Canadian Urological Association guideline: Erectile dysfunction.

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Access to penile prostheses differ across provinces in Canada: A survey of Canadian urologists.

INTRODUCTION: Surgical implantation of a penile prosthesis is the gold standard treatment for refractory erectile dysfunction. The purpose of this study was to investigate the use of and access to these procedures in Canada. METHODS: Canadian urologists known to perform penile prostheses procedures were surveyed on areas such as surgical volume, type of device used, and the direct cost to patients for both malleable and inflatable devices. RESULTS: Of the 50 urologists invited to participate in the study, 34 (68%) completed the online survey. Participants represented nine Canadian provinces and included a mix of academic (65%) and community (35%) urologists. Most participants (79%) performed less than 10 procedures per year. Roughly three-quarters of participants (74%) used inflatable devices in over 90% of cases, while half implanted inflatable devices exclusively. The most common devices implanted were American Medical Systems (AMS). Participants from Alberta, Manitoba, New Brunswick, and Newfoundland reported full coverage for both malleable and inflatable devices. Saskatchewan was the only province where no coverage was reported. The remaining provinces were found to have variable degrees of coverage. Across all centers without full coverage, the median reported cost to patients for a malleable and inflatable device was $5000 and $6000, respectively. CONCLUSIONS: The urologists surveyed most commonly perform inflatable penile prostheses procedures. Significant geographical differences exist with respect to reported coverage for these procedures. This study highlights the need for continued advocacy on behalf of the urological community towards the goal of equity in coverage for penile prostheses across Canada.

Outcome analysis of patients with Peyronie's disease who elect for vacuum erection device therapy.

INTRODUCTION: Peyronie's disease (PD) affects approximately 0.7-11% of men and has numerous proposed treatments. Invasive management options include surgical or injectable therapy, while penile traction therapy with vacuum erection device (VED) represents a non-invasive approach. Our objective is to assess outcomes for patients with PD who opt for non-invasive management. METHODS: We performed a retrospective analysis for patients with PD who were followed for at least three months and opted for noninvasive therapy. All patients were instructed to initiate VED traction therapy for 10 minutes twice per day. Patients were assessed for degree of PD deformity and erectile function (Sexual Health Inventory for Men [SHIM] score) at initial and subsequent encounters. RESULTS: Fifty-three patients met the inclusion criteria. The mean (standard deviation [SD]) age was 57 (12) years, and the mean (SD) duration of PD prior to assessment was 25 (15) months. The mean (SD) duration of followup was 14 (11) months. Among untreated patients who did not use a VED, nine showed improvement, 20 remained stable, and four had worsening curvature. The untreated group had a significant change in curvature, with a mean improvement (SD) of 3.6 (12)° (p=0.048). All 20 men who initiated VED traction therapy had an improvement in curvature with a significant mean (SD) improvement of 23 (16)° (p=2.6×10-6). Changes in SHIM scores did vary significantly between groups. No complications were noted. CONCLUSIONS: In patients who opt for non-invasive management of PD, VED traction therapy provides improved curvature resolution compared to those who do not use such a device. The limitations of this study include the retrospective nature and a small sample size at a single treatment center.

Noninvasive Treatment Options for Peyronie's Disease.

INTRODUCTION: Evidence for noninvasive management of Peyronie's disease contains many options with varying levels of evidence for each. Many first-line treatments recommended by urologists lack strong evidence for their use. AIM: We summarize the noninvasive (oral medications, topical medications, traction, vacuum erection devices, extracorporeal shock wave therapy, intracavernosal injections and electromotive therapy) treatment options for Peyronie's disease and provide the levels of evidence for each. METHODS: A literature search of PubMed, EMBASE, Cochrane Library, and ClinicalKey databases was conducted, current up to April 2019. MAIN OUTCOME MEASURE: For each treatment modality, we measured level of evidence, change in penile curvature, change in erectile function, the percentage of patients with improved angulation, and pain scores. RESULTS: There is weak evidence to support the use of oral or topical medications. Higher levels of evidence exist for intracavernosal injections and extracorporeal shock wave therapy and may be helpful in certain patient populations. CONCLUSION: The mechanisms behind Peyronie's disease are not fully understood. Penile injections provide the highest quality of evidence for noninvasive treatment. Ory J, MacDonald L, Langille G. Noninvasive Treatment Options for Peyronie's Disease. Sex Med Rev 2020;8:603-614.

