[Assessment of cancer RCP meetings in Rhône-Alpes: a survey on the ground]. / Évaluation des réunions de concertation pluridisciplinaire (RCP) en cancérologie dans la région Rhône-Alpes: une enquête de terrain.

The results of a local survey sent to urologists, oncologists and radiotherapeutists working in Rhône-Alpes have been reported to assess the value of multidisciplinary oncological meetings (RCP) in Urology. The results of this short study have been analyzed and compared to the national results published by the Inspection Générale des Affaires Sociales report. Meanwhile, we have created a professional electronic directory collecting all RCP of Rhône-Alpes, which will be accessible soon.

[Erectile dysfunction, a new symptom for the cardiologist]. / La dysfonction erectile, un nouveau symptôme pour le cardiologue.

During many years, the symptom of erectile dysfunction was a matter for the urologist or the sexologist without efficacious treatment. Since 1999, the unexpected efficacy of sildenafil initially tested as a coronary vasodilatator emphasized the major role of an endothelial dysfunction potentially corrected by type 5 phosphodiesterase inhibitors (5-PDEI), which are able to reinforce the NO-dependant vasodilatation of cavernous arteries. Due to the medicalisation and the mediatisation of erectile dysfunction during the past five years, this symptom is now a matter for the cardiologist. The first reason was the query of cardiovascular safety of 5-PDEI. American and Britannic registries have established a good cardiovascular tolerability of these drugs including in patients with coronary heart disease according to the respect of contraindication in cases of coprescription with nitrates. The second was the association of erectile dysfunction with many cardiovascular risk factors concerned by the cardiologist. The third reason was the observation that erectile dysfunction could be a potential marker to identify patients with silent myocardial ischemia and relevant coronary artery disease. The Princeton consensus provides guidelines to help the cardiologist in the evaluation of patients with erectile dysfunction according to the cardiovascular risk level. Henceforth, erectile dysfunction should be considered by the cardiologist as "a sound of silence" of myocardial ischemia and should encourage to more aggressive evaluation and treatment of cardiovascular risk factors.

[The treatment of erectile dysfunction: what are the objectives and the methods?]. / Le traitement de l'insuffisance érectile: quels sont les objectifs et les méthodes?

Despite considerable progress, the treatment of erectile insufficiency is often difficult due to its usually multifactorial aetiology and to the fact that the 3 components of a satisfying sex life are: 1) Sufficient penile rigidity with no other associated sexual dysfunction, 2) an adapted mental state, 3) a loving relationship with the partner. All of these parameters must be taken into account to ensure a lasting success, hence the need for a global approach rather than an approach localized to the organ. Consequently, there is not one, but several treatments which must be adapted to each case. The rarity of easily curable aetiologies explains the very widespread use of symptomatic treatments and the primordial place of clinical assessment. A consensus has currently been reached concerning: a) give the patient objective information, an essential prerequisite for the choice and success of treatment, b) start by proposing minimally invasive medical treatments, c) emphasize the value of a multidisciplinary approach in the case of failure, d) recognize the fact that achievement of a rigid penis is not necessarily synonymous with cure. In practice, two situations can be distinguished: 1) in the presence of predominantly psychogenic disorders, sex therapy and/or sexual advice can be used in all patients, either alone or in combination with drug treatments and/or a vacuum device (especially in the case of failure of either of these treatments), 2) in the presence of predominantly organic abnormalities which are not easily curable drug treatments and/or vacuum must be proposed first, but sexological management is always useful in these so-called "organic" patients. Prosthetic surgery, the only approach with demonstrated efficacy, is only indicated following failure of medical treatment, after rigorous selection. The release onto the market, in the near future, of promising new oral or intraurethral drugs used "on request" will certainly modify the treatment hierarchy. Due to their acceptability and efficacy, they will certainly be prescribed as first-line treatment, regardless of the origin of the erectile insufficiency. However, the therapeutic approach in the case of failure will remain unchanged. Erectile insufficiency can effectively be treated provided a rigorous assessment is performed.

[Is an auto-injector useful in the treatment of erectile insufficiency using intracavernous injection?]. / L'autoinjecteur a-t-il un intérêt dans le traitement de l'insuffisance érectile par injection intracaverneuse?

The technique and the fear of injection constitute a considerable cause for refusal, discontinuation and morbidity of the treatment of erectile insufficiency by intracavernous injection (ICI). The use of an automatic injection device has been proposed to minimize these problems. Despite a follow-up of 6 years, it is difficult to know whether the automatic injection device has had the same positive impact as in diabetic subjects. The use of this technique remains limited due to the lack of objective information concerning its possibilities. However, the rare reported series show that automation of ICI: a) improves the acceptability of self-administered ICI, b) lowers the discontinuation rate and morbidity. The automatic injection device can be proposed in any patient, after objectively informing him about the advantages and disadvantages. It is currently indicated: a) as first-line treatment in weak-hearted, anxious, clumsy subjects, or in patients with a physical handicap interfering with ICI or preferring automatic injection, b) secondarily, in the case of failure, difficulties or discontinuation because of technical problems.

