The anatomic radical perineal prostatectomy: an outcomes-based evolution

OBJECTIVE

Radical prostatectomy is the most effective treatment for localized prostate cancer. With increasing use of minimally invasive treatment methods, clinical outcomes are becoming important assessment tools to compare one option to another. Perineal prostatectomy is modified to incorporate contemporary surgical ideas, including preservation of cavernosal nerve bundles, sphincteric urethra at the prostatic apex, and the bladder neck.

METHODS

Objective parameters and physician-reported clinical outcomes are collected prospectively on 704 consecutive patients undergoing radical perineal prostatectomy (RPP) by one surgeon. The technique described herein is the current state of evolution of RPP. The enclosed digital video is edited from two recent nerve-sparing RPPs.

RESULTS

Freedom from prostate-specific antigen (PSA) detectability by stage is 94.5%, 80.0%, and 81.5% for organ-confined, specimen-confined, and margin-positive disease with actual 5-yr follow-up. Margins are positive in 18% of cases. By 1, 3, 6 mo and 1 yr, 52%, 71%, 85%, and 94% of the men are free from using pads. Although >97% of nerve-spared patients have spontaneous erections, >80% can penetrate to complete intercourse.

CONCLUSIONS

This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function in the majority of men presenting with clinically localized prostate cancer. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic RPP is a cost-efficient, outcome-effective minimally invasive method of treating men with localized prostate cancer.

How can we best characterize the relationship between erectile dysfunction and benign prostatic hyperplasia?

INTRODUCTION

Considerable epidemiological literature exists, showing a relationship between voiding dysfunction and sexual dysfunction. However, few basic science or prospective data are available to determine the nature of the relationship between benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and sexual dysfunction.

METHODS AND DISCUSSION

A critical evaluation of the nature of the relationship between LUTS and erectile dysfunction (ED) must include a look at the nature of the data establishing the relationship, precise definitions of the disease states being evaluated, and adherence to established normative relationships. Criteria for causality will be utilized to best determine the relationship between LUTS and ED. This article will attempt to take a critical and provocative look at where we are presently in establishing a relationship between voiding dysfunction and sexual dysfunction in order to better direct research efforts through evidence-based studies.

CONCLUSION

At present, the epidemiological data do not support a causal relationship based on Hill's criteria for causality between LUTS and ED but suggest a less rigorous association. Additional research is needed to better characterize this relationship.

Menˈs health: whatˈs a GP to do?

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.

Are Lower Urinary Tract Symptoms Associated with Erectile Dysfunction in Aging Males of Taiwan?

INTRODUCTION

This study was conducted to evaluate the relationship between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in aging males of Taiwan.

PATIENTS AND METHODS

A free health screening for aging males (>or=45 years old) was conducted in Kaohsiung Medical University Chung-Ho Memorial Hospital in August 2004. LUTS and ED were assessed by validated symptom scales: the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function-5 (IIEF-5). The subjects also completed a health and demographics questionnaire and underwent detailed physical examination, serum prostate-specific antigen level determination, and transrectal ultrasonography.

RESULTS

The final study population consisted of 141 patients with a mean age of 59.8 years. The severity of LUTS and ED increased with age. After controlling for comorbidities, age (p<0.001) and IPSS score (p<0.001) were significantly associated with the IIEF-5 score. Furthermore, men with moderate to high IPSS scores were more likely to have ED as compared with those with mild symptoms after age adjustment (age-adjusted odds ratio 3.27, p=0.002).

CONCLUSIONS

ED and LUTS are highly prevalent in our study population, and this prevalence increases with age. ED is significantly associated with the severity of LUTS after controlling for age and comorbidities. These results highlight the clinical importance of evaluating LUTS in patients with ED and the need to consider sexual issues in the management of patients with benign prostatic hyperplasia.

The Age Related Decrease in Testosterone is Significantly Exacerbated in Obese Men With the Metabolic Syndrome. What are the Implications for the Relatively High Incidence of Erectile Dysfunction Observed in These Men?

