A first prospective, randomized, double-blind, placebo-controlled clinical trial evaluating extracorporeal shock wave therapy for the treatment of Peyronie's disease

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is a conservative therapy for patients with Peyronie's disease (PD).

OBJECTIVE

To investigate the effects of ESWT in patients with PD.

DESIGN, SETTING, AND PARTICIPANTS

One hundred patients with a history of PD not >12 mo who had not had previous PD-related treatments were enrolled in a prospective, randomized, double-blind, placebo-controlled study. Patients were randomly allocated to either ESWT (n=50) or placebo (n=50). Erectile function (EF), pain during erection, plaque size, penile curvature, and quality of life (QoL) were assessed at baseline, at 12 wk, and at 24 wk follow-up.

INTERVENTION

Four weekly treatment sessions were administered. Each ESWT session consisted of 2000 focused shock waves. For the placebo group, a nonfunctioning transducer was employed.

MEASUREMENTS

EF was evaluated with the shortened version of the International Index of Erectile Function (IIEF-5), pain was evaluated with a visual analog scale (VAS; 0-10), plaque size was measured in cm(2), and penile curvature was measured in degrees.

RESULTS AND LIMITATIONS

After 12 wk, mean VAS score, mean IIEF-5 score, and mean QoL score ameliorated significantly in patients receiving ESWT. Mean plaque size and mean curvature degree were unchanged in the ESWT group, while a slight increase was reported in the placebo group (p-value not significant vs baseline). After 24 wk, mean IIEF-5 score and mean QoL score were stable in the ESWT group, while mean VAS score was significantly lower when compared with baseline in both groups. Interestingly, after 24 wk, mean plaque size and mean curvature degree were significantly higher in the placebo group when compared with both baseline and ESWT values. The main limitations were that the QoL questionnaire was not validated, ED was not etiologically characterized, and inclusion criteria were restricted.

CONCLUSIONS

In patients with PD, ESWT leads to pain resolution and ameliorates both EF and QoL.

Renal transplantation does not improve erectile function in hemodialysed patients

BACKGROUND

Effects of renal transplantation (RT) on erectile dysfunction (ED) is a controversial issue.

OBJECTIVE

To verify the efficacy of RT in restoring erectile function (EF) in hemodialysed patients.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective, interventional, nonrandomised study from September 2001 to September 2005 on 78 hemodialysed male patients undergoing RT. EF was evaluated during the baseline visit and 1 yr after RT, using the International Index of Erectile Function (IIEF) questionnaire. A subanalysis was performed by splitting the total cohort into two age groups: <45 yr and ≥45 yr.

INTERVENTION

RT was performed.

MEASUREMENTS

EF was evaluated using the IIEF scoring system.

RESULTS AND LIMITATIONS

Before RT, 68 patients with a mean total IIEF score of 42.46 complained about ED. One year after RT, 71 patients reported ED, and the mean total IIEF score had decreased to 39.97. The mean pre-RT IIEF EF domain score was 18.48, and it decreased to 17.55 after RT. Patients aged≥45 yr reported no significant variations in any IIEF domain, while patients aged<45 yr reported a significant decrease in mean total IIEF score due to variations in domain scores for erectile function, sexual desire, and overall satisfaction. In the younger age group, we found significant differences between baseline and post-RT IIEF scores in dyslipidaemic patients and in those patients using immunosuppressive (methylprednisolone and cyclosporin) or antihypertensive (ACE-inhibitors, β-blockers, and Ca-antagonists) drugs. The main limitations were the absence of any aetiological characterisation of ED and the small number of patients.

CONCLUSIONS

After RT, EF worsens in patients<45 yr but is not modified in patients≥45 yr.

[Tadalafil versus sildenafil citrate in the treatment of ED:Italian patients' preferences and explanatory notes]

This is an open, multicentre, randomized, crossover study having the aim to evaluate the preference for sildenafil citrate or tadalafil in a population of Italian patients affected by ED, and to compare the efficacy and safety of these two drugs. MATERIAL AND METHODS. From October 2003 to November 2004, thirteen Italian centers enrolled ED patients (age >18) being in steady and naïve relation to ED treatment, both through PDE5 inhibitors and any other treatment option. These patients were randomized to sildenafil or tadalafil for 12 weeks, after which they were switched to the alternative treatment for a further 12 weeks. The preference was evaluated through the Treatment Preference Question (TPQ): "During this clinical trial you have taken tadalafil and sildenafil for the treatment of erectile dysfunction. Which medication do you prefer to take for the next 8 weeks of treatment?". Moreover, patients were asked to express their preference as "strong" or "moderate" and to answer some questions to clarify the reasons behind their preference. SEP and IIEF-EF questionnaires were used for a comparison of efficacy. RESULTS. 167 patients were enrolled, 144 of whom completed both treatment periods. On being asked the TPQ, 75% of patients (n=108) decided to continue treatment with tadalafil, in particular because it made it possible to have an erection many hours after taking the medication (first or second preference reason for 64.8% of patients), while 25% (n=36) preferred sildenafil (p=0.001). Both drugs improved the IIEF-EF and SEP scores compared to baseline, with a slightly but significantly greater improvement with tadalafil for both parameters. CONCLUSIONS. Tadalafil and sildenafil are both effective and well tolerated. Most of the patients prefer tadalafil thanks to the possibility of having sexual intercourse many hours after taking the medication.

