- Email: [email protected]
SEVERITY OF TYPE 2 DIABETES AND ERECTILE DYSFUNCTION: THE TRANSLATING RESEARCH INTO ACTION IN DIABETES (TRIAD) STUDY
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
levels of total testosterone (TT), free testosterone (FT) measured by radioimmunoassay and dehydroepiandrosterone sulfate (DHEA-S) by FKHPLOXPLQHVFHQFH6XEQRUPDOOHYHOVZHUHGH¿QHGDV77QJG/ )7SJP/DQG'+($6QJP/0HQZHUHGLYLGHGLQHLJKW different groups according to age ranges. Mean age was 56.3 ± 12.2 years (range = 15 - 90). RESULTS: Mean (SD) values for TT, FT and DHEA-S were 518.5 (194.7) ng/dL, 15.3(6.7) pg/mL and 141.1(124.7) ng/mL, respectively. Median (25% - 75%) values for TT, FT and DHEA-S were 415 (300 - 549) ng/dL, 15.1 (11.0 - 18.8) pg/mL and 108 (68 - 192) ng/ mL. Median (25% - 75%) values for TT, FT and DHEA-S in different age groups are described in Table 1. Chi-Square analysis showed a VLJQL¿FDQWGLIIHUHQFHIRUWKHSUHYDOHQFHRIVXEQRUPDO77)7DQG'+($6 in the different age groups according to table 2. Proportions followed by GLIIHUHQWVPDOOOHWWHUVGLIIHUVLJQL¿FDQWO\ S Table 1. Median (25% - 75%) values of TT, FT and DHEA-S by age range Age range (y) TT (nd/dL) FT (pg/mL) DHEA-S (ng/dL) 15 - 20 669 (553 - 743) 24.4 (18.6 - 28.5) 236 (181 - 317) 21 - 30 551 (445 - 652) 20.1 (17.2 - 25.6) 199 (175 - 296) 31 - 40 451 (325 - 656) 17.8 (14.6 - 23.0 ) 204 ( 159 - 254) 41 - 50 441 (314 - 563) 15.9 (12.3 - 19.8) 143 ( 97 - 221) 51 - 60 408 (300 -541) 15.0 (11.1 - 18.6) 107 (69 - 176) 61 - 70 397 (287 - 512) 14.1 (9.7 - 16.9) 86 (53 - 121) 71 - 80 391 ( 267 - 537) 13.2 (9.7 - 15.8) 72 (43 - 109) 81 - 90 261 (132 - 496) 11.4 (9.0 - 16.5) 50 (30 - 96) Table 2. Prevalence of subnormal values of TT, FT and DHEA-S by age range (percentage) Age Range (y) 77QJG/ )7SJP/ '+($6QJP/ 0.0 a 0.0 a 15 - 20 0.0 a 21 - 30 7.7 a 0.0 a 5.0 a 31 - 40 17.2 ab 17,6 a 4.1 a 41 - 50 22.5 abc 25.8 a 15.8 b bc b 51 - 60 24.8 32.9 31.4 c cd c 61 - 70 28.2 40.2 44.8 d 71 - 80 34.0 d 45.2 c 51.9 d 81 - 90 60.0 e 57.9 c 65.0 d
CONCLUSIONS: Prevalence of subnormal androgen serum levels in males progressively increases with age. Source of Funding: None
869 IS PSA INFLUENCED BY TESTOSTERONE LEVELS IN AGING MEN? Leonard S Marks*, Claus G Roehrborn, Michael Marberger, Timothy H Wilson, Roger S Rittmaster. Culver City, CA, Dallas, TX, Vienna, Austria, and Research Triangle Park, NC. INTRODUCTION AND OBJECTIVE: PSA is androgenregulated. At puberty, the rise in PSA associated with prostate growth closely parallels the rise in serum testosterone (T). However, in men at PLGOLIHWKHUHODWLRQVKLSRIVHUXP7WR36$OHYHOVKDVQRWEHHQFODUL¿HG We examined that association in a large clinical-trial data set, where T was an independent variable. METHODS: Baseline data of all men from dutasteride Phase 3 BPH trials and the REDUCE prostate cancer risk reduction trials were examined. Entry criteria included age >50 (both trials) and PSA >1.5 %3+WULDOV DQG36$! 5('8&( 7OHYHOPHDVXUHGE\5,$LQ all subjects, was not an entry criteria. Cancer was excluded clinically and by biopsy in Phase 3 men if PSA > 4.0 and in all REDUCE men. >90% of subjects were Caucasian. Baseline Measures Baseline measure, mean (range) Age, yr PSA, ng/ml Prostate Volume by TRUS, cc BMI, kg/m2 Testosterone, ng/dl
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with the other measures above as the independent variables, along with pairwise interactions between them. Baseline PV (p<0.0001), age (p<0.003) and BMI (p<0.001) were simultaneously related to PSA in both studies. However, T was not related to PSA after adjustments for PV, age, and BMI in Phase 3 (p=0.17) or in REDUCE (p=0.21). CONCLUSIONS: Less than 1% of variability in serum PSA levels between 1.5 and 10 ng/ml could be attributed to circulating testosterone concentrations in adult men participating in various prostate WULDOV DQG LQ D PXOWLYDULDWH DQDO\VLV 7 GLG QRW VLJQL¿FDQWO\ LQÀXHQFH PSA levels. In these men, the amount of androgenic stimulation of the prostate, as judged by PSA secretion, was similar over a wide range of circulating testosterone concentrations. These data support the concept that high intra-prostatic levels of 5a-reductase permit DHT accumulation and normal prostate function, even at low circulating T levels. Source of Funding: GlaxoSmithKline and Urological Sciences Research Foundation.
