Relief Of Outflow Obstruction Research Articles

Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020)

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/ProcedureCoding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM+MVR versus SM+MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM+MVR was seen in 3,101 (18.4%), and SM+MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p=0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p=0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p=0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p=0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Changes in the rat urinary bladder after the relief of outflow obstruction – tracing targets for treatment of persistent symptoms in patients

Studies on patients with bladder outflow obstruction who have undergone surgery for benign prostatic hyperplasia, successfully relieving the obstruction, have revealed a persistence of storage symptoms associated with detrusor overactivity (DO) in 20% to 40% of patients. To study the underlying mechanisms, we have used a common rat model of obstruction/de-obstruction, assuming that non-voiding contractions can be used as a surrogate parameter for DO in humans. Using microarray analysis and electron microscopic images from obstructed and de-obstructed bladder tissue we have tried to identify changes that could serve as a basis for the search of new targets for drugs. Even if voiding function is rapidly normalized after release of outflow obstruction and many of the morphological changes are reversed, the microarray analysis revealed that the de-obstructed rat bladder has gene expressions, structural, and functional properties that make it distinctly different from both control and obstructed bladders. We suggest that whole bladder arrays can be used for identifying cellular mechanisms that could be targets for drugs meant for treatment of persistent DO and LUTS after de-obstruction. Based on available array information for some membrane receptors and morphologic structures with corresponding changes in bladder function, it seems worthwhile to re-assess the development potential for e.g., endothelin receptor antagonists, purinergic receptor antagonists and Rho-kinase inhibitors.

Indication for the endoscopic treatment of Zenker’s diverticula

: Zenker’s diverticulum (ZD) is a false pulsion diverticulum located in Killian’s triangle. It accounts for about 70% of all esophageal diverticula. ZD incidence is uncommon, and it is mostly present in the elderly population. Although the pathophysiology has not been completely elucidated, an impaired relaxation of the cricopharyngeal muscle (CPM) has been identified as the leading mechanism. For this reason, the current therapeutic modalities are based on CPM myotomy to eliminate diverticular bolus retention, improve bolus flow, relieve outflow obstruction, and mitigate neuromotor impairment. The conventional open approach through a left cervicotomy has been mostly replaced by transoral techniques using either rigid endoscopy or flexible endoscopes. The minimally invasiveness of these techniques allows for reinterventions in case of recurrence. Endoscopic techniques present several advantages in terms of lower risk of adverse events, can be accomplished without the need for general anesthesia and neck hyperextension, and provide for a rapid patient recovery. The recent introduction of cutting-edge technology Z-POEM allows through a direct septal visualization for a complete myotomy, leading to a lower recurrence rate and higher symptoms resolution than endoscopic septotomy. The potential advantages also account for lower complication rates making it a promising technique.

Heartbeat: time to treat the whole patient, not just the valve, when calcific aortic stenosis is present

A key consideration in timing of aortic valve replacement (AVR) for patients with aortic stenosis (AS) is whether there is an increased risk of sudden cardiac death (SCD) that might...

600.67 Changes in Left Ventricular Mass, Volume, and Function After Successful Alcohol Septal Ablation (ASA) in Hypertrophic Obstructive Cardiomyopathy (HOCM)

Alcohol septal ablation (ASA) produces a targeted infarction of the septum, thereby relieving the outflow obstruction in hypertrophic obstructive cardiomyopathy (HOCM). There are several changes in the left ventricle with the relief of outflow obstruction. We sought to determine the medium-term

Abstract 21016: Left Atrial Dysfunction Persists After Transapical but Not Transfemoral Transcatheter Aortic Valve Replacement and is Associated With Worse Outcomes

