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Biomedical subjects

David Ralph

Publications and source records attributed to David Ralph.

At least 19 recordsLinked to original sources
PubMed2007

Vertical rectus abdominis flap reconstruction in patients with advanced penile squamous cell carcinoma.

OBJECTIVES: To evaluate the role of radical surgical debridement and excision with a vertical rectus abdominis myocutaneous (VRAM) flap reconstruction in patients with advanced penile cancer and subcutaneous metastatic disease, as the quality of life in such patients is extremely poor, multimodal treatments often fail and the outlook for the patient is limited with the development of uncontrollable disease. PATIENTS AND METHODS: Four patients with advanced penile cancer presenting with fungating, cutaneous tumour deposits received palliative surgical resections for abdominal and inguinal disease. A VRAM flap was used in all cases to achieve tissue coverage. RESULTS: All grafts were viable and the mean inpatient stay was 14 days. There were no immediate complications after surgery; patient satisfaction and symptom relief was excellent. CONCLUSIONS: Aggressive palliative resection with a VRAM can dramatically improve the patients' quality of life in advanced penile cancer, permitting disease control with satisfactory cosmesis. However, a multidisciplinary approach involving both the urological reconstructive and plastic surgeon is essential.

Adult↗
PubMed2006

The role of magnetic resonance imaging in the local staging of penile cancer.

OBJECTIVES: To assess the accuracy of magnetic resonance imaging (MRI) as a local staging technique in penile cancer and its role in selecting patients for conservative surgical management. METHODS: Fifty-five men diagnosed with invasive penile carcinoma on biopsy were locally staged with the use of MRI. Prostaglandin E1 (alprostadil) was injected into the corpora to induce an artificial erection. Radiologic staging was compared against final histopathologic stage of the tumour. Sensitivity, specificity, and kappa agreement values were calculated for each tumour stage. Additionally, corpora cavernosa involvement was reviewed in 20 consecutive cases and suitability for conservative surgery assessed. RESULTS: A good correlation between radiologic and histologic staging was achieved with an overall kappa value of 0.75 (p<0.001). Stage-specific sensitivities and specificities were calculated: T1 (85%; 83%), T2 (75%; 89%), and T3 (88%; 98%). MRI accurately predicted corpora cavernosa invasion in all cases of pathologically proven disease. These patients were selected to undergo partial penectomy. There were no complications using this imaging technique. CONCLUSIONS: This study demonstrates that penile MRI is highly accurate in the local staging of penile cancer. Associated improvements in surgical planning allow the provision of conservative surgical treatments over more radical procedures.

Adult↗
PubMed2006

Evaluation of the efficacy and safety of once-a-day dosing of tadalafil 5mg and 10mg in the treatment of erectile dysfunction: results of a multicenter, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Erectile dysfunction (ED) is a chronic disease; however, therapy is currently administered as needed with oral phosphodiesterase 5 (PDE5) inhibitors like tadalafil. Because the 17.5-h half-life of tadalafil enables therapeutic plasma levels to be sustained with daily administration, tadalafil is a good candidate for once daily dosing therapy. METHODS: This multicenter, randomized, double-blind, placebo-controlled, parallel-group, 12-week study enrolled 268 men 1:2:2 to placebo, tadalafil 5mg, and tadalafil 10mg taken once daily. Primary efficacy measures included changes in the International Index of Erectile Function Erectile Function domain (IIEF EF), Sexual Encounter Profile diary Questions 2 (SEP2: successful penetration), and 3 (SEP3: successful completion of intercourse), and tolerability. Secondary measures included percentage of patients at endpoint who reported improved erectile function (EF), and percentage who reported "no ED" (IIEF EF score 26-30). RESULTS: For patients who took placebo, tadalafil 5mg, and tadalafil 10mg, changes from baseline to endpoint were, respectively, 0.9, 9.7, and 9.4 for IIEF EF; 11.2, 36.5, and 39.4 for SEP2; and 13.2, 45.5, and 50.1 for SEP3. At endpoint, 28.3%, 84.5%, and 84.6% reported improved erections, and 8.3%, 51.5%, and 50.5% reported "no ED," respectively. All comparisons between tadalafil and placebo were significant (p<0.001). Adverse events that occurred in at least 5% of patients were dyspepsia, headache, back pain, upper abdominal pain, and myalgia; nine patients (3.4%) discontinued because of adverse events. CONCLUSIONS: Once-a-day tadalafil 5mg or 10mg was well tolerated and significantly improved EF in men with ED.

