Milton M. Lakin

Role of viagra after radical prostatectomy

OBJECTIVES To determine whether the response to sildenafil citrate (Viagra) in patients with erectile dysfunction after radical prostatectomy was influenced by the presence or absence of neurovascular bundles, the interval from surgery to the initiation of drug therapy, and the dose of the drug. METHODS Baseline and follow-up data from 91 patients presenting with erectile dysfunction after radical prostatectomy were obtained. The patients were stratified according to the type of nerve-sparing (NS) procedure: bilateral NS, unilateral NS, and non-NS. They were interviewed using the Cleveland Clinic Post Prostatectomy (CCPP) questionnaire and the International Index of Erectile Function (IIEF) questionnaire. RESULTS The presence or absence of the neurovascular bundles influenced the ability to achieve vaginal intercourse. In the patients who had undergone bilateral NS, 71.7% (38 of 53) responded; in those with unilateral NS, 50% (6 of 12) responded; and in those with non-NS, 15.4% (4 of 26) responded. The IIEF questionnaire confirmed the quality of the positive responses, with significant improvements in response to question 3 (frequency of penetration), question 4 (frequency of maintenance of erection), and question 7 (satisfaction with intercourse). The magnitude of improvement in responses was higher in the bilateral NS group than in the unilateral NS and non-NS groups (P <0.05). When the data of the 48 positive responders were analyzed, no difference in the response rate was found when the interval from surgery to drug therapy was stratified by the following three intervals: 0 to 6 months (44%), 6 to 12 months (55%), and greater than 12 months (53%). Of the positive responders, 14 (29.1%) required the 50-mg dose, and 34 (70.9%) required the 100-mg dose. The most common side effects were transient headaches (28.6%), flushing (21.9%), dizziness (8.8%), dyspepsia (6.5%), and nasal congestion (5.4%), with an increase in the incidence of headaches seen at the higher dose (P = 0.04). CONCLUSIONS Successful treatment of erectile dysfunction with sildenafil citrate after radical prostatectomy depends on the presence of the neurovascular bundles. Our data suggest that the response to sildenafil is not related to the interval between the surgery and initiation of drug therapy but is related to the dose.

Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function

To assess the efficacy of vacuum constriction devices (VCD) following radical prostatectomy (RP) and determine whether early use of VCD facilitates early sexual activity and potentially earlier return of erectile function. This prospective study consisted of 109 patients who underwent nerve-sparing (NS) or non-nerve-sparing (NNS) RP between August 1999 and October 2001 and developed erectile dysfunction following surgery. The patients were randomized to VCD use daily for 9 months (Group 1, N=74) or observation without any erectogenic treatment (Group 2, N=35). Treatment efficacy was analyzed by responses to the Sexual Health Inventory of Men (SHIM) (abridged 5-item International Index of Erectile Function (IIEF-5)), which were stratified by the NS status. Patient outcome regarding compliance, change in penile length, return of natural erection, and ability for vaginal intercourse were also assessed. The mean patient age was 58.2 years, and the minimum follow-up was 9 months. Use of VCD began at an average of 3.9 weeks after RP. In Group 1, 80% (60/74) successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice/week with an overall spousal satisfaction rate of 55% (33/60). In all, 19 of these 60 patients (32%) reported return of natural erections at 9 months, with 10/60 (17%) having erections sufficient for vaginal intercourse. The abridged IIEF-5 score significantly increased after VCD use in both the NS and NNS groups. After a mean use of 3 months, 14/74 (18%) discontinued treatment. In Group 2, 37% (13/35) of patients regained spontaneous erections at a minimum follow-up of 9 months after surgery. However, only four of these patients (29%) had erections sufficient for successful vaginal intercourse and rest of patients (71%) sought adjuvant treatment. Of the 60 successful users, 14 (23%) reported a decrease in penile length and circumference at 9 months (range, 4–8 months) compared to 12/14 (85%) among the nonresponders. However, in control group 22/35 reported decrease in penile length and circumference. Early use of VCD following RP facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and potentially an earlier return of natural erections sufficient for vaginal penetration.