Introduction and Aims of The Study: The relief of outflow obstruction after transcatheter aortic valve replacement (TAVR) is expected to improve cardiac output, LV systolic and diastolic function and to regress left ventricular (LV) mass. The impact of these changes on left atrial (LA) reservoir, conduit and contractile function remains unknown. Our aims were to compare LA functions in patients with transfemoral (TF) vs transapical (TA) TAVR and test whether they have an impact on patient outcomes. Methods: Retrospective analysis of LA deformation by speckle tracking strain echocardiography in 54 patients with TA TAVR and 54 TF TAVR, matched for age, sex and STS score. Measurements were performed pre TAVR and 1 month and 1 year post TAVR. Follow up data was available up to 5 years. Results: At baseline, there were no significant differences between the TF and TA groups with regard to patient age (81 ± 8 vs 82 ± 8 years), male gender (44% vs. 44%) or STS score (8.3 ± 4.4 vs 9.7 ± 4.5, respectively). LV filling pressures (E/e’) at baseline and 1 month were higher in TA vs. TF group (see table). LV global longitudinal strain (GLS) were similar at baseline and improved at 1 month only in the TF group (p=0.0001), while in the TA group it showed an improvement only at 1 year. LA reservoir, conduit and contractile functions improved within 1 month post TAVR in the TF group. In contrast, despite similar baseline LA functions in both groups, no improvement was observed in the TA group (see Table). At Cox proportional hazard analysis, lower LA reservoir function predicted major adverse events (death, cardiac rehospitalization or stroke) even after adjusting for age, gender and group allocation (p=0.034; risk ratio per unit decrease in LA function 1.04). Conclusion: These findings suggest that patients with TA TAVR have poor (if any) recovery of LA functions post TAVR. Presence of a stiff LA, best reflected by a persistently reduced LA reservoir strain, may contribute to the excess morbidity seen in TA patients.

Transaortic Chordal Cutting: Mitral Valve Repair for Obstructive Hypertrophic Cardiomyopathy With Mild Septal Hypertrophy

BackgroundIn severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM) and mild septal hypertrophy, mitral valve (MV) abnormalities may play an important role in MV displacement into the left ventricular (LV) outflow tract. Therefore, isolated myectomy may not relieve outflow obstruction and symptoms, and MV replacement is often the surgical alternative. ObjectivesThis study sought to assess the clinical and hemodynamic results of cutting thickened secondary MV chordae combined with a shallow septal muscular resection in severely symptomatic patients with obstructive HCM and mild septal hypertrophy. MethodsClinical features were compared before surgery and at most recent clinical evaluation in 39 consecutive patients with obstructive HCM. ResultsOver a 23 ± 2 months follow-up, New York Heart Association functional class decreased from 2.9 ± 0.5 pre-operatively to 1.1 ± 1.1 post-operatively (p < 0.001), with no patient in class III at most recent evaluation. The resting outflow gradient decreased from 82 ± 43 mm Hg to 9 ± 5 mm Hg (p < 0.001) and septal thickness decreased from 17 ± 1 mm to 14 ± 2 mm (p < 0.001). No patient had MV prolapse or flail and 1 had residual moderate-to-severe MV regurgitation at most recent evaluation. MV geometry before and after surgery was compared with that of 25 consecutive patients with similar clinical profile and septal thickness that underwent isolated myectomy. After adjustment for differences in pre-operative values between the groups, the post-operative anterior MV leaflet-annulus ratio was 17% greater and tenting area 24% smaller in patients with chordal cutting, indicating that MV apparatus had moved to a more normal posterior position within the LV cavity, preventing MV systolic displacement into the outflow tract and outflow obstruction. ConclusionsThis procedure relieves heart failure symptoms, abolishes LV outflow gradient, and avoids MV replacement in patients with obstructive HCM and mild septal thickness.

Surgically treated pulmonary stenosis: over 50 years of follow-up.