Adult↗
PubMed2006

An audit of implanted penile prostheses in the UK.

OBJECTIVE: To assess whether the outcome of implanting penile prostheses is related to the number of prostheses implanted by surgeons, as several reports showed that the outcome of a urological procedure is directly related to the experience of the surgeon. METHODS: We conducted a retrospective audit of 413 penile prostheses implanted over a 2-year period in the UK by 76 surgeons. RESULTS: About 80% of the surgeons implanted only one or two prostheses per year, usually of the malleable type, and usually on patients in the private sector. Only four surgeons implanted >20 prostheses per year. The overall revision rate for implantation in the UK, at 24%, is far higher than the worldwide average. CONCLUSIONS: Guidelines are needed on the number of prostheses a surgeon should implant per year so that revision rates will decline to more acceptable levels and patients will be offered a genuine choice of product.

Erectile Dysfunction↗
PubMed2006

Recurrent arteriovenous malformation of the scrotum secondary to pelvic trauma.

We describe a case of recurrent scrotal arteriovenous malformation (AVM) in a young man secondary to pelvic fracture sustained during a road traffic accident. This was diagnosed as a lipoma on the ultrasound and clinical examination. To our knowledge, this is the first reported case of recurrent scrotal AVM secondary to trauma.

Accidents, Traffic↗
PubMed2005

Proposals or findings for a new approach about how to define and diagnose premature ejaculation.

PURPOSE: To review and present the proposals or findings for a new approach about how to define and diagnose premature ejaculation (PE). MATERIALS AND METHODS: Using Medline to search for international peer reviewed manuscripts published from 1996 to 2004 about the definition and diagnosis of PE. RESULTS: PE, to date, has not a universally agreed definition and diagnostic criterion. Many definitions are partial, subjective and nonspecific. An ideal definition or diagnostic criterion should consist of intravaginal ejaculatory latency time (IELT), the ability to control over ejaculation, the extent of male sexual satisfaction, the extent of female sexual satisfaction, the frequency of female sexual partner reaching orgasm and the extent of psychological and pathological factors. Therefore, the Chinese Index of Premature Ejaculation (CIPE) seems an ideal tool and criterion used to diagnose PE due to including all the elements above. In the majority of cases, PE is the result of a mix of psychogenic, physiological and organic factors. So, besides some routine tests such as urine routine test, endocrine hormone assay, psychosexual counseling, couple evaluation and physical examination, prostate examination, serum leptin assay, semen magnesium assessment and glans hypersensitivity measurement, are suggested to be performed in the diagnosis of PE. Although elucidated by two clinical trials and further confirmed, serum leptin assay seems a promising and objective marker to diagnose PE because it is related to the serotonergic system whose disorder has been confirmed to contribute to the etiology of PE. CONCLUSION: None of these definitions and diagnoses has been accepted as a universal agreement of PE. CIPE seems an ideal tool and criterion used to diagnose PE and leptin maybe become a promising and objective marker for PE.

Ejaculation↗
PubMed2005

Premature ejaculation: the current literature.

PURPOSE OF REVIEW: The recent increase in research with regard to premature ejaculation has led to a significant number of new papers looking at the diagnosis, definition, aetiology and management of this condition. RECENT FINDINGS: The intravaginal ejaculatory latency time remains the primary measure of ejaculatory time although increasing bother and distress require assessment and establishment of quantifiable measures. Biological and psychogenic causes contribute to a multifactorial model of premature ejaculation with some neurobiological vulnerability. The principal treatments are selective serotonin reuptake inhibitors and behavioural cognitive interventions. New treatment interventions are under investigation. SUMMARY: A number of guideline papers confirm that a primary sexual history and a multimodel treatment approach provide the best approach to patients with this common condition.

