Carlo Trombetta

Efficacy and Safety of Combined Oral Therapy with Tadalafil and Alfuzosin: An Integrated Approach to the Management of Patients with Lower Urinary Tract Symptoms and Erectile Dysfunction. Preliminary Report

INTRODUCTION Alpha1-blockers (AB) are the first-line monotherapy for lower urinary tract symptoms (LUTS). Phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for erectile dysfunction (ED). Numerous studies have supposed a significant association between ED and LUTS, but a causal relationship cannot be established. AIM The aim was to evaluate the efficacy of a combined therapy with an AB (alfuzosin) and PDE5 inhibitors (tadalafil) in patients with LUTS and ED. METHODS This was a randomized, open-label, three-arm study. A total of 66 men complaining of ED and LUTS were included in the study. Patients were assessed at baseline and after 12 weeks of study treatment, and then underwent randomized allocation to either alfuzosin 10 mg once a day (22 patients) or tadalafil 20 mg on alternative days (21 patients), or a combination of both (23 patients). MAIN OUTCOME MEASURES All participants completed the erectile function domain of the International Index of Erectile Function (IIEF-EF) and the International Prostatic Symptom Score (IPSS). Other efficacy variables included maximum urinary flow rate (Qmax) and medium urinary flow rate (Qave). RESULTS IIEF-EF tended to improve with alfuzosin alone (+15%), while it was clearly improved with tadalafil alone (+36.3%). The greatest improvement was experienced with the combination therapy (+37.6%). Improvement in Qmax was observed in all groups, but patients receiving combination therapy had greater improvement (29.6%) than patients receiving either only alfuzosin (21.7%) or only tadalafil (9.5%). IPSS was significantly improved in alfuzosin group (27.2%), was more marked with the combination therapy (41.6%), and a small increase, although not significant, was also observed with tadalafil (8.4%). CONCLUSIONS Combined therapy improved ED and LUTS as demonstrated by the significant improvement in uroflowmetry measures and in IPSS and IIEF-EF scores. A significant improvement was also observed in quality of life assessments. The beneficial effects of tadalafil on LUTS similar to the benefits of alfuzosin on ED, although present, were smaller.

The role of preimplantation diagnosis for aneuploidies.

The clinical application of preimplantation genetic diagnosis (PGD) for aneuploidy has confirmed the hypothesis that implantation failure and spontaneous abortions are frequently due to aneuploidy. Following PGD, a higher implantation rate and a lower incidence of spontaneous abortions are obtained in patient categories where aneuploidy is the main cause of reproductive failure: women in advanced reproductive age, patients with an altered karyotype due to translocations or gonosomal mosaicism, and patients with recurrent spontaneous abortions. In these cases, the transfer of euploid embryos overcomes the poor prognosis condition in these couples. As expected, aneuploidy increases proportionally with female age; however, not all the chromosomes studied show this trend, suggesting that segregation errors could occur at different rates for each chromosome in relation to maternal age. Furthermore, the retrospective analysis of the results obtained in patients who repeated at least twice a PGD cycle permitted to estimate their chances of reproducing the same pattern of chromosomal abnormalities and consequently evaluating their possibility of a pregnancy: when no euploid embryos are detected at the first attempt, the chance of on-term pregnancy is below 10%; however, this chance is approximately 30% for couples with at least two euploid embryos in the first cycle.

Color Doppler ultrasound investigation of varicocele

Varicocele, whose association with male infertility has been clearly documented in the literature, is a common finding in adolescents and adult men, being diagnosed in 20–40% of infertile patients. A correct and early diagnosis of this affliction is of great importance because, in most cases, a timely correction, usually performed using percutaneous sclerotherapy, leads to an improvement in semen quality. Currently, physical examination in a warm room is the mainstay of diagnosis, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele. Colour Doppler ultrasound (CDU) is a new, reliable and non-invasive diagnostic method for the evaluation of varicocele testes which allows the detection of even subclinical varicocele thanks to its capacity for measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic veins. At present, there is a lack of completely standardised diagnostic criteria, but when this problem is solved, clinical examination and CDU will certainly become the “gold standard” in the investigation of varicocele.

