Fabrizio Iacono

Microstructural Disorders of Tunica Albuginea in Patients Affected by Peyronie’s Disease with or without Erection Dysfunction

Peyronies disease, the etiology of which remains unknown, is characterized by a focal or multifocal disorder of penile tunica albuginea. An excessive collagen deposition gives rise to the formation of the plaque, which is fibrotic first and then becomes calcific. Typical symptoms of the disease are painful erection, pathological bending of the erect penis and impotence at the more advanced stages (43% of the cases). There is evidence that the tunica albuginea has a fundamental role in the erection mechanism. We evaluated the tunica albuginea of patients suffering from Peyronies disease, with or without impotence, and found progressive disorders of the microstructure in areas that were not affected by fibrocalcific formations. There was a significant decrease (p < 0.0001) of elastic fiber concentration (55.05 +/- 23.83 per high power field) in patients with Peyronies disease compared to the concentration in the tunica albuginea of a control group (128.50 +/- 11.79 per high power field). Moreover, when the elastic fiber concentration in the tunica albuginea of patients Peyronies disease and normal erection (71.36 +/- 12.00 per high power field) was compared to the concentration in the tunica albuginea of those with Peyronies disease and impotence (33.14 +/- 4.84 per high power field) a significant difference was noted (p < 0.0001).

Histopathologically Proven Prevention of Post-Prostatectomy Cavernosal Fibrosis with Sildenafil

Aim: To evaluate whether a dose of 50 mg preserved the architecture of the corpora cavernosa biopsy in man. Methods: 21 patients (54–70 years old) who underwent radical prostatectomy for prostate cancer were treated with sildenafil citrate (50 mg, 3 times a week for 2 months) soon after surgery. They underwent cavernous biopsy before surgery and after 2 months of sildenafil treatment. Biopsy tissues were fixed in formalin, stained with Masson’s trichrome method, and evaluated with the Eureka Interface system with a per-area analysis, and elastic fibers were counted on 10–12 fields (×400) of five serial sections. Results: Two months after surgery the percent of connective tissue in cavernosa samples in all patients did not differ from that before surgery, being between 30 and 40% in the per-area analysis. Similarly, the elastic fiber count did not differ significantly before and after surgery. Conclusions: Sildenafil prevented the progression of fibrosis in prostatectomized patients. Its efficacy seems to result from an antiproliferative effect exerted on fibroblasts.

Microstructural disorders of tunica albuginea in patients affected by impotence.

The role played by the tunica albuginea in the erection mechanism seems to be very significant in promoting the constriction of sub-albugineal venous reticulum and trans-albugineal effluent veins, as well as providing an inextensible protective structure to the arteriolae and to the intracavernous nerves. The passive function exerted by the tunica albuginea is a result of its structure, which is rich in collagenic fibers, linked by elastic fiber bridges. The presence of structural disorders in the tunica albuginea of 16 patients suffering from psychogenic, arteriogenic and venogenic impotence is evaluated. The results obtained show a significant decrease in elastic fibers in the tunica albuginea of impotent patients compared to a control group of 5 patients with normal erection activity. This structural disorder could result in tunica albuginea alteration and, therefore, in erection insufficiency.

Comparative study between Levobupivacaine and Bupivacaine for hernia surgery in the elderly

BackgroundThe inguinal hernia is one of the most common diseases in the elderly. Treatment of this type of pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.MethodsThe aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine compared with that of bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from April 2010 to May 2012. We collected data of forty male patients, aged between 73 and 85 years, who underwent inguinal hernioplasty with local anesthesia for the first time.ResultsMinimal pain is the same in both groups. Mild pain was more frequent in the group who used bupivacaine, moderate pain was slightly more frequent in the group who used levobupivacaine, and the same for intense pain. It is therefore evident how Bupivacaine is slightly less preferred after four and twenty four hours, while the two drugs seem to have the same effect at a distance of twelve and forty-eight hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. The request for an analgesic was slightly higher in patients receiving levobupivacaine.ConclusionsAfter considering all these elements, we can conclude that the clinical efficacy of levobupivacaine and racemic bupivacaine are essentially similar, when used under local intervention of inguinal hernioplasty.

