Intracavernous injections: still the gold standard for treatment of erectile dysfunction in elderly men.

The objective of this work was to determine the effectiveness of intracavernous injections (ICI) of vasoactive drugs in elderly men with erectile dysfunction and to compare the results obtained with the injection of two different drug combinations. It was a case control study. The sample consisted of 300 men, 63-85 y of age (mean 67.1) with erectile dysfunction of organic origin. Among the patients 180 underwent first trial with injection of prostaglandin E1 (PE). Further on these 180 patients and another 120 (in total 300 patients) were treated with a triple combination of papaverine hydrochlorate, phentolamine messylate and prostaglandin E1 (PPR). The number of responders to the injection of either PE alone or the drug combination was recorded. The quality of the erections was evaluated in the outpatient clinic by the medical staff and through patient's report after home trial. The average volume of either PE or PPR necessary to obtain a functional erection was measured. We observed a statistically significant association between the results obtained after the injection of PPR as compared to PE (chi2 with 2 d.f.: 34.666; P= < 0.001). A functional erection was obtained in 224/300 (74.7%) after the injection of PPR as compared to 87/180 men (48.3%) treated with PE. The average volume of PPR necessary to obtain a functional erection was 0.35+/-0.14 ml whereas that of PE was 1.3+/-0.3 ml. intracavernous injection of vasoactive drugs is still one of the most successful therapies for patients suffering from organic impotence. It is less effective in the older age group as compared to younger. However, if this form of therapy is chosen for aged men the triple combination therapy (PPR) yields a higher response rate than that obtained with prostaglandin alone.

The prognostic value of DNA ploidy in small renal cell carcinoma.

The objective was to study the prognostic value of Deoxyribonucleic Acid (DNA) ploidy status in small renal cell carcinomas (RCC). The nuclear DNA content of renal cell carcinoma tissues from patients who underwent radical or partial nephrectomy has been analyzed by flow cytometry. The results of the DNA ploidy have been correlated to the size of tumors and disease progression. Of the 50 patients with RCC studied, 8 (16%) progressed. Tumors with non-diploid DNA patterns were found in 24 (48%) of the 50 patients and in 4 of the 8 patients who progressed. Overall the median tumor size in our series was 50 mm. A tumor diameter of 50 mm or less was measured in 26 patients (group I) and above 50 mm in 24 (group II). Non-diploid DNA patterns were found in 11 (42.3%) and 13 (54.2%) patients in groups I and II, respectively. This difference between the groups was not significant. Only one patient in group I (3.8%) developed metastatic disease and died 72 months after the operation. In group II, 7 patients (29.2%) presented tumor progression and 5 died of metastatic disease. The survival probability in group I was 95% at 5 and 8 years (95% CI 70% to 99%) and for group II 94% at 5 years (95% CI 67%-99%) and 67% at 8 years (95% CI 39%-83%). DNA ploidy is an inaccurate predictor of tumor behavior in patients with RCC, even in small tumors. Tumor size is a more significant predictor of outcome.

Renal duplication with associated complications in adults: CT findings in 26 cases.

AIM: To review the computed tomography (CT) findings in 26 adult patients with complicated renal duplication, and to assess whether the complications were anomaly-related or superimposed by acquired disease. MATERIALS AND METHODS: Fifteen women and 11 men, aged 17-83 years took part in the study. All CT studies were reviewed to define the moieties affected. RESULTS: The duplication was unilateral in 18 cases and bilateral in six, one patient had a single left kidney and the remaining one a horseshoe kidney. In 14 patients the pathology was related only to the anomaly. Upper pole abnormalities were seen in 13 patients (seven related to the anomaly) and lower pole abnormalities in five (all related to duplication). Both systems were affected in eight cases, six of them by pathological processes unrelated to duplication. Hydronephrosis of the affected collecting system was the most common imaging finding. CONCLUSION: Computed tomography is often used to evaluate abdominal conditions in adults and may therefore be the first imaging modality to reveal a duplex kidney complicated by a pathological process. Involvement of only one moiety was frequently related to the duplication, with a predilection for the upper moiety, while involvement of both systems was used unrelated to the duplication. Zissin, R. (2001). Clinical Radiology, 56, 58-63.

Late complications of ureteral stents.

