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Journal:	Journal of Urology
Authors:	El-Galley R, Rutland H, Talic R, Keane T and Clark H	Issue:	2001; 166: 927-931, 2001

Title:

Long-term efficacy of sildenafil and tachyphylaxis effect.

Abstract:
It is still only 3 years since the worldwide launch of sildenafil and data are starting to emerge regarding long-term efficacy. The authors report a survey of 200 patients with ED contacted by telephone soon after starting sildenafil therapy, and then again 2 years later. ED was of varying aetiologies. Initially good response was seen in 74% of patients, with the majority (83%) of these requiring the 50mg dose. 2 years later, only 59% of the patients with an initially good response were still using sildenafil. Of those still taking sildenafil, 37% had needed to increase the dose from 50mg to 100mg. Of those who had stopped the drug, half had done so because of loss of efficacy. The mean time to loss of efficacy was 11 months after starting treatment. The authors attribute the apparent development of ‘sildenafil resistance’ to be a likely consequence of tachyphylaxis, a pharmacological phenomenon of reduced tissue responsiveness to a drug that occurs in the presence of a constant drug concentration. An alternative explanation may be that the pathological process underlying ED is often a progressive one, and may lead to increasingly limited benefits of successful type 5 PDE inhibition. It remains to be seen whether the results obtained with sildenafil will translate into long lasting benefits for patients with this chronic disorder. This paper may strengthen the case for investigating potential approaches to secondary prevention in ED patients.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Schuster TG, Hollenbeck BK, Faerber GJ and Wolf JS Jr.	Issue:	2001; 166: 538-540

Title:

Complications of ureteroscopy: analysis of predictive factors.

Abstract:
This paper looks at complications of ureteroscopy and associated factors. This is the first paper to use systemic analysis to determine factors predictive of these complications. They retrospectively reviewed all ureteroscopies performed at their institution in Michigan for calculus disease from January 1997 through September 1999. A total of 322 procedures were performed by 5 surgeons. Intraoperative and immediate post-operative complications were identified. Bivariate and multivariate analysis was performed to identify associated factors with ureteral perforation and post-operative complications as the dependant variables. There analysis showed statistical significant association of ureteral perforation(4.7%) with increased operative time. In addition there was a significant association of post-operative complications with stones in the kidney, operative time and decreased surgeon experience, as well as a trend toward significance for the type of ureteroscope used. With the development of more flexible scopes and better disposables to aid surgery future studies would make an interesting comparison to their published results. Possible complications of ureteroscopy identified were: Intraoperative: mucosal abrasion, false passage, ureteral perforation, extravasation, ureteral avulsion, thermal injury intussusception, equipment failure and difficult access. Early postoperative: Infection, clot retention, steinstrasse, oedema, urinary retention. Late postoperative: vesicoureteral reflux, stricture, avascular ureteral necrosis.

Reviewer: Justin Collins

Journal:	Journal of Urology
Authors:	Martin-Morales A, Sanchez-Cruz JJ, Saenz de Tejada I, Rodriguez L, Jimenez-Cruz JF, Burgos-Rodriguez R	Issue:	2001; 166: 569-575, 2001

Title:

Prevalence and independant risk factors for erectile dysfunction in Spain: Results of The Epidemiologica De La Disfuncion Erectil Masculina Study.

Abstract:
This is the largest population-based, epidemiological study of erectile function to date and complements the Massachusetts Male Aging Study (MMAS), to which it is very similar in design. A sample of 2,476 Spanish men aged 25 to 70 years were assessed via the International Index of Erectile Function (IIEF) and a single item assessment of ED. The overall prevalence of ED was 18.9% on the IIEF and 12.1% on the single item, figures much lower than the MMAS and suggested by the authors to be a consequence of cultural differences in the perception of ED. This study also included younger men than the MMAS (which used men aged 40 to 70). ED correlated strongly with age, consistent with previous studies. Significant correlations were confirmed for other established risk factors such as diabetes, hypertension, heart disease, peripheral vascular disease, hypercholesterolaemia, smoking and depression. However, a significant association was demonstrated between ED and other medical conditions, including lung disease, rheumatism, allergy and certain medications (especially sleeping tablets). The authors were unable to explain some of these ‘new’ risk factors. Of particular interest to urologists is the demonstration of a significantly increased likelihood of ED in the presence of benign prostate disease, which conferred an age adjusted odds ratio of 2.93 for ED in this study. This large population-based study confirms established risk factors for ED but also suggests some new ones. This process is essential for the rational design of prevention strategies for ED.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Arslan D, Esen A, Secil M, Aslan G, Ilhan C and Dicle O.	Issue:	2001; 166:181-4.

Title:

A new method for the evaluation of erectile dysfunction: sildenafil plus Doppler ultrasonography.

Abstract:
This paper examines the potential use of oral sildenafil in penile Doppler studies, as an alternative to the intracavernosal injections of vasoactive agents. 42 patients with ED of mixed aetiology underwent penile Doppler on two occasions – once using oral sildenafil 50mg, and once using intracavernosal papaverine 60mg. Ultrasound was performed 30, 45, 60, 75 and 90 minutes after sildenafil and 1, 5, 10 and 20 minutes after papaverine. All scans were performed following tactile and audiovisual sexual stimulation. Flow velocity after sildenafil increased far more slowly than after papaverine, peaking at around one hour in comparison to around one minute. However, peak systolic velocity (PSV) values were not significantly different. Sildenafil showed a sensitivity of 90% and sensitivity of 100% for demonstrating arterial insufficiency (as defined by papaverine values). The proportion of patients who actually had any demonstrable penile vascular abnormalities overall was very low (only 12%). Priapism was seen in 11.9% of patients following intracavernosal papaverine and 47% reported moderate or severe penile pain. No priapism or pain was reported following oral sildenafil. Many units now use intracavernosal alprostadil rather than papaverine during Doppler studies due to increased efficacy and reduced adverse effects. Practical limitations to the use of sildenafil in the x-ray department are its mode and speed of action, in that sexual stimulation is required and patients need to be assessed for up to 90 minutes following dosage. However, this paper does suggest that sildenafil and intracavernosal injections can give very similar Doppler values and, despite these limitations, patient preference may influence the future use of sildenafil in Doppler ultrasound studies.

Reviewer: Rob Jones

Journal:	BJU International
Authors:	Sairam K, Kulinskaya E, Boustead GB, Hanbury DC and McNicholas TA.	Issue:	2001; 88 :68-71

Title:

Prevalence of undiagnosed diabetes mellitus in male erectile dysfunction.

Abstract:
ED is considered a marker symptom for diabetes and this study aimed to determine the prevalence of occult diabetes in patients presenting with ED. A consecutive sample of 129 new ED referrals underwent dipstick testing for glycosuria and plasma fasting blood glucose (FBG) measurement. Twenty-two patients (17%) were known diabetics. Of the remaining 107 patients, five (4.7%) were diagnosed as newly diabetic according to WHO criteria (FBG>7.0). A further 12% had ‘abnormal’ FBG (5.5-6.9), indicative of impaired glucose tolerance. Duration of ED at presentation was significantly greater in the diabetic patients compared to non-diabetics. Glycosuria on urine dipstick was found in only one of the five newly diagnosed patients (i.e. a sensitivity of only 20%) and in none of the patients with FBG in the ‘abnormal’ range. This paper has emphasised the value of screening for diabetes in all patients presenting with ED, as 17% had abnormal results requiring further investigation or management. More importantly, and despite the small numbers involved, the paper emphasises the need to perform fasting blood glucose measurement rather than simple urine dipstick (or random glucose), a view echoed by the British Diabetic Association Professional Advisory Committee.

Reviewer: Rob Jones

Journal:	BJU International
Authors:	G Biagiooti and G Cavallini	Issue:	2001; 88: 63-67

Title:

Acetyl-L-carnitine vs tamoxifen in the oral therapy of Peyronie’s disease: a preliminary report.

Abstract:
This prospective, randomised, double-blind study compared the effect oral Acetyl-L-carnitine (ALC) with oral tamoxifen in patients with early Peyronie’s disease. ALC, an ester of the amino acid L-carnitine, reduces free-radical production and been used in several oxidative/degenerative diseases. 48 men with a clinical diagnosis of Peyronie’s disease in either the ‘acute’ (mean symptom duration 5 weeks) or ‘early chronic’ (mean symptom duration 6.5 months) phases were randomised to receive tamoxifen 20mg bd or ALC 1g bd for 3 months. The outcome measures were penile pain, penile curvature (from Polaroid images) and plaque size. ACL reduced penile pain in 92% of patients and tamoxifen reduced penile pain in 50% of patients. Penile curvature did not alter significantly following tamoxifen, whereas curvature was significantly reduced from mean 15.90 to mean 8.40 following treatment with ALC. Plaque size was significantly reduced in both tamoxifen and ALC groups after treatment. Side effects were reported in 25% of tamoxifen patients but, surprisingly, in none of the patients receiving ALC. This paper does suggest that ALC compares favourably with tamoxifen, an established therapy in early Peyronies’s disease. The study does, however, suffer from the lack of a control group. The authors state that ethically one could not deny treatment with placebo in this disorder (reporting a untreated progression rate of 90%). This is arguable, and the placebo effect in a previous trial of tamoxifen in Peyronie’s disease was surprisingly high. The omission of an assessment of erectile function is also puzzling, for example the number of men who were able to achieve satisfactory intercourse following treatment. Despite these shortcomings the study does suggest that compared to tamoxifen, ALC may be more effective in reducing penile pain and curvature in early Peyronie’s disease, with fewer side effects.

Reviewer: Rob Jones

Journal:	BJU International
Authors:	Hamm R, McLarty E, Ashdown J, Natale S and Dickinson A	Issue:	2001; 87:849-52

Title:

Peyronie’s disease - the Plymouth experience of extracorporeal shockwave treatment.

Abstract:
This series is the second in the UK reporting the results of extracorporeal shockwave treatment (EST) in the treatment of Peyronie’s disease. 28 men who had ‘stable’ disease of over 1 year’s duration were included, and were studied before and after 3-5 sessions of EST (mean 3.9). The initial severity of disease (degree of the penile angulation) is not reported. Outcome measures were: erectile function, satisfaction and penile pain assessed via questionnaire, penile angulation measured during a pharmacologically induced erection, and plaque size measured by ultrasound. The timing of the follow-up assessment in relation to treatment is not recorded. 20 patients (71%) felt that their erections were improved following treatment, and of the 16 patients who had been unable to perform penetrative intercourse pre-treatment, 11 became able to do this afterwards. A similar improvement was seen in penile pain during erections. Improved IEF scores following treatment were seen in all but one patient (mean improvement 12.5). Unfortunately, results from penile angulation measurement do not appear in this paper. However, 15 out of 28 patients (53.5%) reported a subjective decrease in angulation following treatment. This figure is in line with previous series showing a range in improved angulation after EST of 33-64%. US assessment of plaque size was felt to be unreliable as no correlation was seen between this measurement and either palpable abnormality or symptomatic improvement. Despite about half of the patients having penile bruising and one developing urethral bleeding, the treatment was generally well tolerated without major complication. Results from this small, uncontrolled series are consistent with previous, similar studies and suggest that this well tolerated therapy compares favourably with other conservative treatments for Peyronie’s disease. This paper strengthens the case for setting up a multicentre, randomised, controlled clinical trial (with longer and more defined follow up) in order to further define the role of EST in the management of Peyronie’s disease.

Reviewer: Rob Jones

Journal:	BJU International
Authors:	Baniel J, Israilov S, Segenreich E and Livine PM.	Issue:	2001; 88: 56-62, 2001

Title:

Comparative evaluation of treatments for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy.