Efficacy and safety profile of a novel technique, ThuLEP (Thulium laser enucleation of the prostate) for the treatment of benign prostate hypertrophy. Our experience on 148 patients

BackgroundOver the past years laser technology has played a predominant role in prostate surgery, for the treatment of benign prostate hypertrophy (BPH). Various laser devices have been introduced in clinical practice, showing good results in terms of complications and urodynamic outcomes efficacy compared with TURP and Open Prostatectomy.In this study we describe the efficacy and the safety profile of a novel laser technique, ThuLEP (Thulium Laser Enucleation of Prostate) that permits a complete anatomical endoscopic enucleation of prostatic adenoma independently to prostate size.Methods148 patients with a mean age of 68.2 years were enrolled between September 2009 and March 2012 (36 months), and treated for BPH with ThuLEP. Every patient was evaluated at base line according to: Digital Rectal Examination (DRE), prostate volume, Post-Voided volume (PVR), International Prostate Symptoms Score (I-PSS), International Index of Erectile Function-5 (IIEF-5), Quality of Life (QoL), PSA values, urine analysis and urine culture, uroflowmetry. The same evaluation was conducted after a 12 month follow-up. ThuLEP was performed by 2 expert surgeons.ResultsOur data showed a better post-operative outcome in terms of catheter removal, blood loss, TURP syndrome, clot retention and residual tissue compared to large series of TURP and OP. Only 1.3% of patients had bladder wall injury during morcellation. I-PSS, Qmax, Prostate Volume, QoL and PVR showed a highly significant improvement at 12 month follow-up in comparison to preoperative assessment.ConclusionThuLEP represent an innovative option in patients with BPH. It is a size independent surgical endoscopic technique and it can be considered the real alternative, at this time, to TURP and even more to Open Prostatectomy for large prostate, with a complete removal of adenoma and with a low complication rate.

Testosterone deficiency causes penile fibrosis and organic erectile dysfunction in aging men. Evaluating association among Age, TDS and ED.

IntroductionWe studied the possible correlation between age, testosterone deficiency, cavernosal fibrosis and erectile dysfunction (ED).Methods47 patients with ED were enrolled between September 2010 and October 2011. IIEF-EF score, NPTR test using the Rigiscan method, total and free testosterone levels, and cavernosum biopsy were carried out on all patients. Patients aged 65 or over were defined as Old Age (OA) while patients under 65 were defined Young age (YA). The strength of the relationships found was estimated by Odds Ratio.Results74% of patients with values of over 52% collagen fibers in the corpora cavernosa were found to have organic ED. A significant difference was found in age, percentage of collagen fibers, testosterone levels between patients with Positive Rigiscan (PR) and Negative Rigiscan (NR). Hypotestosteronaemia increased the risk of ED with PR (OR: 21.4, 95% CI: 20.2-22.6) and in both young age patients (OR: 4.3, 95% CI: 2.4-6.2) and old age patients (OR: 15.5, 95% CI: 13.4-17.6). Moreover cavernosal fibrosis increased the risk of ED with PR in both young age patients (OR: 8.2, 95% CI: 6.4-10.0 and old age patients (OR: 24.6, 95% CI: 20.8-28.4).ConclusionsThis study demonstrates a strong association among age, testosterone deficiency, cavernosal fibrosis and ED with PR. Age, testosterone deficiency and cavernosal fibrosis are potentially correctable factors of cavernosal fibrosis and organic ED. Further, prospective studies are needed to evaluate if testosterone treatment, alone or in association with PDE5 inhibitors, may lower the risk of cavernosal fibrosis or decrease the severity the fibrosis in ED patients.

Evaluation of Penile Deep Arteries in Psychogenic Impotence by Means of Duplex Ultrasonography

Echo Doppler flowmetric investigation in patients with erectile insufficiency represents an effective method for hemodynamic evaluation of the penis. The detection of referential standard parameters is helpful to understand the pathogenesis of the disease, since patients with erectile insufficiency due to psychogenic factors cannot be distinguished from normal subjects by means of current diagnostic techniques. Echo Doppler flowmetry applied to rigorously selected subjects with psychogenic impotence allowed for detection of hemodynamic parameters in the penis after corpora cavernosa stimulation with 10 micrograms. prostaglandin E1. Flowmetric investigation was performed only on the deep cavernous artery, since it is well known that the penile dorsal artery does not undergo hemodynamic alterations after stimulation with drugs. A statistically meaningful difference existed between the systolic flow in the psychogenic impotence subjects (group 1) and the controls (group 2, p < 0.0001). In the same manner, the diastolic flows (right and left cavernous arteries, p < 0.0002 and p < 0.0001, respectively) and diameter increase rates of the investigated arteries following stimulation were also different. According to these results, echo Doppler flowmetry could represent the only instrumental method able to detect patients with psychogenic impotence.