870 TESTOSTERONE TREATMENT IN HYPOGONADAL PATIENTS DOES NOT CAUSE HIGHER INCIDENCE OF PROSTATE CANCER Aksam A Yassin*, Farid Saad. Norderstedt-Hamburg, Germany, and Berlin, Germany. INTRODUCTION AND OBJECTIVE: To evaluate incidence or SUHYDOHQFHRISURVWDWHFDQFHULQSDWLHQWVZLWKWHVWRVWHURQHGH¿FLHQF\ with LOH (late onset hypogonadism) and ED (erectile dysfunction), receiving long-acting injectable testosterone undecanoate therapy in comparison with similar group of control population. 0(7+2'6 WHVWRVWHURQHGH¿FLHQWSDWLHQWVZLWKDYHUDJH age 56 +/- 2,1 years and mean follow-up of 24 months (11-36 months), received injectable TU 1000 mg (Nebido, Bayer-Schering, Berlin/ Germany) were compared with control cohort of 160 eugonadal (average age 58 +/- 1.6 years) population with similar characteristics visiting our clinic for preventive medical check up. They underwent monitoring protocol at baseline and 3-monthly including age, co-morbidities, FRQFRPLWDQWPHGLFDWLRQ,36636$'5(WRWDO3URVWDWHYROXPHDQG7= measured by TRUS and TRUS-guided biopsies when indicated by PSA velocity > 0.75 ug/L, or elevation over 4.0 ug/L. In all subjects in both groups, no abnormalities in rectal palpation were noticed so far. RESULTS: Initially hypogonadal patients showed at baseline lower PSA values and lower prostate volumes, 0.77 +/- 0.3 ug/L and 27.6 +/- 1.2 ml respectively. The control group subjects had PSA levels at 2.15 +/- 1,42 ug /L, and prostate volume 39.5 +/- 2.33 ml at baseline. Patients in group I (LOH/ED) whose PSA velocity in follow up was > 0,75 ug /L than at baseline, underwent TRUS-guided prostate BX, according to Hamburg’s protocol (10 cores 1.6cm each). We found CaP in 2/11 biopsies, both of them unilateral and 5% tumor cells in a core. Gleason score 3+2 and 3+3 respectively. One more patient had a high grade PIN. In group IUI with 160 control subjects, 5 subjects (5/12) showed CaP, RIWKHPELODWHUDOZLWKDVLJQL¿FDQWO\KLJKHU*OHDVRQVFRUHRIWLOO 4+4 and till 75% tumor cells in a core. CONCLUSIONS: 1) Subjects with T-deficiency have primarily lower prostate volume than eugonadal ones. 2) Subjects with 7GH¿FLHQF\ KDYH SULPDULO\ ORZHU 36$ OHYHOV WKDQ HXJRQDGDO RQHV 3) Indicated Testosterone supplementation does not increase CaP incidences. 4) Smaller tumors and less malignancy (better differentiation) is more evident in group under testosterone treatment Source of Funding: None
Phase 3 BPH Trials N=4259
REDUCE Trial N=8103
66.3 (50-94) 4.0 (1.5-10)
62.8 (48-77) 5.9 (2.5-10)
54.6 (30-274)
44.6 (10-80)
27.5 (17.7-56.3) 400 (39-2940)
27.4 (10.4-73.5) 453 (29-3190)
RESULTS: Using PSA as the dependent variable, correlation with other relevant variables was as follows: Age, r=0.11 (p<0.001 in both WULDOV 39U LQ3KDVHLQ5('8&( S LQERWKWULDOV %0,U LQ3KDVHLQ5('8&( S LQERWKWULDOV DQG Testosterone, r=0.03 in Phase 3 and r=0.025 in REDUCE (p<0.05 in both trials). A multivariate regression using logarithmic transformations was performed in each study with PSA as the dependent variable and
871 SEVERITY OF TYPE 2 DIABETES AND ERECTILE DYSFUNCTION: THE TRANSLATING RESEARCH INTO ACTION IN DIABETES (TRIAD) STUDY Aruna V Sarma*, Hunter Wessells, William Herman. Ann Arbor, MI, and Seattle, WA. INTRODUCTION AND OBJECTIVE: An estimated 10-15 million men in the United States have erectile dysfunction (ED) with the prevalence of ED in men with diabetes to be approximately between 35 and 75%. Diabetes accounts for 30% of ED and in fact, has been described to be a primary presenting symptom of diabetes. Although the prevalence of ED in men with diabetes has been well established,
302
THE JOURNAL OF UROLOGY®
