Pros and Cons of Focal Therapy for Localised Prostate Cancer

In prostate cancer, an interesting and intriguing option to overcome the risks of whole-gland treatment is focal therapy, with the aim of eradicating known cancer foci and reducing collateral damages to the structures essential for maintaining normal urinary and sexual function. Ablation of all known lesions would favorably alter the natural history of the cancer without impacting health-related quality of life and allows for safe retreatment with repeated focal therapy or whole-gland approaches if necessary. Our objective is to reassess the possibilities and criticisms of such procedure: the rationale for focal therapy and the enthusiasm come from the success of conservative approaches in treating other malignancies and in the high incidence of overtreatment introduced by prostate cancer screening programs. One of the challenges in applying such an approach to the treatment of prostate cancer is the multifocal nature of the disease and current difficulties in accurate tumor mapmaking

Simmaco, Sidonio Apollinare e la gloriosa genealogia dei Syagrii di Lione

Abstract The movement of aristocratic people and their literary production between Italy and Gaul during the 4th and 5th centuries progressively restricted itself within different regional horizons. Ammianus, Symmachus and Ausonius offer important information on the career of (Afranius) Syagrius, ordinary consul in 381 AD and praetorian prefect in 380-382 AD, enhanced by the emperor Gratianus. This evidence shows a constant and fluid dialogue between aristocrats located in Italy and in Gaul. Almost a century later, around 470 AD, Sidonius Apollinaris celebrates this Syagrius in some letters and in his carmen 24, as the progenitor of a noble family of his time. The descendants of Syagrius, especially the praetorian prefect of Gaul in 451-453 AD, Tonantius Ferreolus, are praised by Sidonius as a rare example of family continuity at the top of the senatorial administration of Gaul. In the space of less than a century the movement of members of the senatorial order and the circulation of their writings between Italy and Gaul seems to have ceased. Sidonius interprets the political, social and cultural environment of his times within a closed Gallic horizon

The efficacy and safety of duloxetine in a multidrug regimen for chronic prostatitis/chronic pelvic pain syndrome.

OBJECTIVE To evaluate the efficacy and safety of duloxetine hydrochloride in the treatment of patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS Thirty-eight CP/CPPS patients completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and International Index of Erectile Function-Erectile Function-5 (IIEF-5) questionnaires, uroflowmetry, and evaluation of psychologic status using Hamilton Anxiety Scale (HAM-A) and Hamilton Depression Scale (HAM-D). Patients were randomly assigned to 2 treatments groups. Treatment in group 1 consisted of a simultaneous oral administration of tamsulosin (0.4 mg/d, 60 mg/d), saw palmetto (320 mg/d), and duloxetine (60 mg/d). Treatment in group 2 consisted of tamsulosin (0.4 mg/d) and saw palmetto (320 mg/d). NIH-CPSI and IIEF-5 questionnaires, uroflowmetry, and evaluation of the psychological status were repeated at 16 weeks of follow-up. RESULTS At 16 weeks, a significant improvement in NIH-CPSI pain subscore, NIH-CPSI quality of life subscore, and NIH-CPSI total score were observed in group 1 patients compared with those in group 2 (P <.01, respectively), together with a significant improvement in HAM-A and HAM-D scores (P <.01, respectively). Patients in group 2 showed a significant improvement in NIH-CPSI total score, in the urinary symptoms subscore, and in the HAM-A total score. No significant differences were observed in IIEF-5 scores in the 2 groups. Maximum flow rate significantly increased in both groups. In group 1, 20% of patients stopped the study due to adverse effects. CONCLUSION The use of duloxetine in a multimodal treatment with an alpha-blocker medication and a saw palmetto extract allowed better results in controlling clinical symptoms, psychologic status and quality of life patients affected by CP/CPPS

Managing female urinary incontinence: A regional prospective analysis of cost-utility ratios (curs) and effectiveness

Introduction: To evaluate the cost-utility of incontinence treatments, particularly anticholinergic therapy, by examining costs and quality-adjusted life years. Materials and methods: A prospective cohort study of women who were consecutively referred by general practitioners (GPs) to the Urology Department because of urinary incontinence. The primary outcome was evaluation of the cost-utility of incontinence treatments (surgery, medical therapy and physiotherapy) for stress and/or urgency incontinence by examining costs and quality-adjusted life years. Results: 137 consecutive female patients (mean age 60.6 ± 11.6; range 36-81) were enrolled and stratified according to pathologies: SUI and UUI. Group A: SUI grade II-III: 43 patients who underwent mid-urethral sling (MUS); Group B: SUI grade I-II 57 patients who underwent pelvic floor muscle exercise and Group C: UUI: 37 patients who underwent antimuscarinic treatment with 5 mg solifenacin daily. The cost utility ratio (CUR) was estimated as saving more than €1200 per QALY for surgery and physiotherapy and as costing under € 100 per QALY for drug therapy. Conclusions: This study shows that appropriate diagnosis and treatment of a patient with incontinence lowers National Health Service costs and improves the benefits of treatment and quality of life

Pelvic floor muscle behavior during Valsalva leak point pressure measurement in males and females affected by stress urinary incontinence.