Adult↗
PubMed2005

The results of plaque incision and venous grafting (Lue procedure) to correct the penile deformity of Peyronie's disease.

OBJECTIVE: To assess plaque incision and venous grafting (the Lue procedure) to correct the deformity associated with Peyronie's disease and to maintain penile length, evaluating the results over an 8-year period. PATIENTS AND METHODS: The penile deformity of 113 patients (mean age 45 years, range 17-71) with Peyronie's disease was corrected by plaque incision and saphenous vein grafting. All patients had stable Peyronie's disease and had a mean (range) penile deformity of 64.5 (20-180) degrees; the mean follow-up was 12 months. RESULTS: The result was excellent or satisfactory in 105 patients (93%), and the penis completely straightened in 97 (86%). Erectile dysfunction after surgery developed in 10 of 68 potent patients (15%) although they had arterial risk factors of diabetes, hypertension or cardiac disease that may also have contributed. There was penile shortening of > 1 cm in 29 men (25%) but this only prevented intercourse in two. Of the 51 patients with > or = 5 years of follow-up, the penis remained completely straight in 80% but the incidence of erectile dysfunction increased to 22.5% and penile shortening of > 1 cm to 35%. CONCLUSION: The Lue procedure is an effective long-term option in the surgical management of Peyronie's disease, but penile shortening after surgery remains a risk, and patients with vascular risk factors must be warned of the possibility of later erectile dysfunction.

Adolescent↗
PubMed2005

What surgical resection margins are required to achieve oncological control in men with primary penile cancer?

OBJECTIVE: To evaluate the surgical excision margin required for local oncological control in primary penile cancers, as patients with penile cancer who undergo radical amputation suffer marked psychological, functional and cosmetic sequelae, and although organ-sparing surgery has improved the quality of life of these men, the optimum surgical excision margin to achieve oncological control is unknown. PATIENTS AND METHODS: In all, 51 patients (mean age 61 years) diagnosed with squamous cell carcinoma of the penis between May 2000 and December 2004 were selected for treatment with conservative surgical techniques. All patients were staged before surgery using magnetic resonance imaging. Histopathological features of the tumours, including type, grade, stage and distance from the surgical excision margin, were evaluated. All patients were followed in the outpatient department according to European Association of Urology guidelines. RESULTS: The median (range) follow-up of the men was 26 (2-55) months. Patients were treated by wide localized excision (nine), glans excision (26) and partial penectomy (16). The histopathological review included the analysis of 102 surgical margins (deep and skin) with 49 (48%) measured within 10 mm of the tumour edge and 92 (90%) within a <20-mm resection margin. Three patients (6%) had tumour involvement at the surgical margin and had further surgery. During follow-up two patients (4%) developed local tumour recurrence and were treated successfully with partial penectomy. CONCLUSION: A traditional 2-cm excision margin is unnecessary for treating squamous cell carcinoma of the penis. Conservative techniques, involving excision margins of only a few millimetres, appear to offer excellent oncological control.

Adult↗
PubMed2005

An open-label, multicentre, randomized, crossover study comparing sildenafil citrate and tadalafil for treating erectile dysfunction in men naïve to phosphodiesterase 5 inhibitor therapy.