the association between ED and the severity, duration and control of diabetes has not been clearly elucidated. METHODS: 634 men with type 2 diabetes (DM) who participated in the University of Michigan, Translating Research into Action in Diabetes (TRIAD) study provided information on erectile dysfunction using the validated single item question assessing the ability to maintain an erection satisfactory for sexual intercourse. Measures of diabetes severity including duration of disease, glycemic control, mode of therapy and presence of diabetic complications were examined by PRGHUDWHVHYHUH (' VWDWXV GH¿QHG DV µVRPHWLPHV¶ RU µQHYHU¶ EHLQJ DEOH WR PDLQWDLQ DQ HUHFWLRQ IRU VH[XDO LQWHUFRXUVH YV µXVXDOO\¶ DQG µDOZD\V¶ RESULTS: Among this population of men with type 2 diabetes, 53.2% (n=332) reported moderate/severe erectile dysfunction. Duration of diabetes >5 years increased risk of moderate/severe ED 1.6 fold after DGMXVWPHQWIRUDJH3RRUJO\FHPLFFRQWUROZDVVLJQL¿FDQWO\DVVRFLDWHG ED as was the use of insulin. Other characteristics associated with an increased risk of ED included report of neuropathy, retinopathy, and QHSKURSDWK\7KHVHDVVRFLDWLRQVZHUHQRWPRGL¿HGE\ERG\PDVVLQGH[ cardiovascular disease or lower urinary tract symptom severity. CONCLUSIONS: Several measures of the severity of diabetes including duration of disease, glycemic control, mode of therapy and SUHVHQFHRIFRPSOLFDWLRQVZHUHVLJQL¿FDQWO\DVVRFLDWHGZLWKLQFUHDVHG ULVNRISUHYDOHQW('7KHVH¿QGLQJVSURYLGHIXUWKHUVXSSRUWIRUHDUO\ implementation of tight glycemic control and monitoring and prevention of complications in men with type 2 diabetes. Associations between Measures of DM Severity and ED 'XUDWLRQRI'0 !YV\HDUV 1.63 (1.12, 2.39) *O\FHPLF&RQWURO +$FYV 2.14 (1.35, 3.41) Insulin Use (yes vs. no) 1.87 (1.29, 2.71) Retinopathy (yes vs. no) 1.54 (0.97, 2.42) Nueropathy (yes vs. no) 3.08 (1.88, 5.06) Nephropathy (yes vs. no) 2.09 (1.20, 3.64)
Source of Funding: U-48-CCU916373.
872 COLOR DOPPLER ULTRASOUND HEMODYNAMIC CHARACTERISTICS OF PRIAPISM PATIENTS BEFORE AND AFTER THERAPY AND ITS IMPACT ON SUBSEQUENT MANAGEMENT Rei K Chiou*, Himanshu Aggarwal, Fleur Broughton, Christopher R Chiou, Susan Liu. Omaha, NE. INTRODUCTION AND OBJECTIVE: Information in the literature on the hemodynamic of priapism after aspiration or surgical VKXQWWUHDWPHQWLVYHU\OLPLWHG:HDQDO\]HRXUFRORU'RSSOHU8OWUDVRXQG (CDU) studies performed for priapism patients at various stages of management. METHODS: We reviewed 50 CDU studies and medical records in 24 patients with priapism from 1997 to 2007 before and after treatment. Age: 15 to 70 years. Duration of priapism: 4 hours to 10 days. 26 CDU studies were performed when patients presented to our institution (1 patient had recurrent episodes). 6 CDU studies were performed after aspiration and intracavernosal pharmacological therapy. 9 patients had failed previous shunt surgeries by other urologists including cavernosoglandular shunts in 8 patients and both cavernoso-glandular and cavernoso-spongiosal (Quakle) shunt in 1 patient. We performed total 15 penile cavernosa-dorsal vein (CD) shunts in these and other patients. 18 CDU studies were performed after CD shunt surgeries. RESULTS: Priapism of short duration showed varied arteriogenic and venoocclusive components. Priapism >24 hours typically showed ischemic pattern with little or undetectable cavernosal DUWHULDO ÀRZ$IWHU D VXFFHVVIXO SHQLOH VKXQW VXUJHU\ WKH FDYHUQRVDO DUWHULDO ÀRZ XVXDOO\ FRQYHUWHG IURP WKH LVFKHPLF FKDUDFWHULVWLFV WR QRUPDORUKLJKÀRZVWDWXV3DWLHQWVZKRZHUHUHIHUUHGWRXVDIWHUIDLOLQJ previous shunt surgeries showed ischemic characteristics indicating that shunts performed had not relieved veno-occlusive pathophysiology. After we performed penile CD shunts, we observed increase of cavernosal DUWHULDOÀRZ RUÀRZEHFRPHGHWHFWDEOH LQRISDWLHQWVVWXGLHG,Q SDWLHQWVWKHDUWHULDOÀRZUHPDLQHGXQGHWHFWDEOH,QPRVWSDWLHQWVWKH patency of CD shunt was observed in CDU studies. Some patients who FOLQLFDOO\DSSHDUHGWRKDYHSHUVLVWHQWSULDSLVPKDG&'8VWXGLHV¿QGLQJV
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