[Medical treatment of venous priapism apropos of 46 cases: puncture, pharmacologic detumescence or penile cooling?]. / Traitement médical du priapisme veineux à propos de 46 cas: ponction, détumescence pharmacologique ou réfrigération pénienne?

OBJECTIVE: To analyse the efficacy of three nonspecific medical approaches to the first-line treatment of priapism : a) intracavernous injection (ICI) of alpha-adrenergic agonists, b) cavernous puncture, c) penile cutaneous cooling. METHODS: 46 cases of venous priapism, due to various aetiologies, were initially treated by ICI of alpha-adrenergic agonists (23 cases), puncture (14 cases) or cooling (9 cases). These 3 methods were combined only in the case of failure and not uniformly, based on our experience. The results were analysed in terms of successful detumescence and preservation of erectile function. RESULTS: Detumescence was obtained and erectile function was preserved in almost 80% of cases, with conservative treatment alone. ICI (83%) and cooling (78%) were more effective as first-line treatment than puncture (57%). The delay to treatment was a more important parameter than the aetiology. Cooling was no longer effective after the 8th hour, puncture was no longer effective after the 9th hour and ICI was no longer effective after the 34th hour. Failures of conservative treatment and erectile sequelae were only observed in cases of priapism treated after the 24th hour. CONCLUSION: The 3 methods have a similar degree of efficacy, provided they are performed early. Their indication depends on : 1) the duration of priapism, 2) the presence or absence of cavernosal anoxia. Schematically (and in parallel with aetiological treatment when possible) : a) in the case of painless priapism < 12 hours, cooling can be tried first, b) in the case of failure or painless priapism > 12, but < 24 hours, ICI of alpha-adrenergic agonists associated with puncture is indicated (except in the case of contraindications to ICI), c) in the case of painful priapism or > 24 hours, puncture must be the first treatment. In the case of failure, cavernosal blood gases should be performed to evaluate cavernosal anoxia and to guide management.

[Treatment of erectile insufficiency]. / Traitement de l'insuffisance érectile.

Impotency, or impaired erectile function, affects approximately 10% of the adult males in France. The psychological consequences can have a major impact not only on the subject's sexual life but also his familial and professional relationships. The task facing the urologists is to carefully evaluate the patient's request for care and adapt treatment not only to the physiological situation but also the patient's psychological and social context. Several approaches have been developed. Search for an aetiology, excepting exceptional cases with a recognized organic origin, is often unsatisfactory due to the multifactor processes involved and the self-sustaining inter-relationship between the psychological impact and the physiological disorder. Sex therapy is aimed at reducing anxiety and helping the couple better understand their sexual relationship. Such behavioural counselling is particularly indicated in absence of organic disorders or as complementary therapy combined with medical or surgical treatment. The pharmacological approach relies on alphablockers or certain psychotropic drugs which have a moderate but real effect when taken orally. Local non-invasive applications of protaglandin E1 can also improve erectile function. The mechanism of intrapenial injections is to release the erectile smooth muscles. The most widely used drugs in France are papaverine, phentolamine and moxisylite as well as prostaglandin E1. Self-injections may be required in certain cases but are abandoned by about half of the patients after one or two months. Vacuum with a mechanical pump can produce a non-physiological erection but is rarely used in France. Surgical repair of arterial or venous disorders can also provide excellent, particularly long-term, results in carefully selected patients. Despite undeniable progress, the treatment of impotency remains a difficult therapeutic challenge, basically due to the large number of casual factors and their complex interactions.

[Management of drug-induced prolonged erection]. / Conduite à tenir devant une érection pharmacologique prolongée (EPP).

Prolonged pharmacological erection (PPE) is a blocked erection lasting for more than 4 hours after intracavernosal injection (ICI) of an erectogenic drug. This form of priapism is the commonest complication of ICI in the diagnosis and treatment of impotence. It carries a potential risk of acute ischaemia of the corpora cavernosa with subsequent destruction of the erectile tissues. Any blocked erection must therefore be treated within 4 hours. Medical treatment is sufficient in the very great majority of cases, provided it is performed early. The indication for each medical method (simple measures, oral or, more especially, intracavernosal alpha-stimulant treatment, decompressive cavernosal puncture) depends on the duration of PPE and/or the presence of signs of tissue ischaemia (pain). Surgery is only indicated in the rare cases of failure of medical treatment. PPE can now be prevented by means of selection and information of patients and the recent introduction of less dangerous drugs.