OBJECTIVES: To compare treatment preference, efficacy, and tolerability of sildenafil citrate (sildenafil) and tadalafil for treating erectile dysfunction (ED) in men naïve to phosphodiesterase 5 (PDE5) inhibitor therapy. PATIENTS AND METHODS: This was an open-label, crossover study of sildenafil and tadalafil (taken as needed). After a 4-week baseline assessment, 367 men with ED (mean age 54 years) were randomized to receive sildenafil for 12 weeks followed by tadalafil for 12 weeks or vice versa (8-week dose optimization and 4-week assessment phases). During dose optimization, patients started taking 25- or 50-mg sildenafil or 10-mg tadalafil and could titrate to find their optimum dose (25-, 50- or 100-mg sildenafil; 10- or 20-mg tadalafil). After completing both 12-week periods, patients chose which treatment to continue during an 8-week extension. Efficacy was measured with the International Index of Erectile Function (IIEF) and Sexual Encounter Profile (SEP) diary. RESULTS: Of the 291 men who completed both treatments, 85 (29%) chose sildenafil and 206 (71%) chose tadalafil (P < 0.001) for the 8-week extension. The IIEF erectile function domain scores were 14.2 at baseline, 23.9 at endpoint on sildenafil, and 24.3 at endpoint on tadalafil (P = 0.08, sildenafil vs tadalafil). The mean per patient percentage success scores for SEP2 (penetration) were: baseline (46%), sildenafil (post-baseline 82%) and tadalafil (post-baseline 85%; P = 0.06, sildenafil vs tadalafil), and for SEP3 (successful intercourse) were: baseline (19%), sildenafil (post-baseline 72%), and tadalafil (post-baseline 77%; P = 0.003, sildenafil vs tadalafil). The only treatment-emergent adverse events that were reported by >5% of men were headache and flushing. CONCLUSIONS: In men with ED who were naïve to PDE5 inhibitor therapy, sildenafil and tadalafil were both effective and well tolerated. After treatment with sildenafil and tadalafil, 29% of men chose sildenafil and 71% chose tadalafil for ED therapy during an 8-week extension.

Adolescent↗
PubMed2004

Peyronie's disease.

INTRODUCTION: Peyronie's disease is a sexual medicine condition that may adversely affect male sexual function. AIM: To provide expert opinions/recommendations concerning state-of-the-art knowledge for the pathophysiology, diagnosis and treatment of Peyronie's disease. METHODS: An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a scientific and debate process. Concerning the Peyronnie's disease committee, there were 10 experts from six countries. MAIN OUTCOME MEASURE: Expert opinions/recommendations are based on grading of evidence-based medical literature, extensive internal committee discussion over 2 years, public presentation and deliberation. RESULTS: Peyronie's disease is characterized by an inflammatory response beneath the tunica albuginea with fibroblast proliferation forming a thickened fibrous plaque that may cause penile pain, penile curvature and erectile dysfunction. Medical treatments have been described but few prospective controlled trials have revealed significant clinical benefits. Surgical treatments (penile plication, Nesbit excision, plaque incision and grafting and penile prosthesis insertion) should be considered after Peyronie's disease has stabilized. Surgical outcome studies reveal that a stable deformity is best corrected with the least postoperative ED by a Nesbit procedure. Plaque incision and grafting should be reserved for men with good erectile function and marked penile shortening although there is a higher prevalence of postoperative ED. Implantation of a penile prosthesis is an excellent option for men with an accompanying erectile deficit. CONCLUSIONS: Safe and effective treatments for Peyronie's disease examined by prospective, placebo-controlled, multi-institutional clinical trials are needed.

Consensus↗
PubMed2004

Priapism.

INTRODUCTION: There are three different types of priapism: low-flow, ischemic, anoxic or veno-occlusive priapism; high-flow, arterial or nonischemic priapism; and recurrent or stuttering priapism. AIM: To provide recommendations/guidelines concerning state-of-the-art knowledge for the diagnosis and treatment of priapism. METHODS: An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Priapism Committee, there were 10 experts from six countries. MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. RESULTS: Concerning ischemic priapism, persistent cavernous smooth muscle relaxation and failure of contraction is a compartment syndrome with increasing intracavernosal anoxia, rising pCO2 and acidosis. Urgent medical attention should be sought for an erection lasting >4 hours; 90% with priapism >24 hours develop complete erectile dysfunction. After diagnosis and counselling, intracavernosal aspiration and alpha-blockers should precede surgical shunting. Concerning high-flow priapism (congenital, traumatic or iatrogenic), intervention is not urgent and often unnecessary. Definitive management is by selective embolization with autologous blood clot. Concerning recurrent/stuttering priapism, the pathophysiology may be central or local (sickle cell disease). Management needs to be individualized; androgen deprivation has proved useful but has adverse effects. CONCLUSIONS: There is need for prospective, clinical trials to define safe and effective management strategies for patients with low-flow, high-flow or recurrent priapism.

