EFFICACY AND SAFETY OF TRANSURETHRAL ALPROSTADIL IN PATIENTS WITH ERECTILE DYSFUNCTION FOLLOWING RADICAL PROSTATECTOMY

Purpose

A retrospective analysis of the MUSE* clinical trial was performed to evaluate the efficacy and safety of transurethral alprostadil in patients with erectile dysfunction after radical prostatectomy.

Materials and Methods

Patients received doses of transurethral alprostadil in the clinic and those for whom a suitable dose was determined were treated at home with active drug or placebo for 3 months. Patients had undergone radical prostatectomy no less than 3 months before study entry.

Results

Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction 70.3% had an erection believed sufficient for intercourse in the clinic and 57.1% on active medication had sexual intercourse at least once at home. The product of clinic and home success rates (70.3 x 57.1%) was an overall success rate (the likelihood of active treatment to lead to intercourse at home) of 40.1%. The frequency of most adverse effects of radical prostatectomy was comparable to that of other organic etiologies of erectile dysfunction (1,127 patients). The percentage of patients with hypotension in the clinic was lower after radical prostatectomy compared to other erectile dysfunction etiologies (0.8 versus 4.2%, p <0.001) but the percentage of patients with urethral pain/burning was higher (18.3 versus 10.4%, p = 0.027). No urinary tract infection, fibrosis or priapism occurred in the post-radical prostatectomy patients.

Conclusions

Transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy, although psychological changes associated with cancer and surgery may limit home response. The severe neurovascular deficit associated with prostatectomy neither limits the efficacy of transurethral alprostadil nor increases the risks.     

A NEW METHOD FOR THE EVALUATION OF ERECTILE DYSFUNCTION: SILDENAFIL PLUS DOPPLER ULTRASONOGRAPHY

PURPOSE: Of the various methods of hemodynamic studies performed to evaluate erectile dysfunction penile color Doppler ultrasound is currently considered the best. However, intracavernous injection is invasive and has adverse effects, such as prolonged erection. We evaluated whether sildenafil may be used as a substitute for intracavernous agents when assessing impotence on color Doppler ultrasound. MATERIALS AND METHODS: A total of 42 patients with erectile dysfunction underwent color Doppler ultrasound before and after intracavernous injection of 60 mg. papaverine with genital and audiovisual sexual stimulation. Peak flow and end diastolic velocity were measured in the recorded waveforms obtained 0, 1, 5, 10 and 20 minutes after injection. The patients also underwent color Doppler ultrasound after a 50 mg. oral dose of sildenafil with genital and audiovisual sexual stimulation not before 3 days after the papaverine study. The same parameters were measured at 30, 45, 60, 75 and 90 minutes, and compared with the values obtained after papaverine injection. RESULTS: Mean peak flow velocity significantly increased after oral sildenafil starting at 30 minutes and achieving a maximum value at 60 minutes. There were no significant differences in the 2 methods in mean peak velocity 1, 5, 10 and 20 minutes after papaverine injection, and 30, 45, 60, 75 and 90 minutes after oral sildenafil administration. Penile color Doppler ultrasound with intracavernous papaverine injection is accepted as the gold standard but color Doppler ultrasound with sildenafil has 90% sensitivity and 100% selectivity for demonstrating arterial insufficiency. Due to prolonged erection 5 patients (11.9%) in the papaverine group required pharmacological detumescence by intracavernous injection. No adverse effects of sildenafil were observed. CONCLUSIONS: Sildenafil administration achieved increased peak flow velocity comparable to that after intracavernous papaverine injection. With no prolonged erection sildenafil emerges as a safer alternative compared to more invasive intracavernous injection.     