Role of imaging and biopsy to assess local recurrence after definitive treatment for prostate carcinoma (surgery, radiotherapy, cryotherapy, HIFU)

PurposeDefining the site of recurrent disease early after definitive treatment for a localized prostate cancer is a critical issue as it may greatly influence the subsequent therapeutic strategy or patient management.MethodsA systematic review of the literature was performed by searching Medline from January 1995 up to January 2011. Electronic searches were limited to the English language, and the keywords prostate cancer, radiotherapy [RT], high intensity focused ultrasound [HIFU], cryotherapy [CRIO], transrectal ultrasound [TRUS], magnetic resonance [MRI], PET/TC, and prostate biopsy were used.ResultsDespite the fact that diagnosis of a local recurrence is based on PSA values and kinetics, imaging by means of different techniques may be a prerequisite for effective disease management. Unfortunately, prostate cancer local recurrences are very difficult to detect by TRUS and conventional imaging that have shown limited accuracy at least at early stages. On the contrary, functional and molecular imaging such as dynamic contrast-enhanced MRI (DCE–MRI), and diffusion-weighted imaging (DWI), offers the possibility of imaging molecular or cellular processes of individual tumors.Recently, PET/CT, using 11C-choline, 18F-fluorocholine or 11C-acetate has been successfully proposed in detecting local recurrences as well as distant metastases. Nevertheless, in controversial cases, it is necessary to perform a biopsy of the prostatic fossa or a biopsy of the prostate to assess the presence of a local recurrence under guidance of MRI or TRUS findings.ConclusionIt is likely that imaging will be extensively used in the future to detect and localize prostate cancer local recurrences before salvage treatment.

Long-term results with Nesbit's procedure as treatment of Peyronie's disease

The objective was to assess sexual function at long-term follow-up after the Nesbit operation for Peyronies disease.One hundred and fifty seven out of 213 patients treated between 1986 and 1998 using the Nesbit procedure were reassessed by means of IIEF-5 questionnaire together with two questions about residual deformity and treatment satisfaction. The results from this questionnaire together with the patient case records constitute the basis of this paper.After an average 72-month follow-up subjective patient determination of satisfaction indicated that 87.9% were satisfied with the results of surgery, 136 patients (86.7%) had good erectile function (IIEF-5>21). Shortening of the penis (from 1.5 to 3 cm) occurred in 22 patients (14%), but only in 2 (1.3%) was intercourse difficult because of excessive shortening.In conclusion, the Nesbits operation results in the greatest amount of patient satisfaction about sexual function. When penile shortening occurs, it has not been a significant problem for patients who are properly counselled.

Intractable haematuria: long-term results after selective embolization of the internal iliac arteries

Study Type – Therapy (case series)
Level of Evidence 4

Immunohistochemical evaluation of androgen receptor and nerve structure density in human prepuce from patients with persistent sexual side effects after finasteride use for androgenetic alopecia

Finasteride is an inhibitor of 5-α-reductase used against male androgenetic alopecia (AGA). Reported side effects of finasteride comprise sexual dysfunction including erectile dysfunction, male infertility, and loss of libido. Recently these effects were described as persistent in some subjects. Molecular events inducing persistent adverse sexual symptoms are unexplored. This study was designed as a retrospective case-control study to assess if androgen receptor (AR) and nerve density in foreskin prepuce specimens were associated with persistent sexual side effects including loss of sensitivity in the genital area due to former finasteride use against AGA. Cases were 8 males (aged 29–43 years) reporting sexual side effects including loss of penis sensitivity over 6 months after discontinuation of finasteride who were interviewed and clinically visited. After informed consent they were invited to undergo a small excision of skin from prepuce. Controls were 11 otherwise healthy matched men (aged 23–49 years) who undergone circumcision for phimosis, and who never took finasteride or analogues. Differences in AR expression and nerve density in different portions of dermal prepuce were evaluated in the 2 groups. Density of nuclear AR in stromal and epithelial cells was higher in cases (mean 40.0%, and 80.6% of positive cells, respectively) than controls (mean 23.4%, and 65.0% of positive cells, respectively), P = 0.023 and P = 0.043, respectively. Conversely, percentage of vessel smooth muscle cells positive for AR and density of nerves were similar in the 2 groups. The ratio of AR positive stromal cells % to serum testosterone concentrations was 2-fold higher in cases than in controls (P = 0.001). Our findings revealed that modulation of local AR levels might be implicated in long-term side effects of finasteride use. This provides the first evidence of a molecular objective difference between patients with long-term adverse sexual effects after finasteride use versus drug untreated healthy controls in certain tissues.

