Urology Journal
Volume:1 Issue: 4, Autumn 2004

According to a survey, the Massachusetts Male Aging Study, 52% of men beyond 40 years of age may have some degrees of erectile failure, and it is projected to affect 322 million men worldwide by 2025. We present a framework for the evaluation, treatment, and follow-up of the male patient who presents with erectile dysfunction. A comprehensive review of the literature was conducted using the MEDLINE database for all articles from 1975 through 2004 on male sexual dysfunction and the most pertinent articles are discussed. Remarkable progress has been made in the treatment of erectile dysfunction (ED). Erectile dysfunction is a common condition associated with aging, chronic illnesses and various modifiable risk factors. Erectile dysfunction can be due to vasculogenic, neurogenic, hormonal, and/or psychogenic factors as well as alterations in the nitric oxide/cyclic guanosine monophosphate pathway or other regulatory mechanisms. The number of consultations from new patients presenting with erectile dysfunction and resulting costs for health care systems are increasing. Urologist should be the evaluating physician who supervises the surgical, medical, and hormonal treatment and who refers the patient, as necessary, to other members of the multidisciplinary team. Erectile dysfunction has a significant negative impact on quality of life. Male sexual dysfunction, especially erectile dysfunction, necessitates a comprehensive medical and psychologic evaluation involving both partners. All possible risk factors should be outlined and corrected, when feasible.

The increasing incidence of prostate cancer and different viewpoints of medical authorities to it, has lead to conversion of preliminary plan of screening test to a requisite. The objective of this study is to clarify the obscure aspects of this subject using the literature review. We reviewed the following items in the literature: prostate cancer screening, introduction of relevant tests, screening criteria according to World Health Organization, screening experience in different countries, community notification, specialists training in order to establish an integrated approach and treatment, anxiety relief, and promotion of patient awareness in this field. It has been shown that, except in China, programmed and official screening of prostatic cancer has not been accepted by concordant responsible authorities, neither in developed countries nor in developing ones. However, it is performed informally in different parts of the world. There is no unanimous consensus about performance of screening for prostate cancer. Continuing voluntary referral of men above 50 years old for performing prostatic specific antigen (PSA) test has been accepted universally and is being done potentially, defined as “opportunistic screening”.

There are conflicting reports in the literature about correlation of biopsy and prostatectomy Gleason scores in prostate carcinoma. The goal of this study was to determine the correlation of grading in these two types of pathologic materials. The coupled Hematoxylin and Eosin slides of 111 patients with prostate carcinoma were collected. Gleason scores were determined. Patients who had undergone any therapy except surgery were excluded from the study. Correlation between grades was calculated by determination of correlation coefficient. Accuracy of biopsy grading in prediction of final grade was also determined by measuring the sensitivity, specificity, and positive and negative predictive values. In 50 cases (45%), grade was underestimated in the biopsy. After dividing the cases into Gleason scores of 2 to 4, 5 to 6, 7, and 8 to 10, the most of undergraded cases (84.2%) were in the first group (Gleason score 2 to 4) and this rate reached 5% in the fourth group (Gleason score 8 to 10). The correlation coefficient measured was 0.535 in grade to grade comparing and 0.514 in group to group comparison of the specimens. In low-grade tumors, grading in biopsy, in spite of high sensitivity (90.9%), had low positive predictive value (26.3%). There is a moderate direct linear relationship between scores in biopsy and prostatectomy specimens. But there is a high probability of underestimation of real Gleason score of the radical prostatectomy specimen in low-grade tumors. Pathologists and urologists must consider the phenomenon of undergrading in reporting prostate specimens and managing patients.

This study was conducted to evaluate the effects of smoking on the clinical characteristics and growth trend of transitional cell carcinoma (TCC) of the bladder. In a retrospective case-control study from February 2000 to March 2003, patients with TCC of bladder, referred to our clinic, were selected and divided into high-grade and low-grade groups. Groups were matched for other known risk factors and the effect of smoking on size, number, and presenting grade of TCC in each group was evaluated. A total of 185 patients, with a mean age of 65.1 ± 14.0 year, were included in this study, of whom 36 were females and 149 were males (male to female ratio of 4.1 to 1). Eighty-three patients were smokers (44.9%) with a mean 20.01 ± 11.09 pack-year (range 0.75 to 60) smoking history. History of smoking was positive in 36.1% of the patients with low-grade tumors; whereas, 90% of the patients with high-grade tumors were smokers (P = 0.000, OR = 15.9, 95% CI: 6.7-36.9). There was a statistically significant correlation between the history of smoking and size and number of tumoral lesions (P = 0.000, P = 0.000, respectively). Positive history of smoking was also associated with higher grades of tumor in both men and women (OR = 12.8 and 8.8, respectively). This study showed that smoking not only induces bladder cancer, but also, once it develops, it can increase the grade of tumor, resulting in worse prognosis. Thus, smoking cessation might favorably alter the course of bladder cancer.