PURPOSE

We examined pooled baseline data from 2 lipid treatment studies to evaluate the relationship among total serum testosterone levels, obesity and the metabolic syndrome in aging men.

MATERIALS AND METHODS

Baseline total serum testosterone, lipid, glycemic and anthropometric data were obtained from 864 men (mean age 52 years) participating in 2 lipid treatment studies. Inclusion criteria for the 2 studies included low-density lipoprotein cholesterol 130 to 160 mg/dl and triglycerides 350 mg/dl or less.

RESULTS

For all patients as well as the nonmetabolic syndrome and the metabolic syndrome cohorts, testosterone decreased with increasing body mass index (p < 0.0001 for Pearson correlation coefficient in all 3 cohorts). Mean baseline total serum testosterone levels in obese and severely obese aging men with the metabolic syndrome were around 150 and 300 ng/dl, respectively, less than that in aging, lean men with no metabolic syndrome. The relative contributions of each of the individual National Cholesterol Education Program Adult Treatment Panel III components of the metabolic syndrome to low serum testosterone in aging men was examined using multiple linear regression modeling. Based on these analyses the presence of diabetes or fasting serum glucose greater than 110 mg/dl, body mass index 30 kg/m or greater, and triglycerides 150 mg/dl or greater each appeared to have a clinically relevant association with low serum testosterone.

CONCLUSIONS

This study demonstrated that aging men with obesity and the metabolic syndrome have a significant decrease in total serum testosterone levels compared to aging, metabolically healthy men. These data suggest that the well established association between erectile dysfunction and pre-diabetes/diabetes (particularly in obese pre-diabetic/diabetic patients) may involve a hormonal component.

Depression and lower urinary tract symptoms: Two important correlates of erectile dysfunction in middle-aged men in Hong Kong, China

AIM

To evaluate the correlates of erectile dysfunction (ED) in Hong Kong middle-aged Chinese men aged 45-64 years.

METHODS

A community-based cross-sectional household survey was performed in Hong Kong. The Chinese abridged version of the International Index of Erectile Function (IIEF-5) was used to measure erectile function. The International Prostate Symptom Score (IPSS) was used to measure lower urinary tract symptoms (LUTS) and depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D). Demographic and lifestyle data were also collected. The association between ED and its correlates was analyzed using bivariate and multivariate analyses.

RESULTS

Of the 545 subjects who agreed to participate in the survey, 75 refused to answer questions about their sexual activities and function. Out of those who responded, 118 (22%) subjects were not sexually active (not sexually active over the past 4 weeks). Out of 352 subjects, 60.3% suffered from some degree of ED. Age, presence of depression defined by CES-D and moderate LUTS were associated with increased odds of having ED. In multivariate analysis, depressive symptoms identified by CES-D (OR = 2.3, CI: 1.2-4.6) and moderate LUTS (OR = 3.7, CI: 1.6-8.3) were independently associated with increased odds of having ED.

CONCLUSION

ED is an important public health problem in Chinese middle-aged men, with more than half suffering from some degree of ED. Depression and LUTS were significant and important risk factors associated with ED.

Premature ejaculation: definition and prevalence

Premature ejaculation (PE) is likely the most common sexual dysfunction in men, with a worldwide prevalence of approximately 30%. To date, the lack of a universally acknowledged definition of PE has complicated the examination and analysis of PE in clinical and research-related settings. The impact of PE on men and their partners also needs to be clearly defined. Clearly, a better understanding of the epidemiology of this disorder, especially with regard to prevalence and risk factors, is necessary. The prevalence of PE appears to vary across socio-cultural and geographic populations. The elucidation of the etiology of PE and risk factors associated with PE has been difficult. However, several risk factors for PE exist that have strong support in the literature. Clearly, an improved and universal definition and understanding of PE and its epidemiology will improve the clinical management of PE and the success of future epidemiologic studies and clinical trials.

Andropause: a quality-of-life issue in older males

Testosterone deficiency occurs commonly in men as they grow older. This deficiency often is associated with a decline in sexual activity and a loss of muscle mass. Testosterone replacement can reverse many of these effects. At present, no ideal form of testosterone replacement is available. Like the phosphodiesterase-5 inhibitors, testosterone replacement in older men is a quality of life issue.

