The effect of long term testosterone replacement therapy on bone mineral density.

OBJECTIVE: Long-term results of testosterone replacement therapy (TRT) on bone mineral density (BMD) in literature are still missing. MATERIALS AND METHODS: Totally, 45 males with testosterone deficiency syndrome (TDS) underwent TRT. The mean age was 57.84 years and the follow-up period was 94.62 months. Males were treated with three-month intramuscular injections of 1000 mg testosterone undecanoate. BMD was check at beginning of treatment, after two years and after 5 years. For a statistic evaluation, nonparametric Wilcoxon test was used. RESULTS: Mean BMD of lumbar spine was 1.067 at beginning, 1.122 after two years and 1.667 and after 5 years. The results after two and also 5 years showed a significant improvement (p < 0.001). CONCLUSION: Authors proved a positive effect of long-term TRT on BMD of the lumbar spine. Densitometry of the whole hip showed also an improvement, but only after 5 years. Densitometry of the femoral neck was relatively stable. Important is that despite the fact that males became older, BMD values of the lumbar spine were improved (Fig. 6, Ref. 18).

Results of long term testosterone replacement therapy in men with abdominal obesity, erectile dysfunction and testosterone deficiency.

INTRODUCTION: In this article, the authors evaluate subjective and objective results of long testosterone replacement therapy (TRT) and possible risk. METHODS: In a single center study, the authors treated 69 men with testosterone deficiency syndrome (TDS). The average age was 57.84 years and the follow-up period was 94.62 months. All men had at beginning a complete urological and internal examination. All the men were treated with three-month i.m. injections of 1000 mg testosterone undecanoate. The men were regularly checked according to the EAU guidelines. RESULTS: All of the men on treatment felt much better. Weight and waist circumference during monitoring showed a mild improvement. Excellent results were on red blood cells. Glucose, HDL cholesterol, triglycerides had stable values. PSA slightly increased and testosterone was within the normal range. In two men during treatment, we found a prostate cancer (low risk). Bone mineral density (BMD) of lumbar spine revealed a significant improvement. CONCLUSION: TRT had multiple positive effect on affected men with TDS. Our long-term results showed a long mild improvement during the time. Authors concluded that long term treatment had multiple benefit for affected men (Fig. 11, Ref. 13).

Testosterone replacement therapy (TRT) and its effect on bone marrow. How serious is it and is there a true polyglobulia?

INTRODUCTION: TRT in men with testosterone deficiency syndrome (TDS) had multiple positive effects and restore a quality of life of affected men. Polyglobulia is the most common dose-limiting adverse effect of TRT, but the mechanisms of TRT-mediated erythropoesis remain unclear. In this study, we evaluated long term haematological side effects of TRT: polyglobulia, elevated hemoglobin (Hb) and haematocrit (Ht). METHODS: In a cross-sectional descriptive study, the authors treated 69 men with TDS and the average age 59 years and the follow-up period 81.32 months. The men were treated with three-month i.m. injections of 1000 mg testosterone undecanoate. The elevated values were: Hb above 176 g/l, Ht above 0.52 and erythrocytes (Ery) above 6.0 mil/mcl. RESULTS: 21 out of 69 patients (30.43 %) had an increased Hb, Ht or Ery during treatment. The interesting fact was that only five men (7.24 %) had increased the number of Ery (true polyglobulia). No men with elevated level of Hb, Ht or Ery had other side effects (like thrombosis). CONCLUSION: It is still not clear, why in some men on TRT the feedback does not work and bone marrow production of red blood cells continues even if the upper limit is reached. Authors expect that only 7% of men had true polyglobulia, other men had elevated Hb or Ht. Based on our own experience we recommend a regular check of men on TRT on order to avoid possible serious side-effects (Tab. 1, Fig. 2, Ref. 25).

The role of molecular biology in detection and monitoring of prostate cancer.

The study of molecular markers in various types of human carcinomas, as well as in carcinoma of prostate, is focused on genes responsible for the formation of carcinoma. Mutation, amplification or other changes in these genes or in their protein products are being examined and compared with traditional prognostic markers. These genes can be characterized as oncogenes, tumor suppressor genes or genes for other significant cell functions. However, studies are often limited by heterogenity and multifocality of tumors, especially in prostate cancer. In this review, we offer a survey of some of the most frequent diagnostic and prognostic parameters of molecular biology research in relation to prostate cancer.

Long term results of compression sclerotherapy.

AIMS: To compare the short and long term results of different techniques of compression sclerotherapy. PATIENTS AND METHODS: In the past 10 years the authors treated 1622 pts due to chronic venous insufficiency. There were 3 groups of patients: 1) Pts treated by Sigg's technique using Aethoxysclerol, 2) Pts treated by Fegan's technique with Fibrovein, and 3) Pts treated by Fegan's procedure, but using a combination of both sclerosants. In all cases, the techniques of empty vein, bubble air, uninterrupted 6-week compression and forced mobilisation were used. RESULTS: In the group of pats. treated by Sigg's procedure, the average cure rate was 67.47% after 6 months, 60.3% after 5 years of follow-up. In Fegan's group this rate was 83.6% after 6 months and 78.54% after 5 year assessment. Statistically, significant differences were found only by the disappearance of varices and reduction of pain in favour of Fegan's technique. In the group of pts treated by Fegan's (Aethoxysclerol + Fibrovein) this rate after 5 years was 86%. The only statistically significant difference was found by the disappearance of varices in favour of Fegan's technique using a combination of 2 detergent sclerosants. CONCLUSIONS: Sclerotherapy is effective when properly executed in any length of vein no matter how dilated it has become. The recurrences are attributed more to inadequate technique than to the shortcoming of the procedure. Sclerotherapy is miniinvasive, with few complications, and can be repeated on out-patient basis. (Tab. 1, Ref. 22.).