OBJECTIVE: To review morbidity and late complications of ureteral stent insertion and to specifically evaluate hydronephrosis as a radiologic finding of obstruction in the presence of an indwelling ureteral stent. METHODS: In this prospective study, we evaluated 110 stented kidneys in a group of 90 patients. Of 110 stents, 52 were left in place for 3 months, 23 for 6 months, 11 for 9 months, and 24 for up to 12 months. With the stent in place, patients were followed by plain abdominal X-ray 1 and 30 days after stenting. Further follow-up was performed through ultrasound and plain film every 3 months until scheduled date for stent removal or the appearance of complications. RESULTS: In 11 of 110 cases (10%) there was stent fragmentation and in 9 (8.2%) stent migration. In 10 cases (9.1%), there was no change in the severity of the hydronephrosis, but because of flank pain or urinary tract infection with fever, the stents had to be removed. In 6 cases (5.4%) hydronephrosis developed or worsened after stenting. Of the 110 ureteral stents, 32.7% had to be removed because of late complications. CONCLUSIONS: Although ureteral stenting is undoubtedly an important procedure for the release of ureteral obstruction, the indications for stent insertion should be carefully considered in each patient. Late complications of ureteral stents are frequent and appear in one third of the patients. Close follow-up of stented patients is valuable in early detection of morbidity or complications, and in such cases the stent should be removed or exchanged as soon as possible.

The indwelling ureteric stent: a 'friendly' procedure with unfriendly high morbidity.

OBJECTIVE: To review the morbidity and complications of ureteric stent insertion and to evaluate specifically the effect of an indwelling ureteric stent on the changes in hydronephrosis after stenting. PATIENTS AND METHODS: In a prospective study, 110 renal units with a stent in place were evaluated in 90 patients. Of the 110 stents, 52 were left in place for 3 months, 23 for 6, 11 for 9, 19 for 12 and five (forgotten stents) for 13-30 months. The patients were followed using plain abdominal X-ray at 1 and 30 days after stenting. They were further followed using ultrasonography and plain films every 3 months until the scheduled date for stent removal or the appearance of complications. RESULTS: Thirty-four patients had fever and bacteriuria after stent insertion. Of the 110 stents, 11 (10%) fragmented and nine (8%) migrated. Seventeen patients complained of flank pain on voiding. In 21 renal units (19%) there was no change in the severity of hydronephrosis, whereas in six (5.5%) hydronephrosis developed or worsened after stenting. CONCLUSION: Although ureteric stenting is undoubtedly an important procedure to relieve ureteric obstruction, the indications for stent insertion should be considered carefully in every patient. The close follow-up of stented patients is valuable for the early detection of morbidity or complications and in such cases the stent should be removed or exchanged as soon as possible.

Nephrovesical subcutaneous stent: an alternative to permanent nephrostomy.

PURPOSE: We studied whether a subcutaneous ureteral bypass may be an alternative to a permanent nephrostomy tube in patients with ureteral obstruction caused by pelvic malignancy. MATERIALS AND METHODS: Using local anesthesia we inserted an especially designed nephrovesical stent into subcutaneous tissue. The stent consists of 2 J stents that are joined by a connector after insertion into the renal pelvis and bladder. RESULTS: In 8 patients 10 subcutaneous stents were inserted instead of a permanent nephrostomy tube. Nephrostomy was required because of obstructed ureters caused by metastatic prostate or invasive bladder cancer. Attempted Double-J stent insertion into the obstructed ureter had previously failed. The bypass has functioned well in all cases during 6 weeks to 18 months of followup (mean 5.5 months). CONCLUSIONS: The high complication rate of a permanent nephrostomy tube and frequent rehospitalization render the subcutaneous stent an important alternative to nephrostomy. The subcutaneous stent eliminates external devices for urine drainage and improves patient quality of life.

Early postureteroscopy vesicoureteral reflux--a temporary and infrequent complication: prospective study.

BACKGROUND: Early complications after ureteroscopy include discomfort, renal colic, urinary infection, and hematuria. Vesicoureteral reflux has been reported as a late complication. The presence of early vesicoureteral reflux after ureteroscopy has not been investigated. METHODS: Forty patients were randomly selected for a study in which early vesicoureteral reflux after ureteroscopy was searched for through retrograde cystography. RESULTS: In four patients (10%), vesicoureteral reflux was found. Follow-up cystograms 2 weeks after ureteroscopy were normal in all four. CONCLUSION: These results suggest that early vesicoureteral reflux after ureteroscopy is rare and that if it appears, it is of low grade and temporary.

The responsiveness of the ICSmale questionnaire to outcome: evidence from the ICS-'BPH' study.