Erectile dysfunction in healthy subjects predicts reduced coronary flow velocity reserve

BACKGROUND

Erectile dysfunction is associated with, and may be the first sign of coronary artery disease. We aimed to assess whether men with erectile dysfunction but without cardiovascular disease have reduced coronary flow reserve, as a sign of early coronary atherosclerosis.

METHODS

We investigated 12 men aged 68-73 years with erectile dysfunction, and 12 age-matched controls. Erectile function was evaluated using the validated IIEF-5 questionnaire. A score < or = 18 (of 25) was defined as erectile dysfunction and > or = 21 was considered normal. Patients with neurological or psychological reasons for erectile dysfunction were excluded, as were patients with symptoms of or prescribed medication for cardiovascular disease, hypertension or diabetes. Coronary flow velocity reserve was measured non-invasively by Doppler in the left anterior descending artery, before and during adenosine infusion.

RESULTS

Coronary flow velocity reserve was significantly reduced in subjects with erectile dysfunction: 2.36 versus 3.19; P=0.024. In logistic regression analysis, compared to control subjects, men with erectile dysfunction had significantly increased risk of reduced coronary flow velocity reserve (< or = 3.0): odds ratio 15.4, P=0.02. In multivariate analysis, adjusting for age, tobacco use, systolic blood pressure, heart rate and body mass index, erectile dysfunction was the only significant predictor of reduced coronary flow velocity reserve, P=0.016.

CONCLUSIONS

Men with erectile dysfunction but without diabetes or clinical cardiovascular disease have early signs of coronary artery disease. Our findings suggest that a cardiac risk evaluation may be indicated in men with suspected vasculogenic erectile dysfunction, and these individuals should be considered for primary prevention measures regarding cardiovascular disease risk factors.

A Randomised Trial Comparing Holmium Laser Enucleation Versus Transurethral Resection in the Treatment of Prostates Larger Than 40Grams: Results at 2 Years

OBJECTIVE

To compare holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP) for treatment of men with bladder outflow obstruction (BOO) secondary to benign prostatic hyperplasia with a minimum of 24-month follow-up.

PATIENTS AND METHODS

Sixty-one patients were randomised to either HoLEP or TURP. All patients had BOO proven on urodynamic studies pre-operatively (prostate size 40-200 g). One patient died before treatment, which left 30 patients in each group. Perioperative data, as well as symptom scores, Quality of Life (QoL) scores, and maximum urinary flow rates (Qmax) were obtained at one, three, six,12, and 24 months. Post-void residual volumes, transrectal ultrasound (TRUS) volumes, and pressure flow studies were obtained six months post-operatively. Continence and potency data were also recorded.

RESULTS

There were no significant differences between the two surgical groups pre-operatively. Mean pre-operative TRUS volume was 77.8+/-5.6 g (42-152) in the HoLEP group and 70.0+/-5.0 g (46-156) in the TURP group. Patients in the HoLEP group had shorter catheter times and hospital stays. More prostate tissue was retrieved in the HoLEP group. At six months, HoLEP was urodynamically superior to TURP in relieving BOO. At 24 months, there was no significant difference between the two surgical groups with respect to American Urology Association scores, QoL scores, or Qmax values; however, two patients in the TURP group required re-operation.

CONCLUSIONS

HoLEP has less perioperative morbidity and produces superior urodynamic outcomes than TURP, when treating prostates >40 g. At 24 months of follow-up, HoLEP is equivalent to TURP.

[Characteristics of erectile dysfunction in old males with lacunar infarction]

OBJECTIVE

To investigate the characteristics of erectile dysfunction (ED) in old males with lacunar infarction.

METHODS

A total of 38 old patients ages from 60 to 70 years were involved. The questionnaire of international index of erectile function 5 (IIEF -5) was used to determine the status and severity of ED. According to the focus of infarction on MRI, the patients were divided into two groups, Group I with lacunar infarction and minor neurological deficits, and Group II with none. The total IIEF-5 scores were compared between the two groups and repeatedly evaluated six months after discharge.

