Osama Mohamed

Testosterone Replacement Therapy Following Radical Prostatectomy

INTRODUCTION Controversy exists regarding testosterone replacement therapy (TRT) in men following radical prostatectomy (RP). Many clinicians are hesitant to offer patients TRT after an RP, out of concern that the increased androgen levels may promote tumor progression or recurrence from residual tumor. Recently, several small studies have demonstrated the use of TRT in men following an RP and have shown an improvement in serum testosterone levels with no increase in prostate-specific antigen (PSA) values. AIMS The aim of this article is to assess changes in PSA and testosterone values in hypogonadal patients on TRT after RP and also to evaluate the impact of pathologic Gleason grade on ultimate PSA values. METHODS All hypogonadal men who were treated with TRT by members of our department following RP were retrospectively reviewed. PSA values before RP, after RP, and after TRT were evaluated. Serum testosterone levels before and after TRT were also examined. Only patients with undetectable PSA values and negative surgical margins on pathologic specimen were offered TRT and included in the study. MAIN OUTCOME MEASURES Main outcome measures were changes in PSA and testosterone values after initiation of TRT. RESULTS Fifty-seven men, ages 53-83 years (mean 64), were identified as having initiated TRT following RP. Men received TRT for an average of 36 months following RP (range 1-136 months). Patients were followed an average of 13 months after initiation of TRT (range 1-99 months). The mean testosterone values rose from 255 ng/dL before TRT to 459 ng/dL after TRT (P < 0.001). There was no increase in PSA values after initiation of TRT and thus no patient had a biochemical PSA recurrence. CONCLUSION TRT is effective in improving testosterone levels, without increasing PSA values, in hypogonadal men who have undergone RP.

The quantitative ADAM questionnaire: a new tool in quantifying the severity of hypogonadism

Androgen deficiency is a pervasive problem in the older male population and is thought to be responsible for many symptoms once considered to be the result of normal aging. Numerous methods have been proposed to facilitate the detection of men at risk for androgen deficiency. In this article, we propose a novel screening tool, the quantitative Androgen Deficiency in the Aging Male (qADAM) questionnaire and report its successful use in quantifying the severity of androgen deficiency in a group of older men. Fifty-seven males scheduled to undergo radical prostatectomy for prostate cancer completed the qADAM as well as the Sexual Health Inventory for Men (SHIM) and the Expanded Prostate Cancer Index Composite hormonal/sexual (EPICh/EPICs) questionnaires. Thirty-four men also had serum testosterone levels measured for comparison. The qADAM showed statistically significant correlation to the SHIM (P=0.001), EPICh (P=0.016), EPICs (P=<0.001), and serum testosterone (P=0.046). The qADAM represents a viable alternative to existing questionnaires used to detect androgen deficiency and to assess response to treatment.

The Female Factor: Predicting Compliance with a Post-Prostatectomy Erectile Preservation Program

INTRODUCTION Early post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery. AIM To assess if pre-RP female sexual function predicts of partner compliance with an EP protocol. MAIN OUTCOME MEASURES Compliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP. METHODS Records of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant. RESULTS Twenty-nine patients had preoperative SHIM>7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P=0.05). CONCLUSIONS Preoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partners preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor.

The Impact of On-pump Coronary Artery Bypass Surgery vs. Off-pump Coronary Artery Bypass Surgery on Sexual Function

INTRODUCTION Erectile dysfunction and ischemic heart disease are common health problems that affect elderly individuals. Despite advances in treatment strategies, cardiopulmonary bypass (CPB) has been used for coronary artery bypass grafting (CABG) for over three decades for surgical myocardial revascularization. AIM To discuss the difference between the on pump and the newer alternative-the off-pump CABG (OPCABG) surgery-on the sexual function. METHODS This prospective study included 100 patients who underwent CABG. MAIN OUTCOME MEASURES The patients were evaluated by an abridged form of International Index of Erectile Function questionnaire (IIEF-5), Pharmaco-Penile Duplex Ultrasound and finally by the European System for Cardiac Operative Risk Evaluation. The patients were underwent either on-pump CABG or OPCABG. Six months after surgery, the erectile function was revaluated according to the same preoperative measures. RESULTS Patients included in the study were classified into two matched groups: group I-patients who underwent on-pump CABG (N = 50); and group II-patients who underwent OPCABG (N = 50). The frequency of intercourse was significantly higher in OPCABG (P < 0.05) after surgery. The mean +/- standard deviation of the IIEF-5 scores of the on-pump group postoperatively became 12.48 +/- 7.19 whereas it became 15.88 +/- 6.67 in the off-pump group (P < 0.05). Moreover, the number of patients who reported postoperative improvement of their IIEF-5 score was significantly higher in OPCABG group (N = 23) compared with the conventional on-pump CABG group (N = 13) (P < 0.05). There was no significant change in the duplex ultrasound after surgery between both groups. CONCLUSIONS The OPCABG has a diminished impact on the sexual function of patients compared with the conventional on-pump CABG. Therefore, the type of operation can be considered a predictive factor of sexual function following CAB surgery.

