Is there a role for testosterone replacement therapy in reducing biochemical recurrence following radical prostatectomy?

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Background: Historically, the use of testosterone replacement therapy (TRT) has not been recommended in men with a history of prostate cancer (PC). However, low testosterone levels are significantly associated with metabolic complications, decreased sexual function, and (more recently) high-grade PC. In 2009, in hopes of improving sexual function outcomes in men following radical prostatectomy (RP), we began treating low-risk patients with TRT. The current study examines the impact of TRT on biochemical recurrence (BCR). Methods: Between December 2009 and June 2018, a cohort of 850 patients underwent RP by a single surgeon. 152 (18%) men were postoperatively placed on TRT for recovery of sexual function. All data was prospectively collected and retrospectively analyzed. TRT patients were proportionately matched to 419 control patients by pathologic Gleason Grade Group (GGG) and stage. Univariate and multivariate comparisons were used to compare rates and time to BCR (two consecutive PSAs ≥ 0.2 ng/dl); Cox regression modeling was used to generate a survival function at the mean of covariates. Results: There were no statistically significant differences in preoperative PSA, age, prostate weight, pathologic GGG and stage between the control versus TRT groups. Median follow-up time was 3 years in both groups. 7/152 (4.6%) and 39/419 (9.3%) patients experienced BCR in the TRT versus control groups, respectively (unadjusted, p=0.068). In adjusted time to-analysis, TRT was an independent predictor of recurrence-free survival, after controlling for GGG, p-stage, preoperative FT and PSA. A patient on TRT was approximately 53% less likely to experience a BCR (OR: 0.534, 95%CI: 0.288-0.993). Conclusions: After accounting for pathologic GGG, stage, and other significant covariates, the use of TRT independently reduced recurrence post-RP. These results suggest the need for a multi-center randomized control trial.

The predictive power of free (vs. total) testosterone in aggressive prostate cancer

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Background: The role of testosterone in prostate growth and the development of prostate cancer is a controversial topic. Most current data suggest that lower testosterone leads to higher grade conversion, whereas higher testosterone may serve a protective role in preventing both development and recurrence. We seek to analyze whether free testosterone (FT) values can predict aggressiveness in prostate cancers. Methods: We retrospectively reviewed 830 patients who presented to a single surgeon for evaluation and management of prostate cancer. Total Testosterone (TT) and FT values were obtained on each patient at initial visit. All patients underwent radical prostatectomy and samples from surgery were sent for grading and staging. Patients were stratified by FT quartile (25th [≤ 4.42 ng/dL], 50th [4.43 – 5.60 ng/dL], 75th [5.61 – 6.95 ng/dL], and 100th [≥ 6.96 ng/dL]). Results: Of 830 patients, 168 (22.2%), 330 (39.8%), 188 (22.7%), 46 (5.5%), and 98 (11.8%) had GS 3+3, 3+4, 4+3, 4+4, and ≥4+5, respectively. Mean FT values for each Gleason grade group (GGG) were significantly different (p = 0.008). Mean FT was also lower in patients with higher stage disease (p = 0.01). In contrast, TT did not differ significantly among GGG (p = 0.489) or stage (p = 0.670). Patients who had a FT level in the lowest quartile (≤ 4.42 ng/dL) had a higher proportion of GGG 5 (15.6%) than patients in the highest quartile (≥ 6.96 ng/dL) (6.2%) (p = 0.002). After adjusting for age, prostate specific antigen (PSA), and body mass index (BMI) in multivariate analysis, lower FT was a significant predictor of high-risk score 9-10 (OR: 0.912, 95% CI: 0.836-0.994, p = 0.036). These trends showed strong correlation in pathologic stage (p = 0.057), but larger numbers are needed to gauge effect size. Conclusions: Based on our data, biochemically low FT may be a risk factor for high grade and high stage cancer. These results have implications for the current recommendations for testosterone therapy, which is contraindicated in men with prostate cancer. [Table: see text]

Management of Peyronie's disease with collagenase Clostridium histolyticum in the acute phase

INTRODUCTION

Peyronie's disease (PD) can affect men of all ages and is associated with penile pain as well as curvature and erectile dysfunction. Treatment modalities for PD include conservative, less invasive and surgical treatments. Choice of treatment depends on the disease's phase. Injection of collagenase Clostridium histolyticum (CCH) is only the Food and Drug Administration approved treatment for the management of the chronic phase of the disease. Only a few limited studies have evaluated its potential benefits during the acute phase.

