Magdy S. El-Bahnasawy

Recoverability of Erectile Function in Post–Radical Cystectomy Patients: Subjective and Objective Evaluations

BACKGROUND Literature regarding both subjective and objective evaluations of erectile function following radical cystectomy is deficient. OBJECTIVE To study the recoverability of erectile function in post-radical cystectomy patients on subjective and objective bases. DESIGN, SETTING, AND PARTICIPANTS Between March 2003 and March 2005, 45 male patients with organ-confined invasive bladder cancer were prospectively enrolled in this study. INTERVENTION Radical cystectomy and urinary diversion were offered to all patients (21 patients underwent a nerve-sparing [NS] surgical technique, and 24 patients underwent a non-nerve-sparing [NNS] surgical technique). MEASUREMENTS Patients were evaluated preoperatively using the International Index of Erectile Function (IIEF) questionnaire and using penile Doppler ultrasound (PDU). Patients were followed up regularly at 2 mo, 6 mo, and 12 mo using the same parameters. RESULTS AND LIMITATIONS Among patients in the NS group, 17 patients (78.8%) were potent postoperatively: 12 patients (57.8%) with spontaneous complete tumescence and 5 patients (21%) with partial tumescence using phosphodiesterase type 5 inhibitor (PDE5-I) as erectogenic aid; 4 patients needed intracorporeal prostaglandin E1 injections. In contrast, no patients in the NNS group showed spontaneous erection, and they did not improve with sildenafil; all of them needed prostaglandins as an erectogenic aid. The comparison between preoperative and postoperative IIEF domains showed that postoperatively the erectile function and overall satisfaction domains deteriorated initially, but in the NS group they gradually improved with time (p<0.0001). Corresponding PDU findings were comparable in peak systolic velocity during the course of follow-up in both groups. Although the end diastolic velocity was significantly more deteriorated postoperatively than preoperatively in both groups, gradual improvement in patients in the NS group was more evident 12 mo after surgery. CONCLUSION The return of erectile function was better in the NS group on subjective and objective bases. The most significant change was in veno-occlusive function, which improved rapidly and progressively in the NS group during 1 yr of follow-up.

Paediatric penile trauma.

Objective  To report our experience with paediatric penile trauma in a retrospectively evaluated series.

The urethral Kock pouch: long-term functional and oncological results in men

The Department of Urology in Mansoura has a well‐known experience in, among many things, urinary tract reconstruction in patients with bladder cancer. They review their results in 338 male patients who had a radical cystectomy and Kock pouch. They found good functional and oncological outcomes in properly selected patients. However, they also drew attention to several valve‐related complications.

Critical evaluation of the factors influencing erectile function after renal transplantation

A total of 400 male renal transplant recipients (RTR) were investigated. Data on medical, sexual history, clinical examination and laboratory variables were collected. The severity of erectile dysfunction (ED) was assessed using the International Index of Erectile Function questionnaire. Univariate and multivariate logistic regression analyses were used to determine prognostic variables, which have independent impact on erectile function. ED was detected in 35.8% of the whole group. Current erectile function as compared to pretransplant status was improved, deteriorated or remained static in 44, 12.5 and 43.5% of the evaluated transplant recipients, respectively. After logistic regression analysis, age, hemoglobin level and presence of DM and/or peripheral neuropathy had significant and independent negative impact on erectile function. We concluded that renal transplantation has varying effects on erectile function. ED is highly prevalent among RTR and its pathogenesis is multifactorial.

Radical cystectomy and urinary diversion in women: Impact on sexual function

Abstract Objective. The aim of this study was to assess the impact of radical cystectomy and different forms of urinary diversion on female sexual function. Material and methods. Seventy-three consecutive patients were included in the study. The mean age was 52.3 ± 6.5 years. All of them had undergone non-nerve-sparing radical cystectomy and urinary diversion for invasive bladder cancer. Patients were questioned about their current general relations with their husbands in comparison to the preoperative status. The Female Sexual Function Index (FSFI) was used to assess libido, lubrication, orgasm, satisfaction and painful sexual dysfunction. Patients were asked about any urinary complaints during or after sexual intercourse. Results. Twenty-nine patients (39%) reported worsening relations with their husbands. The mean frequency of sexual relations was 2.3 ± 2.3/month; however, sexual relations had ceased completely in 19 patients (26%). Overall satisfaction among sexually active women worsened in 32 (59.2%) and was completely lost in eight patients (14.8%). Absent libido, difficult intromission, dyspareunia, lack of orgasm and sexually related urinary complaints were reported in 89%, 63%, 48%, 63% and 63% of patients, respectively. The mean FSFI score dropped significantly from 18.3 ± 5.1 to 11.3 ± 7.4 postoperatively (p < 0.001). FSFI scores were significantly higher among patients with orthotopic versus non-orthotopic forms of diversion and also higher among patients with no stoma versus those with stomal forms of diversion. Conclusions. Radical cystectomy and urinary diversion have deleterious impacts on all domains of female sexual function. Female patients with orthotopic and non-stomal diversions had better sexual functions than those with stomal diversions.

