Enrico Finazzi Agrò

Lower urinary tract dysfunction and disability status in patients with multiple sclerosis

OBJECTIVE To investigate the correlation between neurologic and urologic status in patients with multiple sclerosis (MS). MATERIALS AND METHODS Between January 1993 and December 1995, 116 patients with MS symptoms were fully assessed neurologically and urologically with urodynamic studies. RESULTS Urodynamic abnormalities were detected in 104 patients (89.6%). Several significant relationships between urinary tract findings and neurologic dysfunction were: (1) the relation between voiding disorder as the presenting symptom of the disease and a higher severity of bladder dysfunction; (2) the relation between reduced bladder sensation and longer duration of voiding disorders, lower detrusor uninhibited contractions threshold, and lower bladder capacity; and (3) the relation between voiding disorders and cerebellar system score. Finally, a significant inverse relationship was found between detrusor hypocontractility and neurologic status (from the Expanded Disability Status Scale, pyramidal system score, and Barthel Index). CONCLUSIONS In this series a high incidence of patients reported voiding disorder as the presenting symptom of MS. These patients also showed a higher severity of urodynamic disorders. They should be rigorously followed up. Furthermore, our data suggest that although the most common cause of altered bladder control in MS is spinal cord pathology, involvement of cortical centers and/or peripheral neuronal lesions may occur.

Central acute D2 stimulation worsens bladder function in patients with mild Parkinson's disease.

PURPOSE The different roles of D1 and D2 dopamine receptors in LUT behavior have been demonstrated in animal studies. In particular D2 selective agonists and D1 selective antagonists seem to produce a reduction of the bladder capacity in conscious rats. This finding has never been confirmed in human studies. Thus, in this study we investigated the role of D1 and D2 agonists/antagonists on LUT behavior in patients with PD. MATERIALS AND METHODS A total of 87 patients with mild PD were evaluated. Patients were evaluated with urodynamic studies (cystometry followed by a pressure flow study with perineal floor electromyography) performed in off status and after oral administration of 250 mg of LD. In 70 patients a third urodynamic evaluation was conducted in one of the following conditions: after simultaneous administration of 250 mg oral LD and 60 or 120 mg oral domperidone (D2 peripheral antagonist); after simultaneous administration of 250 mg oral LD and 25, 50 or 150 mg intramuscular L-sulpiride (D2 central and peripheral antagonist). Several urodynamic parameters were evaluated and results obtained in different conditions compared. RESULTS LD alone worsened detrusor overactivity: in particular, a reduction of first urinary sensation, involuntary detrusor contraction threshold (reflex volume) and bladder capacity was observed. L-sulpiride (central and peripheral D2 antagonist) coadministration counteracted the worsening in a dose dependent manner. Domperidone (peripheral D2 antagonist) coadministration failed to determine the same counteraction. CONCLUSIONS According to our results, a central acute D2 stimulation seems to be responsible of a reduction of bladder capacity with worsening of detrusor overactivity in patients with mild PD.

Does Current Scientific and Clinical Evidence Support the Use of Phosphodiesterase Type 5 Inhibitors for the Treatment of Premature Ejaculation? A Systematic Review and Meta‐analysis

