P. Teloken

Prognostic Impact of Histological Subtype on Surgically Treated Localized Renal Cell Carcinoma

PURPOSEnDespite the clear demonstration that different histological subtypes of renal cell carcinoma show distinct pathogenesis and genetic alterations, the impact of histology on prognosis remains controversial. We evaluated our experience with tumor histology in patients with localized renal cell carcinoma.nnnMATERIALS AND METHODSnWe identified 1,863 patients with localized clear cell, papillary or chromophobe renal cell carcinoma who were treated surgically between 1989 and 2006 at our tertiary care center. Cox proportional hazards regression models were used to evaluate the relationship between tumor histology and outcome, defined as metastasis or death from disease, adjusting for age, sex, operation type, American Society of Anesthesiologists score, TNM stage and tumor size.nnnRESULTSnOf 1,863 patients 1,333 (72%) had clear cell histology, and 310 (17%) and 220 (12%) had papillary and chromophobe renal cell carcinoma, respectively. Median followup in patients without an event was 3.4 years. On univariate analysis patients with clear cell histology had a worse clinical outcome. Five-year probability of freedom from metastasis or death from disease was 86% (95% CI 84, 88), 95% (95% CI 91, 97) and 92% (95% CI 85, 96) in patients with clear cell, papillary and chromophobe histology, respectively (p <0.001). On multivariate analysis chromophobe (HR 0.40; 95% CI 0.20, 0.80) and papillary (HR 0.62; 95% CI 0.34, 1.14) histology was also significantly associated with better outcome (p = 0.014).nnnCONCLUSIONSnClear cell histology seems to be independently associated with worse outcomes in patients who undergo surgery for renal cell carcinoma even after controlling for widely accepted factors influencing prognosis.

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Peyronie's Disease Following Radical Prostatectomy: Incidence and Predictors

INTRODUCTIONnBoth prostate cancer and Peyronies disease (PD) are prevalent in men after their fifth decade of life. The evidence to support or refute a link between radical prostatectomy (RP) and PD is limited.nnnAIMSnTo define the incidence of PD in men who had RP and determine possible predictors of PD development after RP.nnnMETHODSnA review of a prospectively built sexual medicine database, years 2002-2008, looking at subjects who had RP as a monotherapy for localized prostate cancer. We identified and characterized subjects who developed PD within 3 years after RP and compared them with subjects who did not.nnnMAIN OUTCOME MEASURESnThe incidence of PD among men who attended a sexual medicine clinic after they had RP, predictors of PD development after RP.nnnRESULTSnThe study population included 1,011 subjects, and PD incidence in this population was 15.9%. Mean time to develop PD after RP was 13.9 +/- 0.7 months. Mean curvature magnitude was 31 + 17 degrees. On univariate analysis, younger age (mean age of 59 + 7 in men with PD vs. 60 + 7 years in men without PD, P = 0.006) and white race (vs non-white, 18% vs. 7%, P < 0.001) were predictive of PD development after RP, but post-op erectile function was not a predictor of PD development. On multivariate analysis, younger age (odds ratio (OR) = 1.3, for 5-year decrease in age) and white race (OR = 4.1, vs. non-white) remained independent significant predictors.nnnCONCLUSIONSnMen presenting with sexual dysfunction after RP have higher PD incidence then the general population. Therefore, they should be routinely evaluated for PD. Younger men and men of white race are at increased risk for PD. Prospective controlled studies are needed to elucidate the incidence of PD following RP and to conclude if RP has a causative role in the pathogenesis of PD.

Erectile Function Rehabilitation after Radical Prostatectomy: Practice Patterns among AUA Members

INTRODUCTIONnDespite a growing body of evidence supporting erectile function (EF) rehabilitation after radical prostatectomy (RP), there are no guidelines on this subject.nnnAIMnTo explore EF rehabilitation practice patterns of American Urological Association (AUA) urologists.nnnMETHODSnA 35-question instrument was constructed assessing physician demographics, training, and EF rehabilitation practices after RP, and was e-mailed to AUA members by the AUA Office of Education. Data were acquired by the AUA and analyzed by the investigators.nnnMAIN OUTCOME MEASUREnPercentage of responders who recommend EF rehabilitation practices following RP, characterization of prevalent rehabilitation practices.nnnRESULTSnOf the 618 urologists who completed the survey, 71% were in private practice, 28% considered themselves as sexual medicine specialists, although only 4% were fellowship-trained, 43% were urologic oncology specialists (14% fellowship-trained), 86% performed RP, and 86% of responders recommended rehabilitation practices. Being a sexual medicine or a urologic oncology specialist was not predictive of rehabilitation employment. Forty-three percent rehabilitate all patients, 57% only selected patients. Selection for rehabilitation was dependent upon preop EF by 66%, nerve-sparing status by 22%, and age by 5%. Eleven percent started rehab immediately after RP, 97% within 4 months. 24%, 45% and 18% ceased rehab at <12, 12-18, and 18-24 months, respectively. Eighty-nine percent of RP surgeons performed rehabilitation vs. only 66% who do not perform RP (P < 0.0001). Eighty-seven percent prefer phosphodiesterase type 5 inhibitors (PDE5i) as their primary strategy followed (in order) by vacuum erection device (VED), intracavernosal injection (ICI), and urethral suppositories.nnnCONCLUSIONSnAmong the respondents, penile rehabilitation is a common practice. Urologic oncologists and RP surgeons are more likely to use rehabilitation practices. The most commonly employed strategy is regular PDE5i use for 12-18 months after RP. .