Abstract:
This study reported treatment of ED in 85 patients who had recently undergone radical prostatectomy (mostly non nerve-sparing). The unusual study design involved a treatment ladder of 4 different ED therapies that were tried in turn if patients failed to respond. First line treatment was vacuum therapy, then sildenafil, then intracavernosal injections (papaverine/phentolamine) and finally intracavernosal injection/vacuum therapy combined. Justification was not given for this order. ‘Response’ to treatment was assessed using a non-validated measure of erectile function. 92 % of patients developed erections adequate for penetration with vacuum therapy, but only 14% agreed to carry on using this treatment. Only 30% of the remainder responded to sildenafil and the rest tried intracavernosal injections. The majority (85%) of these remaining 60 patients responded well to intracavernosal injections. Collectively, the 4 different therapies gave a positive response in 80 out of the 85 patients. Due to inherent limitations of this type of study, a “comparative evaluation of treatments” has not actually been performed. One would question the authors’ conclusion that intracorporal injections are most effective in treating ED post radical prostatectomy, based solely on this study. However, this paper does emphasise that by utilising the range of therapies currently available for ED, there are very few patients that cannot be successfully treated after non nerve-sparing radical prostatectomy.

Reviewer: Rob Jones

Journal:	European Urology
Authors:	Sommer F, Schwarzer U, Klotz T, Caspers H-P, Haupt G, Engelmann U.	Issue:	2001; 39: 720-723.

Title:

Erectile dysfunction in cyclists. Is there any difference in penile blood flow during cycling in an upright versus a reclining position?

Abstract:
This prospective crossover study from Düsseldorf examined the effect of bicycling in the upright versus reclining position on the transcutaneous penile oxygen pressure (tpO2) at the glans penis. 46 athletic healthy men aged 32 ± 5.13 years with no known sexual dysfunction were recruited and divided into 2 groups of 23 each. No randomisation method was described. A modified Clark p02 electrode was employed to measure penile oxygen partial pressure by a previously established method. Simultaneous cardiovascular monitoring was carried out while the first group cycled in the upright position and the second in the reclining position. The groups were changed over after 3 weeks. Baseline readings were recorded as 60 ± 8.1 mmHg in the standing position prior to the test. The authors found a 70% decline in tpO2 to 18.3 ± 5.2 mmHg after cycling in the upright position (p<0.05), although the duration of cycling and the tpO2 in the sitting position alone without cycling were not reported. In contrast, cycling in the reclining position did not alter penile blood flow (mean 59 ± 4.2 mmHg). The reduction in blood flow was lower (22%) when wider saddles were used with medium padding and no saddle nose but this fact was described in the discussion only with no quantification or description of methodology. After a 15-minute recovery period normal penile blood flow was measured in a standing position. This paper is interesting in that it addresses a scantily-reported phenomenon in a growing population of amateur cyclists. Although the issue of whether cycling is a risk factor for erectile dysfunction (ED) has been recently raised, this paper does not answer that question. The decrease in penile blood flow in this study appears to be short-lived after cycling. The authors correctly acknowledge that erection involves a ‘complex neurovascular mechanism’, but this paper does not address the neural effects of cycling in the context of previous reports of genital numbness following cycling. Consequently it is difficult to draw accurate conclusions yet about the true impact of this sport on the causation of ED.

Reviewer: Jay Khastgir

Journal:	BJU International
Authors:	Souverein PC, Egberts ACG, Sturkenboom MCJM, Meuleman EJH, Leufkens HGM and Urquhart J	Issue:	2001, 87: 648-653

Title:

The Dutch cohort of sildenafil users: baseline characteristics

Abstract:
This ambitious project is looking at patterns of sildenafil use in daily practice in the Netherlands, and has attempted to gather information from every Dutch pharmacy (n=1571). Pharmacists were asked to prospectively identify patient characteristics and prescription details from the first 20 sildenafil prescriptions from each pharmacy, starting approximately six months after the introduction of sildenafil to the Dutch market. 4460 prescriptions from 3477 patients are included. Based on information from concomitant drug administration, the majority of this cohort of ED patients had either cardiovascular disease or diabetes, as one might expect. Surprisingly, 69 patients (2.2% of the cohort) were also prescribed regular nitrates when sildenafil was prescribed. Given this figure, it is interesting to note that the majority of prescriptions overall were from GPs (80% of first time prescriptions) rather than Urologists (only 13.8% of first time prescriptions). But probably the most significant finding of this study to date is that only 195 men (6.3% of the cohort) had previously used other forms of treatment for ED. Therefore, it would appear that, in the Netherlands, the barrier to seek treatment for ED has been reduced and sildenafil seems to have been prescribed to a new, previously untreated population, with prescriptions coming mainly from GPs. Of course, an alternative explanation would be that most patients using other forms of therapy are unwilling to try sildenafil, though this seems far less likely. The patients are now being followed for one year and this should generate information on patterns of sildenafil use in this large cohort of ED patients.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Daitch JA, Bedaiwy MA, Pasqualotto EB, Hendin BN, Hallak J, Falcone T, Thomas	Issue:	2001, 165:1510-3

Title:

Varicocelectomy improves intrauterine insemination success rates in men with varicocele

Abstract:
This paper helps to define the relationship between varicocele treatment in men with abnormal seminalysis and outcome from intrauterine insemination (in a similar way to the documented beneficial role prior to in vitro fertilisation). The non-randomised, retrospective study looked at seminalysis parameters and conception rates in 58 infertile couples in whom women had normal investigations and men had abnormal seminalysis and a varicocele. Varicocele was diagnosed clinically and on Doppler (although no specific diagnostic criteria or gradation of varicocele are given). 34 men had open varicocelectomy (using either inguinal or subinguinal approach) prior to intrauterine insemination, and this group was compared to 24 men who did not have surgery for their varicoceles prior to intrauterine insemination. The two groups were no different in terms of total sperm count, but the untreated varicocele group had significantly increased sperm motility. This may well be due to selection bias in this retrospective study, as men with better seminalysis may have been advised to defer varicocelectomy. Oddly, seminalysis values before and after varicocelectomy in the same patient were not reported in this paper, although previous studies have suggested improved motility following varicocelectomy. Despite this, both pregnancy and live birth rate (per cycle) were significantly higher in the treated varicocele group. The authors suggest that this may be due to improvements in a sperm function parameter not currently measured. They hypothesise that oxidative stress due to reactive oxygen species, which have been shown to be elevated in men with varicoceles and to impair sperm-egg interaction, may provide an explanation and is the basis of current research.

Reviewer: Rob Jones

Journal:	BJU International
Authors:	Souverein PC, Egberts AC, Sturkenboom MC, Meuleman EJ, Leufkens HG and Urquhart J.	Issue:	2001, 87: 648-651

Title:

The Dutch cohort of sildenafil users: baseline characteristics.

Abstract:
This ambitious project is looking at patterns of sildenafil use in daily practice in The Netherlands, and has attempted to gather information from every Dutch pharmacy (n=1571). Pharmacists were asked to prospectively identify patient characteristics and prescription details from the first 20 sildenafil prescriptions from each pharmacy, starting approximately six months after the introduction of sildenafil to the Dutch market. 4460 prescriptions from 3477 patients are included. Based on information from concomitant drug administration, the majority of this cohort of ED patients had either cardiovascular disease or diabetes, as one might expect. Surprisingly, 69 patients (2.2% of the cohort) were also prescribed regular nitrates when sildenafil was prescribed. Given this figure, it is interesting to note that the majority of prescriptions overall were from GPs (80% of first time prescriptions) rather than Urologists (only 13.8% of first time prescriptions). But probably the most significant finding of this study to date is that only 195 men (6.3% of the cohort) had previously used other forms of treatment for ED. Therefore, it would appear that in the Netherlands the barrier to seek treatment for ED has been reduced and sildenafil seems to have been prescribed to a new, previously untreated population, with prescription coming mainly from GPs. Of course, an alternative explanation would be that most patients using other forms of therapy are unwilling to try sildenafil, though this seems far less likely. The patients are now being followed for one year and this should generate information on patterns of sildenafil use in this large cohort of ED patients.

Reviewer: Richard Parkinson

Journal:	BJU International
Authors:	Souverein PC, Egberts AC, Sturkenboom MC, Meuleman EJ, Leufkens HG and Urquhart J.J	Issue:	2001, 87: 648-53

Title:

The Dutch cohort of sildenafil users: baseline characteristics.

Abstract:
This ambitious project is looking at patterns of sildenafil use in daily practice in The Netherlands, and has attempted to gather information from every Dutch pharmacy (n=1571). Pharmacists were asked to prospectively identify patient characteristics and prescription details from the first 20 sildenafil prescriptions from each pharmacy, starting approximately six months after the introduction of sildenafil to the Dutch market. 4460 prescriptions from 3477 patients are included. Based on information from concomitant drug administration, the majority of this cohort of ED patients had either cardiovascular disease or diabetes, as one might expect. Surprisingly, 69 patients (2.2% of the cohort) were also prescribed regular nitrates when sildenafil was prescribed. Given this figure, it is interesting to note that the majority of prescriptions overall were from GPs (80% of first time prescriptions) rather than Urologists (only 13.8% of first time prescriptions). But probably the most significant finding of this study to date is that only 195 men (6.3% of the cohort) had previously used other forms of treatment for ED. Therefore, it would appear that in the Netherlands the barrier to seek treatment for ED has been reduced and sildenafil seems to have been prescribed to a new, previously untreated population, with prescription coming mainly from GPs. Of course, an alternative explanation would be that most patients using other forms of therapy are unwilling to try sildenafil, though this seems far less likely. The patients are now being followed for one year and this should generate information on patterns of sildenafil use in this large cohort of ED patients.

Reviewer: Akhlil Abdul-Hamid

Journal:	Journal of Urology
Authors:	Boehmer AL, Nijman RJ, Lammers BA, de Coninck SJ, Van Hemel JO, Themmen AP, Mureau MA, de Jong FH, Brinkmann AO, Niermeijer MF and Drop SL.	Issue:	2001, 165: 1246-54

Title:

Etiological studies of severe or familial hypospadias.

Abstract:
Hypospadias affects around 1 in 1500 live births, although the aetiology remains unknown in a large proportion of cases. The authors of this paper argue for aggressive investigation of patients with hypospadias, as diagnosis of certain underlying conditions may highlight the need for additional treatment. 63 cases of hypospadias were identified retrospectively, and underwent exhaustive clinical, biochemical and molecular biological tests. An underlying cause was identified in 31%. Complex genetic syndromes constituted 17%; chromosomal abnormalities, 9.5%. There was 1 case diagnosed of each of the following: vanishing testis syndrome, androgen insensitivity syndrome, and 5-alpha-reductase type 2 deficiency. Although a familial tendency for hypospadias is well documented, androgen insensitivity was diagnosed in only 1 out of 16 such families. The authors conclude that extensive investigation of patients with hypospadias is important, and include a suggested protocol of investigations. Unfortunately, it is not stated how many diagnoses result in a change in patient management.

Reviewer: Richard Parkinson

Journal:	European Urology
Authors:	Hakenberg OW, Helke C, Manseck A and Wirth MP.	Issue:	2001, 39: 412-417

Title:

Is There a Relationship between the Amount of Tissue Removed at Transurethral Resection of the Prostate and Clinical Improvement in Benign Prostatic Hyperplasia.

