Worldwide trends in penile implantation surgery: data from over 63,000 implants.

BACKGROUND: Penile prosthesis implantation represents the gold standard of treatment for severe or medically refractory erectile dysfunction (ED). We sought to address the paucity of currently available literature about global penile prosthesis usage in regard to geography, patient age, surgical approach, implanter volume, and etiology of ED. METHODS: From device manufacturer information, we compiled data on over 63,000 implants performed worldwide. Data was grouped and then analyzed to examine trends in penile implantation between the years of 2005-2012. RESULTS: The number of implants was seen to steadily increase over the study period. Of the 63,013 total procedures recorded, 85.9% were performed within the United States. 60-78% of procedures were done using the penoscrotal (PS) approach, with only Belgium/Netherlands as an outlier with an infrapubic (INF) majority. The US was notable for having an increasing number of implanters doing 16-30, 31-50, or >100 implants yearly. Etiology of ED worldwide was variable, but "organic," post-prostatectomy, and diabetes accounted for the vast majority of cases worldwide. CONCLUSIONS: Penile prosthesis implantation is an increasing practice, as evidenced by a steady increase in the number of implants performed over a 7-year study period. Acceptance of this treatment option for ED is variable by region with the US leading the annual number of implantations by a wide margin. Worldwide, there appears to be a predominance of surgeons placing implants via the PS approach.

Multicenter investigation on the influence of climate in penile prosthesis infection.

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of <0.001. Humidity results were similar, and fungal infections correlate with daily humidity. Infected implants performed in the fall and summer were over 3 and 2.3 times, respectively, more likely to grow Gram-positive bacteria compared to implants performed in spring (p = 0.004; p = 0.039). This was consistent across geographic location, including in the Southern hemisphere. We found trends between climate factors and IPP infection like those seen and proven in other surgical literature. To our knowledge these data represent the first exploration of the relationship between temperature and infection in prosthetic urology.

Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database.

INTRODUCTION: Although diabetes mellitus (DM) is often discussed as a risk factor for inflatable penile prosthesis (IPP) infection, the link between DM diagnosis and IPP infection remains controversial. High-quality population-based data linking DM to an increased risk of IPP infection have not been published. AIM: To evaluate the association of DM with IPP infection in a large public New York state database. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for men who underwent initial IPP insertion from 1995-2014. Diabetic patients were identified using ICD-9-CM codes. Patients presenting for first operation with diagnosis or Current Procedural Terminology codes suggestive of prior IPP surgery were excluded. Chi-squared analyses were performed to compare infection rates in diabetics and non-diabetics within the pre- and postantibiotic impregnated eras. Multivariate Cox proportional hazards models were constructed to evaluate whether or not DM was independently associated with IPP infection in the time periods before (1995-2003) and after (2004-2014) the widespread availability of antibiotic impregnated penile prostheses. MAIN OUTCOME MEASURE: Time to prosthesis infection was measured. RESULTS: 14,969 patients underwent initial IPP insertion during the study period. The overall infection rate was 343/14,969 (2.3%). Infections occurred at a median 3.9 months after implant (interquartile ratio: 1.0-25.0 months). Infectious complications were experienced by 3% (133/4,478) of diabetic patients and 2% (210/10,491) of non-diabetic patients (P < .001). Diabetes was associated with a significantly increased IPP infection risk on multivariable analysis controlling for age, race, comorbidities, insurance status, annual surgeon volume, and era of implantation (Hazard Ratio: 1.32, 95% CI: 1.05-1.66, P = .016). CONCLUSION: Our analysis supports the notion that DM is a risk factor for IPP infection. This has important implications for patient selection and counseling, and raises the question of whether this increased risk can be mitigated by optimization of glycemic control before surgery. Lipsky MJ, Onyeji I, Golan R, et al. Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database. Sex Med 2019;7:35-40.

Penile Length: Measurement Technique and Applications.