Percutaneous Management of Renal Artery Aneurysm With a Stent-Graft

A 53-year-old woman presented with systemic hypertension that was not responsive to medical treatment with lacidipine 4 mg. daily. The patient had no risk factors for atherosclerosis. Laboratory results were normal. Abdominal color Doppler ultrasound and selective renal angiography showed fibromuscular dysplasia of the main right renal artery consisting of multiple stenoses and 1 cm. saccular aneurysm (fig. 1). The left renal artery was normal. Various therapeutic options were discussed with the patient, and she elected to undergo an endovascular stent-graft procedure to avoid surgery. The procedure was performed percutaneously via the left axillary artery, in order to obtain a better angle while positioning the stent, through a 7Fr introducer sheath. Heparin 5,000 IU was administered. After renal artery selective catheterization with a multipurpose catheter, the lesion was crossed with a 0.014-inch guide wire. The wire was exchanged via the same catheter with a 0.035-inch Amplatz Super Stiff Guide Wire (Boston, Scientific Corp., Natick, Massachusetts). A 28 mm. Jostent Periphel Stent Graft (JOMED, Helsingborg, Sweden) was then mounted on a 5 40 mm. balloon catheter and advanced through the guide wire. The stent was delivered across the lesion and inflated at 8 atm. for 15 seconds. A final right renal arteriogram showed excellent graft position, aneurysmal exclusion and no sign of residual stenosis (fig. 2). There were no complications, and the patient was discharged home on postoperative day 2 on a regimen of aspirin 100 mg. daily for 3 months. The patient remained normotensive for 10 months. At 24month followup blood pressure was observed in the normal range with amlodipine 5 mg. daily, and serum creatinine was 1.2 mg./dl. (normal 0.4 to 1.3). Color Doppler ultrasound showed wide patency of the renal artery, normal renal perfusion and aneurysmal exclusion.

Acute peritonitis due to introital stenosis and perforation of a bowel neovagina in a transsexual

Background Stenosis of the neovagina is a late postoperative complication of male-to-female sex reassignment surgery when patients do not have frequent sexual intercourse or do not perform vaginal dilation. Case A 39-year-old male-to-female transsexual who had sex reassignment surgery, in which a segment of sigmoid colon was used for neovagina construction, developed total introital stenosis and subsequent peritonitis caused by bowel perforation of the colon conduit. Conclusion To avoid stenosis of the neovagina, an inflatable silicon vaginal stent should be used all day for 30 days, then for 3 months overnight or until sexual function is regular.

Sclerotherapy of hemangioma of the glans penis.

Penile hemangiomas are very rare, small lesions. Possible therapies include surgical excision, electrofulguration, cryotherapy, and sclerotherapy. We describe an extremely rare case of a large hemangioma of the glans that was treated by means of repeated injections of 2% polidocanol under local anesthesia (5% lidocaine-prilocaine cream). No complications were observed after the operation, and a satisfactory aesthetic result was obtained. No relapse was noted 18 months after the treatment. A therapeutic reference standard for the treatment of penile hemangiomas is still lacking because of the rarity of the disease. Sclerotherapy proved to be an effective, low-cost, and easy-to-perform procedure. Moreover, it is repeatable in case of failure.