Nonpharmacologic treatment of erectile dysfunction

Nonpharmacologic treatment for erectile dysfunction (ED) includes sex therapy, the use of vacuum erection devices, penile prosthesis implantation, and penile vascular surgery. Sex therapy is indicated for psychogenic ED and is at times a useful adjunct for other treatments in men with mixed psychogenic and organic ED. Vacuum erection devices produce usable erections in over 90% of patients; however, patient and partner acceptability is an issue. Three-piece inflatable penile prostheses create flaccidity and an erection that comes close to that which occurs naturally. Penile vascular surgery has shown greatest efficacy in young men with vasculogenic ED resulting from pelvic or perineal trauma.     

La place des protheses de verge dans le traitement de la maladie de La Peyronie

In Peyronie’s disease, a penile curvature makes sexual intercouse painful or impossible. Surgery is a treatment option after medical treatment failure. The aim of surgery is to restore an erection allowing sexual intercourse. Beside corpus cavernosus modeling procedures, penile prosthesis implantation (i.e.,semi-rigid, inflatable, orimplants) is rarely indicated. Such procedures should be based on erectile response to intracavernous injection and penile and corpus cavernosus anatomy.     

Penile prosthesis implantation for end-stage erectile dysfunction after radical prostatectomy

When erectile dysfunction occurs after radical prostatectomy and phosphodiesterase-5 inhibitor therapy fails, second-line therapies such as vacuum constriction devices, intraurethral prostaglandins, and penile injection therapy should be offered. When second-line therapies are not effective or acceptable to the man and his partner, penile prosthesis implantation becomes the treatment of choice. Today's 3-piece inflatable devices offer flaccidity and erection that approach the natural state. Design improvements have resulted in devices that have freedom from mechanical failure ranging from 92% to 94%. Antibiotic and hydrophilic coatings have reduced infection rates.     

Evaluation par questionnaire des inconvenients lies aux protheses peniennes chez 25 implantes

Twenty-five patients who had received a penile prosthesis between 1982 and 1991 responded to a postal follow-up questionnaire. Some men reported pain, urinary problems, loss of penile sensitivity, discomfort and difficulties for manipulating the prosthesis. Nevertheless, many of these problems were minimized by the patients themselves. Moroever, the majority of them seem to decrease with time. In such cases a process of spontaneous functional adaptation was operating. A more delicate problem, which may be partially psychosexual in origin, was complaints concerning the frequency and prolonged duration of erections permitted by the prostheses. In order to reduce such problems, as well as facilitating the functional adaptation, psychosexual support for such patients would be highly advisable.     

PHEMA as a fibrous capsule-resistant breast prosthesis

The presence of a silicone (poly-dimethyl siloxane) breast prosthesis in a breast reconstruction patient typically leads to fibrous tissue encapsulation of the prosthesis. Fibrous capsular contracture forces the prosthesis into a hardened sphere. The initially satisfactory cosmetic result can thus be changed into a deformed mass of inappropriate compliance. It is the author's hope with the present study to identify a material for implantation with a diminished tendency to form fibrous encapsulation, to improve the long-term results of prosthetic implants. The purpose of this investigation was to compare the early capsule production quality of poly-2-hydroxyethyl methacrylate (PHEMA) and poly-dimethyl siloxane (silicone). Each of five rats subcutaneously underwent implantation with both a disk of poly-dimethyl siloxane (control) and a similar disk of PHEMA. In this study, the extent of fibrous encapsulation was assessed at 6 weeks after implantation of the two disk types. The five disks of poly-dimethyl siloxane were embedded in fibrous tissue, whereas there was no apparent fibrous tissue surrounding the implants of PHEMA. The author concludes that the results for PHEMA were superior to those for silicone at 6 weeks with regard to fibrous encapsulation (p = 0.0312).     