RI KLJK ÀRZ DQG SDWHQW VKXQW LQGLFDWLQJ SRVWLVFKHPLF K\SHUHPLD In one patient who failed Winter shunt and Quakle shunt previously, &'8VKRZHGXQGHWHFWDEOHEORRGÀRZDWWKHWLPHRISUHVHQWDWLRQ:H performed penile CD shunt and his CDU study showed high cavernosal EORRGÀRZDIWHUVXUJHU\ CONCLUSIONS: CDU study is important in the assessment of priapism treatment and helps the decision for subsequent management. CDU studies should be performed for patients who appear to have persistent priapism after therapy to evaluate for post-ischemic hyperemia vs shunt failure to decide further management. Source of Funding: None
873 ACCURACY OF MRI IN THE DIAGNOSIS OF ISCHAEMIC PRIAPISM Nigel C Borley*, Clare Allen, David Ralph. London, United Kingdom. INTRODUCTION AND OBJECTIVE: Ischaemic priapism is a urological emergency. Within 24 hours, the cavernosal smooth muscle XQGHUJRHVLVFKDHPLFQHFURVLVOHDGLQJWRLUUHYHUVLEOHFRUSRUDO¿EURVLV and erectile dysfunction. Once simple measures such as aspiration and LQVWLOODWLRQRIDQĮDGUHQHUJLFDJHQWKDYHIDLOHGSDWLHQWVUHTXLUHFRUSRUDO washout +/- prosthesis insertion based on cavernosal smooth muscle viability. To help with preoperative assessment and patient counselling, MRI was used to try to determine the viability of cavernosal smooth muscle in prolonged ischaemic priapism by comparing a pre-operative non-invasive technique (MRI) with conventional biopsy at the time of surgery. METHODS: 17 men with a history of priapism lasting longer than 12 hours that had been documented as ischaemic as by blood gas analysis were included. All had received non-surgical interventions to aid relief of the priapism. They underwent a Doppler ultrasound and high resolution multiplanar MRI with gadolinium enhanced sequences. The MRI was reported independently by a radiologist, and if indicated SDWLHQWVZHQWRQWRFRUSRUDOZDVKRXWDQGELRSV\+LVWRORJ\¿QGLQJV ZHUHFRPSDUHGWR05,¿QGLQJV RESULTS: 10 patients had necrosis of corporal tissue shown on MRI and went on to corporal wash out and biopsy. 5 patients had YLDEOHWLVVXHVKRZQRQ05,RUVRPHÀRZRQ'RSSOHUXOWUDVRXQGDQG did not go on to corporal biopsy. 1 patient had viable tissue on MRI but went on to biopsy at the time of implantation of penile prosthesis for stuttering priapism. 1 patient had non-viable tissue secondary WR PDOLJQDQW LQ¿OWUDWLRQ RQ 05, DQG RSWHG QRW IRU ELRSV\7KHUH ZDV complete correlation in viability of tissues on histology compared to 05,¿QGLQJVLQWKHDSSOLFDEOHSDWLHQWV7KLVLQFOXGHGSDWLHQWZKHUH MRI correctly distinguished between viable proximal and non-viable distal tissue. &21&/86,216 7KLVVWXG\VKRZVDKLJK VSHFL¿FLW\ for MRI in determining the viability of corporal tissue after ischaemic priapism as determined by histology.MRI allows the clinician to discuss with the patient pre-operatively the need for prosthesis insertion (or shunt procedure) dependant upon the viability of cavernosal smooth muscle as determined by its MRI appearance. Source of Funding: None
874 THE RELATIONSHIP BETWEEN PREMATURE EJACULATION AND HYPERTHYROIDISM $KPHW&LKDQ2PHU'HPLU7HY¿N'HPLU*XYHQ$VODQ$EGXUUDKPDQ Comlekci, Ahmet A Esen*. Izmir, Turkey. INTRODUCTION AND OBJECTIVE: The aim of the study was to determine ejaculatory latency time alterations in patients with hyperthyroidism before and after the treatment. METHODS: Between January 2004 and June 2007 a total of 43 patients with hyperthyroidism who have not any treatment history were enrolled to study. After detailed sexual anamnesis, international index of erectile function (IIEF) questionnaire and self reported outcome 652 PHDVXUHVRIWKHVXEMHFWVDERXWKDYLQJGLI¿FXOW\WRFRQWURORYHU ejaculation during intercourse were asked. Stop-watch measurements of intra-vaginal ejaculation latency time (IELT) were performed. Patients ZKRKDYH,(/7RIOHVVWKDQVHFRQGVZHUHDFFHSWHGDVGH¿QLWH3(