Efficiency and side effects of intracavernous injections of moxisylyte in impotent patients: a dose-finding study versus placebo.

We assessed the efficiency and tolerance of the alpha-blocking agent moxisylyte in 2 double-blind studies versus placebo performed in 12 neurogenic patients with spinal cord lesions and in 61 patients presenting with either psychogenic impotence (30) or erectile dysfunction that was predominantly neither psychogenic, hormonal nor neurogenic (31). In each etiological group patients were randomized (according to latin square method) to receive 3 single doses (10, 20 and 30 mg.) of moxisylyte and a placebo. The erectile response was determined 5, 10, 15, 20 and 30 minutes after each injection. Whatever etiology of impotence and dosage tested, the erectile response induced by moxisylyte was significantly higher than the placebo-induced response. No difference occurred among the 3 doses. In 93% of the patients moxisylyte induced an erectile response, including tumescence in 6, partial rigidity in 16 and complete rigidity in 46. Thus, in 62 of 73 patients (85%) the drug allowed initiation of erection adequate for intercourse. Placebo induced such erection in only 25% of the cases and in 55% there was no response. Tolerance was good and no priapism occurred. Only 4 patients (5%) reported mild pain during injection but erections were never painful, 1 presented with moderate and transient hypotension at the 20 mg. dose and a painless prolonged erection was observed in 1 case after the lowest dose. Drugs such as moxisylyte should be given before less well tolerated drugs.

[The combination of oral trazodone-moxisylyte: diagnostic and therapeutic value in impotence. Report of 110 cases]. / L'association trazodone-moxisylite par voie orale: intérêt diagnostique et thérapeutique dans l'impuissance. A propos de 110 cas.

An oral drug treatment was prescribed systematically for one month in 110 unselected patients suffering from impotence: Tradozone (75 mg/day)+Moxisylite (180 mg/day) daily, or at higher doses if possible, and Trazodone (25 mg/day)+Moxisylite (60 mg/day) one hour before any sexual intercourse. Adverse effects were uncommon (6.3%). Satisfactory sexual activity was restored in 28% of cases and an improvement in spontaneous erections was obtained in 42% of cases. No improvement was observed in 30% of cases. This oral drug test therefore presents 3 advantages: a) it facilitates the diagnosis and treatment of impotence by eliminating moderate forms of psychogenic impotence, b) it reduces both the morbidity and cost of investigation of impotence by reducing the number of tests performed, c) it emphasizes the role of oral treatment in impotence. In conclusion, this oral drug test should be used because of its simplicity, safety and real efficacy. The current objectives of this test are to improve the efficacy of oral treatment as a result of pharmacological progress.

[New findings on the physiology of erection or the concept of the active sponge]. / Nouvelles données sur la physiologie de l'érection ou le concept de l'éponge active.

Until these last years, erection was mainly explained by neurovascular mechanisms. The erectile bodies were assimilated as a simple sponge passively filled or emptied by an unbalance between the arterial and venous flows. In fact, the erectile bodies themselves control the erection thanks to their potent smooth musculature. By contracting, they induce both flaccidity and detumescence, since their relaxation releases the erection. The erectile bodies work really as a kind of active sponge having the property to be autonomous and distortionable. However, the contractility of the erectile bodies cannot alone explain all the erection. This complex hydraulic process requires also complementary vascular mechanisms (cavernous outflow blockade, arteriodilatation) and tissular mechanisms (extrinsic compression of erectile striated muscles, specific distortion of each erectile body) under both hormonal and neuro-psychic control. By pointing up the fact that the active and passive tissue mechanisms play a major role for erection, this active sponge concept underlines the necessity for investigating the erectile tissues and allows to reconsider both physiopathology and treatment of dyserections.

Clinical study of the longitudinal deformation of the flaccid penis and of its variations with aging.

The length changes of the flaccid penis provoked by a maximum manual stretching of the glans have been measured in 905 men in order to study its biomechanical qualities. Our study shows that the flaccid penis is deformable, extensible and elastic in its longitudinal axis. The analysis of the variations of these biomechanical properties with aging shows a significant decrease. Thus, the biomechanical behavior of the flaccid penis during stretching is highly different in young men and old men. This distortion difference according to age proves the physiological importance of the penile distortion since impotence significantly increases with age. As the vascular mechanisms may be disregarded during flaccidity, these penile physical features of the flaccid penis are only due to tissue mechanisms. Consequently, any distortion loss would reflect a tissue impairment, very likely a progressive senile fibrosis of cavernous tissues.