Abstract:
This is a simple prospective study that evaluates the effect of the extent of tissue resection on symptom improvement after TURP in men with symptomatic BPH. 138 men (mean age 68.2, range 53-89 years) with symptomatic BPH requiring a TURP were recruited. All patients were preoperatively assessed with a routine physical examination including a digital rectal examination (DRE), routine bloods and a flow rate. Prostate volume (PV) and residual urine volume (RUV) were determined using suprapubic ultrasound. Preoperative symptoms were assessed using the following self-administered questionnaires: IPSS, Quality of Life, the American Urological Association Bother Score (AUA-BS), and the BPH Impact Index (BPH-II). The patients then underwent TURP at which complete adenoma resection down to the capsule was performed and the resected tissue weighed immediately. Catheters were removed on the third postoperative day and the patients discharged the next day. Urine flow rates were measured on the day of discharge. Follow up at 3 and 6 months included clinical examination, measurement of flow rates and RUV and the evaluation of symptom and bother scores. The study found a close correlation between the preoperative PV and the resected tissue weight (RTW, p<0.001) and between age and preoperative PV (p<0.05). There was a mean improvement in the Qmax, RUV and IPSS, AUA-BS and BPH-II at 3 and 6 months, but at 3 months, the RTW correlated negatively with the IPSS, AUA-BS and BPH-II. There was no statistically significant correlation between symptom change and the percentage of PV removed or the residual prostatic weight. The study also found that patients with larger preoperative PV tend to gain more symptomatic improvement following TURP. Some of the flaws with this study include the relatively short follow up, and the estimation of PV using suprapubic ultrasound.

Reviewer: Biral Patel

Journal:	International Journal of Impotence Research
Authors:	Y Kawanishi, K S Lee, K Kimura, T Koizumi, H Nakatsuji, K Kojima, A Yamamoto, A Nutama and T Sogou.	Issue:	2001; 13:100-3

Title:

Screening of ischaemic heart disease with cavernous artery blood flow in erectile dysfunction patients.

Abstract:
Ischaemic heart disease (IHD) is more common in patients with ED than in the general population, and this interesting paper proposes a means of identifying a subset of ‘high risk’ ED patients who merit cardiological investigations. 58 patients with ED were assessed by dynamic colour Doppler ultrasound of the penis. They then underwent an independent cardiological assessment that included an exercise ECG in all patients, with additional echocardiograms, thallium scans, treadmill tests and angiography as clinically indicated in each case. 14 patients (24.1%) were diagnosed with IHD on exercise tests, 8 (13.8%) of which were newly diagnosed. Although all but 2 of these patients with IHD had at least one major cardiovascular risk factor, the predictive value of risk factors themselves for IHD was low. However, peak systolic velocity (PSV) on penile Doppler was found to be a strong predictor of IHD. Mean PSV was significantly lower in patients with IHD (22.0cm/s) than in patients without IHD (34.6cm/s). The authors then took the arbitrary cut-off value of PSV 35cm/s, and found that of patients with a PSV>35cm/s (accounting for just under half of all patients) only 3.7% had IHD, while of those with a PSV <35cm/s, 41.9% were shown to have IHD. The authors propose that ED patients with PSV<35 cm/s on penile Doppler should undergo cardiac exercise testing. Clearly, not all patients with ED could have (or indeed need) exercise tests. The value of penile PSV as a means of identifying ‘higher risk’ ED patients in everyday practice is limited by the fact that only a very small proportion of ED patients would normally undergo penile Doppler. More broadly applicable cardiac risk stratification guidelines for patients with ED exist in UK and USA consensus panel documents. Nevertheless, the strong correlation between penile artery function and IHD on exercise tests is an important finding and should promote further research into the relationship between ED and occult IHD.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Pavlovich CP, King P, Goldstein M, Schlegel PN.	Issue:	2001, 165: 837-41

Title:

Evidence of a treatable endocrinopathy in infertile men

Abstract:
A subset of infertile men have increased serum oestradiol and low testosterone, which may impair spermatogenesis. In men, most of the oestradiol is derived from peripheral aromatization of androgens secreted by the Leydig cells in the testes.This interesting study aims to define what the normal testosterone to oestradiol ratio is in fertile men and what it is in a subset of infertile men. The authors then evaluated the response of this ratio to treatment with a low dose aromatase inhibitor, testolectone, and also the impact it has on semen analysis. An age-matched group of 40 men with proven fertility and no evidence of testicular dysfunction was used as a reference group to determine the normal testosterone to oestradiol ratio ( at 1/10, normal ratio=14.5 ; 95% CI 7.2 to 21.8). 45 infertile men with differing aetiologies had testosterone to oestradiol ratios less than the 20th percentile of normal distribution ( at 1/10, ratio <10) and were treated with testolectone at a dose of 50-100mg b.d. orally for a mean duration of 5 months.Of note,there was no control group treated with placebo.Hormone levels were assessed pre and post treatment ( at 1 month after testolectone and 3 monthly thereafter). Semen samples were also analysed after a minimum of 3 months on treatment. The results showed that, in all cases, there was both a statistically significant increase in testosterone level and a decrease in oestradiol, resulting in a marked increase in testosterone to oestradiol ratio ( at 1/10) from 5.0 before to 12.7 after treatment (p<0.01). Furthermore, semen analyses on12 oligospermic men showed an improvement in semen parameters such as sperm concentration and motility during treatment which was significant.Once again there was a lack of appropriate control for this part of the study ( for example, a group of infertile men with normal testosterone to oestradiol ratio treated with testolectone). Similar analyses on 12 azoospermic men did not reveal any improvement after the same duration of treatment. Despite the shortcomings of this study, it nevertheless strongly supports the conclusion that low dose testolectone can increase the testosterone to oestradiol ratio to normal in a subset of infertile men and that it may also improve the sperm quality. However, whether these will actually lead to fertility remains to be seen. What is now needed is a prospective randomized controlled trial to assess the effects of aromatase inhibition more definitively.

Reviewer: Marto Sugiono

Journal:	Journal of Urology
Authors:	Pavlovich CP, King P, Goldstein M and Sclegel P N	Issue:	2001, 165: 837-41

Title:

Evidence of a treatable endocrinopathy in infertile men

Abstract:
This study examined the serum testosterone/estradiol ratio in a subset of infertile men and aimed to establish whether treatment with testolactone, an aromatase inhibitor, could improve hormone profiles and seminalysis parameters in these patients. Estradiol is formed in men through peripheral aromatisation of androgens by the cytochrome P450 enzyme aromatase, and may impair spermatogenesis. 63 infertile men with soft small testes, high serum FSH or abnormal seminalysis were included in the study, 43 of whom were azoospermic (non-obstructive on testicular biopsy) and 20 were oligospermic. When compared to fertile controls, significantly lower serum testosterone (328 vs 543 ng./dl) and higher serum estradiol (58.4 vs 43.5 ng./L.) were found in infertile patients, resulting in significantly lower testosterone:estradiol ratio (6.9 vs 14.5). 45 men with the lowest testosterone:estradiol ratios were treated for a mean of 5 months with oral testolactone, an aromatase inhibitor. This was effective in increasing testosterone and lowering estradiol in all patients treated, and the mean testosterone:estradiol ratio for this group was raised to within the normal range (from 5.0 to 12.7). In 12 oligospermic men, Testolactone significantly improved sperm concentration (16.1 to 28.9 million sperm/ml) and motility (27.1% to 45.3%) on seminalysis. This study has demonstrated evidence of increased aromatase activity in a small group of hypofertile men with azoospermia and/or hypogonadism, and has shown significant improvements in serum testosterol:estradiol ratio and seminalysis with the orally administered aromatase inhibitor, testolactone. It remains to be seen whether successful aromatase inhibition will translate into improvements in fertility in these men, for whom sperm extraction and in vitro fertilisation techniques currently provide the only hope of successful conception.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Kourambas J, Byrne RR and Preminger GM	Issue:	2001, 165: 789-93

Title:

Does ureteral access sheath facilitate ureteroscopy?

Abstract:
Ureteral access sheaths are designed to facilitate instrumentation of the ureter. This study examines the usefulness and cost-effectiveness of these devices in routine ureteroscopic procedures. 59 patients underwent 62 ureteroscopic operations, and were prospectively randomised to ureteroscopy via a 12-14F access sheath, or unaided ureteroscopy. After 3 months follow-up, the complication rate, stone-free rate, and post-operative symptom levels were similar in the two groups. The operation time for the unaided ureteroscopies was a mean of 10 minutes longer than ureteroscopy via the access sheath. The operation costs were also higher in the unaided group, partly due to the need for balloon dilatation in some unaided cases. The authors therefore recommend the routine use of ureteral access sheaths in ureteroscopic procedures.

Reviewer: Richard Parkinson

Journal:	Journal of Urology
Authors:	Niedzielski J and Paduch DA	Issue:	2001, 165: 937-41

Title:

Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography.

Abstract:
The recurrence rate of high retroperitoneal varicocoele repair has been reported as between 7% and 11%. The authors of this paper prospectively investigated the use of intra-operative venography in 177 patients undergoing this procedure. Outcomes were compared to historical controls undergoing the same operation without intra-operative venography. Follow-up was over 1 year, and patients were assessed by clinical examination and ultrasonography. The recurrence rate at 1 year was 2.8% compared with 11% for historical controls. The surgeon was able to identify non-ligated vessels using intra-operative venography in 12%, allowing correction during the same procedure. Although a marked reduction in recurrences was achieved, no mention was made of the effect of venography on operation time and costs, which would have significant implications for the practicality of this approach.

Reviewer: Richard Parkinson

Journal:	BJU International
Authors:	Chahal R, Gogoi NK, Sundaram SK and Weston PM	Issue:	2001, 87: 352-56

Title:

Corporal plication for penile curvature caused by Peyronie’s disease: the patients’ perspective.

Abstract:
This paper evaluated patients’ satisfaction with the results of corporal plication of Peyronie’s disease. A postal questionaire was returned by 44 out of 69 patients. The mean follow-up period was 4 years. 36% reported significantly impaired erections, 16% had penile discomfort, 57% had mild penile deformity and 14% had a severe deformity. 90% reported a shorter penis, and 55% thought that the degree of shortening was significant. The paper states that 57% reported a deterioration in their quality of life, and only 52% would recommend the operation. The study relies on patients’ recollections of their symptoms prior to their procedures, at an average of 4 years later. Also, some of the data presented in the paper does not tally with the questionaire as presented in the appendix. Question 11 asks, "Do you feel your quality of life has improved since the operation? Yes/No", and yet the paper states that 57% of respondents reported a reduction in their quality of life. However, the high level of dissatisfaction following corporal plication suggested in this paper highlights the importance of adequate pre-operative counselling.

Reviewer: Richard Parkinson

Journal:	European Urology
Authors:	Tasci AI, Resim S, Caskurlu T, Dincel C, Bayraktar Z, Gurbuz G.	Issue:	2001; 39: 316-321.

Title:

Color Doppler Ultrasonography and Spectral Analysis of Venous Flow in Diagnosis of Varicocele.

Abstract:
Varicocele is defined as reflux within the spermatic veins with secondary dilatation. The diagnosis of clinical varicocele is straightforward, but subclinical cases require imaging based on reflux or venous diameter. This paper seeks to standardize diagnostic criteria for varicocele by employing colour Doppler Ultrasonography (CDU) and venous flow spectral analysis in 100 men without clinical varicocele, 100 men with clinical left varicocele, and 50 fertile men as controls. Using a 7.5 mHz linear probe, direction of venous flow and changes in direction with breathing and the valsalva manoeuvre were evaluated, with the subject in the upright and supine positions. The Doppler wave spectral patterns were classified into 3 distinct flow types. Type I pattern was considered normal, with flow directed towards the heart and no reflux. Type III indicated venous flow directed towards the testicles, which increased during inspiration or the valsalva manoeuvre. This was found to correlate well during normal inspiration (65%) with clinical varicocele on the left side and poorly (1%) on the right. Type II, which was characterised by intermittent reflux occurring during inspiration and the valsalva manoeuvre, correlated well with clinical varicocele on the left (35%) and was significantly found to be different between patients with subclinical, clinical varicocele and controls with normal breathing (11 & 17% vs 2%). There was no discrimination between clinical or subclinical varicocele and normal patients on the right. The authors suggested that since reflux during valsalva on CDU was found in 42-44% of the fertile patient population, Type III and Type II flow patterns during normal inspiration are true criteria for the diagnosis of varicocele. However, the sensitivity and specificity of these criteria in the diagnosis of subclinical varicocele are not accurately stated in this paper.

