Konstantinos Giannitsas

Switching from long-term treatment with self-injections to oral sildenafil in diabetic patients with severe erectile dysfunction.

OBJECTIVE To assess the efficacy of oral sildenafil in diabetic men with severe erectile dysfunction (ED), who are successfully treated with intracavernous injections of vasoactive drugs. METHODS 81 impotent diabetic men (29 with type 1 and 52 with type 2) were treated for 1-7 years with self-injections. 13 men were treated with 10 microg and 15 with 20 microg of prostaglandin E1 (PGE1), and 53 with a mixture of PGE1 20 microg and papaverine 7.5-40 mg (MIX). After a 1-week washout period, they changed to oral sildenafil in titrating doses up to 100mg. The change was successful if the man achieved an erection and penetration even once. RESULTS Sildenafil was discontinued in 23 men because of insufficiency. Eleven men (13.6%), all with type 2 diabetes, responded to sildenafil (10 previously treated with 10 microg and 1 with 20 microg of PGE1, none treated with MIX). Thus, 39.2% of the treated with PGE1 responded to oral sildenafil. The response was influenced by the age, the type of diabetes (type 2) and the kind of the previously injected drug (PGE1 10 microg); it was not influenced by the duration of diabetes, ED and treatment with self-injections. CONCLUSIONS Despite the well documented efficacy of sildenafil, self-injections continue to be the solely effective therapeutic modality in many diabetic men afflicted by severe ED. Only the younger men with non-insulin-dependent diabetes, treated with low doses of PGE1 are more likely to respond to oral sildenafil and change treatment. Men with insulin-dependent diabetes or treated with mixtures of vasoactive drugs are not likely to respond to oral sildenafil.

Safety of anticholinergics in patients with benign prostatic hyperplasia

Background: Storage lower urinary tract symptoms (LUTS) or overactive bladder (OAB) often coexist with voiding symptoms in patients with benign prostatic obstruction (BPO). Anticholinergic medications to treat storage LUTS are often withheld in such patients for fear of significantly increasing post-void residual urine volumes or provoking acute urinary retention (AUR). Objective: To assess the clinical validity of concerns regarding urinary safety of anticholinergics in patients with benign prostatic hyperplasia. Methods: Review of indexed literature and congress abstracts. Results/conclusions: Existing urinary and non-urinary safety data on BPO patients administered anticholinergics, either alone or in combination with α-blockers, do not seem to support the above-mentioned concerns. Nevertheless, precise criteria for patient and drug selection to ascertain safe and effective administration are not yet established and need to be investigated in future trials.

Sacrocolpopexy for pelvic organ prolapse: evidence-based review and recommendations.

Sacrocolpopexy is considered a reference operation for pelvic organ prolapse repair but its indications and technical aspects are not standardized. A faculty of urogynecology surgeons critically evaluated the peer-reviewed literature published until September 2015 aiming to produce evidence-based recommendations. PubMed, MEDLINE, and the Cochrane Library were searched for randomized controlled trials published in English language. The modified Oxford data grading system was used to access quality of evidence and grade recommendations. The Delphi process was implemented when no data was available. Thirteen randomized, controlled trials were identified, that provided levels 1 to 3 of evidence on various aspects of sacrocolpopexy. Sacrocolpopexy is the preferred procedure for vaginal apical prolapse (Grade A), monofilament polypropylene mesh is the graft of choice and the laparoscopic approach is the preferred technique (Grade B). Grade B recommendation supports the performance of concomitant procedures at the time of sacrocolpopexy. Grade C recommendation suggests either permanent or delayed sutures for securing the mesh to the vagina, permanent tackers or sutures for securing the mesh to the sacral promontory and closing the peritoneum over the mesh. A Delphi process Grade C recommendation supports proceeding with sacrocolpopexy after uncomplicated, intraoperative bladder or small bowel injuries. There is insufficient or conflicting data on hysterectomy (total or subtotal) or uterus preservation during sacrocolpopexy (Grade D). Sacrocolpopexy remains an excellent option for vaginal apical prolapse repair. The issue of uterine preservation or excision during the procedure requires further clarification. Variations exist in the performance of most technical aspects of the procedure.

Male overactive bladder: pharmacotherapy for the male.

Purpose of review To summarize data concerning the medical treatment of men with overactive bladder symptoms published in peer-reviewed journals between January 2012 and March 2013. Recent findings Results of large, randomized trials of solifenacin in combination with tamsulosin in men with lower urinary tract symptoms, including voiding and storage ones, have dominated the medical literature on the subject for the past 12–16 months. Solifenacin in upfront combination with alpha-blockers or as add-on therapy in men with residual storage symptoms despite alpha-blockade offers additional benefits in symptom control. In accordance with data from previous studies on other antimuscarinics, improvements are significant only for some of the efficacy outcomes. Solifenacin in combination with alpha-blockers is associated with an increase in postvoid residual urine volume but not a significantly increased risk of retention. Recent data also indicate that the combination of antimuscarinics with alpha-blockers is cost-effective with long-term efficacy and safety. Summary Recent evidence further supports the efficacy and safety of antimuscarinics in combination with alpha-blockers in treating storage symptoms in men with lower urinary tract symptoms. More studies are needed to evaluate criteria for selecting men likely to benefit more from antimuscarinics and investigate other overactive bladder treatments in male populations.

Correlation of ultrasound-estimated bladder weight to urodynamic diagnoses in women with lower urinary tract symptoms.

