Safety and feasibility of percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting: a pilot study.

The objective of this study is to evaluate the safety and feasibility of the combined simultaneous percutaneous needle tunneling coupled with injection of platelet-rich plasma in the outpatient department for the treatment of Peyronie's disease. This prospective, non-randomized, cohort and preliminary study included patients who underwent this procedure from November 2020 to July 2022. The main outcome was an improvement in penile curvature. Fifty-four patients were enrolled and underwent 6 sessions under local anesthesia followed by vacuum therapy for the treatment of Peyronie's disease in our outpatient unit. The amendment of the curvature angle was significant with a median correction percentage of -44.40% interquartile range (-66.70 to (-39.70)), [p-value = 0.001, 95% CI (-29.76 to (-18.02)), paired Student's t-test]. The median pre-treatment curvature angle was 45° (40-75), and the median post-treatment was 30° (20-40). The median score for pain during the procedure was 3 (0-4.25) according to a 10-point visual analogic scale. After two hours, 20.37% of patients still had pain but none required any pain medication. 50% of patients had a minor hematoma and 75.93% patients reported penile ecchymosis. A single patient reported an injection site skin infection. In our experience percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting is a safe, effective, and feasible treatment of penile deformity for PD.

The role of surgical therapy in the management of premature ejaculation: a narrative review.

Background and Objective: Premature ejaculation (PE) is a common sexual disorder among male adults and negatively impacts a man's sexual life. Currently, the mainstay treatment of PE is still medical therapy which has drawbacks among patients as a consequence of side effects. Despite the new definitions, the evolution of medical therapy, and the consensus for the management of PE, it remains challenging to treat for many clinicians especially when medical treatment fails. However, the International Society for Sexual Medicine (ISSM) and the American Urological Association (AUA) guidelines ignored surgical therapy due to conflicting medical reports and doubts about the safety of surgical management. This article discusses the surgical management of PE based on recent guidelines, reviews, and evolving techniques. Methods: We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, selective dorsal neurectomy, hyaluronic acid, dorsal nerve neuromodulation, cryo-ablation of the dorsal nerve and inner condom technique until May 2023. Seventeen studies were found. Key Content and Findings: Even though the widespread use of many surgical modalities in Asia such as glans penis augmentation (GPA) using hyaluronic acid (HA) selective dorsal neurectomy (SDN), cryo-ablation of the dorsal nerve, neuromodulation of the dorsal nerve (NMDN), and circumcision are still considered as controversial for the guidelines. Conclusions: The mainstay treatment of PE is still pharmaceutical. However, the current body of evidence on surgical treatments for PE is limited. Men considering surgical therapy for PE should be counseled well for the risks and benefits as there may be chronic disabilities. Further, well-designed trials are needed to establish safety and efficacy for the surgical treatment.

Neoadjuvant chemotherapy does not increase peri-operative morbidity following radical cystectomy.

OBJECTIVE: To determine whether use of neoadjuvant chemotherapy (NAC) is associated with a higher risk of post-operative complications following radical cystectomy (RC) for bladder cancer (BCa). MATERIALS AND METHODS: We retrospectively reviewed records of patients undergoing RC for non-metastatic urothelial BCa at 13 tertiary care centres from 2007-2019. Patients who received NAC ('NAC + RC' group) were compared with those who underwent upfront RC ('RC alone' group) for intra-operative variables, incidence of post-operative complications as per the Clavien-Dindo classification (CDC) and rates of re-admission and re-intervention. Multivariable logistic regression analysis was performed to determine predictors of CDC overall and CDC major (grade III-V) complications. We also analysed the trend of NAC utilization over the study period. RESULTS: Of the 3113 patients included, 968 (31.1%) received NAC while the remaining 2145 (68.9%) underwent upfront RC for BCa. There was no significant difference between the NAC + RC and RC alone groups with regards to 30-day CDC overall (53.2% vs 54.6%, p = 0.4) and CDC major (15.5% vs 16.5%, p = 0.6) complications. The two groups were comparable for the rate of surgical re-intervention (14.6% in each group) and re-hospitalization (19.6% in NAC + RC vs 17.9% in RC alone, p = 0.2%) at 90 days. On multivariable regression analysis, NAC use was not found to be a significant predictor of 90-day CDC overall (OR 1.02, CI 0.87-1.19, p = 0.7) and CDC major (OR 1.05, CI 0.87-1.26, p = 0.6) complications. We also observed that the rate of NAC utilization increased significantly (p < 0.001) from 11.1% in 2007 to 41.2% in 2019, reaching a maximum of 48.3% in 2018. CONCLUSION: This large multicentre analysis with a substantial rate of NAC utilization showed that NAC use does not lead to an increased risk of post-operative complications following RC for BCa. This calls for increasing NAC use to allow patients to avail of its proven oncologic benefit.

