Steven P. Petrou

CHRONIC TREATMENT WITH FINASTERIDE DAILY DOES NOT AFFECT SPERMATOGENESIS OR SEMEN PRODUCTION IN YOUNG MEN

PURPOSE Finasteride, an oral type 2, 5alpha-reductase inhibitor, is used in 1 mg. daily doses for the treatment of male pattern hair loss. A dose of 5 mg. finasteride daily reduces ejaculate volume by approximately 25%, and reduces prostate volume by approximately 20% and serum prostate specific antigen (PSA) by approximately 50% in men with benign prostatic hyperplasia. To our knowledge no data exist on the effect of 1 mg. finasteride daily on ejaculate volume or other semen parameters, or on the prostate in young men. Therefore, we studied the potential effect and reversibility of effect of 1 mg. finasteride daily on spermatogenesis, semen production, the prostate and serum PSA in young men. MATERIALS AND METHODS In this double-blind, placebo controlled multicenter study 181 men 19 to 41 years old were randomized to receive 1 mg. finasteride or placebo for 48 weeks followed by a 60-week off-drug period. Of the 181 men 79 were included in a subset for the collection and analysis of sequential semen samples. RESULTS There were no significant effects of 1 mg. finasteride on sperm concentration, total sperm per ejaculate, sperm motility or morphology. Ejaculate volume in subjects on finasteride decreased 0.3 ml. (-11%) compared to a decrease of 0.2 ml. (-8%) for placebo, with a median between treatment group difference of -0.03 ml. (1%, 90% confidence interval -10.4 to 13.1, p = 0.915). There were significant but small decreases in prostate volume (-2.6%) and serum PSA (-0.2 ng./ml.) in the finasteride group, which reversed on discontinuation of the drug. CONCLUSIONS Treatment with 1 mg. finasteride daily for 48 weeks did not affect spermatogenesis or semen production in young men. The effects of 1 mg. finasteride daily on prostate volume and serum PSA in young men without benign prostatic hyperplasia were small and reversible on discontinuation of the drug.

The evaluation and treatment of nocturia: a consensus statement

What’s known on the subject? and What does the study add?

Systematic transperineal ultrasound guided template biopsy of the prostate in patients at high risk.

PURPOSE A negative biopsy result does not necessarily equate with cancer in specific high risk groups. We describe an alternative systematic biopsy technique for evaluating this subgroup of patients. MATERIALS AND METHODS From March 1997 to May 1999 a total of 88 men underwent systematic ultrasound guided biopsy using the transperineal template technique. All patients had undergone at least 1 and 75 (85%) had undergone 2 or more previous sets of biopsies. In addition, study inclusion required high risk parameters, including prostate specific antigen (PSA) velocity greater than 0.75 ng./ml., PSA greater than 10 ng./ml. or previous prostatic intraepithelial neoplasia on biopsy, and/or atypical small cell acinar proliferation. RESULTS Cancer was identified in 38 of the 88 men (43%) in this high risk subgroup undergoing repeat biopsy. A mean of 15.1 previous biopsy cores had been obtained. The most common biopsy grade was 6 (range 4 to 9). Adenocarcinoma was identified in the transition zone area in 29 of 38 cases (76%), including 15 (39%) in which disease was detected in the transition zone only. Persistent PSA acceleration greater than 0.75 ng./ml. was the major indicator for transperineal template biopsy in 83 of the 88 patients (94%). The only significant independent variable predictive of positive biopsy was prostate volume. Mean prostate volume in the positive and negative biopsy groups was 48 and 73 gm., respectively (p <0.001). Complications were rare and self-limiting, consisting primarily of hematuria and urinary retention requiring overnight catheterization in 2 patients. CONCLUSIONS Systematic transperineal template biopsy of the prostate is a safe and precise repeat biopsy technique in patients who remain at high risk for adenocarcinoma.