La consultation psychologique dans l’indication d’une prothèse pénienne : une expérience originale de complémentarité médicopsychologique

In the Center for the Study and Treatment of Male Sexual Dysfunction (CETISM) of our University Department of Urology, a psychological consultation is systematically provided when penile prosthesis implantation is considered by the patient ?? and the urologist ?? as a possible solution to his erectile dysfunction. This consultation has three key objectives: to identify ?? rare ?? cases of psychological contraindication, to complete the information already given to the patient during urologic consultations, and to explore the relational, emotional, cognitive and erotic aspects that could influence the decision-making and the integration of the prosthetic solution. It is also and especially to give to the man a central position, an active position, not only for the decision-making, but also for developing a life project which takes into account the decision (positive or negative), a position he often lost from the time he had become ??powerless??.     

Management of "brittle" diabetes with a preprogrammable implanted insulin pump delivering intraperitoneal insulin.

OBJECTIVE--Glycaemic control in a young woman with "brittle" diabetes. DESIGN--Use of a preprogrammable fully implanted pump (Infusaid) to deliver insulin intraperitoneally at variable rates, giving a total dose of about 60 units/24 h. SETTING--Endocrinology department in a teaching hospital. PATIENT--Thirty year old woman with 15 years'' history of "brittle" diabetes. MAIN OUTCOME MEASURES--Glycated haemoglobin concentration; plasma glucose concentration. RESULTS--After implantation of the pump there was an immediate and sustained improvement in diabetic control. The patient''s glycated haemoglobin concentration decreased from 15.2% to 9.2% over seven months. Her daily glucose concentrations were in the range 3.5-12 mmol/l. She has not been admitted to hospital since implantation of the pump, which was eight months before the time of writing. CONCLUSION--The implanted programmable intraperitoneal insulin pump may be of value in the management of patients with "brittle" diabetes in whom other attempts at glycaemic control have failed.     

Management of the recalcitrant total-hip arthroplasty wound

The infection rate for total-hip arthroplasty is around 1 percent. This small group is usually managed by complete removal of the prosthesis and the cement and closure over suction catheters to "collapse" the wound and eventually achieve a girdlestone arthroplasty. Occasionally, there are patients who have a persistent draining wound after this treatment and repeated efforts at wound closure. We present 27 patients who had recalcitrant, noncollapsible wounds of the hip that were present for many months to years. Twenty-eight cases of infected total-hip arthroplasties that did not respond to removal of the prosthesis and cement and closure were seen by the authors between January of 1977 and December of 1988. One patient had bilateral involvement. Average age was 64 years (range 33 to 79 years). There was an average of 4.2 previous surgical attempts at closure (range 1 to 21). Staphylococcus aureus was the most common organism, but the infections were virtually all multiple. Thirty-three muscles were utilized in 27 patients. The rectus femoris was used in 23 cases, the vastus lateralis in 8, tensor fasciae latae in 1, and combined latissimus dorsi-serratus anterior free-tissue transfers were carried out in 2. Multiple combinations of transpositions and free flaps were utilized. Follow-up ranged from 1 to 10 years, with an average of 6.4 years. Eighteen patients were ambulatory with minor degrees of pain, five ambulated with a cane, seven ambulated with a walker, six ambulated with crutches, and four ambulated unassisted, all of whom had reimplantation of their hip arthroplasty at least 12 months following the muscle flap procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Erectile dysfunction and diabetes mellitus