Malignant progression of a small HCC nodule: hypovascular 'early HCC' converted to hypervascular 'small HCC' within six months

We report a case of hepatocellular carcinoma superimposed on chronic hepatitis C virus (HCV) hepatitis in which final diagnosis of hepatocellular carcinoma was delayed because there was no consensus on hypervascularity with two diagnostic methods at the time of presentation. A 3 cm lesion was initially observed as hypovascular at multidetector-row computed tomography. Conversely, two months later the lesion appeared hypervascular at contrast-ultrasonography and gadolinium-enhanced dynamic magnetic resonance, and hyperintense after superparamagnetic iron oxide-enhanced T2W studies. Only in the late follow-up it was definitively confirmed as hypervascular in the arterial phase of multidetector-row computed tomography. This case clearly highlights some pitfalls in the European Association for the study of the liver guidelines for hepatocellular carcinoma management, which were readdressed in the last American Association for the Study of Liver Diseases (AASLD) and in the forthcoming international proposals, leading to more pragmatic suggestions for clinical practice.

Evaluation of an alternative dosing regimen with tadalafil, three times per week, for men with erectile dysfunction: SURE study in Italy

AIM

To examine the preference for two dosing regimens of 20 mg of tadalafil, on demand or three times per week, in men affected with erectile dysfunction (ED) in Italy.

METHODS

Scheduled Use versus on demand Regimen Evaluation (SURE) is a multicenter, crossover and open-label study, involving 94 urology centers in Italy. Patients aged 18 years or older affected with ED for at least 3 months were enrolled and randomized to 20 mg of tadalafil treatment on demand or three times per week for 5-6 weeks. After a 1-week washout, patients were crossed over to the alternate regimen for 5-6 weeks. A treatment preference question was used to determine the preferred treatment regimen. International Index of Erectile Function (IIEF) and Sexual Encounter Profile (SEP) questionnaire were used as efficacy measures.

RESULTS

A total of 1 058 men (mean age 54.8 years), were randomized to treatment. Overall, 59.1% of patients preferred the on-demand regimen and 41.9% preferred the three times per week dosing. Both regimens were efficacious and well tolerated. Although a statistically higher improvement of the IIEF erectile function (IIEF-EF) domain score and the SEP questionnaire was reported for the three times per week compared to the on-demand treatment regimen, this difference was numerically minimal and lacking in clinical significance.

CONCLUSION

Tadalafil is effective and well tolerated whether used on demand or three times per week. Patients should be given the option to choose the best treatment regimen according to personal needs and preferences.

An identikit of patients seeking treatment for erectile dysfunction in Italy: results from the EDOS Italian database

OBJECTIVES

Erectile Dysfunction Observational Study (EDOS) is a 6 months observational, prospective, multicentre trial, which enrolled more than 8,000 patients referring to physicians to seek treatment for ED or to modify their current therapy; it was conducted in 9 European countries. Objective of this trial was to outline general characteristics of these populations and related treatment patterns, to assess their efficacy, motivation for treatment extension or discontinuation and patients' overall satisfaction in clinical practice. Baseline characteristics of Italian enrolled population provide the Italian patient profile seeking ED treatment.

MATERIALS AND METHODS

The Italian centres involved in this study enrolled, from April 2003 to April 2004, 1,419 men, aged over 18. All of them had already requested to their general practitioner or specialist to start a treatment for ED or to modify a previously initiated therapy. Baseline assessment together with all demographic data, included collecting information about: education, socioeconomic position, clinical history, co-morbidities, ED current therapies, concomitant pharmacological therapies (antidepressants, antihypertensive and other cardiovascular drugs, hypolipidemic drugs, antipsychotics, and anti-cancer agents). All patients filled in IIEF-EF e SF-PAIRS questionnaires, and responded to single item question I (SIQ1: During last 6 months, did not your erection last long enough for you to start and have a successful sexual intercourse?).

RESULTS

Of the 1,419 men enrolled, 1,357 were eligible for the study. Mean age was 55 years and BMI=26.8 kg/mn. 83% of patients' education was above primary school; 52% had a full time job, while 37% was retired. 88.5% reported a steady relationship, and 71.5% reported that this relationship had been longer than 10 years. 70.4% of patients were smokers or ex-smokers, while potus history was infrequent. ED was mild or moderate in 61.6% cases and had a psychogenic, organic or mixed origin respectively in 24%, 33% and 43%; 59% of patients had a story of ED more than one year. 43% was assuming other drugs for concurrent diseases, mainly antihypertensive drugs (71%).

CONCLUSIONS

Italian outcomes from EDOS study allow us to outline the "average patient" profile, who in Italian clinical practice seeks treatment for ED.

The detrusor muscle: an innocent victim of bladder outlet obstruction

OBJECTIVES

Benign prostatic hyperplasia (BPH) is considered a frequent cause of bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS), although the physiopathologic mechanism through which BPH causes LUTS is not clear. Several morphologic and functional modifications of the bladder detrusor have been described in patients with BPH and could play a direct role in determining symptoms. The opinion is spreading that the enlarged prostates in patients with LUTS is nothing more than a mere bystander. Evidence has accumulated, however, supporting the role of BPH-related BOO as the direct cause determining bladder dysfunction and indirectly causing urinary symptoms. The present review addresses the bladder response to BOO, particularly focusing on the physiopathologic cascade that links obstructive BPH to bladder dysfunction.

METHODS

A literature review of peer-reviewed articles has been performed, including both in vivo and in vitro studies on human tissue and animal model experiments.

RESULTS

Epithelial and smooth muscle cells in the bladder wall are mechanosensitive, and in response to mechanical stretch stress caused by BOO, undergo modifications of gene expression and protein synthesis. This process involves several transduction mechanisms and finally alter the ultrastructure and physiology of cell membranes, cytoskeleton, contractile proteins, mitochondria, extracellular matrix, and neuronal networks.

CONCLUSIONS

BOO is the initiator of a physiopathologic cascade leading to deep changing of bladder structure and function. Before being a direct cause of storing-phase urinary symptoms, the bladder is the first innocent victim of prostatic obstruction.