Intracavernous injection therapy: Analysis of results and complications

Experience with 100 patients who used intracavernous injection therapy with a combination of papaverine with or without phentolamine for 29 months is analyzed in detail. The largest group of patients had vasculogenic erectile failure (56%). At the end of followup 50% of the patients were no longer performing injection. Those who discontinued injection therapy were slightly older and had more vasculogenic erectile failure. The nonfibrotic complications were mild in all instances and did not result in discontinuation of injection therapy. These complications consisted of small hematomas in 20.9% of the patients, mild discomfort in 13.6% and mild liver enzyme abnormalities in 9.8%. No episode of priapism or infection occurred during therapy. Fibrotic complications consisted of nodules or plaques, and correlated significantly with the number of months on injection and the number of injections. At 12 months the fibrotic complication rate was 31 +/- 8.6%. Our study suggests caution regarding the long-term complication rate of intracavernous injection therapy with these compounds and underscores the importance of routine followup examinations. While injection therapy is an effective form of treatment for erectile failure, it is not a satisfactory alternative for many patients and is associated with a significant fibrotic complication rate.

Penile prosthesis infections

In this retrospective review we looked at infection rates and risk factors in penile prosthesis recipients. Computer registry records of patients implanted with three-piece inflatable prostheses from April 1986 to March 1999 were reviewed. Bacteriological culture report data were obtained from the medical records. There were 491 three-piece inflatable penile prosthesis recipients with follow-up ranging from 1 to 168 months (mean 83). All patients were implanted more than 1 y ago. There were 10 infections in 491 recipients (2.0%). In 285 primary prosthesis recipients there were seven infections (2.5%). In 206 secondary prosthesis recipients there were three infections (1.5%). Seven infections occurred in 354 non-diabetics (2.0%) and three infections occurred in 137 diabetics (2.2%). None of these differences were statistically significant. Explants for infection were performed in 8 weeks or less following implantation in eight patients. In two patients explants occurred at 17 and 26 months following implantation. Cultures from the periprosthetic space grew E. coli (four), Proteus mirabilis (two), Staph. aureus (two), and bacteroides (two). Infections occurred in 2.0% of three-piece inflatable penile prosthesis recipients. There were no statistically significant differences in infection rates between first time and repeat prosthesis recipients and between diabetic and non-diabetic recipients. Eight of the 10 infections occurred 8 weeks or less following implantation.

Cultures From Genitourinary Prostheses at Reoperation: Questioning the Role of Staphylococcus Epidermidis in Periprosthetic Infection

PURPOSE We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved. MATERIALS AND METHODS Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained. RESULTS Low colony counts of Staphylococcus epidermidis were isolated from 40% of uninfected penile prostheses and 36% of artificial urinary sphincters. Only 3 of these devices later became infected (9%) and in all cases a higher colony count of another organism was found at explanation. CONCLUSIONS While Staph. epidermidis can cause prosthesis infection, low colony counts of the organism may not be associated with clinical infection. Therefore, the high incidence of infection attributed to this organism may be overestimated.

Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3-year follow-up

OBJECTIVES To evaluate the long-term effect and safety of sildenafil citrate for the treatment of erectile dysfunction after radical prostatectomy (RP). METHODS The study consisted of 91 patients with erectile dysfunction from our institution who received oral sildenafil citrate after RP. We surveyed these patients using a self-administered questionnaire during the first year of sildenafil citrate use to determine treatment satisfaction, patient compliance, and safety. Those who had responded positively to the drug were surveyed again 3 years later (n = 48). Sildenafil citrate was prescribed at a dose of 50 mg and increased to 100 mg if needed. Data were collected from a self-administered questionnaire using the abridged five-item version of the International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory of Men, and the Erectile Dysfunction Inventory of Treatment Satisfaction. The patients were stratified according to the type of nerve-sparing (NS) RP procedure they underwent: bilateral NS, unilateral NS, and non-NS. RESULTS At 3 years, 31 (71%) of the 43 patients who had returned the second surveys were still responding to sildenafil. Of these 31 respondents, 10 (31%) had augmented their dose from 50 to 100 mg. The dropout rate was 27%; 6 of 12 had discontinued because of the return of natural erections, 5 because of a loss of efficacy, and 1 because his spouse had died. No differences were found in the 1-year and 3-year five-item International Index of Erectile Function (Sexual Health Inventory of Men) and Erectile Dysfunction Inventory of Treatment Satisfaction scores between the NS groups. The most common side effects at 3 years were headache (12%), flushing (10%), and blue or blurred vision (2%). No patient discontinued the drug at 3 years because of side effects. CONCLUSIONS The results of this study indicate that the vast majority of patients with erectile dysfunction after RP who initially respond to sildenafil continue to do so at 3 years and are satisfied and compliant with the treatment regimen.

Treatment of erectile dysfunction with sildenafil citrate (Viagra) after radiation therapy for prostate cancer

OBJECTIVES To determine the response to sildenafil citrate (Viagra) in patients with erectile dysfunction after radiation therapy for localized prostate cancer. METHODS Baseline and follow-up data from 21 patients presenting with erectile dysfunction after radiation treatment for clinical T1-2 prostate cancer were obtained. Two patients had undergone iodine-125 seed implantation and the remaining 19 conformal external beam irradiation. All 21 patients were considered to have erectile dysfunction as assessed by the International Index of Erectile Function (IIEF) and were prescribed sildenafil at a dosage of 50 mg, with a titration to 100 mg if needed. The mean time between the completion of radiation therapy and initiation of sildenafil was 24.6 +/- 5.8 months. The quality of the erectile function was assessed after a minimum of four doses by using the Cleveland Clinic Erectile Function (CCEF) questionnaire and the IIEF questionnaire. A positive response to sildenafil on the CCEF questionnaire was defined as an erection sufficient for vaginal penetration. The responses on the IIEF questionnaire were rated on a scale of 1 (almost never) to 5 (almost always), with 0 being no sexual activity. RESULTS On the CCEF questionnaire, 71% (15 of 21) of patients had a positive response, with a mean duration of 12.7 +/- 2.5 minutes of intercourse, and a corresponding spousal satisfaction rate of 71%. Twelve (80%) of the 15 responders required titration to the 100-mg dosage for maximal effect. The most common side effects seen were transient flushing (19%), abnormal color vision (14%), and headaches (10%). No patient discontinued the drug because of side effects. On the IIEF questionnaire, the responses to questions 3 (frequency of penetration), 4 (maintenance of erection), 7 (satisfactory intercourse), and 15 (erection confidence) increased from mean baseline scores of 1.3, 1.1, 1.2, and 1.8 to final mean scores of 4.0, 3.9, 3.2, and 3.4, respectively (P <0.001). On the global efficacy question (ability to achieve firm erections), 71% of the patients responded positively. CONCLUSIONS Sildenafil citrate can improve the ability to achieve and maintain an erection in most patients with erectile dysfunction after radiation therapy for prostate cancer.