AIM

To evaluate the current evidence on the use of injectable CCH during the acute or active phase of PD.

METHODS

We performed a PubMed database search for articles published between 2015 and 2018 that investigated the use of CCH for the management of the acute phase of PD. Search keywords included "Peyronie's disease", "collagenase Clostridium histolyticum", and "acute phase".

MAIN OUTCOME MEASURES

Changes in penile curvature after treatment with injectable CCH.

RESULTS

Mean curvature decrease ranged between 15.8° and 22.6° corresponding to 27.4-37.4% decrease from baseline after 2.5-4 cycles, corresponding to 5-8 injections, of CCH treatment in patients during the acute phase of PD.

CONCLUSIONS

Intralesional CCH injection therapy during the acute phase of PD can be both safe and effective and clinically significant improvements in penile curvature may be achieved. Larger multi-institutional studies are, however, still needed to confirm these results and validate this additional indication for CCH.

Immediate Placement of Penile Prosthesis for the Management of Ischemic Priapism as First-line Treatment

In patients presenting with early ischemic priapism, proceeding with the conventional paradigm is recommended. In those presenting late (>48 h), penile prosthesis placement can easily be performed 2-6 wk later, with no increase in surgical difficulty or morbidity. Immediate penile prosthesis implantation should be reserved for motivated patients who understand the increased associated risks, have evidence of corporal fibrosis on imaging, and are being treated in a center of excellence.

Penile Girth Enlargement Strategies: What's the Evidence?

INTRODUCTION

Most men seeking penile girth augmentation have physiologically normal penises but may suffer from severe preoccupation with penis size known as penile dysmorphophobic disorder.

AIM

To describe the medical, procedural, and reconstructive techniques available for penile girth enhancement and to review the success and complications of each modality.

METHODS

A comprehensive review of peer-reviewed publications on the topic was performed through a PubMed search. Key search terms included penis, enhancement, enlargement, phalloplasty, reconstruction, girth, and augmentation.

MAIN OUTCOME MEASURE

We wanted to summarize the motivations behind penile girth enhancement and review the outcomes for girth augmentation treatments.

RESULTS

Various medical, traction, injection, prosthetic, and reconstructive modalities have been studied for penile girth enhancement, with increases in girth ranging from 0-4.9 cm. Complications were reported in a minority of patients, but they may be devastating and include penile fibrosis, sexual dysfunction, device infection, and death.

CONCLUSION

A variety of penile girth augmentation techniques have been studied. Clinical guidelines are lacking, and complications of penile girth enhancement are likely underreported. Until more rigorous investigation with accurate reporting of complications is achieved, penile girth augmentation procedures should be considered experimental. Hehemann MC, Towe M, Huynh LM, et al. Penile Girth Enlargement Strategies: What's the Evidence? Sex Med 2019;7:535-547.

Review of Management Options for Active-Phase Peyronie's Disease

INTRODUCTION

Peyronie's disease (PD) is a fibrotic disorder that leads to plaque formation in ∼3-9% of adult men. Connective tissue buildup results in plaque formation, penile curvature and shortening, and in some cases, pain. In the active phase of PD, penile pain is a common symptom, often accompanied by progression in curvature. Treatment options for PD include oral drugs, topical cream, intralesional injections, traction, and shock wave therapy. This article reviews the different treatment options for active-phase PD.

AIM

To provide a comprehensive review of the current evidence-based treatments, focusing on active-phase PD.