Pharmacology of erectile dysfunction in man

Erectile dysfunction (ED) is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity (2nd International Consultation on Sexual Dysfunction-Paris, June 28th-July 1st, 2003). Following the discovery and introduction of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost and many preclinical and clinical papers have been published in the last 5 years. This review is structured in order to give the reader an overview of the clinical and preclinical data available on the peripheral regulation of and the mediators involved in human penile erection. The most widely accepted risk factors for ED are discussed. The article is focused on human data, and the safety and effectiveness of the 3 commercially available Phosphodiesterase-5 (PDE5) inhibitors used to treat ED are also discussed.

ORIGINAL RESEARCH—ED PHARMACOTHERAPY: Flexible‐Dose Vardenafil in a Community‐Based Population of Men Affected by Erectile Dysfunction: A 12‐Week Open‐Label, Multicenter Trial

AIM

To evaluate the efficacy, safety, and tolerability of a flexible-dose regimen of vardenafil in a community-based population of men with erectile dysfunction (ED).

METHODS

This was a 12-week, open-label, flexible-dose, multicenter study of unselected men with ED of diverse origins and severity. Unlike previous studies, prostatectomy-induced ED and previous unresponsiveness to sildenafil were not exclusion criteria. After 4 weeks of treatment with 10 mg of vardenafil, the dose could be continued or titrated to 5 mg or 20 mg, depending on efficacy and tolerability. After 8 weeks, another dose change was possible. Efficacy was assessed with International Index of Erectile Function erectile function (IIEF-EF) domain scores, diary questions of the Sexual Encounter Profile (SEP), and a global assessment question (GAQ) about erection improvement during the previous 4 weeks.

RESULTS

Safety was evaluated in 497 patients, and 480 were suitable for intention-to-treat analysis. After 12 weeks of treatment, the mean per patient rate of successful intercourse, defined by an affirmative response to SEP questions 1-3, was 72%, and was related to age and ED duration. The overall success rate increased from 66% at week 4 to 77% at week 12. The mean IIEF-EF domain score of the whole population increased from 17.2 (baseline) to 24.4 (endpoint). At week 12, the best scores were obtained by patients taking 5 mg and 10 mg. At week 12, GAQ scores showed improved erection in 97.4%, 94.8%, and 78.8% of patients in the 5 mg, 10 mg, and 20 mg group, respectively. Safety was excellent: no serious drug-related event was reported, and only 2.2% of patients discontinued treatment because of side-effects.

CONCLUSIONS

Vardenafil was effective and well tolerated in this community-based ED population that is truly representative of the general ED population. Dose titration meets the patient's needs and optimizes clinical outcome.

Sphingosine 1-phosphate induces endothelial nitric-oxide synthase activation through phosphorylation in human corpus cavernosum

Sphingosine 1-phosphate (S1P) is the natural ligand for a specific G protein-coupled receptors. In endothelial cells, S1P has been shown to modulate the activity of the endothelial nitric-oxide synthase (eNOS) through phosphorylation operated by Akt. Nitric oxide (NO) produced by neuronal nitric-oxide synthase and eNOS plays a central role in triggering and maintaining penile erection. This study has assessed the possibility of a similar cross-talk between eNOS and S1P in human corpus cavernosum and whether this interaction is connected to penile vascular response. Quantitative reverse transcription-polymerase chain reaction demonstrated the presence of S1P(1), S1P(2), and S1P(3) receptors in both the human corpus cavernosum (HCC) and the penile artery. S1P on its own did not relax or contract HCC strips, but on the other hand, incubation with S1P (0.1 microM) caused a 6-fold increase in relaxation induced by a subliminal dose of acetylcholine. This effect is dependent upon eNOS activation through an Akt-dependent phosphorylation, as demonstrated by pharmacological modulation with l-nitroarginine methyl ester and wortmannin and by Western blot studies. In human tissue, S1P seems to be the possible candidate for the activation of the eNOS calcium-independent pathway. This pathway may represent a new therapeutic area of intervention in erectile dysfunction (ED) to develop a way to selectively promote NO production at the endothelial level. This approach could also be used to enhance phosphodiesterase 5 therapy in patients with ED that are poor responders, such as in the case of diabetes.

Histological alterations in cavernous tissue after radical prostatectomy

PURPOSE

Radical prostatectomy often results in erectile dysfunction because of lesions to the erectile nerves. In this study we evaluated histomorphological alterations in cavernous smooth muscle and collagen content after radical prostatectomy.

MATERIALS AND METHODS

A total of 19 patients between 57 and 69 years old with prostate adenocarcinoma and normal erectile function, as reported and validated by RigiScan (UroHealth Systems, Laguna Niguel, California) testing, underwent corpora cavernosa biopsy in the operating room before radical prostatectomy, and 2 and 12 months after surgery. No patient underwent hormone therapy before or after surgery and none was diabetic. Elastic fibers (manual counting), muscle specific actin (immunostaining) and collagen content (computerized morphometric imaging) were measured in the 3 biopsies.

RESULTS

In all cases the first postoperative histological assessment revealed some disorganization. Trabecular elastic fibers (p <0.0003) and smooth muscle fibers were decreased and collagen content was significantly increased (p <0.0003) compared with preoperative biopsies. One year after surgery elastic fibers (p <0.0003) and smooth muscle fibers were decreased and collagen content was significantly increased (p <0.0003) compared with the first postoperative biopsy. Moreover, organized collagen and trabecular protocollagen deposits were increased.

CONCLUSIONS

Progressive fibrosis in the corpora cavernosa after radical prostatectomy probably results from denervation and/or an ischemic process, which is caused in turn by the ligation of anomalous pudendal artery branches or of venous plexuses that drain to or from the corpora cavernosa. Fibrosis and the subsequent loss in elasticity and function of erectile tissue probably together cause erectile dysfunction.