Reviewer: Jay Khastgir

Journal:	International Journal of Impotence Research
Authors:	H Padma-Nathan, JG McMurray, WE Pullman, JS Whitaker, JB Saoud, KM Ferguson and RC Rosen.	Issue:	2001, 13: 2-9

Title:

On-demand IC351 (CialisTM) enhances erectile function in patients with erectile dysfunction.

Abstract:
At least 2 new PDE5 inhibitors are currently in the late stages of clinical development. This phase II study reports data on the efficacy and side effect profile of IC351, a new, highly selective PDE inhibitor. The multicentre, double blind, placebo-controlled trial investigated the effects of IC351 in 179 men with mild to severe erectile dysfunction. IC351 at doses 5mg, 10mg and 25mg significantly improved International Index of Erectile Dysfunction (IIEF) scores (mean improvement 7 points). The mean increase in the proportion of successful intercourse attempts (from diary data) was 20% with IC351. A positive impact of treatment on erection was reported in up to 80% of patients who initially had moderate ED and up to 90% of those with severe ED. The 2mg dose was far less effective. Men with spinal trauma, diabetes and radical prostatectomy (who have coincidentally been shown to respond less well to sildenafil) were excluded from this study and data on efficacy in these patients is awaited. Overall 25.7% of IC351 patients reported adverse events (placebo 8.6%). The most commonly reported side effects, which were more common among patients taking the higher doses, were headache (5.7-16.7%), dyspepsia (0-8.3%) and backache (2.9-8.3%). Most were mild and abated with further treatment. Interestingly, only one patient reported flushing. The higher selectivity for PDE5 of new PDE inhibitors suggests a potential for improved side effect profiles and efficacy. Direct comparisons with results from trials of other agents should be made with caution. However, this study does provide promising data for IC351 (CialisTM), demonstrating significantly improved erectile function from a well tolerated oral preparation.

Reviewer: Rob Jones

Journal:	Journal of Urology
Authors:	Stock RG, Kao J and Stone NN.	Issue:	2001, 165: 436-9

Title:

Penile erectile function after permanent radioactive seed implantation for treatment of prostate cancer.

Abstract:
The issue of potency after treatment for prostate cancer has been addressed in 416 patients undergoing brachytherapy. A previously verified scoring system was used to assess patients before and following treatment. The potency rate prior to treatment was 75%. Of these men, 79% remained potent at 3 years, and 59% at 6 years post-operatively. Such data are important for decision making in men contemplating treatment for prostate cancer, and these results compare favourably with many published series for erectile dysfunction following external beam radiotherapy, and radical retropubic prostatectomy. However, the lack of a control group, and the failure to include other demographic data, such as co-existing medical problems and alcohol intake, limits comparisons with other series.

Reviewer: Richard Parkinson

Journal:	BJU International
Authors:	Zargooshi J	Issue:	2000, 86: 75-79

Title:

Unconsummated marriage: clarification of aetiology; treatment with intracorporeal injection.

Abstract:
This paper is a revelation to those unaware of marriage rituals amongst different cultures. The author addresses the problem of unconsummated marriages in Iran and the use of intracorporeal injection to help these patients. Failure to perform by the bridegroom results in great social scandal and recriminations from his own family. The bride can also sue for divorce and the cost of the wedding. Failure to perform is not particularly surprising considering the bride and groom may have never met, have a poor understanding of anatomy and physiology of the genitals and are required to perform on the wedding night with relatives waiting outside for proof of consummation. The usual proof is a blood stained handkerchief that also serves to confirm the bride was previously a virgin. The author gives the results of the injection therapy using initially papaverine and then adding phentolamine where necessary. Unsurprisingly 85% of those having success go on to have normal erectile function as the stress of the situation resolves. The prolonged erection and priapism numbers were high in these patients, which probably reflects the agents used and also the high doses. The rural patients were not deemed capable of injecting themselves and so high doses were given in the hospital allowing them time to return to the community to attempt intercourse. The level of sexual education is increasing, particularly in urban areas but the pressure to perform will always be great in these circumstances. Intracorporeal injections are an effective way of crossing this initial hurdle.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Gralnek D, Wessells H, Cui H and Dalkin BL	Issue:	2000, 164: 1166-1170

Title:

Differences in sexual function and quality of life after nerve sparing and non-nerve sparing radical retropubic prostatectomy.

Abstract:
This is a retrospective study based on one surgeon’s series of prostatectomies. The patients were divided into two groups. One group had radical non-nerve sparing surgery if already impotent or both prostatic lobes were involved and the other group had unilateral nerve sparing operations. This was a postal questionnaire study using a previously validated tool (RAND / UCLA). One hundred and twenty nine patients responded including 83 who underwent non-nerve sparing surgery and 46 who underwent nerve sparing surgery. Scores for physical function, physical limitations and sexual function were significantly better after nerve sparing surgery. Of those having nerve sparing operations, half maintained potency and obviously had better function scores. If nerve sparing was unsuccessful, sexual function and bother was improved with erectile aids but not to the level of a successful operation. Urinary continence was not different between the groups. It is not possible to know if the quality of life improvement is due to the potency. The nerve spared patients may have had less disease and less comorbidity. The time elapsed after operation in these patients was widely different making it hard to compare them. Ideally a prospective study is required. There are also newer ED specific QoL measures being validated which might be useful. QoL is undoubtedly very important, particularly with prostate cancer, because of the low cancer specific mortality. However, the current enthusiasm for this area of research could be tempered by the observation that the patients primary concern was not incontinence or sexual function, but being free of disease.

Reviewer: Richard Lockyer

Journal:	BJU International
Authors:	Paick JS, Kim SH and Kim SW	Issue:	2000, 85: 720-724

Title:

Ejaculatory duct obstruction in infertile men.

Abstract:
This is a review of 50 patients with ejaculatory duct obstruction (EDO) over a 7-year period treated at one institution. Patients were evaluated by history, physical examination, semen analysis, hormones, testicular biopsy, TRUS and vasography. All patients had normal sized testis, at least one vas, no varicocoeles, normal sexual characteristics and normal FSH and testosterone. Two semen samples were obtained and assessed for ejaculate volume, sperm density and motility. Fructose in seminal fluid was assessed. Those with low volume ejaculate had a post ejaculate urine sample to exclude retrograde ejaculation. Testicular biopsy confirmed spermatogenesis. They discuss the merits of the investigations and show success rates for several treatments.They conclude TRUS should be the first diagnostic procedure used when EDO is suspected avoiding potential problems from invasive vasography. Patients with atrophic seminal vesicles on TRUS and a history of pulmonary tuberculosis should proceed to microscopic sperm extraction, as further investigations are not necessary. Measurement of semen fructose may be helpful in diagnosing partial EDO. Patients with midline cysts who are treated by transurethral resection are expected to have the best outcome.

Reviewer: Richard Lockyer

Journal:	BJU International
Authors:	Dokucu AI, Ozturk H, Ozdemir E, Ketani A, Buyukbayram H and Yucesan S	Issue:	2000, 85: 767-771

Title:

The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion.

Abstract:
It has been well documented that following unilateral testicular torsion, changes occur in the contralateral testicle which result in long term subfertility. The mechanism for this effect is controversial. Theories proposed include autoimmunity, underlying congenital defects, release of acrosomal enzymes and hypoxia due to reflex reduction in the blood supply to the contralateral testicle. The vasospasm is suggested to arise by a neurovascular pathway, triggered by an ipsilateral testicular stimulus, running through a synaptic reflex arc.The authors assumed the latter theory and hypothesised that vascular dilating agents such as nitric oxide (NO) would reduce such effects. They performed an elegant experiment on rats splitting them into 4 groups: group 1 had a sham operation, group 2 underwent testicular torsion for 6 hours with a saline infusion, group 3 underwent torsion and were infused with L-arginine (a NO precursor) and group 4 underwent torsion with L-arginine infusion, but were also infused with a NO synthase inhibitor (thus controlling for ant effect of L-arginine alone). The opposite testicle was removed after 21 days. The histopathology of groups 1 and 3 were similar and statistically different to groups 2 and 4. L-arginine did not protect against all pathological changes such as Leydig cell reaction and oedema. Thus they have confirmed that torsion can cause long-term damage to the contralateral testicle and L-arginine may have some protective role. A functional study would be the next step to confirm whether fertility is maintained.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Benevides MD and Carson CC	Issue:	2000, 163: 785-787

Title:

Intraurethral application of alprostadil in patients with failed inflatable penile prostheses.

Abstract:
This paper looks at the use of MUSE in a series of patients with either failed penile prostheses or who reported decreased glans penis engorgement. These patients all had inflatable prostheses. Group 1 consisted of 11 patients in whom the prosthesis had failed, but who for various reasons were unable to have the prosthesis revised. Group 2 contained 17 patients who complained of a flaccid or cold glans. MUSE was given to them in the office and the dose escalated from 250 –1000 mg as necessary. Twenty three (82%) of the 28 had a response to MUSE. In group 1, 7 (64%) out of 11 had an erection good enough for intercourse, but only 5 continued to use MUSE. Patients dropped out because of pain and/or lack of efficacy. In group 2, 10 (59%) of the 17 were satisfied with the treatment and, strangely, 11 (65%) continued using it long term. All those not satisfied complained of disabling penile pain and 5 had a poor home response. The mean dose of MUSE was around 500 mg. We have looked at 27 patients similar to group 2 but with malleable prostheses (accepted for publication in Sexual Dysfunction) and found encouraging results with a good response in 92.6%. We also demonstrated an increase in penile girth suggesting engorgement of residual cavernosal tissue around the prosthesis. MUSE is generally felt to lack efficacy, but in these selected patients it is often very helpful. The main side effect seems to be penile discomfort, but 78% in our series still wished to carry on using MUSE.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Romeo JH, Seftel AD, Madhun ZT and Aron DC	Issue:	2000, 163: 788-791

Title:

Sexual function in men with diabetes type 2: association with glycaemic control.

Abstract:
This group set out to look directly at the link between glycaemic control and erectile function. The study sample was 78 sexually active male outpatients with diabetes. All patients suffered type 2 diabetes and were under routine follow-up. The erectile function was assessed using the previously validated international index of erectile function (IIEF) and the haemoglobin A1c (Hb A1c) levels obtained within the previous 3 months. They stratified glycaemic control into 5 groups and found erectile function reduced with increasing Hb A1c ie. with decreasing diabetic control. They found no associations of glycaemic control with alpha blockers, beta blockers, diuretics or duration of diabetic disease. Unsurprisingly poorer control was more common in the younger age groups. Insulin use was more common in those with poor control which may indicate more severe disease, especially as these patients all had type 2 diabetes. Bivariate analysis revealed a significant correlation of Hb A1c with neuropathy but not with age, duration of disease or other drug use. Multivariate analysis showed Hb A1c and neuropathy to be independent predictors of erectile dysfunction. Diabetes has multisystem effects on the body so that it is often difficult to remove confounding variables such as heart disease in these patients. However, it is not surprising that diabetic control will affect erectile dysfunction. This study relies on the previously validated IIEF, but they have left out one question from the erectile function domain. They give their reasons, but surely this affects the merits of the previous validation. It is well known that Hb A1c is a measure of glycaemic control, but it is still a relatively small snap-shot of several weeks. Erectile dysfunction is often quite slow to progress and therefore glycaemic control over several years might be more important. The authors want to study whether good control will improve erectile function. One suspects it will only prevent deterioration but it is still an important question. The effect of glycaemic control on erectile function might be a useful educational ‘arm twister’ for poorly compliant male patients.

