Ross Simon

The Association of Exercise with Both Erectile and Sexual Function in Black and White Men

INTRODUCTION There is growing interest in using exercise to treat. Although many studies have highlighted the relationship between better erectile function and exercise, black men have been underrepresented in the literature. AIMS This study aims to determine whether or not exercise is associated with better erectile as well as sexual function in black men and define a minimum exercise threshold for which better erectile/sexual function is seen in a cross-sectional study. METHODS Our study population consisted of 295 healthy controls from a case-control study assessing risk factors for prostate cancer conducted at the Durham Veterans Affairs Medical Center, which contained a substantial proportion of black men (n = 93; 32%). Exercise and erectile/sexual function were both determined from self-reported questionnaires. Subjects were stratified into four exercise groups: <3 (sedentary), 3-8.9 (mildly active), 9-17.9 (moderately active), and ≥18 (highly active) metabolic equivalents (MET) hours/week. The association between exercise and erectile/sexual function was addressed utilizing multivariable linear regression analyses. MAIN OUTCOME MEASURES Erectile/sexual function was defined by the validated Expanded Prostate Cancer Index Composite sexual assessment, which was analyzed as a continuous variable (sexual function score). Clinically significant better function was defined as half a standard deviation (SD) (16.5 points). RESULTS Median sexual function score was 53 (SD = 33). Higher exercise was associated with a better sexual function score (P < 0.001). Importantly, there was no interaction between black race and exercise (P-interaction = 0.772), meaning more exercise was linked with better erectile/sexual function regardless of race. Overall, exercise ≥18 MET hours/week predicted better erectile/sexual function (P < 0.001) with a clinically significant 17.3-point higher function. Exercise at lower levels was not statistically (P > 0.147) or clinically (≤8.14 points higher function) associated with erectile/sexual function. CONCLUSIONS In a racially diverse population, exercise ≥18 MET hours/week is highly associated with better erectile/sexual function regardless of race.

Tips and Tricks of Inflatable Penile Prosthesis Reservoir Placement: A Case Presentation and Discussion

INTRODUCTION There have been many advances in the inflatable penile prosthesis (IPP) since the 1970s. While these devices were initially fraught with mechanical malfunction, the most recent models prove to be much more reliable. Although reservoir complications are not common, when they do occur, it typically involves damage to the surrounding tissues. The ability to recognize and treat these complications is paramount for any surgeon that routinely places IPPs. AIM The aim of this article was to present a unique reservoir-related complication as well as perform a literature review of reservoir-related complications and techniques for reservoir placement, and provide a summary of dimensions and technical aspects of commonly used reservoirs. METHODS We reviewed a unique reservoir-related complication that presented to our institution with urinary retention and constipation. We also reviewed reservoir-related complications since 1984, reviewed the most recent surgical techniques involved in reservoir placement, and summarized the dimensions and technical characteristics of both the American Medical System and Coloplast reservoirs. MAIN OUTCOME MEASURE A reservoir-related complication that resulted in urinary retention and constipation is the main outcome measure. RESULTS Although uncommon, reservoir complications do occur. The most common case report complication in the published literature is bladder erosion followed by external iliac compression, ileal conduit erosion, and small bowel obstruction. The case that presented at our institution was the result of a reservoir that was improperly placed in the perineum, causing urinary retention and constipation due to the compression of the bulbar urethra and rectum. CONCLUSIONS In this era, mechanical failures of IPP reservoirs are rare as most complications occur due to damage of the surrounding tissues. Prevention, diagnosis, and treatment of these complications are important for any surgeon that implants IPPs.

Do all men with pathological Gleason score 8–10 prostate cancer have poor outcomes? Results from the SEARCH database

To determine whether there are subsets of men with pathological high grade prostate cancer (Gleason score 8–10) with particularly high or low 2‐year biochemical recurrence (BCR) risk after radical prostatectomy (RP) when stratified into groups based on combinations of pathological features, such as surgical margin status, extracapsular extension (ECE) and seminal vesicle invasion (SVI).

Does Prostate Size Predict the Development of Incident Lower Urinary Tract Symptoms in Men with Mild to No Current Symptoms? Results from the REDUCE Trial.