Unresectable hilar cholangiocarcinoma: multimodality treatment with percutaneous and intraluminal plus external radiotherapy

The efficacy of multimodality treatment for unresectable hilar cholangiocarcinoma was evaluated in terms of outcome, survival and quality of life. Eleven patients were enrolled in the following protocol: percutaneous drainage of both right and left biliary systems; Iridium-192 intraluminal brachytherapy; replacement of the drainages with endoprotheses; external radiotherapy. Six patients completed the protocol and 5 were treated with brachytherapy alone. Mean survival was 10.5 months, similar to surgical results and higher than the control group treated with percutaneous stenting (2.75 months) or biliary drainage alone (1.75 months), with an average hospital stay of 10-15 days and no procedure-related mortality.

CORRELATION BETWEEN DETRUSOR COLLAGEN CONTENT AND URINARY SYMPTOMS IN PATIENTS WITH PROSTATIC OBSTRUCTION

PURPOSE

We used computerized imaging analysis to compare the collagen content of detrusor specimens between patients affected with symptomatic obstructive benign prostatic hyperplasia (BPH) and asymptomatic controls.

MATERIALS AND METHODS

In our study we enrolled 36 patients with symptomatic urodynamically obstructed BPH undergoing transurethral resection of the prostate. We also enrolled 28 men (mean age 61.3, range 55 to 70) undergoing transurethral resection of the bladder for primitive, singular Ta bladder cancer, with no significant urinary symptoms, as the control group. During the transurethral surgical procedure in controls and in patients with BPH, a biopsy was performed deep through the muscular layer from either of the lateral bladder walls. Computerized morphometric analysis of the stained sections was performed with an image analysis system, and a percentage of collagen fibers was extracted through morphological filtering and expressed as a mean percentage of the total bioptic area.

RESULTS

Collagen content in bladder detrusor specimens was significantly higher in patients with BPH compared to controls (48% and 17% of bioptic area, respectively, p <0.001). Mean detrusor collagen content was clearly higher in patients with severe symptoms than in patients with moderate symptoms (50.45 +/- 8.22% and 43.09% +/- 7.05%, respectively).

CONCLUSIONS

Our study supports the important role of detrusor collagen neo-deposition in determining lower urinary tract symptoms in obstructive BPH. Detrusor collagen content correlates with urodynamic obstruction, the presence and severity of symptoms and, given that collagen neoformation is irreversible could probably have a role in the postoperative persistence of lower urinary tract symptoms in patients undergoing surgery for BPH.

Ancestral Founder Mutation of the Nude ( FOXN1 ) Gene in Congenital Severe Combined Immunodeficiency Associated with Alopecia in Southern Italy Population

Genetic alterations of the FOXN1 transcription factor, selectively expressed in thymic epithelia and skin, are responsible in both mice and humans for the Nude/SCID phenotype. The first described human FOXN1 mutation was a C792T transition in exon 5 resulting in the nonsense mutation R255X, and was detected in two probands originated from a small community in southern Italy. In this community, four additional children affected with congenital alopecia died in early childhood because of severe infections. In this study, we report on the screening for this mutation in 30% of the village population. This analysis led us to identify 55 heterozygous carriers (6.52%) of the R255X mutation out of 843 inhabitants screened. A genealogical study revealed that these subjects, belonging to 39 families, were linked in an extended 7-generational pedigree comprising 483 individuals. Through the archival database a single ancestral couple, born at the beginning of the 19th century, was identified. To confirm the ancestral origin of the mutation we genotyped two microsatellite markers, D17S2187 and D17S1880, flanking the FOXN1 gene on chromosome 17. The three haplotypes identified, 3/R255X/3, 3/R255X/2 and 3/R255X/1, are consistent with a single ancestral origin for the mutation R255X.

Activation of beta1-adrenoceptors excites striatal cholinergic interneurons through a cAMP-dependent, protein kinase-independent pathway

The role of noradrenergic neurotransmission was analyzed in striatal cholinergic interneurons. Conventional intracellular and whole-cell patch-clamp recordings were made of cholinergic interneurons in rat brain slice preparations. Bath-applied noradrenaline (NA) (1-300 microm) dose-dependently induced both an increase in the spontaneous firing activity and a membrane depolarization of the recorded cells. In voltage-clamped neurons, an inward current was induced by NA. This effect was not prevented by alpha-adrenoceptor antagonists, whereas it was mimicked by the beta-adrenoceptor agonist isoproterenol and blocked by the beta1 antagonists propranolol and betaxolol. Interestingly, forskolin, activator of adenylate cyclase, mimicked and occluded the membrane depolarization obtained at saturating doses of both dopamine and NA. Accordingly, SQ22,536, a selective adenylate cyclase inhibitor, reduced the response to NA. Analysis of the reversal potential of the NA-induced current did not provide homogeneous results, indicating the involvement of multiple membrane conductances. Because cAMP is known to modulate Ih, the effects of ZD7288, a selective inhibitor of Ih current, were examined on the NA-induced membrane depolarization/inward current. ZD7288 mostly reduced the response to NA. However, both KT-5720 and H-89, selective protein kinase A (PKA) blockers, failed to prevent the excitatory action of NA. Likewise, calphostin C, antagonist of PKC, genistein, inhibitor of tyrosine kinase, and 8-Bromo-cGMP, blocker of PKG, did not affect the response to NA. Finally, double-labeling experiments combining beta1-adrenoceptor and choline acetyltransferase immunocytochemistry by means of confocal microscopy revealed a strong beta1-adrenoceptor labeling on cholinergic interneurons. We conclude that NA depolarizes striatal cholinergic interneurons via beta1-adrenoceptor activation, through a cAMP-dependent but PKA-independent mechanism.