Reviewer: Richard Lockyer

Journal:	BJU International
Authors:	Tanyel FC, Erdem S, Buyukpamukcu N and Tan E	Issue:	2000, 85: 116-119

Title:

Cremaster muscles obtained from boys with an undescended testis show significant neurological changes.

Abstract:
This is basic science research looking at differences within the cremaster muscle of 26 boys and 3 girls with inguinal hernia and 12 boys with undescended testicle and 6 with hydrocoele. They analysed the muscle biopsies taken at surgery for the occurrence of various molecular parameters. They also measured the diameter of a selection of the fibres in each case. They summarise what each finding would suggest in the text but it is unclear whether the person analysing the muscle was blinded to the patient diagnosis or not. It would appear that the cremaster muscle from all the undescended testicle patients showed evidence of a neurogenic problem whereas the hernia group showed mainly none specific changes and only neurogenic changes in 2 patients. This suggests that the mechanism behind these two problems is different. The authors summarise some of the various theories regarding undescended testicles in the discussion. They accept that they have simply demonstrated an association that supports some theories and is counter to others. They feel that the dennervation seems to cause the cremaster muscle to act as a barrier to testicular descent rather than hampering a possible role of the cremaster muscle during descent.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Mulcahy JJ	Issue:	2000, 163: 481-482

Title:

Long-term experience with salvage of infected penile implants.

Abstract:
Not long ago it would have been considered surgical suicide to replace an infected penile prosthesis at one sitting. However, simply removing them leaves a limited future to that patient’s erections. Attempting further insertion of a prosthesis some months later is difficult surgically and the penis often loses some length and girth. The vogue now is to remove all foreign material and thoroughly irrigate the wound with multiple antibacterial solutions. Large series are relatively unusual and this paper presents the success of this procedure in 65 patients. They contacted 55 (85%) of the patients and 45 (82%) underwent successful salvage with no subsequent signs of recurrent infection. The results were similar for the 6 patients who required distal corporoplasty during the salvage operation. Understandably the results were less good, but still reasonable, in the 7 patients needing PTFE reconstruction of the tunica covering the prosthesis. Four of these were unsuccessful. Obviously infection needs to be kept to a minimum, but if necessary an immediate salvage procedure may well provide a better long term functional result. A comparison between two groups of patients would be helpful.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Mulhall JP, Jahoda AE, Cairney M, Goldstein B, Leitzes R, Woods J, Payton T, Krane RJ and Goldstein I	Issue:	1999, 162: 1291-1294

Title:

The Causes of Patient Dropout From Penile Self-Injection Therapy for Impotence

Abstract:
This paper looks at quite a large number of patients on a penile self-injection program. It assesses, by way of questionnaire, the reasons behind patients stopping treatment. They mailed 1424 patients who had completed the office training and home use phases of their program. Only 720 men completed the questionnaire. The dropout rate was 31% over a mean follow-up of 38 months. The main reasons were cost, patient and partner problems with the concept of penile injection, lack of partner and improved spontaneous erections. Adverse events such as priapism, penile nodules or pain were only minor contributors to drop out. Lack of efficacy only affected 1 in 7 dropouts. This dropout rate is low compared to previous smaller studies and probably reflects the training and education provided on 2 to 3 occasions for the patient and often partner. Also, the patients questioned had already completed this 'training program' and will therefore be self selected to carry on with treatment. This reason could also apply to the low number of patients dropping off for poor efficacy. The data may also be skewed by the 50% return rate for the questionnaire. Poorly motivated people will be more likely to drop off this regime and will also not return questionnaires. Side effects, particularly pain, were quite low and this probably reflects the authors' drug regime, which favours multi-agent mixtures allowing the dose of prostaglandin to be reduced. Cost to the patient has not previously been an issue in the UK, but with the present guidelines it has become so. It is also interesting to note that the authors, and others, now refer to intracavernosal injections as second line treatment.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Jarow JP, Burnett AL and Geringer AM	Issue:	1999, 162: 722-725

Title:

Clinical efficacy of sildenafil citrate based on etiology and response to prior treatment

Abstract:
This paper reviewed the results of 308 patients treated with sildenafil, following the release of the drug by the FDA in 1998. The study consisted of self administered questionnaires at baseline and follow up, to assess sexual function, aetiology, response to prior therapies, libido, overall satisfaction, quality of life and also whether the drug met with expectations and whether they would use it again. They obtained full data on 267 men with a mean age of 61 and a mean duration of erectile dysfunction (ED) of 4.1 years. The overall success of sildenafil was 65% and success correlated with quality of life improvements. Unsurprisingly, satisfaction correlated with desire to reuse the drug, but surprisingly, desire to reuse was larger than satisfaction. The patients seem to be hoping that it would work in the future. Perhaps this reflects their negative perceptions of other methods of treatment such as injections. Eighty-five percent wished to reuse it, although only 51% felt it met with their expectations. This, the authors point out reflects the media hype and the fact that a tablet will not repair relationships. Side effects occurred in 35% and these were headache 15%, facial flushing 14%, dizziness 2%, visual disturbance 2% and nasal congestion 4%. Success of sildenafil depended on aetiology of ED and baseline sexual function. Satisfaction was 100% for those with mild impairment and was 41% for those with severe impairment. Patients with a neurological cause were least satisfied whereas psychogenic and vascular aetiologies were most satisfied. Interestingly, sildenafil success was much improved following radical prostatectomy if it was a nerve sparing operation. The authors rightly conclude that sildenafil should be offered first line in all patients unless contraindicated. It also seems to be as efficacious in 'real' practice as it was in the trials.

Reviewer: Richard Lockyer

Journal:	British Journal of Urology
Authors:	Rehman J, Christ GJ, Kaynan A, Samadi D and Fleischmann J	Issue:	1999, 84: 305-310

Title:

Intraoperative electrical stimulation of cavernosal nerves with monitoring of intracorporeal pressure in patients undergoing nerve sparing radical prostatectomy

Abstract:
The authors explore the use of cavernosal nerve stimulation during radical prostatectomy in 14 patients. Ten reported that they were potent, and 4 impotent pre-op. Patients and their partners were interviewed at 3, 6, 12 and 18 months after the operation. The cavernosal nerves were stimulated during the operation before and after the nerve dissection. The erectile response was measured objectively using an intracavernosal cannula connected to a manometer. Seven of the 10 potent patients had an increase intracavernosal pressure of > 50 cm H2O during the surgery and were all potent post-op. The other 3 had increases < 30 cm H2O. Two reported partial erections and 1 was impotent. Of the 4 impotent patients, 2 had increased intracavernosal pressure of < 40 cm H2O, 1 an increase < 20 cm H2O and the last no increase at all. All remained impotent post-op. The use of the stimulators added about 20 minutes to the operating time. The authors suggest that this method is useful for predicting potency and this seems to be true. They suggest that it will help with the dissection of the nerves, but to prove this one needs better pre- and post-op assessment of erectile function (e.g. rigiscan studies) and a randomized study. Indeed, 3 patients apparently had their erectile function reduced by the operation despite the use of this technique. They also point out that this technique could be used to locate the site of nerve damage caused by the surgeon, allowing repair to be attempted. In summary, this method allows objective data on the cavernosal response. The next step is to assert whether its use will affect outcomes in terms of potency without affecting surgical tumour margins.

Reviewer: Richard Lockyer

Journal:	International Journal of Impotence Research
Authors:	Caspari D, Huebgen EM and Derouet H	Issue:	1999, 11: 213-217

Title:

Interdisciplinary assessment and follow-up of patients with erectile dysfunction - psychiatric aspects.

Abstract:
The authors set out to assess the psychiatric comorbidity and patient satisfaction in a sample of 73 consecutive men attending the andrology clinic. All patients saw both the andrologist and the psychiatrist. All patients underwent clinical examination, hormone profile and pharmacological provocation of erection (e.g. PGE1) with penile artery Doppler. Further investigations were used if indicated. Psychological evaluation was carried out by interview and previously proven questionnaires and the findings classified according to ICD-9. Forty-nine percent of the patients were shown to have primarily organic causes for their impotence. Thirty-three percent had psychogenic causes and 18% were labelled mixed. Unsurprisingly, the psychogenic group tended to be younger compared with the organic group. Sixty-three percent of all the patients had some psychopathological symptoms. In the organic group psychosyndromes from cerebrovascular diseases predominated, followed by depressive reactions and a few cases of alcohol problems. In the psychogenic group personality disorders were most common, then depression. Depressive reactions dominated the mixed group. Only 41 (56%) patients were followed up for a mean of 2.5 years, and only 37 gave full treatment history. Eighty-five percent of the organic group had tried treatment whereas only 50% of the psychogenic group had. However, the organic group was least likely to be satisfied with treatment. Sixty-five percent of patients trying intracavernosal injections dropped out of treatment. The authors concluded that patients with erectile dysfunction exhibit a considerable rate of psychiatric comorbidity. They feel that close Cupertino between psychiatrist and urologist is essential. This would also allow research into differential treatment assignment and into the factors motivating patients to enter therapy and to maintain it. This Cupertino would no doubt have benefits and reveal some useful information, but it is hard to see it becoming the norm in a busy DGH setting.

Reviewer: Richard Lockyer

Journal:	BJU International
Authors:	Ayta IA, McKinlay JB and Krane RJ	Issue:	1999, 84: 50-56

Title:

The likely world-wide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences.

Abstract:
This is an interesting paper that attempts to predict the world-wide prevalence of erectile dysfunction (ED) for the future. The authors illustrate some of the potential problems by briefly summarising the implications at different levels of clinical practice and public policy for the UK following the launch of Viagra. They used United Nations estimated and projected figures for male population distributions by quinquennial age groups for 1995 and 2025 respectively. The UN data are useful because they take into account all regions of the world and use different sets of assumptions about future trends in fertility, mortality and migration. This provides 3 different population projections and this study uses the lowest (most conservative) projection. The prevalence rates for ED are based on the Massachusetts Male Ageing Study (MMAS) - a prospective observational study of health in randomly selected ageing men. It is felt to be accurate because it provides population-based data rather than data based on clinical samples. One of its main flaws is that 95% of the men are Caucasian. However, this will again tend to reveal conservative figures, as some ethnic minorities are likely to have higher rates of ED. The results show that in 1995 over 152 million men suffered ED (projections for 2025 are about 322 million). This increase of 170 million signals further public health concerns. ED affects quality of life, but it is also associated with other medical risks such as heart disease, depression, diabetes and hypertension, which are even more costly to the healthcare system. Patient numbers are predicted to increase most in the developing world. This, the authors point out, could threaten and undermine their already precarious health care systems.

Reviewer: Richard Lockyer

Journal:	Journal of Urology
Authors:	Scherr D and Goldstein M	Issue:	1999, 162: 58-88

Title:

Comparison of bilateral versus unilateral varicocelectomy in men with palpable bilateral varicoceles.

Abstract:
The left varicocele is usually larger in men with bilateral varicoceles. Numerous studies have reported beneficial effects on semen quantity and quality following varicocelectomy in the subfertile man. These improvements are greater for the larger varicoceles. Using ultrasound routinely increases the number of bilateral cases because impalpable veins are picked up on the right side. A previous study in this type of patient showed no benefit for bilateral varicocelectomy. The present study looked at 91 patients with moderate (grade II) or large (grade III) left side varicocele in association with small but palpable (grade I) right varicocele. The patients were given information regarding the uncertainty of the best option and then asked to decide for themselves whether to have a bilateral or unilateral operation. Sixty-five chose to have a bilateral operation and 26 chose unilateral. All operations were performed by the same surgeon using a microsurgical technique at the external inguinal ring. Semen analysis was carried out preoperatively and at least 3 months postoperatively. They showed that improvements in motile sperm concentration and sperm concentration were significantly better for the bilateral group compared with the unilateral group. They conclude that men with bilateral palpable varicoceles require bilateral varicocelectomy. The main criticism of this paper is that the patients selected their treatment, rather than being randomised. However, there does not seem to be a great difference in the patients between the two groups, although it is a shame that the numbers in the unilateral group are relatively small. Like many studies regarding male subfertility it gives no details of the ‘take home baby rate’.

