James H. Barada

Clinical guidelines panel on erectile dysfunction: Summary report on the treatment of organic erectile dysfunction

PURPOSE The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery. RESULTS Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery. CONCLUSIONS For the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.

Achieving treatment optimization with sildenafil citrate (Viagra) in patients with erectile dysfunction.

Since its approval in 1998, sildenafil citrate (Viagra) has been shown to be efficacious in >100 clinical trials involving >8000 men with erectile dysfunction (ED). In clinical practice, however, many men do not continue long-term use of sildenafil for a variety of reasons; thus, 6 different aspects of optimizing treatment with sildenafil are described here. (1) Intercourse success rates, considered a reflection of real-world effectiveness, were assessed in 1276 patients with ED. Results indicated that the cumulative probability of achieving intercourse success with sildenafil increased with the number of attempts, reaching a plateau after approximately 8 attempts. (2) A comprehensive disease management approach that included a medical history, physical examination, educational material about ED, modifications of risk factors/lifestyle changes, and counseling resulted in successful intercourse in 74% of 111 patients taking sildenafil. (3) A survey conducted among primary care physicians revealed that almost 50% did not routinely question their patients about ED symptoms, although it is known that most patients would prefer their physician to take the initiative. (4) Overall, 55% of 137 men who were previously not successful with sildenafil became successful after reeducation and counseling, which included information on patient and partner expectations, how to properly take the drug, titration to maximum dose, and a minimum trial of 8 attempts for efficacy assessment. (5) Many men with ED have underlying comorbidities or take multiple medications that are risk factors for ED. Controlling these risk factors in 521 men from a multispecialty clinic led to an overall intercourse success rate of 82%; patients with multiple risk factors were less likely to have intercourse success than men with only 1 risk factor. (6) Finally, treatment satisfaction is a pivotal factor in maintaining long-term ED therapy. In an open-label trial, 82% of 443 subjects reported treatment satisfaction with sildenafil. In summary, these findings highlight how important it is for physicians to take a more comprehensive, proactive approach when treating men with ED, including control of risk factors, instructions on how to properly take the drug, partner involvement, and follow-up visits. Using these recommended measures, most men with ED, including those whose treatment was previously unsuccessful, can be treated successfully with sildenafil.

Testicular salvage and age-related delay in the presentation of testicular torsion

Testicular torsion represents a continuing source of morbidity among male patients. Early diagnosis and surgical exploration improve testis salvage but even this approach will result in orchiectomy if there is excessive delay in patient presentation. A 10-year retrospective review of testicular torsion was performed. The interval between onset of scrotal pain and presentation to the emergency department was determined. A specific age-related delay in presentation was identified between patients less than 18 years old (group 1, median delay 20 hours) and those greater than 18 years old (group 2, median delay 4 hours, p less than 0.001). At exploration 44 per cent of the group 1 patients required orchiectomy versus 8 per cent in group 2. Patients less than 18 years old are a high risk group for testicular loss after torsion and represent more than 90 per cent of the orchiectomies performed. We believe that this group should be targeted for improved health education, emphasizing early evaluation of scrotal pain to improve testicular salvage.

An Improved Vasoactive Drug Combination for a Pharmacological Erection Program

Papaverine hydrochloride (smooth muscle relaxant), phentolamine mesylate (alpha-adrenergic blocking agent) and prostaglandin E1 (vasodilator and smooth muscle relaxant) were combined to produce a potent vasoactive drug therapy for use in a pharmacological erection program. Doses of 2.5 cc papaverine (30 mg./cc), 0.5 cc phentolamine (5 mg./cc), 0.05 cc prostaglandin E1 (500 micrograms./cc) and 1.2 cc 0.9% normal saline were combined to produce a vial of 4.25 cc for patient convenience. Twenty unit vials were made from the 1 cc vial of prostaglandin E1, the most expensive ingredient. The solution is physiologically active for at least 6 months and can be stored at room temperature although refrigeration is recommended. The pH of the solution is 4. This vasoactive drug combination has been used in 116 patients for diagnostic testing and subsequent treatment. A dose of 0.25 cc has been effective for diagnosis and treatment in the majority of patients with mild to moderate arteriogenic and/or venogenic and diabetic impotence. For patients with neurogenic dysfunction 0.1 to 0.125 cc was the usual dose. Two patients had a prolonged erection requiring irrigation, 1 on the day of initial testing and 1 on home therapy. Pain at the site of injection or during intercourse was noted in only 2 patients and to date no fibrosis or plaques have been found.

Cecal tubularization: lengthening techniquefor creation of catheterizable conduit

The creation of a continent, catherizable stoma is an integral component of successful continent urinary diversion. A technique is described which allows lengthening of a continent appendicovesicostomy. This technique extends the applications for the Mitrofanoff principle of urinary tract reconstruction.

Mini-Laparotomy Pelvic Lymph Node Dissection Minimizes Morbidity, Hospitalization and Cost of Pelvic Lymph Node Dissection

PURPOSE We compared efficacy, morbidity and cost of mini-laparotomy pelvic lymph node dissection and laparoscopic pelvic lymph node dissection. MATERIALS AND METHODS A total of 40 patients underwent mini-laparatomy, laparoscopic or standard pelvic lymph node dissection during a 24-month period. Nodal yield, complications, hospitalization and postoperative analgesic requirements were retrospectively evaluated. Operative expenses and the cost of postoperative hospitalization were standardized to a base cost for comparison. RESULTS Mini-laparotomy pelvic lymph node dissection has an operative time (90 minutes) and nodal yield (9) similar to those of standard pelvic lymph node dissection, and morbidity and postoperative hospitalization (1.3 days) are comparable to those of laparoscopic pelvic lymph node dissection. The expense of the mini-laparotomy procedure is approximately 50% that of the laparoscopic procedure due primarily to the prolonged operative time (190 minutes) and disposable instrument costs (

Prostatic Carcinosarcoma: Case Report and Review of Literature

665) of laparoscopic pelvic lymph node dissection. CONCLUSIONS Mini-laparotomy pelvic lymph node dissection competes successfully with laparoscopic pelvic lymph node dissection in terms of efficacy and morbidity at significant cost savings.

Verrucous carcinoma of the bladder.

True carcinosarcoma of the prostate is a rare neoplasm, with only 9 cases well documented by immunocytochemistry and ultrastructural examination. We report a case of an unresectable pelvic tumor studied at autopsy. The primary prostatic neoplasm and pulmonary metastases were composed of well differentiated adenocarcinoma admixed with foci of leiomyosarcoma and osteosarcoma. The sarcomatous components showed reactivity with vimentin and desmin, did not express prostatic acid phosphatase (PAP) and prostate specific antigen (PSA), and contained myofilaments on electron microscopic examination. Positive staining of the carcinomatous component for PAP and PSA was noted. These findings confirm the mixed epithelial and mesenchymal components in primary and metastatic sites, and support the diagnosis of true prostatic carcinosarcoma.

Prevention and treatment of erectile dysfunction using lifestyle changes and dietary supplements: what works and what is worthless, part II

Verrucous carcinoma of the bladder unassociated with bilharzial cystitis is an exceedingly rare entity, with only 3 cases reported in the literature. We describe a patient and review the literature concerning verrucous carcinoma.