Predictors of Response to Sildenafil Citrate Following Radiation Therapy for Prostate Cancer

INTRODUCTIONnPhosphodiesterase type 5 inhibitor (PDE5) use is a treatment strategy for prostate cancer patients with post-radiation therapy (RT) erectile dysfunction (ED).nnnAIMnTo define the predictors of sildenafil response in men treated with RT for prostate cancer.nnnMAIN OUTCOME MEASURESnInternational Index of Erectile Function (IIEF).nnnMETHODSnPatients were enrolled prospectively if they met the following criteria: (i) either a three-dimensional conformal external beam (EBRT) or brachytherapy (BT) with or without androgen deprivation (AD) for prostate cancer; (ii) self-reported ability to have sexual intercourse prior to RT; (iii) experienced onset of ED following RT; (iv) candidates for sildenafil citrate use; (v) followed-up periodically; and (vi) completed the IIEF at least 12 months after RT. Failure to respond to sildenafil was defined as IIEF-erectile function (EF) domain score of <22.nnnRESULTSnOne hundred fifty-two patients met all the criteria: 110 in the EBRT group and 42 in the BT group. Mean age was 62 years. The mean follow-up was 38 months. Mean radiation dose for EBRT was 78 Gy and for BT was 101 Gy. Thirty-five patients received AD, 25% of EBRT, and 62% of BT patients. Sixty-one percent of the patients receiving AD had exposure only pre-RT, whereas 39% had pre- and post-RT AD exposure. The mean duration of AD was 4.6 months. Post-RT IIEF-EF domain score at >24 months was 17. Successful response to sildenafil occurred in 68% of men at 12 months after RT, 50% at 24 months, and 36% at 36 months. On multivariable analysis, predictors of failure to respond to sildenafil were: older age, longer time after RT, AD > 4 months duration, and RT dose > 85 Gy. Modality of radiation delivery was not predictive of sildenafil failure.nnnCONCLUSIONSnA steady decrease in sildenafil response was seen with increasing duration after RT. Several factors were predictive of sildenafil failure.

Exploring the Association Between Erectile Rigidity and Treatment Adherence With Sildenafil

INTRODUCTIONnErection hardness has been shown to correlate with increased self-confidence, sexual satisfaction, and improvement in psychosocial factors such as sexual and overall relationship. It is estimated that one-third of men using phosphodiesterase type 5 inhibitors (PDE5) cease use of medication after one prescription and one-half cease use by 6 months.nnnAIMnThis study was undertaken to explore the link between erection hardness and treatment adherence.nnnMETHODSnMen presenting with erectile dysfunction (ED) who were candidates for PDE5 therapy constituted the study population. They were assessed at the baseline regarding their erectile function (EF) and rigidity using autoquestionnaires. Patients then received regular follow-up using the same assessment tools and were also asked about continued use of PDE5. The final patient assessment was conducted at a time point no sooner than 12 months after commencing PDE5. Multivariable analysis was conducted to define predictors of continued PDE5 use.nnnMAIN OUTCOME MEASURESnPatients were assessed using the International Index of Erectile Function (IIEF) questionnaire and the Erection Hardness Score (EHS). Adherence was defined as continued use of PDE5 at least once per month.nnnRESULTSnOne hundred eighty-six men were analyzed. The mean age and the duration of ED were 61 ± 22 and 2.2 ± 2.9 years, respectively. Sixty-three percent were married or partnered. The mean partner age was 52 ± 8 years. Of the 186 patients, 32% had one vascular comorbidity, 34% had two vascular comorbidities, 26% had three vascular comorbidities, and 6% had ≥ 4 vascular comorbidities. All patients were treated with sildenafil and were sexually active. The mean time to end-of-treatment (EOT) interview and repeat completion of questionnaires was 17 ± 4 months. At the baseline, 26% were EHS 3 (mild ED), 42% were EHS 2 (moderate ED), and 32% were EHS 1 (severe ED). The mean baseline EF domain score was 14 ± 10, and at the EOT, it was 22 ± 5 (P < 0.01). At the follow-up interview, 4% were EHS 1, 12% were EHS 2, 28% were EHS 3, and 56% were EHS 4. Overall, 67% of the men continued to use PDE5 at follow-up. The distribution of patients continuing to use PDE5 after commencement was 15% of those achieving EHS 1, 30% for EHS 2, 66% for EHS 3, and 82% for EHS 4. Based on logistic regression analysis, the factors predictive of continued PDE5 use were being partnered, partner age, frequency of sexual activity, a shift of ≥ 2 points on the EHS, and reaching level 4 on the EHS scale.nnnCONCLUSIONnThere is an excellent relationship between erection hardness and adherence to PDE5 treatment. Driving men to greater erectile rigidity appears to translate into lower dropout rates.