PURPOSE: We evaluated pelvic floor muscle (PFM) behavior during Valsalva leak point pressure (VLPP) measurement in males and females affected by stress urinary incontinence and investigated whether VLPP results are influenced by PFM contraction. MATERIALS AND METHODS: A total of 25 females and 14 males underwent surface electromyographic (EMG) recording of PFM activity while performing VLPP. We investigated 2 conditions, VLPP during spontaneous strain (test A), and with simultaneous relaxation of the pelvic floor (test B). We analyzed average EMG activity (microV) at rest and during VLPP in tests A and B, the increasing EMG activity during tests A and B (the difference between average EMG activity during tests A and B and at rest), and the mean duration (seconds) of EMG activity during tests A and B. RESULTS: We detected a significant increase in EMG activity during tests A and B as compared to activity at rest (p <0.0001). Increasing EMG activity during test B was significantly reduced in females (p <0.05) but not in males. During test A patients reporting urinary incontinence showed a significantly lower EMG activity than that of continent patients (p <0.05). A significant reduction in maximum abdominal pressure was detected in test B compared to test A, but there was no difference in VLPP values between tests A and B. CONCLUSIONS: PFM activity significantly increases during VLPP measurement. Eliminating muscular contraction of the pelvic floor does not significantly alter VLPP results

Pelvic Organ Prolapse Repair with and without Concomitant Burch Colposuspension in Incontinent Women: A Randomised Controlled Trial with at Least 5-Year Followup

The aim of this study was to reevaluate and update the followup of a previously published randomized controlled trial (RCT) on the impact of Burch Colposuspension (BC), as an anti-incontinence procedure, in patients with UI and POP, who underwent POP repair. Forty-seven women were randomly assigned to abdominal POP repair and concomitant BC (24 patients; group A) or POP repair alone without any anti-incontinence procedure (23 patients; group B). Median followup was 82 months (range 60–107); from over 47 patients, 30 reached 6-year followup. Two patients were lost at followup. In group A, 2 patients showed a stage I rectocele. In group B, 2 patients had a stage I rectocele and 1 a stage II rectocele. In group A, 13/23 (56.5%) were still incontinent after surgery compared with 9/22 patients (40.9%) in group B (P = 0.298). No significant changes were observed between the first and the current followup. The update of long-term followup confirmed that BC did not improve outcome significantly in incontinent women when they undergo POP repair

Botulinum A toxin intravesical injections in the treatment of painful bladder syndrome: A pilot study

Objective: We evaluated the efficacy and tolerability of botulinum A toxin (BTX-A) intravesical injections in patients affected by painful bladder syndrome with increased urinary frequency, refractory to conventional treatment modalities. Methods: Twelve women and two men were prospectively included in the study. Under short general anaesthesia patients were given injections of 200 U of commercially available BTX-A diluted in 20 ml 0.9% NaCl. Injections were performed submucosally in the trigone and bladder floor under cystoscopic control. Voiding chart, the Visual Analog Scale (VAS) for pain, and urodynamics were performed before treatment and 1 and 3 mo afterward. Results: Overall, 12 patients (85.7%) reported subjective improvement at 1 and 3 mo follow-up. The mean VAS score was significantly reduced at 1 and 3 mo after treatment (p < 0.05 for both); at the same time points daytime and nighttime urinary frequency significantly decreased (p < 0.01 and p < 0.05, respectively), and bladder cystometric capacity significantly increased (p < 0.01). Two patients reported incomplete bladder emptying. We did not detect any systemic side effects during or after treatment. Conclusions: The results of this pilot study indicate that BTX-A intravesical injections are effective in the short-term management of painful bladder syndrome. By modulating afferent C-fiber activity within the bladder walls, BTX-A significantly improves urodynamic parameters and reduces bladder pain and urinary frequency

Intravesical oxybutynin: mode of action assessed by passive diffusion and electromotive administration with pharmacokinetics of oxybutynin and N-desethyl oxybutynin.

PURPOSE: A proportion of patients with detrusor hyperreflexia who are unresponsive to oral oxybutynin often benefit from intravesical oxybutynin instillation. To our knowledge the precise mode of action of this method is obscure. MATERIALS AND METHODS: In 12 patients with detrusor hyperreflexia who were previously unresponsive to oral and intravesical passive diffusion of 5 mg. oxybutynin we administered 5 mg. oxybutynin orally as well as increased doses of 15 mg. oxybutynin intravesically with passive diffusion and with 15 mA. associated electric current. Each administration mode per patient was associated with an 8-hour urodynamic monitoring session during which oxybutynin and N-desethyl oxybutynin plasma levels, and intravesical oxybutynin uptake were measured. RESULTS: A dose of 5 mg. oxybutynin orally induced no urodynamic improvement with an area under the plasma concentration time curve of combined N-desethyl oxybutynin plus oxybutynin of 16,297 ng./8 hours and an area under the curve ratio of N-desethyl oxybutynin-to-oxybutynin of 11:1. Passive diffusion oxybutynin resulted in 12 mg. oxybutynin intravesical uptake and significant improvement in 3 of 8 urodynamic measurements, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was only 2,123 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was 1.1:1.0. Electromotive administration of oxybutynin resulted in almost complete intravesical uptake of the 15 mg. dose, significant improvement in all 8 urodynamic measurements and an increased oxybutynin level versus oral and passive diffusion, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was 4,574 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was inverted at 1.0:1.4. The oral dose of 5 mg. oxybutynin caused anticholinergic side effects in 8 of the 12 patients. Neither intravesical passive diffusion nor electromotive administration caused side effects with an uptake of 12 and 15 mg., respectively. CONCLUSIONS: A large proportion of intravesical oxybutynin is sequestered, probably in the urothelium. Intravesical oxybutynin administration confers therapeutic benefits via localized direct action within the bladder wall. Comment in Intravesical treatment of bladder dysfunction. [J Urol. 2001