Carolina D'Elia

A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder

CONTEXTnAnticholinergic drugs are commonly used in patients with overactive bladder (OAB) who do not achieve symptom relief and quality of life improvement with conservative management. Several drugs, with different doses, formulations, and routes of administration are currently available, making the choice quite difficult.nnnOBJECTIVEnTo evaluate efficacy and safety of different doses, formulations, and route of administration of the available anticholinergic drugs.nnnEVIDENCE ACQUISITIONnA systematic review of the literature was performed in August 2007 using Medline, Embase, and Web of Science. Efficacy (micturitions per 24h, volume voided per micturition, urgency urinary incontinence episodes per 24h, incontinence episodes per 24h) and safety (mainly, adverse events and withdrawal rates) end points were evaluated in the randomized control trials (RCTs) assessing the role of anticholinergic drugs in non-neurogenic OAB. Meta-analysis of RCTs was conducted using the Review Manager software 4.2 (Cochrane Collaboration).nnnEVIDENCE SYNTHESISnOur systematic search identified 50 RCTs and three pooled analyses. Tolterodine immediate release (IR) had a more favorable profile of adverse events than oxybutynin IR. Regarding different dosages of IR formulations, dose escalation might yield some limited improvements in the efficacy but at the cost of significant increase in the rate of adverse events. In the comparisons between IR and extended-release (ER) formulations, the latter showed some advantages, both in terms of efficacy and safety. With regard to the route of administration, use if a transdermal route of administration does not provide significant advantage over an oral one.nnnCONCLUSIONnMany of the available RCTs have good methodological quality. ER formulations should be preferred to the IR ones. With regard to IR formulations, dose escalation might yield some improvements in the efficacy with significant increase in the AE. More clinical studies are needed to indicate which of the drugs should be used as first-, second-, or third-line treatment.

Evaluating Urinary Continence and Preoperative Predictors of Urinary Continence After Robot Assisted Laparoscopic Radical Prostatectomy

PURPOSEnWe evaluated urinary continence using a validated questionnaire in a series of consecutive patients who underwent robot assisted laparoscopic radical prostatectomy, and identified the preoperative predictors of the return to urinary continence.nnnMATERIALS AND METHODSnThe clinical records of 308 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer at a tertiary academic center were prospectively collected. All patients were continent before surgery. Urinary continence was evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form instrument. All of the patients reporting no leak in response to the question, How often do you leak urine? were defined as continent.nnnRESULTSnA total of 273 patients (90%) were continent 12 months after robot assisted laparoscopic radical prostatectomy. Continent patients were significantly younger (61.4 +/- 6.4 vs 64.1 +/- 6.1 years, p = 0.02) than those who were incontinent. On univariable regression analysis patient age at surgery (OR 1.075, p = 0.024) and Charlson comorbidity index (OR 1.671, p = 0.007) were significantly associated with 12-month continence status. On multivariable analysis age (OR 1.076, p = 0.027) and Charlson comorbidity index (OR 1.635, p = 0.009) were independent predictors of continence rates.nnnCONCLUSIONSnUsing the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form 90% of patients undergoing robot assisted laparoscopic radical prostatectomy reported no urine leak 12 months after surgery. Patient age at surgery and Charlson comorbidity index were independent predictors of the return to urinary continence, whereas notably no variable related to prostate cancer was significantly correlated with urinary continence.

Predictors of Positive Surgical Margins After Laparoscopic Robot Assisted Radical Prostatectomy

PURPOSEnWe identified the predictors of positive surgical margins in a series of patients undergoing robot assisted laparoscopic radical prostatectomy.nnnMATERIALS AND METHODSnWe prospectively collected data from 322 patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer between April 2005 and October 2008, and who had not received any prior hormonal therapy.nnnRESULTSnPositive surgical margins were observed in 95 cases (29.5%). Specifically positive surgical margins were at the apex in 22 cases (6.8%), anterior in 5 (1.6%) and posterolateral in 68 (21%). Among the preoperative variables prostate volume on transrectal ultrasound (HR 0.420, p = 0.002) and cT stage (HR 2.217, p = 0.008) were independent predictors of the presence of any positive surgical margin in the cohort while cT stage (HR 2.070, p = 0.025) and biopsy Gleason score (p = 0.019) were predictors of posterolateral positive surgical margins. Considering pathological variables only extraprostatic extension of the primary tumor was an independent predictor of any positive surgical margin (HR 11.852, p <0.001) and posterolateral positive surgical margins (HR 7.484, p <0.001) in the series. Of those patients with organ confined disease positive surgical margins were present in 21 (10.6%). Only perineural invasion was an independent predictor of any positive surgical margin (HR 4.096, p = 0.028) while a not statistically significant trend was identified with regard to posterolateral positive surgical margins (HR 6.938, p = 0.067).nnnCONCLUSIONSnPathological extension of the primary tumor was the most relevant predictor of positive surgical margins. In patients with organ confined disease the presence of perineural invasion was significantly associated with positive surgical margins.