Optimal Surgical Outcome of Minimally Invasive Partial Nephrectomy (MIPN) Based on an Early Postoperative Estimated Glomerular Filtration Rate (eGFR).

PURPOSE OF REVIEW: To compare laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) performed in two European tertiary centers using the classic optimal surgical definition - "MIC" - and a new optimal surgical definition: the "Novel TRIFECTA" (NT) concept. We sought to strengthen the PN evidence and to test the NT's performance. RECENT FINDINGS: The study population comprehended 505 cases of localized kidney cancer from two tertiary centers between 2012 and 2019. The NT achievement was higher in the RAPN group when compared to LPN (70.5 vs. 87.4%; p = 0.004), while no differences were found when considering the MIC criteria. Also, a similar high-grade complications rate (Clavien-Dindo > III) and operative time (105 min vs. 100 min; p = NS) were found. In the multivariable regression, the RAPN approach was a predictor of NT achievement (OR 2.45; p = 0.008). NT achievement was higher in the RAPN group, while similar results were found when evaluating the MIC criteria. The NT definition could be more sensitive to the individual-specific responses related to the PN.

Erectile Dysfunction Resistant to Medical Treatment Caused by Cavernovenous Leakage: An Innovative Surgical Approach Combining Pre-operative Work Up, Embolisation, and Open Surgery.

OBJECTIVE: Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL. METHODS: An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT. RESULTS: Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p < .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p < .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication. CONCLUSIONS: After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

Management of proximal penile prosthetic cylindrical complications: a novel direct crural approach.

INTRODUCTION: Patients with proximal penile prosthetic cylindrical complications (PPPCC) can be treated with a direct crural technique without using the original traditional approach. In this article we present our novel direct crural approach for management of patients with PPPCC. MATERIALS AND METHODS: Between 2014 and 2019, data were retrospectively collected from 13 patients who underwent surgical revision using our novel direct crural approach for PPPCC. The procedure commences with identification of the affected zone. The patient is in a low lithotomy position. A 2-centimeter longitudinal incision is made directly over the affected site. Dissection is carried down through Colles' fascia, followed by a longitudinal incision through the tunica albuginea at the proximal part of the affected cylinder. Via the incision we can deliver out the cylinder and manage its problem. RESULTS: Mean operative time was 40 min. No intra or post-operative complications were reported. All patients (Mean age = 57) were discharged on the same day. Postoperative follow-up found correction of all existing deformities at month 1, 3 and 6. All patients were satisfied and reported less pain and faster recovery than the first procedure. CONCLUSION: Our technique, which can be used for all types of penile prosthesis, is both feasible and safe. It may simplify PPPCC revision by avoiding adhesions below the original incision, without jeopardizing the already implanted materials or the urethra. It may also improve patients' safety and satisfaction, by reducing iatrogenic injury and post-operative recovery time.

Cyclist Endofibrosis (Exercise-Induced Arterial Endofibrosis) Treated by Drug-Coated Balloon Angioplasty.