A critical analysis of candidacy for penile revascularization.

INTRODUCTIONnPenile revascularization (PR) is a potentially curative procedure for young men with isolated arteriogenic erectile dysfunction. Standard preoperative evaluation is erectile hemodynamics (HDX) using duplex Doppler penile ultrasound (DUS) and/or cavernosometry (DIC) and assessment of cavernosal arterial anatomy by selective internal pudendal arteriography (SIPA).nnnAIMnThe aim of this study was to review our experience with men who sought a second opinion from us regarding their candidacy for PR.nnnMETHODnStudy population consisted of men (i) who presented to us for a second opinion regarding PR; (ii) who had DUS/DIC and SIPA; and (iii) had been advised by outside surgeon to undergo PR. Review of the HDX study and SIPA was conducted. Discrepancies between these studies resulted in repeating the DIC in men with normal SIPA or repeating the SIPA in men with normal HDX studies.nnnMAIN OUTCOME MEASURESnDiscrepancies between HDX and SIPA and the results of repeat HDX or SIPA were the main outcome measures.nnnRESULTnForty-five patients participated in the study; mean age was 33 years with 4% ≥50 years old. Median vascular risk factor number was 1 (ranged 0-3). A credible trauma history was present in 11%. Thirty-three percent had prior DIC and 49% of patients had a significant discrepancy between HDX study and SIPA, including all patients seen by a community urologist. Thirty-eight percent had a discrepancy between side of abnormality on HDX and SIPA where both studies were abnormal (group A). Seven percent had abnormal HDX and normal SIPA (group B). Four percent had a normal HDX study with an abnormal SIPA (group C). Repeat DIC (nu2009=u200920) was conducted in groups Au2009+u2009B and was normal in 70% of cases. Repeat SIPA (nu2009=u20092) was conducted in group C and was normal in both patients.nnnCONCLUSIONnAlmost one half of patients had a significant discrepancy between HDX and SIPA. Of these, 73% had normal repeat studies, making them no longer candidates for penile revascularization.

Orgasme retardé secondaire : causes, associations et facteurs prédictifs

Objectifs L’Orgasme retarde est une dysfonction sexuelle peu etudiee, tres peu de donnees existent dans la litterature a l’inverse de l’ejaculation precoce. C’est egalement une pathologie tres complexe a traiter et resistante a beaucoup de therapeutiques. L’objectif de cette etude etait d’analyser les causes, les associations et les facteurs predictifs de l’orgasme retarde secondaire. Methodes Etude descriptive analytique d’une base de donnee prospective menee de 2003xa0a 2011. Experience d’un centre specialise en medecine sexuelle. Resultats Deux cent six patients atteints d’un orgasme retarde ont ete analyses ( Tableau 1 ). Soixante-six pour cent n’avaient jamais d’orgasme et 24xa0% occasionnellement avec leur partenaire. Les causes etaientxa0: l’utilisation d’inhibiteurs selectifs de la recapture de la serotonine ISRS (42xa0%), psychogenes (26xa0%), deficit en testosterone (21xa0%), les troubles sensitifs peniens (7xa0%) et la masturbation excessive (2xa0%) ( Fig. 1 ). Parmi ceux qui n’avaient jamais eu d’orgasme avec leur partenaire et qui en avaient toujours avec la masturbation (nxa0=xa034), 24xa0% avaient des troubles sensitifs et 76xa0% des troubles psychologiques. Pour ceux qui n’avaient jamais eu d’orgasme avec leur partenaire et jamais avec la masturbation (nxa0=xa069), 70xa0% avaient des troubles sensitifs. Le fait de ne jamais avoir eu d’orgasme avec la masturbation augmentait le risque par 6xa0de ne jamais avoir d’orgasme avec la partenaire (pxa0 Tableau 2 ). Conclusion Ces donnees illustrent le profil des patients atteints d’orgasme retarde. Les profils des malades exposes par cette etude pourront aider les medecins a definir la cause de cet orgasme retarde. L’utilisation d’ISRI, les troubles sensitifs peniens et l’absence d’orgasme avec la masturbation sont des facteurs predictifs de ne jamais obtenir l’orgasme avec la partenaire.