Giangiacomo Ollandini

Efficacy and Safety of Combined Oral Therapy with Tadalafil and Alfuzosin: An Integrated Approach to the Management of Patients with Lower Urinary Tract Symptoms and Erectile Dysfunction. Preliminary Report

INTRODUCTION Alpha1-blockers (AB) are the first-line monotherapy for lower urinary tract symptoms (LUTS). Phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for erectile dysfunction (ED). Numerous studies have supposed a significant association between ED and LUTS, but a causal relationship cannot be established. AIM The aim was to evaluate the efficacy of a combined therapy with an AB (alfuzosin) and PDE5 inhibitors (tadalafil) in patients with LUTS and ED. METHODS This was a randomized, open-label, three-arm study. A total of 66 men complaining of ED and LUTS were included in the study. Patients were assessed at baseline and after 12 weeks of study treatment, and then underwent randomized allocation to either alfuzosin 10 mg once a day (22 patients) or tadalafil 20 mg on alternative days (21 patients), or a combination of both (23 patients). MAIN OUTCOME MEASURES All participants completed the erectile function domain of the International Index of Erectile Function (IIEF-EF) and the International Prostatic Symptom Score (IPSS). Other efficacy variables included maximum urinary flow rate (Qmax) and medium urinary flow rate (Qave). RESULTS IIEF-EF tended to improve with alfuzosin alone (+15%), while it was clearly improved with tadalafil alone (+36.3%). The greatest improvement was experienced with the combination therapy (+37.6%). Improvement in Qmax was observed in all groups, but patients receiving combination therapy had greater improvement (29.6%) than patients receiving either only alfuzosin (21.7%) or only tadalafil (9.5%). IPSS was significantly improved in alfuzosin group (27.2%), was more marked with the combination therapy (41.6%), and a small increase, although not significant, was also observed with tadalafil (8.4%). CONCLUSIONS Combined therapy improved ED and LUTS as demonstrated by the significant improvement in uroflowmetry measures and in IPSS and IIEF-EF scores. A significant improvement was also observed in quality of life assessments. The beneficial effects of tadalafil on LUTS similar to the benefits of alfuzosin on ED, although present, were smaller.

Role of US in acute scrotal pain

BackgroundThe acute scrotum is a common emergency department (ED) presentation and can be defined as any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention. Although rarely fatal, acute scrotal pathology can result in testicle infarction and necrosis, testicular atrophy, infertility, and significant morbidity.MethodsScrotal US is best performed with a linear 7.5- to 12-MHz transducer. In addition to imaging in the longitudinal and transverse planes, it is helpful to obtain simultaneous images of both testes for comparison. Color Doppler is used to evaluate for abnormalities of flow and to differentiate vascular from nonvascular lesions. Attention to appropriate color Doppler settings to optimize detection of slow flow is critical.ResultsThe evaluation of acute scrotal pain can be challenging for the clinician initially examining and triaging the patient. Acute scrotal conditions due to traumatic, infectious, vascular, or neoplastic etiologies can all present with pain as the initial complaint. Additionally, the laboratory and physical examination findings in such conditions may overlap; this, coupled with potential patient guarding and lack of collaboration, may result in a limited, non-specific physical examination. Therefore, scrotal ultrasound has emerged to play a central role in the evaluation of the patient presenting with acute scrotal pain.ConclusionsIn conclusion, we are firmly convinced that a scrotal ultrasound should always be performed in the presence of acute scrotal pain. Moreover, urologist should be able to perform a scrotal ultrasound but, if imaging does not supply a clear diagnosis, surgical exploration is still mandatory.

Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience.

Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.

Varicocele treatment: A 2-centers comparison between non microsurgical open correction, laparoscopic approach and retrograde percutaneous sclerotization on 463 cases

OBJECTIVES To determine whether there are differences in sperm parameters improvement after different varicocele correction techniques. To determine the role of age in sperm parameters improvement. METHODS 2 different European centers collected pre- and postoperative sperm parameters of patients undergoing varicocele correction. Among 463 evaluated patients, 367 were included. Patients were divided in procedure-related and age-related groups. Ivanissevich inguinal open surgical procedure (OS), lymphatic-sparing laparoscopic approach (LSL) and retrograde percutaneous transfemoral sclerotization (RPS) were performed. As outcome measurements sperm count (millions/mL, SC) and percentage of mobile sperms were analyzed. Univariate and multivariate regression between the defined groups; bivariate regression analysis between age and sperm count and motility. RESULTS Number of patients: OS 78; LSL 85; RPS 204. Mean age 30.2 (SD 6.83); postoperative SC increased from 18.2 to 30.1 (CI 95% 27.3-32.9; p < 0,001); motility from 25.6 to 32.56% (30.9-34.2; p < 0.001). OS: SC varied from 16.9 to 18.2 (p < 0.001); sperm motility from 29% to 33% (p < 0.001). LSL: SC from 15.5 to 17.2 (p < 0.001); motility from 27 to 31% (p < 0.001). RPS: SC from 18.9 to 36.2 (p < 0.001); motility from 24% to 32% (p < 0.001). Univariate and multivariate analysis confirmed the significant difference of SC variation in RPS, compared to the other groups (p < 0.001). No significance between LSL and OS (p = 0.826). No significant differences regarding motility (p = 0.8). CONCLUSIONS Varicocele correction is confirmed useful in improving sperm parameters; sclerotization technique leads to a better sperm improvement compared to other studied procedures; improvement in seminal parameters is not affected by age of the patients treated.

Anatomy of the Scrotum

An adequate knowledge of normal anatomy of the scrotum and its content is mandatory to identify the structures during imaging evaluation, and to understand their modifications when pathologies occur. In this chapter anatomy of the scrotal wall, testis, and cord will be described with particular emphasis to the structures that are clinically relevant and can be better recognized at ultrasound and other imaging modalities.

Clinical Evaluation of Scrotal Disease

The basic approach to the urological patient is still dependent on taking a complete history and an appropriate physical examination. A well-taken history frequently is sufficient to determine the correct diagnosis. Symptoms which have to be researched with attention are, in particular, pain, and sexual dysfunction. Physical examination should be performed conscientiously. Complete evaluation requires inspection of the breast, testis, vas deferens, and epididymis. In this chapter, those urologic symptoms and clinical signs which are apt to be brought to the physician’s attention would be discussed.

The Infertile Male-4: Management of Obstructive Azoospermia

Azoospermia is the total absence of spermatozoa in the ejaculate. It is found in 10–15% of male infertility cases and is caused by a testicular insufficiency in the majority of patients. Obstructive azoospermia is less frequent and arises in 15–20% of men with azoospermia. Most causes of male infertility are treatable, and many treatments restore the ability to father a children naturally. In case of vasal or epididymal obstruction, microsurgical reconstruction of the seminal pathways, if possible, remains the safest and most cost-effective treatment option for these patients, allowing natural conception in many cases. Not all men with obstructive azoospermia are treatable by microsurgical reconstruction. In such situations, various sperm-retrieval techniques can be employed to take sperm for use with in vitro fertilization (IVF) via intracytoplasmic sperm injection (ICSI).