INTRODUCTION Premature ejaculation (PE) is a highly prevalent and complex syndrome that remains poorly defined and inadequately characterized. Pharmacotherapy represents the current basis of lifelong PE treatment. AIM The goal of this study was to assess the role of phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of patients with PE without associated erectile dysfunction (ED). MAIN OUTCOME MEASURE The posttreatment intravaginal ejaculatory latency time was used as the primary end point of efficacy. METHODS A systematic review of the literature was performed by electronically searching the MedLine database for peer-reviewed articles regarding the mechanism of action and the clinical trials of PDE5 in the management of PE. A meta-analysis of these clinical studies was performed to pool the efficacy. RESULTS Twenty-nine articles that examined the supposed mechanisms of action and 14 articles that reported data from clinical studies were reviewed. The PDE5 may exert their influence by increasing the levels of nitric oxide both centrally (reducing sympathetic drive) and peripherally (leading to smooth-muscle dilatation of the seminal tract). These drugs may also induce peripheral analgesia to prolong the duration of the erection, increase confidence, improve the perception of ejaculatory control and overall sexual satisfaction, and decrease the postorgasmic refractory time for achieving a second erection after ejaculation. Concerning the efficacy, the meta-analysis shows an overall positive effect for the use of PDE5 as monotherapy or as components of a combination regimen in the treatment of PE. The major limitations of the published literature included poor study design, the absence of solid methodology, which was characterized by the lack of a unique PE definition, and the lack of appropriate endpoints for outcome evaluation of a placebo control arm and of Institutional Review Board approval. CONCLUSION There is inadequate, partial basic, and clinical evidence to support the use of PDE5 for the treatment of PE.

Abdominal obesity as risk factor for prostate cancer diagnosis and high grade disease: A prospective multicenter Italian cohort study

OBJECTIVE To evaluate the association between abdominal obesity and prostate cancer (CaP) diagnosis and grade in patients undergoing prostate biopsy. MATERIALS AND METHODS Between 2008 and 2011, we prospectively enrolled patients referred to 3 clinics in Italy who were scheduled for transrectal ultrasound (TRUS) guided prostate biopsy. Before biopsy, digital rectal examination (DRE), prostate specific antigen (PSA), body mass index (BMI), and waist circumference (WC) were measured. Men were categorized in 4 groups of body habitus, according to BMI and waist circumference values. Crude and adjusted logistic regressions were performed to assess the association of BMI (continuous), waist circumference (continuous), body habitus (categorical), and CaP diagnosis and grade. RESULTS Six hundred sixty-eight patients were enrolled. CaP was detected in 246 patients (38%), of whom 136 had low-grade (Gleason score ≤ 6) and 110 high-grade cancer (Gleason score ≥ 7). Logistic regression multivariate analysis showed that BMI (OR 1.05 per unit, CI 95% 1.00-1.10 P = 0.033) and waist circumference (OR 1.02 per cm, CI 95% 1.00-1.04 P = 0.026) were significant predictors of CaP diagnosis. BMI (OR 1.11 95% CI 1.04-1.18 P = 0.001) and WC (OR 1.04 95% CI 1.02-1.06 P = 0.001) were also associated with high-grade CaP. Furthermore, obesity with central adiposity (BMI ≥ 30 kg/m(2) and WC ≥ 102 cm) was significantly associated with CaP diagnosis (OR 1.66, CI 95% 1.05-2.63, P = 0.03) and high-grade disease (OR 2.56, CI 95% 1.38-4.76, P = 0.003). CONCLUSIONS Obesity defined by BMI and WC seems to be associated with CaP and, more specifically, with high-grade disease at the time of biopsy. The relationship between obesity and CaP is complex and remains to be further addressed.

Variability of detrusor overactivity on repeated filling cystometry in men with urge symptoms: comparison with spinal cord injury patients

To investigate the variation in urodynamic variables during repeated filling cystometry and the impact that the variability had on the observed incidence of detrusor overactivity, to evaluate the correlation of detrusor overactivity with the symptoms of urge in men with lower urinary tract symptoms (LUTS), and to compare the variability of detrusor overactivity in men with LUTS to that in men with spinal cord injury (SCI).

Effects of inhibitory rTMS on bladder function in Parkinson's disease patients†

Patients affected by Parkinsons disease (PD) may present with lower urinary tract (LUT) dysfunction characterized by involuntary detrusor overactivity. We evaluated possible impact of a 2‐week course of low frequency 1 Hz repetitive transcranial magnetic stimulation (rTMS) on LUT behavior in eight advanced PD patients complaining of urinary disturbances. We tested the effects of rTMS measuring urodynamic examination and the International Prostate Symptoms Score (IPSS) questionnaire, used for evaluation of subjective LUTS. rTMS was able to improve temporarily LUT behavior in PD patients, increasing bladder capacity and the first sensation of filling phase. Moreover, a reduction of IPSS score was noticed, due to an improvement on filling phase symptoms. The beneficial effects assessed with the IPSS lasted for up to 2 weeks after the end of the stimulation. rTMS seems to be an effective, noninvasive alternative treatment for PD patients with urinary disturbances.