RESULTS

According to the total scores of IIEF-5, the prevalence of ED in Group II (95%) was higher, and the incidence of severe ED was significantly increased (60.0% vs. 44.4%, P < 0.05) as compared with Group II. In both the two groups, severe ED was more often seen in diabetic patients. At six months after discharge, the total scores of IIEF-5 were significantly increased (11.2 +/- 3.2 vs. 15.6 +/- 2.2, P < 0.05).

CONCLUSION

ED is significantly increased in old males with lacunar infarction, and it is more severe in diabetic patients. Post-stroke rehabilitation care helps to improve ED.

Erectile dysfunction and viagra use: what's up with college-age males?

We surveyed 234 sexually active males aged 18-25 years about erectile dysfunction (ED). Thirteen percent reported ED, but rarely discussed this with medical providers; 25% reported ED occurring with condom use, which was associated with risky sex. Six percent used ED medications, rarely under medical supervision, and often mixed with recreational drugs.

Cardiovascular risk factors determine erectile and arterial function response to sildenafil

BACKGROUND

Erectile dysfunction is related to endothelial function. Cardiovascular risk factors determine endothelial function. Sildenafil is effective in treatment of erectile dysfunction but shows variable results. This study investigated the relationship of cardiovascular risk factors to acute and chronic responses to sildenafil.

METHODS

Cardiovascular risk factors and acute and chronic pulse wave responses to a single 50-mg dose of sildenafil were assessed in 45 patients with erectile dysfunction confirmed by low international index of erectile function (IIEF) score before and after chronic therapy with sildenafil.

RESULTS

On recruitment all patients showed evidence of erectile dysfunction with an IIEF score of 5 points (1 to 20 points). Chronic sildenafil therapy resulted in an increase of IIEF score of 13 points (range -1 to +24 points) and 24 patients (53%) achieved an IIEF score>or=21 points. Improvement in erectile function in response to sildenafil (rn=0.79; P<.001) was dependent on initial erectile function (P=.002) and baseline apolipoprotein B (P=.01). Vascular responses to acute treatment with sildenafil were assessed using pulse wave analysis. Acute changes in stiffness index induced by sildenafil (rn=0.65; P<.001) were related to apolipoprotein A-1 (P=.006), B (P=.02), and lipoprotein(a) (P=.008) concentrations, whereas reflection index (rn=0.69; P<.001) was related to pulse pressure (P<.001), albumin-to-creatinine ratio (P=.007), and lipoprotein(a) (P=.02).

CONCLUSIONS

The extent of acute and chronic effects of sildenafil on erectile function and pulse wave profiles is determined by metabolic cardiovascular risk factors. Improved cardiovascular risk factor control is likely to increase the efficacy of phosphodiesterase-5 inhibitor therapy in the treatment of erectile dysfunction.

Erectile Dysfunction—An Observable Marker of Diabetes Mellitus? A Large National Epidemiological Study

PURPOSE

We examined whether men with erectile dysfunction are more likely to have diabetes mellitus than men without erectile dysfunction, and whether erectile dysfunction can be used as an observable early marker of diabetes mellitus.

MATERIALS AND METHODS

Using a nationally representative managed care claims database from 51 health plans and 28 million members in the United States, we conducted a retrospective cohort study to compare the prevalence rates of diabetes mellitus between men with erectile dysfunction (285,436) and men without erectile dysfunction (1,584,230) during 1995 to 2001. Logistic regression models were used to isolate the effect of erectile dysfunction on the likelihood of having diabetes mellitus with adjustment for age, region and 7 concurrent diseases.

RESULTS

The diabetes mellitus prevalence rates were 20.0% in men with erectile dysfunction and 7.5% in men without erectile dysfunction. With adjustment for age, region and concurrent diseases, the odds ratio of having diabetes mellitus between men with erectile dysfunction and without erectile dysfunction was 1.60 (p <0.0001). With adjustment for regions and concurrent diseases, the age specific odds ratios ranged from 2.94 (p <0.0001, age 26 to 35) to 1.05 (p = 0.1717, age 76 to 85).

