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Unal S, Karakus S, Du Comb W, Burnett AL. Clinical outcomes of the Burnett "snake" maneuver shunt modification for ischemic priapism. J Sex Med 2024; 21:723-728. [PMID: 38971576 DOI: 10.1093/jsxmed/qdae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/23/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Major ischemic priapism (IP) is defined as a persistent penile erection for >4 hours. IP may cause serious complications, especially if prompt resolution is not achieved. Therefore, selecting the most effective and usable shunt technique is crucial in IP cases that are refractory to medical therapy. AIM To compare the effectiveness and complication risks of distal corporoglanular shunt procedures with and without the Burnett "snake" maneuver. METHODS We conducted a retrospective study of patients who presented with IP and underwent surgical treatment at our institution between 2005 and 2021. The patients were categorized into 2 groups: group 1 (n = 26) underwent distal shunt + Burnett snake maneuver, and group 2 (n = 56) underwent distal shunt-only. Clinical history, parameters of IP, details of medical and surgical treatments, and follow-up information were evaluated. OUTCOMES Outcomes included differences in IP resolution and recurrence, functional erections, and complications between corporoglanular shunt procedures with and without the Burnett snake maneuver. RESULTS In group 1, 24 of 26 patients (92.3%) experienced priapism resolution with a single surgical intervention, while this outcome was observed in 30 of 56 patients (53.6%) in group 2 (P < .001). Notably, priapism recurrence was significantly lower in group 1, occurring in 1 of 24 patients (4.2%), as opposed to 8 of 30 patients (26.6%) in group 2 (P < .001). Of the patients with documented sexual function status at follow-up, functional erections (capable of penetration with or without phosphodiesterase 5 inhibitors) were noted in 6 of 14 patients (42.8%) in group 1 and 13 of 26 patients (50%) in group 2 (P = .66). CLINICAL IMPLICATIONS This study provides valuable insights regarding technical aspects of distal shunt procedures with and without the Burnett snake maneuver for treating major IP episodes. These results can help surgeons with clinical decision making for patients who present with IP. STRENGTH AND LIMITATIONS Limitations include the single-site retrospective design with potential selection bias, inaccuracies in medical record data, challenges in controlling confounding variables, and the lack of validated questionnaire scores for erectile function evaluation. CONCLUSION Our study demonstrates that modifying distal shunt procedures using the Burnett snake maneuver significantly improves priapism resolution and effectively prevents further priapism episodes without introducing additional complications or erectile function loss, thereby distinguishing it from distal shunt-only procedures.
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Affiliation(s)
- Selman Unal
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Serkan Karakus
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - William Du Comb
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
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Lumbiganon S, Moukhtar Hammad MA, Azad B, Yafi FA. A narrative review of initial treatment for ischemic priapism. Int J Impot Res 2024:10.1038/s41443-024-00951-1. [PMID: 39068212 DOI: 10.1038/s41443-024-00951-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 06/20/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024]
Abstract
Priapism is a rare condition characterized by prolonged and often painful penile erection unrelated to sexual stimulation. Ischemic priapism, the most common subtype, requires immediate attention to prevent irreversible damage to erectile tissue. This narrative review explores the initial management strategies for ischemic priapism. Intracavernosal phenylephrine injection and aspiration with or without irrigation are recommended as first-line treatments, with alternative options available depending on clinical settings and patient factors. While guidelines offer clear recommendations for priapism lasting more than 4 h, management of shorter-duration cases remains challenging due to limited evidence.
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Affiliation(s)
- Supanut Lumbiganon
- Department of Urology, University of California, Irvine, CA, USA
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Babak Azad
- Department of Urology, University of California, Irvine, CA, USA
| | - Faysal A Yafi
- Department of Urology, University of California, Irvine, CA, USA.
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Elmarasi M, Alsaeedi A, Elmakaty I, Elsayed B, Khalil IA, Aldeeb M, Khalafalla K, Al Kubaisi K, Arafa M, Majzoub A. Early vs delayed insertion of penile prosthesis in patients with refractory priapism: a systematic review and meta-analysis. Sex Med Rev 2024; 12:528-536. [PMID: 38465856 DOI: 10.1093/sxmrev/qeae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/09/2024] [Accepted: 01/13/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking. OBJECTIVES To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED). METHODS We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model. RESULTS We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group. CONCLUSION The results from this study favor an early approach to ED (within 30 days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.