Background: Erectile dysfunction (ED) is highly prevalent, affecting ≥50% of men with diabetes mellitus (DM) worldwide.Objective: This article reviews current knowledge on the epidemiology and underlying pathophysiology of ED in men with DM, diagnostic modalities, and treatment options.Methods: A MEDLINE literature search was conducted for articles published in English from inception of the database through November 2008, using the terms erectile dysfunction, diabetes, epidemiology, pathophysiology, phosphodiesterase inhibitors, intracavernosal injection, and penile prosthesis. Data on the epidemiology, diagnosis, and treatment of ED were extracted from all relevant articles.Results: The literature search revealed 685 original articles and reviews, 67 of which were selected for inclusion in this review. DM may cause ED through a number of pathophysiologic changes, including neuropathy, endothe-lial dysfunction, cavernosal smooth muscle structural/functional changes, hormonal changes, and psychological effects. The diagnosis of ED in men with DM is based on their sexual and medical histories and results of validated questionnaires such as the International Index of Erectile Function. Laboratory examinations are usually limited to testosterone and prolactin levels that may independently contribute to ED because specialized examinations are not necessary in most diabetic men with ED. The first step in the treatment of ED in men with DM includes glycemic control and treatment of diabetic comorbidities. The associated hypogonadism must also be treated; otherwise, pharmacologic treatment may be less efficacious or not efficacious at all. Phosphodiesterase type-5 (PDE-5) inhibitors have revolutionized the treatment of ED, and they are considered first-line treatment, with a mean efficacy rate of 50% and a favorable safety profile. Intracavernous administration of vasoactive drugs is the second-line medical treatment when PDE-5 inhibitors have failed. Alprostadil is the most widely used drug for this condition, but the combination of papaverine, phentolamine, and alprostadil represents the most efficacious pharmacologic treatment option for patients whose ED does not respond to monotherapy. Excellent functional and safety results have been reported for penile prosthesis implantation, and this approach, along with proper counseling, can be considered for selected patients with treatment-refractory ED.Conclusions: ED is common in men with DM, who represent one of the most difficult-to-treat subgroups of ED patients. PDE-5 inhibitors are the first-line treatment option, followed by intracavernosal injections and implantation of a penile prosthesis.     

Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device.

A technique for construction of external male genitalia in a transsexual patient is presented in detail. The McGregor groin flap is used for penile construction, and the Scott inflatable prosthesis is used to produce an erection. The shape of the penis is improved by secondary local excisions, and the clitoris is bivalved and inserted at the base of the penis to allow sexual sensation. The appearance and the function of the constructed genitalia have been deemed quite satisfactory by this transsexual patient.     

Morphological evaluation of the viability of silicon-lavsan tracheal prostheses

Time course of the healing process in the tracheal wall during silicon-lavsan tracheal grafting was investigated in experiments on 108 dogs with a new model of tracheal prosthesis. The formation of granulation tissue was noted as a result of postoperative inflammatory reaction in the prosthetic area. The tracheal epithelial layer adjacent to the anastomoses was hypertrophic and acquired the features of squamous epithelium. Later, after the implantation the prosthesis was surrounded by a thick fibrous capsula. In anastomoses, at tracheal tissue--implant border there was a poorly expressed inflammatory reaction, which had a local character and was compatible with 3 and more years of life in most experimental animals.     

Comparison of electrostimulation methods for semen recovery in the rhesus monkey (Macaca mulatta)

Electroejaculation of 17 rhesus monkeys was performed at intervals during a 15-month period using both penile and rectal probe stimulation. The semen quality was compared for the two stimulation methods. Both methods were effective in approximately 90% of attempts, and there was no difference in fertilizing capacity of the sperm. A seasonal difference in semen quality was detected, and samples recovered by penile stimulation showed higher sperm count.     

Radioactive Seed Implantation Combined with Prosthesis Denture in Treatment of Oral and Maxillofacial Malignancy

We sought to evaluate the effect of ¹²⁵I radioactive seed implantation combined with prosthesis denture on the treatment of oral and maxillofacial malignancy. For this purpose, 10 patients with glandule palatine malignancy were selected and subjected to the treatment plan of radioactive seed implantation during CT examination. All patients were treated as follow. The tumor tissues were extracted first. After 2 weeks, radioactive seeds were implanted in the palatine tissue and the prosthesis denture was made and worn for the tissue defect. Several radioactive seeds were still embedded in the tissue surface of the prosthesis at the same time; 24–36 seeds (average: 28) were used for each patient. All patients were followed up for 3–16 months and the results were evaluated. We found no tumor recurrence or metastasis around the target area in all patients. Significant improvement was shown in terms of speech, mastication, and facial appearance in all cases. Therefore, we concluded that in patients with glandule palatine malignancy, tumorectomy followed by radioactive seed implantation and prosthesis denture are effective for preventing the recurrence and metastasis of malignancy and improving the quality of life.     