Reviewer: Richard Lockyer

Journal:	British Journal of Urology
Authors:	Shokeir AA, Alserafi MA and Mutabagani H	Issue:	1999, 83(7): 812-815

Title:

Intracavernosal versus intraurethral alprostadil: a prospective randomized study.

Abstract:
The authors conducted a prospective randomized study to compare MUSE with intracavernosal injection (ICI) of alprostadil (PGE1). They randomized 60 consecutive patients with organic impotence to either MUSE or ICI. Group 1 was taught in the clinic how to use ICI and was given a 20 microgram dose. The erectile response was documented and graded 1 to 5 (grade 4 or 5 is good enough for intercourse). Group 2 was taught the MUSE system and was initially given a 500 microgram dose in the clinic. Of the initial 10 patients only 2 responded well and subsequently all patients were given the 1-milligram dose. Regardless of outpatient response the patients agreed to use their allotted drug once weekly for 3 months and to document the results and side effects. Only 33% of the ICI group completed the 3 month trial whereas 83% completed with MUSE (P<0.05). Of the ICI patients, 90% achieved good erection in the clinic compared with 60% of MUSE patients (P<0.05). Intercourse was reported at least once in 87% of the ICI group compared with 53% of the MUSE group (P<0.05). At home, 85% and 55% respectively of the ICI and MUSE doses resulted in intercourse. Urogenital pain was reported by 47% of the ICI group and 7% of the MUSE group. Of the MUSE group, 90% felt the system was easy to use whereas only 40% of the ICI group felt the same. The authors conclude that MUSE is less effective compared to ICI, but is more appealing and accepted well by most patients as an easy technique with minimal discomfort. This study again reconfirms that MUSE is less effective than ICI. However, the study suffered because over a quarter of the patients were lost to follow up or lost interest. This infers a lack of motivation amongst the sample and might contribute to the high drop out rate, particularly amongst the ICI group (MUSE is easier to use and therefore requires less motivation). Pain is common with alprostadil and the rates here seem high for ICI and low for MUSE. It would have been useful, as in other papers, to grade the pain. There was also no dose titration for ICI and the relatively high dose of 20 micrograms may have contributed to the high numbers with pain in this group.

Reviewer: Richard Lockyer

Journal:	Urology
Authors:	Zelefsky MJ, McKee AB, Lee H and Leibel SA	Issue:	53(4): 775-778

Title:

Efficacy of oral sildenafil in patients with erectile dysfunction after radiotherapy for carcinoma of the prostate

Abstract:
The patients in this trial were derived from a group of 1,050 men that underwent conformal radiotherapy for clinically localised prostate cancer. Of these, 265 were seen at routine follow up. Of this group, 75 were previously potent and had already requested and tried sildenafil. Fifty of these reported that they used the medication and are therefore included in this paper (4.7% of the original group). The authors report that the degree of sexual impairment pre-treatment is the most important predictor of success, with 90% of patients with partial erections reporting success, compared to 52% of those with no erections. Using data from this self-selected group of patients, the authors conclude that sildenafil improves erectile function in 66% of patients with post radiotherapy impotence.

Reviewer: Jon Cartledge

Journal:	Journal of Urology
Authors:	Maillefert JF, Sibilia J, Michel F, Saussine C, Javier RM and Tavernier C	Issue:	1999, 161: 1219-1222

Title:

Bone mineral density in men treated with synthetic gonadotrophin-releasing hormone agonist for prostatic carcinoma

Abstract:
The authors evaluate the relationship between gonadotrophin-releasing hormone agonists and bone density in 12 men with prostate cancer. Bone density for both lumber and femoral neck bone decreased over time although the reduction in bone density did not reach statistical significance. Serum osteocalcin, a marker of bone turnover, increased significantly by 12 months, suggesting accelerated bone turnover. No pathological fractures were observed over the 18-month study period.

Reviewer: Andrew Elves

Journal:	International Journal of Impotence Research
Authors:	Metro MJ and Broderick GA	Issue:	1999, 11: 87-89

Title:

Diabetes and vascular impotence: does insulin dependence increase the relative severity?

Abstract:
This study investigates the relative impact of insulin dependence, hypertension, smoking and coronary artery disease on vascular erectile integrity in 105 diabetics with the complaint of impotence. This was a retrospective study of patients who had been evaluated with colour duplex doppler following intracavernosal PGE1. Three aetiologies of vascular erectile dysfunction were identified: arterial insufficiency (64%), mixed vascular (25%), and venous occlusive disease (11%). Of the 105 patients, 26 were IDDM and 79 were NIDDM. There were more hypertensives in the IDDM group but coronary artery disease (CAD) and smoking were evenly spread over the two groups. The data confirmed previous observations that the incidence of arterial insufficiency causing vascular impotence is similar among IDDM and NIDDM at about 64%, although this is lower than the approximate 85% reported elsewhere. The peak systolic flows (ie. severity of arterial insufficiency) were not significantly lower for IDDM compared with NIDDM. They are also not altered by the presence of smoking or hypertension. However, those with CAD were shown to have significantly more severe arterial insufficiency in the IDDM group. The authors suggest that this relationship could be examined further by targeting men with CAD and assessing them for vascular erectile integrity. It would also be interesting to look at this subgroup in terms of treatment. Presumably they are more likely to be refractive to medical treatment for their impotence. It might also be interesting to perform these non-invasive vascular studies on potent diabetics (both IDDM and NIDDM), and perhaps correlate the findings with diabetic control.

Reviewer: Richard Lockyer

Journal:	British Journal of Urology
Authors:	Nayal W, Schwarzer U, Klotz T, Heidenreich A and Engelmann U	Issue:	1999, 83(6): 623-625

Title:

Transcutaneous penile oxygen pressure during bicycling

Abstract:
Numerous reports have linked cycling with genital numbness and impotence. Previously, authors have suggested that the pudendal nerve may be compressed against the pubic arc because of the forward tilting of the body on the saddle. Others proposed that compression occurred in the pudendal canal. Another possible cause for these problems may be vascular. The saddle may compress the blood supply to the penis. Here, the authors have evaluated the effect of cycling on the oxygen tension within the penis. They recruited 25 fit men (mean age 28 years) and measured partial pressure of oxygen transcutaneously using an oxygen electrode. They quote various sources to confirm the reliability and accuracy of this method. The pO2 was measured standing and then again during cycling in the seated position at 65% of maximal training heart rate for 15 minutes. The subjects then cycled for 5 minutes in the standing position at the same exercise level and then again in the seated position. The mean pO2 during standing was 61.4 mmHg; after 3 minutes of cycling seated it was 19.4 mmHg; after 1 minute of cycling standing it was 68.0 mmHg and after 3 minutes of seating again it was 18.4 mmHg. The pO2 had returned to normal at 10 minutes post exercise. These findings are interesting and clearly show a drop in the pO2 of the glans penis with cycling in the seated position. However, it would be interesting to know the glans pO2 when seated in a chair at rest. It may be that posture effects the penile blood supply. The authors suggest that cyclists should frequently change position during cycling. They are also planning to repeat the study with different saddle positions. This again would be interesting, but cause and effect have not yet been established. The pO2 during cycling needs to be correlated with genital numbness and impotence following this form of exercise.

Reviewer: Richard Lockyer

Journal:	Urology
Authors:	Kaplan SA, Reis RB, Kohn IJ, Ikeguchi EF, Laor E, Te AE and Martins ACP Kaplan SA, Reis RB, Kohn IJ, Ikeguchi EF, Laor E, Te AE and Martins ACP	Issue:	53(3): 481-486

Title:

Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction

Abstract:
In this open, non randomised, non-placebo controlled study the authors gave 50 mg of sildenafil to 33 post-menopausal women who complained of sexual dysfunction for at least 6 months. Efficacy was assessed with a sexual function score and global efficacy question. Although the authors describe an improvement in symptom score this did not reach statistical significance. They conclude that the role of sildenafil in female sexual dysfunction remains to be determined.

Reviewer: Jon Cartledge

Journal:	Journal of Urology
Authors:	Saidi JA, Chang DT, Goluboff ET, Bagiella E, Olsen G and Fisch H	Issue:	1999, 161:460-462

Title:

Declining sperm counts in the United States? A critical review

Abstract:
Much concern has been expressed regarding an apparent decline in male sperm counts. The authors review 29 U.S. studies from 1938 to 1996 determining mean sperm concentrations by geographic location with weighted analysis of variance, and assess any changes with time. Sperm concentrations were highest in New York compared to other U.S. cities (98.6 million versus 72.6 million per cc respectively). Allowing for this geographic variation, the authors conclude that there has been no reduction in sperm concentrations over the last 60 years.

Reviewer: Andrew Elves

Journal:	Urology
Authors:	Marks LS, Duda C, Dorey FJ, Macairan ML and Santos PB.	Issue:	1999, 53(1): 19-24

Title:

Treatment of erectile dysfunction with sildenafil

Abstract:
The authors report their experience in treating men with erectile dysfunction. Out of 100 men that met the inclusion criteria, they only present data for 74. Patients were given 50 mg of sildenafil 1 hour before intercourse and instructed to take a second 50 mg dose if they were unhappy with the efficacy. An overall improvement in symptom score concerning frequency of penetration of 71% and frequency of maintained erections of 95% was found. Out of 30 men unable to achieve penetration prior to treatment only 43% were able to do so after treatment. However, if the ability to achieve penetration was “successful most of the time” before treatment, an 80% improvement was noted. The authors conclude that sildenafil is a safe effective treatment for erectile dysfunction. It should be noted that treatment was successful in mild erectile dysfunction and less successful in severe disease. With 12/14 post radical prostatectomy patients failing treatment, the 2 successes were associated with nerve sparing surgery and some preservation of sexual function.

Reviewer: Jonathan Cartledge

Journal:	Journal of Urology
Authors:	Melman A and Gingell JC	Issue:	1999, 161: 5-11

Title:

The epidemiology and pathophysiology of erectile dysfunction

Abstract:
The authors present a clear, informative and concise review of the epidemiology, risk factors, physiology and pathophysiology of erectile dysfunction.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Su L, Palermo GD and Goldstein M, Veeck LL, Rosenwaks Z and Schlegel PN	Issue:	1999; 161: 121-161

Title:

Testicular sperm extraction with intracytoplasmic sperm injection for non-obstructive azoospermia: testicular histology can predict success of sperm retrieval

Abstract:
Testicular failure affects 1% of all men and 10% of those seeking fertility treatment. Testicular biopsy in azoospermic men shows 3 distinct patterns of histology (hypospermatogensesis, maturation arrest, and pure sertoli cell only) and the authors have attempted to re-evaluate the role of testicular biopsy histology as a predictor of sperm retrieval success. Sperm retrieval was most successful for those with hypospermatogenesis (79%), compared to 47% among those with maturation arrest and 24% for those with Sertoli cell only. Overall, clinical pregnancy rate was 55%, with ongoing or live deliveries in 43%. Fertilisation and clinical pregnancy rates for each histological pattern of biopsy were not cited.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Rucker GB, Mielnik A, King P, Goldstein M and Schlegel PN.	Issue:	1998, 160: 2068-2071

Title:

Preoperative screening for genetic abnormalities in men with non-obstructive azoospermia before sperm extraction.