Erectile dysfunction after surgical treatment

Erectile dysfunction is a recognized complication of prostate and bladder radical surgery, although there is significant variation in the reported risk, much of this variability is related to the retrospective nature of most previous studies. Undoubtedly, the quality of life of bladder and prostate cancer patients would be much improved if both normal micturition and potency are preserved, which is the subject of this article. Quality of life studies can delineate sexual function after radical prostatectomy, including the use of sexual aids. Penile erection is a neurovascular event modulated by neurotransmitters and hormonal status. The penis is innervated by autonomic and somatic nerves. Both surgery and radiation therapy appear to affect such a mechanism. Radiation is thought to produce Erectile Dysfunction (ED) by accelerating microvascular angiopathy causing cavernosal fibrosis or stenosis of the pelvic arteries and by accelerating existing arteriosclerosis, leading to vascular impotence. Years may elapse before clinically significant ED occurs. Criteria that influence recovery of erections after surgery include younger patient age, stronger erections before operation, preservation of the neurovascular bundles, and attention to fine details in the surgical technique. Recovery of erections occurs in 68% of preoperatively potent men treated with bilateral nerve-sparing surgery and in 47% of those treated with unilateral nerve-sparing surgery.

Involvement of beta 3-adrenergic receptor activation via cyclic GMP- but not NO-dependent mechanisms in human corpus cavernosum function

The beta(3)-adrenoreceptor plays a major role in lipolysis but the role and distribution of beta(3)-receptors in other specific sites have not been extensively studied. beta(3)-adrenergic receptors are present not only in adipose tissue but also in human gall bladder, colon, prostate, and skeletal muscle. Recently, beta(3)-adrenergic receptor stimulation was shown to elicit vasorelaxation of rat aorta through the NO-cGMP signal transduction pathway. Here we show that beta(3)-receptors are present in human corpus cavernosum and are localized mainly in smooth muscle cells. After activation by a selective beta(3)-adrenergic receptor agonist, BRL 37344, there was a cGMP-dependent but NO-independent vasorelaxation that was selectively blocked by a specific beta(3)-receptor antagonist. In addition, we report that the human corpus cavernosum exhibits basal beta(3)-receptor-mediated vasorelaxant tone and that beta(3)-receptor activity is linked to inhibition of the RhoA/Rho-kinase pathway. These observations indicate that beta(3)-receptors may play a physiological role in mediating penile erection and, therefore, could represent a therapeutic target for treatment of erectile dysfunction.

Neurophysiologic evaluation of central-peripheral sensory and motor pudendal pathways in primary premature ejaculation

OBJECTIVES

Pudendal nerve somatosensory evoked potentials (SEPs), the bulbocavernosus (BC) reflex, and BC perineal motor evoked potentials after transcranial magnetic cortical stimulation were performed in patients with primary premature ejaculation to investigate the somatic sensory and motor function of the genital area.

METHODS

Fourteen patients with primary premature ejaculation underwent psychological counseling, urologic physical examination, transrectal ultrasound examination, laboratory testing, and the Stamey test. The spinal and cortical pudendal nerve SEPs were performed by dorsal nerve stimulation at the penile shaft (DN-SEPs) in all patients and at the glans penis (GP-SEPs) in 3 of them. The BC reflex was obtained by stimulating the base of the penis.

RESULTS

The mean sensory threshold did not significantly differ between the patients and normal subjects. Cortical DN-SEPs were normal in all patients. The sensory central conduction time, calculated in 6 patients, was normal. The mean cortical DN-SEP amplitude was significantly smaller in patients than in controls. In 3 patients and in 3 controls who underwent both DN-SEP and GP-SEP testing, the glans penis sensory threshold was lower than the dorsal nerve threshold and the cortical GP-SEP latency was longer than the cortical DN-SEP latency. The BC reflex was normal in most patients. The BC motor evoked potentials were normal in all patients, but one.

CONCLUSIONS

We did not confirm either a faster conduction along the pudendal sensory pathway or a greater cortical representation of the sensory stimuli from the genital area in our patients. Moreover, we did not confirm hyperexcitability of the BC reflex in them. Our results suggest that the electrophysiologic approach is probably not sufficient to clarify the causes of primary premature ejaculation. A more integrated investigation could allow better results in this field.

Female sexual dysfunction: an update on physiopathology

Despite the importance of sexuality for both men and women of all ages, only in the last few years extensive research has been carried out into female sexual problems. It has been discovered that sexual problems affect a considerable number of women each year, and this indicates the validity and necessity of further medical studies. We know that female genital sexual response is a combination of vasocongestive and neuromuscular events in the genital tract and pelvic floor which are controlled in part by specific neurotransmitters. Other pelvi-perineal genital structures undergo vasculogenic changes, namely the labia, periurethral glands, urethra and the Halban's fascia but much less attention has been paid to the role of these tissues in sexual response compared to the clitoris and the vagina. The most common etiologies of female sexual dysfunction are vasculogenic, neurogenic, hormonal/endocrine, muscologenic. The increasing various problems of female sexual dysfunction and the interest in the matter and the subsequent research are factors which keep the scientific community involved constantly active.

A new biopsy technique to investigate Peyronie's disease associated histologic alterations: results with two different forms of therapy

OBJECTIVES

Peyronie's disease is the most frequent cause of penile curvature and occurs particularly in middle-age patients. The best technique for penile biopsy, in the evaluation of albuginea and cavernous tissue, has not been delineated yet. We present a new technique of penile biopsy, useful in the study of Peyronie's plaque, fibrosis and erectile dysfunction or any other pathological condition of the penis requiring a biopsy.