Surgical correction was the treatment of choice for pulmonary stenosis until three decades ago, when balloon valvuloplasty was implemented. The natural history of surgically relieved pulmonary stenosis has been considered benign but is actually unknown, as is the need for re-intervention. The objective of this study was to investigate the morbidity and mortality of patients with surgically treated pulmonary stenosis operated at Aarhus University Hospital between 1957 and 2000. The total study population included 80 patients. In-hospital mortality was 2/80 (2.5%), and an additional four patients died after hospital discharge; therefore, the long-term mortality was 5%. The maximum follow-up period was 57 years, with a median of 33 years. In all, 16 patients (20%) required at least one re-intervention. Pulmonary valve replacement due to pulmonary regurgitation was the most common re-intervention (67%). Freedom from re-intervention decreased >20 years after the initial repair. In addition, 45% of patients had moderate/severe pulmonary regurgitation, 38% had some degree of right ventricular dilatation, and 40% had some degree of tricuspid regurgitation, which did not require re-intervention at the present stage. Surgical relief for pulmonary stenosis is efficient in relieving outflow obstruction; however, this efficiency is achieved at the cost of pulmonary regurgitation, leading to right ventricular dilatation and tricuspid regurgitation. When required, pulmonary valve replacement is performed most frequently >20 years after the initial surgery. Lifelong follow-up of patients treated surgically for pulmonary stenosis is emphasised in this group of patients, who might otherwise consider themselves cured.

Current status of minimally invasive endoscopic management for Zenker diverticulum.

Surgical resection has been the mainstay of treatment of pharyngoesophageal (Zenker) diverticula over the past century. Developments in minimally invasive surgery and new endoscopic devices have led to a paradigm change. The concept of dividing the septum between the esophagus and the pouch rather than resecting the pouch itself has been revisited during the last three decades and new technologies have been investigated to make the transoral operation safe and effective. The internal pharyngoesophageal myotomy accomplished through the transoral stapling approach has been shown to effectively relieve outflow obstruction and restore physiological bolus transit in patients with medium size diverticula. Transoral techniques, either through a rigid device or by flexible endoscopy, are gaining popularity over the open surgical approach due the low morbidity, the fast recovery time and the fact that the procedure can be safely repeated. We provide an analysis of the the current status of minimally invasive endoscopic management of Zenker diverticulum.

Calcific Aortic Stenosis

Calcific aortic stenosis is the most common indication for surgical valve replacement in the United States. For years this disease has been described as a passive degenerative process during which serum calcium attaches to the valve surface and binds to the leaflet to form nodules. Therefore, surgical treatment of this disease has been the approach toward relieving outflow obstruction in these patients. Recent studies demonstrate an association between atherosclerosis and its risk factors for aortic valve disease. In 2008, there are increasing number of epidemiology and experimental studies to provide evidence that this disease process is not a passive phenomena. There is an active cellular process that develops within the valve leaflet and causes a regulated bone formation to develop. If the atherosclerotic hypothesis is important in the initiation of aortic stenosis, then treatments used in slowing the progression of atherosclerosis may be effective in patients with aortic valve disease. This review will discuss the pathogenesis and the potential for medical therapy in the management of patients with calcific aortic stenosis by examining the lessons provided from the experimental research.

Hourglass-shaped nitinol prostatic stent in treatment of patients with lower urinary tract symptoms due to bladder outlet obstruction

Objectives To assess the efficacy and safety of the thermoexpandable hourglass-shaped nitinol prostatic stent in the treatment of patients with lower urinary tract symptoms due to bladder outlet obstruction. Methods The stents were inserted in an outpatient setting under local anesthesia and direct vision. Five different stent lengths (2.0 to 4.0 cm) were used, depending on the length of the prostatic urethra. Assessment of voiding function and symptom scores was performed at baseline, directly after stent insertion, at 14 days, and 1, 3, 6, and 12 months after stent placement. Results We enrolled 35 men in the trial. In 5 patients, insertion of the stent failed, mainly because of anatomical limitations. After all placement procedures, minimal temporary hematuria was observed. Spontaneous voiding was achieved in all patients, with immediate significant improvements in voiding parameters and symptom scores. The median indwelling time of the stent was 70 days. Kaplan-Meier survival analysis showed that at 14 days and at 3, 6, and 12 months, the stent was still in situ in 73%, 40%, 33%, and 23% of the patients, respectively. The main reason for removal of the stent was migration (93%), in most cases toward the bladder. Removal was uneventful in all but 1 case. Conclusions The placement of the thermoexpandable hourglass-shaped nitinol stent results in relief of outflow obstruction and improvement of symptom scores. Because of the high migration rate, however, this stent design needs further improvement to be suitable for clinical practice.