Many environmental and occupational risk factors have been proposed for bladder cancer, among which opium consumption has been considered in few studies. We designed a study to determine the relationship between opium consumption and bladder cancer. In a retrospective, case-control study, male patients with bladder cancer, who had been referred to our hospital in a three-year period, were selected. Data regarding age, gender, smoking, and opium consumption were collected from patients’ records and compared with data of a control group, consisting of patients with benign prostatic hyperplasia (BPH). Fifty-two male patients with bladder tumor (group 1) were compared with 108 patients with BPH (group2). Of the patients with bladder cancer, 36 (68%) were smokers, of whom 12 were also opium addicts. In general, 13 (25.5%) patients were opium consumers (one opium consumer was not smoker). From 108 patients with BPH, 25 (23%) were smokers, of whom, 5 were also opium addicts. Mean duration of cigarette smoking was 31 ± 13.6 and 20.2 ± 14.7 years in patients with bladder cancer and BPH, respectively. The duration of opium consumption was 11.9 ± 1.4 and 6.2 ± 1.3 years in groups 1 and 2, respectively. The duration of cigarette smoking and opium consumption in group 1 was greater than that in group 2. In addition, smoking increases the risk of bladder cancer 3.8-fold (OR = 8.3, 95% CI = 1.8 - 7.8). Simultaneous cigarette smoking and opium consumption increases the risk of bladder cancer 6.2-fold (OR = 6.2, 95% CI = 2.04 - 18.7). There are few studies regarding the carcinogenic effect of opium on bladder. We demonstrated that, the incidence of bladder cancer in smokers, who are simultaneously opium consumers, was higher than in patients who were only smokers. Simultaneous opium addiction and cigarette smoking may have some roles in the pathogenesis of bladder tumor. However, further studies with large sample sizes are warranted.

Renal transplantation is an ideal treatment for patients with chronic renal failure. It was demonstrated that despite the adhesion to surgical and anesthetic principles, urinary output is not satisfactory after transplantation. It seems that microvascular spasm of renal vasculature is responsible for this phenomenon. We designed a study to investigate whether lidocaine injection into renal artery can relieve vasospasm and subsequently improve output and graft function better than furosemide. In a randomized clinical trial, from July 2002 to November 2003, 100 consecutive patients who were referred to our center for kidney transplantation were recruited in this study. After obtaining written informed consent, they were divided blindly into two groups. In group 1, lidocaine was injected into renal artery, before arterial anastomosis, and group 2 received furosemide as the conventional intervention. Urine volume within 1, 4, and 24 postoperative hours and serum creatinine levels in the first three weeks were recorded and compared between the two groups. Urine volumes at 1, 4, and 24 hours after transplantation were higher significantly in lidocaine group (P < 0.001). Serum creatinine levels were lower significantly in the first postoperative day and also 21 days after transplantation in group 1 (P < 0.001). Comparing to furosemide, it seems that lidocaine can cause a more effective vasodilation in renal arteries of kidney allograft, resulting in a better diuresis. This may have a role in the betterment of graft function.

Kidney recipients are susceptible to incisional hernia. We studied predisposing factors for incisional hernia in our patients and the results of its repair with propylene mesh. From 1989 to 2002, 589 patients had undergone kidney transplantation in our hospital. Of these, patients who developed incisional hernia were evaluated in this study. The following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method, and the treatment results with propylene mesh. Of 589 recipients, 16 (3%) developed incisional hernia in surgical site. The median interval between kidney transplantation and developing of incisional hernia was 48 (range 12 to 425) days. Predisposing factors were overweight, age over fifty years, and female gender (P < 0.005). In four patients, hernia was small, and the repair was performed without using mesh. Three patients were reluctant to hernia repair, and in 9, due to the large size of hernia, repair was done using propylene mesh. Having these 9 patients treated with propylene mesh, 2 developed serous collection in surgical site, which were managed successfully with multiple punctures. Hernia recurrence or infection was not noted in these patients during 3 to 36 months follow-up periods. Incisional hernia is not a rare entity after kidney transplantation. Predisposing factors, such as overweight, age over 50 years, and female gender have a role in its development. Also, repeated surgeries in kidney recipients can increase the risk of incisional hernia. Managing this complication with propylene mesh is a safe and effective method.