INTRODUCTION: Penile size has long been an important fixation in men's lives. On the one hand, a smaller penis has been associated with anxiety and apprehension; on the other hand, a larger penis has generally been related to virility and strength. These perceptions predominate during an erection, when penile size is representative of a man's masculinity. AIM: To assess adult penile length and summarize average penile length assessments from the literature; analyze how various urologic diseases and therapies affect penile length and volume; and review how surgical treatments for Peyronie's disease, penile prosthesis implantation, and radical prostatectomy can affect penile size to appropriately counsel patients seeking such therapies and set realistic goals for patients. METHODS: To achieve the aim of this review, we analyzed the literature on penile size and volume and how these can be affected by various urologic diagnoses and therapies. We summarize common diagnoses and therapies that can affect penile size. MAIN OUTCOME MEASURE: We thoroughly discuss how the aforementioned diagnoses and therapies can negatively affect penile size. In doing so, we allow readers to understand the intricacies of penile size when faced with such diagnoses and therapies in their patients. RESULTS: Surgical treatments for Peyronie's disease, penile prosthesis implantation for refractory erectile dysfunction, and radical prostatectomy for prostate cancer can lead to a decrease in penile size. CONCLUSION: Urologists must recognize that the different therapies they offer can affect a man's penile size, often negatively. This in turn can lead to poorer satisfaction outcomes in patients. Davoudzadeh EP, Davoudzadeh NP, Margolin E, et al. Penile Length: Measurement Technique and Applications. Sex Med Rev 2018;6:261-271.

Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease.

BACKGROUND: Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie's disease (PD), but the quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, presenting a barrier to clinical research and patient care. AIM: To introduce erect penile volume (EPV) and percentage of erect penile volume loss (percent EPVL) as novel metrics that provide detailed quantitative information about non-curvature penile deformities and to study the feasibility and reliability of three-dimensional (3D) photography for measurement of quantitative penile parameters. METHODS: We constructed seven penis models simulating deformities found in PD. The 3D photographs of each model were captured in triplicate by four observers using a 3D camera. Computer software was used to generate automated measurements of EPV, percent EPVL, penile length, minimum circumference, maximum circumference, and angle of curvature. The automated measurements were statistically compared with measurements obtained using water-displacement experiments, a tape measure, and a goniometer. OUTCOMES: Accuracy of 3D photography for average measurements of all parameters compared with manual measurements; inter-test, intra-observer, and inter-observer reliabilities of EPV and percent EPVL measurements as assessed by the intraclass correlation coefficient. RESULTS: The 3D images were captured in a median of 52 seconds (interquartile range = 45-61). On average, 3D photography was accurate to within 0.3% for measurement of penile length. It overestimated maximum and minimum circumferences by averages of 4.2% and 1.6%, respectively; overestimated EPV by an average of 7.1%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intra-observer intraclass correlation coefficients for EPV and percent EPVL measurements were greater than 0.75, reflective of excellent methodologic reliability. CLINICAL TRANSLATION: By providing highly descriptive and reliable measurements of penile parameters, 3D photography can empower researchers to better study volume-loss deformities in PD and enable clinicians to offer improved clinical assessment, communication, and documentation. STRENGTHS AND LIMITATIONS: This is the first study to apply 3D photography to the assessment of PD and to accurately measure the novel parameters of EPV and percent EPVL. This proof-of-concept study is limited by the lack of data in human subjects, which could present additional challenges in obtaining reliable measurements. CONCLUSION: EPV and percent EPVL are novel metrics that can be quickly, accurately, and reliably measured using computational analysis of 3D photographs and can be useful in describing non-curvature volume-loss deformities resulting from PD. Margolin EJ, Mlynarczyk CM, Muhall JP, et al. Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease. J Sex Med 2017;14:829-833.

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. METHODS: This retrospective institutional review board-exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. MAIN OUTCOME MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two hundred twenty-seven intraoperative cultures (2002-2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. CONCLUSION: This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455-463.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery.

PURPOSE: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. MATERIALS AND METHODS: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. RESULTS: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. CONCLUSIONS: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Management of Perforation Injuries During and Following Penile Prosthesis Surgery.

INTRODUCTION: Distal extrusion of penile prosthesis cylinders is a challenging problem that is associated with pain and imminent erosion through penile skin. Distal extrusion and other perforation injuries, including crural and urethral, are other manifestations of tunica albuginea injuries that result in poor clinical outcomes and patient satisfaction. AIM: A description of Dr. John Mulcahy's landmark article for management of lateral extrusion is presented along with discussion of techniques for managing other types of perforation injuries associated with penile implants. METHODS: Dr. Mulcahy's original article is reviewed and critiqued. Surgical methods to manage perforation injuries are discussed. MAIN OUTCOMES MEASURES: The main outcome measures used were the review of original article, subsequent articles, and commentary by Dr. Mulcahy. RESULTS: Knowledge of techniques for management intraoperative and postoperative complications related to tunical perforation is necessary for implant surgeons. CONCLUSIONS: Perforation injuries are challenging noninfectious complications of penile prosthesis surgery. Familiarity with techniques to manage these problems is essential for ensuring good outcomes and patient satisfaction.

Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome.

INTRODUCTION: Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners. AIM: The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS. METHODS: Method used was a review of relevant publications in PubMed. MAIN OUTCOME MEASURES: Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS. RESULTS: Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD. CONCLUSION: Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.

Is there a rationale for penile rehabilitation following radical prostatectomy?

Erectile function recovery after radical prostatectomy (RP) is an increasingly prominent quality-of-life outcome following surgery. Following RP many men, despite the advent of cavernous nerve-sparing surgical technique, have moderately or significantly impaired erectile function (EF). The term penile rehabilitation (PR) is used to define interventions that maintain the health of erectile tissue in the context of nervous, vascular, and structural tissue injury. The goal of PR is to regain, as closely re-approximate, preoperative erectile function. PR is based on an increasing volume of preclinical and clinical data, but conclusive evidence of efficacy has not been established, and therefore the concept of PR remains controversial. The optimal PR regimen has not been established, but all strategies rely on one or more erectile dysfunction treatments to be administered on a regular basis regardless of actual use for sexual activity. This review highlights recent studies and evidence related to PR.

Pseudo-malfunction of the Coloplast Titan Inflatable Penile Prosthesis One-Touch Release Pump.

OBJECTIVE: To define and describe a type of pseudo-malfunction of the Coloplast Titan Inflatable Penile Prosthesis (IPP) One-Touch Release (OTR) pump (Coloplast Corp, Minneapolis, MN). MATERIALS AND METHODS: We retrospectively reviewed a consecutive series of 550 patients with refractory organic erectile dysfunction who were implanted with a Coloplast Titan IPP with the OTR pump during a period of approximately 4 years. RESULTS: All patients were implanted using standard techniques through an infrapubic or penoscrotal approach. Twenty-nine patients (5.3%) complained that their IPP would not inflate and that the pump bulb felt "hard." Examination revealed that their IPP was working normally; however, the inflate/deflate valve disc had become stuck in the deflate position. Very firm pressure had to be applied to the pump bulb to move the valve disc into the inflate position. Once this was accomplished, the device inflated and deflated normally. Another 14 patients (2.5%) reported this phenomenon to us but were able to apply enough pressure on the pump bulb to rectify it. CONCLUSION: The inflate/deflate valve disc in the Coloplast Titan OTR pump can occasionally become stuck in the deflate position (7.8% of patients in our experience). Patients may be unable to inflate the device and return for evaluation. In all cases we have encountered, firm pressure on the pump bulb caused the valve to shift into the inflate position, and the device worked properly thereafter. Patients and implanting urologists should be aware of this issue and of the way in which it can be rectified.

Use of a preoperative checklist reduces risk of penile prosthesis infection.

PURPOSE: Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. MATERIALS AND METHODS: We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. RESULTS: During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. CONCLUSIONS: After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.

Concordance between patient and physician assessment of the magnitude of Peyronie's disease curvature.

INTRODUCTION: The magnitude of penile deformity is a critically important factor in Peyronie's disease, as it is associated with increased difficulty in penetrative sexual intercourse and in turn with negative psychosocial consequences. Deformity magnitude also influences treatment choice when surgical correction is indicated. AIM: To determine the concordance between patient and physician assessment of magnitude of penile curvature in men with Peyronie's disease. METHODS: Patient assessment of curvature was obtained at initial interview. Physician assessment was performed using intracavernosal injection-assisted erection using a goniometer applied during excellent penile rigidity. MAIN OUTCOME MEASURES: Patient and physician assessments of penile curvature. RESULTS: The sample consisted of 192 men with a mean age of 54 ± 12 years old. Mean curvature on patient and physician assessment was 33 ± 17 and 36 ± 18 degrees, respectively. Only 49% of patients (94) correctly assessed their curvature, whereas 35% underestimated and 16% overestimated it. CONCLUSIONS: Only half of PD patients accurately assess their penile curvature, with more than twice as many patients underestimating it than overestimating it. These data suggest that patient self-reporting of penile curvature should not be used as a clinical marker or end point in Peyronie's disease trials.

Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius.