BACKGROUND It has been shown that increased prostate size is a risk factor for lower urinary tract symptom (LUTS) progression in men who currently have LUTS presumed due to benign prostatic hyperplasia (BPH). OBJECTIVE To determine if prostate size is a risk factor for incident LUTS in men with mild to no symptoms. DESIGN, SETTING, AND PARTICIPANTS We conducted a post hoc analysis of the REDUCE study, which contained a substantial number of men (n=3090) with mild to no LUTS (International Prostate Symptom Score [IPSS] <8). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Our primary outcome was determination of the effect of prostate size on incident LUTS presumed due to BPH defined as two consecutive IPSS values >14, or receiving any medical (α-blockers) or surgical treatment for BPH throughout the study course. To determine the risk of developing incident LUTS, we used univariable and multivariable Cox models, as well as Kaplan-Meier curves and the log-rank test. RESULTS AND LIMITATIONS Among men treated with placebo during the REDUCE study, those with a prostate size of 40.1-80ml had a 67% higher risk (hazard risk 1.67, 95% confidence interval 1.23-2.26, p=0.001) of developing incident LUTS compared to men with a prostate size 40.0ml or smaller. There was no association between prostate size and risk of incident LUTS in men treated with 0.5mg of dutasteride. The post hoc nature of our study design is a potential limitation. CONCLUSIONS Men with mild to no LUTS but increased prostate size are at higher risk of incident LUTS presumed due to BPH. This association was negated by dutasteride treatment. PATIENT SUMMARY Benign prostatic hyperplasia (BPH) is a very common problem among older men, which often manifests as lower urinary tract symptoms (LUTS), and can lead to potentially serious side effects. In our study we determined that men with mild to no current LUTS but increased prostate size are much more likely to develop LUTS presumed due to BPH in the future. This association was not seen in men treated with dutasteride, a drug approved for treatment of BPH. Our study reveals that men with a prostate size of 40.1-80ml are potential candidates for closer follow-up.

Adverse pathology and undetectable ultrasensitive prostate-specific antigen after radical prostatectomy: Is adjuvant radiation warranted?

To determine if men with adverse pathology but undetectable ultrasensitive (<0.01 ng/mL) PSA are at high‐risk for biochemical recurrence (BCR), or if there is a subset of patients at low‐risk for whom the benefit of adjuvant radiation therapy might be limited.

Effect of utilization of veno-venous bypass vs. cardiopulmonary bypass on complications for high level inferior vena cava tumor thrombectomy and concomitant radical nephrectomy

ABSTRACT Purpose: To determine if patients with renal cell carcinoma (RCC) with levels III and IV tumor thrombi are receive any reduction in complication rate utilizing veno-venous bypass (VVB) over cardiopulmonary bypass (CPB) for high level (III/IV) inferior vena cava (IVC) tumor thrombectomy and concomitant radical nephrectomy. Materials and Methods: From May 1990 to August 2011, we reviewed 21 patients that had been treated for RCC with radical nephrectomy and concomitant IVC thrombectomy employing either CPB (n =16) or VVB (n=5). We retrospectively reviewed our study population for complication rates and perioperative characteristics. Results: Our results are reported using the validated Dindo-Clavien Classification system comparing the VVB and CPB cohorts. No significant difference was noted in minor complication rate (60.0% versus 68.7%, P=1.0), major complication rate (40.0% versus 31.3%, P=1.0), or overall complication rate (60.0% versus 62.5%, P=1.0) comparing VVB versus CPB. We also demonstrated a trend towards decreased time on bypass (P=0.09) in the VVB cohort. Conclusion: The use of VVB over CPB provides no decrease in minor, major, or overall complication rate. The use of VVB however, can be employed on an individualized basis with final decision on vascular bypass selection left to the discretion of the surgeon based on specifics of the individual case.

Predictors of operative time during radical retropubic prostatectomy and robot‐assisted laparoscopic prostatectomy

To better predict operative time using patient/surgical characteristics among men undergoing radical retropubic prostatectomy or robot‐assisted laparoscopic prostatectomy in order to achieve more efficient operative scheduling and potentially decrease costs in the Veterans Health System.

