Paul F. Engelhardt

Iontophoresis for treatment of Peyronie's disease

PURPOSE We evaluate the efficacy of iontophoresis of dexamethasone, lidocaine and verapamil to treat Peyronies disease. MATERIALS AND METHODS In an uncontrolled prospective study 100 unselected patients with Peyronies disease were treated with 3 weekly courses of iontophoresis. The drug mixture was administered by an electrical current of 5 mA. and a self-adhesive receptacle fixed to the penile skin overlying the plaque. RESULTS Resolution of pain was observed in 96% of patients, plaque diminution in 53% and improvement of penile deviation in 37%. Impaired sexual function was improved in 19 of 43 patients (44%). The benefit of iontophoresis therapy was more pronounced in patients with a short history of disease. Because of lack of side effects and painless administration iontophoresis was well tolerated and accepted by all patients. CONCLUSIONS Iontophoresis of dexamethasone, lidocaine and verapamil may be regarded as first line nonsurgical treatment for Peyronies disease.

Unilateral or bilateral testicular biopsy in the era of intracytoplasmic sperm injection.

PURPOSE Intracytoplasmic sperm injection has significantly improved the treatment of male infertility. Since only single vital spermatozoa are required for successful fertilization, the value of unilateral or bilateral diagnostic testicular biopsies in patients with azoospermia is controversial. We evaluated differences in bilateral testicular biopsies in azoospermic patients with regard to testicular histology and focal spermatogenesis. MATERIALS AND METHODS Histopathological results of 100 testicular biopsies from 50 patients (mean age 33.3 years) were reviewed. In all cases azoospermia was the indication for diagnostic testicular biopsy. Intra-individual differences of bilateral testicular biopsies were retrospectively reviewed by determining the latest stage of spermatogenesis. RESULTS After bilateral biopsy a difference in testicular histology was found in 28% and identical histopathology was noted in 70% of patients. An unsuspected burned out seminoma with maturation arrest in the contralateral testis was seen in 2% of cases. Testicular symmetry determined by a Prader orchidometer was noted in 54.8% of patients whereas 45.2% had asymmetrical testis. The frequency of divergent histopathologies in relation to testicular symmetry was 21.7 and 26.3%, respectively. Spermatozoa were found in 42% of right and 44% of left testes (p >0.05), and spermatids as the latest stage of differentiation were detected in 14 and 16%, respectively (p >0.05). Differentiation of testicular histologies according to the side of biopsy revealed spermatozoa and/or spermatids in 56% of right and 58% of left testes (p >0.05). Bilateral biopsies increased the detection of focal spermatogenesis to 68%. If only unilateral diagnostic testicular biopsies had been performed, in 20% of patients focal spermatogenesis in the contralateral testis would have been missed. CONCLUSIONS Bilateral testicular biopsies are superior to unilateral biopsies in the evaluation of patients with azoospermia. A 28% intra-individual difference in testicular pathology was seen after bilateral biopsies, and in 20% of patients focal spermatogenesis would have been missed after unilateral biopsy only. Due to the prognostic relevance of testicular biopsies for successful sperm retrieval before assisted reproduction, bilateral diagnostic testicular biopsies are recommended in the evaluation of patients with azoospermia.

Chronic asymptomatic inflammation of the prostate type IV and carcinoma of the prostate: Is there a correlation?