Abstract:
The ability to extract rare spermatozoa from the testis of men with non-obstructive azoospermia has expanded the indications for intra-cytoplasmic sperm injection (ICSI). Previously, the only therapeutic options available to such couples were adoption or donor insemination. The authors present the results of genetic screening in a consecutive series of 190 men with non-obstructive azoospermia presenting for testicular sperm extraction. Thirty-three (17%) men were found to have genetic abnormalities, including 17 Y-chromosome deletions and 21 karyotypic abnormalities. Interestingly, knowledge of the specific genetic defect resulted in 7 of the 33 couples (21%) deferring assisted reproduction.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Renshaw AA	Issue:	1998, 160: 1625-1628

Title:

Testicular calcifications: Incidence, histology and proposed pathological criteria for testicular microlithiasis.

Abstract:
Testicular microlithiasis is a relatively rare clinical syndrome in which men present with innumerable small testicular calcifications on radiological ultrasound examination or histological examination of the testis. There is no single accepted definition of what represents testicular microlithiasis. However, indirect evidence suggests the syndrome may be associated with germ cell neoplasia. The author reviewed 181 orchidectomy specimens to assess the incidence and types of calcification in both diseased and normal testes. Two types of calcification are described: 1) hematoxylin bodies consisting of amorphous calcific debris, specific for germ cell tumours, and 2) laminated calcifications, more common in germ cell tumours and cryptorchid testes, but also occurring in 4% of normal testes.

Reviewer: Andrew Elves

Journal:	Journal of Urology
Authors:	Manning M, Junemann KP, Scheepe JR, Braun P, Krautschick A and Alken P.	Issue:	1998, 160: 1680-1684

Title:

Long-term follow-up and selection criteria for penile revascularisation in erectile failure.

Abstract:
The authors report the outcome of a variety of microsurgical penile re-vascularisation procedures in a cohort of 62 impotent men who had not responded to pharmacological treatment. Thirty-four percent of patients achieved spontaneous erections more than 30 months after surgery while a further 20% were able to achieve erections with the aid of pharmacological therapies. Overall, success was lower in patients with two of the following: diabetes, nicotine abuse, alcoholism, obesity, hyperlipidaemia, arterial hypertension and coronary heart disease. The authors’ results with the Modified Mannheim triple anastomosis are also discussed. The authors compare their experience with those of others and draw attention to the lack of standardisation of surgical methods as well as definition of the successful outcome of revascularisation surgery.

Reviewer: Andrew Elves

Journal:	Urology
Authors:	Kaplan SA, Reis RB, Kohn IJ, Shabsigh R and Te AE.	Issue:	1998, 52 (5): 739-743

Title:

Combination therapy using oral alpha-blockers and intracavernosal injection in men with erectile dysfunction

Abstract:
The authors gave daily doxasocin (an alpha-adrenoceptor blocker) orally for 12 weeks, in addition to intracavernosal alprostadil, to 38 men that had previously shown minimal or no response to alprostadil therapy alone for erectile dysfunction. The authors report their results as changes in International Index of Erectile Function symptom score. They state that the addition of doxasocin increased the score over alprostadil alone from a mean of 36.1 to 51.5. If the questions relating to improvement in frequency of penetration and maintained erections alone are measured, an increase of 61% and 71% respectively are recorded. The mean dose of alprostadil was reduced by 33% by the addition of doxasocin. Side effects of dizziness (2) and asthenia (1) were recorded. The authors conclude that for patients that fail on intracavernosal therapy alone the addition of an oral alpha-blocker may be beneficial.

Reviewer: Jonathan Cartledge

Journal:	Urology
Authors:	Segenreich E, Israilov S, Shmuele J, Niv E, Baniel and Livne P.	Issue:	1998, 52(5): 853-857

Title:

Evaluation of the relationship between semen parameters, pregnancy rate of wives of infertile men with varicocele, and gonadotropin-releasing hormone test before and after varicocelectomy

Abstract:
The authors performed a GnRH test (levels of FSH and LH were evaluated immediately before the test and 45 minutes after intravenous injection of 100 µg of a synthetic GnRH analogue) on 121 infertile men with varicocele before surgical correction and 4 to 6, 9 to 12 and 16 to 18 months afterwards. A positive test was reported as a doubling of FSH and a more than 5-fold increase in LH. They report that 73.5% of the men had a positive test pre-operatively, and of these 80.9% had an improvement in semen parameters and a 67.4% pregnancy rate following surgical correction of varicocele. In comparison, the patients with a negative GnRH test only had an 18.7% improvement in semen parameters and a 9.3% pregnancy rate. The authors conclude that a positive GnRH test is a good predictor of potential improvement in semen parameters and fertility for varicocelectomy

Reviewer: Jonathan Cartledge

Journal:	Urology
Authors:	Ostad M , Liotta D, Ye Z and Schlegel PN.	Issue:	1998, 52 (4): 692-696

Title:

Testicular sperm extraction for non-obstructive azoospermia: results of a multibiopsy approach with optimised tissue dispersion.

Abstract:
The authors report their experience of 81 testicular sperm extraction procedures, which were performed by an open technique. The tunica albuginea was incised using optical magnification and an ophthalmic knife to reduce vessel trauma. Multiple biopsies were performed until adequate sperm were visualised. Sperm were demonstrated in 58% of patients, after an average of 8.9 biopsies. If biopsy specimens were passed through a 24 gauge angio-catheter the number of sperm retrieved was increased. From their experience, the authors make 4 recommendations: 1) if the initial biopsy fails, up to 4 more should be made from the same testis before switching to the contralateral testis, 2) the maximum number of biopsies cannot be defined but care must be taken not to cause vascular injury, 3) optical magnification should be used and 4) passing biopsy material through an angio-catheter improves the sperm yield.

Reviewer: Jonathan Cartledge

Journal:	British Journal of Urology
Authors:	Scott R, Macpherson A, Yates RWS, Hussain B and Dixon J.	Issue:	1998, 82: 76-80

Title:

The effect of oral selenium supplementation on human sperm motility.

Abstract:
Although this is an article that can be criticised in many ways, not least because no mention is made of progressive motility, a more useful marker than motility alone, the findings are interesting and would seem to warrant confirmation by another group. Five pregnancies in the treated group (receiving either selenium or selenium and some vitamins (A, C & E)) against none in the untreated group cannot be ignored.

Reviewer: Jonathan Glass

Journal:	Urology
Authors:	Seftel AD, Vaziri ND,Karim ZN,Razmjouei K, Fogarty J, Hampel N, Polak J, Wang R, Ferguson K, Block C, Haas C.	Issue:	1997, 50 (6): 1016-1026.

Title:

Advanced glycation end products in the human penis: elevation in diabetic tissue, site of deposition, and possible effect through iNOS or eNOS.

Abstract:
Advanced Glycation End (AGEs) products are formed by reaction between proteins and high blood glucose. The authors postulate that they are important in the erectile dysfunction found in diabetic men, and may act by affecting the action of Nitric Oxide (NO). The authors performed high-performance liquid chromatographic analysis and immunohistochemical electron microscopy af non & diabetic human corpus cavernosal tissue to look for AGEs, iNOS and eNOS. They also performed organ chamber relaxation experiments on human corpus cavernoas in the presence of a specific iNOS inhibitor. The authors found elevated AGEs in diabetic penile tissue localised to the tunica and corpus cavernosa.They found no elevation of serum AGEs. Organ bath experiments on tissue from 4 organically impotent men (only 1 diabetic) revealed significant enhancement in relaxation response to Acetylcholine when preincubated with an iNOS inhibitor. The authors conclude that AGEs are elevated in the corpora and tunica of diabetic men, but not in the serum.They suggest that AGEs act by upregulating iNOS and down regulating eNOS. It is difficult to see how they can come to this conclusion on the vey limited amount of data that they present.

Reviewer: Mark Feneley

Journal:	Urology
Authors:	Khoudary KP, Dewoll WC, Brunning CO and Mergentaler A.	Issue:	1997, 50 (3): 395-399.

Title:

Immediate sexual rehabilitation by simultaneous placement of penile prosthesis in patients undergoing radical prostatectomy: Initial results in 50 patients.

Abstract:
Between 1993 and 1996 all men undergoing radical prostatectomy were counselled pre-operatively and offered treatment for impotence post-operatively. This series retrospectively reports 50 men who opted for non-nerve sparing radical prostatectomy and simultaneous penile prosthesis. This group was compared with 72 men undergoing radical prostatectomy alone during the same time period. Mean operative time was extended by 120 mins to insert a prosthesis. There was no significant difference in operative complications, length of hospital stay or analgesic requirement. Four prosthesis were revised due to bending, none were infected after 1.7 years follow up. At 12 weeks post-operatively 96 % of patients were sexually active. They conclude that simultaneous placement of prosthesis allows an uncomplicated return to sexual function. There is however no record of whether patients having radical prostatectomy alone had a nerve sparing procedure or comparison made of post-operative potency between the 2 groups.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Chandiramani VA, Palace J, Fowler CJ.	Issue:	1997, 80: 100-104.

Title:

How to recognise patients with parkinsonism who should not have urological surgery.

Abstract:
Urologists are always wary of operating on men with lower urinary tract symptoms and parkinsonism. This may however mean we are not operating on men who may benefit from a simple procedure. This paper identifies a number of clinical parameters that if present would suggest that certain men with parkinsonism should be treated medically rather than surgically. These include (i) urinary symptoms that precede or present with parkinsonism, (ii) urinary incontinence and idiopathic Parkinson's disease (iii) erectile failure preceding or presenting with parkinsonism (iv) worsening bladder function after urological surgery. At least 80% of patients in this study had two of these characteristics and these patients should be referred for a sphincter EMG before surgery.

Reviewer: Mark Feneley

Journal:	Urology
Authors:	Morales A, Johnston B, Heaton JP and Lundie M.	Issue:	1997, 157: 849-854.

Title:

Testosterone supplementation for hypogonadal impotence: assessment of biochemical measures and therapeutic outcomes.

Abstract:
While hypogonadal impotence is rare, impotent men may find themselves receiving supplemental androgens. The authors evaluated the efficacy of oral testosterone 120mg daily in the treatment of erectile dysfunction in 23 hypogonadal men. Sexual function was assessed using a visual analogue scale and daily diaries. Serum gonadotrophin, testosterone, oestrogens, and sex hormone-binding protein were estimated before, during and after the study. There was no control group. Plasma testosterone was restored to normal levels in all patients but subjective improvement in sexual performance was observed in only 61% of subjects. No correlation was observed between conventional measures of gonadal function and clinical outcome.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Fisch H, Andrews H, Hendricks J, Goluboff ET, Olson JH and Olsson CA.	Issue:	1997, 157: 840-843.

Title:

The relationship of sperm counts to birth rates: a population based study.

Abstract:
In this retrospective study, the authors set out to determine if a relationship exists between sperm counts and birth rates by comparing data from a single geographic region over a 24 year period. Pre-vasectomy sperm samples (n=1972) from men (n=660) in Minnesota were evaluated and analysed after adjustment for age, duration of abstinence and seasonal effects. Multiple regression analysis demonstrated a significant linear increase in mean annual sperm count with little effect of age. Abstinence and month of banking were significantly associated with outcome measures. A strong correlation was observed between adjusted mean yearly sperm count and annual birth rates. The authors discuss some of the recent and alarming data regarding sperm counts and confounding factors which this study highlights.

Reviewer: Mark Feneley

Journal:	New England Journal of Medicine
Authors:	Pryor JL, Kent First M, Muallem A, van Bergen AH, Nolten WE, Meisner L, Roberts KP.	Issue:	1997, 336: 534-539.

Title:

Microdeletions in the Y chromosome of infertile men.

Abstract:
Some infertile men with oligospermia and azospermia have small deletions in the Y chromosome. In this paper, its incidence is reported to be 7% in 200 consecutive infertile men, 23% in men with azospermia and 2% in fertile men. The size and position of the deletion correlated poorly with the severity of spermatogenic failure.