彩超辅助下的皮下深部软组织内海绵状血管瘤的诊治

目的　准确、有效地对皮下深部软组织内海绵状血管瘤进行诊治。方法　 1996年以来对 15例海绵状血管瘤患者采用彩色多普勒超声仪 (CD)确定血管瘤的诊断、定位 ;并在直接引导下行铜针栓塞治疗或者手术切除治疗。术后 2周～ 1年再以 CD对治疗效果进行判定与监测。结果　 10例患者行直接引导下铜针穿刺 ,2例在 CD引导下直接铜针穿刺进行栓塞治疗 ,3例患者经手术切除 ,均取得满意效果。结论　在非创伤性的 CD辅助下 ,皮下深部软组织内的海绵状血管瘤可以明确诊断 ,采用铜针栓塞治疗或切除术可以达到更准确而有效的治疗效果     

YOHIMBINE FOR ERECTILE DYSFUNCTION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

Purpose

Erectile dysfunction is a common problem, particularly in diabetics. It is associated with a considerable burden of suffering. No generally accepted drug treatment exists. We systematically reviewed and meta-analyzed all randomized, placebo controlled trials of yohimbine monotherapy for erectile dysfunction to determine its therapeutic efficacy. Our secondary aim was to evaluate the safety of yohimbine.

Materials and Methods

We used computerized literature searches and standardized data extraction to rate methodological quality in a meta-analysis using computer statistical software.

Results

Seven trials fit the predefined inclusion criteria. Overall methodological quality of these studies was satisfactory. The meta-analysis demonstrated that yohimbine is superior to placebo in the treatment of erectile dysfunction (odds ratio 3.85, 95% confidence interval 6.67 to 2.22). Serious adverse reactions were infrequent and reversible.

Conclusions

The benefit of yohimbine medication for erectile dysfunction seems to outweigh its risks. Therefore, yohimbine is believed to be a reasonable therapeutic option for erectile dysfunction that should be considered as initial pharmacological intervention.     

老年腹部外科急症患者全身性炎症反应综合征和多器官功能不全综合征的临床分析

作者回顾性研究了２９２例老年腹部外科急症患者的全身性炎症反应综合征（ＳＩＲＳ）和多脏器功能不全综合征（ＭＯＤＳ）的临床资料,分析ＳＩＲＳ向ＭＯＤＳ的发展过程,探索ＭＯＤＳ的防治策略。结果：老年腹部外科急症患者入院时ＳＩＲＳ的发生率是４１．１％,其后ＭＯＤＳ的发生率是１４．２％,病死率是１１．７％。经治疗４８小时后（包括手术和保守治疗）,仍伴有ＳＩＲＳ的病例中,４０．５％（１７／４２）发展为ＭＯＤＳ。２９２例老年腹部外科急症患者中,１９例发生ＭＯＤＳ（６．５％）,１６例死亡（８４．２％）,结论：早期诊断ＳＩＲＳ,特别注意分析治疗４８小时后仍伴有ＳＩＲＳ的患者的原因,积极调控机体炎症反应,才是改善老年腹部外科急症患者预后的关键     

PREVALENCE AND INDEPENDENT RISK FACTORS FOR ERECTILE DYSFUNCTION IN SPAIN: RESULTS OF THE EPIDEMIOLOGIA DE LA DISFUNCION ERECTIL MASCULINA STUDY

PURPOSE: We determined the prevalence of and risks factors for erectile dysfunction in Spain in a cross-sectional study. MATERIALS AND METHODS: A total of 2,476 noninstitutionalized Spanish men 25 to 70 years old were interviewed at home and answered a self-administered questionnaire of 71 items, including 2 instruments to define erectile dysfunction, a simple self-assessment question to estimate erectile function and the International Index of Erectile Function. Data on disease, medication and toxic habits were also obtained. RESULTS: With an overall participation rate of 75% the prevalence of erectile dysfunction according to the simple question was 12.1%. According to the erectile function domain of the International Index of Erectile Function the overall prevalence was 18.9%. Several independent risk factors were significantly associated with the probability of erectile dysfunction. Some differences arose according to the tool used to define the condition. However, there was a strong relationship of patient age with frequency or severity no matter which instrument was used to define erectile dysfunction. Diabetes (age adjusted odds ratio 4), high blood pressure (odds ratio 1.58), high cholesterol (1.63), peripheral vascular disorder (2.63), lung disease (3.11), prostate disease (2.93), cardiac problems (1.79), rheumatism (2.37) and allergy (3.08) were significantly associated with erectile dysfunction. Drug intake, which respondents called medication for nerves and sleeping pills, correlated strongly (odds ratio 2.78 and 4.27, respectively), as did tobacco use (2.5) and alcohol consumption (1.53). CONCLUSIONS: This study provides data on the prevalence of and risks factors for erectile dysfunction in Spain. The relationship of erectile dysfunction with certain risk factors, such as cardiovascular risk factors and drugs intake, are well known and our study corroborates these associations. Other associations with erectile dysfunction, such as prostate disease, allergy and rheumatism, support findings in previous reports, although to our knowledge the pathophysiological mechanisms remain unclear. Estimating the strength of the association of erectile dysfunction with distinct risk factors in terms of odds ratios enabled us to identify the factors to pursue when seeking to prevent erectile dysfunction. Furthermore, the relationship of tobacco with erectile dysfunction, which has been controversial in previous series, was well characterized in our study.     