The advantage of transverse laparotomy closed with continuous absorbable single-layer stitch.

The authors emphasize the advantage of transverse incisions because they provide the surgeon not only with excellent bilateral view of the operated area, but what is most important, they have significantly least negative effect on respiratory functions and the composition of blood gases, which are of major importance in patients with chronic respiratory failure. Due to the much smaller retraction forces, the incidence of postoperative dehiscences and hernias is smaller. It is an incision which interferes the least with the innervation of the abdominal wall and thus is not only less painful, but has also better healing parameters, offers excellent access to pathology from oesophagus up to sigmoid. It is an ideal incision for left open abdomen due to much less retraction of the abdominal wall and described closure is safe, simple, cheap, fast and reliable in risk, obese patients with impaired healing. The closure by a continuous, absorbable, looped double suture is not only simple, but what is most important, it is reliable and associated with minimal postoperative complications. The mean time of closure 13.6 min., supuration after 10th post-op day in 2%, none burst abdomen, 4 incisional hernias (0.8%), these are significantly better results than compared to longitudinal incisions. Authors in details describe the running Smead Jones closure technique.

Retrocaval ureter with ureteral carcinoma.

The authors report a rare congenital anomaly, retrocaval ureter (RCU) with carcinoma. The patient had recurrent pyelonephritis, hematuria and renal colic. Urography shows no function on right side. Abdominal ultrasound revealed marked right hydronephrosis. Antegrade ureterography through nephrostomy revealed a RCU. Helical C.T. confirmed the RCU and also revealed a defect in contrast medium in the upper ureter. We performed percutaneus antegrade nephro-ureteroscopy and found carcinoma of the retrocaval ureter. This may be the first case of tumor in the RCU. We did not find any other in the literature. (Fig. 3, Ref. 14.).

Pancreatic duct occlusion with acrylic glue after pancreas resection.

UNLABELLED: Postoperative complications following major pancreatic surgery are mainly due to the difficulties of performing a safe and proper anastomosis between the stomach or small bowel and the rest of the pancreas. We cannot influence the main predisposing factor of pancreatic fistula--soft pancreatic parenchyma, but we can decrease or completely block postoperative pancreatic secretion. In the last 5 years we performed 61 major pancreatic resections. There were 49 men, mean age 63 years (range 31-78) and 12 women, mean age 57 years (range 45-75). The occlusion of the main pancreatic duct was performed in 33 patients with cyanoacrylate manomer indermil (Sherwood, Davies Geck) after pancreatic resection with different types of anastomosis of their pancreatic stump. Fistula developed where glue was used only in 1 case out of 33 patients (1/33-3%) compared with 28 patients where glue was not used--fistula developed in 9 cases (9/28-32%). The difference is highly significant (p < 0.05). Only 1 out of 10 patients with pancreatic fistulation was operated later on; in 9 cases fistula closed spontaneously. Fistulo-jejunoanastomosis was performed in this patient with chronic torpid fistulation. No postoperative pancreatitis developed after blind closure of pancreatic stump. IN CONCLUSION: any decrease of pancreatic secretion from the rest of the pancreas after duodenopancreatectomy can significantly reduce the development of postoperative pancreatic fistula which can have a catastrophic influence on surgery outcome. Using glue in the pancreatic main duct is not only safe but can be an effective simple procedure in any type of pancreatic stump treatment.

Oncological radicality in colonic cancer operation.

Lymphadectomy should extend to the level of the origin of the primary feeding vessel, suspected positive lymph nodes outside the standart resection should be removed when feasible. A minimum 5 cm bowel margins proximally and distally should be used and peroperative histology must confermend tumor free anastomosis. En-block resection should be performed for tumors adherent to local structures. Inadvertent bowel perforation increases the risk of recurrence and should be avoided. Ovaries grossly involved with tumor should be removed. In all women having operations for cancer of the colon bilateral oophorectomy should be performed. In premenopausal women the ovary is a frequent site for metastatic disease (the Krukenberg tumor) which occures as often as 25 percent of the time. The incidence of of ovarian metastasis is much lower in postmenopausal women but the consequences of oophorectomy are also less severe in that age group. (Ref. 9.).

Speedy elimination of ureterolithiasis in lower part of ureters with the alpha 1-blocker--Tamsulosin.

