Elcio Nakano

Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing radical prostatectomy: a prospective, randomized, controlled trial

Erectile dysfunction (ED) and urinary incontinence are common complications following radical prostatectomy (RP). Although pelvic-floor biofeedback training (PFBT) may improve urinary continence following RP, its effects on the recovery of potency are unknown. Fifty-two patients selected for RP were prospectively randomized for a treatment group (n=26) receiving PFBT once a week for 3 months and home exercises or a control group (n=26), in which patients received verbal instructions to contract the pelvic floor. Erectile function (EF) was evaluated with the International Index of Erectile Function-5 (IIEF-5) before surgery and 1, 3, 6 and 12 months postoperatively. Patients were considered potent when they had a total IIEF-5 score >20. Continence status was assessed and defined as the use of no pads. Groups were comparable in terms of age, body mass index, diabetes, pathological tumor stage and neurovascular bundle preservation. A significant reduction in IIEF-5 scores was observed after surgery in both groups. In the treatment group, 8 (47.1%) patients recovered potency 12 months postoperatively, as opposed to 2 (12.5%) in the control group (P=0.032). The absolute risk reduction was 34.6% (95% confidence interval (CI): 3.8–64%) and the number needed to treat was 3 (95% CI: 1.5–17.2). A strong association between recovery of potency and urinary continence was observed, with continent patients having a 5.4 higher chance of being potent (P=0.04). Early PFBT appears to have a significant impact on the recovery of EF after RP. Urinary continence status was a good indicator of EF recovery, with continent patients having a higher chance of being potent.

Standard surgical treatment for benign prostatic hyperplasia is safe for patients over 75 years: analysis of 100 cases from a high-volume urologic center

OBJECTIVES: In this study, we aimed to determine the complications of standard surgical treatments among patients over 75 years in a high-volume urologic center. METHODS: We analyzed 100 consecutive patients older than 75 years who had undergone transurethral prostatic resection of the prostate or open prostatectomy for treatment of benign prostatic hyperplasia from January 2008 to March 2010. We analyzed patient age, prostate volume, prostate-specific antigen level, international prostatic symptom score, quality of life score, urinary retention, co-morbidities, surgical technique and satisfaction with treatment. RESULTS: Median age was 79 years. Forty-eight patients had undergone transurethral prostatic resection of the prostate, and 52 had undergone open prostatectomy. The median International Prostatic Symptom Score was 20, the median prostate volume was 83 g, 51% were using an indwelling bladder catheter, and the median prostate-specific antigen level was 5.0 ng/ml. The most common comorbidities were hypertension, diabetes and coronary disease. After a median follow-up period of 17 months, most patients were satisfied. Complications were present in 20% of cases. The most common urological complication was urethral stenosis, followed by bladder neck sclerosis, urinary fistula, late macroscopic hematuria and persistent urinary incontinence. The most common clinical complication was myocardial infarction, followed by acute renal failure requiring dialysis. Incidental carcinoma of the prostate was present in 6% of cases. One case had urothelial bladder cancer. CONCLUSIONS: Standard surgical treatments for benign prostatic hyperplasia are safe and satisfactory among the elderly. Complications are infrequent, and urethral stenosis is the most common. No clinical variable is associated with the occurrence of complications.

Interactions between Lower Urinary Tract Symptoms and Cardiovascular Risk Factors Determine Distinct Patterns of Erectile Dysfunction: A Latent Class Analysis

PURPOSE An epidemiological association between lower urinary tract symptoms and erectile dysfunction is well established. However, interactions among multiple risk factors and the role of each in pathological mechanisms are not fully elucidated MATERIALS AND METHODS We enrolled 898 men undergoing prostate cancer screening for evaluation with the International Prostate Symptom Score (I-PSS) and simplified International Index of Erectile Function-5 (IIEF-5) questionnaires. Age, race, hypertension, diabetes, dyslipidemia, metabolic syndrome, cardiovascular disease, serum hormones and anthropometric parameters were also evaluated. Risk factors for erectile dysfunction were identified by logistic regression. The 333 men with at least mild to moderate erectile dysfunction (IIEF 16 or less) were included in a latent class model to identify relationships across erectile dysfunction risk factors. RESULTS Age, hypertension, diabetes, lower urinary tract symptoms and cardiovascular event were independent predictors of erectile dysfunction (p<0.05). We identified 3 latent classes of patients with erectile dysfunction (R2 entropy=0.82). Latent class 1 had younger men at low cardiovascular risk and a moderate/high prevalence of lower urinary tract symptoms. Latent class 2 had the oldest patients at moderate cardiovascular risk with an increased prevalence of lower urinary tract symptoms. Latent class 3 had men of intermediate age with the highest prevalence of cardiovascular risk factors and lower urinary tract symptoms. Erectile dysfunction severity and lower urinary tract symptoms increased from latent class 1 to 3. CONCLUSIONS Risk factor interactions determined different severities of lower urinary tract symptoms and erectile dysfunction. The effect of lower urinary tract symptoms and cardiovascular risk outweighed that of age. While in the youngest patients lower urinary tract symptoms acted as a single risk factor for erectile dysfunction, the contribution of vascular disease resulted in significantly more severe dysfunction. Applying a risk factor interaction model to prospective trials could reveal distinct classes of drug responses and help define optimal treatment strategies for specific groups.