INTRODUCTION: Inflatable penile prosthesis (IPP) surgery is a successful therapeutic option for men with erectile dysfunction. Traditional placement of the reservoir in the retropubic space of Retzius is associated with the rare occurrence of significant complications including bladder, bowel, and vascular injury. An alternative site, posterior to the abdominal wall musculature, has been identified as a potentially safer location for reservoir placement. AIMS: The aim of this study was to describe our technique of abdominal reservoir placement during infrapubic IPP surgery and present our outcomes data. METHODS: We retrospectively reviewed our experience with abdominal reservoir placement during virgin IPP cases. Reservoirs placed anterior and posterior to transversalis fascia were analyzed separately. MAIN OUTCOME MEASURE: The main outcome measures was assessment of reservoir-related complications including palpable reservoir, reservoir herniation, and injuries to bowel, bladder, or major blood vessels. RESULTS: There were no injuries to bowel or major blood vessels with abdominal reservoir placement posterior or anterior to the transversalis fascia in properly segregated patients. CONCLUSION: Abdominal reservoir placement is a safe and simple surgical method that can be recommended for most men undergoing IPP placement. Men with a history of pelvic surgery can have the reservoir placed between the rectus abdominis musculature and transversalis fascia, while other men can have the reservoir placed between transversalis fascia and peritoneum in order to avoid a palpable reservoir. By applying this protocol, the catastrophic injuries that occur rarely with retropubic reservoir placement can be reliably avoided.

Erectile dysfunction in men treated for testicular cancer.

OBJECTIVE: To study the unique characteristics of erectile dysfunction (ED) in a population of men who developed ED after testicular cancer (TC) diagnosis and treatment. PATIENTS AND METHODS: All men treated for TC who presented for sexual function evaluation were included in an institutional database. All men underwent standard evaluation including a history/physical examination, completion of the International Index of Erectile Function (IIEF) questionnaire, testosterone/gonadotropin measurement and penile duplex Doppler ultrasonography (DUS). RESULTS: The study population comprised 76 men whose mean (SD) age was 29 (8) years and of whom 25% were married/had a partner. In all, 39% of the patients had seminoma and 61% had non-seminomatous germ-cell tumour (NSGCT). A total of 66% of patients with seminoma underwent radiation therapy. Of the patients with NSGCT, 79% received chemotherapy, 18% underwent primary retroperitoneal lymph node dissection (RPLND) and 20% underwent post-chemotherapy RPLND. The mean (SD) time before seeking sexual medicine consultation was 12 (7) months after treatment completion, the median (range) number of vascular risk factors was 0 (0-2) and the mean (SD) remaining testis volume was 16 (8) mL. Mean (SD) total testosterone, luteinizing hormone, follicle-stimulating hormone levels were 312 (186) ng/dL, 9 (7) IU/mL, 17 (12) IU/mL. A total of 26% of patients had total testosterone levels <300 ng/dL. In all, 84% of patients complained primarily of loss of erection-sustaining capability and 24% had episodes of transient ED before TC diagnosis. The mean (SD) IIEF erectile function domain score was 16 (7). All the patients (100%) had a normal DUS. Mean (SD) peak systolic and end-diastolic velocities were 48 (16) and 1.2 (2.2) cm/s, respectively. A total of 88% of patients responded to phosphodiesterase type 5 inhibitor (PDE5i) use with erections sufficient for penetration, but 12% did not (mean [SD] erectile function domain score 27 [5] vs 17 [6]). There were no differences in haemodynamics between those men with and without hypogonadism. CONCLUSIONS: Men with TC presenting with ED after treatment appear uniformly to have normal erectile haemodynamics, suggesting adrenaline-mediated ED. While the majority of TC survivors with ED respond successfully to PDE5i, a significant minority do not.

Reproductive sequelae of diabetes in male patients.

Diabetes mellitus (DM) is an increasingly prevalent public health concern. A recent study projected the number of people worldwide with DM to increase from 171 million in 2000 to 366 million in 2030. Although DM is a systemic disease that often leads to end-organ dysfunction of multiple body systems, the effects of the condition on male fertility are often not fully appreciated. DM is associated with multiple risk factors for reduced male fertility potential, including erectile dysfunction, various manifestations of ejaculatory dysfunction, and hypogonadism.

Aggressive angiomyxoma of the scrotum.

INTRODUCTION: Aggressive angiomyxoma (AAM) is a rare, benign mass with propensity for local invasion and recurrence after resection. Infrequently, this tumor can be found arising from the scrotum or cord structures in males. AIM/METHODS: A case report is presented followed by a review of relevant literature addressing the diagnosis, imaging, management and follow-up for aggressive angiomyxoma of the scrotum. RESULTS: Imaging can assist in further characterization of masses noted on physical exam. Scrotal sonography is typically the primary imaging modality utilized and magnetic resonance imaging is able to provide further anatomic detail. Treatment mainstay is surgical resection with necessary long term surveillance.