OBJECTIVE: To evaluate the responsiveness of the ICSmale questionnaire to the outcome of treatments for lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: Consecutive men aged >45 years attending 23 urology centres in 12 countries, with symptoms suggestive of bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), were recruited to Phase I of the International Continence Society (ICS)-'BPH' study. In Phase II of the ICS-'BPH' study, 355 men in 15 centres in nine countries were followed up, having proceeded to treatment according to clinical practice. All men completed the ICS-'BPH' study questionnaire at baseline and follow-up, including the ICSmale which concerns LUTS and related problems. RESULTS: Patients included in Phase II were similar to those in Phase I according to age and levels of baseline symptoms. Patients received a range of treatments: 32% TURP, 29% drug therapies, 20% watchful waiting, 9% minimally invasive therapies and 10% 'others' (including open prostatectomy). For patients who underwent TURP, most LUTS, including voiding and filling symptoms, were highly statistically significantly better at follow-up than at baseline (P<0.0001). For drug, minimally invasive and 'other' treatments, fewer LUTS were highly statistically significantly better. For those undergoing watchful waiting, no symptoms were significantly different between baseline and follow-up. CONCLUSION: The ICSmale questionnaire, in addition to being psychometrically valid and reliable, is responsive to change in outcome.

Bladder welding in rats using controlled temperature CO2 laser system.

PURPOSE: Laser tissue welding has potential advantages over conventional suture closure of surgical wounds. It is a noncontact technique that introduces no foreign body and limits the possibility of infections and complications. The closure could be immediately watertight and the procedure may be less traumatic, faster and easier. In spite of these positives laser welding has not yet been approved for wide use. The problem in the clinical implementation of this technique arises from the difficulty in defining the conditions under which a highly reliable weld is formed. We have assumed that the successful welding of tissues depends on the ability to monitor and control the surface temperature during the procedure, thereby avoiding underheating or overheating. The purpose of this work was to develop a laser system for reliable welding of urinary tract tissues under good temperature control. MATERIALS AND METHODS: We have developed a "smart" laser system that is capable of a dual role: transmitting CO2 laser power for tissue heating, and noncontact (radiometric) temperature monitoring and control. Bladder opening (cystotomy) was performed in 38 rats. Thirty-three animals underwent laser welding. In 5 rats (control group) the bladder wound was closed with one layer of continuous 6-0 dexon sutures. Reliable welding was obtained when the surface temperature was kept at 71 + 5C. Quality of weld was controlled immediately after operation. The rats were sacrificed on days 2, 10 and 30 for histological study. RESULTS: Bladder closure using the laser welding system was successful in 31/33 (94%) animals. Histological examination revealed an excellent welding and healing of the tissue. CONCLUSIONS: Efficiency of laser welding of urinary bladder in rats was confirmed by high survival rate and quality of scar that was demonstrated by clinical and histological examinations. In the future, optimal laser welding conditions will be studied in larger animals, using CO2 lasers and other lasers, with deeper radiation penetration into tissues.

Long-term incidence of acute myocardial infarction after open and transurethral resection of the prostate for benign prostatic hyperplasia.

PURPOSE: Acute myocardial infarction was found to be the main cause of increased long-term mortality in patients after transurethral compared to open prostatectomy in various retrospective studies. We performed a randomized prospective study to compare morbidity and incidence of acute myocardial infarction in patients after transurethral compared to open prostatectomy for benign prostatic hyperplasia. MATERIALS AND METHODS: We studied 365 patients who were assigned to transurethral (236) or open (129) prostatectomy only according to the size of the prostate and who were followed for 7 to 8 years. The clinical status of the patients in both groups before and after the operation was compared, and the rate of myocardial infarction and long-term mortality was studied. RESULTS: More patients with a history of cerebrovascular accident (5.4 versus 0.8%) and indwelling catheters (16.3 versus 7.6%) before the operation were in the open prostatectomy group. Among the 236 patients operated on transurethrally 31 were reoperated on (6 more than once) during followup compared to 4 of the 129 patients who underwent open prostatectomy. In 15 patients from the transurethral prostatectomy group myocardial infarction developed compared to 9 patients in the open prostatectomy group. This difference was not statistically significant. The rate of acute myocardial infarction after prostatectomy, no matter which approach was used, was greater than 6% and it appeared to be higher when compared to the rate of infarction in the general population of the same age group, which is approximately 2.5% in our county. There was no statistically significant difference in the overall mortality rate between the transurethral and open prostatectomy groups, which was 14.4 and 8.5% respectively. CONCLUSIONS: Open prostatectomy is more effective in overcoming urinary obstruction than the transurethral approach. No significant differences in myocardial infarction or overall mortality rates were found between the 2 groups.

[Measuring residual urine by portable ultrasound scanner].