To evaluate the results of grade IV cystocele repair by 4-corner bladder and bladder neck suspension technique, using prolene mesh. Thirty-one women with a median age of 61 years and severe anterior vaginal wall prolapse (grade IV cystocele) were treated by 4-corner bladder and bladder neck suspension technique, using prolene mesh. Of these, 3 had associated uterine prolapse, rectocele, and enterocele, one had rectocele and enterocele, and 18 had rectocele only. In these cases, pelvic floor defects were also repaired simultaneously and in 3, vaginal hysterectomy was done. Twelve patients had a previous failed cystocele repair. In a 32-month follow-up, the patients were evaluated with vaginal examination and upright cystography. Urinary continence during increased intra-abdominal pressure was also assessed, based on subjective symptoms. None of the patients had cystocele recurrence. Urinary continence during increased intra-abdominal pressure was seen in all of the patients. Intraoperative rectal or bladder injury did not occur. Transfusion was not required in any of the cases. Early complications (6 to 8 weeks postoperatively) included irritative urinary symptom in 17 patients, of whom, 8 had documented urinary tract infection that were treated successfully. Late complications were spotting in 3 cases (two were treated with topical estrogen and vaginal mucosal repair was done in one), dyspareunia in 4 sexually active patients, changes in urination pattern in 28 (improved significantly with behavioral therapy), long-term urge incontinence (> 8 weeks) in 5 (medical treatment was successful in these patients), and prolonged intermittent catheterization in 1. Pelvic abscess and migration of mesh were not observed. According to our findings, using mesh in patients with grade IV cystocele, who had a previous failed surgery or weakness in supportive pelvic tissue, is an appropriate treatment modality.

In Iranian traditional medicine there is a belief that camphor is a suppressor of sexual activity. Based on this idea and since there are few studies on this issue, we evaluated the effect of camphor on histopathological changes of reproductive system in young male mice of balb/c racial type. Thirty-six premature male balb/c mice, were divided into 3 paired groups of experimental, control, and sham (n = 6). Experimental groups 1 and 2 received 30 mg/kg camphor dissolved in olive oil (orally) for 10 and 20 days, respectively. The control groups received the same volume of olive oil during the same periods of time, and no intervention was done in sham groups. All groups were kept in the same environmental condition. At the end of exposure time, each group was anesthetized and their testes were removed for obtaining serial sections, and histological staining. Comparing to the control groups less vascularization in testis tissue of experimental groups was seen. Furthermore, using stereological methods demonstrated that internal diameters of seminiferous tubules in experimental groups were significantly smaller than those in control groups (P < 0.005). Also, the number of released sexual cells was lower in experimental groups (P < 0.005). No meaningful difference was seen between controls and sham groups. Administration of camphor and its effects on male mice reproductive system may result in significant structural changes, including vascularization and proliferation of sexual cells. This can affect maturation of seminiferous tubules and subsequently, reproductive function of testes in mice.

Our aims were to determine the relation of semen parameters in processed and unprocessed semen samples with pregnancy rate in intrauterine insemination (IUI) in the treatment of male factor infertility. In a quasi experimental study, 412 couples with male factor infertility were studied. To treat male factor infertility, 561 IUI cycles were done. Total pregnancy rate was 7.84% (44 in 561) per cycle. There was an inverse relationship between pregnancy rate and duration of infertility. Total sperm count after processing was higher in pregnant cycles than in non-pregnant ones (P < 0.05). The mean total motile sperms after processing for pregnant and non-pregnant cycles was 72.2 ± 78.8 and 53.2 ± 54.3, respectively (P < 0.05). IUI is a valuable method for the treatment of male factor infertility. The higher number of sperms, total motile sperms and IUI sessions, and lower duration of infertility, all have a positive relationship with pregnancy rate.