Abstract Objective. The aim of this study was to detect possible correlations between chronic asymptomatic inflammation of the prostate type IV and prostate cancer in patients undergoing radical prostatectomy (RPE). Material and methods. Between January and December 2010, 57 RPE specimens were prospectively evaluated with regard to histological signs of chronic inflammation. This RPE group was compared to specimens of 82 men undergoing transurethral resection of the prostate (TURP) or transvesical enucleation (TVE) of a benign prostate (BPH group). To characterize inflammatory changes, inflammatory “hot spots” were defined according to the histological criteria of Irani et al. (J Urol 1997;157:1301–3). Total prostate-specific antigen (PSA), cholesterol, triglycerides, uric acid, International Prostate Symptom Score and body mass index (BMI) were evaluated preoperatively and were correlated to the histological findings. Results. Chronic inflammation was verified in 43.86% of the RPE group, compared to 70.74% of the BPH group (p < 0.001). Multivariate analysis found a significant correlation between older patients and the inflammation score (p < 0.03) and prostate volume (p < 0.03). There was no difference in the PSA values between the inflammation and non-inflammation groups: mean PSA was 5.7 vs 6.1 ng/ml in the RPE group (p < 0.89), and 2.8 vs 2.9 ng/ml in the BPH group (p < 0.94). Gleason score distribution (5–9) and tumour stage (TNM) were similar in the inflammation and non-inflammation groups (p < 0.99, p < 0.21). Conclusions.No significant correlation between chronic prostatic inflammation and carcinoma of the prostate was detected. Contrary to expectations, a significantly higher score of inflammatory changes was found in BPH patients; also, total PSA levels were lower in the inflammation group.

Effects of One-Year Treatment with Isoflavone Extract from Red Clover on Prostate, Liver Function, Sexual Function, and Quality of Life in Men with Elevated PSA Levels and Negative Prostate Biopsy Findings

OBJECTIVES To asses the effect of an isoflavonoid extract from red clover on the prostate, liver function, quality of life, and sexual function in men with an initial elevated prostate-specific antigen (PSA) level and negative prostate biopsy findings during a 1-year treatment period. METHODS A total of 20 men (mean age 65 years) were treated with a daily 60-mg dose of an isoflavone extract for 1 year. Liver function, sexual hormone levels (total testosterone, estrogen, luteotropic hormone, follicle-stimulating hormone, and dehydroepiandrosterone sulfate), transrectal ultrasonography volumetry of the prostate, PSA level, International Prostate Symptom Score, and International Index of Erectile Function score were recorded at the beginning of the study and every 3 months for 1 year. RESULTS The average PSA level was 10.16 ng/mL at baseline versus 7.15 ng/mL after 12 months, for a statistically significant reduction of 33% (P <0.019). The mean prostate volume had decreased slightly from 49.3 cm3 to 44.3 cm3 after 12 months (P <0.097). The sexual hormone levels did not change throughout the study. We registered a significant increase in all three liver transaminases after 3 months (P <0.001). The International Prostate Symptom Score showed a mean value of 7.9 at baseline and 6.68 after 12 months (P <0.421). Sexual function was not influenced by the treatment. CONCLUSIONS Daily oral administration of 60 mg of an isoflavone extract was well tolerated and caused no side effects. The significant increase in liver transaminases and the significant decrease in total PSA levels by >30% indicates that patients, general practitioners, and urologists should be informed about these potential effects of red clover extracts and possibly other phytoestrogens, on liver transaminases and elevated total PSA levels.

Immunohistochemical expression of interleukin-2 receptor and interleukin-6 in patients with prostate cancer and benign prostatic hyperplasia: Association with asymptomatic inflammatory prostatitis NIH category IV

Abstract Objective. This study prospectively investigated the immunohistochemical expression of interleukin-2 receptor (IL-2R) and interleukin-6 (IL-6) in patients with prostate cancer and benign prostatic hyperplasia (BPH), and a possible association of these conditions with asymptomatic inflammatory prostatitis National Institutes of Health (NIH) category IV. Materials and methods. The study included 139 consecutive patients who underwent transurethral resection of the prostate and transvesical enucleation of the prostate (n = 82) or radical prostatectomy (n = 57). To characterize inflammatory changes the criteria proposed by Irani et al. [J Urol 1997;157:1301–3] were used. IL-2R and IL-6 expression was studied by a standard immunohistochemical method. Results were correlated with tumour, node, metastasis stage, Gleason scores, total prostate-specific antigen, International Prostate Symptom Score and body mass index. Results. IL-2R and IL-6 expression was significantly higher in neoplastic prostate cancer tissue than in normal tissue of prostate cancer patients (p < 0.001 and p < 0.04, respectively). Prostate cancer patients with prostatitis showed significantly higher IL-2R expression than those without inflammation (p < 0.03). In patients with BPH, expression of IL-2R as well as IL-6 was higher in patients with prostatitis than in those without (p < 0.01 and p < 0.02, respectively). Conclusions. IL-2R and IL-6 expression was significantly higher in prostate cancer tissue than in normal tissue. Patients with asymptomatic inflammatory prostatitis NIH category IV showed significantly greater activity.