Urethral catheterization, the standard method of measuring residual urine, is uncomfortable and associated with risk of infection and trauma to the urethra. It has also been reported as inaccurate to a certain extent. We compared catheterization with ultrasound scanning in a prospective study of 52 men and 3 women. 100 measurements of postvoiding residual urine by portable ultrasound scanner, were each followed immediately by urethral catheterization (both procedures performed by an experienced nurse in our outpatient clinic). A difference of > 25 ml between measurements by scanner and by catheter was considered significant. The range of residual urine measured by scanner was 1-425 ml, and by catheter 1-410 ml. There was good matching between the 2 methods in 85 of 100 measurements (scanning accuracy 85%). In 30/85 matching was excellent while in 55 cases the mean difference was 8.5 +/- 6.2 ml, range 1-24 ml. The accuracy of scanning was 85%; there was perfect matching between the 2 methods in 30 cases. In the remaining 15 cases the mean difference was 41.8 +/- 13.6 ml (range 25-56). Each catheterization took 4-5 minutes and scanning 30 seconds. There were no complications after catheterization, but all reported discomfort and dysuria for 1-2 hours thereafter. Scanning was absolutely uneventful in all. The cost per catheterization, including medication, disposable materials and personnel time was approximately 80 NIS. Our 80-90 measurements of residual urine a month require annually about 80 hours and a budget of about NIS 80,000. Scanning requires only 8 hours, while the cost of the portable scanner is significantly less than NIS 80,000 and it can be used for more than a year. We conclude that measuring urine residual with the noninvasive scanner instead of by catheterization is easier, more accurate, and more cost-effective.

Cytokeratin 20: a new marker for early detection of bladder cell carcinoma?

PURPOSE: Cytokeratins are constituents of the intermediate filaments of epithelial cells in which they are expressed in various combinations depending on epithelial type and degree of differentiation. Of the 20 known cytokeratins, cytokeratin 19 is expressed in normal urothelium cells, whereas the recently identified cytokeratin 20 (CK-20) is expressed in urothelial carcinoma but not normal urothelium cells. We examine whether CK-20 expression can be used as a bladder tumor marker for transitional cell carcinoma in cells isolated from urine. MATERIALS AND METHODS: The reverse transcriptase polymerase chain reaction method was used to determine expression of CK-20 in cells separated from urine of patients with bladder carcinoma. Cells were obtained from urine of 192 patients stratified into 3 groups of 21 healthy young volunteers without a history of transitional cell carcinoma, 27 with a negative bladder biopsy for transitional cell carcinoma and 144 with bladder transitional cell carcinoma. The parameters were tumor stage and grade, tumor size, number of tumors, urinary cytology and CK-20. RESULTS: CK-20 amplification band (370 base pairs) was obtained with messenger ribonucleic acid extracted from transitional cell carcinoma cells of bladder tumor. CK-20 in the urine samples of the control group was negative (no false-positive results, specificity 100%). Among the 27 patients with pTo disease CK-20 was negative in 20 (specificity 74.1%). In the 7 patients with positive CK-20 histology showed chronic inflammation in 2, atypical hyperplasia in 3 and metaplasia in 1. In 1 patient who had a known history of transitional cell carcinoma the urothelium was normal. Among 144 patients with bladder transitional cell carcinoma CK-20 was positive in 131. Sensitivity of the method was much higher than urinary cytology (91 versus 56.3%, p <0.0001). We demonstrated no correlation between CK-20 and tumor grade. CONCLUSIONS: Our results indicate that CK-20 is a potential marker for bladder cancer. The noninvasive detection method assesses urothelial cells from the voided urine specimen using reverse transcriptase-polymerase chain reaction. The CK-20 marker was significantly more sensitive than urinary cytology.

Effect of exogenous adenosine and its monophosphate on the contractile response to acetylcholine in the human isolated detrusor muscle strips.

1. Adenosine (0.1-1 mM) or its 5'-monophosphate (5'-AMP) induced a concentration-dependent relaxation of tension caused by acetylcholine (0.2 microM) in human urinary bladder detrusor strips. 2. This effect was antagonized concentration dependently by theophylline at an apparent pA2 value of about 5. 3. Maximum relaxation by adenosine or 5'-AMP never exceeded 50% and 80%, respectively, of acetylcholine-induced tension. Relaxation by some beta2-adrenoceptor agonists (0.1-0.2 mM) or norepinephrine was limited to about 50% of maximum. 4. The responses to adenosine and terbutaline were additive, causing full relaxation, and suggesting mobilization of distinct mechanisms underlying muscle relaxation.

Does the narrow operating field in perineal radical prostatectomy lead to more positive surgical margins?

