Is sildenafil citrate associated with an amelioration of the symptomatology of androgen decline in the aging male?

PURPOSE: We examined whether treatment of erectile dysfunction with sildenafil citrate is associated with amelioration of the symptomatology of androgen decline in the aging male, and whether this alters the endocrine pattern. MATERIALS AND METHODS: A double-blind, randomized, placebo controlled, crossover study with sildenafil citrate was conducted in 60 men (age range 47 to 75 years old) who presented with erectile dysfunction and screened positively for androgen decline in the aging male by the questionnaire of the same name. The patients were randomized to receive sildenafil citrate or placebo in a 1:1 ratio and were crossed over after 3 months of treatment for an additional 3 months. The evaluation included International Index Erectile Function and Aging Male Symptoms questionnaires, hormonal profiles, total testosterone, and bioavailable testosterone. RESULTS: A total of 40 patients completed the study. Compared to placebo, sildenafil citrate improved erectile function (52.7 +/- 2 vs 39 +/- 1.9, p <0.001) and Aging Male Symptoms score (33.5 +/- 1.3 vs 28.6 +/- 1.3, p <0.001) in the total group. Breakdown into hypogonadal and normal men showed that the International Index of Erectile Function score improved more in normal (Delta 18.5 +/- 3.6) than in hypogonadal men (Delta 6.7 +/- 2.7). There were no differences in improvement on the Aging Male Symptoms questionnaire between hypogonadal and normal men. No treatment changes were observed in total testosterone and bioavailable testosterone. CONCLUSIONS: In the total group of patients sildenafil citrate was associated with expected improvement in erectile function and in the Aging Male Symptoms questionnaire without any alteration in hormonal pattern. The available questionnaires for androgen decline in the aging male are not specific for the diagnosis of biochemical androgen decline in the aging male, although the suboptimal response to sildenafil citrate suggests the presence of hypogonadism.     

Is duplex ultrasonography an effective single modality for the preoperative evaluation of peripheral vascular disease?

The purpose of this study was to determine whether duplex ultrasonography can be used as an effective modality for the preoperative evaluation of lower-extremity arterial occlusive disease. The records of all patients undergoing both color flow duplex scanning and contrast arteriography of the lower extremities during a 13-month period were reviewed. Comparisons between the two modalities were made at the femoral, popliteal, and tibial artery levels. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for duplex scanning using angiography as the gold standard. Three hundred fifteen arterial segments were evaluated. Color flow imaging overestimated the degree of stenosis in seven vessels and underestimated the degree of stenosis in four vessels. Overall duplex ultrasonography accurately determined lower-extremity arterial anatomy as defined by contrast arteriography with a sensitivity of 96.9 per cent, a specificity of 96.2 per cent, a positive predictive value of 94.6 per cent, a negative predictive value of 97.8 per cent, and an overall accuracy of 96 per cent. The accuracy of duplex ultrasonography must be determined in each individual vascular laboratory. Once this is satisfactorily accomplished color flow scanning may be used as the single imaging modality for lower-extremity arterial occlusive disease in selected patients deemed to be at high risk for contrast angiography.     

Does the type of the Peyronie's curvature effect penile vascular parameters in normopotent men?

The aim of this study is to assess whether the type of penile curvature in normopotent men with Peyronie's disease affects the penile vascular doppler ultrasound parameters. Fifty-three normopotent patients within the stabilization phase of Peyronie's disease were evaluated retrospectively by means of color doppler ultrasonography. Bilateral cavernosal artery diameters before and after intracavernous papaverine injections, peak systolic and end diastolic velocities and the amount of leakage in the deep dorsal penile vein were compared in dorsal and ventral curvature groups of Peyronie's disease. 61% of the patients in dorsal and 59% in ventral Peyronie's curvature group have normal ultrasonographic penile vascular system. 35% and 3.3% in dorsal curvature group and 36.4% and 4.5% in ventral curvature group have venoocclusive dysfunction and mixed vascular pathologies, respectively, having no statistical correlation between them (p > 0.05). No arterial pathology was observed in any group. There was no correlation between the type of Peyronie's curvature and the penile doppler ultrasonographic findings in normopotent patients.     

Is the use of specific scoring system still justified in early evaluation of acute pancreatitis?

STUDY AIM: Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission. PATIENTS AND METHODS: Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve. RESULTS: Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death. CONCLUSION: Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.     

Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children?

Background: Penile nerve block (PNB) is a well‐established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound‐guided PNB versus the classical landmark‐based technique (LBT) in children undergoing circumcision. Methods: Forty boys, aged 1–14 years old that were scheduled for circumcision were randomly assigned to ultrasound‐guided and landmark‐based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg^?1 per side, and 0.05 mg·kg^?1 at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. Results: The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound‐guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US‐guided group (P = 0.001). Conclusion: Ultrasound‐guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.     