Vascular Risk Factors as Predictors of Sexual Function Following Coronary Artery Bypass Graft

INTRODUCTION A strong association between cardiovascular risk factors and erectile dysfunction (ED) was suggested. Coronary artery bypass grafting (CABG) is the gold standard for surgical myocardial revascularization. AIM We herein evaluate the impact of vascular risk factors on postoperative sexual functions in patients undergo CABG. MAIN OUTCOME MEASURES ED severity by the International Index of Erectile Function (IIEF-5) and penile duplex study. METHODS The present study included 100 patients who underwent CABG. The patients were evaluated by an abridged form of the IIEF-5 questionnaire, followed by CABG. Six months after surgery the erectile function of all patients was re-evaluated utilizing the IIEF-5. RESULTS Number of risk factors was significantly associated with postoperative change in IIEF-5 score (P = 0.02). A post hoc analysis of the association revealed that patients with one risk factor were significantly more likely to have increased IIEF-5 scores (N = 18), whereas those with two or more risk factors were significantly more likely to have decreased IIEF-5 scores (N = 21, P < 0.05). Furthermore, those with no risk factors were significantly more likely to be stable (N = 8) compared with those with more than two risk factors, who were more likely to have decreased scores (P < 0.05). The hierarchical logistic regression results showed that when examining all risk factors simultaneously, because of multicollinearity, only hyperlipidemia was significantly associated with postoperative ED (odds ratio [OR] = 11.33, confidence interval [CI] = 1.25, 102.82). Frequency of intercourse was also significantly associated with postoperative ED after controlling for risk factors (OR = 0.71, CI = 0.52, 0.97). CONCLUSIONS This data clearly shows that the number of cardiovascular risk factors is an essential predictive factor for sexual function following surgery. Only hyperlipidemia may play a predictive role for the future sexual function of patients undergo CABG.

IGF-1 levels are significantly correlated with patient-reported measures of sexual function.

Growth hormone (GH) supplementation may help to preserve erectile function. We assessed whether serum insulin-like growth factor 1 (IGF-1) levels, a surrogate for GH levels, correlate with sexual function scores in 65 men who completed the Sexual Health Inventory for Men (SHIM) and Expanded Prostate Cancer Index Composite (EPIC) questionnaires, and had serum IGF-1 and testosterone levels determined. Median±s.d. IGF-1 level, SHIM and EPIC scores were 235.0±86.4, 19.5±8.7 and 56.4±28.3 mg ml−1, respectively. IGF-1 levels and total SHIM score correlate significantly (r=0.31, P=0.02), as do IGF-1 levels and all individual SHIM question scores, and IGF-1 levels and the sexual domain of the EPIC questionnaire (r=0.30, P=0.02). No correlation was observed between IGF-1 levels and Gleason score, IGF-1 and testosterone level or SHIM score and testosterone level. These data support a potential role for the GH axis in erectile function.

Correlation Between the European System for Cardiac Operative Risk Evaluation and Sexual Function After Coronary Artery Bypass Graft Surgery

INTRODUCTION The published studies discussing the prognostic factors for expected sexual function after coronary artery bypass graft (CABG) are still limited. AIM Examining the correlation between the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the abridged form of International Index of Erectile Function questionnaire (IIEF-5), as a quick and inexpensive tool for the cardiologist to predict the sexual function after CABG. MAIN OUTCOME MEASURES Validated standardized questionnaire commonly used by cardiologists in identifying appropriate weight to various risk factors related to adult cardiac operations. METHODS Preoperatively patients were evaluated as regards to the sexual function by (IIEF-5) and pharmaco-penile duplex ultrasound. Moreover all patients were evaluated bu EuroSCORE. Six months after surgery, the erectile function of all patients was revaluated according to the same preoperative procedures. The patients were categorized with EuroSCORE as follows: The low-risk group (EuroSCORE 0–2), the medium-risk group (EuroSCORE 3–5), and the high-risk group (EuroSCORE 6 plus). RESULTS The EuroSCORE was negatively correlated with the IIEF-5 score (r = -0.224, P = 0.025 or rs = -0.259, P = 0.009). Moreover, low-risk patients had significantly higher IIEF-5 scores compared with medium-risk patients (mean standard deviation = 15.27 6.03 vs. 12.18 6.07, P < 0.05). CONCLUSIONS There is an inverse correlation between the components of EuroSCORE and the IIEF-5 score. Patients with higher EuroSCORE had lower IIEF-5 scores and vice versa. The EuroSCORE is a useful, quick, and inexpensive tool that allows prediction of ED in those patients with coronary artery disease patients who are undergoing CABG.

