Photoselective Vaporization of the Prostate in the Management of Lower Urinary Tract Symptoms in Prostate Cancer Patients on Active Surveillance.

OBJECTIVE: To demonstrate the safety and efficacy of photoselective vaporization of the prostate in alleviating refractory lower urinary tract symptoms in prostate cancer patients who are managed with active surveillance and to explore the association of this procedure with prostate specific antigen (PSA) levels and cancer progression rates. METHODS: Between 2008-2018, active surveillance patients who had refractory symptoms and needed surgery were studied. Perioperative functional variables were collected and analyzed. Disease progression was defined as an upgrade or upstage on surveillance biopsies or multiparametric prostate magnetic resonance imaging. Mean postop scores were estimated using locally-weighted methods. The risk of progression was reported using Kaplan-Meier's method. RESULTS: Seventy-one patients were included in the study. The median age was 68 years and the median surveillance time before surgery was 4 years. At 12 months, there were substantial improvements in the mean International Prostate Symptom Score (18-5.9), maximum flow rate (6.8-14 mL/s), postvoid residual (240-73mL), PSA (8.1-5.2 ng/mL), and prostate volume (85-57mL). At 30-days, only 2 patients with grade-III complications. Late consequences included tissue regrowth in 4 and urethral stricture (requiring a single dilation) in 3 patients. PSA levels decreased by 36% at 12 months postoperatively. With a median follow-up of 3.7 years, 7 men progressed and received radical treatment. At 3 years, the probability of remaining on surveillance was 93% (95% CI 87%- 100%). CONCLUSION: Photoselective vaporization of the prostate offers substantial relief of symptoms in active surveillance patients with refractory symptoms, without adverse effects on disease progression rates.

Management of Lower Urinary Tract Symptoms After Pelvic Radiation in Females.

PURPOSE OF REVIEW: To present the available literature pertaining to the management of lower urinary tract symptoms (LUTS) after pelvic radiation (RT) in female patients treated for pelvic malignancy. RECENT FINDINGS: Recent publications have focused on isolating de novo RT-induced LUTS in women from other contributors to urinary symptoms such as pelvic surgery and chemotherapy. There is a paucity of literature on the treatment of RT-related changes to urinary function. The treatment of pelvic malignancies in women alters voiding function. RT contributes to the deterioration of voiding function. More study is needed to evaluate the efficacy of available therapies.

Preoperative symptoms predict continence after post-radiation transurethral resection of prostate.

INTRODUCTION: Lower urinary tract symptoms and retention are known complications of radiation for prostate cancer and traditionally transurethral resection of the prostate (TURP) has been avoided in these patients because of the risk of incontinence. The purpose of this study was to evaluate the incidence and predictors of post-TURP incontinence in previously radiated patients. MATERIALS AND METHODS: One-hundred and eleven patients who underwent brachytherapy or external beam radiotherapy for prostate cancer with subsequent TURP performed between 1992 and 2012 at a single institution were identified. We tested for associations between post-TURP continence status and pre-TURP predictors including age, preoperative urinary symptoms and type and timing of radiation therapy. RESULTS: New-onset incontinence developed in 27% (95% CI 17%, 39%) of patients after first post-radiation TURP and 32% (95% CI 23%, 42%) of patients after any TURP, including repeat TURPs. Forty-three percent of patients had resolution of incontinence with first TURP (95% CI 25%, 63%); only 25% (95% CI 7%, 52%) of patients had resolution following repeat TURPs. Age was significantly associated with incontinence (OR per 10 years 2.02, 95% CI 1.10, 3.74, p = 0.024). Post-TURP incontinence was more common in men with pre-TURP urgency. CONCLUSIONS: Rates of post-TURP incontinence were higher in men who were older or had pre-TURP urinary urgency. Assessment of preoperative symptoms would allow for better patient selection. Further research should determine whether this results in better outcomes, including decreased incidence of new onset incontinence and increase in resolution of incontinence.

Simple circumcision device: proof of concept for a single-visit, adjustable device to facilitate safe adult male circumcision.