Is there an inhibitory role of cortisol in the mechanism of male sexual arousal and penile erection?

Background. It has been speculated for more than 2 decades whether there is a significance of adrenal corticosteroids, such as cortisol, in the process of normal male sexual function, especially in the control of sexual arousal and the penile erectile tissue. However, only few in vivo studies have been carried out up until now on the effects of cortisol on human male sexual performance and penile erection. In order to evaluate further the role of cortisol in male sexual activity, the present study was conducted to detect serum levels of cortisol in the systemic and cavernous blood taken during different penile conditions from healthy males. Material and Methods. The effects of cortisol derivative prednisolone, catecholamine norepinephrine (NE) and the peptide endothelin-1 (ET-1) on isolated human corpus cavernosum (HCC) were investigated using the organ bath technique. Fifty-four healthy adult male subjects were exposed to erotic stimuli in order to elicit penile tumescence and rigidity. Whole blood was simultaneously aspirated from the corpus cavernosum and the cubital vein during different penile conditions. Serum levels of cortisol (g/dl) were determined by means of a radioimmunoassay (ELISA). Results. In the healthy volunteers, cortisol serum levels significantly decreased in the systemic circulation and the cavernous blood with increasing sexual arousal, when the flaccid penis became rigid. During detumescence, the mean cortisol level remained unaltered in the systemic circulation, whereas in the cavernous compartment, it was found to decrease further. Under all penile conditions, no significant differences were registered between cortisol levels in the systemic circulation and in the cavernous blood. Cumulative addition of NE and ET-1 (0.001–10 M) induced contraction of isolated HCC strips, whereas the contractile response to prednisolone was negligible. Conclusion. Our results strongly suggest an inhibitory role for cortisol in the mechanism of male sexual response and behaviour. These properties are mediated rather via an effect on central structures than on the penile erectile tissue. Future studies to include patients suffering from erectile dysfunction may reveal whether or not there are differences in the cortisol serum profiles of healthy subjects and patients under different stages of sexual arousal.     

Should we rely on Doppler ultrasound for evaluation of testicular solid lesions?

Purpose

Colour Doppler ultrasound (CDUS) is the main radiologic tool to evaluate scrotal masses and intratesticular-vascularised solid lesions are mostly considered malign lesions. Objective of this trial is determine ratio of benign lesions in patients with hypervascularised solid intratesticular lesions.

Material and method

Patients who underwent radical orchiectomy due to hypervascularised intratesticular solid lesions detected in CDUS are evaluated retrospectively. Those with previous testicular cancer history and inguinal/scrotal surgeries were excluded from the study. All patients are evaluated for age, preoperative testicular atrophy, multicentricity, echotexture and size of solid lesions, preoperative tumor markers (AFP, bHCG and LDH), and postoperative pathology results. Two tailed p value test was used to evaluate numeric parameters and Fisher’s exact test was used to evaluate non-numeric parameters.

Results

A total of 117 patients with a mean age of 35.9 (5–86) were included to the study. Mean size of solid lesions was 4.39 cm. Seven patients had subcentimeter (subcm) lesions. 101 patients had hypoechoic, ten patients had isoechoic and six patients hyperechoic solid lesions. Preoperatively 60 patients (51.2%) had at least one tumor marker elevated. Postoperative pathology examination resulted to; 21 patients (17.9%) had benign lesions. Elevation of tumor markers, palpability, hypoechoic texture and larger size of the solid lesion were found to be parameters that predict malignancy.

Conclusion

Benign incidence of vascular testicular solid lesions detected with scrotal ultrasound with colour Doppler is greater than expected. In patients with smaller, non-palpable lesions without elevated tumor markers, treatment options other than radical orchiectomy such as testicular sparing surgery should be considered.

     

Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative?