Long-Term Effects of Surgical Septal Myectomy on Survival in Patients With Obstructive Hypertrophic Cardiomyopathy

This study sought to determine the impact of surgical myectomy on long-term survival in hypertrophic cardiomyopathy (HCM). Left ventricular (LV) outflow tract obstruction in HCM increases the likelihood of heart failure and cardiovascular death. Although surgical myectomy is the primary treatment for amelioration of outflow obstruction and advanced drug-refractory heart failure symptoms, its impact on long-term survival remains unresolved. Total and HCM-related mortality were compared in three subgroups comprised of 1,337 consecutive HCM patients evaluated from 1983 to 2001: 1) surgical myectomy (n = 289); 2) LV outflow obstruction without operation (n = 228); and 3) nonobstructive (n = 820). Mean follow-up duration was 6 +/- 6 years. Including two operative deaths (procedural mortality, 0.8%), 1-, 5-, and 10-year overall survival after myectomy was 98%, 96%, and 83%, respectively, and did not differ from that of the general U.S. population matched for age and gender (p = 0.2) nor from patients with nonobstructive HCM (p = 0.8). Compared to nonoperated obstructive HCM patients, myectomy patients experienced superior survival free from all-cause mortality (98%, 96%, and 83% vs. 90%, 79%, and 61%, respectively; p < 0.001), HCM-related mortality (99%, 98%, and 95% vs. 94%, 89%, and 73%, respectively; p < 0.001), and sudden cardiac death (100%, 99%, and 99% vs. 97%, 93%, and 89%, respectively; p = 0.003). Multivariate analysis showed myectomy to have a strong, independent association with survival (hazard ratio 0.43; p < 0.001). Surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation. In this retrospective study, septal myectomy seems to reduce mortality risk in severely symptomatic patients with obstructive HCM.

Can prostate stents be used to predict the outcome of transurethral resection of the prostate in the difficult cases?

Endoprosthesis has been used to maintain luminal patency in several different diseases and is well established in cardiovascular and gastrointestinal pathologies. The usefulness and application in prostatic pathology and benign prostatic hyperplasia are not as clear. This report reviews the development of overactive bladder in patients with bladder outlet obstruction due to benign prostatic hyperplasia. It also describes a new application of prostatic stents in patients with combined overactive bladder and bladder outlet obstruction. Over the last few decades, interest has been focused on the pathology of overactive bladder due to bladder outlet obstruction. Persistent outlet obstruction can certainly induce overactivity in some cases. However, the significance of preoperative identification of the latter problem is still an open issue, and it is obviously of vital importance to find instruments to identify parameters of prognostic significance. Different prostatic stents have been used for a variety of purposes. Recent studies have demonstrated that prostatic stents are effective in relieving obstruction and urinary retention. However, the role of prostatic stents in bladder outlet obstruction is still not clear when compared with other minimally invasive options. By using a prostatic stent to simulate transurethral resection of the prostate, the risk of post-resection incontinence in patients with combined severe bladder outlet obstruction and severe overactive bladder has been possible to assess before the operation. However, larger controlled clinical studies are needed to corroborate the value of the test. Prostatic obstruction can induce severe overactive bladder in some cases. A prostatic stent to relieve outflow obstruction and to simulate transurethral resection of the prostate decreases the risk of post-resection incontinence in patients with combined severe bladder outlet obstruction and severe overactive bladder because very high risk patients can be excluded from surgery. The stent test indicates that patients who do not leak and experience reduced symptoms when they are relieved of their outlet obstruction can be advised to have a transurethral resection of the prostate.