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Affiliation(s)
| | - Ahmad Alsaeedi
- Department of Urology, Hamad Medical Corporation, Doha, 3050,Qatar
| | | | - Basel Elsayed
- College of Medicine, Qatar University, Doha, 2713, Qatar
| | - Ibrahim A Khalil
- Department of Urology, Hamad Medical Corporation, Doha, 3050,Qatar
| | - Maya Aldeeb
- Department of Medical Education, Family Medicine Residency Program, Hamad Medical Corporation, Doha, 3050, Qatar
| | | | | | - Mohamed Arafa
- Department of Urology, Hamad Medical Corporation, Doha, 3050,Qatar
| | - Ahmed Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, 3050,Qatar
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VanDyke ME, Smith WJ, Holland LC, Langford BT, Joshi EG, Dropkin BM, Breyer BN, Yafi FA, Johnsen NV, Barham DW, Joice GA, Fode M, Franzen BP, Hudak SJ, Morey AF. Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling? Int J Impot Res 2024; 36:62-67. [PMID: 38114594 DOI: 10.1038/s41443-023-00808-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
Prolonged ischemic priapism presents a treatment challenge given the difficulty in achieving detumescence and effects on sexual function. To evaluate current practice patterns, an open, web-based multi-institutional survey querying surgeons' experience with and perceived efficacy of tunneling maneuvers (corporoglanular tunneling and penoscrotal decompression), as well as impressions of erectile recovery, was administered to members of societies specializing in male genital surgery. Following distribution, 141 responses were received. Tunneling procedures were the favored first-line surgical intervention in the prolonged setting (99/139, 71.2% tunneling vs. 14/139, 10.1% implant, p < .001). Although respondents were more likely to have performed corporoglanular tunneling than penoscrotal decompression (124/138, 89.9% vs. 86/137, 62.8%, p < .001), penoscrotal decompression was perceived as more effective among those who had performed both (47.3% Very or Extremely Effective for penoscrotal decompression vs. 18.7% for corporoglanular tunneling; p < .001). Many respondents who had performed both tunneling procedures felt that most regained meaningful sexual function after either corporoglanular tunneling or penoscrotal decompression (33/75, 44.0% vs. 33/74, 44.6%, p = .942). While further patient-centered investigation is warranted, this study suggests that penoscrotal decompression may outperform corporoglanular tunneling for prolonged priapism, and that recovery of sexual function may be higher than previously thought after tunneling procedures.
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Affiliation(s)
- Maia E VanDyke
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
| | - Wesley J Smith
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Levi C Holland
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Brian T Langford
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Eshan G Joshi
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | | | - Benjamin N Breyer
- Department of Urology and Epidemiology and Biostatistics, University of California - San Francisco, San Francisco, CA, USA
| | - Faysal A Yafi
- Department of Urology, University of California -Irvine, Irvine, CA, USA
| | - Niels V Johnsen
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | - David W Barham
- Department of Urology, University of California -Irvine, Irvine, CA, USA
| | - Gregory A Joice
- Department of Urology, Columbia University, New York, NY, USA
| | - Mikkel Fode
- Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Bryce P Franzen
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Steven J Hudak
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Milenkovic U, Cocci A, Veeratterapillay R, Dimitropoulos K, Boeri L, Capogrosso P, Cilesiz NC, Gul M, Hatzichristodoulou G, Modgil V, Russo GI, Tharakan T, Omar MI, Bettocchi C, Carvalho J, Yuhong Y, Corona G, Jones H, Kadioglu A, Martinez-Salamanca JI, Verze P, Serefoglu EC, Minhas S, Salonia A. Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel. Int J Impot Res 2024; 36:36-49. [PMID: 36151318 DOI: 10.1038/s41443-022-00604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/13/2022] [Accepted: 07/28/2022] [Indexed: 11/09/2022]
Abstract
Surgical treatments for ischemic priapism (IP) include shunts or penile implants. Non-ischemic priapism (NIP) is usually the result of penile/perineal trauma causing an arterial fistula and embolisation may be required. We conducted a systematic review on behalf of the EAU Sexual and Reproductive health Guidelines panel to analyse the available evidence on efficacy and safety of surgical modalities for IP and NIP. Outcomes were priapism resolution, sexual function and adverse events following surgery. Overall, 63 studies (n = 923) met inclusion criteria up to September 2021. For IP (n = 702), surgery comprised distal (n = 274), proximal shunts (n = 209) and penile prostheses (n = 194). Resolution occurred in 18.7-100% for distal, 5.7-100% for proximal shunts and 100% for penile prostheses. Potency rate was 20-100% for distal, 11.1-77.2% for proximal shunts, and 26.3-100% for penile prostheses, respectively. Patient satisfaction was 60-100% following penile prostheses implantation. Complications were 0-42.5% for shunts and 0-13.6% for IPP. For NIP (n = 221), embolisation success was 85.7-100% and potency 80-100%. The majority of studies were retrospective cohort studies. Risk of bias was high. Overall, surgical shunts have acceptable success rates in IP. Proximal/venous shunts should be abandoned due to morbidity/ED rates. In IP > 48 h, best outcomes are seen with penile prostheses implantation. Embolisation is the mainstay technique for NIP with high resolution rates and adequate erectile function.
