Implants,Mechanical Devices,and Vascular Surgery for Erectile Dysfunction

IntroductionThe field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment.AimTo develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery.MethodsTo provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period.Main Outcome MeasureExpert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.ResultsThe inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended.ConclusionsIt is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery. Hellstrom WJG, Montague DK, Moncada I, Carson C, Minhas S, Faria G, and Krishnamurti S. Implants, mechanical devices, and vascular surgery for erectile dysfunction.     

The penile suspensory ligament: abnormalities and repair

OBJECTIVE: To assess men presenting with abnormalities of the penile suspensory ligament (PSL) and its correction. PATIENTS AND METHODS: In all, 35 men presenting with abnormalities of the PSL that were subsequently repaired were included in this series. The causes included; sexual trauma (15 men), congenital absence of the PSL/congenital penile curvature (14), and two each with venogenic erectile dysfunction, Peyronie's disease and penile dysmorphic disorder. The diagnosis was made clinically by the presence of a palpable gap between the symphysis pubis and the penis, together with medical history and examination of penile torsion or instability. The surgical repair used nonabsorbable sutures placed between the symphysis pubis and the tunica albuginea of the penis. RESULTS: A 'good' surgical outcome was defined as correction of the penile deformity or instability and achieving normal sexual function. There was a good surgical outcome in 91% of men as defined, and 86% of the men were happy with the outcome. There were no significant complications, but three men needed a repeat PSL repair. CONCLUSION: Men with abnormalities of the PSL can present with a variety of clinical symptoms, but when correctly diagnosed the repair is a simple technique with a successful cosmetic and functional outcome.     

A prospective study of 100 cases of penile cancer managed according to European Association of Urology guidelines

OBJECTIVE: To prospectively assess the outcome of patients treated according to the European Association of Urology (EAU) guidelines on the management of penile cancer, a system originally based on retrospective series. PATIENTS AND METHODS: Between 2002 and 2005, 100 consecutive patients (median age 62 years) with penile cancer were treated at one institution; all were categorized and treated according to EAU guidelines. Data were analysed using the z-test, with significance defined as P < 0.05. RESULTS: Survival curves were limited to those with >12 months of follow-up (mean 29); the survival of the whole group was 92%. Of men with palpable nodes, 72% had lymph node involvement, whereas 18% of those with impalpable nodes who had lymphadenectomy according to the guidelines had lymph node disease. The grade of the primary tumour was more predictive than T stage for lymph node involvement and survival. The 3-year disease-specific survival for N0, N1 and N2 disease was 100%, 100% and 73%, respectively, and survival at 12 months for N3 disease was 67%. The median survival for those with metastases was 3 months. CONCLUSION: The overall survival of men with penile cancer is high, with a clear benefit for early lymphadenectomy in men with positive nodal disease. However, the current EAU guidelines are limited in predicting those patients with micrometastatic disease, with the result that 82% of patients undergo unnecessary prophylactic lymphadenectomy. There is a need to identify more accurate molecular markers for predicting lymph node disease, or the role of novel staging techniques must be assessed.     

Analysis of the outcome of intracytoplasmic sperm injection using fresh or frozen sperm

Study Type – Diagnostic (retrospective cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? The results of ICSI using fresh or frozen sperm on the site of sperm retrieval remains controversial with respect to outcome. The results of this study showed no difference in outcome using ICSI either with respect to the site of retrieval or whether the sperm used was fresh or frozen. It also showed that the outcome of ICSI is not related to the underlying cause of the azoospermia.

OBJECTIVES

? To compare the outcome of first‐attempt intracytoplasmic sperm injection (ICSI) ICSI–embryo transfer (ET) cycles using frozen‐thawed testicular sperm (FTTS), fresh testicular sperm (FTS), frozen‐thawed epididymal sperm (FTES) and fresh epididymal sperm (FES) so as to determine which of these has the most successful ICSI outcome with respect to fertilization rate (FR), pregnancy rate (PR) and birth rate. ? To assess the outcomes according to the underlying aetiology of azoospermia.

PATIENTS AND METHODS

? The records of 493 patients undergoing first‐attempt ICSI between 1993 and 2008 were reviewed retrospectively. FTS was used in 112 cycles, FTTS in 43 cycles, FES in 279 cycles, and FTES in 59 cycles. ? Within each group, the aetiology of the azoospermia was recorded according to history, clinical examination and histological analysis (n= 316). ? The FR, clinical PR and delivery rate were calculated for each group with respect to the type of sperm retrieval used.

RESULTS

? Analysis of the data showed no significant differences between any of the four groups in the FR, PR or delivery rate (P > 0.05). ? There were no significant differences seen between fresh sperm (FTS and FES) and frozen sperm (FTTS and FTES) or between epididymal sperm (FES and FTES) and testicular sperm (FTS and FTTS) in any of the outcomes measured (P > 0.05). However, sub‐set analysis showed a statistically higher FR and PR for FTTS over fresh sperm. ? When comparing aetiologies, there was no significant difference in the FR, clinical PR and delivery rate between obstructive azoospermia (OA) and non‐obstructive azoospermia (NOA) groups. However, sub‐set analysis showed a higher PR and birth rate for FTTS over fresh sperm in both OA and NOA groups.

CONCLUSIONS

? The results of the present study suggest that using frozen sperm in ICSI cycles is a reliable and favourable method with the same outcome as fresh sperm. ? Testicular and epididymal sperm have similar ICSI outcomes for both fresh and frozen samples. However, results suggest a tendency for higher PRs and birth rates for frozen than for fresh testicular sperm in both OA and NOA aetiologies. ? The aetiology of azoospermia does not significantly affect the outcome of first‐attempt ICSI. The higher rates in the frozen groups suggest that these patients have had better quality semen when they were initially harvested and frozen.     

The role of magnetic resonance imaging in the local staging of penile cancer

OBJECTIVES: To assess the accuracy of magnetic resonance imaging (MRI) as a local staging technique in penile cancer and its role in selecting patients for conservative surgical management. METHODS: Fifty-five men diagnosed with invasive penile carcinoma on biopsy were locally staged with the use of MRI. Prostaglandin E1 (alprostadil) was injected into the corpora to induce an artificial erection. Radiologic staging was compared against final histopathologic stage of the tumour. Sensitivity, specificity, and kappa agreement values were calculated for each tumour stage. Additionally, corpora cavernosa involvement was reviewed in 20 consecutive cases and suitability for conservative surgery assessed. RESULTS: A good correlation between radiologic and histologic staging was achieved with an overall kappa value of 0.75 (p<0.001). Stage-specific sensitivities and specificities were calculated: T1 (85%; 83%), T2 (75%; 89%), and T3 (88%; 98%). MRI accurately predicted corpora cavernosa invasion in all cases of pathologically proven disease. These patients were selected to undergo partial penectomy. There were no complications using this imaging technique. CONCLUSIONS: This study demonstrates that penile MRI is highly accurate in the local staging of penile cancer. Associated improvements in surgical planning allow the provision of conservative surgical treatments over more radical procedures.     

英国泌尿科医生协会2005年年会纪要(非泌尿生殖系肿瘤部分)

英国泌尿科医生协会2005年年会纪要-非泌尿生殖系肿瘤部涉及面广,内容丰富,并提出了许多新看法及观点。重点是男科、尿动力学、结石及泌尿科管理学方面的进展。亮点是前列腺增生症的治疗及泌尿科管理学的研究。特点是临床论文多,病例数量大,随访时间长,新技术及新材料应用广。