AIMS: To assess the risk of leaving cancer-positive surgical margins in the perineal approach for radical prostatectomy as compared to the retropubic approach. METHODS: Seventy-six patients with clinically organ-confined prostate cancer (stage T1-2 NoMo) underwent radical prostatectomy. The 57 patients who underwent retropubic prostatectomy were compared to 19 patients in whom the perineal approach was undertaken. The two groups were compared for pre-operative PSA levels, clinical stage, biopsy Gleasson score, and any correlation between pre- and post-operative stage and grade of the disease and rate of cancer-positive surgical margins. RESULTS: Although there were no significant differences in the rate of organ-confined diseases and specimen Gleasson score in the two groups, the rate of positive surgical margins in the perineal approach was significantly lower (15.7 vs 29.8%) and the rate of extracapsular disease with negative margins was significantly higher (15.7 vs 7%). CONCLUSIONS: The narrow surgical field in the perineal approach for radical prostatectomy does not pose a higher risk for positive surgical margins and it might be the procedure of choice in stage T1C prostate cancer with a Gleasson score of below 7.

Expression of cytokeratin 20 in urinary cytology of patients with bladder carcinoma.

BACKGROUND: Of the 20 known cytokeratins, CK-19 is expressed in normal urothelium, whereas the recently identified CK-20 is expressed in urothelial carcinoma cells but not in normal urothelial cells. The aim of this study was to examine whether CK-20 expression could serve as a noninvasive test in which malignant urothelial cells in urine are detected and monitored. METHODS: In the current study, the authors used reverse transcriptase-polymerase chain reaction (RT-PCR) methods to determine the expression of CK-20 in cells separated from the urine of patients with bladder carcinoma. Cells were obtained from the urine of 87 patients divided into the following 2 groups: 1) 14 healthy volunteers without any known history of transitional cell carcinoma (TCC), and 2) 73 patients with hematuria suspected for TCC of the bladder. For control purposes, CK-20 expression was examined in cells of 1) bladder carcinoma tumors of 5 patients, 2) blood of either patients with bladder carcinoma (n = 5) or healthy controls (n = 5), and 3) three different cell lines. RNA of the various cell pellets was extracted and RT-PCR was performed with CK-20 and CK-19 primers (CK-19 was used as a marker for normal epithelial cells). RESULTS: CK-20 amplification band (370 bp) was obtained with mRNA extracted from TCC cells of either bladder tumor or HT-29 line (a CK-20 colon carcinoma line). Sensitivity of the method was found to be 91%, whereas specificity was 67%. Among the 7 false-positive cases, 3 showed atypia, 3 hyperplasia, and 1 metaplasia, and 2 underwent previously successful TCC tumor removals, suggesting that the CK-20 test also responded to premalignant lesions. No false-positive cases were found in the healthy control group. No other preparation, including blood of the patients of with TCC, showed the CK-20 amplification band. CONCLUSIONS: These results indicate that CK-20 is a potential biomarker for noninvasive detection of bladder carcinoma by assaying uroepithelial cells from the voided urine specimen with RT-PCR.

Using the ICSOoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-'BPH' Study. International Continence Society--Benign Prostatic Hyperplasia.

OBJECTIVE: To present and describe the validity and reliability of the International Continence Society-Benign Prostatic Hyperplasia study quality-of-life (ICSQoL) instrument, a new set of questions to assess the impact of lower urinary tract symptoms (LUTS) on quality of life (QoL) in middle-aged and elderly men. PATIENTS AND METHODS: The study comprised 1271 consecutive men over the age of 45 years, attending urology departments in 12 countries, with LUTS and possible benign prostatic obstruction who were recruited to the ICS-'BPH' study (the clinic group); 423 ambulant men were recruited from a general practice in the UK to provide a community group. Each individual completed the ICS-'BPH' study questionnaire which includes six items addressing general and specific aspects of QoL (the ICSQoL). Content and construct validity were assessed by interviews with patients and by testing hypotheses within the study groups, e.g. the relationships with age, individual LUTS (as measured on the ICSmale questionnaire) and generic health status, as measured by the Short Form (SF-36) and EuroQol instruments. Reliability was assessed by measures of internal consistency and a test-retest analysis. RESULTS: The ICSQoL items were easily understood by patients, were completed with low levels of missing data, and address some (but not all) concerns about the impact of LUTS on QoL. The ICSQoL items have good construct validity, showing expected differences between community and clinic samples, and expected relationships with each other and individual LUTS. Items had good test-retest reliability, but their internal consistency was poor, confirming that ICSQoL questions should not be combined into a score. General ICSQoL items were closely related with most domains of the SF-36 and the EuroQol. CONCLUSION: ICSQoL items may be used individually or as a group in research studies or in clinical practice.