Bone remodelling of the scapula after a total shoulder arthroplasty

According to Wolff’s law, the changes in stress after a prosthesis implantation may modify the shape and internal structure of bone, thus compromising the long-term prosthesis fixation and, consequently, be a significant factor for glenoid loosening. The aim of the present study is to evaluate the changes in the bone adaptation process of the scapula after an anatomical and reverse total shoulder arthroplasty. Five finite element models of the implanted scapula are developed considering the implantation of three anatomical, cemented, all-polyethylene components; an anatomical, cementless, metal-backed component; and a reverse, all-metal component. The methodology followed to simulate the bone adaptation of the scapula was previously validated for the intact model, prior to the prosthesis implantation. Additionally, the influence of the bone quality on the adaptation process is also investigated by considering an osteoporotic condition. The results show that the stress shielding phenomenon is more concerning in cementless, metal-based components than in cemented, all-polyethylene components, regardless of the bone quality. Consequently, as far as the bone adaptation process of the bone is concerned, cemented, all-polyethylene components are better suited for the treatment of the shoulder joint.     

CT-Angiography–Based Evaluation of the Aortic Annulus for Prosthesis Sizing in Transcatheter Aortic Valve Implantation (TAVI)–Predictive Value and Optimal Thresholds for Major Anatomic Parameters

Background/Objectives

To evaluate the predictive value of CT-derived measurements of the aortic annulus for prosthesis sizing in transcatheter aortic valve implantation (TAVI) and to calculate optimal cutoff values for the selection of various prosthesis sizes.

Methods

The local IRB waived approval for this single-center retrospective analysis. Of 441 consecutive TAVI-patients, 90 were excluded (death within 30 days: 13; more than mild aortic regurgitation: 10; other reasons: 67). In the remaining 351 patients, the CoreValve (Medtronic) and the Edwards Sapien XT valve (Edwards Lifesciences) were implanted in 235 and 116 patients. Optimal prosthesis size was determined during TAVI by inflation of a balloon catheter at the aortic annulus. All patients had undergone CT-angiography of the heart or body trunk prior to TAVI. Using these datasets, the diameter of the long and short axis as well as the circumference and the area of the aortic annulus were measured. Multi-Class Receiver-Operator-Curve analyses were used to determine the predictive value of all variables and to define optimal cutoff-values.

Results

Differences between patients who underwent implantation of the small, medium or large prosthesis were significant for all except the large vs. medium CoreValve (all p’s<0.05). Furthermore, mean diameter, annulus area and circumference had equally high predictive value for prosthesis size for both manufacturers (multi-class AUC’s: 0.80, 0.88, 0.91, 0.88, 0.88, 0.89). Using the calculated optimal cutoff-values, prosthesis size is predicted correctly in 85% of cases.

Conclusion

CT-based aortic root measurements permit excellent prediction of the prosthesis size considered optimal during TAVI.     

Implantation of dihydrotestosterone propionate into the lateral septum or medial amygdala facilitates copulation in castrated male rats given estradiol systemically

Two experiments were conducted to determine whether unilateral implantation of dihydrotestosterone propionate (DHTP) into different brain regions of castrated rats, bearing silastic capsules containing estradiol, could augment sexual behavior without appreciable leakage of androgen into the peripheral circulation. In Experiment 1 implanation of pulverized crystalline DHTP (via 25-gauge, 1-mm-long pellets) facilitated mating significantly without stimulating penile spine growth, provided the pellets were positioned in the lateral septum or medial amygdala. Insertion of DHTP pellets into the preoptic area-anterior hypothalamus, caudate-putamen, or the border of the substantia nigra and ventral tegmental nucleus or of cholesterol pellets into lateral septum or medial amygdala had no behavioral effects. Implanation of DHTP into the lateral septum also failed to activate penile erections in rats restrained in a supine position. In Experiment 2 implantation of different bone wax dilutions of DHTP (via 25-gauge, 1-mm-long pellets) into the preoptic area-anterior hypothalamus augmented males' sexual performance only in that group in which penile spine growth was also significantly stimulated. The results sugggst that 5α-reduced androgen is capable of activating mating in the male rat by acting locally in the lateral septum and/ or medial amygdala.     

