Lorenzo Rocchini

Are Infertile Men Less Healthy than Fertile Men? Results of a Prospective Case-Control Survey

BACKGROUND An association between either subfertility or infertility and an elevated risk of certain male cancers has been previously reported. Nothing is known about abnormalities in infertility and general health conditions. OBJECTIVE To assess whether men with male factor infertility (MFI) are overall less healthy than fertile men, regardless of the reasons for infertility. DESIGN, SETTING, AND PARTICIPANTS From September 2006 to September 2007, 344 consecutive European Caucasian men with MFI were enrolled in this prospective case-controlled study. Patients were compared with a control group of 293 consecutive age-comparable fertile men. Infertile men were consecutively attending the outpatient male reproductive clinic at a tertiary academic center. Fertile controls were consecutively recruited by use of advertisements posted within our hospital. MEASUREMENTS Comorbidities of patients and fertile men were objectively scored with the Charlson Comorbidity Index (CCI) according to the International Classification of Diseases modified ninth version (ICD-9-CM) codes. Multivariate linear regression models tested the association between predictors and CCI score, as a proxy of general health status. RESULTS According to the CCI scores, infertile men had a significantly higher rate of comorbidities compared with the fertile controls (CCI: 0.33 [0.8] vs 0.14 [0.5]; p<0.001; 95% CI: 0.08-0.29). Linear regression analyses showed that although educational status did not have an impact on CCI (β: 0.035; p=0.365), while CCI linearly increased with age (β: 0.196; p<0.001) and body mass index (BMI; β: 0.161; p<0.001). After adjusting for age, BMI, and educational status, a significantly lower CCI was calculated for fertile men and compared with MFI patients (β: -0.199; p<0.001). CONCLUSIONS These results show that MFI accounts for a higher CCI, which may be considered a reliable proxy of a lower general health status.

Is erectile dysfunction a reliable proxy of general male health status? The case for the International Index of Erectile Function-Erectile Function domain.

INTRODUCTION Erectile dysfunction (ED) has emerged progressively as a sentinel marker of cardiovascular disease (CVD). The correlation between ED and the burden arising from multiple comorbid conditions has been incompletely analyzed. AIM Assess whether erectile function, defined with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score, is associated with health-significant comorbidities scored with the Charlson comorbidity index (CCI). METHODS Clinical and hemodynamic variables of the last 140 consecutive patients who underwent penile color Doppler ultrasonography for new-onset ED were considered. Patients were assessed with a thorough medical and sexual history. Health-significant comorbidities were scored with the CCI. MAIN OUTCOME MEASURE Descriptive statistics and either linear or logistic regression models tested the association among IIEF-EF, hemodynamic parameters, and CCI, which was included in the model both as continuous and categorized variable (0 vs. ≥1). RESULTS Complete data were available for 138 patients (98.6%) (mean age 46.6 years [standard deviation 13.0]; range 21-75 years). CCI was 0, 1, and ≥2 in 94 (68.1%), 23 (16.7%), and 21 (15.25%) patients, respectively. Of all, 35 patients (79.5%) did not have a CVD comorbidity. Mean IIEF-EF was 13.7 (9.3). ED severity was no ED, mild, mild to moderate, moderate, and severe in 12 (9.1%), 28 (20.2%), 12 (9.1%), 23 (16.2%), and 63 (45.5%) patients, respectively. At multivariable linear regression analysis, CCI significantly worsened with increased age (β=0.33; P=0.001) and decreased IIEF-EF values (β=-0.25; P=0.01). At logistic regression analysis, age (odds ratio [OR]: 1.05; P=0.004) and IIEF-EF (OR: 0.95; P=0.04) emerged as significant predictors of categorized CCI. CONCLUSIONS Severity of ED, as objectively interpreted with IIEF-EF, accounts for a higher CCI, which may be considered a reliable proxy of a lower general male health status regardless of the etiology of ED.