Exercise-induced arterial endofibrosis is an uncommon entity that is most frequently identified in high-performance athletes, especially cyclists. We present this disease in a male professional cyclist of 22 years of age. The course of his condition, clinical manifestations, modalities of investigation, and a nonprecedent treatment plan are demonstrated.

Comparing Perioperative Complications Between Laparoscopic and Robotic Radical Cystectomy for Bladder Cancer.

Background: Minimally invasive cystectomy is being increasingly performed, however, data comparing laparoscopic radical cystectomy (LRC) and robotic radical cystectomy (RRC) are scarce. We compared 30- and 90-day Clavien-Dindo Classification (CDC) complications between patients undergoing LRC and RRC at our center. Materials and Methods: We retrospectively evaluated 300 patients who underwent minimally invasive radical cystectomy from January 2007 to July 2019 and grouped them into LRC (112 patients) and RRC (188 patients). We compared the two groups for demographic variables, perioperative characteristics, and 30- and 90-day CDC overall, minor, and major complications. Multivariable logistic regression analysis was performed to identify variables that predict perioperative complications. Results: The two groups were comparable for the duration of surgery (270 minutes in LRC vs 265 minutes in RRC) and rate of conversion to open surgery. The RRC cohort had a higher estimated blood loss (EBL) (675 mL vs 500 mL, p = 0.006), but the two groups had a comparable need for intraoperative transfusion. Patients undergoing RRC also had a shorter duration of hospital stay (13 days vs 14 days, p < 0.001). There was no difference between the two groups for 30- and 90-day CDC overall, minor, and major complications. The incidence of rehospitalization within 30 days (p = 0.1) and surgical reintervention (p = 0.5) was also comparable between the two groups. On multivariable logistic regression analysis, approach to cystectomy (RRC vs LRC) was not a significant predictor of 30-day CDC overall and major complications. Conclusion: LRC was associated with lesser EBL, whereas the hospital stay was shorter in patients undergoing RRC. The two approaches were comparable with each other for 30- and 90-day CDC overall, minor, and major complications. The choice between the two approaches should depend on availability and surgeon experience and preference, rather than any specific perioperative parameter.

Higher nodal yield with robot-assisted pelvic lymph node dissection for bladder cancer compared to laparoscopic dissection: implications for more accurate staging.

OBJECTIVES: To compare the lymph node (LN) yield and adequacy of laparoscopic pelvic lymph node dissection (L-PLND) and robot-assisted PLND (R-PLND), as PLND is a fundamental component of radical cystectomy (RC) for bladder cancer (BCa), where a positive status is the most powerful predictor of disease recurrence and survival. PATENTS AND METHODS: We retrospectively reviewed patients undergoing RC with PLND for BCa from January 2007 to July 2019 and grouped them in to L- and R-PLND. Until 2011, patients underwent a standard PLND (S-PLND) with the cranial limit as bifurcation of common iliac artery. Since 2012, an extended PLND (E-PLND) up to aortic bifurcation has been performed. An adequate S- and E-PLND were defined as those that yielded at least 10 and 16 LNs, respectively. The groups were compared for LN yield and adequacy of PLND. RESULTS: During the study period, 305 patients underwent minimally invasive RC in our centre, of which 274 (89.8%) underwent a concomitant PLND (98 L-PLND, 176 R-PLND). R-PLND resulted in a significantly greater median LN yield compared to L-PLND, both in the S-PLND (16 vs 11, P < 0.001) and the E-PLND (19 vs 14, P < 0.001) eras. Also, a significantly higher proportion of patients in the R-PLND group had an adequate PLND compared to the L-PLND group. Surgical approach to PLND (R- vs L-PLND) was the only variable that was significantly associated with an adequate PLND on both univariable (odds ratio [OR] 1.860, 95% confidence interval [CI] 1.114-3.105; P = 0.01) and multivariable (OR 2.109, 95% CI 1.222-3.641; P = 0.007) analyses. CONCLUSION: R-PLND leads to a higher LN yield and a greater probability of an adequate PLND compared to L-PLND for both standard and extended templates. Therefore, the robot-assisted approach would lead to more accurate staging following RC with PLND.