AORTIC STENOSIS: Clinical Evaluation and Optimal Timing of Surgery

Aortic valve disease is common in the elderly with recent data suggesting that aortic sclerosis and stenosis are the end-stage of an active disease process. Aortic atenosis may be diagnosed at symptom onset (angina, heart failure or syncope) but often the diagnosis is suspected in an asymptomatic patient with a systolic murmur. The diagnosis can be confirmed and disease severity evaluated reliably using Doppler echocardiography. Symptomatic severe aortic stenosis is treated with valve replacement, even in the elderly, due to the extremely poor prognosis without relief of outflow obstruction. Management is controversial when there is coexisting moderate aortic stenosis and left ventricular systolic dysfunction.

Venous stents in chronic iliac vein occlusions

Stents in the venous circulation have been used to relieve malignant obstructions of the superior vena cava with rapid relief of acute symptoms. The experience with stents in iliac vein obstruction is limited.14 To relieve outflow obstruction following chronic iliofemoral vein occlusion femoral cross-over bypasses have mostly been used. 5 Iliac vein thromboses often extend into the leg, with destruction of valves and concomitant reflux. Hopefully, recanalisation by a stent will result in disappearance of obstructive symptoms without increased reflux and with long-term patency. This report describes three patients with severe postthrombotic symptoms, where iliac vein stenting successfully reduced the outflow obstruction.

BENIGN PROSTATIC HYPERPLASIA: Hormonal Treatment

Androgen withdrawal therapy appears to produce a 20% to 30% decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy. Longer periods of treatment do not result in further prostatic regression, but further growth of the gland is not apparent in men treated with finasteride for 4 years. Although biopsy studies indicate that epithelial regression occurs to a much more significant degree than stromal regression, this may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uroflow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on hormonal therapy, as opposed to surgery, where relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of androgen withdrawal therapy. Most importantly, partial involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does following surgery. Incomplete blockade of androgen action, as well as compliance issues, may also limit efficacy. Long-term studies validate a modest but significant clinical response rate of finasteride therapy with preservation of sexual function in most men. Of the available hormonal therapeutic agents, only finasteride appears to have an acceptable risk-benefit ratio. Other 5 alpha-reductase inhibitors in the "pipeline," such as episteride, may have similar benefits. In the long term, this class of drugs may have a much larger role in patients who present with the early signs of BPH, to prevent any further progression of the disease. Presently, no form of antiandrogen therapy is as effective as transurethral resection of the prostate in relieving symptomatology. Because of patient preferences, however, medical therapy will play an increasingly important role in the management of patients with BPH.

Bladder-outlet obstruction--assessment of symptoms.

Assessment of symptoms plays a central role in the evaluation of men with suspected bladder-outflow obstruction (BOO) secondary to benign prostatic hyperplasia (BPH). It is on the basis of symptoms that treatment designed to relieve outflow obstruction is recommended. However, a variety of studies have suggested that a considerable proportion of men presenting with suspected outflow obstruction are not obstructed as determined by pressure-flow criteria. The relationship between many so-called "obstructive" symptoms and BOO has not yet been defined. Furthermore, all previous studies have defined BOO on the basis of urethral resistance factors, which are now regarded as outdated. Using current concepts of urethral pressure-flow relationships, we studied in detail the relationship between the "obstructive" symptoms of BPH, objective evidence of abnormal voiding and BOO. Only the symptoms of hesitancy and poor flow were found to be significantly related to BOO. The symptoms of straining to void, intermittency, terminal dribbling and feeling of incomplete bladder emptying were not specific for BOO. Objective evidence of an intermittent flow pattern and of terminal dribbling do, however, have a high specificity and positive predictive value for BOO. The assessment of men with lower-urinary-tract symptoms must include objective tests of voiding function. A better understanding of the pathophysiology of lower-urinary-tract symptoms should lead to an improved symptomatic outcome of prostatectomy.