COMPLICATIONS AND INITIAL CONTINENCE RATES AFTER A REPEAT PUBOVAGINAL SLING PROCEDURE FOR RECURRENT STRESS URINARY INCONTINENCE

PURPOSE We evaluated the safety and efficacy of repeat pubovaginal sling procedures for recurrent stress urinary incontinence. MATERIALS AND METHODS We retrospectively reviewed the records of 14 patients in whom an initial suburethral sling procedure failed, who then underwent a repeat pubovaginal sling procedure for recurrent stress urinary incontinence at our institution and who were available for followup evaluation. Mean followup after re-operation was 17 months (range 5 to 41). The response to surgery was assessed using the Blaivas-Groutz anti-incontinence surgery response score. RESULTS There were no intraoperative complications. Mean blood loss was 155 cc (range 50 to 750) and average operative time was 101 minutes (range 80 to 145). Long-term urinary retention developed in 1 of the 14 patients (7%). There were no deaths. Two patients (14%) had postoperative complications, including a pelvic abscess and osteomyelitis pubis in 1 each. Based on the Blaivas-Groutz anti-incontinence scale 7 of the 14 patients (50%) were cured, 1 (7%) had a good response, 4 (29%) had a fair response, 2 (14%) had a poor response and none had treatment failure. Subjectively 12 of the 14 women (86%) considered themselves cured or improved and 2 (14%) considered the operation to have failed. CONCLUSIONS Our data imply that a repeat pubovaginal sling procedure after an initial failed operation is associated with low complication and acceptable continence rates. It should be considered a reasonable treatment option in select women with recurrent stress urinary incontinence.

RATE OF RECURRENT STRESS URINARY INCONTINENCE AFTER RETROPUBIC URETHROLYSIS

PURPOSE We determined the rate of recurrent female stress urinary incontinence after retropubic urethrolysis without a concomitant anti-incontinence procedure. MATERIALS AND METHODS We reviewed the charts of all women who underwent urethrolysis at our institution for urethral obstruction due to an anti-incontinence procedure. The study was limited to patients who underwent retropubic urethrolysis without a synchronous anti-incontinence operation or interposition flap inlay for obstruction associated with a suburethral sling. Variables reviewed included the history of urethrolysis, success of retropubic urethrolysis and incidence of urinary incontinence after the operation. RESULTS A total of 12 patients met our study criteria, of whom 1 had stress urinary incontinence before retropubic urethrolysis. Of the 12 patients 10 achieved a successful result after urethrolysis and 2 achieved improvement but not success secondary to urinary urge incontinence. Protective padding was needed postoperatively for urinary incontinence in 5 of the 12 cases, including 3 (25%) and 2 (17%) due to stress and urgency incontinence, respectively. New onset stress urinary incontinence developed postoperatively in 2 of the 11 patients (18%) who did not have stress urinary incontinence before retropubic urethrolysis. A history of failed urethrolysis did not significantly increase the urinary incontinence rate postoperatively. CONCLUSIONS Although retropubic urethrolysis has a high potential success rate for resolving urethral obstruction, it may cause a higher incidence of recurrent stress urinary incontinence than transvaginal approaches. There is no clear need for a synchronous anti-incontinence procedure at the time of retropubic urethrolysis.

Robotic-assisted Bladder Diverticulectomy: Tips and Tricks

INTRODUCTION The da Vinci Surgical System has become extremely popular in the field of urology for procedures requiring complex reconstructive maneuvers, such as radical prostatectomy and pyeloplasty. A natural extension of these procedures is the use of the da Vinci system for complex urinary tract reconstruction deep in the pelvis, such as bladder diverticulectomy. TECHNICAL CONSIDERATIONS In our report and accompanying Video, we have demonstrated some technical tips and tricks with regard to patient selection, preoperative imaging, patient positioning, port placement, intraoperative diverticulum recognition/excision, and cystotomy repair that the surgeon might find beneficial for successful completion of robotic-assisted bladder diverticulectomy. CONCLUSIONS The tips and tricks we have presented might aid in the successful completion of robotic bladder diverticulectomy.