Ureteral endometriosis: Proposal for a diagnostic and therapeutic algorithm with a review of the literature

Introduction: The ureteral involvement in deep pelvic endometriosis in usually asymptomatic and might lead to a silent loss of renal function. As a matter of fact, the diagnosis and the treatment modalities are still a matter of debate. Materials and Methods: We performed a literature review by searching the MEDLINE database for articles published in English between 1996 and 2010, using the key words urinary tract endometriosis, ureteral endometriosis, diagnosis and treatment. We found more than 200 cases of ureteral endometriosis (UE). Results: The disease most commonly affects a single distal segment of the ureter, with a left predisposition in most of the patients. Two major pathological types of UE may be distinguished: intrinsic and extrinsic. The symptoms are usually nonspecific and owing to secondary obstruction. The diagnosis has to be considered as a step- by-step procedure, starting from physical examination to highly detailed imaging methods. Nowadays, the treatment is usually chosen according to the type of UE, the site lesion and the distance to the ureteral orifice, with the use of JJ stents remaining a matter of debate. Conclusions: A close collaboration between the gynecologist and the urologist is advisable, especially in referral centers. Surgical treatment can lead to good results in terms of both patient compliance and prognosis.

Diagnosis and Treatment of Bladder Endometriosis: State of the Art

Background: The bladder is the most common affected site in urinary tract endometriosis, being diagnosed during gynecologic follow-up. The surgical urological treatment might lead to good results. Study Objective: To define the state of the art in the diagnosis and treatment of bladder endometriosis. Methods: We performed a literature review by searching the MEDLINE database for articles published between 1996 and 2011, limiting the searches to the words: urinary tract endometriosis, bladderendometriosis, symptoms, diagnosis and treatment.Results: Deep pelvic endometriosis usually involves the urinary system, with the bladder being affected in 85% of cases. The diagnosis has to be considered as a step-by-step procedure. Currently, the treatment is usually surgical, consisting of either transurethral resection or partial cystectomy, and eventually associated with hormonal therapy. The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation, with no effects on the scarring caused by this tissue. The overall recurrence rate is about 30% for combined therapies and about 35% for the hormonal treatment alone. Conclusions: The bladder is the most common affected site in urinary tract endometriosis. Most of the time, this condition is diagnosed because of the complaint of urinary symptoms during gynecologic follow-up procedures for a deep pelvic endometriosis: a close collaboration between the gynecologist and the urologist is advisable, especially in highly specialized centers. The surgical urological treatment might lead to good results in terms of patients’ compliance and prognosis.

Clinical Reliability of the 2004 WHO Histological Classification System Compared With the 1973 WHO System for Ta Primary Bladder Tumors

PURPOSE Histopathological grade remains the most important predictive factor for the prognosis of nonmuscle invasive bladder cancer. We defined the clinical reliability of the 2004 WHO and International Society of Urological Pathology histological classification system compared with that of the 1973 WHO system for Ta primary bladder tumors. MATERIALS AND METHODS We evaluated 270 consecutive patients with a first episode of low grade pTa bladder cancer at transurethral resection of the bladder between 2004 and 2008. Grade was assigned by a single uropathologist simultaneously as low grade, and as G1 or G2 according to the 2004 and 1973 WHO classification systems, respectively. All patients received a single early prophylaxis instillation of 50 mg epirubicin as the only adjuvant treatment. Followup included urine cytology and cystoscopy 3 months after resection and every 6 months thereafter for 5 years. Univariate and multivariate analysis of recurrence-free and progression-free survival was done with the Kaplan-Meier method and the log rank test. RESULTS Mean patient age was 67.3 years (median 67, range 27 to 91). Of the patients 50 were female (18.1%) and 220 (81.9%) were male. According to the 1973 system, grade was G1 in 87 patients (32.2%) and G2 in 183 (67.8%). Median followup was 25 months (mean 27.4, range 3 to 72). The 5-year recurrence-free survival rate was 49.4% for the low grade population, and 62% and 40% for the G1 and G2 groups, respectively (p = 0.004). The 5-year progression-free survival rate was 93% for the low grade population, and 97.6% and 93.3% for the G1 and G2 groups, respectively (p = 0.06). CONCLUSIONS The 1973 WHO classification system predicted the risk of recurrence in primary pTa cases more accurately than the 2004 WHO system. Each classification had the same accuracy when predicting the risk of progression. Our study confirms the clinical reliability of the new histological classification in clinical practice from a prognostic point of view.