Aortic aneurysm thrombosis with extra-anatomic bypass has been proposed for persons with infrarenal aortic aneurysms who are "too debilitated" to undergo standard aortic reconstruction. Thirteen patients (mean age, 75 years) were selected between January 1980 and June 1984 for axillobifemoral bypass with bilateral iliac artery occlusion to manage their infrarenal aortic aneurysms (mean size, 6.3 cm; range, 4.9 to 7.5 cm). Preoperative risk factors were cardiac (angina, compensated congestive heart failure, and significant preoperative arrhythmias), 100% of patients; pulmonary (symptomatic chronic obstructive pulmonary disease with a 1-second forced expiratory volume less than 50% of the predicted value), 46% of patients; renal (creatinine value greater than or equal to 2.0 mg/dl or creatinine clearance less than 20 ml/min), 46% of patients; or nutritional (albumin less than or equal to 3.5 gm/dl or body weight less than 90% of ideal), 46%. Ninety-two percent of the patients had two risk factors whereas 46% had three or more risk factors. The operative mortality rate was 31%; three patients died of multisystem organ failure and another died of thrombin-induced consumptive coagulopathy and hemorrhage. (Our operative mortality rate for conventional graft replacement of abdominal aortic aneurysms is less than 3%.) Morbidity in persons surviving at least 1 month included thrombosis of the extra-anatomic bypass graft requiring thrombectomy (three patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and bilateral above-knee amputations (one patient). Thrombosis of the aneurysm was not achieved in two patients despite use of fluoroscopically controlled embolization of runoff vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is ultrasound really helpful in the detection of rib fractures?

OBJECTIVE: To determine the usefulness of ultrasound in the detection of rib fractures. PATIENTS AND METHODS: A prospective study was performed over a 3-month period. Patients presenting with a high clinical suspicion of rib fracture(s) to the Accident and Emergency Department were referred for radiological work-up with a PA chest radiograph, an oblique rib view and a chest ultrasound. Associated lesions, e.g. pleural effusion, splenic laceration and pneumothorax were recorded. RESULTS: Fourteen patients were radiologically assessed. The mean patient age was 31 years (range 16-55 years) and the M:F ratio 3.7:1 (11 men and 3 women). Ten patients displayed a total of 15 broken ribs. Chest radiography detected 11, oblique rib views 13 and ultrasound 14 broken ribs. Ultrasound findings included discontinuity of cortical alignment in 12 fractures, an acoustic linear edge shadow in nine and a reverberation artifact in six. Concordance with plain film findings, and especially oblique rib views, was good, though better when the rib fractures fragments were markedly displaced. One splenic laceration was detected with an associated small pleural effusion. There were no pneumothoraces. The average time of ultrasound examination was 13 min. CONCLUSION: Ultrasound does not significantly increase the detection rate of rib fractures, may be uncomfortable for the patient and is too time-consuming to justify its routine use to detect rib fractures.     

Can lemon juice be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia? A prospective randomized study

To investigate that lemon juice could be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia, 30 patients with hypocitraturic urinary calcium stones were enrolled into study. The patients were divided into three groups equally. Exactly 60 mEq/day fresh lemon juice (≈85 cc/day) and potassium citrate (60 mEq/day) were given to the patients of first and second group, respectively. Dietary recommendations were made for the third group. Blood and 24-h urine tests were performed before treatment and repeated 3 months later. The differences between demographic datas of groups were not significant. There was no significant difference between values of blood tests performed before and after treatment in all groups. Statistically significant differences were found between pre- and post-treatment urine values in each group. Although there was no significant difference between pre-treatment citrate levels of the groups. A significant difference was found between post-treatment citrate levels of the groups. There was 2.5-, 3.5- and 0.8-fold increase in urinary citrate level of lemon juice, potassium citrate and dietary recommendation groups, respectively. Urinary calcium level was decreased only in lemon juice and potassium citrate groups after treatment. While there was no significant difference between pre- and post-treatment urinary oxalate levels in all groups, a significant decrease in urinary uric acid levels was determined in all groups. We suggest that lemon juice can be an alternative in the treatment of urinary calcium stones in patients with hypocitraturia. Additionally, dietary recommendations can increase effectiveness of the treatment.     

Is transcranial Doppler effective in avoiding the hazards of carotid surgery?

The middle cerebral artery flow velocities were measured to test the hypothesis that transcranial Doppler is a useful technique for intraoperative monitoring in 50 consecutive carotid endarterectomies which were performed under local anaesthesia. The patients' neurological status was continuously monitored. The peak middle cerebral artery velocities were measured before clamping, during clamping and after restoration of flow, and again 24 h and 4 weeks later. Clamping produced a decrease in the velocity of the middle cerebral artery, from 97 to 45cm/s (P < 0.001). Neurological manifestations occurred in eight patients; one patient lost consciousness, and seven experienced transient focal deficits during the procedure. Another three (6%) developed minor strokes postoperatively. The velocity changes were similar in those who developed complications to those who did not. These results do not support the view that transcranial Doppler monitoring is helpful in deciding whether to use a shunt during carotid endarterectomy. Further data are needed to evaluate the importance of transcranial Doppler monitoring during carotid surgery.     

What's new in the management of penile cancer?