levels of total testosterone (TT), free testosterone (FT) measured by radioimmunoassay and dehydroepiandrosterone sulfate (DHEA-S) by FKHPLOXPLQHVFHQFH6XEQRUPDOOHYHOVZHUHGH¿QHGDV77QJG/ )7SJP/DQG'+($6QJP/0HQZHUHGLYLGHGLQHLJKW different groups according to age ranges. Mean age was 56.3 ± 12.2 years (range = 15 - 90). RESULTS: Mean (SD) values for TT, FT and DHEA-S were 518.5 (194.7) ng/dL, 15.3(6.7) pg/mL and 141.1(124.7) ng/mL, respectively. Median (25% - 75%) values for TT, FT and DHEA-S were 415 (300 - 549) ng/dL, 15.1 (11.0 - 18.8) pg/mL and 108 (68 - 192) ng/ mL. Median (25% - 75%) values for TT, FT and DHEA-S in different age groups are described in Table 1. Chi-Square analysis showed a VLJQL¿FDQWGLIIHUHQFHIRUWKHSUHYDOHQFHRIVXEQRUPDO77)7DQG'+($6 in the different age groups according to table 2. Proportions followed by GLIIHUHQWVPDOOOHWWHUVGLIIHUVLJQL¿FDQWO\ S Table 1. Median (25% - 75%) values of TT, FT and DHEA-S by age range Age range (y) TT (nd/dL) FT (pg/mL) DHEA-S (ng/dL) 15 - 20 669 (553 - 743) 24.4 (18.6 - 28.5) 236 (181 - 317) 21 - 30 551 (445 - 652) 20.1 (17.2 - 25.6) 199 (175 - 296) 31 - 40 451 (325 - 656) 17.8 (14.6 - 23.0 ) 204 ( 159 - 254) 41 - 50 441 (314 - 563) 15.9 (12.3 - 19.8) 143 ( 97 - 221) 51 - 60 408 (300 -541) 15.0 (11.1 - 18.6) 107 (69 - 176) 61 - 70 397 (287 - 512) 14.1 (9.7 - 16.9) 86 (53 - 121) 71 - 80 391 ( 267 - 537) 13.2 (9.7 - 15.8) 72 (43 - 109) 81 - 90 261 (132 - 496) 11.4 (9.0 - 16.5) 50 (30 - 96) Table 2. Prevalence of subnormal values of TT, FT and DHEA-S by age range (percentage) Age Range (y) 77QJG/ )7SJP/ '+($6QJP/ 0.0 a 0.0 a 15 - 20 0.0 a 21 - 30 7.7 a 0.0 a 5.0 a 31 - 40 17.2 ab 17,6 a 4.1 a 41 - 50 22.5 abc 25.8 a 15.8 b bc b 51 - 60 24.8 32.9 31.4 c cd c 61 - 70 28.2 40.2 44.8 d 71 - 80 34.0 d 45.2 c 51.9 d 81 - 90 60.0 e 57.9 c 65.0 d
CONCLUSIONS: Prevalence of subnormal androgen serum levels in males progressively increases with age. Source of Funding: None
869 IS PSA INFLUENCED BY TESTOSTERONE LEVELS IN AGING MEN? Leonard S Marks*, Claus G Roehrborn, Michael Marberger, Timothy H Wilson, Roger S Rittmaster. Culver City, CA, Dallas, TX, Vienna, Austria, and Research Triangle Park, NC. INTRODUCTION AND OBJECTIVE: PSA is androgenregulated. At puberty, the rise in PSA associated with prostate growth closely parallels the rise in serum testosterone (T). However, in men at PLGOLIHWKHUHODWLRQVKLSRIVHUXP7WR36$OHYHOVKDVQRWEHHQFODUL¿HG We examined that association in a large clinical-trial data set, where T was an independent variable. METHODS: Baseline data of all men from dutasteride Phase 3 BPH trials and the REDUCE prostate cancer risk reduction trials were examined. Entry criteria included age >50 (both trials) and PSA >1.5 %3+WULDOV DQG36$! 5('8&( 7OHYHOPHDVXUHGE\5,$LQ all subjects, was not an entry criteria. Cancer was excluded clinically and by biopsy in Phase 3 men if PSA > 4.0 and in all REDUCE men. >90% of subjects were Caucasian. Baseline Measures Baseline measure, mean (range) Age, yr PSA, ng/ml Prostate Volume by TRUS, cc BMI, kg/m2 Testosterone, ng/dl
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301
with the other measures above as the independent variables, along with pairwise interactions between them. Baseline PV (p<0.0001), age (p<0.003) and BMI (p<0.001) were simultaneously related to PSA in both studies. However, T was not related to PSA after adjustments for PV, age, and BMI in Phase 3 (p=0.17) or in REDUCE (p=0.21). CONCLUSIONS: Less than 1% of variability in serum PSA levels between 1.5 and 10 ng/ml could be attributed to circulating testosterone concentrations in adult men participating in various prostate WULDOV DQG LQ D PXOWLYDULDWH DQDO\VLV 7 GLG QRW VLJQL¿FDQWO\ LQÀXHQFH PSA levels. In these men, the amount of androgenic stimulation of the prostate, as judged by PSA secretion, was similar over a wide range of circulating testosterone concentrations. These data support the concept that high intra-prostatic levels of 5a-reductase permit DHT accumulation and normal prostate function, even at low circulating T levels. Source of Funding: GlaxoSmithKline and Urological Sciences Research Foundation.