HEMODYNAMIC EFFECTS OF TRANSURETHRAL ALPROSTADIL MEASURED BY COLOR DUPLEX ULTRASONOGRAPHY IN MEN WITH ERECTILE DYSFUNCTION

Purpose

We evaluated the hemodynamic effects of transurethral alprostadil in 21 patients with erectile dysfunction using color duplex ultrasonography.

Materials and Methods

Penile arterial diameter, peak flow velocity and end diastolic velocity were compared following intraurethral administration of 500 micro g. alprostadil and intracavernosal injection of 10 micro g. alprostadil.

Results

A dose of 500 micro g. transurethral alprostadil resulted in significant increases in corporeal blood flow comparable to those achieved with intracavernosal injection of 10 micro g. alprostadil as measured by duplex ultrasonography in men with erectile dysfunction. Transurethral alprostadil resulted in statistically significant increases in arterial diameter and peak flow velocity comparable to those achieved with intracavernosal injection. End diastolic velocities were higher after transurethral alprostadil than intracavernosal injections. Color ultrasonography following transurethral alprostadil showed arterial and venous hyperemia of the corpus spongiosum and corpora cavernosa. Furthermore, color ultrasonography revealed communicating vessels between the corpus spongiosum and corpora cavernosa following administration of transurethral alprostadil.

Conclusions

The visualization of communicating vessels between the corpus spongiosum and corpora cavernosa after transurethral alprostadil suggests local mechanisms of drug transfer from one to the other. In addition to potential clinical benefits, transurethral alprostadil may be useful to visualize the vascular anatomy of the penis and to test for patient responsiveness to local vasoactive agents.     

EFFECTS OF INTRAVENOUS METHOHEXITONE ON PERIPHERAL BLOOD FLOW IN PATIENTS WITH AND WITHOUT ARTERIAL DISEASE

The effects of light methohexitone anaesthesia on peripheralblood flow were studied in 23 patients, using a mercury in rubberplethysmograph on the leg. Fifteen patients had peripheral arterialdisease and 5 of these had previously undergone lumbar sympathectomy.The remaining 8 patients had a normal cardiovascular system.The blood flow in the leg increased by a mean of 45 per centin the patients with peripheral arterial disease without sympathectomyand by a mean of 89 per cent in patients without vascular disease.By contrast, in 4 out of the 5 patients who had previously undergonesympathectomy the blood flow decreased. It is, therefore, thoughtthat methohexitone causes peripheral vasodilatration by an actionon the sympathetic nervous system. Analysis of the changes inarterial blood pressure in relation to the calculated changesin peripheral resistance suggests that methohexitone has anadditional central effect on the heart.     

POSTOPERATIVE INFECTION IN ARTERIAL SURGERY: A REVIEW OF THE INCIDENCE AND DISTRIBUTION IN 386 PATIENTS

The clinical recorda of 386 patients undergoing surgery for peripheral arterial disease during the period 1958 to 1974 were examined for patterns of wound infection. The incidence of infection in arterial reconstructive procedures was 7.4%, of which infections 2.2% were major. A high incidence of minor wound infection was found not to be of significance with regard to patient morbidity. The greater risk of wound infection occurring when there was an ischaemic skin lesion present distally in the limb was confirmed. An incision in the groin was not clearly identified as a significant factor in the development of wound infection. The prophylactic use of antibiotics has not resulted in a lower incidence of infection, when compared with those results reported from centres where antibiotic prophylaxis has not been routine. Analysis by year has demonstrated a lower incidence of infection in the more recent years 1969 to 1974.     