PURPOSE OF REVIEW: Penile cancer is a rare disease. This has led to little in the way of therapeutic advances in the last two decades. Efforts have been made to minimize the use of disfiguring or morbid procedures in treating the primary tumor or managing the inguinal region. In addition, new insights have been gained into multimodal therapy for treating metastatic disease. We reviewed the literature published during the past two years to define the recent insights into the diagnosis and management of penile cancer. RECENT FINDINGS: Surveillance, Epidemiology and End Results Program data revealed poor outcome among African-American patients compared with Caucasians with penile cancer. Risk factors, including human papilloma virus, HIV, and the practice of circumcision have been reassessed. To improve diagnosis and staging, new modifications in imaging have been developed including magnetic resonance imaging with artificial erection. In addition, the technique of dynamic sentinel node biopsy has been refined. Pathologic features of the primary tumor (i.e., stage, grade, vascular invasion) assist in identifying patients who would benefit from lymphadenectomy. Organ-sparing treatments using laser ablation and reconstructive procedures to preserve glans or phallus length have also been developed. Systemic chemotherapy regimens, including consolidative approaches with surgery or radiotherapy, are discussed for advanced penile cancer. SUMMARY: Penile cancer remains a rare disease. Epidemiologic insights reveal provocative findings with respect to risk factors and racial differences in the outcome. Recent literature provides information that will aid urologists in (1) minimizing the need for disfiguring treatment of penile tumors in some patients and (2) reducing the number of unnecessary inguinal staging procedures in others. Novel systemic therapies that generate durable responses tested in multi-institutional treatment trials are needed.     

Is dextran infusion as an antithrombotic agent necessary in microvascular reconstruction of the upper aerodigestive tract?

Patent microvascular anastomoses are mandatory for a successful free tissue transfer. Dextran 40 is widely used by reconstructive microsurgeons in conjunction with free tissue transfer, to prevent flap loss. Unfortunately, dextran-induced adverse reactions, such as anaphylactoid reactions, adult respiratory distress syndrome, cardiac overload, hemorrhage, and renal damage, remain the major risks in routine use of dextran 40. The authors retrospectively analyzed the patency rates of 55 microvascular tissue transfers of a single microsurgeon after tumor ablation of malignancies of the upper aerodigestive tract between August, 1997 and March, 2001. The patency rates of free flap reconstructions were 96 percent for the dextran-infusion group and 100 percent for the dextran-free group. There was no statistically significant difference between the patency rates of these two groups. The results showed that the routine use of dextran as an antithrombotic agent is not necessary in microvascular reconstruction. The disadvantages of dextran infusion can be effectively prevented.     

Is serotonin significant for the control of penile flaccidity and detumescence in the human male?

For more then 15 years, there has been speculation on the significance of serotonergic pathways in the control of male sexual function, especially in the maintenance of penile flaccidity and the initiation of detumescence. However, only a few in vivo studies on peripheral serotonergic transmission have been carried out. The aim of the present study was to evaluate further the effects of serotonin (5-HT) on isolated human erectile tissue and to detect serum levels of 5-HT in the systemic and cavernous blood taken during different penile conditions from healthy males. The effects of 5-HT on isolated human corpus cavernosum (HCC) were investigated using the organ bath technique. A total of 41 healthy, adult male subjects were exposed to erotic stimuli in order to elicit penile tumescence and rigidity. Whole blood was simultaneously aspirated from the corpus cavernosum and the cubital vein during different penile conditions. Serum levels of 5-HT (ng/ml) were determined by means of an enzyme-linked immunosorbent assay. The cumulative addition of 5-HT (0.001-10 microM) induced contraction in the isolated HCC strips. The contractile response was abolished in the presence of 5-HT(1alpha)-receptor antagonist NAN-190. No attenuating effect of 5-HT was observed on electrically induced relaxation of the tissue. Moreover, amplitudes of relaxation remained unaltered in the presence of NAN-190. In the healthy volunteers, a significant increase in 5-HT levels was detected in the cavernous serum from flaccidity (113+/-62) to tumescence and rigidity (140+/-69 and 141+/-54, respectively), followed by a decrease in the detumescence phase (123+/-79). Changes in 5-HT levels in the systemic serum were less pronounced. Under all penile conditions, systemic 5-HT levels were higher than those registered in the cavernous serum. Although 5-HT does not appear to be involved in postsynaptic transmission in the HCC, our results may provide evidence for a physiological significance of 5-HT in the control of penile flaccidity and detumescence. Thus, our findings may give a rationale for the use of 5-HT antagonists in the pharmacotherapy of erectile dysfunction.