Consensus↗
PubMed2003

Cytogenetic and Y chromosome microdeletion screening of a random group of infertile males.

OBJECTIVE: To assess whether to perform routine cytogenetic and Y chromosome microdeletion screening on all infertile male patients. DESIGN: A cytogenetic and Y microdeletion study of a random group of infertile men. SETTING: University department. PATIENT(S): In total, 40 patients had azoospermia (21 nonidiopathic), 27 had severe oligozoospermia/oligoasthenozoospermia (<or=5 x 10(6)/mL) (5 nonidiopathic), 20 had oligozoospermia/oligoasthenozoospermia (5-20 x 10(6)/mL) (6 nonidiopathic), and 16 had asthenozoospermia (5 nonidiopathic). Many were candidates for intracytoplasmic sperm injection (ICSI). INTERVENTION(S): Collection of blood samples from all patients and buccal cells from one patient. MAIN OUTCOME MEASURE(S): Karyotype analysis, polymerase chain reaction (PCR) screening for Y chromosome microdeletions, and fluorescence in situ hybridization of abnormal chromosomes. RESULT(S): Ten (9.7%) subjects, including one nonidiopathic patient, were found to have an abnormal karyotype. Two idiopathic azoospermic patients were missing large portions of Y chromosome euchromatin, confirmed by PCR analysis and an additional idiopathic azoospermic patient had a Y chromosome microdeletion. CONCLUSION(S): Routine cytogenetic analysis of all infertile male patients is required but it may be advisable to limit routine Y chromosome microdeletion screening to patients with severe male factor infertility (<or=5 x 10(6)/mL).

Chromosome Deletion↗
PubMed2002

Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension.

OBJECTIVES: The aim of this study was to evaluate the relationships between echocardiographic findings and clinical outcomes in patients with severe primary pulmonary hypertension (PPH). BACKGROUND: Primary pulmonary hypertension is associated with abnormalities of right heart structure and function that contribute to the poor prognosis of the disease. Echocardiographic abnormalities associated with PPH have been described, but the prognostic significance of these findings remains poorly characterized. METHODS: Echocardiographic studies, invasive hemodynamic measurements and 6-min walk tests were performed and outcomes prospectively followed in 81 patients with severe PPH. Subjects were participants in a 12-week randomized trial examining the effects of prostacyclin plus conventional therapy compared with conventional therapy alone. RESULTS: During the mean follow-up period of 36.9 +/- 15.4 months, 20 patients died and 21 patients underwent transplantation. Pericardial effusion (p = 0.003) and indexed right atrial area (p = 0.005) were predictors of mortality. Pericardial effusion (p = 0.017), indexed right atrial area (p = 0.012) and the degree of septal shift in diastole (p = 0.004) were predictors of a composite end point of death or transplantation. In multivariable analyses incorporating clinical, hemodynamic and echocardiographic variables, pericardial effusion and an enlarged right atrium remained predictors of adverse outcomes. Six-minute walk results, mixed venous oxygen saturation and initial treatment randomization were also independently associated with a poor prognosis. CONCLUSIONS: Pericardial effusion, right atrial enlargement and septal displacement are echocardiographic abnormalities that reflect the severity of right heart failure and predict adverse outcomes in patients with severe PPH. These characteristics may help identify patients appropriate for more intensive medical therapy or earlier transplantation.

Adult↗