Preoperative erectile function is an independent predictor for decision to spare cavernous nerves during radical prostatectomy.

INTRODUCTION: Cavernous nerve sparing (NS) is critical for recovery of erectile function (EF) as well as erectile tissue preservation following radical prostatectomy (RP). Clinical experience suggests that surgeons may opt for non-NS RP in patients with impaired baseline EF. AIM: This study was performed to define if baseline EF is an independent predictor of NS status during RP. METHODS: A total of 2,323 mean (mean age 59 ± 7 years) who underwent RP at a tertiary referral academic medical center were retrospectively evaluated. Patients who underwent preoperative radiation therapy or androgen deprivation treatment were excluded. MAIN OUTCOME MEASURES: Preoperative parameters evaluated included biopsy pathological characteristics, prostate-specific antigen (PSA) level, patient age, and EF. Baseline EF was graded on a validated five-point patient reported scale. NSS was graded intraoperatively by the surgeon, using a four-point NS score assigned to each nerve where 1 = fully preserved, 2 = partially preserved, 3 = minimally preserved, and 4 = resected. NS surgery was defined as NSS of 1 or 2 on both sides, and nerve resection surgery was defined as NSS of 3 or greater on both sides. RESULTS: On univariate analysis, factors related to nerve resection surgery included (all P < 0.01): increasing age (r = 0.16), Gleason score (r = 0.19), EF score (r = 0.21), percentage biopsy cores positive (r = 0.11), higher preoperative PSA (relative risk [RR] 1.72, 95% confidence interval [CI] 1.23-2.40), and clinical stage ≥T2 (RR 2.17, 95% CI 1.68-2.78). On multivariable analysis, factors independently predicting for non-NS surgery included (all P < 0.01): baseline EF (odds ratio [OR] 1.50, 95% CI 1.33-1.68), biopsy Gleason sum (OR 1.95, 95% CI 1.65-2.36), clinical T stage ≥T2 (OR 1.59, 95% CI 1.15-2.20), patient age (OR 1.07, 95% CI 1.04-1.09), and percentage of biopsy cores positive (OR 1.01, 95% CI 1.00-1.02). CONCLUSIONS: While unfavorable clinical and prostate biopsy characteristics predict less NS, we have shown that poorer baseline EF also independently predicts for nerve resection RP. For every point increase in EF score (that is, worsening EF) the odds of not receiving NS during surgery increase by a factor of 1.5. Although NS is not associated with worse cancer outcomes in appropriately selected patients, failure to spare nerves is associated with poor post-operative EF, urinary continence, and increased severity of cavernous venous leak. Patient anxiety related to cancer diagnosis and impending treatment may lead to falsely-worsened apparent EF when recent erections are assessed during a pre-operative planning visit. For these reasons prostatectomists should consider NS based solely on factors other than patient's baseline EF, even when it is impaired.

Defining the aetiology of erectile dysfunction in men with chronic pelvic pain syndrome.

Men presenting with chronic pelvic pain syndrome (CPPS) frequently report concomitant erectile dysfunction (ED), but the underlying cause of ED in this patient population has not been previously studied. This study prospectively investigated the aetiology of ED in men with CPPS. The study population comprised 46 men with penile pain or dysorgasmia, and concomitant ED. All participants completed the NIH-CPSI and international index of erectile function- erectile function domain (IIEF-EFD) questionnaires, and underwent penile duplex Doppler ultrasonography (DUS), following intracavernosal trimix injection, to evaluate erectile hemodynamic parameters. Pearson's correlation between NIH-CPSI and IIEF-EFD scores, and between NIH-CPSI score and the erectile response to trimix injections was investigated. The prevalence of mild, moderate and severe CPPS symptoms was 26, 48 and 26% respectively. The severity of ED was mild, moderate or severe in 15, 61 and 24% of men respectively. NIH-CPSI and IIEF-EFD scores were negatively correlated (r = -0.32, p = 0.002). Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were normal in 96 and 100% of men respectively. The majority of men (78%) required ≥2 trimix injections to attain an adequate erection for DUS. NIH-CPSI scores and the number of trimix injections needed were positively correlated (r = 0.22, p = 0.035). The aetiology of erectile dysfunction in men who present with CPPS and concomitant ED is almost always psychogenic. Penile DUS in this population of men is fraught with the potential for error, and frequently necessitates more than one dose of a vasoactive agent.