870 TESTOSTERONE TREATMENT IN HYPOGONADAL PATIENTS DOES NOT CAUSE HIGHER INCIDENCE OF PROSTATE CANCER Aksam A Yassin*, Farid Saad. Norderstedt-Hamburg, Germany, and Berlin, Germany. INTRODUCTION AND OBJECTIVE: To evaluate incidence or SUHYDOHQFHRISURVWDWHFDQFHULQSDWLHQWVZLWKWHVWRVWHURQHGH¿FLHQF\ with LOH (late onset hypogonadism) and ED (erectile dysfunction), receiving long-acting injectable testosterone undecanoate therapy in comparison with similar group of control population. 0(7+2'6 WHVWRVWHURQHGH¿FLHQWSDWLHQWVZLWKDYHUDJH age 56 +/- 2,1 years and mean follow-up of 24 months (11-36 months), received injectable TU 1000 mg (Nebido, Bayer-Schering, Berlin/ Germany) were compared with control cohort of 160 eugonadal (average age 58 +/- 1.6 years) population with similar characteristics visiting our clinic for preventive medical check up. They underwent monitoring protocol at baseline and 3-monthly including age, co-morbidities, FRQFRPLWDQWPHGLFDWLRQ,36636$'5(WRWDO3URVWDWHYROXPHDQG7= measured by TRUS and TRUS-guided biopsies when indicated by PSA velocity > 0.75 ug/L, or elevation over 4.0 ug/L. In all subjects in both groups, no abnormalities in rectal palpation were noticed so far. RESULTS: Initially hypogonadal patients showed at baseline lower PSA values and lower prostate volumes, 0.77 +/- 0.3 ug/L and 27.6 +/- 1.2 ml respectively. The control group subjects had PSA levels at 2.15 +/- 1,42 ug /L, and prostate volume 39.5 +/- 2.33 ml at baseline. Patients in group I (LOH/ED) whose PSA velocity in follow up was > 0,75 ug /L than at baseline, underwent TRUS-guided prostate BX, according to Hamburg’s protocol (10 cores 1.6cm each). We found CaP in 2/11 biopsies, both of them unilateral and 5% tumor cells in a core. Gleason score 3+2 and 3+3 respectively. One more patient had a high grade PIN. In group IUI with 160 control subjects, 5 subjects (5/12) showed CaP, RIWKHPELODWHUDOZLWKDVLJQL¿FDQWO\KLJKHU*OHDVRQVFRUHRIWLOO 4+4 and till 75% tumor cells in a core. CONCLUSIONS: 1) Subjects with T-deficiency have primarily lower prostate volume than eugonadal ones. 2) Subjects with 7GH¿FLHQF\ KDYH SULPDULO\ ORZHU 36$ OHYHOV WKDQ HXJRQDGDO RQHV 3) Indicated Testosterone supplementation does not increase CaP incidences. 4) Smaller tumors and less malignancy (better differentiation) is more evident in group under testosterone treatment Source of Funding: None
Phase 3 BPH Trials N=4259
REDUCE Trial N=8103
66.3 (50-94) 4.0 (1.5-10)
62.8 (48-77) 5.9 (2.5-10)
54.6 (30-274)
44.6 (10-80)
27.5 (17.7-56.3) 400 (39-2940)
27.4 (10.4-73.5) 453 (29-3190)
RESULTS: Using PSA as the dependent variable, correlation with other relevant variables was as follows: Age, r=0.11 (p<0.001 in both WULDOV 39U LQ3KDVHLQ5('8&( S LQERWKWULDOV %0,U LQ3KDVHLQ5('8&( S LQERWKWULDOV DQG Testosterone, r=0.03 in Phase 3 and r=0.025 in REDUCE (p<0.05 in both trials). A multivariate regression using logarithmic transformations was performed in each study with PSA as the dependent variable and
871 SEVERITY OF TYPE 2 DIABETES AND ERECTILE DYSFUNCTION: THE TRANSLATING RESEARCH INTO ACTION IN DIABETES (TRIAD) STUDY Aruna V Sarma*, Hunter Wessells, William Herman. Ann Arbor, MI, and Seattle, WA. INTRODUCTION AND OBJECTIVE: An estimated 10-15 million men in the United States have erectile dysfunction (ED) with the prevalence of ED in men with diabetes to be approximately between 35 and 75%. Diabetes accounts for 30% of ED and in fact, has been described to be a primary presenting symptom of diabetes. Although the prevalence of ED in men with diabetes has been well established,
302
THE JOURNAL OF UROLOGY®