Botulinum A Toxin/Dimethyl Sulfoxide Bladder Instillations for Women With Refractory Idiopathic Detrusor Overactivity: A Phase 1/2 Study

We completed a phase 1/2 trial to evaluate the safety and potential efficacy of direct intravesical instillation of a botulinum type A toxin/dimethyl sulfoxide (DMSO) solution for treatment of idiopathic detrusor overactivity in women. Twenty-five women with medication-resistant, urodynamic-confirmed idiopathic detrusor overactivity were enrolled. A total of 9 patients were treated in phase 1 of the study. Three patients were given a 66% dosing of solution; 22 patients received the full 300 units of botulinum toxin and 50 mL of DMSO (50% concentration). Adverse effects, 24-hour pad weights, episodes of incontinence, postvoid residuals, and scores on the Blaivas-Groutz anti-incontinence scale, Indevus Urgency Severity Scale, Incontinence Impact Questionnaire-short form, and Urogenital Distress Inventory (6 items) questionnaire were recorded at baseline, 1 month, and 3 months after instillation. No serious adverse effects or clinically important increases in postvoid residual occurred. Among the 21 women who completed phase 2 of the study, the median number of incontinent episodes decreased from 4 at baseline to 2 at 1 month ( P =.004) and increased to 4 at 3 months ( P =.81). Median scores improved from baseline to 1 month on the Incontinence Impact Questionnaire (from 13 to 7; P =.007) and Urogenital Distress Inventory (from 10 to 5; P =.003). Although 11 women (52%) reported severe urgency based on the Indevus Urgency Severity Scale at baseline, only 1 (5%; P P =.004) women reported severe scores at 1 and 3 months, respectively. Direct instillation of botulinum toxin/DMSO solution is safe. Its promising clinical effect warrants further evaluation in a randomized, placebo-controlled phase 3 setting.

Martius Flap Harvest Site: Patient Self-Perception

PURPOSE We elucidated patient perception of the external genitalia after Martius flap harvesting. MATERIALS AND METHODS We identified 8 women in whom a Martius interposition flap was used in association with transvaginal urethrolysis. Patients were contacted by an independent nurse and asked to evaluate the cosmetic appearance of the labium majus harvest site. They were also queried on any associated pain, numbness or altered sensation, or perceived interference with vaginal sexual relations. RESULTS Of the 8 patients 2 (25%) believed that the harvest site appeared to be identical to its preoperative appearance, 2 (25%) believed that there were only minimal changes from the preoperative appearance, 1 (12%) believed that it appeared markedly different from the contralateral side and 3 (38%) stated that they had never performed self-examination. Of the 8 patients 1 (13%) complained of dyspareunia, 3 (38%) had intermittent discomfort in the harvest area 1 year after the operation and 5 (62%) perceived permanently decreased sensation or numbness at the harvest site. CONCLUSIONS The Martius flap is not associated with a significant amount of perceived cosmetic disfigurement. It has relatively little effect on sexual relations. Postoperatively discomfort is minimal but there may be associated numbness or decreased sensation at the harvest site.

VALSALVA LEAK POINT PRESSURE AND BLADDER VOLUME

Twenty‐nine females with stress urinary incontinence (SUI) were evaluated with fluoro‐urodynamics, including Valsalva leak point pressure (VLLP) determinations. VLPP was determined at bladder volumes of 150 ml, 300 ml, and total bladder capacity. The VLPP determinations were analyzed using the signed rank and sign tests. Fluoroscopy was used to analyze change in type of SUI based on bladder volume. No significant difference in VLPP determinations was noted at various bladder volumes. No change in type of SUI was noted at various bladder volumes. We believe the volume in the bladder does not alter the category of SUI or statistically change the VLPP determination. Neurourol. Urodynam. 17:3–7, 1998.

VLPP in the evaluation of the female with stress urinary incontinence.

Abstract: The Valsalva leak-point pressure has become an important urodynamic test in the evaluation of incontinent women. A review of the history of the test, its methodology, and variables that can influence its performance is presented. Correlation with clinical findings, reproducibility and comparison with other urodynamic tests are discussed. Although the test is still evolving and several major variables have been recognized as affecting its results, it remains sound and reliable. It has excellent correlation with the clinical severity of incontinence and a high degree of inter- and intraexaminer reproducibility.