BACKGROUND: Alpha-I blockers decrease the tension and release the spasm of smooth muscles and thus lessen the obstruction and irritation symptoms in the lower urinary tract (LUTS). They make a faster passing of calculi from the terminal part of the ureters possible. OBJECTIVES: The goal of this study was to objectively assess the improvement of difficulties caused by obstructions in ureterolithiasis localized in the lower part of the ureters of 104 randomly chosen patients (pts.) in a double-blind study. METHODS: During a period of 2 and half years (June 1999-January 2002) 104 pts. suffering from ureterolithiasis of the lower urinary tract were treated and observed. Patients were divided into two groups: A (n:53; later only 51 were evaluated) which was subjected to standard treatment and group B (n:51) where the standard treatment was supplemented by the alpha-1 blocker. As alpha-1 blocker one capsule of Tamsulosin/OMNIC 0.4/ was administered daily. RESULTS: With alpha-1 blocker, we have registered a more speedy passing of calculi from the terminal parts of ureters in 17.6% of pts. Recurrence of renal colics was less frequent and occurred in one of eight pts. as compared with group A (without the alpha-1 blocker) where a recurrence of the renal colic was observed in about every fifth pts. In group A (n:51), 62.8% of the pts. passed the calculi, whereas in group B (n:51), where standard treatment was supplemented by the administration of the alpha-1 blocker Tamsulosin, this percentage increased to 80.4%. CONCLUSION: The treatment by alpha-1 blockers considerably decreased not only LUTS but also helped to accelerate the passing of minor calculi from the terminal parts of the ureters of 80.4% of pts. It seems that alpha-1 blockers potentiate the spasmoanalgetic action of drugs used in standard methods of treatment.

Our experience with the treatment of benign prostatic hyperplasia (BPH) with tamsulosin.

BACKGROUND: Alpha 1-blockers decrease the tension, ease the tonus of smooth muscles and thus alleviate the voiding and storage symptoms of the lower urogenital tract. OBJECTIVES: The goal of this study was to assess objectively the improvement of the voidings and storage difficulties in 72 randomly chosen patients suffering from Benign Prostatic Hyperplasia (BPH) prior to, and in the course of 15 months of treatment with this alpha 1-blocker in a dose of one capsule of tamsulosin daily after meal. METHODS: During the period of three years (1997-1999), we have treated and studied 72 patients suffering from lower urinary tract symptoms (LUTS). The age of the patients ranged from 55 to 80 years with the median age of 71 years. The patients were examined physically, by laboratory methods, by ultrasonography (USG) and by uroflowmetry. Anamnestic data were justified by the application of the IPSS questionnaire and blood pressure tests (BP). The eventual volume of residual urine, as well as the condition of the kidneys were checked by USG. The Qmax values were measured by uroflowmetry prior to, and during treatment (0-3 weeks--6 months). We have continued with this treatment even after 6 months, but we have discontinued the biochemical, haematological and uroflowmetrical assessments. On the other hand, we have continued with quarterly examinations of urine, digital rectal examinations (DRE), measuring of BP and IPSS evaluation. PSA was checked at least once a year. Our patients were checked in this way for 12 to 18 months (median of 15 months). One capsule of tamsulosin was administered daily after meal. RESULTS: The prostatoselective alpha 1-blocker tamsulosin is a well-tolerated medication applied in the treatment of BPH. We did not have to discontinue the treatment with any of the patients during the 15 months of assessment. It is equally well tolerated at a dose of one capsule of tamsulosin daily, administered after the morning or evening meal without any orthostatic defect symptomatology. The quality of life has improved by three symptomatic units; the blood pressure remained practically unchanged, the IPSS score for BPH decreased by 6.8 score and the Qmax was upgraded from 10.1 ml/s to 14.9 ml/s. This finding remained practically unchanged during the 15 months of assessment and later. CONCLUSION: In the course of the recent years, the conservative treatment of BPH by phytotherapeutics but mainly by alpha 1-blockers have resulted in a considerable reduction of transurethral resections of the prostate (TURP), and of the transvesical "open" prostatectomy (PE open). This reduction down to 50% can be observed nearly all over the world. The presence of alpha 1-a, alpha 1-b, alpha 1-d receptors in the lower urinary tract is a good prerequisite for successful treatment of voiding and storage symptoms. In the assessment of the effects of a 15-month continuous treatment by tamsulosin, we have registered a considerable improvement in the quality of life (QOL), an increase in the Qmax, and decrease in the IPSS score. The age of patients under or over 60 years as well as their weight did not play significant roles. We have not registered any interaction with other medications generally used by older patients. (Ref. 30.)

Fournier's gangrene: can aggressive treatment save life?

Fournier's gangrene (FG) is a rapidly progressive, fulminant infection of the scrotum, perineum and the abdominal wall. FG is caused by synergic aerobic and anaerobic organisms. Modern surgical series report mortality of up to 67%. This originally rare disease has become more frequent. Aggressive treatment including antibiotics, antigangrenous serum, and treatment of all accompanied diseases and disorders can be successful. Treatment also includes debridement and plastic corrections. Authors describe management of 8 patients with FG. Treatment of FG and all accompanied diseases was in all cases successful. Treatment costs of this kind of patients were approximately 20 times higher than treatment of patients with other urologic diseases.