Treatment of Urinary Incontinence in Patients With Erectile Dysfunction.

INTRODUCTION: Concurrent urinary incontinence (UI) and erectile dysfunction (ED) can greatly damage a patient's quality of life. Owing to the intertwined anatomy, treatment options for one most certainly have implications on the other. OBJECTIVE: The aim of this review is to characterize and elucidate the treatment patients with postprostatectomy UI undergoing concurrent or subsequent treatment of ED. These principles can be extrapolated to all patients with UI and ED. METHODS: The literature on postprostatectomy UI treatment in the context of concurrent ED was reviewed through a Medline search. Original research using quantitative and qualitative methodologies was considered. RESULTS: The epidemiology, workup, and management of postprostatectomy UI being mindful of ongoing or future ED treatments are the main outcome measures. Owing to the intertwined anatomy, treatment options for UI and ED have implications on the other. It is essential for the surgeon to obtain an understanding of the patient's degree of bother for each process, personal preference on treatment options, and management of expectations. Surgical treatment options include a combination of the artificial urinary sphincter, sling, inflatable penile prosthesis, semi-rigid penile prosthesis, and new techniques such as the Mini-Jupette. The appropriate combinations will be determined by patient factors of dexterity, preference, degree of leakage, history of radiation, and so on. The decision of staged vs dual implant will be largely driven by the surgeons' preference, payor limitations, and comfort level. This issue is particularly challenging in redo cases where we advocate for cuff downsizing or tandem cuff before the transcorporal approach is used with the goal of preserving sexual function. CONCLUSION: The concurrent treatment of ED and UI requires thoughtful workup, meticulous attention to detail, and an armamentarium of surgical skills. It is crucial for the surgeon to understand and manage patient expectations in treating these delicate and difficult pathologies. Ajay D, Mendez MH, Wang R, et al. Treatment of Urinary Incontinence in Patients With Erectile Dysfunction. Sex Med Rev 2021;9:593-604.

Contemporary Review of Male and Female Climacturia and Urinary Leakage During Sexual Activities.

INTRODUCTION: Urinary leakage during sexual activity is a prevalent and often distressing condition that is under-addressed despite having a range of reasonable treatment options. AIM: To review the available literature on prevalence, pathophysiology, and treatment of urinary leakage during sexual activities. METHODS: A literature review was performed through PubMed from 1996 to 2017 regarding urinary leakage during sexual activities for men and women including foreplay incontinence, coital incontinence, and climacturia. MAIN OUTCOME MEASURES: To assess various physiologic and social factors of urinary leakage during sexual activities for men and women, treatment options, and their reported outcomes. RESULTS: Urinary leakage during sexual activity is a prevalent condition that is underdiagnosed and undertreated. The pathophysiology of sexual incontinence is very similar between men and women and is influenced by injury to the pelvic and pudendal nerves, pelvic floor and external sphincter incompetence, and detrusor overactivity. There are different treatment options that are effective and should be offered to patients bothered by their symptoms. CONCLUSION: Improved awareness is critical for better addressing the issue of sexual incontinence. There is likely a common pathophysiologic pathway between men and women and many treatment options are effective. However, further study is required to better elucidate this disease process and most effective treatment options. Mendez MH, Sexton SJ, Lentz AC. Contemporary Review of Male and Female Climacturia and Urinary Leakage During Sexual Activities. Sex Med Rev 2018;6:16-28.

Assessing clinically significant prostate cancer: Diagnostic properties of multiparametric magnetic resonance imaging compared to three-dimensional transperineal template mapping histopathology.