Urethral pressure profile following orthotopic neobladder: differences between nerve sparing and standard radical cystectomy techniques.

PURPOSE Some authors reported that adopting a nerve sparing technique during radical cystoprostatectomy improves the continence outcome of orthotopic diversion in patients with invasive bladder carcinoma. We urodynamically evaluated the effect of nerve sparing cystoprostatectomy on external urethral sphincteric function. MATERIALS AND METHODS A total of 30 consecutive male patients who underwent nerve sparing cystoprostatectomy and ileal neobladder (NS group) were compared to a control group of 30 patients who underwent a similar procedure but without nerve sparing (non-NS group). Continence status was thoroughly clinically evaluated in parallel to erectile function in both groups. The urethral sphincteric mechanism was evaluated with urethral pressure profilometry in different positions. RESULTS Better urethral pressure profile parameters were found in patients in the NS group. Significantly longer functional urethral length (34.8 mm) was detected in NS group than in the non-NS group (30.1 mm). Moreover, the maximum urethral pressure was higher in the NS group but not to a statistically significant level. In the NS group there were no statistically significant differences between potent and impotent subgroups regarding the continence rate or urethral pressure parameters. CONCLUSIONS There is urodynamic evidence that the nerve sparing technique improved urethral sphincteric function and, consequently, the continence rate. The denervated, most proximal part of the urethra in non-NS cases with lack of contraction and, therefore, any pressure, is a possible explanation for the difference in UPP.

Clinical and urodynamic efficacy of oxybutynin and verapamil in the treatment of nocturnal enuresis after formation of orthotopic ileal neobladders : A prospective, randomized, crossover study

Objective. To evaluate the efficacy of two drugs: the anticholinergic agent oxybutynin (Ditropan) and the calcium channel blocker verapamil (Isoptin) in the management of nocturnal enuresis in patients with orthotopic ileal reservoirs. Material and methods. The study population comprised 20 male enuretic patients who had undergone radical cystoprostatectomy and formation of an orthotopic ileal reservoir (hemi-Kock or W-neobladder). All patients were clinically evaluated regarding their continence state. Basal medium-fill enterocystometry was performed for every patient. The patients were randomized on entry into one of the two arms of the study: oxybutynin followed by verapamil (n=10); or verapamil followed by oxybutynin (n=10). Each group received both drugs for a period of 2 weeks each. After administration of each drug, patients were re-evaluated both clinically and urodynamically. Results. Oxybutynin and verapamil improved continence status in 70% and 55% of the patients, respectively. Both drugs significantly increased the bladder volume at first desire, at normal desire and at the maximum enterocystometric capacity. The maximum enterocystometric capacity increased from 585±148.6 ml at baseline to 667.5±180.8 and 621.05±170.5 ml after administration of oxybutynin and verapamil, respectively. Despite this, there was no significant change in any of the pressure parameters with the exception of the basal pressure at maximum enterocystometric capacity, which decreased significantly from 20.1±8.3 cmH2O at baseline to 16.07±5.1 cmH2O after administration of verapamil. The number of uninhibited contractions in the last 5 min of filling decreased significantly from 3.6±0.7 at baseline to 1.9±1.2 after administration of oxybutynin and to 2.1±1.26 after administration of verapamil. The amplitude of maximum uninhibited contraction decreased from 41.15±9.1 cmH2O at baseline to 34.95±12.77 and 33.25±11.52 cmH2O after treatment with oxybutynin and verapamil, respectively. Neither drug significantly changed the initial, late or total compliance of the pouch. No significant side-effects occurred with either drug. Conclusions. Both drugs used in this study had beneficial effects on the continence status of our patients, with minimal side-effects. Both drugs clinically improved nocturnal incontinence after radical cystoprostatectomy and formation of orthotopic ileal reservoirs, which was verified by the associated improvements in urodynamic characteristics.