LONG-TERM MECHANICAL RELIABILITY OF AMS 700 SERIES INFLATABLE PENILE PROSTHESES: COMPARISON OF CX/CXM AND ULTREX CYLINDERS

PURPOSE Recently, we have noted an increasing incidence of revisions being performed in patients implanted with the length and girth expanding AMS 700 Ultrex* inflatable penile prosthesis. This observation prompted us to compare the long-term mechanical reliability of the AMS Ultrex inflatable penile prosthesis versus the girth-expanding AMS 700 CX* or CXM* inflatable penile prosthesis in men with organic erectile dysfunction. MATERIALS AND METHODS Using chart review, mailed questionnaires and telephone interviews, we obtained accurate followup on 111 of 142 (78.2%) patients with CX/CXM implanted between June 1986 and September 1995, and on 152 of 179 (84.9%) patients implanted with Ultrex between October 1989 and September 1995. The CX/CXM and Ultrex groups were compared with regard to 3 end points: 1) mechanical failure caused by any malfunctioning component, 2) device failure caused by any cylinder complication and 3) cylinder aneurysms/leaks. RESULTS Followup ranged from 1.0 to 112.0 months for the CX/CXM group (mean 47.2 months), and 0.7 to 71.5 months for the Ultrex group (mean 34.4 months). CX/CXM versus Ultrex group comparison demonstrated 10 CX/CXM mechanical failures (9.0%) versus 26 Ultrex failures (17.1%), p = 0.001; 5 CX/CXM cylinder complications (4.5%) versus 13 Ultrex cylinder complications (8.6%), p = 0.0292; and 3 CX/CXM cylinder aneurysms/leaks (2.7%) versus 9 in the Ultrex group (5.9%), p = 0.0162. Kaplan-Meier estimates demonstrated significantly decreased mechanical survival in all 3 categories for Ultrex inflatable penile prosthesis versus CX/CXM inflatable penile prosthesis. CONCLUSIONS Although Ultrex cylinders provide length and girth expansion, Ultrex cylinders exhibit an increased mechanical failure rate at shorter followup compared with CX/CXM cylinders. This increased propensity for Ultrex cylinder problems should be closely monitored.

AMS 3-Piece Inflatable Penile Prosthesis Implantation in Men with Peyronie's Disease: Comparison of CX and Ultrex Cylinders

PURPOSE We compared the ability of the CX and Ultrex cylinders to straighten the penis in men who received a 3-piece AMS 700 series inflatable penile prosthesis for erectile dysfunction and erectile deformity due to Peyronies disease. MATERIALS AND METHODS The records of 34 and 38 patients receiving devices CX and Ultrex cylinders, respectively, were reviewed. RESULTS All 34 patients receiving the CX cylinders achieved complete penile straightening with cylinder inflation and bending alone. In 10 of 38 patients receiving the Ultrex cylinders complete straightening with cylinder inflation and bending could not be achieved, and simultaneous corporoplasty was necessary. CONCLUSIONS Girth expanding CX cylinders have better penile straightening properties than girth and length expanding Ultrex cylinders. We recommend use of CX cylinders for 3-piece AMS 700 series inflatable penile prosthesis implantation in men with Peyronies disease.

Long-term efficacy and compliance of intracorporeal (IC) injection for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis

Baseline and follow-up data from 102 patients using intracorporeal (IC) injection for erectile dysfunction (ED) following RP were retrospectively collected. We compared baseline International Index for Erectile Function (IIEF) questionnaires with the abridged IIEF-5 questionnaires, referred to as the Sexual Health Inventory of Men (SHIM) to determine drug efficacy. The mean presurgery SHIM score was 21.75±5.23, which decreased to 4.23±3.48 after surgery and increased to 19.46±8.78 post-treatment. Overall, 68% (69/102) of patients achieved and maintained erections sufficient for sexual intercourse and 48% (49/102) of patients continued long-term therapy with a mean use of 3.7±1.9 y. In all, 52% (53/102) patients discontinued IC therapy. However when excluding patients who switched to oral therapy, had loss of partner or return of normal erections; the compliance to IC injections was 70.6% (71/102). There was no difference in the SHIM analysis between the nerve sparing (NS) and the non-NS or between the types of medications used. IC injections can provide excellent long-term efficacy and compliance in up to 70% of the patients. This study suggests that IC injections are an excellent salvage option in NS patients who fail oral therapy and a first option in patients with non-NS procedures.