Systematic review of surgical treatment of post radical prostatectomy stress urinary incontinence

Context Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient quality of life and other critical postoperative outcomes.

Recent finding and new technologies in nephrolithiasis: a review of the recent literature

This review summarizes recent literature on advances regarding renal and ureteral calculi, with particular focus in areas of recent advances in the overall field of urolithiasis. Clinical management in everyday practice requires a complete understanding of the issues regarding metabolic evaluation and subgrouping of stone-forming patients, diagnostic procedures, effective treatment regime in acute stone colic, medical expulsive therapy, and active stone removal. In this review we focus on new perspectives in managing nephrolitihiasis and discuss recentadvances, including medical expulsive therapy, new technologies, and refinements of classical therapy such as shock wave lithotripsy, give a fundamental modification of nephrolithiasis management. Overall, this field appears to be the most promising, capable of new developments in ureterorenoscopy and percutaneous approaches. Further improvements are expected from robotic-assisted procedures, such as flexible robotics in ureterorenoscopy.

An International Continence Society (ICS) report on the terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD)

The terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD) should be defined and organized in a clinically based consensus Report.

HIFU as salvage first-line treatment for palpable, TRUS-evidenced, biopsy-proven locally recurrent prostate cancer after radical prostatectomy: A pilot study

OBJECTIVE To test high-intensity focused ultrasound (HIFU) as salvage first-line treatment for palpable, TRUS-evidenced, biopsy-proven locally recurrent prostate cancer (CaP) after radical prostatectomy (RP). MATERIALS AND METHODS Nineteen patients with palpable, TRUS-evidenced, biopsy-proven local recurrence of CaP after RP, unwilling to undergo salvage radiotherapy (SRT), underwent HIFU as a single-session procedure. Pre-, intra-, and postoperative data including early and late complications, and oncologic outcomes (PSA nadir, biochemical recurrence (BCR)-free survival, and need of secondary adjuvant treatment) were prospectively evaluated. Success was defined as PSA nadir ≤0.1 ng/ml obtained within 3 months from HIFU. In case of PSA nadir >0.1 ng/ml or PSA increase ≥1 ng/ml above the PSA nadir, a biopsy of the treated lesion was performed, and if negative, maximum androgen blockade (MAB) was adopted. In case of positive biopsy, RT was performed. Failure was defined as use of secondary adjuvant treatment (MAB or RT). RESULTS Median follow-up was 48 months. All cases were performed as overnight procedure. No case of urethrorectal fistula or anastomotic stricture was observed. Two cases of acute urinary retention were resolved with prolonged urethral catheterization. Four cases of stress urinary incontinence were observed; 2 (mild incontinence) were resolved after pelvic floor exercises within 6 months, while 2 cases of severe incontinence required surgical minimally invasive treatment;17/19 patients (89,5%) were classified as success. Two patients failed to show a PSA nadir <0.1 ng/ml. During follow-up, 8/17 patients (47%) were classified as failure, with consequent total rate of failures 10/19 (52.6%). A statistically significant difference was observed in pre-HIFU median PSA (2 vs. 5.45 ng/ml, respectively, P = 0.013) and Gleason score of the RP specimen (P = 0.01) between the success and failure group. CONCLUSIONS Salvage first-line HIFU for palpable, TRUS-evidenced, biopsy-proven local recurrence of CaP is a feasible, minimally invasive day-case procedure, with an acceptable morbidity profile. It seems to have a good cancer control in the short- and mid-term. Patients with lower pre-HIFU PSA level and favorable pathologic Gleason score presented better oncologic outcomes. A prospective randomized trial with an adequate recruitment and follow-up is necessary to confirm our preliminary oncologic results.