Analysis of the learning curve for transurethral resection of the prostate. Is there any influence of musical instrument and video game skills on surgical performance

OBJECTIVE To evaluate the learning curve for transurethral resection of the prostate (TURP) among urology residents and study the impact of video game and musical instrument playing abilities on its performance. MATERIAL AND METHODS A prospective study was performed from July 2009 to January 2013 with patients submitted to TURP for benign prostatic hyperplasia. Fourteen residents operated on 324 patients. The following parameters were analyzed: age, prostate-specific antigen levels, prostate weight on ultrasound, pre- and postoperative serum sodium and hemoglobin levels, weight of resected tissue, operation time, speed of resection, and incidence of capsular lesions. Gender, handedness, and prior musical instrument and video game playing experience were recorded using survey responses. RESULTS The mean resection speed in the first 10 procedures was 0.36 g/min and reached a mean of 0.51 g/min after the 20(th) procedure. The incidence of capsular lesions decreased progressively. The operation time decreased progressively for each subgroup regardless of the difference in the weight of tissue resected. Those experienced in playing video games presented superior resection speed (0.45 g/min) when compared with the novice (0.35 g/min) and intermediate (0.38 g/min) groups (p=0.112). Musical instrument playing abilities did not affect the surgical performance. CONCLUSION Speed of resection, weight of resected tissue, and percentage of resected tissue improve significantly and the incidence of capsular lesions reduces after the performance of 10 TURP procedures. Experience in playing video games or musical instruments does not have a significant effect on outcomes.

Obesity may influence the relationship between sex hormones and lower urinary tract symptoms

PURPOSE The effects of serum testosterone in the lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) are not well established. The objective of the study is to evaluate the association of sex hormones with LUTS and control the results by patient weight. MATERIALS AND METHODS The study comprised a cross-sectional analysis of 725 men included in a prostate cancer screening program at University of Sao Paulo Medical School. The serum concentrations of total testosterone (TT), free testosterone (FT) and sex hormone binding globulin (SHBG) were measured. Variables analyzed were age, American Urological Association (AUA) symptom score, storage symptoms, voiding symptoms, quality of life score, prostate specific antigen levels and prostate volume. Obesity was measured through the calculation of body mass index (BMI). A regression analysis model was performed. RESULTS Median patient age was 65 years (48 to 94). A higher TT level was significantly associated with a severe AUA symptom score only among patients with a BMI ≥ 25. Median TT was 371, 370 and 427ng/dL (p = 0.017) in patients with mild, moderate and severe LUTS respectively. The multivariate regression analysis in patients with BMI ≥ 25 showed that only age, TT and sex score were related to LUTS. CONCLUSIONS A higher TT is associated with a severe AUA score symptom index only in obese patients. Further analysis are necessary to evaluate the mechanisms through which testosterone may influence LUTS in these patients.

MP71-18 LOW-VOLUME PROSTATE IN BENIGN PROSTATIC HYPERPLASIA (BPH): A RISK FACTOR FOR SYMPTOMATIC BLADDER DIVERTICULA REQUIRING SURGICAL TREATMENT

INTRODUCTION AND OBJECTIVES: to evaluate the association between prostate volume, age, and occurrence of bladder diverticula requiring surgical treatment on patients with symptomatic BPH. METHODS: we performed a retrospective search on our prospectively collected database searching for patients with BPH managed surgically between Jan/10 and Oct/14. Analyzed data comprised age at, prostatic volume measured on abdominal ultrasound, type of prostatic surgery, and presence of bladder diverticula requiring surgical treatment ( 3cm and/or symptomatic). Patients were divided in regards to diverticula requiring surgical treatment. Groups were compared using Student T test and Chi-square/Fisher exact test. Logistic regression was performed to seek for associations between the presence of the symptomatic diverticula and preoperative parameters. Significance was set at p<0.05. RESULTS: A total of 1532 patients were surgically treated for BPH in the analyzed period and 41 (2.6%) had symptomatic bladder diverticula. Mean diverticula size was 6.8 2.9cm and mean number of diverticula per patient was 1.5 0.8 (1-5). Treatment of the diverticula was performed laparoscopically in 13 (31.8%) patients, by endoscopic incision in 14 (34.1%), and by open resection in 14 cases (34.1%). Patients with treated diverticula did not differ from the other cohort in regards to age (66.9 8.3 vs. 68.5 8.8 years, respectively; p1⁄40.16) and surgical technique (p1⁄40.11). Mean prostate volume was significantly lower in the treated diverticula group (53.6 45.0 vs. 80.7 51.9g, respectively; p<0.01). Prostate volume and age distributions among patients with and without diverticula are depicted in figures 1A and B. Logistic regression revealed only prostate volume to significantly impact the presence of symptomatic diverticula requiring surgical treatment (OR1⁄4-0.03; 95% CI 0.955 e 0.988; p1⁄40.01). Roc curve analysis revealed a significant association with an AUC of 0.73 (p<0.001)(fig.1c). CONCLUSIONS: In patients with BPH, there is a significant association between prostate volume and risk of symptomatic bladder diverticulum. Bladder diverticula requiring surgical treatment are more common in patients with low prostate volume.