METHODS

A PubMed database search was performed for studies on conservative therapy. We reviewed current clinical practices and trials for the treatment of active-phase PD and assessed their applicability as treatment options.

MAIN OUTCOME MEASURE

Define the most recent and effective therapies for the improvement in penile curvature in men presenting with acute PD.

RESULTS

A number of trials have resulted in significant benefits in the treatment of PD. Many of the oral therapies studied improved patient outcomes, but the data are insufficient. Similarly, there is no approved topical therapy by guidelines. The best options are intralesional injections of collagenase Clostridium histolyticum (CCh) and interferon-α2b. Shock wave therapy is not recommended for treatment of curvature, but has been shown to improve pain. Traction therapy may have a role in improving PD curve and penile length.

CONCLUSION

PD remains a challenge for urologists. Evidence suggests that, for oral therapy, a combination of drugs produces better results. Shock wave therapy is still unproven. Intralesional therapy delivers the best evidence for improvement in the active phase. CCh is the only FDA-approved treatment option available. Penile traction therapy may improve patient outcomes. Brimley SC, Yafi FA, Greenberg J, et al. Review of Management Options for Active-Phase Peyronie's Disease. Sex Med Rev 2019;7:329-337.

Intralesional collagenase Clostridium histolyticum in the management of Peyronie's disease: current best practice

The use of Clostridium histolyticum collagenase (CCH) has become increasingly widespread for the treatment of Peyronie's disease (PD) in recent years. Numerous trials have confirmed both its safety and efficacy in appropriately selected patients with this condition. The purpose of this review is to examine pivotal trials demonstrating the efficacy of CCH, revisit viable candidates for treatment with intralesional injection therapy, and provide a summary of injection technique and appropriate management of patients receiving this treatment at the time of therapy and in follow up.

Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence

BACKGROUND

After radical prostatectomy (RP), erectile dysfunction, often necessitating the need for inflatable penile prosthesis (IPP) insertion, and urinary incontinence and climacturia can ensue.

AIM

To assess the efficacy and safety of the mini-jupette, a mesh used to approximate the medial aspects of the 2 corporotomies at the time of IPP insertion, for the management of climacturia and urine leakage in patients with minimal incontinence.

METHODS

We conducted a pilot multicenter study of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence (≤2 pads/day [ppd]) undergoing IPP insertion with concomitant placement of a mini-jupette graft.

OUTCOMES

Pre- and postoperative erectile function, continence and climacturia, and overall surgical outcomes were assessed.

RESULTS

38 patients underwent the mini-jupette procedure. The mean age of the population was 65.3 years (SD = 7.7). 30 had post-RP climacturia and 32 patients had post-RP incontinence (mean = 1.3 ppd, SD = 0.8). 31 patients received Coloplast Titan, 4 received AMS 700 LGX, and 3 received AMS 700 CX IPPs. Mean corporotomy size was 2.9 cm (SD = 1.0). Mean graft measurements were 3.2 cm (SD = 0.9) for width, 3.3 cm (SD = 1.3) for length, and 11.0 cm² (SD = 5.1) for surface area. At a mean follow-up of 5.1 months (SD = 6.9), there were 5 postoperative complications (13.2%) of which 4 required explantation. Climacturia and incontinence were subjectively improved in 92.8% and 85.7%, respectively. Mean ppd decreased by 1.3 postoperatively.

CLINICAL IMPLICATIONS

The Andrianne mini-jupette is a feasible adjunct to IPP placement that can be used for subsets of patients with post-RP climacturia and/or minimal incontinence.

STRENGTHS AND LIMITATIONS

Strengths of this study include the novel nature of this intervention, the multi-institutional nature of the study, and the promising results demonstrated. Limitations include the retrospective nature of the study and the heterogeneity of the techniques and grafts used by different surgeons involved.

CONCLUSION

Longer follow-up and larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention. Yafi FA, Andrianne R, Alzweri L, et al. Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence. J Sex Med 2018;15:789-796.