the association between ED and the severity, duration and control of diabetes has not been clearly elucidated. METHODS: 634 men with type 2 diabetes (DM) who participated in the University of Michigan, Translating Research into Action in Diabetes (TRIAD) study provided information on erectile dysfunction using the validated single item question assessing the ability to maintain an erection satisfactory for sexual intercourse. Measures of diabetes severity including duration of disease, glycemic control, mode of therapy and presence of diabetic complications were examined by PRGHUDWHVHYHUH (' VWDWXV GH¿QHG DV µVRPHWLPHV¶ RU µQHYHU¶ EHLQJ DEOH WR PDLQWDLQ DQ HUHFWLRQ IRU VH[XDO LQWHUFRXUVH YV µXVXDOO\¶ DQG µDOZD\V¶ RESULTS: Among this population of men with type 2 diabetes, 53.2% (n=332) reported moderate/severe erectile dysfunction. Duration of diabetes >5 years increased risk of moderate/severe ED 1.6 fold after DGMXVWPHQWIRUDJH3RRUJO\FHPLFFRQWUROZDVVLJQL¿FDQWO\DVVRFLDWHG ED as was the use of insulin. Other characteristics associated with an increased risk of ED included report of neuropathy, retinopathy, and QHSKURSDWK\7KHVHDVVRFLDWLRQVZHUHQRWPRGL¿HGE\ERG\PDVVLQGH[ cardiovascular disease or lower urinary tract symptom severity. CONCLUSIONS: Several measures of the severity of diabetes including duration of disease, glycemic control, mode of therapy and SUHVHQFHRIFRPSOLFDWLRQVZHUHVLJQL¿FDQWO\DVVRFLDWHGZLWKLQFUHDVHG ULVNRISUHYDOHQW('7KHVH¿QGLQJVSURYLGHIXUWKHUVXSSRUWIRUHDUO\ implementation of tight glycemic control and monitoring and prevention of complications in men with type 2 diabetes. Associations between Measures of DM Severity and ED 'XUDWLRQRI'0 !YV\HDUV 1.63 (1.12, 2.39) *O\FHPLF&RQWURO +$FYV 2.14 (1.35, 3.41) Insulin Use (yes vs. no) 1.87 (1.29, 2.71) Retinopathy (yes vs. no) 1.54 (0.97, 2.42) Nueropathy (yes vs. no) 3.08 (1.88, 5.06) Nephropathy (yes vs. no) 2.09 (1.20, 3.64)
Source of Funding: U-48-CCU916373.
872 COLOR DOPPLER ULTRASOUND HEMODYNAMIC CHARACTERISTICS OF PRIAPISM PATIENTS BEFORE AND AFTER THERAPY AND ITS IMPACT ON SUBSEQUENT MANAGEMENT Rei K Chiou*, Himanshu Aggarwal, Fleur Broughton, Christopher R Chiou, Susan Liu. Omaha, NE. INTRODUCTION AND OBJECTIVE: Information in the literature on the hemodynamic of priapism after aspiration or surgical VKXQWWUHDWPHQWLVYHU\OLPLWHG:HDQDO\]HRXUFRORU'RSSOHU8OWUDVRXQG (CDU) studies performed for priapism patients at various stages of management. METHODS: We reviewed 50 CDU studies and medical records in 24 patients with priapism from 1997 to 2007 before and after treatment. Age: 15 to 70 years. Duration of priapism: 4 hours to 10 days. 26 CDU studies were performed when patients presented to our institution (1 patient had recurrent episodes). 6 CDU studies were performed after aspiration and intracavernosal pharmacological therapy. 9 patients had failed previous shunt surgeries by other urologists including cavernosoglandular shunts in 8 patients and both cavernoso-glandular and cavernoso-spongiosal (Quakle) shunt in 1 patient. We performed total 15 penile cavernosa-dorsal vein (CD) shunts in these and other patients. 18 CDU studies were performed after CD shunt surgeries. RESULTS: Priapism of short duration showed varied arteriogenic and venoocclusive components. Priapism >24 hours typically showed ischemic pattern with little or undetectable cavernosal DUWHULDO ÀRZ$IWHU D VXFFHVVIXO SHQLOH VKXQW VXUJHU\ WKH FDYHUQRVDO DUWHULDO ÀRZ XVXDOO\ FRQYHUWHG IURP WKH LVFKHPLF FKDUDFWHULVWLFV WR QRUPDORUKLJKÀRZVWDWXV3DWLHQWVZKRZHUHUHIHUUHGWRXVDIWHUIDLOLQJ previous shunt surgeries showed ischemic characteristics indicating that shunts performed had not relieved veno-occlusive pathophysiology. After we performed penile CD shunts, we observed increase of cavernosal DUWHULDOÀRZ RUÀRZEHFRPHGHWHFWDEOH LQRISDWLHQWVVWXGLHG,Q SDWLHQWVWKHDUWHULDOÀRZUHPDLQHGXQGHWHFWDEOH,QPRVWSDWLHQWVWKH patency of CD shunt was observed in CDU studies. Some patients who FOLQLFDOO\DSSHDUHGWRKDYHSHUVLVWHQWSULDSLVPKDG&'8VWXGLHV¿QGLQJV