Percutaneous Radiofrequency Ablation of Renal Tumors: A Single-Center Experience

Purpose To evaluate the oncological outcomes, complications, and changes in renal function in patients treated with computed tomography-guided percutaneous radiofrequency ablation (RFA) for small renal tumors. Materials and Methods The charts of patients who underwent RFA from 2006 to 2011 at a single institution were reviewed. Oncological and functional outcomes were assessed. Statistical analyses were performed with IBM SPSS ver. 18.0 (IBM Co., Armonk, NY, USA). Results A total of 44 RFAs were done in 40 patients. Biopsy prior to RFA was performed in 79.6% of procedures. Of those, 68.6% had renal cell carcinoma (RCC). Mean tumor diameter was 26.2 mm. Grade I complications occurred in 25% of cases (n=11, pain or elevated temperature) and grade II complications in 2.3% (n=1, perirenal bleeding needing two units of blood transfusion). Serum creatinine slightly increased by 0.14 mg/dL at 2 years after RFA (p<0.004). Tumor recurrences were suspected in 8 of 43 cases during follow-up. In five patients, the suspected recurrence was a false-positive as shown by a negative biopsy result or lack of contrast enhancement on subsequent imaging. The verified recurrence rate was 7.7% in all tumors and 2.5% in RCC at a mean follow-up of 2 years. Tumor-free survival was 90% in all patients and 87.5% in those with RCC. Metastasis-free survival was 97.5% and cancer-specific survival was 100%. Conclusions Percutaneous computed tomography-guided RFA shows promising results at intermediate follow-up. Suspected tumor recurrences are frequently false-positives findings. A longer follow-up is required to verify the durability of these results.

A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal

ObjectiveTo evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal.Materials and methodsA decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA).ResultsStone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure.ConclusionSemirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Tumor necrosis factor-α expression in patients with obstructive benign prostatic hyperplasia is associated with a higher incidence of asymptomatic inflammatory prostatitis NIH category IV and prostatic calcification

Abstract Objective. The aim of this study was to investigate the association of the expression of tumor necrosis factor-α (TNF-α) with asymptomatic inflammatory prostatitis National Institutes of Health (NIH) category IV and prostatic calculi, in patients with obstructive benign prostatic hyperplasia (BPH) treated by transurethral electroresection of the prostate (TURP). Materials and methods. Ninety-six patients with obstructive BPH and TURP were evaluated in a prospective study. Based on a preoperative transrectal ultrasound examination of the prostate gland, patients were divided into two groups, one with prostatic calculi (n = 31) and one without (n = 65). Prostatitis NIH category IV was classified according to Irani’s histological grading system (Irani et al. J Urol 1997;157:1301–3). Associations between the incidence of prostatic calculi, histological prostatitis, TNF-α expression, prostate-specific antigen, uric acid, cholesterol, triglycerides, C-reactive protein, International Prostate Symptom Score (IPSS), the International Index for Erectile Function (IIEF-5) and the NIH-Chronic Prostatitis Symptom Index Score (NIH-CPSI) were analyzed. Results. Prostatitis was confirmed by histological investigation in 71.9% of patients: 83.9% of those with prostatic calculi versus 66.1% of those without (p < 0.04). TNF-α expression was significantly higher in patients with prostatic calculi. Association calculations yielded significant values for the severity (histological grading) of inflammation (p < 0.029), TNF-α expression (p < 0.007), uric acid (p < 0.005), cholesterol (p < 0.028) and the NIH-CPS subdomain of urinary symptoms (p < 0.044) in patients with prostatic calculi. Conclusions. In patients with obstructive BPH, prostatic calculi were found on ultrasound in one-third of the cases, and histological NIH category IV prostatitis in two-thirds of cases. The incidence of both prostatitis NIH category IV and TNF-α expression was significantly higher in patients with prostatic calculi than in those without.