An Examination of the Relationship between Mental Distress, Functional and Psychosocial Quality of Life Indicators in a Population Based Sample of Prostate Cancer Survivors Who Received Curative Treatment.

INTRODUCTION: Although survival rates are highest among prostate cancer survivors compared to any other forms of cancer, nearly 60% suffer from mental distress. Here we examine urinary function and psychosocial stressors and their association with poor mental health in a younger group of prostate cancer survivors who have undergone curative treatment. METHODS: The study includes 128 men (47 to 70 years old) who received active treatment for prostate cancer, and completed a survivorship online survey between 2017 and 2018. Psychological distress was assessed with Kessler Psychological Distress Scale. International Prostate Symptom Score subscales (incomplete urinary emptying, frequency, intermittency, urgency, weak stream, straining and nocturia) and number of current prostate cancer survivorship stressors were predictors. Multivariate logistic regression was used to fit the model while controlling for months of survivorship since diagnosis, the presence or absence of surgery, radiation or hormone therapy treatment, current medication for depression and demographics. RESULTS: A total of 19.5% of men scored positive for current mental health issues. Prostate cancer survivors who reported increased number of current survivorship stressors (OR 1.48, 95% CI 1.09-2.01), had higher frequency of urination (OR 2.05, 95% CI 1.15-3.64), history of radiation treatment (OR 7.15, 95% CI 1.02-50.35) and were currently on prescribed medication for depression (OR 33.47, 95% CI 3.80-294.87) had higher odds for screening positive for psychological distress compared with their counterparts. CONCLUSIONS: These results corroborate recent findings showing an intersection between urological oncology and poor mental health during survivorship, and warrant the development of multidisciplinary teams in addressing survivorship issues in this population.

The use of penile prostheses in the management of priapism.

Priapism is a relatively uncommon condition that can result in erectile dysfunction (ED) and corporal fibrosis. Cases of prolonged priapism are particularly prone to ED, which arises when priapism is treatment refractory or had a delayed presentation. Due to the emergent nature of priapism, it behooves urologists to be familiar with all potential treatment modalities to minimize adverse outcomes. In this review paper, we aim to summarize the literature regarding the use of penile prosthesis (PP) implantation in the setting of ischemic priapism (IP). In some patients who present later or have prolonged initial treatment, early insertion of PP may be indicated.

The Use of HCG-Based Combination Therapy for Recovery of Spermatogenesis after Testosterone Use.

INTRODUCTION AND AIM: About 3 million men take testosterone in the United States with many reproductive-age men unaware of the negative impact of testosterone supplementation on fertility. Addressing this population, we provide an early report on the use of human chorionic gonadotropin (HCG)-based combination therapy in the treatment of a series of men with likely testosterone-related azoospermia or severe oligospermia. METHODS: We retrospectively reviewed charts from two tertiary care infertility clinics to identify men presenting with azoospermia or severe oligospermia (<1 million sperm/mL) while taking exogenous testosterone. All were noted to have been placed on combination therapy, which included 3,000 units HCG subcutaneously every other day supplemented with clomiphene citrate, tamoxifen, anastrozole, or recombinant follicle-stimulating hormone (or combination) according to physician preference. MAIN OUTCOME MEASURE: Clinical outcomes, including hormone values, semen analyses, and clinical pregnancies, were tracked. RESULTS: Forty-nine men were included in this case series. Return of spermatogenesis for azoospermic men or improved counts for men with severe oligospermia was documented in 47 men (95.9%), with one additional man (2.1%) having a documented pregnancy without follow-up semen analysis. The average time to return of spermatogenesis was 4.6 months with a mean first density of 22.6 million/mL. There was no significant difference in recovery by type of testosterone administered or supplemental therapy. No men stopped HCG or supplemental medications because of adverse events. CONCLUSIONS: We here provide an early report of the feasibility of using combination therapy with HCG and supplemental medications in treating men with testosterone-related infertility. Future discussion and studies are needed to further characterize this therapeutic approach and document the presumed improved tolerability and speed of recovery compared with unaided withdrawal of exogenous testosterone.

The safety of testosterone supplementation therapy in prostate cancer.