OBJECTIVE: To evaluate the diagnostic properties of multiparametric magnetic resonance imaging in the detection, localization and characterization of prostate cancer using three-dimensional transperineal template mapping biopsy histopathology as the comparator. METHODS: A retrospective analysis of patients undergoing prostate multiparametric magnetic resonance imaging followed by three-dimensional transperineal template mapping biopsy was carried out. For imaging and pathology data, the prostate was divided in octants with the urethra being the midline. The index test properties were calculated using the biopsy histopathology as the reference test with the following end-points: any cancer, any Gleason ≥7, any Gleason ≥7 or cancer length of ≥4 mm and any Gleason ≥7 or 6 mm in any given core. The latter two definitions correspond to 0.2 and 0.5 mL of cancer volume, respectively. Diagnostic properties including sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: A total of 50 patients were included in the study. A median of 55 (interquartile range 42-63) biopsy cores were obtained per patient. Of 400 prostate octants evaluated, 28.5% had prostate cancer on mapping biopsy, whereas 23% of octants were considered suspicious for cancer on imaging. Multiparametric magnetic resonance imaging negative predictive values for Gleason ≥7 and clinically significant cancers were 84-100%. Similarly, specificity ranged between 79% and 85%. Sensitivity and positive predictive value remained moderate for all the reference test definitions. CONCLUSIONS: Multiparametric magnetic resonance imaging is a useful minimally-invasive tool for detection, localization and characterization of prostate cancer. This imaging modality has high negative predictive value and specificity, and therefore it could be used to reliably rule out clinically significant cancer, obviating the multicore mapping biopsy.

Comparison of Outcomes Between Preoperatively Potent Men Treated with Focal Versus Whole Gland Cryotherapy in a Matched Population.

BACKGROUND AND PURPOSE: The refinement in the localization of prostate cancer tumor foci through transperineal template-mapping biopsies and MRI has led to an increased interest in lesion-directed focal prostatic cryoablation. Data are lacking, however, that compare the outcomes of whole-gland (WG) to focal ablation therapy (FT). The aim of our study was to assess both oncologic and functional outcomes between WG and FT cryoablation of the prostate after having matched patients for preoperative characteristics. PATIENTS AND METHODS: We matched with a 1:1 ratio 317 men who underwent FT with 317 who underwent WG treatment in the Cryo Online Data (COLD) registry between 2007 and 2013. All patients were low-risk according to the D'Amico risk groups and were matched according to age at surgery. We only included preoperatively potent men. Oncologic outcomes were biochemical recurrence (BCR) free-survival defined according to the American Society for Radiation Oncology (ASTRO) and Phoenix criteria and assessed by Kaplan-Meier curves. Only patients with prostate-specific antigen (PSA) nadir data were included in oncologic outcome analysis. Functional outcomes were assessed at 6, 12, and 24 months after the procedure for erectile function (defined as ability to have intercourse with or without erectile aids), urinary continence, urinary retention, and rates of fistula formation. RESULTS: Median age at the time of the procedure was 66.5 years (standard deviation [SD] 6.6 y), and median follow-up time was 58.3 months. After surgery, 30% (n=95) and 17% (n=55) of the men who received WG and FT, respectively, underwent biopsy, with positive biopsy rates of 11.6% and 14.5%, respectively. BCR-free survival rates at 60 months according to the Phoenix definition were 80.1% and 71.3% in the WG and FT cohorts, respectively, with a hazard ratio of 0.827; according to the ASTRO definition, they were 82.1% and 73%, respectively (all P ≥ 0.1). Erectile function data at 24 months was available for 172 WG and 160 FT treated men. Recovery of erection was achieved in 46.8% and 68.8% of patients in the WG and FT cohorts, respectively (P=0.001). Urinary function data at 24 months was available for 307 WG and 313 FT patients. Continence rates were 98.7% and 100% for WG and FT groups, respectively (P=0.02). Urinary retention at 6, 12, and 24 months was reported in 7.3%, 1.9%, and 0.6%, respectively, in the WG arm, and in 5%, 1.3%, and 0.9%, respectively, in the FT arm. Finally, only one fistula was reported in each group. CONCLUSIONS: Men with low-risk prostate cancer who underwent FT cryoablation had comparable BCR-survival rates at 60 months to patients treated with WG. However, FT patients had higher erectile function preservation rates at 24 months post-procedure. Urinary continence, retention and fistula rates were similar between the two treatment groups.

Current trends and new frontiers in focal therapy for localized prostate cancer.

Prostate cancer (PCa) care is an ever-evolving field. Research and technological developments continue to refine our definitions and management of this disease. Now, with a greater understanding of the natural history of PCa, the prevention of overtreatment has shaped a new era with the adoption of active surveillance (AS) and advancement of focal therapy (FT). Multiparametric magnetic resonance imaging (mpMRI) allows us to define, locate, and monitor cancers in a way never before possible. These capabilities combined with promising results from current prospective studies have changed the face of FT. This review presents the latest developments, current trends, and next steps in FT.