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
RI KLJK ÀRZ DQG SDWHQW VKXQW LQGLFDWLQJ SRVWLVFKHPLF K\SHUHPLD In one patient who failed Winter shunt and Quakle shunt previously, &'8VKRZHGXQGHWHFWDEOHEORRGÀRZDWWKHWLPHRISUHVHQWDWLRQ:H performed penile CD shunt and his CDU study showed high cavernosal EORRGÀRZDIWHUVXUJHU\ CONCLUSIONS: CDU study is important in the assessment of priapism treatment and helps the decision for subsequent management. CDU studies should be performed for patients who appear to have persistent priapism after therapy to evaluate for post-ischemic hyperemia vs shunt failure to decide further management. Source of Funding: None
873 ACCURACY OF MRI IN THE DIAGNOSIS OF ISCHAEMIC PRIAPISM Nigel C Borley*, Clare Allen, David Ralph. London, United Kingdom. INTRODUCTION AND OBJECTIVE: Ischaemic priapism is a urological emergency. Within 24 hours, the cavernosal smooth muscle XQGHUJRHVLVFKDHPLFQHFURVLVOHDGLQJWRLUUHYHUVLEOHFRUSRUDO¿EURVLV and erectile dysfunction. Once simple measures such as aspiration and LQVWLOODWLRQRIDQĮDGUHQHUJLFDJHQWKDYHIDLOHGSDWLHQWVUHTXLUHFRUSRUDO washout +/- prosthesis insertion based on cavernosal smooth muscle viability. To help with preoperative assessment and patient counselling, MRI was used to try to determine the viability of cavernosal smooth muscle in prolonged ischaemic priapism by comparing a pre-operative non-invasive technique (MRI) with conventional biopsy at the time of surgery. METHODS: 17 men with a history of priapism lasting longer than 12 hours that had been documented as ischaemic as by blood gas analysis were included. All had received non-surgical interventions to aid relief of the priapism. They underwent a Doppler ultrasound and high resolution multiplanar MRI with gadolinium enhanced sequences. The MRI was reported independently by a radiologist, and if indicated SDWLHQWVZHQWRQWRFRUSRUDOZDVKRXWDQGELRSV\+LVWRORJ\¿QGLQJV ZHUHFRPSDUHGWR05,¿QGLQJV RESULTS: 10 patients had necrosis of corporal tissue shown on MRI and went on to corporal wash out and biopsy. 5 patients had YLDEOHWLVVXHVKRZQRQ05,RUVRPHÀRZRQ'RSSOHUXOWUDVRXQGDQG did not go on to corporal biopsy. 1 patient had viable tissue on MRI but went on to biopsy at the time of implantation of penile prosthesis for stuttering priapism. 1 patient had non-viable tissue secondary WR PDOLJQDQW LQ¿OWUDWLRQ RQ 05, DQG RSWHG QRW IRU ELRSV\7KHUH ZDV complete correlation in viability of tissues on histology compared to 05,¿QGLQJVLQWKHDSSOLFDEOHSDWLHQWV7KLVLQFOXGHGSDWLHQWZKHUH MRI correctly distinguished between viable proximal and non-viable distal tissue. &21&/86,216 7KLVVWXG\VKRZVDKLJK VSHFL¿FLW\ for MRI in determining the viability of corporal tissue after ischaemic priapism as determined by histology.MRI allows the clinician to discuss with the patient pre-operatively the need for prosthesis insertion (or shunt procedure) dependant upon the viability of cavernosal smooth muscle as determined by its MRI appearance. Source of Funding: None
874 THE RELATIONSHIP BETWEEN PREMATURE EJACULATION AND HYPERTHYROIDISM $KPHW&LKDQ2PHU'HPLU7HY¿N'HPLU*XYHQ$VODQ$EGXUUDKPDQ Comlekci, Ahmet A Esen*. Izmir, Turkey. INTRODUCTION AND OBJECTIVE: The aim of the study was to determine ejaculatory latency time alterations in patients with hyperthyroidism before and after the treatment. METHODS: Between January 2004 and June 2007 a total of 43 patients with hyperthyroidism who have not any treatment history were enrolled to study. After detailed sexual anamnesis, international index of erectile function (IIEF) questionnaire and self reported outcome 652 PHDVXUHVRIWKHVXEMHFWVDERXWKDYLQJGLI¿FXOW\WRFRQWURORYHU ejaculation during intercourse were asked. Stop-watch measurements of intra-vaginal ejaculation latency time (IELT) were performed. Patients ZKRKDYH,(/7RIOHVVWKDQVHFRQGVZHUHDFFHSWHGDVGH¿QLWH3(