METHODS

A treatment group (A) of 380 patients underwent Extra Shock Waves Treatment (ESWT) three times a week for 20 minutes, followed by a complete cycle of 12 injections of verapamil (10mg), every two weeks for six months. A control group (B) of 92 patients underwent verapamil injections alone. Three months after the end of the treatment, each patient underwent penile biopsy performed with Acu-Punch (Acuderm Inc.), a biopsy-punch armed with a well-sharpened rotating cylindrical blade, first used by dermatologists for cutaneous lesions.

RESULTS

A reduction of the plaque volume was found in 260/380 patients (68.4%) of group A and in 28/92 (30.4%) of group B; painful erection weaned off in 312/340 patients of group A (91.7%) and in 36/82 patients (43.9%) of group B. In all 472 patients an excellent specimen was obtained and both the tunica albuginea and the cavernous tissue were easily identified. In the 260 cases, in which the Extra Shock Waves Treatment was successful, scanning and transmission electron microscopy demonstrated a reduction in packing and clumping of the collagen fibers.

CONCLUSIONS

This new technique of penile biopsy with Acu-Punch can replace surgical biopsies when a surgical operation is not indicated. Such a low-invasive technique could be performed in all cases of Peyronie's disease and allows a more extensive use of microscopic analysis in the study of Peyronie's disease.

Did men with erectile dysfunction discuss their condition with partner and physicians? A survey of men attending a free call information service

We present data collected among men attending a free call service on information on erectile dysfunction (ED) activated in Italy during the period 1997-1999. Their attitudes towards discussion with their partner and physician about the condition are considered. Each subject, was asked if he was affected by ED (defined as inability to achieve and maintain an erection sufficient for satisfactory sexual performance). In the case of a positive answer, the subject was asked if he had ever discussed his condition with partner or a physician. A total of 12 761 subjects with ED called the service: 7265 (56.9%) reported to have discussed their condition with their partner. The proportion tended to increase with duration of ED, being 47.9% in subjects reporting ED lasting <6 months and 59.9% in those reporting ED lasting >3 y (w(2)(1) trend <0.05). Likewise, the proportion of subjects reporting to have discussed ED with a physician was 50.3% (6416 subjects), being 33.6% in subjects with ED lasting <6 months and 57.9% of those with ED lasting >3 y (w(2)(1) trend, P<0.01).

[Abdominal actinomycosis and retroperitoneal fibrosis. Considerations on a clinical case]

Abdominal actinomycosis is a rare disease which often resembles an acute suppurative infection or/and abdominal tumour causing abscesses, fistulas and massive fibrosis. The preoperative diagnosis is difficult and surgical exploration is always needed because of major involvement of visceral and retroperitoneal structures. The disease can be diagnosed with certainty only on the basis of findings of bacterial colonies in histopathologic sections and typical sulphur grains in secretions from fistulas. The authors describe a case of abdominal actinomycosis involving the caecum and right colon, causing extensive retroperitoneal fibrosis and a fistula tract with an external cutaneous orifice at the level of the right iliac crest. These features resembled an acute appendicitis at first, and several surgical explorations were required before a correct diagnosis could be achieved. Abdominal actinomycosis can be treated by simple administration of antibiotics. With a correct diagnosis, medical therapy alone has proved effective in a substantial percentage of patients, thus avoiding the need for surgery, if important visceral or retroperitoneal structures are not involved. Abdominal actinomycosis always requires a careful differential diagnosis and must be considered in patients presenting abdominal tumours associated with abscesses and/or fistulas since early and efficient medical therapy, along with surgical intervention, where necessary, can lead to definitive recovery. Useful diagnostic tools are abdominal CT and selective FNAB.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices

PURPOSE

We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms.

MATERIALS AND METHODS

We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers.

RESULTS

Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively.

CONCLUSIONS

The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

[Non-surgical treatment of aortic aneurysms and dissections: indications, strategies and outcome]

PURPOSE

The endovascular treatment of the thoracic aorta is an effective alternative to open surgical repair and offers a therapeutic option even to patients at high risk for surgery. Our experience in the treatment of different diseases of descending thoracic aorta is reported.

MATERIAL AND METHODS

Between July 1997 and January 2001, 50 patients were selected for endovascular treatment: 36/50 patients presented high risk for conventional surgery. Six patients presented clinical and imaging features suggesting impending rupture and were treated on emergency basis. The stent-graft prosthesis was individually manufactured or selected on the basis of spiral CT or MRI measurements.

RESULTS

Endovascular stent positioning and deployment was technically successful in 49 cases. In one patient the tortuosity of the aortic arch prevented graft deployment. Complete aneurysm exclusion was achieved in 48 cases as assessed by post-procedure angiography and TEE. One proximal endoleak was noted and surgical conversion was performed 40 days later. There were no intraoperative mortality or complications. One patient presented extension of dissection at the 8th postoperative day and required of surgical repair. CT scan showed an endoleak in 4 cases that sealed spontaneously in three cases while the fourth case was treated by graft extension. In the long term two secondary endoleak were observed (12 and 24 months after the procedure).

CONCLUSIONS

Endovascular stent-graft repair provides a less invasive opportunity to patients affected by thoracic aortic disease. Careful cases selection is the first postulate for the efficacy and safety of the procedure.