Reviewer: Mark Feneley

Journal:	New England Journal of Medicine
Authors:	Padma Nathan H, Hellstrom WJG, Kuiser FE, et al for the MUSE study group.	Issue:	1997, 336: 1-7.

Title:

Treatment of men with erectile dysfunction with transurethral alprostadil

Abstract:
Treatment of men with erectile dysfunction with transurethral alprostadil Padma Nathan H, Hellstrom WJG, Kuiser FE, et al for the MUSE study group. New England Journal of Medicine 1997; 336: 1-7 1511 men with erectile dysfunction thought to be organic in origin were given a test dose of alprostadil (125-1000mgm) administered intra-urethrally in the office. 996 men had a erectile response satisfactory for intercourse and were entered into a placebo controlled double-blind trial. 65% of patients using placebo had intercourse at least once during the 3 month study period compared to 19% receiving placebo (p < 0.001) . 10.8% of patients suffered from penile pain but this rarely resulted in discontinuing treatment. The response rates appear surprisingly good in patients with vasculogenic impotence. This is an important paper with large numbers of patients in a well organised study.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Brackett NL, Padron OF and Lynne CM.	Issue:	1997, 157: 151-157.

Title:

Semen quality of spinal cord injured men is better when obtained by vibratory stimulation versus electroejaculation.

Abstract:
The majority of spinal cord injured men require medically assisted ejaculation procedures to obtain semen. This study compares the sperm count, percent of motile sperm, and percent of sperm with rapid linear motion in ejaculates obtained by vibratory stimulus or electroejaculation. While some men could only ejaculate using one or other method, no statistically significant difference in the measured outcome parameters was observed between the two methods in those patients using both techniques, though the numbers were small.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Kim ED, Gilbaugh JH3, Patel VR, Turek PJ and Lipshultz LI.	Issue:	1997, 157: 144-146.

Title:

Testis biopsies frequently demonstrate sperm in men with azoospermia and significantly elevated follicle-stimulating hormone levels.

Abstract:
Men with azoospermia, significantly elevated serum FSH levels and testicular atrophy were regarded as irreversibly infertile until the advent of ICSI. The authors reviewed the presence of mature sperm in touch-preparation cytology and testis biopsy specimens from 57 men with testicular atrophy. Mature sperm were identified in 30% of men. Men without sperm most commonly had Sertoli-cell-only pattern. The authors conclude that men with azoospermia and testicular atrophy associated with significantly elevated FSH levels should undergo testicular biopsy if in vitro fertilisation with ICSI is acceptable to the couple.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Clarnette TD, Sugita Y and Hutson JM	Issue:	1997, 79: 99-112.

Title:

Genital anomalies in human and animal models reveal the mechanisms and hormones governing testicular descent.

Abstract:
Normal sexual differentiation and the roles of the SRY gene complex, Mullerian inhibitory substance, Leydig cells, the gubernaculum, the cranial suspensory ligament, the genito-femoral nerve nucleus and calcitonin gene-related peptide are described. The biphasic model of testicular descent is described and correlated with disorders then discussed under the heading "abnormal sexual development". These include persistent Mullerian duct syndrome, androgen disorders (androgen insensitivity / testicular feminisation and female pseudohermaphroditism e.g. CAH), true hermaphroditism and mixed gonadal dysgenesis.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Mitropoulos D, Deliconstantinos G, Zervas S, Villotou V, et al.	Issue:	1996, 156:1952-1958.

Title:

Nitric oxide synthetase and xanthine oxidase activities in the spermatic vein of patients with varicocele: A potential role for nitric oxide and peroxynitrite in sperm dysfunction.

Abstract:
The association between varicocele and infertility is recognised and a number of mechanisms have been postulated. In this paper blood from a peripheral vein and a dilated varicocele were taken before ligation and nitric oxide synthetase and xanthine oxidase activity measured along with nitric oxide peroxynitrite and S-nitrosthiol levels. Antioxidant capacity of serum and red blood cells from peripheral blood and varicocele were also estimated. Nitric oxide synthetase, xanthine oxidase, nitric oxide peroxynitrite, S-nitrosthiol, and serum antioxidant capacity levels were all greater in the varicocele compared to peripheral blood. Antioxidant capacity of red blood cells was less in the varicocele veins. The authors conclude that the production of increased amounts of peroxynitrite creating a highly oxidising environment may be a causative factor for impaired sperm function in patients with varicocele.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Nachtshiem DA and Rearden A.	Issue:	1996, 156: 1330-4.

Title:

Peyronie’s disease is associated with an HLA class II antigen, HLA-DQ5, implying an autoimmune etiology.

Abstract:
The investigators used a molecular HLA typing method in 31 patients with Peyronie’s disease, 19 age matched urological patients and 75 major organ donor cadavers representative of the general population. The frequency of HLA-DQ5 was significantly increased in patients with Peyronie’s disease (61%) compared to age matched controls (11%) and general population controls (25%). The authors suggest that the association of HLA-DQ5 with Peyronie’s disease indicates an autoimmune basis for this disorder.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Haensel SF, Rowland DL, Kallan KTHK, and Slob AK.	Issue:	1996, 156: 1310-5.

Title:

Clomipramine and sexual function in men with premature ejaculation and controls.

Abstract:
The authors evaluated the efficacy of clomipramine (25 mg) in 16 patients with premature ejaculation and 8 controls in a prospective, double blind, placebo controlled, crossover study. Clomipramine was taken 12 -24 hours before anticipated sexual activity (coitus or masturbation). Outcome was assessed by a detailed sexual function questionnaire, assessment of nocturnal penile tumescence and waking erectile assessment procedures using visual sexual stimulation with and without concomitant vibration of the penis. Clomipramine significantly increased the latency to ejaculation during sexual activity and satisfaction with sex life, with no significant effects upon controls or those subjects with both premature ejaculation and erectile dysfunction.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Takada T, Kitamura M, Matsumiya K, Miki T, et al	Issue:	1996, 156: 1652-1654.

Title:

Infrared thermometry to detect reflux of spermatic vein in varicocele

Abstract:
The authors evaluate the use of infrared thermometry (a technique more commonly used to record body temperature from the external auditory canal) for measurement of reflux of blood via the internal spermatic vein in 20 men with clinical diagnosis of unilateral varicocele. A control group of 10 men without a palpable varicocele while standing during the Valsalva manoeuvre was included for comparison. Scrotal neck temperature increased in the patients during the Valsalva manoeuvre in the upright position, while no statistically significant increase was observed among the controls. Following treatment of the varicocele by high ligation scrotal neck temperature decreased to that found in controls.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Harrington T G, Schauer D, and Gilbert B R.	Issue:	1996, 156: 1647-1651.

Title:

Percutaneous testis biopsy: An alternative to open testicular biopsy in the evaluation of the subfertile man.

Abstract:
This paper examines the acceptability, morbidity and efficacy of percutaneous testis biopsy (31 patients) with open testis biopsy (20 patients) in 51 consecutive infertile men with azospermia or impaired semen quality in whom ductal obstruction was suspected. All biopsies yielded adequate tissue for diagnosis and morphometric analysis. Percutaneous testis biopsy was well tolerated by patients, with fewer apparent complications and equal diagnostic efficacy. Percutaneous testis biopsy is proposed as an alternative to open biopsy.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Gil-Salom M, Minguez Y, Rubio C, Ruiz A, Remohi J, and Pellicer A	Issue:	1996, 156: 1001-1004.

Title:

Intracytoplasmic sperm injection: a treatment for extreme oligospermia.

Abstract:
The authors of this paper report the results of 67 intracytoplasmic sperm injections attempted in 58 infertile couples in which the sperm count was less than 100,000/ml. Fertilisation was achieved in 65 of 67 cycles and a total of 18 clinical pregnancies resulted. There were 4 miscarriages and 8 live births from 5 deliveries. Nine pregnancies were ongoing. The authors conclude this to be a technique offering high fertilisation rates and the chance of pregnancy in otherwise intractably infertile couples.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Jarrow JP and DeFranzo AJ	Issue:	1996, 156: 982-985.

Title:

Long-term results of arterial bypass surgery for impotence secondary to segmental vascular disease.

Abstract:
This paper is a retrospective review of arterial bypass surgery in 11 impotent men with non-atheromatous vascular disease. Initial evaluation included history, physical examination and failure to respond adequately to pharmacological therapy. Nine patients underwent dorsal artery bypass and 2 arterialisation of the deep dorsal vein. Mean follow-up was 50 months. Initial duplex ultrasonography demonstrated a significant increase in cavernosal artery peak systolic pressure blood flow velocity and patent anastomosis in all but 1 patient. Success rate (satisfactory vaginal intercourse without supplemental therapy) initially was 82% falling to 64% at long-term follow-up. The authors suggest arterial bypass surgery can be successful in selected patients without generalised atheroma or other risk factors for impotence.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Boolell M, Gepi-Attee S, Gingell JC, Allen MJ.	Issue:	1996, 78: 257-261.

Title:

Sildenafil, a novel effective oral therapy for male erectile dysfunction.

Abstract:
Currently there are no licensed oral therapies to offer the estimated 52% of men aged 50-70 whose erections are unsatisfactory for penetration and intercourse. Sildenafil is an orally-active type-V cGMP-specific phosphodiesterase which may be expected to enhance relaxation of the smooth muscle in the corpora cavernosa. Twelve patients with male erectile dysfunction were entered into a double-blind randomised placebo-controlled crossover trial. Evaluations included penile plethysmography and a daily diary for 7 days. Adverse effects were all mild and transient, occuring in both treatment groups, including headaches and dyspepsia. Men taking Sildenafil enjoyed longer durations of > 80% rigidity at the base and tip of the penis, got more erections and reported them to be of better quality than those taking the placebo. Long-term safety and efficacy studies are underway.

Reviewer: Mark Feneley

Journal:	Journal of Urology
Authors:	Taskinen S, Hovatta O and Wilstrom S	Issue:	1996, 156: 82-84.

Title:

Early treatment of cryptorchidism, semen quality and testicular endocrinology.

Abstract:
Testicular maldescent may influence male fertility even when treated, particularly in cases of bilateral cryptorchidism. This article evaluates the effect of patient age at treatment of cryptorchidism in relation to subsequent semen quality and hormone levels. Among the 39 patients with unilateral cryptorchidism there was no significant correlation between patient age at treatment and sperm concentration, motility or morphology. Poor semen quality was uncommon in the unilateral cryptorchidism group and appeared only in those patients treated after 4 years of age. Of the 12 patients treated for bilateral cryptorchidism all those treated before the age of 4 years had normal sperm concentration. Elevated FSH levels were associated with azospermia and severe oligospermia, indicating testicular damage. The authors conclude that surgery for cryptorchidism should be undertaken early and before the age of 4 years in patients with bilateral cryptorchidism if conservation of normal semen quality is to be achieved.

Reviewer: Mark Feneley

Journal:	British Journal of Urology
Authors:	Lund l and Nielsen KT.	Issue:	1996, 78: 113-115.

Title:

Varicocoele testis and testicular temperature.

Abstract:
Semen quality (concentration, total count, motility and volume of ejaculate) and scrotal skin temperature (assumed on the basis of a pilot of four patients to be consistently 10C less than testicular temperature) were compared in 39 men with asymptomatic varicoceles and 38 control Danish subjects. Sperm concentrations and total counts were significantly less in the varicocele group, while no difference in skin temperature was found between the two groups. It would appear from these results that the deleterious effect of varicocele on semen quality is not due to alteration of testicular temperature, although examination of the results tables reveals a 0.50C difference between left and right sides in varicocele patients compared with controls in which no difference is observed.

Reviewer: Mark Feneley