Sexual asthenia: Tradamixina versus Tadalafil 5 mg daily

BackgroundReduced libido is widely considered the most prominent symptomatic reflection of low testosterone (T) levels in men. Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years. This study seeks to evaluate the effect of a new natural compound “tradamixina “in order to improve male sexual function in elderly men, particularly libido and possible erectile dysfunction, versus administration of tadalafil 5 mg daily.MethodsSeventy patients (67.3± 3.7 years) with stable marital relations and affected by reduced libido, with or without erectile dysfunction were recruited. They were randomly separated in 2 groups A-B of 35. Group A was administered twice a day a new compound “Tradamixina” (150 mg of Alga Ecklonia Bicyclis, 396 mg of Tribulus Terrestris and 144 mg of D-Glucosamine and N-Acetyl-D-Glucosamine) for two months, while Group B was administered tadalafil 5 mg daily, for two months. At visit and after 60 days of treatment patients were evaluated by means of detailed medical and sexual history, clinical examination, laboratory investigations (Total and Free T), instrumental examination (NPTR- nocturnal penile tumescence and rigidity test- with Rigiscan). Patients completed a self-administered IIEF questionnaire (The international index of erectile function) and SQoLM questionnaire (Sexual quality of life Questionnarie-Male). The results pre and post treatment were compared by Student t test (p<0.005).ResultsAfter 2 months of treatment in group A serum TT levels (230±18 ng/dl vs 671±14 ng/dl ) and FT levels(56± 2.4 pg/ml vs 120± 3.9pg/ml) increased, while in group B serum TT levels (245±12 ng/dl vs 247±15 ng/dl ) and FT levels(53± 0.3 pg/ml vs 55± 0.5pg/ml) increased not statistically significant. The patient’s numbers with negative NPTR improved after treatment in group A and B (15 vs 18 and 13 vs 25 respectively). The IIEF total score in group A increased after treatment with tradamixina (15±1.5 vs 29.77±1.2); the IIEF total score in group B increased slightly (12±1.3 vs 23.40±1.2). The SQoLM total score improved in both groups (A:16±2,3 vs 33±4,1 and B: 16±3,4 vs 31±2,1).ConclusionThe treatment twice a day with “Tradamixina” for 2 months improved libido in elderly men without side effects of Tadalafil.

Safety and efficacy of low intensity shockwave (LISW) treatment in patients with erectile dysfunction

ABSTRACT The primary goal in the management strategy of a patient with ED would be to determine its etiology and cure it when possible, and not just to treat the symptoms alone. One of the new therapeutic strategies is the use of low intensity extracorporeal shockwave (LISW) therapy. The mechanism of shockwave therapy is not completely clear. It is suggested that LISW induces neovascularization and improvement of cavernosal arterial flow which can lead to an improvement of erectile function by releasing NO, VEGF and PCNA. Materials and Methods: 31 patients between February and June 2013 with mild to severe ED and non-Phosphodiesterase 5 inhibitors responders were enrolled. Patients underwent four weekly treatment sessions. During each session 3600 shocks at 0.09mJ/ mm2 were given, 900 shocks at each anatomical area (right and left corpus cavernosum, right and left crus). Improvement of the erectile function was evaluated using the International Index of Erectile Function (IIEF-EF), the Sexual Encounter Profile (SEP) diaries (SEP-Questions 2 and 3) and Global Assessment Questions (GAQ-Q1 and GAQ-Q2). Results: At 3-month follow-up IIEF-EF scores improved from 16.54±6.35 at baseline to 21.03±6.38. Patients answering ‘yes’ to the SEP-Q2 elevated from 61% to 89% and from 32% to 62% in the SEP-Q3. A statistically significant improvement was reported to the Global Assessment Questions (GAQ-Q1 and GAQ-Q2). Conclusion: In conclusion, we can affirm that LISW is a confirmed therapeutic approach to erectile dysfunction that definitely needs more long-term trials to be clarified and further verified.

Risk of acute myocardial infarction after transurethral resection of prostate in elderly

BackgroundBenign prostatic hyperplasia is a frequent disease among elderly, and is responsible for considerable disability. Benign prostatic hyperplasia can be clinically significant due to lower urinary tract symptoms that take place because the gland is enlarged and obstructs urine flow. Transurethral resection of the prostate remains the gold standard treatment for patients with moderate or severe symptoms who need active treatment or who either fail or do not want medical therapy. Moreover, perioperative and postoperative surgery complications as cardiovascular ones still occur. The incidence of acute myocardial infarction in patients undergoing transurethral resection of the prostate is controversial. The first studies showed an increase in mortality and relative risk of death from myocardial infarction in transurethral resection of the prostate group vs open prostatectomy but these results are in contrast with more recent data.DiscussionGiven the conflicting evidence of the studies in the literature, in this review we are going to discuss the factors that may influence the risk of myocardial infarction in elderly patients undergoing prostate surgery. We analyzed the possible common factors that lead to the development of myocardial infarction and benign prostatic hyperplasia (cardiovascular and metabolic), the stressor factors related to prostatectomy (surgical and haemodynamic) and the risk factors specific of the elderly population (comorbidity and therapies).SummaryAlthough transurethral resection of the prostate is considered at low risk for severe complications, there are several reports indicating that cardiovascular events in elderly patients undergoing this surgical operation are more common than in the general population. Several cardio-metabolic, surgical and aging-related factors may help explain this observation but results in literature are not concord, especially due to the fact that most data derive from retrospective studies in which selection bias cannot be excluded. Subsequently, further studies are necessary to clarify the incidence of acute myocardial infarction in old people.