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Affiliation(s)
- U Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - A Cocci
- Department of Urology, University of Florence, Florence, Italy
| | | | - K Dimitropoulos
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - L Boeri
- Department of Urology, IRCCCS Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Capogrosso
- ASST-Sette Laghi, Circolo & Fondazione Macchi Hospital, University of Insurbria, Varese, Italy
| | - N C Cilesiz
- Department. of Urology, Istanbul Taksim GOP Training and Research Hospital, Istanbul, Turkey
| | - M Gul
- Department of Reproductive Biology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - V Modgil
- Department of Urology, Manchester Royal Infirmary, Manchester, UK
| | - G I Russo
- Department of Urology, University of Catania, Catania, Italy
| | - T Tharakan
- Department of Urology, Charing Cross Hospital, London, UK
| | - M I Omar
- Department of Urology, University of Aberdeen, Abderdeen, UK
| | - C Bettocchi
- Department of Urology, University of Foggia, Foggia, Italy
| | - J Carvalho
- Department of Psychology and Health Sciences, Universidade Lusofona de Humanidades e Tecnologias, Lisbon, Portugal
| | - Y Yuhong
- Department of Medicine, McMaster University, Hamilton, Canada
| | - G Corona
- Department of Endocrinology, Maggiore-Bellaria Hospital, Bologna, Italy
| | - H Jones
- Department of Endocrinology, Barnsley Hospital, Barnsley, UK
| | - A Kadioglu
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - J I Martinez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - P Verze
- Department of Urology, University Federico II of Naples, Naples, Italy
| | - E C Serefoglu
- Department of Urology, Bahceci Health Group, Istanbul, Turkey
| | - S Minhas
- Department of Urology, Imperial College, London, UK
| | - A Salonia
- Division of Experimental Oncology/Unit of Urology, URI; IRCCS Ospedale San Raffaele, Milan, Italy.
- University Vita-Salute San Raffaele, Milan, Italy.
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Abstract
This JAMA Clinical Guidelines Synopsis summarizes the 2022 American Urological Association/Sexual Medicine Society of North America guidelines on diagnosis and management of priapism.
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Affiliation(s)
- Richard J Fantus
- Department of Urology, University of Kansas Medical Center, Kansas City
| | - Robert E Brannigan
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Andrew M Davis
- Section of General Internal Medicine, University of Chicago Medicine, Chicago, Illinois
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Dekalo S, Stern N, Broderick GA, Brock G. Priapism or Prolonged Erection: Is 4 - 6 Hours of Cavernous Ischemia the Time Point of Irreversible Tissue Injury? Sex Med Rev 2022; 10:660-668. [PMID: 37051958 DOI: 10.1016/j.sxmr.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/02/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Ischemic priapism remains a significant cause of morbidity among men. To date, the precise time when penile ischemia results in permanent, non-reversible cavernosal smooth muscle injury, compromising subsequent erectile integrity, remains ill-defined. OBJECTIVES To review the medical literature pertaining to ischemic priapism, focusing on factors that predict the exact timeline of irreversible cavernous tissue injury. METHODS A comprehensive literature search was performed. Our search included both publications on animal models and retrospective clinical series through January 2022. Articles were eligible for inclusion if they contained original data regarding nonreversible tissue injury on histology and/or provided a timeline of erectile function loss or preservation and had full text available in English. RESULTS Innovative studies in the 1990s using invitro models with strips of rabbit, rat, canine and monkey corpus cavernosal tissue demonstrated that anoxia eliminated spontaneous contractile activity and reduced tissue responsiveness to electrical field stimulation or pharmacological agents. The same models demonstrated that the inhibitory effects of field stimulated relaxation, were mediated by nitric oxide. Subsequent studies using similar models demonstrated that exposure of corpus cavernosum smooth muscle to an acidotic environment impairs its ability to contract. A pH of 6.9 was chosen for these experiments based on a case series of men with priapism, in whom a mean pH of 6.9 was measured in corporal blood after 4-6 hours of priapism. Invivo animal studies demonstrated that after erection periods of 6-8 hours, microscopy shows sporadic endothelial defects but otherwise normal cavernous smooth muscle. In these studies, greater durations of ischemic priapism were shown to result in more pronounced ultrastructural changes and presumably irreversibility. In studies involving human corporal tissues, samples were obtained from men who had experienced priapism for at least 12 hours. Overall, erectile function outcome data is deficient in priapism reporting, especially within treatment windows less than 6 hours. Some reports on ischemic priapism have documented good erectile function outcomes with reversal by 12 hours. CONCLUSION Based on our extensive review of animal models and clinical reports, we found that many clinical papers rely on the same small set of animal studies to suggest the time point of irreversible ischemic damage at 4-6 hours. Our review suggests an equal number of retrospective clinical studies demonstrate that ischemic priapism reversed within 6-12 hours may preserve erectile function in many patients. Dekalo S, Stern N, Broderick GA, et al. Priapism or Prolonged Erection: Is 4 - 6 Hours of Cavernous Ischemia the Time Point of Irreversible Tissue Injury? Sex Med Rev 2022;XX:XXX-XXX.