OBJECTIVE To test the hypothesis that the ultrasound-estimated bladder weight (UEBW) will correlate with the urodynamic diagnoses in women with lower urinary tract symptoms, in particular, detrusor underactivity and bladder outflow obstruction. Ultrasonography has been increasingly used in the assessment of lower urinary tract conditions. METHODS Adult women referred to the urodynamics suite for investigation of lower urinary tract symptoms were enrolled. After urodynamic evaluation, the portable BladderScan BVM 6500 device was used to calculate the bladder wall thickness and UEBW according to a standardized protocol. The patients were categorized according to the urodynamic findings. Women with normal findings, despite the symptoms for which they were referred, were used as the control group. The UEBW and bladder wall thickness measurements were compared between the groups and controls, using the Mann-Whitney and Kolmogorov-Smirnov tests. P <.05 was considered statistically significant. RESULTS A total of 187 women were enrolled. The UEBW was significantly lower in the patients with detrusor underactivity than in the controls (39.3 ± 3.0 g vs 45.7 ± 3.1 g, P <.001). Significant differences were also noted between the controls and patients with bladder outflow obstruction, with or without detrusor overactivity (45.7 ± 3.1 g vs 52.1 ± 3.9 g and 52.3 ± 6.2 g, respectively; P <.001 for both). The difference, in terms of the UEBW, between controls and patients with detrusor overactivity was not statistically significant (45.7 ± 3.1 g vs 45.3 ± 3.0, P > .05). CONCLUSION A significantly reduced UEBW in female patients with detrusor underactivity and a significantly increased UEBW in patients with bladder outflow obstruction were found. However, the finding of a significantly increased bladder weight in patients with detrusor overactivity was not confirmed in the present study.

Present and future therapeutic options for locally advanced and metastatic renal cell carcinoma

Introduction: Locally advanced or metastatic renal cell carcinoma (RCC) is notoriously chemo- and radioresistant, leaving immunotherapy as the only treatment option. In recent years, targeted therapies have offered significant increases in progression-free survival (PFS). Despite this, the majority of patients soon develops resistant disease and finally succumbs. The need to implement treatment strategies that improve overall survival while having an acceptable safety profile is imperative. Areas covered: This review provides information on the efficacy of recently studied treatment strategies for advanced RCC. These include sequential and combination therapy of established drugs as well as data on agents in early clinical development. The Medline and ASCO database were searched for clinical trials on medical therapy of advanced RCC from 2004 until May 2010. Data on targeted therapies, including tyrosine kinase inhibitors, vascular endothelial growth factor inhibitors, mammalian target of rapamycin inhibitors, and antiepidermal growth factor receptor agents are summarized. Expert opinion: Improvements in response rates and PFS in patients with advanced RCC have been observed with new treatment strategies. The benefit in overall survival is less clear and needs further evaluation. Toxicity represents a concern especially in combination regiments.

Safety of sildenafil in the treatment of erectile dysfunction in patients with obstructive sleep apnoea.

Obstructive sleep apnoea, characterised by repetitive occlusion of the upper airway during sleep, is recognised as a risk or even an aetiological factor for erectile dysfunction. On the other hand, sleep-disordered breathing has been reported by many patients with erectile dysfunction. Sildenafil, a very commonly used erectile dysfunction treatment, could, at least theoretically, exacerbate sleep apnoea by interfering with pharyngeal muscle tone, nasal patency and gas exchange in the lung. A recent safety study suggested a detrimental effect of oral sildenafil on respiratory events in patients with obstructive sleep apnoea. Given the inconclusiveness of evidence on pathophysiological mechanisms and the paucity of relevant clinical data the safety risk of sildenafil administration in patients with obstructive sleep apnoea should be questioned. More clinical trials are needed to clarify this issue.

Injectables for the treatment of stress urinary incontinence: current use and future perspectives

Stress urinary incontinence is a prevalent symptom among women. It also affects men, primarily those operated on for prostate disease. Even though it is not life threatening, it seriously impacts quality of life. Bulking agents have been used in the treatment of incontinence for many decades, offering a treatment option for both women and men. Their short-term efficacy is satisfactory, but there is concern regarding durability of effect. Despite concerns regarding efficacy, the minimally invasive nature of the technique, with uncommon and self-limited complications, has made injectables quite popular among both physicians and patients. In light of recent developments in the surgical treatment of incontinence, resulting in highly efficacious, but also easy and safe-to-perform, procedures, the role of injectables must be re-evaluated. In these cost-conscious times, health economics is also an important issue, and comparative cost-effectiveness assessment of available treatment options is becoming imperative.

How to Deal with Pain Following a Vaginal Mesh Insertion

Pain as an isolated complication of vaginal mesh insertion is uncommon, and its pathophysiology not well understood. Management is complex and involves technically demanding surgical mesh removal. Results are reported as good in the majority of cases.

Non-steroidal anti-inflammatory drugs in the treatment of genitourinary malignancies: focus on clinical data

The antitumour activity of NSAIDs in preclinical trials has lead to their evaluation in the management of various malignancies in humans. Evidence regarding their use in the treatment of genitourinary tumours is reviewed here, focusing primarily on clinical data. The majority of available evidence comes from meeting abstracts and only a few published manuscripts were detected. The efficacy of selective COX-2 inhibitors, a subcategory of anti-inflammatory drugs, is promising in prostate cancer, in either biochemical recurrence after initial treatment or advanced disease. This does not seem to be the case for renal tumours in which efficacy in the advanced disease setting is not satisfactory. Despite the well-documented rationale for the application of NSAIDs in bladder cancer management, clinical evidence is not available. More studies are needed to assess the efficacy of anti-inflammatory agents in bladder cancer treatment and further clarify their therapeutic benefit in patients with prostate cancer, in which initial results are encouraging.