Sleep related painful erection: an algorithm for evaluation and management.

BACKGROUND: Sleep related painful erection (SRPE) is a rare parasomnia consisting of nocturnal penile tumescence accompanied by pain that awakens the individual. Normal non-painful erections are experienced when awake. No penile anatomic abnormalities are present. No conclusive randomized clinical trial is present in the literature about the management of this rare condition. The aim of this article is to review the current knowledge about the management of SRPE and to suggest an algorithm to help physicians evaluate and manage SRPE. MATERIAL AND METHODS: A literature review was conducted through PubMed database using the terms: sleep, pain, painful, penile, and erection. The reference lists of the articles were also reviewed. The search returned 23 references that were published between 1987 and 2019. Results were presented in a descriptive manner. RESULTS: Treatment decision for now is based on reports of the treatment success, the sustainability of remission, the tolerability by the patients and the potential side effects of each medication. From data available in literature, Baclofen is the mostly used medication with a tolerable profile of adverse effects. Phosphodiesterase type 5 inhibitors are considered potential treatments and are already widely used and tolerated for other indications, but so far only 2 successful trials have been reported for SRPE. Cinitapride is very promising, but only one case was studied and no side effects were reported. Clozapine can be very dangerous although highly effective. CONCLUSION: Based on the limited number of treatment trials and reported cases, the low level of evidence and the lack of randomized clinical trials, no treatment consensus for SRPE can be reached. We suggested a useful tool for clinicians: an algorithm for the management of SRPE to facilitate their access to the literature without exhaustive return to case reports and series upon each case faced.

CONTEXTE: L'érection nocturne douloureuse est. une parasomnie, caractérisée par des épisodes de tumescence douloureuse provenant exclusivement lors du sommeil, avec une anatomie normale et des érections indolores lorsque le patient est. réveillé. La prise en charge de cette maladie est. inconnue vue le petit nombre de cas et le manque d'études randomisées. Nous présentons dans cet article une revue de la littérature concentrée sur les stratégies thérapeutiques décrites. Un algorithme est. suggéré pour faciliter l'évaluation et la prise en charge des patients. MATÉRIEL ET MÉTHODES: La revue de la littérature a été réalisée en utilisant la base de donnée PubMed et les termes: « sleep, pain, painful, penile, erection ¼. Les références des articles ont été revues. En total 23 références ont été utiles pour notre revue. Les résultats ont été présentés d'une manière descriptive. RÉSULTATS: Les stratégies thérapeutiques actuelles se basent sur les essais décrits dans la littérature à travers un nombre limité de patients. La durée de la rémission et les effets secondaires minimes rendent certains traitements supérieurs. Le baclofen est. le plus utilisé grâce à son efficacité et à son faible potentiel d'effets secondaires. Le cinitapride a été très efficace lors d'un essai unique chez un seul patient, sans effets secondaires rapportés. Les inhibiteurs de la phosphodiesterase de type 5, largement utilisés en urologie, ont été trouvés utiles pour le traitement des érections nocturnes douloureuses chez 2 patients. La clozapine qui est. très efficace, présente un profil d'effets secondaires dangereux. CONCLUSION: A cause du faible nombre de cas et des essais thérapeutiques rapportés, le meilleur traitement des patients ayant des érections douloureuses nocturnes reste indéterminé. Nous suggérons un algorithme utile aux praticiens pour l'évaluation, le diagnostic et la prise en charge de ces patients.

Splenorenal fusion mimicking renal cancer: One case report and literature review.

Splenorenal fusion is an extremely rare benign entity. This abnormality is presented in a case of a 29-year-old-male patient. We discuss the distinction between this condition and renal splenosis and their embryology. The course of this condition and modalities of investigation including radiological imaging, management, and pitfalls are reviewed.

Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study.