Association between residual mitral regurgitation and left ventricular outflow obstruction after carpentier ring mitral annuloplasty

In 1971, Carpentier et al 1 reported the use of a new technique for mitral valve repair using an annuloplasty ring. Although this technique avoids some complications of prosthetic valves, spatial changes in the mitral apparatus after this operation may result in systolic anterior motion of the mitral valve which may cause left ventricular (LV) outflow obstruction similar to that seen in hypertrophic cardiomyopathy. 2,3 In a series of 439 patients, systolic anterior motion was seen in 6.4% of patients after Carpentier ring repair, and LV outflow obstruction was present in 2.3%. 4 Although outflow obstruction may be treated successfully medically, 4 it may also be a cause of immediate (intraoperative) failure of the technique. 5 We have previously reported a relation between mitral regurgitation (MR) and LV outflow obstruction in 2 groups. In those who have undergone aortic valve replacement for aortic stenosis, the relief of outflow obstruction after aortic valve replacement was associated with a significant reduction in the degree of MR. 6 In the second group, those with hypertrophic cardiomyopathy, the degree of MR was directly associated with the severity of outflow obstruction. 7 The current study evaluates the possible mechanisms of LV outflow obstruction after Carpentier ring mitral annuloplasty, and investigates the relation, if any, of MR to the presence of LV outflow obstruction.

Androgen Ablation and Blockade in the Treatment of Benign Prostatic Hyperplasia

Antiandrogen therapy appears to produce a 30 to 40 per cent decrease in the volume of the hyperplastic prostate after 3 to 6 months of therapy (Table 5). Longer treatment may result in further prostatic regression, although this remains to be seen. Biopsy studies suggest that epithelial regression occurs to a much more significant degree than does stromal regression, but this finding may simply reflect the relatively longer turnover of the stromal cell population. The significant placebo effect of oral medication in patients with BPH makes interpretation of clinical symptomatology and uro-flow data difficult. Analysis of symptom improvement is further complicated by the relatively slow improvement of patients on antiandrogen therapy, in contrast to surgery, in which relief is immediate. In addition to limited stromal involution and inadequate treatment duration, other biologic factors may limit the clinical efficacy of antiandrogen therapy. Most importantly, prostatic involution may not necessarily decrease urethral resistance. In addition, obstruction-induced detrusor dysfunction may persist after relief of outflow obstruction in some patients, as it does after surgery. Incomplete antiandrogen action of the compounds, as well as compliance issues, may likewise limit efficacy. Although there are no data to suggest that the 5 alpha-reductase inhibitor finasteride will be more effective than other antiandrogen compounds in the treatment of BPH, preliminary studies suggest that it has less toxicity. If long-term studies validate a modest but significant clinical response rate and preservation of sexual function, then finasteride therapy may well be acceptable to a subgroup of men presenting with the symptoms of BPH.(ABSTRACT TRUNCATED AT 250 WORDS)

Ejaculation and sexual function after endoscopic bladder neck incision.

Endoscopic incision of the bladder neck, performed to relieve outflow obstruction, was evaluated as regards effects on ejaculation and orgasm in 61 men (mean age 48 years) by analyses of seminal fluid and a questionnaire. Relief of obstruction was confirmed by post-operative normalisation of urinary flow. In 47 cases there was unchanged antegrade ejaculation, while reduced semen volume was reported by 11 men and retrograde ejaculation by only 3. The quality of orgasm and sexual satisfaction were not permanently changed by the operation. Post-operative analysis of seminal fluid was performed in 27 patients, with normal results in 26. In 16 men who provided specimens both before and after bladder neck incision, no consistent change was found in the semen. An incision completely splitting the bladder neck but not extending distal to the verumontanum will relieve outlet obstruction. Maintenance of antegrade ejaculation can be expected in most patients undergoing this operation.