Preoperative Criteria to Select Patients for Bilateral Nerve-sparing Robotic-assisted Radical Prostatectomy

INTRODUCTIONnTo date, no study has analyzed the predictors of potency recovery in a robot-assisted laparoscopic radical prostatectomy (RALP) series. A novel risk stratification for erectile function recovery after retropubic radical prostatectomy (RRP) has been proposed recently by Briganti et al. from the University Vita-Salute San Raffaele in Milan, Italy.nnnAIMnTo evaluate the potency rate in a series of consecutive patients who underwent bilateral nerve-sparing RALP, to identify the preoperative predictors of erectile function recovery, and to validate the risk-group stratification of Briganti et al.nnnMETHODSnThe clinical records of all patients who underwent RALP for clinically localized prostate cancer between April 2005 and April 2009 were prospectively collected in the Prostate Cancer Padua Database. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up > or =12 months.nnnMAIN OUTCOME MEASURESnTwelve-month potency rate after RALP, defined as an International Index of Erectile Function 6 (IIEF-6) score > or =18.nnnRESULTSnData showed that 129 out of 208 enrolled patients (62%) were potent 12 months after surgery. Age (hazard ratio [HR]: 2.8; P < 0.001), Charlson score (HR: 2.9; P = 0.007), and baseline IIEF-6 score (HR: 0.8; P < 0.001) were independent predictors of potency recovery at multivariate analysis. According to Briganti et al.s risk-group stratification, the 12-month potency rate following RALP was 81.9% in the low-risk group, 56.7% in the intermediate-risk group, and 28.6% in the high-risk group (P < 0.001).nnnCONCLUSIONSnIn the era of robotic surgery, the key point for the success of the nerve-sparing technique remains the accurate selection of patients. Age < or =65 years, absence of associated comorbidities, and good preoperative erectile function are the most important preoperative factors to select those patients for whom bilateral nerve-sparing RALP can achieve the best results.

Improvement of seminal parameters and pregnancy rates after antegrade sclerotherapy of internal spermatic veins

OBJECTIVEnTo evaluate the impact of antegrade scrotal sclerotherapy on seminal parameters and pregnancy rates in varicocele patients who have impairment of seminal parameters and/or couple infertility.nnnDESIGNnLongitudinal, noncomparative study.nnnSETTINGnTertiary university hospital.nnnPATIENT(S)nThree hundred sixty-four consecutive varicocele patients with seminal impairment, including 173 (47.5%) patients who were not interested in fertility and 191 (52.5%) who were infertile.nnnINTERVENTION(S)nModified antegrade scrotal sclerotherapy.nnnMAIN OUTCOME MEASURE(S)nIncrease in sperm count, motility, and/or normal forms in all patients. Pregnancy rates 12 months after treatment in infertile men.nnnRESULT(S)nThe median patient age was 32 years. Twelve months after treatment, persistent reflux was present in 45 (12.4%) cases. In 188 (51.6%) patients with low sperm number, sperm count statistically significantly improved, from 12 to 19.5 x 10(6) per milliliter. In the 336 (92.3%) patients with asthenospermia, progressive motile forms statistically significantly improved, from 25% to 45%. In the 147 (40.4%) patients with teratospermia, normal forms increased from 17% to 35%. In infertile patients without persistent varicocele, 65 (37.4%) patients fathered offspring. Patients obtaining a pregnancy presented a significantly higher sperm motility than did infertile patients (46% vs. 35%).nnnCONCLUSION(S)nAntegrade scrotal sclerotherapy significantly improves sperm count, motility, and morphology. Patients with couple infertility achieved a pregnancy in 37% of cases. Patients achieving pregnancy present a better progressive motility after treatment than patients who did not father any child.