ORIGINAL RESEARCH—EJACULATORY DISORDERS: Quantitative Sensory Testing of Peripheral Thresholds in Patients with Lifelong Premature Ejaculation: A Case-Controlled Study

INTRODUCTION The main functional factors related to lifelong premature ejaculation (PE) etiology have been suggested to be penile hypersensitivity, greater cortical penile representation, and disturbance of central serotoninergic neurotransmission. AIMS To quantitatively assess penile sensory thresholds in European Caucasian patients with lifelong PE using the Genito-Sensory Analyzer (GSA, Medoc, Ramat Yishai, Israel) as compared with those of an age-comparable sample of volunteers without any ejaculatory compliant. METHODS Forty-two consecutive right-handed, fully potent patients with lifelong PE and 41 right-handed, fully potent, age-comparable volunteers with normal ejaculatory function were enrolled. Each man was assessed via comprehensive medical and sexual history; detailed physical examination; subjective scoring of sexual symptoms with the International Index of Erectile Function; and four consecutive measurements of intravaginal ejaculatory latency time with the stopwatch method. All men completed a detailed genital sensory evaluation using the GSA; thermal and vibratory sensation thresholds were computed at the pulp of the right index finger, and lateral aspect of penile shaft and glans, bilaterally. MAIN OUTCOME MEASURES Comparing quantitatively assessed penile thermal and vibratory sensory thresholds between men with lifelong PE and controls without any ejaculatory compliant. RESULTS Patients showed significantly higher (P < 0.001) thresholds at the right index finger but similar penile and glans thresholds for warm sensation as compared with controls. Cold sensation thresholds were not significantly different between groups at the right index finger or penile shaft, but glans thresholds for cold sensation were bilaterally significantly lower (P = 0.01) in patients. Patients showed significantly higher (all P < or = 0.04) vibratory sensation thresholds for right index finger, penile shaft, and glans, bilaterally, as compared with controls. CONCLUSIONS Quantitative sensory testing analysis suggests that patients with lifelong PE might have a hypo- rather than hypersensitivity profile in terms of peripheral sensory thresholds. The peripheral neuropathophysiology of lifelong PE remains to be clarified.

Postoperative Orgasmic Function Increases over Time in Patients Undergoing Nerve‐Sparing Radical Prostatectomy

INTRODUCTION Postprostatectomy orgasmic function (OF) remains poorly defined. AIMS To assess OF over time in patients who underwent bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP) for organ-confined prostate cancer (PCa). METHODS Baseline data were obtained from 334 consecutive preoperatively sexually active PCa patients at hospital admission; data included a medical and sexual history, IIEF domain scores, and ICIQ-SF. Questionnaire were then completed every 12 months postoperatively, and patients participated in a semistructured interview at the 12-month (191/334 [57.2%] patients), 24-month (95/334 [28.4%] patients), 36-month (42/334 [12.6%] patients), and 48-month (19/334 [5.7%] patients) follow-up (FU). MAIN OUTCOME MEASURES IIEF-OF domain values throughout the FU. Multivariate linear regression analysis (MVA) of the association between predictors (patients age, IIEF-erectile function [EF], ICIQ-SF, and the use of postoperative proerectile pharmacological treatments) and the IIEF-OF at 12-month, 24-month, and 36-month FU. RESULTS Preoperative mean (median) IIEF-OF was 7.6 (10). The anova analysis showed an increase of the IIEF-OF values (P = 0.008; F = 4.009) throughout the FU (namely, IIEF-OF 12-month: 6.1 [6]; 24-month: 7.2 [8]; 36-month: 7.3 [8]; and 48-month: 7.7 [9.50]). The 12-month MVA showed that while proerectile oral therapy did not affect postoperative OF (P = 0.150; Beta 0.081), IIEF-OF linearly increased with IIEF-EF (P < 0.001; Beta 0.425). Conversely, IIEF-OF linearly decreased with patients age (P < 0.001; Beta -0.135) and with ICQ-SF scores (P < 0.001; Beta -0.438). The 24-month and 36-month analyses showed that IIEF-OF still linearly increased with IIEF-EF (P < 0.001; Beta 0.540, and P < 0.001; Beta 0.536 respectively at the 24- and 36-month FU), whereas pharmacological therapy, rate of urinary continence, and patients age did not significantly affect postoperative OF. CONCLUSIONS Postoperative OF significantly ameliorates over time in patients undergoing BNSRRP. The higher the postoperative EF score, the higher the OF throughout the FU time frame.