PURPOSE: To evaluate patients' tolerance to indwelling urinary catheters (IUCs) before and after reducing their balloon volumes. IUCs are a source of discomfort or pain. MATERIALS AND METHODS: All consecutive patients hospitalized in our department with IUCs were included during the study period with some exclusion. Each patient was his/her own control before and two hours after reduction of the balloon volume (RBV) by half using two types of assessments, a visual analog scale for pain and a catheter-related bladder discomfort (CRBD) symptom questionnaire. RESULTS: Forty-nine patients were included in our study that completed the assessments. The mean scores for pain before and after RBVs were 2.80 and 2.02, respectively. The difference was significant (p<0.05). The mean grades of the CRBD before and after RBVs were 1.02 and 0.75, respectively. The difference was significant (p<0.05). CONCLUSIONS: A 50% RBV has shown a significant amelioration in tolerating the catheter.

Angiomyxoma of the ureter imitating an upper tract urothelial carcinoma: A case report.

INTRODUCTION: Angiomyxomas are rare benign neoplasms of mesenchymal origin arising from the soft tissues of the perineum and pelvis. CASE PRESENTATION: To our knowledge, we report the first case of ureteral angiomyxoma arising de novo in a fifty-four-year-old female patient who presented with macroscopic hematuria. DISCUSSION: The pathological findings, radiological features and operative management will be discussed. CONCLUSION: Angiomyxomas are notorious for their locally infiltrative nature and their propensity to recur. Clinical suspicion is capital to reach the diagnosis and a holistic care is key to a good outcome.

Oddities Sporadic Neurofibroma of the Urinary Bladder. A Case Report.

Neurofibromas of the urinary bladder are an exceedingly rare entity and are considered mostly in conjunction with the disease of neurofibromatosis type 1. The fortuitous discovery of vesical plexiform neurofibromas without other stigmata of the disease is presented in a 57-year-old male patient. The course of his condition, modalities of investigation and a non-precedent treatment plan are demonstrated.

Novel augmentation ileocystoplasty technique to manage non-compliant bladders in the presence of obstructed megaureters: the "fez procedure".

OBJECTIVES: To show the efficacy and safety of a novel modification of Studer's neobladder, herein defined as the "fez procedure." METHODS: The medical records of 21 children (mean age 9.4 ± 1.3 years) who underwent the "fez procedure" at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, to manage refractory poorly-compliant bladders and concomitantly obstructed megaureters were retrospectively reviewed. The patients had been previously managed by either preliminary cutaneous ureterostomy (17 patients) or temporary nephrostomy (four patients) to improve and stabilize the renal functions. The "fez procedure" entailed augmentation ileocystoplasty and the use of an afferent tubularized ileal loop for direct ureteroileal anastomosis. The augmented bladder together with the tubularized loop were fashioned as a "fez" with its tassel. The outcome measures were changes in cystometric capacity, bladder compliance, glomerular filtration rate, serum creatinine, technetium 99m-diethylene triamine pentaacetic acid diuretic renography (T1/2), ureteral diameter, vesicoureteral reflux, febrile urinary tract infections, continence and complications. RESULTS: The mean study follow-up period was 52.5 ± 12.8 months. Means of changes of cystometric capacity (273.2 ± 60.9 mL) and bladder compliance (15.6 ± 4.2 mL/cm H2 O) were significant (P < 0.0001). Resolution of ureteral obstruction was documented with improved T1/2 and ureteral diameter (P < 0.0001, each) of all patients. The initially improved renal functions after ureterostomies or nephrostomies were maintained after "fez surgery," with non-significant changes in the improved glomerular filtration rate (P = 0.22) and serum creatinine (P = 0.18). None of the patients experienced ureteral restenosis, vesicoureteral reflux, febrile urinary tract infections, incontinence or significant complications. CONCLUSIONS: The "fez procedure" represents a versatile and successful surgical option for these selected patients, as it offers improved bladder capacity/compliance, resolution of ureteral obstruction and vesicoureteral reflux, preservation of the renal function, control of urinary tract infections and urinary continence, and acceptable morbidity.