Effect of collagenase Clostridium histolyticum on penile vascular and morphological parameters in patients with Peyronie's disease

Background

To examine the changes in penile vascular parameters after the administration of collagenase Clostridium histolyticum (CCH) in patients with Peyronie’s disease (PD).

Methods

We retrospectively reviewed the records for all patients treated with CCH for PD between 04/2014 and 05/2017 who underwent penile duplex Doppler ultrasound (PDDU) after pharmacologically induced erection both before and after four cycles of CCH treatment. The primary outcomes measured were changes in peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) after CCH treatment. Paired t-tests, chi-squared tests, and correlation coefficients were performed between functional and vascular parameters before and after four rounds of CCH to determine statistical significance (P<0.05).

Results

A total of 51 patients were included in the study. After four cycles of CCH therapy, there was no statistically significant change in PSV, EDV, RI, or International Index of Erectile Function score when compared to baseline. Similarly, there was no correlation between vascular parameters and change in curvature. There was a statistically significant change in penile curvature (60˚±16.9˚ to 40.8˚±14.9˚, P<0.001) and erect penile circumference (11.6±1.0 to 11.9±1.0 cm, P<0.05) after treatment.

Conclusions

In spite of a significant change in penile curvature, this change did not correlate with changing penile vascular or morphological parameters. Overall, CCH therapy seems to have a negligible impact on penile vasculature, furthering evidence of its favorable safety profile.

Update on the Safety of Phosphodiesterase Type 5 Inhibitors for the Treatment of Erectile Dysfunction

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5Is) have demonstrated efficacy in the treatment of erectile dysfunction (ED). Although historically found to have limited drug-related adverse events, emerging data have suggested that PDE5Is might be associated with melanoma or recurrence of prostate cancer after radical prostatectomy.

AIM

To summarize the literature on the safety of PDE5Is.

METHODS

A literature review was performed through PubMed from 1990 through 2016 regarding ED. Keywords used for the search were erectile dysfunction, phosphodiesterase type 5 inhibitors, sildenafil, vardenafil, tadalafil, avanafil, safety, side effects, and adverse events, among others.

MAIN OUTCOME MEASURES

Visual, auditory, cardiovascular, renal, hepatic, priapic, and oncologic outcomes associated with the intake of PDE5Is for the treatment of ED, in addition to drug interactions, abuse, overdose, and the phenomenon of counterfeit medications.

RESULTS

PDE5Is are safe drugs for the management of ED. Although recent studies have shown an increased risk of non-arteritic ischemic optic neuropathy with PDE5Is, the magnitude of that risk is small. The possibility that PDE5Is cause sensorineural hearing loss remains uncertain. PDE5Is display a safe cardiovascular profile if used according to the Princeton III Consensus guidelines. There appears to be an association between PDE5I use and melanoma but the absence of a mechanism of causation raises doubt that the association is cause and effect. PDE5Is do not increase the risk of biochemical recurrence after prostate cancer management. PDE5I abuse and use of counterfeit medications present serious global health concerns.

CONCLUSION

Current data strongly support the efficacy, tolerability, and overall safety of PDE5Is for the treatment of ED. PDE5Is probably cause a small increase in the risk of non-arteritic ischemic optic neuropathy. Evidence on increased rates of melanoma and prostate cancer recurrence is weak and controversial. PDE5Is should still be considered first-line therapy for the treatment of most etiologies of ED. Yafi FA, Sharlip ID, Becher EF. Update on the Safety of Phosphodiesterase Type 5 Inhibitors for the Treatment of Erectile Dysfunction. Sex Med Rev 2018;6:242-252.

Racial variations in response to intralesional collagenase clostridium histolyticum in men with Peyronie's disease

Background

An examination of potential racial variations between Caucasian American (CA) and African American (AA) men in the efficacy and safety of collagenase clostridium histolyticum (CCH) in the treatment of Peyronie’s disease (PD).