Is sperm banking of interest to patients with nongerm cell urological cancer before potentially fertility damaging treatments

PURPOSE We assessed the opinions of patients with nongerm cell urological cancer on sperm banking before undergoing surgical or nonsurgical therapy that could potentially endanger subsequent fertility. MATERIALS AND METHODS Between April 2007 and July 2008, 753 patients visited a urological office and were invited to complete a brief self-administered questionnaire to assess opinions on sperm banking before undergoing any eventual therapy potentially dangerous for male fertility. Logistic regression models tested the association between predictors (age, educational level, relationship status, previous fatherhood and benign disorder vs nongerm cell urological cancer) and patient wishes for sperm banking. RESULTS Median patient age was 65 years (mean 61.6, range 18 to 76). Overall 522 patients (69.3%) had nongerm cell urological cancer and only 242 (32.1%) were in favor of pretreatment sperm banking. On univariate analysis age (OR 0.961, p <0.001), a stable relationship (OR 0.486, p <0.001) and previous fatherhood (OR 0.390, p <0.001) were inversely associated with the wish for sperm banking, whereas having cancer and educational status were not significantly correlated. Multivariate analysis indicated that aging (OR 0.966, p = 0.001) and previous fatherhood (OR 0.587, p = 0.029) maintained inverse associations. Having urological cancer was positively (OR 1.494, p = 0.045) associated with the wish for sperm banking. CONCLUSIONS In urological patients there is a low rate of willingness to bank sperm before any potential fertility damaging therapeutic approach. Having nongerm cell urological cancer is an independent predictor that is positively associated with the wish to bank sperm. It is vitally important to provide comprehensive information about pretreatment sperm banking to young adults with nongerm cell urological cancer.

Does Educational Status Affect a Patient's Behavior Toward Erectile Dysfunction?

INTRODUCTION Educational status has been investigated rarely as a potential factor affecting the behavior of patients with new onset erectile dysfunction (ED) toward seeking first medical help and subsequent compliance with prescribed phosphodiesterase type 5 inhibitor (PDE5) therapy. AIM To test whether the educational status of patients with new onset ED and naïve to PDE5 therapy may have a significant impact on the delay before seeking first medical help (DSH) and compliance with the suggested PDE5. MAIN OUTCOME MEASURES Assessing DSH and compliance with PDE5 in new onset ED patients according to their educational status by means of detailed logistic regression analyses. METHODS Data from 302 consecutive patients with new onset ED and naïve to PDE5s were comprehensively analyzed. Patients were segregated according to their educational status into low (elementary and/or secondary school education) and high (high school and/or university degrees) educational levels. Complete data were available for 231 assessable patients. Univariate (UVA) and multivariate (MVA) logistic regression analyses addressed the association between educational status and DSH after adjusting for age, relationship status, and Sexual Health Inventory for Men score. Likewise, UVA and MVA were performed to test the association between educational status and patient compliance with PDE5 at the 9-month median follow-up. RESULTS Median DSH was 24 months (range 1-350; mean 38.1 +/- 42.8). The lower the educational status, the shorter the DSH (P = 0.03). In contrast, a significantly (P < 0.0001) greater proportion of patients with a higher educational status showed compliance with the suggested PDE5 at the 9-month follow-up. Overall, educational status was not an independent predictor of either DSH or patient compliance with PDE5 therapy. CONCLUSIONS After adjusting for other variables, our findings suggest that in new onset ED patients, educational status does not independently affect the DSH and patient compliance with PDE5 therapy.

Oncological predictive value of the 2004 World Health Organisation grading classification in primary T1 non-muscle-invasive bladder cancer. A step forward or back?

To compare the clinical reliability of the 1973 and 2004 World Health Organisation (WHO) classification systems in pT1 bladder cancer.