OBJECTIVE: To conduct a proof-of-concept study to determine the potential utility of a novel, adjustable single-visit, disposable device to facilitate rapid adult circumcision. DESIGN: Prospective pilot trial of a novel surgical device. SETTING: Tertiary care Veterans Administration medical center. PATIENT(S): Five adult males. INTERVENTION(S): Circumcisions performed by junior trainees using an adjustable, single-size surgical-assist device constructed by the University of Washington Applied Physics Laboratory. MAIN OUTCOME MEASURE(S): The attending surgeon and trainees completed standardized forms after each procedure to assess technical problems and ease of use. Follow-up visits were scheduled to evaluate adverse events, postoperative pain, cosmetic outcomes, and participant satisfaction at 3, 8, 30, and 90 days postoperatively. RESULT(S): The average operative time was 16.4 minutes. All cases were performed with local anesthesia, and no case required electrocautery or conversion to standard surgery. At the postoperative day 3 visit, all subjects were happy with their results and would recommend the procedure to another patient. One participant had a minor wound separation noted at the 30-day visit that resolved during follow-up. There were no wound infections, hematomas, or other adverse events. CONCLUSION(S): This proof-of-study suggests that the Simple Circumcision Device may facilitate delivery of safe adult male circumcision services.

Influence of sildenafil on genital engorgement in women with female sexual arousal disorder.

INTRODUCTION: We previously described dynamic, noncontrast magnetic resonance imaging (MRI) of the female genitalia as a reproducible, nonintrusive, objective means of quantifying sexual arousal response in women without sexual difficulties. These studies showed an increase in clitoral engorgement ranging from 50 to 300% in healthy women during sexual arousal. AIM: This study sought to evaluate the genital arousal response in women with female sexual arousal disorder (FSAD) after administration of sildenafil and placebo. We performed a multicenter, double-blind, placebo-controlled, cross-over study to assess the clitoral engorgement response using dynamic MRI in women with FSAD after administering sildenafil and placebo followed by audiovisual sexual stimulation (AVSS). METHODS: Nineteen premenopausal women with FSAD underwent two MRI sessions. Subjects were randomized to receive either (i) sildenafil 100 mg during the first session followed by placebo during the second session, or (ii) placebo followed by sildenafil. During each session, baseline MR images were obtained while subjects viewed a neutral video. Subjects then ingested sildenafil or placebo. After 30 minutes, a series of MRIs were obtained at 3-minute intervals for 10 time points while subjects viewed AVSS. MAIN OUTCOME MEASURES: A positive sexual arousal response was achieved if clitoral volume increased ≥50% from baseline. RESULTS: Thirteen of 19 (68%) subjects achieved a ≥50% increase in clitoral engorgement from baseline when administered sildenafil or placebo 30 minutes after dose administration. At 60 minutes after administration, 17/19 (89%) subjects receiving sildenafil and 16/19 (84%) subjects receiving placebo had responded (P value 0.3173). CONCLUSIONS: Sildenafil did not augment the genital response in women with FSAD. Secondarily, a majority of women in this study did not have impaired clitoral engorgement as measured by MRI, suggesting that FSAD is not predominantly a disorder of genital engorgement.

Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center.

PURPOSE: We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma. MATERIALS AND METHODS: A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal. RESULTS: A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years. CONCLUSIONS: Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

Corpus cavernosum electromyography revisited: defining the origin of the signal.

PURPOSE: We performed this study to identify the source of complexes recorded during corpus cavernosum electromyography. MATERIALS AND METHODS: A total of 10 healthy male volunteers 19 to 54 years old (mean age 36) with normal erectile function, participated in the study. A Porti electrodiagnostic system (TMS International, Enschede, The Netherlands) connected to a notebook computer recorded low frequency corpus cavernosum electromyography complexes via penile surface electrodes in 3 phases. In phase 1 baseline corpus cavernosum electromyography was recorded for 30 minutes. In phase 2 penile skin block was performed followed by 30 minutes of corpus cavernosum electromyography recording. Phase 3 consisted of intracavernous block followed by corpus cavernosum electromyography recording for 30 minutes. During all 3 phases startling auditory stimuli and median nerve stimulation were used at random intervals to evoke a sympathetic nervous system response. A suprapubic electrode was used as a control to record sympathetic electrodermal activity. RESULTS: In phase 1 all subjects had spontaneous and evoked corpus cavernosum complexes. The penile skin block used in phase 2 did not affect the presence of these complexes, which remained present in all subjects. During phase 3 no spontaneous or evoked corpus cavernosum complexes were recorded in any subjects, indicating that the intracavernous block eliminated the corporally generated signal. All subjects in all 3 phases demonstrated a sympathetic electrodermal response in the suprapubic electrode in response to evoking stimuli. CONCLUSIONS: This study confirms the penile cavernous tissue, and not the penile skin or surrounding tissue, as the origin of the corpus cavernosum electromyography complex. Further refinement of this technique may render it useful in the evaluation of neurogenic and myogenic erectile dysfunction.