Patients with prostate cancer can present with hypogonadism and experience health and quality-of-life declines related to low testosterone levels. Despite generations of urological dogma suggesting that testosterone supplementation therapy (TST) for hypogonadism causes prostate-cancer progression, a review of the contemporary literature provides evidence to the contrary. The prostate saturation model suggests that the androgen receptor (AR) is saturated at serum testosterone levels of 150-200 ng/dl, and that additional serum testosterone above this level has limited, if any, effects within the prostate. Indeed, studies in the modern era of PSA assessments indicate that TST does not affect prostate size, intraprostatic testosterone levels, or prostate-cancer progression, provided the baseline serum testosterone level is greater than this AR saturation point. However, the body of data on this subject comes from a small number of cases, and TST should only be administered to patients with prostate cancer after thorough discussions of the risks and benefits, with subsequent careful monitoring.

Access to the extrapleural space at the time of surgery for continuous paravertebral block after flank incision: description of the technique and case series.

OBJECTIVE: To test our hypothesis that surgeon-placed paravertebral block (PVB) placement during open renal surgery is effective, feasible, and safe. Neuraxial analgesia represents the current standard of care for perioperative anesthesia for open renal surgery. However, potential catastrophic complications such as neuraxial bleeding and infection may occur. An alternative to neuraxial analgesia widely used in thoracic surgery is the surgeon-placed PVB. TECHNICAL CONSIDERATIONS: The surgeon-placed catheter is directed in the paravertebral space through the flank incision at the time of surgery. The postoperative catheter management was directed by anesthesiologists. All patients undergoing open renal surgery by a single urologist were provided a PVB for this series. Twenty-nine consecutive patients undergoing open renal surgery were given PVBs. Patients received an average of 5.1 mg of subcutaneous equivalent hydromorphone in the 48-hour postoperative period. No complications because of the PVB were found. CONCLUSION: PVB represents a safe and effective surgeon-placed alternative to neuraxial analgesia for open renal operative procedures.

Psoas abscess from ureteric stone perforation.

This case illustrates a rare complication of an impacted ureteric stone which eroded through the wall of the ureter leading to formation of a psoas abscess. Ureteric stent placement and percutaneous drainage of the abscess were insufficient to resolve the problem. Renal scan revealed poor function and the left kidney was removed. It showed evidence of acute supporative pyelonephritis with nephrolithiasis.

Tryptophan fluorescence reveals induced folding of Vibrio harveyi acyl carrier protein upon interaction with partner enzymes.

We have introduced tryptophan as a local fluorescent probe to monitor the conformation of Vibrio harveyi acyl carrier protein (ACP), a small flexible protein that is unfolded at neutral pH but must undergo reversible conformational change during the synthesis and delivery of bacterial fatty acids. Consistent with known 3D structures of ACP, steady-state fluorescence and quenching experiments indicated that Trp at positions 46, 50, and 72 are buried in the hydrophobic core upon Mg(2+)-induced ACP folding, whereas residues 25 and 45 remain in a hydrophilic environment on the protein surface. Attachment of fatty acids to the phosphopantetheine prosthetic group progressively stabilized the folded conformation of all Trp-substituted ACPs, but longer chains (14:0) were less effective than medium chains (8:0) in shielding Trp from acrylamide quenching in the L46W protein. Interaction with ACP-dependent enzymes LpxA and holo-ACP synthase also caused folding of L46W; fluorescence quenching indicated proximity of Trp-45 in helix II of ACP in LpxA binding. Our results suggest that divalent cations and fatty acylation produce differing environments in the ACP core and also reveal enzyme partner-induced folding of ACP, a key feature of "natively unfolded" proteins.

Metastatic renal cell carcinoma to the head and neck: summary of 21 cases.

OBJECTIVE: Metastasis of renal cell carcinoma (RCC) to the head and neck is a relatively uncommon phenomenon, but such lesions can be the initial presentation of disease. RCC should be considered a source for lesions in this region, especially in patients who have received a previous diagnosis of RCC. METHODS: In this study, we review the presentation, management, and outcomes for 21 patients with documented metastasis of RCC to the head and neck outside the central nervous system. This study is a retrospective review of cases ascertained during a 17-year period from a large teaching hospital. RESULTS: Of the 21 patients observed, 10 were found to have metastatic disease at the time of RCC diagnosis, involving the head and neck in 5 cases. The most common sites of head and neck metastasis were to bone (n = 6), skin and subcutaneous tissue (n = 6), and lymph nodes (n = 5). CONCLUSIONS: This study is a reminder to consider a renal primary tumour for metastatic disease identified in the head and neck, particularly metastases with a "clear cell" histologic pattern. A head and neck metastasis may occasionally be the presenting sign in a patient with RCC, or it may follow the primary diagnosis by many years.