Penile Sensory Changes After Plaque Incision and Grafting Surgery for Peyronie's Disease.

INTRODUCTION: Plaque incision and grafting (PIG) for Peyronie's disease (PD) is not devoid of complications such as erectile dysfunction and penile sensory changes. AIM: To define the rate and chronology of penile sensation loss after PIG surgery and to define predictors of such. METHODS: The study population consisted of patients with PD-associated penile curvature who underwent PIG surgery with at least 6 months of follow-up. Demographics and PD factors were recorded. Patient had preoperative assessment of penile sensation and deformity. Postoperative follow-up occurred at 1 week, 1 month, 6 months, and 1 year after surgery. Neurovascular bundle elevation was conducted with loupe magnification. MAIN OUTCOME MEASURE: Penile sensation was evaluated with a biothesiometer and graded on a patient-reported visual analog scale (0-10) in which 0 defined a completely numb area and 10 defined perfect sensation. The degree of sensation loss was defined as extensive (any 1 area >5 cm), major (2-5 cm), and minor (≤2 cm). The penile sensation loss distribution was defined as focal (1 site) or diffuse (>1 site). RESULTS: 63 patients were analyzed. Mean age was 56 ± 10 years. Mean duration of PD at the time of PIG was 15 ± 7 (12-38) months. 75% had curvature alone, and 25% had hourglass/indentation deformities. Mean primary curvature was 64˚ ± 28˚. The mean operation duration was 3.5 ± 1.8 hours. 21% had some degree of sensation loss at 1 week, 21% at 1 month, 8% at 6 months, and 3% at 12 months. Only 1 patient (1.5%) at 2 years continued to have extensive sensation loss on the glans and distal shaft with a very elevated sensitivity threshold. Using multivariable analysis, the only predictor of penile sensation loss ≥6 months was a duration of operation >4 hours (odds ratio = 2.1; 95% confidence interval = 1.2-3.0; P < .01). CLINICAL IMPLICATIONS: The study highlights the need during patient consent to discuss penile sensation loss. Patients should be informed that rates of penile sensation loss ranges from 2-30% and most patients will have complete resolution of any sensation loss within one year of follow-up. STRENGTH AND LIMITATIONS: To our knowledge no other studies have described the chronology and severity of penile sensation following PIG, our study demonstrates the utility of biothesiometry in measuring penile sensation before and after PIG. Number of patients and absence of control group represent a limitation. CONCLUSION: Sensation loss is not uncommon after PIG surgery. It decreases in frequency and severity with time with only rare cases occurring >12 months. Longer operations appeared to be more likely associated with sensation loss. Terrier JE, Tal R, Nelson CJ. Penile sensory changes after plaque incision and grafting surgery for Peyronie's disease. J Sex Med 2018;15:1491-1497.

Decrease in Intercourse Satisfaction in Men Who Recover Erections After Radical Prostatectomy.

INTRODUCTION: Recovery of erections after radical prostatectomy (RP) is assumed to lead to recovery in sexual satisfaction. Although data suggest a relationship between sexual function and sexual satisfaction, it is unclear whether presurgical levels of sexual satisfaction are attained for men who "recover" erections post-RP. AIM: The goal of this analysis is to determine whether the recovery of erectile function restores presurgical levels of sexual satisfaction. METHODS: We assessed 229 men pre-RP and 24-months post-RP. At both time points, participants completed the Erectile Function Domain (EFD) and the Intercourse Satisfaction Domain (ISD) of the International Index of Erectile Function (IIEF). Erectile function recovery at 24 months was defined as (1) (EFD≥24) or (2) EFD back to baseline (BTB). One hundred sixty-six men with penetration hardness erections (PHEs) at baseline (EFD >24) were included in the analyses. Repeated measure t-tests were used to compare changes in ISD scores and effect size (Cohen's d) was calculated to determine the clinical significance of these changes. Multivariable analyses (MVA) were used to test the relationship between EFD and ISD. RESULTS: The mean age of men was 58 (SD = 7) years. The mean EFD score at baseline was 29 (SD = 2), which declined significantly to 20 (SD = 10) at 24 months. ISD also decreased significantly between baseline and 24 months (12 to 8.3, P < .001, d = 0.87), even among men with PHEs at 24 months (12.3 to 11.3, P < .001, d = 0.50) and men who achieved BTB erections at 24 months (12.4 to 11.7, P = .02, d = 0.35). For men with PHEs at 24 months, MVAs identified baseline ISD (beta = 0.46) and 24-month EFD (beta = 0.23) as the only significant predictors of 24-month ISD. However, among men who achieved BTB erections at 24 months, baseline ISD (beta = 0.49) was the only significant predictor of 24-month ISD. CLINICAL IMPLICATIONS: These findings underscore the importance of the integration of psychological support and medical care to best meet the needs of patients. Furthermore, these results can be used to facilitate pre-RP communication and counseling with patients to improve understanding and manage post-RP expectations. STRENGTHS & LIMITATIONS: The study methodology, specifically the use of BTB as a means of defining erectile function and the longitudinal, prospective study design are relative strengths. Despite the longitudinal design, the study did not include a control group of healthy, age-matched men. CONCLUSION: Results highlight the enduring impact of sexual dysfunction, namely erectile dysfunction, on intercourse satisfaction following RP and suggest that restoration of function in and of itself does not ensure the restoration of satisfaction. Terrier JE, Masterson M, Mulhall JP, et al. Decrease in intercourse satisfaction in men who recover erections after radical prostatectomy. J Sex Med 2018;15:1133-1139.

Non-invasive prediction of recurrence in bladder cancer by detecting somatic TERT promoter mutations in urine.