Vena cava injury. A serious complication during laparoscopic right adrenalectomy

We report our experience with a case of vena cava injury during laparoscopic right adrenalectomy. A laparoscopic right adrenalectomy was performed in a 22-year-old woman who suffered from a right surrenalian adenoma. Four trocars were used for the transperitoneal laparoscopic approach with the patient in the lateral decubitus position. After isolation of the medial margin of the gland and clipping and sectioning of the main adrenal vein, the right side of the vena cava was injured during dissection of the right upper pole, due to the use of monopolar scissors. The hemorrhage was managed immediately with the aid of fenestrated atraumatic forceps and an aspiration probe. A fifth trocar was inserted to evaluate the size of the lesion, which was then sutured laparoscopically with croised 5/0 nonresorbable stitches. No transfusion was needed. Operating time was 210 min. The post-operative course was uneventful. Hospital stay was 7 days. At 10-month follow-up, the patient had no problems related to the intraoperative complication. Our preliminary experience shows that the laparoscopic approach enables safer management of lesions involving large abdominal vessels. We believe that the transperitoneal approach is the preferential route for laparoscopic adrenalectomies. Monopolar coagulation can be dangerous and must be avoided when dissecting large vessels.

Transient global ischemia in rats yields striatal projection neuron and interneuron loss resembling that in Huntington's disease

The various types of striatal projection neurons and interneurons show a differential pattern of loss in Huntington's disease (HD). Since striatal injury has been suggested to involve similar mechanisms in transient global brain ischemia and HD, we examined the possibility that the patterns of survival for striatal neurons after transient global ischemic damage to the striatum in rats resemble that in HD. The perikarya of specific types of striatal interneurons were identified by histochemical or immunohistochemical labeling while projection neuron abundance was assessed by cresyl violet staining. Projectionneuron survival was assessed by neurotransmitter immunolabeling of their efferent fibers in striatal target areas. The relative survival of neuron types was determined quantitatively within the region of ischemic damage, and the degree of fiber loss in striatal target areas was quantified by computer-assisted image analysis. We found that NADPHd(+) and cholinergic interneurons were largely unaffected, even in the striatal area of maximal damage. Parvalbumin interneurons, however, were as vulnerable as projection neurons. Among immunolabeled striatal projection systems, striatoentopeduncular fibers survived global ischemia better than did striatopallidal or striatonigral fibers. The order of vulnerability observed in this study among the striatal projection systems, and the resistance to damage shown by NADPHd(+) and cholinergic interneurons, is similar to that reported in HD. The high vulnerability of projection neurons and parvalbumin interneurons to global ischemia also resembles that seen in HD. Our results thus indicate that global ischemic damage to striatum in rat closely mimics HD in its neuronal selectivity, which supports the notion that the mechanisms of injury may be similar in both.

Papular-purpuric gloves and socks syndrome in HIV-positive patients

Three HIV-positive women showed clinical signs of papular-purpuric gloves and socks syndrome and serologic evidence of acute Parvovirus B19 infection. The course of the disease was complicated by anemia and persistent skin lesions, probably related to inadequate immune response. Because anemia in AIDS patients may be due to many causes, the history of recent Parvovirus B19 infection is helpful in suggesting the etiologic diagnosis.

A standardized procedure for using human corpus cavernosum strips to evaluate drug activity

The main problem of using human corpus cavernosum (HCC) tissue to perform bioassay is linked to its limited availability further complicated by the heterogeneous source of the tissues used. Here, we show that gender reassignment is a reliable source of human tissue without major ethical problems. Indeed, the entire corpus cavernosum is obtained from the surgery procedure, which allows creating a standardized procedure to prepare HCC strip. In addition, human tissue, if kept in the fridge in the condition described, does not loose its ability to contract to phenylephrine (PE; alpha agonist), angiotensin II (AG II) and KCl up to 4 days. Furthermore, once contracted with PE, HCC relaxes to acetylcholine (endothelium-dependent mechanism); sodium nitroprusside (endothelium-independent mechanism); cromakalim (CRK), a K(ATP) channel opener; or alprostadil, a synthetic PGE2 (ALPR). In conclusion, we have standardized a procedure that allows the use of HCC strips to evaluate drug activity and/or to study pathophysiological mechanisms with an intact functional human tissue up to 4 days from the surgery procedure.

Evolution of aortic dissection after surgical repair

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.

[Endovascular treatment in diseases of the thoracic aorta]

PURPOSE

To determine whether endovascular treatment of thoracic aorta conditions can be an effective alternative approach to surgical repair.

MATERIAL AND METHODS

July 1997 to February 1999, eighteen patients (16 men and 2 women; 58.6 +/- 14.8 years) presenting with different kinds of descending aorta conditions were selected for the endovascular treatment. All patients exhibited severe comorbid pulmonary and/or cardiovascular medical conditions which increased surgical risk. All implants were performed in the operating room under fluoroscopic and TEE guidance. Clinical and imaging follow-up was performed 1, 3, 6 and 12 months later.

RESULTS

The endovascular treatment was successful in 17 cases. No deaths or major complications occurred. No leakage was evident at post-procedure angiography. The patients were discharged after 6 +/- 4 days. MRI or CT study performed before hospital discharge showed aneurysms exclusion in 16 patients. In the four cases of dissection, thrombosis of the false lumen was evident since the first follow-up study. In the group of patients (11 cases) with 6 months follow-up, the diameters of stented aortic segments decreased. No late leakage was observed and thrombosis was complete in all cases.

DISCUSSION

The natural history of aortic aneurysms and dissection is progressive toward dilation and aortic rupture. Surgery of descending thoracic aorta is burdened with a mortality of 8-12% in elective cases and over 50% in emergency cases or aortic dissection. The endovascular treatment of aortic conditions was introduced in clinical practice in 1991 and literature data show that it is effective, with lower mortality and morbidity rates than surgical treatment.

CONCLUSION

Our results stress the feasibility and effectiveness of endovascular procedure in the treatment of complex thoracic aorta conditions even in high risk patients. Thus, endovascular treatment of thoracic aorta can be considered an effective alternative approach to conventional surgery.