CONCLUSIONS

Men with erectile dysfunction were more than twice as likely to have diabetes mellitus as men without erectile dysfunction. Erectile dysfunction is an observable marker of diabetes mellitus, strongly so for men 45 years old or younger and likely for men 46 to 65 years old, but it is not a marker for men older than 66 years.

Physical activity and erectile dysfunction: meta-analysis of population-based studies

We searched for population-based cross-sectional studies, cohort studies and randomized controlled trials (RCTs) on erectile dysfunction (ED) through Medline, PubMed, PsychInfo and scanned though reference lists. Studies that did not include adjusted odds ratios (OR) of physical activity were excluded. Seven cross-sectional studies were suitable for meta-analysis, and the results from one cross-section study, two cohort studies and one RCT were summarized. Pooling the ORs using random effects models, we derived summary estimate for adjusted OR of physical activity in those with ED compared with those without ED, which was 0.53 (0.31, 0.91). Moderate and high physical activities were associated with a lower risk of ED, with ORs at 0.63 (0.43, 0.93) and 0.42 (0.22, 0.82), respectively. Funnel plot by visual inspection, and Begg's test and Egger's test did not detect significant publication bias. Sensitivity analyses revealed that the summary estimate from the random effects model was robust to changes in study sample size and level of statistical adjustment, but not so robust to changes in ED definition, although the summary estimate for each ED definition did not differ significantly. Although causality cannot be demonstrated from cross-sectional studies, the apparent 'protective' effect of physical activity on ED should be further investigated using large-scale cohort studies or RCTs.

Sexual dysfunction in essential hypertension: myth or reality?

Erectile dysfunction is currently considered a condition with high prevalence in the general population, exerting a major impact on patients' and their sexual partners' quality of life. Available data indicate that hypertension represents a risk factor for erectile dysfunction, which is more frequent in hypertensive compared with normotensive subjects. The pathophysiologic basis of erectile dysfunction in hypertension is under thorough investigation, and several mechanisms have been proposed. Erectile dysfunction has also been related to cardiovascular risk factors and might be used as a marker of cardiovascular disease in the future. Although male sexuality has been studied rather extensively, female sexual dysfunction in hypertension is underexplored. Recently published hypertension guidelines either ignore or superficially address sexual dysfunction, underlining the need for more attention and better education of health care professionals on this issue.

The prevalence of Peyronie's disease in diabetic patients with erectile dysfunction

We attempted in this study to investigate the prevalence of Peyronie's disease (PD) among diabetic patients with erectile dysfunction (ED). Two-hundred and six diabetic patients were further evaluated in this study. Forty-two (20.3%) patients had PD. There were significant associations between PD and risk factors of age, obesity and smoking. All patients with PD had also ED. Penile curvature was present in 82.1% of all patients with PD. Of the patients with PD, 25.4% had pain with or without erection. Significant associations between PD and ED and ED duration were detected. This study confirmed the high prevalence of PD among diabetic patients with ED. Further work is needed probing the mechanisms through which diabetes affects the pathogenesis of ED and PD.

Prevalence of erectile dysfunction in kidney transplant recipients

Prevalence and severity of erectile dysfunction increase with advancing age. Patients with end-stage renal disease (ESRD) experience disturbances in erectile function related to organic factors including as uremia, hypertension, endocrine, and nonorganic factors like depression. Recipients of kidney transplants show a high prevalence of erectile dysfunction, 32.2% to 50.7%. We conducted a study of the prevalence of erectile dysfunction among male renal transplant recipients using the International Index of Erectile Function. Among 182 men with kidney transplantations, there were 89 recipients (48.9%) with erectile dysfunction; 60 recipients had normal sexual function (32.9%); and whereas 33 recipients had no sexual activity.

