Enrico Spera

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.

The Surgical Treatment of a Large Prostatic Adenoma: The Laparoscopic Approach-A Systematic Review

PURPOSE To present a critical overview of the current literature on the role of laparoscopy for the surgical treatment of patients with large prostatic adenomas. MATERIALS AND METHODS A MedLine search for peer-reviewed studies on laparoscopic simple prostatectomy (LSP) was performed. The clinical studies that reported most of the following information were included: number of patients, prostate volume, operative time, blood loss, hospital stay, and the duration of catheterization, as well as functional outcomes and complications. Articles reporting a mean total prostate volume of <80 mL or a mean prostatic adenoma of <60 mL were excluded. The review was performed according to the PRISMA statement. RESULTS Fourteen articles on LSP were included in this systematic review with a total of 626 patients treated. Both transperitoneal and extraperitoneal approaches, as well as transvesical and transcapsular routes, have been described. Eleven articles were case-series and three were comparative retrospective nonrandomized studies. When compared with open simple prostatectomy (OP), LSP is associated with a less blood loss and a reduced irrigation requirement, a shorter postoperative catheterization period, and a shorter hospital stay, at the expense of an extended operative time. The limited number of patients treated, the selection biases due to the retrospective nature of several published articles on LSP, and the short follow-up periods are evident limits of the literature. I-square test demonstrated a high heterogeneity (93%) and consequently a high variability in the intervention effects in terms of maximum urinary flow rate (Qmax). CONCLUSIONS Even if LSP seems feasible and safe, there is still limited evidence regarding its long-term outcomes compared with OP.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach.

To provide an overview of the anatomical landmarks needed to guide a retropubic (Retzius)‐sparing robot‐assisted laparoscopic prostatectomy (RALP), and a step‐by‐step description of the surgical technique that maximizes preservation of the periprostatic neural network. The anatomy of the pelvic fossae is presented, including the recto‐vesical pouch (pouch of Douglas) created by the reflections of the peritoneum. The actual technique of the trans‐Douglas, intrafascial nerve‐sparing robotic radical prostatectomy is described. The technique allows the prostate gland to be shelled out from under the overlying detrusor apron and dorsal vascular complex (DVC‐Santorini plexus), entirely avoiding the pubovesical ligaments. There is no need to control the DVC, since the line of dissection passes beneath the plexus. Three key points to ensure enhanced nerve preservation should be respected: (1) the tips of the seminal vesicles, enclosed in a “cage” of neuronal tissue; a seminal vesicle‐sparing technique is therefore advised when oncologically safe; (2) the external prostate‐vesicular angle; (3) the lateral surface of the prostate gland and the apex. The principles of tension and energy‐free dissection should guide all the maneuvers in order to minimize neuropathy. Using robotic technology, a complete intrafascial dissection of the prostate gland can be achieved through the Douglas space, reducing surgical trauma and providing excellent functional and oncological outcomes. Clin. Anat. 28:896–902, 2015.

Autologous split‐thickness skin graft for penile coverage in the treatment of buried (trapped) penis after radical circumcision

Introduction. About 25% of the total world male population is circumcised and circumcision remains one of the oldest and commonest operations performed worldwide [ 1 – 4 ] . Over 30 000 operations are performed annually in the UK, mostly on children [ 5 ] . The aim of the procedure is to remove suffi cient foreskin from the penile shaft and the inner preputial epithelium to uncover the glans. The main factors to consider for minimising morbidity are attention to asepsis, adequate but not excessive excision of the foreskin, haemostasis and cosmesis [ 6 ] . Despite the precautions, complications occur in 2 – 10% of cases [ 6 – 8 ] . Haemorrhage and sepsis are the most common. Removal of excessive preputial skin can lead to an unsatisfactory cosmetic and functional result and is considered a major cause of acquired buried (trapped) penis (BP). BP is an unusual, diffi cult-to-treat condition that presents a unique challenge to the plastic surgeon and the urologist. Although no specifi c approach can be applicable to all patients, a combination of various techniques to tackle the problem of skin coverage may be applied. Large Z-plasties, based at the penopubic angle to transfer skin for proximal shaft coverage have been suggested. However, in cases involving extensive penile denudation, an autologous split-thickness skin graft (STSG) to the penile shaft may be indicated [ 9 ] . The aim of the present manuscript is to provide a step-by-step description of our technique of coverage of the penile shaft using an autologous STSG of the lateral thigh surface.

Holmium Laser Enucleation of the Prostate and Iatrogenic Arteriovenous Fistula Treated by Superselective Arterial Embolization.

Iatrogenic pelvic pseudoaneurysm with concomitant arteriovenous fistula has been described as a rare and challenging complication, which may occur during transurethral resection of the prostate. We provide the first report of this complication after holmium laser enucleation of the prostate for the treatment of benign prostatic hyperplasia. The attempt to control the bleeding by conversion to open surgery and placement of haemostatic stitches into the prostatic fossa failed. Angiography with superselective arterial embolization proved to be a modern, quick, safe, and efficient treatment of this uncommon complication.

Surgical Therapy for Peyronie’s Disease: Why and When (An Overview)

Peyronie’s disease is a fibrotic wound-healing disorder of the tunica albuginea. Although it may be precipitated by either blunt penile trauma or trauma incurred during sexual intercourse, as much as 70 % of Peyronie’s disease is idiopathic, without an inciting event. Most commonly, the associated penile deformity is characterised by penile curvature, although other features may include palpable penile plaques, hourglass defects, penile hinging/instability and penile shortening. Additionally, there may be associated psychological distress for the patient and the partner, as well as relationship strife.