Trends in the Utilization of Percutaneous and Open Nephrolithotomy in the Treatment of Renal Calculi

PURPOSE To evaluate trends in the use of percutaneous nephrolithotomy (PCNL) and nephrolithotomy (NL) in patients with renal pelvis calculi. MATERIALS AND METHODS An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007, and 2010) was performed to assess changes in the use of PCNL and NL over a 10-year period. Patients were identified using the International Classification of Diseases-9 (cm) and Current Procedure Terminology codes. Statistical analyses, including the Fisher and chi-square tests and multivariate regression analyses, were performed using SAS 9.3 (SAS Institute Inc, Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). RESULTS A total of 26,100 patients underwent either PCNL or NL. Use of PCNL and NL decreased from 3.1% to 2.5% in patients with a diagnosis of stones (P<0.0001). Women (odds ration [OR]=1.19, P=0.003) were more likely to undergo surgery. Patients aged ≥65 years were less likely to be treated (OR=0.65-0.71, P<0.05). Patients treated after 2004 were less likely to undergo surgery (OR=0.77-0.84, P<0.05). The use of PCNL exceeded NL at a stable 10:1 ratio. CONCLUSIONS The use of PCNL and NL for treatment of patients with stone disease slightly decreased from 2001 to 2010, although the number of patients with renal calculi increased. The use of PCNL vs NL was unchanged during this period. Multiple inequalities existed in overall surgical treatment rates and were influenced by sociodemographic factors such as age and sex.

Impact of hours worked by a urologist prior to performing ureteroscopy on its safety and efficacy

Abstract Objective: The aim of this study was to evaluate the impact of hours worked by a urologist before performing ureteroscopy on its safety and efficacy. Materials and methods: Patients treated at a single institution from January 2010 to December 2013 were analyzed. The study assessed patient, stone and surgical parameters, stone-free rates and intraoperative complications performed in three work duration categories: less than 6 h, 6–12 h and more than 12 h of urologist’s work. Statistical analyses included the chi-squared test, Kruskal–Wallis test, and univariate and multivariate logistic regression analyses. Results: In total, 469 ureteroscopies were analyzed. Intraoperative complications differed non-significantly in the corresponding time categories: ureteral perforations (< 6 h 4.4%, 6–12 h 3.2%, > 12 h 7%, p = 0.46) and avulsions (all 0%). Rates for complete stone removal were 82% within the first 12 h vs 70.2% after 12 h (p = 0.03). Corresponding partial stone-free rates were 4.1% vs 3.5% (p = 0.83) and rates of unsuccessful ureteroscopy were 13.8% vs 26.3% (p = 0.01). In multivariate regression analysis, patients treated after 12 h of urologist’s work had a 2.4 times higher risk of an unsuccessful ureteroscopy [odds ratio (OR) = 2.4, 95% confidence interval (CI) 1.2–4.7, p = 0.001] and lower chances of complete stone removal (OR = 0.46, 95% CI 0.24–0.89, p = 0.02). The odds of ureteral perforations were similar (p = 0.28). Conclusion: Work duration before ureteroscopy did not affect its safety. Stone-free rates decreased with increasing working time. Working time exceeding 12 h was identified as an independent risk factor for impaired stone-free rates.