Cardiovascular drug use and the incidence of erectile dysfunction

It is unclear whether high blood pressure per se or antihypertensive drug use causes erectile dysfunction (ED). The aim of this study was to investigate the effect of cardiovascular diseases and their concomitant medications use on the incidence of ED. The target population consisted of men aged 55, 65 or 75 years old residing in the study area in Finland in 1999. Questionnaires were mailed to 2837 men in 1999 and to 2510 of them 5 years later. The follow-up sample consisted of 1665 men (66% of those eligible) who responded to both baseline and follow-up questionnaires. Men free of moderate or severe ED at baseline (N=1000) were included in the study. ED was assessed by two questions on subject ability to achieve or maintain an erection sufficient for intercourse. Poisson regression model was used in the multivariable analyses. The risk of ED was higher in men suffering from treated hypertension or heart disease than in those with the untreated condition. The risk of ED was higher in men using calcium channel inhibitor (adjusted relative risk (RR)=1.6, 95% confidence interval (CI) 1.0-2.4), angiotensin II antagonist (RR=2.2, 95% CI 1.0-4.7), non-selective beta-blocker (RR=1.7, 95% CI 0.9-3.2) or diuretic (RR=1.3, CI 0.7-2.4) compared with non-users. ED was not associated with using organic nitrates, angiotensin-converting enzyme inhibitors, selective beta-blockers and serum lipid-lowering agents. In summary, calcium channel inhibitors, angiotensin II antagonists, non-selective beta-blockers and diuretics may increase the risk of ED.

Prevalence of erectile dysfunction among middle-aged men in a metropolitan area in Germany

The comparison of results of previous studies on the prevalence of erectile dysfunction is hampered due to differences in study design and research instruments including definitions used. The aim of the study was to determine the prevalence of erectile dysfunction/erectile disorder (ED) using different definitions. An epidemiological cross-sectional study was conducted between May and November 2002 in Berlin, Germany. A total of 6000 men between 40 and 79 years of age were randomly selected by the Berlin Office of Vital Statistics and were sent a questionnaire by mail. The prevalence of ED was determined using five different methods. A total of 1915 questionnaires were eligible for analysis. The five different definitions yielded age-adjusted ED prevalence rates between 18 and 48%. Age was strongly correlated with all five definitions (P<0.001). These results indicate the need for standardized criteria when conducting future studies on ED and may aid in designing public health and clinical management strategies.

Efficacy and safety of two dosing regimens of tadalafil and patterns of sexual activity in men with diabetes mellitus and erectile dysfunction: Scheduled use vs. on-demand regimen evaluation (SURE) study in 14 European countries

AIM

The aim of this article is to evaluate the efficacy and safety of 20-mg tadalafil taken on demand or three times per week and its effect on the sexual activity of patients with diabetes mellitus and erectile dysfunction (ED).

METHODS

The scheduled use vs. on-demand regimen evaluation (SURE) was a randomized, crossover, open-label study with 4,262 patients in 14 European countries. The efficacy measures for the 762 patients with diabetes and ED included changes from baseline in the erectile function (EF) domain of the International Index of Erectile Function (IIEF), and the proportion of "yes" responses to patient Sexual Encounter Profile (SEP) questions 2 (SEP2) and 3 (SEP3). The treatment satisfaction was measured with responses to SEP question 4 (SEP4) and SEP question 5 (SEP5), and sexual attempts data were collected. Patient preference for either regimen was determined by the treatment preference question (TPQ).

RESULTS

At end point on both regimens, the mean IIEF EF domain score was 22, and >40% of the patients had a normal EF domain score (> or =26). The proportion of "yes" responses was > or =73% for SEP2 (penetration), > or =58% for SEP3 (successful intercourse), >46% for SEP4 (hardness of erection), and > or =45% for SEP5 (overall satisfaction). Efficacy was maintained up to 36 hours post-dosing. More than 70% of sexual attempts while on the three-times-per-week regimen and approximately 50% of the attempts on the on-demand treatment occurred >4 hours post-dosing. Tadalafil was well tolerated, with dyspepsia and headache as the most frequent adverse events reported. Treatment preference was 57.2% for on demand and 42.8% for three times per week.

CONCLUSIONS

Tadalafil, when taken on demand or three times per week, is efficacious and safe in men with diabetes and ED.