T09-O-33 Vascular risk factors as predictors for the sexual function following coronary artery bypass surgery

Introduction and objective Massachusetts Male Aging Study’ and the ‘Cologne Male Survey’ revealed an association of cardiovascular risk factors and ED with a prevalence of 30–75%of ED in cardiovascular high-risk patients. Coronary artery bypass grafting (CABG) is the gold standard for surgical myocardial revascularization. The published studies discussing the predictor factors of the future sexual function following CABG is limited. We herein evaluate the impact of vascular risk factors on the future sexual functions after CABG. Methods The study included 100 patients who underwent CABG. The patients were evaluated by abridged form of International Index of Erectile Function questionnaire (IIEF-5), Pharmaco-Penile Duplex Ultrasound. The patients were underwent CABG, six months later the erectile function of all patients was revaluated according to the same preoperative procedures. Results Preoperatively there was a significant correlation between age, diabetes mellitus, hypertension, hyperlipidemia and IIEF-5 scores (p Diabetes mellitus showed a positive correlation with the change in IIEF-5 scores after surgery (p Conclusions Only DM may predict the future sexual function in patients undergo CABG.

T09-O-32 Does EuroSCORE predict sexual function after cardiac surgery?

Introduction and objective Erectile dysfunction (ED) shared risk factors with coronary artery diseases (CVD). Coronary artery bypass grafting (CABG) is the standard for surgical myocardial revascularization. Although there is an association between CAD and ED yet most cardiologists do not ask about ED. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) gives appropriate weight to various risk factors in adult cardiac operations. We herein evaluate using the EuroSCORE in predicting the sexual function in patients undergo CABG. Methods The study included 100 patients who underwent CABG. The patients were evaluated by abridged form of International Index of Erectile Function questionnaire (IIEF-5), Pharmaco-Penile Duplex Ultrasound and finally by the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Six months after surgery all patients were revaluated according to the same preoperative procedures. Results The EuroSCORE results showed that 56/ 100 patients were low risk patients while 44/ 100 were medium risk patients. Preoperatively the EuroSCORE showed significant negative correlation to the IIEF-5 score (r = -0.229, p Conclusion We can conclude that the EuroSCORE is a useful, quick and inexpensive tool for prediction of ED in patients who undergoing CABG.

T09-P-09 Artery size hypothesis, does it exist?

Introduction Erectile dysfunction (ED) is related to atherosclerosis risk factors. Of clinical importance is the potential link between ED and coronary artery disease (CAD). Montoresi and his collegues 2004 proposed a pathophysiological mechanism termed the ‘artery-size hypothesis’ to explain the link between ED and CAD. They also postulated that if this hypothesis holds true, the chance of a patient with proved CAD having concomitant erectile dysfunction should be high. Moreover symptoms of ED should come before CAD symptoms. We evaluated this theory by detecting the distribution of ED in CAD patients and the onset of ED in relation to the occurrence of the first cardiac attack. Methods The present study included 100 patients with established ischemic heart disease. The patients were evaluated by abridged form of International Index of Erectile Function questionnaire (IIEF-5), Pharmaco-Penile Duplex Ultrasound. Results The results of the IIEF-5 questionnaire demonstrated 20/100 patients showed normal results while 80/100 patients showed ED. Among patients with ED (57.5%) reported the onset of ED before the occurrence of the first cardiac attack by a period of time ranging from 3 months to 10 years while (42.5%) experienced ED after the first cardiac attack in a period of 15 days to one year. Penile duplex results showed significantly higher incidence of arteriogenic factor (57 patients) compared to either venocclusive dysfunction (17 patients) or normal duplex results ( 6 patients) (p Conclusion We conclude that “artery size hypothesis” could explain the relation between the ED and the CAD.