阻塞性黄疸患者外周血内毒素和T淋巴细胞亚群变化的研究

对３２例阻塞性黄疸（下称阻黄）患者的外周血内毒素含量和Ｔ淋巴细胞亚群进行测定。结果发现阻黄患者内毒素阳性率为５９．３８％，平均０．０２８±０．０６ＥＵ／ｍｌ。中重度组的阳性率远高于轻度组（Ｐ＜０．０５）。术后一周９２．８６％患者转为阴性，术后二周全部阴性。胆道阻塞患者ＣＤ３降低（Ｐ＜０．０５），ＣＯ４在中重度组也明显降低（Ｐ＜０．０５），中重度组和恶性组的Ｃ０／ＣＤ８比值降低（Ｐ＜０．０５），术后二周患者的免疫功能尚未恢复正常。术后并发症发生率和手术死亡率以中重度组和恶性组为高。上述结果表明阻黄患者存在内毒素血症和细胞免疫功能降低，与阻黄患者术后并发症多和死亡率高有关。     

THE USE OF DIFFERENT DOSES OF VECURONIUM IN PATIENTS WITH LIVER DYSFUNCTION

The clinical neuromuscular effects of two doses of vecuronium(0.15 mg kg^-1 and 0.2 mg kg^-1) were investigated in 20 healthypatients and 20 patients with cirrhosis, and compared with previouswork in which vecuronium 0.1 mg kg^-1 was given under identicalconditions of anaesthesia and monitoring. Ten healthy patientsreceived vecuronium 0.15 mg kg^-1 and 10 received 0.2 mg kg^-1.Similarly, 10 patients with cirrhosis received vecuronium 0.15mg kg^-1 and 10 received 0.2 mg kg^-1. Vecuronium 0.1 mg kg^-1has previously been shown to have a somewhat shorter durationof action in cirrhotic as opposed to healthy patients. In thisstudy, vecuronium 0.15 mg kg^-1 was found to have a similar durationof action in both groups, and vecuronium 0.2 mg kg^-1 had a significantlylonger action in the cirrhotic group. It is suggested that vecuroniumshould be used with caution in patients with hepatic dysfunctionand that, in such patients, monitoring of neuromuscular functionis desirable.     

ARTERIAL WASHIN OF HALOTHANE AND ISOFLURANE IN YOUNG AND ELDERLY ADULT PATIENTS

We have studied the effect of age on washin of isoflurane andhalothane by comparing end - tidal (PE') and arterial (Pa) partialpressures of the agents in young (18–32 yr) and elderly(63–82 yr) healthy patients for 20 min after introductionof the agents, before surgery. PE' was measured by infra - redanalysis and Pa by gas chromatography. Washin of isofluraneoccurred at the same rate in the young and elderly, with nosignificant difference between young and elderly in PE' or Paas proportions of the inspired partial pressure (PI). After20 min of isoflurane administration, mean Pa/Pl in the youngwas 0.57 (95% confidence limit (CL) 0.53–0.62) and 0.55in the elderly (95% CL 0.51–0.59). Washin of halothanewas slower in the elderly than in the young, with Pa/Pl significantlyless in the elderly from 10 min after introduction of halothane.The difference between age groups, however, was small: meanPa/Pl after 20 min of halothane administration 0.45 (95% CL0.41–0.49) in the young and 0.38 (95% CL 0.35–0.41)in the elderly. Washin of isoflurane was significantly fasterthan that of halothane in both young and elderly subjects. Forisoflurane, the PE'-Pa gradient was small relative to Pa anddid not differ significantly between young and elderly. Forhalothane, PE'-Pa in the young did not differ significantlyfrom that for isoflurane. In the elderly, PE'-Pa for halothanewas significantly greater than in the young and than PE'-Pafor isoflurane.     

94例腹直肌肌皮瓣肌皮动脉穿支的研究

目的 了解腹直肌肌皮瓣、肌瓣与皮瓣之间的血管穿支的分布,以及在体表的定位和动脉收缩期血流速度。方法 采用彩色超声血管检查仪对９４例进行检测,术中进一步验证检涮 结果。对腹部各区内肌皮穿支出现频率、位置及收缩期血流速度,腹直肌肌皮瓣转移后肌皮穿支动脉的收缩期血流速度进行检测和统计。结果 左右两侧腹直肌肌皮瓣、肌瓣与皮瓣之间血管穿支呈非对称性分布,脐周的肌皮穿支含量占８１．１％,同一分区内第二条穿支的