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Affiliation(s)
- Snir Dekalo
- Division of Urology, Western University, Department of Surgery, London, ON, Canada.
| | - Noah Stern
- Division of Urology, Western University, Department of Surgery, London, ON, Canada
| | | | - Gerald Brock
- Division of Urology, Western University, Department of Surgery, London, ON, Canada; Omega Fertility and Andrology Clinic, London, ON, Canada
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Adawi EA, Ghanem MA. Platelet volume parameters as a tool in the evaluation of acute ischemic priapism in patients with sickle cell anemia. Arch Ital Urol Androl 2022; 94:217-221. [PMID: 35775350 DOI: 10.4081/aiua.2022.2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the predictive value of platelet volume indices (PVIs), such as mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT), as prognostic parameters of detumescence in acute ischemic priapism (IP) patients with sickle cell anemia (SCA) in steady-state who received intracavernosal injections of phenylephrine with aspiration and saline irrigation. METHODS Fifty-six SCA patients with acute IP and 54 healthy male control subjects were included in the research. Priapism was diagnosed by penile Doppler ultrasound and corporal blood gas tests before intervention. Measurements of PVIs (MPV, PDW, and PCT) and TLC were ordered for all participants. Additionally, the duration of priapism was recorded. The area under the curves was calculated by receiver operating characteristic (ROC) regression analysis. RESULTS The detumescence rate was 71.4% after the intervention. Compared to the control group, priapic SCA patients showed significantly higher PLT (p = 0.011), MPV (p = 0.002), PDW (p = 0.032), PCT values (p = 0.022), and TLC (p = 0.027). Higher MPV, PDW, and PCT values were observed in unsuccessful detumescence patients compared to the resolution group (p < 0.05). Statistically significant cutoff values for persistent priapism were measured by ROC as PLT: ⩾ 254x103/μL; MPV: ⩾ 13.2 fL; PDW: ⩾ 15.6 fL; PCT: ⩾ 24%; and TLC ≥ 8.5x103/L. Priapism duration of ≤ 17.9 hours was significantly related to detumescence rate (p = 0.000). Multivariable logistic regression analysis showed that priapism duration and higher MPV are prognostic parameters for detumescence in SCA. CONCLUSIONS The higher MPV and duration of priapism can be used as parameters for evaluating detumescence outcomes in steady-state SCA with acute IP.
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Masterson JM, Zhao H, Choi E, Kim HH, Anger JT. Characteristics and Long Term Follow up of Men Who Suffer Ischemic Priapism Secondary to Recreational Use of Intracavernosal Injectable Medications. Urology 2021; 156:163-168. [PMID: 34273403 DOI: 10.1016/j.urology.2021.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To better understand patient experience, risk factors, culture, and ED outcomes surrounding recreational ICI use that led to ischemic priapism. METHODS After IRB approval, men presenting for ischemic priapism secondary to recreational ICI use from January 2010 to December 2018 were contacted by mail and then via telephone. Standardized questions were asked of all study participants on the topics of erectile function (IIEF-5), sexual practices, and at-risk behavior at the time of priapism. Qualitative data analysis was performed using grounded theory methodology. RESULTS 14 men age 24-59 were successfully recruited. All men described themselves as men having sex with men (MSM) and one (7.1%) as having both male and female sexual partners. Average follow up IIEF-5 among participants was 13 (SD 4.0). Eleven men (78.6 %) described illicit drug use at the time of priapism. Qualitative data analysis yielded several preliminary themes: concomitant drug use, naivety, peer pressure, and delay in seeking treatment. Men frequently reported illicit drug use in group sex scenarios and ICI use under pressure to perform sexually or to counteract effects of illicit substances. CONCLUSIONS Recreational ICI in this cohort was part of a lifestyle of risky behavior. Methamphetamine use and group sex encounters strongly motivate recreational ICI use. Substance abuse centers may offer an entry point into this population for counseling and primary prevention.
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Affiliation(s)
- John M Masterson
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hanson Zhao
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eunice Choi
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard H Kim
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
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