The association between sexual function and prostate cancer risk in US veterans

Sexual dysfunction and prostate cancer are common among older men. Few studies explored the association between these two illnesses. We examined whether sexual function is associated with prostate cancer risk among older men. Among 448 men undergoing prostate biopsy at the Durham Veterans Affairs Hospital, sexual function was ascertained from the Expanded Prostate Cancer Index Composite sexual assessment. We tested the link between sexual function and prostate cancer risk adjusting for multiple demographic and clinical characteristics using logistic regression. Multinomial logistic regression was used to test the associations with risk of low-grade (Gleason ≤6) and high-grade (Gleason ≥7 or ≥4 + 3) disease versus no cancer. Of 448 men, 209 (47%) had a positive biopsy; these men were less likely to be white (43% vs 55%, P = 0.013), had higher prostate-specific antigen (PSA) (6.0 vs 5.4 ng ml−1 , P < 0.001), but with lower mean sexual function score (47 vs 54, P = 0.007). There was no difference in age, BMI, pack years smoked, history of heart disease and/or diabetes. After adjusting for baseline differences, sexual function was linked with a decreased risk of overall prostate cancer risk (OR: 0.91 per 10-point change in sexual function, P = 0.004) and high-grade disease whether defined as Gleason ≥7 (OR: 0.86, P = 0.001) or ≥4 + 3 (OR: 0.85, P = 0.009). Sexual function was unrelated to low-grade prostate cancer (OR: 0.94, P = 0.13). Thus, among men undergoing prostate biopsy, higher sexual function was associated with a decreased risk of overall and high-grade prostate cancer. Confirmatory studies are needed.

PSA predicts development of incident lower urinary tract symptoms: results from the REDUCE study

BackgroundThe relationship between baseline prostate-specific antigen (PSA) and development of lower urinary tract symptoms (LUTS) in asymptomatic and mildly symptomatic men is unclear. We sought to determine if PSA predicts incident LUTS in these men.MethodsA post-hoc analysis of the 4-year REDUCE study was performed to assess for incident LUTS in 1534 men with mild to no LUTS at baseline. The primary aim was to determine whether PSA independently predicted incident LUTS after adjusting for the key clinical variables of age, prostate size, and baseline International prostate symptom score (IPSS). Incident LUTS was defined as the first report of medical treatment, surgery, or sustained clinically significant symptoms (two IPSS >14). Cox proportional hazards, cumulative incidence curves, and the log-rank test were used to test our hypothesis.ResultsA total of 1534 men with baseline IPSS <8 were included in the study cohort. At baseline, there were 335 men with PSA 2.5–4 ng/mL, 589 with PSA 4.1–6 ng/mL, and 610 with PSA 6–10 ng/mL. During the 4-year study, 196 men progressed to incident LUTS (50.5% medical treatment, 9% surgery, and 40.5% new symptoms). As a continuous variable, higher PSA was associated with increased incident LUTS on univariable (HR 1.09, p = 0.019) and multivariable (HR 1.08, p = 0.040) analysis. Likewise, baseline PSA 6–10 ng/mL was associated with increased incident LUTS vs. PSA 2.5–4 ng/mL in adjusted models (HR 1.68, p = 0.016). This association was also observed in men with PSA 4.1–6 ng/mL vs. PSA 2.5–4 ng/mL (HR 1.60, p = 0.032).ConclusionsMen with mild to no LUTS but increased baseline PSA are at increased risk of developing incident LUTS presumed due to benign prostatic hyperplasia.

Does Peak Urine Flow Rate Predict the Development of Incident Lower Urinary Tract Symptoms in Men with Mild to No Current Symptoms? Results from REDUCE

Purpose: We determined whether decreased peak urine flow is associated with future incident lower urinary tract symptoms in men with mild to no lower urinary tract symptoms. Materials and Methods: Our population consisted of 3,140 men from the REDUCE (Reduction by Dutasteride of Prostate Cancer Events) trial with mild to no lower urinary tract symptoms, defined as I‐PSS (International Prostate Symptom Score) less than 8. REDUCE was a randomized trial of dutasteride vs placebo for prostate cancer prevention in men with elevated prostate specific antigen and negative biopsy. I‐PSS measures were obtained every 6 months throughout the 4‐year study. The association between peak urine flow rate and progression to incident lower urinary tract symptoms, defined as the first of medical treatment, surgery or sustained and clinically significant lower urinary tract symptoms, was tested by multivariable Cox models, adjusting for various baseline characteristics and treatment arm. Results: On multivariable analysis as a continuous variable, decreased peak urine flow rate was significantly associated with an increased risk of incident lower urinary tract symptoms (p = 0.002). Results were similar in the dutasteride and placebo arms. On univariable analysis when peak flow was categorized as 15 or greater, 10 to 14.9 and less than 10 ml per second, flow rates of 10 to 14.9 and less than 10 ml per second were associated with a significantly increased risk of incident lower urinary tract symptoms (HR 1.39, p = 0.011 and 1.67, p <0.001, respectively). Results were similar on multivariable analysis, although in the 10 to 14.9 ml per second group findings were no longer statistically significant (HR 1.26, p = 0.071). Conclusions: In men with mild to no lower urinary tract symptoms a decreased peak urine flow rate is independently associated with incident lower urinary tract symptoms. If confirmed, these men should be followed closer for incident lower urinary tract symptoms.