Prognostic factors predicting successful response to sildenafil after radical cystoprostatectomy.

Objectives. To assess the efficacy and safety of sildenafil citrate in the management of erectile dysfunction (ED) following radical cystectomy (RC) and to define the different prognostic factors predicting the response to sildenafil in such a challenging group of patients. Material and methods. One hundred patients with ED following RC participated in an open-label, non-randomized, prospective, dose-escalation study. The median age of the patients was 53 years and the mean period after RC was 80.7±54.8 months. The study duration was 12 weeks, comprising a 4-week run-in period followed by two active treatment periods of 4 weeks each with 50 and 100 mg of sildenafil. Patients were assessed by means of the International Index of Erectile Function (IIEF) questionnaire at baseline and after each treatment period. At the end of the study, the Global Efficacy Assessment Question was used to evaluate treatment satisfaction. Factors affecting the patients response to sildenafil were assessed by means of uni- and multivariate analysis. Results. The entire study group was suffering from severe ED at baseline, with a mean erectile function (EF) domain score of 6.5±0.93. EF scores improved to 12.2±7.76 and 18±10.3 with 50 and 100 mg of sildenafil, respectively. Sildenafil therapy significantly improved the ability of many patients to achieve and maintain an erection. The mean scores for question 3 of the IIEF were 1±0.14, 2.1±1.4 and 3±1.8 at baseline and with 50 and 100 mg of sildenafil, respectively, while the corresponding scores for question 4 were 1±0.10, 1.9±1.35 and 3±1.85. The satisfaction rate was 54%. The response was dose-dependent but the incidence of adverse effects increased from 6% with 50 mg of sildenafil to 34% with 100 mg. In univariate analysis, tumor histology and grade and postoperative partial tumescence were found to significantly impact the patients response to sildenafil. In multivariate analysis, postoperative partial tumescence was the only independent predictive variable. Conclusions. Sildenafil was found to be a safe and satisfactory treatment for post-RC ED. The effect was dose-related. Patients with postoperative partial tumescence were the best responders.

Persistent and occasional nocturnal enuresis in orthotopic urinary diversion: is there a urodynamic difference?

Authors from Mansoura attempted to determine the urodynamic criteria differentiating patients who have an ileal neobladder and who are either persistently enuretic or are occasionally enuretic. They found that all enuretic patients had significantly higher residual urine volumes than continent patients, and that there were differences in the two groups of enuretics, suggesting areas that can be targeted therapeutically.

Vasculogenic erectile dysfunction in renal transplant recipients--assessment of potential risk factors.

Objectives: This study was performed to determine the effects of renal transplantation on penile haemodynamics using pharmaco‐stimulation and colour Duplex ultrasonographic examination and then to determine the possible vascular risk factors for impotence in these patients. Material and Methods: A total of 100 renal transplant recipients (RTRs; 80 impotent, 20 potent) and 20 potent uraemic patients on haemodialysis waiting for transplantation (control group) were included in the study. The patients were evaluated by means of detailed medical and sexual histories, clinical examination and laboratory investigations. The severity of erectile dysfunction was assessed using the International Index of Erectile Function questionnaire. Pharmacodynamic penile Duplex ultrasonography was carried out for all patients. Results: The following factors were more commonly associated with impotent compared to potent RTRs: older age, diabetes mellitus, a longer pre‐transplant duration of uraemia, impaired graft function and the use of cyclosporin A‐based immunosuppressive therapy. Arterial occlusive disease was identified among 11 RTRs (11%), all of whom were impotent. Impotent RTRs had a significantly lower penile blood flow compared to potent RTRs or controls. Age, duration of pre‐transplant uraemia and cyclosporin A level had a negative impact on penile haemodynamic parameters. Conclusions: Penile vascular insufficiency is less common in RTRs than previously reported. The pathogenesis of penile arterial occlusive disease in impotent RTRs is mainly due to associated vascular risk factors. After unilateral interruption of the internal iliac artery, an adequate penile blood supply is maintained in the majority of cases. Early transplantation may delay or prevent the development of penile vasculopathy.