Methods

We retrospectively reviewed the records for all patients treated with CCH for PD between 04/2014 and 05/2017. Patients were divided into two groups based on their self-reported race. The primary outcomes of interest were final change in curvature after CCH treatment regardless of number of CCH cycles received, and frequency of treatment-related adverse events (TRAEs).

Results

A total of 159 patients were included in the study, of which 146 (91.8%) were CA while 13 (8.2%) were AA. Mean duration of PD was 28.3 months for CA patients and 16.8 months for CA patients (P=0.436). There was no significant difference in final change in curvature CA and AA patients (15.9° vs. 13.1° respectively, P=0.445). There was no statistically significant difference in frequency of TRAEs between CA patients (17, 12%) and AA patients (0, 0%) (P=0.208).

Conclusions

Although racial variations in efficacy and safety of CCH in patients with PD have not been addressed in the literature, preliminary results from our study suggest that CCH therapy may be equally efficacious and safe in both CA and AA men. There was no statistically significant difference in final change in curvature, International Index of Erectile Function (IIEF) scores, penile length, or TRAEs after CCH treatment between CA and AA patients.

Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions

OBJECTIVE

To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation.

METHODS

Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation.

RESULTS

The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae.

CONCLUSION

Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

Practice Patterns in the Diagnosis and Management of Hypogonadism: A Survey of Sexual Medicine Society of North America Members

OBJECTIVE

To describe practice patterns in the diagnosis and treatment of hypogonadism, as the optimal approaches are controversial. Multiple therapeutic options are currently available for hypogonadal men and treatment patterns vary considerably. The safety of testosterone therapy (TTh) remains understudied.

MATERIALS AND METHODS

A 23-question survey regarding diagnosis and treatment of hypogonadism was sent to all members of the Sexual Medicine Society of North America. Subgroup analyses compared responses between sexual medicine fellows and non-fellows, as well as between academic and nonacademic physicians, using a chi-squared analysis.

RESULTS

A total of 101 responses were included for analysis. The most common cutoff value used to diagnose hypogonadism was 300 ng/dL (55%, range = 200-400 ng/dL), and 31% felt comfortable giving TTh to a symptomatic patient with normal serum testosterone levels. No respondents felt that TTh increased a cardiovascular event risk. Of those surveyed, 68% would prescribe TTh to a hypogonadal man with severe lower urinary tract symptoms, and 64% would offer TTh to a man with low-risk prostate cancer on active surveillance. Fellowship-trained physicians were more likely to prescribe TTh to a man with hypogonadism but normal serum testosterone (P = .038), but they differed in the types of therapy they would use for men with hypogonadism who wish to preserve or regain fertility.

CONCLUSION

Significant variety exists in the diagnosis and treatment of hypogonadism. The majority of physicians will only prescribe TTh in the setting of subnormal serum testosterone levels, despite the presence of symptoms. None of the surveyed physicians reported concern over the risk of cardiovascular events.

Collagenase Clostridium histolyticum in the treatment of Peyronie's disease: patient selection and perspectives

The safety and efficacy of the use of collagenase Clostridium histolyticum (CCH) for the treatment of Peyronie's disease has been confirmed over the past several years. However, identification of the ideal patient population for use of this treatment is not well established. Multiple studies have attempted to delineate various patient-specific factors that may predict response to treatment with CCH, with the intent of enhancing patient selection. To date, these include baseline curvature severity, duration of disease, disease phase at presentation, plaque calcification, baseline erectile function, plaque size, age, comorbid diabetes, previous penile trauma, responsiveness to first treatment cycle, baseline penile shortening or pain, prior treatment with intralesional injection, compliance with plaque modeling, and atypical curvature. In addition, other studies have sought to explore various aspects of treatment with CCH that may affect patient perspective of treatment. They have focused on patient-reported outcomes, female partner considerations, cost of treatment, and potential confounders of patient satisfaction. This review provides a summary and analysis of currently available literature on topics of patient selection and perspectives in regard to treatment of Peyronie's disease with CCH.