and it was partial in 11 cases and complete in 3. Long-term follow-up (mean=90 months) was available for 12 patients; among whom there was no complications in 4 (33%), painful erection in 1 (8%), erectile dysfunction in 2 (17%), and palpable fibrous nodule in 5 (47%). All patients had a normal urinary flow except one who developed relative urethral narrowing that required regular dilatation for 1 month. CONCLUSIONS: The urethral injury complicating penile fracture is often partial and localized at the level of the corpora cavenosa tear. Standard treatment consists of immediate surgical repair of both urethral and corporal ruptures with no harmful long-term sequelae on urethral and erectile function in most of patients.

Penile fracture: long-term outcome of immediate surgical intervention.

OBJECTIVES: To assess the etiology and the late effects of penile fractures treated by immediate surgical intervention. METHODS: Between 1986 and 2008, a total of 155 patients with penile fracture were treated surgically in our center. The interval from injury to presentation was between 1 and 96 hours. Those patients were contacted by mail or phone and were re-evaluated. All patients were re-evaluated by questionnaire and local examination. Patients with erectile dysfunction were evaluated by color Doppler ultrasonography. RESULTS: The most common cause of fracture of penis is sexual intercourse (51.5%). Unilateral and bilateral corporeal ruptures were present in 139 (89.7%) and 3 (1.9%) cases, respectively, whereas no tunical tear was found in 13 (8.4%) cases. Concomitant urethral injury was present in 14 (9%) cases. Long-term follow-up (>12 months) was available for 141 patients; among whom there was no complications in 108 (77%), painful erection in 2 (1.3%), penile deviation in 5 (3.2%), both in 1 (0.7%), erectile dysfunction in 11 (7.8%), and palpable scarring in 14 (10%). Scar formation was highly associated using nonabsorbable sutures (P <.001). CONCLUSIONS: Vigorous sexual intercourse was found to be the most common cause of penile fracture. Immediate surgical intervention has low morbidity, short hospital stay, rapid functional recovery, and no serious long-term sequelae. Nonabsorbable sutures should be avoided as it has a higher incidence of scar formation.

The use of local anesthetic gel during retrograde urethrography: does it cause a false negative result?

PURPOSE: To investigate the implication of topical urethral anesthetic gel on the evaluation of retrograde urethrography (RGU) MATERIAL AND METHODS: In this prospective study, 20 patients with a mean age of 46 years were enrolled. All these patients were subjected to RGU because of suspecting a urethral stricture. Of these 13 had a history of open or endoscopic urethral manipulation, while seven had no such history. In all patients 10 ml of Gelicain gel 2% (lidocainhydrocloride) was used as local anesthetic gel at temperature of 22 degrees C. The injection was made gradually over 10 s. The first set of RGU was done without local anesthesia and the second image was taken after 10 min of instillation of 2% gelicain gel. All images were evaluated by the same radiologist. The diameter of the urethra was measured by capture screen during fluoroscopy immediately distal to the stricture site in case of urethral strictures and at the middle of the bulbous urethra in other cases. RESULTS: In all patients, the mean diameter of the urethra at the selected site was 8.7 +/- 2.5 mm before and 9.4 +/- 2.9 mm after instillation of local anesthetic gel (P = 0.005). The stricture was diagnosed in 13 cases while seven patients had no stricture. The clinical diagnosis of a possible stricture was the same before and after instillation of the local agent in all patients. CONCLUSION: Instillation of the local anesthetic gel before RGU produces a slight but statistically significant increase in the diameter of the urethra at the selected sites. However, neither the radiologic reading of RGU nor the clinical diagnosis of a possible stricture was changed because of this increment.