Preoperative electrocardiography effect of new abnormalities on clinical decisions.

Determining the cause of genital ulcers requires extensive laboratory investigation, particularly if there is no history of sexually transmitted disease. In a patient with a solitary penile erosion who was tired, weak, sweaty and febrile, hematologic and serologic tests suggested infectious mononucleosis, and bacteriologic and serologic studies, along with attempts at virus culture, ruled out syphilis and herpes simplex. The erosion healed soon after the other signs and symptoms resolved. It therefore appears that solitary penile erosions may be a presenting feature of infectious mononucleosis.     

Experimental evaluation of ceramic calcium phosphate as a substitute for bone grafts.

Tricalcium phosphate (Synthos) is a bioceramic material which can be carved with a scalpel and wired into place as a bone graft would be. The process of bone replacement of the prosthesis begins with an ingrowth of cellular loose connective tissue, which is replaced later by dense connective tissue. Around the periphery of this dense fibrous connective tissue, osteoid tissue becomes evident and on later specimens this mixture seems to be converted to bone--which at first is in the form of spicules but later takes on the characteristics of lamellar bone (with tricalcium phosphate particles seen within its lacunae). The progressive replacement occurs in a circumferential pattern, but most heavily at the bone-prosthesis interface. Although the periosteum is beneficial, we do not feel that the major source of bone formation is as the soft tissue or subperiosteal area. The replacement of the tricalcium phosphate prosthesis is slower than we originally thought, or than reported by others. We have noted pockets of tricalcium phosphate, incompletely replaced, in dogs up to 18 months after implantation. We believe this may be related to the larger sized prostheses we used (2 x 2 cm blocks) with, therefore, longer distances that the ingrowth and calcification had to traverse.     

Patient-specific simulation of a stentless aortic valve implant: the impact of fibres on leaflet performance

In some cases of aortic valve leaflet disease, the implant of a stentless biological prosthesis represents an excellent option for aortic valve replacement (AVR). In particular, if compared with the implant of mechanical valves, it provides a more physiological haemodynamic performance and a reduced thrombogeneticity, avoiding the use of anticoagulants. The clinical outcomes of AVR are strongly dependent on an appropriate choice of both prosthesis size and replacement technique, which is, at present, strictly related to surgeon's experience and skill. This represents the motivation for patient-specific finite element analysis able to virtually reproduce stentless valve implantation. With the aim of performing reliable patient-specific simulations, we remark that, on the one hand, it is not well established in the literature whether bioprosthetic leaflet tissue is isotropic or anisotropic; on the other hand, it is of fundamental importance to incorporate an accurate material model to realistically predict post-operative performance. Within this framework, using a novel computational methodology to simulate stentless valve implantation, we test the impact of using different material models on both the stress pattern and post-operative coaptation parameters (i.e. coaptation area, length and height). As expected, the simulation results suggest that the material properties of the valve leaflets affect significantly the post-operative prosthesis performance.     

Assessment of the efficacy and safety of low frequency,low intensity magnetic fields in patients after knee endoprosthesis plasty. Part 1: In vitro safety

The purpose of this in vitro study was to assess the potential influence of low frequency, low intensity magnetic fields (rectangular pulse, 5 mT, 30 Hz) applied in therapy on the temperature, contact electric potential, and magnetization in knee endoprosthesis, which might be dangerous for implantation and stability of knee prosthesis, and later slacking it off, causing postoperative complications. The experimental investigation was carried out on a knee endoprosthesis which had been placed in a container with physiological saline. The prosthesis located inside the container was under the exposure of the magnetic field applied by a solenoid. The results indicated that magnetic fields did not influence thermal and electromagnetic properties of knee endoprosthesis in vitro. The magnetic fields of examined parameters should not be dangerous for implantation and stability of knee endoprosthesis. Bioelectromagnetics 30:159–162, 2009. © 2008 Wiley‐Liss, Inc.