BACKGROUND: Urothelial bladder cancer (UBC) is characterised by a high risk of recurrence. Patient monitoring is currently based on iterative cystoscopy and on urine cytology with low sensitivity in non-muscle-invasive bladder cancer (NMIBC). Telomerase reverse transcriptase (TERT) is frequently reactivated in UBC by promoter mutations. METHODS: We studied whether detection of TERT mutation in urine could be a predictor of UBC recurrence and compared this to cytology/cystoscopy for patient follow-up. A total of 348 patients treated by transurethral bladder resection for UBC were included together with 167 control patients. RESULTS: Overall sensitivity was 80.5% and specificity 89.8%, and was not greatly impacted by inflammation or infection. TERT remaining positive after initial surgery was associated with residual carcinoma in situ. TERT in urine was a reliable and dynamic predictor of recurrence in NMIBC (P<0.0001). In univariate analysis, TERT positive-status after initial surgery increased risk of recurrence by 5.34-fold (P=0.0004). TERT positive-status was still associated with recurrence in the subset of patients with negative cystoscopy (P=0.034). CONCLUSIONS: TERT mutations in urine might be helpful for early detection of recurrence in UBC, especially in NMIBC.

Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy.

INTRODUCTION: The International Index of Erectile Function (IIEF) is the gold standard validated instrument for defining erectile function (EF) and its response to treatment. The EF domain (EFD) contains six questions and is a sensitive and specific measurement of treatment-related changes in EF. The EFD score has been widely used as a primary assessment end point for clinical trials of EF recovery after radical prostatectomy (RP). Various EFD scores have been used to define functional erections. Recently, an EFD score of at least 22 has been used as a threshold in major post-RP penile rehabilitation studies. AIM: To define the EFD score that optimally defines "functional" erections after RP. METHODS: We assessed men 24 months after RP using the IIEF and specifically analyzed the scores of the EFD and intercourse satisfaction domain (ISD). MAIN OUTCOME MEASURES: We used two questions on satisfaction (score = 0-5) and enjoyment (score = 0-5) from the ISD to classify IS (score = 0-10). We tested the following intercourse satisfaction classifications: ISD score equal to 10, ISD score of at least 8, and a score of at least 4 for the ISD questions on satisfaction and enjoyment. We used the classification that produced the largest area under the curve (AUC) using a receiver operating characteristic (ROC) curve. Then, we used a three-step process to determine the optimal EFD score cutoff using sensitivity and specificity analysis. RESULTS: One hundred seventy-eight men had an average age at RP of 58 ± 7 years and a 24-month EFD score of 20 ± 9. Sixty-four percent had complete nerve-sparing surgery, 35% had partial nerve-sparing surgery, and 1% had the nerves fully resected. Thirty-three percent had laparoscopic RP and 67% had open RP. The ROC curves produced AUCs of 0.80 (ISD score = 10), 0.85 (ISD score ≥ 8), and 0.86 (ISD scores for satisfaction and enjoyment ≥ 4; P < .001 for all comparisons). Using the IS criterion of ISD scores for satisfaction and enjoyment of at least 4 (largest AUC), the sensitivity and specificity values were 0.89 and 0.66 for an ESD score equal to 22, 0.78 and 0.71 for a score equal to 23, 0.78 and 0.80 for a score equal to 24, 0.77 and 0.82 for a score equal to 25, and 0.73 and 0.85 for a score equal to 26. The scores of 24 and 25 met the criteria outlined in the first two steps of analysis. The score of 24 was selected as the cutoff using face valid judgment and the previous literature. CONCLUSION: These data support an EFD score of 24 as a valid cutoff defining "functional" erection in men with erectile dysfunction after RP. These data are important for clinicians in counseling patients and to researchers to define inclusion criteria and treatment end points for trials of erectile dysfunction after RP. Terrier JE, Muhall JP, Nelson CJ. Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy. J Sex Med 2017;14:804-809.

Psychological aspects of Peyronie's disease.

BACKGROUND: Peyronie's disease (PD) is an acquired fibrotic disorder (disorganized collagen deposition) in the tunica albuginea. This scar tissue or "plaque" builds up in the tunica albuginea and results in penile deformities. PD can have a significant negative impact on mood and quality of life. Although the psychological impact of PD has generally been understudied, there has been a growing body of literature that has assessed the impact PD can have on men's mental health and relationships. The aim of this study is to review the current literature focused on the psychological and relationship impact of PD. METHODS: We performed a MEDLINE search limited to English language literature using the terms: "Peyronie's Disease AND Psychological OR Psychosocial". Select references were then included for review. RESULTS: The research in this area confirms the clinical impressions of men with PD, which is that depression and relationship distress is prevalent. Approximately 50% of men with PD suffer from depressive symptoms and upwards of 80% report distress related to PD. It appears that these rates remain relatively stable over time. High rates of relationship stress were also reported as over 50% of men reported that PD had negatively impacted their relationship. Qualitative work in this area helps us understand the nature of this distress. Regarding body image and self-esteem, men described themselves as "abnormal", "ugly", "disgusting", "like a cripple", and a "half man", and some of them described feelings of shame. Many men reported that they lost their sexual confidence, or ability to initiate sex with a partner, while most reported a decrease in sexual interest. Additionally, many men expressed a sense of stigmatization and isolation. This led to difficulties in speaking about their disease with sexual partners or healthcare professionals. CONCLUSIONS: Taken in total, these studies indicate that those who actively treat PD should assess for distress or depressive symptoms. The standard assessment of PD could include the Peyronie's Disease Questionnaire (PDQ), and at least two questions on individual and relationship distress, or the use of a validated questionnaire to assess depression.