Our experience on the association of a new physical and medical therapy in patients suffering from induratio penis plastica

OBJECTIVES

To check the efficiency of shock waves in the treatment of induratio penis plastica. The Minilith SL1, successfully used in orthopedic or salivary stones because of its lithotriptic power, can be used to break plaques in Peyronie's disease.

METHODS

A total of 130 patients affected with Peyronie's disease were entered into a prospective trial. Patients with completely calcified plaques as determined by ultrasound evaluation were excluded. We divided the patients into three treatment groups: (A) shock waves alone in 21 patients; (B) a combination of shock waves and verapamil (perilesional injection) in 36 patients, and (C) verapamil alone in 73 patients. First, we treated all groups A and B patients 3 times, 20 min each time, with a Minilith SL1, and then only the patients of the second group received a complete cycle of twelve injections of verapamil (10 mg) every 2 weeks for 6 months. The group of 73 patients (group C) treated during the previous 2 years with a medical therapy (only injection of verapamil) was used as a control group.

RESULTS

Ultrasound evaluation showed a reduction of plaque in 11/21 group A patients and 7/36 group B patients. The treatment was tolerated very well and only 11 petechiae in some patients were noticed after ESW treatment.

CONCLUSIONS

The therapeutic association of shock waves with verapamil injection is an effective nonoperative treatment for the stabilization of Peyronie's disease.

Molecular anatomy of the human glucose 6-phosphate dehydrogenase core promoter

The gene encoding glucose 6-phosphate dehydrogenase (G6PD), which plays a pivotal role in cell defense against oxidative stress, is ubiquitously expressed at widely different levels in various tissues; moreover, G6PD expression is regulated by a number of stimuli. In this study we have analyzed the molecular anatomy of the G6PD core promoter. Our results indicate that the G6PD promoter is more complex than previously assumed; G6PD expression is under the control of several elements that are all required for correct promoter functioning and, furthermore, a still unidentified mammalian specific factor is needed.

Quality-of-life evaluation: when do terminal cancer patients and health-care providers agree?

A multicenter study involving six palliative care units in Italy was carried out on 159 terminal cancer patients seen at home or in hospital. The physician or the nurse completed independently from the patient the Therapy Impact Questionnaire (TIQ), a questionnaire devised for quality-of-life evaluation in terminal cancer patients. The patient's assessment was used as the valid reference measurement to compare with the health-care workers' evaluation to assess the validity of the latter. The results showed that percentages of agreement were higher for physical than for psychological and cognitive symptoms, and that there was a greater agreement on the absence rather than on the presence of a problem. None of the characteristics of the patient nor of the proxy showed any statistically significant relationship with the two disagreement indexes. The results suggest that caution is needed in the use of health-care workers as alternative sources of information regarding patients' quality of life.

Real-time digital control of optical interferometers by the mechanical-modulation technique

We discuss the application of digital systems to the automatic control of dual-wave optical interferometers. We show that, if the mechanical-modulation technique is used for error-signal extraction, digital techniques can be used both for error-signal extraction and for control-signal generation. Therefore, apart from two front/end amplifiers that are necessary to match the dynamics of the detectors and actuators to the dynamics of the analog-to-digital converters and digital-to-analog converters, no other analog devices are required. In particular, the mechanical-modulation technique requires the synchronous demodulation of the photodiode output signal. Hence we need to implement a digital lock-in amplifier whose algorithm is described here. Finally, we describe one of the possible applications of this digital control procedure, such as the control of a classic Mach-Zehnder interferometer in air.

Fringe-counting technique used to lock a suspended interferometer

We implement a digital fringe-counting technique to measure in real time the relative mirror displacement of a suspended Michelson interferometer with modulated optical path length for oscillations much larger than the laser wavelength (λ). This provides the proper error signal for a servo mechanism that reduces the relative displacement within λ/2. The implemented technique does not require extra optics or polarizers and thus can be used for interferometric gravitational wave detectors as a starting procedure to get the system locked.

NADPH diaphorase activity is inhibited by EDTA in neurons but not in choroid plexus epithelium

NADPH diaphorase histochemical staining was investigated in rat brain and choroid plexuses. All epithelial cells of the latter as well as some sparse neurons in striatum and cerebral cortex showed strong NADPH reaction product. While staining was homogeneous in neuronal cytoplasm, it was particulate in epithelial cells. Preincubation with EDTA (0.1 mM, 2h) prevented appearance of NADPH diaphorase reaction in neurons but not in choroid plexuses. These data show that in rat brain two forms of NADPH diaphorase are present; they are specifically localized in neurons and choroidal cells, respectively.

Sequential monitoring of leprosy patients with serum antibody levels to phenolic glycolipid-I, a synthetic analog of phenolic glycolipid-I, and mycobacterial lipoarabinomannan

Sequential serum samples from leprosy patients at various stages of antibacterial treatment were tested by an ELISA for antibodies to phenolic glycolipid I (PGL-I), a synthetic PGL-I analog (ND-BSA), and lipoarabinomannan (LAM) from Mycobacterium tuberculosis to determine if these antibodies could be useful in monitoring response to therapy. Among patients with positive initial anti-PGL-I IgM, a significant decrease in this antibody was seen over time (p less than 0.01), whether assayed by PGL-I or ND-BSA. The two antigens showed good agreement in the detection of decrease in anti-PGL-I IgM. The greatest decrease was seen in patients with a high initial anti-PGL-I IgM and a high bacterial index (BI). Patients with a declining BI were seen to have generally declining antibody levels to PGL-I and to LAM; in those patients with a fluctuating BI, antibody levels were less predictable. We conclude that antibodies to PGL-I and LAM can be useful in following response to therapy in leprosy patients and that either the native PGL-I or ND-BSA can serve as antigen for the ELISA.